Effect of CR Supplementation on Athletic Performance

Effect of CR Supplementation on Athletic Performance Introduction To succeed in a given sport at any level of competition, athletes must possess specific physiologic, psychologic, and biomechanic traits critical to success in that sport, but they must also receive optimal physical, mental, and biomechanical training to maximise this genetic potential (Williams, Kreider Branch, 1999). However many athletes believe that the combination of genetic traits and optimal training alone are not sufficient to achieve maximum performance, therefore the use of ergogenic aids has become common to improve sports performance beyond the effect of training (Sundgot-Borgen, Berglund Torstveit, 2003). The use of ergogenic aids will allow athletes to gain that competitive advantage over opponents therefore leading to potential success. According to Williams, Kreider Branch, (1999) ergogenic aids are substances or treatments that are theoretically designed to enhance physical power, mental strength or mechanical edge therefore potentially improving athletic performa nce. Given the various demands of team sports such as Soccer, Rugby and Hockey, which require short intermittent bouts of high intensity exercise which are interspersed by low level exercise, it seems feasible the use of ergogenic aids in such sports may enhance and benefit performance to gain that competitive edge over opponents. One ergogenic aid which has become popular among amateur, professional and recreational athletes over recent years is Creatine Monohydrate (Cr). Creatine is a naturally occurring amino acid derivative which is found in skeletal muscle, but is also a normal dietary constituent with a daily requirement of approximately 2 to 3 grams depending on body size (Ostojic, 2001). The majority of creatine in muscles is stored in the form of phosphocreatine (PCr) which serves as an important contributor to energy metabolism during high intensity exercise (Williams, Kreider Branch, 1999). PCr provides the high energy phosphate for adenine diphosphate (ADP) to restore adenine triphosphate (ATP) concentration rapidly via the Cr kinase (CK) reaction (Clarkson, 1996). Hultman, Bergstrom and McLennan-Anderson, (1967) demonstrated that depletion of PCr stores within the muscles can lead to a decline in athletic performance during high intensity exercise, so theoretically increasing PCr stores through Cr supplementation would enhance the ability to maintain high intensity exercise over a prolonged period of time, leading to increases in sporting performance. Ahmun (2005) and Hultman, Soderlund, Timmons, Cederblad, Greenhaff, (1996) demonstrated that the average Cr concentration in human muscle can be increased through Cr supplementation over a 7 day period from 20% pre Cr to 50% post Cr. Since PCr is a substrate for the ATP-PCr energy system which is essential for high intensity exercise of 30 seconds or less it seems logical that the supplementation of Cr would be beneficial to exercise tasks of this duration. Therefore the majority of previous research has focused on bouts of anaerobic performance of To date the effect of Cr supplementation on athletic performance has been widely researched. This includes include positive effects of Cr supplementation over a prolonged period of over 4 weeks which is otherwise known as the maintenance phase (Knehans, Bemben, Bemben and Loftiss, 1998; Larson, Hunter, Trowbridge, Turk, Harbin and Torman, 1998). Also demonstrated have been positive effects of Cr supplementation on exercise performance using a shorter ingestion period known as the loading phase (Stout, Echerson, Noonan, Moore, and Cullen, 1999; Volek, Boetes, Bush, Putukian, Sebastianelli and Kraemer, 1997a). This includes improvements in performance variables such as strength, speed and delaying the onset of fatigue (Okudan and Gokbel, 2004; Volek, Kraemer, Bush, Boetes, Incledon, Clark and Lynch 1997b; Kocak Karli , 2003) Team sports consist of repeated bouts of intermittent high intensity exercise therefore consistently relying on the ATP-PCr energy system which if depleted can have a major factor on performance and the outcome of a game (Ostojic, 2004). One such sport which consists of repeated bouts of high intensity exercise is soccer. Soccer players are required to produce high power outputs and maintain or repeat them with only a few seconds of recovery, (Reilly and Williams, 2003). Such high intensity instances could be the deciding factor of a game, for example sprinting back to make a game saving tackle or sprinting past a defender to the ball to make a shot. One high intensity exercise instance which occurs in a soccer match are bouts of sprinting, which are estimated to consist of 8.1% of a 90 minute match and occur approximately every 90 seconds lasting between two to four seconds in duration (Bangsbo, Norregard Thorso, 1991). Given the fact that there is considerable support for Cr as an ergogenic aid it would be reasonable to suggest that a soccer players sprint performance would benefit from Cr supplementation. However there is minimal research which has looked into the effects of Cr on sprint performance and variables of soccer match play such as agility running, lateral stepping and running backwards( Cox, Mujika, Tumilty and Burke 2002; Ostojic, 2004; Mujika, Padilla, Ibanez, Izquierdo and Gorostiaga, 2000). The aforementioned studies have determined the effects of Cr on elite soccer players, female soccer players and youth soccer players (Ostojic, 2004; Mujika et al., 2000; Smart et al 1998; Cox et al., 2002). However there is no present research that looks into the effects of acute ( Another aspect to consider upon testing the effects of Cr on sprint performance on amateur soccer players is the protocol to be used. Although there have been many protocols which have been designed to measure and simulate soccer performance, plenty of these have failed to adequately simulate the different movement patterns (sprinting, walking, running backwards, lateral stepping) which are involved in a game of soccer (Drust, Reilly and Cable, 2000; Abt, Reaburn, Holmes and Gear, 2003; Thatcher and Batterham, 2004). It seems rational that when assessing components of soccer performance that the protocol that is utilised replicates the different activity patterns and demands of soccer match. If this is not taken into consideration it becomes difficult to determine whether Cr supplementation will have any benefit on soccer performance. Therefore the utilised protocol needs to concisely replicate movement patterns in soccer so that a valid assumption can be made to determine the erogen eity of acute Cr supplementation on sprint performance in amateur soccer players. Thus the purpose of this study is to conduct an investigation that will determine the effect of acute Cr supplementation on sprint performance in Caucasian male amateur soccer players, using a soccer simulation protocol in an accurate, valid and reliable manner with two trials consisting over a 7 day period. Concluding whether or not acute Cr supplementation can be used as an ergogenic aid to improve a footballers sprint performance, therefore recommending to athletes and coaches alike. Literature Review Creatine Monohydrate: Background Creatine monohydrate is one of the most popular sporting supplements in the world today and is used by high school athletes, the elderly, professional and recreational athletes in the hope of improving physical performance (Bemben and Lamont, 2005). It is the most commonly available Cr supplement and the form primarily used in most research studies. Cr monohydrate comes in a number of forms including powder, tablets, gel, liquid, chewing gum and candy (Williams, Kreider and Branch, 1999, p.43). Greenhaff (1997) indicated powdered Cr, ingested with solution to have a quicker absorption rate at raising muscle Cr concentration than using Cr supplementation of a tablet form. Conversely Vuckovich and Michaelis (1999) reported no significant difference in absorption rate between the two different forms. Dosage methods The supplementation dosages of Cr can be broken down into two different phases, otherwise known as the loading phase and maintenance phase. The loading phase that is commonly used in research consists of ingesting daily, 20-30g of Cr in four equal doses of 5-7g dissolved in around 250ml of fluid interspersed throughout the course of the day (preferably morning, noon, afternoon and evening) for a period of 5 to 7 days (Greenhaff, 1997; Kreider, 1997). Hultman et al (1996) utilised a less intense loading method of 3g/day for 28 days and proposed it to be just as effective as the aforementioned loading protocol. However this method places a longer dependency on subjects to comply with the supplementation program, therefore placing more variables into the reliability of results. Following the loading phase, maintenance dosages are considerably lower. Most research investigating the effects of Cr using the maintenance phase, have utilised dosages of 3 to 15g over a 4 to 10 week period (Bemben et al., 2001; Kreider et al., 1998; Stone et al., 1999; Vandenberghe et al., 1997). It is recommended to consume Cr with warm water, as it facilitates the dissolving of the solution and also aid absorption (Harris et al., 1992). It should also be noted that the ingestion of caffeine during Cr supplementation eradicates its potential ergogenic effect (Vandenberghe et al., 1996; Van Leemputte, Vanstapel Hespel, 1997). Vandenberghe et al (1996) demonstrated that a control group that ingested Cr combined with caffeine to have a lessened ergogenic potential compared to a group that ingested Cr without caffein e during repeated bouts of high intensity exercise. Side effects There is no conclusive scientific evidence to suggest that Cr ingestion has any negative side effects utilising the proposed dosage methods ( Larson et al., 1998; Schroder, Terrados Tramullas, 2005). There is further evidence to support this as Kreider et al (1999) found no negative side effects in athletes who had been ingesting Cr for up to 3 years. Poortmans and Francaux (1999) demonstrated similar findings for athletes for taking Cr for up to 5 years. Only undocumented anecdotal reports have reported any adverse negative side effects through Cr supplementation, this includes gastrointestinal distress, muscle cramping and dehydration (Associated press 1997, 1998). Taking dehydration into consideration such anecdotal research can be scrutinised. Oopik, Timpmann and Medijainen, (1995) demonstrated that Cr supplementation increased body mass, while also reporting increases in total body water. Such findings signify that Cr supplementation may prevent dehydration rather than be a cause, due to the fact it can promote water retention. Cr supplementation has been demonstrated to increase body mass by up to 2kg over an acute period of time (Balsom et al., 1995; Becque et al., 1997). This could be recognised as a negative side effect for athletes that compete in weight control sports, as Cr ingestion may impede their ability to make regulated weight in a forthcoming event. This gives a consensus that athletes in such activities need to be made aware that although Cr can promote gains in strength and power, it can increase body mass. Physiology of Soccer Soccer players are frequently required to produce high power outputs and maintain of repeat them with only a few seconds of recovery (Reilly and Thomas, 2003). This includes intermittent bouts of kicking, tackling, turning, sprinting, changing pace and maintaining balance and control of the ball whilst under pressure from an opponent (Wisloff, Helgerud Hoff, 1998). To gain a scientific perspective of the different physiological demands of soccer performance, match and time motion analysis have been utilised (Bangsbo, 1994). This analysis has allowed researchers to determine the overall workload of players during a 90 minute match by calculating total distance covered, and the pattern of activities performed during a game (e.g. sprinting, cruising, walking etc). Movement patterns of Soccer It is estimated that the total distance covered during a 90 minute soccer match varies from 8.7km to 11.5km ( Bangsbo Lindquist, 1992; Ekblom, 1986; Ohashi et al., (1988); Reilly and Thomas, 1976; 1988; Rampini et al., 2007; Wade, 1962). The large variance in distances covered