Overall Curriculum Outline
We plan a structured two-year program, with an optional third year for Scholars whose projects require additional time. The first year will fulfill requirements for a Masters of Health and Health Care Research, a new degree program designed specifically to meet the needs of Clinical Scholars and now undergoing University review. The CSP starts with a two-month series of preparatory seminars. The first academic year includes a course on research design and analysis with a separate laboratory, a pair of yearlong courses on research approaches to health and health care, and a series of seminars on leadership and career development. The heart of the first year is a yearlong “Research Practica,” which will integrate curricular content with specific research projects for each Scholar. The second (and third) year will be largely devoted to research. Guest lectures will be an essential part of most didactic courses. We outline below the overall shape of the proposed program.

This curriculum is designed specifically to meet the needs of Clinical Scholars. We will allow a limited number of carefully selected fellows from other programs to enroll, with acceptance into the program decided on a case-by-case basis after consideration of what each fellow could add to the overall value of the course for Clinical Scholars. To assure appropriate intensity, Clinical Scholars would always make up at least 2/3 of the students enrolled in the course, which would enroll a maximum of 10 fellows per year.

Preparatory Summer Seminars
Because people enter the CSP with a diverse range of backgrounds and skills, a series of summer seminars will provide Scholars with a common foundation in fundamental concepts about health and health care before the start of the intensive fall curriculum. Our existing, very successful CSP summer course will be revised to serve as a prologue to first year coursework. This seminar will model interdisciplinary collaboration to introduce Scholars to the key elements of the health care system and to a basic outline of essential research methods.

Introduction to Health and Society, 2 weeks. (Joel Howell) Scholars will analyze readings on the history and sociology of health and health care, as well as readings that examine how social and political factors have shaped the current health care system. Special attention will be given to the importance of culture in the conceptualization of health care. Discussions will help Scholars move from reading and thinking as clinical practitioners to reading and thinking as research investigators.

Introduction to Health Care Delivery, Financing and Policy, 3 weeks. (Paula Lantz and Richard Lichtenstein) This seminar will provide a broad overview of the US health care system. Special emphasis will be given to current trends in the organization and delivery of health care as well as to proposed legislative or regulatory changes that are salient at the time the course is offered. Discussions will cover health disparities, access to care, population health, and measurement of health status. Approaches to health policy evaluation will be introduced.

Introduction to Clinical Epidemiology and Basic Biostatistics, 3 weeks. (Rodney Hayward, Timothy Hofer, Sonya DeMonner) This seminar will include an initial overview of clinical epidemiology. It will cover critical appraisal and construction of commonly used study designs, such as experimental, quasi-experimental, cohort, and case-control designs. Students will start to learn how to assess and incorporate evidence from medical literature into clinical practice. Basic biostatistical concepts needed for critically appraising the clinical literature will be introduced. In addition to didactic sessions, a laboratory course will include a hands-on overview of statistical analysis. Using a standard statistical program, students will learn basic data management and how to conduct univariate and basic bivariate analyses.

Research Design and Analysis
(Rodney Hayward, Myra Kim, and Timothy Hofer)
(2 semesters, 6 units total). Scholars will develop competency in research design and data analysis using state-of-the-art methods for health services research and health policy research. This course will be based upon three key principles. First, Scholars should have a basic understanding of the broad spectrum of both qualitative and quantitative methods, coupled with in-depth expertise in specific methods relevant to their particular area of research. Second, a carefully coordinated mixture of classroom, experiential/hands-on and self-directed learning is the most efficient and effective approach to developing superior methodological expertise. Third, methods are not ends in their own right, but are tools that should be carefully selected to pursue new knowledge that will advance our understanding of important health and health care issues. The research question should drive the selection of the most appropriate method. The foundation for the methods curriculum will be laid in the Summer Seminar, reinforced and greatly expanded during this year-long course (with its companion laboratory), and further expanded and solidified through advanced seminars and close mentoring during the second and third years.

