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If you are a person of many interests or passions, with an entrepreneurial streak, becoming a “slash person” is an important reinvention option. I certainly wish someone had told me about it a long time ago! If you’re interested, Marci Alboher’s book is a great place to start!

When Should We Reinvent Ourselves?

Most of us assume that we only need to reinvent ourselves when we get fired or when our current self isn’t working. Just like Lewis Carroll’s immortal Mad Hatter who moved down the table every time he made a mess at his seat at the tea party, we think, “Ok, we’ve made a mess at this job here. Let’s dump this persona and move onto the next one” as if the reinvented you is a completely new you with no real connection to the past (failed?) you.

Others of us assume that reinvention is the privileged prerogative of the chosen few: college students, newcomers/initial starters, those in the official “reappraisal age” (about 28-35 years old), the downsized and outsourced, mid-career restructurists (about 40-45 years old), workers taking an early corporate parachute or public service retirees (in their 50’s), and/or traditional retirement age workers (65). Certainly there are expected periods of life and career transitions (Kanchier, 2000) and anticipating and preparing for transitions is important and helpful.

However, as the previous personal communications and Appendix A show, there are dozens of reasons to think about reinventing yourself (Ballback & Slater, 1996; Harkness, 1997; Helfand, 1995; Solovic, 2003). The reasons can be personal, job-related, organization-related, industry-related, or world-related! Sometimes one at a time ― sometimes all at a time.

You probably know the personal and negative triggers (feelings of pessimism, frustrations, dissatisfaction, boredom, feeling unfulfilled, recovering from an illness or disability). These, I suspect, are the most common reasons you’ll hear why people reinvent themselves.

The personal and positive may not comes as easily to mind, such as when you come back to work after a hiatus, you have a creative spurt, you recognize that you have some skills or talents you weren’t aware of previously, your self-awareness grows through therapy, you want or need more money, you become free(r) in some way, you finish a training program, or you simply feel you need a break/to do something different. These come out of a positive place and are usually overlooked.

At a “higher” level, there are positive and negative job-related experiences that can trigger a desire or need for reinvention. Your job might be eliminated, the work becomes boring, your skills aren’t being used or salaries get cut. On the positive side, sometimes you get to reinvent yourself ― see, not just have to, but get to ― you’re your job is expanded ― you get to do more ― or enriched ― you get to go deeper into a responsibility.

And sometimes, we reinvent ourselves personally in order to survive professionally. As S.G., a health educator with more than 30 years of experience (S.G., personal communication, May 4, 2007) wrote: “My career as a health educator has been varied ― so I guess I reinvented [myself] several times. I went from a volunteer with the Red Cross teaching first aid courses to a part-time staff person with the Red Cross directing the Health and Safety programs at a local chapter to teaching at a high school, to college level teaching, to a full time curriculum developer with a science education organization (writing the health component of the curriculum) to a project officer at CDC to a consultant, to an Executive Director of a professional association. Is that what you had in mind? I also reinvented myself as I was coping with an adolescent child who was having serious problems. The reinvention was to redirect my thinking from “Why me? What did I do to deserve this?” and a focus on her and her problems to, “What am I supposed to learn out of all this?” It was a huge change and made a big difference in my ability to cope ([though] it did not change her acting out).”

A final story, anonymous because of its sensitivity, (personal communication, May 11, 2007) underscores the importance of doing due diligence before reinventing yourself. This health education graduate student decided to reinvent herself when advised that her current health education professional preparation program would prepare her for great success and great future marketability in another field. She therefore studied for her Certification in Alcohol/Substance Abuse Counseling (CASAC) in addition to health education, only to discover she had reinvented herself into a product that was no more marketable than either profession e separately given who decision makers were hiring (clinicians) for counseling positions.

Serial vs. Sequential Reinvention
A final word, if you will, on the concept of reinvention: reinvention need not be sequential ― in fact you can and sometimes have to juggle two or more work experiences at a time. Let me explain.

