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Research consultation clinic: impetus towards facilitating primary care research
Research consultation clinic: impetus towards facilitating primary care research Tan, Ngiap; Tan, Yang; Kin, Patricia 2013-09-16 00:00:00 Background: In Singapore, SingHealth Polyclinics (SHP) is an accredited Family Medicine (FM) training centre which managed 1.8 million primary care patient-visits in 2012. To promote research in the institution, research consultation clinics (RCC) are being introduced in 2010 to enable free face-to-face consultation between experienced and novice researchers on specific research topics. Each RCC session allows about an hour or more for the SHP staff, medical undergraduates and general practitioners to seek advice and clarification on key research areas, ranging from research question refinement, study design and execution, data analysis, result presentation to publication. The consultants comprise of two FM researchers with postgraduate research qualification. Aim: This article aims to review the implementation of RCC from 2010 to 2012 and its impact on research activities and outcome indicators in the same period of time. Methods: The study comprised of two segments. Part I was a three-year retrospective review of the RCC administrative record. The total number of RCC sessions, hours utilised, participants' profiles, the number of research studies initiated by them and their research presentations at local and overseas scientific meetings/conferences were computed. Part 2 was an anonymous web-based questionnaire survey fielded to RCC participants to collect their feedback on the RCC service and their self-reported initiation and completion of research study after the RCC consultation. Results: The RCC sessions increased from 17 to 40 sessions, resulting in increment of 2 to 14 research presentations and from 2 to 6 initiations of new research studies per annum from 2010–2012. The response rate to the questionnaire survey was 70.3%, with the majority of multi-disciplinary respondents rated the RCC service to be accessible, adequate and were satisfied with its quality. Study design, data management and study execution were ranked as important areas of research for consultation. 79% of them had started a research project and 36% had completed their studies. Conclusions: The RCC is a feasible model to catalyse multi-disciplinary research in primary care institutions. Further study is needed to evaluate its relevance when research advances and novice researchers become experienced investigators to take on more complex projects. Keywords: Research, Consultation, Primary care * Correspondence: tan.ngiap.chuan@singhealth.com.sg Research Department, SingHealth Polyclinics Head Office, 167 Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore 150167, Singapore DUKE-NUS Graduate Medical School, 8 College Rd, Singapore 169857, Singapore © 2013 Tan et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 2 of 7 http://www.apfmj.com/content/12/1/4 Background and in the respective master degree programmes for A strong primary healthcare system is vital to improve community nurses and pharmacists who take on ad- the health of the general population and reduce the vanced professional training. healthcare burden to the nation [1,2]. Research in pri- Aside from training, mentorship appears to be pivotal mary care aims largely to seek better understanding of in moulding primary care practitioners into researchers. disease management in relation to the individuals, fam- Curtis P et al. reported that amongst Family Medicine ilies and the community, and to evaluate the effective- (FM) graduates who received the American National Re- ness and efficiency of healthcare practices and health search Service Awards, they were less successful in policies [3]. Beyond general practice and family medi- terms of research and publication output compared to cine, primary care research is multi-disciplinary, cove- fellow recipients such as internists and paediatricians ring community nursing and pharmacy, sociology, health [10]. The authors attributed the differences to a lack of service and policy research. As primary care supports protected time and sustained research mentorship for the base of the population pyramid and amidst a rapidly the family physicians. Likewise, in Israel, FM residents expanding global population, there is an urgency to scale trained under pro-research mentors were likely to be up primary care research to seek medical evidence to more intensely involved in research when they became prevent, cure, and care for diseases; to translate these family physicians [11]. evidences into regular clinical practice and to formu- A strong and increased level of commitment from pri- late policies to ensure universal equity of care [4]. mary care organisations is needed to provide support and However, primary care research faces challenges, even resources and to reduce barriers for family physicians to in resource-rich countries, due to limitations of research carry out research [12]. Hannaford P et al. showed that a capacity in general practice, inadequate research infra- modest investment of resources and support will create structure in primary care and poor provision of support substantial increases in both the quality and quantity of to individual general practitioners to conduct research. primary care research [13]. They recommended that this Saad H. Al-Abdullateef in a survey of general practi- investment should be targeted at both existing primary tioners in selected primary care centres in Saudi Arabia care professionals working in service settings in primary showed that while a majority expressed interest (66%) care and those in the academic departments in the univer- and planned to carry out research (74.2%), they cited sities [13]. Various funding models for primary care re- insufficient time (83.5%) and lack of support (58.8%) as search have since been developed and implemented in key barriers to research [5]. various countries, centred largely on channelling govern- Practice-based research networks (PBRNs) are groups ment funding via FM departments in universities in of practices networked together to undertake research Australia & the Netherlands, or via the Royal College of relevant to general practice and the local community's General Practitioners in Britain [14-16]. However how needs [6,7]. These PBRNs, often involving collaborations effective and efficient are these funding models in promo- between practitioners and academicians, can expand the ting primary care research and enhance research-related capacity and bandwidth of primary care physicians [8]. training for the general practitioners are seldom measured, Nonetheless, these PBRNs are largely medical, whist and its translation into actual research endeavours are nurses and other researchers tend to form their respec- rarely evaluated. A new model to expedite primary care tive research networks. Furthermore, a survey of a New research in terms of effective individual coaching and effi- York based PBRNs revealed that only 25% of the physi- cient application is urgently needed to empower the pri- cians had formal research training and 21% of them had mary care practitioners. clinical research certification [9]. Lack of time or com- Primary care research faces similar challenges in peting demands for time was the top ranked barrier Singapore, where infrastructure constraints and healthcare resources were hithertho barriers to its development [17]. (92%) in the survey, and 80% of the clinicians reported that their lack of appropriate training was a barrier [9]. However in recent years, despite the lack of dedicated Thus, participation in PBRNs may not adequately ad- research funding for primary care researchers from the local official research agencies, rapid development of aca- dress the specific research needs nor provide training for the individual primary care researchers; neither does it demic medicine in the local public healthcare institutions add impetus towards multi-disciplinary research in pri- resulted in unprecedented support for primary care re- search from primary healthcare organisations, such as mary care. Nevertheless, there are ample research related training SingHealth Polyclinics (SHP). The latter comprises a clus- opportunities that are available from the local academic ter of nine public primary care clinics or polyclinics in institutions to equip primary care professionals with Singapore, which is also a recognised FM training centre basic research skills. Basic research training is incorpo- accredited by the American College of General Medical rated in medical undergraduate education curriculum, Education. Whilst governance, policy and finance are Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 3 of 7 http://www.apfmj.com/content/12/1/4 centrally administered in SHP, the polyclinics operate at FM researchers within the institution with post-graduate various sites to serve the local communities in the south- qualifications in research. ern and eastern parts of Singapore using a common and Periodic evaluation of the service provided by RCC integrated electronic medical records system. Thus in from the participants is vital to ensure that this model of terms of primary care research, the institution can be research support remains relevant and its service caters regarded as a de-facto practice-based multi-disciplinary adequately to their needs. This study aims to determine research network. the level of satisfaction amongst the RCC participants in Novice researchers from SHP can seek seed funding terms of their perception of the accessibility of the ser- from SHP to support their approved research projects vice, adequacy of the duration of the consultation, effec- whilst established researchers are encouraged to vie for tiveness of the consultancy, the key research areas in competitive research grants from national research agen- which they seek consultation, and the outcomes of the cies. Whilst financial support to kick-start research for RCC consultation. these researchers is no longer a barrier, approval for seed funding is based on the evaluation of research proposals' Methods scientific merits and logistic considerations. Hence novice The evaluation of the RCC service comprises of two seg- researchers find it propitious to consult experienced re- ments. The first part was a retrospective review of the searchers for guidance in order to optimise their success RCC records from 2010–2012 to determine the short- rates in their seed funding or other grant applications. term accomplishments of past participants in terms of With the endorsement from senior management in SHP, their research study initiation and subsequent oral or pos- research consultation clinics (RCC) are established in May ter presentation at academic meetings and/or scientific 2010 to support budding FM researchers in the institution. conferences. "New study" is defined as study initiated Dedicated resources are channelled centrally from institu- within the respective calendar year with reference to its tion annual operating budget to set up the RCC service. date of approval from the institutional review board. The This caters to the opportunistic cost for the consultants, research presentations refer to investigators' presentations as well as the participants to meet at the RCC for free of their research findings at local or overseas scientific face-to-face consultations during clinic operating hours. It meetings or conferences which are approved by SHP. Both also provides for the seed funding for researchers to sup- outcomes were traced from the respective databases in the port the execution of their project. SHP Department of Research. Each RCC session allows at least an hour for any indi- The second segment was a questionnaire survey of the vidual or group of multi-disciplinary SHP staff to seek same cohort of participants. Each participant was invited advice and clarification on any issues pertaining to their to undertake a web-based questionnaire survey regar- research endeavours. During the consultation sessions, dless of the frequency of RCC participation. The sam- the topics covered include the various domains in re- pling frame comprised of participants who had utilised search, ranging from exploring research idea, definition the RCC service at least once and who had provided of research question, research method, project design, their email contact. The records show a list of 75 RCC application for ethics committee review, logistic plan- participants between January 2010 and December 2012, ning, data analysis and interpretation to results presenta- of which email addresses were provided by 64 of them. tion and publication. The participants can arrange for The questionnaire collected data on the participant's multiple consultations to clarify queries for their same study or repeat consultation for another study. 1. demographic profile such as age, gender, education The RCC sessions are taken up by SHP multi- status, staff category disciplinary staff, including doctors, nurses and phar- 2. views on accessibility of the service, macists who plan to commence research as part of their 3. quality of the consultancy, professional development or are pursuing advanced 4. ranking of key research domains for which they training programmes which incorporate research as sought consultation part of the curriculum. The service is also open to ex- 5. outcome measures of RCC in terms of initiation and ternal primary care researchers, including private ge- completion of their respective research projects neral practitioners, and medical students from the two local medical colleges, under the over-arching objective The questionnaire survey was anonymous to ensure of enhancing primary care research development and truthful responses from the participants. The investiga- foster research collaborations between different pri- tors notified the participants of the survey via their email mary healthcare providers in Singapore. This necessi- addresses. Second and third round of notices were deli- tates the increase of consultants from one to two to vered to the participants' email addresses to serve as re- manage the expanded RCC capacity. The consultants are minders to participate in the survey on the second and Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 4 of 7 http://www.apfmj.com/content/12/1/4 third week respectively after the commencement of the the key areas of research for which participants sought first survey. consultation at RCC (Figure 2). Almost 8 out of 10 The survey was designed using the web-based Qualtrics (79%) participants had started a research project after platform to field the questionnaire. The participants would RCC consultation and 36% (14/39) of them had com- read the study's objectives and other research-related in- pleted their studies (Figure 3). formation according to the Participant Information Sheet Some investigators have already started their study and prior to answering the questionnaire. Due to anonymity of sought consultation at RCC in the midst of their study the questionnaire and the minimal risk nature of the execution. This accounted for the difference between study, approval was obtained from the Institutional Review those who indicated that they had initiated their research Board (CIRB reference no: 2013/253/E ) to waive the writ- (79%) and those who have completed or in the process of ten consent of the participant. The data from the com- carrying out their studies (36% + 49% or 85%). pleted questionnaire were imported into MS Excel for computation and analysis. Discussion The study shows that the establishment of RCC can be a Results catalyst to facilitate research in primary healthcare institu- The number of RCC sessions and hours increased from tion. It is a system approach to empower novice re- 17 sessions (17 hours) in 2010, 47 sessions (48.5 hours) searchers to embark on research. The RCC serves as a in 2011, to 40 sessions (46 hours) in 2012. The number platform for researcher-centric coaching, which caters to of new research projects or conference presentations their individual or team's specific needs when they plan or resulting directly from the investigators' participations in are in the midst of executing research. Most of the partici- the RCC also increased from 2010 to 2012 (Figure 1). pants have undertaken basic research training at local aca- For the questionnaire survey, 64 email addresses from demic institutions. However these generic structured a list of 75 participants were found to be unique and training programs may not provide answers to specific currently valid. 45 of them responded to the survey, con- questions or solutions to problems encountered by the stituting a response rate of 70.3% (45/64). 39 of them individual or team members during the planning or execu- completed the entire questionnaire, which formed the tion stages. The RCC bridges this gap, with the consul- denominator for the computation of the results. tants functioning as mentors to guide these researchers. Majority of participants were medical staff of SHP Once these researchers gain hands-on experience and (56%), predominantly females (67%), aged 21–40 years confidence after these beginners' trials or studies, it sets (58%) and with post-graduate qualifications (49%). Table 1 the stage for them to pursue advanced research training shows the demographic profile of participants in the ques- program and to take on more complex studies. tionnaire survey. The key elements for a successful set-up include sup- Most participants considered the RCC as accessible and port from senior management to provide the appropriate adequate in time provision. All of them were satisfied with resources, ensuring that the service is accessible and the quality of consultancy at RCC (Table 2). Study design, convenient. Adequate time allocation and quality of the data management and study execution were ranked as consultancy are essential elements for successful service Number of Research Projects 6 initiated by Non-RCC participants No. of oral/poster Number of Research Projects presentations and initiated by RCC participants no. of research projects initiated by SHP investigators Non-RCC participants who presented 6 RCC participants who presented 2010 2011 2012 Year Figure 1 New research projects initiated in SHP and research presentation by SHP staff. Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 5 of 7 http://www.apfmj.com/content/12/1/4 Table 1 Demographic profile of RCC participants Retrospective review of department record Questionnaire survey Demographic characteristics Number (n) Total = 64 % Number (n) Total = 45 % Domain of work SHP Staff 43 67 33 73 Non-SHP Staff (e.g. GP, Medical students) 21 33 12 27 Gender Male 23 36 15 33 Female 41 64 30 67 Age group (Year) 21-40 37 58 26 58 41-60 26 41 18 40 61 and above 1 2 1 2 Education status Undergraduate 12 19 6 13 Degree holder 21 33 17 38 Post graduate 31 48 22 49 Profession Medical (Medical students and GP inclusive) 39 61 25 56 Nursing and pharmacy 25 39 20 44 delivery to the participants. Based on their rankings, the RCC consultation. Further research will be required most participants value the consultation in critical areas to understand their other unmet needs and identify of research, such as study design, execution and data other barriers that could have hindered their initiation. management. These components will appeal to novice There is also a lag time between research consultation researchers who are commencing their early phases and the initiation of new studies due to logistic reasons of research planning and execution. Nonetheless, es- such as application for ethics approval and lack of re- tablished researchers can also use the RCC service, as search funding. peer reviews by consultants serve to polish up their The evaluation of the research support service needs presentations and publications. to be implemented on a regular basis to stay relevant to This study is the first in the healthcare institution and the evolving research developments in SHP. As novice provides a timely evaluation of the needs of the staff researchers become more experienced and take on more members, who are planning or have already embarked complex research studies, the service will need to expand. on research for the past three years. However, about one To enhance the RCC service, additional expertise is re- in five participants have yet to initiate their study after quired to augment the small pool of family physicians Table 2 Accessibility, quality and perceived value of consultancy at RCC Accessibility to RCC Views of participants n = 39 Total disagree/disagree n/(%) Totally agree/agree n/(%) I can easily book a RCC appointment. 4 (10) 35 (90) I feel that the RCC, currently held on two afternoons per week are adequate. 7 (18) 32 (82) The venue at a centralised location in HQ is convenient. 1 (3) 38 (97) The one-hour time slot per RCC session is adequate. 8 (21) 31 (79) Quality and perceived value of consultancy at RCC Views of participants n = 39 Agree n/(%) Totally agree n/(%) The consultant at RCC is qualified to provide the consultation. 21 (54) 18 (46) The consultation provides the information that I need for my research project. 23 (59) 16 (41) The consultation helps in my research. 22 (56) 17 (44) I appreciate that RCC service is currently free of charge. 12 (31) 27 (69) Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 6 of 7 http://www.apfmj.com/content/12/1/4 Rank 1 Rank 2 Rank 3 No. of participants who 15 selected the respective areaof research 16 8 Define research Study design Study Data Results Publications question execution management presentation Figure 2 Participants' ranking of top three key areas of research for their consultation at RCC. cum consultants, including biostatistician, epidemio- participants' contacts are periodically updated, which logist and bioinformatics professional. A biostatistical may ameliorate the response rate of subsequent surveys. consultation clinic, facilitated by a biostatistician, has In addition, absolute and opportunistic cost of providing been set up in SHP to complement the RCC in Septem- the resources in operating the RCC, including time and ber 2012. Further study will be carried out to determine manpower, will be computed in future surveys, as the its effectiveness in providing biostatistical support to basis of cost effectiveness analysis. the researchers. Gathering qualitative feedback from the consultants on the RCC service will close the evaluation Conclusions loop in future study. The establishment of research consultation clinic in a One limitation of the survey is the failure of the inves- primary healthcare institution helps to support and facili- tigators to reach out to all the RCC participants. These tate research amongst its staff. Accessibility, convenience, include individuals who had left the organisation or adequacy and quality of the consultancy are key elements medical students who had already graduated, resulting for its successful implementation. It can be measured by in change of their email addresses. Administrative sup- process outcomes such as the number of new research port will need to be enhanced to ensure that the projects initiated and publications in journals. Yes No Did not start 15% (6) 21% (8) Did not start No % of RCC 49% (19) participants No 79% (31) Yes 36% (14) Yes Initiation of research project Completion of research project Figure 3 Outcomes of consultation at RCC. Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 7 of 7 http://www.apfmj.com/content/12/1/4 Competing interests 15. van Weel C, Rosser WW: Improving health care globally. A critical review The authors declare that they have no competing interests. of the necessity of family medicine research and recommendations to build research capacity. Ann Fam Med 2004, 2(Suppl 2):S5–S16. 16. Campbell SM, Roland MO, Bentley E, Dowell J, Hassal K, Pooley JE, et al: Authors' contributions Research capacity in UK primary care. Br J Gen Pract 1999, 49:967–970. TNC contributed in the conception and design of the study, the content 17. Tan NC, Goh LG: Primary Care Research – A Blueprint for Action for of the survey questions, analysis of data publication and manuscript drafting. Singapore. APJPH 2001, 43(1):49–53. KPT contributed in the content of the survey questions, survey distribution and the review of manuscript. TYT participated creating the web base doi:10.1186/1447-056X-12-4 survey, collection and processing of data and the review of manuscript. Cite this article as: Tan et al.: Research consultation clinic: impetus All authors read and approved the final manuscript. towards facilitating primary care research. Asia Pacific Family Medicine 2013 12:4. Authors' information KPT is the manager of department of research, SingHealth Polyclinics. TYT is the executive of department of research, SingHealth Polyclinics. TNC is the director of department of research, SingHealth Polyclinics. He is also a family physician (senior consultant) at SingHealth Polyclinics (Pasir Ris), an adjunct assistant professor of Duke-NUS Graduate Medical School. Acknowledgements We would like to thank Qualtrics which provided us free online platform to carry out data collection and analysis. Received: 7 June 2013 Accepted: 13 September 2013 Published: 16 September 2013 References 1. Macinko J, Starfield B, Shi L: The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Serv Res 2003, 38(3):831–865. 2. Starfield B, Shi L, Macinko J: Contribution of primary care to health systems and health. Milbank Q 2005, 83:457–502. 7. 3. Green LA: The research domain of family medicine. Ann Fam Med 2004, 2(Suppl 2):S23–S29. 4. De Maeseneer JM, van Driel ML, Green LA, van Weel C: The need for research in primary care. Lancet 2003, 362(9392):1314–1319. 5. Al-Abdullateef SH: A survey of the attitude and practice of research among doctors in Riyadh Military Hospital primary care centers, Saudi Arabia. J Fam Community Med 2012, 19(1):38–42. 6. Jones C: Laboratories of primary care: Practice-based research networks in Canada. Canadian Fam Physician 2006, 2006(52):1045–1046. 7. Dwan KM, Magin PJ: The desire for research in general practice. Aust Fam Physician 2008, 37(10):871–873. 8. Pearce K, et al: How and Why to Study the Practice Content of a Practice- Based Research Network. Ann Fam Med 2004, 2(5):425–428. 9. Bakken S, Lantigua RA, Busacca LV, Bigger JT: Barriers, enablers, and incentives for research participation: a report from the Ambulatory Care Research Network (ACRN). J Am Board Fam Med 2009, 22(4):436–445. 10. Curtis P, Dickinson P, Steiner J, Lanphear B, Vu K: Building capacity for research in family medicine: is the blueprint faulty? Fam Med 2003, 35(2):124–130. 11. Giveon S, Kahan E, Kitai E: Factors associated with family physicians' involvement in research in Israel. Acad Med 1997, 72(5):388–390. 12. Beasley JW, Starfield B, van Weel C, Rosser WW, Haq CL: Global health and primary care research. J Am Board Fam Med 2007, 20(6):518–526. 13. Hannaford P, Hunt J, Sullivan F, Wyke S: Shaping the future: a primary care Submit your next manuscript to BioMed Central research and development strategy for Scotland. Health Bull (Edinb) 1999, and take full advantage of: 57(5):295–299. 14. Del Mar C, Askew D: Building family/general practice research capacity. • Convenient online submission Ann Fam Med 2004, 2(Suppl 2):S35–S40. • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals http://www.deepdyve.com/lp/springer-journals/research-consultation-clinic-impetus-towards-facilitating-primary-care-cuLjafl3XB
Tan, Ngiap; Tan, Yang; Kin, Patricia
Asia Pacific Family Medicine
, Volume 12 (1) – Sep 16, 2013
/lp/springer-journals/research-consultation-clinic-impetus-towards-facilitating-primary-care-cuLjafl3XB
Asia Pacific Family Medicine /
Copyright © 2013 by Tan et al.; licensee BioMed Central Ltd.
Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
10.1186/1447-056X-12-4
