Analysis of LAP and Modified LAP

Analysis of LAP and Modified LAP 1. Critically review a test item that you have designed for inclusion in an assessment instrument It is nearly two decades since the St Vincent Declaration (1989) called for a marked reduction in morbidity with diabetes related problems to be achieved through better patient management. The available evidence suggests that the process of care in Britain is still very variable in quality. (J. Mason, 1999) et al. conducted trial on diabetes foot care, and provided an important message that vigilant and trained health care professionals can identify the emerging risk factors for ulceration at relatively low cost. The National Institute for Clinical Excellence (NICE 2004) clinical guideline on type 2 diabetes foot care on the prevention and management of foot problems recommends that healthcare professionals and other personnel involved in the assessment of diabetic feet should receive adequate training. Hence, it is imperative that the Diabetes Specialist Registrars [SPR], the future diabetologists, who look after diabetic feet in the community and secondary care, should be trained and adequately assessed if they want to make an impact on patient outcomes. Thus, the need arises for a training CME [Continued Medical Education] day for the management of diabetes foot and assessment before they treat patients with these problems. The main aim of the assessment is to optimize the capabilities of all learners and practitioners by providing motivation and direction for future learning. The assessment has to be formative in this case guiding future learning by providing reassurance, promoting reflection and shaping values. At the end of the training day (Appendix 2) the plan is to conduct a modified, observed, long case type of assessment tool with 3-4 items and knowledge based assessment. One such item an observed modified long case is described in Appendix 1. The plan to use a real case is to illustrate the some of the day to day difficulties and uncertainties one faces during clinical judgement. The time breakdown is to prepare them for thinking about various aspects in given time. They are assessed in different generic skills as well as speciality knowledge and management of the case. Appendix 1 [page 24-26] Properties Even though it is used as an item here, the long case has traditionally been used as a summative tool by itself in the past and its properties in those situations have been studied extensively. Hence, the properties like reliability and validity have been discussed briefly with others of the items such as facility. The reliability of a long case can be improved by structuring the long case i.e. elements of discussion and questioning (Olson et al 2000, Wass and Jolly 2001). Thus observation and structuring is applied here to improve the reliability. This increases student perception of fairness. Validity This can be addressed by introduction of examiners who observe trainee performance throughout and so the trainee is observed by the team in all parts of the long case out here (Olson et al 2000). Facility It could be made low facility depending on the complexity of the case. Discrimination is not really applicable since it will be used as part of formative tool but can be made into a highly discriminatory one by following global assessment. The other properties of the assessment tool are not discussed as it is used mainly as an item. Item Response Theory This is not discussed here as it is mainly used in the context of Multiple Choice Questions. There is not much in the literature about the strengths and weaknesses of the long case when used as an item in a formative assessment tool. So here is an attempt to look at both the positive aspects and potential drawbacks of this item should this be used in the context of this formative assessment. The positive aspects of this item Observed Modified Long Case Holistic and Robust This item in the long case is real and looks at competency and some aspects of performance. Multidisciplinary Approach mimics how the clinics are conducted in most hospitals and assess candidates knowledge across specialities. Written and Verbal Constructive feedback Ende (1983) proposed that the process of feedback should be expected and well timed, based on first hand data (observable behaviour) and regulated in quantity. In a systematic review by Best Evidence in Medical Education (BEME) collaboration (Veloski, et al., 2006) the positive impact of the feedback process was confirmed, with the most marked effects if provided by an authoritative source. These principles are strictly followed in this item. The method of feedback can be either Pendleton or ALOBA- Agenda-Led Outcome Based Analysis. Some of the potential drawbacks of this item-How they can be overcome Risk of assessing the short term memory This argument stems from the fact that the assessment is done just after the CME program as suggested. Based on Bligh (2000), the above graph, demonstrates the retention power if tested early after the learning experience. Hence the argument: the item should be administered immediately after the CME to increase retention. Resources and Standardisation The number of people including specialists involved and the organisation will require resources, including money, but some of the funding could be organised by the educational fund for the SPR in the region. Some contribution can be arranged from other sources including pharmaceutical company help. Since it is a formative assessment tool, it need not be rigidly standardised in assessment and it is to promote the professional development of the SPRs. Why rigid time limits and not just global assessment? This rigid structure is to give an opportunity for each of specialists to have an opportunity to observe and feed back. In real life, the time spent on each task may be different but giving stringent time limits also gives the opportunity to observe how the candidates perform within these time constraints. The global assessment is avoided so that the feedback component needs to be broken down to each level to make sense and promote specific areas for improvement. Bias Since some of the examiners and experts would have taught these SPRs in the course there may be bias from these examiners after observing the candidates interaction over a day and might want them to do well or otherwise in the assessment. This can be avoided by formal training of the examiners. Organisational consideration The main difficulty will be getting the team of assessors together as given in the item and making sure they are trained in giving constructive feedback to the candidates. Getting a real life patient to participate in such a scenario might not be difficult as patients are often happy to share their experiences. CONCLUSIONS If used in conjunction with variety of other items, perhaps it can be used as a cog in the wheel of summative assessment for the high stake assessment e.g. as a part of portfolio in final year Rotation In Training Assessment [RITA]. It fulfils the learning objectives of the course and what the item intends to measure. This item also comes close to what is usually measured in items of work place based assessment [WPBA]. Element 2 Assessment option Using relevant theoretical and/or research literature, critically review one instrument of assessment used in clinical education. LAP and Modified LAP BACKGROUND In the traditional long case candidates spend 30-45mins with a patient from whom they take a history and examine. An examiner is not present and the candidate is not observed. The student summarises and is examined by a pair of examiners over a 20-30 minute period. The usual format of practice in long cases is to examine patients that are already known to the examiner or are in the examiners own specialty. The long case, patient based examinations have been used for decades both in undergraduate and postgraduate settings both as a formative and summative tool. They were specifically used for final certification exam for postgraduates both here and elsewhere. They had their strengths in that it evaluates performance with real patients and enables candidates to gather information and develop treatment plans under realistic circumstances (Norcini, 2002). However, this method has drawn lot of criticism. The problem lies with inter case reliability (Wass, et al., 2001) and whe n subjected to psychometric analysis, these examinations were found to be unreliable and so have fallen from favour (Turnbull, et al., 2005). Particular problems were with the reproducibility of scores generated by the long case. To improve this required large sampling which itself required a lot more resources which made the long case difficult to use as a summative assessment tool. Recent work suggests that the long case is still a highly relevant tool in that it appears to test a different clinical process to that of the structured short case examination (Wass and Jolly, 2001). A study, performed with undergraduates in London found that, by observing the process in the long case, the above problems could be overcome. This probably led to a return of long