Development and validity evidence for the resident-led large group teaching assessment instrument in the United States: a methodological study.

PURPOSE: Despite educational mandates to assess resident teaching competence, limited instruments with validity evidence exist for this purpose. Existing instruments do not allow faculty to assess resident-led teaching in a large group format or whether teaching was interactive. This study gathers validity evidence on the use of the Resident-led Large Group Teaching Assessment Instrument (Relate), an instrument used by faculty to assess resident teaching competency. Relate comprises 23 behaviors divided into six elements: learning environment, goals and objectives, content of talk, promotion of understanding and retention, session management, and closure. METHODS: Messick's unified validity framework was used for this study. Investigators used video recordings of resident-led teaching from three pediatric residency programs to develop Relate and a rater guidebook. Faculty were trained on instrument use through frame-of-reference training. Resident teaching at all sites was video-recorded during 2018-2019. Two trained faculty raters assessed each video. Descriptive statistics on performance were obtained. Validity evidence sources include: rater training effect (response process), reliability and variability (internal structure), and impact on Milestones assessment (relations to other variables). RESULTS: Forty-eight videos, from 16 residents, were analyzed. Rater training improved inter-rater reliability from 0.04 to 0.64. The Φ-coefficient reliability was 0.50. There was a significant correlation between overall Relate performance and the pediatric teaching Milestone, r = 0.34, P = .019. CONCLUSION: Relate provides validity evidence with sufficient reliability to measure resident-led large-group teaching competence.

How Do Postgraduate Trainees Prepare for New Clinical Learning Environments.

Background: Transitioning to a new clinical learning environment (CLE) requires learning new skills, roles, teams, workflows, and culture. We previously identified activities and questions to guide orientation in the categories of who, what, where, when, why, and how. There is limited literature about how learners plan for this transition. Objective: Describe how postgraduate trainees prepare for a clinical rotation, based on qualitative analysis of narrative responses within a simulated orientation experience. Methods: In June 2018, incoming residents and fellows in multiple specialties at Dartmouth Hitchcock Medical Center completed an online simulated orientation that asked how they intended to prepare for their first rotation. We used directed content analysis to code their anonymously collected responses using the orientation activities and question categories from our prior study. We used open coding to describe additional themes. Results: Narrative responses were available for 97% (116 of 120) of learners. While 46% (53 of 116) of learners listed preparations related to what happens in the CLE, responses fitting into other question categories were less frequent: who (9%, 11 of 116), where (7%, 8 of 116), when (4%, 5 of 116), why (<1%, 1 of 116), and how (0%, 0 of 116). Learners also infrequently described activities to aid the transition: reading orientation materials (11%, 13 of 116), speaking with a colleague (11%, 13 of 116), and arriving early (3%, 3 of 116). They more frequently commented on content reading (40%, 46 of 116), asking for advice (28%, 33 of 116), and self-care (12%, 14 of 116). Conclusions: When describing preparation for a new CLE, residents focused on tasks in the what category more than understanding the system and learning goals in other categories.

A Qualitative Analysis of Assessment and Evaluation Practices Within the Individualized Curriculum.

OBJECTIVE: The Accreditation Council of Graduate Medical Education requires an "individualized curriculum" (IC) in pediatric residency. A shared understanding across programs of methods to evaluate the IC is lacking. We explored pediatric program leaders' perceptions of assessment and evaluation within the IC to further understand and inform most useful practices. METHODS: We conducted a phenomenology study using semi-structured interviews to 1) determine what IC assessment and evaluation strategies are utilized in pediatric residency programs, and 2) explore program leaders' perceptions of the feasibility and value of assessment and evaluation in the IC. We recruited a purposive sample of leaders from 15 pediatric residency programs of various sizes and regions. Interviews were recorded and transcribed. Data were analyzed to produce themes. RESULTS: Three themes arose from our analysis: 1) Systematic assessment of the IC, though desired, is not robust in pediatric residency training; 2) Program differences present unique barriers and facilitators that impact the feasibility of assessment within the IC; and 3) Meaningfulness of assessment in the IC varies by stakeholder. Themes reflected perspectives on individual learner assessment and program evaluation. CONCLUSIONS: While systematic assessment and evaluation of the IC in pediatric residency training is lacking, program leaders desire feasible strategies that are meaningful to the resident, the program, and its leadership team. Leveraging current assessment and evaluation tools and aligning new assessment strategies could promote the integration of IC assessment with other assessments, minimizing burden. More structured IC assessment and evaluation could inform how to best achieve curricular goals of the IC.