Background: In Singapore, SingHealth Polyclinics (SHP) is an accredited Family Medicine (FM) training centre which managed 1.8 million primary care patient-visits in 2012. To promote research in the institution, research consultation clinics (RCC) are being introduced in 2010 to enable free face-to-face consultation between experienced and novice researchers on specific research topics. Each RCC session allows about an hour or more for the SHP staff, medical undergraduates and general practitioners to seek advice and clarification on key research areas, ranging from research question refinement, study design and execution, data analysis, result presentation to publication. The consultants comprise of two FM researchers with postgraduate research qualification. Aim: This article aims to review the implementation of RCC from 2010 to 2012 and its impact on research activities and outcome indicators in the same period of time. Methods: The study comprised of two segments. Part I was a three-year retrospective review of the RCC administrative record. The total number of RCC sessions, hours utilised, participants' profiles, the number of research studies initiated by them and their research presentations at local and overseas scientific meetings/conferences were computed. Part 2 was an anonymous web-based questionnaire survey fielded to RCC participants to collect their feedback on the RCC service and their self-reported initiation and completion of research study after the RCC consultation. Results: The RCC sessions increased from 17 to 40 sessions, resulting in increment of 2 to 14 research presentations and from 2 to 6 initiations of new research studies per annum from 2010–2012. The response rate to the questionnaire survey was 70.3%, with the majority of multi-disciplinary respondents rated the RCC service to be accessible, adequate and were satisfied with its quality. Study design, data management and study execution were ranked as important areas of research for consultation. 79% of them had started a research project and 36% had completed their studies. Conclusions: The RCC is a feasible model to catalyse multi-disciplinary research in primary care institutions. Further study is needed to evaluate its relevance when research advances and novice researchers become experienced investigators to take on more complex projects. Keywords: Research, Consultation, Primary care * Correspondence: tan.ngiap.chuan@singhealth.com.sg Research Department, SingHealth Polyclinics Head Office, 167 Jalan Bukit Merah, Connection One, Tower 5, #15-10, Singapore 150167, Singapore DUKE-NUS Graduate Medical School, 8 College Rd, Singapore 169857, Singapore © 2013 Tan et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 2 of 7 http://www.apfmj.com/content/12/1/4 Background and in the respective master degree programmes for A strong primary healthcare system is vital to improve community nurses and pharmacists who take on ad- the health of the general population and reduce the vanced professional training. healthcare burden to the nation [1,2]. Research in pri- Aside from training, mentorship appears to be pivotal mary care aims largely to seek better understanding of in moulding primary care practitioners into researchers. disease management in relation to the individuals, fam- Curtis P et al. reported that amongst Family Medicine ilies and the community, and to evaluate the effective- (FM) graduates who received the American National Re- ness and efficiency of healthcare practices and health search Service Awards, they were less successful in policies [3]. Beyond general practice and family medi- terms of research and publication output compared to cine, primary care research is multi-disciplinary, cove- fellow recipients such as internists and paediatricians ring community nursing and pharmacy, sociology, health [10]. The authors attributed the differences to a lack of service and policy research. As primary care supports protected time and sustained research mentorship for the base of the population pyramid and amidst a rapidly the family physicians. Likewise, in Israel, FM residents expanding global population, there is an urgency to scale trained under pro-research mentors were likely to be up primary care research to seek medical evidence to more intensely involved in research when they became prevent, cure, and care for diseases; to translate these family physicians [11]. evidences into regular clinical practice and to formu- A strong and increased level of commitment from pri- late policies to ensure universal equity of care [4]. mary care organisations is needed to provide support and However, primary care research faces challenges, even resources and to reduce barriers for family physicians to in resource-rich countries, due to limitations of research carry out research [12]. Hannaford P et al. showed that a capacity in general practice, inadequate research infra- modest investment of resources and support will create structure in primary care and poor provision of support substantial increases in both the quality and quantity of to individual general practitioners to conduct research. primary care research [13]. They recommended that this Saad H. Al-Abdullateef in a survey of general practi- investment should be targeted at both existing primary tioners in selected primary care centres in Saudi Arabia care professionals working in service settings in primary showed that while a majority expressed interest (66%) care and those in the academic departments in the univer- and planned to carry out research (74.2%), they cited sities [13]. Various funding models for primary care re- insufficient time (83.5%) and lack of support (58.8%) as search have since been developed and implemented in key barriers to research [5]. various countries, centred largely on channelling govern- Practice-based research networks (PBRNs) are groups ment funding via FM departments in universities in of practices networked together to undertake research Australia & the Netherlands, or via the Royal College of relevant to general practice and the local community's General Practitioners in Britain [14-16]. However how needs [6,7]. These PBRNs, often involving collaborations effective and efficient are these funding models in promo- between practitioners and academicians, can expand the ting primary care research and enhance research-related capacity and bandwidth of primary care physicians [8]. training for the general practitioners are seldom measured, Nonetheless, these PBRNs are largely medical, whist and its translation into actual research endeavours are nurses and other researchers tend to form their respec- rarely evaluated. A new model to expedite primary care tive research networks. Furthermore, a survey of a New research in terms of effective individual coaching and effi- York based PBRNs revealed that only 25% of the physi- cient application is urgently needed to empower the pri- cians had formal research training and 21% of them had mary care practitioners. clinical research certification [9]. Lack of time or com- Primary care research faces similar challenges in peting demands for time was the top ranked barrier Singapore, where infrastructure constraints and healthcare resources were hithertho barriers to its development [17]. (92%) in the survey, and 80% of the clinicians reported that their lack of appropriate training was a barrier [9]. However in recent years, despite the lack of dedicated Thus, participation in PBRNs may not adequately ad- research funding for primary care researchers from the local official research agencies, rapid development of aca- dress the specific research needs nor provide training for the individual primary care researchers; neither does it demic medicine in the local public healthcare institutions add impetus towards multi-disciplinary research in pri- resulted in unprecedented support for primary care re- search from primary healthcare organisations, such as mary care. Nevertheless, there are ample research related training SingHealth Polyclinics (SHP). The latter comprises a clus- opportunities that are available from the local academic ter of nine public primary care clinics or polyclinics in institutions to equip primary care professionals with Singapore, which is also a recognised FM training centre basic research skills. Basic research training is incorpo- accredited by the American College of General Medical rated in medical undergraduate education curriculum, Education. Whilst governance, policy and finance are Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 3 of 7 http://www.apfmj.com/content/12/1/4 centrally administered in SHP, the polyclinics operate at FM researchers within the institution with post-graduate various sites to serve the local communities in the south- qualifications in research. ern and eastern parts of Singapore using a common and Periodic evaluation of the service provided by RCC integrated electronic medical records system. Thus in from the participants is vital to ensure that this model of terms of primary care research, the institution can be research support remains relevant and its service caters regarded as a de-facto practice-based multi-disciplinary adequately to their needs. This study aims to determine research network. the level of satisfaction amongst the RCC participants in Novice researchers from SHP can seek seed funding terms of their perception of the accessibility of the ser- from SHP to support their approved research projects vice, adequacy of the duration of the consultation, effec- whilst established researchers are encouraged to vie for tiveness of the consultancy, the key research areas in competitive research grants from national research agen- which they seek consultation, and the outcomes of the cies. Whilst financial support to kick-start research for RCC consultation. these researchers is no longer a barrier, approval for seed funding is based on the evaluation of research proposals' Methods scientific merits and logistic considerations. Hence novice The evaluation of the RCC service comprises of two seg- researchers find it propitious to consult experienced re- ments. The first part was a retrospective review of the searchers for guidance in order to optimise their success RCC records from 2010–2012 to determine the short- rates in their seed funding or other grant applications. term accomplishments of past participants in terms of With the endorsement from senior management in SHP, their research study initiation and subsequent oral or pos- research consultation clinics (RCC) are established in May ter presentation at academic meetings and/or scientific 2010 to support budding FM researchers in the institution. conferences. "New study" is defined as study initiated Dedicated resources are channelled centrally from institu- within the respective calendar year with reference to its tion annual operating budget to set up the RCC service. date of approval from the institutional review board. The This caters to the opportunistic cost for the consultants, research presentations refer to investigators' presentations as well as the participants to meet at the RCC for free of their research findings at local or overseas scientific face-to-face consultations during clinic operating hours. It meetings or conferences which are approved by SHP. Both also provides for the seed funding for researchers to sup- outcomes were traced from the respective databases in the port the execution of their project. SHP Department of Research. Each RCC session allows at least an hour for any indi- The second segment was a questionnaire survey of the vidual or group of multi-disciplinary SHP staff to seek same cohort of participants. Each participant was invited advice and clarification on any issues pertaining to their to undertake a web-based questionnaire survey regar- research endeavours. During the consultation sessions, dless of the frequency of RCC participation. The sam- the topics covered include the various domains in re- pling frame comprised of participants who had utilised search, ranging from exploring research idea, definition the RCC service at least once and who had provided of research question, research method, project design, their email contact. The records show a list of 75 RCC application for ethics committee review, logistic plan- participants between January 2010 and December 2012, ning, data analysis and interpretation to results presenta- of which email addresses were provided by 64 of them. tion and publication. The participants can arrange for The questionnaire collected data on the participant's multiple consultations to clarify queries for their same study or repeat consultation for another study. 1. demographic profile such as age, gender, education The RCC sessions are taken up by SHP multi- status, staff category disciplinary staff, including doctors, nurses and phar- 2. views on accessibility of the service, macists who plan to commence research as part of their 3. quality of the consultancy, professional development or are pursuing advanced 4. ranking of key research domains for which they training programmes which incorporate research as sought consultation part of the curriculum. The service is also open to ex- 5. outcome measures of RCC in terms of initiation and ternal primary care researchers, including private ge- completion of their respective research projects neral practitioners, and medical students from the two local medical colleges, under the over-arching objective The questionnaire survey was anonymous to ensure of enhancing primary care research development and truthful responses from the participants. The investiga- foster research collaborations between different pri- tors notified the participants of the survey via their email mary healthcare providers in Singapore. This necessi- addresses. Second and third round of notices were deli- tates the increase of consultants from one to two to vered to the participants' email addresses to serve as re- manage the expanded RCC capacity. The consultants are minders to participate in the survey on the second and Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 4 of 7 http://www.apfmj.com/content/12/1/4 third week respectively after the commencement of the the key areas of research for which participants sought first survey. consultation at RCC (Figure 2). Almost 8 out of 10 The survey was designed using the web-based Qualtrics (79%) participants had started a research project after platform to field the questionnaire. The participants would RCC consultation and 36% (14/39) of them had com- read the study's objectives and other research-related in- pleted their studies (Figure 3). formation according to the Participant Information Sheet Some investigators have already started their study and prior to answering the questionnaire. Due to anonymity of sought consultation at RCC in the midst of their study the questionnaire and the minimal risk nature of the execution. This accounted for the difference between study, approval was obtained from the Institutional Review those who indicated that they had initiated their research Board (CIRB reference no: 2013/253/E ) to waive the writ- (79%) and those who have completed or in the process of ten consent of the participant. The data from the com- carrying out their studies (36% + 49% or 85%). pleted questionnaire were imported into MS Excel for computation and analysis. Discussion The study shows that the establishment of RCC can be a Results catalyst to facilitate research in primary healthcare institu- The number of RCC sessions and hours increased from tion. It is a system approach to empower novice re- 17 sessions (17 hours) in 2010, 47 sessions (48.5 hours) searchers to embark on research. The RCC serves as a in 2011, to 40 sessions (46 hours) in 2012. The number platform for researcher-centric coaching, which caters to of new research projects or conference presentations their individual or team's specific needs when they plan or resulting directly from the investigators' participations in are in the midst of executing research. Most of the partici- the RCC also increased from 2010 to 2012 (Figure 1). pants have undertaken basic research training at local aca- For the questionnaire survey, 64 email addresses from demic institutions. However these generic structured a list of 75 participants were found to be unique and training programs may not provide answers to specific currently valid. 45 of them responded to the survey, con- questions or solutions to problems encountered by the stituting a response rate of 70.3% (45/64). 39 of them individual or team members during the planning or execu- completed the entire questionnaire, which formed the tion stages. The RCC bridges this gap, with the consul- denominator for the computation of the results. tants functioning as mentors to guide these researchers. Majority of participants were medical staff of SHP Once these researchers gain hands-on experience and (56%), predominantly females (67%), aged 21–40 years confidence after these beginners' trials or studies, it sets (58%) and with post-graduate qualifications (49%). Table 1 the stage for them to pursue advanced research training shows the demographic profile of participants in the ques- program and to take on more complex studies. tionnaire survey. The key elements for a successful set-up include sup- Most participants considered the RCC as accessible and port from senior management to provide the appropriate adequate in time provision. All of them were satisfied with resources, ensuring that the service is accessible and the quality of consultancy at RCC (Table 2). Study design, convenient. Adequate time allocation and quality of the data management and study execution were ranked as consultancy are essential elements for successful service Number of Research Projects 6 initiated by Non-RCC participants No. of oral/poster Number of Research Projects presentations and initiated by RCC participants no. of research projects initiated by SHP investigators Non-RCC participants who presented 6 RCC participants who presented 2010 2011 2012 Year Figure 1 New research projects initiated in SHP and research presentation by SHP staff. Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 5 of 7 http://www.apfmj.com/content/12/1/4 Table 1 Demographic profile of RCC participants Retrospective review of department record Questionnaire survey Demographic characteristics Number (n) Total = 64 % Number (n) Total = 45 % Domain of work SHP Staff 43 67 33 73 Non-SHP Staff (e.g. GP, Medical students) 21 33 12 27 Gender Male 23 36 15 33 Female 41 64 30 67 Age group (Year) 21-40 37 58 26 58 41-60 26 41 18 40 61 and above 1 2 1 2 Education status Undergraduate 12 19 6 13 Degree holder 21 33 17 38 Post graduate 31 48 22 49 Profession Medical (Medical students and GP inclusive) 39 61 25 56 Nursing and pharmacy 25 39 20 44 delivery to the participants. Based on their rankings, the RCC consultation. Further research will be required most participants value the consultation in critical areas to understand their other unmet needs and identify of research, such as study design, execution and data other barriers that could have hindered their initiation. management. These components will appeal to novice There is also a lag time between research consultation researchers who are commencing their early phases and the initiation of new studies due to logistic reasons of research planning and execution. Nonetheless, es- such as application for ethics approval and lack of re- tablished researchers can also use the RCC service, as search funding. peer reviews by consultants serve to polish up their The evaluation of the research support service needs presentations and publications. to be implemented on a regular basis to stay relevant to This study is the first in the healthcare institution and the evolving research developments in SHP. As novice provides a timely evaluation of the needs of the staff researchers become more experienced and take on more members, who are planning or have already embarked complex research studies, the service will need to expand. on research for the past three years. However, about one To enhance the RCC service, additional expertise is re- in five participants have yet to initiate their study after quired to augment the small pool of family physicians Table 2 Accessibility, quality and perceived value of consultancy at RCC Accessibility to RCC Views of participants n = 39 Total disagree/disagree n/(%) Totally agree/agree n/(%) I can easily book a RCC appointment. 4 (10) 35 (90) I feel that the RCC, currently held on two afternoons per week are adequate. 7 (18) 32 (82) The venue at a centralised location in HQ is convenient. 1 (3) 38 (97) The one-hour time slot per RCC session is adequate. 8 (21) 31 (79) Quality and perceived value of consultancy at RCC Views of participants n = 39 Agree n/(%) Totally agree n/(%) The consultant at RCC is qualified to provide the consultation. 21 (54) 18 (46) The consultation provides the information that I need for my research project. 23 (59) 16 (41) The consultation helps in my research. 22 (56) 17 (44) I appreciate that RCC service is currently free of charge. 12 (31) 27 (69) Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 6 of 7 http://www.apfmj.com/content/12/1/4 Rank 1 Rank 2 Rank 3 No. of participants who 15 selected the respective areaof research 16 8 Define research Study design Study Data Results Publications question execution management presentation Figure 2 Participants' ranking of top three key areas of research for their consultation at RCC. cum consultants, including biostatistician, epidemio- participants' contacts are periodically updated, which logist and bioinformatics professional. A biostatistical may ameliorate the response rate of subsequent surveys. consultation clinic, facilitated by a biostatistician, has In addition, absolute and opportunistic cost of providing been set up in SHP to complement the RCC in Septem- the resources in operating the RCC, including time and ber 2012. Further study will be carried out to determine manpower, will be computed in future surveys, as the its effectiveness in providing biostatistical support to basis of cost effectiveness analysis. the researchers. Gathering qualitative feedback from the consultants on the RCC service will close the evaluation Conclusions loop in future study. The establishment of research consultation clinic in a One limitation of the survey is the failure of the inves- primary healthcare institution helps to support and facili- tigators to reach out to all the RCC participants. These tate research amongst its staff. Accessibility, convenience, include individuals who had left the organisation or adequacy and quality of the consultancy are key elements medical students who had already graduated, resulting for its successful implementation. It can be measured by in change of their email addresses. Administrative sup- process outcomes such as the number of new research port will need to be enhanced to ensure that the projects initiated and publications in journals. Yes No Did not start 15% (6) 21% (8) Did not start No % of RCC 49% (19) participants No 79% (31) Yes 36% (14) Yes Initiation of research project Completion of research project Figure 3 Outcomes of consultation at RCC. Tan et al. Asia Pacific Family Medicine 2013, 12:4 Page 7 of 7 http://www.apfmj.com/content/12/1/4 Competing interests 15. van Weel C, Rosser WW: Improving health care globally. A critical review The authors declare that they have no competing interests. of the necessity of family medicine research and recommendations to build research capacity. Ann Fam Med 2004, 2(Suppl 2):S5–S16. 16. Campbell SM, Roland MO, Bentley E, Dowell J, Hassal K, Pooley JE, et al: Authors' contributions Research capacity in UK primary care. Br J Gen Pract 1999, 49:967–970. TNC contributed in the conception and design of the study, the content 17. Tan NC, Goh LG: Primary Care Research – A Blueprint for Action for of the survey questions, analysis of data publication and manuscript drafting. Singapore. APJPH 2001, 43(1):49–53. KPT contributed in the content of the survey questions, survey distribution and the review of manuscript. TYT participated creating the web base doi:10.1186/1447-056X-12-4 survey, collection and processing of data and the review of manuscript. Cite this article as: Tan et al.: Research consultation clinic: impetus All authors read and approved the final manuscript. towards facilitating primary care research. Asia Pacific Family Medicine 2013 12:4. Authors' information KPT is the manager of department of research, SingHealth Polyclinics. TYT is the executive of department of research, SingHealth Polyclinics. TNC is the director of department of research, SingHealth Polyclinics. He is also a family physician (senior consultant) at SingHealth Polyclinics (Pasir Ris), an adjunct assistant professor of Duke-NUS Graduate Medical School. Acknowledgements We would like to thank Qualtrics which provided us free online platform to carry out data collection and analysis. Received: 7 June 2013 Accepted: 13 September 2013 Published: 16 September 2013 References 1. Macinko J, Starfield B, Shi L: The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998. Health Serv Res 2003, 38(3):831–865. 2. Starfield B, Shi L, Macinko J: Contribution of primary care to health systems and health. Milbank Q 2005, 83:457–502. 7. 3. Green LA: The research domain of family medicine. Ann Fam Med 2004, 2(Suppl 2):S23–S29. 4. De Maeseneer JM, van Driel ML, Green LA, van Weel C: The need for research in primary care. Lancet 2003, 362(9392):1314–1319. 5. Al-Abdullateef SH: A survey of the attitude and practice of research among doctors in Riyadh Military Hospital primary care centers, Saudi Arabia. J Fam Community Med 2012, 19(1):38–42. 6. Jones C: Laboratories of primary care: Practice-based research networks in Canada. Canadian Fam Physician 2006, 2006(52):1045–1046. 7. Dwan KM, Magin PJ: The desire for research in general practice. Aust Fam Physician 2008, 37(10):871–873. 8. Pearce K, et al: How and Why to Study the Practice Content of a Practice- Based Research Network. Ann Fam Med 2004, 2(5):425–428. 9. Bakken S, Lantigua RA, Busacca LV, Bigger JT: Barriers, enablers, and incentives for research participation: a report from the Ambulatory Care Research Network (ACRN). J Am Board Fam Med 2009, 22(4):436–445. 10. Curtis P, Dickinson P, Steiner J, Lanphear B, Vu K: Building capacity for research in family medicine: is the blueprint faulty? Fam Med 2003, 35(2):124–130. 11. Giveon S, Kahan E, Kitai E: Factors associated with family physicians' involvement in research in Israel. Acad Med 1997, 72(5):388–390. 12. Beasley JW, Starfield B, van Weel C, Rosser WW, Haq CL: Global health and primary care research. J Am Board Fam Med 2007, 20(6):518–526. 13. Hannaford P, Hunt J, Sullivan F, Wyke S: Shaping the future: a primary care Submit your next manuscript to BioMed Central research and development strategy for Scotland. Health Bull (Edinb) 1999, and take full advantage of: 57(5):295–299. 14. Del Mar C, Askew D: Building family/general practice research capacity. • Convenient online submission Ann Fam Med 2004, 2(Suppl 2):S35–S40. • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit
Asia Pacific Family Medicine – Springer Journals
The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970–1998
Macinko, J; Starfield, B; Shi, L
Contribution of primary care to health systems and health
Starfield, B; Shi, L; Macinko, J
The research domain of family medicine
Green, LA
The need for research in primary care
De Maeseneer, JM; van Driel, ML; Green, LA; van Weel, C
A survey of the attitude and practice of research among doctors in Riyadh Military Hospital primary care centers, Saudi Arabia
Al-Abdullateef, SH
Laboratories of primary care: Practice-based research networks in Canada
Jones, C
The desire for research in general practice
Dwan, KM; Magin, PJ
How and Why to Study the Practice Content of a Practice-Based Research Network
Pearce, K
Barriers, enablers, and incentives for research participation: a report from the Ambulatory Care Research Network (ACRN)
Bakken, S; Lantigua, RA; Busacca, LV; Bigger, JT
Building capacity for research in family medicine: is the blueprint faulty?
Curtis, P; Dickinson, P; Steiner, J; Lanphear, B; Vu, K
Factors associated with family physicians' involvement in research in Israel
Giveon, S; Kahan, E; Kitai, E
Global health and primary care research
Beasley, JW; Starfield, B; van Weel, C; Rosser, WW; Haq, CL
Shaping the future: a primary care research and development strategy for Scotland
Hannaford, P; Hunt, J; Sullivan, F; Wyke, S
Building family/general practice research capacity
Del Mar, C; Askew, D
Improving health care globally. A critical review of the necessity of family medicine research and recommendations to build research capacity
van Weel, C; Rosser, WW
Research capacity in UK primary care
Campbell, SM; Roland, MO; Bentley, E; Dowell, J; Hassal, K; Pooley, JE
Primary Care Research – A Blueprint for Action for Singapore
Tan, NC; Goh, LG
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Tan, N., Tan, Y., & Kin, P. (2013). Research consultation clinic: impetus towards facilitating primary care research. Asia Pacific Family Medicine, 12(1), 1-7.
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redpajama_set_name: RedPajamaCommonCrawl


