MSUCOM/Lakeland Regional Medical Center Application for Dermatology Residency Program Program Mission The mission of the MSUCOM/Lakeland Regional Medical Center Osteopathic Dermatology Residency Program is to provide each trainee with a comprehensive, structured education in the field of dermatology to enable each individual to become a thoroughly competent, compassionate, and professional osteopathic dermatologist. The program curriculum is tailored to allow for optimal progression and successful achievement of all core competencies as established by the American Osteopathic College of Dermatology (AOCD) and American Osteopathic Association (AOA) at the end of a three-year training period, and to provide trainees with the best opportunity for satisfactory completion of the board-certification examination as set forth by the American Osteopathic Board of Dermatology (AOBD). Emphasis will be placed on integrating core osteopathic philosophies and principles (OPP) into clinical practice throughout the training period. During this time, residents will be exposed to the entire spectrum of dermatologic disease manifestations. They will be given increased autonomy and responsibility as deemed appropriate by the staff physicians over the course of their training to better prepare for the independent patient management seen in practice. While in training, residents will be continuously supervised and evaluated by faculty to ensure satisfactory development of knowledge base and skill level. Program Description I. Facilities Description Lakeland Regional Medical Center in St. Joseph, MI will serve as the base hospital for the Dermatology Residency Program. This facility is one of the largest hospitals in Southwestern Michigan and provides a multitude of clinical services. This hospital currently has four (4) AOA approved programs, which include Internal Medicine, General Surgery, Family Medicine and Emergency Medicine. The facility has an affiliation agreement with Michigan State University Statewide Campus System (MSU-SCS) OPTI. This OPTI supports this new residency program and will oversee its progress. Mark Smalley, D.O., is the current Director of Medical Education for this institution and has agreed to serve in this position for the dermatology residency program. Mark Kuriata, D.O., is on staff as a clinical dermatologist who maintains hospital privileges, and will serve as the Program Director. Residents will be exposed to three (3) primary sites during the course of their training under the guidance of board-certified physicians:

1) Advanced Dermatology is a thriving dermatologic practice located in the heart of St Joseph, MI. This 6200 square foot facility has 13 examination rooms including 3 surgical suites, resident’s library, and a CLIA-certified

pathology lab. This office typically treats greater than 100 patients daily and 4-6 Mohs micrographic surgery cases weekly. This location will serve as the primary training site for residents and is the largest dermatologic practice in the entire Southwestern Michigan area. Currently, this practice maintains over 100,000 active patients.

2) Advanced Dermatology has a second satellite location that has recently opened in Niles, MI. This facility has 3 examination rooms and treats approximately 30-40 patients once weekly, with the ability to expand as patient demand increases.

3) The Lakeland Healthcare system is composed of three acute care hospitals throughout Southwestern Michigan and is one of the largest healthcare providers in the area. Lakeland Regional Medical Center is a 339-bed hospital located in St, Joseph, MI and serves as the largest of these sites. These facilities are within close proximity to Advanced Dermatology and will allow residents to perform inpatient consultations under the direct supervision of medical staff and actively participate in didactic lectures.

These facilities have established affiliation agreements with physicians to provide the following rotations/instruction: Pediatric Dermatology and Dermatopathology. II. Dermatology Residency Program Goals and Objectives

The primary goals and objectives of this residency program include the following:

A. Incorporate the most advanced and up-to-date basic medical science in a clinical setting that allows for optimal educational development over the course of training in the field of dermatology. B. Provide extensive clinical experience under direct guidance from faculty to allow residents to become fully competent and comfortable in the evaluation, diagnosis, management, and treatment of the entire spectrum of dermatologic disease processes encountered from the neonatal through geriatric periods of life. C. Progressively increase the level of responsibility of residents over their training period and provide more control in medical management of patients to develop leadership characteristics. D. Be thoroughly prepared for the board-certification examination as administered by the American Osteopathic Board of Dermatology (AOBD) upon successful completion of residency training. E. Educate residents on effective methods utilized to teach others (i.e. junior residents, medical students, patients, etc.). F. Provide the resident with significant patient encounters to develop and improve interpersonal communication skills. G. Establish and maintain the highest level of medical ethics and educate residents on following these practices.

