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Postgraduate Program Standards
Emergency Medicine Physician Assistant Postgraduate
Education Program Standards
These standards were originally developed by the SEMPA Postgraduate Education Committee and approved by the SEMPA Board of Directors on October 26, 2014.
In 2021, the committee updated the original SEMPA Postgraduate Education Program Standards with revisions made in alignment with the 2020 Accreditation Council for Graduate Medical Education (ACGME) guidelines and Accreditation Review Commission on Education for the Physician Assistant (ARC-PA) Clinical Postgraduate Standards, 3rd Edition.
SEMPA thanks the members of the Postgraduate Education Committee for their time, efforts, insight, and collaboration in the development of these standards. The volunteer participation in such an important initiative is commended.
2014 SEMPA Postgraduate Education Committee
Chair Lynn Scherer, PA-C
Postgraduate Committee Members
Matthew Boutte, PA-C
Bartholomew Cambria, PA-C
Scott Fillman, PA-C
John Graykoski, PA-C
Jonathan Lerner, PA-C
Adam Lloyd, PA-C
Mary Masterson, PA-C
Douglas McGee, DO, FACOEP, FACEP
Gregory Raines, PA-C
Dennis Tankersley, PA-C
Ann Verhoeven, PA-C
Mary Jo Wagner, MD, FACEP
Fred Wu, PA-C
Chair Ann Verhoeven, PA-C
Workgroup Committee Members
Jeff Callard, PA-C
Lynn Scherer, PA-C
Nathaniel Shekem, PA-C
Sara DeSanctis, PA-C
Tara Igneri, PA-C
Jennine McAuley, PA-C
Paul Mochmer, PA-C
Jennifer Spisak, PA-C
Kevin Wyne, PA-C
The following is the summary of standards developed by SEMPA for postgraduate training programs in emergency medicine for physician assistants. Portions of this document have been adapted from the applicable and relevant published standards for graduate medical education by the ACGME. A list of references can be found at the end of this document.
Int. A. Preface
The education of physician assistants to practice the specialty of emergency medicine is experiential and necessarily occurs within the context of the health care delivery system. Developing the skills, knowledge, and attitudes leading to proficiency in all the domains of clinical competency requires the physician assistant to assume personal responsibility for the care of individual patients in an educational setting. For the physician assistant resident/fellow, the essential learning activity is interaction with patients under the guidance and supervision of faculty members who give value, context, and meaning to those interactions. As emergency medicine physician assistant (EMPA) residents/fellows gain experience and demonstrate growth in their ability to care for patients, they assume roles that permit them to exercise those skills with greater autonomy. This concept-graded and progressive responsibility is one of the core tenets of the American graduate medical education. Supervision in the setting of graduate medical education has the goals of: assuring the provision of safe and effective care to the individual patient; assuring each resident's/fellow's development of the skills, knowledge, and attitudes required to practice medicine proficiently; and establishing a foundation for continued professional growth.
Postgraduate medical training in emergency medicine prepares physician assistants for the practice of emergency medicine. These EMPA postgraduate programs must teach the fundamental skills, knowledge, and humanistic qualities that constitute the foundations of emergency medicine practice. The EMPA postgraduate programs provide progressive responsibility and experience in these areas to enable effective management of clinical problems. EMPA residents/fellows must have the opportunity, under the guidance and supervision of a qualified faculty member, to develop a satisfactory level of clinical maturity, judgment, and technical skill. On completion of the EMPA postgraduate program, EMPA residents/fellows should be capable of practicing emergency medicine, able to incorporate new skills and knowledge during their careers, and able to monitor their own physical and mental well-being.
Int. B. Program Titles
Based on institutional preference, the term residency, fellowship, or postgraduate program is appropriate to describe physician assistant clinical postgraduate medical education. The programs should clearly identify themselves as emergency medicine physician assistant postgraduate education programs.
Int. C. Program Length
EMPA postgraduate programs in emergency medicine are typically configured in a 12-month to 18-month format. The lengthier programs are commonly those that have additional off-service rotation opportunities.
Int. D. Completion of EMPA postgraduate Program
Completion of an EMPA postgraduate education training program in emergency medicine should prepare the candidate to sit for the Certificate of Added Qualifications in Emergency Medicine (CAQ-EM) granted through the National Commission on Certification of Physician Assistants (NCCPA). Additionally, there is significant value in developing a universal internal metric for postgraduate programs to utilize annually in evaluating their program's performance relative to all other EMPA postgraduate programs throughout the country. SEMPA will continue to evaluate and make recommendations regarding the use and development of a universal internal metric.
Each EMPA resident/fellow must meet all the requirements set forth for the didactic, clinical, and procedural guidelines. Additionally, each EMPA resident/fellow must meet the requirements of professional and ethical behavior as outlined in this document. Each postgraduate program must provide honest, objective data, and feedback to EMPA residents/fellows and provide accurate references to future employers upon completion of the postgraduate program.
Int. E. Integration
SEMPA advises that if an EMPA postgraduate education program exists in an institution that has a physician emergency medicine residency, that it operates in parallel with the physician emergency medicine residency to promote team-based clinical care in the practice of emergency medicine. Additionally, EMPA program directors should work in conjunction with emergency medicine physician program directors to ensure the best possible didactic, clinical, and procedural experiences for all learners. It is important to establish whether there are sufficient training opportunities for both programs to meet their experiential needs prior to initiating an EMPA postgraduate education program at a site with an existing physician emergency medicine residency.
Int. F. Recognition/Accreditation
The goal of each EMPA postgraduate program should be to meet the Standards as outlined in this document and follow the process that SEMPA delineates. In addition, EMPA postgraduate programs may consider obtaining accreditation through the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA).
It. G. Collaboration
SEMPA encourages established EMPA postgraduate education programs to work collaboratively with SEMPA and other EMPA postgraduate programs to share resources and curricula with other entities that are providing or developing postgraduate specialty training programs in emergency medicine and commit to assisting new EMPA postgraduate programs.
Int. H. Definitions
Critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition.
Critical Care services are defined as the direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition. Examples of vital organ system failure include but are not limited to central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic and/or respiratory failure.
Instructional faculty include those who regularly educate, supervise, and evaluate the residents/fellows.
Primary Site
The primary clinical site is the medical institution in which the EMPA postgraduate program is based, and the majority of the clinical rotations and didactic education are done. Office space for the EMPA postgraduate program personnel shall be provided there.
I. Oversight
I.A. Sponsoring Institution
One sponsoring institution must assume ultimate responsibility for the EMPA postgraduate program, as described in the Institutional Requirements, and this responsibility extends to EMPA resident/fellow assignments at all participating sites.
The sponsoring institution should provide a minimum of 3,000 clinical hours or 18 months of training for each individual EMPA resident/fellow.
The primary clinical site in which EMPA residents/fellows rotate must have at least 30,000 emergency department visits annually to ensure that there are a sufficient number of patient encounters for all learners.
The sponsoring institution and the EMPA postgraduate program must ensure that the EMPA program director has sufficient protected time and financial support for his or her educational and administrative responsibilities to the program.
The sponsoring institution and participating sites must provide salary support and/or protected time for:
The EMPA program director.
All core faculty members.
I.B. Participating Sites
There must be a Program Letter of Agreement (PLA) between the EMPA postgraduate program and each participating site providing an assignment/rotation. The PLA must be renewed at least every five (5) years.
The PLA should:
Identify the faculty who will assume both educational and supervisory responsibilities for EMPA residents/fellows
Specify their responsibilities for teaching, supervision, and formal evaluation of EMPA residents/fellows, as specified later in this document.
Specify the duration and content of the educational experience.
State the policies and procedures that will govern EMPA resident/fellow education during the assignment.
The EMPA postgraduate program should be based at the primary clinical site.
EMPA postgraduate programs using multiple participating sites must ensure the provision of a unified educational experience for the EMPA residents/fellows.
Each participating site must offer significant educational opportunities to the overall EMPA postgraduate program.
The majority of assigned rotations should be situated at the primary clinical site. The program should ensure that residents are not unduly burdened by required rotations at geographically distant sites.
II. Personnel and Resources
II.A. EMPA Program Director
There must be a single EMPA program director or co-directors with authority and accountability for the operation of the EMPA postgraduate program.
The EMPA program director should continue in his or her position for a length of time adequate to maintain continuity of leadership and program stability.
Qualifications of the EMPA program director must include:
Should be a PA. If the program director is not a PA, then the program director must be an emergency medicine physician.
Requisite specialty expertise and a clear strong interest in education and administration.
Current medical licensure and appropriate medical staff appointment.
At least five (5) years of experience as a physician assistant practicing in emergency medicine.
The EMPA program director must administer and maintain an educational environment conducive to educating the EMPA residents/fellows.
The program director must be knowledgeable about and responsible for the program's:
continuous review and analysis
accreditation requirements and process
The EMPA program director must oversee and ensure the quality of didactic and clinical education in all sites that participate in the EMPA postgraduate program.
The program director must design and conduct the program in a fashion consistent with the needs of the community, the missions of the Sponsoring Institution and the missions of the program.
The EMPA program director must be clinically active in emergency medicine.
The EMPA program director should not work more than 30 hours per week clinically, on average, or 1,560 clinical hours per year and no less than 12 hours per week clinically, on average, or 624 hours per year.
The EMPA program director must:
Approve the selection of program faculty as appropriate.
Evaluate program faculty on an annual basis at a minimum.
Approve the continued participation of program faculty based on evaluation.
Monitor EMPA resident/fellow supervision at all participating sites.
Provide a learning and working environment in which residents/fellows have the opportunity to raise concerns and provide feedback in a confidential manner as appropriate, without fear of intimidation or retaliation.
Ensure compliance with grievance and due process procedures as set forth in the Institutional Requirements and implemented by the sponsoring institution.
Ensure the program's compliance with the Sponsoring institution's policies and procedures for due process when action is taken to suspend or dismiss, not to promote, or not to renew the appointment of a resident.
Ensure the program's compliance with the Sponsoring Institution's policies and procedures on equal opportunity employment and non-discrimination.
Provide verification of education for all EMPA residents/fellows, including those who leave the program prior to completion.
Implement policies and procedures consistent with the institutional and EMPA postgraduate program requirements for EMPA resident/fellow duty hours and the working environment, including moonlighting,
and, to that end, must:
Distribute these policies and procedures to the EMPA residents/fellows and faculty.
Monitor EMPA resident/fellow duty hours, according to sponsoring institutional policies.
Adjust schedules as necessary to mitigate excessive service demands and/or fatigue.
If applicable, monitor the demands of at-home call and adjust schedules as necessary to mitigate excessive service demands and/or fatigue.
Monitor the need for and ensure the provision of back up support systems when patient care responsibilities are unusually difficult or prolonged.
Comply with the sponsoring institution's written policies and procedures.
II.B. Medical Director
The medical director must:
Hold a current, valid, unrestricted, and unqualified license to practice medicine as an allopathic or osteopathic physician in the state in which the program exists (unless exempt under state or federal law).
Be currently certified by ABMS or AOA approved specialty board and experienced in the delivery of the type of health care services for which the PA trainee is being educated.
Be knowledgeable about current practice standards and the PA role.
Support the program director to ensure proficient medical guidance for didactic and supervised clinical instruction that meets best practice guidelines and the accepted standards of care.
Be an advocate for the program within the sponsoring institution and the medical and academic communities.
II.C. Faculty
At each participating site, there must be a sufficient number of instructional faculty with documented qualifications to instruct and supervise all EMPA residents/fellows at that location.
The faculty must:
Demonstrate a strong interest in the education of EMPA residents/fellows.
Devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities.
