Pre-clinical block-based medical school curriculum
The pre-clinical, block-based, medical school curriculum is designed to increase integration of normal human biology with disease processes and clinical skills from the first week of medical school onward. Basic science is taught in the context of its application with planned reiteration. Instruction is coordinated throughout sequentially taught blocks.
Overview of Legacy Curriculum
The clinical, medical school curriculum, begins with a two-week course, Transition to Clerkships (Clinical Foundations), focused on the basics of clinical care, including a review of the physical examination, BCLS, basic radiology, write-ups and presentations, with an emphasis on learning environment, professionalism and ethical standards.
Transition to Clerkships is followed by 48 weeks of core clerkships, each of which includes an orientation period to prepare medical school students with the clinical skills needed in the specific rotation. Medical students join one of five academic colleges during the latter part of their third year based on career interest or enrollment in special programs. Students work closely with their College faculty members in the third and fourth year of training.
Legacy Curriculum: Year by Year
Human Biology and Disease
The block-based medical school curriculum for years one and two have been designed to increase integration of normal human biology with disease processes and clinical skills from the first week of medical school onward. Basic science is taught in the context of its application with planned reiteration. Instruction is coordinated throughout sequentially taught blocks.
Characteristics of Human Biology and Disease
- Instruction is driven by cases explored via problem-based learning, laboratories, conferences, clinical skills workshops, and independent study accompanied by approximately 10 hours of lecture a week.
- Contact time is limited to 24 hours a week to allow time for independent study and electives.
- All but one of the thematic blocks are taught in two "passes". There is planned redundancy as well as progressive depth and expectations of competency. Most blocks are 9 weeks in length.
- Curricular Threads are woven into the fabric of each block and include:
- Anatomy, Histopathology, and Embryology
- Chair: Elena Stark, MD, PhD, Pathology
- Chair: Esteban Dell'Angelica, PhD, Human Genetics
- Clinical Reasoning
- Chair: David Schriger, MD, Medicine/Emergency Medicine
- Year 1 Chair: Rachel Brook, MD, Medicine
- Year 1 Associate Chair: Grace Deukmedjian, MD, Medicine
- Year 2 Chair: Arthur Gomez, MD, Medicine
- Clinical Skills
- Year 1 Co-Chairs:
- Magdalena Ptaszny, MD, Medicine
- Tyler Larsen, MD, Medicine
- Michael Lazarus, MD, Medicine
- Year 2 Chair: Robert Oye, MD, Medicine
- Year 1 Co-Chairs:
- Genetics and Genomics
- Chair: Sulagna Saitta, MD
- Chair: Gary Holland, MD, Medicine
- Chair: William Melega, PhD, Molecular & Medical Pharmacology
- Year 2 Chair: Robert Oye, MD, Medicine
- Special issues are addressed across the medical school curriculum in all four years
- Cancer prevention and survivorship
- Complementary and alternative medicine
- Cultural components of health and disease
- Gender-specific health
- Progress through this curriculum is evaluated with computer based exams and clinical performance exams at the end of each block. Weekly self-assessment quizzes during each block allow students to track their understanding and adjust study practices or emphasis as indicated.
- Anatomy, Histopathology, and Embryology
Block 1: HB&D 401 Foundations of Medicine I (9 Weeks)
Pathologic processes, genetics, molecular and cellular biology, basic immunology, and critical appraisal.
- Chandra Smart, MD, Pathology
- Bernard Ribalet, PhD, Physiology
Block 2: Cardiovascular, Renal, and Respiratory Medicine I (10 weeks)
Anatomy, histopathology, physiology, biochemistry, genetics, imaging, and selected pathophysiologic mechanisms plus clinical assessment of these systems.
- Christopher Cooper, MD, Medicine/Pulmonology
- Holly Middlekauff, MD, Medicine/Cardiology
Block 3: Gastrointestinal, Endocrine, and Reproductive Medicine I (9 weeks)
Anatomy, histopathology, biochemistry, nutrition, genetics, and selected pathophysiologic mechanisms, coupled with clinical assessment of these systems.
