Effective approaches that engage men in weight loss and lifestyle change are important because of worldwide increases, including in Canada, in obesity and chronic diseases. Football Fans in Training (FFIT), developed in Scotland, successfully tackled these problems by engaging overweight/obese male football fans in sustained weight loss and positive health behaviours, through program deliveries at professional football stadia.eSteps™ (evidence-based lifestyle program) to develop Hockey Fans in Training (Hockey FIT); 2) Explore potential for Hockey FIT to help overweight/obese men lose weight and improve other outcomes by 12 weeks, and retain these improvements to 12 months; 3) Evaluate feasibility of recruiting and retaining overweight/obese men; 4) Evaluate acceptability of Hockey FIT; and 5) Conduct program optimization via a process evaluation. We conducted a two-arm pilot pragmatic randomized controlled trial (pRCT) whereby 80 overweight/obese male hockey fans  were recruited through their connection to two junior A hockey teams  and randomized to Intervention (Hockey FIT) or Comparator (Wait-List Control). Hockey FIT includes a 12-week Active Phase (classroom instruction and exercise sessions delivered weekly by trained coaches) and a 40-week Maintenance Phase. Data collected at baseline and 12 weeks (both groups), and 12 months (Intervention only), will inform evaluation of the potential of Hockey FIT to help men lose weight and improve other health outcomes. Feasibility and acceptability will be assessed using data from self-reports at screening and baseline, program fidelity (program observations and coach reflections), participant focus group discussions, coach interviews, as well as program questionnaires and interviews with participants. This information will be analyzed to inform program optimization.Aims: 1) Adapt FFIT to hockey within the Canadian context and integrate with HealthHockey FIT is a gender-sensitive program designed to engage overweight/obese male hockey fans to improve physical activity and healthy eating choices, thereby leading to weight loss and other positive changes in health outcomes. We expect this study to provide evidence for a full-scale confirmatory pRCT.NCT02396524 . Date of registration: Feb 26, 2015. Participants were allocated in correspondence to the numerical order of the randomization envelopes and their order of appointments.All participants (intervention and comparator) were provided with copies of Canada’s Food Guide  and the Due to the nature of the study, participants and coaches could not be blinded to group allocation. During 12-week measurement sessions, a blinded assessor conducted all weight measurements in a separate room; no other measurements were blinded.The Hockey FIT program uses group-based delivery to help men achieve changes in health behaviours and indicators. The program was delivered by two trained Hockey FIT coaches (one Head Coach and one Assistant Coach) to groups of 20 men, over 12, weekly, 90-min sessions. See Table All participants received Hockey FIT handbooks at the first session. Nine sessions took place at a local GoodLife Fitness club, whereas three sessions  were held at the affiliated hockey team’s arena. It was not possible to hold all Hockey FIT sessions at the hockey team arena due to logistical reasons; however, sessions at the arenas were critical in that they provided an association between the team and program. Hockey FIT head coaches were male graduate students in Kinesiology with extensive backgrounds in coaching (one with extensive background in hockey coaching). The Hockey FIT assistant coaches were senior female university students in Kinesiology, who also had a background in playing hockey.Sessions are comprised of: 1) classroom-based education focusing on healthy eating and physical activity, delivered in an interactive, non-didactic style; and 2) exercise sessions where men receive training in aerobic, strength and flexibility exercises, incorporating their love of hockey “off the ice” , and tailored to individual abilities. At the start of the program, more time is allocated to education during each session, but as the program progresses, the amount of time spent on the classroom education decreases, while the amount of time spent on group-based exercise increases. This also coincides with the intensity of the exercise sessions increasing and the educational content becoming more focused on reviewing previously learned content.Similar to FFIT , the delCoaches also provide instruction on behaviour change techniques (BCTs) effective in physical activity and dietary interventions  . These BAt two different time points (session #4 and #10), participants completed the Step Test and Exercise Prescription (STEP) tool in order to receive a personalized target heart rate (65–85 % of estimated maximum heart rate) , 44. CoaMaintenance Phase, men were introduced to eHealth technology support tools, including the HealtheSteps smartphone app  and their own team’s Hockey FIT social network – a secure, closed, web-based network of their Hockey FIT group and Head Coach on Tyze Personal Networks .In preparing for the eSteps app and the Hockey FIT Social Network. Men were encouraged to use the Network to share success stories, share resources , ask questions and keep in touch with others in the group, including the Hockey FIT coach. The platform was a place where resources from the program were shared and made available to all participants. In addition to being used for casual exchange, the Hockey FIT Social Network platform was also used by the Head Coach to send out standardized messages  containing reminders and encouraging messages about sustaining healthy lifestyle behaviours.Participants were encouraged to continue with their lifestyle prescriptions and sustain their behaviour change with the support of the HealthSix months after the completion of the Active Phase, participants were invited to attend a Hockey FIT Reunion (combining participants from both sites), which consisted of a one-hour booster session followed by lunch and free entry to a London Knights vs. Sarnia Sting game . The Head Coaches from both London and Sarnia ran the booster session, which focused on reinforcing topics such as goal setting, stages of change and re-setting lifestyle prescriptions, and included an exercise segment focused on aerobic activities.At each site, all participants began the study at the same time and teams of research staff completed measurement sessions over an approximate 2-week period (at each time point). All randomized men were contacted at each follow-up, including those in the intervention group who did not complete the Hockey FIT program. Questionnaires were mailed for self-completion (and a time arranged with the study team for pick-up) for any participants who agreed to assessment but were not willing or able to come to a measurement session. Since the comparator group were offered the opportunity to take part in the Hockey FIT program shortly following the 12-week measurement session, individuals in this group did not participate in any follow up measurements beyond 12 weeks.At baseline, participant demographic and clinical characteristics were collected including: age, marital status, education, occupation, ethnicity, health status, smoking status, medical conditions/history and medications.Objectively-measured clinical characteristics: weight (kg and % of baseline weight), BMI , waist circumference (cm), and resting systolic and diastolic blood pressure .Self-reported physical activity and sitting time: average steps/day, measured using Yamax Digiwalker SW-200 pedometers and self-reported by participants using a 7-day paper log [aper log , 58; totaper log ; and timSelf-reported eating and alcohol: healthful eating score, measured using Starting the Conversation (STC) questionnaire [ionnaire ; fatty fionnaire  and follionnaire ; and totionnaire .Psychological and health-related quality of life: self-esteem score, measured using the Rosenberg Self-Esteem Scale (RSES); positive and negative affect scores, measured using the International Positive and Negative Affect Schedule Short Form (I-PANAS-SF) [ANAS-SF) ; and selANAS-SF) , 65.The following outcome measures were taken at baseline and 12 weeks in both groups, and then again at 12 months in the intervention group only:All self-reported measures were collected using paper-based, self-administered questionnaires. Outcome measures were modelled after the FFIT evaluation but included a few differences: 1) the Hockey FIT evaluation replaced the Short Form-12 with the EQ-5D-3 L questionnaire for a simple measurement of health-related quality of life and pilot of the EQ-5D-3 L for ease of use for planning for a future economic evaluation; 2) Hockey FIT added the Starting the Conversation Questionnaire to obtain a simple single score of healthful eating; and 3) Hockey FIT also included measurement of physical activity via pedometers. See Table All participants received free promotional materials from GoodLife and Sarnia Sting/London Knights hockey teams . Participants also received a Hockey FIT t-shirt, a Hockey FIT puck, a healthy lunch and free game tickets if they attended the reunion/booster session. Further, the intervention group received a $20 gift card to a local sports store if they attended the 12-month measurement session. Attendance raffles were held at the end of the 12-week active phase to encourage attendance at all 12 sessions . See Table For all outcome measures, observed values at baseline and 12 weeks will be summarized descriptively for each group. In addition, for the Hockey FIT group only, observed values at 12 months will be summarized descriptively. For data (average steps/day), participants were required to have at least three complete days of data, in order for data to be utilized in analyses .Analyses will be performed following intent-to-treat principles; thus, we will include all participants with at least