Administer and maintain an educational environment conducive to educating EMPA residents/fellows.
Have current certification in the specialty by the American Board of Emergency Medicine or possess acceptable qualifications.
Instructional faculty must be knowledgeable in course content and effective in teaching assigned content.
Possess current medical licensure and appropriate medical staff appointment.
Regularly participate in organized clinical discussions, rounds, journal clubs, and conferences.
Pursue faculty development designed to enhance their skills at least annually.
Encourage and support EMPA residents/fellows in scholarly activities.
II.D. Professional Development
The Sponsoring Institution must provide the opportunity for continuing professional development of the program faculty by supporting the development of the clinical, teaching, scholarly and administrative skills/abilities required for their role in the program.
Professional development involves remaining current with clinical and academic skills and developing new skills needed for position responsibilities. The types of opportunities supported by institutions vary and may include funding to attend continuing education conferences, non-vacation time to attend professional organizational meetings, funding to attend professional organizational meetings, time for research/scholarly activities, time to pursue advanced degree and/or tuition remission for an advanced degree, payment of dues and fees related to certification maintenance and/or time needed for review and study.
II.E. Other EMPA Postgraduate Program Personnel
The institution and the EMPA postgraduate program must jointly ensure the availability of all necessary professional, technical, and clerical personnel for the effective administration of the program.
A designated Program Coordinator is recommended with an adequate Full Time Equivalent (FTE) to meet the needs of the program, faculty, and EMPA residents/fellows.
An FTE of 0.2 or above is recommended.
II.F. Resources
The institution and the EMPA postgraduate program must jointly ensure the availability of adequate resources for EMPA postgraduate education, as defined in the emergency medicine EMPA postgraduate program requirements.
At every site in which the emergency department provides EMPA postgraduate education, the following must be provided:
Adequate space for patient care.
Space for clinical support services.
Diagnostic imaging completed and results available on a timely basis, especially those required on a STAT basis.
Laboratory studies completed and results available on a timely basis, especially those required on a STAT basis.
Office space for the EMPA postgraduate program director, core faculty members, and EMPA residents/fellows.
Instructional space.
Information systems.
Appropriate security services and systems to ensure a safe working environment.
Clinical support services must include nursing, clerical, intravenous, electrocardiogram (EKG), respiratory therapy, messenger/transporter, and phlebotomy, and must be available on a 24- hour basis.
Office space for program coordinators and additional support personnel must be provided at the primary clinical site.
Each clinical site must provide timely consultation from services based on a patient's acuity.
If any clinical services are not available for consultation or admission, each clinical site must have a written protocol for provision of these services elsewhere.
Each clinical site must ensure timely consultation decisions by a provider from admitting and consulting services with decision-making authority.
The patient population must include patients of all ages and genders as well as patients with a wide variety of clinical problems.
The primary clinical site to which EMPA residents/fellows rotate must have at least 30,000 emergency department visits annually.
The primary clinical site should have a significant number of critically ill or critically injured patients constituting at least three percent or 1,200 (whichever is greater) of the emergency department patients per year.
EMPA residents/fellows must be provided with prompt, reliable systems for communication and interaction with supervisory physicians.
The program, in partnership with its Sponsoring Institution, must ensure healthy and safe learning and working environments that promote resident well-being and provide for:
Access to food while on duty.
Safe, quiet, clean, and private sleep/rest facilities available and accessible with close proximity appropriate for safe patient care.
Clean and private facilities for lactation that have refrigeration capabilities with proximity appropriate for patient care.
Security and safety measures appropriate to the participating site.
Accommodations for residents/fellows with disabilities consistent with the Sponsoring Institution's policy.
The program's educational and clinical resources must be adequate to support the number of residents/fellows appointed to the program.
II.G. Medical Information Access
EMPA residents/fellows must have ready access to specialty-specific and other appropriate reference material in print or electronic format. Electronic medical literature databases with search capabilities should be available.
III. Resident Appointments
III.A. Eligibility Requirements
An applicant must meet the following qualifications to be eligible for appointment to EMPA postgraduate education program:
Graduate from an ARC-PA accredited entry-level physician assistant program.
Be eligible for licensure as a physician assistant in the applicable state.
III.B. Operations for Fair Practices and Admissions
The program, program faculty and EMPA residents/fellows must comply with applicable state PA practice legislation and regulations.
Announcements and advertising must accurately reflect the program offered.
All personnel and program policies must be consistent with federal and state statutes, rules and regulations.
The program must clearly define and publish the admission requirements and practices upon which admissions decisions are made.
The program must provide notification of acceptance to potential residents/fellows according to its published practice/timeline and include the notification of acceptance and the written conditions of appointment.
Applicants being considered for acceptance into the program must be informed in writing or by electronic means of the terms, conditions and benefits of appointment, to include:
PA trainee responsibilities,
duration of appointment and conditions for reappointment,
available financial support,
policies about paid time off (such as vacation, sick, leave of absence, professional development),
policies about parental, sick and other leaves of absence,
professional liability insurance,
hospitalization, health, disability and other insurance provided for PA trainees and their families, and
conditions under which living quarters, meals, laundry services are to be provided, if applicable.
The following must be defined, published, and readily available to prospective and enrolled EMPA residents/fellows:
ARC-PA accreditation status,
policies and practices that favor specific groups of applicants in the admissions process, c) program eligibility requirements,
policies regarding advanced placement,
policies related to required duty hours,
policies related to instructional faculty supervision of resident/fellows,
required technical standards,
all required curricular components,
academic credit offered by the program, if applicable,
estimates of all costs related to the program which may be incurred by the residents/fellows,
policies and procedures for refunds of tuition and fees, if applicable,
policies regarding residents/fellows moonlighting or outside work during the program,
policies related to remuneration and benefits,
policies addressing reduction in size or closure of a clinical postgraduate PA program, and how residents/fellows would be assisted in completing their education in such instances, and
defined training duties and weekly time expectations.
The following must be defined, published, and readily available to enrolled EMPA residents/fellows:
required academic standards for progression in the program,
policies and procedures for resident/fellow withdrawal from the program,
policies and procedures for resident/fellow dismissal from the program,
policies and procedures for resident fellow grievances,
policies describing how resident/fellow impairment, including that due to substance abuse, will be handled, and
policies covering sexual and other forms of harassment.
Grievance and due process policies and procedures must address:
academic or other disciplinary actions taken against residents/fellows that could result in dismissal, nonrenewal of resident/fellow's agreement or other actions that could significantly threaten a resident/fellow's intended career development,
adjudication of resident/fellow's complaints and grievances related to the work environment or issues related to the program or program faculty.
Policies and procedures for processing resident/fellow grievances must be defined, published, and readily available to program faculty.
Residents/fellows must not be required or expected to perform non-patient related clerical or administrative work for the program that is not a component of the curriculum.
Resident/fellows must not have access to the records or other confidential information about other resident/fellows or program faculty.
III.C. Number of EMPA Residents/Fellows
The EMPA postgraduate program's educational resources must be adequate to support the number of EMPA residents/fellows appointed to the program.
III.D. Resident/Fellow Transfers
The program must obtain verification of previous educational experiences and a summative competency-based performance evaluation prior to acceptance of a transferring resident/fellow.
The sponsoring institution must be responsible for teaching out currently matriculated PA residents/fellows in accordance with the institution's regional accreditor or state and/or federal law and in compliance with these standards in the event of program closure.
IV. Educational Program
IV.A. Curriculum Components
The program must be responsible for the selection of clinical sites to which the EMPA residents/fellows will be assigned for clinical experiences to ensure that sites and preceptors meet program expectations for learning outcomes and performance evaluation measures.
The program must assure that the volume and variety of clinical experiences provides for a sufficient number and distribution of appropriate experiences/cases for each EMPA resident/fellow in the program to meet defined program expected learning outcomes.
The program must not require that EMPA residents/fellows provide or solicit their own clinical sites or preceptors for program-required clinical experiences. The program must coordinate clinical sites and preceptors for program required clinical experiences to meet expected learning outcomes
The curriculum must contain the following educational components:
Overall educational goals for the EMPA postgraduate program, consistent with the Sponsoring Institutions' mission, the needs of the community it serves, and the desired capabilities of its graduates.
The program's aims must be made available to program applicants, EMPA residents/fellows and faculty.
For each didactic course and clinical experience, the program must provide each EMPA resident/fellow with a written syllabus that includes instructional objectives to guide resident/fellow acquisition of learning outcomes and required competencies.
Competency-based goals and objectives for each assignment at each educational level, which the EMPA postgraduate program must distribute to EMPA residents/fellows and faculty at least annually, in either written or electronic form.
Regularly scheduled didactic sessions.
Didactic experiences should include administrative seminars, journal review, presentations based on the defined curriculum, morbidity and mortality conferences, and research seminars.
Educational methods should include problem-based learning, evidence-based learning, and computer-based instruction.
The majority of didactic experiences must occur at the primary clinical site.
There must be an average of at least four (4) hours per week of planned didactic experiences developed by the program's faculty members.
Individualized interactive instruction must not exceed 20 percent of the planned didactic experiences.
Didactic experiences should be supervised by program and instructional faculty members.
EMPA residents/fellows must actively participate, on average, in at least 70 percent of the planned didactic experiences offered.
All planned didactic experiences must have an evaluative component to measure EMPA resident/fellow participation and educational effectiveness.
Delineation of EMPA resident/fellow responsibilities for patient care, progressive responsibility for patient management, and supervision of EMPA residents/fellows over the continuum of the program.
Curriculum should include components specifically covering the following topics:
Providing medical care to patients from diverse populations
Addressing disparities in health status from diverse racial, ethnic, and cultural background
Principles of quality improvement and patient safety
Incorporating interprofessional teamwork into practice
Performance improvement methods used by healthcare organizations focused on improving healthcare outcomes
Principles and practice of medical ethics
Evolving biomedical and clinical sciences and the application of this knowledge to patient care
Evidence-based medicine principles to allow EMPA residents/fellows to search, interpret, and evaluate medical literature relevant to the practice of emergency medicine
IV.B. Educational Competencies
The EMPA postgraduate program must integrate the following ACGME competencies into the curriculum:
Patient Care and Procedural Skills
EMPA residents/fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. EMPA residents/fellows must demonstrate proficiency in:
Synthesizing essential data necessary for the correct management of a patient with multiple chronic medical problems and, when appropriate, comparing with a prior medical record and identifying significant differences between the current presentation and past presentation.
Generating an appropriate differential diagnosis.
Applying the results of diagnostic testing based on the probability of disease and the likelihood of test results altering management.
Narrowing and prioritizing the list of weighted differential diagnoses to determine appropriate management based on all of the available data.
Implementing an effective patient management plan.
Selecting and prescribing appropriate pharmaceutical agents based upon relevant considerations, such as: allergies; clinical guidelines; intended effect; financial considerations; institutional policies; mechanism of action; patient preferences; possible adverse effects; and potential drug-food and drug-drug interactions; and effectively combining agents and monitoring and intervening in the advent of adverse effects in the emergency department.
