Variety Of Specialties Research Articles

Prospective analysis of STRATAFIX™ symmetric PDS plus suture for fascial closure in spinal surgery: a pilot study

Wound closure is an integral part of every spinal procedure. Effective and secure wound closure is paramount in the prevention of infection, wound dehiscence and the preservation of cosmesis. Barbed suture technologies such as STRATAFIX™ Symmetric have been studied and are used in a variety of specialties, including obstetrics and orthopedic surgery, but is underutilized in neurosurgery. This study aims to assess the time and rate of closure using STRATAFIX™ Symmetric technology for fascial closure and compare this method to the more traditionally used method of fascial closure using braided absorbable sutures below the epidermis. 20 patients were recruited for the study. 10 patients underwent fascial approximation with braided absorbable sutures and definitive fascial closure with STRATAFIX™ Symmetric. In the control group, fascial closure was completed entirely with interrupted braided absorbable stitches. Patients assigned to STRATAFIX™ Symmetric group had shorter mean time for fascial closure, faster rate of average fascial closure, and lower number of total sutures used. The use of barbed suture technology such as STRATAFIX™ Symmetric may reduce the time to closure in thoracolumbar spine surgery without increasing the risk of adverse events. This pilot study forms the framework for a larger randomized, controlled trial appropriately powered for such an analysis.

Science of Moscow University for the Humanities: 80 years of experience as a leading private university

At each stage of the development of the Moscow University for the Humanities, its scientifi c research was determined by the challenges of the time and had a high degree of social and scientifi c demand, which was refl ected in the priority areas approved by the order of the rector. The university provides training in a variety of specialties and areas: economics, management, applied computer science, psychology, pedagogy, law, sociology, international relations, regional studies, journalism, advertising, tourism, hotel management, design, cultural studies, acting and vocalism; therefore, the scientifi c interests of teachers and scientists cover a signifi cant range of those tasks that are a priority for the development of the country. The article discusses priority scientific directions at the Moscow University for the Humanities and the principles of scientific work of the university.

State-of-the-Art Review: Evaluation and Management of Delusional Infestation.

Delusional infestation is a condition encountered frequently by healthcare professionals across a variety of specialties in which patients have a fixed, false belief that they are infested with living creatures, such as bugs, parasites, worms, or mites, or nonliving objects, such as fibers. Delusional infestation can be debilitating for patients, who not only present with intense psychological distress and physical discomfort but are also at risk of developing numerous dermatological and psychiatric complications. This condition poses unique diagnostic challenges, as these symptoms can occur secondary to many metabolic or infectious causes, as well as unique treatment challenges, with patients frequently refusing psychiatric care and consequently seeking evaluation by other healthcare professionals. In this review, we aim to use existing literature to provide clinicians in infectious diseases or other specialties with sufficient clinical context and treatment guidance for the appropriate management of delusional infestation.

Are There Differences in Short-Term Postoperative Outcomes Among Surgical Subspecialists Performing Lower Extremity Flap Procedures? A National Surgical Quality Improvement Project (NSQIP) Analysis of 1324 Patients

Introduction: Soft tissue flaps are an integral and versatile tool to help manage soft tissue defects of varying severities. These complex procedures can be done by a variety of specialties and can lead to a variety of postoperative complications. Locoregional flaps are the middle rung of the reconstructive ladder and can be performed by surgeons of various training pathways. The profile of patients and their complications when stratified by surgical specialty is unknown. The purpose of this study was to compare short-term postoperative outcomes between surgical subspecialists performing a locoregional flap of the lower extremity to determine factors influencing complication rates. Methods: The National Surgical Quality Improvement Project (NSQIP) database was queried using Current Procedural Terminology code 15,738 to identify adult patients undergoing a muscle, myocutaneous, or fasciocutaneous lower extremity flap procedure from 2016 to 2019. We examined the primary outcome of a pooled wound complication rate with secondary outcomes including the individual NSQIP wound- and nonwound complications. Results: A total of 1324 patients were identified. Plastic surgeons performed 926 (70%) procedures, general surgeons performed 243 (18%) procedures, orthopedic surgeons performed 89 (7%) procedures, and vascular surgeons performed 66 (5%) procedures. On multivariate analysis, surgical subspecialty was not associated with the primary outcome, but malignancy-related operations and nonelective status were considered significant. Conclusions: Patient characteristics, but not surgeon subspecialty, account for the variation in patient outcomes in lower extremity flap reconstruction. Larger, prospective studies examining these outcomes are needed to further characterize complication risk factors in this patient population.

