Napster essays

Napster essays There are many different controversies when consulting the topic on Napster. Napster is a computer program that lets people download mp3 music files from other people with the program. Lots of people and music companies believe that this is bad and Napster should be stopped or should charge people. Many other people believe that that Napster is a good thing and should remain free of charge. There are many people who think that the way Napster is distributing music is bad. One reason they think it is bad is because they consider it stealing the copyrighted music. These people also believe that Napster should be shut down or they should start to charge people for the service. The way these people see Napster is that it is stealing their copyrighted music and then distributing it for free. There are other people who believe that Napster is a good thing and should stay the way it is, free of charge. These people think that the music on Napster is a great way for advertising that is also free. This is also a great way for new bands to get discovered and get more people to listen to them. These are the people that are fighting to try to keep Napster the way it is and keep it free of charge. Napster has gone to court to try and make a deal with the companies and the people against them. Napster has offered to try and block the copyrighted music to make the people happy but that was impossible to block all of them. The court ended up ruling for Napster to start to charge people to use the computer program. In conclusion, even thought there are many different controversies consulting the topic of Napster and the people, the court has now made a decision to make Napster charge people. There are still many people that strongly believe in both sides, but it is just time until Napster has to start charging people. ...

Free Essays on George Meridiths Lucifer In Starlight

GEORGE MEREDITH (1828-1909) "Lucifer in Starlight† When one thinks of Lucifer, they usually envision a large red monster with a tail, breathing fire out of his nose; however, when one is asked what kind of personality Lucifer has, many different ideas come to thought. Some may say he is wicked. Others may say he is jealous. In the sonnet, â€Å"Lucifer in Starlight,† he is described differently. Throughout the sonnet the author uses a structure that is based on the order of primacy, an Italian rhyme pattern, and an undefined meter. He also uses artistic diction to create images, symbols, and a plot theme to help the audience better understand the meaning of his story. In fact, Meredith goes so far to describe the personality of Satan. In many sonnets, authors wrote about love, a feeling, or a place. Meredith took All those ideas farther and created a sonnet based on an event. The structure of the story, is based upon a method I call primacy. This means that what happened first is described first. It is just like telling a bedtime story. One would never tell a young child what happened last before telling him or her what happened first. Meredith did this to capture the interest of the audience. The readers already know that Satan will fail in all his attempts to destroy God, but the story beforehand creates suspense and curiosity. The rhyme pattern begins as an octave, â€Å"ABBAABBA,† form, but by the ninth line changes into a sestet, â€Å"CDCEED,† form. This was typical of the Italian sonnets; however, Meredith was English. When I first read the sonnet, the thing that caught my eye was the meter, or the lack there of. It seemed to me that he decided the story was more important than the meter or flow of the sonnet. This sonnet was written to describe Satan’s evil effort against God, and his inability to win. To analyze the sonnet, one must understand the context, or environment, of the situation. Mere... Free Essays on George Meridith's Lucifer In Starlight Free Essays on George Meridith's Lucifer In Starlight GEORGE MEREDITH (1828-1909) "Lucifer in Starlight† When one thinks of Lucifer, they usually envision a large red monster with a tail, breathing fire out of his nose; however, when one is asked what kind of personality Lucifer has, many different ideas come to thought. Some may say he is wicked. Others may say he is jealous. In the sonnet, â€Å"Lucifer in Starlight,† he is described differently. Throughout the sonnet the author uses a structure that is based on the order of primacy, an Italian rhyme pattern, and an undefined meter. He also uses artistic diction to create images, symbols, and a plot theme to help the audience better understand the meaning of his story. In fact, Meredith goes so far to describe the personality of Satan. In many sonnets, authors wrote about love, a feeling, or a place. Meredith took All those ideas farther and created a sonnet based on an event. The structure of the story, is based upon a method I call primacy. This means that what happened first is described first. It is just like telling a bedtime story. One would never tell a young child what happened last before telling him or her what happened first. Meredith did this to capture the interest of the audience. The readers already know that Satan will fail in all his attempts to destroy God, but the story beforehand creates suspense and curiosity. The rhyme pattern begins as an octave, â€Å"ABBAABBA,† form, but by the ninth line changes into a sestet, â€Å"CDCEED,† form. This was typical of the Italian sonnets; however, Meredith was English. When I first read the sonnet, the thing that caught my eye was the meter, or the lack there of. It seemed to me that he decided the story was more important than the meter or flow of the sonnet. This sonnet was written to describe Satan’s evil effort against God, and his inability to win. To analyze the sonnet, one must understand the context, or environment, of the situation. Mere...

