Education Specialists Research Articles

Assessing Current Knowledge of Hearing Impairment With Diabetes by Surveying Providers With CBDCE Certification.

The purpose of this study was to assess current knowledge, attitudes, and practices regarding hearing impairment and screening referrals in patients with diabetes among providers who have a Certified Diabetes Care and Education Specialist (CBDCE) Certification. A cross-sectional survey created through Qualtrics was emailed to health care providers in the United States with CDCES certification. Providers responded regarding knowledge and importance of hearing impairment compared to other diabetes complications, when they would refer a patient to an audiologist, the percentage of patients referred, and awareness of over-the-counter hearing aids. Descriptive statistics were calculated for all questionnaire items. One thousand four hundred and ninety-five CDCES providers completed the survey. Participants selected the most common conditions associated with diabetes as kidney dysfunction (96.7%), retinopathy (96.5%), obesity (95.6%), and foot infection (94.5%); 44.5% chose hearing impairment. Over 60% of providers were not familiar with how to refer patients to an audiologist and acknowledged being unfamiliar with recommended screening frequency as the most common barrier. Most providers had referred fewer than 20% of patients to an audiologist. Over half of providers were not aware of over-the-counter hearing aids. Among a national sample of health care providers with comprehensive knowledge in diabetes care, many providers do not associate hearing impairment with diabetes and rate other microvascular complications of higher importance.

The Longitudinal Implementation of a Mental Health Literacy Resource Among Grade 8 and 9 Students in a Catholic School Setting

ABSTRACT Background Mental disorders most likely manifest during adolescence, providing opportunities for schools and professionals to implement standardized mental health literacy (MHL) interventions to support improvement of mental health outcomes. Purpose This study aimed to evaluate the impact of an MHL intervention (the Guide) on knowledge, stigma, help-seeking and overall mental health among grade 8–9 students. Methods We developed a longitudinal cohort study to evaluate the Guide among 523 students, delivered across subsequent grade levels within a Catholic school board in Canada. We utilized validated measures to assess mental health knowledge, stigma, help seeking attitudes, and mental health across four time-points: baseline, end of grade 8, beginning of grade 9, and end of grade 9. Teachers undertook training to learn how to administer the intervention, utilize included teaching aids, and collect data. Results Students demonstrated improvements on knowledge and stigma at all measurement intervals, however statistically significant differences in help-seeking and well-being outcomes were not observed. Discussion This study suggests the plausibility of longer-term delivery of the Guide and similar resources in enhancing knowledge and reducing stigma among similar youth cohorts. Translation to Health Education Practice Certified Health Education Specialists may adapt the Guide to accommodate youth mental health needs in different contexts.

Positive Influences of Integrating Information Communication Technology in Teaching English at a Technical and Vocational Training College

The paper investigated the positive influence of integrating Information Communication Technology (ICT) in teaching English to National Certificate NC (V) students at a Technical and Vocational Education and Training (TVET) college. A qualitative research approach was used in this research to explore and determine ways in which ICT can be used in teaching English. The research’s participants were fifteen NC (V) lecturers offering English. Semi-structured interviews and focus group interviews were conducted with Heads of Departments (HODs), Senior Education Specialists (SES), Education Specialists (ES), and NC(V) English lecturers. This paper found that there are barriers when it comes to integrating ICT in teaching English, and these were teacher-level barriers, student-level barriers, and school-level barriers. It is hoped that this research will contribute towards strategic ways that will ensure that ICT is integrated in teaching English at Nkangala TVET College, as this will improve students’ class attendance and enhance teaching and learning.

Why I Became a Diabetes Care and Education Specialist?

Why I Became a Diabetes Care and Education Specialist?