Resources for clinical learning environment orientation.

INTRODUCTION: Each clinical learning environment (CLE) requires learners to navigate a different set of complex interactions to engage in safe patient care while learning from real patients. Orientation forms the foundation for learning, yet CLE models in the literature are primarily written for an educator audience and practical advice for orienting learners to a new CLE is limited. To address this gap, we designed resources to support both supervisors and learners in the orientation process. MATERIALS/METHODS: We reviewed the CLE literature to select critical content for orientation and interviewed high performing residents to identify their best practices. We synthesized the literature and resident interviews into a visually appealing and easy to digest infographic designed to simultaneously remind teachers of the critical areas to cover in orientation and empower learners to ask about them. We integrated these principles into an online module for Graduate Medical Education onboarding and surveyed users about how well they could meet the module learning objectives. RESULTS: We organized the literature review and resident advice regarding questions learners should ask about a new CLE into the typical question categories (why, who, what, when, where, and how) and described strategies for orientation to each category. Our infographic has been incorporated into CLE orientation for multiple types of learners at our institution. After completing the orientation module, 112/124(90%) residents indicated that they could, 'Orient yourself or a learner to a clinical learning environment using orientation questions' moderately to extremely well. DISCUSSION: We developed resources that can be used by educators to create orientation materials and by learners to ensure they understand important features, resources, and expectations in a new CLE. Because the foundational principles of CLE apply to a variety of clinical settings and learner types, the resources may be broadly applicable.

Describing Overarching Curricular Goals for Individualized Education.

Phenomenon: The phenomenon of individualized education, an essential component of competency-based medical education, addresses individual learner needs while working toward standardized learning outcomes. One challenge with broadly implementing individualized education is the lack of a pragmatic operational definition. To formalize expectations for individualized education, the Accreditation Council of Graduate Medical Education in 2013 began requiring six months of individualized curriculum (IC) during pediatric residency; however, there is not a national standard of formal curricular goals for the IC as an educational entity. Examining and describing the overarching curricular goals of IC could provide a framework for discourse about and further study of individualized education in medicine across disciplines and the continuum of medical education. Thus, we aimed to describe the phenomenon of individualized education through the lens of the goals of the IC in pediatric residency in the United States. Approach: In 2017, a purposeful sample of Pediatric Residency leaders were recruited to represent a diverse sample of program sizes, regions of the country, and importance of the IC to the program leadership. They completed an online survey with open-ended questions describing formal and implicit goals of their program's IC. The authors analyzed responses initially using conventional content analysis, then investigated whether the themes for program goals aligned with any existing educational theory. The concepts and language aligned with the principles of self-determination theory (SDT); therefore, the IC goals were subsequently grouped using the SDT domains of relatedness, autonomy, and competence. A focus group with a subset of survey respondents was conducted for member checking and elaboration of concepts. Findings: Program leaders from a diverse sample of 36 programs participated in the survey and a subset of 11 programs participated in the focus group. The common goals across all programs are listed in parentheses and organized by domains of SDT: 1)Relatedness goals (engage in mentorship, select a career) cultivate resident's professional identity based on their desired future career path; 2)autonomy goals (create a learning plan, practice accountability) help residents plan their path; and fulfillment of their plans lead to 3)competence goals (develop targeted clinical skills and knowledge, ensure comprehensive exposure, address learning gaps), ensuring they have a comprehensive skill set for their chosen identity. Insights: This study provides a framework to describe the phenomenon of individualized education through the lens of IC curricular goals in pediatric residency. The goals for IC that emerged from this study serve as a pragmatic framework for implementation of individualized education. They provide a common language and structure to promote more rigorous and collaborative study of individualized education across programs, disciplines, and settings in medicine. They may function as a roadmap for learners to navigate educational activities and for programs to help shape the experiences of their learners and examine outcomes of individualized education in their programs. The framework can also help individual pediatric residency programs structure improvements to their IC. Disciplines beyond pediatrics may also use this framework to better structure elective experiences to capitalize on the benefits of individual education.