- Rashmi Mullur, MD, VAGLAHS Endocrinology
- Esteban Dell'Angelica, PhD, Human Genetics
Block 4: Musculoskeletal Medicine (6 weeks)
Anatomy, imaging, histopathology, pathophysiology and pharmacology related to this system with a focus on rheumatology and physical medicine.
- Quynh Pham, MD, Physical Medicine and Rehabilitation
- Madhuri Wadehra, PhD, Pathology and Laboratory Medicine
Block 5: Medical Neurosciences I (6 weeks)
Neuroanatomy, histopathology, neurobiology, neurology, imaging, pharmacology, pathophysiology, and clinical assessment of the neurological systems
- Carolyn Houser, PhD, Neurobiology
- Chris DeGiorgio, MD, Neurology
Year 2 Courses
Block 6: Foundations of Medicine II (9 weeks)
Basic pharmacology; microbes, host defense, and immunity; immune disorders; clinical trials & epidemiology; infectious diseases, including classification of pathogens & therapeutics; cancer, including classification, causes & therapeutics of other blood disorders.
- Omai Garner, PhD, Pathology
- Tara Vijayan, MD, Medicine/Infectious Diseases
Block 7: Medical Neurosciences II (6 weeks)
Neuroanatomy, neurobiology, psychopathology, neurology, and psycho pharmacology.
Chair: Misty C. Richards, MD, Psychiatry
Block 8: Gastrointestinal, Endocrine, & Reproductive Medicine II (8 weeks)
Endocrinology; reproductive health & disease; breast; GI diseases; gender-specific diseases; skin diseases; common infectious diseases; therapeutics; and prevention, including nutrition.
- Jane Weinreb, MD, Medicine/Endocrinology
- Catia Sternini, MD, Medicine/ Digestive Disease/ Gastroenterology
Block 9: Cardiovascular, Renal & Respiratory Medicine II (8 weeks)
Pathology & pathophysiology of these systems; including hypertension, developmental disorders; therapeutics - pharmaceuticals and other treatments; clinical trials & epidemiology; prevention; common infectious agents.
- Jason Napolitano, MD, Medicine/General Internal Medicine
- Michael Sopher, MD, Anesthesiology
Core Clinical Clerkships
Grading is a 4-tier system: Honors- High Pass- Pass- Fail in the clinical medical school curriculum effective with students who matriculated in Fall 2014.
Transition to Clerkships
The third year begins with a two-week foundations course, Transition to Clerkships (formerly known as Clinical Foundations), is designed to provide students the key elements for success in the clinical clerkships. Course lectures, simulation, and skill building help students bridge previous knowledge and skills with new concepts, practices, expectations, and attitudes that they will encounter on their upcoming clinical rotations.
- Areti Tillou, MD
- Antonio Pessegueiro, MD
Core Clinical Clerkships
Transition to Clerkships is followed by 48 weeks of core clerkships, each of which includes an orientation period to prepare students with the clinical skills needed in the specific rotation. Click on the Clerkship to learn more about their sites, leadership, and their educational course objectives.
Clerkship sites, leadership, and educational course objectives.
- Ambulatory Internal Medicine Clerkship
- Emergency Medicine
- Family Medicine
- Inpatient Internal Medicine
- Obstetrics and Gynecology
Three longitudinal courses continue throughout the year:
Longitudinal Preceptorship - Students spend two afternoons a month with a community-based outpatient preceptor to improve skills in clinical assessment and explore possible career choices.
Chair: Tahlia Spector, MD
Longitudinal Radiology - Core topics in radiology are included in the didactic sessions for each of the clerkships and include an emphasis on the use of imaging as diagnostic and treatment modalities.
Chair: Theodore R. Hall, MD
Systems Based Health Care (SBHC) - Small groups of students meet twice a month to develop an understanding of the dimensions of the health care system and implications for patient care, access to care, and interprofessional collaborative practice.
Chair: Margaret Stuber, MD
If needed, please use the policies and procedures outlined in this document to request an alternative site/team:
Clinical Performance Examination (CPX)
Phase II ends with a required Clinical Performance Examination (CPX). All students are required to complete and pass the examination which consists of eight clinical cases which are decided on by the California Consortium for the Assessment of Clinical Competence, CCACC.
