text:
J Thorac Cardiovasc Surg 2003;126:1235-1242
© 2003 The American Association for Thoracic Surgery
a Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.
Received for publication May 1, 2003; accepted for publication May 28, 2003.
* Address for reprints Fred A. Crawford, Jr, MD, Horace G. Smithy Professor & Chairman, Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St, Room 409, Charleston, SC 29425, USA
It is human nature to believe that the changes we witness and participate in are the most profound in history. In one lifetime, my grandfather witnessed a change in transportation from horseback to space travel and flights to the moon. In roughly the same 100 years, our specialty evolved from draining empyemas and a fear of even suturing the heart to repairing the most complex congenital defects, heart and lung transplantation, and even replacement of the heart with a mechanical device. Despite these advances, some fear that our specialty may be facing significant declineeven extinctionbecause of equally impressive advances by our colleagues, especially in cardiology. Bill Baumgartner, in his wonderful presidential address to The Society of Thoracic Surgeons (STS), described the changes occurring in our specialty and the opportunities afforded by these changes.1 Today I would like to discuss how these changes and the environment in which they are occurring are affecting our educational process and how cardiothoracic surgery education is evolving to respond to this changing environment. Please note that I chose the title "Thoracic Surgery Education" not "Thoracic Surgery Resident Education," because surgical education is a continuous process extending from medical school through the postgraduate years. Because general and thoracic surgery education have been so closely intertwined, many of the issues important to one are also critical to the other.
The American Association for Thoracic Surgery (AATS) was founded in 1917, and the first president was Samuel Meltzer, who stated in his presidential address, "The chief aims of the Association are the advancement of knowledge and skill in thoracic surgery."2 He went on to say in the discussion, "I am confident that a time will come when thoracic surgery will be equal in importance to surgery of the abdomen."2 One prospective member disapproved of the founding of the AATS, indicating that once empyema was cured, the association would dry up for lack of other topics. Instead, our specialty and the association have thrived. Today, 86 years later, we have a 5-day international meeting with multiple simultaneous sessions, a record 717 abstracts submitted, and 4389 attendees from 79 different countries.
The first thoracic residency was established at Michigan by John Alexander in 1928. At the 1936 meeting of the AATS, in an article entitled, "The Training of a Surgeon Who Expects to Specialize in Thoracic Surgery," Alexander stated that "two years of intensive study and practice in an active...thoracic surgery clinic are sufficient to take the examination of a board," but went on to say that "a greater length of time would be desirable."3 This 2-year training requirement was initiated when our specialty treated mostly empyema and tuberculosis. Predating the 80-hour work week requirements by 67 years, Alexander stated that his residents' work "occupies an average of nine or ten hours a day during two years except for two vacations of a month each."3
The American Board of Surgery (ABS) was formed in 1937, and initially there was a strong determination for thoracic surgery to stay within the specialty of general surgery. However, thoracic surgery matured rapidly during World War II, and at the 1947 meeting the members of the AATS voted for establishment of a subsidiary American Board of Thoracic Surgery (ABTS). Thus the board was a direct outgrowth of this association. The first written examination (28 candidates) was held August 1, 1949, and the first oral examination was held the following October. The only cardiac question on the first written examination was, "Discuss the alterations in physiology which occur in children with congenital heart anomalies resulting in cyanosis."4 The other 9 questions dealt with pulmonary problems.4 As our specialty continues to evolve, I wonder what questions will be on the 2049 examination at the time of the board's 100th anniversary. The ABTS subsequently became an independent board in 1971. Other milestones in thoracic surgery education included the Residency Review Committee for Thoracic Surgery (RRC-TS) founded in 1967, the Thoracic Surgery Directors Association in 1977, the matching program in 1982, the first in-training examination in 1983, and the Joint Council on Thoracic Surgery Education in 1996.
Most cardiothoracic surgeons educated in the United States probably believe that cardiothoracic surgery education is reasonably similar throughout the world. Only recently have I learned how significant the variations are. Some of these differences were noted by Bainbridge5 in 1992, and again recently by José Pomar6 in an address at last year's European Association for Cardio-thoracic Surgery (EACTS) meeting. Pomar6 found that in Europe the total length of cardiothoracic training ranged from a low of 22 months to a high of 90 months and was not even defined in 2 countries. Exposure to general surgery (before cardiothoracic surgery) varied between 0 and 72 months, most often between 12 and 24 months. The time subsequently dedicated to cardiothoracic education ranged from 2 to 9 years, in most cases 5 or 6 years. Significant differences exist among other countries as well. Clearly, there are different ways to educate cardiothoracic surgeons. We will learn tomorrow from Frank Culbertson about the international space station and the future of space exploration. Participation in such ventures by international crews necessitates a significant commonality of training, and as the world grows smaller through improved communication, it is likely that the education of cardiothoracic surgeons will become increasingly similar throughout the world.
Medical education is an interesting process. My parents were both professional educators and were appropriately prepared for their careers. It is safe to say that academic cardiothoracic surgeons are surgeons first and educators a more or less distant second. Few of us were taught how to teach, how to examine, or how to evaluate our students. One change to improve future surgical education will almost certainly involve increased reliance on professionally trained educators, as is occurring in some departments. With the many changes currently affecting our specialty, now is an appropriate time to comprehensively reevaluate our educational system to determine whether it can be improved. Bill Baumgartner1 spoke about the pioneers who developed our specialtywe must be sure that our educational process inspires and equips new pioneers to meet the challenges of the future.
It would of course be inaccurate to imply that no change has occurred since Alexander developed the first residency. The Thoracic Surgery Directors Association has been responsible for many positive changes, including the matching program, the development of a standardized curriculum, and the exciting new computer-based prerequisite curriculum for incoming residents. The RRC-TS has moved from a more or less "old boy" network to a rigorous process for program evaluation and accreditation, and in recent years it has closed or forced reorganization of programs that have emphasized service over education. However, in my opinion, much work remains to be done in this area. The examination process by the ABTS has been strengthened by the adoption of criterion-referenced written and oral examinations and by the use of advanced psychometric statistical evaluation of the examination itself. The resident in-training examination has been significantly improved and is now computer-based and administered through the Cardiothoracic Surgery Network (CTSNet). In the near future, part I of the board examination will also be computer-based and administered to candidates closer to or at home. Recent changes in board requirements will be discussed later in this article. The STS database is an extremely valuable resource that has educated us about our patient outcomes relative to those of our peers.
The role of CTSNet as an educational tool by providing access to databases, on-line journals, multimedia programs, and the like is sure to increase. The significant financial support provided by the STS, AATS, and EACTS will at some point be viewed by our successors as an extraordinarily wise investment. In addition, CTSNet has made the world much smaller by increasing communications and collaboration with our colleagues in other countries.
Despite these significant advances, much remains to be done.
I believe that additional changes in the educational process are needed to address the following issues:
Changes that will be proposed should not be viewed as attempts to simply make our specialty more attractive. Instead we must make the educational process the best that it can be and then let supply and demand take over. The goal remains to attract the best qualified candidates and provide them with the best possible education.
First, let's consider the potential effects of the decreased interest in medicine as a career. Medical school applications in the United States were down in 2002 for the seventh year in a row, some 26% below the peak of 1996.7 This has occurred despite the change from a previously predicted physician oversupply to now a projected shortage of 75,00 to 100,000 physicians (mostly specialists) by 2020.8 The number of medical students choosing general surgery has declined, from 12.1% in 1981 to 5.1% in 2002.9 In the last several years, the number of unmatched general surgery positions has increased, and more positions are being filled by international graduates, although this trend did improve in this year's match. Because historically general surgery has been the only pathway to a thoracic surgery residency, this decline in interest in general surgery has real implications for our specialty and may partially explain the recent decline in interest in cardiothoracic surgery. This decreased interest has occurred despite the projection from our most recent manpower study that cardiothoracic surgeons will decrease from 1.3/100,000 population to 0.9/100,000 population by the year 2020.10 Because of the continued population growth, especially in the elderly component with the aging of the baby boomers, and the growing epidemic of obesity, diabetes, and related diseases, I believe that the current difficulties in the job market being experienced by our residents are temporary and that we are heading toward a real shortage of general and cardiothoracic surgeons in the next 2 decades, despite the continuing inroads made by other specialties.
Surgical educators must quickly address these issues, because the pipeline for surgical training is so long. First we must rekindle the interest of our most talented students in a career in medicine by taking every opportunity to serve as mentors and advisors, even at the high school level. The bursting of the stock market bubble and the economic recession will probably cause some highly qualified candidates to once again consider medicine as an attractive career, but the bias of medical school admission committees against candidates interested in specialty careers must be overcome. Today's malpractice climate clearly deters some students, but there are encouraging developments on the horizon. I believe that our patients will be more effective on our behalf than professional lobbyists. When patients begin to experience decreased access to physicians, as has been the case recently in Nevada, Mississippi, West Virginia, and other states, then tort reform will begin to occur, as happened in Mississippi in the past year. It is encouraging that President Bush has made this a priority, and I was further encouraged by Secretary Thompson in his remarks to the STS as well as by recent activities in Congress.
Continued decline in physician reimbursement will also adversely affect patient access, and eventually this will result in changes favorable to cardiothoracic surgery. Senator Frist, our colleague and now Senate majority leader, spoke out last fall on the issue of physician reimbursement, stating, "There is simply no choice but to act...to prevent draconian cuts in physician reimbursement and other areas that will prevent beneficiaries from gaining access to quality health care."11) Indeed, recent acts by Congress have decreased but not eliminated further cuts scheduled for the next few years.
However, we must stop focusing on our personal income. Tom Krizek,12 in the 2001 American College of Surgeons ethics lecture, stated, "We have run the risk of exchanging virtue and respect for money. One of the most impairing facts of our profession may be that we have become rich, that we expect to be rich, and at the same time society does not highly regard the rich." In fact, the average income of cardiothoracic surgeons easily places us in the top 1% of US wage earners. It is to be hoped that few of us chose cardiothoracic surgery for purely economic reasons, and society is unlikely to have much sympathy for our small profession unless the debate is framed in the context of decreased access to care by patients caused by continued decline in physician reimbursement.
Surgeons must aggressively seek access to medical students in the first year by serving as advisors, by participating in basic science teaching, by sponsoring surgical interest clubs, and by welcoming them to operating rooms, grand rounds, and conferences. Surgical faculty members must be acutely aware of their importance as role models and transmit more of the satisfaction that we all get from patient care, research, and teaching instead of focusing on our unhappiness with government regulation and reimbursement. Curriculum changes, including true redesign of the fourth year, could potentially shorten surgical residencies of all types by a full year. The balance between service and education must clearly shift toward education. Students and residents can no longer be expected to function as cheap labor for the hospital or for individual attendings. Program director turnover, currently as high as 30%/y, must be decreased by recognition of this important position through appropriate compensation, and promotion.
The changing demographic characteristics of medical students and residents necessitate a change in thoracic surgery education. Today's students are older, they have often had one or more previous careers, they are frequently married, usually with children, and their debt load at graduation averages $100,000, all factors making it less likely that they will pursue a 7- to 10-year cardiothoracic residency. The number of women in medical school has increased dramatically, but the number of women interested in surgery has remained relatively constant. I find that women are just as fascinated by the technical aspects of surgery as men, but they are simultaneously afraid that the surgical lifestyle will be intolerable. Currently only about 20% of candidates certified by the ABS are women. Since the founding of the ABTS, only 139 of 6748 diplomates (2.1%) have been women. In the past 10 years the percentage has increased, but only to 4.6% (Glennis Lundberg, ABTS. Personal communication, 2002). An optimistic view is that women represent virtually an untapped source for future cardiothoracic surgeons. However, thoracic residency and the current practice of cardiothoracic surgery are not friendly to women. If we are to attract this important segment of medical students into surgical specialties, we must recognize and increase our sensitivity to their special needs. The emphasis of education over service, the 80-hour work week mandate, team continuity of care, and the gradual increase in women surgeons who can serve as role models should help in this regard. Surgical residency programs must be permitted increased flexibility by the RRC-TS to more easily address medical leave for pregnancy. We should consider shared residency positions that, although requiring more years for completion, would allow women surgeons to begin a family at an earlier age.
Thoracic surgery education must change to improve the lifestyles not just of women but of all residents and subsequently of practicing cardiothoracic surgeons. Modern surgical education was initiated by William S. Halsted at Johns Hopkins. Most of us, particularly those who were outgrowths of the Halsted system as was the case at Duke, were not too concerned about the work environment as residents. We just wanted to be cardiothoracic surgeons, and this was part of the price. Few of us were perceptive enough to recognize the impact on either ourselves or our families. I vividly recall two quotes from medical school and residency that set the tone. Eugene Stead, the chairman of medicine at Duke, frequently stated, "If you can't get your work done in 24 hours, you had better work nights."13 Dr Sabiston often reminded us of Osler's statement that the "master word (in medicine) is WORK."14 It is interesting that both statements came from internists. Times have obviously changed!