H. Incorporate basic osteopathic philosophy and principles (OPP) into clinical practice. I. Education of proper scientific manuscript preparation techniques with emphasis on the involvement of clinical research in an exceptional academic environment.

III. Osteopathic Principles and Practice (OPP)

This program will emphasize core osteopathic principles and practice through the following:

A. Instruction of accepted standards of diagnosis of somatic dysfunctions and appropriate osteopathic manipulative treatment (OMT) for corresponding dysfunctions in the field of dermatology. B. Understand and incorporate this knowledge into clinical practice and patient management in the general practice of dermatology. C. Compassionate approach towards dermatologic patients with an emphasis on the evaluation of the entire individual, as well as building strong interpersonal communication skills with patients and families. D. Integrate basic osteopathic principles and practices into every patient interaction. E. Critical evaluation of methods used in clinical practice while integrating traditional osteopathic principles to improve patient care. F. Develop an understanding of healthcare delivery systems while practicing cost-effective medical practices for patients. G. Continued emphasis of osteopathic standards and practices throughout the course of dermatologic training.

IV. Rotation Goals and Objectives

A. General Dermatology and Dermatologic Surgery

1. Train residents in becoming highly proficient and comfortable in the diagnosis, management, and treatment of diverse dermatologic case presentations. 2. Emphasis on proper methods of performing a dermatologic history and physical examination. 3. Optimal exposure to proper dermatologic surgical techniques and treatments including the following: preparation of the patient for dermatologic surgery, wound healing, wound care, and wound dressings; cryosurgery/electrosurgery of various benign and malignant lesions, multiple forms of biopsy techniques, excisional surgery with appropriate closures, phototherapy and photodynamic therapy, laser and nail surgery, MOHS surgery with appropriate skin flaps and graft closure techniques, dermabrasion, etc.

4. Exposure to various cosmetic modalities such as collagen injection, sclerotherapy, chemical peel, etc. 5. Enhance interpersonal communication skills to properly educate and interact with patients. 6. Incorporate osteopathic principles and beliefs, as well as diagnostic and treatment modalities, into all patient encounters.

B. Dermatopathology

1. To familiarize residents with histologic slides consistent with cutaneous manifestations of disease processes. At the completion of training, residents should be able to recognize and diagnose over 200 of the most common neoplasms and inflammatory skin conditions, as well as demonstrate an advanced level of understanding of the pathogenesis of these conditions. 2. To educate residents on the primary methods necessary to transform a gross anatomic specimen into a histopathologic slide to optimize interpretation by the pathologist. 3. Instruct residents on the following: proper handling, labeling, and transport of specimens from the office setting to the pathology lab; proper dissection and sectioning of specimens, slide preparation techniques, paraffin block preparation, standard slide staining with specialty stains when indicated. 4. Exposure to special techniques such as histochemistry, immunofluorescence, immunoperoxidase, etc. 5. Familiarize residents with techniques in microbiology such as gram stain, Wright-Giemsa stain, KOH stain, bacterial and fungal cultures.

C. Radiation Oncology

1. Teach residents how to perform a thorough, appropriate history and physical examination of a cancer patient. 2. Become familiar with appropriate diagnostic modalities and methods used to stage different malignancies. 3. Educate residents on the proper treatments available for a specific tumor based on type, site, and histopathology. 4. Expose residents to the most advanced treatment modalities including intensity-modulated radiation therapy, brachytherapy, stereotactic radiosurgery, photodynamic therapy, etc.

D. Pediatric Dermatology

1. To provide residents with expertise in the diagnosis, management, and treatment of the full range of pediatric skin conditions. 2. Expose residents to various dermatologic genetic and vascular anomalies. 3. Formulate age-appropriate differential diagnoses based on clinical manifestations.

4. Allow residents to develop interpersonal communication skills to successfully interact with pediatric patients and their families.

E. Allergy/Immunology

1. Develop skills in the diagnosis, management, and treatment of cutaneous manifestations of allergic/immunologic disorders including the following: atopic dermatitis, anaphylactic reactions, food and drug reactions, urticaria, allergy skin testing, contact dermatitis, immunodeficient states, autoimmune and autoinflammatory disorders, etc. 2. Become familiar with the pathophysiologic mechanisms behind these disease processes.