Hiring Airplus to install our air conditioning unit was a mistake. Not only were they hours late to the initial install, we had many issues with the unit afterwards, and AirPlus did little to resolve the problem in a timely manner.
The issue stemmed from them leaving a large piece of cardboard on the unit (from the box it was shipped in) during the installation. This means the unit could not function the way in which it's meant. This led to multiple floods in our basement and significant, unnecessary stress.
They came several times to resolve the issue and could not, until one of their people finally found the root of the issue.
To have them respond in any way took many phone calls. We had to constantly remind them to make good on any of their commitments. Messages to the company owner were unreturned. Barb, the Manager, is nice on the phone; however, falls short on action.
Eventually, they did respond and did some extra work to the unit.
I do not recommend AirPlus. They are indifferent to providing even third-rate customer service.
Unfortunately, this comment from the customer doesn't tell the whole story. The job was quoted on June20/07 and installed on Saturday June23/07. This time of the year is the busiest. We are booked 2 weeks in advance, and the customer pleaded with us to install it on the following Sat, when we had no openings for at least 2 wks. So one of our installation crews ( normally they do one installation each on Sat)offered to accommodate this customers demands, and installed this a/c on his off time . Yes a small foam packing was stuck in the bottom of the evaporation coil, which was missed by the installers. Which caused the coil to freeze up after extended usage and stop the a/c from working. When a/c was shut off the ice would melt and consequently a small puddle formed around the furnace. We admit the mistake, and came out there 3 times because it was difficlt to figure out but finally solved. Because this was in an very old home with some small ductwork and limited return air, it seemed to be an air flow problem, but didn't expect it in a new coil. We did a free a/c and furnace clean and tuneup in May/08, in which the a/c is working fine but the tech found lack of combustion air for proper furnace operation for heating.( we did not install the furnace). Therefore by gas code my technician had to red tag the furnace and told him how to fix the problem. Obviously customer was upset with our diagnosis which prompted these comments after that service call. We bent over backwards trying to satisfy this customer, but human nature being what it is, one bad event wipes out all the good efforts.


