Exploring preparedness transitions in medicine and pharmacy: a qualitative longitudinal study to inform multiprofessional learning opportunities.

Despite extensive preparedness literature, existing studies fail to adequately explore healthcare graduates' feelings of preparedness longitudinally across new graduate transition journeys, nor do they compare different healthcare professions to ascertain what opportunities exist for multiprofessional transition interventions. Therefore, this Australian study, underpinned by temporal theory, explores the preparedness transitions of medicine and pharmacy graduates. Our 6-month qualitative longitudinal study involved 12 medicine and 7 pharmacy learners after purposive sampling. They participated in an entrance interview before starting internship, longitudinal audio-diaries during their first three months of internship, and an exit interview. Framework analysis explored patterns in the data cross-sectionally and longitudinally for the whole cohort (thinking over time), with pen portraits illustrating individuals' journeys (thinking through time). Preparedness and unpreparedness narratives involved practical skills and tasks, interpersonal skills, knowledge, and professional practice for medicine and pharmacy. However, narratives for practical skills and tasks, and professional practice were dominant amongst medicine graduates, while narratives for interpersonal skills and knowledge were dominant amongst pharmacy graduates. We found numerous cohort changes in feelings of preparedness over time, but the illustrative pen portraits demonstrated the complexities and nuances through time, including feelings of preparedness before internship becoming unpreparedness during internship (e.g., cannulas), improving preparedness through time (e.g., cover shifts), and persistent feelings of unpreparedness (e.g., patient interactions). While our cross-sectional findings are reasonably consistent with existing research, our comparative and longitudinal findings are novel. We recommend that educators build learners' preparedness through uniprofessional transition interventions involving practical skills and tasks, and professional practice in medicine, and interpersonal skills and knowledge in pharmacy. More importantly, we recommend multiprofessional transition interventions for medicine and pharmacy learners before internship focusing on knowledge, and during internship focusing on practical skills and tasks.

Prevention of osteoradionecrosis in patients with head and neck cancer treated with radiation therapy.

BACKGROUND: Osteoradionecrosis is a long-term, serious side effect of head and neck radiation therapy and is associated with significant morbidity and quality of life issues. METHODS: This paper sought to determine consensus on the prevention and management of osteoradionecrosis by an international panel of multidisciplinary professionals expert in the management of patients with head and neck cancer using a Delphi methodology. Unique to this work is our direct inclusion of the views of patients and carers in our findings. RESULTS: This study reached consensus on the importance of pre and post oral health assessment and education for patients with head and neck cancer. This was also noted by the patients and carers who took part in the study. CONCLUSIONS: This work highlights the need for a standardized oral health assessment tool and multidisciplinary care of patients to prevent and manage osteoradionecrosis.

What do we know about dietary perceptions and beliefs of patients with rheumatoid arthritis? A scoping review.

Rheumatoid arthritis is a debilitating inflammatory condition which has a high disease burden. While there is emerging evidence that certain foods and diets could have anti-inflammatory properties and there are published 'anti-inflammatory' diets, there is very little understanding of patient beliefs and perceptions about the impact of diet on symptom management or attitudes to particular dietary interventions. This scoping review aims to summarize the existing literature around the beliefs that patients with rheumatoid arthritis hold regarding the impact of diet on disease activity and joint pain. It also examines the current state of evidence regarding the impact of specific dietary interventions on patient reported and objective parameters of RA disease activity. A search was conducted across seven databases for studies which included reporting on dietary beliefs related to disease management or investigations on the effect of particular diets on disease activity or joint pain. Articles were excluded if they examined extracted compounds or individual dietary supplements. Included studies were synthesized narratively. We retrieved 25,585 papers from which 68 were included in this review: 7 assessed dietary beliefs, 61 explored dietary interventions. The available literature on patient beliefs has been largely limited to quantitative studies with limited qualitative exploration. The Mediterranean, fasting and vegan diets appear to have the most benefit with regards to rheumatoid arthritis outcomes for patients. Research which examines RA patient's beliefs and attitudes about the impact of diet on their RA symptoms and disease is currently lacking.

