Phuong Linh Doan, MD

• Assistant Professor of Medicine
• Member of the Duke Cancer Institute
• Affiliate of the Regeneration Next Initiative

https://medicine.duke.edu/faculty/phuong-linh-doan-md

Thus erectile dysfunction gel 40/60 mg cialis with dapoxetine with mastercard, these calculations actually estimate the number of individuals potentially exposed to 160 dB (rms) that would occur if there were no avoidance of the area ensonified to that level erectile dysfunction injections youtube cheap cialis with dapoxetine 40/60mg on-line. Survey tracklines falling within the <100 m (328 ft) erectile dysfunction pills cape town order 20/60 mg cialis with dapoxetine amex, 100­1 impotence l-arginine buy cialis with dapoxetine 40/60 mg with visa, 000 m (328­3, 281 ft), and >1, 000 m (3, 281 ft) water depth categories were buffered by distances of 27. The total area of water that would be exposed to sound >160 dB (rms) on one or more occasions is estimated to be 209, 752 km2. Based on the operational plans and marine mammal densities described above, the estimates of marine mammals potentially exposed to sounds 160 dB (rms) are presented in Table 5 in this document. For species likely to be present, the requested numbers are calculated as described above. For less common species, estimates were set to minimal numbers to allow for chance encounters. Discussion of the number of potential exposures is summarized by species in the following subsections. It is likely that some members of one endangered cetacean species (bowhead whale) will be exposed to received sound levels 160 dB (rms) unless bowheads avoid the survey vessel before the received levels reach 160 dB (rms). However, the late autumn timing and the design of the proposed survey will minimize the number of bowheads and other cetaceans that may be exposed to seismic sounds generated by this survey. The best estimates of the number of whales potentially exposed to 160 dB (rms) are 282 and 4, 315 for bowheads and belugas, respectively (Table 5). The ringed seal is the most widespread and abundant pinniped species in ice-covered arctic waters, and there is a great deal of variation in estimates of population size and distribution of these marine mammals. Ringed seals account for the vast majority of marine mammals expected to be encountered, and hence exposed to airgun sounds with received levels >160 dB (rms) during the proposed marine survey. It should be noted that there is no evidence that most seals exposed to airgun pulses with received levels 160 dB re 1 mPa (rms) are disturbed appreciably, and even at a received level of 180 dB (rms) disturbance is not 49951 conspicuous (Harris et al. Therefore, for seals, the estimates of numbers exposed to 160 dB re 1 mPa (rms) greatly exceed the numbers of seals that will actually be disturbed in any major or (presumably) biologically significant manner. Thus, all sounds produced by icebreaking are expected to diminish below 120 dB re 1 mPa within the zone where we assume mammals will be exposed to 160 dB (rms) from seismic sounds. Exposures of marine mammals to icebreaking sounds with received levels 120 dB would effectively duplicate or ``double-count' animals already included in the estimates of exposure to strong (160 dB) airgun sounds. Beaufort Sea, and seismic survey activity along all those lines has been assumed in the estimation of takes. Any non-seismic periods, when only icebreaking might occur, would therefore result in fewer exposures than estimated from seismic activities. If refueling of the Geo Arctic is required during the survey and the Polar Prince transits to and from Canadian waters to acquire additional fuel for itself, an additional 200 km (124 mi) of transit may occur. Most of this transit would likely occur through ice in offshore waters >200 m (656 ft) in depth. For estimation purposes we have assumed 25% of the transit will occur in 200­1, 000 m (656­3, 281 ft) of water and the remaining 75% will occur in >1, 000 m (3, 281 ft) of water. This results in an estimated 2, 160 km2 of water in areas 200­1, 000 m (656­3, 281 ft) deep and 6, 487 km2 in waters >1, 000 m (3, 281 ft) deep being ensonified to 120 dB by icebreaking sounds. Using the density estimates for the east survey area shown in Tables 2 and 3, the estimated exposures of cetaceans and pinnipeds are shown in Table 6 here. Again, it is expected that most of this transit would likely occur in offshore waters >200 m (656 ft) in depth. This results in an estimated 3, 240 km2 of water in areas 200­1, 000 m (656­3, 281 ft) deep and 9, 720 km2 in waters >1, 000 m (3, 281 ft) deep being ensonified to 120 dB by icebreaking sounds within each half of the U. Using the density estimates in Tables 2­3, estimated exposures of cetaceans and pinnipeds are shown in Table 7 here. Only two cetacean species, beluga and bowhead, are likely to be present in the Alaskan Beaufort Sea late in the survey period or where extensive ice cover is present. Gray whale vocalizations have been recorded throughout one winter (2003­2004) in the western Alaskan