Dr. Mamie L. McKnight has three underlying themes in her professional and volunteer career: 1) commitment to family and community development; 2) dedication to historic preservation; and 3) a desire to educate Dallas youth. Dr. McKnight is regarded as a true historian of Black Dallas.
She is founder of Black Dallas Remembered, Inc., a nonprofit organization devoted to the preservation of Dallas heritage, especially the legacy and importance of the African-American community. Its goal is to uncover black participation in the history of Dallas through four areas: structural preservation, research, publication and free educational activities targeting youth.
Perhaps one of Dr. McKnight's most challenging endeavors revolved around the Texas Department of Transportation and City of Dallas' planned expansion of Central Expressway. Freedman's Cemetery, a cemetery for more than 8,000 of Dallas' earliest black residents (many former slaves), would have been unearthed and destroyed by the expansion. Under Dr. McKnight's direction, Black Dallas Remembered, Inc. initiated an investigation of the breadth of this historic gravesite. Dr. McKnight played a key role in the coordination, archiving and relocation of graves to help preserve an important part of Dallas' heritage.
Dr. McKnight is President of GEM-MAC Consulting, a family-owned firm specializing in education, community development, African-American heritage and preservation.
Her organizational activity includes serving on the boards of Friends of Fair Park, the Texas CAN Academy, National Women's Museum Local Advisory Committee, Dallas Black Chamber of Commerce and the Texas Historical Commission Review Board. She also served as chairman of the Dallas Landmark Commission. In 1999 Governor George Bush appointed Dr. McKnight to serve a six-year term on the Texas Historical Commission.