valid baseline data according to the randomization scheme and regardless of compliance with the intervention and data at follow-up. We will analyze data using mixed models for repeated measurements; linear mixed models will be used for continuous outcomes and generalized linear mixed models will be used for categorical and discrete outcomes. We will follow recommendations of Fitzmaurice et al.  and retaTerms included in models will include time, group (treatment) × time, age and site. Time will be modeled categorically with indicator variables (with baseline as the reference category). Residuals from models will be examined and subject to assumptions checks.p-values less than 0.05 will be reported as statistically significant. Analyses will be performed using SAS version 9.4 .Based on our past experience, we do not expect substantial missing data; nonetheless, results will be valid provided data are missing at random and no imputation of data will be required by using a mixed model analysis approach . To addrProcess data will be collected through self-reports, interviews, observation, questionnaires, and focus group discussions.Potential participants were contacted by the research coordinator and screened via email or phone to assess initial eligibility including: gender, age, height, weight, and how they heard about the Hockey FIT program. If the potential participant was deemed “likely” to be eligible after this stage, they were invited to a formal in-person screening session. Once registered in the program, participants attended a baseline measurement session, and demographic information was gathered such as age, postal code, marital status, education, occupation, and ethnicity, overall self-rated health, and clinical characteristics (described in greater detail in the outcome measures section above). These measures were collected to compare the demographics and health of the Hockey FIT participants to the health of men in the general Canadian population.Non-completers were defined as participants randomized to the intervention group who attended less than six program sessions (<50 %) and did not attend any of the final six program sessions.Non-completers were contacted after all 12 sessions were completed and were asked to complete a program exit survey over the phone. Participants were asked about why they initially joined the program, why they stopped attending the program, if their involvement in the program has changed their lifestyle habits, and if (and how) the program could be changed to encourage them to complete the program.Hockey FIT coaches took attendance at the beginning of each of the 12 weekly sessions for both sites.A member of the Hockey FIT research team was trained to observe program delivery at both London and Sarnia sites. All 12 weekly sessions at both sites were observed and notes were taken during the sessions. These notes detailed the overall session flow  and were summarized by the central research team. The research team member who observed the program delivery interviewed coaches after each session. Questions were specific to the experience delivering the program components and were standardized to what went well with delivery and what could be done differently.Participants randomized to the intervention group who had attended a minimum of six Hockey FIT coaching sessions (50 %), including at least one of the sessions in the final six weeks of the intervention were asked to complete a 12-week online questionnaire. The program questionnaires, created through the Qualtrics® platform, were e-mailed to participants via an individual link immediately following the final program session. A reminder was sent to men who had not completed the questionnaire after the final session. Questions explored reasons for joining, usefulness of program components, experience with the program and coaches, and any suggestions for improvement.At both sites, participants randomized to the intervention group were asked during sessions 11 and 12 to sign-up for a pre-determined focus group time slot. Focus groups were audio-recorded, semi-structured in nature, and moderated by a trained qualitative interviewer at both sites. Questions explored participants’ reasons for joining the program, experience with the program and health behaviour changes, and suggestions for future program improvement. Along with the interviewer, there was also an observer who made notes about group interactions, dynamics and flow of the focus group discussion. Focus groups were an hour and a half in length and the men were provided with healthy snacks, beverages and water bottles as a token of appreciation.The four coaches (two Head Coaches and two Assistant Coaches) participated in one-on-one interviews by a trained qualitative interviewer. Questions were semi-structured and allowed for elaboration on key components of the program such as the strengths and weaknesses of the program, program delivery, and any suggested changes to the program.During the 12-month measurement session, intervention group participants were asked to fill out a questionnaire detailing their overall experience with the program and their experience with maintaining their healthy lifestyle behaviours, including use of eHealth technology support tools, following the active phase of the program. Participants were also asked whether they would recommend the program to others.eSteps app, and reunion/ booster session), and suggestions on how to improve the program.All willing intervention group participants were interviewed one-on-one with trained qualitative researchers either in-person or via the telephone. Participants were asked about their experience maintaining behaviour changes made during the program, satisfaction with support from Hockey FIT staff and coaches, effectiveness of maintenance resources  will be included in the qualitative analysis to ensure accuracy of the analysis process and to look for confirmatory data. The 12-month participant interviews augment our qualitative analysis. We will look for both unique as well as confirmatory elements. The previously developed coding list will be used, if appropriate, and augmented to include new findings.To ensure reliability and trustworthiness of both our analysis process and the results of our coding process, narrative summaries will be developed. These summaries will include the 12-week participant focus groups, 12-week coach interviews and 12-month participant interviews, organized primarily according to each process measure  and acceptability of Hockey FIT; and finally to optimize Hockey FIT using findings from a process evaluation. If our pilot results are promising, we intend to conduct a large-scale pRCT to be able to gain confirmatory evidence on effectiveness and cost-effectiveness of Hockey FIT, as well as acceptability of the Hockey FIT program in overweight and obese men. These future efforts will then be used to support scale-up of the program across a broad distribution of settings and communities, with the overall goal of improving men’s health.In this study our aims are to: adapt FFIT and integrate this with Health


AAPM Report Number 90. This work group includes AAPM members with extensive experience in clinical, professional, and educational aspects of medical physics. The resulting report, AAPM Report Number 249, concentrates on the clinical and professional knowledge needed to function independently as a practicing medical physicist in the areas of radiation oncology, imaging, and nuclear medicine, and constitutes a revision to AAPM Report Number 90. This manuscript presents an executive summary of AAPM Report Number 249.There is a clear need for established standards for medical physics residency training. The complexity of techniques in imaging, nuclear medicine, and radiation oncology continues to increase with each passing year. It is therefore imperative that training requirements and competencies are routinely reviewed and updated to reflect the changing environment in hospitals and clinics across the country. In 2010, the AAPM Work Group on Periodic Review of Medical Physics Residency Training was formed and charged with updating PACS number: 87.10.‐e I.According to the AAPM, medical physics is a branch of physics that applies the concepts and principles of physics to the diagnosis and treatment of human diseases.II.A.Following the appropriate didactic training (see Section IV),Next, training should build on this clinical foundation in terms of both the level of responsibility and the depth of coverage of topics such as specification, commissioning and acceptance testing, quality assurance, special procedures, and patient safety measures. After two years of clinical training, residents are expected to have sufficient competence to function independently and safely as medical physicists in a clinical environment. Some residency programs may choose to require more than two years of training, allowing residents time to obtain further supervised experience and/or an opportunity to participate in research/developmental projects.AAPM Task Group 133 Report.It is important to note that portions of clinical training may take place at affiliated institutions. This form of training is acceptable, provided the recommendations and requirements described in this document are followed and the residency model is consistent with the B.1)must contribute sufficient time to the program to ensure adequate direction;2)is responsible for program organization and direction, as well as instruction and supervision of physics residents;3)must arrange for the provision of adequate facilities, teaching staff, and clinical and educational resources;4)must oversee and ensure the quality of the didactic and clinical education at all sites participating in resident education;5)must oversee and approve all assigned supervisors or lead mentors for resident education at either the primary facility or affiliated institutions;6)is responsible for the recruitment