cases in the form of OSLER Objective Structured Long Examination Record introduced by Gleeson(Gleeson, 1997) and LAP the Leicester Assessment Package. The LAP was originally developed to assess the consultation competence of general practitioners in the UK. In the LAP, the patient is not known to the examiners and at least one of the examiners is not an expert in the specialty being examined. It has been designed for use in live and/or video recorded consultations with either real or simulated patients. It was subsequently adapted for use in undergraduate teaching. The LAP is designed to provide assessment by directly observed consultations with real patients/simulated patients, but to present this in a structured format closer to an OSCE, which also allows other aspects of performance to be assessed. Seven prioritized categories of consultation competence which need to be mastered are assessed with marking (Appendix 3). The modified LAP varies from the LAP in a couple of areas. Performance is assessed against predefined standards which are different compared to the LAP. The examiners attend training before they become assessors in the modified LAP. The guidelines to the examiners [how to mark and assess] and the assessment forms are appended (Appendix 4 5). Inevitably, some overlap occurs between components of differing categories. (Bhakta, et al., 2005) acknowledge that no single assessment format can adequately assess all the learning objectives within the course blueprint, a combination of assessments (including OSCE, EMQ, essays, short case, and long case) are currently used to assess the students competence. The authors main objective is to use theoretical and research literature to critically review the LAP and modified LAP used in the assessment of clinical practice. This review is based on the seven key concepts (Van der Vleuten, 1996; Schuwirth and van der Vleuten, 2006; PMETB, 2007) liste d below: Purposes Alignment Properties Standards Sampling Evidence Level 1. PURPOSES It can be used for both formative and summative assessment. (Fraser, et al., 1994) argued that the modified LAP is designed for both purposes. The focus of the examination in the intermediate clinical exam for undergraduate is to promote further improvement as they have done only one clinical year [e.g. WMS and Leicester Medical School]. Hence, the feedback is handed to the students which helps them to focus on their strengths and improve on their performance The 3rd and 4th year medical students of these Schools believed that it was likely to enhance their consultation performance (McKinley, et al., 2000). It has also been used as a formative tool in improving professional competence in different countries and different specialties (Lau, et al., 2003, Redsell, et al., 2003). When (Teoh and Bowden, 2008), arguing for the resurrection of the long case, state that the observed long case such as the Modified LAP doesnt encourage the reductionist approach as in Objective Structured Clinical Examination [OSCE ]. Thus, it can be an ideal summative assessment tool for the high stake exam but perhaps has to be used in conjunction with other tools as discussed below. Additionally, in most cases, the assessment is an end of year high-stakes assessment and, for failing students, there is generally only a short time available for remediation. The feedback provides a way to focus them on the areas of their consultation skills and prepare for their remedial exam. 2. ALIGNMENT The Education Committee of the General Medical Council (GMC) sets and monitors standards in all UK medical schools. Medical students must be able to demonstrate their competency and professionalism through a list of educational outcomes set out in the publication of Tomorrows Doctors (2003 and 2009) prior to graduation. The intended outcome envisaged by WMS is to produce a generation of doctors who have knowledge, proficient clinical skills and the appropriate attitudes and behaviours ready for work as Foundation Year one doctors. The modified LAP forms a part of the summative assessment in assessing mainly clinical skills e.g. examination techniques. As described, it has various components and proper, planned blueprinting against the learning objectives of the MBChB course and competencies of the various specialties (Wass, Van der Vleuten, Shatzer and Jones, 2001). Thus, assessment and curriculum design should be intricately interwoven and the assessment of course drives the learning (Wass, Van der Vleuten, Shatzer and Jones, 2001). Similarly, in postgraduate exams, it usually follows knowledge based assessment in the form of MCQs and careful alignment should be done considering the curriculum set by the institutions like the Royal Colleges. 3. PROPERTIES The property of an assessment or more commonly described as the utility or usefulness of an assessment, was originally described by Van der Vleuten (1996) as a product of its validity, reliability, educational impact, cost-effectiveness and acceptability. In later years, the term feasibility is explicitly acknowledged and has been described as an added component of an assessments utility in clinical education (Schuwirth and Van der Vleuten, 2006; PMETB, 2007). Validity Validity represents the extent to which a measurement actually measures what it intended to measure. In medical education, this signifies the degree of meaningfulness for any interpretation of a test score. (Downing, 2003) A recent study demonstrated that observation does measure a useful and distinctive component of history taking clinical competence over and above the contribution made by the presentation (Wass and Jolly, 2001). It would seem logical that, rather than relying on a presentation alone, observation of the candidate while eliciting the history and carrying out the examination would be a more valid assessment of the candidates competencies in LAP. There is data in the literature for the face validity and content of the seven categories and the various components of consultation competence as contained in the Leicester Assessment Package (Fraser, McKinley and Mulholland, 1994). Whether or not the test scores obtained, in any particular LAP, are an accurate representation of real world competency is subjected to a vast array of variables (Downing and Haladyna, 2004). For instance, the design of the test items, number of representative cases, experience training and leniency of examiners, co nsistency of simulated patients [ used mainly in psychiatry], completeness of marking schemes and the characteristics of the candidates, can all affect the validity of a LAP, making it a valid assessment in one education institute, but not another. However McKinley et al in their study of modified LAP in the general practise setting concluded that students will be exposed to a valid set of challenges to their consultation skills during consultations with minimum six largely unselected patients(McKinley, Fraser, Vleuten and Hastings, 2000). Concurrent validity whether the results are consistent with those tests of similar constructs? There are studies comparing OSCEs with observed long cases [which is similar to LAPs in some ways]; however, the author has not come across studies comparing different types of observed long case e.g. OSLER vs. Modified LAP. Does it predict the future performance need to be assessed by more studies by following up the generation of students where the LAP is used as an assessment tool. Also, more studies are needed to investigate the construct validity of LAP. Reliability Reliability refers to the degree of consistency within a measurement tool, the extent to which an instrument is capable of repeatedly producing the same test score even when administered at different times and locations, with different candidates (Schuwirth and van der Vleuten, 2006). An assessment approach may be considered reliable when it yields consistent results regardless of when it is used, who uses it and which item or case is assessed. The importance of a specific type of reliability depends upon what is being assessed and the method by which it is being assessed. Generally speaking, the reliability or generalisability coefficient [since there is multiple potential sources of variability in this assessment tool] of 0.8 or higher are desirable (Shea and Fortna, 2002). Since the LAP has its roots in the long case and considering that it has evolved as a modified observed long case the author will attempt to address how the deficiencies in reliability of long cases were addressed to make it a LAP. Attempts to improve the reliability of the long case and make it into an effective LAP fall into three categories. First, studies have considered how many additional long cases would be required, with Kroboth et al (1992) suggesting that 6-10 long cases (each of 1-1.5 h) would achieve a generalisability coefficient of 0.8. Thus it would take a minimum of 4 different cases with at least 2 assessors in each to be reliable and therefore, careful sampling of representative cases with the use of blueprints is of paramount importance (Cangelosi, 1990).Second, commentators have attempted to increase the number of long