It is an understatement to say that Americans are busy. The average work week involves stress and lack of sleep, and can take a toll on a person’s health. However, many people do not realize how physically detrimental the average work week can be when we neglect our body.

Let’s consider a normal work day. We get up early, gather our things, eat a quick breakfast, and head straight to the car. Most of us set the alarm with no time to spare so we maximize our sleep time. We all know that sleep is vital to the human body, but we forget to leave time to wake up our musculoskeletal system. We forget to stretch and engage our core musculature that was just dormant for hours.

Back to the normal work day. Once in the car, with our core still in a dormant state, we begin our slouching regimen. Then we make our way into work and slouch at our desks, only to be interrupted by further slouching at lunch and a slouching finale on our way home from work.

Once we arrive home we have a decision on whether or not we exercise. The question then becomes…Do we really expect our core to be engaged enough to support our extremities in any form of exercise in its current state? I propose a different approach.

What if we wake up 10 minutes earlier? This would give us time to adequately engage the core with a few stretches and exercises. This would prepare the entire body for a day of improved posture. With the core engaged, proper posture can be supported throughout the work day. Granted, when sitting at a desk for a prolonged period of time, it will be necessary to carve out some time to stretch those muscles that are in a constant shortened position and to reengage the core.

We can’t forget our core and we can’t forget how important posture stability is to our physical well being. People wonder why they constantly have pain in their shoulders, hips, and backs after a long day of work. The answer is simple. You are forgetting your core. As you are seated for hours in a flexed position, gravity is constantly pressing down on your head and shoulders. Without engaging your core, you are doing nothing to counteract this force.

Wake up 10 minutes earlier and engage you core throughout the day. Practice proper posture and spinal alignment. Your body will thank you.

Michael Neal LAT, ATC

Interprofessional Education (IPE) occurs when educators and learners from 2 or more health professions jointly create and foster a collaborative learning environment.1,2 The intention is to develop knowledge, skills and attitudes that result in interprofessional team behaviors and competence.1,2  IPE is intended to improve patient care by enhancing the quality of care, decreasing cost, decreasing patients’ length of stay and reducing medical errors.1,3-6   The Institute of Medicine suggests that patients receive safer, high quality care when health care professionals worked effectively in a team, communicated productively, and understood each other’s roles.1

At this point it should be easy to understand… if we all worked well with one another, our patients can get better faster and without error.  But how many times have you had a patient come to you and say… well my previous PROVIDER said (insert whomever/whichever suits your fancy)… and instead of embracing the previous health care provider and his/her findings and/or treatment plan, we decide he or she was wrong…  Interprofessional, collaborative practice requires that we incorporate those other providers into our patient care, because even if we might not agree, something can be gleaned from his/her findings and care. 

So, how do we get there… how do we get to a place where we have mutual respect and understanding for each other’s disciplines? This is where IPE comes in… taking a collaborative learning environment facilitated by faculty and practitioners from various disciplines can help students understand how to complement one another’s skills and scopes of practice.  At Indiana State University, we try to help students understand collaborative practice early in the curriculum, engaging them in case studies in our Introduction to Health Professions Course.7  Then, as they approach the professional stage of the Athletic Training Program, they engage in teambuilding activities8 and are evaluated on their ability to work within a team to earn admission.9  At various stages throughout the curriculum, they engage in activities forcing interaction with other health care and wellness professions through an IPE day,10 a mass casualty event, and an Emergency Medicine Collaborative.11  Whether the activities are large or small, they are connected to the core competencies of interprofessional practice (IPP), to help them work toward understanding the values and ethics of IPP and the roles and responsibilities of collaborative practice, while honing skills in interprofessional communication, interprofessional teamwork and team-based care.12 

Well many of us think we know what other professions do… research suggests otherwise.11,13  We need to do a better job of working well together, but also working toward understanding our roles more thoroughly, so we can transition patients to the expert provider when appropriate.  The patients need us to do a better job of knowing who is best for them.  Aren’t they the reason we got into this business in the first place?

If you are interested in knowing more about IPE and IPP, follow @GamesKenneth and @isuathltraining while we attend the All Together Better Health Conference in Pittsburgh, PA this week.  Have questions about IPE, IPP and Athletic Training, use #at4at.