During the fall semester the course will cover an overview of the basics of standard study design and study analysis, with content selected to support the critical literature review required for Practicum 1, described below. Content will then move on to the skills necessary for the secondary data analysis required for Practicum 2. The winter semester will include methods and skills important for primary data collection as Scholars are also working on Practicum 3, as well as covering specialized analytic methods. Specifically, the fall semester will include 1) study designs and their applications, 2) population sampling, 3) systematic reviews, including teaching critical appraisal of the medical literature, 4) meta-analysis, 5) simulations and decision-analytic models (Markov and Monte Carlo methods), 6) applications of basic biostatistics (including parametric and non-parametric statistics and an introduction to multivariable modeling). Winter semester will include: 1) scientific and pragmatic issues in data collection, including qualitative methods (such as unstructured interviews, group interviews, and direct observation), 2) ethical and professional responsibilities of researchers, 3) survey and interviewing methods, 4) measurement science, including psychometrics, 5) selected qualitative analytic methods (such as coding schemes and constant comparative methods), and 6) selected topics in advanced biostatistics (such as multiple imputation, multi-level modeling and basic econometrics).

Whenever possible, examples for this course and the companion laboratory will be taken from ongoing research by Scholars and faculty, selected to reflect potential (or actual) content interests of the specific Scholar cohort. By choosing content examples specific for each cohort, this course will be continuously modified to meet the specific needs of our students, a feature that differentiates this course from the typical graduate curriculum. The course will thus link theory with practice in ways that will enhance the salience for the Scholars and introduce them to cutting-edge methodologies relevant to their area of research. It will also provide additional mentoring and support for the Scholars.

Laboratory in Research Methods & Analysis
(Rodney Hayward, Susan D. Goold, and Sonya DeMonner) (2 semesters, 4 units total).
This series of practical exercises parallels the lectures in Research Design and Analysis . This laboratory will enable Scholars to master use of a statistical and a qualitative methods software package. Specific modules will emphasize independent problem solving and generation of analysis plans, converting study objectives into a specific and actionable analytic design. Most work will be done out of class; formal class time will be limited to one session each week. Most sessions will be devoted to discussion and review of hands-on laboratory assignments.

Occasionally, sessions will have one of two other formats. Some sessions will be mainly devoted to data interpretation. In such instances, pairs of Scholars will have received raw statistical output from one of their colleague's research projects. They will review this material independently and come prepared to co-lead a seminar-style discussion in which the group would interpret the analyses, suggest options for presenting these analyses to different readerships, and discuss the need for additional analyses. Other sessions will be dedicated to peer-review of Scholar's Research Practica, the three research assignments required as part of the first-year curriculum and discussed below. These sessions will link material from Research Design and Analysis to each Practicum. The sessions will also provide an opportunity for Scholars to rehearse their presentation and defense of their practica before having to do so before their formal Research Committees. Finally, these sessions will be used to ensure that each Scholar is making appropriate progress towards mastering the course materials.

Research Practica
(Laurence McMahon, Jr. and Sanjay Saint) (2 semesters, 8 units total).
In this independent study course Scholars will progress from crafting an initial research question to analyzing secondary data to designing and presenting a research plan. A Research Committee selected for each Scholar will oversee both the practica and the Scholar's future research in years 2 (and 3). The committee will include a clinician familiar with the content area for that Scholar, a member(s) with expertise in the proposed research methods, and a member of the CSP leadership (the four Directors). The CSP Curriculum Committee must approve the composition of the Research Committee, and Scholars must formally present and defend each of their practica results to their Research Committee. The Research Committee will provide close mentoring and will also assess the writing, the scholarship of the critical analysis, and the quality of the oral presentation. The potential research projects noted below provide examples of content areas for these practica.

Research Practicum 1 is a critical literature review of a policy-relevant topic in health or health care, selected to serve as the springboard to the Scholar's future research interests. This systematic, evidence-based review will focus on identifying and assessing key research methods and will be written in a format appropriate for a medical journal. A mini-writing course and materials on critical appraisal of the medical and policy literature are offered early in the first semester to integrate with this practicum. This Practicum must be presented and defended by the end of the first semester (mid-December). We anticipate that this review would be suitable for submission to a peer-reviewed journal.

Research Practicum 2 requires an oral presentation and defense of a critical analysis that uses empirical methods to address a hypothesis or policies relevant to health or healthcare. In most instances, this critical analysis will include use of secondary data sources and demonstrate skill in the use of rigorous methods covered in Research Design and Analysis, such as multivariable statistical modeling, psychometric scaling, simulations, constant comparative methods, or other types of qualitative data analysis. Practicum 2 requires a 10-15 minute oral research presentation and should generally be completed by the end of the second semester (late May). We anticipate that the Scholar would later produce a modified version of this analysis for submission to a peer-reviewed journal in their second year.