are due in part to the differing styles of play, levels of competition and skill level of the teams that were utilised (Luxbacher, 1997). Reilly (1994) documented the different activity patterns of elite outfield players from the English top division and other major national leagues in Europe and Japan using different methods of match analysis. Results found that a 90 minute match consists of 24% walking, 36% jogging, 20% cruising sub maximally (striding), 11% sprinting, 7% moving backwards and 2% moving in possession of the ball. The categories of sprinting and cruising are defined as high intensity exercise. In terms of distances covered the ratio of low intensity exercise to high intensity exercise during a soccer match is 7 to 1 denoting that the outlay of energy for soccer is predominately aerobic ( Reilly and Thomas, 1976). However the importance for high intensity bouts during soccer match play should not be underestimated. The timing of such a bout could be the defining factor of a game whether in possession of the ball or without the ball. Although work-rate profiles are relatively consistent for players from game to game it is the high intensity exercise which is the most constant feature (Bangsbo, 1994). The number of sprints reported in a soccer game varies greatly from 17 to 62 (Bangsbo et al., 1991; Mohr, Krustrup Bangsbo, 2003). This variance is largely determined by the positional role of the player. Findings by Reilly (1996) demonstrated that midfielders and strikers completed more sprinting bouts than centre backs or full backs therefore relying more on the anaerobic energy system. However if there is not a prolonged recovery period or an individual is not properly conditioned they will not subsequently recovery from high intensity bouts of exercise and fatigue will occur (Reilly, 1996). This is evident as Reilly (1996, p.72) documented that the majority of goals conceded during a soccer match occurred in the final ten minutes of play. A popular theory for this occurrence has been found to be mental fatigue or lapses in concentration from defenders (Reilly, 1996, p.72). However this can theory can be scrutinised as research found that the onset of fatigue in intermittent exercise such as soccer is caused by low muscle glycogen stores (Balsom et al., 1999). Acute Cr supplementation and sprint performance in team sports Athletes in team sports such as soccer, rugby, hockey and American football are required to repeatedly reproduce intermittent bouts of high intensity exercise with minimal recovery. Being able to consistently reproduce such bouts at maximal ability (e.g. sprinting, jumping, running backwards) could be the deciding factor in competition to gain that extra edge of an opponent. During high intensity exercise of an intermittent nature the main contributor of energy is PCr (Williams, Kreider Branch, 1999, p29). Depletion of PCr stores during high intensity exercise has been found to be a factor which has lead to a decline in athletic performance (Hultman, Bergstrom and McLennan-Anderson, 1967). Through the supplementation of Cr, it hypothesised that PCr stores are replenished at a faster rate therefore improving an athletes ability to recover and perform intermittent high intensity bouts of exercise, leading to improved athletic performance (Greenhaff et al, 1993). There have been various studies that have tested this hypothesis by investigating the ergogenic effect of acute Cr supplementation on sprint performance of athletes in team sports (Ahmun et al., 2005; Cornish, Chilibeck Burke, 2006; Izquierdo et al., 2001; Kocak Karli, 2003; Romer et al., 2001; Vandebuerie et al., 1998). However the aforementioned studies have contrasting findings with a quantity of studies finding a significant improvement in sprint performance through Cr supplementation (Izquierdo et al., 2001; Romer et al., 2001; Vandebuerie et al., 1998). On the contrary other studies have found no significant improvements in sprint performance through acute Cr ingestion (Ahmun et al., 2005; Cornish, Chilibeck Burke, 2006; Kocak Karli, 2003). Ahmun et al., (2005) investigated the ergogenic effect of Cr on sprint performance in male rugby players. For this study a Wingate test protocol was utilised prior and post Cr supplementation. Findings of this study were that there was no significant improvement in maximal cycle sprints through Cr ingestion. However in contrast Izquierdo et al., (2001) found that acute Cr supplementation improved sprint times in male hand ball players. For this study subjects were either assigned Cr or placebo over a 5 day period. The protocol that was utilised consisted of repeated sprint runs that were consistent with sprint distances achieved during handball match play. One issue that could have had a determining factor of the non significant results found by Ahmun et al (2005) is the protocol that was utilised. A Wingate test was utilised to test the sprint performance in rugby players, however the relevance of a Wingate test to measure rugby performance is not sports specific there scrutinising the validity of the results. In contrast Izquierdo et al (2001) utilised a protocol which successfully replicated distances found in handball match play therefore maintaining validity. Ahmun et al (2005) also failed to incorporate a dietary analysis into the experimental design of the protocol, therefore whether or not Cr stores within the subjects utilised were full cannot be determined, which gives rationale for results showing no significant improvement. In contrast Izquierdo et al (2001) implemented a dietary examination of subjects that were utilised; this was initiated to determine whether any subjects had ingested Cr or any ergogenic aids prior to baseline testing. This assisted with maintaining validity during research. This can be supported by Romer et al (2001) and Vandebuerie et al (1998) who utilised a protocol containing a dietary analysis and concluded a significant improvement in sprint times within subjects. Cr supplementation and Soccer performance Given the intermittent physical demands of soccer, which requires players to produce high power outputs and maintain or repeat them with only a few seconds of recovery, (Reilly and Williams, 2003) it seems feasible that soccer players would benefit from the supplementation of Cr as an ergogenic aid to improve their overall performance. However research that has investigated the effect on acute Cr supplementation on different variables of soccer performance and predominately sprint performance utilising a soccer simulation protocol is limited (Ostojic, 2004; Mujika et al 2000; Cox et al 2002). The Aforementioned studies have primarily focused on the effects of Cr supplementation on highly trained athletes that are competing at a high standard of competition. However no previous research has looked into the effects of acute Cr supplementation on amateur soccer players. Being as though Cr monohydrate is an immensely popular ergogenic aid not only among professional athletes but also amateur and recreational athletes, the benefit to amateur athletes needs to recognised. Previous research that has looked into the effects of acute Cr supplementation on soccer players using a soccer simulation protocol is discussed below. Ostojic (2004) examined the effects of acute Cr supplementation (3 x 10g doses for 7 days) on 20 young male soccer players (16.6 Â ± 1.9 years). For the testing procedure a double blind method was used and where subjects were either administered either Cr or placebo. Subjects completed two separate trials prior and post to Cr or placebo. The testing procedure consisted of a number of soccer specific skill tests which included a dribble test, sprint-power test, endurance test and a vertical jump test. Results found that there was a significant improvement in a number of the soccer specific tests; this includes superior improvements in sprint times, vertical jump scores and the dribble test. However no significant improvements were made on endurance performance after the two trials. Although a significant improvement was found in vertical jump performance, it is of concern to future researchers to whether the vertical jump test that was utilised during the design is a soccer specific test. During the test subjects were instructed to keep their trunk as straight as possible whilst keeping their hands on their hips to avoid contribution from the arms which doesnt successfully replicate jumping movements in soccer therefore questioning the validity of the vertical jump test as to whether or not it is a measure of soccer specific performance. The age of the subjects in this research can also be scrutinised. Eichner, King, Myhal, Prentice and Ziegenfuss (1999) confirmed that there was insufficient research to determine the acute and chronic side effects of Cr consumption in athletes under the age of 18 therefore places the subjects which were used in the mentioned study under possible risk. Eichner et al (1999) also highlighted that Cr supplementation in young athletes could have a possible degradation of ethics, by where a win at all costs mentality is fostered and an attitude by where ergogenic aids are necessary to win, which is the wrong message to be installing in young athletes. Likewise Mujika, Padilla, Ibanez, Izquerido and Gorostiaga (2000) concluded acute Cr supplementation (20g a day x 6 days) significantly improved sprint performance and found no significant improvement in endurance performance using a soccer simulation protocol. Mujika et al (2000) also documented no increase in vertical jump performance using a similar protocol to Ostojic (2004) which has minimal significance in a soccer simulation study. Mujika et al (2000) tested 19 elite male soccer players who at the time of investigation were highly trained, however only 17 fully completed the testing due to illness or injury. The protocol for this investigation consisted of a circuit of different exercises which consisted of a repeated sprint test (5 and 15m), vertical jump test and an intermittent endurance test. Findings in this study concluded that mean sprint times improved significantly (p This de-training effect is evident for the vertical jump test as no significant improvement between the two trials was found. However if there was a significant de training effect it would have had negative consequences on other testing variables such as sprint performance, this however is not the case as sprint performance significantly improved. Mujika et al (2000) should have took into consideration a possible detraining effect when devising the experimental design as this could have negatively affect the validity of the results. Cox, Mujika, Tumilty and Burke (2002) devised a study which tested Cr supplementation (20g a day) or placebo (20g glucose a day) on 14 elite female soccer players from the Australian institute of sport (AIS) using a soccer simulated protocol. The experimental design consisted of two trials before and after Cr or placebo over a 6 day period. The protocol consisted of fifty five 20m sprints, ten agility runs and a precision ball kicking drill which are separated by recovery walks, jogs and runs. The main findings in this study were that the average 20m sprint time in the Cr group decreased from 3.75 Â ± 0.19 to 3.69 Â ± 0.18s however this decrease in sprint time failed to reach the statistical significance level (p Cox et al (2002) also incorporated a standardised training regime and a controlled diet for the intervention week and also scheduled testing so that it would occur at the same time of day before and after supplementation. In contrast Mujika et al (2000) failed to utilise effective standardised procedures during their experimental design. As previously mentioned Mujika et al (2000) testing procedures took place 3 days after the subjects season had finished therefore training was not standardised due to the fact that subjects had no organised training sessions during the intervention week. Mujika et al (2000) also lacked a familiarisation trial, subjects were only familiarised with the testing procedures prior to arriving for the 1st trial which could substantially affect the results. However although Cox et al (2000) standardised procedures by included a controlled diet for the subjects, it is interesting to note that one of the subjects was a vegetarian, whos Cr content is