Future of Electronic Commerce Technology Essay Example | Topics and Well Written Essays - 1000 words

Future of Electronic Commerce Technology - Essay Example It allows manufacturers to buy at a low cost worldwide, and it offers enterprises the chance to sell at a global market right from the start. The major change it has gone through since the past 5 years is the growing market opportunity it has provided to the developing countries. E-commerce has helped them enter the prosperous global market place, and so it has helped reduce the gap between rich and poor countries. In the upcoming era the B2B e-commerce would create new and better job opportunities and placements and would be expected to grow at double the rate it is growing today. B2C (Business to Consumer) e-commerce, despite of all the benefits of new technology along with a lot of media attention, is still in its early stages. The reason behind the slow growth of B2C e-commerce is those threats and vulnerabilities that lead to critical security measures in this respect and are creating new risks and hypes for consumers as well as retailers. There is a need to secure online services along with the factor of "availability" as most shoppers prefer to travel umpteen distances rather than to do discounted shopping online, just because of the threat of security issues like hacking, stealing or losing their credit card numbers. This means there is a desperate need to update the security measures of e-commerce and if the issue resolves to some extent, there would be a drastic change in the slow performance of B2C e-commerce in the next 5-10 years. In this respect the upcoming technology would focus more on the client side security than on ordinary security measures. The information would be more protected and secured between the customer's system and the server, which would be seen as an outcome in the form of enhanced retailing and wholesaling. The security issues would be resolved and the threat to hack would be minimized resulting in the benefits of new technology not limited to only e-commerce companies. Consumers would also be empowered with the ability to counter many of the current micro-marketing tools. If the success of online dynamic pricing rests on the asymmetry of information between consumers and retailers, new technology may hold the promise of "blowing" such asymmetries to "bits" (Philip & Thomas, 2000). The explosion of shopping comparison Web sites and the prevalence of "shopping bots" used by consumers to track competitive prices are just two examples of how technology can be used by consumers to combat the potentially exploitive practices of dynamic pricing. (Jason, 2000) The Internet has already revolutionized the world of Investment and finance. E-commerce has enabled online stock trading to be done online by just logging on to the website and making a few key strokes along with few clicks of mouse to identify the stock and number of shares involved in the transaction, one can buy and sell securities in seconds. Several trading platforms has been built in order to revolutionize the concept of stocks and trading, e-commerce has enabled a common man to engage in any type of online business which in the other case had not been possible. However the major issue to be considered behind the spectrum of online trading is

Tax on unhealthy foods Essay Example | Topics and Well Written Essays - 1000 words

Tax on unhealthy foods - Essay Example The government has taken a measure on this issue and has planned on the implementation of a policy towards the imposition of taxes on unhealthy foods so as to promote a healthy living for the people. But this has raised many questions as it is considered an intrusion on the liberty of the people and opponents have argued that every person has the right to choose what is right for them and imposition of taxes will actually open ways for the government to intrude on personal choices. The American Against Food Taxes is an organization which works with the aim of creating awareness amongst all the groups of the society to explain the fact that the imposition of taxes on beverages and foods is not a solution but is rather a creation of a problem for the economy and the people. It explains the fact that the beverage industry has been putting in much effort to support proper health amongst children and individuals. The steps include proper awareness and education accompanied by the labeling of the amount of calories as well as the reduction of calories in the beverages. This has been accompanied by the provision of proper dietary plans for school going children. The advertisement and marketing policy used by The American Against Food Taxes is very efficient and can be graded as A. This is because they have selected the most suitable methods of communication for convincing the readers about their point. The website caters to all the arguments provided in favor of the tax with very good counterarguments which actually tend to put the reader in thought. The advertisements by the agency explain the problems of the common man presenting the fact that such taxes would only burden the people who are already working very hard to meet their financial requirements. It then caters to the requirements of the parents by explaining to them that the implementation of proper dietary plans for children have been put into action to improve the health status of the children. They also a rgue that many programs have been initiated for children to increase their physical activities which play a more important role than the consumption. They also present the fact that the government would not utilize these taxes to assist the health but rather they would be used in other sectors. It then addresses to the issue of the working class that many people could get unemployed if the beverage industry is affected. Hence, a very effective communication method is utilized by providing support with the assistance of different advertisements and journals. The problems of all the different people of the society are also addressed to explain their point and support it with evidence. The Americans Against Food Taxes seems more of a propaganda and it maintains its primary focus on convincing the individual to believe against the taxes imposed on unhealthy foods. It does not provide with a clear picture explaining both sides of the issue but rather focuses on one point. It seems to be very pro-beverage industry focusing upon the positive steps of the beverage industry. It does not present the researches that also claim the role of these beverages in leading to diseases. As it is known that in today’s world of economic crisis, many people are facing financial setbacks. The

How to Improve College Education in the United States Essay

How to Improve College Education in the United States - Essay Example This essay stresses that the importance of education is that it plays a major role in determining the future of the concerned individuals. At times, it seems to widen the gap between the high and low income families with regard to the level of education that is present. Placing hopes on education simply means that only those who are educated prosper in life. Needless to mention, that the gap between the rich and the poor widen with the presence of education. In reference to this, it is important that the United States assesses student learning in higher education institutions. Assessment basically entails educational improvement where ideas are enacted on the type of learning that has more value to students and aim at assisting in its achievement. The values should incorporate both, what we choose to assess and how we do it. This paper makes a conclusion that the United States should ensure their colleges and universities regain back their glory as some of the best universities worldwide. This could be done through ensuring that the level of education is taken to a notch higher and more complex cognitive skills are taught to prepare graduated to a working experienced world. The college and universities should not be highly taxed especially for foreign students as this discourages them from joining the institutions. Through this, there will be a grantee of an improvement in the college education in the United States.