Beaufort Sea near Pt. However, the presence of gray whales in October and November in the Alaskan Beaufort Sea does not appear to be a regular occurrence or involve a significant number of animals when it does occur. Beluga whales have shown avoidance of icebreaking sounds at relatively low received levels. In the Canadian Arctic, belugas showed initial avoidance of icebreaking sounds at received levels from 94­105 dB in the 20­1, 000 Hz band, although some animals returned to the same location within 1­2 days and tolerated noise levels as high as 120 dB in that band (Finley et al. Playback experiments of icebreaker sounds resulted in 35% of beluga groups showing avoidance at received levels between 78­84 dB in the 1/3octave band centered at 5, 000 Hz, or 8­ 14 dB above ambient levels (Richardson et al. Based on these results, it was estimated that reactions by belugas to an actual icebreaker would likely occur at 10 km (6. Erbe and Farmer (2000) estimated that zones of disturbance from icebreaking sounds could extend 19­46 km (12­28. Erbe and Farmer (2000) also estimated that a beluga whale would have to remain within 2 km (1. Aerial and vessel based monitoring of seismic surveys in the central Beaufort Sea showed significant avoidance of active airguns by belugas. Results of the aerial monitoring suggested an area of avoidance out to 10­20 km (6. The nearest aerial ``transect' beluga sighting during seismic activity was at a distance of 7. Only seven beluga sightings were recorded from the survey vessel during the entire study, three of which occurred during airgun activity. Two of the seismic period sightings were made at the beginning of active airgun periods and the other was during seismic testing of a limited number of guns. Similarly, few beluga whales were observed near seismic surveys in the Alaskan Beaufort Sea in 1996­1998 (Richardson 1999), although the beluga migration corridor is typically well offshore of where most of the seismic survey occurred. Observers on seismic and associated support vessels operating in the Alaskan Beaufort Sea during 2006­2008 seasons reported no beluga sightings during seismic or non-seismic periods, suggesting avoidance of both seismic and vessel sounds (Savarese et al. No mitigation measures during seismic operations (power down or shut down of airgun arrays) have been required as a result of beluga sightings during surveys in the Chukchi or Beaufort seas in 2006­2009 (Ireland et al. Based on the reported avoidance of vessel, icebreaking, and seismic sounds by beluga whales, and the low and seasonally decreasing density during the time of the proposed survey, the likelihood of beluga whales occurring within the 180 dB zone during the proposed project is extremely low. A cautionary estimate that assumes 10% of belugas will show no avoidance of the 180 dB zone results in an estimate of 23 beluga whales exposed to sounds 180 dB (based on the densities described above and the area of water that may be ensonified to 180 dB) during the proposed project. Less information is available regarding avoidance of icebreaking sounds; however, avoidance of the overall activity was noted during intensive icebreaking around drill sites in the Alaskan Beaufort Sea in 1992. Migrating bowhead whales appeared to avoid the area of drilling and icebreaking by 25 km (15. Also, monitoring of drilling activities in a previous year, during which much less icebreaking occurred, showed avoidance by migrating bowheads out to 20 km (12. Therefore, the relative influence of icebreaking versus drilling sounds is difficult to determine. Only 1 bowhead was observed from the survey vessel during the three seasons (1996­1998) when seismic surveys continued into September. Bowheads not actively engaged in migration have shown less avoidance of seismic operations. During seismic surveys in the Canadian Beaufort Sea in late August and early September bowhead whales appeared to avoid an area within 2 km (1. Vessel-based sightings showed a statistically significant difference of 600 m (1, 969 ft) in the mean sighting distances of bowheads (relative to the survey vessel) between periods with and without airgun activity. This, along with significantly lower sighting rates of bowhead whales during periods of airgun activity, suggests that bowheads still avoided close approach to the area of seismic operation (Miller and Davis, 2002). Results from vessel-based and aerial monitoring in the Alaskan Beaufort Sea during 2006­2008 were similar to those described above (Funk et al. Sighting rates from seismic vessels were significantly lower during airgun activity than during non-seismic periods. Support vessels reported 12 sightings of bowhead whales in areas where received levels from seismic were 160 dB (Savarese et al. Aerial surveys reported bowhead whales feeding in areas where received levels of seismic sounds were up to 160 dB. Bowheads were not observed in locations with higher received levels (Christie et al. Based on four direct approach experiments in northern Alaskan waters, Ljungblad et al.