and appointment of physics residents and must ensure that the appointed residents meet the eligibility requirements listed in Section IV;7)is responsible for ensuring that physics residents are making satisfactory progress, and for providing appropriate remedial action should this not be the case; and8)must ensure physics residents' performance is periodically evaluated, and that documented feedback is provided to residents in a timely manner.There must be a single, identified program director who is authorized to oversee the medical physics residency program and is accountable for the operation of the program.1)must be certified in the subfield of medical physics that he or she is overseeing by an appropriate certifying board; and2)should have at least five years of full‐time experience beyond clinical residency training as a qualified medical physicist practicing in the subfield of medical physics that he or she is overseeing.With regard to qualifications, the program director:C.A program steering committee shall be formed to review the status of the residency program, track the progress of individual residents, address specific issues that may arise concerning the program or the residents, and discuss any necessary changes to the program. The committee should meet on a schedule sufficient to attend to program matters, but no less than three times annually. The steering committee should consist of the program director, relevant staff, and faculty members involved in residency training. It is recommended that a physician and a resident representative be involved, at least during select portions of the meeting or select meetings. At a minimum, there should be a pathway for residents' concerns to be expressed to the committee. It may also be helpful to have an institutional administrative representative on the committee in a nonvoting position or as a liaison to the committee. Minutes of all meetings should be maintained.D.1)participating in regional and national scientific societies;2)participating in their own continuing education;3)participating in programs developed to improve teaching and/or mentoring skills;4)producing scientific publications and presentations; and5)teaching, mentoring, or supervising trainees.The program must provide adequate staff for the teaching of medical physics in the program's area of specialty.An adequate staff should include at least two full‐time medical physicists certified by an appropriate certifying board, and a diagnostic or imaging radiologist, radiation oncologist, or nuclear medical physician certified by the American Board of Radiology (ABR) or its equivalent, depending on the subfield of medical physics in which the program specializes. The ratio of full‐time medical physicists participating in medical physics resident training to residents should be at least 1:1. It is recommended that access to training from a radiation biologist be available.E.The institution sponsoring the medical physics residency program should provide administrative support in terms of funding and space, in addition to clinical and educational resources.Each resident should be allotted office space within the department and be provided a personal computer with network connections, an email account, telephone, office supplies, and access to a copying machine and scanner.The financial support provided, including benefits should be clearly defined for the resident prior to his/her entry into the residency program.F.The medical physics residency program should be conducted in an environment that encourages the exchange of knowledge, experience, and ideas.G.The training program should include opportunities for residents to participate in scholarly activities. These may include presentations at departmental conferences and journal clubs, teaching opportunities, and research. Although optional, clinical research and development projects should be included as part of the clinical training program, provided they do not detract from the residents' clinical training. Opportunities for residents to participate in the clinical commissioning of new technology introduced into a facility will prepare residents and provide them with the necessary skills to practice independently as clinical medical physicists.H.Conferences and teaching rounds should provide for progressive resident participation.® Adequate frequency of conferences and attendance by physics residents, staff physicists, physicians, and other staff should be documented. Gatherings available to residents could include intradepartmental clinical conferences, such as staff meetings, patient case conferences, and physics meetings. Other conferences could include radiation safety training sessions, quality assurance (QA) committee meetings, and journal reviews. As a complement to resident education, it is encouraged that the physics residents periodically present at institutional conferences.I.The program should maintain documentation of residents' attendance at departmental conferences, seminars, journal clubs, or other educational activities. In addition, to monitor residents' progress, a log detailing their clinical and didactic activities should be maintained. Residents should maintain these records, but it is the program director's responsibility to periodically review these documents to ensure that they are kept current and residents are progressing adequately in the program.J.A sufficient variety of journals, reference books, and other resource materials pertinent to medical physics, basic sciences, diagnostic and interventional radiology, nuclear medicine, and radiation oncology should be provided and be immediately accessible for resident study.III.Medical physics residency programs must develop a curriculum and competencies for their residents. Written expectations regarding residents' performance, behavior, and training schedule should be provided to residents upon their entry into the residency program. These objectives should be discussed with each resident and periodically monitored through an established evaluation process. Following their evaluation, residents should be provided with written feedback regarding their performance. If their performance is deemed inadequate, a course of action for remediation should be developed in a timely manner.AAPM Report Number 249.1)AAPM TG 159,ethics and professionalism — for example, AAPM Code of Ethics, 2)professional liability;3)professional activities and societies — for example, AAPM, Radiological Society of North America (RSNA), ABR, American College of Radiology (ACR), American Society for Radiation Oncology (ASTRO), Canadian College of Physicists in Medicine (CCPM), Canadian Organization of Medical Physicists (COMP), Society of Nuclear Medicine (SNM), Society for Imaging Informatics in Medicine (SIIM), and International Society for Optics and Photonics (SPIE);4)soft skills such as communication, teamwork, and leadership training;5)administration skills, includingSpecific recommendations for curricula and competencies in imaging, nuclear medicine, and radiation oncology physics are detailed in a. personnel management (staffing models),6)accreditation and regulatory agencies;7)continuous quality improvement (CQI); and8)FDA)/Safe Medical Devices Act of 1990 (SMDA).U.S. Food and Drug Administration  and the Accreditation Council for Graduate Medical Education (ACGME), and make efforts to integrate these competencies in their curricula and evaluation process. These competencies include: (1) patient care and procedural skills, (2) medical physics knowledge, (3) practice‐based learning and improvement, (4) interpersonal and communication skills, (5) professionalism, and (6) systems‐based practice.Patient Care and Procedural Skills. Medical physics residents should provide information that is appropriate, accurate, and relevant to the diagnosing or treating of medical conditions. Residents shall develop patient care and procedural skills by:demonstrating an understanding of radiological anatomy and physiology in clinical contexts;demonstrating an understanding of the major factors that affect patient care;providing physicians with appropriate technical and dosimetric information; and d. improving and maintaining medical image quality on a variety of systems.Medical Physics Knowledge. Medical physics residents should be knowledgeable, scholarly, and committed to lifelong learning. A resident's knowledge of medical physics shall include:specification, acceptance testing, and quality assurance of imaging and therapeutic equipment;measurement and calculation of radiation exposure and dose;demonstrations of investigatory and analytic thinking in solving clinical problems; and d. applications of physics problem‐solving skills to clinical medical physics problems.Practice‐based Learning and Improvement. Medical physics residents should investigate and evaluate patient care practices, and appraise and assimilate scientific evidence and improve patient care practices. The resident shall pursue practice‐based learning and improvement which will include:investigating and evaluating patient care practices;understanding and applying radiation biology and epidemiology to clinical situations;assimilating scientific evidence to improve patient care practices;contributing to research and development projects in cooperation with radiologists, nuclear medicine physicians, radiation oncologists, and others;analyzing results of testing and recognizing unexpected findings;investigating equipment performance and possible performance problems; and g. recognizing and correcting personal errors.Interpersonal and Communication Skills. Medical physics residents should demonstrate effective communication with physicians, technologists, service personnel, and professional associates. The medical physics resident shall develop interpersonal and communication skills by:demonstrating clear and concise expression, both orally and in writing;independently communicating with