PERSPECTIVE: Journalism and Medicine - Comfortable with Uncertainty

by Dr. Jon LaPook I thought you might want me to talk about what I've learned from blending medicine and journalism. If I'm wrong, I'm sure I'll find out soon enough from today's Quinnipiac graduation exit poll.  I work in two worlds. Thirty-seven years ago, I graduated from medical school. Eleven years ago, I started as a correspondent for CBS News. But I continue to love medicine and still see patients.

I want to make sure you leave here today with at least one piece of advice that will help you be a better physician, will set you apart from the pack, no matter what specialty you enter. I'll tell you one story from each world, then leave you with a single piece of practical advice I've learned from doing both jobs.

Since the Hippocratic Oath outranks the Nielsen ratings, I'll start with medicine.

At this moment, you are about to become a doctor. When I was in your shoes, I remember thinking that every test, every paper, every minute of studying since kindergarten had led to this one enormous achievement: a medical degree. So breathe it in. But you are not doctors yet. At this delicious moment, breathe that in, too.

Remember what it can feel like to be a patient: the mixture of emotions, from helplessness to embarrassment to fear. I know you've been studying for years to learn the science of medicine, but today I'm also asking you to consider the art of healing. Don't let all those facts and figures crowd out your ability to connect with your patients. But how in the world do you do that—especially during your internship and residency, when you'll be multitasking, tired, and just trying to keep your head above water?

It starts with a decision about the emotional wall we all build between ourselves and our patients. Constructing it is tricky. You don't want to make it too thin and porous, because that can be emotionally devastating. But you don't want to make it too thick and impervious, because then you miss out on all the good stuff, the precious moments when you connect with a patient as a person. I treasure the time an elderly patient showed up for an office visit on a beautiful spring day, and I wheeled her over to the Central Park Zoo to watch the sea lions. No medicine I have ever prescribed has had a more powerful therapeutic response.

Everybody has to find a comfort level. For me, erring on the side of "too empathetic" is the way to go. Patients pick up on it, and if they feel you really care, they're more likely to open up to you.

When I was a third-year medical student rotating through psychiatry, I saw an 8-year-old girl referred by the school psychologist. My preceptor and I met her in clinic once a week, but we couldn't figure out what was going on. For some reason, during the last visit of my rotation, I asked her mother, a single mom—I can still see her smile—what she would do when her daughter, the youngest of three, grew up and left home. She said, "Oh, I'll jump that bridge when I come to it."

The words were almost around the corner—in fact, my preceptor went right on to the next question—when I interrupted him and said, "You know, you just said 'I'll jump that bridge when I come to it,' and the expression is I'll cross that bridge when I come to it. Are you upset about the thought of one day being alone?" Her smile evaporated and she started crying. She was not only depressed, which helped explain what was bothering her 8-year-old daughter, but she was suicidal, and we immediately arranged for treatment. That moment was simultaneously the most exhilarating and the most terrifying moment of medical school. What if I had missed it? What if we had just gone on to the next question? What had I already missed with other patients? And what was I going to miss in the future?

Here's the point. Here's a piece of advice that will set you apart: When we're watching a movie and an important moment is about to happen, how do we know? Because there's a close-up and the music changes. Well, in life, there's no close-up and there's no change of music. You have to play the soundtrack in your own head. You have to control the zoom button yourself. You must catch that moment when the patient—consciously or unconsciously—tells you what's the matter. You need to get them to open up to you as one human being to another. And they will not do that unless they know they are talking to a human being!

Now part two. Journalism and medicine go together well. There's a lot of overlap between what I do as a journalist and what I do—and you will do—as a physician: communicate. It doesn't matter if it's to one person or millions. Our job is to explain things clearly and provide perspective based on the most reliable information available. It's easy to slip into medspeak. But, believe me, not everybody knows what a cohort is, or a subset. Instead of "contraindicated," how about just saying, "not a good idea?"

These days, there's a lot to explain, and it's tough to do that if you have only 15 or 20 minutes with a patient. The key is taking complex topics and presenting them in simple, accessible terms. So communicating clearly—and succinctly—is an important skill. Work on it.

Your patients will look to you for guidance concerning what they should and should not worry about, and that's where staying up to date will be crucial. I did 66 segments about Ebola—we counted—and the message was the same every time. Ebola was a huge problem in West Africa, but the odds of it spreading widely in the United States were extremely low.

I'm more concerned about Zika, and have been saying that on air, over and over, for a year, including in a "60 Minutes" piece last fall. It's the first mosquito-borne virus ever known to cause a birth defect, including microcephaly, and the first mosquito-borne virus to be sexually transmitted. I've covered this story in Brazil, Puerto Rico, and—two weeks ago—in south Texas. With a vaccine not expected until next year, at the earliest, it seems inevitable the virus will spread further in the United States, especially to mosquitoes along the Gulf Coast. But people are still not aware enough about the risks, and about how to protect themselves. This is a perfect example of where I can help by talking to a large audience, and you can help by talking to your patients and friends. And with especially complicated issues like Zika, point them to reliable online information, like the CDC website.

My experience in journalism has helped me see how we—as doctors—can make a difference beyond what we might imagine.

Three months after the terrible 2010 earthquake, I was in Port-de-Paix in northern Haiti—the poorest part of the poorest country in the Western Hemisphere. I was in a one-room combination delivery room and neonatal ICU. To my right was a premature baby boy, clinging to life with the help of the one portable oxygen machine on hand. To my left was a woman in labor. Suddenly, the unborn baby's pulse dropped. After a few minutes, the oxygen machine was wheeled from the premature baby to the woman in labor, who delivered a healthy girl. The premature baby died. In the United States, that baby would have had more than a ninety percent chance of survival.

You certainly don't have to go to Haiti to see health care inequity. You find it throughout the world and across the United States—disparities in outcomes based on factors like race, ethnicity, and socioeconomic status. I won't quote facts and figures: You've undoubtedly seen them already. But I'd like to convince you that you can make a difference here. You have that power. And it doesn't have to be on a grand, policy-level scale—although that would be nice!

You don't have to be Dr. Paul Farmer, a co-founder of Partners In Health, who helped build a modern hospital in central Haiti that opened two years after the earthquake. Oxygen outlets in the walls by every bed, for the next premature baby. You can make a difference, one person at a time, in your own community.