Research Practicum 3 is a 5-7-page research proposal that clearly presents the justification and methods for an original project, usually one that will involve collection of primary data. We believe that primary data collection ought to be an important element in the training of every Clinical Scholar. The choice of where to collect that data will depend on the research question. The option of a third CSP year will allow selected Scholars the time necessary to gather primary data from a community-based setting. Communities are often the appropriate site for primary data collection, such as studies evaluating proposed protective programs for high-risk youth, or examining barriers to pursuing healthy lifestyles in difficult socioeconomic or cultural environments. In other instances, primary data collection is best undertaken in the setting of the medical system, such as evaluating initiatives for improving patient-physician communication in an outpatient office or examining influences on decision-making for dialysis or renal transplantation. Other types of primary data might best be obtained using chart abstraction or interviews. Our philosophy is that the data collection ought to be done in the site and using the sources and methods most likely to answer important questions as well as to aid the Scholar in efficiently acquiring the necessary research skills. Finally, the Scholar's research questions should lead naturally to additional questions, and thus help to establish a research trajectory.

In most instances Praticum 3 will represent the Scholar's main CSP research project. A draft must be completed by the end of February of the first year with the final defense in June.

Social and Cultural Aspects of Research on Health and Society
(Joel Howell and Peter Jacobson) (2 semesters, 6 units total).
This course will introduce students to methods for evaluating critical issues in health and health care from a societal and cultural perspective. Scholars will examine the use of social sciences and humanities to study health and health care, including evaluations of past research and suggestions for future work. The class will be an introduction to essential themes, not a comprehensive analysis of a single discipline. It will be conducted as a seminar, with outside readings including a variety of analytic approaches as well as a mix of classic publications and cutting-edge research. Assignments will include conceptualizing and developing research questions about the relationship between culture and health care. The fall semester will cover topics in the history of medicine, focusing on the relationship of race, ethnicity, and gender for health and health care. Population health and health care issues related to social environment, culture, and community will receive special emphasis. Examples of community-based, school-based, and employment-based interventions to improve health and social well being will be discussed. A special 2-day introduction to community-based research will be provided as part of a collaborative effort with the Kellogg Community Health Scholars Program. During the winter semester the course will address legal issues relevant to public health and health care delivery, and their effects on individuals, communities and providers. Scholars will also discuss the history and ethics of human experimentation, the politics of health policy, and the use of narrative methods as well as narratives themselves to understand health and health care. Readings in the sociology and anthropology of health care will be included, with discussions led by experts in those fields.

Research on Health Care Delivery, Financing and Policy
(Eve Kerr, Catherine McLaughlin) (2 semesters, 6 units total).
This course will analyze selected topics in health care and health policy. Clinical scholars will critically appraise recent research findings and their impact on policy formulation, evaluation, and program implementation. They will learn how to appraise critically how health and health care policy alternatives may influence the quality and efficiency of health care. Attention will be paid to local, state, and national policy issues. Topics in the fall semester will include 1) comparisons of the US healthcare system with healthcare systems in other countries, 2) factors influencing behavior within healthcare organizations, 3) factors that influence the behavior of providers and professional groups, and 4) economic issues related to health care delivery (including expenditures, utilization, and insurance concepts). Topics in the winter semester will include 1) conceptualization and measurement of health status, health care costs, technology assessment, access, quality of care and efficiency, 2) health care needs and utilization, 3) regulatory, financial and market “controls” on costs, quality and efficiency, 4) effects of policy changes on population health, and 5) the health and health care needs of disadvantaged populations. Throughout the course emphasis will be placed on the complementary roles played by medical and non-medical interventions to improve population health.

In addition to classroom experiences, this course will incorporate our successful health policy “field trips.” For the past several years we have taken Scholars to visit key policy makers, alternating each year between the Michigan state capital, Lansing , and Washington DC . This experience has both demystified some of the nature of the legislative process and has enlightened Scholars about some potential ways to relate their research to health policy initiatives within a specific political system.