virtually zero (Greenhaff, 1997). Research has found that vegetarians respond quicker and more effectively to Cr supplementation than those who follow a normal sedentary diet and have natural muscle creatine content (Burke, Chilibeck, Parise, Candow, Mahoney Tamopolsky., 2003; Watt, Garnham Snow, 2004) therefore scrutinising the validity of the results. It may be of future reference to eradicate vegetarians in a experimental design which utilises Cr supplementation due to the diet implications that vegetarians have. Soccer Simulation performance tests To date there has been a number of soccer simulation performance tests which have been utilised to assess and measure different physiological aspects of the game (Bangsbo and Lindquist, 1992; Cox, 2002; Drust, Reilly and Cable, 2000; Nicholas, Nuttall and Williams, 2000). These protocols have been implemented so that they take into consideration different aspects of soccer performance and try to replicate the exercise patterns that are observed during match play, however due to the spontaneity of the soccer it is difficult to assess every physical or metabolic demand (Drust, Reilly and Cable, 2000). Researchers have used different protocols when investigating the metabolic and physical demands of soccer, these can documented into laboratory based protocols (Drust, Reilly and Cable, 2000; Thatcher and Batterham, 2004) and field based protocols (Bangsbo and Lindquist, 1992; Cox, 2002; Nicholas et al 2000). Laboratory based soccer performance protocols Drust, Reilly and Cable (2000) devised a laboratory based protocol on a motorised treadmill what represented the work rates that are observed during soccer match play. For the experimental design 7 male university soccer players (24 Â ± 2 years) were used and the testing consisted of three separate testing blocks which were separated by 6 days. The protocol consisted of the different exercise intensities that are utilised during soccer match play; this consisted of walking, jogging, cruising and sprinting. The speeds at which these exercises were performed on the treadmill were consistent with speeds observed by Van Gool, Van Gervan and Boutmans (1988) during a match analysis. Each testing block consisted of two 22.5 minute cycles which consisted of 23 bouts which were followed by a recovery period of 71 seconds. During each bout the duration of each activity was as follows: walking 35 seconds (s), jogging 50.3s, cruising 51.4s and sprinting 10.5s. However in relevance to this research project it should be noted that the duration covered during the sprint bouts of the protocol of Drust, Reilly and Cable (2000) which is 10.5s does not successfully coincide with match analysis from several soccer studies that have documented the duration of sprint bouts during soccer match play. Research has found that the average sprint time during soccer match play lasts between on average two to four seconds in duration (Bangsbo, Norregard Thorso,1991; Mayhew and Wenger, 1985) therefore concluding in some instances Drust, Reilly and Cables (2000) laboratory based soccer specific protocol can be deemed as in valid as it fails to accurately replicate different soccer performance variables that take place in match play. Another lab based test that was utilised to measure specific variables in soccer performance was devised by Thatcher and Batterham (2004). For this protocol six male professional soccer players were used and the testing consisted of 29 minute exercise bouts on a non motorised treadmill that focused on replicating different speeds, durations, distances and heart rates that occur during soccer match play. Findings from this study suggest that the protocol that was utilised induced a similar physiological load to soccer match play and can be determined as a valid measure of soccer performance. Although lab based soccer specific protocols have been found to replicate some instances of soccer performance it is of consideration of this research project that the limitations and positives of such protocols be noted. The aforementioned lab based failed to perform a re-test procedure to conclude whether their protocols maintained reliability therefore the amount of error in each protocol cannot be determined. Another limitation of lab based testing is that due to tests being performed on treadmills, this limits the subjects to straight-line running only, therefore does not take into consideration lateral movements and agility patterns, which have found to be major characteristics of soccer performance (Bangsbo and Lindquist, 1992). These unorthodox movement patterns need to be taken into consideration when assessing soccer performance as they increase energy expenditure significantly (Nicholas et al., 2000). One positive aspect of lab based protocols are that procedures such as a ir temperature, equipment utilised and humidity can be easily standardised to remain constant throughout performance testing. Field Tests Nicholas et al (2000) devised the Loughborough Intermittent Shuttle test (LIST) to simulate the activity patterns during a game of soccer. The LIST consisted of two separate stages which were known as part A and part B. Part A lasted 70 minutes and consisted of five 15 minute exercise pe Effect of CR Supplementation on Athletic Performance Effect of CR Supplementation on Athletic Performance Introduction To succeed in a given sport at any level of competition, athletes must possess specific physiologic, psychologic, and biomechanic traits critical to success in that sport, but they must also receive optimal physical, mental, and biomechanical training to maximise this genetic potential (Williams, Kreider Branch, 1999). However many athletes believe that the combination of genetic traits and optimal training alone are not sufficient to achieve maximum performance, therefore the use of ergogenic aids has become common to improve sports performance beyond the effect of training (Sundgot-Borgen, Berglund Torstveit, 2003). The use of ergogenic aids will allow athletes to gain that competitive advantage over opponents therefore leading to potential success. According to Williams, Kreider Branch, (1999) ergogenic aids are substances or treatments that are theoretically designed to enhance physical power, mental strength or mechanical edge therefore potentially improving athletic performa nce. Given the various demands of team sports such as Soccer, Rugby and Hockey, which require short intermittent bouts of high intensity exercise which are interspersed by low level exercise, it seems feasible the use of ergogenic aids in such sports may enhance and benefit performance to gain that competitive edge over opponents. One ergogenic aid which has become popular among amateur, professional and recreational athletes over recent years is Creatine Monohydrate (Cr). Creatine is a naturally occurring amino acid derivative which is found in skeletal muscle, but is also a normal dietary constituent with a daily requirement of approximately 2 to 3 grams depending on body size (Ostojic, 2001). The majority of creatine in muscles is stored in the form of phosphocreatine (PCr) which serves as an important contributor to energy metabolism during high intensity exercise (Williams, Kreider Branch, 1999). PCr provides the high energy phosphate for adenine diphosphate (ADP) to restore adenine triphosphate (ATP) concentration rapidly via the Cr kinase (CK) reaction (Clarkson, 1996). Hultman, Bergstrom and McLennan-Anderson, (1967) demonstrated that depletion of PCr stores within the muscles can lead to a decline in athletic performance during high intensity exercise, so theoretically increasing PCr stores through Cr supplementation would enhance the ability to maintain high intensity exercise over a prolonged period of time, leading to increases in sporting performance. Ahmun (2005) and Hultman, Soderlund, Timmons, Cederblad, Greenhaff, (1996) demonstrated that the average Cr concentration in human muscle can be increased through Cr supplementation over a 7 day period from 20% pre Cr to 50% post Cr. Since PCr is a substrate for the ATP-PCr energy system which is essential for high intensity exercise of 30 seconds or less it seems logical that the supplementation of Cr would be beneficial to exercise tasks of this duration. Therefore the majority of previous research has focused on bouts of anaerobic performance of To date the effect of Cr supplementation on athletic performance has been widely researched. This includes include positive effects of Cr supplementation over a prolonged period of over 4 weeks which is otherwise known as the maintenance phase (Knehans, Bemben, Bemben and Loftiss, 1998; Larson, Hunter, Trowbridge, Turk, Harbin and Torman, 1998). Also demonstrated have been positive effects of Cr supplementation on exercise performance using a shorter ingestion period known as the loading phase (Stout, Echerson, Noonan, Moore, and Cullen, 1999; Volek, Boetes, Bush, Putukian, Sebastianelli and Kraemer, 1997a). This includes improvements in performance variables such as strength, speed and delaying the onset of fatigue (Okudan and Gokbel, 2004; Volek, Kraemer, Bush, Boetes, Incledon, Clark and Lynch 1997b; Kocak Karli , 2003) Team sports consist of repeated bouts of intermittent high intensity exercise therefore consistently relying on the ATP-PCr energy system which if depleted can have a major factor on performance and the outcome of a game (Ostojic, 2004). One such sport which consists of repeated bouts of high intensity exercise is soccer. Soccer players are required to produce high power outputs and maintain or repeat them with only a few seconds of recovery, (Reilly and Williams, 2003). Such high intensity instances could be the deciding factor of a game, for example sprinting back to make a game saving tackle or sprinting past a defender to the ball to make a shot. One high intensity exercise instance which occurs in a soccer match are bouts of sprinting, which are estimated to consist of 8.1% of a 90 minute match and occur approximately every 90 seconds lasting between two to four seconds in duration (Bangsbo, Norregard Thorso, 1991). Given the fact that there is considerable support for Cr as an ergogenic aid it would be reasonable to suggest that a soccer players sprint performance would benefit from Cr supplementation. However there is minimal research which has looked into the effects of Cr on sprint performance and variables of soccer match play such as agility running, lateral stepping and running backwards( Cox, Mujika, Tumilty and Burke 2002; Ostojic, 2004; Mujika, Padilla, Ibanez, Izquierdo and Gorostiaga, 2000). The aforementioned studies have determined the effects of Cr on elite soccer players, female soccer players and youth soccer players (Ostojic, 2004; Mujika et al., 2000; Smart et al 1998; Cox et al., 2002). However there is no present research that looks into the effects of acute ( Another aspect to consider upon testing the effects of Cr on sprint performance on amateur soccer players is the protocol to be used. Although there have been many protocols which have been designed to measure and simulate soccer performance, plenty of these have failed to adequately simulate the different movement patterns (sprinting, walking, running backwards, lateral stepping) which are involved in a game of soccer (Drust, Reilly and Cable, 2000; Abt, Reaburn, Holmes and Gear, 2003; Thatcher and Batterham, 2004). It seems rational that when assessing components of soccer performance that the protocol that is utilised replicates the different activity patterns and demands of soccer match. If this is not taken into consideration it becomes difficult to determine whether Cr supplementation will have any benefit on soccer performance. Therefore the utilised protocol needs to concisely replicate movement patterns in soccer so that a valid assumption can be made to determine the erogen eity of acute Cr supplementation on sprint performance in amateur soccer players. Thus the purpose of this study is to conduct an investigation that will determine the effect of acute Cr supplementation on sprint performance in Caucasian male amateur soccer players, using a soccer simulation protocol in an accurate, valid and reliable manner with two trials consisting over a 7 day period. Concluding whether or not acute Cr supplementation can be used as an ergogenic aid to improve a footballers sprint