Satisfaction with life and depressive symptoms in living organ donors and non-donors: New insights from the National Living Donor Assistance Center.

BACKGROUND: Previous studies indicate there may be psychological consequences of being unable to serve as a living donor, but these have not been explored in a large national cohort of low-income individuals who initiated living donor evaluation in US transplant centers. METHODS: Using data from 6574 National Living Donor Assistance Center (NLDAC) participants (November 1, 2007-December 31, 2018), we utilized a cross-sectional study design to evaluate short-term depressive symptoms and satisfaction with life in living donors and non-donors (those who were declined or withdrew from evaluation) using the Satisfaction with Life Scale (SWLS) and the PHQ-8, with and without risk adjustment using linear regression. RESULTS: National Living Donor Assistance Center participants originated from 207 US transplant centers. 52% of NLDAC participants responded to the survey (n = 3423; donors = 2848 (58.6% of all donors), non-donors = 575 (33.5% of all non-donors); ncenters  = 201)). Respondents were significantly older, more likely to be female, white, non-Hispanic, married, more educated, more full-time employed, and more likely to be unrelated to the recipient vs non-respondents (all, P < .001). Among survey respondents, donors were significantly younger, more likely to be non-Hispanic, employed, and related to the recipient compared to non-donors (all, P < .05). Higher PHQ-8 scores were correlated with lower SWL scores (r = -.32, P < .001). Both groups displayed high SWLS (donors vs non-donors: 27.1 vs 26.3, P = .002). Both groups had low levels of depressive symptoms overall, but donors had more symptoms than non-donors (3.5 vs 2.4, P < .001). After risk adjustment, non-donors had significantly less depressive symptoms by PHQ-8 (28% lower, P < .001), but had lower life satisfaction (1.2 points lower, P < .001). CONCLUSIONS: Donors and non-donors have high global levels of overall life satisfaction and low levels of depressive symptoms at 8 weeks after donation or denial. While small effect sizes were observed between groups in these outcomes, being a non-donor was an independent risk factor for lower life satisfaction, which warrants further evaluation.

Longitudinal Assessment of Resident Performance Using Entrustable Professional Activities.

Importance: Entrustable professional activities (EPAs) are an emerging workplace-based, patient-oriented assessment approach with limited empirical evidence. Objective: To measure the development of pediatric trainees' clinical skills over time using EPA-based assessment data. Design, Setting, and Participants: Prospective cohort study of categorical pediatric residents over 3 academic years (2015-2016, 2016-2017, and 2017-2018) assessed on 17 American Board of Pediatrics EPAs. Residents in training at 23 pediatric residency programs in the Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network were included. Assessment was conducted by clinical competency committee members, who made summative assessment decisions regarding levels of supervision required for each resident and each EPA. Data were collected from May 2016 to November 2018 and analyzed from November to December 2018. Interventions: Longitudinal, prospective assessment using EPAs. Main Outcomes and Measures: Trajectories of supervision levels by EPA during residency training and how often graduating residents were deemed ready for unsupervised practice in each EPA. Results: Across the 5 data collection cycles, 1987 residents from all 3 postgraduate years in 23 residency programs were assigned 25 503 supervision level reports for the 17 general pediatrics EPAs. The 4 EPAs that required the most supervision across training were EPA 14 (quality improvement) on the 5-level scale (estimated mean level at graduation, 3.7; 95% CI, 3.6-3.7) and EPAs 8 (transition to adult care; mean, 7.0; 95% CI, 7.0-7.1), 9 (behavioral and mental health; mean, 6.6; 95% CI, 6.5-6.6), and 10 (resuscitate and stabilize; mean, 6.9; 95% CI, 6.8-7.0) on the expanded 5-level scale. At the time of graduation (36 months), the percentage of trainees who were rated at a supervision level corresponding to "unsupervised practice" varied by EPA from 53% to 98%. If performance standards were set to align with 90% of trainees achieving the level of unsupervised practice, this standard would be met for only 8 of the 17 EPAs (although 89% met this standard for EPA 17, performing the common procedures of the general pediatrician). Conclusions and Relevance: This study presents initial evidence for empirically derived practice readiness and sets the stage for identifying curricular gaps that contribute to discrepancy between observed practice readiness and standards needed to produce physicians able to meet the health needs of the patient populations they serve. Future work should compare these findings with postgraduation outcomes data as a means of seeking validity evidence.