The Toyota FJ Cruiser is just asking to be modified. As and owner and enthusiast, I purchased my FJ as a platform for modifications. Prior to my purchase I researched and found that there were a number of companies providing aftermarket parts for the FJ Cruiser. If you are, as I am, interested in modifying your FJ Cruiser much thought needs to go into the order and types of modifications you want to make.
I recommend first determining what the function of your FJ will be and the type of terrain you will be dealing with.
Each on of these types of uses will dictate the order of and the types of modifications you should consider. My Toyota FJ Cruiser has been built up for Adventure / Expedition travel which includes trail head access.
Anyone know if I can put the compass, outside temp, inclinometer cluster into a 2007 Toyota FJ Cruiser that did not come with it?
The Toyota dealer up here in the frozen north says it can't be done!?


A Greenwood County man is facing federal charges after authorities said he reached out to a white supremacist group for help with a plot to kill his black neighbor.
Brandon Cory Lecroy, a 25-year-old Hodges resident, was indicted on charges of solicitation to commit a crime of violence and use of interstate commerce facilities in the commission of murder for hire, the U.S. Attorney's Office announced Tuesday.
Authorities said Lecroy, who is white, wanted his neighbor, who is black, dead.
If convicted, Lecroy would face up to 10 years in prison and a fine of $250,000.
Court documents described the alleged plot.
FBI agents started investigating after a confidential source reported Lecroy contacted a white supremacist extremist organization "to seek assistance with the murder of his African-American neighbor," according to a criminal complaint.
After the tip came in, an undercover agent on March 20 spoke with Lecroy, who made arrangements to pay for his neighbor's murder, the complaint stated.
Lecroy told the agent during a phone call: "$500 and he's a ghost," according to the complaint.
He asked the agent to put a "flaming cross" in the front yard and "hang his neighbor from a tree," the records added.
Lecroy and the undercover agent spoke again two days later, the complaint stated. He told the agent that he wanted to get a 9 mm handgun with two magazines and that he wanted a "ghost gun" that was untraceable but not stolen.
"Lecroy also advised (the agent) that he has more jobs for him in the future," the complaint stated.
On April 9, Lecroy met with the undercover agent, pointed out his neighbor's residence and made a $100 down payment in cash "with acknowledgement that this payment was for the murder of his neighbor," the documents stated. They also discussed "future targets," the records added.
He was arrested that day. He had not been arrested before in South Carolina, according to State Law Enforcement Division records.
A federal judge later ordered a psychiatric examination. Lecroy was being held Tuesday at a federal prison hospital in Massachusetts.