performance, therefore recommending to athletes and coaches alike. Literature Review Creatine Monohydrate: Background Creatine monohydrate is one of the most popular sporting supplements in the world today and is used by high school athletes, the elderly, professional and recreational athletes in the hope of improving physical performance (Bemben and Lamont, 2005). It is the most commonly available Cr supplement and the form primarily used in most research studies. Cr monohydrate comes in a number of forms including powder, tablets, gel, liquid, chewing gum and candy (Williams, Kreider and Branch, 1999, p.43). Greenhaff (1997) indicated powdered Cr, ingested with solution to have a quicker absorption rate at raising muscle Cr concentration than using Cr supplementation of a tablet form. Conversely Vuckovich and Michaelis (1999) reported no significant difference in absorption rate between the two different forms. Dosage methods The supplementation dosages of Cr can be broken down into two different phases, otherwise known as the loading phase and maintenance phase. The loading phase that is commonly used in research consists of ingesting daily, 20-30g of Cr in four equal doses of 5-7g dissolved in around 250ml of fluid interspersed throughout the course of the day (preferably morning, noon, afternoon and evening) for a period of 5 to 7 days (Greenhaff, 1997; Kreider, 1997). Hultman et al (1996) utilised a less intense loading method of 3g/day for 28 days and proposed it to be just as effective as the aforementioned loading protocol. However this method places a longer dependency on subjects to comply with the supplementation program, therefore placing more variables into the reliability of results. Following the loading phase, maintenance dosages are considerably lower. Most research investigating the effects of Cr using the maintenance phase, have utilised dosages of 3 to 15g over a 4 to 10 week period (Bemben et al., 2001; Kreider et al., 1998; Stone et al., 1999; Vandenberghe et al., 1997). It is recommended to consume Cr with warm water, as it facilitates the dissolving of the solution and also aid absorption (Harris et al., 1992). It should also be noted that the ingestion of caffeine during Cr supplementation eradicates its potential ergogenic effect (Vandenberghe et al., 1996; Van Leemputte, Vanstapel Hespel, 1997). Vandenberghe et al (1996) demonstrated that a control group that ingested Cr combined with caffeine to have a lessened ergogenic potential compared to a group that ingested Cr without caffein e during repeated bouts of high intensity exercise. Side effects There is no conclusive scientific evidence to suggest that Cr ingestion has any negative side effects utilising the proposed dosage methods ( Larson et al., 1998; Schroder, Terrados Tramullas, 2005). There is further evidence to support this as Kreider et al (1999) found no negative side effects in athletes who had been ingesting Cr for up to 3 years. Poortmans and Francaux (1999) demonstrated similar findings for athletes for taking Cr for up to 5 years. Only undocumented anecdotal reports have reported any adverse negative side effects through Cr supplementation, this includes gastrointestinal distress, muscle cramping and dehydration (Associated press 1997, 1998). Taking dehydration into consideration such anecdotal research can be scrutinised. Oopik, Timpmann and Medijainen, (1995) demonstrated that Cr supplementation increased body mass, while also reporting increases in total body water. Such findings signify that Cr supplementation may prevent dehydration rather than be a cause, due to the fact it can promote water retention. Cr supplementation has been demonstrated to increase body mass by up to 2kg over an acute period of time (Balsom et al., 1995; Becque et al., 1997). This could be recognised as a negative side effect for athletes that compete in weight control sports, as Cr ingestion may impede their ability to make regulated weight in a forthcoming event. This gives a consensus that athletes in such activities need to be made aware that although Cr can promote gains in strength and power, it can increase body mass. Physiology of Soccer Soccer players are frequently required to produce high power outputs and maintain of repeat them with only a few seconds of recovery (Reilly and Thomas, 2003). This includes intermittent bouts of kicking, tackling, turning, sprinting, changing pace and maintaining balance and control of the ball whilst under pressure from an opponent (Wisloff, Helgerud Hoff, 1998). To gain a scientific perspective of the different physiological demands of soccer performance, match and time motion analysis have been utilised (Bangsbo, 1994). This analysis has allowed researchers to determine the overall workload of players during a 90 minute match by calculating total distance covered, and the pattern of activities performed during a game (e.g. sprinting, cruising, walking etc). Movement patterns of Soccer It is estimated that the total distance covered during a 90 minute soccer match varies from 8.7km to 11.5km ( Bangsbo Lindquist, 1992; Ekblom, 1986; Ohashi et al., (1988); Reilly and Thomas, 1976; 1988; Rampini et al., 2007; Wade, 1962). The large variance in distances covered are due in part to the differing styles of play, levels of competition and skill level of the teams that were utilised (Luxbacher, 1997). Reilly (1994) documented the different activity patterns of elite outfield players from the English top division and other major national leagues in Europe and Japan using different methods of match analysis. Results found that a 90 minute match consists of 24% walking, 36% jogging, 20% cruising sub maximally (striding), 11% sprinting, 7% moving backwards and 2% moving in possession of the ball. The categories of sprinting and cruising are defined as high intensity exercise. In terms of distances covered the ratio of low intensity exercise to high intensity exercise during a soccer match is 7 to 1 denoting that the outlay of energy for soccer is predominately aerobic ( Reilly and Thomas, 1976). However the importance for high intensity bouts during soccer match play should not be underestimated. The timing of such a bout could be the defining factor of a game whether in possession of the ball or without the ball. Although work-rate profiles are relatively consistent for players from game to game it is the high intensity exercise which is the most constant feature (Bangsbo, 1994). The number of sprints reported in a soccer game varies greatly from 17 to 62 (Bangsbo et al., 1991; Mohr, Krustrup Bangsbo, 2003). This variance is largely determined by the positional role of the player. Findings by Reilly (1996) demonstrated that midfielders and strikers completed more sprinting bouts than centre backs or full backs therefore relying more on the anaerobic energy system. However if there is not a prolonged recovery period or an individual is not properly conditioned they will not subsequently recovery from high intensity bouts of exercise and fatigue will occur (Reilly, 1996). This is evident as Reilly (1996, p.72) documented that the majority of goals conceded during a soccer match occurred in the final ten minutes of play. A popular theory for this occurrence has been found to be mental fatigue or lapses in concentration from defenders (Reilly, 1996, p.72). However this can theory can be scrutinised as research found that the onset of fatigue in intermittent exercise such as soccer is caused by low muscle glycogen stores (Balsom et al., 1999). Acute Cr supplementation and sprint performance in team sports Athletes in team sports such as soccer, rugby, hockey and American football are required to repeatedly reproduce intermittent bouts of high intensity exercise with minimal recovery. Being able to consistently reproduce such bouts at maximal ability (e.g. sprinting, jumping, running backwards) could be the deciding factor in competition to gain that extra edge of an opponent. During high intensity exercise of an intermittent nature the main contributor of energy is PCr (Williams, Kreider Branch, 1999, p29). Depletion of PCr stores during high intensity exercise has been found to be a factor which has lead to a decline in athletic performance (Hultman, Bergstrom and McLennan-Anderson, 1967). Through the supplementation of Cr, it hypothesised that PCr stores are replenished at a faster rate therefore improving an athletes ability to recover and perform intermittent high intensity bouts of exercise, leading to improved athletic performance (Greenhaff et al, 1993). There have been various studies that have tested this hypothesis by investigating the ergogenic effect of acute Cr supplementation on sprint performance of athletes in team sports (Ahmun et al., 2005; Cornish, Chilibeck Burke, 2006; Izquierdo et al., 2001; Kocak Karli, 2003; Romer et al., 2001; Vandebuerie et al., 1998). However the aforementioned studies have contrasting findings with a quantity of studies finding a significant improvement in sprint performance through Cr supplementation (Izquierdo et al., 2001; Romer et al., 2001; Vandebuerie et al., 1998). On the contrary other studies have found no significant improvements in sprint performance through acute Cr ingestion (Ahmun et al., 2005; Cornish, Chilibeck Burke, 2006; Kocak Karli, 2003). Ahmun et al., (2005) investigated the ergogenic effect of Cr on sprint performance in male rugby players. For this study a Wingate test protocol was utilised prior and post Cr supplementation. Findings of this study were that there was no significant improvement in maximal cycle sprints through Cr ingestion. However in contrast Izquierdo et al., (2001) found that acute Cr supplementation improved sprint times in male hand ball players. For this study subjects were either assigned Cr or placebo over a 5 day period. The protocol that was utilised consisted of repeated sprint runs that were consistent with sprint distances achieved during handball match play. One issue that could have had a determining factor of the non significant results found by Ahmun et al (2005) is the protocol that was utilised. A Wingate test was utilised to test the sprint performance in rugby players, however the relevance of a Wingate test to measure rugby performance is not sports specific there scrutinising the validity of the results. In contrast Izquierdo et al (2001) utilised a protocol which successfully replicated distances found in handball match play therefore maintaining validity. Ahmun et al (2005) also failed to incorporate a dietary analysis into the experimental design of the protocol, therefore whether or not Cr stores within the subjects utilised were full cannot be determined, which gives rationale for results showing no significant improvement. In contrast Izquierdo et al (2001) implemented a dietary examination of subjects that were utilised; this was initiated to determine whether any subjects had ingested Cr or any ergogenic aids prior to baseline testing. This assisted with maintaining validity during research. This can be supported by Romer et al (2001) and Vandebuerie et al (1998) who utilised a protocol containing a dietary analysis and concluded a significant improvement in sprint times within subjects. Cr supplementation and Soccer performance Given the intermittent physical demands of soccer, which requires players to produce high power outputs and maintain or repeat them with only a few seconds of recovery, (Reilly and Williams, 2003) it seems feasible that soccer players would benefit from the supplementation of Cr as an ergogenic aid to improve their overall performance. However research that has investigated the effect on acute Cr supplementation on different variables of soccer performance and predominately sprint performance utilising a soccer simulation protocol is limited (Ostojic, 2004; Mujika et al 2000; Cox et al 2002). The Aforementioned studies have primarily focused on the effects of Cr supplementation on highly trained athletes that are competing at a high standard of competition. However no previous research has looked into the effects of acute Cr supplementation on amateur soccer players. Being as though Cr monohydrate is an immensely popular ergogenic aid not only among professional athletes but also amateur and recreational athletes, the benefit to amateur athletes needs to recognised. Previous research that has looked into the