Redesigning Diabetes Care: Defining the Role of Endocrinologists Among Alternative Providers.

The current diabetes epidemic threatens to overwhelm the healthcare system unless we redesign how diabetes care is delivered. The number of endocrinologists is grossly inadequate to provide care for all individuals with diabetes, but with the appropriate utilization of the primary care workforce and alternative healthcare providers working together in teams, effective diabetes care can be provided to all. We propose a patient-centered, goal-based approach with resources devoted to care coordination, measurement of outcomes, appropriate use of technology, and measurement of patient satisfaction. Financial incentives to healthcare systems and providers need to be based on defined outcome measures and reducing long-term total medical expenditures, rather than reimbursement based on number of visits and lengthy documentation. Endocrinologists have a responsibility in setting up effective diabetes care delivery systems within their organizations, in addition to delivering diabetes care and serving as a resource for the educational needs for other medical professionals in the community. There are major challenges to implementing such systems, both at the financial and organizational levels. We suggest a stepwise implementation of discrete components based on the local priorities and resources and provide some examples of steps we have taken at our institution.

Compelling evidence from meta-epidemiological studies demonstrates overestimation of effects in randomized trials that fail to optimize randomization and blind patients and outcome assessors.

OBJECTIVES: To investigate the impact of potential risk of bias elements on effect estimates in randomized trials. STUDY DESIGN AND SETTING: We conducted a systematic survey of meta-epidemiological studies examining the influence of potential risk of bias elements on effect estimates in randomized trials. We included only meta-epidemiological studies that either preserved the clustering of trials within meta-analyses (compared effect estimates between trials with and without the potential risk of bias element within each meta-analysis, then combined across meta-analyses; between-trial comparisons), or preserved the clustering of substudies within trials (compared effect estimates between substudies with and without the element, then combined across trials; within-trial comparisons). Separately for studies based on between- and within-trial comparisons, we extracted ratios of odds ratios (RORs) from each study and combined them using a random-effects model. We made overall inferences and assessed certainty of evidence based on Grading of Recommendations, Assessment, development, and Evaluation and Instrument to assess the Credibility of Effect Modification Analyses. RESULTS: Forty-one meta-epidemiological studies (34 of between-, 7 of within-trial comparisons) proved eligible. Inadequate random sequence generation (ROR 0.94, 95% confidence interval [CI] 0.90-0.97) and allocation concealment (ROR 0.92, 95% CI 0.88-0.97) probably lead to effect overestimation (moderate certainty). Lack of patients blinding probably overestimates effects for patient-reported outcomes (ROR 0.36, 95% CI 0.28-0.48; moderate certainty). Lack of blinding of outcome assessors results in effect overestimation for subjective outcomes (ROR 0.69, 95% CI 0.51-0.93; high certainty). The impact of patients or outcome assessors blinding on other outcomes, and the impact of blinding of health-care providers, data collectors, or data analysts, remain uncertain. Trials stopped early for benefit probably overestimate effects (moderate certainty). Trials with imbalanced cointerventions may overestimate effects, while trials with missing outcome data may underestimate effects (low certainty). Influence of baseline imbalance, compliance, selective reporting, and intention-to-treat analysis remain uncertain. CONCLUSION: Failure to ensure random sequence generation or adequate allocation concealment probably results in modest overestimates of effects. Lack of patients blinding probably leads to substantial overestimates of effects for patient-reported outcomes. Lack of blinding of outcome assessors results in substantial effect overestimation for subjective outcomes. For other elements, though evidence for consistent systematic overestimate of effect remains limited, failure to implement these safeguards may still introduce important bias.

Finding New Meaning in the Practice of Medicine: A Quality Improvement Project Evaluating the Remote Communication Liaison Program During the Initial COVID Pandemic Surge.