clinicians, technologists, and others regarding the physical principles of clinical problems;demonstrating effective teaching of medical physics and radiation effects to trainees, technologists, and other health‐care professionals;interfacing with agents external to the institution, including equipment service personnel, government regulators, and accreditation agency representatives;producing accurate, concise, and grammatically correct written reports; and f. listening effectively.Professionalism. Medical physics residents should carry out all assigned duties, adhere to ethical principles, and show sensitivity to a diverse patient population. Residents shall develop professionalism by:demonstrating a commitment to carrying out responsibilities;understanding professional issues and participating in the activities of professional societies;showing leadership and adhering to ethical principles;demonstrating sensitivity to diverse patient populations;being responsive to the needs of patients and prioritizing those needs over self‐interest;respecting patient privacy and confidentiality; and g. demonstrating a commitment to excellence and ongoing professional development.Systems‐based Practice. Medical physics residents should be aware of the system of health care at their institution and effectively call on system resources to provide optimal care. Residents shall undertake systems‐based practices that may include:showing competence in information technology (IT) issues such as electronic media, software licensing, levels of access, and information security;understanding policy development procedures and quality management systems at the departmental and institutional levels;developing knowledge of aspects of the institution's capital equipment procurement process, such as relevant business plans and tender documents;being aware of and responsive to the larger context and system of health‐care provision; and e. partnering with managers and providers to assess, coordinate, and improve health care.IV.Upon satisfactory completion of a medical physics residency program, the graduate will have the knowledge of medical physics comparable to that of a graduate of a Commission on Accreditation of Medical Physics Educational Programs (CAMPEP) accredited medical physics graduate program. This is accomplished most directly by accepting graduates from accredited medical physics graduate programs into the residency program.AAPM Report Number 197S has defined six core graduate‐level topics that must be covered prior to the candidate's completion of a medical physics residency program:1)radiological physics and dosimetry;2)radiation protection and radiation safety;3)fundamentals of imaging in medicine;4)radiobiology;5)anatomy and physiology; and6)radiation therapy physics.Alternatively, graduates of non‐accredited medical physics graduate programs and graduates of physics or related graduate programs may be accepted into a medical physics residency program if they can demonstrate they have successfully completed the undergraduate and graduate didactic prerequisites as mandated by the ABR and AAPM. To demonstrate that the resident has the equivalent of a minor in physics, the resident's undergraduate or graduate transcript should include at least three upper‐division (third‐ or fourth‐year undergraduate) physics courses or their equivalent. In addition, These core topics are equivalent to 18 semester credits of coursework.AAPM Report Number 197.The contents of these courses should comply with the recommendations provided in V.The number of residents in the training program must be commensurate with the program's capacity to offer an adequate educational experience.VI.A.The program director is responsible for continuing evaluation of the program and documentation of the educational progress and performance of each resident.The resident must be evaluated upon completion of an area of study or clinical rotation. The resident's performance and progress should be assessed periodically by the program faculty . The results of these evaluations should be discussed with the resident and be documented.The program director should document any prior training from another institution that is being used to satisfy the training requirements of the program. A resident's prior training may be a reason to modify the training content of a rotation . The duration of a rotation or the total length of the clinical residency may not be modified, however. It is the program director's responsibility to counsel, censure, and, after due process, dismiss residents who fail to demonstrate appropriate industry, competence, responsibility, learning abilities, or ethical behavior.B.The training program should provide a means by which residents can give feedback regarding the performance of their clinical supervisors or rotation mentors. Measures should be taken to ensure the confidentiality of residents comments . Staff evaluations should be reviewed by the program director as evaluations are submitted. If an area of concern is identified, a plan of remediation should be developed and discussed with the staff members of interest.Upon completion of the program, the resident should be given an opportunity to evaluate the training program in its entirety. This evaluation should include a discussion of the teaching abilities, commitment to the training program, clinical knowledge, and professionalism of the staff and program director.C.The program steering committee should convene an annual meeting to discuss the training program in its entirety. During this meeting, the committee should review evaluations of residents, staff, and the program. Any issues or concerns should be identified and, if necessary, a plan of improvement should be developed. The program steering committee shall ensure the training program remains in compliance with the program self‐study. Changes to the program made after the writing of the self‐study should be identified and discussed. The training program should maintain documentation of the program steering committee minutes.VII.A.The program director, mentors, and staff must set a positive example of professional behavior and educate residents regarding proper professional behavior in the clinic. The clinical culture must stress personal responsibility for each team member's role in patient care. Residents should be provided with direct instruction regarding the medical physicist's responsibility in patient care, as well as the roles of physicians and other staff.The institution and program should promote and demonstrate a commitment to patient safety, emphasizing that patient safety is first and foremost amongst their core values. Direct instruction on the role of the medical physicist in the safe use of imaging and therapeutic equipment and procedures is integral to a successful program. Resources regarding patient safety are available through several professional societies and national and international organizationsB.Health Insurance Portability and Accountability Act (HIPAA) compliance training must first be provided. Additionally, the program director or program faculty should have an open discussion with the residents about the proper use of patient and human research data; it should be made clear that collecting patient‐related data for research purposes without institutional review board (IRB) approval is not permissible.Residents should be permitted access to relevant medical records and patient information . If such access is permitted, C.AAPM Report Number 159.A residency program should include instruction on medical ethics. Specific attention should be given to ethical decision‐making in medical physics practice. Guidance for ethical training of medical physicists has been provided in D.All clinical duties performed by residents should involve some level of supervision commensurate with the task by staff physicists, physicians, or other qualified staff. Supervision of residents performing clinical duties shall also comply with the statutes of the state/province in which the program resides. These statutes may vary widely between states/provinces. Generally, first‐year residents require closer supervision and oversight for day‐to‐day tasks than do second‐year residents. Second‐year residents should be working toward doing more independent duties. The program steering committee and institution or department physician leadership should approve any independent duties given to residents.E.General supervision. This includes clinical duties that are performed under the overall direction and authorization of a supervisor. Performance of these duties does not require the presence of the supervisor.Direct supervision. This includes clinical duties that are performed while a supervisor is available within the immediate vicinity of a resident. The supervisor is not required to be physically present, but he or she is available to provide assistance and direction as needed throughout the performance of the procedure.Personal supervision. This includes clinical duties that are performed in the physical presence of a supervisor.VIII.AAPM Report Number 249.This summary represents the recommended design of a residency program based on the collective wisdom and experience of many clinical medical physicists, the majority of whom are residency program directors. The complete report, including the recommended curricula and competencies in imaging, nuclear medicine, and radiation oncology, is detailed in We strongly believe in a structured, formal training model for clinical residencies, and we strongly encourage the development of residency programs in any facility that meets a set of minimum requirements and has the will to meet the goal of independent practice for its graduates. These minimum requirements can also be satisfied through collaboration agreements between two or more facilities.Supplementary MaterialClick here for additional data file.Supplementary MaterialClick here for additional data file.