References

1.       Institute of Medicine Committee on the Health Professions Education Summit. Health Professions Education: A Bridge to Quality. Greiner AC, Knebel E, eds. 2003; National Academy Press, Washington, DC. 11. Andrus NC, Bennett NM. Developing an interdisciplinary, community-based education program for health professions students: the Rochester experience. Acad Med. 2006;81(4):326-331.

2.       Center for Advancement of Interprofessional Education (CAIPE). http://www.caipe.org.uk. Accessed November 6, 2013.

3.       Barr H, Koppel I, Reeves S, Hammick M, Freeth D. Effective Interprofessional Education: Argument, Assumption & Evidence. Oxford, UK: Blackwell; 2005.

4.       Brashers VL, Curry CE, Harper DC, et al. Interprofessional health care education: recommendations of the National Academies of Practice expert panel on health care in the 21st century. Issues in Interdisciplinary Care: National Academies of Practice Forum. 2001;3(1):21-31.

5.       Freeth D, Hammick M, Reeves S, Koppel I, Barr H. Effective Interprofessional Education: Development, Delivery & Evaluation. Oxford, UK: Blackwell; 2005.

6.       TeamStepps: Strategies and Tools to Enhance Performance and Patient Safety, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. http://teamstepps.ahrq.gov. Accessed November 6, 2013.

7.       Games KE, Eberman LE, Kahanov L. Integrating IPE into “Pre-Professional” Educational Experiences Using Case Studies.  Presented at the All Together Better Health VII Conference, Pittsburgh, PA on June 7, 2014.

8.       Eberman LE, Kahanov L, Games KE. Teamwork Competence… As Important as Our Clinical Competence. Presented at the All Together Better Health VII Conference, Pittsburgh, PA on June 6, 2014.

9.       Eberman LE, Kahanov L, Young A, Games KE. Interprofessional Admissions Approach Using Team Dynamics Evaluation. Presented at the All Together Better Health VII Conference, Pittsburgh, PA on June 6, 2014.

10.   Kahanov L, Eberman LE, Games KE. Comparison of Differing Interprofessional Education Activities to Assess Student Outcomes. Presented at the All Together Better Health VII Conference, Pittsburgh, PA on June 7, 2014.

11.   Eberman LE, Jaeger JE, Landis M, Williams DJ, Livingston LB, Kahanov L. Emergency Medicine Collaborative: Interprofessional Practice in Emergency Care. Presented at the All Together Better Health VII Conference, Pittsburgh, PA on June 8, 2014.

12.   Interprofessional Education Collaborative. Core Competencies for interprofessional collaborative practice. 2011.

13.   Coffey D, Eberman LE, Kahanov L, Southard E. Interprofessional Practice: What Health Care Provider Students Know about other HCPs. J Interprof Care. 2014 (In Process). 

In the last few months, as a member of GLATA and now a member of the NATA, I have been approached or asked to participate in surveys used to evaluate my perceptions about a transition to an entry-level masters professional degree in athletic training.  Although I believe in discourse and discussion on the issue, I do neither endorse nor encourage surveys that are intended to provide “evidence” when they are steeped in poor methodology.  I am a quantitative, survey researcher and frankly I am offended that people think they can slap some questions into surveymonkey or qualtrics and call it research… in any journal, this kind of research would be rejected for failed/invalid instrumentation.  The same would be true if I measured temperature using an oral thermometer in a heat illness study!

You can find the link to the survey here:

So let’s begin… how does this particular survey fail in methodology…

1.  Bias is a systematic error that can prejudice the findings in some way 
     a. In the introduction letter the authors suggest that “The questions included in this survey have been put together to address some issues that the white paper either ignored or did not address.”
          i.       How does this influence the reader? Does this suggest that the NATA and those that served on this committee did not appropriately represent you?  How would that make you feel? Angry? Disoriented? Unappreciated? Might this impact the findings?

2.  Sampling bias occurs when a sample does not accurately reflect true representation within the target population
     a. Also in the introduction, the authors tell us how they hope to distribute this survey… “We are distributing this survey to some members via email. But we are going to rely mainly on the power of the social media- Facebook, Twitter, professional blogs, etc., so please send the site of this survey or to as many of your athletic training colleagues or professional friends as possible including educators, clinical staff, and even undergraduate, graduate and doctoral students over e-mail and social media outlets.”
           i.      Does this seem systematic to you? What kind of respondents will you get if you focus solely on social media? Will you access some of the older, more seasoned athletic trainers in the profession? Will you only entice the youth… those of whom are 50% likely to leave the profession in the next 5 years? And how will that impact the findings?