Each case is portrayed by standardized patients and requires a focused work up and is followed by a written exercise. Individual feedback is provided for purposes of improving history taking, physical examination, information sharing, and patient/doctor relationship skills.
- Estebes Hernandez, MD
- Daniel Kahn, MD
4th Year Colleges
Faculty members and students interested in common career activities are grouped into academic colleges based on differing approaches to clinical reasoning and diagnostic approaches.
Students must successfully complete Phase II Curriculum before proceeding to Phase III.
Faculty members and students interested in common career activities are grouped into academic colleges based on differing approaches to clinical reasoning and diagnostic approaches. Medical students select one of five colleges during the latter part of their third year based on career interest or enrollment in special programs. The colleges are designed to:
- strengthen career advising
- improve the quality and selection of electives
- provide a means of honing clinical skills
- stimulate discussion of new findings in the basic, social, and clinical sciences relevant to the future practice of medicine
College activities include an introductory course focused on advanced clinical skills and decision making, a monthly series of evening seminars, a longitudinal academic activity that can be either teaching or scholarship, and regular advisory meetings.
Acute Care College
The mission of the Acute Care College is to provide mentorship, foster time-based decision-making, broaden the clinical correlation of Physiology, Anatomy and Pharmacology to Acute Care, and probe ethical and psychosocial aspects of crisis management.
The medical school curriculum consists of the week-long Foundations Course at the beginning of the senior year and a series of monthly meetings that address:
- didactic sessions focusing on acute management
- career preparation seminars
- physician well-being and life strategies after medical school.
Typical careers represented by the Acute Care College:
- Emergency Medicine
- Adult Critical Care (Cardiology, Pulmonary Medicine and Hospitalist)
- Pediatric Critical Care (Cardiology and Neonatology).
Co-Chairs: Ed Ha, MD and Tomer Begaz, MD
Vice Chairs: Jaime Jordan, MD, Alexandra Glaeser, MD and Jennifer Nguyen-Lee, MD
Applied Anatomy College
The mission of the Applied Anatomy College is to develop the knowledge and skills to support a career choice in those specialties in which expertise in anatomy is critical. The typical careers in the College of Applied Anatomy are Surgery and the Surgical Subspecialties (i.e. General, Gynecology, Head & Neck, Neurosurgery, Oncology, Ophthalmology, Orthopaedics, Plastics, Thoracic, Urology and Vascular); Radiology, Radiation Oncology, and Pathology. The unifying theme is anatomical implications in medical practice. The faculty and students of the College of Applied Anatomy are committed to the development of knowledge and skills that will support the choice of a career in those specialties in which expertise in anatomy is critical to competency. Through organized activities, including personal advising and counseling, the college will create a meaningful adjunctive program for the medical school for its fourth-year students.
Co-Chairs: Formosa Chen, MD and Christian de Virgilio, MD
Vice Chairs: Devon Jeffcoat, MD and Aparna Sridhar, MD
Academic Medicine College
The mission of the Academic Medicine College is to develop an individualized educational pathway for those students who are considering a career in subspecialty Internal Medicine, Pediatrics, or Pathology; or for students who have remained actively engaged in research, enjoyed their STTP summer research project but have not had a chance to continue, or who are considering some type of academic career involving research and teaching. Members of this college include all specialties, including surgical specialties, with a focus on academics.
Co-Chairs: Rachel Brook, MD and Marmar Vaseghi, MD
Vice Chair: John Lee, MD
Primary Care College
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. The Primary Care College’s mission is to train students to continue to attain the knowledge, skills, and attitudes to become excellent generalists who are committed to upholding the highest ethical and professional standards of medicine including an emphasis on patient-centered care; wellness, and preventive care; the provision of timely and high-quality medical care; delivering cost-effective health care; promoting health education; delivery of innovative healthcare; and striving for high levels of patient satisfaction. Members of the Primary Care College include, but are not limited to, those with interests in General Internal Medicine, General Pediatrics, Family Medicine, Obstetrics/Gynecology, and Psychiatry. As a part of the College, the faculty provide intensive mentoring for students applying for their residency positions, opportunities in the community and service-learning activities, exposure to public health and public policy, and mentoring on research and other scholarly projects during the fourth year to prepare for Senior Scholarship Day.
