Three-legged Stool Research Articles

Research on Forecasting for the Manmade Global Warming Alarm

The validity of the manmade global warming alarm requires the support of scientific forecasts of (1) a substantive long-term rise in global mean temperatures in the absence of regulations, (2) serious net harmful effects due to global warming, and (3) cost-effective regulations that would produce net beneficial effects versus alternatives policies, including doing nothing. Without scientific forecasts for all three aspects of the alarm, there is no scientific basis to enact regulations. In effect, the warming alarm is like a three-legged stool: Each leg needs to be strong. Despite repeated appeals to global warming alarmists, we have been unable to find scientific forecasts for any of the three legs. We drew upon scientific (evidence-based) forecasting principles to audit the forecasting procedures used to forecast global mean temperatures by the Intergovernmental Panel on Climate Change (IPCC) — leg “1” of the stool. This audit found that the IPCC procedures violated 81% of the 89 relevant forecasting principles. We also audited forecasting procedures, used in two papers, that were written to support regulation regarding the protection of polar bears from global warming — leg “3” of the stool. On average, the forecasting procedures violated 85% of the 90 relevant principles. The warming alarmists have not demonstrated the predictive validity of their procedures. Instead, their argument for predictive validity is based on their claim that nearly all scientists agree with the forecasts. This count of “votes” by scientists is not only an incorrect tally of scientific opinion, it is also, and most importantly, contrary to the scientific method. We conducted a validation test of the IPCC forecasts that were based on the assumption that there would be no regulations. The errors for the IPCC model long-term forecasts (for 91 to 100 years in the future) were 12.6 times larger than those from an evidence-based “no change” model. Based on our own analyses and the documented unscientific behavior of global warming alarmists, we concluded that the global warming alarm is the product of an anti-scientific political movement. Having come to this conclusion, we turned to the “structured analogies” method to forecast the likely outcomes of the warming alarmist movement. In our ongoing study we have, to date, identified 26 similar historical alarmist movements. None of the forecasts behind the analogous alarms proved correct. Twenty-five alarms involved calls for government intervention and the government imposed regulations in 23. None of the 23 interventions was effective and harm was caused by 20 of them. Our findings on the scientific evidence related to global warming forecasts lead to the following recommendations: End government funding for climate change research. End government funding for research predicated on global warming (e.g., alternative energy; CO2 reduction; habitat loss). End government programs and repeal regulations predicated on global warming. End government support for organizations that lobby or campaign predicated on global warming.

Perpetual Illegality: Results of Border Enforcement and Policies for Mexican Undocumented Migrants in the United States

In this paper, I will first discuss the historical development of the Mexican migrant as “illegal.” Second, I will discuss current border control and legalization policies and their effects on the undocumented population in the United States. Finally, reflecting on the effects of previous policies, I will discuss Homeland Security Secretary Janet Napolitano's proposed “three‐legged stool” and its likely effects on the undocumented population in the United States. I will argue that the current immigration system, and any future proposals that include border enforcement as the primary mechanism to stop undocumented migrants from entering the United States will likely result in the continual perpetuation of an undocumented population of Mexican migrants in the United States. This paper is informed by the ethnographic data collected from July 2009 to August 2010 in the border city of Mexicali, Baja California, Mexico. During this time at the border, I talked to migrants deported from the United States.