3.  Forced responses within a survey violate your rights as a respondent… you should have the right to choose which items you respond to or not. This falls under the protection for persons under federal guidelines and the Belmont Report of 1979.

4.  The orientation of responses in this survey lists strongly agree from left to right suggesting that upon downloading the data a strongly agree response will be indicative of a “1” and a strongly disagree will be indicative of a “5”.  Did the authors mean to provide the results backwards? That will certainly make data analysis difficult!

5.  The orientation of the responses are also listed horizontally; however, methodologists in survey research, particularly Dillman and colleagues have identified that vertical responses are likely to yield the most accurate results.  Apparently how we read things MATTERS!

6.  Double barreling items occurs when a respondent is asked to evaluate two concepts within the same item.
     a. “Advancing the entry-level degree for professional practice from the current Bachelors degree to a Masters degree will be more likely to improve patient outcomes and ensure longevity of the profession of athletic training.”
          i.      Here the authors ask that you rate your level of agreement (well actually, they don’t give you any directions at all, but they assume you will rate your level of agreement) with two concepts: 1) that an entry-level masters will improve patient care and 2) that it will ensure longevity in the profession.  Are those two things the same? Or different? Can you have opposing views on each? Should you be able to?

7.  Items that ask about factual things like the presence of evidence cannot be perceived… they are factual.
     a. “There is clear evidence in the athletic training research journals that suggests improved patient outcomes are likely to result from transitioning to a Masters degree as our entry-level professional degree.”
          i.      Is this true or is this untrue? Furthermore… the use of the word “clear” to describe the evidence also incites confusion in the reader… is it clear to me? Or is it clear to you?

Need I go on? I understand people want their voices to be heard!  But don’t do it by using my responses to a poor survey to manipulate my perceptions.  This is a poorly constructed method of quantitative survey research… if you want to ask the question… ask the question… do you agree or disagree with the NATA Whitepaper finding… I AGREE and I will continue to support the progress of the profession and my national organization because I have faith in their due diligence.  I believe in the NATA, the BOC, and the CAATE in that they have the best interest of the profession as the driving force…

Lindsey E. Eberman PhD, LAT, ATC

Recent college graduates that pass the board of certification (BOC) exam are determined to have met the requirements necessary to practice as entry-level athletic trainers. Despite demonstrating competency to practice independently as credentialed professionals, many young professionals and recent college graduates have the desire to gain advanced knowledge within the field of athletic training and to develop their clinical skills before heading out into the world with full autonomy. As a result many young professionals will seek further education in athletic training within the first 2-3 years after becoming certified.

Currently there are 16 active post-professional athletic training education programs that are accredited by the commission on accreditation of athletic training education (CAATE). CAATE accredited post-professional programs are designed to prepare athletic trainers for advanced clinical practice, research and scholarship, in order to enhance the quality of patient care, optimize patient outcomes, and improve patients’ health-related quality of life. The CAATE states that: “The mission of a Post-Professional Athletic Training Graduate Degree Program is to expand the depth and breadth of the applied, experiential, and propositional knowledge and skills of athletic trainers, expand the athletic training body of knowledge, and to disseminate new knowledge in the discipline. Post-professional graduate education in athletic training is characterized by advanced systematic study and experience—advanced in knowledge, understanding, scholarly competence, inquiry, and discovery.”

Post-professional programs in athletic training are now a popular choice for further education amongst newly certified athletic trainers. However, with the potential move to professional masters degrees in athletic training in the pipeline post-professional masters degrees may no longer continue to exist. Instead the transition to athletic training residency programs and athletic training doctoral degrees is being considered. Post-professional residency programs in athletic training provide advanced preparation of athletic training practitioners through a planned program of clinical and didactic education in specialized content areas using an evidence-based approach to enhance the quality of patient care, optimize patient outcomes, and improve patients’ health-related quality of life.

As a student currently enrolled in a CAATE accredited post-professional program, I believe that my program is meeting the purpose defined by the CAATE and is allowing me to achieve my goals of gaining further clinical and experiential knowledge whilst also being exposed to research opportunities, adding to the current body of knowledge and advancing my scholarly competence.

