Do we teach critical thinking? A mixed methods study of faculty and student perceptions of teaching and learning critical thinking at three professional schools.

INTRODUCTION: Critical thinking (CT) is an essential set of skills and dispositions for professionals. While viewed as an important part of professional education, approaches to teaching and assessing critical thinking have been siloed within disciplines and there are limited data on whether student perceptions of learning align with faculty perceptions of teaching. MATERIALS AND METHODS: The authors used a convergent mixed methods approach in required core courses in schools of education, government, and medicine at one university in the Northeast United States. Faculty surveys and student focus groups (FG) addressed definitions, strategies, and barriers to teaching CT. RESULTS AND CONCLUSIONS: Sixty-four (51.6%) faculty completed the survey, and 34 students participated in FGs. Among faculty, 54.0% (34/63) reported explicitly teaching CT; but students suggested teaching CT was predominantly implicit. Faculty-reported strategies differed among schools. Faculty defined CT in process terms such as 'analyzing'; students defined CT in terms of viewpoints and biases. Our results reveal a lack of explicit, shared CT mental models between faculty and students and across professional schools. Explicit teaching of CT may help develop a shared language and lead to better understanding and application of the skills and dispositions necessary to succeed in professional life.

Eureka moments: ICU physicians' views on teaching.

BACKGROUND: Teaching hospitals are fast-paced health care environments where clinical supervisors constantly balance teaching and patient care. Although hospital-based clinicians in acute care settings regularly teach trainees, views regarding their teaching roles and how this relates to professional satisfaction are less well studied. We explored perspectives of physicians who teach trainees in medical intensive care units (MICUs), to understand whether their engagement in teaching has any impact on professional (job) satisfaction. METHODS: This qualitative study used focus groups of MICU fellows (postgraduate clinical trainees) and attending physicians (consultants) to explore participants' perceptions of their teaching roles. Focus groups were audiotaped and transcribed; thematic analysis was conducted on de-identified transcripts. FINDINGS: Four focus groups were held; two with MICU attendings (n = 13) and two with MICU fellows (n = 12). We identified four key themes: two challenges of teaching (being a chameleon; calibrating learner abilities), one benefit of teaching (facilitating learners' eureka moments) and a call for professional development (peer coaching to enhance teaching skills). DISCUSSION: Although teaching in acute clinical environments requires balancing dynamic learner needs and complex patient care needs, participants found it highly rewarding. They called for peer coaching initiatives to enhance professional development as teachers and demonstrate departmental commitment to teaching. CONCLUSION: While teaching in acute clinical settings is challenging for many reasons, clinical teachers emphasise that it is very satisfying when learners see the 'light'. Overt institutional support and recognition for clinical teachers along with peer coaching and debriefing may tilt the balance towards the rewards side of the equation and foster professional satisfaction.

Creation and Expansion of a Mixed Patient Intermediate Care Unit to Improve ICU Capacity.

OBJECTIVES: ICU capacity strain is associated with worsened outcomes. Intermediate care units (IMCs) comprise one potential option to offload ICUs while providing appropriate care for intermediate acuity patients, but their impact on ICU capacity has not been thoroughly characterized. The aims of this study are to describe the creation of a medical-surgical IMC and assess how the IMC affected ICU capacity. DESIGN: Descriptive report with retrospective cohort review. SETTING: Six hundred seventy-three-bed tertiary care academic medical center with 77 ICU beds. PATIENTS: Adult inpatients who were admitted to the IMC. INTERVENTIONS: An interdisciplinary working group created an IMC which was located on a general ward. The IMC was staffed by hospitalists and surgeons and supported by critical care consultants. The initial maximum census was three, but this number increased to six in response to heightened critical care demand. IMC admission criteria also expanded to include advanced noninvasive respiratory support defined as patients requiring high-flow nasal cannula, noninvasive positive pressure ventilation, or mechanical ventilation in patients with tracheostomies. MEASUREMENTS AND MAIN RESULTS: The primary outcome entailed the number of ICU bed-days saved. Adverse outcomes, including ICU transfer, intubation, and death, were also recorded. From August 2021 to July 2022, 230 patients were admitted to the IMC. The most frequent IMC indications were respiratory support for medical patients and post-operative care for surgical patients. A total of 1023 ICU bed-days were made available. Most patients were discharged from the IMC to a general ward, while 8% of all patients required transfer to an ICU within 48 hours of admission. Intubation (2%) and death (1%) occurred infrequently within 48 hours of admission. Respiratory support was the indication associated with the most ICU transfers. CONCLUSIONS: Despite a modest daily census, an IMC generated substantial ICU bed capacity during a time of peak critical care demand.