cases, but have done so by employing a format that draws on shorter assessments (20-45 min) and multiple cases (4-6) assessed directly after each other in a single session (McKinley et al, 2000; Wass Jolly, 2001; Hamdy et al, 2003; Norcini et al, 2003). Third, elements of the discussion and questioning aspects of the long case have been stan dardised in an attempt to improve reliability and student perceptions of fairness (Olson et al, 2000). Thus, having all relevant domains and enough numbers would increase the reliability and validity of the instrument. All these are incorporated in LAP and modified LAP to make a reliable instrument. This is further demonstrated by McKinley et al that the required levels of reliability can be achieved when the modified LAP is used by multiple markers in assessing the same consultation, that is, the package produces inter-assessor reliability. Their generalizability analysis indicates that two independent assessors assessing the performance of students across six consultations would achieve a reliability of 0ÂÂ ·94 in making pass or fail decisions. Also in this study ninety-eight percent of students perceived that their particular strengths and weaknesses were correctly identified, 99% that they were given specific advice on how to improve their performance and 98% believed that the feedback they had received would have long-term benefit(McKinley, Fraser, Vleuten and Hastings, 2000). The example of assessment criteria and guidelines of the modified LAP used in the study are incorporated as Appendix 4 and 5. Reliability of the LAP would not be severely threatened if the details of the test items have leaked out to the candidates unintentionally. However, it might if they have seen this patient before in the clinical setting. There were chances of this happening as the same banks of patients were used. This has been rectified by updating the bank and recruiting different patients. Broad sampling across cases is essential to assess clinical competence reliably (Wass and Vleuten, 2004). Feasibility The design and running of the modified LAP has significant resource implications. The crux of the issue for this kind of assessment is feasibility and cost effectiveness in terms of finance, space and manpower. Lots of time and effort are required to prepare and administer the instrument with high quality. Recruiting enough assessors, real patients, [simulated patients in case of psychiatry] and the equipment is always a huge challenge. Finding the trained assessors, who mostly tend to be busy clinicians, to take time from their heavy work schedule is also a challenge. However, lots of these issues can be overcome if this test is administered regularly i.e. sequential testing. This is further helped by having a database for the patients and assessors. Good advanced planning will also go a long way. Acceptability John B Cookson, et al. (2008), in a letter to the BMJ, say that feedback from students who have faced this examination in Leicester for the past 9 years strongly indicate that it is perceived as a fair and acceptable test of their abilities. From the organizational point of view it has been acceptable because of sequential testing. There is a healthy debate about replacing this with OSCEs or at least using OSCEs to supplement this for the assessment of clinical based practice. Educational Impact From the students point of view, the high-stakes LAP certainly exerts a great educational impact. The outcome of the examination will be used to decide the fate of the students. The LAP provides a platform for students to demonstrate their knowledge, skills, attitudes and behaviours in a single direct observational setting. Among other advantages it encourages students to develop the essential links between history, physical examination, diagnosis and management in each clinical challenge as the consultation progresses, not at some remote point thereafter. This is true as they practise for these exams in this way with peer group or supervision. It definitely has a huge educational impact as the students keep the final assessment in mind and practice the required domains in a structured way from various colleagues and peers. The impact is even greater in some medical schools like WMS as the feedback is given to the students in the formative intermediate exams. This enables the students to reflect on their performance and improve upon them. 4. STANDARDS The Standards can be criterion-referenced (absolute standard) or peer-referenced (relative standard). Borderline approach , fixed percentage , Angoffs and Hofstee methods are but a few of the many methods described in the literature for standard-setting (Norcini, 2003). Livingstone and Zieky (1989) proposed that the higher the stakes of the assessment, the greater the significance in using criterion-referenced standards. Thus criterion referenced can be used for LAP in the setting of high stakes exams like final professional exams in WMS or postgraduate exit exams SAMPLING It is impractical to combine all of the learning outcomes into a single, summative assessment. On a practical note one has to be careful while allotting the students and examiners for the different station/patients/item so that they get a wide variety of sampling that gives a different case mix. Thus, it also needs to be made sure that they are observed and examined by different examiners to increase the sampling. Thus a careful and effective blueprinting should be done to make LAP a high utility instrument. Moreover, qualitative triangulation of evidence [sampling] from different sources such as satisfactory performance in each block, including other types of exams likes OSCE for practical skills will further improve the reliability (Stern, et al., 2003). 6. EVIDENCE Evidence from a single point is not sufficiently generalisable to be extrapolated to all occasions (PMETB, 2007). Studies regarding validity and reliability are costly and difficult to design. Triangulation is an excellent solution to critique the evidence collated qualitatively, where evidence from at least 3 occasions/ resources indicating the same outcome is analyzed (PMETB, 2007). Each LAP item should be treated independently, as an entity of its own, and, although literature can prove LAP do possess the potential to be highly valid and reliable, such study would need to be conducted on separate occasions to demonstrate convincing evidence. This is continuous ongoing process at most of the institutions including WMS. 7. LEVEL It is suggested that using the LAP for direct observation of the consultation would be a useful tool to assess whether the student has successfully acquired the necessary competencies expected at the end of undergraduate or postgraduate training. One of the interesting components is to attempt to judge the overall relationship with the patient. Attitudes are most likely to be conveyed to the patient through the doctors behaviour and should, therefore, be assessed by the observation of behaviours in the clinical setting (REZLER, 1976). Nevertheless, this approach relies on judgements, made by experts, of non-standardised material and is, therefore, open to question. Because professionalism is a complex construct, it is unlikely that a single assessment will adequately measure it even though this assessment makes the attempt. Systematic assessment of professionalism should also include many different assessors, more than one assessment method and assessment in different settings (Lynch , et al., 2004). Hence, these assessments are a continuous process throughout the MBChB and, indeed, afterwards. In essence the LAP, as an assessment tool, is close to competency based assessment and demonstrates shows how in the Miller triangle. CONCLUSIONS Long cases on their own have been criticised for poor reliability of examiner assessments and the lack of direct observation by the examiner of the trainee patient encounter [reducing the validity of the assessments]. There is evidence that adding an observing examiner to the history and physical examination part of the long case assessment increases reliability and helps to reconcile the complex interactions between the context and the skills/knowledge (construct) that the long case attempts to measure (Wass and Jolly, 2001). The LAP is one such tool where there is observation during history and physical examination and structured assessment and proves to be of high utility. This is supported by some studies in the formative setting(McKinley, Fraser, Vleuten and Hastings, 2000) The LAP, when analysed via its properties, is a good tool to assess observed clinical practice. It might not be so effective for practical skills and, for these, it probably needs to be supplemented by work based assessments or even OSCEs. When supplemented with other assessment tools [Triangulation] LAPs can be used effectively for summative assessment in high stake assessments such as the final examinations for medical students. The main drawbacks are feasibility, difficulty in blue-printing and cost effectiveness. It encourages students to develop the essential skills together rather than combining them afterwards. REFERENCES Bhakta, B., Tennant, A., Horton, M., Lawton, G. and Andrich, D. (2005) Using item response theory to explore the psychometric properties of extended matching questions examination in undergraduate medical education. BMC Medical Education, 5 (1): 9. Fraser, R. C., McKinley, R. K. and Mulholland, H. (1994) Consultation competence in general practice: establishing the face validity of prioritized criteria in the Leicester assessment package.