This study examines the influence of clinical social franchise program on modern contraceptive use.This was a cross-sectional survey of contraceptive use among 2390 currently married women across 25 townships in Myanmar in 2014. Social franchise program measures were from programmatic records.Multivariable models show that women who lived in communities with at least 1-5 years of a clinical social franchise intrauterine device (IUD) program had 4.770 higher odds of using a modern contraceptive method compared to women living in communities with no IUD program [CI: 3.739-6.084]. Townships where the reproductive health program had existed for at least 10 years had 1.428 higher odds of reporting modern method use compared to women living in townships where the programs had existed for less than 10 years [CI: 1.016-2.008].This study found consistent and robust evidence for an increase in family planning methods over program duration as well as intensity of social franchise programs. With a total population of 51.4 million people, Myanmar continues to lag behind other countries in the region across multiple maternal and child health indicators , 3. The Historically in Myanmar, reproductive health (RH) services have been delivered through the public health sector in both urban and rural areas . HoweverCurrently, the majority of modern family planning methods are delivered through the private sector (51.8%) compared to the public sector (42.4%); however, the large majority of long-term methods are provided by the public sector . Long tePopulation Services International/Myanmar (PSI/M) is one of the key organizations that provide reproductive and family health care services in the private sector in Myanmar through clinical social franchising. Globally, clinical social franchising has gained popularity in the past two decades as one approach to engaging the private sector . A cliniWhile studies have documented that social franchise programs improve facility-level outcomes, less is known about how franchise programs influence women’s contraceptive use. The few studies that do exist highlight the promise of social franchise programs in family planning use. One study found that social franchise clinics increased monthly reproductive health client volume in Myanmar, the number of family planning brands available, and had somewhat higher client satisfaction . In VietThe objective of this study was to examine the influence of clinical social franchise program on modern contraceptive use. This study is novel because it assesses the influence of social franchise programs across 25 townships. Because of the stepped-wise approach of introduction of reproductive health and IUD programs across townships to franchised clinics, this study is able to assess the impact of duration of program as well as intensity of the programs on modern contraceptive use.Mynamar offers a unique setting to assess the impact of clinical social franchising on reproductive health and family planning. In 2001, Population Services International (PSI) Myanmar started a social franchising network by recruiting general practitioners (GPs) branded as the Sun Quality Health (SQH) clinics In 2004, PSI/M introduced the IUD program to those clinics that were already part of the RH program. IUD insertion training was conducted with doctors that were part of he RH program. The training covered counseling, infection prevention, IUD insertion and management of complication and side effects. Trained doctors also participated in practical session on IUD insertion of live patients after the training. Their performance and skills were monitored through supportive supervision visits by a training team as well as quality assurance visits by a quality assurance team of PSI/M until they could perform the IUD insertion independently. PSI/M provided IUD products at a highly subsidized rate. As part of this program, PSI also used RH promoters to build awareness on family planning through community health talks followed by the distribution of referral cards to eligible women to go to a SQH clinic for family planning services. RH promoters are trained and employed by PSI/M. At the time of the survey, 116 clinics in 93 townships had joined the IUD program.A cross-sectional study with a multistage cluster sampling approach was conducted among 2390 currently married women to assess contraceptive use. Only currently married women were recruited for our household survey because the majority of PSI’s clients who attend clinical social franchise clinics for family planning are married. Married and unmarried women would have different determinants and therefore only married women were recruited in this sample. A total of 25 program townships were included to allow for sufficient power and precision to detect contraceptive use among the representative sample of women. At the first stage, using proportionate to population size method (PPS), we selected 25 townships out of 93 townships where at least one Sun Quality Health (SQH) clinic provided family planning services. Because the selected sample size was 2390 women across selected 25 townships we selected 95 respondents from each township. In Myanmar 30% of the total population live in urban areas and the other 70% in rural areas on average the sample distribution is 30% in urban and 70% in rural areas that yielded 734 respondents and 1656 respondents from urban and rural areas respectively. A total of 29 respondents from urban and 66 from rural were recruited for each selected township.The second stage involved selecting wards in urban areas and village tracts in rural areas of the selected townships. The number of wards varies by township. Population sizes are not available at ward and village tract level and the number of wards varied from two to 39 wards in selected townships. We used systematic random sampling method for sampling respondents. For rural areas, the number of village tracts did not vary as much as in wards, and an equal number of six villages were randomly selected in each township. Systematic random sampling was used, with 11 households selected from each village.On arriving at the selected ward/village, interviewers drew a rough map of the ward/village and identified the households (by door to door visits to each house) where the women currently married within the ages of 18 and 49 years  were living because the list of all households and households with currently married women was not available. Using the rough map and systematic random sampling we selected 29 households in a ward and 11 households in a village. We interviewed only one currently married woman fitting the age requirement.The survey covered a number of demographic characteristics and health outcomes, including household roster, socio-economic status, contraceptive history, fertility preferences, ability and motivation factors related to the use of contraceptives, and source of family planning method. In addition, social franchise program measures were derived from programmatic records and measured at a township level.Verbal informed consent was collected. Verbal consent, rather than written consent, was used because these areas have high illiteracy rates and therefore verbal consent is more appropriate. Verbal consent was also used to reduce the risks associated with potential breach of confidentiality.The main outcome of interest is use of modern family planning method. This measure was generated using a series of questions in the survey of current method that women used. Women were categorized as using a modern method of contraception if they indicated that they used IUDs, injectables, male or female condoms, pills, female sterilization, or implants. To assess social franchise program measures, township level data was included. First, the study assessed the association between duration of the reproductive health program and family planning use. The duration of reproductive health program is defined as the difference between the survey year (2014) and the introduction of the program. The duration of the IUD program was constructed in a similar manner. To assess the intensity of the program, the study included data on the number of reproductive health providers that were franchised as well as the number of IUD providers that were franchised in each township. Because these four measures are collinear , each program measure was modeled separately with the outcome data.The study also included a variable on source of method, and includes public, private, and other sources. “Public sector” included government hospitals, health centers, government mobile clinics, and government field workers. “Private sector” included private hospitals, private clinics, pharmacies, private mobile clinics, franchised clinics, field workers, and grocery stores. “Other sources” included friend and relatives.Demographic characteristics were also included in the models, including urban/rural residency, age categories, education level of the participant, parity and religion.All analyses were carried out in STATA 12MP. Three sets of analyses were conducted. First, bivariate analyses, including chi-2 for categorical variables and t-tests for continuous