The Radiation Therapist profession through the lens of new technology: A practice development paper based on the ESTRO Radiation Therapist Workshops.

Technological advances in radiation therapy impact on the role and scope of practice of the radiation therapist. The European Society of Radiotherapy and Oncology (ESTRO) recently held two workshops on this topic and this position paper reflects the outcome of this workshop, which included radiation therapists from all global regions. Workflows, quality assurance, research, IGRT and ART as well as clinical decision making are the areas of radiation therapist practice that will be highly influenced by advancing technology in the near future. This position paper captures the opportunities that this will bring to the radiation therapist profession, to the practice of radiation therapy and ultimately to patient care.

Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review.

BACKGROUND: Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them. AIM: The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies. DESIGN: Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies. METHODS: Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions. RESULTS: Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity. CONCLUSION: Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.

Established advanced practice roles in radiation therapy: A scoping review.

Advanced practitioners are healthcare professionals that are highly skilled with a particular area of expertise. These roles have been successfully implemented in many healthcare settings, improving efficiency of the service, as well as enhancing the standard of care received by patients. Although advanced practice roles have been implemented in some radiation therapy departments, their implementation have yet to be facilitated in the majority of countries. The purpose of this review is to scope the literature available regarding established advanced practice roles in radiation therapy. The PRISMA strategy for the identification of relevant literature was adhered to. Two data bases, EMBASE and PubMed, were searched using combinations of the key words 'Advanced', 'Practice', 'APRT', 'Radiation', 'Therapy' and 'Radiotherapy'. Exclusion criteria were applied, and citation lists were also screened for additional relevant sources, including grey literature sources. A total of 35 relevant sources were identified that discussed advanced practice radiation therapy roles in the United Kingdom, Singapore, Canada, Australia and the USA. Means of role establishment and scope of practice were defined, and a number of advantages and challenges for advanced practice radiation therapist roles were identified. There are many benefits of implementing advanced practice roles in radiation therapy departments. Though the implementation of these roles can be challenging, the existing evidence indicates that it would be beneficial for the patient, the radiation therapist and the department as a whole. A more systematic approach, including reporting of quantitative outcomes may assist in the more widespread implementation of these roles.

SMART-SLE: serology monitoring and repeat testing in systemic lupus erythematosus-an analysis of anti-double-stranded DNA monitoring.

OBJECTIVE: Disease activity monitoring in SLE includes serial measurement of anti-double stranded-DNA (dsDNA) antibodies, but in patients who are persistently anti-dsDNA positive, the utility of repeated measurement is unclear. We investigated the usefulness of serial anti-dsDNA testing in predicting flare in SLE patients who are persistently anti-dsDNA positive. METHODS: Data were analysed from patients in a multinational longitudinal cohort with known anti-dsDNA results from 2013 to 2021. Patients were categorized based on their anti-dsDNA results as persistently negative, fluctuating or persistently positive. Cox regression models were used to examine longitudinal associations of anti-dsDNA results with flare. RESULTS: Data from 37 582 visits of 3484 patients were analysed. Of the patients 1029 (29.5%) had persistently positive anti-dsDNA and 1195 (34.3%) had fluctuating results. Anti-dsDNA expressed as a ratio to the normal cut-off was associated with the risk of subsequent flare, including in the persistently positive cohort (adjusted hazard ratio [HR] 1.56; 95% CI: 1.30, 1.87; P < 0.001) and fluctuating cohort (adjusted HR 1.46; 95% CI: 1.28, 1.66), both for a ratio >3. Both increases and decreases in anti-dsDNA more than 2-fold compared with the previous visit were associated with increased risk of flare in the fluctuating cohort (adjusted HR 1.33; 95% CI: 1.08, 1.65; P = 0.008) and the persistently positive cohort (adjusted HR 1.36; 95% CI: 1.08, 1.71; P = 0.009). CONCLUSION: Absolute value and change in anti-dsDNA titres predict flares, including in persistently anti-dsDNA positive patients. This indicates that repeat monitoring of dsDNA has value in routine testing.