How I Teach: Liberation from Mechanical Ventilation.

Liberation from mechanical ventilation is one of the most important decisions in the intensive care unit (ICU), as extubation failure is associated with worse outcomes. Determining readiness to extubate can be challenging in complex patients and lead to provider stress. Here, we provide our approach to teaching liberation from mechanical ventilation for learners in the ICU. We use a case-based didactic session that purposefully introduces ambiguous cases without a clear answer, utilizing aspects of both cognitive load theory and adult learning theories.

A National Survey of Stress and Burnout in Critical Care Nurses: A Prepandemic Study.

BACKGROUND: Critical care nurses (CCNs) experience a higher level of stress and burnout than nurses in other specialties. Approximately 50% of CCNs are mildly stressed, and almost 20% are moderately stressed. Prolonged periods of stress can lead to burnout, which has been shown to have deleterious effects on quality and patient safety. OBJECTIVES: The purpose of this study is to determine the prevalence of burnout among a national sample of CCNs and the association with environmental factors. METHODS: A national survey of CCNs working in the United States was implemented using an exploratory descriptive design. The anonymous survey was developed iteratively according to best practices of survey design. The survey included the Perceived Stress Scale and the Copenhagen Burnout Inventory tool. Pretesting and pilot testing were conducted with CCN specialists, and the survey was revised based on their feedback. An anonymous link was distributed to respondents using convenience sampling through social media and further disseminated via snowball sampling. RESULTS: Two hundred seventy nurses responded to the survey. The mean (SD) Perceived Stress Scale score in the study population was 18.5 (6.4), indicating moderate stress. The mean (SD) Copenhagen Burnout Inventory score was 61.9 (16.5), indicating moderate burnout. Our study found that the overall health of the work environment was one of the most important factors associated with both stress and burnout. CONCLUSIONS: This study has demonstrated the relationship between the health of the work environment and burnout among CCNs. It is imperative that health care organizations evaluate and implement strategies to optimize the health of the work environment to mitigate burnout and its negative sequelae on the nurse, patient, and system.

Community consultation in the pediatric intensive care unit for an exception from informed consent Trial: A survey of patient caregivers.

Aim: To explore perspectives of families in the pediatric intensive care unit (PICU) about an emergency interventional trial on peri-arrest bolus epinephrine for acute hypotension using Exception From Informed Consent (EFIC). Methods: We performed face-to-face interviews with families whose children were hospitalized in the PICU. A research team member provided an educational presentation about the planned trial and administered a survey with open- and closed-ended items. Analyses included descriptive statistics for quantitative data and thematic analysis for qualitative data. Results: Sixty-seven participants contributed to 60 survey responses (53 individuals and 7 families for whom 2 family members participated). Most participants answered favorably toward the planned trial: 55/58 (95%) reported that the trial seemed "somewhat" or "very important"; 52/57 (91%) felt the use of EFIC was "somewhat" or "completely acceptable"; and 43/58 (74%) said they would be "somewhat" or "very likely" to allow their child to participate. Five themes emerged supporting participation in the planned trial: 1) trust in the clinical team; 2) familiarity with the study intervention (epinephrine); 3) study protocol being similar to standard care; 4) informed consent during an emergency was not feasible; and 5) importance of research. Barriers to potential participation included requests for additional time to decide about participating and misconceptions about study elements, especially eligibility. Conclusions: Families of PICU patients generally supported plans for an emergency interventional trial using EFIC. Future inpatient EFIC studies may benefit from highlighting the themes identified here in their educational materials.

A multisite randomized trial of implicit versus explicit modeling in clinical teaching.