Ask the patient to remain still throughout the procedure because movement produces unreliable results impotence at 17 buy 20/60 mg cialis with dapoxetine amex. The right- or left-side-up position may be used to allow gravity to reposition the liver impotence propecia cheap 20/60mg cialis with dapoxetine with mastercard, gas erectile dysfunction age graph generic cialis with dapoxetine 20/60 mg with visa, and fluid to facilitate better organ visualization candida causes erectile dysfunction 40/60 mg cialis with dapoxetine otc. Conductive gel is applied to the skin, and a transducer is moved over the skin to obtain images of the area of interest. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in Access additional resources at davisplus. Refer to the Hematopoietic, Immune, and Gastrointestinal System tables at the back of the book for related tests by body system. The waves are bounced back, converted to electrical energy, amplified by the transducer, and displayed on a monitor to determine the position, size, shape, weight, and presence of masses of the thyroid gland; enlargement of the parathyroid glands; and other abnormalities of the thyroid and parathyroid glands and surrounding tissues. The primary purpose of this procedure is to determine whether a nodule is a fluid-filled cyst (usually benign) or a solid tumor (possibly malignant). The procedure may be indicated as a guide for biopsy, aspiration, or other interventional procedures. Despite the advantages of the procedure, in some cases it may not detect small nodules and lesions (less than 1 cm), leading to false-negative findings. Refer to the Endocrine System table in the back of the book for related tests by body system. The reflected sound waves or echoes are transformed by a computer into scans, graphs, or audible sounds. The velocity of the blood flow is transformed as a "swishing" noise, audible through the audio speaker. The sound emitted by the equipment corresponds to the velocity of the blood flow through the vessel occurring with spontaneous respirations. Changes in these sounds during respirations indicate the possibility of abnormal venous flow secondary to occlusive disease; the absence of sound indicates complete obstruction. Plethysmography may be performed to determine the filling time of calf veins to diagnose thrombotic disorder of a major vein and to identify incompetent valves in the venous system. An additional method used to evaluate incompetent valves is the Valsalva technique combined with venous duplex imaging. Report the presence of a lesion that is open or draining; maintain clean, dry dressing for the ulcer; protect the limb from trauma. There should be 24 hr between administration of barium- or iodine-based contrast medium and this test. Endoscopic retrograde cholangiopancreatography, colonoscopy, and computed tomography of the abdomen, if ordered, should be scheduled after this procedure. Instruct the patient to remove jewelry and other metallic objects from the area to be examined. Place the patient in the supine position on an exam table; other positions may be used during the examination. Conductive gel is applied to the skin, and a transducer is moved over the area to obtain images of the area of interest. Images with and without compression are performed proximally or distally to an obstruction to obtain information about a venous occlusion or obstruction. The procedure can be performed for both arms and legs to obtain bilateral blood flow determination. Do not place the transducer on an ulcer site when there is evidence of venous stasis or ulcer. Nutritional considerations: A low-fat, lowcholesterol, and low-sodium diet should be consumed to reduce current disease processes and/or decrease risk of hypertension and coronary artery disease. Air may be instilled to provide double contrast and better visualization of the lumen of the esophagus, stomach, and duodenum. If perforation or obstruction is suspected, a water-soluble iodinated contrast medium is used. This test is