effects of acute Cr supplementation on soccer players using a soccer simulation protocol is discussed below. Ostojic (2004) examined the effects of acute Cr supplementation (3 x 10g doses for 7 days) on 20 young male soccer players (16.6 Â ± 1.9 years). For the testing procedure a double blind method was used and where subjects were either administered either Cr or placebo. Subjects completed two separate trials prior and post to Cr or placebo. The testing procedure consisted of a number of soccer specific skill tests which included a dribble test, sprint-power test, endurance test and a vertical jump test. Results found that there was a significant improvement in a number of the soccer specific tests; this includes superior improvements in sprint times, vertical jump scores and the dribble test. However no significant improvements were made on endurance performance after the two trials. Although a significant improvement was found in vertical jump performance, it is of concern to future researchers to whether the vertical jump test that was utilised during the design is a soccer specific test. During the test subjects were instructed to keep their trunk as straight as possible whilst keeping their hands on their hips to avoid contribution from the arms which doesnt successfully replicate jumping movements in soccer therefore questioning the validity of the vertical jump test as to whether or not it is a measure of soccer specific performance. The age of the subjects in this research can also be scrutinised. Eichner, King, Myhal, Prentice and Ziegenfuss (1999) confirmed that there was insufficient research to determine the acute and chronic side effects of Cr consumption in athletes under the age of 18 therefore places the subjects which were used in the mentioned study under possible risk. Eichner et al (1999) also highlighted that Cr supplementation in young athletes could have a possible degradation of ethics, by where a win at all costs mentality is fostered and an attitude by where ergogenic aids are necessary to win, which is the wrong message to be installing in young athletes. Likewise Mujika, Padilla, Ibanez, Izquerido and Gorostiaga (2000) concluded acute Cr supplementation (20g a day x 6 days) significantly improved sprint performance and found no significant improvement in endurance performance using a soccer simulation protocol. Mujika et al (2000) also documented no increase in vertical jump performance using a similar protocol to Ostojic (2004) which has minimal significance in a soccer simulation study. Mujika et al (2000) tested 19 elite male soccer players who at the time of investigation were highly trained, however only 17 fully completed the testing due to illness or injury. The protocol for this investigation consisted of a circuit of different exercises which consisted of a repeated sprint test (5 and 15m), vertical jump test and an intermittent endurance test. Findings in this study concluded that mean sprint times improved significantly (p This de-training effect is evident for the vertical jump test as no significant improvement between the two trials was found. However if there was a significant de training effect it would have had negative consequences on other testing variables such as sprint performance, this however is not the case as sprint performance significantly improved. Mujika et al (2000) should have took into consideration a possible detraining effect when devising the experimental design as this could have negatively affect the validity of the results. Cox, Mujika, Tumilty and Burke (2002) devised a study which tested Cr supplementation (20g a day) or placebo (20g glucose a day) on 14 elite female soccer players from the Australian institute of sport (AIS) using a soccer simulated protocol. The experimental design consisted of two trials before and after Cr or placebo over a 6 day period. The protocol consisted of fifty five 20m sprints, ten agility runs and a precision ball kicking drill which are separated by recovery walks, jogs and runs. The main findings in this study were that the average 20m sprint time in the Cr group decreased from 3.75 Â ± 0.19 to 3.69 Â ± 0.18s however this decrease in sprint time failed to reach the statistical significance level (p Cox et al (2002) also incorporated a standardised training regime and a controlled diet for the intervention week and also scheduled testing so that it would occur at the same time of day before and after supplementation. In contrast Mujika et al (2000) failed to utilise effective standardised procedures during their experimental design. As previously mentioned Mujika et al (2000) testing procedures took place 3 days after the subjects season had finished therefore training was not standardised due to the fact that subjects had no organised training sessions during the intervention week. Mujika et al (2000) also lacked a familiarisation trial, subjects were only familiarised with the testing procedures prior to arriving for the 1st trial which could substantially affect the results. However although Cox et al (2000) standardised procedures by included a controlled diet for the subjects, it is interesting to note that one of the subjects was a vegetarian, whos Cr content is virtually zero (Greenhaff, 1997). Research has found that vegetarians respond quicker and more effectively to Cr supplementation than those who follow a normal sedentary diet and have natural muscle creatine content (Burke, Chilibeck, Parise, Candow, Mahoney Tamopolsky., 2003; Watt, Garnham Snow, 2004) therefore scrutinising the validity of the results. It may be of future reference to eradicate vegetarians in a experimental design which utilises Cr supplementation due to the diet implications that vegetarians have. Soccer Simulation performance tests To date there has been a number of soccer simulation performance tests which have been utilised to assess and measure different physiological aspects of the game (Bangsbo and Lindquist, 1992; Cox, 2002; Drust, Reilly and Cable, 2000; Nicholas, Nuttall and Williams, 2000). These protocols have been implemented so that they take into consideration different aspects of soccer performance and try to replicate the exercise patterns that are observed during match play, however due to the spontaneity of the soccer it is difficult to assess every physical or metabolic demand (Drust, Reilly and Cable, 2000). Researchers have used different protocols when investigating the metabolic and physical demands of soccer, these can documented into laboratory based protocols (Drust, Reilly and Cable, 2000; Thatcher and Batterham, 2004) and field based protocols (Bangsbo and Lindquist, 1992; Cox, 2002; Nicholas et al 2000). Laboratory based soccer performance protocols Drust, Reilly and Cable (2000) devised a laboratory based protocol on a motorised treadmill what represented the work rates that are observed during soccer match play. For the experimental design 7 male university soccer players (24 Â ± 2 years) were used and the testing consisted of three separate testing blocks which were separated by 6 days. The protocol consisted of the different exercise intensities that are utilised during soccer match play; this consisted of walking, jogging, cruising and sprinting. The speeds at which these exercises were performed on the treadmill were consistent with speeds observed by Van Gool, Van Gervan and Boutmans (1988) during a match analysis. Each testing block consisted of two 22.5 minute cycles which consisted of 23 bouts which were followed by a recovery period of 71 seconds. During each bout the duration of each activity was as follows: walking 35 seconds (s), jogging 50.3s, cruising 51.4s and sprinting 10.5s. However in relevance to this research project it should be noted that the duration covered during the sprint bouts of the protocol of Drust, Reilly and Cable (2000) which is 10.5s does not successfully coincide with match analysis from several soccer studies that have documented the duration of sprint bouts during soccer match play. Research has found that the average sprint time during soccer match play lasts between on average two to four seconds in duration (Bangsbo, Norregard Thorso,1991; Mayhew and Wenger, 1985) therefore concluding in some instances Drust, Reilly and Cables (2000) laboratory based soccer specific protocol can be deemed as in valid as it fails to accurately replicate different soccer performance variables that take place in match play. Another lab based test that was utilised to measure specific variables in soccer performance was devised by Thatcher and Batterham (2004). For this protocol six male professional soccer players were used and the testing consisted of 29 minute exercise bouts on a non motorised treadmill that focused on replicating different speeds, durations, distances and heart rates that occur during soccer match play. Findings from this study suggest that the protocol that was utilised induced a similar physiological load to soccer match play and can be determined as a valid measure of soccer performance. Although lab based soccer specific protocols have been found to replicate some instances of soccer performance it is of consideration of this research project that the limitations and positives of such protocols be noted. The aforementioned lab based failed to perform a re-test procedure to conclude whether their protocols maintained reliability therefore the amount of error in each protocol cannot be determined. Another limitation of lab based testing is that due to tests being performed on treadmills, this limits the subjects to straight-line running only, therefore does not take into consideration lateral movements and agility patterns, which have found to be major characteristics of soccer performance (Bangsbo and Lindquist, 1992). These unorthodox movement patterns need to be taken into consideration when assessing soccer performance as they increase energy expenditure significantly (Nicholas et al., 2000). One positive aspect of lab based protocols are that procedures such as a ir temperature, equipment utilised and humidity can be easily standardised to remain constant throughout performance testing. Field Tests Nicholas et al (2000) devised the Loughborough Intermittent Shuttle test (LIST) to simulate the activity patterns during a game of soccer. The LIST consisted of two separate stages which were known as part A and part B. Part A lasted 70 minutes and consisted of five 15 minute exercise pe

Private Hospitals for Undergraduate Medical Training

Private Hospitals for Undergraduate Medical Training Private Hospitals for undergraduate medical training an untapped resource in Ireland. Introduction Undergraduate medical education and training is a subject of considerable importance in relation to the quality of learning and teaching opportunities for students, and the ability of the learning environments to support the development of clinical skills and knowledge, professional practice and patient-focused high quality care delivery. The Irish context presents a particular challenge due to changes in the organisation and delivery of medical care into two distinct sectors, private or public, which alters the opportunities offered for medical student experience and focuses services in different ways. While the acute care sector (public) is the one in which most medical students train, it is apparent that there are opportunities to be gained from utilising private hospital and medical locations as well, in order to expose medical students to the widest possible and available medical expertise. However, the quality of the experience in such locations may be questionable, and the ran ge of experiences available may be severely limited A review of the literature pertaining to the title will demonstrate some of the key issues around this topic, drawing on literature from the UK and internationally, due to the commonalities in medical education structure, form and pedagogy that are found globally, and in particular, referring to the UK model as being the one which dominates still even in the Irish medical education sector. Discussion Due to changes in the healthcare structure in Ireland private, there has been a split in the way that doctors provide acute medical and surgical care services. Within Ireland in the healthcare model which has evolved, there are now public only or private only contracts for consultants, meaning that consultants cannot work across both sectors. Prior to this change, a doctor could work across both sectors, meaning that while they could engage in the public sector work that is the meat and drink of medicine and surgery, most consultants made their money in private hospitals, leaving their NCHD team to do their public work. However, the challenges this change poses for the way in which medical education is delivered in Ireland have not really been picked up on in the literature, and so an exploration of pertinent literature, in the light of the author’s contextual knowledge, is important, to explore this impact and to appreciate the scope and opportunities inherent within the new structure. There is some evidence that the changes to medical education, whilst global, are very real in the Irish context. The issues affecting medical education include â€Å"increasing service demands on clinical teachers, the need for shared teaching among different health-related disciplines, the need to incorporate modern educational principles and technologies, adapting to changing societal views of health and disease and the demand for health professionals to be more accountable.