The Father of Chicago Blues Essay Example for Free

The Father of Chicago Blues Essay He is known for creating some of the greatest blues songs of all time â€Å"I Can’t Be Satisfied†, â€Å"I feel Like Going Home†, and â€Å"Hoochie Coochie Man†. His unique and distinctive voice conveyed intense feelings and emotions to audiences all over the globe, while his guitar skills inspired some of rock history’s greatest legends. He was known as Muddy Waters; a man whose raw talent and tenacity led him out of Mississippi, to Chicago, to winning several industry awards, and finally into the Rock and Roll Hall of Fame. Much of the development of the blues genre, as well rock and roll, has been accredited to him and rightly so. Bringing the heart and soul of blues music to Chicago, Muddy Waters single-handedly led the progression of Delta blues to Chicago blues, from which much of today’s popular music has sprung. The origin of the blues dates back centuries. In commercial terms, it was once referred to as â€Å"race music†, as the artists were primarily black and the music was marketed to black audiences. The genre eventually became know as â€Å"rhythm and blues† or â€Å"RB† a music style rooted in Africa and brought over to the US when slaves would sing African spirituals while working on plantations. American Popular Music (2006) describes RB as such: RB, as the genre came to be known, was a loose cluster of styles, rooted in southern fold traditions and shaped by the experience of returning military personnel and hundreds of thousands of black Americans who had migrated to urban centers such as New York, Chicago, Detroit, and Los Angeles during and just after the war. (p. 38) As the music world expanded, sub-genres of the blues came into existence. Delta blues, jump blues, and Chicago electric blues were the most popular categories. Muddy Waters himself grew up singing Delta blues songs from that region, until he moved north to Chicago. It was in Chicago that his sound evolved and he was labeled as a â€Å"Chicago electric blues† artist. During the 1940s, Chicago became one of the most rapidly-growing cities in terms of black neighborhoods, which fueled the popularity and demand for blues music. Although Delta blues artists had been a favorite amongst the African American community for decades before the emergence of Muddy Waters, it was a new type of blues sound that soon became the iconic music of Chicago: A very different urban blues tradition of the postwar era, Chicago electric blues, derived more directly from the rural Mississippi Delta†¦ The musical taste of black Chicagoans, many of them recent migrants from the Deep South, tended toward rougher, grittier styles, closely linked to African American folk traditions but also reflective of their new, urban orientation†¦ Muddy Waters exemplifies these developments. (Starr Waterman, 2006, p. 41) The Chicago blues scene was essentially a combination of both northern and southern influences. This is an example of how music, as well as society, evolves in order to embrace a new way of life while retaining its roots. Although people still embraced musical themes from traditional Delta blues frustration, loneliness, pain they were looking for a more developed and refined sound. This new blues style, Chicago electric blues, soon became personified through Muddy Waters. His voice contained all of the grittiness and rough sounds of traditional African American music, yet his innovative guitar skills and musical phrasing appealed to audiences who were demanding a more urban feel. Muddy Waters was born McKinley Morganfield on April 4, 1913 in Issaquena County, Mississippi however, he later changed his birth year to 1915 in order to appear younger to the entertainment industry. He was born to Berta Grant, who was only a teenager at the time, and Ollie Morganfield, a cotton farmer. Muddy’s parents were an unconventional couple, as they never married; and after his mother passed away in 1918, his grandmother Della Grant took over in raising him. He was only three years-old at the time, and Della was an extremely young grandmother of 32 years of age when he was born. Muddy’s world seemed to revolve around music from a very early age, although he did enjoy fishing and playing down by a nearby creek. He would always get dirt on his clothes and mud on his face, which is how he was nicknamed Muddy Waters. Muddy was not the only musical talent in the family. His father Ollie was well-known amongst locals as a very skilled singer, guitarist, and washboard-player. This seemed to fuel Muddy’s interest in music, as he began to learn how to play a variety of