Improving lung point-of-care ultrasound (POCUS) training and accreditation - a multidisciplinary, multi-centre and multi-pronged approach to development and delivery using the action learning process

BackgroundPoint-of-Care Ultrasound (POCUS) consists of a range of increasingly important imaging modalities across a variety of specialties. Despite a variety of accreditation pathways available in the UK, lung POCUS training remains difficult to deliver and accreditation rates remain suboptimal. We describe a multidisciplinary, multi-centre, and multi-pronged approach to lung POCUS education within a region.MethodsA survey was conducted in a region. From these results, bottlenecks were identified for improvement. We utilised key stages in an established accreditation pathway, and the Action Learning process. Analysing participant feedback, consensus amongst the team, regional educational needs, and leveraging the expertise within the faculty, we implemented several solutions which were multidisciplinary, multi-centre, and multi-pronged. We also set up a database across several accreditation pathways to facilitate supervision and assessment of rotational trainees.ResultsUtilising the Action Learning process, we implemented several improvements at elements of the lung ultrasound accreditation pathways. An initial regional survey identified key barriers to accreditation: lack of courses (52%), lack of mentors (93%), and difficulty arranging directly supervised scans (73%). A multidisciplinary team of trainers was assembled. Regular courses were organised and altered based on feedback and anecdotal educational needs within the region. Courses were set up to also facilitate continuing professional development and exchange of knowledge and ideas amongst trainers. The barrier of supervision was removed through the organisation of regular supervision sessions, facilitating up to fifty scans per half day per trainer. We collected feedback from courses and optimised them. Remote mentoring platforms were utilised to encourage asynchronous supervision. A database of trainers was collated to facilitate triggered assessments. These approaches promoted a conducive environment and a commitment to learning. Repeat survey results support this.ConclusionLung ultrasound accreditation remains a complex educational training pathway. Utilising an education framework, recruiting a multidisciplinary team, ensuring a multi-pronged approach, and fostering a commitment to learning can improve accreditation success.

127 Advance RI-K Scholar Career Development Program: A one-year intensive program for developing early career faculty in an IDeA state

OBJECTIVES/GOALS: We developed a state-wide program to support early career faculty in preparing mentored career development awards, and connect them to resources, mentorship, and career development opportunities. We aimed to build self-efficacy along multiple axes, including research design and grantsmanship, and to facilitate networking with mentors and peers. METHODS/STUDY POPULATION: The program recruited four cohorts of faculty over the course of four years, for a total of 32 faculty participants (63% physician scientists). Participants were selected by a Steering Committee, and represented a variety of specialties from 19 departments across Brown University, University of Rhode Island, and affiliated hospitals. Participation required an institutional commitment of 20% minimum protected time to engage in research and a year-long curriculum that included biweekly didactic sessions, project development support, individual consultations, feedback on drafts, and internal study section review. Participants completed pre-, interim-, and final-assessments, which collected measures of self-efficacy, professional development needs, program satisfaction, and formative feedback. RESULTS/ANTICIPATED RESULTS: Over the first 3 years, 21 participants completed the program, 43% have received NIH or VA K/CDA awards so far, and 48% received other federal or non-federal awards. Over 25 faculty from across institutions participated in leadership and didactics, with even greater participation on mentorship teams, panels, and grant review. All cohorts showed improvements in measures of self-efficacy in grantsmanship and research and reported high satisfaction with program activities. Participants found individualized proposal feedback and internal study sections to be most valuable, and frequently cited the value of peer-learning opportunities. Challenges for scholars include mentorship challenges, competing priorities/protected time, and various external factors that impacted individual research progress. DISCUSSION/SIGNIFICANCE: The program has successfully supported cohorts of junior clinical and translational faculty from across the state in launching their independent research careers. The program may serve as a model for IDeA state inter-institutional collaboration in developing diverse faculty cohorts in the early stages of preparing their career development award.

Strabismic Adults' Experiences of Psychosocial Influence of Strabismus-A Qualitative Study.