As the interest in surgery has declined, interest has increased in specialties with more controllable lifestyles, such as radiology, emergency medicine, dermatology, and others. When I talk to third-year medical students rotating on surgery and ask what will be the most important factor influencing their choice of a career, almost invariably the first answer is "lifestyle," and, as noted by a medical student recently, the definition of lifestyle is "time."15 Surgeons, and especially surgical residents, are not perceived as having a particularly good lifestyle, primarily because of the number of hours worked by both residents and surgeons in practice. The newly mandated 80-hour work week should have a positive effect in this regard, although surgeons will continue to work more hours than most other specialists. One obvious consequence of the new regulations, however, is that surgical residents will miss some operative procedures, conferences, and clinics. To maintain these educational experiences, some 2-year programs will probably apply to become 3-year programs. Two-year programs with one resident in each year will find it difficult to meet the work hour requirements, and some may close. Virtually all programs will need significant financial assistance from their hospitals for physician extenders to meet service requirements currently being provided by residents. From an educational standpoint, the net effect should be positive. However, more time away from the hospital will require residents to assume increased responsibility for self-education. It is our responsibility as educators to design methods and teach residents the most effective ways to educate themselves, first as residents and, equally important, for the remainder of their careers. Innovative tools such as those currently being developed by the Thoracic Surgery Directors Association will be extremely useful in this regard.16
The work hour regulations will also preclude the type of continuity of care provided by previous generations of residents and surgeons. Continuity of care will by necessity become more of a team effort, and we must teach residents how to do this without compromising patient safety. In the process, the responsibility and accountability for the patient's welfare that has characterized cardiothoracic surgeons must not be lost. Team continuity of care involving the attending surgeon, residents, intensivists, and others could provide both superior patient care and the opportunity for a better lifestyle for the surgeon. However, I am concerned about the rigidity of these work hour requirements and especially about the development of a "shift mentality" among surgical residents. We must carefully evaluate both the positive and negative effects of the work hour mandate on surgical resident education and be ready to modify it if needed.
If limitation of work hours is good (supposedly because of decreased errors) for airline pilots, commercial truck drivers, and now surgical residents, it is inevitable that these limitations will also be applied to practicing surgeons, as predicted in this recent quote from The New England Journal of Medicine: "Although residents have been the focus of the debate, the strategy should ultimately apply to experienced clinicians as well, especially since older persons are more likely than younger persons to be adversely effected by sleep deprivation."18 This is already an issue for our colleagues in Europe, where resident and attending work hours are being severely restricted.
Societal changes are dictating changes in surgical education. Concern about work hours has just been discussed. Alexander3 in his 1936 article on thoracic surgery education stated, "The time has passed when surgeons must gain their experience at the expense of their patients." However, 66 years later, Antul Gawande,18 a surgical resident at the Brigham and Womens Hospital, points out that "surgical residency still largely relies on the wonderful, time honored, throat constricting methods of learning-by-doing." In his book Complications,19 he states, "In medicine we have long faced the conflict between the imperative to give patients the best possible care and the need to provide novices with experience." The old surgical dictum of "see one, do one, teach one" is no longer acceptable in an environment charged by the report from the Institute of Medicine documenting the large number of errors committed in patient care. Future residents will learn to perfect basic surgical skills in the laboratory and more advanced skills by surgical simulation. As we will learn tomorrow from Frank Culbertson, enormous advances are being made in imaging techniques that will allow the surgical attending and resident to practice, in advance, different operative approaches to a particular problem in an environment that poses no threat to the patient or the surgeon. Further advances in technology, including imaging, simulation, and virtual reality, will provide important educational tools not only for residents but also as ways of measuring and maintaining technical competence after residency is completed. The increasing emphasis on minimally invasive surgery, continued development of robotically assisted procedures, and other technologic advances, will provide additional challenges, because we must teach all these new skills without further prolonging the cardiothoracic residency.
As we teach technical skills, we must remain cognizant of what Gawande18 has termed the fundamental conflict in surgical education "between the desire to create technical experts and the desire to create surgeons with a larger vision of what they do." He goes on to say, "If the surgeon is to be more than a technician, surgical training should not be confined to learning operative care. It needs to involve learning the broader base of skills required for managing the diseases we care for."18 Although we as surgeons should never apologize for our technical skills, at the same time we must be careful neither to de-emphasize the underlying disease process nor to abandon the overall care of the patient to others. In the future a significant part of the education of cardiac and vascular surgeons, cardiologists, and perhaps interventional radiologists will involve the mastery of a fundamental core of knowledge about cardiovascular disease before moving on to the technical skills peculiar to the individual specialty, and even these will increasingly overlap. The same will be true for thoracic surgeons, pulmonologists, gastroenterologists, and oncologists.
The assessment of surgical education is changing. Historically, we have been more concerned with assessing the educational process by making sure that an appropriate learning environment existed, that appropriate conferences were held, and that adequate numbers of each kind of operative procedure were performed by each resident. We have then depended on the program director's honesty in recommending a resident for the ABTS examination, although aware that some have in turn relied on the ABTS examination to hopefully weed out marginal and unqualified candidates.
The emphasis is changing from evaluating process to evaluating the outcome of resident education, with success on the ABTS examination as only one of the variables. Resident evaluation, which has been highly variable from program to program, will become increasingly standardized, and residents will now be evaluated not only by faculty but by peers, nurses, patients, and others in the six core areas of competence: (1) patient care, (2) clinical science, (3) practice-based learning, (4) interpersonal skills and communication, (5) professionalism, and 6) systems-based practice. Although the exact definitions of these terms continue to evolve, this clearly represents a major change in the assessment of a resident's progress toward assuming independent care of patients. In the future, successful accomplishment of specific objectives, rather than an arbitrary number of years, may determine the length of the residency. Improved methods of assessing the outcomes of resident education will be extremely important in determining the success or failure of changes that are currently being proposed in thoracic resident education.
Continuing medical education is assuming increasing importance as more stringent methods are used to assess the ongoing competence of practicing surgeons. The original stated purpose of the AATS was to "advance knowledge and skills in thoracic surgery."2 Education continues to be the most important responsibility of the AATS, and this annual educational meeting and our journals have become our most important activities. In recognition of the diversity of educational needs and tools, this meeting has evolved to include plenary and breakout sessions, postgraduate courses, fundamental forums for surgical investigation, ethical and practical debates, and exhibits. In recent years the meeting has even been broadcast live worldwide on the Internet in an attempt to disseminate new information as widely and quickly as possible.
Originally the ABTS certificate was good for life, but in 1976 our specialty actually helped lead the way in the development of a 10-year limited certificate that required a recertification process for renewal. In the future, recertification at much shorter intervals than 10 years will be required. As a part of this process, the practicing surgeon will also be assessed by peers and coworkers on the six core areas of competence. A more rigorous examination will replace the current open-book examination. The evaluation of surgical skills will require documentation of patient outcomes, perhaps by using the STS database for comparisons with peers. Technical skills may be assessed in the future by surgical simulators. An unanswered question is whether recertification will continue for the specialty as a whole or be directed toward one or more of its components (general thoracic, adult cardiac, or congenital heart surgery).
Will Sealy20 pointed out in his 1971 STS presidential address that many organizations influence thoracic surgery education, thus making it difficult for any single organization to effect real change. The Joint Council on Thoracic Surgery Education was formed in 1996 in an attempt to address this issue by bringing together representatives from the key thoracic surgical organizations. After several meetings, it became clear that the major issue blocking substantive change was the ongoing requirement for ABS certification. Subsequently, in 1999, the board unanimously passed a resolution that recommended that the ABTS change its policy regarding ABS certification so that at some time in the future yet to be determined, ABS certification will become optional. The reason for making the time of implementation indefinite was to allow all those interested in thoracic surgery education the opportunity to provide input. The joint council subsequently proposed a series of recommendations that were carefully considered, modified and approved by the ABTS in October 2001. It is important that the entire community of thoracic surgery understand the logic behind this process and the opportunity for educational change that these proposals have brought about.
The most important changes adapted by the ABTS can be summarized by some quotes from the board's Web site. "Certification by the American Board of Surgery (ABS) is optional rather than mandatory for residents who begin thoracic surgery training in July 2003 and after."21
"One pathway to ABTS certification will consist of successful completion of a full General Surgery residency in an ACGME-approved or a Royal College of Physicians and Surgeons of Canada (RCPSC)approved program, with or without ABS certification, followed by successful completion of a 2 or 3 year ACGME-approved Thoracic Surgery residency. Individuals entering Thoracic Surgery residencies in July 2003 or after will be eligible under this path."21 The traditional pathway of cardiothoracic education was thereby preserved, but ABS certification is now optional.
"A second pathway to ABTS certification will be a categorical-integrated 6-year Thoracic Surgery residency, to be developed by the Thoracic Surgery Directors Association (TSDA). Residents in these programs will be under the direction of the Thoracic Surgery program director. Before this pathway is implemented, the Residency Review Committee for Thoracic Surgery (RRC-TS) must first approve the standards and requirements for such programs. Individuals will match for such programs directly from medical school or at some later time. It is estimated that the first such programs would begin to accept residents in 2004 at the earliest."21 Candidates choosing this pathway would spend their entire residency under the direction of the thoracic surgery program director. Some of the first 3 years would be devoted to traditional surgical rotations, but significant elective time would be available, and I expect much of this time to be spent in areas that overlap with related specialties, such as cardiology and pulmonology. Concern has been expressed that few individuals might choose this pathway because of the lack of exposure to cardiothoracic surgery by current medical students. However, other surgical specialties including neurosurgery, orthopedic surgery, and urology have had no difficulty matching superior candidates directly out of medical school, and it is unclear to me why cardiothoracic surgery should be significantly different.
"A third pathway to ABTS certification will be through successful completion of an ACGME-approved 3-year Thoracic Surgery residency after a minimum of 3 years in an ACGME-approved General Surgery residency, so long as certain prerequisite criteria are met during the general surgery training."21 This pathway could prove disruptive to general surgery residency programs, because individuals would leave the program before completing it, thus creating midlevel vacancies that could probably not be filled.
"The ABTS is committed to working closely with the ABS and other organizations in General Surgery toward the development of combined 4/3 programs leading to the possibility of certification by both the ABS and the ABTS."21 These actions by the ABTS, the recent initiative by vascular surgery and the declining number of applicants for general surgery positions have stimulated the ABS. In recent months a proposal has been made that would allow an individual to complete 4 years of general surgery, take part I of the ABS examination, and then pursue a residency in pediatric or vascular surgery. On completion of the second residency, such individuals would then be eligible to be certified by both boards. Such a program would be attractive for thoracic surgery as well, because it would permit an additional year of cardiothoracic education without prolonging the overall process. After literally years of negotiations and even tentative approval by the ABS, however, this proposal has been stalled once again, and the executive secretary of the board indicates that the 4/3 option appears to be a dead issue for thoracic surgery.
Another alternative not currently under serious consideration but favored by some would allow individuals to use a significant portion of the fourth year of medical school to study the basic science of surgery. The first 3 years after medical school would be spent in a core program developing the basic surgical skill set in such areas as gastroenterology, pediatric care, vascular surgery, and trauma and critical care. Near the end of the core program, the individual would take an examination and, if successful, would then be eligible to begin a residency in a subspecialty such as cardiothoracic, pediatric, plastic, or colorectal surgery or in a specialized residency program in an area currently included in general surgery, such as vascular surgery, trauma and critical care, gastroenterology, surgical oncology, or transplantation. For an individual who sought more broad-based training, a combination of several of these might be designed. Such a program would obviate the need for subsequent fellowship years in most cases, thus shortening the educational process (Figure 1).
It is impossible to predict how changes already made by the ABTS, as well as other proposals that have been suggested, will affect cardiothoracic surgery. They have been made carefully and deliberately and with the best possible intentions. For those who prefer it, the traditional route with full certification by both boards is possible, and programs and individuals who want to continue this approach are encouraged to do so. Although thoracic surgery is an outgrowth of general surgery, and the close association of our specialties has been important, the fund of knowledge and skills required by our specialty today has now increased to the point that most of the time allocated to a cardiothoracic surgeon's education needs to be devoted to those areas unique to cardiothoracic surgery, with less emphasis on general surgery. Accordingly, I believe that ultimately the cardiothoracic resident educational process will evolve either into the "core plus subspecialty" process or into a 6-year completely integrated residency that matches directly out of medical school. I believe that the current "one-size-fits-all" approach by the RRC-TS to cardiothoracic resident education will change, that we will see increased subspecialty tracking, and that there will be increasing educational overlap with related specialties, such as between cardiology and cardiac surgery.