instruments. He improvised by turning a kerosene can into a drum, which became his first instrument, and that was followed by the accordion, a harp, and a box and stick that he made into his first guitar. He recalled, â€Å"Couldn’t do much with it, but that’s how you learn! † (Roots, 2007). As a teenager, Muddy began listening to blues artists such as Charlie Patton and Roosevelt Sykes. One of his greatest influences, however, was Son House. He was inspired by House’s guitar technique and would often attend live performances: â€Å"I was there every night, close to him. You couldn’t get me out of that corner, listening to him. I watched that man’s fingers and look like to me he was so good he was unlimited† (Roots, 2007). By the age of 17, Muddy was able to purchase his first guitar a used Stella and began making a name for himself as a local blues artist. With his own makeshift band, Muddy performed in several local Delta clubs until he was discovered by Alan Lomax in 1941 a folklore collector who invited him to record for the Library of Congress. Lomax was searching for a blues singer comparable to Robert Johnson, whose guitar style influenced Muddy’s own way of playing. It was most likely Lomax’s encouragement that persuaded him to move to Chicago in 1943 he had been contemplating the idea for awhile, yet decided against it as he did not want to leave his grandmother. After his move to Chicago, Muddy started working at a paper mill. Three years later, a man by the name of Sunnyland Slim helped him get signed to Aristocrat Records; but his first series of recordings proved to be unsuccessful, and he would have to earn money by driving trucks for six days out of the week, while performing nightly in local clubs. His career did not fully launch until 1948 when Aristocrat Records was sold and became Chess Records. Under this new label, he recorded his first single â€Å"Rollin’ Stone†. It was an absolute hit, and was even used to name one of the world’s most famous rock bands the Rolling Stones. By 1951, Muddy had a complete band with Otis Spann on the piano, Little Walter on the harmonica, Jimmie Rodgers on the second guitar, and Elgin Evans on the drums (Rolling Stone, 2009). He was now a major blues performer, creating some of the most iconic and influential songs in the music industry: Waters’s approach to the blues is different from that of blues crooners†¦ Waters was a master of the bottleneck slide guitar technique. He used his guitar to create a rock-stead, churning rhythm, interspersed with blues licks, which were counterpoised with his voice in a kind of musical conversation. (Starr Waterman, 2009, p. 42) He mastered the electric guitar after moving to Chicago, as the crowds were noisier than his previous audience in the Delta, and there was a high demand for dance music. He brought the traditional blues sound up from the Mississippi Delta, turned it into a more electric sound, and Chicago electric blues was born. It was this emotionally distressing style of guitar-playing that won him the name â€Å"The Father of Chicago Blues†, subsequently inspiring future rock artists such as Jimmy Hendrix, Eric Clapton, and bands of the 1960s and 1970s British explosion (Rolling Stone, 2009). Even though Muddy’s records were mostly sold in the Delta, New Orleans, and Chicago, his reputation spanned the globe. Over the years, Muddy would be cited as a great influence for many artists, including Chuck Berry, Leg Zeppelin, and Angus Young of AC/DC. His songs would also be covered by other industry heavyweights such as Cream, Etta James, and Bob Dylan. Muddy’s success was later signified by several Grammy Awards, Blues Foundation Awards, and his posthumous induction into the Rock and Roll Hall of Fame in 1987 (Rolling Stone, 2009). It is impossible to think of history’s greatest blues artists without naming Muddy Waters he epitomizes Chicago blues. Today’s artists still praise his name and discuss how he has impacted the music world with his talent and innovation. Coming up from the Delta, he brought the true soul of blues to Chicago while simultaneously melding it with a more popular sound. He created a new sub-genre in music; and his voice and phenomenal guitar skills won him the respect of the entire music industry, both past and present. References Rolling Stone. (2009). Retrieved July 28, 2009, from http://www. rollingstone. com/ artists/muddywaters/biography Roots, A. (2007). So Into Blues. Retrieved July 28, 2009, from http://www. blues- finland. com/english/muddy_waters_biography_1. html Starr, L. , Waterman, C. (2006). American Popular Music: The Rock Years. Oxford: Oxford University Press.