†[1] Issues such as professionalism and widening understanding of diversity are inherent in these issues. What this suggests, among other things, is that in order to make best use of the existing resources, areas still untapped need to be accessed, and at the same time, the way that medical ‘education’ is delivered needs to evolve.[2] Up until the present day, the private hospitals have not really been involved in med education. However, now they are currently making associations with universities who are eager to tap this resource, in order to make use of the private hospital setting for clinical experiences for medical students (and other healthcare students). It could be posited that these hospital present a hitherto untapped resource, full of opportunities, but also as a point of great scope for development of new ways of thinking about and providing more appropriate forms of education. As a public private system becomes more defined we need to start using the private sector to teach medical students. This is particularly important as there have been, recently, significant increases in the numbers of medical students[3], with public sector hospitals overwhelmed by medical student numbers, exacerbated by graduate entry into medicine adding to the larger and more diverse pool.[4] This may be affecting the qualit y of their learning, and also the quality of care provision.[5] There are, however, challenges, because as an unused resource, and an untested learning environemtn, there are not the internal resources, skills, systems and the like already in existence to support the influx of medical students. Similarly, there are lots of new private hospitals opening that are not used for teaching, and these hospitals are not equipped for teaching. This is something to bear in mind, and there is a need to identify the requirements of a hospital being equipped for medical student teaching and learning. Basic needs would be structural, such as the provision of a student centre, student accessible IT services, student support, changing rooms, training laboratories, and the like. Some of the major concerns are that private hospitals not equipped and did not make considerations for medical student education at the design phase, meaning that making them primary locations for medical student clinical experience could be very challenging and costly. There is also the issue private patients may not welcome students, particularly as they have paid for their care and so want complete control over it. This may mean students being excluded from key experiences. However, all patients in public sector healthcare have the option to not have students present, so this may not be insurmountable, but it would require rewriting protocols, mission statements, and the like to include an educational component. Another concern is the fact that private hospitals have not yet got to the same level of provision or range of clinical disciplines as public ones. For example, very few have intensive care departments, full time 24/7 consultant cover, emergency departments or major trauma units. Therefore the casemix of patients is elective, and limited, and students if only placed in private hospitals, will not be exposed to emergency. However, the contrary is also true as public teaching hospitals are now getting less elective patients for routine surgeries such as cholecystectomies and hernias. There is evidence to suggest that the relevance of the training medical students receive is of some importance to the quality of their experience and their future skills.[6] There could, therefore, be an argument for cross-sector placements, on rotation, with students doing different placements in different hospitals. This may have the advantage of exposing students to a wider socio-cultural mix of patient s as well as a wider pool of medical expertise, both of which may be of significance in the requirements of medical staff in the current climate.[7] Certainly, there is an emergence of a need to develop more creative approaches to clinical medical education which address the social and societal issues affecting health and illness as well as the medical knowledge itself.[8] This is evident in the emergence of debate around professionalism and professionalisation/socialisation of medical students into their profession, but also into the wider healthcare workforce. While traditionally, medicine has enjoyed a hegemonic position with near godlike autonomy[9], things have changed and new ways of viewing the medical profession have emerged. This has included a demand for more transparent, ethical practice, for doctors to view patients as individuals within their personal, social context, and the need for doctors to demonstrate respect for others, teamworking skills, and more self-awareness and increased awareness of social responsibility.[10] It also includes the reflexivity and awareness required to underpin the development of clinical decision making and problem solving skills, in general, and in application to particular disciplines and cases.[11] These notions of professionalism and reducing the divide between physician and patient are deemed important fo r the profession, as long as professional standards are also maintained.[12] This is where the challenge seems to reside, in providing medical students in Ireland with the scope to develop their professional knowledge and skills, along with the development of themselves, and their professional role, across two radically different healthcare provision domains.[13] Yet the research shows that it is the quality of the clinical or practical experience that medical students have which affects both aspects of their development, their clinical skills and their professionalism.[14] Medical education has moved away from the didactic forms that have characterised it for centuries towards a more interactive, student-centred type of training, although not as far as the other healthcare professions have.[15] Therefore, developing the private sector provision could serve a number of purposes, not just providing a useful place for the runoff of extra students currently flooding the public sector h ospitals. It could provide the opportunities for students to be assessed in skills and attributes relevant to each sector, as well as each individual case they are addressing. This would represent a more individualised approach to medical education.[16] There is a high likelihood of a considerable amount of resistance to such a reorientation, however, because the traditional, hierarchical and hegemonic structures of the medical profession will not be easily overcome.[17] What changes there are may not be fully bedded down within the Irish healthcare sector.[18] There is also the challenge of ensuring that there are adequate clinical educators available or even employed within this sector.[19] However, it would also be important to consider the impact of a large amount of private sector clinical experience on the professional development and socialisation of medical students, because much of this occurs within the institutional setting and is affecting by that setting, by the organisational culture, and by the behaviours of others within that setting.[20] Therefore, if students are modelling themselves primarily on what they are seeing within the private sector, this exposure could be detrimental, in the long run, to their professionalism, their awareness, and the ways that the work with others.[21] The nature of medical education itself is one which may need to change, to reorient itself to a different model of teaching and learning which is more appropriate to modern day medicine[22]. â€Å"Continued efforts are needed to reduce the factual load of the curriculum.†[23] It is apparent that in the current climate, with rapid developments in science and technology applied to medicine, and the increasing speed of these developments, that delivering a didactic curriculum is not practical, and instead, medical schools need to be able to â€Å"equip students with the skills and attitudes needed to cope with rapid change and lifelong learning.†[24] This includes students learning how to learn in a self-directed, more autonomous way,[25] which would then help to overcome the differences between the sectors and support students in cross-sector working and identifying the learning and development opportunities specific to each. However, the literature shows that in Ireland (as in many other places), the nature of medical education remains quite didactic and offers only limited opportunities for students to work in alternative ways. Yet the requirement for personal and professional development has already begun to be realised in the UK and Ireland, and as such the groundwork has already been laid.[26] Similarly, literature shows that medical student learning differs depending on the clinical environment,[27] which may be related to the culture of the environment and the purpose of the medical provision,[28] and if this is the case, then a great deal of research will be needed, along with ongoing evaluation, in order to assess the impact of the use of private sector hospitals within Ireland. The literature demonstrates that new ways of learning can be developed and implemented, based on more social, interactive, collaborative models[29], such as the development of communities of practice.[30] In this case, such communities would need to span the different sectors effectively, and overcome the differences between them, but these could expand to make better use of and collaborate more effectively with the training of interprofessional colleages[31]. This raises the question of whether there are the skills, capacity and even inclination to develop medical education along such lines, a lthough the ongoing benefits of communities of practice would be exponential.[32],[33]. The need for medical students to emerge as knowledgeable professionalss with the requisite understanding and skills must not be overlooked.[34],[35] Conclusion It would appear that there is a great untapped potential in the use of private sector hospitals in the Republic of Ireland to supplement medical student education by providing clinical locations for practice-based learning. However, this learning may need to be located in a different paradigm to the traditional medical apprenticeship model that has dominated this sector to date. The private sector hospitals would need to be come part of the partnership teams with universities and public sector hospitals. They would need to develop the facilities and infrastructure to support medical students. Medical students would gain a lot from such placements, but it would appear to be best that these form part of a cross-sector rotation of placements, rather than a private setting constituting their dominant clinical learning setting. The ways in which medical students are ‘taught’ would also need to change, to become more focused on personal and professional development, self-directed learning, and on all the elements of being professional in relation to current definitions of the word, and the social expectations placed upon healthcare professionals. Research is required into how private sector hospitals can be used, how medical education is changed by this and will change the nature of these locations, and how different approaches to new pedagogies will benefit medical students overall. The impact of these changes on professionalism, and the resistance from the profession, will also need to be considered. Ultimately, private hospitals can support the current provision, but the nature of the healthcare provision in Ireland would have to be considered also in the light of international models and how it intersects with these. 