Progressing along a continuum of managing a single patient, to managing multiple patients and resources efficiently within the emergency department.
Providing health care services aimed at preventing health problems or maintaining health.
Working with health care professionals to provide patient-focused care.
Identifying life-threatening conditions and the most likely diagnosis, synthesizing acquired patient data, and identifying how and when to access current pertinent medical information.
Establishing and implementing a comprehensive disposition plan that uses appropriate consultation resources, patient education regarding diagnosis, treatment plan, medications, and time and location specific disposition instructions.
Re-evaluating patients undergoing emergency department observation (and monitoring) and using appropriate data and resources, and determining the differential diagnosis, treatment plan, and disposition.
Additionally, EMPA residents/fellows must be able to competently perform all medical, diagnostic and surgical procedures considered essential for the area of practice. EMPA residents/fellows must demonstrate proficiency in:
Performing diagnostic and therapeutic procedures and emergency stabilization.
Managing critically ill and injured patients who present to the emergency department, prioritizing critical initial stabilization action, mobilizing hospital support services in the resuscitation of critically ill or injured patients and reassessing after a stabilizing intervention.
Properly sequencing critical actions for patient care and generating a differential diagnosis for an undifferentiated patient.
Mobilizing and managing necessary personnel and other hospital resources to meet critical needs of multiple patients.
Performing invasive procedures, monitoring unstable patients, and directing major resuscitations of all types on all age groups.
Must perform indicated procedures on all appropriate patients, including those who are uncooperative, at the extremes of age, hemodynamically unstable and who have multiple comorbidities, poorly defined anatomy at high risk for pain or procedural complications, or require sedation, and take the steps to avoid potential complications; and recognize the outcome and/or complications resulting from the procedures.
Must demonstrate competence in performing the following key index procedures:
Adult medical resuscitation
Adult trauma resuscitation
EMPA residents/fellows must provide safe acute pain management, anesthesia, and procedural sedation to patients of all ages regardless of the clinical situation.
Chest tubes
Dislocation reduction
Emergency department bedside ultrasound - EMPA residents/fellows must use ultrasound for the bedside diagnostic evaluation of emergency medical conditions and diagnoses, resuscitation of the acutely ill or injured patient, and procedural guidance.
Intubations
Lumbar puncture
Pediatric medical resuscitation
Pediatric trauma resuscitation
Pericardiocentesis
Vaginal delivery
Vascular access - Must be able to obtain vascular access in patients of all ages regardless of clinical situation.
Wound management - Must be able to appropriately manage wounds in patient of all ages regardless of the clinical situation.
EMPA residents/fellows must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care.
EMPA residents/fellows:
Must demonstrate appropriate medical knowledge in the care of emergency medicine patients.
The EMPA postgraduate programs are expected to follow the American Board of Emergency Medicine (ABEM) Model of the Clinical Practice in Emergency Medicine. It should prepare the physician assistant to manage critical, emergent, and lower acuity patients within the emergency setting.
Must demonstrate knowledge of the scientific method of problem solving, evidence-based decision-making, a commitment to lifelong learning, and an attitude of caring derived from humanistic and professional values.
Practice-based Learning and Improvement
EMPA residents/fellows must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.
EMPA residents/fellows are expected to develop skills and habits to be able to meet the following goals:
Identify strengths, deficiencies, and limits in one's knowledge and expertise.
Set learning and improvement goals.
Identify and perform appropriate learning activities.
Systematically analyze practice using quality improvement methods and implement changes with the goal of practice improvement.
Incorporate formative evaluation feedback into daily practice.
Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems.
Use information technology to optimize learning and improve patient care.
Participate in the education of patients, families, students, EMPA residents/fellows and other health professionals.
Apply knowledge of study design and statistical methods to critically appraise the medical literature.
Interpersonal and Communication Skills
EMPA residents/fellows must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.
EMPA residents/fellows are expected to:
Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds.
Communicate effectively with physicians, other health professionals, and health related agencies.
Work effectively as a member or leader of a health care team or other professional group.
Educate patients families students, residents and other health professionals.
Act in a consultative role to other physicians and health professionals.
Maintain comprehensive, timely, and legible medical records, if applicable;
Communicate sensitive issues or unexpected outcomes, including:
Diagnostic findings
End-of-life issues and death
Lead patient care teams, ensuring effective communication and mutual respect among team members.
EMPA residents/fellows must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
EMPA residents/fellows are expected to demonstrate:
Compassion, integrity, and respect for others.
Responsiveness to patient needs that supersedes self-interest.
Respect for patient privacy and autonomy.
Accountability to patients, society and the profession.
Respect and responsiveness to a diverse patient population., including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
Ability to recognize and develop a plan for one's own personal and professional wellbeing.
Appropriately disclosing and addressing conflict or duality of interest.
Systems-based Practice
EMPA residents/fellows must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.
Work effectively in various health care delivery settings and systems relevant to their clinical specialty.
Coordinate patient care within the healthcare system relevant to their clinical specialty.
Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate.
Advocate for quality patient care and optimal patient care systems.
Work in interprofessional teams to enhance patient safety and improve patient care quality.
Participate in identifying system errors and implementing potential systems solutions.
Participate in performance improvement to optimize self-learning, emergency department function, and patient safety; and,
Use technology to accomplish and document safe health care delivery.
Advocate for patients within the health care system to achieve the patient's and family's care goals, including, when appropriate, end-of-life goals.
IV.C. Curriculum Organization and EMPA Resident/Fellow Experiences
The curriculum must include:
Emergency medicine specific training should encompass a minimum 1,500 hours and at least 50% of the total time in the EMPA postgraduate program (i.e., if the program is 18-months in length, EM specific training should include 1500 hours and at least nine (9) months of EM specific clinical experiences).
Dedicated critical care experiences, including critical care of infants and children. EMPA residents/fellows should treat a significant number of the critically ill or critically injured patients; approximating at least one month or 160 hours of critical care experience overall. These experiences can occur within the emergency department or on an off-service rotation.
15% of all emergency department encounters dedicated to the care of pediatric patients less than 18 years of age in the pediatric emergency department or other pediatric settings.
EMPA residents/fellows should treat a significant number of critically ill or critically injured patients at participating sites.
Each EMPA resident/fellow must maintain, in an accurate and timely manner, a record of all major resuscitations and procedures performed throughout the entire educational program.
The record must document each procedure type, adult or pediatric patient, and circumstances of each procedure (live or simulation).
Only one EMPA resident/fellow must be credited with the direction of each resuscitation and the performance of each procedure.
The EMPA residents/fellows must have significant direct patient care experiences specific to the specialties of orthopedics and surgery. Each of these experiences should approximate at least one month or 160 hours overall during the EMPA postgraduate program. These experiences can occur within the emergency department or on an off-service rotation.
EMPA residents/fellows should have experience in emergency medical services (EMS), emergency preparedness, and disaster management.
IV.D. EMPA Resident/Fellow Scholarly Activities
The curriculum must advance EMPA residents/fellows' knowledge of the basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.
EMPA residents/fellows should have the opportunity to participate in scholarly activity.
V. Evaluation
V.A. EMPA Resident/Fellow Evaluation
Postgraduate training programs should consider establishing a Clinical Competency Committee4 to systematically evaluate EMPA resident/fellow performance and progression. The EMPA program director may appoint the members of a Clinical Competency Committee and must be included in the committee or advised of the results of their evaluations. At a minimum the Clinical Competency Committee must be composed of three members of the program or institutional faculty. Others eligible for appointment to the committee include non-physician members of the health care team. There must be a written description of the responsibilities of the Clinical Competency Committee.
The Clinical Competency Committee or the EMPA program director should:
Review all EMPA resident/fellow evaluations semi-annually.
Evaluate each individual EMPA resident/fellow's progress, including promotion, remediation, and dismissal.
V.B. Formative Evaluation
The faculty must evaluate EMPA resident/fellow performance in a timely manner during each rotation or similar educational assignment and document this evaluation at completion of the assignment.
The EMPA postgraduate program must:
Provide objective assessments of competence in patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice based on the specialty-specific milestones.
Use multiple evaluators (e.g., faculty, peers, patients, self, and other professional staff).
Document progressive EMPA resident/fellow performance improvement appropriate to educational level.
Develop defined thresholds of expected competencies for EMPA residents/fellows at regular intervals during the course of the postgraduate program that assists program faculty in determining when a remediation plan is necessary for residents/fellows
Provide each EMPA resident/fellow with documented semiannual evaluation of performance with feedback.
The EMPA program director must verify each EMPA resident's/fellow's records of major resuscitations and procedures as part of the semiannual evaluation.
The evaluations of EMPA resident/fellow performance must be accessible for review by the resident/fellow, in accordance with institutional policy.
At least semi-annually, each EMPA resident's/fellow's competency in procedures and resuscitations must be formally evaluated by the EMPA program director.
A plan to remedy deficiencies must be in writing and on file.
Progress and improvement must be monitored at a minimum of every month if a EMPA resident/fellow has been identified as needing a remediation plan.
V.C. Summative Evaluation
The EMPA postgraduate milestones must be used as one of the tools to ensure EMPA residents/fellows are able to practice core professional activities upon completion of the EMPA postgraduate program.
The EMPA program director must provide a summative evaluation for each EMPA resident/fellow upon completion of the program.
This evaluation must:
Become part of the EMPA resident's/fellow's permanent record maintained by the institution and must be accessible for review by the resident in accordance with institutional policy.
Document the EMPA resident's/fellow's performance during the final period of education.
Verify that the EMPA resident/fellow has demonstrated sufficient competence to enter practice.
V.D. Faculty Evaluation
At least annually, the EMPA postgraduate program must evaluate program and instructional faculty performance as it relates to the educational program.
These evaluations should include a review of the faculty's clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities.
Faculty member evaluations must also include administrative and interpersonal skills, quality of feedback and mentoring for EMPA residents/fellows, and participation in and contributions to EMPA resident/fellow conferences.
This evaluation must include at least annual written confidential evaluations by the EMPA residents/fellows.
Faculty members must receive feedback on their evaluations at least annually.
Results of the faculty educational evaluations should be incorporated into program-wide faculty development plans.
V.E. Clinical Site Evaluation
The program must define and maintain consistent and effective processes for the initial and ongoing evaluation of all sites and preceptors used for PA trainees' clinical practice experiences.
The program should establish criteria by which to initially evaluate new sites and preceptors as well as those that have an ongoing relationship with the program.
The program must assure and document that each clinical site provides the PA trainees access to the physical facilities, patient populations, and clinical supervision necessary to fulfill the program's learning outcomes.
V.F. EMPA Postgraduate Program Evaluation and Improvement
The EMPA program director should consider the appointment of the Program Evaluation Committee (PEC).
The Program Evaluation Committee:
Should be composed of the EMPA program director, the medical director and should include all current EMPA residents/fellows.
Should have a written description of its responsibilities.
Should participate actively in:
Planning, developing, implementing, and evaluating educational activities of the program.
Reviewing and making recommendations for revision of competency-based curriculum goals and objectives.
Reviewing the program annually using evaluations of faculty, EMPA residents/fellows, and others, as specified below.