Health and Social Care Essays red dot system

Health and Social Care Essays red dot system Introduction In the frequently frantic and universally pressured world of the AE departments of this countrys hospitals, mistakes get made. This is a fact of life. In any human endeavour this is sadly true. Until recently, the blame culture that was prevalent within the NHS, made certain defensive behaviour patterns amongst staff almost endemic (Vincent, 1994). It is one of the characteristics of a professional life that you have to take responsibility for your actions. If you take the wrong action, you will be criticised. This defensive attitude was, to a large extent, fostered by the professional health insurers who, worried about paying out large quantities of their funds, demanded secrecy, no apology and a defensive stance from those that they insured.(Clinical Services Committee) It became apparent to those who were in a position to have an overview of the situation that such a situation was actually in nobodys interest (Barley, 2000). Healthcare professionals were practising defensive medicine, patients were being kept in the dark when mistakes were made, and most important of all, because problems were not examined in an open and constructive way, productive lessons were not learnt. All that was happening was that defensive stances were becoming entrenched. The advent of the no-blame culture is helping to erode these stances and attitudes (Aldridge 2000). It is allowing the development of practices which may help the efficiency of our hospitals and provide the patient with a better service. The red dot system arose as a product of both of these factors. The pressure on the AE department staff is often relentless and great. The structure of the system is that many decisions are taken by comparatively inexperienced staff members and often not the most appropriate for the decision that needs to be taken. Huge numbers of X-Rays are seen by junior doctors and decisions regarding treatment are initially made before a senior specialist has a chance to oversee them. It would follow, by any common sense analysis of the situation, that any measure that could help in the decision making process should be welcomed. This argument is taken further by the article by Vincent et al. (1988) . In the days before the red dot system was seriously considered, Vincent and his colleagues carried out a study of the radiological errors made by junior hospital doctors. They found an error rate of 35% when the X-Ray was assessed by the SHO alone. For errors with a clinically significant impact the rate was 39% (of abnormal films). The red dot system represents a mechanism to try to address this gap. It involves the radiographer usually, but not always, the one who has taken the film giving the clinician some feed back. Radiographers see many thousands of films and are generally very familiar with the structures that they show. Quite apart from their formal training, simply by everyday familiarity and experience, they get to know what is normal and what is not. The radiographer is therefore well placed to recognise an abnormality even though they may not fully appreciate the full clinical significance of what is on the film. The same argument can be applied to the clinician, who can generally recognise pathology in a patient but may not be so familiar with the X-Ray changes. The red dot system requires the radiographers to examine the film after it has been ordered by the clinician. If they feel that there is an abnormality on it they will place a self-adhesive red dot on it to denote that they believe that it contains an abnormality. Clearly this does not relieve the clinician of the responsibility of examining the film as, the legal responsibility for interpreting the film must rest with him. This is only reasonable since even the most experienced radiologist would only give a report on what he could see on the film, the full significance of the changes seen can only be fully assessed by a healthcare professional who has also seen and assessed the patient. As we will discuss later, the converse argument that the absence of a red dot does not imply that there isnt an abnormality it only denotes that the radiographer hasnt seen one. The red dot system In a letter to the BMJ Keith Piper (2003) outlined the case for the red dot system and the radiographer reporting system (See on). It was initially suggested by the Audit Commission in 1993 that radiographers could be trained to interpret certain images and this was found to be of particular interest in view of the difficulties that some departments currently experience with the reporting service The first accredited course was run in 1994 many radiographers have since been reporting on primary skeletal X-Rays in AE departments Piper points out that the system is designed to reduce errors in reporting X-Rays. It is ultimately totally reliant on the radiographs being finally reported by a senior radiologist in a timely fashion. Unfortunately, this is not always the case as Beggs pointed out in 1990 when it was found that over 20% of UK teaching hospitals did not report on all accident and emergency films With specific reference to the red dot system, the letter by Aldridge and Freeland (2000) passes comment on the system which is in use in their hospital and, having audited it, they present their results. The system in use conforms to that currently outlined by British Association of Accident and Emergencys guidelines (1983). The important facets of their system include The rapid return of X-Rays to the requesting clinician Reporting of X-Rays by a consultant radiologist within 24 hrs. Telephone recall of patients who have mistakes picked up The use of the red dot system by the radiographers The use of such X-Rays for teaching purposes for staff As far as the audit of the red dot system was concerned, they report the last audit showed an 1.5% false positive result, 2.0% false negative result with the rest categorised as true positive or negative results. The authors felt that this represented an excellent approach to what they described as an error prone activity, reducing mistakes by accident and emergency staff (often junior), increasing patient satisfaction, and reducing long term patient morbidity and litigation. This letter is a significant piece of evidence as it is written by two clinicians who are clearly anxious to assess the system and to make it work. They appreciate the problems, quantify them and address them by placing safeguards to minimise problems. Significantly, they suggest the use of the red dot system where it has picked up omissions by the clinical staff to be the basis of teaching junior staff in an attempt to further reduce potential problems. These results should be seen in the context of a study by de Lacey et al.