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General Medical Council (2002) Tomorrow’s doctors: recommendations on undergraduate medical education. London: GMC. Gordon, J. (2003) Fostering students’ personal and professional development in medicine: a new framework for PPD. Medical Education 37 (4) 341-349. Hilton, S.R. and Slotnick, H.B. (2005) Proto-professionalism: how professionalisation occurs across the continuum of medical education. Medical Education 29 58-65. Howe, A., Campion, P., Searle, J. and Smith, H. (2004) New perspectives approaches to medical education at four new UK medical schools. BMJ 329 327-331. Irvine, D. (1999) The performance of doctors: new professionalism. Lancet 353 1174-1177. Littlewood, S., Ypinazar, V., Margolis, S.A. et al (2005) Early practical experience and the social responsiveness of clinical education: systematic review. BMJ331 387-391. Lloyd Jones, M. (2005) Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis. Journal of Advanced Nursing 49 (2) 191-209. McMahon, T. (2005) Teaching medicine and allied disciplines in the 21st century lessons for Ireland on the continuing need for reform. Radiography 11 61-65. Medical Council (2001) Review of medical schools in Ireland Dublin: Medical Council. Moercje, A.M. and Elika, B. (2002) What are the clinical skills levels of newly graduated physicians? Self-assessment study of an intended curriculum identified by a Delphi process. Medical Education 36 472-478. Norman, G. (2002) Research in medical education: three decades of progress. BMJ 324 1560-1562. Nuffield Trust (2000) University Clinical Partnership: Harnessing Clinical and Academic Resources London: Nuffield Trust Working Group on NHS/University Relations. Ostler, D.T., (2005) Flexner, apprenticeship and ‘the new medical education.’ Journal of the Royal Society of Medicine 98 91-95. Perkins, G.D., Barrett, H., Bullock, I. et al (2005) The Acute Care Undergraduate Teaching (ACUTE) Initiative: consensus development of core competencies in acute care for undergraduates in the United Kingdom. Intensive Care Medicine 31 1627-1633. Rogers, J.C., Swee, D.E. and Ullian, J.A. (1991) Teaching medical decision making and students’ clinical problem solving skills. Medical Teacher 13 157-164. Satran, L., Harris, I.B., Allen, S. et al (1993) Hospital-based versus community-based clinical education: comparing performances and course evaluations by students in their second-year pediatrics rotation. Acad Med 68 380-382. Sinclair, S. (1997) Making doctors: an institutional apprenticeship Oxford: Berg. Smith, T. and Sime, P. (2001) A survey of clinical academic staffing levels in UK medical and dental schools: a report to the Council for Heads of Medical Schools London: Council for Heads of Medical Schools. Stewart, J., O’Halloran, C., Harrigan, P. et al (1999) Identifying appropriate tasks for the preregistration year: modified Delphi technique. BMJ 224-229. Swick, H. (2000) towards a normative definition of medical professionalism. Acad Med. 75 (6) 77-81. Thakore, H. and McMahon, T. (2006) Sink or swim: the future of medical education in Ireland. The Clinical Teacher 3 129-132. Wenger, E.C. and Snyder, W.M. (2000) Communities of practice: the organisational frontier. Harvard Business Review 78 (1) 139-147. Williams, G. and Lau, A. (2004) Reform of undergraduate medical teaching in the United Kingdom: a triumph of evangelism over common sense. BMJ 329 92-94. Worley, P., Esterman, A. and Prideaux, D. (2004) Cohort study of examination performance of undergraduate medical students learning in community settings. BMJ 328 207-209. Footnotes [1] Finucane, P. and Kellet, J. (2007) [2] Thakore, H. and McMahon, T. (2006) [3] Bligh, J. (2004) [4] Thakore, H. and McMahon, T. (2006) [5] Bligh, J. (2004) [6] Chastonay, P., Brenner, F., Peel, S. and Guilbert, J-J. (1996) [7] Dogra, N., Conning, S., and Gill, P. (2005) [8] Department of Health (2004) [9] Hilton, S.R. and Slotnick, H.B. (2005) [10] Hilton, S.R. and Slotnick, H.B. (2005) [11] Rogers, J.C., Swee, D.E. and Ullian, J.A. (1991) [12] General Medical Council (2002) [13] Arnold, L. (2002) [14] Littlewood, S., Ypinazar, V., Margolis, S.A. et al (2005 [15] Norman, G. (2002) [16] Ostler, D.T., (2005 [17] Williams, G. and Lau, A. (2004) [18] Currie, G. and Suhomlinova, O. (2006) [19] Smith, T. and Sime, P. (2001) [20] Sinclair, S. (1997) [21] Swick, H. (2000) [22] Howe, A., Campion, P., Searle, J. and Smith, H. (2004) [23] Medical Council (2001) [24] Medical Council (ibid) [25] Dornan, T., Hadfield, J., Brown, M. et al (2005) [26] Gordon, J. (2003) [27] Worley, P., Esterman, A. and Prideaux, D. (2004) [28] Satran, L., Harris, I.B., Allen, S. et al (1993) [29] Perkins, G.D., Barrett, H., Bullock, I. et al (2005) [30] Wenger, E.C. and Snyder, W.M. (2000) [31] Lloyd Jones, M. (2005) [32] Wenger, E.C. and Snyder, W.M. (2000) [33] Nuffield Trust (2000) [34] Moercje, A.M. and Elika, B. (2002) [35] Irvine, D. (1999)

Hester as A Self-Reliant Character Essay -- essays research papers

Individualism in a Society-Based World   Ã‚  Ã‚  Ã‚  Ã‚   In a society-centered world, living as self-reliant can be a difficult task to accomplish because society puts pressure on its members to conform to its standards. Nonconformists are eluded by society and consequently have difficulty retaining their nonconformist position. According to Ralph Waldo Emerson’s â€Å"Self Reliance†, those who express themselves and dismiss the role of consistency are misunderstood, but great and as a result will ultimately rise in a â€Å"morally perfect,† but hypocritical society. In Nathaniel Hawthorne’s Scarlet Letter, Hester Prynne was created as a self-reliant character that indirectly exploits the flaws and hypocrisy of Puritan society, as well as to prove Hester as a survivor. In addition to Hester and self-reliance, Hawthorne reveals the hypocrisy of Puritan society.   Ã‚  Ã‚  Ã‚  Ã‚   Hester is a symbol of self-reliance because she resumes wearing the scarlet letter â€Å"A,† a symbol of her adulterous act and she stayed loyal to herself by daring to live beyond the petty rules of Puritan society. She is obviously not repentant, as she chooses to remain in Boston, even when she is free to go elsewhere and start a new life. â€Å"Here had been the scene of her guilt, and here should be the scene her earthly punishment; and so perchance, the torture of her daily shame would at length purge her soil, and work out another purity than that which she had lost; more saint-like bec...

Essay on The Holy Bible - The Nature of God in Genesis -- Holy Bible G

The Nature of God in Genesis  Ã‚   The depiction of God in the Bible’s story of creation, namely Genesis, brings to mind the image of an omnipotent, almighty and all-powerful child playing in a sandbox. Like a child his sole purpose seems to be to simply amuse himself, and possibly acquire a source of unconditional love. These needs are in contrast to the classic view of God acting with the idea of an ultimate plan. His actions clearly show that there is no perfect plan, or if there is it must be grossly overcomplicated. Consistently God makes poor decisions, and then eventually acts to fix the situation. The whole scenario conjures up an image of the crew of Apollo 13, alternately breaking things and then patching it together with duck tape.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   God’s initial idea was a good one. He was alone in the void. Either out of boredom or perhaps out of a need to have someone else to confirm his greatness, he creates the Earth, plants, animals and most important (both for the sake of this argument and in God’s own mind) mankind. By design, man is supposed to be ignorant. So, for a time, God is happy and he has a source of praise. This is a rather mundane existence, however. As any kid will tell you, the game is no fun if you know you are going to win. Sure, it’s amusing for a while, but in the long run what the hell good is it? The game, in this case, is life, namely God’s life. (If that concept strikes you as odd, feel free to call it God’s existence) In any case, God makes sure there is temptation for man. It’s no accident that Adam and Eve have been made to live in close proximity to the one thing that is forbidden to them, the tree of knowledge. God wants his children to not o... ...en dominion over animals, which is completely different. Dominion would mean that mankind were the keepers of animals, looking after them essentially. With Noah, God specifically says that the animals will fear man, and they will provide mankind with food. Once again, this forces us to ask why God didn’t just do this in the first place, with Adam? Once again this indicates not a plan on the part of God, but more like him throwing things together on the fly.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   If God does have a plan, it seems to hold mankind’s welfare in little regard. A great example of this is the tower of Babel, where God willfully acts to destroy the clear progress of man. If God is not interested in mankind’s evolution, then it seems very clear to me that we should have as little to do with him as possible. It appears to be working so far.    Essay on The Holy Bible - The Nature of God in Genesis -- Holy Bible G The Nature of God in Genesis  Ã‚   The depiction of God in the Bible’s story of creation, namely Genesis, brings to mind the image of an omnipotent, almighty and all-powerful child playing in a sandbox. Like a child his sole purpose seems to be to simply amuse himself, and possibly acquire a source of unconditional love. These needs are in contrast to the classic view of God acting with the idea of an ultimate plan. His actions clearly show that there is no perfect plan, or if there is it must be grossly overcomplicated. Consistently God makes poor decisions, and then eventually acts to fix the situation. The whole scenario conjures up an image of the crew of Apollo 13, alternately breaking things and then patching it together with duck tape.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   God’s initial idea was a good one. He was alone in the void. Either out of boredom or perhaps out of a need to have someone else to confirm his greatness, he creates the Earth, plants, animals and most important (both for the sake of this argument and in God’s own mind) mankind. By design, man is supposed to be ignorant. So, for a time, God is happy and he has a source of praise. This is a rather mundane existence, however. As any kid will tell you, the game is no fun if you know you are going to win. Sure, it’s amusing for a while, but in the long run what the hell good is it? The game, in this case, is life, namely God’s life. (If that concept strikes you as odd, feel free to call it God’s existence) In any case, God makes sure there is temptation for man. It’s no accident that Adam and Eve have been made to live in close proximity to the one thing that is forbidden to them, the tree of knowledge. God wants his children to not o... ...en dominion over animals, which is completely different. Dominion would mean that mankind were the keepers of animals, looking after them essentially. With Noah, God specifically says that the animals will fear man, and they will provide mankind with food. Once again, this forces us to ask why God didn’t just do this in the first place, with Adam? Once again this indicates not a plan on the part of God, but more like him throwing things together on the fly.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   If God does have a plan, it seems to hold mankind’s welfare in little regard. A great example of this is the tower of Babel, where God willfully acts to destroy the clear progress of man. If God is not interested in mankind’s evolution, then it seems very clear to me that we should have as little to do with him as possible. It appears to be working so far.   