variables, were used to assess differences across outcomes. Next, the study conducted a population average model analysis accounting for clustering at the township level. Township level variables included social franchise program characteristics such as duration of the program and number of providers. Finally, multivariable logistic regression was used to test the associations between program characteristics and modern contraceptive use, accounting for differences in demographic characteristics across townships.n = 1320) and 10 or more years (n = 1070).Table p = 0.056). Similarly, the age categories and education achievement of participating women were not different between the areas (p < 0.05). However, there were slight differences in parity across the two groups. We found that the proportion of women with three or four live children were slightly higher in the less-than-10-years serviced townships. The proportion of women with 5 or more live children was higher in the 10- or-more-years serviced townships . Women in the study were mostly Buddhists (93.8%); however, the proportion of women in 10- or-more-years serviced townships who were Buddhists was slightly but significantly higher than the proportion of women in less-than-10-years serviced townships .Across these two groups, the study found that there were no statistically significant differences across urban/rural residency  and similarly by 1 (62.2 vs. 53.8%) or more than one IUD providers .At the township level, we found that there were more RH or IUD service providers in longer serviced townships. Women from 10-or-more-years serviced townships were likely to be serviced by 13 or more RH providers , even after adjusting for township-level effects and demographic characteristics. In this model, young ages, higher education levels, and being Buddhist was associated with modern method use.Model 3 tested the association between the number of IUD providers living in a township and modern method use. Compared to townships with no providers, townships with one provider had 3.647 higher odds of using a modern method and townships with two or more providers had 2.667 higher odds of using a modern method. Both were statistically significant (p < 0.1). Similarly, women who lived in townships with 13 or more providers had 1.458 higher odds of using a modern method compared to women who lived in townships with less than 6 providers [CI: 0.945-2.249] . Similar to other models, younger age, higher education status, and being Buddhist was associated with higher odds of using a modern method of contraception.Lastly, model 4 tested the association between the number of reproductive health providers that belonged to the PSI franchise network and use of modern method. Women who live in townships with 6-12 providers 1.519 times as likely to use a modern method compared to women living in townships with less than 6 providers [CI: 0.972-2.375], although this was only marginally statically significant  vs. IUD program. While modern contraceptive use increased with the longer duration of the program for both the RH and IUD program, the effect size was higher for the IUD program. This further corroborates the findings that social franchise programs increase modern contraceptive use because the IUD program is considered to be more intensive and comprehensive compared to the RH-only program. First, the IUD programs recruited clinics that had a certain level of skill. The IUD program also included community public awareness campaigns regarding the IUD, as well as RH more broadly. In addition to providing RH services, including IUDs, the program also included a component in which Reproductive Health Promoters would bring women into the clinics and support them through the process of having an IUD inserted. Although we were unable to test this directly, one potential explanation for increased overall contraceptive use may be attributed to community health worker’s education around acceptance and knowledge of family planning at the township level. Further work should explore potential explanations for these findings. The study found that the odds of using a modern contraceptive method increased more with the duration IUD program and number of IUD program’s providers than that of RH program. While the study was not able to assess the impact of community and educational campaigns, it can be hypothesized that increasing community-level awareness and method choice increased contraceptive use at the township level.Moreover, the study also found that more than 40% of women were accessing their modern contraceptive methods from the private sector. While this study was not able to assess whether the private sector was specifically a franchised clinic, this finding is important for future program planning for reproductive health services. Traditionally, modern contraceptive methods, except for condoms and pills, were largely available in the public sector. A significant portion of women in both rural and urban areas went to the private sector, particularly for IUDs.There are a number of limitations to this study. First, because there is no comparison group, our ability to assess the impact of the social franchise program on family planning is limited. This study is not able to assess whether contraceptive prevalence would have increased in these townships even without the program. Contraceptive use may have naturally increased due to other interventions, programs, or increased community knowledge and acceptance of family planning methods. However, this study attempted to account for this limitation by including the duration that reproductive health services and the IUD program has existed in each township as well as the number of providers. Therefore, the study was able to assess both the intensity and dose-response of the intervention.Second, social franchise program measures, including duration of the program and number of clinics, were at the township level. There was an assumption that all providers started the reproductive health program and IUD program at the same time; however, this may not have been the case as providers may have been recruited at different time points. Other information about the social franchise program, such as quality of providers or location of clinics, would have also been useful in assessing the impact of the program on family planning use.Finally, although this study includes information on the source of family planning method, we are unable to distinguish between franchised clinics from other private clinics. It is uncertain what percentage of women actually received their family planning method from a PSI franchise clinic. In many contexts, PSI will engage private clinics but do not brand the clinic as a franchise program; therefore, women may not know that they are attending a franchise clinic. Despite this, approximately 40% of women indicated that they received their most recent method from a private sector outlet, highlighting the importance of the private sector in future family planning programs.Despite these limitations, this is the first study to examine the role of social franchise programs, duration of the program, and intensity of the program on the use of modern contraceptive methods. Reproductive health data is critically limited in Myanmar. This study used a large, population-based dataset that included 25 townships and allowed for township-level analyses. Programmatic data allowed for assessing differences across RH-only program and RH + IUD programs.A number of programmatic and policy recommendations result from this study. Overall, the study suggests that there should be increased engagement of the private sector in Myanmar, as approximately 40% of women are receiving their family planning method from private hospitals and clinics. In particular, the private sector plays a particularly important role in the uptake of IUDs. Historically in Myanmar, only OBGYNS are able to insert IUDs in the public sector. PSI/Myanmar has trained a network of general practitioners (GPs) to also provide IUDs, a novel approach in the country. This increases the accessibility and availability of family planning methods, suggesting that this should perhaps be implemented at wider scale.Social franchise programs engage private providers to not only provide modern contraceptive methods and increase choice of method, but also advertise different methods with the goal of increasing family planning knowledge and awareness. Therefore, social franchise programs show promise as a means to increase the availability of family planning, particularly in underserved areas of Myanmar. Moreover, study results indicate that IUD programs, in addition to the reproductive health program, are particularly influential in increasing family planning methods. Future reproductive health programs may want to integrate an IUD component in order to increase choice of method and overall method uptake.This study found evidence for an association between clinical social franchise programs and increased use of family planning methods. This study is important given the dearth of reproductive health information in Myanmar and clinical social franchise programs.