Spirituality, Religion and Psychopathology: Towards an integrative psychiatry

The concepts of person-centred medicine and of psychiatry for the person offer, perhaps more than any other current biopsychosocial concept, the opportunity to develop a truly integrated approach to the psychiatric patient as a person suffering from mental turmoil. Within this approach to patients as people it is often necessary to give thorough attention to the patient’s spirituality, religious beliefs or worldview. Person centred psychiatry offers a well grounded reason for incorporating spirituality and religion into psychiatric assessment, diagnosis, case-formulation, therapy, and as a component of psychiatric training and continuous professional development. In this paper we consider the need for increased understanding of the nature of religious belief and of the variety of spiritual practice if a truly person centered psychiatry is to be practiced. Psychiatry sits on a three-legged stool of science, art and ethics [1]. Its provenance therefore includes understanding the spirit (soul) of patients, their Weltanschauung (View of the World) and the quality and meaning of their personal and professional relationships. The bio-psychosocial model of George Engel was based on general systems theory and yet successfully encouraged doctors to consider the social and psychological aspects of patient care in addition to biological parameters. The model however was considered primarily as a causal scientific framework, which could neglect its full potential to promote a humanistic person centered medicine. A biosocial/psychospiritual relationship based approach to health care provision is perhaps therefore closer to the essence of a Psychiatry of the person [2] as it is within this wider perspective that consideration of religious faith and spiritual practice optimally resides. Paul Tournier, pioneer of ‘medicine of the person’, encouraged crossing the boundaries of science, spirituality and psychology within the specific context of the doctor-patient relationship [3]. This bridging of disciplines is facilitated by new knowledge of the complexity of neuronal circuits, and recognition that religious belief has a partial origin in brain function and yet also determined by metaphysical events and transformational experiences. For Tournier, a Genevan family practitioner, there were no contradictions between his understanding of religious belief, the importance of spiritual practice (meditation), the dynamic of personal growth, and the scientific/biological exploration of illness for the optimal practice of medicine.

Perspective: Academic Obstetrics–Gynecology Departments in the City of Philadelphia: Are the Wheels Coming Off?

Maternity care in Philadelphia is in an unprecedented and precarious situation, as all the community hospitals that once provided maternity care services have either closed completely or stopped providing maternity services. Six academic medical centers (AMCs) in the city of Philadelphia now provide care to a population of 1.5 million requiring increasingly complex and expensive maternity care, at the same time as insurance premiums and the malpractice crisis in Pennsylvania peaked. The AMCs are able to continue providing maternity care to this population that includes a large proportion of poor, minority, and un- or underinsured patients thanks to government subsidization of resident education, the services provided by resident physicians, and the influx of government and industry research funds, but the financial outlook of academic obstetrics-gynecology departments in this city is dire. Obstetric academic medicine in Philadelphia has come to more closely resemble a "big wheel" tricycle than Flexner's "three-legged stool." Clinical medicine is the driver (the large front wheel and pedal) pulling along education and research, the two smaller wheels in the back. A maternity care alliance is needed in Philadelphia allowing area AMCs to pool and trade resources, reduce costs, improve quality and innovation, and share risks. Philadelphia may serve as an early warning for other cities and AMCs around the country and has the opportunity to serve as a model for how to overcome these serious challenges.

Cambridge Act and Tripos Verses, 1565-1894. By J. J. HALL.

The scholastic disputation remained in use as an exercise to be performed by candidates for degrees, or as a display for eminent visitors, long after it had ceased to be taken seriously as a means of advancing knowledge. At Cambridge the exercise came to be enlivened by verses, which at least from 1565 were distributed in print or manuscript; this custom outlived the actual exercises, lasting nearly to the end of the nineteenth century, till it ceased not by abolition but from indifference. The verses, as we learn from this diligent book, were generally in the academic language, Latin; down to 1602 there was sometimes a coda in Greek, which from 1866 onwards was used for whole poems. One poem was written in Hebrew, but not recorded. The author, sometime Under-Librarian of Cambridge University Library, expresses the hope (p. 1) that his work will ‘be of interest to students of neo-Latin (and neo-ancient Greek) verse, and to those interested in the history of university ceremonies’; accordingly he presents an extensive historical introduction on the ceremonies, the degrees awarded, the lists of honours men, the theses (‘positions’) for disputation, and the verses themselves, although no literary comment is offered except on the metres used. We learn that ‘Tripos’ originally denoted the more junior (and often more frivolous) of the two performers, who sat on a three-legged stool. There follows a brief comparison with proceedings at Oxford and Dublin.

No University Is an Island: Saving Academic Freedom (review)