Background: In spring 2020, the COVID-19 pandemic overwhelmed intensive care teams with severely ill patients. Even at the end of life, families were barred from hospitals, relying solely on remote communication. A Remote Communication Liaison Program (RCLP) was established to ensure daily communication for families, while supporting overstretched intensivists. Objectives: To evaluate the effectiveness and impact of the RCLP on participating liaisons and intensivists. Design: Two quality improvement surveys were developed and administered electronically. Setting/Subjects: Based in the United States, all liaisons and intensivists who participated in this program were invited to take the surveys. Measurements: Descriptive statistics were used to analyze the quantitative Likert-scale data, and qualitative analysis was used to assess themes. Results: Among respondents, all (100%) liaisons and more than 90% of intensivists agreed or strongly agreed that the RCLP provided a valuable service to families. More than 70% of intensivists agreed or strongly agreed that the program lessened their workload. More than 90% of liaisons agreed or strongly agreed that participation in the program improved their confidence and skills in end-of-life decision making, difficult conversations, and comprehension of critical care charts. Themes elicited from the liaisons revealed that participation fostered a renewed sense of purpose as physicians, meaningful connection, and opportunities for growth. Conclusions: RCLP successfully trained and deployed liaisons to rapidly develop skills in communication with beleaguered families during COVID-19 surge. Participation in the program had a profound effect on liaisons, who experienced a renewed sense of meaning and connection to the practice of medicine.

Instruments assessing risk of bias of randomized trials frequently included items that are not addressing risk of bias issues.

OBJECTIVES: To establish whether items included in instruments published in the last decade assessing risk of bias of randomized controlled trials (RCTs) are indeed addressing risk of bias. STUDY DESIGN AND SETTING: We searched Medline, Embase, Web of Science, and Scopus from 2010 to October 2021 for instruments assessing risk of bias of RCTs. By extracting items and summarizing their essential content, we generated an item list. Items that two reviewers agreed clearly did not address risk of bias were excluded. We included the remaining items in a survey in which 13 experts judged the issue each item is addressing: risk of bias, applicability, random error, reporting quality, or none of the above. RESULTS: Seventeen eligible instruments included 127 unique items. After excluding 61 items deemed as clearly not addressing risk of bias, the item classification survey included 66 items, of which the majority of respondents deemed 20 items (30.3%) as addressing risk of bias; the majority deemed 11 (16.7%) as not addressing risk of bias; and there proved substantial disagreement for 35 (53.0%) items. CONCLUSION: Existing risk of bias instruments frequently include items that do not address risk of bias. For many items, experts disagree on whether or not they are addressing risk of bias.

Training satisfaction for subspecialty fellows in internal medicine: findings from the Veterans Affairs (VA) Learners' Perceptions Survey.

BACKGROUND: Learner satisfaction assessment is critical in the design and improvement of training programs. However, little is known about what influences satisfaction and whether trainee specialty is correlated. A national comparison of satisfaction among internal medicine subspecialty fellows in the Department of Veterans Affairs (VA) provides a unique opportunity to examine educational factors associated with learner satisfaction. We compared satisfaction across internal medicine fellows by subspecialty and compared factors associated with satisfaction between procedural versus non-procedural subspecialty fellows, using data from the Learners' Perceptions Survey (LPS), a validated survey tool. METHODS: We surveyed 2,221 internal medicine subspecialty fellows rotating through VA between 2001 and 2008. Learners rated their overall training satisfaction on a 100-point scale, and on a five-point Likert scale ranked satisfaction with items within six educational domains: learning, clinical, working and physical environments; personal experience; and clinical faculty/preceptor. RESULTS: Procedural and non-procedural fellows reported similar overall satisfaction scores (81.2 and 81.6). Non-procedural fellows reported higher satisfaction with 79 of 81 items within the 6 domains and with the domain of physical environment (4.06 vs. 3.85, p <0.001). Satisfaction with clinical faculty/preceptor and personal experience had the strongest impact on overall satisfaction for both. Procedural fellows reported lower satisfaction with physical environment. CONCLUSIONS: Internal medicine fellows are highly satisfied with their VA training. Nonprocedural fellows reported higher satisfaction with most items. For both procedural and non-procedural fellows, clinical faculty/preceptor and personal experience have the strongest impact on overall satisfaction.

Development of a Novel Communication Liaison Program to Support COVID-19 Patients and Their Families.

In the spring of 2020, our hospital faced a surge of critically ill coronavirus disease 2019 patients, with intensive care unit (ICU) occupancy peaking at 204% of the baseline maximum capacity. In anticipation of this surge, we developed a remote communication liaison program to help the ICU and palliative care teams support families of critically ill patients. In just nine days from inception until implementation, we recruited and prepared ambulatory specialty providers to serve in this role effectively, despite minimal prior critical care experience. We report here the primary elements needed to reproduce and scale this program in other hospitals facing similar ICU surges, including a checklist for replication (Appendix I). Keys to success include strong logistical support, clinical reference material designed for rapid evolution, and a liaison team structure with peer coaching.