External validation of a radiomic signature to predict p16 (HPV) status from standard CT images of anal cancer patients.

The paper deals with the evaluation of the performance of an existing and previously validated CT based radiomic signature, developed in oropharyngeal cancer to predict human papillomavirus (HPV) status, in the context of anal cancer. For the validation in anal cancer, a dataset of 59 patients coming from two different centers was collected. The primary endpoint was HPV status according to p16 immunohistochemistry. Predefined statistical tests were performed to evaluate the performance of the model. The AUC obtained here in anal cancer is 0.68 [95% CI (0.32-1.00)] with F1 score of 0.78. This signature is TRIPOD level 4 (57%) with an RQS of 61%. This study provides proof of concept that this radiomic signature has the potential to identify a clinically relevant molecular phenotype (i.e., the HPV-ness) across multiple cancers and demonstrates potential for this radiomic signature as a CT imaging biomarker of p16 status.

A systematic literature review of definitions and classification systems for radiotherapy innovation: A first step towards building a value-based assessment tool for radiation oncology.

INTRODUCTION: Timely access to radiotherapy innovations remains suboptimal, partly because there is no commonly agreed appraisal system suitable for the broad range of radiotherapy interventions. The Health Economics in Radiation Oncology (HERO) programme of ESTRO therefore engaged in building a radiotherapy-specific value-based framework. We report on a first step towards that aim, documenting the available definitions and classification systems for radiotherapy interventions. METHODS: A systematic literature search was carried out in Pubmed and Embase, following PRISMA methodology and using search terms on 'innovation', 'radiotherapy', 'definition' and 'classification'. Data were extracted from articles that met prespecified inclusion criteria. RESULTS: Out of 13,353 articles, 25 met the inclusion criteria, resulting in the identification of 7 definitions of innovation and 15 classification systems applicable to radiation oncology. Iterative appraisal divided the classification systems into two groups. A first group of 11 systems categorized innovations according to the perceived magnitude of innovation, typically 'minor' versus 'major'. The remaining 4 systems categorised innovations according to radiotherapy-specific characteristics, such as the type of radiation equipment or radiobiological properties. Here, commonly used terms as 'technique' or 'treatment' were found to be used in different meanings. DISCUSSION: There is no widely accepted definition or classification system for radiotherapy innovations. The data however suggest that unique properties of radiotherapy interventions can be used to categorise innovations in radiation oncology. Still, there remains a need for clear terminology denoting radiotherapy-specific characteristics. CONCLUSION: Building on this review, the ESTRO-HERO project will define what is required for a radiotherapy-specific value-based assessment tool.

Frequency and Clinical Utility of Antibodies to Extractable Nuclear Antigen in the Setting of a Negative Antinuclear Antibody Test.

OBJECTIVE: Simultaneous antibody testing during screening for autoimmune conditions is discouraged. The incidence of positive extractable nuclear antigen (ENA) in the setting of a negative antinuclear antibody (ANA) has been reported as low. Our objective was to characterize the frequency of diagnosis of new ANA-associated rheumatic disease (AARD) in the setting of a negative ANA with a positive ENA. METHODS: This was a 7-year retrospective study from a multicenter tertiary health network in Australia. Clinical information was sought on patients over 18 years old who had a negative ANA but positive ENA test result. Results were extracted from hospital computer systems. RESULTS: From March 19, 2011, to July 23, 2018, ENA testing was ordered simultaneously with an ANA test on 4,248 occasions in 3,484 patients. ANA was positive in 2,520 patients (59.3%) and ENA was positive in 1,980 patients (46.6%). Among positive ANA patients, ENA was positive in 1,563 patients (62.0%). Among 1,728 negative ANA tests, ENA was positive in 417 (24.1%) (P < 0.001). A total of 328 patients with discordant ANA/ENA results had data available for further analysis, of whom 279 had no pre-established rheumatologic condition. A new AARD was diagnosed in 17 of 279 patients, yielding a positive predictive value of 6.09% (95% confidence interval 3.59-9.58). CONCLUSION: Despite the higher-than-expected incidence of positive ENA in the setting of a negative ANA, the yield of newly diagnosed rheumatic diseases was low. Our findings support the stepwise addition of ENA requests when an ANA test result is positive and clinical suspicion of an AARD is high.

