ABR Exam of the Future: Update from APDR - Slide 1

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  • The numbers are only provided as examples, and are not to be taken literally. The message is that the grid is dynamic, and will change from year to year; and anisotropic, with no need for every intersection to have the same value.
  • The numbers are only provided as examples, and are not to be taken literally. The message is that the grid is dynamic, and will change from year to year; and anisotropic, with no need for every intersection to have the same value.
  • Probably not as good a question as the real physics team would write, but an example of the clinical relevance that the majority of physics questions will have
  • Unclear how ABR will test communication skills on any exam of the future; certainly will not be a prominent feature of the Core exam.
  • We have no agreed definition of the terms “basic” and “intermediate” and desperately need a defined curriculum
  • In hopes that we can define X pretty soon
  • Probable that Board review courses, now given in our place every evening and some mornings between February and May 30, will be displaced into the end of 3rd year.
  • And probably more…
  • My philosophy of why we still have no clear agreement on the nature of the Certifying exam.
  • Open questions: will we allow any selection of modules by the candidate (not discussed at the RSNA)
  • Again, for demonstration only. Much better questions will be written, but I wanted to illustrate some of the features that we’ve all talked about: no single “correct” answer, practical decisions, “whole case” types of material.
  • Real important unanswered questions: how will new structure affect fellowships, especially those not ACGME approved; and, will it adversely affect research-oriented training at any time? If it does, we are doing something wrong, and need to change.
  • AR Specialist Salary Range: 32k-35k
    Accountant Salary Range: 42k-45k
  • ABR Exam of the Future: Update from APDR - Slide 1

    1. 1. APDR/APCR ABR UPDATEAPDR/APCR ABR UPDATE March 2010March 2010 Duane Mezwa MDDuane Mezwa MD William Beaumont HospitalsWilliam Beaumont Hospitals Past President, APDRPast President, APDR GI Trustee, ABRGI Trustee, ABR
    2. 2. Exam of the Future (EOF):Exam of the Future (EOF): StructureStructure Core examinationCore examination Certifying examinationCertifying examination
    3. 3. R1 R2 R3 R4 Fellowship/ employment Internship 12 mos 12 mos 12 mos 12 mos 12 mos 12 mos 3 mos Core Exam Certifying Exam
    4. 4. EOF: Core ExaminationEOF: Core Examination Given at 36 monthsGiven at 36 months CoversCovers allall of diagnostic radiologyof diagnostic radiology – Only comprehensive exam in EOFOnly comprehensive exam in EOF – Candidate must pass every category toCandidate must pass every category to qualify for certifying examinationqualify for certifying examination – Level of knowledge expected:Level of knowledge expected: basic/intermediatebasic/intermediate
    5. 5. EOF: Core Exam CategoriesEOF: Core Exam Categories Organ Systems* (10):Organ Systems* (10): – Breast, Cardiac, Endocrine/Reproductive,Breast, Cardiac, Endocrine/Reproductive, Gastrointestinal, Musculoskeletal, Neuro, Pediatric,Gastrointestinal, Musculoskeletal, Neuro, Pediatric, Thoracic, Urinary, VascularThoracic, Urinary, Vascular Modalities (6):Modalities (6): – Rad/fluoro, CT, MR, Nuclear/Molecular, US,Rad/fluoro, CT, MR, Nuclear/Molecular, US, InterventionalInterventional Fundamentals (2)Fundamentals (2):: – Physics, patient safetyPhysics, patient safety * Clinically relevant anatomy, pathophysiology, etc
    6. 6. BreastBreast CardiacCardiac GIGI MSKMSK NeuroNeuro PedsPeds ThoraxThorax Repro /Repro / EndoEndo UrinaryUrinary VascularVascular Q#Q# CTCT 45 IRIR 45 MRMR 45 NM/MolecularNM/Molecular 45 Rad/FluoroRad/Fluoro 45 USUS 45 PhysicsPhysics 90 SafetySafety 45 Q#Q# 45 45 45 45 45 45 45 45 45 45 500 minimum 45 questions per category EOF: Core Exam Blueprint
    7. 7.    BreastBreast CardCard GIGI MSKMSK NeuroNeuro PedsPeds ThoraxThorax Repr/endoRepr/endo GUGU VascVasc Q#Q# CTCT 4545 IRIR 4545 MRMR 4545 NM/MolecNM/Molec 4545 Rad/FluoroRad/Fluoro 4545 USUS 4545 PhysicsPhysics SafetySafety 4545 Q#Q# 4545 4545 4545 4545 4545 4545 4545 4545 4545 4545 500500 0 25 90 Minimum of 45 questions if category is to be scored separately EOF: Examination Blueprint 15
    8. 8. EOF: Core Exam—ScoringEOF: Core Exam—Scoring Each organ systemEach organ system Each methodEach method Patient safety, physicsPatient safety, physics Assuming sufficient breadth of contentAssuming sufficient breadth of content that a confident pass/fail decision isthat a confident pass/fail decision is possiblepossible Minimum 45 questions/categoryMinimum 45 questions/category } Scored pass/fail
    9. 9. EOF: Core Exam - PhysicsEOF: Core Exam - Physics ContentContent Minimum of 90 questionsMinimum of 90 questions Each item writing organ system-based categoryEach item writing organ system-based category has a physicisthas a physicist Questions: “Clinically relevant” physicsQuestions: “Clinically relevant” physics – How can image quality be improved?How can image quality be improved? – What is the source of this artifact?What is the source of this artifact? – How would you design this examination to minimizeHow would you design this examination to minimize excessive radiation exposure?excessive radiation exposure?