Most of us think of reinventing ourselves as a chronologic process: First, I was “x”and then (for whatever reason) I became “y.” Certainly that’s one way of looking at it, but many people are not x’s or y’s. They’re “slashes”: x/y…two, or even x/y/z three things at once (Alboher, 2007). It’s a great way to try out a new career or work challenge when you already have a job but want to consider changing or expanding what you do for financial or personal fulfillment reasons. It’s easiest when you have a “safe” “cushy” job as your “main” or “anchor” job to then add on additional “orbiters” or secondary or separate jobs. At one point I was Karen Denard, program manager/adjunct/graduate student, and later I became Karen Denard Goldman, professor/ author/ speaker/ Broadway musical parody lyricist. My very favorite “slash” person is a health educator I met this past year who, after attending my career development workshop, told me she is a school health educator/ dominatrix. You can’t make this stuff up.

In the 1990s, involvement in public policy setting became a significant health education skill as chronic and communicable disease management issues were joined by environmental hazard issues. Health education efforts and programs became geared to the home and to pre-school settings. In the past decade, new skills have been integrated into the health educator’s repertoire: social marketing; computer technology; distance learning; grant writing; evaluation; translating research into practice; and diffusing best practices. Issues such crisis management and terrorism, particularly bioterrorism and emergency preparedness have driven most government funding programs.

In 1998 the Competency Update Project began and in 2006 the second edition of the Competency-Based Framework for Health Educators was released by the National Commission for Health Education Credentialing, Inc.. The framework was reinvented to include 82 sub-competencies with three levels: Entry, Advanced I, and Advanced II. The certification examination was reinvented/revised accordingly in time for the October 2007 test (NCHEC, 2006).

Therefore, if “reinvention” is “in our blood”, is it not wise for us to learn more about and perhaps consider preparing for our own professional reinvention transfusions?

What Does It Mean to “Reinvent Yourself”?
“Reinvention is any type of change, from the material to the spiritual, in which you become a whole person or a different person, hopefully a better person, but certainly a changed person” (Davidson, 2001). Reinvention is about taking charge of who you are and where you’re going and what you’re doing, and it usually involves a willingness to take calculated risks, to start all over again, and to weather some setbacks.

Reinvention is a proactive, not a reactive activity. People who choose to reinvent themselves, for whatever reason, are, by and large, assertive people, with a sense of personal responsibility and accountability for their lives (Chandler, 2004). They reject the role of “victim of circumstance” and assume ownership, if not total control, of situations and set about seeing what they can do about them. They refuse to be part of the problem; they insist, instead, of being part of and often the driving force behind the solution (Chandler, 2004).

Personal reinvention can involve changes in one or more aspects of your life. Reinvention is about shifting, reframing, reformatting, restructuring your perspective, attitude, and actions to whatever degree is necessary in response to a particular trigger. It doesn’t have to imply or involve a wholesale upheaval in who you are and how you do things ― though for some of us at some time, it might actually come to that. It can mean adjusting your attitude toward life; your body and the shape it’s in or out of; your relationships or lack thereof with people, your community, your money, any higher power you might believe in; how and with whom you spend your discretionary time; and, the focus of this article, your work life.

If any profession should value and encourage reinvention, it’s health education. Over its 100-year history, health education has reinvented itself many times.

Originally, in the early 1900s, when epidemics were of major concern, health education was conducted through journalism, public speaking, and information sharing.

Beginning in 1910, interest shifted to alcohol and drugs and elementary school health programs were launched with an eye toward producing draft-worthy adults to better defend our country and its ideals. Health education was conducted through lectures and pamphlets.

This continued into the late teens and twenties, when, after the influenza epidemic and World War I, communicable diseases (particularly sexually transmitted diseases) were the focus of attention. Hospital and community-based lectures and pamphlets were enhanced by other methods of information communication: newsletters, films, filmstrips, and exhibits. Physical education was very important and went hand in glove with health education.

During the 1930s and 40s, and as the first masters degree program in public health education began to graduate students, community organizing became a major health education intervention.

