Educational Assessment, Interventions, and Outcomes

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Visualizing the Future:Technology Competency Development in Clinical Medicine,

and Implications for Medical Education

Malathi Srinivasan, M.D., Craig R. Keenan, M.D., Joel Yager, M.D.

Received February 2, 2006; revised May 1, 2006; accepted May 23,2006. Drs. Srinivasan and Keenan are affiliated with the Departmentof Internal Medicine, University of California, Davis, Sacramento,California. Dr. Yager is affiliated with the Department of Psychiatry,University of New Mexico, Albuquerque, New Mexico. Address cor-respondence to Dr. Srinivasan, 2315 Stockton Boulevard, Sacra-mento, CA 95817; malathi@ucdavis.edu (e-mail).

Copyright � 2006 Academic Psychiatry

Objective: In this article, the authors ask three questions. First,what will physicians need to know in order to be effective in thefuture? Second, what role will technology play in achieving thathigh level of effectiveness? Third, what specific skill sets will phy-sicians need to master in order to become effective?

Method: Through three case vignettes describing past, present,and potential future medical practices, the authors identify trendsin major medical, technological and cultural shifts that willshape medical education and practice.

Results: From these cases, the authors generate a series of tech-nology-related competencies and skill sets that physicians willneed to remain leaders in the delivery of medical care. Physicianswill choose how they will be end-users of technology, technologydevelopers, and/or the interface between users and developers.These choices will guide the types of skills each physician willneed to acquire. Finally, the authors explore the implications ofthese trends for medical educators, including the competenciesthat will be required of educators as they develop the medicalcurriculum.

Conclusions: Examining historical and social trends, includinghow users adopt current and emerging technologies, allows us toanticipate changes in the practice of medicine. By consideringmarket pressures, global trends and emerging technologies, medi-cal educators and practicing physicians may prepare themselvesfor the changes likely to occur in the medical curriculum and inthe marketplace.

Academic Psychiatry 2006; 30:480–490

Thinking about competencies related to current andemerging information technologies raises several in-

teresting questions for physicians: What will they need toknow about information technology in order to be effectivein the future? What role will technology play in achievinghigh levels of effectiveness? And what specific skill sets willphysicians require to achieve and maintain these levels ofeffectiveness?

To address these questions, we paint the picture of apotential medical future, briefly outline emerging technol-ogies that will shape that future, and discuss how physi-cians may lead in the use of these technologies and, con-currently, expect to use them on a daily basis. We close byconsidering competencies related to medical technologiesand their implications for clinical educators preparinglearners for a new medical world.

To quickly envision how technology has affected medicalpractice over the years, consider these brief scenarios re-garding the assessment and treatment of a mid-40s malewith fever, chills, and a hacking cough.

The Past, Circa 1890

A physician in a horse-drawn carriage arrives at the pa-tient’s home, summoned earlier in the day by the man’swife, who sent her son on horseback to the physician’s of-fice several miles away. At the age of 40, the man is alreadyapproaching the end of his natural life but has now devel-oped a fever, chills, and a hacking cough. Physical exami-nation leads to the diagnosis of pneumonia, an often fatalcondition. The physician prescribes a morphine tonic withalcohol to relieve the patient’s pain and dyspnea. Hespends time comforting the distraught family who realizesthat the patient may die. The physician will return the nextday to the patient’s home. He creates a written patientrecord in his notebook and returns to his private hospital.Using his microscope, he sees the causative organism in

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the patient’s sputum sample. Therapeutic options are lim-ited. The physician looks through his few books on medi-cine and surgery and discusses the case with a colleaguedown the street.

The Present, Circa 2006

In his urgent care clinic, a physician sees the patient,whom he has never met, for fever, chills, and a hackingcough. The man is in the prime of his life—mid-40s witha young family. He has traveled about 20 miles by car forthis appointment, driven by his wife. The physician logsonto the hospital’s electronic medical record system andquickly reviews prior appointments and laboratory results.After diagnosing pneumonia on the basis of a quickly ob-tained chest X-ray, the physician prescribes antimicrobialagents to be picked up at the local pharmacy. The patient’swife asks about resistant bacteria and further instructionsfor care. Using the in-room desktop computer, the physi-cian does a quick online search for local bacterial resis-tance patterns and prints out current information from aproprietary medical database. The physician asks the pa-tient to call his nurse the next day. If the patient fails toimprove, he is instructed to return to the office for re-evaluation and possible hospital admission.