(client to supply date) who considered the accuracy of casualty officers interpretation or X-Rays in their departments. They found that by comparing the casualty officers interpretation with that of a radiologist, it only compared favourably in 83% of cases. The 17% discrepancy clearly represents a major burden in terms of clinical implications for the patient, financial implications for the hospital and possibly litigation implications for the casualty officer. The study also examines the implications of a delayed reporting system (by the radiologist). It was found to reduce their workload by 25% by restricting their reporting to those films which the casualty officer was unsure or thought may have an abnormality. It clearly follows from this that any measure that is likely to increase efficiency inaccuracy of reporting is likely to have benefits of both economy and patient suffering. We therefore need to exami ne the premise that the red dot system does exactly that. These figures are clearly worrying insofar as the 17% discrepancy is a wide margin. The figures still have to be viewed in context however as, although they represent the interpretation of as specialist (the radiologist) as compared with that of the non-specialist (the clinician), the paper does not draw any distinction between the experience levels of the two groups. The clinicians may be comparatively inexperienced casualty officers and the radiologists probably are consultant grade. If that is the case, then the figures are much less alarming. This point is discussed in detail further on in the piece (Williams et al 2000) where radiologists in training are compared to radiologists of consultant grade. The point is brought into sharper focus by consideration of the next two papers. Before we consider this aspect however, we need to evaluate the accuracy of reporting in the AE Department environment. Benger and Lyburn (2003) attempted to investigate exactly that. They scrutinised the X-Ray output of an AE Department over a six month period (nearly 12,000 films). They identified the films which had discrepancies in reporting between the X-Ray staff and the AE Department staff. From the 12,000 films they found (only) 175 discrepancies. In clinical terms, this equated to a rate of 0.3% of patients who needed a change of management as a result. In all our deliberations on the subject, perhaps it is this that actually is the subjective criteria for whether a system works within tolerable limits or not. Different studies may find different discrepancy rates in interpretation of X-Ray films, but what is of practical value is the actual number of patients who require a change of management as a result. If a minor degree of subluxation of a proximal interphalangeal joint is missed by a casualty officer and subsequently picked up by a radiologist, it will appear on inventories of discrepancies such as the ones discussed above. In terms of patient care or treatment, it will not make a scrap of difference. This point is made, rather more eloquently and in a different context, by Fineberg (1977) and the Institute of Medicine (1977). This point should not be taken lightly and indeed, it goes to the core of this piece. Academic studies may show different abnormality detection rates between the different professional groups. While recognising that these are clearly important, they are not the yardstick by which we must judge the red dot system. We have already examined two papers on the subject that have reported differences in abnormality detection at each end of the spectrum one of 17% and one of 1.5%. We should not be blinded by these figures themselves. What actually matters is the number of patients who have a change of management decision as a result of this discrepancy. The paper quoted above (Benger and Lyburn 2003) is one of the few which actually gives us this information. They quote an observed change of management in only 0.3% of patients which, for any system, is a very tolerable level of error. This is clearly a very fundamental point and one that we need to examine further. The next paper that we sh ould consider looks at exactly this point and examines it in great detail. Taking a more academic approach Brealey and Scally (2001) tackle the difficult issue of just how to interpret the findings of a study that purports to evaluate the reading of X-Rays by two or more different professional groups. This is a very technical paper and is included here for the sake of completeness. It examines all of the possible margins for error and bias when reporting a trial. It throws little direct light onto our deliberations here because of its very technical nature, but it would be of considerable importance to one who wished to interpret the findings of a major trial independently. The point needs making that the trial design can influence the outcome of the trial (and therefore its usefulness) to a great extent. As we have made the point above, the actual figures produced at the end of the trial must be interpreted in the light of the trial design. Actual detected differences in readings between two groups of professionals may be of academic interest, but in the c ontext of our examination of the red dot system, they are not nearly as important as a critical examination of the discrepancies which resulted in a change of patient menagement. On the direct issue of the red dot system, an almost immediate precursor to the system was reported in the BMJ in 1991 by Renwick et al. . He discussed a system that was tried out of getting radiologists to indicate their diagnoses on the pre-reported X-Rays, in order to guide the casualty officers in their decisions. The conclusions of the study were that, because of the high rate of false positive reporting (7%) and higher rate of false negatives (14%) it was appropriate for radiologists to offer useful advice but to take no more responsibility than that. We shall discuss the issues of false positives and false negatives further on in this piece and clearly they are an inherent problem with the system. It follows that we should, perhaps, address the reasons why there are these discrepancies and use them as a learning exercise to try to reduce the gap. In the excellent and concise article written by Touquet et al. (1995) the authors address the Ten Commandments of AE Department radiology. They discuss the red dot system in the following terms. Inexperienced doctors will inevitably come across injuries that they have never seen before. In these cases it may not be possible to make a diagnosis but you will notice that the films do not look quite right. Good examples of this are lunate and perilunate dislocations of the hand. It is important to seek senior advice and also to listen to the radiographer. Many departments operate a red dot system, in which the radiographer flags up an abnormality. An experienced radiographer