Chair: Allison Diamant, MD
Vice Chairs: Rebecca Dudovitz, MD and Daniel T. Lee, MD
Drew Urban Underserved College
Students enrolled in the Drew/UCLA Medical Education Program have selected the Urban/Underserved College at the Charles Drew University of Medicine and Science for their fourth year. The Urban/Underserved College is committed to providing excellent didactic and practical training, and career counseling for individuals interested in serving urban, underserved populations. Students enrolled in the College also complete a longitudinal research thesis project. While the overall theme of the thesis project is to eliminate health care disparities, students have wide latitude to choose research projects and mentors across a spectrum of specialties with application to underserved communities. The fourth-year medical students present their research thesis results at the Annual Medical Student Research Colloquium. The Chair of the Urban/Underserved College is charged with planning scholarly and mentorship activities and career counseling. College activities include clinical skills workshops, mentorship support program, dinner seminars, and community service.
Chair: Cesar Barba, MD
College Evening Seminars
The colleges will be holding a series of evening seminars addressing multiple topics throughout the senior year. They will focus on a number of subjects, ranging from preparation for the residency application process, to the development of advanced clinical skills to the discussion of issues related, to career development and health policy, to name just a few. All senior students must attend 6 total evening seminars throughout the year. This is a graduation requirement and students will be asked to document the evening seminars that they attended.
Individual College Requirements
In addition to the aforementioned requirements, each college has specific requirements as well. These are covered during the Intro to Colleges mandatory class meeting in the third-year.
All senior students are required to submit an abstract and present a poster based on individual scholarly work for Senior Scholarship Day (point to new Senior Scholarship Day page). This may be ongoing work that the student has done or a new project. In addition to traditional clinical and basic science research, scholarly work can include quality improvement or medical education projects, case reports, or other scholarly work done with a faculty mentor. Any questions regarding the selection of an appropriate scholarly project can be reviewed with the College Chairs. The College Chairs will also work with those students who want to develop a new project for the year and will provide guidance on preparing for a presentation on Senior Scholarship Day.
Foundations for Fourth Year
As a required foundations course, all senior students must successfully complete this one-week course to graduate and enroll in 300- and 400-level coursework. This course is the first week of the MS4 curriculum and focuses on the development and reinforcement of core clinical skills that will be used in sub-internship rotations. The attendance policy for this course can be found in the Medical Student Handbook.
The required number of weeks required of MS4 electives will depend on the length of core clerkships that you have completed. The total number of core clerkship weeks plus electives should equal 78 weeks (for example, if you completed 48 weeks of core clerkships, then you need 30 weeks of electives). You can review your progress towards meeting degree requirements in MyCourses.
- 12 weeks must be sub-internship coursework; 300 and 400 level UCLA electives listed in MyCourses of which:
- 3 weeks must be a 300 level clerkship of consecutive weeks
- 3 weeks must be a 400 level clerkship of consecutive weeks
- 3 weeks can be either a 300 or 400 level clerkship of consecutive weeks
- 3 consecutive weeks of a College Approved ICU Elective & ICU Exam. All senior students are required to complete a three-week, 400-level Intensive Care Unit rotation from a list of approved rotations. To pass the ICU rotation, students must successfully complete a simulation and written exam on the final day of the ICU rotation. Students may not request an excused absence for the day of the ICU examination.
- 6 of the 30 weeks may be non-clinical coursework (i.e. 100 level coursework or research, 600 level)
Please submit the 4th Year Elective proposal form through Qualtrics.
New elective proposals will be sent to the appropriate Director of 4th Year Medical Education for review and approval then reviewed and approved by the Medical Education Committee (MEC) semiannually. We recommend that all new elective submissions are submitted by the October 1st deadline to have the approved electives listed and scheduled for the following academic year’s Course Catalog. The courses approved in April will be announced to the students via email as this is a late add.
For example, if an elective proposal was submitted on October 1st, 2021 and is approved, this course will be added to the 2022-2023 Course Catalog, where students will select the courses in December 2021 before the lottery.
If an elective proposal was submitted on April 1st, 2022, and is approved, this course will be announced to the current MS4 for the manual enrollment process.