The EMPA postgraduate program must document formal, systematic evaluation of the curriculum at least annually, and is responsible for rendering a written and Annual Program Evaluation (APE).
EMPA residents/fellows and faculty must have the opportunity to evaluate the EMPA
postgraduate program confidentially and in writing at least annually.
The EMPA postgraduate program must use the results of EMPA residents'/fellows' and faculty members' assessments of the program together with other program evaluation results to improve the program.
The EMPA postgraduate program must prepare a written plan of action to document initiatives to improve performance in one or more of the areas listed in section, as well as delineate how they will be measured and monitored.
The program must apply the results of its on-going self-assessment to the curriculum and other dimensions of the program including:
self-identified program strengths (identified from self-assessment),
program areas in need of improvement, opportunities for improvement and plans for each of the areas identified as needing improvement, and
program modifications that have been completed by the program since last review (identified from self-assessment).
VI. EMPA Resident/Fellow Learning and Working Environment
VI.A. Professionalism, Personal Responsibility, and Patient Safety
EMPA postgraduate programs and sponsoring institutions must educate EMPA residents/fellows and faculty members concerning the professional responsibilities of physician assistants to appear for duty appropriately rested and fit to provide the services required by their patients.
The EMPA postgraduate program must be committed to and responsible for promoting patient safety and EMPA resident/fellow well-being in a supportive educational environment.
The EMPA program director must ensure that EMPA residents/fellows are integrated and actively participate in interdisciplinary clinical quality improvement and patient safety programs.
The learning objectives of the EMPA postgraduate program must:
Be accomplished through an appropriate blend of supervised patient care responsibilities, clinical teaching, and didactic educational events.
Not be compromised by excessive reliance on EMPA residents/fellows to fulfill clerical duties or patient care tasks typically performed by other health care team members.
The EMPA program director and institution must ensure a culture of professionalism that supports patient safety and personal responsibility.
EMPA residents/fellows and faculty members must demonstrate an understanding and acceptance of their personal role in the following:
Assurance of the safety and welfare of patients entrusted to their care.
Provision of patient- and family-centered care.
Assurance of their fitness for duty.
Management of their time before, during, and after clinical assignments.
Recognition of impairment, including illness and fatigue, in themselves and in their peers.
Attention to lifelong learning.
The monitoring of their patient care performance improvement indicators.
Honest and accurate reporting of duty hours, patient outcomes, and clinical experience data.
All EMPA residents/fellows and faculty members must demonstrate responsiveness to patient needs that supersedes self-interest. They must recognize that under certain circumstances, the
best interests of the patient may be served by transitioning that patient's care to another qualified and rested provider.
VI.B. Transitions of Care
Programs must design clinical assignments to optimize transitions in patient care, including their safety, frequency, and structure.
Programs in partnership with their Sponsoring Institutions, must ensure and monitor effective, structured hand-over processes to facility both continuity of care and patient safety.
Programs must ensure that EMPA residents/fellows are competent in communicating with team members in hand-over process.
Programs and clinical sites must maintain and communicate schedules of attending physicians and residents/fellows currently responsible for care.
VI.C. Alertness Management/Fatigue Mitigation
Educate all faculty members and EMPA residents/fellows to recognize the signs of fatigue and sleep deprivation.
Educate all faculty members and EMPA residents/fellows in alertness management and fatigue mitigation processes.
Adopt fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, such as naps or back-up call schedules.
Each EMPA postgraduate program must have a process to ensure continuity of patient care in the event that a EMPA resident/fellow may be unable to perform his/her patient care duties.
The sponsoring institution must provide adequate sleep facilities and/or safe transportation options for EMPA residents/fellows who may be too fatigued to safely return home.
VI.D. Well-Being
The responsibility of the program, in partnership with the Sponsoring Institution, to address well-being must include:
Efforts to enhance the meaning that each EMPA resident/fellow finds in the experience of being a physician assistant, including protecting time with patients; minimizing clerical duties and patient care tasks typically performed by other health care team members; providing administrative support; promoting progressive autonomy and flexibility and enhancing professional relationships.
Attention to scheduling, work intensity, and work compression that impacts resident well-being.
Evaluating workplace safety data and addressing the safety of EMPA residents/fellows and faculty members.
Policies and programs that encourage optimal EMPA resident/fellow and faculty member well-being.
EMPA residents/fellows must be given the opportunity to attend medical, mental health, and dental appointments, including those scheduled during their working hours.
Attention to EMPA resident/fellow and faculty member burnout, depression, and substance abuse. The program, in partnership with the Sponsoring Institution, must educate faculty members and EMPA residents/fellows in identifying the symptoms of burnout, depression, and substance abuse, including means to assist those who experience these conditions. EMPA residents/fellows and faculty members must also be educated to recognize those symptoms in themselves and how to seek appropriate care.
The program, in partnership with its Sponsoring Intuition, must:
Encourage EMPA residents and faculty members to alert the program director or other designated personnel or programs when they are concerned that another member may be displaying signs of burnout, depression, substance abuse, suicidal ideation, or potential for violence.
Provide access to appropriate tools for self-screening.
Provide access to confidential, affordable mental health assessment, counseling, and treatment, including access to urgent and emergent 24 hours a day, seven days a week.
There are circumstances in which EMPA residents/fellows may be unable to attend work, including but not limited to fatigue, illness, family emergencies, and parental leave. Each program must allow an appropriate length of absence for residents unable to perform their patient care responsibilities.
The program must have policies and procedures in place to ensure coverage of patient care.
The policies must be implemented without fear of negative consequences for the EMPA resident/fellow who is or was unable to provide the clinical work.
VI.E. Supervision of EMPA Residents/Fellows
In the clinical learning environment, each patient must have an identifiable, appropriately credentialed and privileged attending physician (or licensed independent practitioner as approved by each Review Committee) who is ultimately responsible for that patient's care.
This information should be available to EMPA residents/fellows, faculty members, and
patients. EMPA residents/fellows and faculty members should inform patients of their respective roles in each patient's care.
The EMPA postgraduate program must demonstrate that the appropriate level of supervision is in place for all EMPA residents/fellows who care for patients.
Supervision may be exercised through a variety of methods. Some activities require the physical presence of the supervising faculty member. Portions of care provided by the EMPA resident/fellow can be adequately supervised by the immediate availability of the supervising faculty member or resident physician, either in the institution, or by means of telephonic and/or electronic modalities. In some circumstances, supervision may include post-hoc review of EMPA resident/fellow-delivered care with feedback as to the appropriateness of that care.
VI.F. Levels of Supervision
To ensure oversight of EMPA resident/fellow supervision and graded authority and responsibility, the EMPA postgraduate program must use the following classification of supervision:
Direct Supervision – the supervising physician is physically present with the EMPA resident/fellow and patient.
Indirect Supervision:
With direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care and is immediately available to provide Direct Supervision.
With direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care but is immediately available by means of telephonic and/or electronic modalities and is available to provide Direct Supervision.
Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
The EMPA program director and faculty members must assign the privilege of progressive authority and responsibility, conditional independence, and a supervisory role in patient care delegated to each EMPA resident/fellow.
The EMPA program director must evaluate each EMPA resident's/fellow's abilities based on specific criteria. When available, evaluation should be guided by specific national standards- based criteria.
Faculty members functioning as supervising physicians should delegate portions of care to EMPA residents/fellows, based on the needs of the patient and the skills of the EMPA residents/fellows.
EMPA postgraduate programs must set guidelines for circumstances and events in which EMPA residents/fellows must communicate with appropriate supervising faculty members.
Each resident/fellow must know the limits of their scope of authority, and the circumstances under which the resident/fellow is permitted to act with conditional independence.
Faculty supervision assignments should be of sufficient duration to assess the knowledge and skills of each EMPA resident/fellow and delegate to him/her the appropriate level of patient care authority and responsibility.
VI.G. Clinical Responsibilities
The clinical responsibilities for each EMPA resident/fellow must be based on level of training, patient safety, EMPA resident/fellow education, severity and complexity of patient illness/condition and available support services.
When EMPA residents/fellows are on emergency medicine rotations, the following standards apply:
While on duty in the emergency department, EMPA residents/fellows may not work longer than 12 continuous scheduled hours.
There must be at least an equivalent period of continuous time off between scheduled work periods.
An EMPA resident/fellow. should not work more than 60 scheduled hours per week seeing patients in the emergency department, and no more than 72 duty hours per week.
Duty hours comprise all clinical duty time and conferences, whether spent within or outside the EMPA postgraduate program, including all on-call hours.
Emergency medicine EMPA residents/fellows must have one day (24-hour period) free per each seven-day period. This cannot be averaged over a four-week period.
VI.H. Teamwork
EMPA residents/fellows must care for patients in an environment that maximizes effective communication. This must include the opportunity to work as a member of effective interprofessional teams that are appropriate to the delivery of care in the specialty and larger health system.
Interprofessional teams must be used to ensure effective and efficient communication for appropriate patient care for emergency medicine department admissions, transfers, and discharges.
VI.I. EMPA Resident/Fellow Duty Hours
Maximum Hours of Clinical and Educational Work per Week
Clinical and educational work hours must be limited to no more than 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities, clinical work done from home and all moonlighting.
Moonlighting must not interfere with the ability of the EMPA resident/fellow to achieve the goals and objectives of the educational program and must not interfere with the residents'/fellows' fitness for work nor compromise patient safety.
Mandatory Time Free of Clinical Work and Education
EMPA residents/fellows should have 10 hours, but must have eight hours, free of duty between scheduled duty periods.
EMPA residents/fellows must have at least 14 hours free of clinical work and education after 24 hours of in-house call.
EMPA residents/fellows must be scheduled for a minimum of one day free of duty every week (when averaged over four weeks). At-home call cannot be assigned on these free days.
Maximum Clinical Work and Education Period Length
Clinical and educational work periods for residents/fellows must not exceed 24 hours of continuous scheduled clinical assignments.
It is essential for patient safety and EMPA resident/fellow education that effective transitions in care occur. EMPA residents/fellows may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours.
Additional patient care responsibilities must not be assigned to a resident/fellow during this time.
In unusual circumstances, EMPA residents/fellows, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family.
In-House Night Float
Night float must occur within the context of the 80-hour and one-day-off-in-seven requirements.
Maximum In-House On-Call Frequency
EMPA residents/fellows must be scheduled for in-house call no more frequently than every- third night (when averaged over a four-week period).
At-Home Call
Time spent on patient care activities by EMPA residents/fellows on at-home call must count towards the 80-hour maximum weekly hour limit. The frequency of at-home call is not subject to the every-third night limitation but must satisfy the requirement for one-day-in-seven free of duty, when averaged over four weeks.
At-home call must not be so frequent or taxing as to preclude rest or reasonable personal time for each EMPA resident/fellow.
Residents are permitted to return to the hospital while on at-home call to provide direct care for new or established patients. These hours of inpatient care must be included in the 80-hour maximum weekly limit.
Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Graduate Medical Education in Emergency Medicine. 2021. Accessed: 7/22/2021
Accreditation Review Commission on Education for the Physician Assistant, Inc. Accreditation Standards for Clinical Postgraduate PA Programs. 2019. Accessed: 7/22/2021
Counselman FL, Babu K, Edens MA, et al. The 2016 Model of the Clinical Practice of Emergency Medicine. J Emerg Med. 2017;52(6):846-849.
Ekpenyong A, Padmore JS, Hauer KE. The Purpose, Structure, and Process of Clinical Competency Committees: Guidance for Members and Program Directors. J Grad Med Educ. 2021;13(2 Suppl):45-50.