The ABTS has set the stage for new and innovative approaches to cardiothoracic resident education, and it is time that we moved ahead with the changes that will best position our specialty for the future without waiting any longer for action by others. It is completely appropriate that new approaches be tried at first by a few dedicated and committed programs and program directors and that the outcomes be carefully assessed. If nothing else, our generation of thoracic surgery educators can look back with confidence that change and new alternatives were carefully considered and tried.
In summary, I believe that the following changes in thoracic surgical education and actions by thoracic surgery educators are extremely important to the continued success of our specialty:
In closing, I am indebted and grateful to those who provided me my educationmy parents and family, my teachers and mentors at Duke, and those who continue the process today. I cannot imagine having selected a better career than cardiothoracic surgery, and believe that its future continues to be bright. Finally, I could not have had a greater honor than the opportunity to serve as your president. Thank you for your help and support.17
This article has been cited by other articles:
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Continuing in my series of articles on the remote villages of Spiti Valley, in this post, I will talk about Komic Village near Kaza. Also sometimes spelled as Comic Village or Komik Village, it is located beautifully between the majestic peaks of Spiti Valley, a part of the belt that forms the tiny hamlets scattered in the upper hills around Kaza town.
The most common way of visiting these villages is by making it a day-long sightseeing tour but if you had the time, you can even stay overnight here as a paying guest. Read on to find out more.
If you want to truly experience the cultural and local life of Spiti Valley, in my opinion, spending some time in these villages is the best way. If you just travel to Kaza and went on your way, you will experience the road; and the landscape that comes along. That is quite a lot of fun as well; but the best way to know the culture of the valley and to see some even more amazing vistas, a visit to villages like Komik will well serve the purpose.
For a complete travel guide on visiting Spiti, please read How to Plan a Trip to Spiti Valley.
Komic Village, as you can see in the board above, is often credited as being the highest village in the world connected with a motorable road. While this claim is not really valid and highly disputable, it is still among the highest villages in the world and one of the most scenic ones. The correct altitude of the village is 4,520 meters (14,830 ft).
The name Komik in the local language literally means “Eye of the Snow Cock”. The scenic beauty of Komic is beyond words and it is one of those villages that you just cannot miss visiting while you were in the valley. There has been a boost in tourism here in recent years that has helped the local economy a lot. Thousands of people arrive here each year to get a taste of both the natural beauty of Spiti and its culture.
Komik Village Location
Komic Village is located in Spiti Valley at a distance of 19 kilometers from Kaza, 220 kilometers from Manali, and 440 kilometers from Shimla.
How to reach Komic Village
In order to reach Komic, you will first have to reach Kaza in Spiti Valley. This can be done in two ways, either via Shimla or Manali.
If you started the journey from Shimla, you will travel via Narkanda, Rampur, Pooh, Nako, and Tabo to reach Kaza. The journey will be of 420 kilometers approximately and will take you at least 2 days with a night halt at either Rampur or Reckong Peo. This route remains open for all 12 months including January and February as well.
If you started the journey from Manali, then you will travel via Rohtang Pass, Gramphu, Batal, Kunzum Pass, and Losar to reach Kaza. This will be a total of 200 kilometers approximately and can be covered in 8-10 hours. This route is only open from late May to Mid October.
The route from Shimla is longer but remains open for all 12 months and is better in terms of high altitude acclimatization. This is an ideal way of starting a journey to Spiti. The route from Manali is shorter but is way more difficult due to the bad condition of the road. It is also only open from the end of May to early October.
There are regular daily buses from both Shimla and Manali for Kaza. From Shimla’s side, the bus will take two days to get to Kaza and from Manali’s side; it is a one-day journey. Please read How to reach Spiti Valley by Road, Bus, Air or Train.
Kaza to Komic
Once you have arrived in Kaza, you can drive up to Komic Village which will hardly take 60-90 minutes at most. Let me post a map of the route to explain it better.
From Kaza, start driving towards Manali, and about 1.5 kilometers later, you will come across a road climbing up to your right. This same road goes to other villages like Hikkim and Langza as well.
As you can see in the map above, you can complete this journey is in the form of a circuit as well. You can first go towards Langza and drive back down via Komic and Hikkim or you can do it the other way around. It took me about 5 hours from Kaza to complete the entire circuit with plenty of breaks and sightseeing in between
Bus to Komic Village
There is a daily bus that starts from Kaza at 5.00 PM and reaches Komic via Langza and Hikkim by 6.30 PM. It stays in the village for the nights and then travels back to Kaza the next day at 7.30 AM following the same route.
Where to Stay in Komic
There are no hotels or guest houses in Komic, and the only choice of accommodation available is in the form of homestays. Just talk to the villagers and anyone will be happy to let you stay as a paying guest for a nominal charge. Your stay will be very basic but comfortable. You also need to consider the fact that you are staying in the house of a simple villager so please do not keep your expectations high.
Tanpa Homestay here is probably the most known one. You can contact them at 9459483143. Another one is called Gompa’s House near Tangyud Monastery (9873146404). A third one is called Padma Homestay and can be contacted at 9459357872.
A friend of mine stayed at the monastery in the village so that is also an option that you can try. Talk to any of the lamas and see if they will let you stay at the monastery overnight. This is the most budget-friendly option. My friend paid only Rs. 200 per day at the monastery.
If not in Komic, then you can try your luck in the nearby Hikkim Village. There is one homestay there by the name of Tsedup’s house that can be contacted at 9873146404 / 9971799092. You can also stay at Hikkim Himalayan Cafe & Home Stay (9459040980 – 94598418090).
You can also try driving towards Langza Village, about 10 kilometers away. There are three homestays there as mentioned below.
- Lara Homestay – 094185 37689
- Sonam Homestay – 094187 57464
- Phan Dhey Homestay – 094186 20454
Where to Eat
There is one small restaurant here that goes by the name of ‘Spiti Organic Kitchen – World’s Highest Restaurant’ and is a good place to eat. It is located near the monastery. You savor not only good food but also amazing scenery. Other than this, there are no other eateries and you will be having your meals at the homestay only.
What to See in Komic Village
Komik is just a small village and as such, there is no long list of tourist attractions here. The natural beauty of the place is its greatest attraction. Irrespective of the time of the year you arrived here, the views you get from the village will just take your breath away.
Other than the landscape, listed below are some other places that are worth a mention.
Built like a fortified castle, The Tangyud Monastery is a small monastery located in the village. It is also referred to as the Komic Monastery and is one of the highest altitude gompas in the world. It is located on the periphery of the Kibber Wildlife Sanctuary.
The monastery was originally located in Hikkim village but then was shifted to Komic after the Spiti Earthquake of 1975 destroyed it. The ruins of the old monastery can still be seen while crossing Hikkim village.
One of the attractions of the monastery is a stuffed Leopard that hangs from its roofs on one of the rooms.
Please note that ladies are not allowed inside the main prayer sections of the monastery. I do not know why this rule exists but you will have to follow it.
If you speak to the monks, they will tell you that even before this monastery was made, there was already a prophecy about it in Tibet that a monastery in the shape of an eye of a snow cock would be built in Spiti.
The masked dances at Tangyud monastery, held around mid-October each year, are a big attraction for the locals.
There is also a grand Maitreya Buddha statue located in the Monastery known as Mahakaal (also spelled Mahakala Statue). It is located in the main prayer room where women and photography are both not allowed. There is a very interesting tale related to Komic Monastery and this Mahakaal statue.
A common belief is that the Tangyud Monastery is a newer one, moved from Hikkim to Komic but the villagers will tell you otherwise. The original monastery was in Komic only for centuries. Then a long time ago, due to a drought, the monks of Komic decided to move the monastery to a slightly lower village of Hikkim.
A new monastery was built in Hikkim but when it was time to shift, the Mahakaal statue refused to move and stayed at its foundation in Komic. Efforts continued for several days to lift and relocate the statue but all of them failed.
The villagers then decided to leave it where it sat and moved the rest of the monastery to Hikkim. Only one monk was left at the old monastery to continue the prayers.
In 1975, a devastating earthquake hit the Spiti region and leveled the monastery in Hikkim. This is the one that you will see the ruins of while traveling between the two villages. To everyone’s surprise, the old Monastery in Komic however remained intact with no damage at all. The Mahakala statue too sat royally with not an inch of damage on it.
The monks took this as a divine sign that Komic was the holiest place for the monastery to be in. The old Monastery was then rebuilt into the new existing one.
Post Office in Hikkim
As you travel to or from Komic Village, you must also stop briefly at the post office in Hikkim. Situated at an altitude of 14,400 ft, it is famed as the world’s highest post office. It came into existence on November 5, 1983, and covers a group of about 7 small villages nearby. It only remains operational for about 6 months and is forced to shut during winter months due to heavy snowfall.
Considering the fact that there is no cellphone signal or internet here, it is the only connection to the world for the residents of Hikkim and other villages nearby. The post office also maintains savings accounts for locals where villagers can deposit or withdraw money.
Komic, like the other villages nearby in this area, is rich in fossils. Langza is commonly known as the fossil village but you can very easily find those in Komic as well, provided that you know what you were looking for. Otherwise, a fossil will look like just another piece of rock to people like us. The villagers, however, have a few that they can show and can even sell you for a small price.
There is a wildlife sanctuary quite close to Komic Village. It is known as Kibber Wildlife Sanctuary (named after the village Kibber) and is home to several endangered animals like Snow Leopard, Ibex, and Red Fox. If you were lucky, you may get a glimpse of the local wildlife.
What to do in Komic
To be honest, you do not come to a place like Komic hoping to do a million things. Rather, you arrive at a place like this to do nothing. The best thing to do in the village will be to just sit down with a cup of tea in your hand and sip on it while enjoying the landscape. You come to villages like Komic to slow life down for a few days and rejuvenate yourself.
With that being said, listed below are a few things that you can enjoy in Komic Village.
If you do not want to buy the fossils that the villagers have to sell, you can hire a local and spend a day finding some fossils yourself.
Take a Walk around the Village
The best thing to do in Komic village would be to just sit back, relax and take a stroll through the village. See the local vistas, visit the monastery, talk to the locals, learn about their culture and get a taste of how life in Spiti goes on.
This is one of my favorite things to do in Komic. It does not matter whether you were carrying a huge professional DSLR or just a cell phone camera, you will have loads of fun clicking hundreds of pictures here. From Landscape to wildlife to people, Komic is capable to cater to a wide range of photography enthusiasts.
Also Read: How to Plan a Trip to Kinnaur Valley
Be Amazed by the Skies and the Stars
That is right, you will definitely be amazed by the view that each night of Komic brings. The pollution-free sky lights up with millions of stars each night; a sight that city folks like you and I rarely get to see. If you were into photography and were carrying a capable enough camera, you will have fun getting some long exposure shots of the Milky Way and star trails.
Send a Post Card from Hikkim Village
Let me first explain how the entire process works. You visit the post office and buy a postcard, which will cost you about Rs. 25, including all charges. The two postmen will then carry the mail to Kaza, on foot. From Kaza, the mail will then be loaded on an HRTC bus to Reckong Peo, then on another bus to Shimla, and then finally on a third bus to Delhi. From Delhi then, it will be distributed by rail or air depending upon its destination.
Why would you send a postcard from here? For fun really and also to support the local livelihood. A lot of travelers make it this far to Hikkim village to take pride in mailing their letters from one of the highest post offices on Earth.
It is a feeling one of its kind. Buy a postcard and then sit down in the middle of nowhere to write a message. Mail it over to your family or friends or even yourself. It serves as a small souvenir that you bought from Hikkim but only mailed to yourself.
To be honest, this post office really puts the village of Hikkim and other villages around it on the tourist map. Is it worth coming to Hikkim and send a postcard from here? My answer is that yes it is.
The weather in Komic Village remains cold throughout the year. Even in the months like May and June, you will need to woolens and jackets to survive here. During the winter season, the entire region gets buried under a thick sheet of snow and the temperature drops down to almost 20 degrees below zero.
During the summer, however, the temperature remains at around 10-15°C during the day and 5°C at night. The weather at this time is very enjoyable with moderately warm days and pleasantly cold nights.
Spiti is in a rain shadow area so it almost never rains here. If you were looking to spend a night in the village, make sure to bring plenty of woolens to handle the cold at night, irrespective of the month of your arrival.
Best time to Visit Komic Village
The best time to visit Komic is between the months of May and September, which is also the best time to visit Spiti Valley. The valley is completely and easily accessible at this time with both the roads leading from Shimla and Manali open. The weather too will be pleasant and since this is the peak tourist season, you will be able to cover all of the tourist places in Spiti Valley and Kinnaur.
A lot of people however make a winter trip as well to this region. The nearby Kibber Wildlife sanctuary is home to several snow leopards. It attracts a lot of wildlife enthusiasts and photographers each year; hoping to catch a glimpse of the elusive cat.
So if you wanted to enjoy a white Spiti or were hoping to go spot a snow leopard, the months of January and February would be ideal. But please know that winters in Spiti are extremely harsh. This is when then the temperature can drop to as low as -35°C. Electricity can remain gone for weeks and there will not be any phone connectivity as well. If the roads got blocked, you will be stuck here until the authorities are able to clear the snow and restore connectivity.
Hence, the best time to visit Komic village will be from June to September. You can plan in April and May as well but would then have to keep Manali Kaza Highway and Chandratal out of your Spiti Itinerary.
Mobile Connectivity in Komik Village
BSNL has the widest coverage in Spiti Valley but even that does not work here. If you were on BSNL, Jio, or Airtel networks, your phone will work in and around Kaza town. But it will go off the network a few kilometers out of the town.
Highest Village in the World
Is Komic the highest village in the world? It actually is not. That is something that the locals just put up on a board to attract tourists and adventure junkies.
There are several other villages in India and Tibet that are at a higher altitude than this. One example is of Karzok Village in Ladakh at a height of 4,595 meters. Another one is the Koyul Village in Ladakh at a height of 4,660 meters. There are several other villages in Tibet that are at much higher elevations than this.
ATM / Banks
There are no ATMs or banks here. The nearest one is located in Kaza.
I hope the information above on visiting Komic Village in Spiti Valley was of help. If you have any questions; or need any other details; please feel free to ask in the comments section below, or at our Community Forum, and I will be glad to answer.