PURPOSE: Faculty modeling of desired behaviors has historically been a part of the apprenticeship model of clinical teaching, yet little is known about best practices for modeling. This study compared the educational impact of implicitly versus explicitly modeled communication skills among U.S. medical students. METHOD: Fourth-year medical students from six U.S. academic medical centers were randomly assigned one simulated clinical encounter in which faculty provided either implicit or explicit modeling of important communication skills. Outcomes were assessed by electronic surveys immediately before and after the simulations. Students were blinded to the purpose of the study. RESULTS: Students in the explicit arm were more likely to correctly cite two of the three key specific communication elements modeled by faculty: deliberate body position (53.3% vs. 18.6%, p < 0.001) and summarizing patient understanding (62.2% vs. 11.6%, p < 0.001). More students in the explicit study arm reported faculty 'demonstrated a key behavior that they wanted me to be able to perform in the future' (93.2% versus 62.8%, p = 0.002). Participating faculty stated they would modify their teaching approach in response to their experiences in the study. CONCLUSIONS: In a multi-center randomized trial, explicit faculty role-modeling led to greater uptake of communication knowledge, greater recognition of skills, and a greater sense that faculty expected these skills to be adopted by students. These results must be considered in the context, however, of a simulated environment and a short timeframe for assessing learning with students who volunteered for a simulated experience.

Beyond the ICU Rotation: The Importance of Trainee Involvement in Post-Intensive Care Unit Clinics.

Medical learners are vital to the care of critically ill patients in the intensive care unit (ICU). Although these learners are exposed to the challenges and stresses of acute ICU management, they do not typically experience the benefits of following ICU patients and families longitudinally after their ICU rotation. Post-ICU clinics and recovery programs may fill this crucial gap in trainee education. These clinics have emerged as an appealing approach to potentially support patient recovery, enhance provider satisfaction, and provide feedback on vital lessons learned in long-term follow-up to improve the quality of ICU care. Notably, the effect of such a program on trainee education has not been explored. In this article, we propose a framework for medical learner participation in post-ICU follow-up based on the Accreditation Council for Graduate Medical Education milestones and discuss the potential benefits, including: education about post-ICU recovery, including post-intensive care syndrome and post-intensive care syndrome-family; experience in quality improvement to enhance ICU care by understanding long-term outcomes; engagement in reflection; and mitigation of compassion fatigue and burnout.

A Way Forward in the COVID-19 Pandemic: Making the Case for Narrative Competence in Pulmonary and Critical Care Medicine.

Each surge of the coronavirus disease (COVID-19) pandemic presented new challenges to pulmonary and critical care practitioners. Although some of the initial challenges were somewhat less acute, clinicians now are left to face the physical, emotional, and mental toll of the past 2 years. The pandemic revealed a need for a more varied skillset, including space for reflection, tolerance of uncertainty, and humanism. These skills can assist clinicians who are left to heal from the difficulty of caring for patients in the absence of families who were excluded from the intensive care unit, public distrust of vaccines, and morgues overtaken by our patients. As pulmonary and critical care medicine practitioners and educators, we believe that cultivating practices, pedagogies, and institutional structures that foster narrative competence, "the ability to acknowledge, absorb, interpret, and act on the stories and plights of others," in our ourselves, our trainees, and our colleagues, may provide a productive way forward. In addition to fostering needed skills, this practice can promote necessary healing as well. This perspective introduces the practice of narrative competence, provides evidence of support for its implementation, and suggests opportunities for curricular integration.

Enhancing Clinical Teaching in Critical Thinking, High-Value Care, and Health Care Equity.

INTRODUCTION: Faculty development in the clinical setting is challenging to implement and assess. This study evaluated an intervention (IG) to enhance bedside teaching in three content areas: critical thinking (CT), high-value care (HVC), and health care equity (HCE). METHODS: The Communities of Practice model and Theoretical Domains Framework informed IG development. Three multidepartmental working groups (WGs) (CT, HVC, HCE) developed three 2-hour sessions delivered over three months. Evaluation addressed faculty satisfaction, knowledge acquisition, and behavior change. Data collection included surveys and observations of teaching during patient care. Primary analyses compared counts of post-IG teaching behaviors per hour across intervention group (IG), comparison group (CG), and WG groups. Statistical analyses of counts were modeled with generalized linear models using the Poisson distribution. RESULTS: Eighty-seven faculty members participated (IG n = 30, CG n = 28, WG n = 29). Sixty-eight (IG n = 28, CG n = 23, WG n = 17) were observed, with a median of 3 observation sessions and 5.2 hours each. Postintervention comparison of teaching (average counts/hour) showed statistically significant differences across groups: CT CG = 4.1, IG = 4.8, WG = 8.2; HVC CG = 0.6, IG = 0.9, WG = 1.6; and HCE CG = 0.2, IG = 0.4, WG = 1.4 ( P < .001). DISCUSSION: A faculty development intervention focused on teaching in the context of providing clinical care resulted in more frequent teaching of CT, HVC, and HCE in the intervention group compared with controls. WG faculty demonstrated highest teaching counts and provide benchmarks to assess future interventions. With the creation of durable teaching materials and a cadre of trained faculty, this project sets a foundation for infusing substantive content into clinical teaching.