also used to evaluate the results of gastric surgery, especially when an anastomotic leak is suspected. When a small bowel series is included, the test detects disorders of the jejunum and ileum. The images are visualized on a fluoroscopic screen, recorded, and stored electronically or on x-ray film for review by a physician. When the small bowel series is performed separately, the patient may be asked to drink several glasses of barium, or enteroclysis may be used to instill the barium. With entero- clysis, a catheter is passed through the nose or mouth and advanced past the pylorus and into the duodenum. Barium, followed by methylcellulose solution, is instilled via the catheter directly into the small bowel. Sensitivity to social and cultural issues, as well as concern for modesty, is important Access additional resources at davisplus. Explain to the patient that he or she will be asked to drink a milkshake-like solution that has an unpleasant chalky taste. Upper Gastrointestinal Series: Place the patient on the x-ray table in a supine position, or ask the patient to stand in front of an fluoroscopy screen. Instruct the patient to take several swallows of the barium mixture through a straw while images are taken of the pharyngeal motion. Images are taken at 30- to 60-min intervals until the barium reaches the ileocecal valve. Monitor for reaction to iodinated contrast medium, including rash, urticaria, tachycardia, hyperpnea, hypertension, palpitations, nausea, or vomiting, if iodine is used. Instruct the patient to take a mild laxative and increase fluid intake (four glasses) to aid in the elimination of barium, unless contraindicated. Inform the patient that his or her stool will be white or light in color for 2 to 3 days. Instruct the patient to fast, restrict fluids, and, by medical direction, withhold medication for 6 hr prior to the procedure. Instruct the patient to blow into a balloon prior to the start of the procedure to collect a sample of breath. Instruct the patient to swallow the C-14 capsule directly from a cup followed by 20 mL of lukewarm water. Provide an additional 20 mL of lukewarm water for the patient to drink at 3 min after the dose. Breath samples are taken at different periods of time by instructing the patient to take in a deep breath and hold it for approximately 5­10 sec before exhaling through a straw into a mylar balloon. Unless contraindicated, advise patient to drink increased amounts of fluids for 12 to 24 hr to eliminate the radionuclide from the body. If a woman who is breastfeeding must have a breathe test, she should not breastfeed the infant until the radionuclide has been eliminated. She should be instructed to express the milk and discard it during a 3-day period to prevent cessation of milk production. Record the date of the last menstrual period and determine the possibility of pregnancy in premenopausal women. Inform the patient that the procedure is done in the nuclear medicine department by technologists and support staff and usually takes approximately 30 to 60 min. Sensitivity to social and cultural issues is important in providing psychological support before, during, and after the procedure. Depending on the results of the procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for change in therapy. See the Gastrointestinal System table at the end of the book for related tests by body system. Monitor intake and output for fluid imbalance in renal dysfunction and dehydration. Nutritional considerations: Nitrogen balance is commonly used as a nutritional assessment tool to indicate protein change. During various disease states, nutritional intake decreases, resulting in a negative balance. During recovery from illness and with proper nutritional support, the nitrogen balance becomes positive. Educate the patient, as appropriate, in dietary adjustments required to maintain proper nitrogen balance. Unless medically restricted, a healthy diet consisting of the five food groups of the food pyramid should be consumed daily.