Tips for teachers of evidence-based medicine: making sense of decision analysis using a decision tree.

Decision analysis is a tool that clinicians can use to choose an option that maximizes the overall net benefit to a patient. It is an explicit, quantitative, and systematic approach to decision making under conditions of uncertainty. In this article, we present two teaching tips aimed at helping clinical learners understand the use and relevance of decision analysis. The first tip demonstrates the structure of a decision tree. With this tree, a clinician may identify the optimal choice among complicated options by calculating probabilities of events and incorporating patient valuations of possible outcomes. The second tip demonstrates how to address uncertainty regarding the estimates used in a decision tree. We field tested the tips twice with interns and senior residents. Teacher preparatory time was approximately 90 minutes. The field test utilized a board and a calculator. Two handouts were prepared. Learners identified the importance of incorporating values into the decision-making process as well as the role of uncertainty. The educational objectives appeared to be reached. These teaching tips introduce clinical learners to decision analysis in a fashion aimed to illustrate principles of clinical reasoning and how patient values can be actively incorporated into complex decision making.

Impact of clinical training on recruiting graduating health professionals.

OBJECTIVES: Recruiting professional staff is an important business reason for hospitals allowing health trainees to engage in supervised patient care. Whereas prior studies have focused on educational institutions, this study focuses on teaching hospitals and whether trainees' clinical experiences affect their willingness to work (ie, recruitability) for the type of healthcare center where they trained. STUDY DESIGN: A pre-post, observational study based on Learners' Perceptions Survey data in which respondents served as their own controls. METHODS: Convenience sample of 15,207 physician, 11,844 nursing, and 13,012 associated health trainees who rotated through 1 of 169 US Department of Veterans Affairs (VA) medical centers between July 1, 2014, and June 30, 2017. Generalized estimating equations computed how clinical, learning, working, and cultural experiences influenced pre-post differences in willingness to consider VA for future employment. RESULTS: VA recruitability increased dramatically from 55% pretraining to 75% post training (adjusted odds ratio [OR], 2.1; 95% CI, 2.0-2.1; P <.001) in all 3 cohorts: physician (from 39% to 59%; OR, 1.6; 95% CI, 1.5-1.6; P <.001), nursing (from 61% to 84%; OR, 2.5; 95% CI, 2.4-2.6; P <.001), and associated health trainees (from 68% to 87%; OR, 2.7; 95% CI, 2.6-2.9; P <.001). For all trainees, changes in recruitability (P <.001) were associated with how trainees rated their clinical learning environment, personal experiences, and culture of psychological safety. Satisfaction ratings with faculty and preceptors (P <.001) were associated with positive changes in recruitability among nursing and associated health students but not physician residents, whereas nursing students who gave higher ratings for interprofessional team culture became less recruitable. CONCLUSIONS: Academic medical centers can attract their health trainees for future employment if they provide positive clinical, working, learning, and cultural experiences.

Tips for teachers of evidence-based medicine: clinical prediction rules (CPRs) and estimating pretest probability.

BACKGROUND: Clinical prediction rules (CPR) are tools that clinicians can use to predict the most likely diagnosis, prognosis, or response to treatment in a patient based on individual characteristics. CPRs attempt to standardize, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. The teaching tips series is designed to give teachers advice and materials they can use to attain specific educational objectives. EDUCATIONAL OBJECTIVES: In this article, we present 3 teaching tips aimed at helping clinical learners use clinical prediction rules and to more accurately assess pretest probability in every day practice. The first tip is designed to demonstrate variability in physician estimation of pretest probability. The second tip demonstrates how the estimate of pretest probability influences the interpretation of diagnostic tests and patient management. The third tip exposes learners to various examples and different types of Clinical Prediction Rules (CPR) and how to apply them in practice. PILOT TESTING: We field tested all 3 tips with 16 learners, a mix of interns and senior residents. Teacher preparatory time was approximately 2 hours. The field test utilized a board and a data projector; 3 handouts were prepared. The tips were felt to be clear and the educational objectives reached. Potential teaching pitfalls were identified. CONCLUSION: Teaching with these tips will help physicians appreciate the importance of applying evidence to their every day decisions. In 2 or 3 short teaching sessions, clinicians can also become familiar with the use of CPRs in applying evidence consistently in everyday practice.