The use of research associates (RA) programs to facilitate study enrollment in the emergency department was initiated during the mid-1990s. The University of Rochester Medical Center (URMC) was an early adopting site for this model, which has experienced considerable growth and development over the past 20 years.Our goal was to detail the Emergency Department Research Associates (EDRA) program processes developed at the URMC that has led to our program’s sustainability and productivity. These processes, and the lessons learned during their development, can assist institutions seeking to establish an RA program or refine an existing program.Defined procedures for selecting, training, and monitoring EDRAs have been created and refined with the goal of maximizing study enrollment and minimizing protocol deviations. Our EDRA program functions as a paid service center for investigators, and our EDRAs engage in a variety of study-related activities including screening and enrolling patients, administering surveys, collecting bio-specimens, and making follow-up calls. Over the past two years, our program has averaged 222 enrollments/month (standard deviation = 79.93), gathering roughly 25 participants per study per month.Our EDRA model has consistently resulted in some of the highest number of enrollments across a variety of recently funded, multi-center studies. Maintaining a high-quality EDRA program requires continual investment on the part of the leadership team, though the benefits to investigators within and outside the department outweigh these costs. Research in emergency medicine has been accelerating rapidly over the past several decades, with increasing quality and quantity of publications and grant mechanisms. Concomitant to the increased output have been maturations in processes and procedures for conducting widely heterogeneous research in the emergency department (ED) setting. In the fast-paced ED environment, practicing clinicians have historically found it difficult to identify and enroll patients into their research studies.5In the mid-1990s, Drs. Judd Hollander,Academic Emergency Medicine, Journal of Emergency Medicine, Annals of Emergency Medicine, Western Journal of Emergency Medicine, the American Journal of Emergency Medicine, PLOS One, Prehospital Emergency Care, Pediatric Emergency Care, Prehospital and Disaster Medicine, Journal of Trauma, JAMA Oncology, Journal of the American Geriatric Society, and Psychiatric Services. Given this success, our team is frequently asked to share our model with collaborators across the country. Our goal here was to describe the evolution of our RA program model from its early roots, present quantitative evidence of our program activities, and provide a brief overview of our structure and processes for investigators interested in program creation, refinement, and/or expansion.For example, in the past year our center (a) was the second among 22 participating centers to meet the enrollment goal in a National Cancer Institute-supported study of ED utilization by patients with active cancer, despite being late to join the consortium; (b) was the highest enrolling site among 11 sites, enrolling over 1,000 subjects , into a National Heart, Lung, & Blood Institute-funded multi-center study of syncope in older adults; and (c) was the top enrolling site in several industry-sponsored, multisite clinical trials and validation studies on mild traumatic brain injury. Recent research using our program has been published in outlets including Our EDRA program aims to maximize recruitment for research studies within the department. Each faculty member in the research division of our ED has published using EDRA-collected data. Furthermore, more clinically focused EM faculty have also frequently published using our EDRA program, as the program strengths in data acquisition complement the clinical knowledge of these providers. Our program has also established a significant institutional profile, as investigators from numerous other departments and divisions frequently use our EDRA program to recruit patients into their studies. For example, in the past six months alone, our program has worked with the departments/divisions of infectious disease, laboratory medicine, obstetrics, psychiatry, and pediatrics, among others. For context, Strong Memorial Hospital (SMH), where the vast majority of our EDRA-related research takes place, is a Level I ACS trauma center, regional stroke center, regional heart center, and burn center with 830 beds. The ED in which the program is housed employs 85 fulltime faculty members and 42 residents . The SMH ED, including the pediatric ED, is a 29,000 square-foot unit that in 2016 saw over 116,000 patients. The University of Rochester, directly next door to SMH, had an enrollment of 6,170 fulltime undergraduate students during the 2016–2017 academic year.Over the past 20 years,Our EDRA program is structured as a university service center, with funding received from investigators using our services and as-needed support from the ED. . The need for departmental support is mitigated through monthly budget reconciliation meetings where program costs and revenues are discussed and managed to avoid propagation of a deficit. Program costs consist primarily of faculty/administrative effort, EDRA salaries (students are paid an hourly wage), and training expenses , resulting in a fixed hourly rate for program utilization. This hourly rate is adjusted annually with the goal of cost neutrality in accordance with cost center status.Investigators interested in using our program contact our team, meet with the program director, supervisor, and coordinator to discuss their project and potential levels of EDRA involvement, and then work with our team on planning the operationalization of their protocol. Pertinent information for this process includes the length of the study, the amount of initial and continuing study-specific training required, the number of patients expected to be screened , expected patient enrollment, and duration of EDRA study procedures (in minutes) including screening, consent, enrollment, and/or follow-up. This phase is particularly important for investigators from other departments as they often require guidance regarding the clinical workflow of the ED and our developed best practices for facilitating enrollment and study success.Investigators then work with our team to develop an acceptable quote for service based on our annually fixed program rate and the agreed-upon amount of time EDRAs would devote to the specific project. EDRA time includes administrative startup time and continual program oversight, EDRA training, and EDRA coverage of the ED for 16 hours per day, seven days per week, with 8–12 of those hours necessitating two EDRAs to keep up with the patient volume and study demands. The total investigator cost for using our program is highly variable, from short-term studies with simple screening and referral requirements that cost as little as $1,000 to larger studies with more extensive EDRA involvement entailing program budgets in excess of $65,000 over the course of four years. The EDRA budget for any given study is modified, as needed, as the project progresses.Importantly, our EDRA leadership team is closely linked with our departmental research review committee (chaired by the EDRA faculty advisor), which evaluates research protocols involving the ED for potential human subjects, clinical flow, and scientific concerns before investigators can receive institutional review board approval. This involvement allows the EDRA program to assist investigators in the creation of effective, efficient, and ethical research protocols. Given our track record of successful completion of enrollment protocols, human subjects training, and leadership oversight, our program has applied for and received “umbrella approval” from the URMC review board for EDRA involvement in enrollment, consent, and basic study procedures  across different research studies. When an investigator references this annually reviewed umbrella protocol, it allows our team of EDRAs to participate in disparate research projects without the potentially burdensome paperwork associated with including each EDRA as study personnel on each project.Our program compensates the EDRAs both experientially and monetarily, as students are hired as part-time staff. While other models for RA programs have demonstrated considerable successThe University of Rochester has an undergraduate population that is very enthusiastic about careers in health sciences given the proximity and accessibility of the URMC (campuses directly adjacent). This close proximity to an exceptional undergraduate population is, no doubt, a strong asset to our program and significantly contributes to our program’s success . It is not only our reputation and compensation that ensures our high quality EDRA team. We ask our senior EDRAs for recommendations of peers who they think would be successful in the position, send solicitations via e-mail to apply for an EDRA position to pre-medical and health-science student groups, give announcements to traditional pre-medical curriculum classes when the application periods are open, and attend Student Employment Office (SEO) events such as the bi-annual undergraduate job fair.Once applications have been submitted to the SEO, additional paper applications are sent to all interested applicants that solicit short answers regarding previous work, clinical experiences, and