[see comment]. British Journal of General Practice, 44 (380): 109-113. Gleeson, F. (1997) AMEE Medical Education Guide No. 9. Assessment of clinical competence using the objective structured long examination record (OSLER). Medical Teacher, 19 (1): 7-14. J. Mason, C. O. K. A. M. A. H. A. B. R. J. Y. (1999) A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. I: prevention. Diabetic Medicine, 16 (10): 801-812. Lau, J. K. C., Fraser, R. C. and Lam, C. L. K. (2003) Establishing the content validity in Hong Kong of the prioritised criteria of consultation competence in the Leicester Assessment Package (LAP). Hong Kong Practitioner, 25 (12): 596-602. Lynch, D. C., Surdyk, P. M. and Eiser, A. R. (2004) Assessing professionalism: a review of the literature. Medical teacher, 26 (4): 366-373. McKinley, R. K., Fraser, R. C., Vleuten, C. v. d. and Hastings, A. M. (2000) Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the Leicester Assessment Package. Medical Education, 34 (7): 573-579. Norcini, J. J. (2002) The death of the long case? BMJ, 324 (7334): 408-409. Norcini, J. J. (2003) Setting standards on educational tests. Medical Education, 37 (5): 464-469. Redsell, S. A., Hastings, A. M., Cheater, F. M. and Fraser, R. C. (2003) Devising and establishing the face and content validity of explicit criteria of consultation competence in UK primary care nurses. Nurse Education Today, 23 (4): 299-306. REZLER, A. G. (1976) Methods of attitude assessment for medical teachers. Medical Education, 10 (1): 43-51. Shea, J. A. and Fortna, G. S. (2002) 3 Psychometric Methods. International handbook of research in medical education, 97. Stern, D. T., Wojtczak, A. and Schwarz, M. R. (2003) The assessment of global minimum essential requirements in medical education. Medical Teacher, 25 (6): 589-595. Teoh, N. C. and Bowden, F. J. (2008) The case for resurrecting the long case. BMJ, 336 (7655): 1250. Turnbull, J., Turnbull, J., Jacob, P., Brown, J., Duplessis, M. and Rivest, J. (2005) Contextual Considerations in Summative Competency Examinations: Relevance to the Long Case. Academic Medicine, 80 (12): Wass, V. and Jolly, B. (2001) Does observation add to the validity of the long case? Medical Education, 35 (8): 729-734. Wass, V., Van der Vleuten, C., Shatzer, J. and Jones, R. (2001) Assessment of clinical competence. The Lancet, 357 (9260): 945-949. Wass, V. and Vleuten, C. v. d. (2004) The long case. Medical Education, 38 (11): 1176-1180. APPENDIX 1- PROPOSED ITEM AN OBSERVED MODIFIED LONG CASE CONTEXT- Following Continued Medical Education day for Diabetes Specialist Registrars-SPRs[CME Appendix 2] Aimed at senior SPR that is year 4-5 just a year before completion of their training Formative Assessment Can be used in their portfolios for Continued Professional Development CPD Generic skills assessed- Communication, Professionalism, Clinical reasoning in uncertain environment, Teamwork and Multidisciplinary Approach Assessment involves 4 items of observed long modified long cases and MCQ-paper aiming mainly at knowledge base. One such item an observed modified long case has been described below. Expected learning outcomes for this formative assessment item- Able to assess vascular, neurological status of foot and in a patient with diabetes Diagnose pedal pathologies in the

Macbeth Soliloquy

Macbeth’s Soliloquy In Macbeth’s soliloquy Shakespeare uses many rhetorical devices to magnify Macbeth’s change in attitude about killing Duncan. Two of the main rhetorical devices used in the soliloquy are rhetorical questions and allusions to Hecate and Tarquin. These two devices help Shakespeare depict the change in Macbeth’s attitude about killing Duncan and also represent his decision to kill Duncan. Macbeth’s rhetorical questions share his lack of clarity and conviction to kill Duncan while the allusions represent his decision forming and becoming clear to him.At the beginning of Macbeth’s soliloquy Shakespeare uses rhetorical questions to represent Macbeth’s feelings about killing Duncan. In the first seven lines we see three rhetorical questions. These questions lead into the conversation Macbeth has with himself to decide if he will kill Duncan. At the beginning of the soliloquy he seems unsure if he actually wants to go throu gh with the plan. This uncertainty is represented by his uncertainty of the dagger’s existence. The first question he asks is whether or not he actually sees a dagger in front of him.It is a simple question but leads us into the others. The second question he asks is if the dagger was sent by a â€Å"fatal vision† (II. i. 35). Here, the word fatal acts as a double entendre. Fatal can either mean someone’s destiny or it can mean a deadly action and in this case it works with both definitions. Macbeth wonders if it is his fate to kill Duncan with the dagger and the dagger is the deadly weapon that will be used to kill Duncan later on in the play. The final question Macbeth asks himself is whether this dagger is real or not and if it is formed by his â€Å"heat-oppressed brain† (II. i. 38).The fact that he does not even know if he really sees a dagger or not makes it clear to the audience that he is going crazy over the thought of killing Duncan. When Macbet h asks himself this question he is wondering whether he really wants to kill Duncan or if he is just caught in the moment. Later in the soliloquy he even says â€Å"[his] eyes are made†¦fools† (II. i. 43) and that it is â€Å"the bloody business which informs/ [the dagger] to [his] eyes† (II. i. 47-48). Since the dagger is not real we know Shakespeare is telling us that Macbeth is thinking about killing Duncan but is still too scared to actually do it.As the soliloquy progresses, and so does his idea of killing Duncan, he starts talking about more concrete ideas, such as witchcraft, and this represents his growing desire to kill Duncan. In the second half of the soliloquy Macbeth finally decides to kill Duncan. When Macbeth says â€Å"now o’er the one half-world† (II. i. 48) he is talking about the time when people are asleep, or nighttime. While he does this he alludes to two famous and immoral people, the goddess Hecate and the Roman King Tarquin. At the time when Shakespeare was alive the audience knew who Shakespeare was referring when Macbeth said the names Tarquin and Hecate.This simple connection would allow the audience to understand where Macbeth’s decision would go and why he finally came to that decision. Shakespeare draws many parallels between Macbeth and these two people. Shakespeare alludes to Hecate because she was the goddess of magic, witchcraft, the night, the moon, ghosts, and necromancy. All of these things are affiliated with evil and when Macbeth says that â€Å"witchcraft celebrates/Pale Hecate’s offerings† (II. i. 50-51) he is trying to persuade himself that even though she is the goddess of these evil things, people still celebrate her and something good may come from killing Duncan.Shakespeare draws a parallel between Hecate and Macbeth because Macbeth finally decides he will kill Duncan after the bell rings in the same way Hecate’s ritual sacrifices were summoned by the wo lf’s howl. Shakespeare also connects Macbeth to Tarquin in a similar way. Tarquin became the King of Rome by killing King Tullius. After Tarquin became the King of Rome he started a reign of terror. Besides killing King Tullius, Tarquin put many senators to death, his son raped a woman named Lucretia and eventually the Tarquin family was banished from Italy.By connecting Tarquin to Macbeth Shakespeare wants to show that they both knew what they were doing before committing the crime and chose to do it anyway. Also, Shakespeare is showing Macbeth’s change from an innocent man to a ruthless king whether Macbeth wants that or not and we see this later on in the play when Macbeth orders men to kill Banquo and his son, Fleance in fear that they may try to overthrow him. Shakespeare ends the soliloquy by saying that the â€Å"words to the heat of deeds too cold breath gives† (II. i. 60). By ending the soliloquy with this statement shows the change in Macbeth’s decision to kill Duncan and become king.The reason why Shakespeare included the soliloquy into the play is to show the audience how Macbeth finally comes to the decision to kill Duncan. Through the rhetorical devices used in the soliloquy Shakespeare is able to give the audience insight on how Macbeth goes from a guiltless man with no gall to a cold blood killer. We know by the end of it Macbeth has decided to kill Duncan and when the bell rings he goes to Duncan’s room to complete the job. We also know that later on he sends men to kill more people in order to keep his position as king and it is much easier for him to make that decision.