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Victor Wembanyama is putting the NBA world on notice.
The 18-year-old French player has hoops fans dreaming of a transcendent star after his performance in Tuesday night's exhibition between his Metropolitans 92 and Scoot Henderson's G League Ignite. Wembanyama displayed an unprecedented skill set for a 7-foot-4 prospect by draining seven three-pointers and swatting five blocks.
As one anonymous NBA general manager told ESPN's Adrian Wojnarowski, teams are already salivating over the opportunity to draft Wembanyama next year.
“It feels like last night will start a race to the bottom like we've never seen."
Wembanyama dazzled viewers by scoring 37 points in Nevada, his first game in the United States. While Henderson also validated the hype with 28 points, the big man made a convincing case to warrant the No. 1 spot in the 2023 NBA Draft.
The hype is only going to grow. Wojnarowski and Jonathan Givony reported a lofty comparison from a general manager "with a chance to contend" for the top pick.
"He's a 7-foot-4 [Kevin] Durant who blocks shots -- and he's not even close to what he's going to be," the GM said. "He will be the most hyped player since LeBron [James]."
Woj and Givony examined how Wembanyama could impact the upcoming NBA season. The chance to select Henderson as a worthy consolation prize could further motivate tanking in 2022-23.
"There won't only be a race to the bottom, but an opportunity for playoff and championship contenders to have more impactful players available to acquire in deals," they wrote. "Executives believe that could include more players available far sooner than the February trade deadline. The NBA flattened draft lottery odds to curb tanking in 2019, giving the teams with the three worst records a 14 percent chance each at winning the No. 1 pick in the draft lottery. The possibility of landing either Wembanyama or Henderson rises to 27 percent for the teams with the three worst records."
Lottery-bound NBA teams -- and fans of those clubs -- will get one more opportunity to watch Wembanyama and Henderson oppose each other on Thursday.