The Near Future, Circa 2025

A physician on call in his office in India receives a video-conference call from a patient suffering from fever, chills,and a hacking cough. The patient, located 8,500 miles awayin his local med-terminal, is a member of an internationalhealth network. In his mid-40s, he is a young man withanother 60 to 70 years of life ahead of him. The physicianpulls up the patient’s records from his computer terminal.With the patient in the med-terminal, the physician per-forms a noninvasive MRI-like scan remotely and diagnosespneumonia. Vital signs are taken automatically by meansof pressure gauges. The patient enters a biometric accesscode to allow the physician to obtain his pharmaco-ge-nomic profile from an embedded microchip to begin coun-seling. The patient’s personal digital assistant captures keywords of their conversation via voice recognition softwareand displays pertinent patient-related information for thepatient to view synchronously. The physician prescribes along-acting antibiotic, which the patient receives on-sitefrom an injection terminal. His counseling is complete af-ter the patient receives standardized information from amedical database about self-care. The patient uses a con-tinuous home monitoring device (pulse, blood pressure,

oxygenation), which routes his vital signs to the local phy-sician network to monitor trends and complications. If thepatient’s vital signs fall below acceptable parameters, anambulance network will be automatically notified and hewill be transported to a local hospital for reevaluation andadditional therapy. The Indian physician does a quick lit-erature search on aspects of caring for American patientswith pneumonia and enters his thoughts and lessonslearned into a learning portfolio for his own CME credit.The patient completes his customer satisfaction form onthe insurance company’s Web site in order to receive hisparticipation bonus of a reduced copayment.

This view of the future simply extends already existingmajor medical trends that represent market force pres-sures for cost containment (1, 2), globalization/outsourcing(3–6), and data consolidation (7–11). Another equallyplausible view of the medical future might envision betterpersonal relationships between patients and their physi-cians (12, 13), using local coverage networks and personalcommunications modalities (e.g., next evolution of e-mail,home monitoring) to allow longitudinal and home-basedinteractions. Optimists might even imagine that doctorsmight make home visits (14–16) because their patient poolhas become smaller due to their negotiated rates increas-ing and with risk pools shared across demographic groups.

The major fallacy of trying to predict a medical futurebased on present technologies or current social/economic/political trends is that major shifts are difficult to antici-pate. For instance, while functional nanotechnology andincreased domestic terrorism are recognized as near-fu-ture possibilities, the next major paradigm shift is as yetunknown. These shifts (such as Internet-based shared net-works, massive inexpensive computing power, ease of in-ternational travel, changing unemployment) have a dra-matic impact on the medical horizon in unpredictable,nonlinear ways.

Even with these uncertainties, educators are obliged toprepare their learners for near- and far-future practice sce-narios. They need to consider critical elements embeddedin these known trends, and devise strategies to help learn-ers meet those needs. Similarly, examining critical aspectsof those scenarios (Appendix 1) allows us to describe thespectrum of competencies that physicians may need to de-velop. Foreseeable major trends in medicine include:

• CommunicationEvolution of the doctor-patient relationship into amore client-supplier model (17, 18).Greater emphasis on patient responsibility forhealth (19).

TECHNOLOGY COMPETENCY DEVELOPMENT AND EDUCATION

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• Information managementAvailability of high quality, transparent medical in-formation for the lay public (20, 21).Internationally available patient medical/pharmacyrecords (22, 23).Stringent new privacy standards, with biometric andother coded data schemas (24–27).User-friendly, decentralized continual education,tailored to individual practices (28).Emphasis on self-directed learning and continuingself-education (29–31).

• DiagnosisDevelopment of pharmocogenomic profiles for in-dividual patients (32–35).Inexpensive high-quality imaging techniques forclinic use (36).Creation of better home monitoring equipment forself/system management (37, 38).