The Role of the Diabetes Care and Education Specialist in Pediatric Diabetes - Type 1 Diabetes: ADCES Practice Paper

The Role of the Diabetes Care and Education Specialist in Pediatric Diabetes - Type 1 Diabetes: ADCES Practice Paper

Principles of practice-oriented mathematics education for future specialists in the financial sector

Principles of practice-oriented mathematics education for future specialists in the financial sector

THE POSSIBILITIES OF USING VIRTUAL AND AUGMENTED REALITY TECHNOLOGIES IN MODERN CARDIOLOGY

Justification. Technological innovations have revolutionized medical practice, especially in the field of cardiac surgery, where the complex nature of interventions requires precision and foresight. The use of virtual (VR) and augmented reality (AR) in this field opens up huge prospects for improving preoperative planning, improving the quality of medical education and, ultimately, improving patient treatment outcomes. Aim. to analyze the literature on the role of VR/AR in modern cardiology, to discuss the current role and future directions in this field. Material and methods. As a result of the search, 3,858 publications were extracted from PubMed/MEDLINE, 69 publications from eLibrary and 1,115 publications found using Google Scholar. The search queries included the following keywords and their combinations: virtual reality, augmented reality, cardiology, cardiac surgery, virtual reality, augmented reality, cardiology, cardiac surgery. Search time interval: since the foundation of the corresponding database until May 2024. Results. Modern cardiological care includes increasingly complex procedures that require a high level of expertise. VR is becoming a powerful tool for both pre-procedural planning and educational events. VR opens up new opportunities for education and training of specialists in the field of cardiology. With its help, you can create realistic simulations of various situations that doctors may encounter in their work. This allows students to gain hands-on experience without risking real patients. Conclusion. The integration of VR into cardiology practice has great potential, but for full integration it is necessary to solve a number of problems. It is necessary to develop standards for the safety and effectiveness of using VR for medical purposes. Additional research is also needed to assess the long-term health effects of VR use on patients.

Analysis of the Russian market of educational programs in the field of additional professional education for specialists of pharmaceutical companies

Abstract Aim conduct an analysis of the Russian market of educational programs in the field of additional professional education for specialists of pharmaceutical companies. Material and methods. The analysis of the market of educational programs was based on the data of the annual reporting of a number of institutions of higher education (reports on the results of the annual self-examination, reports on the results of activities and on the use of assigned state property, monitoring in the main areas of the educational institution of higher education, information and analytical materials based on the results of monitoring the effectiveness of activities educational institutions of higher education) for the period from 2017 to 2021. Based on data obtained, the share indicators of educational organizations in the Russian market of educational services in the field of additional education for specialists of pharmaceutical enterprises were determined. The share indicator was used to determine the concentration of educational services and the level of competition in the market using the concentration index and the Herfindahl-Hirschman index. In addition, during the work, such methods of analysis as generalization, methods of logical, systemic and comparative analysis, expert forecasting were used. Results. Based on the analysis, data were obtained on the profitability of the market for additional professional education services for pharmaceutical industry specialists; the presence of a high level of concentration of educational services in the market of additional professional education with a slight level of competition was established; the features of the implementation of additional professional training for specialists in the pharmaceutical industry are determined. Conclusion. The importance of additional professional education for specialists in the pharmaceutical industry has been confirmed. The further direction of development of the sphere of additional professional education for workers of pharmaceutical enterprises has been determined. The increase in the Russian market of additional educational programs based on current data on the development of the industry was justified. Recommendations have been formulated to expand the currently implemented programs of additional professional education based on the growing needs of the pharmaceutical market.

Older Adults Benefit From Virtual Support for Continuous Glucose Monitor Use But Require Longer Visits.

Older adults may be less comfortable with continuous glucose monitoring (CGM) technology or require additional education to support use. The Virtual Diabetes Specialty Clinic study provided the opportunity to understand glycemic outcomes and support needed for older versus younger adults living with diabetes and using CGM. Prospective, virtual study of adults with type 1 diabetes (T1D, N = 160) or type 2 diabetes (T2D, N = 74) using basal-bolus insulin injections or insulin pump therapy. Remote CGM diabetes education (3 scheduled visits over 1 month) was provided by Certified Diabetes Care and Education Specialists with additional visits as needed. CGM-measured glycemic metrics, HbA1c and visit duration were evaluated by age (<40, 40-64 and ≥65 years). Median CGM use was ≥95% in all age groups. From baseline to 6 months, time 70 to 180 mg/dL improved from 45% ± 22 to 57% ± 16%; 50 ± 25 to 65 ± 18%; and 60 ± 28 to 69% ± 18% in the <40, 40-64, and ≥65-year groups, respectively (<40 vs 40-64 years P = 0.006). Corresponding values for HbA1c were 8.0% ± 1.6 to 7.3% ± 1.0%; 7.9 ± 1.6 to 7.0 ± 1.0%; and 7.4 ± 1.4 to 7.1% ± 0.9% (all P > 0.05). Visit duration was 41 min longer for ages ≥65 versus <40 years (P = 0.001). Adults with diabetes experience glycemic benefit after remote CGM use training, but training time for those >65 years is longer compared with younger adults. Addressing individual training-related needs, including needs that may vary by age, should be considered.