Strabismus influences health-related quality of life. Individuals may have functional and psychosocial consequences of strabismus that impact their well-being. As strabismus is prevalent in all age groups, patients are seen in varied specialties in healthcare organizations. Therefore, healthcare professionals need to be aware of the psychosocial consequences when caring for strabismic individuals. To describe strabismic adults' experiences of the psychosocial influence of strabismus. Twelve strabismic adults participated in face-to-face or online semistructured individual interviews to share their experiences of the psychosocial influence of strabismus. The participants were selected purposefully. The data were analyzed using inductive content analysis. The participating adults described challenges with social environments, which showed stress in social situations and pressure in interactions. Strabismic adults had experienced staring from others, avoided social situations, and were uncomfortable with photography. They hid their strabismus, avoided eye contact, and struggled with intimate relationships. They also expressed struggles with mental well-being, which were emotional and psychological burdens. The adults described feeling negative emotions, worry, and irritation due to their condition. Struggles with self-confidence, difficulties with acceptance, negative thoughts about their appearance, experiences of bullying, and dealing with being different were described. Strabismic adults experience psychosocial consequences of strabismus, influencing their psychosocial health-related quality of life. Further studies should focus on how healthcare professionals could support strabismic individuals' psychosocial well-being.

Outcomes From a Physician Health Center

This retrospective cohort study describes the population of physicians seeking medical evaluation in a dedicated physician health center and identifies factors associated with needing practice restrictions. Participants had an initial evaluation between January 1, 2016, and December 31, 2022. We report personal and professional demographics and types of medical conditions in this cohort. An ordinal logistic regression analysis was used to identify factors associated with occupational outcomes. Physicians in a wide variety of specialties from 34 different states presented for evaluation of diverse medical problems. More than half of the participants presented with occupational concerns. The presence of a neurologic or psychiatric illness were the only factors associated with temporary or permanent restrictions. Physicians with medical conditions impacting their ability to practice have a professional obligation to obtain a thorough, objective medical evaluation. Such evaluations should support and protect patients, employers, and the physicians themselves.

COMPETENCE APPROACH WITHIN PROFESSIONAL AND FUNDAMENTAL TRAINING OF FUTURE UNDERGRADUATE ENGINEERS UNDER CONDITIONS OF EDUCATIONAL TRANSFORMATIONS

Summary: the article addresses to the problem of the introduction of competence approach in bachelors’ professional and fundamental training as future engineers in varied specialties at a technical university under educational transformations and joining the European education environment. The authors accentuate on the fact that under conditions of native education modernization, special significance attains the problem of professional training for specialists to be competitive in the labor market, competent, and to master their profession extensively. In the course of the study, it was established that educational activity modernization is taking place within the context of the European requirements, principles and standards of the EU states. It is established that the introduction of the competence approach to the education of the EU member-states assumes that the knowledge obtained corresponds to the following four constituents: to know what, to know why, to know how, to know who.
 A number of inner and outer factors are dealt with in the article that determine the urgency of introduction of the competence approach to the education practices of Ukraine.
 The presented analysis of scientific researches has enabled defining the key elements of professional competence in a future engineer. The content of the main traits is disclosed as well as peculiarities in the introduction of the competence approach in the process of professional and fundamental training of bachelors – future engineers – in varied specialties under educational transformations.

Distribution Pattern of Artisan Gastronomy Tourism Location in Bandung City

The artisan gastronomy tourism sector has the potential to attract and support tourism in the city. This research aims to analyze the distribution pattern of famous eating places in the City and analyze the characteristics of tourists in attracting tourism in Surakarta City. The method applied in this research is descriptive qualitative approach, using primary and secondary data. The sampling technique used is non probability sampling with purposive sampling type. The results of data analysis show that the pattern of distribution of eating places in Bandung City is in groups, with location points scattered around the sate building, as well as adjacent to economic centers, cultural tourism centers, and other centers. Characteristics and attractiveness. Bandung has an influence as a tourism developer that attracts tourists, influenced by technological developments, easy accessibility, and a variety of specialties. In terms of the level of interest in artisan gastronomy places in Bandung, tourists are of the opinionthat artisan gastronomy products in this city are attractive

An Insight into the Potential of Flavonoids and Furanocoumarins in the Treatment of Psoriasis