• TherapyInformation management systems for physicianeducation and practice-based updates (39).Compilation of individual patient health statisticsinto searchable databases (40).Testing of complementary, alternative and tradi-tional/local medical practices (41, 42).Increasing emphasis on nonallopathic practice andancillary practitioners (43, 44).

• Quality control and locationDecentralization of medical care via telemedicinetechnologies (45, 46).International standards for medical practice, “in-ternationalizing” medicine (47, 48).Medical outsourcing to other countries for non-emergent treatment (49, 50).

Likelihood of Technology Adoptionby Physicians and Society

In medicine and the rest of society, the rate of technol-ogy introduction and adoption has been rapid. Enhancedcompetency by physicians may be directly related to tech-nology adoption. The incorporation of new technology inmedical practice is influenced by four strong forces, thefour “As,” which are driving pressures toward greater ef-ficiencies and effectiveness in medical care: accessibility,affordability, accountability, and affability (Appendix 2).These driving pressures are fluid and change over time for

any given technology. For example, as more competitorstry to develop similar products (such as Internet accessproviders [AOL, Comcast, telecom companies]), the tech-nologies will decrease in price (affordability). This de-crease in price and increase in manufacturing/distributionwill increase the consumer’s access to the technology. Witheach iteration, the consumer will find the technology easierto use and more functional (affability). Physicians will berequired to critically assess the cost-benefit-harm-limita-tions for each new technological tool and be accountablefor the use and results of the technologies in practice.

Physician Role Adoption and CompetencyDevelopment

In preparation for this future, physicians will have todecide how involved they will want to be with emergingmedical technologies. Some will elect to remain “end-users” of technology, whereas others will participate in de-veloping and evolving those technologies or will interfacebetween the developers and the end-users (Appendix 3).Physicians who are on the development end of technologywill, of course, need to develop specialized expertise inthose technologies: affecting communication, diagnosticand therapeutic options, data management, self-educationstrategies and other constantly changing areas.

These major trends will have significant implications forphysician training and competency development (51, 52).As with other professionals, all physicians will be requiredto become “technology literate”—understanding how touse basic software programs, communication/e-mail pro-grams, messaging systems, common organizers, commonpresentation-related hardware. Psychiatrists, for example,might be expected to acquire skills for interacting with re-mote patients via teleconferencing (tele-psychiatry) (53).Most of these technologies currently exist and are alreadybeing used in tele-consultation. Physicians who bridge twoassociated fields of medicine (e.g., electronic medical rec-ord development) and medical practitioners will requirefamiliarity with practice patterns/usage in the associatedfields. As physicians seek additional leadership opportu-nities, those who are dually trained will enjoy competitiveadvantages in the medical marketplace, where obtainingand disseminating medical information will become in-creasingly simple. Medical informatics, the field of man-aging and interfacing with medical information, will com-prise only a subset of the total types of skills that dualcompetency physicians may acquire.

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Implications for Medical Training

Future medical school selection committees may be in-creasingly inclined to recruit physician leaders who bringsubstantial experiences outside of medicine to their medi-cal education. Because of the increasingly rapid expansionand evolution of the knowledge base, students will need tospend more time learning to assess data critically. Withubiquitous information access, the amount of basic knowl-edge that physicians will need to memorize may decrease.They will also require skills in new ways of communicatingwith their patients via remote means. These shifts may en-courage some physicians to spend more time than in thepast understanding the systems and social implications ofpractice (health economics, health disparities, evidence as-sessment, research training, epidemiology).

Currently, the competencies outlined by the ACGME(54) are flexible enough to allow incorporation of the tech-nology-related skills into a standard residency training pro-gram. Educators will be faced with an even more compli-cated task: keeping their core curriculum (e.g.,pathophysiology) stable while incorporating new infor-mation at a reasonable pace. In Appendix 4, we havemapped a few very basic technology-related competenciesfor the end-user physician, who may have minimal inputinto technology development. Educators will need to con-sider core skill sets for each user type from a competencyperspective. Since many of the core skills affect the differ-ent areas of medical practice, educators will need to care-fully consider how “stacked” they want their competencygrids to appear.