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Governmental entities 286 as well as private businesses comprise the licensees for these services. All governmental entities with populations of less than 50, 000 fall within the definition of a small entity. They are (1) Internet Publishing and Broadcasting and Web Search Portals, 288 and (2) All Other Information Services. For the first category, the data show that 396 firms operated for the entire year, of the 39 channels allocated to this service for emergency medical service communications related to the delivery of emergency medical treatment. The approximately 20, 000 licensees in the special emergency service include medical services, rescue organizations, veterinarians, handicapped persons, disaster relief organizations, school buses, beach patrols, establishments in isolated areas, communications standby facilities, and emergency repair of public communications facilities. Steps Taken To Minimize Significant Economic Impact on Small Entities, and Significant Alternatives Considered 124. In particular, as stated supra in Section I, our concern with minimizing any adverse economic impact of our proposed rules on small entities is guided by our goals of fairness, administrability, and sustainability. Accordingly, we believe that adjustments to fees paid by fee payors should be consistent with those goals. Specifically, we intend to mitigate any inequities that might result from imposition of substantial fee increases. In keeping with the requirements of the Regulatory Flexibility Act, we have considered certain alternative means of mitigating the effects of fee increases to a particular industry segment. Another option is to provide interim adjustments, by phasing in the new fees over a period of time. On the issue of revisiting the allocation resulting from this rulemaking, the Commission is considering undertaking this reexamination at regular intervals. In light of our stated goals, the Commission seeks comment on the abovementioned, and any other, means and methods that would minimize any significant economic impact of our proposed rules on small entities. Federal Rules That May Duplicate, Overlap, or Conflict With the Proposed Rules 130. Accordingly, it is ordered that, pursuant to Sections 4(i) and (j), 9, and 303(r) of the Communications Act of 1934, as amended, 47 U. Notices of hearings and investigations, committee meetings, agency decisions and rulings, delegations of authority, filing of petitions and applications and agency statements of organization and functions are examples of documents appearing in this section. Authority for obtaining information from customers is included in the Freedom to E-File Act (7 U. Comments on this notice must be received by October 16, 2012 to be assured of consideration. Fax comments should be sent to the attention of Pam Weber at fax number (970) 295­5528. Type of Request: Extension and revision of a currently approved information collection. Due to the increased customer access associated with a Level 2 Access account, customers must be identity proofed, in addition to completing an electronic self registration. The new on-line identity proofing service will provide registrants with a more efficient mechanism to have their identity proofed. Estimate of Burden: Public reporting burden for this collection of information is estimated to take eight (8) minutes to complete the self registration process for a Level 1 Access account. Estimated Number of Respondents: 114, 841 Level 1 and 14, 860 Level 2 for an estimated total of 129, 701 respondents. As specified by law, the boundary will not be effective until ninety (90) days after Congress receives the transmittal. This project is not a general management plan for the area, nor is it a programmatic environmental analysis for domestic livestock grazing on the entire forest. The draft environmental impact statement is expected March of 2013 and the final environmental impact statement is expected September of 2013. Russell Riebe, Wisdom/Wise River District Ranger at (406) 689­3243 or via email at rriebe@fs. Proposed Action the authorizing official proposes to: -Re-issue domestic livestock grazing permits for the eleven allotments for a period of ten years. Seven of the allotments would see a decrease and four allotments would remain at the current permitted levels. Within these five allotments structural improvements would include the addition of one mile of fencing, a quarter mile of piping, development of two springs, addition of two water tanks, one new exclosure, three hardened crossings, and the conversion of three temporary exclosures to permanent exclosures. Domestic livestock grazing would continue based on the Interim Livestock Grazing Standards (Forest Plan Ch. Responsible Official the Wisdom/Wise River District Ranger will be the responsible official. Nature of Decision To Be Made the decision to be made is whether to implement the proposed action, another alternative, or a combination of the alternatives. Permits or Licenses Required Grazing permits for domestic livestock grazing would be issued for ten years for each of the eleven allotments. Scoping Process this notice of intent initiates the scoping process, which guides the development of the environmental impact statement. A scoping letter and maps will be mailed to interested publics, Tribes, and federal, state, and local governments. Comments received in response to this solicitation, including names and addresses of those who comment, will be part of the public record for this proposed action. Please call ahead to 575­ 434­7200 to facilitate entry into the building to view comments. The full agenda and order of proposal presentations can be found at fsplaces. Anyone who would like to bring related matters to the attention of the committee may file written statements with the committee staff before or after the meeting. Individuals wishing to make an oral statement should request in writing by August 24 to be scheduled on the agenda. Written comments and requests for time for oral comments must be sent to Patti Turpin by postal service, email, or facsimile (575­434­7218). The El Dorado County Resource Advisory Committee will meet in Placerville, California. The committee is authorized under the Secure Rural Schools and Community SelfDetermination Act (Pub. Please call ahead to 530­621­5268 to facilitate entry into the building to view comments. Individuals wishing to make an oral statement should request in writing by August 27 for the September 10 meeting, September 3 for the September 17 meeting, and September 19 for the September 24 meeting to be scheduled on the agenda. OpenView&Count= 1000&RestrictToCategory=E1+Dorado+ County within 21 days of the meeting. Meeting Accommodations: If you are a person requiring resonable accomodation, please make requests in advance for sign language interpreting, assistive listening devices or other reasonable accomodation for access to the facility or procedings by contacting the person listed under For Further Information Contact. Please call ahead to (435) 896­1070 to facilitate entry into the building to view comments. The agenda will include time for people to make oral statements of three minutes or less. Individuals wishing to make an oral statement should request in writing by September 14, 2012 to be scheduled on the agenda. A summary of the meeting will be posted on the web site listed above within 21 days of the meeting.