Pedagogical conditions justification of professional multilingual personality building of non-language future specialists

Introduction. New guidelines in the development of economy, informatisation of society, the process of integration of cultures in the world have changed the requirements for the education of future specialists. One of the most important characteristics of modern society is the international interaction of organisations and specialists. This need necessitates the training of professional staff capable of working effectively in an open polylingual space. The purpose of the research is to substantiate the pedagogical conditions for the professional multilingual personality building of non-language future specialists and to develop a set of innovative teaching technologies in the multilingual educational space of higher education institution. Materials and methods. The study involved 43 teachers of Russian State Agrarian University – Moscow Timiryazev Agricultural Academy and National Research Mordovia State University, 255 student-respondents studying in the above-mentioned universities. The participants of the pedagogical experiment were provided with materials aimed at the professional multylingual personality building (teaching aids, reference materials, open mass online courses, digital resources). Technical means, digital tools were used to record the obtained results. Methods: analysis of theoretical sources, analysis and generalization of the experience of Russian universities in training non-language future specialists, results of students' and teachers' educational activities, pedagogical experiment, statistical processing of the results using the Pearson's chi-square test. Results. The pedagogical conditions of professional multilingual personality building of non-language future specialists were revealed and substantiated. The students training on the basis of the developed complex of technologies of professional multilingual personality building of future specialists was carried out. The results are summarised, which testify to the effectiveness of the identified pedagogical conditions and the potential of the applied complex of innovative teaching technologies in the polylingual educational space of the higher education institution. The results are summarised and the statistical significance of the differences in the qualitative changes in the results between the professional polylingual personality levels оf future specialists obtained before and after the experiment was determined (χ2 emp. = 19,987; p &lt; 0,01). Conclusions. The identified pedagogical conditions and the proposed set of technologies for the professional polylingual personality building of future specialists of non-linguistic training profiles allow to increase their competitiveness in the labour market. The pedagogical potential of innovative teaching technologies in the multilingual educational space of higher education institution is aimed at the development of creative individual abilities of students, meeting their needs in moral, physical and intellectual improvement, their self-organisation. The developed set of technologies can be applied in the training of undergraduate, graduate, postgraduate students of non-language universities, students of further professional retraining.

METHODS OF DEVELOPMENT OF PROFESSIONAL MOBILITY OF STUDENTS STUDYING IN THE FIELD OF SPECIAL PEDAGOGY

The development of professional mobility among students in the field of special pedagogy is crucial for fostering adaptable, internationally-minded educators. This abstract explores various methods designed to enhance students' professional mobility, including experiential learning, international internships, cross-cultural communication training, and the integration of digital platforms for virtual exchange. These methods aim to equip students with the skills needed to engage in diverse educational environments, promoting an inclusive and globally competent approach to special education. By focusing on active learning and international collaboration, these strategies encourage the development of skills that are essential for educators in an increasingly interconnected world.

Identification and optimisation of a risk stratified cohort of patients with type 2 diabetes through the delivery of a enhanced pharmacist-led service