But, of course, we do need large-scale, public health and policy solutions to health care inequity. Please keep your eyes open so you recognize it—whether in your practice or in some far off place. Think about what you can do to help. And triage this as "stat."

And now this: a single piece of advice based on what I've learned in both fields, as a physician and a journalist. Be comfortable with uncertainty.

If you've been practicing medicine for five years and you think you have all the answers, you're in the wrong profession. Patients get understandably frustrated when one year we say one thing, and the next year it appears we're saying the exact opposite—whether it's about postmenopausal hormone replacement, mammography, PSA screening, or whatever. But YOU shouldn't be frustrated. Medicine has always been about trying to think logically, based on the best available data. And thank goodness that data changes. For thousands of years, holes were drilled into the skulls of patients to release evil spirits, and people were bled to help restore the correct balance of "bodily humors." What are we doing now that doctors a hundred years from now will look back at and think, "Can you believe they used to do that? Antibiotics for infections? Didn't they know about drilling a hole into the skull to release the evil spirits?" Don't laugh; we're using leeches again, not for bloodletting but to help improve microcirculation and wound healing.

All this should actually take the pressure off. You may be thinking, "Do I really know enough to be a doctor?" I certainly had that question. Well, you DO know enough—and there will be supervision! Your colleagues and teachers are there to help. And you have the foundation: a knowledge of anatomy, pathophysiology, all the basics. After that, no matter how many facts you've memorized, it's still only a tiny fraction of all medical knowledge. So relax. Practicing medicine is open-book. You have a ton of electronic medical information at your fingertips, and you're going to have the fun of learning something new every single day.

And you're allowed to say, "I don't know"—an especially good idea when you don't know.

What's going to distinguish you as true healers is the way you embrace humility, compassion, and empathy. Turn away from the computer screen and look your patient straight in the eyes. Understand the extraordinary importance of listening. And realize that even when you don't have the answer for a patient in need, you can still help—with a sympathetic ear, a reassuring touch of the hand, and by sticking by them, through sickness and health.

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Dr. Jon LaPook is the CBS News chief medical correspondent, a professor at the NYU School of Medicine, an internist and gastroenterologist at NYU Langone Medical Center, and the Director of the NYU Langone Empathy Project. He delivered the 2017 commencement address to the first graduating class of new doctors from the Quinnipiac University Frank H. Netter, M.D., School of Medicine.  The full address is available on the CBS News website.

PERSPECTIVE: Beyond the Land of Unsteady Habits

by Kevin B. Sullivan These days, it may seem like Connecticut is the land of unsteady habits.  As Governor Malloy says, sometimes it just feels like we always see the glass half empty.

For example, those of us in the capital area get a steady stream of bad news about our capital city in crisis.  Yet, right next door, there’s West Hartford where our state’s 8^th largest municipality exemplifies diversity, good governance, fiscal sustainability and continuous economic re-invention.

So let’s not waste time obsessing about Aetna’s headquarters move, like we did with GE.  Neither move is about competitiveness in taxes or cost of living.  Both are more about the beggar-thy-neighbor bidding war among the states for public subsidies.

Make no mistake, our rhetoric – especially our political rhetoric – influences how we see ourselves and how others see us.  No democracy or economy, national or state, can thrive by looking backwards, devaluing our shared assets or chasing short-term satisfactions.  So stow the political back-biting and skip the pity party.  Let’s get back to work.

I am a realist, but not a pessimist.  Being a realist means building from our strengths, facing our weaknesses, embracing our challenges and creating new opportunities.  Right now is the best opportunity we have to get it right.  That starts by understanding there is no magic – just smart decisions, hard work and a vision that’s fiscally sustainable and economically nimble.

With long years of service in the State Legislature behind me, I see so many things we did right but also many that we did wrong or just ignored.  Now, as Revenue Services Commissioner, I get to have a new window on the state economy every day.  So what do I see?

Prior to the Great Recession, Connecticut experienced one of the strongest and longest runs of economic growth in the nation.  Confident in our highest per capita income and traditional economic base, we were complacent.  Then, in the hard times that followed, we failed to see that a very long and very deep recession also masked tectonic economic shifts.   We have been struggling ever since just to understand that this time it’s not about recovery – it’s about renewal.

Under Republicans and Democrats, state spending has outpaced economic growth and personal income growth for the past twenty years.  Worse still, most of the growth and most of every state budget is fixed costs.  Unfunded liabilities that no one before Governor Malloy has challenged.  No wonder, under Republican and Democratic governors, three major tax increases in the past twenty years have now reached a point of diminishing return.

Connecticut’s income tax is the third most progressive in the nation.  It includes an earned income credit that helps working families and puts money back into the economy.  Income taxes should be progressive.  But over-reliance on a highly progressive income tax and a relatively small segment of very high income taxpayers produces big revenue volatility.

While our [tax] rates are comparatively high, the business-backed national Council on State Taxation continues to rank Connecticut among the lowest total effective tax burden states.  But that does not mean we cannot do better.

Led by DRS, supported by the Governor and working with the business community, we have already achieved a trifecta of corporate tax reforms.  With conversion to a unitary, single factor, destination sourced approach, we have ended a tax regime that used to favor out of state businesses while burdening Connecticut-based businesses.  Whether corporate income or pass-through income, DRS is also stepping up in audit to challenge those who tilt the playing field through off-shoring and transfer pricing schemes that are tax evasion by any other name.

However, fewer and fewer businesses are organized as corporations.   Personal taxation of pass-through business income now drives state business tax revenue.  Different taxes and different rules for businesses that differ in form only.  There are also many other types of Connecticut business taxes determined solely by the nature of the product or service provided.

Add to that the irritant of Connecticut’s so-called Business Entity Tax, a fee that is often the first tax slap experienced by new enterprises well before turning even a first dollar of profit.  As other states have done, it’s time to at least consider rationalizing this mess with a single receipts-based tax that includes meaningful start-up and reinvestment credits.

In fact, there are so many ways to use smart revenue policy as an economic driver.  With transportation gridlock and aged infrastructure ham-stringing growth, we need a modern toll system that generates essential reinvestment.  Let’s ramp up tax credits for R&D, job creation, training for new workers, retraining for displaced workers and business reinvestment.

We can even pay for it by getting rid the remaining mishmash of credits and abatements that make no appreciable economic difference at all.  Rather than pile on more loans, let’s drag antiquated systems of public and private higher education into the 21^st century and then use tax policy to provide incentives for graduates to stay in Connecticut as next generation entrepreneurs and skilled workers.