What is your position regarding post-professional programs?

Are they more beneficial to entry level athletic trainers than degrees in other specializations? such as…exercise physiology, kinesiology, sport psychology, sport administration, etc.?

If our profession is to make the move to professional masters degrees, would you consider additional schooling and consider an athletic training residency or doctoral program? 


Stephen Edwards LAT, ATC

There is much debate regarding the future of Athletic Training education. We have already discussed the way Athletic Training is currently housed in educational institutions and the way Undergraduate ATs can be negatively perceived by other health care programs. Under the current system, ATs are not being perceived as highly educated individuals by other students preparing to enter the healthcare workforce. We have also identified a maturity issue, in which students graduating from baccalaureate programs have not adequately developed emotional intelligence needed to provide high quality patient care.

Two main resolutions are possible if an entry-level masters system is adopted. 1) Increased respect from health care providers, insurance companies, and patients. 2) More prepared and qualified Athletic Trainers.

A professional degree at the masters level has the potential to develop stronger curriculum with more time to focus on core classes. Instead of cutting classes or attempting to combine two classes into one, programs can adapt to an integrated model to help students better blend all the domains of the profession.

In some of the arguments for/against a professional degree at the masters level, individuals have cited that 70% of Athletic Trainers get a Masters degree, yet there are currently only 16 accredited Post-Professional ATEP programs… so let’s ask ourselves… what are they studying? Clinical experience only? If individuals are earning Master degrees in fields not directly focused on Athletic Training, clinicians are not further enhancing AT knowledge, critical thinking, or evidence-based medicine.

I understand the argument that there is no current evidence stating that this new system will work; however, I believe it is a step forward. We are already falling behind other healthcare professions. Our goal is not to simply change our requirements from Bachelors to a Masters; we are working to reform the entire educational system! Furthermore, I believe most individuals with still strive to further their education, particularly as more opportunities for clinically-based, Doctorate of Athletic Training (DAT) programs emerge (stay tuned for that discussion tomorrow).

In many of the arguments against the development of professional degrees at the masters level, individuals cite the need for more clinical experience and development as students are “working” as graduate assistants.  In my opinion this is a double-edged sword of sorts.  Is the real issue, a loss of workforce, or is it that students develop and enhance skills while pursuing a masters degree… couldn’t one argue this means we aren’t adequately preparing our students at the baccalaureate level and therefore we NEED the advanced clinical practice?  Couldn’t one argue that this is because our baccalaureate level students have competing demands and different goals… which could be solved by more focused experiences in a more controlled environment at the masters level?

Michael Neal, LAT, ATC

In continuation with our education series, one of the biggest concerns that many educators face today is asking whether or not their students are ready. With the current expansion of work settings and a diversification of our patient population, we are giving more all-around standards for athletic trainers. From the Professional Education in Athletic Training White Paper, finding #2 states, “Transition to graduate professional education facilitates continued evolution in the professional competency requirements to better reflect the clinical practice requirements of current and future ATs in a changing healthcare environment.”

Presently, topics such as special populations, pharmacology, mental health, third-party reimbursements and professional growth are gaining wide exposure all over the country and yet we do not cover them adequately; most of these emerging expected skills and issues are touched briefly in class sessions, but not explored comprehensively. This is a barrier to the evolving healthcare policies that embrace interprofessional standards for healthcare disciplines. Practicing evidence based medicine, interprofessional education, and information technology are just some of these prime examples of expected core standards, not well done in all of our programs. These standards are important part of our current Athletic Training Education Competencies. This brings me into thinking that, what if we are not adequately preparing our undergraduates?

With my current master thesis in relation to transition-to-practice, I have discovered that the literature equates and references Emotional intelligence (EI) as an important factor in medicine and other healthcare disciplines.  It is suggested that professional mental health is as important as effective practice.  According to a study on EI, good EI includes the ability to understand and control emotions, to be empathetic, to be socially competent. In this study, 33.6% of first year medical students were poor in all six domains of EI. Besides EI, there is evidence that non-technical skills of young emerging adults from age 18-23 are underdeveloped.  For example, a consortium reports conducted by four government organizations interviewed over 400 employers across the United States, and in their findings, employers rank professionalism (93.8%), teamwork (94.4%) and oral communication skills (95.5%) as the top three most important workforce skills for collegiate graduates, and yet around 43% believe that 4-year college graduates qualify as “satisfactory” in these three categories.