In the 1950s, after World War II, veterans’ health was a major concern, and hospitals and clinics jumped onto the health education bandwagon. Written and oral communication skills continued to be the sine qua non of good health education, but there was a definite change in emphasis from publicist to educator.
Self-help and consumerism were all the rage in the 1960s as was social engineering. Health education began to include service planning and evaluation, behavior change, and group dynamics.

By the 1970s, worksite and occupational wellness programs were being implemented by employers, unions, health maintenance organizations, and public agencies. Interventions became behavior-change theory based and the focus shifted to lifestyles and personal behaviors and chronic disease management. Outreach and follow up became important health education tasks.

With the HIV/AIDS crisis in the 1980s, communicable diseases emerged once again as a major health concern and joined chronic disease management as a critical health education focus. Interventions included traditional information sharing strategies, community organizing and individual and group behavior change therapies. But new health education methods were also being introduced or solidifying their toe-hold in the health and medical communities: audio-visual communication, mass media campaigns, and advocacy. Initiatives were introduced into prisons and other institutions.

Though health education skill and competence requirements clearly were ever-changing depending upon the health issues of the time, the 1978 Health Education Role Delineation Project set out to identify core health education responsibilities. Following the role verification profess and the national Conference for Institutions Preparing Health Educators in Birmingham, AL in 1981, the Framework for the Development of Competency-Based Curricula for Entry-Level Health Educators was published in 1985. The framework outlined seven areas of entry-level responsibilities for health education specialists, including 79 sub-competencies. The framework gave direction and focus to the professional preparation of health educators and was supported by a new national health education specialist certification exam first administered in 1990.

Everyone (not just people who have been fired or fear they are about to be) reinvents themselves personally and professionally at some time or other…deliberately or inadvertently, strategically or impetuously. In fact, the author argues that professional reinvention is not only a good defense, but a great offense, pointing out how reinvention can help you take charge of your life as well as accommodate new work world realities. To support and encourage professional reinvention, the author couches the value of being able to transform yourself professionally in the context that health education itself is a profession that is constantly reinventing itself. The article includes a definition of reinvention and discussions about who reinvents themselves and when and why, and stories of six health educators and how they reinvented themselves. The article ends with suggested reinvention pre-requisites to foster successful work life transitions and transformations, and a list of ten tips for successful professional reinvention(s).

Do You Dare?
If you’re thinking, “Hey, I don’t need to read this. I’ve never been fired and I won’t ever get fired,” here are three important news flashes. One: if you’re going to survive and thrive in your personal life as well as in your work life, you need to be able to reinvent yourself. Two: reinvention is something you are doing all the time already, just unconsciously; so consciously can only help. Three: there’s a pretty good chance you will get fired, merged into unemployment, urged into early retirement, or purged in a lay off somewhere along the line ― and so what? You’ll survive. I did!

Writing this article is part of my nth professional reinvention ― this time as a “Career Development Lifeguard” ― after 40 years of work experience…since high school. That experience includes four so-called “careers” (a term I find too confining) in my work life, 15 full-time jobs, and dozens of part-time jobs. Therefore, I have not only become a fervent believer in personal and professional reinvention, I have become a staunch advocate of it!

As a health education specialist who is also certified as a senior professional in human resources, I am eager to present the concept of reinvention ― or worklife reincarnation, if you will ― within a career development context and its value as a core career development skill – right up there with strategic thinking, creativity, problem solving, writing and speaking skills, and so on. We will explore what it means to “reinvent yourself”, how you might reinvent yourself, and when you might do so. In short, we will discuss how being able to reinvent yourself ― once, twice, or as many times as professionally politic or personally pleasing ― can be a key to your success.

Our abstracted data include diagnosis; presence or absence of specific key diagnostic criteria in the case of sinusitis, otitis media, or pharyngitis; whether an antibiotic was prescribed or not; and if an antibiotic was prescribed, which one (to assess use of narrow- vs. broad- spectrum antibiotics).