Medical educators will be faced with the even morecomplicated tasks of retaining their fundamental core cur-riculum requirements (e.g., pathophysiology) while incor-porating new information at a reasonable pace. Traditionalmedical education models are already challenged, as medi-

cal students already acquire and assimilate knowledge viatheir wireless laptops and PDAs during classes, seminars,and at the bedside. Inexpensive, high-quality digital videorecording technologies allow easy demonstration of best/worst communication and clinical skills practices in class-rooms. As high quality core curricula become universallyavailable through the Web, educators will have to deter-mine the best use of classroom time—how much time tospend to deliver core content and/or using a small groupsetting to assess learner understanding and push skills incontent application. Each of the specific competencies thateducators will instruct or encourage will entail knowledge,skills, attitudes, and habits. Some competencies related tothe incorporation of these technologies into a medical ed-ucator’s practice are detailed in Appendix 5.

Conclusions

Cultural and technological shifts often provoke anxietyabout a loss of values or autonomy while simultaneouslyprovoking excitement about new opportunities. The prac-tice of medicine is evolving quickly, and global trends inthe marketplace place pressure to reduce cost while in-creasing quality. The American physician of the future willface international competition, and all competitors will beequipped with powerful new tools for patient care, datamanagement, and communication. Examining these majortrends can help educators understand the new technolog-ical competencies that will be required of physicians.Medical education itself will evolve in learner selection,content, and methods. Physician leaders in education willhelp guide the appropriate implementation of medicaltechnologies in practice, fostering practices that use tech-nology to increase accessible, affordable, accountable, andaffable medical care.

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APPENDIX 1.

Past Present Near Future

Characteristic CommunicationPatient role Passive, little medical knowledge Participatory Participatory, perhaps directivePhysician role Directive Directive or participatory Customer service orientation predominates.

Competition increases for patient rosterPatient-physician

relationshipKnown each other intimately over time Relationship is local, but physician may not know

patientRelationship decentralized, international. Physician

may not know patientFamily role Caregivers for all patient needs When patient significantly ill, most care delivered

in the hospitalSignificant caregiving, since much medical care is

transferred to the homeDiagnosisDiagnostic options Limited to history, physical, and microscopic

examinationNon-invasive diagnostics done in specific

departments, not in physician’s direct officeNon-invasive diagnostics available at point of

interaction (terminals, offices, etc.). Homemonitoring with health-system interface

TherapyTherapeutic options Surgery, analgesics, herbal tinctures,

compounds, comfortTherapeutic options based on patient

demographics (age, smoking, ethnicity)Customized therapeutic options based on

patient’s individual genomic profileEvidence base Anecdotal medicine, case series, ‘‘eminence-

based medicine’’Evidence-based, from population-based

therapeutic outcomes dataPopulation and individual probabilistic outcomes

from international outcomes databasesInformation ManagementPatient records Individual clinic notes kept by physician Local data networks increase. Moderate privacy

standardsInternationally available records, with stringent

privacy standardsPatient outcomes

(positive, nochange, adverse)

Noted by physician, patient, and family Noted by physician, patient, and family. Adverseoutcomes tracked by health system

Patient outcomes automatically entered intointernational databases. Monitoring allowsearly adverse outcomes alerts

Medicalinformation

Learned in medical school, few updates Learned in medical school and residency programsPeriodic updates

Point of service information delivery. Informationdelivery simultaneously to patient andphysician

Continuing EducationPhysician’s

continuingeducation

Not much change since medical school. Text-based learning. Opinion leader discussions

Recertification every 5 to 10 years, with state-mandated education hours for licensure.Education is sporadic and idiosyncratic

Continual certification, each patient as acertification case. Reflection-based portfoliosystems linked to CME. Information systemsmanage CME and physician time

Physician outcomes Medical knowledge Medical knowledge, some procedural/communication skills

Medical knowledge, skills, attitudes, habits, self-reflection

Professionalinteractions

Local physicians, limited conferences Local and national meetings. Mainly localinteractions with colleagues

Virtual meetings internationally, supplementary in-person meetings

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Quality Control and LocationLocation Patient’s home, perhaps hospital or office Physician clinic or hospital. Geographically close Physician and patient geographically distant.