text:
Wilful Blindness
Is ignorance a choice? If so, who does it protect?
Issue 46, 28th February 2016
Margaret Heffernan
| International businesswoman, CEO and Financial Times' best-selling author of Women on Top.
Read time: approx. 2 mins
Are you the sum total of your experiences – or a sum total of your memories? The fact that the two are so wildly different isn't only because, over time, memories fade. It is also because we may not fully experience what we see in front of us at the time.
In my book, Wilful Blindness, I was intrigued by the common human experience in which we ignore crucial information, people or events that stare us in the face. Albert Speer, Hitler's favourite architect and, later on, the man responsible for supplying the army with manpower, weapons and material, famously could not remember what he had known of Hitler's final solution. He wasn't sure whether he'd been at the Wannsee conference or, if he had, how long he had stayed. And this was not because he believed himself innocent – he pleaded guilty at Nuremberg – but because, even under intense and sustained interrogation by Gitta Sereny, he simply could not remember.
Many people believed Speer lied. But Sereny considered Speer's experience. He did know, she thought – but only enough to ensure that he looked away. After all, she explained, you have to know it's bad to make the choice to look in the other direction.
In essence, Speer could have been editing his experience in real time, in order to preserve and protect his self esteem and his love for the Fuhrer, which was a cornerstone of his fragile identity. And although most of us don't readily identify with Speer, we do adopt similar strategies. We may carefully ignore, minimise or trivialise information that would challenge our sense of well-being or security. The partners of child abusers frequently do so; partners in adulterous marriages frequently do the same: why is the wife always the last to know? Not because the information isn't visible but because it is visible enough for us to look in the other direction.
For Speer, this was a legal and ethical minefield and I think it is for the rest of us too. When we know something is going wrong – in our families, communities or neighbourhoods – it can feel far safer not to look closely. So we have the experience (knowing it's dangerous) but not the memory (because we chose not to look). Under the law of wilful blindness, you are deemed guilty because your ignorance was a choice. But in daily life, it can be a means of self-preservation. But it does beg the question: what is the self that is being preserved?
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redpajama_set_name: RedPajamaCommonCrawl