Abstract Introduction Cardio-renal metabolic (CRM) diseases are each associated with significant morbidity and mortality, and due to their shared pathology, the benefit of managing these diseases holistically is becoming increasingly evident. The East Belfast Federation practices have sought to review patients living with type 2 diabetes (T2D), prioritising those not meeting their 3 Treatment Targets (3TT, HbA1c, blood pressure [BP] and cholesterol) to optimise treatment through a pharmacist-led model of care. Aims and Objectives 1. Improve adherence to latest update of NICE T2D [NG28, 2022], with a focus on patients with Cardiovascular Disease (CVD) &amp; Chronic Kidney Disease (CKD). 2. Upskill diabetes teams, to create a legacy effect and ensure improved holistic management will continue beyond the project period. 3. Use a clinical audit tool to identify, stratify and optimise T2D patients not meeting their 3TTs. 4. Improve identification, coding and recall of patients with non-diabetic hyperglycaemia (NDH) as per QOF Indicator NDH001NI [QOF 2022/23]. 5. Enhanced focus on review of sulphonylureas (SU) in relation to frailty and risk of hypoglycaemia [Strain, 2021]. Method Patients not meeting their 3TTs (HbA1c&amp;gt;58 mmol/mol, BP&amp;gt;140/80mmHg, total cholesterol&amp;gt;5mmol/L) were identified from October 2022 to July 2023. Primary care based clinics created which we tailored to the specific needs of the practices with a focus on optimising patients with CVD &amp; CKD co-morbidities. Dedicated specialist education and clinical support was provided to existing diabetes teams in CRM patient management. Additional searches were created and patients identified to review patients experiencing NDH and on a SU. Results At 9 months from baseline, there was a statistically significant improvement of 8.9% in patients achieving all 3TTs (n=373, P=0.013). This was accompanied by an increase in the number of patients optimised for CV risk reduction, with a 39% and 42% increase in patient receiving sodium glucose co-transporter-2 (SGLT2) inhibitors (n=542) and Glucagon-like peptide-1 receptor agonists (GLP1RA) (n=190), respectively. A 5.5% (n=28) reduction in the number of patients on a SU was observed, as well as a 44% (n=76) increase in the number of referrals into the Diabetes Prevention Programme (DPP). 151 statins and 51 BP medications were started/optimised. Discussion and Conclusion The project further exemplifies the feasibility of a pharmacist-led T2D service in a primary care setting. In addition to improvement in established T2D markers, the role promoted collaboration and facilitated best-practice sharing across multiple diabetes teams. This approach allows for more co-ordinated care for patients who may otherwise be referred to multiple specialists, which often results in fragmented care. Future work should focus on promoting CRM protection as early as possible to reduce disease progression and improve outcomes.Number of patients on antidiabetic meds% attainment of 3TT

Debunking neuromyths: Pre‐service teachers' insights on autism spectrum disorder

AbstractTeachers' beliefs in certain neuromyths about neurodevelopmental disorders can negatively impact the educational inclusion of students who present them. This study aims to analyse the prevalence of neuromyths about the health and the emotional competences of people with autism spectrum disorder (ASD) in pre‐service teachers; and to assess the possible contribution of university training to constructing accurate knowledge about autism. This prevalence was compared in three groups of pre‐service teachers: 1st‐year students, 4th‐year students who will be regular teachers and 4th‐year students training to be special education specialists. Additionally, it was proposed to identify the topic with the most myths (health or emotional competences) and the most frequent myths. A validated instrument was completed by 167 pre‐service teachers. Overall, the 4th‐year specialist group had more correct answers and fewer doubts that the 4th‐year regular group, which had more correct answers than the 1st‐year group. The prevalence of errors was not statistically different among the three groups. Moreover, participants answered more questions and made more errors about emotional competences in autism than about health. Among the most frequent myths are those concerning empathy or the cause of ASD. Based on these results, some implications for pre‐service teacher education are discussed.

EVALUATION OF INTERNET ACCESS BY STUDENTS AT A FEDERAL EDUCATIONAL INSTITUTION IN NORTHERN BRAZIL

Objective: This study presents the results of assessing Internet access by students at a federal educational institution in northern Brazil. Theoretical Framework: The study's theoretical framework relates information technologies through Internet access to learning. It shows that the more adequate Internet access is in educational institutions' daily routines, the better the students' performance in learning and its developments in technical, scientific, and technological production. Method: The method used was a survey, the population of which consisted of students who attended classes during the three shifts during which the institution operated. The students were consulted through a questionnaire with multiple-choice questions, the results of which were generated using descriptive statistics and presented in frequency tables. Results and Discussion: The findings showed deficiencies in a) the connection attributes, b) insufficient connection about the types of use by students, c) the connection provided is of low quality, and d) there is excess demand about the low institutional supply, especially in the evening shift. Research Implications: This study shows that internet services must be the object of multidisciplinary treatment and cannot represent the exclusive view of ICT professionals or education specialists. Unidisciplinary views prevent several fundamental nuances of institutional core activities from being overlooked. Originality/Value: The research's originality lies in the empirical observation that educational institutions must strategically plan long-term internet provision jointly by ICT professionals, education specialists, teachers, and students.