Nelson, Gary. No University Is an Island: Saving Academic Freedom. 2010. New York: NewYork University Press. $27.95 sc. ix + 289 pp.Initially, the most striking thing about No University Is an Island is how mainstream - almost conservative - its author's definitions of many of the key terms are. Not all U.S. academics will place quite as much emphasis as Gary Nelson does on the need for higher education to cultivate critical citizenship among students. But the great majority will approve of his definition of academic ireedoni: an institutionalized guarantee tur academic professionals to pursue research and teaching according to their interests, their proven expertise, and the standards of their disciplines. Academic freedom, Nelson further offers, covers freedom of expression in a range of possible venues, extramurally as well as intramurally. Only slightly more debatable is Nelsons contention that shared governance and tenure constitute, along with academic freedom, the three-legged stool upholding the academic profession (s I). For academic freedom to be genuine and for it to be maintained, he asserts, faculty need to have job security and to exercise real power in decision-making at their institutions. In short. Nelson defends academia as a professional guild, with its own self-generated, self^correcting, and semiautonomous disciplines, professional protocols, and standards of value. And the only thing that seems surprising in all this is that these middle-of-theroad concepts are articulated by the same scholar who penned Maw/rjfo (^a Tenured Radical and has relentlessly challenged received knowledge about modern American poetry.More novel are Nelson's analysis of the threats besetting intellectual freedom and the remedies he advocates to counteract them. One of Nelson's core contentions is the interconnectedness of every institution and every class of academic. Every time that a president or board of trustees revokes a faculty member's tenure or denies tenure outside of established procedures and peer review - as has recently happened to Ward Churchill at the University of Colorado and Norman Finkelstein at DePaul University - precedents are established that might be appealed to by other administrators. And just in case less-outspoken tenured faculty imagine Churchill and Finkelstein to be outliers. Nelson points out that Hurricane Katrina provided presidents at the University of New Orleans, Tulane, and Loyola with emergency powers that enabled them to cut whole programs and departments, firing tenured as well as untenured faculty in spite of university-handbook guarantees of tenure, due process, and shared governance.More pervasive than the threat of natural disasters and outside political forces are economic pressures both inside and outside academia. Under the guise of fostering translational research (70), programs and individuals that generate cash-flow for the university are prioritized ahead of those who engage in cultural critique. Under the banner of globalization, administrators have instituted programs with teachers neither held to the same standards nor protected by the same rules as regular faculty. The common denominator connecting many of these threats to academic freedom. Nelson persuasively argues, is neoliberalism, which takes the marketplace to be the ultimate test of any program, idea, or individual. The natural and often all-too-effective ally of these threats is a culture of complacency among faculty, founded upon the illusion that academic freedom and tenure remain sacrosanct. For complacent faculty, Nelson has news. Over the past thirty years, tenure has become increasingly rare. The trend is probably captured best by Nelson s straightforward citation of government statistics: in 1975, U.S. faculty who were tenured or on the tenure track constituted 56.8 percent of all faculty; by 2007, the percentage had been nearly halved, to 31. …

Fight or flight

The role of the sense of smell in human communication has been debated for many years.1 Apparently, our bodily odours are involved in attracting us towards the most suitable mates while repelling us from genetic mismatches. In an interesting study undertaken almost 10 years ago, Austrian researchers showed that blinded volunteers could differentiate between the axillary scents of people who had just watched a horror movie versus those who had watched something bland.2 The rank stench of fear is easily identifiable. All of which does have something to do with clinical teaching. That smell assailed me yesterday as I walked down a long corridor lined by medical students waiting to go into their first clinical examination stations. Not that it was the first OSCE (objective structured clinical examination) these students had ever undertaken, nor was it a particularly high-stakes assessment: just one history station and a mini mental state exam in the third year of their course. The stench of fear was undeniable, however, and very different to the usual odours that permeate the crowded corridors of our medical school. Fear is a powerful motivator for survival, but how much fear can be generated by a clinical assessment before the candidate’s performance begins to suffer? Most clinical teachers will recall students who have performed exceptionally well in the clinical context, but who have fallen apart in the simulated setting of the exam room. Part of the skill of the clinical teacher is to create a supportive environment within which the student is able to do their best. Although ‘grace under pressure’ is clearly a desirable attribute of the competent clinician, it is hard to extrapolate surviving the stresses of the exam room to good patient care. Assessment techniques such as direct observation and the mini-CEX (mini clinical examination), which are more grounded in the reality of the workplace, seem better suited to measuring competence rather than performance under pressure. If students perform poorly when excessively challenged, it is likely that their clinical teachers will do the same. It is an interesting time to be a clinical teacher. Global workforce shortages have driven increases in medical school numbers, with unprecedented demands for clinical placements.3-5 Inevitably, this flood of new students washes up at the clinical teacher’s door to be properly prepared for practice. Equally inevitably, a medical workforce shortage means that clinicians are under enormous pressure to increase their patient throughput, and so they are frustrated in their efforts to teach.6 In Australia, at least, the government has begun to understand the ‘three-legged stool’ that supports a student’s clinical teaching: a patient, a teacher and somewhere for the learning to occur. Money has become available through the federal government for teaching spaces to be added to non-traditional clinical teaching sites (such as private clinics and aged care facilities), and more is coming to support teacher training and simulation facilities. The aim is to increase clinical teaching capacity to deal with the extra students entering the system,7 but there is no clear vision of funding reform to ensure the adequate payment of clinical teachers to sustain these new placements. Without clinical teachers being adequately recompensed for the time they spend teaching – and without clinical teaching being recognised as a vital professional activity – we run the risk of having students neglected while their teachers deal with burdensome clinical loads. There is a worldwide need for funding bodies to rank clinical teaching alongside clinical service as equally vital. After all, the provision of clinical services depends on a sustainable supply of students who know what to do. Editor in Chief