    10. 10. EOF: Core Exam—ExampleEOF: Core Exam—Example Physics QuestionPhysics Question Repeat CT is requestedRepeat CT is requested to determine whetherto determine whether the CBD lesion is athe CBD lesion is a tumor or a stone. Whattumor or a stone. What is the most appropriateis the most appropriate maneuver?maneuver? a) Decrease kVpa) Decrease kVp b) Increase kVpb) Increase kVp c) Decrease masc) Decrease mas d) Increase masd) Increase mas e) Buy new unite) Buy new unit
    11. 11. Update on Physics ActivitiesUpdate on Physics Activities CurriculumCurriculum – Revision completed:Revision completed: www.aapm.orgwww.aapm.org – Teaching objectives: spring 2009Teaching objectives: spring 2009 – Questions matched to curriculumQuestions matched to curriculum Web-based modules – RSNA WebsiteWeb-based modules – RSNA Website – Phase 1 (completed - RSNA 2009)Phase 1 (completed - RSNA 2009) X-ray, CT, Nucs, US, MR, BiologyX-ray, CT, Nucs, US, MR, Biology 32 modules developed by radiologist/physicsist32 modules developed by radiologist/physicsist – Phase 2 (target June ’10 or so)Phase 2 (target June ’10 or so) Processing, display, quality, perception, PACSProcessing, display, quality, perception, PACS 30 additional modules30 additional modules AAPM Summer School on Teaching Medical Physics:AAPM Summer School on Teaching Medical Physics: Innovations in LearningInnovations in Learning July 2010.July 2010.
    12. 12. Bloom’s Bloom’s HierarchicalHierarchical Taxonomy of  Taxonomy of  Educational ObjectivesEducational Objectives 1. Knowledge 2. Comprehension 3. Application 4. Analysis 5. Synthesis 6. Evaluation “Written” “Written” Oral Oral Oral Oral Define, Describe, List Distinguish, Convert Interpret, Solve Identify, Analyze Plan, Categorize Rank, Rate
    13. 13. EOF: Core Exam—Contrast withEOF: Core Exam—Contrast with Current Written ExamCurrent Written Exam Written examWritten exam – Fact retrieval onlyFact retrieval only – Individual organ systems and imaging methods notIndividual organ systems and imaging methods not separately evaluatedseparately evaluated – ? Relevance of some physics questions? Relevance of some physics questions Core examCore exam – Roughly 40% fact retrievalRoughly 40% fact retrieval – Comprehensive, all systems/methods scoredComprehensive, all systems/methods scored – Questions based on specific imagesQuestions based on specific images
    14. 14. EOF: Core Exam—Contrast WithEOF: Core Exam—Contrast With Oral ExamOral Exam Oral examOral exam – ObservationObservation – SynthesisSynthesis – ManagementManagement – CommunicationCommunication Core examCore exam – 60% will test all of the above60% will test all of the above – Communication skills?Communication skills?