Exploring Hypoxia in Prostate Cancer With T2-weighted Magnetic Resonance Imaging Radiomics and Pimonidazole Scoring.

BACKGROUND/AIM: Radiomics involves high throughput extraction of mineable precise quantitative imaging features that serve as non-invasive prognostic or predictive biomarkers. High levels of hypoxia are associated with a poorer prognosis in prostate cancer and limit radiation therapy efficacy. Most patients with prostate cancer undergo magnetic resonance imaging (MRI) as a part of their diagnostics, and T2 imaging is the most utilised imaging method. The aim of this study was to determine whether hypoxia in prostate tumors could be identified using a radiomics model extracted from T2-weighted MR images. MATERIALS AND METHODS: Eighty eight intermediate or high-risk prostate cancer patients were evaluated. Prior to radical prostatectomy, all patients received pimonidazole (PIMO). PIMO hypoxic scores were assigned in whole-mount sections from prostatectomy specimens by an experienced pathologist who was blinded to MRI. The region of interest used for radiomics analysis included the prostatic index tumor. Radiomics extraction yielded 165 features using a special evaluation version of RadiomiX [RadiomiX Research Toolbox version 20180831 (OncoRadiomics SA, Liège, Belgium)] for non-clinical use. Multivariable logistic regression with Elastic Net regularization was utilised using 10 times repeated 10-fold cross-validation to select the best model hyperparameters, optimizing for area under the receiver operating characteristic curve (AUC). RESULTS: The average (out of sample) performance based on the repeated cross validation using the ONESE model yielded an AUC of 0.60±0.2. Shape-based features were the most prominent in the model. CONCLUSION: The development of a radiomics hypoxia model using T2 weighted MR images, standard in the staging of prostate cancer, is possible.

Utility of repeat extractable nuclear antigen antibody testing: a retrospective audit.

OBJECTIVES: Autoantibodies to ENA are frequently ordered during the workup of suspected autoimmune connective tissue diseases. There are no current guidelines for repeat test ordering. The objective of this study was to assess the utility of repeat ENA testing after an initial negative result. METHODS: A retrospective study was conducted in a single, multicentre tertiary health network in Melbourne, Australia. Results of all ENA tests were extracted from the hospital laboratory information system. For patients who had a change in ENA result from negative to positive, clinical information was obtained from the hospital records regarding new diagnosis of an ANA-associated rheumatic disease (AARD). RESULTS: A total of 23 438 ENA tests were performed in 19 603 patients from 29 July 2013 to 28 September 2020. In total, 20 918 (89.2%) were negative with 215 (0.9%) being equivocal. Of the 2305 positive tests, the most common ENA auto-antibody specificity detected was anti-Ro52 (1185, 51.4%). A total of 2636 of 19 603 patients (13.4%) had more than one ENA test performed during the study period. Of these, most (2523, 95.7%) had stable ENA results with no change compared with the first test. Only 53 patients (2.2%) had an ENA result that changed from negative to positive. Excluding patients with pre-existing rheumatic conditions and those under 18, there were five new AARDs found in the remaining 34 patients. CONCLUSION: Repeat ENA test results rarely change or result in a new diagnosis of an AARD, with repeated testing only warranted if there is a change in clinical manifestations.

A new wave of leaders: Early evaluation of the interdisciplinary Foundations of Leadership in Radiation Oncology (FLiRO) program.