The Excellence Center is responsible for analyzing, planning and coordinating to support and develop outstanding treatment for people with mental health problem who are affected by alcohol-related disorders.
To gain better understanding in how alcohol-related disorders related to people with mental health problem using clinical approaches. This will be done through research and provide counseling and treatment for people suffering from mental health problem due to alcohol-related disorders.
To promote and cooperate with other health institutes to resolve issues arise from alcohol-related disorders both domestically and internationally.
To coordinate and collect data related in solving alcohol-related disorders problem by supporting, preventing, treating and rehabilitating.
Specialize center for research using clinical cases of alcohol dependence at Suanprung Psychiatric Hospital and acquiring locals to form the clinical models for alcohol dependence treatment.
To share the knowledge and technology by providing training, seminars and conferences for both health and other associate professionals to improve the understanding on the prevention and treatment for alcohol dependence. This service will be provided to both within and outside the organization.
To establish the database on the information collected on alcohol dependence treatment.
Provide at least two outstanding research works yearly that have a big impact on alcohol-related disorders.
Provide at least one publication yearly in national and international levels.
Provide at least two recognized research works yearly through oral or poster presentation in national and international conferences that related to alcohol dependence problem.
Provide corporate research work with other international collaborator, at least one project yearly.
Provide training program in alcohol dependence treatment at least one course yearly.
Published database and statistic collected from alcohol dependence patient on the Suanprung Psychiatric Hospital website.
Develop the system for alcohol dependence treatment with PCT Alcohol Clinic and Supra Specialist Service.
Develop the staff members' skill in alcohol dependence treatment.
Develop the training program, publication and knowledge in alcohol dependence treatment.
Develop the academic and research works in alcohol dependence treatment.
Develop information technology (IT) to support service, training and research in alcohol dependence treatment.


point of view · Henry narrates the story in the first person but sometimes switches to the second person during his more philosophical reflections. Henry relates only what he sees and does and only what he could have learned of other characters from his experiences with them.
tone · As the autobiographical nature of the work suggests, Hemingway's apparent attitude toward the story is identical to that of the narrator.
major conflict · While there is no single, clear-cut conflict, friction does arise when Henry's love for Catherine cannot quell his innate restlessness.
rising action · Henry and Catherine's flirtatious games prepare and sometimes foreshadow their love for each other; their last days together before Henry's return to the front zero in on the demands of love versus Henry's life outside his relationship with Catherine.
falling action · Henry's decision to flee and quit the army marks his farewell to arms and his commitment to Catherine.
symbols · While Hemingway avoids the sort of symbol that neatly equates an object with some lofty abstraction, he offers many powerfully evocative descriptions that often resonate with several meanings. Among these are the rain, which scares Catherine and into which Henry walks at the end of the novel; Henry's description of her hair; the painted horse; and the silhouette cutter Henry meets on the street.