In exchange for real political and structural reform, we can also use tax policy - rather than bailouts, bankruptcies or yet another layer of government – to re-invent livability and economic viability in our struggling cities.

Connecticut’s economic strengths need to be the basis of any diagnostic for improved competitiveness.  A long and strong run of economic performance still leaves us a great state to live and work.  We continue to rank highly on so many key economic measures: personal income, low poverty levels (although dangerously concentrated), R&D investment, GDP per capita, invention and productivity, manufacturing and finance as competitive growth engines, educational attainment, public safety and livability, and location.

Connecticut may not economically be what it was, but there is no good reason why we cannot be what we want to be now and into the future.

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Kevin B. Sullivan is Commissioner of the state Department of Revenue Services, and previously served as Lieutenant Governor, Senate President Pro Tempore and a member of the State Senate.  This is adapted from remarks delivered in June at the Connecticut Business Summit. 

PERSPECTIVE: Enduring Impact of Risky Driving Can Change Anyone’s Life

by Nikole Doolittle and Sherry Chapman "This upcoming New Year’s Day will mark 14 years since I woke up in the intensive care unit of Hartford Hospital, unable to walk, talk, eat, or even breathe on my own.  I had been in a coma for 28 days, and had sustained a traumatic brain injury.

I can still remember that night like it was yesterday.  I headed out with a group of friends and the newly licensed driver decided to test out his speed.  When we hit what seemed like 100, all of us in the car screamed for the driver to stop or at least slow down, we were so scared.  One of my friends remembers the boys counting the speed up to 127 trying to beat their last record of 125.

I was told the driver had lost control of the car, it hit the guardrails on the right side of the highway and then flipped left rolling across the highway, through the median, landing on the other side.  At some point while the car was rolling I was thrown through the back window.   Once the paramedics showed up, I was unresponsive so they put me on life support right in the median of the highway.  For the next 30 days, I never took another breath on my own."

This is how Nikole Doolittle begins as she shares her heart wrenching experience with students at high schools and, most recently, Windham Middle School, as a part !MPACT's Drive 4 Tomorrow program.

Early in Nikole's recovery, she knew she had to do something to help combat motor vehicle crashes caused by young drivers, the number one killer of teens in America. She met members of !MPACT (an acronym for Mourning Parents Act, Inc.) at a presentation she made at Cromwell High School. Not long afterwards, she began delivering her safe teen driving message with the !MPACT moms at high schools across Connecticut and into greater New England.

All members of !MPACT have been directly affected by tragedy involving teen driving. Everyone has a horrific story. Sadly, Nikole fit right in.

!MPACT's mission is to eliminate tragedies caused by inexperienced drivers through awareness, education and legislation. The group raises awareness with their "Somebody Loves You" billboard initiative. They educate by delivering their heart wrenching Drive 4 Tomorrow presentations, in which members share their personal stories and teach teens how to protect themselves and their friends from becoming statistics. They fight hard for safety legislation to protect teen drivers, their passengers, and those of us who share the roads with them. The group was instrumental in helping to develop and pass into law Connecticut's graduated drivers licensing program, which serves to introduce the novice driver to the driving experience in a gradual manner.

This is how Nikole ends her story:

"I had taken for granted the daily routine of my life, getting up, brushing my teeth, combing my hair, eating, walking, even the simple task of talking.  These were all ordinary events which suddenly disappeared on the night of January 1, 2004. 

A lot has happened since then, one year of hospitals, two years of therapy, three eye surgeries, one stomach surgery, one mouth surgery, and a lifetime of memory problems. It has taken me well over eight years of rehab, therapy, and figuring out who I had become. Despite this, I landed a job with United Technologies, moved over 12 hours away and thrived on my own for five years. I finally returned home to Connecticut to be near family this past September.

When sharing my story, I try to remind these newly licensed drivers, that anything can happen to anybody – and driving is a huge responsibility.  I appear to be like everyone else, but I am not. I try to remind my audience that I could have been.  Once you make a bad decision, there is no turning back."

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Sherry Chapman is Co-founder and President of Mourning Parents Act, Inc.

All of !MPACT's services are offered for free. Members of !MPACT include families, friends, and victims, and all donate their own time and resources to advance the mission of the organization.  If you are interested in having !MPACT present its Drive 4 Tomorrow program at your high school or other forum, please contact Sherry Chapman at 860-209-7070.  !MPACT is a 501(c)(3) nonprofit organization supported by donations, grants, and one annual fundraiser––their annual Tee Off For Teen Driving Safety golf tournament will be held at Blackledge Country Club in Hebron on Monday, June 26.

PERSPECTIVE: Law is the Fabric That Holds Society Together

by Richard A. Robinson Let's face it, regardless of one's political leaning, economic philosophy, or cultural beliefs, we are in the midst of great turmoil. In the face of so much uncertainty, I initially found it somewhat difficult to be both sincere and inspiring.  But as I continued preparing, I realized that I had been looking for inspiration in all of the wrong places.

In our busy lives, we turn to video clips and sound bites for news and let the tenor of these brief snippets shape our outlook. Our mood is at the mercy of headlines, news feeds, and 140 character messages. We are accustomed to looking to our leaders and other public figures for encouragement and inspiration, and when it isn't readily available, we are easily discouraged. So, in times like these, we need to think a little bit more about the sources of our hope, encouragement, and inspiration.

When you think about it, doesn't real inspiration come from the people we live with, the people that we work with, and the people that we interact with on a daily basis? People who work hard and do their best to make the world a better place in their own unique way. People who make a commitment to something worthwhile and important, just as all of you have done.

The bottom line is that the reason we are celebrating today is because you are the future. The direction we will follow as a profession, as a nation, and as a world, is up to you.  Is that a bit scary? It should be! But it should also be exciting and exhilarating. As you graduate and prepare to embark on your career in the law, you hold tremendous power. On this most important day, I'd like for you to think about that power and to truly comprehend its significance.

So what does this mean for you? It means that, as you begin your career in the law, it is essential for you to understand that your obligations as an attorney extend far beyond the interests of your clients. They extend to the justice system, to the legal profession, and to society at large.