Best practices to optimize utilization of the National Living Donor Assistance Center for the financial assistance of living organ donors.

Living organ donors face direct costs when donating an organ, including transportation, lodging, meals, and lost wages. For those most in need, the National Living Donor Assistance Center (NLDAC) provides reimbursement to defray travel and subsistence costs associated with living donor evaluation, surgery, and follow-up. While this program currently supports 9% of all US living donors, there is tremendous variability in its utilization across US transplant centers, which may limit patient access to living donor transplantation. Based on feedback from the transplant community, NLDAC convened a Best Practices Workshop on August 2, 2018, in Arlington, VA, to identify strategies to optimize transplant program utilization of this valuable resource. Attendees included team members from transplant centers that are high NLDAC users; the NLDAC program team; and Advisory Group members. After a robust review of NLDAC data and engagement in group discussions, the workgroup identified concrete best practices for administrative and transplant center leadership involvement; for individuals filing NLDAC applications at transplant centers; and to improve patient education about potential financial barriers to living organ donation. Multiple opportunities were identified for intervention to increase transplant programs' NLDAC utilization and reduce financial burdens inhibiting expansion of living donor transplantation in the United States.

The Development of an Instrument for Faculty to Assess Resident-Led Large Group Teaching.

OBJECTIVE: The Accreditation Council on Graduate Medical Education requires residents to teach and many residency programs assess resident teaching competency. While much formal resident-led teaching is for large groups, no corresponding published assessment instrument with validity evidence exists. We developed an instrument for faculty to assess pediatric resident-led large group teaching and gathered preliminary validity evidence. METHODS: Literature review and our experience leading resident-as-teacher curricula informed initial instrument content. Resident focus groups from 3 northeastern pediatric residency programs provided stakeholder input. A modified Delphi panel of international experts provided iterative feedback. Three investigators piloted the instrument in 2018; each assessed 8 video recordings of resident-led teaching. We calculated Cronbach's alpha for internal consistency and intraclass correlation (ICC) for inter-rater reliability. RESULTS: The instrument has 6 elements: learning climate, goals/objectives, content, promotion of understanding/retention, session management, and closure. Each element contains behavioral subelements. Cronbach's alpha was .844. ICC was excellent for 6 subelements, good for 1, fair for 1, and poor for 3. CONCLUSIONS: We developed an instrument for faculty assessment of resident-led large group teaching. Pilot data showed assessed behaviors had good internal consistency, but inconsistent interrater reliability. With further development, this instrument has potential to assess resident teaching competency.

Return on investment for financial assistance for living kidney donors in the United States.

BACKGROUND: The National Living Donor Assistance Center (NLDAC) enables living donor kidney transplants through financial assistance of living donors, but its return on investment (ROI) through savings on dialysis costs remains unknown. METHODS: We retrospectively reviewed 2012-2015 data from NLDAC, the United States Renal Data System, and the Scientific Registry of Transplant Recipients to construct 1-, 3-, and 5-year ROI models based on NLDAC applications and national dialysis and transplant cost data. ROI was defined as state-specific federal dialysis cost minus (NLDAC program costs plus state-specific transplant cost), adjusted for median waiting time (WT). RESULTS: A total of 2425 NLDAC applications were approved, and NLDAC costs were USD $6.76 million. Median donor age was 41 years, 66.1% were female, and median income was $33 759; 43.6% were evaluated at centers with WT >72 months. Median dialysis cost/patient-year was $81 485 (IQR $74 489-$89 802). Median kidney transplant cost/patient-year was $30 101 (IQR $26 832-$33 916). Overall, ROI varied from 5.1-fold (1-year) to 28.2-fold (5-year), resulting in $256 million in savings. Higher ROI was significantly associated with high WT, larger dialysis and transplant costs differences, and more NLDAC applicants completing the donation process. CONCLUSIONS: Financial support for donor out-of-pocket expenses produces dramatic federal savings through incremental living donor kidney transplants.