text:
Q: Google Places API Error, but returns success I was working with the google places autocomplete api when I noticed certain address would return error while others worked perfectly. Even on error however, the error callback would show the error message had an error code : 0 and status of Success. I'm using the google places autocomplete Fragment.
The error printed out : I/DESTINATION: An error occurred: SUCCESS
private void setDestinationAutocompleteCallbacks() {
    DestinationautocompleteFragment.setOnPlaceSelectedListener(new PlaceSelectionListener() {
      @Override
      public void onPlaceSelected(Place place) {
        LatLng destinationLatLng = place.getLatLng();
        OriginAndDestinationLocations[1] = destinationLatLng;

        mMap.addMarker(new MarkerOptions()
            .position(destinationLatLng)
            .title(getString(R.string.destinationLocation))
            .snippet(place.getAddress().toString()))
            .showInfoWindow();

        if (OriginAndDestinationLocations[0] != null) {
          adjustZoom();
        } else {
          mMap.animateCamera(CameraUpdateFactory.newLatLngZoom(destinationLatLng, Zoom), 2000, null);
        }
      }

      @Override
      public void onError(Status status) {
        Log.i(DESTINATIONTAG, "An error occurred: " + status.getStatusMessage());
      }
    });
}

A: check your manifest
<meta-data android:name="com.google.android.geo.API_KEY" android:value="YOUR_API_KEY"/>

You may be use same google api key for more than one Application in android. so remove the google api key from other application.
   Another way is generate new api key for current application.

redpajama_set_name: RedPajamaStackExchange


Last night I met Gordon, and some other friends in a Meet-Up group we're in up on Mt. Tamilpias in Marin County to photograph the sunset, and then image the night sky.
There was an Astrology lecture in the Amphitheater so the park was open much later than it normally is which allowed us to stay late. YEAH! Normally the park closes a bit after sunset.
This is 74 frames stacked in PS CC 2015.5.
4 planes, and one shooting star flew through the sky while I was imaging. I didn't see the shooting star at the time as I was looking away helping a friend with her settings and intervalometer. I was thrilled to see I caught it on film though.
It was a lovely night, not windy, or cold, and the company was great!
Interesting article, can i reblog this one?
Thank you so much Vikas! I'd be thrilled to have you reblog my image and article.
Outstanding images, I have never done any night photos like this, beautifully done!
Oh my, thank you so much John!
I had the good fortune of being in the same Meet-Up group with Steven Christenson who taught me how to shoot star trails back in the Fall of 2009. I've been hooked on this type of photography since!
You certainly are out in the dark skies enough to make some fantastic images!
Thank you so, so much Cheryl! I'm thrilled that you love it! I haven't been able to get out much this year to photograph the night sky, and I've missed it! It was so good to be out under the stars with good friends.
It must have been a gorgeous night. I love being under the stars. The only real moments the entire world can feel unified.
Deborah, this is amazing! I love it!!
What a great image! As usual, your composition was spot-on!
Yes, Spring is on its way, indeed.
All is well. The little ones are just growing up too fast!
Don't they though! My little guy will be 4 right before Christmas!
I'm happy to hear all is well with you and the family!
Thank you so much Myriam! Yes, PS is the abbreviation for Photoshop. I get to lazy to type it out.
Yes, the diagonal like red streaks on the left side are the airplanes flying through the airspace I was photographing. Were you able to spot the Shooting Star? I'm addicted to night imaging.
This is really cool Deborah!
Magical Mt. Tamilpias! Amazing image!
Thank you so much Katie for the compliment and comment!
These stacked photos are always so interesting! What was the time period over which these photos were shot?
This question might sound like of dumb, but I'm assuming the centre of the star swirl is the point where your camera was focused?
Thank you Joanne! No not dumb! I shot this sequence for just under an hour.
Yes, my focus point was Polaris the North Star.
As Earth spins on its axis the two celestial poles North and South remain fixed, all other points/stars rotate around them completing one circuit per day.
If you photograph a series of star images facing East, West, or South here in North America you get angled streaks like meteors.
That's a simple explanation. Hope it helps you understand how I made it a bit more.
it's like falling into the space time continuum!!
🙂 It feels that way to me sometimes too.
Thank you so much Judy for the lovely comment!
That is so cool, Deborah. I feel motion just looking at that. I love the color.
Thank you so much Geo!!