ENCINITAS — Mayor Catherine Blakespear recently signed on to a national effort that she hopes will be a “Perfect 10” for the city of Encinitas.
Blakespear, at 10:10 a.m. Oct. 10, joined the “10-Minute Walk” parks advocacy campaign, a nationwide campaign to ensure that all Americans live within a 10-minute walk (or a half mile) of a high-quality park or green space.
“Parks are an essential part of the community here in Encinitas,” Blakespear said. “This campaign will help provide our residents with the opportunity to engage in activities that lead to a better quality of life that is close to home.”
This bipartisan group includes mayors from all across the country and represents cities large and small, including America’s four largest cities — New York, Los Angeles, Chicago and Houston — and cities across California.
The U.S. Conference of Mayors, which represents more than 1,000 U.S. mayors, also unanimously passed a resolution at the 85th Annual Meeting urging all mayors to actively pursue the 10-minute walk to a park goal.
The campaign marks the start of a multi-year partnership with cities and mayors across the country. Beginning in 2018, the campaign — led by The Trust for Public Land in partnership with the National Recreation and Park Association and Urban Land Institute — will be working with select cities across the country on measurable policies and strategies to advance the 10-minute walk vision.


Watch: Psaki Blames Unvaccinated People For Biden’s Terrible Polls
Flustered Psaki uses Covid pandemic, unvaccinated as scapegoat to hide real reasons Biden’s horrible poll numbers.
White House Press Secretary Jen Psaki on Friday struggled to explain why Joe Biden’s approval rating continues to spiral downwards.
Asked by a reporter, “ What do you make of these really terrible polls? ” Psaki deflected to the coronavirus pandemic and the large number of unvaccinated people as reasons Biden’s so unpopular.
“ I would say that this is a really tough time in our country, ” a flustered Psaki responded.
“ We’re still battling Covid, and a lot of people thought we’d be through it, including us. And because of the rise of the Delta variant, due to the fact that even though it was a vaccine that was approved under a Republican administration, despite the fact that we now have full FDA approval and even though it’s widely available over the country… we still have a quarter of the country… less than that… 20% of the country who’ve decided not to get vaccinated. No question that’s having an impact. ”
“ Biden’s approval rating has dropped to 38%, according to a Quinnipiac University poll released Wednesday , ” reports USA Today . “ That’s down from 42% three weeks ago and from a a lot of 50% in mid-February. ”
Despite Psaki’s superficial explanation, the polls likely reflect Americans’ dissatisfaction with an increasingly high number of Biden administration failures, such as the border crisis, the bungled Afghanistan withdrawal, the stagnant economy and inflation, high gas prices, not to mention recent Covid-19 vaccine mandates which may have put thousands out of work.
Johns Hopkins Illustration Proves COVID Shots Causing Majority of Illness and Death