Leadership and Career Development Skills
(Peter Ubel and Jayne Thorson) (2 semesters, 2 units total).
This course will combine an overview of leadership theory with a selection of skills needed for career development. Various leadership strategies will be examined; case studies will link theory to leaders' actual practice, especially within academic medicine. Scholars will gain an appreciation for the diversity of successful leadership styles and will consider the influence of cultural aspects such as gender. Interwoven with this yearlong overview of leadership will be a series of skill-building exercises. Fall semester will include 1) time management and allocation, 2) public speaking, teaching, and presentation skills, 3) effective writing for the health and health care literature, 4) running effective meetings, and 5) supervision and management of staff. Winter semester will include: 1) a survey of career opportunities, job searching, and interviewing, 2) negotiation skills, 3) working in teams and team-building, 4) working with the media, 5) self-assessment of productivity and barriers to productivity, 6) networking, and 7) balancing clinical care, research and life outside work. Scholars in their second and third year will join the seminar for one session per month.

The second and third year
The second and third year of the CSP will be primarily devoted to research, with the Scholar's Research Committee continuing as an advisory committee. Education in the 2nd year will focus on each Scholar's specific needs. Carefully selected classes will be available to Scholars. For example, the Institute for Social Research, in addition to serving as a valuable resource for research assistance, offers an excellent set of intensive classes on specific advanced research topics that attract students and faculty from all over the world and have been attended by many previous Scholars. Other classes throughout the University will allow Scholars to benefit from the many excellent faculty and courses. There are numerous seminars available on campus, and some scholars may find especially useful the series run by the Decision Consortium, the Program in Health Policy Research, the Program in Society and Medicine, the Institute for Research on Women and Gender, and the Center for Social Epidemiology and Public Health.

Advanced Methods Seminars: These Seminars are based on our recent experiences. A group of Scholars with specific interests in advanced quantitative methods created a new, biweekly course that they called the “Regression Support Group.” This seminar was so successful that Scholars have now created another seminar on advanced issues in qualitative methodology. This sort of learning is focused on the needs of a specific Scholar or group (just-in-time learning) and facilitates their continued cohesiveness as a cohort. A faculty advisor helps to coordinate the seminars, which have led to collaborative papers, research grants, and have helped to launch careers. Thus, each 2nd (and 3rd ) year Scholar in the Michigan CSP will participate in at least one advanced seminar. Additional seminar topics will be added as appropriate for a cohort's needs. Twice each semester we will have a combined seminar, an Advanced Mixed Methods Seminar, which will examine the selection and use of complementary methods to address clinical or policy questions. When only one or two Scholars require instruction on a specific topic, they will be encouraged to arrange individual tutorials with faculty members.

Third Year : Particularly for those Scholars whose primary data collection will be labor intensive (such as Scholars doing most community-based or interventional research), or for those whose work requires particularly complex and time-consuming analytic techniques, we welcome the opportunity for a third year as a Clinical Scholar.

Research/Policy Seminars
A weekly 1.5-hour seminar will alternate between presentation of research findings by Scholars, faculty, or invited guests, and presentations about health policy by Michigan faculty or invited guests. Look for the noon research seminars listed on the current Seminar Schedule for examples. All Scholars will attend this seminar each week, as well as the CSP leadership, most core faculty, and selected guests. During the current CSP it has often been the place for lively, interactive discussion involving all levels of participants, with those participants coming from a wide range of disciplines. The seminar has given Scholars the chance to observe and participate in energetic scholarly debate about the very topics and methods that they are studying.

Assessment and Organization
The Scholar's Research Committee will monitor Scholars' development and progress through their 2-3 year tenure. It will periodically assess Scholars' progress towards achieving a defined set of core competencies, which are updated yearly.

Scholars whose research requires a specialized type of analytic skill – such as ethnographic or narrative analysis – will be required to also demonstrate competency in such skills.

Scholar Research Projects
The development of Scholar's research projects during the first year will be tightly integrated with the formal courses, starting with a systematic review of the literature, moving to secondary analysis, and finally to primary data collection. We will encourage Scholars to consider community-based research. The Research Committee will meet at least once each quarter to oversee each Scholar's research and ensure the policy relevance of the research. In addition, each Scholar will meet much more often with her or his mentor(s), as well as with the CSP Directors, each of whom will share office space with the Scholars.