Former Cronulla Sharks star Valentine Holmes has left the door open to the possibility of an NRL return within the year.
Holmes stunned the rugby league community in December when he announced he'd be leaving the NRL effective immediately to pursue a dream career in America's National Football League.
The decision incensed his former captain and Sharks Talisman Paul Gallen who emphatically called for the winger to be barred from returning after what many perceived as a shirking of responsibility in the breaking of his professional contract.
Currently, Holmes is trialling in the NFL's 12-week International Player Pathway Program at IMG Academy in Bradenton, Florida, where he has been training alongside six other NFL hopefuls from the UK, Brazil, Germany and Mexico.
And while previously stated that he had "zero" interest in returning down under, it appears Holmes has re-evaluated his stance.
"If it was up to me, I'd like to finish [my career] here [the US]," Holmes told Fox Sports.
The 23-year-old will have to be one of four players selected out of the seven in the pathway program if he is a shot at being assigned to a team in the AFC East conference. Even then, being selected doesn't necessarily mean cracking into the first team, and he won't be eligible to play until 2020.
While he admitted, he hadn't given it too much thought, Holmes said he would be open to the possibility of a return to Shark park within the year should he falter in the US.
Holmes was once widely expected to move north in a shock swap deal for the then returning Ben Barba at the Cowboys.
While the bulk of the plan lies in tatters, Holmes express a fondness to return to one day play professionally for his corner of the world.


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Leonard (Len) Duncan (New York, 25 juli 1911 – Lansdale, 1 augustus 1998) was een Amerikaans Formule 1-coureur.

Hij reed één race in zijn Formule 1-carrière. Dit was de Indianapolis 500, die tussen 1950 en 1960 meetelde in de Formule 1, van 1954. Hij viel in deze race uit in de 101e ronde met een remdefect en had als eindklassering 31e plaats.

Naast zijn Formule 1-carrière reed Duncan in zeven decennia (jaren 20 tot en met de jaren 80) in de zogenaamde 'midget cars'. In de Tweede Wereldoorlog had Duncan eenmaal de eer om de chauffeur te zijn van Harry S. Truman tijdens een van zijn bezoeken aan Engeland.

Amerikaans autocoureur
Formule 1-coureur

redpajama_set_name: RedPajamaWikipedia


WASHINGTON — Rep. Luis Gutierrez, D-Ill., was arrested at a rally and sit-in in front of the White House on Tuesday, a protest to pressure the Trump administration to embrace the Deferred Action for Childhood Arrivals (DACA) program protecting youths in the U.S. illegally through no fault of their own.
The North Side lawmaker was taken into custody by the U.S. Park Police with about 25 others. After being held for 2 hours, Gutierrez paid a $50 fine and was released at about 4:30 p.m. ET, according to his spokesman, Douglas Rivlin.
Tuesday marked the fifth anniversary of the kickoff of DACA.
Gutierrez said in a statement, "While the President is coddling racist white supremacists because he is afraid to lose their votes, we took a stand today for justice.
"There is no doubt the American people stand with the young people who face deportation if Republicans kill DACA or fail to defend it in court. . . . I think as the reality of mass deportation, of ending DACA or ending TPS, as that sinks in and becomes more palpable for people, we will see an escalation of non-violent protest across the country.
"It is a shame and an embarrassment — es una vergüenza — the way this White House has turned on immigrants and fomented animosity towards immigrant families.
Gutierrez, whose has been crusading for years on behalf of undocumented youths, was arrested at the White House 2010 and 2011 to ramp up pressure on then President Barack Obama to protect "DREAMers" from deportation.
Obama created DACA on June 15, 2012, and the program started accepting applications on Aug. 15, 2012.


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Josep Oriol Jansana d'Anzizu (Barcelona 1913- 1993) fou un pintor barceloní, que signava com "J.O. Jansana". Format amb Nolasc Valls i a l'escola de la Llotja, va rebre el mestratge amical de Marià Pidelaserra. Il·lustrà el llibre de poesia d'avantguarda Poèma d'Eugeni Peidro-Miró (Barcelona 1934). Va fer la seva primera individual a Barcelona el 1935. En la postguerra, en no poder anar cap a Europa per la II Guerra Mundial pintà al Marroc, amb una beca (1944).

Al seu taller de Barcelona s'hi reunien musics destacats, com ara Frederic Mompou, Ernest Xancó o Giocasta Corma, que hi feien concerts informals per als seus amics. Els anys de postguerra fou un dels integrants destacats del grup d'artistes de Tossa, continuador del que hi havia hagut abans de la guerra civil. Vers 1945 formà part del grup de "La Campana de Sant Gervasi".

Afectat d'esquizofrènia entre 1947 i 1963, va poder remprendre després la seva activitat i reprengué les seves exposicions a Barcelona (especialment a les Galeries Syra i Subex) o a Bilbao. En una llarga estada a Itàlia guanyà la medalla d'or del IV concurs Cadorago-Lario, de Como (1971). Els museus de Milà i de Montecatini-Terme varen adquirir obra seva.

Fou un hereu de la generació del 1917, en una línia derivada del fauvisme i a estones força expressionista, i es dedicà especialment al paisatge rural i urbà de Catalunya, el Marroc, Itàlia, etc. Tanmateix fou també un retratista de molt caràcter.

Referències
 Gran Enciclopèdia Catalana.
 Centenari del Centre Excursionista de Catalunya. Homenatge dels artistes catalans. Barcelona, 1976.