Outsourcing if non-urgentExpertise Local. Walking, horse, cart or driving distance Regional/national. Limited by time and budget

(flights)International. Telemedicine predominates when

local availability/expertise limitedAccreditation By medical schools, when certification

availableState/national organizations accredit/license

individuals, groups, hospitals, medical schoolsInternational organizations. Once quality

standards are met, practices gain access toprosperous markets

Medical EconomicsPayment Negotiated based on patient resources, often

individually bargainedInsured patients have small co-pays. Government/

safety net hospitals absorb cost for poor. Un/underinsured pay heavily

Patients may choose from catastrophic healthinsurance to complete medical coverage. Co-payment varies with patient health prevention

Insurance None Employer-based insurance, negotiated healthplans. Government insures some poor/elderly

Risk pool spread across all populations. Nationalor international health consortium and scaledrates for socio-economic status

Performancestandards

None Large practices receive increased payments to meetcrude quality standards. Minor risk adjustmentfor patient factors

Health information systems facilitate meetinginternational practice standards. Sophisticatedrisk adjustment. Best practices incentives

APPENDIX 2. Critical Characteristics of Medically-Related Technologies Influencing the Likelihood for Adoption by Medical Profession and Society

Competencies Related to Use of . . . Accessibility Accountability Affordability Affability

Laptop computers and standard software � � � �LCD projectors and presentation software � � � �Pocket information organizers � � � �Internet—information utilization � � � �Learning portfolios � � �Decision algorithms � �Distance consultations via videocam/videophone � � �Patient simulators: mega-codes � �Patient simulators: cardiac catheterizations � �Patient simulators: computer-based virtual schizophrenia patients �Voice recognition software � � � �Distance surgery �Biometric privacy modalities (retinal, fingerprint scans) �Non-invasive functional imaging (fMRI, PET, etc.) � �Nanotechnology intervention

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APPENDIX 3. Fields of Evolving Knowledge, With Some Examples

Domain Evolving Field Skills for Physician Developing Technology

Individual patient Genomic profiling Basic science training in genetic chip design and genetic sequencing. Understandingof genetic pattern variation

Individual data search interpretation Health services research training for database manipulation and construction foruseful queries. Programming skills and database construction skills useful, viamedical informatics training

Understanding cultural norms for decision-making Cultural anthropology and field experience with native/self/other culturesUnderstanding individual care preferences and expectations Communication and listening skills training, individual and systems change

strategiesDiagnostic options New noninvasive imaging and testing technology Algorithm and mathematics training. Training in nuclear physics. Programming skills

Understanding cultural variations in disease presentation Cultural anthropology and field experience with native/self/other cultures. Ethicstraining to understand societal conflict

Therapeutic options Nanotechnology Training in nanotechnology design and development. Chip design and hardwaredesign training

Genetic manipulation Chemistry/genetic training. Proteomics and cellular biology training. Softwareprogramming skills

Customized pharmaceuticals Chemistry and cellular biology training. Research trials training. Management andmarketing training

Understanding neurocognitive-behavioral links Neurocognitive biology training. Manipulation and use of neural imaging techniquesNon-pharmaceutical interventions Testing alternative, complementary medicine via health services research and clinical

trial training. Statistical analysis package useCommunication Distance/remote communication strategies Communication and listening skills training, without face-to-face visual cues.

Distance physical examination and interventionsCommunicating with multi-lingual populations Expertise and medical fluency in multiple languages. Training in cultural values and

expectations for those populationsCustomer-centered care Customer service and retail training. Business management training. Personnel

management trainingPolicy development Communication, media relations, and advocacy trainingValues conflict Ethical and communications training to anticipate, recognize, address emerging

values conflicts (e.g. reproduction and life-prolonging care)Data management Tools to critically synthesize information Training in epidemiology, educational content delivery, algorithmic decision aids,

and information delivery systemData interface tools Training in natural language processing, voice recognition programming, data

architecture, and software programmingEducation Decentralized education strategies Training in educational content delivery, software programming (JAVA, Zope, Flash,

etc.), video production, and Web-based toolsCreation of high-quality current patient/physician information Training in educational research methodology, educational delivery timing/

reinforcement, and curriculum developmentSelf-education and self-reflection strategies Training in reflective learning and reinforcement strategies, educational delivery

mechanismsSimulation technology for skills practice Training in educational content delivery, plastics manufacturing, hardware

development, algorithmic & event-driven decision-makingLicensure International standards development for medical practice Health services research training for assessment of efficacy, content expertise. Health

advocacy trainingMonitoring and enforcement of practice violations Educational assessment expertise and health advocacy training. Governmental and

policy trainingRemediation strategies for substandard physicians Educational curriculum development, faculty development, communication skills

training, and decision-making analysisPrivacy Evolving privacy standards Training in medical ethics, medical economics, media relations, and health advocacy