Abstract: Psoriasis is a hereditary, immune-mediated illness that can affect the skin, joints, or both. The condition frequently requires the treatment of a wide group of specialists with a variety of specialties. Numerous difficulties are presented by psoriasis, such as its high prevalence, chronicity, disfigurement, disability, and related comorbidities. Natural treatment of psoriasis can be provided by flavonoids and furanocoumarins. Flavonoids, a group of chemical compounds with various phenolic structures, are found in a wide variety of foods, including fruits, vegetables, cereals, bark, roots, stems, flowers, tea, and wine. The health benefits of these natural compounds are well known, and efforts are being made to extract the components known as flavonoids. Furanocoumarin is a subgroup of coumarins with phenolic compounds. It can be divided into two groups: linear generic name psoralens, which include psoralen, xanthotoxin, and bergapten, and angular generic name angelicins, which include sphondin and pimpinellin. The most important plant source is psoralen, which has been used for generations in traditional medicine to treat psoriasis and vitiligo. The creation of alternative psoralen molecules that do not generate the bifunctional adducts that serve as the foundation for DNA crosslinking is one of the future directions for further improving psoriasis treatment. This article focuses on flavonoid and furanocoumarin research and development trends, modes of action, functions, and applications.

Access to care among patients with osteogenesis imperfecta during the COVID-19 pandemic.

Individuals with osteogenesis imperfecta (OI) often have complex care needs requiring that they see a variety of specialists. The onset of the COVID-19 pandemic in March 2020 led to delays in medical care for many health conditions. The goal of this study was to describe the experiences of individuals with OI accessing medical care during this time. Responses to an electronic survey distributed via the OI Foundation mailing list were collected from August 2020 until February 2021. Participants were instructed to compare their experiences in the months since the start of the pandemic with their experiences prior to this date. Data were analyzed using descriptive statistics and were compared across demographic groups using logistic regression and chi-squared tests. Surveys were completed by 110 participants. Most participants (72%) reported experiencing delays in accessing at least one care provider. The majority of participants reported less or similar amounts of bone pain (74.3%) and less or the same rate of fracture (88.6%) as before the start of the pandemic. While most study participants experienced delays in care, they did not report an increase in symptoms associated with OI. They also frequently utilized telehealth as a tool to see their providers. Future research should focus on the impact of changes in telehealth legislation on patients' ability to access care. As methods for care delivery evolve, the needs of people with OI and other rare diseases should be considered and prioritized.

Contemporary art from the Global South in the art auction market from 2020 to 2022

In recent years, emerging artists from the Global South have garnered substantial attention in the art market. This study seeks to examine the market value and ecosystem evolving around these emerging artists by analyzing the sales results of 51 artists between 2020 and 2022. This research aims to establish patterns linking unprecedented sales results with exhibition history and highlights the essential network required for these artists’ commercial success. The study reveals that the emergence of artists in the global art market results from a deliberate effort by a network of stakeholders. Our exhibition database led us to a group of 438 stakeholders who promote this sample of artists. By examining artists’ origins, backgrounds, and careers, this study provides context for analyzing the impact of artistic migration on artists’ visibility, the importance of being promoted by a variety of specialists, and the surge of African artists in the global art market since 2020. Our findings indicate that the structure of the art world has shifted toward a decentralized global art market characterized by a diverse range of actors and inputs dispersed globally. This diversification has disrupted traditional power structures in the art world, opening up new possibilities for emerging artists from the Global South, thereby contributing to a more equitable and inclusive art market.

Depressive disorders and their pharmacotherapy in routine clinical practice

Depression is one of the most common medical causes of disability and mortality in patients of all ages. Depressive disorders are common in the practice of physicians of a variety of specialties, including psychiatrists, neurologists, and physicians. This paper provides a summary review of the literature on modern ideas about the epidemiology, classification, and clinical picture of depression. Current approaches to the diagnosis and treatment of depressive disorders in neurological and psychiatric practice are discussed. Modern pharmacotherapeutic strategies for the treatment of depression in various patient populations are described in detail. Current clinical practice indicates the high importance of an interdisciplinary approach in the diagnosis and management of patients with depressive symptoms in Russia. The paper suggests organizational and educational strategies that can be recommended to improve the effectiveness of medical care for patients with depressive disorders.