may be as good as or even better than a junior doctor at interpreting films. The problem with this system is that the absence of a red dot does not necessary mean that there is no abnormality. This is important to remember because the final responsibility lies with the doctor, and not the radiographer. Therefore never accept poor quality or inadequate films. The most salient point of this article is in the last paragraph. The absence of a red dot does not mean the absence of an abnormality and the liability lies with the doctor not the radiographer. This is clearly proper, as any experienced healthcare professional will state, any investigation (particularly an X-Ray) is only an adjunct to diagnosis, it is the person who is clinically in charge of the patient who has to assimilate all the available evidence to make a diagnosis. The radiographer has not seen the patient to examine, and certainly will not have to hand all of the other potential diagnostic aids that are available in a modern AE Department. It is entirely reasonable to ask for his opinion on an X-Ray film, but it is not reasonable to hold him responsible for its definitive interpretation when he has not seen it in the context of the patient. This statement is behind the reasoning for the legal responsibility of X-Ray interpretation. It would be clearly inappropriate to ask a radiographer for his opinion on a film and then make him responsible for any subsequent management decisions that were based on that opinion. Some commentators have criticised the red dot system for its clear lack of apportionment of responsibility to the radiographer. We would suggest that this shows a fundamental lack of appreciation of the problems involved. The radiographers are trained to be experts in taking X-Ray films. They are not, and do not pretend to be, trained in the biological sciences and their applications to pathology and the human disease processes. It is quite appropriate to ask their opinion in an area of their expertise (the interpretation of the X-Ray film), but it is quite inappropriate to ask them to make clinical management decisions. For this reason, all questions of liability always rest on the clinician in charge of the p atient, and it is only right that this should be the case. It is fair to say that some of the views reviewed so far have been old school necessarily so, as the intention was to document the evolution of the red dot system. It is equally fair to state that we have only considered the use of the system in the AE Department. The truth of the matter is that in the recent past, the status of the radiographer has increased in professionalism both within their own speciality and within the NHS as a whole. Many of the comments made in some of the earlier papers quoted will therefore, now seem rather outmoded and not consistent with the modern experience of working in the NHS. To redress the balance we shall look at an article from Papworth hospital by Sonnex et al; (2001) . The authors describe a system currently in use at an acute cardiothoracic unit. Radiographers were asked to assess all the X-Rays taken over a six month trial period. Those that were assessed as showing acute changes had a red dot placed on them to denote an abnormality and these were then assessed by a radiologist. The success or failure rate was then measured against this standard. The figures are rather different from the figures quoted in the studies that looked at skeletal X-Ray in AE Departments. The reason for this is almost certainly that a chest X-Ray is notoriously hard to interpret, even more so when it is a post operative X-Ray. The results were reported as a total sample of 8614, of which 464 (5%) had red dots applied. Over 100 of these were considered inappropriate. 38 X-Rays which were abnormal were not picked up. It would appear that radiographers tend to err on the side of caution when reviewing an abnormal chest X-Ray, even more so when previous comparative films were not available for comparison. This particular study had a high false positive rate. One should not lose sight of the fact that the radiographers concerned were dealing with a different population to those that we were considering earlier. The patients were generally very ill and often in a post operative state making assessment far more critical than perhaps the colder X-Ray of the AE Department where decisions could reasonably be delayed safely for 24-48 hrs. there was therefore perhaps far more pressure on them to report any possible abnormality. It is also appropriate to comment that this was the first stage of a study which then went on to review the radiographers performance after a further period of training. One would reasonably anticipate a higher agreement rate after appropriate training. As we have already seen the red dot system has evolved in several different variants. The basic premise is the same in each case how is it possible to minimise the potential sources of error caused by inexperience? A further variant is outlined by Williams et al (2000). His paper title specifically involves the cost effectiveness of the scheme as well as the overall impact on patient management. In this scheme ( which was running at the Radcliffe Hospital in Oxford) the original AE Department films were reviewed by radiologists-in-training. They identified 684 incorrect diagnoses over a one year period. These were then called red reports and reviewed by a consultant radiologist. During this process 351 missed fractures were detected with ankle, finger and elbow fractures being the main areas where pathology was missed. Williams also reported 11 incidences of pathology on a chest X-Ray as being missed. This amplifies the point made earlier that the radiologists-in-training tended to produce false positives at a rate of about 18% when compared to the subsequent, more expert opinion. In this particular study, further action was taken by the AE Department staff in 42% of those cases although no operative intervention was required in any patient as a result of the missed diagnosis. Despite these figures, it must be noted that these cases form a very small percentage of the X-Rays taken in a busy AE Department False positives and false negatives We have looked at a number of studies that have compared radiographers interpretations of X-Ray films against that of a Consultant Radiologist who has generally been used as the Gold Standard. The difference between the two sets of interpretations is then subdivided into false positives and false negatives. This group is actually the most important as it is firstly an indication of the usefulness of the whole system of red dot reporting and secondly it is also an indication of how much more training any particular reader (radiographer or casualty officer ), of the films has to undergo, in order to make fully competent