F. Rheumatology

1. To educate residents on the rheumatologic conditions encountered in dermatologic practice such as psoriatic arthritis, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, dermatomyositis, etc. 2. Become familiar with the diagnosis, management, and treatment of these conditions. 3. Understand the pathophysiologic reactions behind these disease states.

G. Electives

1. Residents will have the opportunity to further their training in various subspecialties throughout the course of training including the following: Plastic Surgery, Cutaneous Oncology, Phototherapy, Laser, Cosmetics, etc. 2. All choices for electives are at the discretion of the Program Director and Director of Medical Education, and must be approved by them prior to the beginning of the rotation.

The above goals and objectives provide a general overview of the expectations of this program. Continuous effort will be made to expand on and progress these ideals to match the rapidly changing medical education landscape.

V. Curriculum I. Schedule

A. Residents will be assigned to individual teaching faculty. Management of office and hospital patients will occur under the direct supervision of the staff physician. B. Rotations will include general dermatologic training, dermatopathology, dermatologic surgery, as well as additional subspecialty and elective rotations. C. Discussion of patient presentations between the resident and staff physician will be mandated on a daily basis.

D. Regular duty hours will be 7:00 am to 7:00 pm in a hospital or clinical setting unless otherwise specified by the attending physician. E. Residents will be on-call a maximum of every third night for dermatology cases (7:00 pm to 8:00 am) and every other weekend. The resident will not be on-call during elective months.

II. Didactics

A. Weekly reading assignments will be required from standardized general and dermatologic subspecialty textbooks and additional sources per house staff recommendations (i.e. Bologna, Fitzpatric, Andrews, Dahl, Arndt, Lever, Hurwitz, Morison, Baker, Gross, Ackerman, Baumann, Dzubow, Stegman, etc.) B. Weekly clinical lecture series with residents and staff. C. Weekly dermatopathology “unknown” slide and text review. D. Journal review from the following sources: Journal of the American Academy of Dermatology, Archives of Dermatology, Journal of Dermatologic Surgery and Oncology, Journal of Investigative Dermatology, British Journal of Dermatology, Cutis, Journal of the American Osteopathic College of Dermatology, The Journal of Clinical and Aesthetic Dermatology, Practical Dermatology, and other pertinent references. E. Basic/clinical science lecture series over a three year residency training period to cover a broad spectrum of dermatologic topics including the following: anatomy, allergy, physiology of the skin, histopathology, bacteriology, virology, genetics, histology, immunology, mycology, oncology, parasitology, pathology, pharmacology, embryology, photobiology, radiation oncology, serology, primary therapeutic modalities, and additional topics per house staff.

III. Required Conferences A. B. C. D.

Monthly “Dermatology Grand Rounds” at Wayne State University. Michigan Osteopathic Dermatology Society meetings as scheduled. American Osteopathic College of Dermatology annual and mid-year meetings. American Academy of Dermatology annual or midyear meetings.

A. B. C. D.

American Society of Dermatologic Surgery Meeting. American Society for Mohs Surgery Course. SCRIPPS Clinic, Superficial Anatomy and Cutaneous Surgery Conference. Additional recommendations per Program Director and Faculty.

IV. Recommended Courses During 2nd and 3rd Year of Training

V. Research/Publications/Presentations

A. Residents are required to submit one manuscript acceptable for publication yearly on a topic approved by the Program Director.

B. Residents must prepare oral presentations as required by the American Osteopathic College of Dermatology. C. Residents are required to submit an individual poster at the Annual AOA meeting during the second year of training. D. During the three-year training period, residents must submit an abstract at the annual meeting of the AAD to the “Gross & Microscopic Symposium” at least once. E. Residents shall be encouraged to participate in presentations at local and national dermatologic meetings. F. Residents will be required to give monthly lectures for the house staff at Lakeland Regional Medical Center.

VI. Supervision

A. Residents will be responsible to assigned staff members at all times. B. Staff must review all patients seen by first year residents. C. Review of patients seen by second and third year residents will be discussed on an individual basis.

VII. Moonlighting

A. First year residents will be prohibited from moonlighting. B. Second and third year residents must receive permission from the department prior to moonlighting.

VIII. Logs

A. Residents are required to keep logs of all dermatologic cases (patients and procedures) for their service via the New Innovations Residency Management Suite, which will be reviewed regularly by his/her respective trainer and quarterly with the director of medical education. B. Logs must be recorded in a timely fashion and up-to-date on a weekly basis.