In vitro characterization of bionanocomposites with green silver nanoparticles: A step towards sustainable wound healing materials

AbstractThis study investigated the characterization, antifungal activity, and biocompatibility of green agar/silver and collagen/silver bionanocomposite films for wound healing and cell growth scaffolds. Silver nanoparticles (AgNPs) are known for their antimicrobial properties, but their toxicity and harsh synthesis limit their applications. To address this, green‐synthesized AgNPs G‐AgNPs were incorporated into agar/collagen suspensions at specific concentrations and three different G‐AgNP‐agar and two different G‐AgNP‐col bionanocomposite films were produced. Nanoparticle homogeneity and film quality were characterized through SEM analysis. Mechanical properties were tested using a uniaxial tensile tester, revealing that the bioplastic control samples exhibited UTS of 3.86 MPa compared to 0.60 MPa for collagen, a 6‐fold improvement. Viable cell metabolic activity derived from MTT assay showed that Col‐4%AgNPs and Bio‐30%AgNPs had a 42.9% and 51.6% increase in net metabolic activity respectively compared to control on day 4. Fluorescence microscopy confirmed enhanced cell adhesion and proliferation in G‐AgNP‐incorporated samples. Antifungal properties were evaluated against Cladosporium spores, able to cause severe diseases when in contact with human skins, following ISO 16869:2008 standards. The demonstrated unique properties and tunability of G‐AgNPs bionanocomposites can be employed in a variety of specialties for wound‐healing applications, to improve rate and quality of healing while reducing the risk of infection.

Physicians' Lived Experience of Breaking Bad News in Clinical Practice: Five Essentials of a Relational Process.

The purpose of this study was to develop deeper knowledge about physicians' lived experiences of breaking bad news by identifying their common meanings and interrelatedness along with their potential alignment with process-oriented and relational aspects. Based on the methodology of descriptive phenomenology, in-depth interviews were conducted with 22 physicians from a wide variety of specialties. The participants were invited to freely reflect upon their experiences of breaking bad news by describing situations that had worked well and less well. Results showed that breaking bad news was fundamentally experienced as a relational process constituted by the five essentials of Becoming the bad messenger, Expecting the unpredictable, Being on stage, Professionally managing hope, and Mindfulness of the emotional relationship. In line with recent research, this study confirms that clinical communication involves much more than just delivering the message. However, it also contributes to existing knowledge by focusing on the phenomenology of physicians' experiences, which enables deeper understanding of the medical profession and the relational process of breaking bad news. As such, our findings are important to enable broader learning in, for example, medical education and continuing courses for clinical staff.

Global Surgeon Opinion on the Impact of Surgical Access When Using Endocutters Across Specialties

Background: Despite design enhancements in endocutters, key challenges related to limited surgical access and space can impact stapling and, potentially, surgical outcomes. Objectives: This study aimed to develop consensus statements outlining the clinical value of precise articulation and greater anatomical access in minimally invasive surgery performed by bariatric, colorectal, and thoracic surgeons. Methods: Colorectal, bariatric, and thoracic surgeons from Japan, the United States, United Kingdom, and France participated in a 2-round modified Delphi panel. Round 1 included binary, Likert scale–type, multiple-response, and open-ended questions. These were converted to affirmative statements for round 2 if sufficient agreement was reached. Consensus was set at a predefined threshold of at least 90% of panelists across all surgical specialties and regions selecting the same option (“agree” or “disagree”) for the affirmative statements. Results: Of the 49 statements in the round 2 questionnaire, panelists (n=135) reached consensus that (1) tissue slippage outside stapler jaws can occur due to limited access and space; (2) greater jaw aperture could help to manipulate thick or fragile tissue more easily; (3) articulation of an endocutter is clinically important in laparoscopic surgeries; (4) improved access to hard-to-reach targets and in limited space would improve safety; and (5) an endocutter with improved access through greater articulation would become common use. Discussion: By understanding user-specific challenges and needs from both specialty- and region-wide perspectives, endoscopic stapling devices can continue to be refined. In this study, improved articulation and greater jaw aperture were the key design features examined. Improved articulation and greater jaw aperture were key stapler design features identified in this study that may mitigate the risk of instrument clashes and intraoperative complications such as anastomotic leaks. Conclusions: This study gained insights into surgeons’ perspective across a variety of specialties and from 3 distinct geographies. Participating surgeons reached consensus that an endocutter with greater jaw aperture and articulation may improve surgical access and has potential to improve surgical outcomes.