Behind closed doors: management of patient expectations in primary care practices.

BACKGROUND: Managed care restrictions on resource use may affect communication between patients and health care professionals. METHODS: To characterize negotiations between primary care physicians and patients with expectations for new medications, tests, or referrals, this observational study combined survey data with audiotape recordings of clinical encounters. Fifty-five physicians from 20 randomly selected primary care practices in a managed care network and 211 patients who voiced specific expectations in a previsit survey were included. From the recorded clinic visits we determined modes of negotiation of patient expectations and requests. From the surveys we determined patient previsit expectations, postvisit fulfillment of expectations, satisfaction, and trust. RESULTS: Two-hundred fifty-six self-reported expectations were captured in 200 audiotape-recorded encounters. Of the previsit expectations, 97.3% were discussed during the encounter. Expectations were expressed by direct patient request (40.6%), mentioning of symptoms related to request (29.7%), or physician-initiated discussion (27.0%). Most expectations were met (66.8%); physicians suggested an alternative 21.6% of the time. Expectations for medications and tests were met more frequently than expectations for referrals (75.6% and 71.4% vs 40.8%). Patient satisfaction and trust remained high regardless of whether expectations were met. Physicians reported that they would not have ordered 62 (44.9%) of 138 requests had the patients not directly asked, and they were uncomfortable filling 8 requests (12.9%). CONCLUSIONS: Previsit expectations for medications, tests, or referrals were discussed at the visit, and physicians met or offered alternatives for nearly 90%. Patients generally received what they asked for and altered physician behavior nearly half of the time.

Utilization of the PICO framework to improve searching PubMed for clinical questions.

BACKGROUND: Supporting 21st century health care and the practice of evidence-based medicine (EBM) requires ubiquitous access to clinical information and to knowledge-based resources to answer clinical questions. Many questions go unanswered, however, due to lack of skills in formulating questions, crafting effective search strategies, and accessing databases to identify best levels of evidence. METHODS: This randomized trial was designed as a pilot study to measure the relevancy of search results using three different interfaces for the PubMed search system. Two of the search interfaces utilized a specific framework called PICO, which was designed to focus clinical questions and to prompt for publication type or type of question asked. The third interface was the standard PubMed interface readily available on the Web. Study subjects were recruited from interns and residents on an inpatient general medicine rotation at an academic medical center in the US. Thirty-one subjects were randomized to one of the three interfaces, given 3 clinical questions, and asked to search PubMed for a set of relevant articles that would provide an answer for each question. The success of the search results was determined by a precision score, which compared the number of relevant or gold standard articles retrieved in a result set to the total number of articles retrieved in that set. RESULTS: Participants using the PICO templates (Protocol A or Protocol B) had higher precision scores for each question than the participants who used Protocol C, the standard PubMed Web interface. (Question 1: A = 35%, B = 28%, C = 20%; Question 2: A = 5%, B = 6%, C = 4%; Question 3: A = 1%, B = 0%, C = 0%) 95% confidence intervals were calculated for the precision for each question using a lower boundary of zero. However, the 95% confidence limits were overlapping, suggesting no statistical difference between the groups. CONCLUSION: Due to the small number of searches for each arm, this pilot study could not demonstrate a statistically significant difference between the search protocols. However there was a trend towards higher precision that needs to be investigated in a larger study to determine if PICO can improve the relevancy of search results.

Has Interprofessional Education Changed Learning Preferences? A National Perspective.