We are very pleased to offer a site for VA Scholars. Co-Director Rodney Hayward, Director of the Health Services Research & Development (HSR&D) Service at the Ann Arbor VA , will serve as the VA liaison, a role he recently assumed for the existing CSP. The Ann Arbor VA will continue to play a very active role in the new CSP, and takes its commitment to the program seriously. We have learned the importance of making sure that VA scholars are well informed and frequently reminded of their VA opportunities (such as supplemental project funds through the local HSR&D) and VA responsibilities (such as conducting clinical work at the VA, conducting research that is clearly and directly relevant to veteran health and healthcare, and always acknowledging their VA affiliation). VA Scholars will be assigned office space at the VA as well as in the CSP office suite. Rodney Hayward will continue to discuss VA opportunities and responsibilities with CSP applicants and meet with VA Scholars at least quarterly to review their research, educational, and clinical activities.

Sample research projects
We offer below four brief sample research projects, selected to emphasize integration of research with the proposed curriculum as well as to highlight local strengths

Example 1 : A pediatrician interested in health promotion could fruitfully study the effects of family beliefs and physician practice patterns on the implementation of childhood vaccination policy. That Scholar could start by reviewing existing data about how parental concerns shape the use of new vaccines. (This review would fulfill the requirements for part of the first-year curriculum, Practicum 1.) She or he could then use a secondary data set to derive some preliminary hypotheses about what drives the utilization of new vaccines (Practicum 2). Such data sets could include the CDC National Immunization Survey, or data derived from a CDC-funded study by the Michigan Division of General Pediatrics that surveyed a nationally representative sample of physicians to discover their attitudes about safety issues. Finally, grounded in this preliminary work, a Scholar could propose a small interventional study (Practicum 3) while requesting a third year as a Scholar. That study could propose using a brief parent survey to personalize educational information about vaccination (an intervention that that has been used successfully for smoking cessation and work place safety). The intervention could be piloted in four pediatrics clinics using an experimental or quasi-experimental design. Using mixed methods such as focus groups or unstructured interviews, the Scholar could explore the cultural and social factors related to why parents accept or refuse vaccines for their children (with or without the intervention). This information could help the Scholar modify the intervention in future research or applications, as well as improve our general understanding of health promotion. Scholars asking these questions could work with members of the Division of General Pediatrics such as the Director, Gary Freed, a former Clinical Scholar who has done extensive work on vaccine policy, or another former Scholar Matthew Davis (Chicago 2000), principal investigator on a CDC-funded immunization policy grant. Victor Strecher, PhD, Professor Health Behavior and Health Education and an international authority on health promotion and behavioral medicine, could serve as a valuable resource. Since the continued introduction of new vaccines and prophylactic treatments (including those related to bioterrorism) will be accompanied by continued questions about safety, these studies would provide an excellent start for a career in pediatric HSR.

Example 2 : A Scholar from OB/GYN could take advantage of several Michigan strengths to design and evaluate new approaches for reducing the incidence of low-birth-weight infants. That Scholar could start by reviewing the literature on predictors of low birth weight, including literature on ethnic and class differences (Practicum 1). She or he could then do a secondary data analysis, perhaps working with a mentor who is familiar with using birth certificate data for the city of Detroit that has been geocoded to indicate the census tract of each birth. The Scholar could conduct multilevel analysis of the incidence of low birth weight as a function of individual characteristics of the mother and of the social environment, including the level of poverty, the rate of unemployment, or the degree of crowding in housing in the census tract (Practicum 2). The Scholar could also analyze the effects of prenatal care across different social environments and test the hypothesis that standard prenatal care does not appreciably improve birth outcomes in areas of profound socioeconomic deprivation. Finally, the Scholar could work with community members and health care providers to design and evaluate an intervention that would focus enhanced prenatal care to areas with significant social and economic needs, tailoring the specific social intervention components to the communities' biggest needs (Practicum 3). This series of related projects would build on the strong working relationship already in place between the University of Michigan and Detroit community organizations/agencies. A scholar interested in this type of research could work with mentors such as Paula Lantz, PhD, Associate Professors of Health Management and Policy, who has studied social determinants of infant health and birth outcomes, prenatal care policy, and community interventions (and has worked with past Clinical Scholars). Jeff Morenoff, PhD, Assistant Professor of Sociology and Faculty Associate, ISR, as well as Tim Hofer, MD, MSc, could help guide the multilevel analysis of birth outcomes .