Second, future Oregon BRFSS data will provide valuable information about changes in public knowledge about safe antibiotic use and expectations surrounding the receipt of antibiotics to treat upper respiratory infections.
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Third, annual analysis of prescribing trends in the Oregon Medicaid fee-for-service population will continue to shed light on clinician prescribing behaviors. This analysis will allow comparisons between prescribing rates in the general community as opposed to those in the residency clinics assessed as part of the curriculum project.

Finally, we hope to analyze trends in two new measures in the Health Plan Employer Data Information Set (HEDIS®) related to appropriate treatment of children with upper respiratory infections and appropriate testing for pediatric pharyngitis.

Conclusion
Effecting change in antibiotic use requires interventions at multiple levels to all types of health care professionals and to lay audiences. These interventions work best when performed in different settings (e.g., community health talks, education forums for health professionals, or media messages), and through the combined efforts of both public health and medical education organizations. Physicians and other clinicians play a key role in education their patients about the dangers of inappropriate antibiotic use, how and when to use antibiotics appropriately, and how best to care for symptoms caused by viral pathogens. To do this effectively, clinicians must possess good communication skills to use in eliciting the patients’ true concerns, in educating patients both directly and through printed or Web-based materials, and in negotiating with patients when antibiotics are not indicated. Given the time constraints common in today’s outpatient environment, they must also have easy access to high-quality patient education materials that can reinforce verbal messages and reduce the time needed for direct education.

The programs described in this article provide a wide range of educational opportunities for both clinicians and lay audiences. Many of them are intended to empower clinicians to educate their patients about this important public health issue. By pursuing these avenues, we expect clinicians to become much more active in this area of health promotion.

In the absence of a paid public service announcement campaign, the Oregon AWARE coalition has generated media coverage through a number of creative strategies, including a staged media event, press releases, and release of expert editorial opinion pieces to newspapers. We have augmented this effort by placing informational articles in newsletters generated by health plans, parent-teacher organizations, childcare provider groups and school nurses, and by launching a consumer-friendly Web site. These educational efforts encourage consumers to develop realistic expectations about receipt and use of antibiotics before unpleasant symptoms prompt them to seek medical attention.

Posters and brochures in clinic waiting rooms reinforce realistic expectations and encourage patients to ask for the most appropriate symptomatic treatments rather than to simply request antibiotics. A variety of staff, as well as the clinician, may present these materials.

Because antibiotic prescribing rates are particularly high for children aged 0-6 years (McCraig, Besser & Hughes, 2002), Oregon AWARE is now making a special effort to reach the parents of young children with information about appropriate use. Partnerships have been established with childcare provider groups and early childhood education programs. Future educational interventions will aim to reduce the incidence of upper respiratory infections and promote parent and staff awareness of the observation option for otitis media (AAFP/AAO-HNS/AAP, 2004). New child care provider training curricula will emphasize the importance of following standard disinfection procedures and reinforce recommendations regarding frequent, thorough hand washing among children and child care staff.

Oregon AWARE also provides direct continuing education for clinicians. The Oregon AWARE medical director and infectious disease consultants have given regular presentations at statewide and local conferences. This group collaborated to produce a self-study, continuing medical education booklet, entitled Judicious Use of Antibiotics: A Guide for Oregon Clinicians. The monograph is approved for one hour of continuing education credit for physicians, physician assistants and nurses. It provides a local perspective on the issue of antibiotic resistance, as well as the pharmacokinetic and pharmacodynamic principles that guide rational use of antibiotics. It also outlines consensus-derived treatment guidelines for pediatric and adult cough illness, sinusitis, pharyngitis, and pediatric otitis media. Oregon AWARE mailed the monograph to 6,500 primary care clinicians in 2003.