Prospective evaluation of extended reality for neonatal intubation education

Purpose360° immersive videos may be useful in procedure-based healthcare settings. We hypothesized that extended reality (XR) neonatal intubation education is a feasible alternative to live demonstration in skill and knowledge transfer.MethodsThis was a prospective single center evaluation of an educational XR intubation video using Premature Anne™ (Laerdal Medical, Stavanger, Norway) comparing to a live demonstration. Participants were randomly allocated to either live demonstration or XR group. Each group received 20 min of teaching from the pediatric respiratory care education specialist, either in person or in video format. Intubation success, knowledge and skill acquisition were measured using a questionnaire and checklist.ResultsWe had a total of 23 participants, XR (n = 11) and live demonstration (n = 12). The groups were heterogeneous in experience level.The XR group was successful at intubating 73% of the time (n = 8), which was not significantly different to the live demonstration group 58% (n = 7) (p = 0.667). For patients who achieved intubation, there was no difference between groups in the mean time to successful intubation; 98 s (SD 73) for the XR group and 65 s (SD 22) for the live demonstration group (p = 0.685).When comparing scores between groups there were no statistically significant differences regarding knowledge scores (p = 0.514), skill scores (p = 0.826) and total scores (p = 0.926).ConclusionThese preliminary findings indicated no significant differences between the XR and live demonstration groups in terms of intubation success, knowledge acquisition, skill performance, total scores or time to successful intubation.

An Evidence-Based Nurse-Led Intervention to Reduce Diabetes Distress Among Adults With Type 1 Diabetes and Diabetes Distress (REDUCE): Development of a Complex Intervention Using Qualitative Methods Informed by the Medical Research Council Framework.

Diabetes distress refers to the negative emotional reaction to living with the demands of diabetes; it occurs in >40% of adults with type 1 diabetes (T1D). However, no interventions to reduce diabetes distress are specifically designed to be an integral part of diabetes care. This study aims to modify and adapt existing evidence-based methods into a nurse-led group intervention to reduce diabetes distress among adults with T1D and moderate to severe diabetes distress. The overall framework of this study was informed by the initial phase of the Medical Research Council's complex intervention framework that focused on undertaking intervention identification and development to guide the adaptation of the intervention. This study took place at 2 specialized diabetes centers in Denmark from November 2019 to June 2021. A total of 36 adults with T1D participated in 10 parallel workshops. A total of 12 diabetes-specialized nurses were interviewed and participated in 1 cocreation workshop; 12 multidisciplinary specialists, including psychologists, educational specialists, and researchers, participated in 4 cocreation workshops and 14 feedback meetings. Data were analyzed by applying a deductive analytic approach. The intervention included 5 biweekly 2.5-hour small group sessions involving adults with T1D and diabetes distress. Guided by a detailed step-by-step manual, the intervention was delivered by 2 trained diabetes specialist nurses. The intervention material included visual conversation tools covering seven diabetes-specific sources derived from the 28-item Type 1 Diabetes Distress Scale for measuring diabetes distress: (1) powerlessness, (2) self-management, (3) fear of hypoglycemia, (4) food and eating, (5) friends and family, (6) negative social perception, and (7) physician distress. The tools are designed to kick-start awareness and sharing of diabetes-specific challenges and strengths, individual reflections, as well as plenary and peer-to-peer discussions about strategies to manage diabetes distress, providing new perspectives on diabetes worries and strategies to overcome negative emotions. Diabetes specialist nurses expressed a need for a manual with descriptions of methods and detailed guidelines for using the tools. To deliver the intervention, nurses need increased knowledge about diabetes distress, how to support diabetes distress reduction, and training and supervision to improve skills. This co-design study describes the adaptation of a complex intervention with a strong evidence base, including detailed reporting of the theoretical underpinnings and core mechanisms.

Advocacy Skill Development in Public Health Education Curriculum: A Pilot Study.