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OPINION – This article could contain comment that reflects author’s view.
Joe Biden’s approval ratings are once again approaching the lowest level of his presidency even though his Democratic Party did better in the November midterms than many analyses had predicted.
According to a new Reuters survey, roughly 40 percent of Americans approve of Biden’s job performance, just a tad higher than his 39 percent approval rating from December. In May and June of 2022, however, Biden’s approval sank to just 36 percent in the same poll as inflation hit highs along with gasoline and diesel prices.
Democrats managed to increase their majority in the Senate by one seat, while Republicans took back control of the House with a narrow majority, making Biden’s next two years in terms of getting his agenda through much more difficult.
Biden’s falling approval rating comes as inflation continues to remain higher than normal, oil prices are starting rise again, companies are laying off tens of thousands of workers, and he faces a new scandal regarding his potentially illegal possession of classified documents.
A growing number of Senate Democrats are concerned that President Joe Biden had at least dozens classified documents, potentially violating the law. They support an investigation.
Unlike former President Donald Trump, who — as head of the Executive Branch — had the authority to declassify documents virtually at will, Biden, as a U.S. senator and even as Barack Obama’s vice president, never did, so the fact that he had them at all is troubling to a growing number of Dems, Fox News reported.
“The reports about President Biden’s mishandling of classified documents are extremely irresponsible and disturbing. These allegations should be investigated fully,”On Friday, Sen. Joe Manchin (D-W. Va.) spoke to the network.
Sen. Tim Kaine (D-Va.), who was Hillary Clinton’s running mate in 2016, agreed.
“This news raises serious questions and the appointment of an unbiased special prosecutor to investigate the matter is the right step,”Kaine stated.
“Classified documents belong in classified settings, and I think you heard me say oversight is not a partisan thing. Good oversight means you’re willing to hold any rule breaker to account,” Rep. Katie Porter (D-Calif.) added. “We should be asking for answers in a respectful way, and we should be expecting to get honest ones.”
“Well, it’s certainly embarrassing. Right?”Debbie Stabenow (retiring Michigan Senator) said it during an interview last week on NBC. “I mean, it’s embarrassing that you would find a small number of documents, certainly not on purpose. They don’t think it’s the right thing, and they’ve been moving to correct it, working with the Department of Justice, working with everyone involved, with the [National] Archives, and so from my perspective, you know, it’s one of those moments that obviously they wish hadn’t happened.”
A brutal June survey revealed that Biden’s popularity is low.
According to the Yahoo/YouGov survey, 64 percent said Biden shouldn’t run, or 9 points worse than Trump.
What’s more, the same survey found that Trump beats Biden in a head-to-head rematch, according to Mediaite, though 55 percent said they did not want the former president to run again, either.
You can find the ‘yes’Column, Biden was polled at 21% versus 31% for Trump.
Biden was also hit with more negativity in the poll. Even among Democrats, most would not encourage him to seek reelection: Just 42 percent want him to, while just over one-third, or 36 percent, said he shouldn’t.
Meanwhile, a good majority of Republicans — 58 percent — would encourage Trump to run again, while just one-quarter, or 25 percent, would not.
Worse still, 40% of his 2020 voters want him to be back in the race again. Only 37% don’t. In a rematch, according to the poll, Trump wins 42 percent to 39 percent.
Overall, Biden’s approval ratings had been in a freefall for nearly a year prior to that survey, reaching a level that was below that of his predecessor.
What’s more, according to NBC News in late May, Biden wasn’t pleased with being undermined after nearly every major policy statement he makes, becoming particularly peeved by aides underlings who quickly ‘correct the record’ and ‘explain what he really meant.’
Check out the complete article here