Evaluation of Combined Program Impact
Because behavior change is a long-term phenomenon, it will take several years to evaluate the results of this integrated public/patient/clinician education effort. Our evaluation utilizes multiple components to assess antibiotic use and patient/clinician attitudes about antibiotics from several perspectives. First, the resident curriculum project uses chart abstract data to determine prescribing rates for five common upper respiratory infections before and after implementation of the curriculum. Using Oregon Medicaid claims data, the AWARE program determined crude baseline antibiotic prescribing rates for sinusitis, acute bronchitis, pharyngitis, acute otitis media, and upper respiratory infection (common cold) in 2000. Based on these rates, we are targeting a 40% reduction in prescribing rates, and are abstracting data from charts of patients seen with these diagnoses in the respiratory season (November – March) of the years preceding and following curriculum implementation.

Our curriculum also includes a wide range of patient education materials, including those prepared by the Oregon Alliance Working for Antibiotic Resistance Education (AWARE) and other reliable public health agencies, and online materials found on both professional (e.g., American Academy of Family Physicians) and lay (e.g., WebMD®) Web sites. We educate about how best to assess the validity of patient education content, and also teach them how to pass this information on to patients, so they can assess for reliability as well. We also provide patient education materials for all the residency clinics. We make presentations at clinic staff meetings to help nurses, medical assistants, and front office staff be active partners in distributing these materials as part of this health promotion effort. We provide information sheets, algorithms, and advice on self-care for phone triage nurses to use in caring for patients who call in with respiratory complaints.

Public Education About Judicious Use
Although Oregon AWARE’s key educational messages closely reflect those of the CDC’s national antibiotic resistance awareness campaign, the coalition has relied on locally collected data to hone and target its messages. In 2002, a set of questions measuring consumer knowledge, attitudes and expectations surrounding the use of antibiotics for upper respiratory infections was added to the Oregon Behavioral Risk Factor Surveillance System (BRFSS) telephone survey (Dowler et al., 2003). In addition to determining rates of recent antibiotic use and knowledge of the dangers of antibiotic resistance, we found that persons with lower income and education levels had more misconceptions about when antibiotics were needed, as did persons of non-white race and Hispanic ethnicity. The data have underscored the importance of gearing key messages toward consumers with lower literacy levels.

Stimulated by the BRFSS findings, Oregon AWARE has also used local input to evaluate and redesign its Spanish language educational materials. In 2003, the coalition conducted a series of focus groups with recently immigrated Spanish-speaking women to elucidate culturally mediated beliefs, behaviors and attitudes related to antibiotic use, and to evaluate the effectiveness of existing Spanish materials (Sola et al., 2003). Key findings were that “penicilina” is a more meaningful term than “antibiotico” to recent immigrants, pictures of healthy families on posters and brochures are more appealing than pictures of sick children, and that this audience was not likely to understand technical explanations about viruses and bacteria and which types of illness they cause. The results of this evaluation allowed us to create more effective, culturally appropriate educational materials for Spanish-speaking patients.

Residents often work in remote locations or on schedules that do not permit them to attend formal didactic conferences. To address this problem, the curriculum is almost entirely Web-based, which allows asynchronous learning at times and locations convenient to the residents. The Web-based components include 11 short didactic segments in Microsoft PowerPoint® format with voice/text narration and photo/video images; outpatient clinical case scenarios that mirror the clinical encounter for residents to work through and apply knowledge and skills learned in the didactic sessions (Table 2); reference materials; and links to outside resources.

Additionally, adult learners tend to have preferred learning styles (primarily visual, auditory, or kinesthetic), thus curricula targeted at adults must include all three styles of presentation. The Web-based components address the needs of visual and auditory learners well, but do not have a kinesthetic component. Therefore, the curriculum will also include hands-on practice of relevant clinical skills such as pneumatic otoscopy (critical for accurate diagnosis of otitis media), and effective patient communication skills.

First, the didactic section on patient education describes common patient understandings of when and how to use antibiotics; addresses misconceptions about what patients with respiratory infections really expect from their office visit; explains the advantages and disadvantages of various forms of patient education; and illustrates crucial communication skills that can help clinicians educate their patients about antibiotic use. Second, the online cases include some scenarios in which antibiotics are not indicated. Those cases include questions about how to negotiate with the patient about not prescribing antibiotics. Third, one conference session for the residents focuses on negotiation and patient education.