Purpose: Effective leadership across all areas of radiation oncology (RO) is vital to fully realise the benefits of radiation therapy in cancer care. We report outcomes of a novel interdisciplinary leadership program designed for RO professionals under a global joint society initiative. Methods: The Foundations of Leadership in RO (FLiRO) program was designed for aspiring RO leaders. Initially delivered in a blended learning format, it was adapted to fully virtual in 2021. It comprised a webinar tutorial, on-line modules and homework followed by 'live' in-person/virtual workshops over an approximately 6-week period. Topics included personal awareness, effective teamwork, quality improvement skills, leading change and conflict management. An immediate post-program online survey was performed using Likert scales to measure self-reported educational value, interaction with others and the likely application of learning to practice. Open comments were invited. Results: 170 participants from 36 countries and 6 continents took part from 2018 to 2021 (99 doctors, 36 physicists, 32 radiation therapists/RTTs and 3 others). 141 (83%) participants responded to the post-program survey. Average weightings for responders' views on whether pre-determined learning objectives were met ranged from 4.30 to 4.61 on a 5-point scale (1 = 'not met at all' and 5 = completely met). For the question addressing potential value of learning for application to their workplace, 124 of 130 (95%) of responders indicated that FLIRO would be 'very useful' or 'extremely useful'. Conclusion: Initial evaluation of the FLiRO program supports its continuation and expansion with ongoing evolution based on emerging evidence around leadership education and participant feedback.

Exploring radiation therapist education and training.

Radiation therapy has become increasingly complex over time and is rapidly evolving. Radiation therapists play a key role within the interdisciplinary team and their education must prepare them to function effectively in the future in order to ensure a safe, high quality radiation therapy service. The aim of this research was to evaluate the current status of radiation therapist education to establish the duration of education programs, the percentage of radiation therapy-specific content and the professional title on graduation. A survey was developed, based on the questionnaire used for the ESTRO 3rd Revision of the Core Curriculum for Radiation Therapists. This was piloted by colleagues to verify the validity of the survey and also its use outside of the European context. The final survey was distributed purposively through Survey Monkey via a local gatekeeper to key radiation therapy personnel covering all of Europe and Australia, New Zealand, USA and South Korea in January 2021 who distributed it to educational institutes and clinical departments in their respective countries. 101 responses were received of which 58 were fully complete and available for analysis representing 30 countries, 26 European and 4 beyond Europe. The duration and radiation therapy-specific content of education programs varied considerably with dedicated radiation therapy programs from the respondents offered only in Ireland, Australia, New Zealand, and the U.S.A. 17 countries in the survey offer 'combined' programs with the majority dedicating less than 20% of their content to radiation therapy. Of note is that several respondents were unable to state the percentage of content related to radiation therapy and there was a variation in content and duration of programs, even within a single country. This survey has demonstrated that there remains a significant deficit in the educational programs of radiation therapists in many regions.

Exploring the impact of metabolic imaging in head and neck cancer treatment.

BACKGROUND: Target volume delineation is performed with anatomical imaging for head and neck cancer. Molecular imaging allows the recognition of specific tumor regions. Its inclusion in the pathway could lead to changes in delineation and resultant treatment plans. METHODS: PRISMA methodology was adhered to when selecting the articles for analysis and only full articles were quality assessed. RESULTS: Seventeen articles were included. Gross tumor volume (GTV) primary, GTV nodal, and other target volumes were evaluated. Positron emission tomography/computerized tomography (PET/CT) produced smaller primary GTVs, although not with diffusion-weighted imaging-magnetic resonance imaging (DWI-MRI) or PET/MRI. The impact of these image modalities on GTV nodal did not display any consistency. Additionally, there was considerable heterogeneity in metrics comparing delineations. Four studies included appraised the dosimetric impact of the changes in target volume delineation. CONCLUSION: Quantifying the impact of molecular imaging is difficult, due to heterogeneity in reporting metrics in molecular imaging modalities and a paucity of detail regarding delineation method and guideline adherence.

Feasibility of surface guided radiotherapy for patient positioning in breast radiotherapy versus conventional tattoo-based setups- a systematic review.