The Crucible By Arthur Miller - 1829 Words

Humans are inherently drawn to chaos. Humanity is involved in an endless war between madness and logic. Though society attempts to preserve logic and maintain order, a single event can trigger chaos and lead to the deaths of thousands; this has happened several times in every civilization and in every time period, and will continue to happen in the future. One example of this is the Red Scare in the 1900s, which disrupted decades of peace and harmony. The fear of McCarthyism was tangible and widespread; people were accused of being Communists based solely on circumstantial evidence and unfounded suspicions. Reputations and careers were destroyed over simple rumors. In some cases, innocent people were killed. Arthur Miller drew a parallel between the Salem witch trials in the late 1600s and the Red Scare in the 1950s in his novel, The Crucible. Through careful exposition, Miller argues that mayhem and hysteria can occur in any society at any time, and that logic and truth are needed i n order to overcome the dark evil in the world. Underneath the surface, Salem has an extremely rigid theocratic government with an almost cult-like, bitter society, needing only a small trigger to push it to complete chaos. The town of Salem is governed by a theocracy, meaning that God is the ultimate ruler, and reverends are given almost complete power to interpret the bible to their liking and arrest individuals. According to Miller, the theocracy ultimately fails because â€Å"the repressions ofShow MoreRelatedThe Crucible By Arthur Miller1269 Words   |  6 PagesAt first glance, the playwright Arthur Miller in The Crucible highlights the historical significance of the Salem Witch Trials of 1692, but in fact it is an allegorical expression of his perception of McCarthyism. If the reader has some background information on Arthur Miller’s victimization as a communist, it is evident that the play is a didactic vessel illustrating the flaws of the court system in the 1950à ¢â‚¬â„¢s. The communist allegations were launched at government employees, entertainers and writersRead MoreThe Crucible By Arthur Miller1681 Words   |  7 Pagesof their way to the last dying breath to make sure they leave with a good or bad reputation. In one of the recent literature study in class â€Å"The Crucible† by Arthur Miller, Miller uses characterization to illustrate reputation throughout the play. â€Å"The Crucible† takes place in Salem, Massachusetts. It is based upon the Salem witch trails. In â€Å"The Crucible†, we journey through the life of three characters who reputations plays a major role in the play. The three characters are John Proctor, AbigailRead MoreThe Crucible By Arthur Miller1333 Words   |  6 PagesAs the various characters in The Crucible by Arthur Miller interact, the dominant theme of the consequences of women’s nonconformity begins to slide out from behind the curtains of the play. Such a theme reveals the grippin g fear that inundated the Puritans during the seventeenth century. This fear led to the famous witch-hunts that primarily terrorized women who deviated from the Puritan vision of absolute obedience and orthodoxy. Arthur Miller presents his interpretation of the suffering by subtlyRead MoreThe Crucible By Arthur Miller998 Words   |  4 Pagesmotivated by jealousy and spite. The Crucible is a four-act dramatic play production that was first performed on January 22, 1953. Arthur Miller used dialogue within the characters to cover the multiple themes; conflicts and resolutions, plus the few directions for the different actions of the play. The Salem Witch Trials were intended to be performed as the play however, when read, it can be more carefully examined and broken down to analyze the techniques. Miller, the playwright, uses literaryRead MoreThe Crucible By Arthur Miller1145 Words   |  5 PagesUnbalance Through The Centuries In Arthur Miller’s play, The Crucible, the author reflects the persecution of communists in America in the 1950’s through a recount of the Salem witch trials. It is often presumed that Miller based his drama directly off of events that were particularly prevalent in the years surrounding the publication of The Crucible- which was released in the year 1953, towards the conclusion of the Korean War. Although there was not a literal witch hunt occurring during this timeRead MoreThe Crucible By Arthur Miller1063 Words   |  5 PagesIn the English dictionary, there are three definitions of the word crucible. One is a metal container in which metals are mixed and melted. Another is a severe test. But the third definition, and the one that I think fits the best for this book, is a place or situation in which different elements interact to create something new. In my mind, this fits because all of the characters had their little grudges and dirty secrets. But when all th ose seemingly little things interact, they formed somethingRead MoreThe Crucible By Arthur Miller1285 Words   |  6 Pages Rationale, Morality, Stereotypes, Pressure, Self-Censorship, Unanimity, and Mindguards. Groupthink has also taken place in our history a a country. The play, The Crucible by Arthur Miller is about a the real-life Salem Witch Trials that happened in 1692 - 1693, in Salem, Massachusetts. Some symptoms of Groupthink found in the Crucible are Rationale, Pressure, and Self-Censorship. The Groupthink symptom, Rationale, is described as when victims of Groupthink ignore warnings: they also collectivelyRead MoreThe Crucible By Arthur Miller811 Words   |  4 Pages While The Crucible, by Arthur Miller, is only a four act play, it still resembles the format of a five act play. The five-act structure evolved from a three-act structure, which was made famous by Roman Aelius Donatus. Donatus came up with three types of plays: Protasis, Epitasis, and Catastrophe. The five-act structure helped to expand the three act structure, mainly made famous by Shakespeare through his many tragedies. Even though The Crucible contains only four acts, it still has the commonRead MoreThe Crucible By Arthur Miller1052 Words   |  5 PagesBuddy Al-Aydi Ms.Healy English 9 CP 14th October 2014 The Crucible Essay The Crucible was a novel written by Arthur Miller in the 1950’s. It was written in a format of the play, portraying an allegory of the Salem Witch-Hunts led by Senator Joseph McCarthy. The book is known to have a inexplicable plot. This plot is advanced by multiple characters in the book in order to ensure that the reader maintains interest with the material that is being read. The farmer, John Proctor, would be theRead MoreThe Crucible By Arthur Miller841 Words   |  4 PagesThe Crucible is a chaotic play, throughout this American classic Arthur Miller takes the reader through multiple events of terror and insanity. While creating a great on-stage play, Arthur Miller portrays his life through the events, the characters, and plot of The Crucible. Using vivid imagery and comprehensible symbolism, Miller manipulates the real personalities of the characters and events in 1600 Salem, Massachusetts to create a symbolic autobiography. Throughout this play, the reader experie nces

Henry Ford Health Systems Human Resources Models Essay

During my senior year of undergraduate studies at Wayne State University, I shadowed a pediatrics physician at a Henry Ford Medical Group center in Dearborn, MI. The HFMG is part of Henry Ford Health Systems. The Henry Ford Health Systems employs over 23,000 employees while the HFMG employs over 1,300 senior staff physicians and researchers along with 3,100 non-physician providers and support staff. â€Å"The HFMG generates $750M in net revenue, which represents about 33% of total HFHS provider revenues† (Kelley 2011). The HFMG physicians specialize in over 40 different medical specialties and work in 30 different medical centers and 5 different hospitals across southeast Michigan. The specialties include cardiology, cardiovascular surgery,†¦show more content†¦However, the HR department is a staff operation within the organization chart of Henry Ford. Meaning that if the HR department was suddenly removed, there would be no short-term effect on the workflow of the he alth system (Fallon 2007). According to a human resources department job description posted by Henry Ford, the many functions of the HR department at Henry Ford include working on issues and policies of employee benefits, employee compensation, employment, e-HR, organizational performance and learning, payroll, training and education, performance evaluation, employee retention, and legal and regulatory issues, among many other functions (Linkedin). Having a wide range of duties like this requires a complex model that can cover all aspects of the job without over-stepping the boundaries between HR and other departments. â€Å"The human resources department of any healthcare entity is responsible for the people side of the business. Not only must human resources department protect and encourage the quality of the patient’s relationship with the healthcare entity, but it also must protect and encourage the quality of the employee’s relationship with the healthcare entity† (Shi 2007). This is a macro look at the basic function of the HR department within a health setting. From myShow MoreRelatedManaging An Effective Workforce Ie People Essay1512 Words   |  7 Pagesor as a manager in a coffee shop or as a director of the Human Resources department in a private company, the common aspect here is the ‘responsibility of managing an effective workforce ie people’. In any field, the four important resources are