New methods of ensuring unique information access Training in biometrics, genomics, and computer programming

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APPENDIX 4. Relationship of Some Technology-Related Competencies to ACGME Core Competencies

ACGME Competencies

BASIC Computer and Informatics CompetenciesPatient

CareMedical

KnowledgePractice-Based

LearningInterpersonal

Communication ProfessionalismSystems-Based

Practice

Computer operation skillsDemonstrate ability to use computers, storage/back-up

(e.g., hard disk, flash drives, CD/DVD), and relevantsoftware � �

Use common peripherals, including scanners, projectors,organizers, biometrics, simulators, tele-medicine units � �

Software application competenciesWord processor skills – start, write, save, print. Use

special manuscript features (e.g., tracking, insertcomment, references) � �

Graphing and spreadsheet programs (e.g., Excel): createand use graphs, spreadsheets, and databases � �

Project management software � � � �Voice recognition software � � � �Electronic medical record use � � � � � �Software development competenciesUse of natural language processing tools � �Development of information database architecture � �Utilization, testing, and feedback of user interfaces � �Communications utilization competenciesInternet: Locate, evaluate, and select resources for

personal life-long learning and patient education � � � �E-mail and list-servs � � � � � �Videophone/videocam � � � �

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APPENDIX 5. Competencies Related to Use of Technology in Medical Education and Patient Education

Developing Educational MaterialBasic Knowledge: The educator should be able to describe and discuss:

Characteristics, strengths, and weaknesses of different media, including available media communication resourcesSocial, legal and ethical issues related to technology use (fair use, copyrights, accessibility, HIPAA, etc.)Role of technology/media in application of core educational principles (e.g., adult learning)

Skills: The educator should be able to:Develop, maintain, and modify a Web pageProduce electronic slides/overheads using PowerPoint or similar programs to create stills, insert videoclipsOperate basic media-related technology: video recorder/player, digital cameras, monitor/TV, LCD projectors, computer, etc.Edit voice/video files, provide high quality videos and graphicsUse these skills to produce integrated multimedia presentations, including non-linear hypermedia presentationsProduce print-based products using desktop publishing

Curriculum DevelopmentThe educator should be able to:

Identify target audience, learner needs, appropriate curricular goals, resources for curricular development/implementationDevelop creative and useful learning experiences, using media to present material in a comprehensible mannerLocate, evaluate, and select resources/material (digital information, local experts, primary documents/artifacts, text, etc.)Use technology in the discipline/subject for learning and external communicationUse technology to facilitate teaching strategies specific to the disciplineDevelop physical settings and organizational and management strategies that support active student inquiry and collaborationIncorporate media and technology for teaching where appropriate, and support learner expression in a variety of media

Educational AssessmentThe educator should be able to:

Create study designs that allow development and testing of educational hypothesisRigorously analyze data from studies for effectiveness of interventionsDemonstrate effectiveness of learning modalityDevelop performance tasks for students to locate/analyze information, synthesize, and apply information in new contextsDevelop needs assessments using tools, such as SurveyMonkeyUse appropriate technologies effectively to collect information on student learning, using a variety of methods

Dissemination of Education MaterialsCreate sustainable systems of change within institutions and nationsDevelop on-line e-learning courses using formats such as WebCT, Angel, etc.Establish on-line conferences via WebDevelop interactive Web-based curriculumDevelop and provide feedback on learning portfoliosPresent material at national educator and patient care conferencesUse media to disseminate appropriate educational material to policy makers

Some data adapted from standards developed for educators in North Carolina (tps.dpi.state.nc.us/standards.html)

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