IX. Evaluations

A. Residents are required to obtain an evaluation from their clinical trainer after each rotation. Evaluations are completed and/or maintained in the New Innovations Residency Software. A copy of each resident evaluation will be sent to the Program Director and Director of Medical Education for review, as well as to the AOCD. B. Quarterly evaluations of each resident, as well as an annual evaluation, will be completed by the Program Director and submitted to the Director of Medical Education. A copy of these evaluations will be sent to the AOCD.

X. Examinations

A. Residents are required to participate in the annual in-training examination through the American Osteopathic College of Dermatology that is held during the AOA convention.

XI. Resident Selection and Renewal Process

A. The program anticipates available funding for one dermatology residency position each year, and perhaps additional positions in future application seasons. B. Applications for candidates will be accepted through ERAS with program participation in the Osteopathic Dermatology Match. C. Potential residency applicants may be offered interviews and selected to enter into the dermatology program based on several qualifications. Important considerations for the selection of candidates include board scores, dermatologic research involvement, knowledge base, performance on clinical rotations, passion and commitment to the field, etc. D. Resident contracts will be renewed annually at the discretion of the Program Director and Director of Medical Education.

XII. Qualifications and Expectations of Teaching Faculty

A. The dermatology program will continue to recruit and provide trainers of the highest standard for all trainees. Individuals with exceptional distinctions in their respected specialties, ability and passion for teaching, and capability to offer new advancement and innovation into the training program will be particularly desired. B. Teaching faculty is expected to uphold all residency regulations and standards, provide adequate supervision for all trainees based on their level of training, and make a genuine commitment to utilizing time and resources to teaching in the field.

XIII. Clinical Program

A. Primary focus will involve direct patient care for greater than 75% of the training period. 1. Outpatient dermatology will involve one-on-one interaction between the resident and staff physician in an office setting. 2. Inpatient dermatology will include a hospital and nursing home consultation service that provides continued management and monitoring of patients in an inpatient environment under house staff supervision. 3. Continued participation in the review and presentation of a broad spectrum of clinical cases throughout the course of residency training.

B. Dermatopathology

1. Residents will participate in the review of approximately 50 cases twice a week through the Dermatopathology Laboratory of Central States (DLCS) in Dayton, OH. Cases will be transmitted via the Internet to computers at the residency site. Residents will listen to the actual sign-out of each case with key teaching points being emphasized, and will be able to ask questions and provide insight during this process. 2. DLCS will provide two conferences a month on a designated day. Each conference will be approximately 90 minutes and be focused on unknown slides that will be available to the residents one-week prior. During each conference, residents will describe the particular lesion being examined, as well as provide a differential and final diagnosis. Didactic conferences will also be included. 3. Residents will have full access to the DLCS glass slide teaching sets. This includes approximately 600 cases that have been compiled and will serve as an extremely useful tool for independent study. 4. Opportunities will be available for independent study at DLCS laboratory in Dayton, OH to further enhance educational development. 5. Residents will be tested on 30 dermatopathology unknowns three times yearly and the results will be submitted to the Program Director and faculty. 6. Structured weekly reading program based on standardized dermatopathology texts (i.e. Lever, Weedon, McKee, etc.). 7. Additional exposure to gross anatomical pathology and slide preparation techniques.

C. Dermatologic Surgery

1. Outpatient surgery consisting of cryosurgery, biopsies, electrosurgery, excisions with closure, nail surgery, etc. 2. Direct exposure to Mohs, flap closure, skin grafting techniques, laser, and a multitude of cosmetic procedures. 3. Additional exposure to anatomic dissection and interaction with related specialties (ENT, plastics, etc.).

D. Osteopathic Medicine in Dermatology

1. Lectures and conferences pertaining to osteopathic principles in the field of dermatology. 2. Interactive online modules to further enhance education in osteopathic philosophies and principles.

E. Additional Rotations/Electives

1. Rotations in other subspecialties will incorporate the primary principles in their respective fields to the practice of clinical dermatology as seen fit by each faculty member. 2. Emphasis will be placed on the relationship between each subspecialty and the evaluation, diagnosis, management, and treatment of dermatologic patients.