men, material, machinery and money. Out of these, I believe that ‘men’ ie humans are the most important because they are the ones that effectively and strategically employ and use the other resources/factors of production. Years ago, workers were treated asRead More The History of the Ford Motor Company Essay examples3137 Words   |  13 Pagesbreathed easier, and a young Ford Motor Company had taken its first step. During the next five years, young Henry Ford, as chief engineer and later as president, directed a development and production program which started in a converted wagon shop on Mack Avenue in Detroit and later moved to a larger building at Piquette and Beaubien Streets In the Ford Motor Companys first 15 months, 1,700 Model A cars chugged out of the old wagon shop. Between 1903 and 1908, Henry Ford and his engineers used theRead MoreThe Between Authority And Other Forms Of Power Essay1465 Words   |  6 Pageshierarchal structure by which the power flows downward from those with the greatest authority; (2) counter-balancing power, by which those below the most powerful may relationally exercise control using their personal characteristics, expertise, force, resource control, application o f sanctions via rules and cultural assumptions and values, and accessing people with more power; (3) authoritative power based on a legitimized source that, in the members’ perceptions, has become accepted and expected, andRead MoreProfiles of Ford Motor Company and Toyota Company4248 Words   |  17 PagesResearch on TOYOTA MOTOR CORPORARION and the FORD MOTOR COMPANY †¢ Describe and critically analyze the supply chain management practices employed by both of these companies. †¢ Are they involved in strategic alliances with major trading partners? 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The changes made in notionRead MoreDegree of Globalisation of Ford Motor Company3667 Words   |  15 Pagesdegree of globalisation of the automotive industry with special interest in Ford motor company. This analysis begins with an introduction to the automotive industry then it covers industrialisation of the automotive industry, also globalisation of the automotive industry and lastly global integration of the automotive industry. Secondly we focus more on a case study of ford motor company which covers a brief background of Ford, then i consider the challenges of competing globally and end with productRead MoreCompany Analysis : Ryan Company1449 Words   |  6 Pagesthat specializes in integrated project delivery, building information modeling (BIM), Lean construction practices and sustainable design for office, retail, industrial, public sector, alternative energy (biomass and gasification,[2] wind, solar), health care, higher education, hospitality, mission critical, multi-family and senior housing and mixed-use projects. With in-house construction, design, development, capital markets and real estate management, Ryan uses integrated project delivery (IPD)

Diagnosis And Treatment Of Cancer Essay - 1844 Words

Cancer is very large throughout the U.S. and Canada, it is said that one and a half million people will receive a new diagnosis of cancer each year (Ignatavicius Workman, 2013).Many years back a diagnosis of cancer had a very poor outcome and you were basically considered dead. Technology and research have been focusing on cancer, and how to prevent it. This paper will review the diagnosis of cancer as well as the staging of cancer, as well as possible treatment options and side effects related and how to deal with the psychological burden that cancer patients deal with. Diagnosis and Staging of Cancer The body consists of millions of tissues and cells that are grown from conception to adulthood. Cancer cells are cells that are not normal and have the capability of infinite replication, they are harmful to the normal cells and serve no benefit to the body (Ignatavicius Workman, 2013).Cancer cells are also defined as malignant cells; they tend to start in one spot which is called the primary location. They may break from the primary location and spread to other locations to establish more colonies. When the cancer spreads it is known as metastasis. There are several tests that are needed to be done prior to confirming a cancer diagnosis. Depending on the cancer suspected, different tests may be done. It is very common to take a biopsy of the infected area and wait for pathologists to evaluate the specimen. 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The World Health Organization has described the number of mortalities to be greater than 8.2 million annually around the world (World Health Organization [WHO], 2015). As nurses, we must serve as the patientà ¢â‚¬â„¢s advocate and empower them throughout the course of theirRead MoreDiagnosis And Treatment Of Cancer1954 Words   |  8 PagesIntroduction When it comes to the topic of cancer, most people readily agree that we have made leaps and bounds in diagnosis and treatment mechanisms. Where this disagreement usually begins, is on the question if finding a â€Å"cure† for cancer can be a reality. While some are convinced that a cure will come with time, others believe that a single cure is just not logical. The US waged a war on cancer when Nixon was in office, 1971, yet we haven’t overcome it yet (Gorski). 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Prevention Of Orthopaedic Implant Infection Health And Social Care Essay Free Essays

Abstraction: The American Academy of Orthopaedic Surgeons ( AAOS ) and the American Dental Association ( ADA ) , along with 10 other academic associations and societies late ( December 2012 ) published their common clinical pattern guideline â€Å" Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. † This evidence-based guideline, detailed in 325 pages, has three recommendations and substitutes the old AAOS guideline. The new published clinical guideline is a protocol to forestall patients set abouting dental processs from orthopedic implant infection. We will write a custom essay sample on Prevention Of Orthopaedic Implant Infection Health And Social Care Essay or any similar topic only for you Order Now The guideline is developed on the footing of a collaborative systematic reappraisal to supply practical advice for preparation clinicians, tooth doctors and any qualified doctors who need to see bar of orthopedic implant ( prosthetic device ) infection in their patients. This systematic reappraisal found no expressed grounds of cause-and-effect relationship between dental processs and periprosthetic articulation infection ( PJI ) . This short communicating wants to show a graphic sum-up of AAOS/ADA clinical pattern guideline as a clinical update and an academic execution to inform and help Persian competent clinicians and tooth doctors in the class of their intervention determinations, to enrich the value and quality of wellness attention based on the latest international footing. â€Å" Evidence Insufficient to Recommend Prophylactic Antibiotics for Dental Patients with Orthopaedic Implants. † was one of the nailing headlines of the dental updates in the winter 2013. [ 4-7 ] The American Academy of Orthopaedic Surgeons ( AAOS ) and the American Dental Association ( ADA ) , along with 10 other academic associations and societies late ( December 2012 ) published their common clinical pattern guideline â€Å" Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. † This 325-page evidence-based guideline has three recommendations and substitutes the old AAOS guideline. The new clinical pattern guideline was established utilizing the published AAOS CPG ( Clinical Practice Guideline ) development procedure and besides sing the all criterions recommended for systematic reappraisals and clinical pattern guidelines. The full guideline presents a comprehensive systematic reappraisal of available grounds directing on the bar of orthopedic implant ( OI ) infection in patients having dental processs. [ 1 ] Jevsar ( Chairman of AAOS group ) and Abt ( on behalf of ADA group ) published and editorial to this guideline and described how the recommendations have been evidence-based. They believe that antibiotic prophylaxis recommendations, in the 2009 AAOS information statement, can merely be regarded as an educational assistance and non as an official guideline. [ 3 ] SYNOPSIS OF THE NEW GUIDELINE The workgroup, ab initio developed three recommendations for antibiotic prophylaxis in dental patients with joint replacings. These recommendations shaped the basic foundation for systematic reappraisals of the literature sing the alveolar consonant processs and periprosthetic articulation infection ( PJI ) . The workgroup besides determined elaborate standards for quality assessment of the published informations and accordingly avoiding any prejudice. To avoid prejudice, the AAOS uses specific words for its recommendations and gives rationals for their use. Due to the restrictions in available grounds, the three recommendations presented in the new guideline are classified as limited, inconclusive, and consensus with one recommendation for each class of grounds. Higher class recommendations are relatively rare within published CPGs. The work squad emphasized that they did non say this new guideline to be an impartial papers. All three recommendations should be integrated into the de cision-making procedure to better patient attention. The guideline accentuates on the coaction between the doctors, tooth doctors and patients to be after a intervention based on the grounds, clinical findings and patient penchants. [ 1-3 ] The