William Shakespeare focused on this duality in his play Henry the Sixth. The play includes a scene in which a character named Jack Cade, the leader of a rebellion against the crown, muses about what he would do if he were king. It is then that one of his followers, Dick the Butcher, utters what I believe is the most misunderstood line in all of Shakespeare's writings: "The first thing we do, let’s kill all the lawyers." Cade heartily agrees. i

While many people believe that Shakespeare was expressing society's frustration with the lawyers and the legal profession, others, including myself, believe that he was actually paying us the ultimate compliment by pointing out that lawyers and the rule of law are the only things protecting society from anarchy. If you want to bring down society and render the people powerless, the first thing that you must do is get rid of the rule of law and all those who fight to protect it.

John Curtin, a former president of the American Bar Association once remarked that "[a]nyone who believes a better day dawns when lawyers are eliminated has the burden of explaining who will take their place. Who will protect the poor, the injured, the victims of negligence, the victims of . . . discrimination, and the victims of . . . violence? . . . Lawyers are the simple yet essential means by which people seek to vindicate their rights and we must not foreclose that means." ii

As you prepare to enter the practice of law, I urge you to think about the power that you hold, and strive to balance your obligation to your clients with your duties as an officer of the legal system. Our profession needs individuals who understand that, when a single attorney starts to chip away at the rule of law in order to secure an easy win for their client, it undermines the bedrock of our society. I recognize that, at times, this may not be easy. This is why our profession is in dire need of individuals who are willing to devote their time to working through these issues. Our small steps matter.

What we do every day affects the way that our profession is perceived by the public. The way that we act in the courtroom, the tone of voice that we employ, and whether we choose to treat others with dignity and respect. Our everyday words and deeds express our commitment, or lack thereof, to a fair and effective justice system. The simple decision to conduct ourselves in a manner that fosters respect also builds respect for what we do. When our own actions are added to those of our colleagues, we have an effective force for improvement.

If each of us strives to balance our duties to the public with our commitment to fairness, justice, and the rule of law, it will go a long way to restoring the public's faith in our profession and our legal system as a whole. This is particularly important in times of uncertainty. As you embark on your legal career, I urge you to keep this balance in mind. In doing so, you will serve as a source of inspiration and motivate others to take similar action.

Today you are taking a great step in your journey toward the practice of law and, on this special occasion, we celebrate the success that comes from many years of your hard work, sacrifice, and dedication. You have achieved a major goal by making major sacrifices. However, as others have said, what you get by achieving your goals is not as important as what you become by achieving your goals. The power to practice law brings not only the financial ability to support yourself and your family; it also brings along with it the responsibility to assist others and to help shape the legal profession of the future.

We are a remarkable people, living in a remarkable country, with a remarkable system of laws and justice, yet we are not perfect. As a quinquagenarian, I can remember some very turbulent times, the crescendo of the civil rights movement, the assassination of a United States President, a Presidential candidate, and several national civil rights leaders. I remember what happened at Kent State, and the burning of some of our major cities. These are the type of things that have destroyed other nations. Yet, we did more than survive; we thrived. So what saved us? What was different?

I believe that it was the hard work, dedication and sacrifices of people like you. People that chose paths similar to the ones that brought you here today. People who know that a lawyer assumes not only an obligation to their clients, but also solemn duties as an officer of the legal system and a public citizen having special responsibility for the quality of justice.

The oaths that you will eventually take and various rules, laws and regulations related to the practice of law are all designed to help you reach this lofty goal; you would be wise to heed them. But make no mistake, what I am asking you to do runs much deeper.

The legal profession is a noble one, but it is often greatly misunderstood. Many assume that lawyers are merely troublemakers that bring lawsuits that should not be brought and defend that which should not be defended. In reality, the law is the very fabric that holds our society together and, as lawyers, you bear the responsibility of being its tailors.

Look at any form of mass media today and you will see that we are living in interesting and troubling times. Both present events and those which lie on the horizon will stretch this fabric beyond its tearing point. As lawyers, you bear the tremendous burden of mending any rift that may occur.

Bear this responsibility well. Approach it with civility, reason, respect, compassion, and great purpose. The cold dispassionate procedures and technicalities of the legal profession often makes people think that lawyers are more interested in money, papers, forms, and procedures than they are in the everyday struggles of life.

People go to lawyers because they believe them to be problem solvers that will help them get through life's struggles. It would be a great disservice to let them leave feeling that they were not heard or, even worse, believing that your involvement not only failed to put out the embers of their angst, but fanned the flames that eventually consumed them.

Remember that you are more than just a representative of your clients. You are an officer of the legal system and a public citizen having special responsibility for the quality of justice. Persuade when you can, compromise when you should, and fight when you must.

Your responsibilities as lawyers will be great. You are the tailors of the very fabric of our society. Although you may never receive a hero's welcome for the work that you do, please know that you are our heroes.

I ask that you do more than just follow the rules, oaths, laws, and regulations that I mentioned earlier. I ask you to fully accept your responsibilities as lawyers, and to continue to listen ever so closely for that subtle tearing sound because you are the keepers of the cloth.

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Richard A. Robinson is an Associate Justice of the Connecticut Supreme Court. He graduated with a Bachelor of Arts Degree from the University of Connecticut in 1979 and a Juris Doctor degree from West Virginia University School of Law in 1984. Justice Robinson’s career is complimented by an array of public and judicial service.  This is an excerpt of remarks delivered on May 14 at the Commencement and Doctoral Hooding ceremony of the Quinnipiac University School of Law in the TD Bank Sports Center on the university’s York Hill Campus.

i WILLIAM SHAKESPEARE, THE SECOND PART OF KING HENRY THE SIXTH act 4, sc. 2.

ii THOMAS F. BURKE, LAWYERS, LAWSUITS AND LEGAL RIGHTS 24 (2002).

PERSPECTIVE: On the Job Hunt After Cancer

by Julie Jansen A recent Harris Poll survey conducted on behalf of Cancer and Careers (CancerAndCareers.org) found that 78% of the cancer survivors surveyed were concerned that their cancer diagnosis would hinder their ability to find a new job. For many survivors, job hunting after cancer proves to be a challenging experience. However, you can rest assured that if you are qualified for a job, an employer cannot refuse to hire you simply because you have had cancer.

If you are one of those survivors who is back on the job market after battling cancer, here are some tips to help make your job search a success.

Spiff Up Your Resume

The primary goal of your resume is to describe your experience and achievements in a way that makes a prospective employer want to set up an interview with you to talk about how you can do the same great things for them. A resume is not a job description. So keep lists of tasks and responsibilities short and to the point. Instead, your resume should focus more on your accomplishments and how you were able to make a positive difference to your department or company. A bulleted format works best for this part of your resume.