text:
Items tagged with Google-Maps
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Google Updates Mobile Maps For Android with Enhanced Navigation
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Google Maps Now Empowered with Live Public Transit Information
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Google Maps Updated with Glorious Street Views of The Grand Canyon
Google Maps has changed the way we navigate the world, whether it's planning out a trip (or adjusting on the fly), using your smartphone to figure out where the dang ballet studio is, having a Street View look at the town you're about to move to, and so on, and the service just keeps getting better. This... Read more...
by Seth Colaner - Sat, Oct 27, 2012
Google Adds Geographic Terrain Imagery To Maps
Google continues to improve upon its Google Maps; earlier this week it announced that Googlers were mapping the Grand Canyon with backpack-mounted cameras, and now the company has added layers to its maps that show the terrain, color gradation indicating vegetation, and additional labels that show natural land formations. This is all an effort... Read more...
Google Street View Team Treks The Grand Canyon For Mapping
The value of Google Maps has been highlighted in recent weeks after Apple launched its own maps app, soliciting a collective "boo" from most users and generating a slew of (somewhat unfairly over-the-top) Internet jokes and memes, but Google is not content to sit on its laurels. The company is taking mapping just about everywhere... Read more...
Street View Comes to Google Maps Web App on iOS
Users frustrated with Apple's built-in maps app in iOS 6 have another option: use Google Maps in the Safari mobile web browser. Today, Google announced that its the mobile web-based version of its maps service was getting even better with the addition of Street View on mobile web browsers. Using Street View on your mobile device is the... Read more...
by Seth Colaner - Mon, Sep 17, 2012
Amazon Edges Further from Google Reliance with Nokia-Licensed Amazon Maps API Beta
We knew that Amazon was ditching Google Maps for its Kindle Fire tablets, but now it's official: Amazon announced today that it's Amazon Maps API is now in beta and ready for developers to migrate from the Google Maps API on Android. The two core features of Amazon's maps are Interactive Maps--so... Read more...
by Seth Colaner - Sun, Sep 02, 2012
Amazon Says No Thanks to Google, Teams with Nokia on Maps for Kindle Fire
According to Reuters, Amazon will be adding integrated mapping to the Kindle Fire by partnering with Nokia, which means that Google Maps won't be on yet another platform, Apple having ditched it with the iOS 6 release. Amazon is expected to announce a new round of Kindle Fires (and possibly other devices) at a... Read more...
Google Maps Goes 3D, Offline, and Offroad
We can't remember how we got around before Google Maps; scratch that, actually we do, but we try to forget, because the present technology is so much better, easier to use, and more powerful. Not content to sit on its laurels, though, Google announced some significant upgrades to Google Maps at an event in San Francisco. First off, Street... Read more...


text:
Q: How to bold certain text only in PDFsharp? I'm programming on VB.NET, and making use of the PDFsharp library to create PDF pages according to my program's needs. Now, I need to bold only certain parts of text, but I only know how to bold entire parts of it at once. How do I go about doing this?
Currently, the code I'm using to render words is as follows:
Dim graph As XGraphics = XGraphics.FromPdfPage(pdfPage)
graph.DrawString("Sample Text", New XFont("Arial", 12, FontStyle.Bold), New SolidBrush(Color.Black), New RectangleF(X, Y, 700, 30), New XStringFormat())

A: In your example above, if you wish to write "Sample Text" with the word "Text" in bold, perform the following;

*

*Include the MigraDoc+PDFsharp NuGet package, as mentioned by previous reply.

*Replace the graph.DrawString line with the following code (although this is C#, sorry) to render the text using a MigraDoc Paragraph instance, using your existing XGraphics graph instance from PDFsharp.
var document = new Document();
var section = document.AddSection();
var paragraph = section.AddParagraph();
paragraph.Format.Alignment = ParagraphAlignment.Left;
paragraph.Format.Font.Name = "Arial";
paragraph.Format.Font.Size = 12;

paragraph.AddText("Sample ");
paragraph.AddFormattedText("Text", TextFormat.Bold);

var docRenderer = new DocumentRenderer(document);
docRenderer.PrepareDocument();
docRenderer.RenderObject(graph, XUnit.FromPoint(X), XUnit.FromPoint(Y), XUnit.FromPoint(700), paragraph);

A: Invoke DrawString for the regular part, then invoke DrawString for the bold part, then invoke DrawString for the next regular part. Always give the correct position for each string.
You can look at the XTextFormatter class. It implements automatic linebreaks, but does not support mixing different font styles yet. It can get you started.
Pro tip: You can get MigraDoc and PDFsharp in one NuGet package. MigraDoc allows mixing in a single paragraph, handles linebreaks and pagebreaks automatically and also brings other benefits like page headers and footers.


text:
Sandy Sasso
» print
Sandy Eisenberg Sasso – The Writer
In the 1980s, while surveying children's religious literature to find good books for her own children and for the students she taught, she was disappointed. No one was taking children's innate spirituality seriously. In fact, most of what was written was limiting their imagination. So, she began writing about God and spirituality in ways that would both engage children and allow the ideas presented to grow with them. She was more interested in the questions and the conversation, than the answers. In 1992, her first children's book, God's Paintbrush, was published. It was an immediate success, selling over 100,000 copies. Many consider it a classic.
Subsequent children's books have also received national acclaim. Publisher's Weekly selected two of her books, But God Remembered and Noah's Wife; The Story of Na'amah, as Best Books of the Year. Abuelita's Secret Matzahs is the winner of the 2005 Sugarman Family Children's Book Award and the 2006 Best Books of Indiana Award. Rabbi Sasso is the 2004 recipient of the Helen Keating Ott Award for Outstanding Contribution to Children's Literature. And her latest children's book—The Shemah in the Mezuzah—won the 2012 National Jewish Book Award for Best Illustrated Children's Book.
Rabbi Sasso has also been a successful writer for adults. "It is my belief that difficult and complex ideas must be accessible to all, if we are to have an intelligent conversation about faith, meaning and purpose. What is required is not a simplification of ideas, but a simplification of language." Sasso's writings for adults appear in numerous collections and in her book Midrash – Reading the Bible with Question Marks. She reminds us; "I believe that opposites are best when matched, lover and power, justice and compassion, faith and doubt, seriousness and play. The Sacred is the "and" that brings those opposites into one harmonious whole."
© 2016. Illustrative rights, credits and thanks to Joani Rothenberg