Pediatric Program Director Minimum Milestone Expectations Before Allowing Supervision of Others and Unsupervised Practice.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires semiannual Milestone reporting on all residents. Milestone expectations of performance are unknown. OBJECTIVE: To determine pediatric program director (PD) minimum Milestone expectations for residents before being ready to supervise and before being ready to graduate. METHODS: Mixed methods survey of pediatric PDs on their programs' Milestone expectations before residents are ready to supervise and before they are ready to graduate, and in what ways PDs use Milestones to make supervision and graduation decisions. If programs had no established Milestone expectations, PDs indicated expectations they considered for use in their program. Mean minimum Milestone level expectations were adjusted for program size, region, and clustering of Milestone expectations by program were calculated for before supervise and before graduate. Free-text questions were analyzed using thematic analysis. RESULTS: The response rate was 56.8% (113 of 199). Most programs had no required minimum Milestone level before residents are ready to supervise (80%; 76 of 95) or ready to graduate (84%; 80 of 95). For readiness to supervise, minimum Milestone expectations PDs considered establishing for their program were highest for humanism (2.46; 95% confidence interval [CI], 2.21-2.71) and professionalization (2.37; 95% CI, 2.15-2.60). Minimum Milestone expectations for graduates were highest for help-seeking (3.14; 95% CI, 2.83-3.46). Main themes included the use of Milestones in combination with other information to assess learner performance and Milestones are not equally weighted when making advancement decisions. CONCLUSIONS: Most PDs have not established program minimum Milestones, but would vary such expectations according to competency.

A novel workplace-based assessment for competency-based decisions and learner feedback.

BACKGROUND: Increased recognition of the importance of competency-based education and assessment has led to the need for practical and reliable methods to assess relevant skills in the workplace. METHODS: A novel milestone-based workplace assessment system was implemented in 15 pediatrics residency programs. The system provided: (1) web-based multisource feedback (MSF) and structured clinical observation (SCO) instruments that could be completed on any computer or mobile device; and (2) monthly feedback reports that included competency-level scores and recommendations for improvement. RESULTS: For the final instruments, an average of five MSF and 3.7 SCO assessment instruments were completed for each of 292 interns; instruments required an average of 4-8 min to complete. Generalizability coefficients >0.80 were attainable with six MSF observations. Users indicated that the new system added value to their existing assessment program; the need to complete the local assessments in addition to the new assessments was identified as a burden of the overall process. CONCLUSIONS: Outcomes - including high participation rates and high reliability compared to what has traditionally been found with workplace-based assessment - provide evidence for the validity of scores resulting from this novel competency-based assessment system. The development of this assessment model is generalizable to other specialties.

Identifying Gaps in the Performance of Pediatric Trainees Who Receive Marginal/Unsatisfactory Ratings.

PURPOSE: To perform a derivation study to determine in which subcompetencies marginal/unsatisfactory pediatric residents had the greatest deficits compared with their satisfactorily performing peers and which subcompetencies best discriminated between marginal/unsatisfactory and satisfactorily performing residents. METHOD: Multi-institutional cohort study of all 21 milestones (rated on four or five levels) reported to the Accreditation Council for Graduate Medical Education, and global marginal/unsatisfactory versus satisfactory performance reported to the American Board of Pediatrics. Data were gathered in 2013-2014. For each level of training (postgraduate year [PGY] 1, 2, and 3), mean differences between milestone levels of residents with marginal/unsatisfactory and satisfactory performance adjusted for clustering by program and C-statistics (area under receiver operating characteristic curve) were calculated. A Bonferroni-corrected significance threshold of .0007963 was used to account for multiple comparisons. RESULTS: Milestone and overall performance evaluations for 1,704 pediatric residents in 41 programs were obtained. For PGY1s, two subcompetencies had almost a one-point difference in milestone levels between marginal/unsatisfactory and satisfactory trainees and outstanding discrimination (≥ 0.90): organize/prioritize (0.93; C-statistic: 0.91) and transfer of care (0.97; C-statistic: 0.90). The largest difference between marginal/unsatisfactory and satisfactory PGY2s was trustworthiness (0.78). The largest differences between marginal/unsatisfactory and satisfactory PGY3s were ethical behavior (1.17), incorporating feedback (1.03), and professionalization (0.96). For PGY2s and PGY3s, no subcompetencies had outstanding discrimination. CONCLUSIONS: Marginal/unsatisfactory pediatric residents had different subcompetency gaps at different training levels. While PGY1s may have global deficits, senior residents may have different performance deficiencies requiring individualized counseling and targeted performance improvement plans.