Another important element of a contemporary resume is a profile or summary, which is a brief paragraph at the top of your resume that summarizes your work experience. Your summary can be used to add a bit of personality to your resume. This is a good place to list the unique qualities that make you the right fit for the job.

Most companies use applicant-tracking software to scan your resume’s keywords before a human reads it. So it’s important to add the right keywords to your resume. Use technical or functional descriptors such as project management, event planning, and website design, rather than clichéd phrases like effective communicator and team player.

Absolutely add volunteer experience to your resume, especially if you have an employment gap because you took time off for treatment or had to leave your job. Include a list of achievements for your volunteer experience, just as you would for your paid jobs.

Finally, despite the persistent myth that a resume should only be one page, if you have worked for two or more years, then a two-page resume is the new rule of thumb.

Prepare for the Interview

Interviewing for a new job is nerve wracking for most people, with or without a cancer history. Preparation is the key to feeling more comfortable and confident during the interview process – and to getting invited back for that second interview.

The most important thing an employer is looking for during the interview process is how you, the job candidate, can solve their problems and meet their needs. Research the company as much as you can so that you can incorporate your knowledge of the company into the interview. This will also help you to ask smart, thoughtful questions about the job you’re applying for.

Prepare answers to the standard questions that are often asked during an interview, for example:

• Tell me about yourself.
• What are your strengths and weaknesses?
• Describe a time when you failed.

When answering, tell stories about your achievements and use concrete examples – but keep your answers brief and meaningful. Stay composed, and don’t let an interviewer’s quirky questions rattle you. Unless a question or request is discriminatory, just go with the flow.

Speaking of discrimination, you are not obligated to share the fact that you had cancer. And a prospective employer legally cannot ask you this question. However, in case a question about your health history does come up, you should decide in advance what your response will be. It is also a good idea to come up with a brief answer to questions about gaps in your work history.

If you are asked an uncomfortable question, try not to ramble. Instead, turn the conversation back to how you can make a positive difference for your potential employer.

The thought of looking for employment after cancer can be a frightening one. However, the good news is that many companies are hiring, and now that you are armed with these job- hunting tips, you’re more prepared than ever to land that job you’re after.

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Julie Jansen is a career coach, resume and LinkedIn profile writer, and the author of I Don’t Know What I Want, But I Know It’s Not This: A Step-By-Step Guide to Finding Gratifying Work. She is a graduate of the University of Hartford.  This article first appeared in Coping magazine.  Her website is JulieJansen.net.

PERSPECTIVE: 10 Reasons Your Performance Appraisal Might Be Useless

by Karen Hinds Are your performance appraisals useless? If you are a manager, end of year can often make you feel like a Christmas Grinch. You feel rushed, stressed, and even dread as you try to summarize an entire year of highs and lows on an employee’s performance appraisal. Invariably, someone will feel like they received a lump of coal after reading what they hoped would be a good review.

For employees, it’s a source of anxiety and even anger as they anticipate the results of their performance appraisals. Why do we tolerate this annual drain on productivity and morale? There are simple fixes, if done throughout the year, to make this process relevant and valuable to an employee’s growth. Here are 10 reasons why your current process might be of little or no value.

1. Emphasis is on the mistakes and the past.

Unfortunately, there are managers who view the appraisal process as an opportunity to only recap everything an employee has gotten wrong throughout the year. This is incredibly demotivating and hampers morale as well as trust in that relationship. Focusing on the past leaves no room for forward thinking and growth, which is the intent of an appraisal.

2. Appraisal is full of surprises.

An employee should not be surprised by what is written on their appraisal if the manager has done a great job communicating throughout the year. If surprises exist, it is an indication the manager/employee relationship is damaged and ineffective. Errors are inevitable, but the manager should immediately identify the error and help to design a plan of action that helps the employee correct the mistake and keep growing. When an employee does well, it also should be immediately acknowledged, documented, and celebrated.

3. No regular check-in.

Many performance appraisals only see the light of day when it’s time to write a new one for the upcoming year. If this is how your team operates, it is a complete waste of time. The appraisal should be a living, breathing document used as a roadmap throughout the year. Monthly and quarterly reviews with adjustments will increase the probability of the employee meeting and even exceeding the expectations set.

4. One-way conversations.

If an employee is simply sitting and listening to the manager during a performance appraisal or given a report to read, it is a sure sign the process is deeply flawed. This should be a two-way conversation where the employee and manager are both engaged. The manager and employee should be reviewing progress, examining the best way going forward, celebrating milestones, and setting new goals together.  As mentioned earlier, it’s an ongoing conversation, not an end-of-year marathon to talk and fill out paperwork.

5. No preparation for advancement.

An effective manager should know their primary job is to provide the environment where each employee can reach their peak performance and then move on, whether a vertical or lateral move.  Even when the organization is flat, advancement can still be made by varying projects and learning new roles and skills sets.

6. Setting goals that are not S.M.A.R.T.

Effective evaluation of an employee’s progress depends on the quality of the goals set. All goals must be measurable and adhere to the S.M.A.R.T standards of being Specific, Measurable, Attainable, Realistic, and Time-specific.

7. Manager’s unconscious bias.

Managers are not perfect and even the best-intentioned manager has unconscious bias. The bias could be based on an employee’s personal style, preferences, gender, age, accomplishments, race, ethnicity, etc. It’s also not unusual for managers to carry a chip on their shoulder caused by an incident going back months. When these behaviors are present, a successful appraisal is impossible.

8. Avoiding negative feedback.

Some managers cower at the thought of having to deliver negative feedback, especially to employees who may have a reputation of being difficult. They might tiptoe around the real issues and deliver a weak appraisal with no value by only highlighting what worked well.

9. Confusing performance and attitude.

Some employees are great talkers, enthusiastic, and friendly around the office but are poor performers. There are also employees who are exceptional performers but lack the social skills or choose not to be overly enthusiastic because that’s their personality style. They may also consciously choose to be less engaged socially due to the work environment. Managers need to be clear on what they are measuring: Is it performance or attitude?

10. Manager was never trained.

No one was born with excellent managerial skills, and even if you have managed people for many years, it is not an indication you are a competent manager or you know how to execute an effective performance evaluation. Companies should hold educational sessions to teach managers how to review an employee’s performance in a fair manner and set them up for future success.