text:
Approved cancer drug may help treat diabetes
September 16, 2013 ScienceBlog.com
A pair of studies by researchers at the Stanford University School of Medicine has identified a molecular pathway — a series of interaction among proteins — involved in the development of diabetes. Furthermore, they have found that a drug already approved for use in humans can regulate the pathway.
The findings will be published online Sept. 15 in two articles in Nature Medicine.
The studies, done in mice, identify a previously unexpected link between a low-oxygen condition called hypoxia and the ability of cells in the liver to respond to insulin. The drug, aflibercept (marketed as Eylea or Zaltrap), is used to treat metastatic colorectal cancer and a form of macular degeneration. Aflibercept is a member of a family of proteins that inhibit the vascular endothelial growth factor, or VEGF, pathway. It works by blocking the growth of the blood vessels into tumors and starving them of oxygen.
The lab of Calvin Kuo, MD, PhD, professor of medicine, identified a series of protein interactions that link VEGF inhibitors and blood glucose levels. "We were surprised to find that this drug currently used in patients for cancer treatment had beneficial effects on diabetes in laboratory mice and could, potentially, in humans," said Kuo, senior author of one of the Nature Medicine papers.
Amato Giaccia, PhD, the Jack, Lulu and Sam Willson Professor of Cancer Biology, is senior author of the other paper. "Proteins involved in this pathway could also be targeted for the development of new diabetes therapies," said Giaccia, who also is a professor and director of radiation oncology. His laboratory has identified a protein called PhD3 that could be a particularly attractive target.
The lead author of the Giaccia paper is Cullen Taniguchi MD, PhD, a radiation oncology resident at Stanford; former graduate students Kevin Wei, MD, PhD, and Lisa McGinnis, MD, PhD, and postdoctoral scholar Stephanie Piecewicz, PhD, are lead authors of the Kuo paper.
Together, the studies explain an observation made several years ago by Kuo and his lab members that VEGF inhibitors, such as aflibercept, could lower blood glucose levels in mice. There have been intriguing hints that these inhibitors could function in a similar way in humans, but human studies have not been formally conducted.
"Anecdotally, there have been reports that diabetic patients who have been prescribed VEGF inhibitors to treat their cancer are better able to control their diabetes," Kuo said.
The liver is commonly known as the organ responsible for removing toxins from our blood. But it also serves as the body's energy warehouse. After a meal, blood glucose levels rise and insulin triggers cells in the liver to squirrel away the glucose in long, branching chains of a substance called glycogen (imagine an ever-growing Lego structure, where each block is a glucose molecule). When we are asleep or fasting, the liver breaks down that Lego structure unit by unit to deliver glucose into the blood for cells to use as an energy source until the next meal.
When this process goes awry, blood glucose levels can become dangerously high. This can happen when the body either can't make insulin (in the case of type-1, or juvenile, diabetes) or when it can't respond appropriately to the insulin the body does make (type-2 diabetes).
The liver's critical function requires that most of its cells have ready access to blood, which carries both glucose and oxygen. Oxygen diffuses as a gradient outward from blood vessels; those cells that are more removed have less oxygen and can become hypoxic. Hypoxic cells naturally produce certain proteins to enable them to live and function under these more severe conditions.
Wei, McGinnis and Piecewicz, in Kuo's lab, found that one protein induced by hypoxia, HIF-2alpha, activates the expression of insulin receptor substrate 2. IRS2 enhances the ability of the cells to respond to insulin. Treatment of normal and diabetic laboratory mice with a variety of VEGF inhibitors, including aflibercept, causes regression of blood vessels and increases the number of hypoxic cells in the liver. As a result, HIF-2alpha levels increase, IRS2 expression rises and the animals become better able to tolerate increases in blood-glucose levels.
The researchers found that deletion of HIF-2alpha blocked the effect of the VEGF inhibitors, while liver-specific induction of HIF-2alpha expression also significantly improved the animals' glucose tolerance.
"Much work remains to translate these mouse studies to human patients, but it will be interesting to explore VEGF inhibitors or drugs that can stabilize HIF-2alpha, such as prolyl hydroxylase inhibitors, for diabetes treatment, possibly in combination with pre-existing therapies to minimize toxicities," Kuo said.
Taniguchi, in Giaccia's lab, focused on the biology of HIF-2alpha. He and his colleagues found that blocking the expression of a protein called Phd3 specifically taps into the pathway identified by the Kuo group, stabilizing the HIF-2alpha protein and prolonging its effect on IRS2 expression. Laboratory mice missing Phd3 are more sensitive to insulin and exhibit improved glucose tolerance.
The specificity of the effect of Phd3 on HIF-2alpha is important. Because it doesn't appear to regulate other proteins in the HIF family in the liver, it's possible a diabetes treatment could be designed that would avoid unwanted or dangerous side effects that could occur by blocking the production of a more broadly acting protein.
"Targeting the Phd3/HIF-2 pathway represents a new therapeutic approach for the treatment of diabetes with little toxicity," said Giaccia. "These studies indicate that Phd specific inhibitors, especially Phd3, should be more widely developed for clinical development."
Categories Health Tags Blood sugar, nature medicine, Stanford, stanford university school of medicine
Quantum entanglement only dependent upon area
Diminishing fear vicariously by watching others


text:
import os

from django.core.management.base import BaseCommand

from FRS.settings import BASE_DIR, DEFAULT_MU, DEFAULT_SIGMA
from TBAW.models import Team

class Command(BaseCommand):
    def handle(self, *args, **options):
        with open(os.path.join(BASE_DIR, 'logs\\elo\\elo_{}_{}.csv'.format(DEFAULT_MU, DEFAULT_SIGMA)), 'a+') as f:
            for t in Team.objects.exclude(elo_mu=1500.0).order_by('id'):
                f.write('{},{},{},{},{},{},{}\n'.format(t.team_number, t.rookie_year, t.match_wins_count,
                                                        t.match_losses_count, t.match_ties_count, t.elo_mu,
                                                        t.elo_sigma))

redpajama_set_name: RedPajamaGithub


text:
Who is Tessa Virtue husband? |
Tessa Virtue is a Canadian ice dancer and Olympic champion, the 2017 World Champion with her partner Scott Moir. They are the most decorated figure skaters in history of modern Olympics from which they have won five gold medals.
The "scott moir wedding pictures" is a famous Canadian figure skater. The "Tessa Virtue husband?" question is about her husband, Scott Moir.
Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress.
Born London, Ontario, Canada, May 17, 1989
Residence London, Ontario, Canada and Toronto, Ontario, Canada are both located in the province of Ontario.
Height 1.65 meters (5 ft 5 in)
Partner Moir, Scott
Similarly, you may ask, who is Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. marrying?
Moir, Scott sits with his ice dance partner Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress., right, and his fiancée Jackie Mascarin, left, during the ceremony for the unveiling of his Canada's Walk of Fame in Ilderton, Ont. on Aug. 7, 2019.
Is Tessa and Scott a couple, too? They aren't together, but Scott and Tessa don't seem to be in another relationship right now.
Also to know is, is Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. in a relationship?
Virtue and Moir claim that their relationship is purely platonic — and has always been, save for one childhood hiccup — to to the dismay of many admirers, particularly veteran Canadian fans who have followed them for years.
Did Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. marry Moir, Scott?
Very few engagement announcements stirred the souls of Canadians as that of figure skating ice dance champion Moir, Scott. That's because he isn't betrothed to his longtime skating partner, Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress.. Moir is engaged to his very first pairs partner: Jackie Mascarin.
Is Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. married?
Ex-colleague Moir, Scott
Is Tessa dating someone?
About Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress.'s boyfriend
Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. doesn't have a boyfriend right now.
How old is Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress.?
Thirty years (May 17, 1989)
Who is Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. boyfriend?
Ryan Semple is a writer and musician.
How tall is Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress.?
Is Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress.s family rich?
Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress., figure skater
Virtue has been skating with her pairs partner Moir, Scott since she was seven years old. Moir are a romantic couple. Among her sponsors are Adidas, Nivea and Visa, and various sources on the Web peg her net worth at around US$2-million.
What did Moir, Scott say to Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress.?
Canadian ice dancing stars Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. and Moir, Scott say they are "stepping away" from the sport. Their retirement was revealed late Tuesday night in a video message posted on their separate Twitter accounts.
Who is Moir, Scott engaged to?
What happened to Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. and Moir, Scott?
Canadians Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. and Moir, Scott, the most decorated Olympic figure skaters in history, announced their retirement late Tuesday. They're done competing in ice dance, and their upcoming Canadian tour will be their last together.
Does Moir, Scott have a girlfriend?
Scott had a girlfriend named Cassandra a while back, and on a reality show called Tessa & Scott, Virtue called their relationship "complicated" per Global News.
How many gold medals has Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. won?
They are the first figure skaters to win five career Olympic medals, having won gold in both the ice dance and team competitions. In 2016-17, Virtue and Moir had one of their finest seasons ever, skating unbeaten on their way to their third career world championship.
How old is Moir, Scott?
32 years old (September 2, 1987)
Tessa and Scott are from where?
Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. and Moir, Scott, (respectively, born May 17, 1989, London, Ontario, Canada; born September 2, 1987, London, Ontario, Canada), Canadian ice dancers who became the first North Americans to win the Olympic gold medal in ice dancing when they triumphed at the 2010 Olympic Winter Games in Vancouver.
Elvis Stojko's net worth is unknown.
Elvis Stojko's net worth ranges between $100,000 and $1 million.
Elvis Stojko is a 47-year-old Canadian figure skater with a net worth of $100,000 to $1 million.
Who is Jamie Sale's spouse?
Simpson, Craig
m. 2012
2005–2010 m.
Did Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. retire?
17th of September, 2019
Are Tessa and Scott no longer working?
Two-time Olympic champions Tessa Virtue is a well-known actress. is a well-known actress. is a well-known actress. and Moir, Scott are retiring. Genevieve Beauchemin looks back on their historic career. The ice dancing champions announced on social media that they will retire after 22 years together.
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