Approved Course Added
October MEC Meeting
Following academic year
April MEC Meeting
Current academic year
Assessment for Internship
DGSOM's capstone foundation course. This week-long course is designed to assess proficiency in key skills and activities that will be vital to functioning as a resident physician from the first day of internship. All students must complete this course to graduate. The Clerkship Attendance Policy for this course can be found in the Medical Student Handbook.
Graduation Competencies for the Legacy Curriculum
PATIENT CARE that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.
MEDICAL KNOWLEDGE about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care.
PRACTICE-BASED LEARNING AND IMPROVEMENT
PRACTICE-BASED LEARNING AND IMPROVEMENT involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care.
- Conduct patient-centered encounters that balance the needs of the patient with time constraints of practice.
- ascertaining the patient’s goals for the encounter,
- appreciating the patient’s experience of illness,
- performing a focused physical examination, and
- negotiating diagnostic and management priorities.
- Accurately perform and document both complete and focused histories and physical examinations that are based on the pathophysiology of presenting complaints, and that address relevant psychosocial and family issues.
- Prioritize patients’ problems, formulate appropriate differential diagnoses, and develop appropriate plans for diagnosis and/or management.
- Perform the following basic diagnostic and therapeutic procedures
- Basic first aid
- Basic Life Support (BLS Certification)
- Suturing simple lacerations
- Drawing venous blood
- Starting an IV
- Basic airway management
- Be familiar with the technique for normal vaginal delivery.
- Be able to discuss the principles of and the relative advantages and disadvantages of various therapeutic modalities, including surgery, pharmacology, physical rehabilitation, mental health care, behavioral modification, and complementary and alternative medicine, as applied to common clinical situations.
- Use epidemiological principles and data to formulate measures for the care of individuals and communities and be able to read the medical literature.
- Evaluate the roles that unemployment, poverty, and lack of education play as obstacles to quality health care.
- Develop and implement individualized risk reduction plans based on a culturally-sensitive assessment of important medical and social conditions, including sexually transmitted diseases, substance abuse, and interpersonal violence.
- Know the scientific principles that underlie current understanding of normal human development, function, and disease. Be able to accurately express and use these principles in discussing health maintenance, common disease processes, and disease evaluation and management.
- Demonstrate an understanding of social and behavioral factors that influence patients' responses to health and disease. Such factors include:
- specific cultural, ethnic and societal beliefs and behaviors,
- patients' age, education, finances, and family resources,
- alternative or complementary medical practices within patients' communities.
- Understand the scientific basis and interpretation of common diagnostic modalities, including: imaging, electrocardiograms, blood and urine chemistries, pathologic studies, and functional assessment tests. Discuss the indications, contraindications and cost-effectiveness of common diagnostic studies.
- Demonstrate knowledge of common problems and diseases for diverse populations:
- Presenting complaints
- Abdominal pain
- Change in mental status
- Chest pain
- Chronic pain
- Low back pain
- Shortness of breath
- Substance abuse
- Otitis Media
- Upper respiratory infection
- Domestic violence
- End-of-life issues
- Presenting complaints
- Understand basic issues for promoting health and preventing disease, including nutrition, exercise, psychological health, preventive pharmacology, genetic predisposition to disease, sanitation, environmental and workplace hazards, life-styles, immunizations, and apply this understanding to patient management.
- Assess the health status, demographics and socioeconomic characteristics of medically underserved populations.
- Recognize differences in belief systems, values, languages, religions, and health practices that impact the medical care of culturally diverse medically underserved populations.
- Know when and how to report incidents of domestic violence including: child, elder, and spousal abuse.
- Understand the importance of life-long learning to adequately care for patients, to participate in patient education, and to pursue creative scholarly endeavors.
- PubMed and other relevant databases, to acquire new information and resources for learning.
- Identify and use reliable, authoritative sources of medical information.
- Organize personal resources efficiently and systematically using electronic tools and other methods.
- Describe and assess common scientific methodologies used in clinically-relevant medical research.
- Identify the evidential value, organization, and logistics of various types of clinical trials, and be able to advise patients concerning their participation in or interpretation of these.
- Read, summarize and critique research and disease review articles in peer-reviewed journals such as New England Journal of Medicine.