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Karen Hinds is president and CEO of Workplace Success Group, a Connecticut-based strategic talent development company. She has delivered talks about how to properly develop emerging leaders to companies, associations and organizations throughout the Greater Hartford region. She has presented “Bounce-Back Power: Everyday Strategies to Develop Resilience” as part of the University of Hartford’s Entrepreneurial Center professional development series. 

PERSPECTIVE: Lawsuits, Libel Laws and the Imperative to Protect Journalists

by Michelle Xiong On August 4, 1735, a lawyer stood in a crowded New York courthouse and proclaimed, “The question before you, gentlemen of the jury, is not of small or private concern. It is not the cause of one poor printer … It is the cause of liberty … the liberty both of exposing and opposing arbitrary power by speaking and writing the truth.” (Williams).

The man was Andrew Hamilton and he was defending John Peter Zenger from charges of seditious libel against the royal governor (Williams). The case would become a milestone in the development of the freedom of the press in America when the jury strayed from English common law and acquitted Zenger (Williams).

Over 200 years after the famous Zenger trial, Donald Trump’s campaign promise to “open up” libel laws is a selfish idea that would only open the doors again to the abuse of power. The press occupies a critical role in a democratic society. Current libel laws and interpretations of the First Amendment are designed to ensure government institutions and public officials can be held accountable.

Libel laws in the United States provide significant protection for the press because of the First Amendment. Distinct from European practices, “truth is an absolute defense against defamation” in the United States (“Substantial Truth”). This was formally enacted through legislation at the state and federal level after judges deadlocked over the issue in People v. Croswell (McGrath).

New York Times v. Sullivan was the landmark case that made it especially difficult for public officials to sue for damages (“New York Times Co. v. Sullivan”). The Supreme Court’s ruling established the need for actual malice which means the defendant published material with the “knowledge that it was false or with reckless disregard of whether it was false or not,” (“New York Times Co. v. Sullivan”).

While this standard may seem unfair to public officials, the high burden of proof required is fundamental to preventing the abuse of governmental power. Without strict libel laws, public officials can use lawsuits to suppress content that is critical of their behavior. Such was the case during the Civil Rights movement when southern state officials attacked news organizations that published unfavorable reports by bringing almost $300 million in libel actions against them (Schmitt).

What Donald Trump considers a ¨hit piece” may just be investigative reporting that dispute his actions and policies. Trump has a history of filing libel suits with 4,000 lawsuits over the last 30 years (Seager). Opening libel laws will allow Trump and other public officials the dangerous opportunity to intimidate political opposition and reduce government transparency.

Fortunately, Donald Trump’s threat to “open up” libel laws is easier said than done. Because libel laws are determined by individual states, Trump as president does not have the authority to alter libel laws directly (Ember). Trump would need to impose new limits on the First Amendment through an overturn of New York Times v. Sullivan by the Supreme Court or an amendment of the Constitution. According to Sandra S. Baron, former executive director of the Media Law Resource Center, both processes would be difficult and unlikely to happen successfully (Ember).

In the modern era of the Internet, the way people communicate and receive news is changing rapidly. However, concerns over “fake news” online should not detract from the fact that legitimate journalism must remain protected. To ensure that the government remains answerable to the people, prevailing libel laws should be preserved.

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Michelle Xiong is in her junior year at Greenwich High School.  This essay was written for the Connecticut Foundation for Open Government annual essay contest for high school students, were it was selected to receive First Place recognition.

Ember, Sydney. “Can Libel Laws Be Changed Under Trump?” The New York Times, 13 Nov. 2016, www.nytimes.com/2016/11/14/business/media/can-libel-laws-be-changed-under-trump.html. Accessed 31 Mar. 2017.

McGrath, Paul. “People v. Croswell Andrew Hamilton and the Transformation of the Common Law of Libel.” The Historical Society of the New York Courts, 2011, www.nycourts.gov/history/programs-events/images/Judicial-Notice-07.pdf#page=6. Accessed 31 Mar. 2017.

“New York Times Co. v. Sullivan.” Cornell University Law School, Legal Information Institute, www.law.cornell.edu/supremecourt/text/376/254. Accessed 31 Mar. 2017.

Schmitt, Rick. “Window to the Past: New York Times Co. v. Sullivan.” District of Columbia Bar, Oct. 2014, www.dcbar.org/bar-resources/publications/washington-lawyer/articles/october-2014-nyt-sullivan.cfm. Accessed 31 Mar. 2017.

Seager, Susan E. “Donald J. Trump Is a Libel Bully But Also a Libel Loser.” Media Law Resource Center, www.medialaw.org/index.php?option=com_k2&view=item&id=3470. Accessed 31 Mar. 2017.

“Substantial Truth.” Digital Media Law Project, Berkman Center for Internet and Society, www.dmlp.org/legal-guide/substantial-truth. Accessed 31 Mar. 2017.

Williams, James A. “The Trial of John Peter Zenger in 1735.” Founders and Patriots of America, 1993, www.founderspatriots.org/articles/trial_zenger.php. Accessed 31 Mar. 2017.

New Ventures Impress, Receive Funds to Advance Entrepreneurial Efforts

reSET, the Social Enterprise Trust (www.reSETCo.org), whose mission is advancing the social enterprise sector and supporting entrepreneurs of all stripes, revealed the winners of its 2017 Venture Showcase last night at The Mark Twain House and Museum to a sellout crowd of 200. The annual event recognizes the talented entrepreneurs and innovative businesses that have just graduated from reSET’s nationally recognized accelerator. 17 early stage enterprises graduated from the recent cohort, and last night, seven finalists competed for $30,000 in unrestricted funding.

The entrepreneurs pitched their business models to an audience of founders, investors, and community and corporate stakeholders. An esteemed panel of judges, including Tony Vengrove of Miles Finch Innovation, Michael Nicastro of Continuity, and Lalitha Shivaswamy of Helios Management Corporation, selected the ultimate winners.

Recipients of the competition’s three “reSET Impact Awards” are listed below, as is the winner of the “Tech Impact Award,” which was given by reSET’s Founding Partner and the evening’s Presenting Platinum Sponsor The Walker Group.

reSET Impact Awards:

$10,000 - Career Path  http://www.careerpathmobile.com

$6,000- Pelletric  http://www.pelletric.com

$4,000 - Phood  http://phoodsolutions.com

The Walker Group’s Tech Impact Award:

$10,000 - Phood http://phoodsolutions.com

Other finalists included:  Almasuite http://www.almasuite.com, Eureeka BI http://www.eureekabi.com, Optima Sports System http://optimasports.es,

and Sweetflexx http://sweetflexx.com/en.