OBJECTIVE: To assess how changes in curriculum, accreditation standards, and certification and licensure competencies impacted how medical students and physician residents value interprofessional team and patient-centered care. PRIMARY DATA SOURCE: The Department of Veterans Affairs Learners' Perceptions Survey (2003-2013). The nationally administered survey asked a representative sample of 56,569 U.S. medical students and physician residents, with a comparison group of 78,038 nonphysician trainees, to rate satisfaction with 28 elements, in two overall domains, describing their clinical learning experiences at VA medical centers. STUDY DESIGN: Value preferences were scored as independent adjusted associations between an element (interprofessional team, patient-centered preceptor) and the respective overall domain (clinical learning environment, faculty, and preceptors) relative to a referent element (quality of clinical care, quality of preceptor). PRINCIPAL FINDINGS: Physician trainees valued interprofessional (14 percent vs. 37 percent, p < .001) and patient-centered learning (21 percent vs. 36 percent, p < .001) less than their nonphysician counterparts. Physician preferences for interprofessional learning showed modest increases over time (2.5 percent/year, p < .001), driven mostly by internal medicine and surgery residents. Preferences did not increase with trainees' academic progress. CONCLUSIONS: Despite changes in medical education, physician trainees continue to lag behind their nonphysician counterparts in valuing experience with interprofessional team and patient-centered care.

Beyond journal clubs. Moving toward an integrated evidence-based medicine curriculum.

Incorporating evidence-based medicine (EBM) into clinical practice is an important competency that residency training must address. Residency program directors, and the clinical educators who work with them, should develop curricula to enhance residents' capacity for independent evidence-based practice. In this article, the authors argue that residency programs must move beyond journal club formats to promote the practice of EBM by trainees. The authors highlight the limitations of journal club, and suggest additional curricular approaches for an integrated EBM curriculum. Helping residents become effective evidence users will require a sustained effort on the part of residents, faculty, and their educational institutions.

A controlled trial of a short course to improve residents' communication with patients at the end of life.

PURPOSE: High-quality palliative care requires physicians who communicate effectively, yet many do not receive adequate training. Leading efforts to demonstrate the effectiveness of such training have involved time-intensive programs that included primarily attending physicians, which have been conducted outside of the United States. The goal was to evaluate the effect of a short course to improve residents' communication skills delivering bad news and eliciting patients' preferences for end-of-life care. METHOD: This prospective trial enrolled internal medicine residents at Duke University Medical Center from 1999 to 2001. The course consisted of small-group teaching with lecture, discussion, and role-play. The outcome measure was observed communication skills delivering bad news and eliciting patients' preferences for end-of-life treatment, assessed via audio-recorded standardized patient encounters before and after receiving the intervention. RESULTS: Thirty-seven residents received the intervention and 19 were in the control group. Residents attending the course demonstrated statistically significant increases in their overall skill ratings in the delivery of bad news, with improvement in the specific areas of information giving and responding to emotional cues. Although cumulative scores for discussions about patient preferences for treatment did not increase, residents demonstrated enhanced specific skills including discussing probability, presenting clinical scenarios, and asking about prior experience with end-of-life decision making. CONCLUSION: A relatively short, intensive course can improve the end-of-life communication skills of U.S. medical residents.

Randomized trial for answers to clinical questions: evaluating a pre-appraised versus a MEDLINE search protocol.

OBJECTIVE: The paper compares the speed, validity, and applicability of two different protocols for searching the primary medical literature. DESIGN: A randomized trial involving medicine residents was performed. SETTING: An inpatient general medicine rotation was used. PARTICIPANTS: Thirty-two internal medicine residents were block randomized into four groups of eight. MAIN OUTCOME MEASURES: Success rate of each search protocol was measured by perceived search time, number of questions answered, and proportion of articles that were applicable and valid. RESULTS: Residents randomized to the MEDLINE-first (protocol A) group searched 120 questions, and residents randomized to the MEDLINE-last (protocol B) searched 133 questions. In protocol A, 104 answers (86.7%) and, in protocol B, 117 answers (88%) were found to clinical questions. In protocol A, residents reported that 26 (25.2%) of the answers were obtained quickly or rated as "fast" (<5 minutes) as opposed to 55 (51.9%) in protocol B, (P = 0.0004). A subset of questions and articles (n = 79) were reviewed by faculty who found that both protocols identified similar numbers of answer articles that addressed the questions and were felt to be valid using critical appraisal criteria. CONCLUSION: For resident-generated clinical questions, both protocols produced a similarly high percentage of applicable and valid articles. The MEDLINE-last search protocol was perceived to be faster. However, in the MEDLINE-last protocol, a significant portion of questions (23%) still required searching MEDLINE to find an answer.

Does Psychological Safety Impact the Clinical Learning Environment for Resident Physicians? Results From the VA's Learners' Perceptions Survey.