Balancing business empathy and psychology in coaching practice

The skills-based session at the 2nd European Coaching Psychology Conference prompted coaching psychologists who work with businesses to reflect on three areas: where they may focus their continuing development as a business coach; how to manage their boundaries more adequately or to provide different support to clients; and how they present their coaching practice to clients. The session used some practical, unpublished frameworks called the ‘three-legged stool’ to consider the different knowledge and experience bases business coaches draw on and the ‘supply and demand framework’ for exploring the dynamics of offering a successful service to clients. Finally, the session used Sull and Houlder’s (2006) article ‘How companies can avoid a mid-life crisis’ to explore how knowledge and application of a business tool can add value to a coaching psychologist’s coaching range.

The Three Legs of the Practitioner’s Learning Stool: Practice, Research/Theory, and Personal Life

The goal of this article is to introduce the many guides that serve as our knowledge base in the helping professions. Practitioners work with the complexity of human emotion, thought, and variability, which at times makes the work confusing. In order to deal with the confusion, the practitioner attends many years of school and intensive practical experiences to be optimally prepared to work with human beings. Even so, different philosophies exist as to what the best sources of practitioner knowledge are. Where should practitioners get their ideas? The academic culture suggests it should be science; the practitioner culture suggests reflection on practice; candid discussion with practitioners suggests that the therapist’s personal life is the richest source of knowledge. This article argues that practitioner expertise is like a three-legged stool with each of the foregoing areas essential to optimal functioning.

Jerry Bywaters, Lone Star Printmaker: A Study of His Printing Notebook with a Catalogue of His Prints and a Checklist of His Illustrations and Ephemeral Works (review)