Electronic portfolio use in pediatric residency and perceived efficacy as a tool for teaching lifelong learning.

BACKGROUND: Residency programs use electronic portfolios (efolios) to organize data, track resident performance, and sometimes teach and assess lifelong learning (LLL) skills. Published studies on efolios in graduate medical education are mostly descriptions of implementation at individual institutions. METHODS: An anonymous online survey was sent to 199 pediatric residency program directors across the United States. Efolio usage patterns were described and compared between program directors that perceived efolios effective at fostering LLL and those that did not. RESULTS: Surveys were completed by 82 of 199 program directors (41%), and 55% used efolios. The 20% (9 of 45) of program directors that believed efolios were effective at teaching LLL more often used self-assessment (88% vs. 50%, p = 0.05) and goal-setting (75% vs. 40%, p = 0.03) functionalities. Common efolio challenges included limited usability and difficulty integrating data. Most non-users (65%) would like to invest in efolios. CONCLUSIONS: Respondents reported technical and convenience-related challenges to efolio use, which need to be addressed for efolios to meet their potential as valuable learning tools. The use of self-assessments and goal-setting features was associated with program directors' perceptions that efolios were effective at fostering LLL.

Competent for Unsupervised Practice: Use of Pediatric Residency Training Milestones to Assess Readiness.

PURPOSE: To describe clinical skills progression during pediatric residency using the distribution of pediatric milestone assessments by subcompetency and year of training and to determine reasonable milestone expectations at time of graduation. METHOD: Multi-institutional cohort study of the milestones reported to the Accreditation Council for Graduate Medical Education for all 21 pediatric subcompetencies. Most subcompetencies were measured using five milestone levels (1 = novice, 2 = advanced beginner, 3 = competent, 4 = proficient, 5 = master); 3 subcompetencies had only four levels defined. RESULTS: Milestone assessments for 2,030 pediatric residents in 47 programs during academic year 2013-2014 were obtained. There was significant variation in end-of-year milestone ratings for residents within each level of training, which decreased as training level increased. Most (78.9%; 434/550) graduating third-year pediatric residents received a milestone rating of ≥ 3 in all 21 subcompetencies; fewer (21.1%; 116/550) received a rating of ≥ 4 in all subcompetencies. Across all training levels, professionalism and interpersonal communication skills were rated highest; quality improvement was rated lowest. CONCLUSIONS: Trainees entered residency with a wide range of skills. As they advanced, skill variability within a training level decreased. Most graduating pediatric residents were still advancing on the milestone continuum toward proficiency and mastery, and an expectation of milestone ratings ≥ 4 in all categories upon graduation is unrealistic; milestone ratings ≥ 3 upon graduation may be more realistic. Understanding current pediatric residents' and graduates' skills can help to identify key areas that should be specifically targeted during training.

In Pursuit of Meaningful Use of Learning Goals in Residency: A Qualitative Study of Pediatric Residents.

PURPOSE: Medical education aims to equip physicians for lifelong learning, an objective supported by the conceptual framework of self-regulated learning (SRL). Learning goals have been used to develop SRL skills in learners across the medical education continuum. This study's purpose was to elicit residents' perspectives on learning goal use and to develop explanations suggesting how aspects of the learning environment may facilitate or hinder the meaningful use of learning goals in residency. METHOD: Resident focus groups and program director interviews were conducted in 2012-2013, audio-recorded, and transcribed. Programs were selected to maximize diversity of size, geographic location, type of program, and current use of learning goals. Data were analyzed using the constant comparative method associated with grounded theory. Further analysis compared themes frequently occurring together to strengthen the understanding of relationships between the themes. Through iterative discussions, investigators built a grounded theory. RESULTS: Ninety-five third-year residents and 12 program directors at 12 pediatric residency programs participated. The analysis identified 21 subthemes grouped into 5 themes: program support, faculty roles, goal characteristics and purposes, resident attributes, and accountability and goal follow-through. Review of relationships between the themes revealed a pyramid of support with program support as the foundation that facilitates the layers above it, leading to goal follow-through. CONCLUSIONS: Program support facilitates each step of the SRL process that leads to meaningful use of learning goals in residency. A strong foundation of program support should include attention to aspects of the implicit curriculum as well as the explicit curriculum.