    15. 15. EOF: Core Exam—ContentEOF: Core Exam—Content Entire spectrum of diagnostic radiologyEntire spectrum of diagnostic radiology Basic/intermediate level*Basic/intermediate level* Probably at least 500 questionsProbably at least 500 questions Administered over 1Administered over 1½ days½ days *Clearly needed: a curriculum for every*Clearly needed: a curriculum for every scorable categoryscorable category
    16. 16. EOF: Core Exam—Conditions ofEOF: Core Exam—Conditions of ContestContest Pass all categories:Pass all categories: PassPass Fail 5 categories:Fail 5 categories: ConditionCondition Fail > 5 categories:Fail > 5 categories: FailFail Conditioned candidates retake only theConditioned candidates retake only the failed category(ies)failed category(ies) Failed candidates retake entire examFailed candidates retake entire exam Both will be offered in six monthsBoth will be offered in six months
    17. 17. EOF: Core Exam—Effects onEOF: Core Exam—Effects on Training ProgramsTraining Programs ABR-RRC meeting yearlyABR-RRC meeting yearly All residents exposed to every clinicalAll residents exposed to every clinical category to be testedcategory to be tested Board preparation displaced into 3Board preparation displaced into 3rdrd yearyear Structure of 4Structure of 4thth yearyear – Smaller programs—may be no changeSmaller programs—may be no change – Larger programs—may be competition forLarger programs—may be competition for highly sought clinical subspecialtieshighly sought clinical subspecialties
    18. 18. EOF: Core Exam—What We NeedEOF: Core Exam—What We Need Written curricula for all categoriesWritten curricula for all categories About 100 item-writersAbout 100 item-writers About 2000 questions before 2013About 2000 questions before 2013 Sage advice from all of youSage advice from all of you Goodwill of the radiology communityGoodwill of the radiology community
    19. 19. EOF: Certifying Exam— 2015EOF: Certifying Exam— 2015 Underlying DualityUnderlying Duality Conceived as the first MOC exam, butConceived as the first MOC exam, but alsoalso Final certifying exam given by ABRFinal certifying exam given by ABR – Must pass test of public scrutinyMust pass test of public scrutiny – Must test competenciesMust test competencies – Need not test entire breadth of radiologyNeed not test entire breadth of radiology
    20. 20. EOF: Certifying ExamEOF: Certifying Exam Given 15 months after residency graduationGiven 15 months after residency graduation Will contain 5 modulesWill contain 5 modules – Noninterpretive skills (common to physicians)Noninterpretive skills (common to physicians) – Essentials of radiology (common to radiologists)Essentials of radiology (common to radiologists) – 3 modules chosen by candidate3 modules chosen by candidate General radiologyGeneral radiology Subspecialty radiologySubspecialty radiology
    21. 21. EOF Certifying Exam—ContentEOF Certifying Exam—Content Emulate practice of radiologist at workEmulate practice of radiologist at work – Some normal examsSome normal exams – Many “real-life” decisionsMany “real-life” decisions Differential (not single) diagnosesDifferential (not single) diagnoses Management decisionsManagement decisions More complicated question typesMore complicated question types – Many possible right answersMany possible right answers – Layout mimicking real patient workupsLayout mimicking real patient workups
    22. 22. What are the clinical practice areas on the certifying examination? The clinical practice area choices will reflect current radiology practice: Breast, Cardiac, GI, MSK, Neuro, NM, Peds, Repro/Endo, Thoracic, Ultrasound, Urinary, Vascular- Interventional and General Diagnostic Radiology. The ABR will monitor the numbers of candidates taking each module and modify this list as seems appropriate after 3 years depending on the choices made by candidates.