Background: Traditionally tattoos are used for patient setup in radiotherapy. However they may pose challenges for the radiotherapists to achieve precise patient alignment, and serve as a permanent visual reminder of the patient's diagnosis and often challenging cancer journey. The psychological impact of tattoos has been recognized in recent years. The increasing complexity of treatment techniques and the utilization of hypofractionated regimes, requires an enhanced level of accuracy and safety. Surface guided radiotherapy (SGRT) enables improvements in the accuracy and reproducibility of patient isocentric and postural alignment, enhanced efficiency, and safety in breast radiotherapy. Purpose: The aim of this review was to compare the accuracy and reproducibility of SGRT to conventional tattoo-based setups in free-breathing breast radiotherapy and to determine if SGRT can reduce the frequency of routine image guided radiotherapy (IGRT). Materials and Methods: A systematic literature review was performed as per PRISMA guidelines. Papers identified through PubMed, Embase, Web of Science and Google Scholar database searches between 2010 and 2021, were critically appraised. Systematic, random, mean residual errors and 3D vector shifts as determined by IGRT verification were analysed. Results: A review of 13 full papers suggests SGRT improves the accuracy and reproducibility of patient setup in breast radiotherapy with consistent reductions in the residual errors. There appears to be a good correlation between SGRT setups and radiographic imaging. The frequency of IGRT and the corresponding dose could potentially be reduced. Additionally, SGRT improves treatment efficiency. Conclusion: SGRT appears to have improved the accuracy and reproducibility of patient setup and treatment efficiency of breast radiotherapy compared to conventional tattoo/laser-based method, with the potential to reduce the frequency of routine IGRT. The reliance on tattoos in breast radiotherapy are likely to become obsolete with positive implications for both patients and clinical practice.

When the wheels fall off - Medical students' experiences of interrupted academic progression.

INTRODUCTION: There is limited published research on medical students' perspectives of a significant interruption to their academic progression. This study sought to identify the factors that contribute to difficulties with academic progression and to understand how medical students successfully respond. METHODS: This interpretive phenomenological study reports on the findings from in-depth interviews of 38 final year medical students who had experienced a significant academic interruption. RESULTS: The two superordinate themes were: the factors contributing to the interruption and their experience of the interruption. Factors identified as contributing to the interruption were: workload, learning in medicine, motivation for medicine, isolation, adapting to local culture, health and external factors. Their experience of the interruption focused on stages of working through the process: 'what happened,' 'how it felt,' 'managing the failure,' 'accepting the failure' and 'making some changes.' DISCUSSION: Each factor affected how the participants reacted and responded to the interruption. Regardless of the origins of the interruption, most reacted and responded in a comparable process, albeit with varying timespans. These reactions and responses were in a state of fluctuation. In order to succeed many stated they shifted their motivation from external to internal, in direct response to the interruption, resulting in changed learning behaviours. CONCLUSIONS: The process of working through an interruption to academic progression for students may benefit from a model of interval debriefing, restorative academic and personal development support. Facilitation of this process could enable students to face an interruption constructively rather than as an insurmountable emotionally burdensome barrier. Medical schools could utilise these findings to implement further support strategies to reduce the number of significant academic disruptions.

Outlook of women in science: an interview with our authors.

Diversity in research teams ties alternative perspectives into research projects, and this can fast-forward scientific progress. Concerted efforts have been aimed at encouraging and supporting women to pursue a career in science, yet a gender disparity can still be observed at senior positions, with fewer women in leadership roles. To get insight into how the current landscape for women in science is perceived by different career stages, we interviewed female authors of Molecular Oncology from diverse career stages and disciplines about their inspiration, challenges they have faced as scientists as well as their thoughts on how gender diversity can be further enhanced.

Twelve tips for medical students experiencing an interruption in their academic progress.

For every commencing cohort of medical students, a small but significant number will experience an interruption to their academic progression because of academic difficulties, health concerns or external influences outside of the students' control. During the process of researching the factors surrounding difficulties with academic progression, students told us many ways that they have learned from that experience, which then allowed most of them to graduate. This paper combines the shared experiences of students who have had an interruption, and those of the authors as medical educators.