domain: politics


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As Boris Johnson’s economic adviser while Mayor of London, and a Brexiteer to boot, Gerard Lyons is one of the favourites to succeed Mark Carney as Governor of the Bank of England.
Lyons insists that he has never been offered or promised any post by the new Prime Minister, or his Government, but he’s a long-standing proponent of the “opportunities” of Brexit, and is said to be Mr Johnson’s “favourite economist”.
These attributes naturally support his candidacy. A decision is expected to be made before Britain leaves the European Union on Oct 31, though the new Governor will not take up the post until the end of January.
So what approach might Lyons adopt, if offered the job?
In a wide-ranging interview with The Telegraph, Lyons insisted that the status quo for the British economy no longer sufficed either in terms of addressing the UK’s domestic challenges or positioning the country for a fast changing world.
Regardless of Brexit, he believes the Bank of England will soon have to join the global loosening in monetary policy and that there is a case for re-examining the Bank of England’s inflation targeting mandate to make it more pro-growth.
A no-deal Brexit is likely to require monetary support, Lyons believes, contrary to suggestions that inflationary pressures might prompt rates to rise. He is pragmatic about such a scenario, saying no-deal will definitely be some kind of an economic shock and that Mark Carney was right to highlight its immediate challenges in recent comments.
But he also thinks it should have been made clear that, whatever the short-term disruption, the economy can cope. Lyons believes the Bank of England should be more visible at international gatherings in putting forward a positive global vision for the UK and “closing the pessimism gap”.
Deal or no deal, he says there is a good case for more overt fiscal activism in the UK and that monetary policy might have to be used to improve the quantity of lending to the UK economy.
Lyons predicts that the pound might well weaken further. But this is not necessarily a bad thing. The currency is now very competitive and there might come a time we look back at the current level of the pound and think that was a very attractive rate at which to buy sterling assets.
Tight-lipped on speculation
Lyons is keen to stress that he’s never commented and doesn’t intend to on the rumours surrounding the Bank of England job, but he is equally keen to dispel suggestions that he lacks the international connections and authority required of the position.
“Obviously people keep commenting on my association with Boris – I worked with him at City Hall – but with over 30 years of experience at the cutting edge of financial and capital markets, my experience is much broader.
“Indeed, very few economists have the depth and knowledge of experience in markets that I would argue I have, and likewise many people in the international market scene might not have the depth and knowledge of the UK economy that I have.
“I know the global economy incredibly well, in terms of having worked for the Japanese, the Swiss, the Americans and at Standard Chartered. I know Japan inside out... China inside out... So at a time of post-Brexit, when the UK needs to position itself globally, I bring that aspect.
“And I have great experience of how international banks work, not just in terms of being head of research and chief economist at Standard Chartered. I was also on the global markets management team, which was responsible for a big chunk of the wholesale bank, as well as the risk management team.”
A tough background
Born into a working class family of four children, crammed into a two-bedroom Kilburn dwelling with outdoor toilet, and entirely educated at state schools, Lyons was forced to learn the hard way what the real world looks like. He knows first hand about deprivation.
As part of an immigrant Irish, Catholic family, he also knows all about the struggles of the outsider, and the discrimination they are prone to encounter. I ask whether that background influences the way he thinks about the economy, and he agrees that it probably has.
Over the years, Lyons has had some excellent contrarian calls on the economy, from the bust of the Lawson boom, to the economic benefits of leaving the European exchange rate mechanism and the financial crisis. As someone who has repeatedly proved himself unafraid to go against the consensus, Lyons therefore makes a natural Brexiteer.
“I think the biggest challenge in economics is groupthink and status quo bias," he says. "There will always be a cost involved in making a big change. But sometimes it is necessary to push back at the right time, not constantly, because much of the time the consensus is spot on, but it is important to have the confidence and clarity of mind to challenge the groupthink when appropriate.”
Brexit a "stepping stone"
On Brexit, he says that no-deal will undoubtedly be a shock to the economy and potentially very disruptive.
“But too often the discussion assumes no-deal is the end state, whereas in fact no-deal is just a stepping stone to something else, which is a future mutually beneficial trading relationship.
“Once you take out the politics, it is obvious that the UK and the EU have to have a sensible relationship. Indeed that is why I think we will reach an agreement and avoid a no deal.”
On Mark Carney’s recent warnings of a possible recession, Lyons insists that the Governor was right to highlight the immediate challenges of Brexit. However, “its impact will depend on how prepared we are and how the EU reacts, and it should have been made clear that, whatever the short-term disruption, the economy would cope and policy would respond in an immediate and appropriate way".
“I would say that it is more likely there will be monetary easing post a no deal. But even without Brexit, the economy looks to be softer than anticipated, and that has prompted a U-turn in global monetary policy, which I would expect the Bank of England to have to join in soon.”
Dispelling the gloom
What of the “gloomster” allegations repeatedly levelled at the Bank of England, and the general sense of bewilderment that many foreign observers express over the whole Brexit endeavour?
Lyons thinks it important to use the opportunity presented by meetings of global leaders to give an upbeat but realistic assessment of the UK.
“The UK hasn’t articulated what it hopes to achieve, and I think that is partly because in the last few years we have been talking about Brexit as if it is about making the most of a bad job rather than as a great opportunity. We have had politicians saying we have to deliver on the referendum as if it is an imposition, whereas it should be seen as a great opportunity.
“Despite all the challenges of the West, the global economy is growing. For the UK, the status quo will not suffice to address domestic issues and will not suffice in terms of positioning ourselves globally. We’ve got lots of strengths going for us, but we need to adapt and change. Maybe the Bank of England’s policy mandate has to be part of that.
“No-one should rush into any changes. But it is an appropriate time, given both domestic and global developments, to re-examine what might work best. For instance, should the inflation target change or, given high debt to GDP, would a money GDP target be credible, or even achievable? Or, should the remit, like in the US, be broader?
“It is about ensuring the Bank’s remit not only continues to achieve monetary and financial stability, but helps towards stronger, sustainable growth.”

domain: news


Select Product Concept(s)
Table of Contents
Step 1 - 2. Development and Concept SelectionBased on the Customer Needs and Engineering Specifications, the team has developed four different concept ideas to evaluate. The four concept names were given based on their process location:
1. Cat Eye Location
2. Conveyor Location
3. Belt Location
4. Oven Bed Location
Since each process have similar functions, a selection matrix was developed to select the best location where the system could be implemented to.
The Pugh Diagram tool was used to identify and rate each concept according to their location benefits. An ideal location would facilitate the input of water to the system design, output of water to the cheesecake pans, adequate time to complete the job.
Used the link below to access The Pugh Diagram
Step 3. Rank the Concepts
|Cat Eye Location||46||1|
|Oven Bed Location||0||3|
Step 4. Combine and Improve the Concepts
After reviewing the Pugh Diagram, a decision was made to use the Cat Eye Location concept. This concept would allow us to deliver a system capable to meet most of the Customer Specifications. Based on the fact that the four concepts previously mentioned have strong similarities, it was decided to combine them in order to design a system capable of pouring water to the sheet pans at the Cat Eye Location.
It was also decided that using a four hose dispense system is the most efficient concept.
Step 5. Select One or More Concepts
The Team decided to select concept 1 (Cat Eye Location)
Step 6. Reflect on the Results and the Process
The results of the Pugh diagram and the agreement of the group the design was based on a fixed system. The system was designed with a main control box that controlled two sensors. The first sensor would read when the first 4 pans had arrived signaling the control box to open the first valve filling the first 4 pans through fixed tubing. The timer that is set based on the flow rate and pressure will count down filling the pans to 2.5 quarts and then close the first valve. When the 8th pan arrives this will trigger the control box to open the second valve using the last 4 fixed tubes to fill the other pans. The timer here will also control how long it needs to be open to fill the pans to 2.5 quarts. After the valve closes depending on time remaining the sensor will then signal the release mechanism when the oven needs the next set of pans sending them through. The release mechanism will engage when the final pan passes the sensor point reengaging the mechanism and the process will repeat itself.
The reason a two sensor system was picked was to essentially over design the system in case the flow of 10 gallons per minute at 50 psi is not enough to fill all of the 8 pans at once. The reason why the conveyor at the cat eye position was chosen because of the controls already in place allowing for easy adaptation and evolution of the system. Piping without the pump was chosen because of the high flow rate and pressure.