    23. 23. Clinical Practice AreasClinical Practice Areas BreastBreast GENERALGENERAL CardiacCardiac GIGI MSKMSK NeuroNeuro NuclearNuclear PediatricPediatric Reproductive/EndoReproductive/Endo ThoracicThoracic UltrasoundUltrasound UrinaryUrinary Vascular-InterventionalVascular-Interventional
    24. 24. EOF: Certifying Exam—ExampleEOF: Certifying Exam—Example CaseCase A 43 year old man experienced intermittentA 43 year old man experienced intermittent episodes of hematochezia. Capsule endoscopyepisodes of hematochezia. Capsule endoscopy showed angiodysplastic changes in the ileal mucosa.showed angiodysplastic changes in the ileal mucosa. Which of the following radiologic examinations isWhich of the following radiologic examinations is MOST appropriate for further evaluationMOST appropriate for further evaluation a)a) CT enterographyCT enterography b)b) MR enterographyMR enterography c)c) Selective angiographySelective angiography d)d) EnteroclysisEnteroclysis Warning: Once you have made a selection, you may not return to this screen
    25. 25. What is the MOST likely diagnosis? a) Carcinoid b) GI stromal tumor c) Adenocarcinoma d) Metastatic melanoma
    26. 26. What is the MOST likely diagnosis? a) Carcinoid b) GI stromal tumor c) Adenocarcinoma d) Metastatic melanoma
    27. 27. Exam PhilosophyExam Philosophy “The important thing is to make the lesson of each case tell on your education.” William Osler
    28. 28. Certifying Exam- 2015Certifying Exam- 2015 How will the exam be graded?How will the exam be graded? 5 modules: Noninterpretive skills,5 modules: Noninterpretive skills, essentials, three candidate-selectedessentials, three candidate-selected modulesmodules Each will be graded with own passingEach will be graded with own passing standardstandard Candidate must pass all 5 componentsCandidate must pass all 5 components No “condition” statusNo “condition” status
    29. 29. Rationale:   *Both psychometric and “face” validity are necessary  to our various stakeholders.  We are currently the only board with a condition category at this time.   *Elimination of “condition” is reasonable because we  have narrowed the scope of the exam and eliminated  subjectivity of an oral exam.   Assuming that the examination is available in testing  centers every six months, additional preparation by  candidates and prompt reexamination will be feasible.
    30. 30. Certifying Exam:Certifying Exam: Of the three clinical modules, how many can be chosen in theOf the three clinical modules, how many can be chosen in the same category?same category? All 3. Candidates allowed free choice to construct their examAll 3. Candidates allowed free choice to construct their exam among General or Subspecialty Categoryamong General or Subspecialty Category Rationale: The clinical modules will comprise only 60% of theRationale: The clinical modules will comprise only 60% of the exam. Allowing free choice permits early subspecialization, whileexam. Allowing free choice permits early subspecialization, while still testing all of DR.still testing all of DR. It is expected that candidates selecting more modules in a givenIt is expected that candidates selecting more modules in a given subject will be answering questions of higher difficulty.subject will be answering questions of higher difficulty.
    31. 31. We are testing what the candidate  feels is most important to his/her  future practice, not what their past  training has been.
    32. 32. EOF: Certifying Exam—What WeEOF: Certifying Exam—What We NeedNeed Even more help!Even more help! Sufficient material and question-writingSufficient material and question-writing expertise to create graded spectrum ofexpertise to create graded spectrum of sophistication within every categorysophistication within every category Example: Neuroradiology contentExample: Neuroradiology content Core General Modules CAQ Increasing sophistication
    33. 33. EOF: Certifying Exam—Effect onEOF: Certifying Exam—Effect on Training ProgramsTraining Programs Restructured 4Restructured 4thth yearyear – Depends on size and orientationDepends on size and orientation – Will not include Boards frenzyWill not include Boards frenzy Effect on FellowshipsEffect on Fellowships – Research-orientedResearch-oriented – Narrowly definedNarrowly defined
    34. 34. Recent DecisionsRecent Decisions
    35. 35. Orals ResultsOrals Results Distribution of Orals resultsDistribution of Orals results Beta tested in Louisville last OctoberBeta tested in Louisville last October Very successfulVery successful Results were available on line quickerResults were available on line quicker than US mailthan US mail Will do this for upcoming exam in May.Will do this for upcoming exam in May. PD to get results very close in time toPD to get results very close in time to release of results to residents.release of results to residents.
    36. 36. September 30 RuleSeptember 30 Rule If a candidate plans to take the currentIf a candidate plans to take the current Orals then training must be completed byOrals then training must be completed by Sept 30Sept 30thth of that year.of that year. Certificate will be held until completed.Certificate will be held until completed. Extenuating CircumstancesExtenuating Circumstances Exception must be attested by PDException must be attested by PD Review by ABRReview by ABR
    37. 37. Enough is Enough RuleEnough is Enough Rule Applies to candidates that repeatedly try to passApplies to candidates that repeatedly try to pass the Examthe Exam Currently 10 yearsCurrently 10 years In EOF it will be 5 years to pass Core afterIn EOF it will be 5 years to pass Core after becoming eligible ( 36 months of training).becoming eligible ( 36 months of training). In EOF it will be 5 years to pass Certifying afterIn EOF it will be 5 years to pass Certifying after first qualifying to take exam. (15 mos)first qualifying to take exam. (15 mos) Additional year of training if not able to meet theAdditional year of training if not able to meet the requirement.requirement. No need to take Core again once passed.No need to take Core again once passed.