In this lesson erectile dysfunction cause of divorce purchase 40/60 mg cialis with dapoxetine amex, you learned about factors that affect access to health care for vulnerable and underserved consumers erectile dysfunction treatment blog discount cialis with dapoxetine 40/60 mg on-line. Resources Serving Vulnerable and Underserved Populations Resources: Specific Populations: Learn about the unique mental health and substance use issues faced by different U problems with erectile dysfunction drugs cialis with dapoxetine 20/60mg line. National Library of Medicine and National Institutes of Health on health disparities erectile dysfunction treatment spray order 20/60mg cialis with dapoxetine with mastercard. Beginning with tax year 2019, individuals who choose to go without insurance will no longer be subject to making shared responsibility payments. National Council on Aging: Benefits Check-up: A resource that helps consumers identify and locate federal, state, and private benefits programs. National Council on Aging: A resource for older consumers that provides information on health, health care, and economic stability programs. The goals of the plan include increasing understanding and awareness of disparities, creating and sharing solutions, and accelerating implementation of effective actions. The Q&A explains that consumers who enroll in a Statebased Marketplace need to contact their state to find out whether this policy applies. The authors also would like to thank several people who reviewed earlier drafts of this report and provided helpful comments and guidance. AcademyHealth acknowledges the Robert Wood Johnson Foundation for its support of this work on diversity. We recognize that aspects of diversity may include age, country of birth, disability, ethnicity, gender, gender identity, language, national origin, race, refugee status, religion, culture, sexual orientation, health status, community affiliation, and socioeconomic status. The imperative for diversity stems not only from the need to reflect the changing demographics in the U. One of the principles in our strategic plan is that "diversity of opinion and perspective produces better evidence. The first minority fellowship program at AcademyHealth was launched in 2010 with support from the Aetna Foundation and is still continuing. Mentors come from many different areas of professional expertise and represent a variety of racial and ethnic backgrounds. The program is being evaluated by mentees, mentors, and program staff during the summer and fall of 2015. While it is beyond the scope of this report to provide an exhaustive review, the next section highlights some examples of approaches and what is known about these efforts. Recruiting, Mentoring, and Retention Programs for Individual Researchers Successful efforts to promote diversity have focused on individuals at different phases of the research career pipeline, including K-12 education; mentoring and supportive interventions at the college and graduate school levels; mentoring and minority fellowships for postgraduate and postdoctoral professionals; and faculty development programs for junior faculty. Some are supported by national organizations, and others are specific to an individual institution. Successful efforts to promote diversity have focused on individuals at different phases of the research career pipeline. Department of Education may be the best example of these pipeline programs for K-12. Mentoring programs are an important first step toward diversity, but they do not directly address racial bias or the discrimination mentees may encounter in or from predominantly white institutions. Thus, individual-focused programs need reinforcement from organizationally-based programs to build a culture of diversity and inclusion across the institution, which may be defined as valuing diverse perspectives and backgrounds as an asset and making all participants feel engaged and respected. Communities of Practice While some communities are institutional or geographic, others are virtual. Over time, organizers hope that many connections made at these meetings will lead to increased citations of work presented there, as well as new collaborations among researchers with similar interests. Similarly, the AcademyHealth Disparities Interest Group has more than 800 members who conduct disparities research, present their work at the AcademyHealth Annual Research Meeting, are active in an online community, publish findings, and share information throughout the year. Diversity programs are driven not only by recognition of changing demographics, but also because the organizations value the variety of perspectives that diversity brings. These programs are driven not only by recognition of changing demographics, but also because the organizations value the variety of perspectives that diversity brings. Many of these diversity programs have been in place for several years, and most have dedicated websites, sponsor and produce events, and report publicly on their progress. AcademyHealth is currently evaluating its programs to find out more about their career impact and relationship to institutional culture changes. The organization is also seeking input on further changes fellows believe would