- Use evidence-based approaches as tools to decide whether to accept new findings, therapies, and technologies for incorporation into medical practice.
- Utilize decision-support systems and guidelines for clinical decision-making, including an understanding of the roles of preferences and probabilities.
- Understand and use continuous quality improvement practices.
- Translate questions that arise from daily clinical practice into formal research hypotheses.
- Utilize computer technology to aid in the design, writing, analysis, and presentation of data from a clinical research project (this competency is currently unique to the Drew program).
- Design, implement and complete a clinical research project that will meet the criteria for a Thesis (this competency is currently unique to the Drew program).
INTERPERSONAL AND COMMUNICATION SKILLS
INTERPERSONAL AND COMMUNICATION SKILLS that result in effective information exchange and teaming with patients, their families, and other health professionals.
PROFESSIONALISM, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
SYSTEM-BASED PRACTICE, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, and the ability to effectively call on system resources to provide care that is of optimal value.
- Demonstrate interpersonal skills that build rapport and empathic communication with patients and their families across socioeconomic, racial, and cultural boundaries.
- Make both complete and focused case presentations that are accurate and well-organized; prepare and maintain complete, accurate, well-organized medical records.
- Demonstrate a commitment to and skill in teaching medical students, colleagues, and other members of the allied health profession using the concepts and vocabulary of contemporary basic and clinical science.
- Function as a productive member of a team.
- Work collaboratively with health professionals from other disciplines.
- Skillfully address sensitive issues in an effective, compassionate, non-judgmental manner.
- screening for alcohol and drug abuse, domestic violence, and sexual activities
- screening for cancer risks
- giving “bad news”
- Describe and use sound principles for changing patients’ behavior in order to promote and improve their health.
- Inform patients and their families about health and illness in a way that is culturally sensitive, jargon-free, and appropriate to their needs, including counseling on prevention and psychosocial issues.
- Obtain informed consent from patients by clearly explaining the risks, benefits, and alternatives for common medical and surgical procedures in a culturally sensitive manner.
- Demonstrate reliability, dependability, and integrity in interactions with colleagues and patients.
- Deal with professional mistakes openly and honestly in ways that promote patient trust and self-learning.
- Accurately assess one’s personal strengths and limitations, relevant to one’s practice of medicine and continued learning.
- Develop abilities to receive and provide constructive feedback as part of peer and self-assessment of professional behaviors.
- Understand appropriate coping mechanisms for dealing with stress, intellectual uncertainty, interpersonal conflict, and issues related to power.
- Use basic ethical concepts and approaches to identify and analyze the ethical dimensions of common situations in medical practice, health policy, and research.
- Understand the obligation to treat the individual patient, and discuss the conflicts between caring for a patient and caring for a population.
- Recognize an obligation to the health of society, locally, regionally, and nationally.
- Demonstrate the ability to provide leadership to groups of colleagues or patients.
- Know the structure and functions of the health care delivery and insurance systems currently in place in California and the United States. Compare and contrast these to alternative systems used in other industrialized countries.
- Describe major current health system reform initiatives, including possible benefits and barriers to achieving them.
- Discuss the concept of a medical safety net and strategies for lowering access barriers for vulnerable populations.
- Define an integrated delivery system, list its key components and describe how they function together to deliver optimal patient care and outcomes.
- Discuss applications of health information technologies including electronic health records, patient registries, and computerized order entry and prescribing.
- Understand and explain the concept of value in health care, and provide examples of methods physicians use to improve value, including comparative effectiveness research, evidence-based guidelines and quality improvement.
- Compare current and emerging physician reimbursement methodologies, and discuss their likely impacts on utilization, costs, quality, access and provider incomes.
- Distinguish the roles of primary care providers and specialists, and discuss the options communities have to achieve an appropriate balance between primary and specialty care.
- Understand the flow of funds through the U.S. health care system, from their points of origin through public (Medicare and Medicaid) and private (insurance companies and health plans) intermediaries, down to the provider tier (physicians and hospitals). Distinguish between costs and charges.
- Identify and use resources and ancillary health care services for patients in situations in which social and economic barriers to access exist.
- Articulate the physician’s special responsibilities toward both individual patients and society at large, and discuss ways to balance these competing needs and priorities.