The National Commission for Health Education Credentialing (NCHEC) released updated Responsibilities and Competencies for Health Education Specialists based on the 2020 HESPA II. For the first time, advocacy is a standalone area of responsibility (Area V: Advocacy) for health education specialists. Although this is exciting for the field of health education, there is limited consensus on how to effectively teach advocacy or what content and skills to include. Furthermore, while the HESPA II was updated, the Council on Education for Public Health (CEPH) criteria for advocacy have not been. This pilot study examined how CEPH-accredited programs in the United States are addressing the profession-wide advocacy competency in their health education curricula. A cross-sectional research design with single-point data collection was used to assess how CEPH-accredited university programs (including Standalone Baccalaureate Programs, Public Health Programs, and Schools of Public Health) are preparing health education students to meet the national advocacy responsibility. The survey included items from the Advocacy Area of Responsibility and potential barriers for faculty teaching advocacy. Results indicate that most programs are teaching something about advocacy, but there is no program teaching all listed sub-competencies. Barriers to including all components of the advocacy responsibility were largely related to faculty motivation, knowledge, and time. With a full responsibility area devoted to advocacy, it is reasonable to expect that programs will adjust with the profession. However, program administrators must be catalysts for these changes in their individual programs.

Actual problems of physical education of school- aged children in the conditions of an inclusive environment

The article examines the results of an analysis of statistical data from the Ministry of Education and Science of Ukraine on the state of inclusive education in general secondary education institutions, as well as current issues in the physical education of children with special educational needs (SEN). The study uses official reports from 2020 to 2023, along with data on access to inclusive education for children with SEN in the Lviv and Ternopil regions. It has been established that over the past four years, Ukraine has seen an increasing trend in the number of children with special educational needs involved in the educational process in general secondary education institutions, rising from 0.45% in 2020 to 0.89% in 2023. However, pedagogical approaches for each specific type of developmental disorder among children with SEN, considering their level of support and educational-methodical provision in physical education, have not been developed. Moreover, there is a pressing issue of staffing and the need to train physical education specialists for inclusive education.

Recipient selection for lung transplantation: perspective in decision-making.

To determine the conditions that prevented transplant in patients referred to our center due to end-stage lung disease. Descriptive study. Department of lung transplant clinic, Koşuyolu High Specialization Education and Research Hospital, Istanbul, Turkey, from December 2017 to January 2022. Patients with end-stage lung disease referred to our clinic were retrospectively evaluated with regard to reasons for exclusion, diagnosis, and demographic data. The Karnofsky Performance Status scoring scale was used to measure the functional status of the patients. A total of 311 patients were evaluated during the study period. The mean age was 44.2 (range 4-73) years. There were 207 (66.6%) male patients. The most common indications were idiopathic interstitial pneumonia in 104 (33.4%) patients, chronic obstructive pulmonary disease in 53 (17%) patients, bronchiectasis in 49 (15.7%) patients, and cystic fibrosis in 28 (9%) patients. Of the patients, 106 (34%) were not appropriate candidates for a lung transplant. The most common reasons for refusal were preventable situations such as activity limitation and poor performance in 53 (50%) patients, weight in 49 (46.2%) patients, and smoking in 10 (9.4%) patients. Impaired performance status was the most common cause of lung transplant exclusion. Weight and smoking were preventable causes of exclusion. Implementing pulmonary rehabilitation in very few patients was the most important handicap. It is believed that providing optimal treatment with a multidisciplinary approach and timely referral to transplant centers will significantly reduce the reasons for exclusion. Key message What is already known on this topic? Referring lung transplant candidates to clinics at the earliest stage is essential for assessing their condition and exploring treatment options. What this study adds? Factors like smoking, obesity, and muscle loss can hinder the transplantation process; thus, timely interventions are crucial. The primary reason for excluding candidates from lung transplantation is the decline in performance status. How this study might affect research, practice or policy? Programs focused on smoking cessation, weight management, and muscle strengthening can play a vital role in enhancing patients' health before transplantation. It is imperative to expand and enhance the accessibility of pulmonary rehabilitation programs.

Развитие вечернего обучения в системе среднего специального образования на европейском севере России в 1950-1960-е годы

In the presented paper, based on the materials of regional statistical collections and annual reports of secondary specialized educational institutions, the process of development of the evening form of education in this system in the territory of the European North of Russia is traced. The chronological framework of the study is justified by the educational reform carried out in the USSR at that time, one of the significant aspects of which was the development of the form of education under consideration. It was revealed that by the end of the 1960s, in the system of secondary specialized education in the European North of the RSFSR, the list of technical shools and colleges in which evening departments functioned, noticeably expanded, and the number of students in these departments increased significantly. Thanks to the development of the evening form of education, technical schools and colleges managed to significantly increase the training of mid-level specialists.