The Showcase’s prize purse was made possible by a handful of reSET’s community partners: The Walker Group (Presenting Platinum Sponsor), The Hartford (Platinum Sponsor), Eversource (Gold Sponsor), AT&T (Gold Sponsor), Accounting Resources, Inc. (Silver Sponsor), Qualidigm (Silver Sponsor), CT by the Numbers (Silver Sponsor), and Aeton Law Partners (Silver Sponsor). The David Alan Hospitality Group and Capture provided in-kind services.

CareerPath is a platform that enables career planning teams to "effectively connect and communicate with students." Using a series of milestones, tasks, and events as drivers, CareerPath allows students to "tackle their career planning objectives in an organized and manageable way."

reSET also receives generous support from its Strategic Partners: The Walker Group, Connecticut Innovations, MetroHartford Alliance, and the Connecticut Department of Economic and Community Development.  reSET, the Social Enterprise Trust is a non-profit organization whose mission is to advance the social enterprise sector. Its strategic goals are threefold: to be the “go-to” place for impact entrepreneurs, to make Hartford the Impact City, and Connecticut the social enterprise state.  Since its inception, reSET has awarded more than a quarter of a million dollars to scaling ventures. Graduates of the organization’s accelerator have generated $4.4 million in revenue and have taken on $5.5 million in investment.

https://youtu.be/EAC6W3Dn_k8

PERSPECTIVE: Recycled Rubber Playing Surfaces Should be Prohibited Until Proven Safe

by Robert Wright and Sarah Evans Given the hazards associated with recycled tire rubber, these products should never be used as surfaces where children play.  We should all be concerned that there are significant gaps in the evidence supporting the safety of recycled rubber turf products. We raise concerns as pediatricians, epidemiologists, and laboratory scientists at the Children’s Environmental Health Center of the Icahn School of Medicine at Mount Sinai, which hosts one of 10 nationally funded Pediatric Environmental Health Specialty Units.

Children are uniquely vulnerable to harmful exposures from recycled rubber surfaces.  Public playgrounds are typically utilized by children age 6 months to 12 years, a population exquisitely vulnerable to the health effects of toxic environmental exposures. This vulnerability is due to a number of factors including, but not limited to, their unique physiology and behaviors, rapidly developing organ systems, and immature detoxification mechanisms[1]. Additionally, because of their young age, children have more future years of life and therefore more time to develop chronic diseases.

Concerns about the safety of recycled rubber playing surfaces have been raised by the federal government, based on the lack of comprehensive studies.

On February 12, 2016, the United States Environmental Protection Agency (USEPA) announced the launch of an investigation into the safety of crumb rubber in partnership with the Centers for Disease Control and Prevention and the Consumer Product Safety Commission, stating “existing studies do not comprehensively evaluate the concerns about health risks from exposure to tire crumb”[2].  

In December of 2016, USEPA published a status report describing the activities to date related to this investigation[3]. Although research findings are not yet available, the report describes the completed review of the scientific literature related to recycled rubber playing surfaces, noting that data gaps were more pronounced for playground surfaces than for athletic fields. Of 88 reviewed studies, only 8 were related to playground surfaces.

According to the report, the limited scientific literature concludes that “additional studies are needed to support the safety of recycled tire rubber in playground surfaces”.  Importantly, no studies have addressed children’s exposure to chemicals from recycled rubber playground surfaces via oral, inhalational, and dermal routes. To address identified gaps, CPSC plans to conduct field observation studies, focus groups, a national survey of caregivers, and exposure modeling based on recycled rubber composition and bioavailability data currently being collected by USEPA and ATSDR.

Until the findings of these studies are available and conclusively demonstrate the safety of recycled rubber playground surfaces, we recommend a ban on the use of these materials where children play. We have identified several potential dangers that playing on recycled rubber playing surfaces pose to children, including:

1. Extreme heat. On hot summer days, temperatures of over 160 degrees Fahrenheit have been recorded on recycled rubber play surfaces[4]. Vigorous play in these conditions conveys a very real risk of burns, dehydration, heat stress, or heat stroke. Children are less able to regulate their body temperature than adults, making them particularly susceptible to conditions of extreme heat[5]. In addition, children have a higher surface area to body mass ratio, produce more body heat per unit mass, and sweat less than adults, all factors that increase susceptibility to heat injury[6].
2. Inhalation and ingestion of toxic and carcinogenic chemicals. Children are particularly vulnerable to chemical exposures from playground surfaces due to their developmentally appropriate hand to mouth behaviors. In addition, their close proximity to the ground and higher respiratory rates compared with adults increase the likelihood of inhalational exposures.  Thus, there is a potential for toxins to be inhaled, absorbed through the skin and even swallowed by children who play on recycled rubber surfaces.  The major chemical components of recycled rubber are styrene and butadiene, the principal ingredients of the synthetic rubber used for tires in the United States[7]. Styrene is neurotoxic and reasonably anticipated to be a human carcinogen[8].  Butadiene is a proven human carcinogen that has been shown to cause leukemia and lymphoma[9].  Shredded and crumb rubber also contain lead, cadmium, and other metals known to damage the developing nervous system[10]^,[11]. Some of these metals are included in tires during manufacture, and others picked up by tires as they roll down the nation’s streets and highways. It is important to note that risk of harm due to exposures from recycled rubber turf has been assessed only for single chemicals, yet children are exposed to numerous harmful chemicals in aggregate during play on these surfaces.

3. Transportation home of rubber pellets. Recycled rubber materials used in play surfaces break down into smaller pieces over time that may be picked up on children’s shoes, clothing and skin. The rubber is then tracked into children’s homes and cars, and carried into the places where children live, play, eat and sleep. Thus exposure can continue for many hours beyond the time that a child spends in the play area.
4. Escape of chemical hazards from rubber surfaces to the environment. A number of the toxic and chemical components of the recycled rubber that is installed on playgrounds are soluble in water. When rain and snow fall on synthetic fields, these materials can leach from the surface to contaminate ground water and soil[12]. In addition, chemicals in turf can be released into the air and inhaled, particularly on hot days.