Aryabhatta Biography Essay

While there is a tendency to misspell his name as â€Å"Aryabhatta† by analogy with other names having the â€Å"bhatta† suffix, his name is properly spelled Aryabhata: every astronomical text spells his name thus, including Brahmagupta’s references to him â€Å"in more than a hundred places by name†. Furthermore, in most instances â€Å"Aryabhatta† does not fit the metre either. Time and place of birth Aryabhata mentions in the Aryabhatiya that it was composed 3,630 years into the Kali Yuga, when he was 23 years old. This corresponds to 499 CE, and implies that he was born in 476. Aryabhata was born in Taregna (literally, song of the stars), which is a small town in Bihar, India, about 30 km (19 mi) from Patna (then known as Pataliputra), the capital city of Bihar State. Evidences justify his birth there. In Taregna Aryabhata set up an Astronomical Observatory in the Sun Temple 6th century. There is no evidence that he was born outside Patliputra and traveled to Magadha, the centre of instruction, culture and knowledge for his studies where he even set up a coaching institute. However, early Buddhist texts describe Ashmaka as being further south, in dakshinapath or the Deccan, while other texts describe the Ashmakas as having fought Alexander. Education It is fairly certain that, at some point, he went to Kusumapura for advanced studies and lived there for some time. Both Hindu and Buddhist tradition, as well as BhÄ skara I (CE 629), identify Kusumapura as PÄ Ã¡ ¹ ­aliputra, modern Patna. A verse mentions that Aryabhata was the head of an institution (kulapati) at Kusumapura, and, because the university of Nalanda was in Pataliputra at the time and had an astronomical observatory, it is speculated that Aryabhata might have been the head of the Nalanda university as well. Aryabhata is also reputed to have set up an observatory at the Sun temple in Taregana, Bihar. Other hypotheses Some archeological evidence suggests that Aryabhata could have originated from the present day Kodungallur which was the historical capital city of Thiruvanchikkulam of ancient Kerala. For instance, one hypothesis was that aÅ›maka (Sanskrit for â€Å"stone†) may be the region in Kerala that is now known as Koá ¹ ­uá ¹â€¦Ã¡ ¹â€¦allÃ… «r, based on the belief that it was earlier known as Koá ¹ ­um-Kal-l-Ã… «r (â€Å"city of hard stones†); however, old records show that the city was actually Koá ¹ ­um-kol-Ã… «r (â€Å"city of strict governance†). Similarly, the fact that several commentaries on the Aryabhatiya have come from Kerala were used to suggest that it was Aryabhata’s main place of life and activity; however, many commentaries have come from outside Kerala. Aryabhata mentions â€Å"Lanka† on several occasions in the Aryabhatiya, but his â€Å"Lanka† is an abstraction, standing for a point on the equator at the same longitude as his Ujjayini. Works Aryabhata is the author of several treatises on mathematics and astronomy, some of which are lost. His major work, Aryabhatiya, a compendium of mathematics and astronomy, was extensively referred to in the Indian mathematical literature and has survived to modern times. The mathematical part of the Aryabhatiya covers arithmetic, algebra, plane trigonometry, and spherical trigonometry. It also contains continued fractions, quadratic equations, sums-of-power series, and a table of sines. The Arya-siddhanta, a lot work on astronomical computations, is known through the writings of Aryabhata’s contemporary, Varahamihira, and later mathematicians and commentators, including Brahmagupta and Bhaskara I. This work appears to be based on the older Surya Siddhanta and uses the midnight-day reckoning, as opposed to sunrise in Aryabhatiya. It also contained a description of several astronomical instruments: the gnomon (shanku-yantra), a shadow instrument (chhAyA-yantra), possibly angle-measuring devices, semicircular and circular (dhanur-yantra / chakra-yantra), a cylindrical stick yasti-yantra, an umbrella-shaped device called the chhatra-yantra, and water clocks of at least two types, bow-shaped and cylindrical. A third text, which may have survived in the Arabic translation, is Al ntf or Al-nanf. It claims that it is a translation by Aryabhata, but the Sanskrit name of this work is not known. Probably dating from the 9th century, it is mentioned by the Persian scholar and chronicler of India

Book Critique on Sharing Jesus Without Fear

Liberty Theological Seminary Book Critique Sharing Jesus without Fear A Paper Submitted to Dr. Gregory Hammond In Partial Fulfillment Of the Requirements for the Course Contemporary Evangelism Evan 565 Bibliographical Information Fay, William and Linda Evans Shepherd, â€Å"Sharing Jesus Without Fear†, B&H Publishing Group, Nashville, Tennessee, 1999. Author Information William Fay, author of Sharing Jesus without fear, shares his testimony in the beginning of his book. Fay was once president and CEO of a large company. This was not all that he dabbled in as he had ties to illegal activities such as racketeering, bookmaking, gambling, and even ran a house of prostitution. (Fay,1) According to Fay, he felt at this time in his life he had everything that life could offer. The expensive watches, money, multiple marriages, but this trend in his life did not continue. Fay, eventually came to Jesus Christ and went to Denver Seminary, and now is an evangelist that travels throughout the U. S. Content Summary Fay states at the very beginning what the purpose of his work. He states that it’s objective is to provide liberty and to build the believer so he can present the Gospel and not fail. (Fay, Preface) The book is broken down into 11 chapters each dealing with aspects when presenting the Gospel. Fay starts with establishing the fact that just because you present the Gospel and someone does not respond it does not mean that you failed. Success when it comes to the Gospel is presenting the Gospel and living out the Gospel. Fay points to the fact that it boils down to obedience. The next couple of chapters, Fay address the issue of not sharing the Gospel and common objections and fears that Christians have when presenting the Gospel. In Chapter 2, the author states that we must repent of the sin of silence. Christians, who never discuss the Gospel, instead talk about unsaved world, but does nothing about it. In this same chapter the author tries to instill in the believer to see the vision that Jesus Christ has for the world and for us to share this same message with the world that can change their life. Fay advocates there are some Christians that will tell people they will pray for them and perform other nice gestures, but never share the Gospel at all. Fay stress that believers need to escape from this philosophy and see the need to reach people in their need. The next chapter in Fay work addresses common objections or fears that Christians have when it comes to witness. Fay in Chapter 3 present the question is it the Christian responsibility to share the Gospel if so then why are we not doing so. He goes through several reasons why we might not share the Gospel. Some of the objections are as follows: afraid of rejection, what friends might think, and not knowing enough scripture knowledge to highlight some. Fay advocates that it is time for the Christian to drop the excuses. He also states in this chapter if the Christian wants to see true joy in his life then the Christian needs to start sharing his faith with others. (Fay,28) The rest of his book is dedicated to explaining his philosophy and approach when it comes to sharing the Christian faith. Fay takes the next several chapters in particular 4-6 sharing the format which he uses and encourages believers to follow as well. He starts off in Chapter 4 how to lead a conversation to discuss spiritual matters. He shares several icebreakers that can be used to lead a conversation to spiritual matters. He also shares in this chapter that 5 simple questions can be asked that will open the conversation towards the topic of Jesus Christ. The difference is that the believer is not to argue or defend right away, but to simply listen. The next chapter deals with the power of the Gospel and as one are engaged in a spiritual conversation to introduce scripture, but have the person read it for themselves and not explain it. Let scripture speak for itself and let the Holy Spirit do the work of convicting. His last chapter in regards to presenting the Gospel is to bring the discussion to a decision and asking several more questions about making a decision. The questions are as follows: are you a sinner, do you want forgiveness of sins, do you believe Jesus died on the cross for your and rose again, are you willing to surrender your life to Jesus Christ, and are you ready to invite Jesus into your life and into your heart. (Fay, 62-63) At this point in the conversation Fay charges the believer to be quiet and not say anything and let God work. In the final several chapters of Fay book, he addresses common objections raised by those who chose not to receive Christ and how to address those objections. He list 36 common objections as the ones that are the most prominent. Fay also states that when addressing objections to make sure that one asks the question why. If we are quick to defend we might not get the right answer, but rather asking why usually reveals the reason and we can try to address it. The last two chapters of his book deal with having a mixture of Christian and non-Christian friends and how our lives around our non-Christian friends can make an impact. As well, he does cover how to pray for the lost and follow a simple plan to follow to pray for them using a seven day model. His last chapter deals with more of an exhortation to go and start sharing our faith with the lost. His last question he poses before closing the chapter is does the believer talk to the lost or about them which was his main question in the beginning of his work. Evaluation In examining, â€Å"Sharing Jesus without Fear† one should have some heighten confident in regards to sharing the Gospel. The author’s original intend for this book is freedom and confidence when presenting the Gospel. The author takes the approach in his work to start when Christian are at, and charges them to break from silence. Author does relieve the Christians of undue pressure that a belief might feel in regards to witness. He states that we are just obeying Jesus Christ my sharing the message that He left for us. It is not about how many we can stuff into a church or put on a badge of honor like we accomplished the work ourselves. The question is will the believer respond to the call of Jesus Christ. He states that a lot Christians are not following the command of Jesus Christ and a lot of Christians are afraid. The author does not cite any surveys to proof this, but giving the condition of society today, it is probably an accurate statement. He does address the common objections or reasons why Christians do not go out and share the Gospel with several scripture passages that address each reason why believers do not share their faith like they should. He also explains that God promises the believer that he will be with us when the believer shares his faith. To site another problem that believers have when presenting the Gospel, is how to introduce the topic without being to obtrusive. He gave some examples of icebreakers or ways to lead a conversation to the desire result of sharing the Gospel. What is unique about the author approach to the topic is his simple, but direct approach to the Gospel. The states the five questions he asked acts as guide to get to the heart of the matter which would be sharing the Gospel. He says by asking these questions people are more open then we realize and willing to share their personal beliefs. The comforting point he makes is that Christians are to share and live out the Gospel. The book takes on more of a practical tone. Basically, the whole of idea is that sharing the Gospel does not have to be so complex and overwhelming as it seems as it is made out to be. The author teaches the believer that sharing the Gospel will bring joy that is sometimes missing from the believer life. The believer can share the message of the cross quietly easily without fear knowing that God is there to support the believer and success of the presentation is not depended on the fact that the person comes to Christ or not. Success for the believer is that fact that he we went out and obeyed Christ and if it results in a person coming to the knowledge of Jesus Christ then that is a blessing. A couple of items worth highlighting showing some elements that are quite good. The redefining of what success is in terms of witness. The second is the how approach to witness by asking the five questions and just listen and not interrupting which is the hardest thing to do. Another element of his presentation is the use of scripture. Have the person read it for themselves and discover the meaning of the passage by having the Holy Spirit illuminate their minds to the truth of the Gospel. Finally, the common objections that often that do come up are worth taking the time to read, and see if the responds are really helpful when a believer is in a conversation with an unbeliever. Some negative aspects of the book are as follows. First, there were very few references to other materials to support some of his claims. For example, the most common reason believers do not share their faith. He never indicated that he took a poll. Secondly, the author makes an assumption that a Christian can not experience joy unless he shares the Gospel. (p. 27) The author makes this statement, but does not support this statement with other believers’ testimonies nor with Scripture. The demographic of the person who should read this book is a believer wanting to share their faith, but does not know how. This resource offers innovate way in expressing what has changed the believers heart. This could also be taught to an entire church on how to start an evangelism program. This philosophy can be implemented right away into an every day conversation. A person would probably need to read through the work possibly twice to fully understand the concepts being presented and to see how to implement them into their daily lives. It would have to become part of them. This book helps clarify a simple way to share the faith. There are a multiple of programs, methods, and marketing technique that are available to sharing the Gospel these days. However, the approach that was examined in â€Å"Sharing Jesus without Fear† alleviates the pressure that some might feel to follow a system. This system is heavily dependent on the scripture and the work of the Holy Spirit to do the convicting. It really does help me to understand that the Gospel can be shared virtually anywhere without being so in the face of people. This is opening a door to ask someone to share what they believe with the believer and in return showing the true. Instead of saying out from the beginning, you are going to hell. It does take evangelism in a different direction and his emphasis on living out the Gospel. To having a powerful impact in regards to the Gospel one must be living it and this is so important. Having the balance is what will make the difference.