research involvement. From the paper applications, roughly 25% of these applicants are granted half-hour interviews to further evaluate their ability and experience, of whom roughly one-third are accepted. The total number of EDRA position offers made during each hiring cycle is based on position needs. Over the past two years, we have averaged seven new EDRAs across five hiring classes. The majority of our accepted EDRAs are in their second or third year of undergraduate education. This ensures that our EDRAs are committed to their future in healthcare and have had sufficient time to acclimate to the college atmosphere, as well as reduces the amount of new hires that leave the position before providing the program with at least a year of service. As a result, the average length of time EDRAs have served in the program, based on completed terms of employment since Fall 2013, is 20.0 months (SD = 8.90).Training for each EDRA is extensive and consistent . InitialDue to the longevity of EDRAs in the program and the length of certain studies, the initial training is insufficient to maintain a high quality of work. EDRAs receive weekly update notifications via e-mail. Monthly staff meetings are held to communicate major updates and protocol changes, as well as providing EDRAs an opportunity to discuss any obstacles they may have encountered. This opportunity for peer interaction and problem solving afforded by these meetings has proven to be a very effective means of developing and communicating best practices relative to specific trials. When new studies are accepted, EDRAs are called in for new study-specific trainings.For more involved protocols, in-service “boot camp” training sessions are held with the entire EDRA staff, including a review of all study documents, procedures, and best practices in patient approach. These in-service trainings occur 1–2 months after the initiation of the protocol and again every six months for the duration of the protocol. A similar investment in continuing education is the quality assurance process that the program undertakes. All errors in screening, enrollment, or other study-related procedures and guidelines are addressed individually within one week. This time-sensitive response allows for the mistake to be promptly corrected and for the EDRA to learn from the mistake.Because the EDRAs are college students, there are often long periods of excused absence while they are with the program . During these absences, other EDRAs increase their hours spent enrolling  or additional EDRAs are hired to sustain the quality of service provided by our program. Those EDRAs who enroll on a more intensive schedule during the winter and/or summer breaks tend to develop rapidly, as they are afforded greater opportunities to refine their patient-approach style. To maintain the quality of the work upon an EDRA’s return from an absence, EDRAs have three learning modules to complete: an online policy review with a competency check; a classroom review of study and training updates; and an abbreviated evaluation shift with the EDRA coordinator.In addition to our extensive training protocols, we have developed a rigorous quality assurance (QA) process for monitoring study progress and efficiency, as well as for providing quantifiable, formative feedback to the EDRAs. Specifically, EDRAs are required to maintain a shift chart including the name, medical record number, chief complaint, and research disposition of all eligible patients arriving to the ED during enrollment hours. Twice a month, every visit to the ED is pulled in an EMR report for age, sex, chief complaint, method of arrival, and diagnosis. These data are then compared to the hard-copy shift charts that the EDRAs use to ensure that all potentially eligible patients are being screened during enrollment hours. The shift chart allows the EDRA to demonstrate that work is being done, even on patients who are not eligible, who refuse to participate, or who are missed for other reasons.Formal performance assessments are done quarterly throughout the program, as well as at the end of the EDRA’s time as a student or at the request of the individual. These assessments are based on feedback from clinical and research staff, and focus on five core competencies identified in successful EDRAs: communication skills, community interaction skills, critical thinking, personal presentation, and policy adherence. EDRAs are also assessed on their enrollment performance and any quality assurance and improvement concerns that have arisen. These assessments also serve as a mechanism by which EDRA readiness can be evaluated for additional clinical and research opportunities.Monitoring of patients presenting to the ED is required for nearly all of the studies that our EDRA program engages in. As representatives of the Department of EmergencyMedicine, our EDRAs are able to use the URMC EMR track-board to monitor the basic characteristics of patients presenting to the ED. Each EDRA has a separate EMR login with rights to view information on ED patients, and each login is monitored by hospital administration for appropriate usage . EDRAs use this tool to initially screen patients for eligibility . Some studies then require the EDRA to contact a principal investigator or study coordinator to alert them of a potentially eligible patient, at which point our program involvement with the patient may be complete. Other studies require the EDRA to approach those patients who meet the inclusion criteria in the EMR. EDRAs then introduce themselves and the study to the patient, offer to answer any questions, determine capacity for providing consent using standardized procedures appropriate for the particular study,Over the past 26 months, EDRAs have averaged 222 enrolled participants per month , or performing brief interventions .Our EDRAs are also often required to approach and survey providers  involved in the care of enrolled patients. We have developed procedures for collecting needed study information without hampering clinical efforts, and clinical leadership provides consistent support for our research efforts.Our program at URMC has developed a system for both rewarding EDRAs who demonstrate excellence and facilitating sustainability/institutional memory long term. Specifically, the breadth and depth of studies that our program is simultaneously engaged in often requires additional performance analysis, data management, and administrative work. Those EDRAs who perform well enrolling patients and who demonstrate an interest in expanding their experience level are used to fill these roles on a temporary basis . Developing this experience base greatly assists our long-term efforts for the program, as we primarily hire into the EDRA supervisor and coordinator positions from within the program.Our program is also relatively unique among RA programs with regard to clinical integration. Specifically, since the summer of 2010 senior members of the EDRA program who show significant aptitude have been offered positions as a provider assistant and liaison (PAL). The PAL position provides an undergraduate support staff person to attending emergency physicians in the ED during peak hours to improve provider productivity, residency teaching and tracking, and patient satisfaction. PALs work side by side with attending physicians to help maintain assessments details , make phone calls , coordinate discharge resources, care for patient comfort needs, assist with traumas and critically ill patients in a non-medical role, and assist visitors. We have received consistent feedback from providers that the PAL program helps improve ED efficiency. Over the past five years, PALs have provided an average of 142.18 hours of service in the ED per month (SD = 48.56).We also offer exceptional EDRAs study-specific training opportunities that will generalize to their future work. For example, a subset of our EDRA team recently received phlebotomy training and certification to better facilitate enrollment on several of our ongoing studies. Other EDRAs have become certified to work in a clinical laboratory as a way to enhance the efficiency of a set of studies examining biomarkers among ED patients. These students are then able to perform study-related procedures outside of the ED. Our program aims to continually develop these types of skills among our EDRAs to enhance our capacity for engaging in a broad set of research protocols.The EDRA program at URMC has evolved significantly over its 20 years of service to the university. Our current model has consistently resulted in high enrollment rates across a variety of recently funded, multi-center studies. Much of this success can be attributed to (a) the formalized, extensive, and continuous training of the EDRAs, and (b) program efforts to integrate EDRAs into the clinical environment . Nascent programs are encouraged to place much of their efforts into these specific areas of program development, as well as identifying and formalizing methods for accessing high-quality, engaged enrollers . The design of our program has allowed for continual improvement in the quality of the enroller workforce, with the majority of students applying for and enrolling in post-graduate education in the health professions. This improvement and expansion in the URMC EDRA program requires continual investment on the part of the leadership team and ED, as a whole, though the benefits to investigators within and outside the department significantly outweigh these costs.