452Southwestern Historical QuarterlyApril impediment, the varied status of die workers' setdements, added complexity to attempts at coordinating production. Walsh discusses the ejidos, die colonos, die campesinos and their relative suitability for the work. Today, where once cotton covered diousands of hectares, sorghum and corn are now the dominant crops. Walsh suggests diat promoting these basic grains is part of Mexico's federal "national food system designed to support die rural sector and provide security in an increasingly volatile and politicized world market" (P- 175)· Building the Borderlands is divided into nine chapters, widi a certain amount of overlap, each encapsulated in a brief conclusion. This is indeed useful as the story is convoluted. Along with being an extremely detailed narrative history, between the lines the book is a saga of villainy and political treachery, with presidents , state governors, and project directors promising improved quality of life and dien retracting their pledges. This distasteful element is hard to ignore. Maps, charts, and an index complement the text and footnotes. The bibliography includes extensive direct and peripheral subject matter and full historical coverage. As a geographer, I wish for more informative maps and, having limited skill in Spanish, would welcome a glossary. Austin, TexasJane Manaster Jerry Bywaters, Ij>ne Star Printmaker: A Study ofHis Printing Notebook with a Catalogue ofHis Prints and a Checklist ofHis Illustrations and Ephemeral Works. By Ellen Buie Niewyk. Foreword by Ron Tyler. (Dallas: Southern Methodist University Press. 2007. Pp. 208. Illustrations, bibliography, index. ISBN 9780870745195, $35.00 cloth.) Perhaps it would not be amiss to state upfront that the book review editor had difficulty finding an impartial reviewer for this volume because the author had guidance from the likes of Francine Carraro, author of Bywaters' definitive biography , and Sam Ratcliffe, author of the equally reliable Jerry Bywaters: Interpreter of the Southwest. The audior's reliance on such authorities as these is surely an indication of her thoroughness. Unlike die earlier work of Carraro and Ratcliffe, however, Ms. Niewyk's effort is focused on Bywaters's role as a printmaker, a role that ended in 1 948 as he became increasingly burdened with administrative responsibilities as director of the Dallas Museum of Fine Arts. Moreover, Ms. Niewyk was vastly aided by her discovery of his manuscript "Print Notebook" in Bywaters' archives. Ms. Niewyk's book opens with brief reminiscent essays by two long-time Dallasites diat seem long on charm but wanting in perception. Ron Tyler's brief foreword lends a certain cachet to this heroic endeavor. Names once familiar in Dallas art circles in die ig20S and '30s have since faded but Ms. Niewyk revives diem for one last turn on stage. How many nowadays (outside museum circles) could identify the so-called "Dallas Nine"? A high school English teacher once explained to me that certain adjectives should be routinely avoided, to wit: first, last, always, never, best, worse, biggest 20ogBook Reviews453 smallest, etc. Had she thought of it at the moment, she might have added "definitive ." This work will surely be die last word for years to come on Bywaters's contribution to the printmaker's art. It may even be definitive. But it is surely safe to describe it as authoritative. Jerry Bywaters's legacy seems securely situated on a three-legged stool lovingly constructed by the joint effort of Carraro, Ratcliffe, and now Niewyk, whose meticulously researched and well-written treatise will stand die test of time. The book itself is handsomely turned out with excellent reproductions of the lithographs, plus much of Bywaters's book illustration work. It is printed in double -columns with extra leading (spacing) between the lines in order to facilitate ease of reading. As a matter of convention, lengthy quotations are usually singlespaced , and are usually indented. Here, the indentions are inconsistent. These are matters that cannot, of course, blamed on an author because once that individual lets go his or her manuscript, it become the responsibility of a production manager to get it into print with a relentless eye on the bottom line. The author sums up the significance of Bywaters's contribution to Southwest regionalism, a contribution at once influential and long-lasting. StringlownAl Lowman A TexasJourney...

Ethicist-Educator Insists Community Must Be Engaged

Ethicist-Educator Insists Community Must Be Engaged

Integrating Environmental Perspectives into Pavement Management

Sustainability is characterized as a three-legged stool supported by economic, environmental, and social considerations. This paper demonstrates the feasibility of integrating environmental performance measures, one aspect of sustainable practices, into asset and pavement management. To illustrate these concepts, a Microsoft Excel workbook-based pavement construction decision support tool named Pavement Life-Cycle Assessment Tool for Environmental and Economic Effects (PaLATE) is introduced. Background information is given on life-cycle assessment (LCA) pavement construction tools. PaLATE product life-cycle and LCA phases are covered, in addition to PaLATE data and data sources. A table describing the data used for environmental calculations is included, and the use of an asphalt emulsion seal and the use of an ultrathin hot-mix asphalt overlay are compared by use of the tool. Special attention is given to recycled materials and environmental measures. Concluding remarks suggest different contexts for potential applications of PaLATE, together with network tools that can be used to meet user needs and applications as well as to address feasibility and cost.

Locating benefits: Decision-spaces, resource access and equity in US community-based forestry

In the US, the Ford Foundation’s Community-based Forestry Demonstration Program (2000–2005) promoted an internationally prominent model of community forestry centered on the simultaneous, balanced pursuit of ecological, economic and social goals (often symbolized as the “three-legged stool,” or “triple bottom line”). This paper develops an alternative framework for analysis that emphasizes the causal precedence of shifts in power relations, specifically the devolution of resource access and decision-making authority, rather than environmental, social and economic outcomes. These outcomes are not necessarily beneficial, and any benefits realized seldom occur simultaneously. Rather, they can be envisioned as the floors of a house erected sequentially on a foundation of resource access and control. While no universal claim is made, the “house” model proves an apt fit for many community-based forestry initiatives, including the two case studies presented. Who among the differentiated social groups within a community gained access to resources and decision-making influence largely predicted who gained individually. Nonetheless, indirect benefits felt at community and higher scales were significant. The findings further indicate that community forestry generally will not advance social equity unless it specifically targets marginalized groups. Crucially, equity is understood to embrace not only distributional justice, but also capacity-building and empowerment.