undermentioned guideline is a sum-up of the AAOS-ADA recommendations for bar of OI infection in patients having procedural dental interventions. Recommendation 1. â€Å" The practician might see stoping the pattern of routinely ordering contraceptive antibiotics for patients with hip and knee prosthetic articulation implants undergoing dental processs. † [ 1 ] Bing graded as Limited, this recommendation is based on limited grounds and depicts that dental processs are non related to OI infection.Moreover, it indicates that practicians should see altering their customary pattern of ordering contraceptive antibiotics for dental patients. [ 1,5-7 ] The phrase limited is unequivocal ; which means low degrees of grounds is present to back up the recommendation.Practitioners should be watchful to up-coming publications that hold grounds and their determinations should reflect their single judgement and the patient ‘s penchants. [ 1 ] Stronger groundss support this recommendation compared to other two recommendations: Clinical practicians believe in altering their longstanding tradition in the prescription of contraceptive antibiotics for dental patients. The groundss indicate that dental processs are non linked to the OI infections. The hazard of OI infections is non reduced by the pre-procedural antibiotic prophylaxis. Strong grounds indicates that pre-procedural antibiotic prophylaxis reduces the incidence of bacteriemia induced by station dental process. No grounds proves that bacteriemia increases the hazard of OI infections [ 1,3,5 ] Recommendation 2. â€Å" The work group was unable to urge for or against the usage of topical unwritten disinfectants in patients with prosthetic articulation implants or other orthopedic implants undergoing dental processs. † [ 1 ] This recommendation is graded as Inconclusive, sing the strength of the grounds. The guidelines implies that practicians should see a small restraint in their determination that whether to follow an inconclusive recommendation or non. The guideline emphasizes that patient penchant should hold a important influencing function and practicians should carefully wait for future publications that elucidate the bing grounds to find the balance between benefits and possible hazard. [ 1,2,4 ] Apparently, this recommendation refers to the application of unwritten topical disinfectants in the bar of OI infections in dental patients. It indicates that there is no direct grounds to corroborate that application of unwritten topical antiseptics ( before alveolar consonant processs ) would cut down bactermia and hence prevent OI infections. [ 5 ] The guideline points out the followerss as illustrations of topical antiseptics administered by tooth doctors: Chlorhexidine Gluconate unwritten rinse, povidone-iodine oral cavity rinse, H peroxide oral cavity rinse and mouthrinses with sodium-p-toluene ( chloramine-T ) . [ 1-3,5 ] Recommendation 3. â€Å" In the absence of dependable grounds associating hapless unwritten wellness to prosthetic joint infection, it is the sentiment of the work group that patients with prosthetic articulation implants or other orthopedic implants maintain appropriate unwritten hygiene. † [ 1 ] This recommendation was graded as Consensus, bespeaking that adept sentiment supports the guideline recommendation albeit the fact that no available grounds can meet the inclusion standards. The guideline emphasized on the imperative function of patients ‘ penchant in determination devising and besides affirmed the flexibleness of practicians in make up one’s minding whether to follow a recommendation rated as Consensus or non. Consensus recommendations are the weakest signifier of recommendation, and can non be used to disregard recommendations developed from higher degrees of grounds. [ 1-3 ] This recommendation conveys the care of good unwritten hygiene and seemingly, it is the lone consensus recommendation in the new guideline. Oral hygiene steps are available and inexpensive, supply possible benefit, are consistent with current clinical pattern and are in harmony with good unwritten wellness. [ 3 ] Goals and Implications for Clinical Practice The rate of OI infection is recorded from 0.3 % to 8.3 % in the available published literature. Invasion of beings into the surgical lesion during the surgery, haematogenous spread, return of infection in antecedently involved and septic articulations, or extension from an morbific local beginning may bring forth such infection. [ 1 ] Established on the best bing grounds, the rational for this clinical pattern guideline is to help the related clinicians and tooth doctors to take a paramount preventing and intervention mode when it is needed. Contemporary dental pattern necessarily depends on evidence-based criterions and stipulates doctors and tooth doctors to use the best available grounds for intervention planning in their clinical pattern. That ‘s why this guideline consists a systematic reappraisal of literature, conducted between October 2010 and July 2011 by AAOS and ADA methodologists and the doctor/dentist vocational groups and declared wherever the grounds was equal or unequal.They even discussed the spreads in the literature, where future researches are peculiarly needed. [ 1 ] Jevsevar, an orthopedic sawbones and president of the AAOS squad, declared that this clinical pattern guideline was non supposed to be an impartial papers and he confirmed that clinicians should utilize it as an informative tool in their intervention planning to better the quality and efficaciousness of their wellness attention. [ 3 ] In drumhead, the guideline is deliberated to carry on clinical pattern and besides to supply a beginning of information for all qualified practicians covering with bar of OI infection in dental patients. The AAOS and ADA hope that this guideline would besides help to guarantee patients sing the logics behind their intervention planning. [ 1 ] Therefore, The new guideline replaces the old AAOS Information Statement and the full guideline with all wining certificates and workgroup declarations is available to entree on the AAOS web site: hypertext transfer protocol: //www.aaos.org/research/guidelines/PUDP/PUDP_guideline.pdf and the ADA web site: hypertext transfer protocol: //www.ada.org/sections/professionalResources/pdfs/PUDP_guideline.pdf How to cite Prevention Of Orthopaedic Implant Infection Health And Social Care Essay, Essay examples

Discussed In This Critique Is Shortcomings Observed In Accounting

Question: 1.To what magnitude does the shortfalls in the PAT research application occasioned the ineffectiveness of PAT research program than forecast? 2.How does PAT research applied presently in accounting practice? Answer: Introducation: The underlying topic discussed in this critique is shortcomings observed in accounting practice which has fell short of the dominant cosmic positivist research program. The central purpose of this critique is to appraise censoriously the Paul V Dunmores Half a Defense of Positive Accounting Research. This will demonstrate the influence of inadequacies in practice in attaining the potential of the authoritative extensive positive accounting theory research program. The main thesis is that without satisfactory practice in PAT research program, the prospective dominant comprehensive positivist research program shall be unachievable (Christie 2007). The author argues that the contemporary practice in PAT seem like very demonstrative of mounting the scientific purposes. The author additionally upheld that besides the inconsistencies accounting practice, normal science grants a groundwork and a background anchored on Kuhns calamity in addition to uprising since it stays possible to discharge PAT to appreciate its anticipated potential. The analysis assumes the following structure to profligately capture the foremost argument acknowledged overhead. It begins with an ephemeral summary of this article by concentrating principally on the leading argument as presented in the Pauls article. It will include the aim, main findings and theoretical framework and significance of the study. The next section delves deeper into study question. This section will mainly determine the research question and hypothesis presented in the article. The discussion of hypothesis and the research questions value as recognized in the article is also given in this section. Section two will primarily determine if the research question and hypothesis clearly flow from the literature review. The next section details the theoretical framework whereby the appreciation alongside discussion of the framework is presented besides the theoretical framework that informed this study. The next section provides a protracted discussion of limitation alongside implication. The deficiencies of theory alongside the methodological approach are detailed. It also look at whe ther the study has appreciated such weakness or limitations. Further, whether the researcher has drawn conclusions based on the assumed methodology is authenticated. This section further establishes whether the recognized limitations have impacted the significance and substance of the article in regards to accounting practices anchored on results established vis--vis the method of the study. In the final section, a brief conclusion and summary of the entire discussion is presented pointing out the significant facts as well as highlighting the entire critiques limitation to the accounting practice. Summary The article being critiqued was written by Paul V Dunmores Half a Defense of Positive Accounting Research. The