Jansana, Josep Oriol


Introduction: Animal bites are a common reason for visits to the Emergency Department in the US and worldwide. There are many different approaches to managing these wounds.
Case Presentation: We present a case of a 90-year-old white woman who sustained a large dog bite to her hand, over the dorsal aspect of the first metacarpal. We used the avulsion flap as a biologic dressing and employed a perforating technique to successfully treat the wound and allow for optimal wound healing.
Discussion: Pitfalls to this dog bite management approach include the risk of infection and flap necrosis. Patients must obtain proper follow-up in 24 to 72 hours to reevaluate the wound. To optimize outcomes, comorbidities, location of the bite, complexity of the bite wound, and the risks of infection must be considered when one is choosing the best approach.
Animal bites are a common chief complaint seen in the Emergency Department (ED) and urgent care centers. There are many different approaches and considerations in the management of these wounds. It is always important to consider and identify the best approach to allow for maximal wound healing and to reduce the risk of infection as much as possible. We present one possible approach to treating a patient with a dog bite who had an avulsion flap that was used as a biologic dressing, allowing for optimal wound healing.
A 90-year-old white woman came to our ED less than 1 hour after sustaining a dog bite to her nondominant hand. There was a 4 cm × 1 cm, gaping wound over the dorsal aspect of the first metacarpal. Of note, there was a large full-thickness avulsion flap attached distally (Figure 1).
Radiographs confirmed that the patient did not have an acute fracture or retained a foreign body.
The decision was made to reapproximate the skin flap loosely using 4.0 single interrupted nylon sutures. We ultimately elected to use a fenestration technique. With use of an 18-gauge needle, multiple puncture wounds were made in the skin flap. The skin flap was loosely reapproximated, to allow the wound to drain while providing the best biologic dressing, with fenestrations in the skin flap (Figure 2). A pressure dressing was applied using petrolatum and 3% bismuth tribromophenate-infused gauze dressing, a woven gauze bandage, and a splint.
On Day 13, the patient returned for a scheduled wound recheck. The flap continued to be viable without signs of skin necrosis (Figure 3).
On Day 19, the decision was made to remove the woman's sutures despite some concerns for possible epidermolysis of the skin flap (Figure 4). The wound was gently cleaned using hydrogen peroxide. Another pressure dressing and a splint were reapplied.
On Day 29, the wound was almost completely healed and the skin flap was viable (Figure 5). A timeline of the case is shown in Table 1.
Complex dog bite wounds are often seen for the first time in the ED. Primary closure of a dog bite wound remains controversial. This case offered several challenges in the decision making of the proper wound care of a dog bite. The first was the advanced age of the patient. Second was the location of the bite on the hand. Last, the wound involved a large skin flap avulsion. Fortunately, despite her advanced age, this patient was very healthy.
The time to presentation to the ED or urgent care center is another important consideration. In this case, the patient presented to our ED within 1 hour of the time of injury. Previous studies have shown that the rate of infection increases from 4.5% to 22.2% if the patient seeks medical attention after 8 hours.2 Therefore, primary closure should be avoided in patients who have a delayed presentation to the ED.
Prophylactic antibiotics should be considered in patients with dog bite wounds. There are several common organisms in the oral flora of dogs. Pasteurella species are isolated from 50% of dog bite wounds and 75% of cat bite wounds.5 Other considerations are gram-negative organisms as well as common skin flora such as staphylococci and streptococci. Amoxicillin-clavulanate is often a good choice for antibiotic coverage in these patients given the common organisms. Furthermore, tetanus prophylaxis should be considered in all patients with open wounds.
This case provides one approach to managing dog bites. Some pitfalls to this approach include the risk of infection and flap necrosis. It is important that patients obtain proper follow-up in 24 to 72 hours to reevaluate the wound. There are many factors involved in wound management, as discussed earlier. To optimize outcomes, comorbidities, patient population, location of the bite, complexity of the bite wound, and the risks of infection must be considered when one is choosing the best approach.
Williamson A, Thomas C. A clinical approach to animal bites with an avulsion flap: A case report. Perm J 2017;21:16-156. DOI: https://doi.org/10.7812/TPP/16-156.
1. Fleisher GR. The management of bite wounds. N Engl J Med 1999 Jan 14;340(2):138-40. DOI: https://doi.org/10.1056/NEJM199901143400210.
2. Paschos NK, Makris EA, Gantsos A, Georgoulis AD. Primary closure versus non-closure of dog bite wounds. A randomised controlled trial. Injury 2014 Jan;45(1):237-40. DOI: https://doi.org/10.1016/j.injury.2013.07.010.
3. Kannikeswaran N, Kamat D. Mammalian bites. Clin Pediatr (Phila) 2009 Mar;48(2):145-8. DOI: https://doi.org/10.1177/00099228080324494.
4. Stevens DL, Bisno AL, Chambers HF, et al; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014 Jul;59(2):e10-52. DOI: https://doi.org/10.1093/cid/ciu444. Erratum in: Stevens DL et al (Clin Infect Dis 2014;59:147-59). Clin Infect Dis 2015 May 1;60(9):1448. DOI: https://doi.org/10.1093/cid/civ114.
5. Baddour LM. Soft tissue infections due to dog and cat bites [Internet]. Alphen aan den Rijn, The Netherlands: Wolters Kluwer: UptoDate; updated 2005 Oct 6 [cited 2017 Jan 24]. Available from: www.uptodate.com/contents/soft-tissue-infections-due-to-dog-and-cat-bites.


"So what's the problem?" you might ask… According to a Greenpeace quote highlighted by Boy Genius Report, everyone's favorite eco-terrorism troupe based their siting scores on the typical sources of electricity for the states where the datacenters are located. But if we're going to talk genuine "sustainability" (which, by the way, eco-nuts are completely uninterested in) then you've got to consider a lot more factors than just the makeup of the power grid sources in a particular host state.
So greener is always better, right? Not necessarily. Greenpeace specifically bad-mouthed Apple for choosing to locate its newest datacenter in North Carolina, where the energy supply is notoriously un-green. But what were their alternatives? A California site would expose the datacenter to earthquake risks – and I'm sure your neighborhood Greenpeace operative isn't keen on downtime for their favorite iDevice. Coastal Texas isn't really an option due to the risk of severe weather. That leaves inland Texas, the Pacific Northwest, and New York.
"Great, relocate there!" say our tree-hugging friends. Not so fast – remember that inland Texas can throw down a wicked heat gauntlet in the summer, while Oregon, Washington and New York get downright frigid in the winters. The DOE estimates that almost half of a typical datacenter's energy consumption is used for climate control – what happens to that number when the ambient temperature is well over 100°F? Or -10°F? Suddenly, choosing a comfortably-temperate and relatively disaster-free state like North Carolina or Virginia – despite the un-greenness of their energy supplies – doesn't seem like such a bad idea. I'm sure the stewards of these datacenters would much rather not use as much as 10X the total energy – along with all it's concomitant transmission inefficiencies – and keep their overall consumption low.
When you start factoring in second-order causes and effects – such as the environmental impact of pulling power, water, fiber and vehicle conduits into remote places, landfill and recycling capacities, employee commute emissions, construction impact – the sites that Apple, Google, Facebook and others have chosen start to look even better. As is almost always the case, monovariatic analysis in pursuit of a pre-selected conclusion falls flat on its face when a bigger-picture view is considered.
Unfortunately, datacenters consume a lot of energy. Choosing their sites carefully – not only based on energy sources but also based on consumption – can reduce this. The people whose jobs, reputations and employers' solvency are on the line have no choice but to look at the big picture. Ultimately the true solution for Greenpeace's gripes is likely for them (and the rest of us) to give up their iPhones and App Stores – but then – how would they coordinate their naval blocades, nuclear power plant break-ins and cargo ship boardings?


Ireland head coach Joe Schmidt will name his team to face Canada at the Aviva this Saturday at lunchtime.
It's expexted there's going to be wholesale changes to the side that beat World Champions New Zealand at Soldier Field last weekend.
Gary Ringrose looks in line to win his first cap at centre.
Despite Irish management declaring Johnny Sexton fit, it's expected that he will be rested ahead of the return of the All Blacks to Dublin next weekend.
Schmidt then has a big decision to make with Joey Carbery and Paddy Jackson battling for the number ten jersey.
While a number of players including James Tracy, Billy Holland, John Ryan and Niyi Adeolokun could earn first caps off the bench.
Sean O'Brien and Peter O'Mahony, the likely captain, are expected to be called into the pack.
Ireland (possible, cred, Irish Times): Tiernan O'Halloran; Craig Gilroy, Garry Ringrose, Luke Marshall, Keith Earls; Paddy Jackson, Kieran Marmion; Cian Healy, Seán Cronin, Finlay Bealham; Ultan Dillane, Iain Henderson; Peter O'Mahony, Josh van der Flier, Seán O'Brien.
Replacements: David Kilcoyne, James Tracy, John Ryan, Billy Holland, Dan Leavy, Jack McGrath, Joey Carbery, Niyi Adeolokun.


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Flora L. Thornton Opera Program to Present Cendrillon
Seaver College students enrolled in the Flora L. Thornton Opera Program will perform Jules Massenet's Cendrillon in a digital performance on April 22 and 23 at 7:30 PM PST and April 24 at 2 PM PST. Combining the classic Cinderella story with Massenet's soaring melodies, the opera will be sung in French and presented with English supertitles.
Keith Colclough, assistant professor of music and director of opera at Seaver College, will direct the all-student cast, featuring Malone Blaich, Kaitlyn Chui, Molly Day, Anika DeLong, Carmen Edano, Jack Gerding, Andrea Hupman, Alison Kiasaleh, Anahi Casas Perez, Sydney Swearengin, Haily Watson, Brittany Weinstock, and Kaytlin Withers. Long Tao "Pierre" Tang, assistant professor of music and director of instrumental ensembles at Seaver College, will conduct the performance.
"The cast has prepared and recorded the entire project while socially distant in accordance with COVID-19 safety protocols. The logistics of rehearsing this complicated music over the Internet have required extra innovation and planning on behalf of the cast and production team," shared Colclough. "I am extremely proud of our cast's resilience and cannot wait to share their work with an audience."
The Flora L. Thornton Opera Program at Pepperdine University has developed a reputation as one of the nation's leading undergraduate vocal programs. It features an annual fully staged opera, a biennial summer intensive in Heidelberg, Germany, and master classes with top industry professionals. A one-million-dollar endowment from Flora Laney Thornton, one of Southern California's most beloved and honored arts philanthropists, ensures high-quality productions. Pepperdine graduates have won scholarships to many of the nation's most prestigious graduate programs, including the Juilliard School, Yale Graduate Opera Program, Cincinnati College Conservatory of Music, Northwestern University, Rice University, and USC. Pepperdine graduates are now gracing the rosters of America's leading opera companies, including the Metropolitan Opera, Chicago Lyric Opera, Los Angeles Opera, Santa Fe Opera, San Francisco Opera, and Seattle Opera.
Tickets for this performance are free and registration is required. A viewing link will be sent to all registered attendees in advance of the performance. For additional information about Cendrillon, visit the event's registration page.


Bingo has been one of the most popular gambling games for the last few decades and its popularity is still on the rise. It is one of the simplest games to learn to play along with having fantastic prizes should your numbers drop in. The game is based on luck but there are a number of tricks and tips you should follow to improve your outcome. In this article, we will talk about the different ways you can improve your chances of winning when playing Bingo online.
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