Keeping the Psyche in Psychiatry: Eight Years Later

My first column as editor of this journal’s psychotherapy columns declared my prime objective in taking on the task: “Keeping the Psyche in Psychiatry.” 1,2 I am concerned about the practice by psychiatrists of well founded forms of psychotherapy in all psychiatric settings. I am a senior psychiatrist and psychoanalyst in private practice with a longstanding involvement in medical education and in professional organizations. To counterbalance my own perspective, I have often tried to write in more general terms than my own psychodynamic orientation. Invited guest columnists have written from the perspective of other schools of psychotherapy as well as other professional environments. Of course, I have not been alone in this quest. Numerous psychiatrists in leadership positions—from widely varying practice settings and all parts of the country, as well as academic psychiatrists and even some leaders in managed care—have expressed their concern about the fading role of psychotherapy and the decreasing interest in the patient’s personal narrative 3 in psychiatric practice. They lament the decline of the psychotherapy skill set in many recentlytrained psychiatrists. In my initial column, I highlighted the American Psychiatric Association’s Commission on Psychotherapy by Psychiatrists (COPP), of which I had been chair. COPP is now a committee of the same name reporting to the Council on Quality Care. It comments frequently on psychotherapy issues, writes or revises position statements, reviews practice guidelines, contributes to the design of psychiatric practice surveys, makes presentations at scientific meetings of the American Psychiatric Association, and has completed a paper differentiating the common, often supportive denominators of psychotherapies and their divergence into distinctively psychodynamic and cognitive-behavioral methodologies. COPP continues to be a respected voice for psychotherapy by psychiatrists in the American Psychiatric Association. However, it is only one of many forces at work to advance the cause. Now, almost 8 years later, what has been accomplished? In the past year, several major, longstanding efforts have come to fruition with beneficial implications for psychotherapy by psychiatrists. On the down side, a recent study shows that the trend continues for psychiatrists to provide psychotherapy for a smaller proportion of their patients, with more psychiatrists doing no psychotherapy at all. The well-rounded psychiatrist skilled in the full armamentarium of treatments is still an endangered species. Like the proverbial three-legged stool, the viability of psychotherapy by psychiatrists rests on the complex interaction of three bases—scientific support, availability of training, and financial reimbursement. However, in the new healthcare environment, a fourth leg is equally essential—privacy.

The New Three-Legged Stool of American Economic Growth

The New Three-Legged Stool of American Economic Growth

Leading Up: Moving Pharmacy Toward the 2015 Vision

Discussions about leadership generally assume the model that leaders lead and followers follow. Many thoughtful analyses of leadership have provided varying assessments about leadership styles and motivational strategies. But what if the followers chose to lead? What would this model and its impact look like? Perhaps it would be the study of a revolution! But what if the leaders embraced, encouraged, and even expected leadership from the followers? What if they truly listened to the voices of the followers? And further, what if the followers were focused on the greater good of their cause rather than self-interest? What if their goal was to create positive change as the first result, rather than the outcome of a second or third effort? What if this happened in pharmacy? Arguably, pharmacy is on the cusp of the greatest opportunity it will have for professional practice change in the 21st century. I draw this conclusion based on the following 2 facts. First, our collective national pharmacy leadership, both volunteers and staff members, are actively working to achieve the vision for pharmacy practice in the year 2015 articulated by the Joint Commission of Pharmacy Practice (JCPP). Closely aligned with the work by JCPP, the American Society of Health System Pharmacists (ASHP) is well into their fourth year of Health-system Pharmacy 2015. This is their contribution to improving the practice of pharmacy in health systems by the year 2015. A parallel effort specific to community pharmacy's advancement of health care, which is labeled Project Destiny, was initiated in July 2007 by the American Pharmacists Association (APhA), National Association of Chain Drug Stores (NACDS), and the National Community Pharmacists Association (NCPA). This level of energy, and the associated commitment of resources, is remarkable, but perhaps more exciting is the level of cooperation among our national organizations. I can only assume they realize the magnitude of the opportunity as well. The second fact has to do with a force completely outside of pharmacy, which is the unprecedented and pending impact of the baby boomer generation. A 2003 article in USA Today by Fred Bayles highlights that the wealth and size of the baby boomer generation alone makes then impossible to ignore. (1) Most are aware of the size, but consider that between 2003 and 2030, which is when all the boomers turn 65, the number of Americans 65 and older will double from 35.6 million to 71.5 million. This will represent nearly 20% of the US population, which is an increase from 12% in 2003. Specific to wealth, Bayles points out that this cohort will ultimately control 40% of the nation's disposable income and 77% of the private investments. As the boomer's health care needs increase, one can only imagine the time they will spend seeking counsel from a pharmacist and the opportunity for pharmacists to receive compensation for this effort. Remember, baby boomers have always played by their own rules. They have rejected everything from their parent's car, which they replaced with a painted van, to their parent's clothes and music! We clearly have a reason to suppose that boomers will reject their parent's health care expectations for pharmacy when they reach the years of increasing medication use. If one envisions this reality, then what will be the expected model of pharmacy service? And, for a generation that has redefined our expectations of consumers, what will they pay for? Again, the opportunity for pharmacy is significant and unprecedented. If we view the professional practice model that supports the pharmacist in 2015 as a three-legged stool, then the efforts by our national leaders and the impact of baby boomers turning 65 serve as 2 sturdy legs of this stool. They represent our practice model and our patients, respectively. My suggestion is that the critical third leg is every pharmacist who we can respectfully characterize as a follower, and the individual and collective efforts of this group to lead toward the 2015 vision. …