BACKGROUND: Psychological safety (PS) is the perception that it is safe to take interpersonal risks in the work environment. In teaching hospitals, PS may influence the clinical learning environment for trainees. OBJECTIVE: We assessed whether resident physicians believe they are psychologically safe, and if PS is associated with how they rate satisfaction with their clinical learning experience. METHODS: Data were extracted from the Learners' Perceptions Survey (LPS) of residents who rotated through a Department of Veterans Affairs health care facility for academic years 2011-2014. Predictors of PS and its association with resident satisfaction were adjusted to account for confounding and response rate biases using generalized linear models. RESULTS: The 13 044 respondents who completed the LPS (30% response rate) were comparable to nonpediatric, non-obstetrics-gynecology residents enrolled in US residency programs. Among respondents, 11 599 (89%) agreed that ". . . members of the clinical team of which I was part are able to bring up problems and tough issues." Residents were more likely to report PS if they were male, were in a less complex clinical facility, in an other medicine or psychiatry specialty, or cared for patients who were aged, had multiple illnesses, or had social supports. Nonpsychiatric residents felt safer when treating patients with no concurrent mental health diagnoses. PS was strongly associated with how residents rated their satisfaction across 4 domains of their clinical learning experience (P < .001). CONCLUSIONS: PS appears to be an important factor in resident satisfaction across 4 domains that evaluators of graduate medical education programs should consider when assessing clinical learning experiences.

The Veterans Affairs Learners' Perceptions Survey: the foundation for educational quality improvement.

PURPOSE: The U.S. Department of Veterans Affairs (VA) supports 8,700 resident positions nationally to enhance quality of care for veterans and to educate physicians. This study sought to establish a yearly quality indicator to identify and follow strengths and opportunities for improvement in VA clinical training programs. METHOD: In March 2001, the VA Learners' Perceptions Survey, a validated 57-item questionnaire, was mailed to 3,338 residents registered at 130 VA facilities. They were asked to rate their overall satisfaction with the VA clinical training experience and their satisfaction in four domains: faculty/preceptor, learning, working, and physical environments using a five-point Likert scale. Questionnaires were received from 1,775 residents (53.2%). A full analysis was conducted using 1,436 of these questionnaires, whose respondents were categorized in four training programs: medicine (n = 706), surgery (n = 291), subspecialty (n = 266), and psychiatry (n = 173). RESULTS: On a scale of 0 to 100, residents gave their clinical training experience an average score of 79. Eighty-four percent would have recommended VA training to peers, and 81% would have chosen VA training again. Overall, 87% were satisfied with their faculty/preceptors, 78% with the learning environment, and 67% with the working and physical environments. The survey was sensitive to differences in satisfaction among the trainee groups, with residents in internal medicine (IM) the least satisfied. CONCLUSION: The VA Learners' Perceptions Survey is the first validated survey to address comprehensive satisfaction issues in clinical training. The survey highlights strengths and opportunities for improvement in VA clinical training and is the first step toward improving education.

A Web-based compendium of clinical questions and medical evidence to educate internal medicine residents.

The authors designed an electronic database of clinical questions (CQs) and medical evidence and implemented it in 2001-02 at Duke University Medical Center and the Veterans Administration Medical Center in Durham, North Carolina. This Web-based data collection system is called the Critical Appraisal Resource (CAR) and is still in operation. This report is of ten months of the system's operation. During their medicine ward rotations, residents entered CQs into the CAR; they also entered Medline reference links and validated article summaries. Residents' utilization of the CAR database, Medline, and other electronic resources was prospectively measured. In addition, residents were prospectively surveyed regarding the impact of each question and associated reference on medical decision making for individual patients. Over ten months, residents entered 625 patient-based CQs into the CAR and were able to obtain useful information from the medical literature on 82% of the CQs they searched. The two most prevalent CQ types were therapy and diagnosis questions (53% and 22%). Sixty percent of the therapy articles considered useful were reports of randomized controlled trials. Residents obtained 77% of their useful data from Medline. They reported that obtaining useful data altered patient management 47% of the time. Residents used the CAR as a resource, searching the database for information 1,035 times over the study period. In summary, the use of an evidence-based critical appraisal resource led residents to engage the medical literature on behalf of their patients and influenced approximately half of their patient-care decisions. Residents benefited from questions previously searched by other residents, allowing them to address a wider spectrum of CQs during ward rotations.