As an athletic trainer who graduated from a traditional 4-year undergraduate program, I understand how rewarding it was to go through school in 4 years. However, I do feel that there are certain aspects of non-technical skills I needed to brush upon once I was at my first job. I was blessed to be able to work as a Resident Assistant in my undergraduate study and would perceive myself as adequately prepared for the workforce. But I will admit that when I was working at a small div II institution in Colorado, I never thought I would be so challenged with mental health and social issues of athletes… all on top of managing my new administrative duties. My point is this: There are times when entry-level undergraduate athletic trainers will be put in situations that they have never been challenged before and consequently, it may affect the quality of care. I am not saying all baccalaureate prepared athletic trainers an inadequate, but I am saying that perhaps we are starting to expect much more from our profession and that a graduate level program may be a better route for preparing our students for the workforce.


Denny Wongosari, LAT, ATC

With the current clamoring of ATs regarding the “Professional Education in Athletic Training” whitepaper, we thought it best to engage you all in a healthy discussion.  While some will choose to stand by their position, we simply encourage everyone to become informed. Today’s topic, within the scope of transiting our degree to a masters level, we will be discussing the impact on curriculum.

Finding #5 of the whitepaper states that the “Transition to professional education at the graduate level would increase the likelihood that education programs are better aligned with other health care professional programs.”  In 1996, 17 years ago the NATA Board of Directors called upon us in education to align our programs with schools of health professions.  To date, that has not occurred given that only 21% of programs are housed within colleges/schools with other peer health professions programs.  As a member of a department with athletic training, physical therapy, physician assistant studies, and occupational therapy, I can tell you… my job as a Program Director is eased by the commonalities between programs. I do not face the same administrative misunderstanding that my colleagues often experience. Our programs are financially and administratively supported because of the similarities we share with other health professions.

Finding #6 of the whitepapers states that “Professional education at the graduate level should facilitate interprofessional education.”  For the 33% of programs housed in separate units and the 16% that are the only Athletic Training programs at their respective institutions, interprofessional education (IPE) is not only difficult, it can sometimes be impossible.  Moreover, programs, like ours at Indiana State, face different, less tangible challenges with IPE. We face circumstances where IPE with undergraduate students is scoffed at… because obviously it is “beneath” graduate students (from other disciplines) to spend time learning from with and about Athletic Training students learning at an undergraduate level.  Other disciplines sometimes fail to see the difference between professional and post-professional degrees… and while my graduate students are practicing clinicians and have already shaped their professional identity… the other disciplines would prefer work with them, simply because they are earning the “same” degree.

Finding #8 of the whitepaper states that “Professional education should not complete with general education, liberal arts, and foundational science requirements because it detracts from the effectiveness of the professional educational experience.” This, in my opinion, is the greatest challenge faced by our current educational model.  While a general education curricula is crucial to establishing contributing citizens, the competing demands of shaping a young person to contribute in the world and the development of a fine-tuned clinician is often at odds.  Add to this the competing demands of the millennial student and their needs to have life-work balance (NOT A CRITICISM from me!) and often jobs to support the growing cost of higher education.  Our undergraduate students are expected to do more, to be more than their classmates in other majors.  And the consequences are found in the quality of their clinical experience and the expectations, we as educators, can hold within our classrooms.

From this singular, only curricular perspective, a transition to a professional degree at the masters level has the potential to improve the quality of education and ability to interact with other disciplines with ease.  Furthermore, it will allow undergraduate to focus on the things that will make them strong contributors and effective graduate students.  And who knows… with a little creative curricular artistry, programs could be delivered in a 3+2=5 model to quicken the time to degree and potentially decrease cost, all without compromising the quality of the clinician.

Lindsey E. Eberman PhD, ATC  

This week, our blog has raised awareness about tolerance and open-mindedness. Collectively, we agree that equal opportunity is important, both as practitioners and colleagues. 

The evidence tells us hiring bias still exists.  When we know that regardless of gender, managers are twice as likely to hire a man (read more)… When we know that unqualified individuals are measuring our worth as health care providers based on wins and losses (read more)… we are losing!  As long as the individual is qualified for the position; their gender, ethnicity, sexual orientation, and/or religious affiliation should not matter.