article fundamentally discusses the PAT research program as concocted by Watts and Zimmerman. This claim was staked by the Watts and Zimmerman to the Positive Accounting Theory (PAT) for their assumed theory. The scholar pursued the scrutiny of the positive methodology to the accounting research. Paul viewed PAT research program as an important constituent of a wide-ranging well-informed project of scientific research. This program is pursued to understand the cause-effect relationship in the essential research world. Paul has successively viewed PAT in the broader viewpoint of research program which aims at developing causal intensification of the human behavior under accounting setting (Volovski et al. 2017). The researcher has furthermore undertaken a scrutiny of epistemology in addition to ontology of PAT program. Plentiful valuations surrounding statistical hypothesis logic while cursorily conforming to construction standard of Popper have moreover been recorded as mediocre. Paul has moreover recognized that besides the inclusive PAT program being hypothetically impressive, the insufficiencies in practice deter the apprehension of the programs needed potential (Dunmore 2011). The extensive happenstances hindering the PAT program have likewise been documented besides the casual creation of theoretical models that necessitates testing as well as unwarranted reliance on logic hypothesis testing (Roth, Suldo and Ferron 2017). Nonexistence of interest in statistical value of parameters together with insufficient replication to permit confidence in determining the reception have supplementary been recognized as shared incapacitations (Dunmore 2011). Using theories as standards for investigating alongside assessing qualitative data rather than as intensifications for tests is an additionally shared challenge fronting PAT program. The researcher has additionally considered evidence from pertinent alongside trustworthy articles for the authentication of the views presented in this article (Christie 2007). The researcher also appraised the broader well-informed project alongside the ontological as well as epistemological assumptions to comprehend both the implication as well as irregularities of positive accounting research. The appraisal uncovered serious shortcomings in the manner that PAT study is undertaken that hinders it from realizing evocative contribution to the inclusive project (Kim et al. 2017). Paul foreshadowed that the present practice in accounting leaves PAT with considerable clumsiness to reach the envisioned scientific purposes. Though, Paul displayed self-confident that Kuhns illumination of the normal science competently fits the PAT research (Kim et al. 201). The predictions of Kuhns story are clarified in brief based on Kuhnian crisis together with insurgence. It is believed that such a crux as well as insurgence is repressed to unlock the PAT accordingly achieving its jammed potential (Pandey et al. 2017). Question/Hypothesis The author has engaged many hypotheses besides research questions and clarified that he is never declared their truth, but somewhat just fact-finding for a passionate deferment of amazement to authorize their consistent conversation. Four hypotheses are highlighted by Paul and developed independently hesitantly, mindful that for plentiful of human being, they might have imagined outrageous and wicked and that seemingly an unwarranted fraction of humanity might bear to discern. Hypotheses: There is a world of self-governing of fancy of people that was never created by persons and its activities are not subjected to the ambitions of folks control It was feasible for normal folks to get impartially dependable information around the events of the world via considerate reflection. This, nevertheless, not ever imply that folks will never once be mistaken the point they are witnessing, rather such comments are never exclusively unrelated to such a world The logical scrutiny bestows to use observations to attain a comprehension of such a world, and precisely of interconnection. This suggests that people pursue mental models that indeed map the procedure of causal that transpire in such a realm The proceedings of this world have practicalities that are unconventionally component of the world therefore suggesting that neither totally haphazard nor the results of the interruptions from alfresco world Theoretical Framework A theoretical framework assumed by Paul evolved from a positivist position of a displeased hypothetical physicist whose accounting research stayed positivist emphasizing either model testing/ building. The disapprovals of the author, consequently, dedicated the position of an individual discriminating that the study arrangement is amazing, however distressed by the unskilled and unfertile diversities that are currently practiced in accounting. Paul used this understanding to instinct both editors besides referees to prefer such arrangements to shove the modern arrangements towards the deliverance of PAT research to realize the wanted prospective. The articles theoretical substance, consequently, builds on the acknowledgment from the literature review on auditing that thoughtful shortages occur in the modern practice in accounting research thereby obstructing PAT research program from making a material effect to the broader project. This is predestined to founding positive accounting research as a deep-rooted social system to contribute to the scheme of scientific investigation (Fleischman et al. 2017). The framework is devoted on the awareness that favorable findings of Kuhn (1970) research would be desperate to stimulate elites to hold a more than ever operative model. The author additionally differentiates an amnesty offered by the info that ascended from the study by Fogarty and Markarian in 2007 that implied elites proportional deportment being diminishing. Thus, the author predictable imminent upcoming tragedy and the opportunity for the assumption of an additionally ever respected model. Paul consecutively based his premise on suggesting proposals for actions by editor in chief as well as arbitrators to nudge the contemporary schemes in the direction of redeeming PAT investigation to hit its jam-packed potential. The author is informed by the acknowledgement that it is significant to appreciate the global Modus Operandi and later viewed it as undesirability that the connected to investigation watercourse is unfertile and ineffective, and, henceforth he has delivered definite proposals for advancement. Limitation and Significance The systematic review of available literature on auditing via the qualitative technique assumed in this investigation is devoted to certain limitations or inadequacies. A probability of carrying onward certain errors and liabilities made by preceding investigators into the modern study is high labels one of such limitations. Furthermore, the technique limits the building of fresh results since there is no chance to collect the primary data where secondary data is used which did not capture the differences professionally. The author has moreover documented the absence of improved dimensions to document demanding theoretical models testing due to failed notions operationalization. The nonexistence of standardized trustworthy unshakable relationship-focused way to be adopted in each study measuring is additional limitation confessed. The recurrent dimensions re-invention besides re-estimation of parameters with individual sample a study has additionally been recognized as the shortcoming to PAT research from achieving its teeming prospective. Additional limitation in the theory assumed in this study is the lack of theoretical models that are tremendously specified and, therefore, it is vulnerable to permit thorough testing. Paul has documented these limitations by suggesting the need for better theoretical models. This proposal arises from the background of the developing luxurious models from analytical research that are not ever admissible to be test due to their inacceptable development together with concentration on controllability hinged on concepts that are never meritoriously distinct hypothetically to permit operationalization (Watts and Zimmerman 2012). Paul has positively drawn hypothetical implications from the study which are defensible systematically. This is because the limits have been acknowledged from the systematic review of the previous auditing literature that have in turn molded the basis for proposing enhancements to allow positive research to meet its chockfull potential. The recommended need for ever-changing focus away from the testing hypotheses towards estimating parameters afterwards being informed by the attentiveness of testing hypothesis from the previous reviewed studies (Pandey et al. 2017). The precincts have meaningfully censoriously biased the insinuation of the study even though they have concomitantly unreservedly disadvantaged the contribution of the article to the accounting practice. This is caused by the awkwardness in methodology together with theories in the article that did not avail chance that present dependable results, nevertheless, the accounting is better going forward by suggesting recommendation that are indispensable to describe subsequent study to sanction PAT study to recognize its jam-packed package. Conclusion The author has exhumed that models that are tremendously stated and, hence, remarkably defenseless, besides being undertaken extremely as thorough testing subjects are required. 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