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TALLAHASSEE, Fl. (WTXL) -- Every Tuesday on WTXL Sunrise, you'll be able to have one of your own weather questions answered by Meteorologist Alex Cordero.
This week, our question was emailed by viewer Chris Floyd, from Tallahassee, Florida.
His question: What is the Fujiwhara Effect?
The National Weather Service defines it as "The tendency of two nearby tropical cyclones to rotate cyclonically about each other." It is a very rare phenomenon. This can happen with hurricanes in the Atlantic, Typhoons in the Pacific, and other low pressure systems worldwide. Hurricane Nicole and Hurricane Matthew had slight interactions with each other as Matthew was barreling down the U.S. east coast.
When two tropical systems get very close to each other, they can interact with one another. The influence of the storms rotations can cause them to rotate about a single point. And if one storm becomes large enough, its circulation can "eat" the smaller one. The resulting storm isn't always stronger, but it can certainly look intimidating.
Remember you can send your questions to Facebook, Twitter, Instagram, or send them to firstname.lastname@example.org

domain: geography


text:
Dismissal director: violation of good employment practices?
An interesting employment case about the dismissal of a director. A director becomes incapacitated to work due to work-related stress. On the day that his reintegration process starts and the director shows up at work, he is given notice of dismissal. Is this a manifestly unreasonable dismissal or is this the underperformance risk of a director (under
articles of association
A document, drawn up when a Dutch company or legal person is set up, and which regulates the operations of the company and defines its purpose.
» Meer over articles of association Articles of Association)? The subdistrict court answers this in a recent ruling. Employment lawyer in The Netherlands Sander Schouten explains the case.
Director incapacitated to work due to stress
The claimant in this case was a director (under articles of association) at ATP (his employer), an international company. At a certain point the claimant called in sick due to stress-related complaints. The company doctor found that he was incapacitated to work due to illness. The report states that the stress complaints were, among others, work-related. The claimant stays home for 5 months. In consultation with the company’s Health and Safety doctor, the claimant and the employer agree on a reintegration treatment plan.
Director dismissed by the General Meeting of Shareholders
However, on the first day that the claimant was due to resume work, he failed to appear at the office (without notice). After a mediation process, the claimant eventually resumed work on 19 June. On that same day, the employer handed the director an invitation for the general meeting of shareholders for 19 July, where the item on the agenda was his dismissal. At this meeting the General Meeting of Shareholders decided to dismiss the director. The employer, taking into account the term of notice, terminated the employment contract. The claimant does not agree with the termination of his employment and engages an employment lawyer. He instigates proceedings in which he claims damages for manifestly unreasonable dismissal.
Underperformance risk of director
To assess the issue of whether the dismissal is manifestly unreasonable, the court finds, firstly, that the position of a director cannot be compared to that of a ‘normal’ employee. A director’s personal qualities to a large extent form the basis of the development and profitability of a company. If the results are disappointing or if a director has an insufficient base of support from the employees, shareholders can lose confidence in a director. A loss of confidence usually results in the director leaving. This underperformance risk of a director is usually taken into account when determining the employment conditions, such as, for example, higher remunerations, a bonus, a longer term of notice etc.
Employment lawyer in The Netherlands
In this case the court considers that the employer no longer had confidence in the claimant as a director. According to the employer, this was due to, on the one hand, the manner in which the claimant behaved during the reintegration process, and, on the other hand, with his (unsatisfactory) performance prior to his incapacity to work. However, the court finds that the employer can be blamed for this latter reason. Before he called in sick, the claimant was never confronted with complaints by employees or about his management style. In that respect the employer acted contrary to the requirements of proper employment practices. The court also finds that the fact that the employer did not offer the claimant a realistic opportunity to reintegrate (he was dismissed on the first day that he resumed work) is culpable. The court finds that the dismissal was manifestly unreasonable and awards damages to the claimant.

domain: law


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With just three days left till Summer in Southside, our Hippodrome Ambassadors Heather and Sipho caught up with some of the artists set to perform at the festival to find out more about their work.
They chatted to singer-songwriter Alisha Kadir, one of four acoustic acts opening Saturday night’s MIX UP event in the Stageside Bar opposite the theatre. Alisha will lead the line-up from 8pm, followed by Birmingham-based performers Transits, Ed Geater and Elektric.
Alisha describes her music as “ranty, political songs that are presented very softly”
“I like writing about the balance of power and how power works,” she said.
Nevertheless, she doesn’t see herself as having been heavily influenced by other political artists.
“I tend not to listen to anything that’s like the stuff I do. There are artists that I admire but they don’t necessarily influence my work. For example, I listen to a lot of digital music, but I’d never make any myself.”
Earlier in her musical career (according to Alisha, she has been “singing since [she] could talk”), she provided vocals for various bands, but more recently, she has felt liberated by a decision to go solo.
“You reach a point where you realise you’re relying on six people to all turn up on time and bring their instruments, and that doesn’t always happen. So I picked up a guitar and started learning myself. That was probably four years ago.”
Having performed locally for a few years now, Alisha is already familiar with some of the other artists performing at MIX UP, including Transits and our headline VJ, Tommy XJ.
“Tommy is one of my favourite people – he’s great!” she exclaimed.
Though not a regular Hippodrome visitor, she remembers attending events at the theatre in the past, including last year’s Summer in Southside festival.
“I seem to accidentally end up at all of them. It’s always a good vibe for this end of the city, being out in public space and trying to get more people involved in the arts.”
With more time to plan and a clearer sense of what’s happening at this year’s festival, she hopes to see more of what’s on offer, and seemed particularly keen to get stuck in to Polyglot’s ‘Tangle‘, an interactive installation that will see visitors stretching and weaving colourful elastic around the Southside area.
Asked what she would hope to find at an alternative night out for young creatives, Alisha talked about the importance of freedom to experiment and do things differently.
“I think having space to be strange and accepted is really important for a young creative. Even within the arts there are so many stereotypes and it’s not always okay to be strange and out there. So I think the most important thing is to have somewhere that’s comfortably weird.”

domain: entertainment


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‘Don’t know why few players were left out, this is not the right team’ – Shahid Afridi on Pakistan’s T20 World Cup 2021 squad
Don’t agree with the squad chosen but this is our team so we have to support it at the World Cup, Afridi said,
Updated - Sep 26, 2021 2:18 pm
Former Pakistan all-rounder Shahid Afridi is not satisfied with Pakistan’s selection choices for the upcoming T20 World Cup 2021, scheduled to be played between October 17 to November 14 in the United Arab Emirates and Oman.
Afridi stated that he does not understand why were few players left out, although he stated that given this is his nation’s team, he would back them to win nonetheless.
“I don’t know why certain players were picked and a few were left out. I have heard that there are plans to announce a modified T20 World Cup squad. My individual thinking is that this is not the right team. Ideally, there should have been two three changes. So yeah, don’t agree with the squad chosen but this is our team so we have to support it at the World Cup,” Afridi told Cricket Pakistan.
All the teams have time until October 10 to finalize their squad, which could mean certain inclusions and exclusions from the Pakistan team, who have key players including Fakhar Zaman, Sarfaraz Ahmed and Shoaib Malik missing out from the 15-member squad.
Decision to hire new coaches should’ve been taken after World Cup: Shahid Afridi
While opening up regarding Pakistan’s decision to rope in former Australia opener Matthew Hayden and former South Africa pacer Vernon Philander as mentors for the multi-team tournament, Afridi said that it was a decision that should have been made after the tournament.
“Don’t think the new coaching staff (Hayden and Philander) will be able to make much of a difference at the T20 World Cup. This decision to hire new coaches should ideally have been taken after the World Cup.”
“If the coaches who have left quit on their own will, then they have wronged Pakistan cricket. The new ones who have come in will obviously say we have just taken over. I think the same coaches should have stayed till the T20 World Cup.”
Notably, Pakistan head coach Misbah-ul-Haq and bowling coach Waqar Younis resigned the same day Pakistan Cricket Board announced the 15-member T20 World Cup squad. Pakistan being their campaign on October 24 against arch-rivals India.