Global Surgeon Opinion on the Impact of Surgical Access When Using Endocutters Across Specialties.

Background: Despite design enhancements in endocutters, key challenges related to limited surgical access and space can impact stapling and, potentially, surgical outcomes. Objectives: This study aimed to develop consensus statements outlining the clinical value of precise articulation and greater anatomical access in minimally invasive surgery performed by bariatric, colorectal, and thoracic surgeons. Methods: Colorectal, bariatric, and thoracic surgeons from Japan, the United States, United Kingdom, and France participated in a 2-round modified Delphi panel. Round 1 included binary, Likert scale-type, multiple-response, and open-ended questions. These were converted to affirmative statements for round 2 if sufficient agreement was reached. Consensus was set at a predefined threshold of at least 90% of panelists across all surgical specialties and regions selecting the same option ("agree" or "disagree") for the affirmative statements. Results: Of the 49 statements in the round 2 questionnaire, panelists (n=135) reached consensus that (1) tissue slippage outside stapler jaws can occur due to limited access and space; (2) greater jaw aperture could help to manipulate thick or fragile tissue more easily; (3) articulation of an endocutter is clinically important in laparoscopic surgeries; (4) improved access to hard-to-reach targets and in limited space would improve safety; and (5) an endocutter with improved access through greater articulation would become common use. Discussion: By understanding user-specific challenges and needs from both specialty- and region-wide perspectives, endoscopic stapling devices can continue to be refined. In this study, improved articulation and greater jaw aperture were the key design features examined. Improved articulation and greater jaw aperture were key stapler design features identified in this study that may mitigate the risk of instrument clashes and intraoperative complications such as anastomotic leaks. Conclusions: This study gained insights into surgeons' perspective across a variety of specialties and from 3 distinct geographies. Participating surgeons reached consensus that an endocutter with greater jaw aperture and articulation may improve surgical access and has potential to improve surgical outcomes.

Automatic recognition of defects in plasma-facing material using image processing technology

Observing and analyzing surface images is critical for studying the interaction between plasma and irradiated plasma-facing materials. This paper presents a method for the automatic recognition of bubbles in transmission electron microscope (TEM) images of W nanofibers using image processing techniques and convolutional neural network (CNN). We employ a three-stage approach consisting of Otsu, local-threshold, and watershed segmentation to extract bubbles from noisy images. To address over-segmentation, we propose a combination of area factor and radial pixel intensity scanning. A CNN is used to recognize bubbles, outperforming traditional neural network models such as AlexNet and GoogleNet with an accuracy of 97.1% and recall of 98.6%. Our method is tested on both clear and blurred TEM images, and demonstrates human-like performance in recognizing bubbles. This work contributes to the development of quantitative image analysis in the field of plasma-material interactions, offering a scalable solution for analyzing material defects. Overall, this study’s findings establish the potential for automatic defect recognition and its applications in the assessment of plasma-material interactions. This method can be employed in a variety of specialties, including plasma physics and materials science.

How often do medical students change career preferences over the course of medical school?

IntroductionDuring the preclinical years, students typically do not have extensive exposure to clinical medicine. When they begin their clinical rotations, usually in the third year, the majority of the time is spent on core rotations with limited experience in other fields of medicine. Students then must decide on their careers early in their fourth year. We aimed to analyze how often medical students change their career preferences between the end of their second and their fourth year.MethodsWe conducted a retrospective, cohort study using the American Association of Medical Colleges Year 2 Questionnaire (Y2Q) and Graduating Questionnaire (GQ) from 2016 to 2020.Results20,408 students answered both surveys, but 2,165 had missing values on the career choice question and were excluded. Of the remaining students, 10,233 (56%) changed their career choice between the Y2 and GQ surveys. Fields into which students preferentially switched by the GQ survey included anesthesia, dermatology, ENT, family medicine, OB/GYN, pathology, PM&R, psychiatry, radiology, urology, and vascular surgery. Many characteristics, including future salary, the competitiveness of the field, and the importance of work-life balance, were significantly associated with a higher likelihood of changing career choices. On the other hand, having a mentor and the specialty content were associated with a lower likelihood of change.ConclusionA majority of students switched their career preferences from the Y2Q to the GQ. Additional research should be focused on curricular design that optimizes student satisfaction with career decisions. This may include early integration of a variety of specialties.