assessments. The false positive is the situation where the radiographer has identified a problem that is not there. Conversely, the false negative is when they have missed pathology that is there. In most of the assessments that we have seen, there are more false positives than negatives. This implies that the radiographers are being over cautious when confronted with an equivocal film. Several of the papers that we have seen so far have stated (either explicitly or otherwise) that the absence of a red dot does not imply the absence of any pathology. Any common-sense analysis of the situation would suggest that this is clearly self-evident. It must be the case where two highly trained but clearly not expert healthcare professionals are looking at a film for pathology, they are probably more likely to arrive at the right answer than one alone. Brealey (2005) produced a Meta-analysis of studies involving radiographers input in interpreting films and found that radiographers involved either in the red dot system of X-Ray reading improved with experience and with training, acquired an accuracy approaching that of radiologists when dealing with skeletal X-Rays. The red dot system is designed to utilise the expertise of specially trained radiographers to interpret plain X-Rays. From the evidence presented above we can say that there is evidence that radiographers are clearly more expert in interpreting plain skeletal X-Rays than chest X-Rays or visceral radiographs. The red dot system appears to be a growing movement within the profession. A paper by Brealey (2003) pointed out the fact that between 1968 and 1991 the radiologists workload increased by 322% but the number of posts increased by only 213%. As a result of this the number of films successfully reported within 48hrs fell to 60%. As a result of this trend the Royal College of Radiologists decided to endorse the trend of radiographers giving indications of pathology on X-Rays . Brealeys paper examines the initial cohort of radiographers who were trained under this scheme and found that, statistically, there was no significant difference between the reading of an X-Ray by a radiograph er or a radiologist (in the case of plain skeletal X-Rays) which supports the view that the red dot system is viable. Any examination of this issue would be incomplete without a consideration of the detailed and analytical paper by Friedenberg (2000) which he provocatively entitled The advent of the supertechnologist. It is particularly relevant to our consideration of the red dot system and the role of the radiographer as it looks at the background to the whole issue. Friedenberg uses the term Skill mix as a specific term to define the current trend in medicine away from specialisation and departmentalisation and towards the communal utilisation of expertise from different individuals in related fields to complement or increase the expertise available to patients. He points out that this is not actually a new concept and cites the optician who relieves the workload of the ophthalmologist and the nurse specialist anaesthetist who relieves the anaesthesiologist by performing uncomplicated procedures. He quotes a whole host of paramedical providers who now assist the physician, in most cases without p roblems Loughran et al (1996a, 1996b, 1992) have specifically looked at the practicality of utilising the skills of the radiographer to better advantage than just taking the films. He contrasts the difference in practice between the UK and the USA, citing the cause of the complete separation of the roles of radiographer and radiologist in the USA as being due to the fact that in the USA, the radiologists still operate largely on a fee-per-service basis whereas in the UK the pressure is primarily on clinicians to become more efficient and to keep costs down. Friedenberg, interestingly also examines the evolution of the legality of the roles of radiographer and radiologist. Between 1900 and 1920, there was competition between radiographers and radiologists with regard to the performance of radiography and the interpretation of radiographs. In the middle 1920s in England, radiographers were prohibited from accepting patients for radiography except under the direction of a qualified medical practitioner (Quotes Larkin 1983) After this the professions came closer and by 1971 Swinburne (1971) was suggesting that radiographers could perfectly well separate normal from abnormal films, which after all is the basis behind the red dot system . As we have discussed earlier, this move then progressed into the first formal appearance of the red dot system in North Park Hospital in 1985. The first trials of the system found that approximately half of the abnormalities that were not picked up by the junior casualty officers were detected by the radiographers. The early safe guards were outlined by Loughran (1996) as follows: 1. It is made clear to the referring physician that the report is a technologists report. The physician is encouraged to consult the radiologist if there is a lack of clinical correlation. 2. The technologist must consult the radiologist if he or she is in doubt. 3. The physicians, radiologists, and technologists have devised a set of guidelines to create a safe environment for this practice. 4. Initially, the technologists practice is monitored on a regular basis. After the technologist is experienced, however, monitoring is no longer performed. Such monitoring should be performed if a new technologist enters this practice. Interestingly, Loughran also subsequently produced a set of guidelines for the radiographer : 1. The technologist should be confident in his or her report. 2. In cases of doubt, a radiologists opinion should be obtained. 3. In such cases, although the report may be issued by the reporting technologist, the consultants name should be appended to the report. 4. All reports by a technologist should be clearly designated as a technologists report. 5. If the patient re-presents for radiography of the same body part within 2 months, this should be reported by a radiologist. 6. Non-trauma examination findings should be reported by the radiologist. 7. All accident department images in patients who are subsequently admitted as inpatients should be reported by the radiologist. 8. Clinicians are to be advised to consult the radiologist if clinical findings do not match those in the technologists report. 9. Regular combined reporting sessions are to be held with the consultant radiologist. Robinson (1999) Defines the ideal areas for radiographers and radiologists with the following definition between cognitive and procedural tasks thus: Procedural tasks can be described, defined, taught, and subjected to performance standards that make them transferable to other staff with appropriate training. 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