Example 3 : Care for patients with chronic illness is a major problem in US health care. Scholars who work in Internal Medicine could critically evaluate evidence in the literature for specific hypotheses regarding what causes deficiencies in chronic disease care. For example, the Scholar might examine what is known about the influence of having multiple comorbidities on the quality of care for a particular chronic illness (such as CHF, depression, diabetes, major psychoses, or HIV infection). While working on the critical review (Practicum 1), the Scholar could develop hypotheses that could be tested using clinically-rich national databases that are available through the Ann Arbor VA HSR&D Center. One can often add new data fields to these registries to facilitate answering specific clinical questions. Findings from Practicum 1 would help guide secondary analyses using such databases (Practicum 2). For example, based on the literature review, the Scholar might examine how self-reported health status (a measure of self-assessed health needs), number and severity of comorbidities (a measure of medical complexity and need) versus the SF-36 physical function index (a measure of physical debility) are associated with measures of quality of care and satisfaction. The data to address this question could easily be obtained by merging clinical registry data with VA patient satisfaction data, and then providing the Scholar with a completely de-identified, anonymous dataset. Using this data set, the Scholar would test hypotheses about which health factors are most associated with deficiencies in care for chronically ill patients. The richness of the data sources would increase the likelihood of robust results from such secondary analyses. However, some valuable information would be unavailable in the databases, and important issues of generalizability would remain. Therefore, in their main CSP study (Practicum 3) the Scholar would collect primary data to test the hypotheses generated by secondary data analysis. This project might compare care within one or two VA facilities with care within an HMO. This study could explore obstacles to chronic disease care using mixed quantitative and qualitative methods, such as chart review and patient and provider interviews. The skills, expertise and track-record gained from the literature review, secondary analyses, and primary research study, would position the Scholar to seek funding for an intervention study shortly after completing the CSP. Faculty resources to support such a Scholar include, Sarah Krein, PhD, RN (extensive experience with evaluating resource utilization, casemix, and quality, using VA and community medical information system data), Rodney Hayward, MD (expertise in quality improvement for chronic illness), and Julie Lowery, PhD (expertise in case-management and resource allocation).

Example 4 : We do not fully understand why race and ethnicity are associated with large variations in receipt of medical or surgical procedures. This important topic could be addressed by, among others, a Scholar trained in urology. That Scholar could begin by reviewing the literature on racial and ethnic disparities related to the receipt of invasive procedures to treat prostate cancer, perhaps contrasting this literature with the pattern of racial and ethnic disparities found for chronic illness care and prevention (Practicum 1). The Scholar could then use a database such as the American College of Surgeons prostate cancer database (combined with census tract data) to test hypotheses from the literature review. The Scholar might examine in Practicum 2 the relationship between race and the aggressiveness of prostate cancer evaluation and treatment (controlling for insurance, income, education, and community vs. tertiary setting), and assessing the extent of disparities due to within-site versus between-site variations. Finally, based upon Practica 1 and 2, the Scholar could design a study to gain further insights into reasons for disparities (Practicum 3). For example, if Practicum 2 found substantial within-site racial/ethnic disparities, the Scholar could use a combination of qualitative and quantitative interview/survey methods to explore patient and provider beliefs, attitudes, and decision-making processes. Focus groups and unstructured interviews might be followed or supplemented with a self-administered or telephone survey of prostate cancer patients. In contrast, the Scholar may feel that there is already sufficient information on the causes of disparities, and could propose conducting an interventional study and apply for a third year. Faculty support could include, John Wei, MD, MSc (expertise in prostate cancer and outcomes research, and former Michigan Clinical Scholar 1999), Peter Ubel, MD, MA (expertise in the sociology and psychology of decision making), Michele Heisler, MD, MPA (expertise in ethnic/racial disparities, and former Michigan Clinical Scholar 2002), and Steven Katz, MD, MPH (expertise in cancer care decision-making, and former Clinical Scholar, Washington 1991).

Leadership Development
Numerous leadership training programs exist at Michigan, including some in the Medical School, the Business School, the Institute for Research on Women and Gender, and other academic units. Jayne Thorson, PhD, who will help direct the leadership program, has lectured widely on leadership and has received national awards for her work in this area. We have proposed our leadership training as an integrated part of the overall curricular structure. Aware of plans for a national component to this training, we note our enthusiasm about offering local resources as appropriate.