XIV. First Year

A. As a first year dermatology resident, days will consist of rotating with the staff dermatologists for a total of 10 months in both the office and hospital setting. B. Must adhere to the training guidelines as stated in the Dermatology Residency Protocol. C. First year resident will do a 1-month rotation in Radiation Oncology. D. 2 weeks Allergy/Immunology; 2 weeks Rheumatology. E. Resident is required to attend all sessions of grand rounds, dermatopathology lectures, journal clubs, Michigan Dermatology Society meetings, and all other required lectures as stated by the Program Director and Dermatology Residency Training Protocol.

XV. Second Year

A. Second year dermatology residents will rotate with the staff dermatologists for a total of 10 months in both the office and hospital setting. B. Must adhere to training guidelines as stated in the Dermatology Residency Protocol. C. Second-year residents will have 1 month available for an elective rotation in the second year of training, exclusive of the two weeks available for the annual AOCD and AAD conventions. D. 1 month of Pediatric Dermatology. E. Resident is required to attend all sessions of grand rounds, dermatopathology lectures, journal clubs, Michigan Dermatology Society meetings, and all other required lectures as stated by the Program Director and Dermatology Residency Training Protocol.

XVI. Third Year

A. Third year dermatology residents will rotate with the staff dermatologists for a total of 10 months in both the office and hospital setting. B. Must adhere to the training guidelines as stated in the Dermatology Residency Protocol.

C. Third-year residents will have 1 month available for an elective rotation in the third year of training, exclusive of the two weeks available for the annual AOCD and AAD conventions. D. Resident is required to attend all sessions of grand rounds, dermatopathology lectures, journal clubs, Michigan Dermatology Society meetings, and all other required lectures as stated by the Program Director and Dermatology Residency Training Protocol.

The rotation schedule is subject to change annually, depending on the program needs and recommendations made by faculty in the best interests of the residencytraining program. VI. Teaching Faculty Roster with Certification Status

The Dermatology Residency Program will be under the direct supervision of the Program Director, Mark Kuriata, D.O., F.A.O.C.D. He graduated Cum Laude with a Bachelor of Science in Medicine from Western Michigan University in 1989, completing training as a Physician Assistant. He then went on to graduate from the Des Moines University-College of Osteopathic Medicine (DMU-COM) in 1994. Dr. Kuriata completed his residency in Dermatology at Northeast Regional Medical Center in 1999, and is certified by the American Osteopathic Board of Dermatology as a specialist in dermatology with added qualifications in Mohs Micrographic Surgery.

As Program Director, Dr. Kuriata will oversee the entire scope of this training program and is committed to providing a foundation for academic and clinical excellence. His desire and passion for teaching have been clearly exhibited over the course of his career, and he is highly respected for both his knowledge and commitment to the field of dermatology among his peers and colleagues. As Program Director, he will fulfill and maintain all residency standards and requirements as set forth by the AOA in The Basic Documents for Postdoctoral Training, and the AOCD in the Basic Standards for Residency Training in Dermatology. He will also strive to achieve all goals and objectives as described in this program. Additional teaching faculty to be involved in the Dermatology Residency Program include the following: 1) 4) 5) 6) 7)

Thomas G. Olsen, MD, Specialty: Dermatopathology. Peter P. Lai, PhD/MD, Specialty: Radiation Oncology. Byra M. Reddy, MD, Specialty: Allergy/Immunology. Amrit Anand, MD, Specialty: Rheumatology. Anthony J. Mancini, MD, Specialty: Pediatric Dermatology.

The above faculty have agreed to contribute their knowledge and expertise in their respected specialties to the education of dermatology residents in this program.

These efforts include training residents through rotations, lectures, research opportunities, etc. Additional trainers will be added over time as seen fit by faculty to further enhance the education of all residents. VII. Core Competency Plan I. First Year

A. By the completion of the first year of training, the Dermatology Resident should be proficient in the following for satisfactory progression in the program:

1. Ability to complete a thorough history and physical examination regarding a patient’s primary dermatologic chief complaint. 2. Present an informative and organized clinical presentation of any dermatologic case during daily rounds or during a lecture. 3. Have an understanding of the basic structure and functionality of the integumentary system as pertaining to development, morphology, and physiology. 4. Understand basic histopathology reaction patterns and physiologic reactions. 5. Formulate basic principles of clinical dermatologic differential diagnoses. 6. Have a basic understanding for disorders involving immunity, hypersensitivity, and inflammation as pertains to clinical immunology and anaphylactic syndromes. 7. Have an understanding for the diagnosis, management, and treatment of the following disease processes: contact and atopic dermatitis, drug eruptions, photosensitivity reactions, bullous diseases, papulosquamous eruption, exfoliative dermatitis, bacterial infections, viral and rickettsial diseases, nonvenereal spirochete infections, treponemal and non-treponemal venereal infections, acne and acneiform dermatoses, superficial and deep mycotic infections, and tumors of the skin. 8. Be able to perform the following procedures: excisional, incisional, and punch biopsies, as well as basic surgical techniques for skin closure. 9. Become familiar with the indications for patch testing, UV light therapy, cryosurgery/electrosurgery, and Mohs Surgery. 10. Incorporation of basic osteopathic philosophy and principles into clinical practice.

II. Second Year

A. By the completion of the second year of training, the Dermatology Resident should be proficient in the following for satisfactory progression in the program: 1. Understanding and performance all objectives as listed in the first year requirements of a dermatology resident. 2. Provide concise history and physical examination findings with a management plan for both simple and complex disease processes.

3. Have an in depth understanding for the diagnosis, management, and treatment of the following disease processes: connective tissue diseases, reticuloendothelial diseases, peripheral vessel diseases, cornium and subcutaneous tissue diseases, pigmentation changes, cornification disorders, apocrine and eccrine gland diseases, hair and nail disorders, skin tumors, metabolic and nutritional diseases pertaining to the skin, cutaneous manifestations of systemic disease processes, physical agent skin reactions, industrial dermatoses, parasitology and tropical dermatology, oral cavity diseases, psychogenic and neurogenic skin disorders, etc. 4. Become proficient in dermatologic plastic skin closure techniques. 5. Understand the histopathological correlation to varying cutaneous disease processes. 6. Develop growing independence in the topical and systemic management of complex diseases. 7. Be proficient in teaching basic dermatologic principles as well as proper methods of skin examination to junior residents, medical students, etc. 8. Be familiar with laboratory tests appropriate for different dermatologic disease presentations.

III. Third Year

A. By the completion of the third year of training, the Dermatology Resident should be proficient in the following for satisfactory progression in the program:

1. Understanding and performance of all objectives listed as first and second year requirements of a dermatology resident 2. Have a significantly advanced knowledge base of all topics outlined in the first and second years of training. 3. Have an advanced understanding of dermatologic therapeutic modalities related to disease processes covered over the course of residency. 4. Have an advanced understanding of physical treatment modalities such as UV light, cryosurgery, and dermatologic radiation therapy. 5. Be involved in scholarly elective activities in dermatology. 6. Understand rare and controversial disease processes in the dermatologic field. 7. Continue to improve knowledge base by reading the most current scientific literature in the dermatologic field.

Satisfactory fulfillment of all of the above listed objectives is required for successful completion of the dermatology residency program by each resident. The foundation and core curriculum of this program have been suited to achieve these goals.

VIII. Sample Evaluation Form A copy of the resident rotation evaluation form has been included in this application. Please see the attached copy. IX. Work Hours and Leave Policy

A. This program will strictly follow the AOA Duty Hours Policy. Duty hours are identified as all clinical and academic experiences pertaining to the residency program. These hours do not include additional reading and study time spent outside of the hospital or clinical setting. B. Duty hours are requirements are defined in the Lakeland House Staff Manual. C. Residents will not be allowed modify or change their schedules without prior approval from the Program Director. D. Residents will be required to log their duty hours daily to help monitor and avoid duty hour violations. E. The Program Director will certify monthly to the Graduate Medical Education Office, as well as the Graduate Medical Education Committee, that all residents have complied with this policy. If a duty hour violation occurs, the Program Director must account for this episode and determine an appropriate resolution to avoid future violations. F. Residents on clinical rotations are responsible to their assigned staff physician who must be notified and approve all absences. G. Residents will be provided with 20 business days of paid time off for each contract year. These days must be scheduled through the chief resident and approved in advance by the staff physician and Program Director. H. Other time away from a rotation must be discussed with the chief resident and approved by the staff physician and Program Director.

X. Remediation Policy

Refer to the Lakeland House Staff Manual