support equity in promotions and improve retention rates at their respective institutions. As another example, the Finding Answers: Disparities Research for Change program has developed an equity self-assessment questionnaire for medical schools to help them identify concrete actions to address equity among students and faculty, with an additional goal of reducing health care disparities through advocacy and systems level changes. They are intended to advance health equity, improve [healthcare] quality, and help eliminate health disparities. However, the ramifications of such injustices play an important role in the overall health and well-being of many African American communities. There is a growing body of evidence that suggests implicit and often unconscious biases about minority patients lead white physicians to inadvertently provide poorer quality care to those patients. Thus, racism and discrimination are not always obvious either to an observer or even to the person making discriminatory judgments in a single incident or over time. Health disparities are also due to widespread but often subtle discrimination by white people against people of color, even against those who are well-educated and affluent. It requires that each school develop a learning environment in which "self-awareness, open-minded inquiry and assessment, and the ability to adopt to cultural differences" are defined and evaluated (see Appendix F). Its goal was to convene health, education, and business leaders and hold public hearings across the country to gather testimony about the lack of diversity in medicine, nursing, and dentistry as a means of addressing the growing body of evidence of health disparities. Over the same period of time that the health professions workforce community has been calling for more diversity, the health disparities research community has evolved through three stages: (1) making the case for disparities by documenting them; (2) determining reasons for the disparities; and (3) suggesting solutions for reducing or eliminating disparities through social action based on the available evidence. While research and the published literature are replete with evidence addressing the first two stages ­ detecting and understanding ­ there are far fewer examples of the development and deployment of effective interventions to reduce disparities. But the report also found strong evidence that racial bias, discrimination, stereotyping, and clinical uncertainty also play a role. Smedley, the Lived Experience of Race and Its Health Consequences, American Journal of Public Health, May 2012, Vol 102(5), p. In 2004, the Sullivan Commission on Diversity in the Healthcare Workforce also called for an increase in diversity of the health care and research workforce, noting that the workforce was not keeping pace with changing demographics and that access to a health professions career "remains largely separate and unequal. For example, mentoring is primarily an individualized approach to promoting diversity, and evidence shows that it is more effective when it is accompanied by organizational supports, such as multi-component programs involving community-building, public events, and policies for retention and promotion (see Accreditation Criteria for School of Public Health, 2011, Appendix F). Individuals create organizations in which there is differential access to goods, services, and opportunities based on race, creating "inherited disadvantages" which are codified into social structures, practices, and laws. Thus, institutionalized racism and structural factors in society perpetuate historical injustices. Jones called for a national conversation and design of interventions to eliminate the differences. Building on the work of Jones and others, Brian Smedley also proposed that racism operates at individualized, institutional, and structural levels. Thomas used the same theoretical underpinning when he proposed the fourth generation of health equity research (see Figure 1). As a transdisciplinary organization, AcademyHealth is actively looking for ways to continuously bridge multiple disciplines and constituencies. To help better address these systemic challenges, AcademyHealth invited a group of experts from inside and outside of its immediate community to advise on next steps. The imperative for diversity is not only to reflect the changing demographics in the U. This helps participants to visualize the relationships among evolving ideas as they emerge in discussions (see Figure 3). As a result of the scan, the scenarios focused on the key drivers shown in Table 1 below. In terms of external forces built into scenarios, planners reviewed current demographic and descriptive information about the U. The day began with a presentation of the four scenarios to the full group, and then participants met in two small groups with facilitators. Each small group considered two scenarios and then developed recommendations for what would need to happen in order to achieve diversity, considering the positive and challenging drivers of change embedded in their scenarios. After the groups reconvened as a whole and reported out to each other, the entire group worked to synthesize and agree on the recommendations presented in Figure 3.