The Three-Legged Stool: A Model for the Practicing Clinical Gastroenterologist

The Three-Legged Stool: A Model for the Practicing Clinical Gastroenterologist

Response: Setting the Stage for Improvement and Accountability

Deborah Garnick: Dr. McCorry provides a concise overview of several large, national efforts in performance measurement and quality improvement. He has done an excellent job of bringing together the work of the Washington Circle, Network for the Improvement of Addiction Treatment (NIATx), National Outcome Measures, and Clinical Trials Network. The article is a fine starting point for someone to get a sense of the landscape and to jump off, using the links and references he provides, to more detail about each of the projects. Daniel Kivlahan: I particularly like the image of the three-legged stool, emphasizing how interrelated these three major themes are— the content, the data and measurement features, and then the quality improvement efforts. That’s the broad context that makes a huge difference in how far a particular agency is likely to get with implementation. Each of the projects discussed in the paper provides a different spectrum of options for instituting quality and performance measurement and improvement. The NIATx system starts at the front door of the organization, so it can give a lot of clues about patient-level experiences and barriers to better outcomes that programs might overlook. The National Registry of Evidence-Based Programs and Practices becomes useful when clients have gotten through those early treatment hoops and are waiting for at least some initial intervention. Linda Bradshaw: Of Dr. McCorry’s tips on how to get started, I was impressed by the create-a-crisis concept: challenging your local boards and people in your agency to take a hard look at the wave of the very near future and start getting ready for it. That seems a very practical way to go about getting someone’s attention. Kivlahan: Another approach might be to ask the line staff what kind of information was on the last list or spreadsheet they saw. For example, staff members frequently get lists of chart deficiencies, things they haven’t documented appropriately. Reviewing these together would reinforce the commitment to measurement by reiterating the importance of the items on the list. The discussion might produce a consensus that you are tracking the right things, or it might lead to a shift to other, more productive measures.

Hospital Leadership and Quality Improvement

The sine qua non of leadership is high performance. Many studies and commentaries have shown that the quality of care in America is not what it ought to be. This performance gap has been attributed to failures in leadership that were perpetuated over the decades by ineffective organizational structures and processes as well as apathy, neglect, and a lack of individual and collective will. Based upon interviews in 18 community hospitals with 96 hospital leaders including CEOs, CMOs, and governing board members, this qualitative study examined interest and involvement in quality improvement. Although a high level of rhetoric in support of quality improvement exists, the reality is that the performance gap continues to persist. The authors conclude that the "three-legged stool" is in need of substantial repair. New resources, rethinking, and redesign of structures and processes are vital steps. Construction and implementation of reliable and valid measures of organizational performance are also imperative.

Investment, Consumption and Asset Pricing: A Three-Legged Stool

This paper surveys literature related to interactions among the macroeconomic forces that drive investment. It reviews the primary literature that develops the classical/neoclassical and Keynesian theories regarding investment and consumption, and further reviews the literature related to asset pricing, especially as it is related to consumption. Finally, it brings these three areas together and identifies both existing literature related to the three-way interaction and also suggests unexplored areas for future research.