Safe alternatives to recycled rubber playground surfaces exist.  Daily outdoor play and physical activity are essential components of a healthy childhood.  Thus safe play areas are critical to any school environment.  Our priority should be ensuring that the health risks do not outweigh the rewards.

__________________________________

Robert Wright, MD, MPH is Director, and Sarah Evans, PhD, MPH, is a faculty member of the Children’s Environmental Health Center, Icahn School of Medicine at Mount Sinai, in New York City.  This article is based on testimony provided to the Connecticut General Assembly’s Committee on Children during the current legislative session regarding HB 6998, An Act Concerning the Use of Recycled Tire Rubber at Municipal and Public School Playgrounds. Artificial Turf: A Health-­Based Consumer Guide was published this month. 

[1] Bearer, CF. Neurotoxicology 21:925-934, 2000.

[2] http://www.epa.gov/sites/production/files/2016-02/documents/us_federal_research_action_plan_tirecrumb_final_0.pdf

[3] https://www.epa.gov/chemical-research/december-2016-status-report-federal-research-action-plan-recycled-tire-crumb

[4] Devitt, D.A., M.H. Young, M. Baghzouz, and B.M. Bird. 2007. Surface temperature, heat loading and spectral reflectance of artificial turfgrass. Journal of Turfgrass and Sports Surface Science 83:68-82

[5] https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/Extreme-Temperatures-Heat-and-Cold.aspx

[6] Falk B, Dotan R. Appl Physiol Nutr Metab. 2008 Apr;33(2):420-7. doi: 10.1139/H07-185.

[7] Denly et al A Review of the Potential Health and Safety Risks from Synthetic Turf Fields Containing Crumb Rubber Infill. May 2008.  http://www.nyc.gov/html/doh/downloads/pdf/eode/turf_report_05-08.pdf

[8] ATSDR Toxicological Profile for Styrene, November 2010. http://www.atsdr.cdc.gov/toxprofiles/tp53.pdf.

[9] International Agency for Research on Cancer, 2008. http://monographs.iarc.fr/ENG/Monographs/vol100F/mono100F-26.pdf

[10] Timothy Ciesielski et al. Cadmium Exposure and Neurodevelopmental Outcomes in U.S. Children. Environ Health Perspect. 2012 May; 120(5): 758–763.  27. doi: 10.1289/ehp.1104152

[11] CDC (2012) Low Level Lead Exposure Harms Children: A Renewed Call for Primary Prevention. http://www.cdc.gov/nceh/lead/acclpp/final_document_010412.pdf

[12] Connecticut Department of Environmental Protection (2010) Artificial Turf Study: Leachate and Stormwater Characteristics. http://www.ct.gov/deep/lib/deep/artificialturf/dep_artificial_turf_report.pdf

PERSPECTIVE: Keeping Up the Clean Energy Momentum in Connecticut

by Claire Coleman Despite President Trump’s best efforts to return to dirty, outdated fuels, clean energy is spreading like a wildfire across the country – in red and blue states alike. From California to Iowa, and Minnesota to Massachusetts, states are building affordable, local wind and solar power because they know the long-term benefits will free them from outdated fuels that pollute our air and water and change our climate.

Connecticut has historically been a leader on clean energy for the same reasons, and as a coastal state, knows the impacts of climate change: intense storms, serious drought, and unusual weather patterns. But despite the rising tides, recently our efforts to combat climate change are lagging behind many of our neighboring states. For example, Connecticut is largely absent from a recently published report by Union of Concerned Scientists, ranking states for leadership on “clean energy momentum,” and was not ranked among the top 15 states.

So what can Connecticut do to keep up clean energy momentum?

A first critical step is to make Connecticut accountable for the commitment the state made to reduce carbon pollution when it passed the Global Warming Solutions Act in 2008. Despite the robust, science-based targets to reduce greenhouse gas (GHG) emissions by 10 percent below 1990 emissions by 2020, and by 80 percent below 2001 emissions by 2050, Connecticut’s  GHG emissions are rising rather than declining. We need to change course and ensure Connecticut stays on track by adding interim targets. Connecticut Fund for the Environment supports a 55 percent reduction by 2030 and 75 percent reduction by 2040. Additionally, state agencies should be required to take climate change impacts into consideration when making planning and policy decisions. These new targets will hold our government accountable to stop further damage to the climate and create healthy and safe communities.

A second crucial step is to strengthen standards that require cleaner energy in the electric sector. Connecticut’s Renewable Portfolio Standard (RPS) requires electric suppliers to obtain 20 percent of their energy from renewables like wind and solar by 2020. But Connecticut can realize greater returns by establishing longer-term targets. Other states in the region have put more aggressive standards in place: New York has a mandate of achieving 50 percent renewable generation by 2030; Rhode Island’s mandate is 38.5 percent by 2035; and Maine’s is 40 percent by 2017. Extending and strengthening our Renewable Portfolio Standard as our neighbors have done will make the air we breathe safer and drive investment in solar and wind development in Connecticut.

Ramping up local clean energy efforts will also create high-wage work in Connecticut—rather than buying our clean energy from neighboring states and Canada, fueling their economy instead of our own. Establishing a full-scale shared solar program, like so many other states already benefit from, would promote equal access to clean energy and spur local, private investment. Likewise, developing off-shore wind resources would create jobs at our ports and generate low-cost, reliable wind power for Connecticut residents.

This legislative session, the Connecticut legislature can put us back on the map of clean energy leaders. They can take action to create stronger standards that will halt further damage to our climate and reduce unhealthy air pollution. Connecticut’s residents deserve robust metrics to hold our government accountable, to prevent climate damage, and to ensure Connecticut is prepared to take advantage of clean energy innovations that will bring jobs to the state.

Delays in renewing our commitment to clean energy will harm our families, our children, and future generations. The time is now to go all-in on a solid clean energy future for Connecticut.

_______________________________

Connecticut Fund for the Environment climate and energy attorney Claire Coleman previously served as Counsel for the U.S. House of Representatives Oversight and Government Reform Committee, where she worked on issues including energy policy and regulation, and in private practice.  

Connecticut Fund for the Environment and its bi-state program Save the Sound protect the land, air, and water of Connecticut and Long Island Sound. CFE uses legal and scientific expertise to benefit our environment for current and future generations, and in 2008 helped lead a grassroots coalition to pass the groundbreaking Global Warming Solutions Act.