Physicians often express concern about their skills at negotiating with patients about antibiotic use, and have misconceptions about when patients truly want antibiotics as opposed to simply a more complete understanding of their illness and how to treat it symptomatically (Linder & Singer, 2003; Mangione-Smith, McGlynn, Elliott, Krogstad, & Brook, 1999; Mangione-Smith, McGlynn, Elliott, McDonald, Franz, & Kravitz, 2001; van Duijn, Kuyenhoven, Welschen, den Ouden, Slootweg, & Verheij, 2002). We present information about proven negotiating techniques; effective use of written patient education materials to improve retention and decrease time needed to educate patients; and how to elicit the patient’s true agenda for an office visit. We discuss other evidence-based techniques such as delayed prescribing (Arroll, Knealy, & Kerse, 2003) to reduce antibiotic use. We then divide into groups of three to role play clinical scenarios The observer/timer times the encounter, which should be limited to two minutes, and takes notes on body language, phrasing, and other features of the communication. The patient and physician describe their responses to the encounter, and the observer then reviews the encounter. Practice such as this enhances the residents’ confidence in their ability to negotiate with and educate patients as needed.

Antibiotics are also obtainable through means other than prescription. Available over the counter in Mexico and many other countries, antibiotics can make their way to U.S. consumers across the border, through the mail, at swap meets and in local import shops (Calva, Ceron, Bjalil, & Holbrook, 1993; Casner & Guerra, 1992; Sola & Saddler, 2003). Regardless of how antibiotics are obtained, consumer behaviors determine the eventual pattern of antibiotic use. Many of these behaviors may contribute to the development of resistant organisms; examples include not completing the entire course of therapy, sharing the antibiotics between family members, and hoarding leftover medication for future use.

Fortunately, controlled interventions that included components of both clinician and patient education have demonstrated significant decreases in prescribing rates for adult and pediatric upper respiratory infections (Finkelstein, Davis, & Dowell, 2001; Gonzales, Steiner, Lum, & Barrett, 1999; Welschen, Kuyenhoven, Hoes, & Verheij, 2004,). Trials that expanded educational efforts to the community have also shown efficacy in reducing both the inappropriate prescribing of antibiotics and resistant pneumococcal carriage rates in the general public (Belongia, Sullivan, Chyou, Madagame, Reed & Schwartz, 2001; Hennessy, Petersen, Bruden, Parkinson, Hurlburt, Getty, Schwartz & Butler, 2002; Perz, Craig, Coffey, Jorgensen, Mitchel, Hall, Schaffner, & Griffin, 2002).

Public education about judicious use may also provide a degree of moral support for prescribing clinicians. Promotion of realistic expectations among consumers may reduce the likelihood of confrontational patient/clinician encounters regarding the prescription of antibiotics. In one study, pediatricians suggested that parental education would be the most important means of reducing inappropriate antibiotic use (Bauchner, Pelton, & Klein, 1999). In a focus group of physicians, Barden, Dowell, Schwartz and Lackey (1998) noted that unrealistic patient expectations were the single most important cause of inappropriate prescribing.

Thus, the combined goals of the OHSU “Teaching Primary Care Residents Judicious Antibiotic Use” project and the Oregon AWARE program include extensive training for clinicians on how to use patient education materials effectively, how to understand the patient’s true agenda accurately, and how to negotiate with and educate patients about when and how to use antibiotics appropriately.

The Resident Curriculum on Judicious Use
To accomplish this goal, our team is developing a curriculum for primary care residents to improve both understanding of judicious antibiotic use and how to educate patients about this important public health issue. The curriculum is evidence-based, using sources such as the joint American Academy of Pediatrics/American Academy of Family Physicians guidelines on diagnosis and treatment of otitis media (AAFP/AAO-HNS/AAP, 2004) as the basis for the information presented. We encouraged the faculty in each residency program to complete the curriculum by offering continuing medical education (CME) credit as well. This helps improve the likelihood that the residents will get consistent messages from both the curriculum and their faculty preceptors.