    38. 38. 20132013 Last year of full Orals June 2-5, 2013Last year of full Orals June 2-5, 2013 First year of Core ExamFirst year of Core Exam Week of September 30-October 4, 2013Week of September 30-October 4, 2013 Following year will move Core earlier to 3Following year will move Core earlier to 3rdrd week of June---probablyweek of June---probably
    39. 39. Transition PlanTransition Plan What happens to those in process who do notWhat happens to those in process who do not finish Written or Orals when we convert in 2013?finish Written or Orals when we convert in 2013? Elaborate timing diagram with every permutationElaborate timing diagram with every permutation with Condition and Failwith Condition and Fail Fail Written 3 timesFail Written 3 times  CoreCore Fail Orals 3 timesFail Orals 3 times  CoreCore Condition Orals 3 timesCondition Orals 3 times  Certifying ModuleCertifying Module Plus Essentials and Non-InterpretativePlus Essentials and Non-Interpretative
    40. 40. Louisville and BeyondLouisville and Beyond After 2015 will go onAfter 2015 will go on RP and RO plan on continuing their OralRP and RO plan on continuing their Oral exams for the futureexams for the future Now assessing the sites available to giveNow assessing the sites available to give the future exams: computer storage, abilitythe future exams: computer storage, ability to show our exam material etcto show our exam material etc Simulation possibilitiesSimulation possibilities
    41. 41. MQSA- CurentlyMQSA- Curently "The interpreting physician shall have interpreted or multi-read at least 240 mammographic examinations within the 6- month period immediately prior to the date that the physician qualifies as an interpreting physician. This interpretation or multi-reading shall be under the direct supervision of an interpreting physician."
    42. 42. Exemption- CurrentlyExemption- Currently But if you pass your Boards first time:But if you pass your Boards first time: "Physicians who have interpreted or multi-read at least 240 mammographic examinations under the direct supervision of an interpreting physician in any 6-month period during the last 2 years of a diagnostic radiology residency and who become appropriately board certified at the first allowable time, as defined by an eligible certifying body, are otherwise exempt"
    43. 43. MQSA- EOFMQSA- EOF Works in progress -Awaiting final FDAWorks in progress -Awaiting final FDA Graduates after 2014Graduates after 2014 "Physicians who 1) successfully complete a diagnostic radiology residency program in 2014 (or later), 2) have interpreted or multi- read at least 240 mammographic examinations under the direct supervision of an interpreting physician in any 6-month period during the last 2 years of this residency, and 3) have passed their certifying board's core exam by the end of their residency are otherwise exempt."
    44. 44. Current MQSA Requirements, Before 2014 No Exemption etc. With Exemption etc. Proposed MQSA Requirements, After 2014 No Exemption (no change) etc. With Exemption (proposed) etc. Date qualifies as Interpreting Physician R1 R2 R3 R4 F2/PR1 R2 R3 Interpreting Physician P 960 exams in 24 months continuing experience  If not enough exams, must requalify F1/P F2/P or 240 exams 960 exams in 24 months continuing experience P P  Date qualifies as 240 exams or 240 exams or 240 exams Year of Residency  Oral Certifying Exam (Pass)  240 exams 960 exams in 24 months continuing experience R4 Year of Fellowship or Practice  If not enough exams, must requalify  Oral Certifying Exam (Fail) P 960 exams in 24 months continuing experience F1/P Core Exam (Fail)  R1 R2 R3 R4 F1/P F2/P P P 240 exams 960 exams in 24 months continuing experience 960 exams in 24 months continuing experience   Date qualifies as If not enough exams, Interpreting Physician must requalify Certifying Exam   Core Exam (Pass before residency end) R1 R2 R3 R4 F1/P F2/P P P 240 exams or 240 exams or 240 exams or 240 exams Exams under Supervision Initial and Continuing Experience Requirements for New Interpreting Physicians Under MQSA Date qualifies as If not enough exams, Interpreting Physician must requalify 960 exams in 24 months continuing experience 960 exams in 24 months continuing experience  