What’s worse is when we handicap ourselves even more to bias based on things we can’t see… Commonly in Athletic Training, hiring committees select individuals based on previous sport experience… not education, qualifications or dedication to the profession. Why are we making things even harder to succeed?

As Athletic Trainers we specialize in musculoskeletal injuries. Our education at the professional level focuses on gaining a variety of experiences with multiple sports, including acute and chronic conditions for the lower and upper extremity, equipment intensive experiences, and general medical conditions.  We are well-versed in the prevention, recognition, and treatment of musculoskeletal injuries regardless of sport.

I understand that each of us comes to the profession with our own set of values and perspective, but when we insert those values onto other people, particularly in the hiring process, what are we actually doing? What are the long term implications? Are we creating an environment that never changes, where people hire others that are only like themselves? Do we achieve the diversity in our profession that is reflective of the diversity in our patients?

Michael Neal LAT, ATC

As we continue to encourage open mindedness and advocacy for minorities throughout this week’s blog, I have the privilege to talk about a very sensitive topic: the Lesbian Gay Bisexual and Transgender community (LGBT). With the movement for same-sex marriage and related social awareness, the United States has become more socially accepting and supportive for the LGBT community compared to a decade ago. For more info, check out this survey on social acceptance.

However, there is still ongoing discrimination towards the LGBT community especially in healthcare, both as providers and patients. As patients, the LGBT community is known to have a higher prevalence of HIV, mental illness, substance use, smoking, and other health conditions. They face a number of challenges when trying to access health services, including barriers in obtaining insurance coverage, gaps in coverage, cost-related hurdles, and poor treatment by health care providers.  For example, a recent survey from Center for American Progress found that one in three LGBT individuals with incomes under 400% FPL are uninsured, a group that could qualify for assistance under the Affordable Care Act. Some have been left out of the system due to denial (pre-existing condition) of coverage or provider inexperience with their health needs.  Even a majority of members of the LGBT community with insurance have been reportedly dissatisfied with their service.  As healthcare providers, the LGBT community is facing similar discrimination as well.  The intolerance may be in the form of judgment from colleagues or even denial of employment.  For these reasons, the Gay and Lesbian Medical Association (GLMA) was founded to advocate and support for medical providers and students who are LGBT. Check out their GLMA site. 

Consider that some of us may not discuss patient and practitioner interactions like these during our undergraduate preparation. This is a failure in our education… we have a responsibility toward cultural awareness and competency.  The go-to should always be toward a culture of openness, a culture of inclusion.  We should treat others how we wish to be treated ourselves. I fervently believe that to be an athletic trainer, one must have a heart for service.  Continue to love other people and be mindful/sensitive for their needs.  At the end of the day, we are all humans and we should see each other as such, instead of judging and isolating others.

Denny Wongosari LAT, ATC

The topic of religion in any work place can be a topic of controversy.  But why? Simply stating that you are “religious” can have various meanings.  Some religions may take Communion in a different way or believe in a different God or leader, but all in all they provide their constituents with guidelines to help realize their own specific moral values.  In our clinical settings most of us come from different educational backgrounds or learning experiences and we see different techniques from our coworkers.  If we can take the time to learn a technique from a colleague or look it up ourselves then why can’t we take the time to understand where others beliefs are developed from.  Just because we understand other religions doesn’t mean that we have to convert or follow those guidelines, but it gives us a platform of understanding to not offend anyone or be offended ourselves. From a personal perspective, I am willing to be open about my Christianity to others.  This does not mean that I feel a need to “preach” to everyone I come in contact with.  Yes, I do not share the same beliefs with all my coworkers or patients but that does not change at all my interaction or care.  That is what makes people unique.  If we, as a society, could focus more on treating everyone with kindness and learning about our differences, many of these prejudices would not exist. 

Beyond the scope of interactions with others, it is also good clinical practice to listen to the goals, needs, and values of our patients.  In fact, this is one of the three pillars of evidence-based practice.  Faith may be a major factor in the decisions of our patients and judging those choices, either as a person of a different faith, or simply from a scientific perspective, diminishes the role of the patient’s values in our clinical practice. 

Openness is the key… to good clinical practice… to life.  

Beth Neil LAT, ATC