    45. 45. IMG PolicyIMG Policy Most candidates from India.Most candidates from India. India advisory committee to ABR.India advisory committee to ABR. Must have completed training and certification .Must have completed training and certification . Chair is PD. Hired as junior faculty.Chair is PD. Hired as junior faculty. All 4 years MUST be in same institution.All 4 years MUST be in same institution. If they switch the 4 years start over again.If they switch the 4 years start over again. Can take Certifying Exam after 4 years ofCan take Certifying Exam after 4 years of training. Do not have to wait the 15 monthstraining. Do not have to wait the 15 months
    46. 46. Practice AnalysisPractice Analysis Survey instruments finalizedSurvey instruments finalized Could add question about focusedCould add question about focused practicepractice Will be distributed electronicallyWill be distributed electronically Results to be discussed by October, 2010Results to be discussed by October, 2010 Recognized not most scientific way toRecognized not most scientific way to gather datagather data Should look at feasibility of obtainingShould look at feasibility of obtaining CTP/ICD-9 codes from sample practicesCTP/ICD-9 codes from sample practices
    47. 47. ABRF ProposalABRF Proposal ABRF –President Bill HendeeABRF –President Bill Hendee New venture to help Residents and PDsNew venture to help Residents and PDs RFP to go out soonRFP to go out soon 14 Ethics and Professionalism modules14 Ethics and Professionalism modules Modeled after the Physics modulesModeled after the Physics modules ETA: April 2011ETA: April 2011
    48. 48. VolunteerismVolunteerism EOF Committees all formedEOF Committees all formed BUT…..BUT….. Terms of service on these committeeTerms of service on these committee range from 2-4 yearsrange from 2-4 years Still need 1000s of items for the exams,Still need 1000s of items for the exams, both Core and Certifyingboth Core and Certifying Orals still around for a few more years….Orals still around for a few more years….
    49. 49. MIRCMIRC Medical Imaging Resource CenterMedical Imaging Resource Center A simple way to identify, index and retrieve images,A simple way to identify, index and retrieve images, teaching files and other radiology informationteaching files and other radiology information The ability to search multiple imaging libraries as if theyThe ability to search multiple imaging libraries as if they were a single library organized by medically importantwere a single library organized by medically important categoriescategories An authoring tool that makes it easy to create radiologyAn authoring tool that makes it easy to create radiology teaching files and other electronic documents in flexibleteaching files and other electronic documents in flexible formats with a common underlying structureformats with a common underlying structure Tools to enable sites to manage and exchange imagesTools to enable sites to manage and exchange images and research data sets for imaging clinical trialsand research data sets for imaging clinical trials
    50. 50. 17 Ways ABR Communicates17 Ways ABR Communicates  Leadership meetingsLeadership meetings  Discussions at ABR boothDiscussions at ABR booth  Trustee presentations atTrustee presentations at society meetingssociety meetings  The BeamThe Beam  Email from ABREmail from ABR  Web content, FAQsWeb content, FAQs  1-on-1 phone1-on-1 phone conversations in officeconversations in office  ““Open microphone”Open microphone”  Pamphlet distributionPamphlet distribution  Paper & electronicPaper & electronic newsletters of societiesnewsletters of societies  Major journal articlesMajor journal articles  Snail mail from ABRSnail mail from ABR  Responses to emailResponses to email questions (individual)questions (individual)  SurveysSurveys  Annual reportAnnual report  VideoVideo  Phone or Webex withPhone or Webex with
    51. 51. EOF: Final ThoughtsEOF: Final Thoughts ABR mission, to protect the public, is vitalABR mission, to protect the public, is vital No part of its mission is possible without the work ofNo part of its mission is possible without the work of hundreds of volunteershundreds of volunteers Thanks to everyone who has or will contribute theirThanks to everyone who has or will contribute their cases and writing expertise to continue our missioncases and writing expertise to continue our mission If we are to survive, we must establish the cultureIf we are to survive, we must establish the culture of lifelong learning in each of our diplomatesof lifelong learning in each of our diplomates
    52. 52. Concluding ThoughtConcluding Thought “One never notices what has been done, one can only see what remains to be done.” Mdm Marie Curie Contact : dmezwa@beaumont.edu

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