Optimizing allocation of curricular content across the Undergraduate & Graduate Medical Education Continuum.

BACKGROUND: Medical educators struggle to incorporate socio-cultural topics into crowded curricula. The "continuum of learning" includes undergraduate and graduate medical education. Utilizing an exemplar socio-cultural topic, we studied the feasibility of achieving expert consensus among two groups of faculty (experts in medical education and experts in social determinants of health) on which aspects of the topic could be taught during undergraduate versus graduate medical education. METHODS: A modified Delphi method was used to generate expert consensus on which learning objectives of social determinants of health are best taught at each stage of medical education. Delphi respondents included experts in medical education or social determinants of health. A survey was created using nationally published criteria for social determinants of health learning objectives. Respondents were asked 1) which learning objectives were necessary for every physician (irrespective of specialty) to develop competence upon completion of medical training and 2) when the learning objective should be taught. Respondents were also asked an open-ended question on how they made the determination of when in the medical education continuum the learning objective should be taught. RESULTS: 26 out of 55 experts (13 social determinants of health and 13 education experts) responded to all 3 Delphi rounds. Experts evaluated a total of 49 learning objectives and were able to achieve consensus for at least one of the two research questions for 45 of 49 (92%) learning objectives. 50% more learning objectives reached consensus for inclusion in undergraduate (n = 21) versus graduate medical education (n = 14). CONCLUSIONS: A modified Delphi technique demonstrated that experts could identify key learning objectives of social determinants of health needed by all physicians and allocate content along the undergraduate and graduate medical education continuum. This approach could serve as a model for similar socio-cultural content. Future work should employ a qualitative approach to capture principles utilized by experts when making these decisions.

How We Review a Medical Education Research Manuscript.

Peer review is a necessary and important component of scholarly publication. When done well, it benefits both the reviewer and authors and improves the science itself. However, the skills of effective peer review are rarely taught. In the adolescent field of medical education research, peer review is especially important to advance the scientific rigor of the field. From our experience reviewing biomedical and medical education research, we have found that a thorough review takes multiple readings and multiple hours. The first reading provides a general overview of the aims and methods. Subsequent readings focus on the details of the methodology, results, and interpretation. The written review should provide firm but gentle feedback that the authors can use to improve their work, even if we have recommended rejection for this submission. We hope that this description of our process for reviewing a medical education research manuscript will assist others and thereby advance the quality of publications in our field.

Six-Month Impairment in Cognition, Mental Health, and Physical Function Following COVID-19-Associated Respiratory Failure.

To determine the prevalence and extent of impairments impacting health-related quality of life among survivors of COVID-19 who required mechanical ventilation, 6 months after hospital discharge. DESIGN: Multicenter, prospective cohort study, enrolling adults 18 years old or older with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection who received mechanical ventilation for 48 hours or more and survived to hospital discharge. Eligible patients were contacted 6 months after discharge for telephone-based interviews from March 2020 to December 2020. Assessments included: Montreal Cognitive Assessment-Blind, Hospital Anxiety and Depression Scale, Impact of Event Scale-6, EuroQOL 5 domain quality-of-life questionnaire, and components of the Multidimensional Dyspnea Profile. SETTING: Two tertiary academic health systems. PATIENTS: Of 173 eligible survivors, a random sample of 63 were contacted and 60 consented and completed interviews. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Mean age was 57 + 13 years and mean duration of invasive mechanical ventilation was 14 + 8.2 days. Six months post-discharge, 48 patients (80%; 95% CI, 68-88%) met criteria for post-intensive care syndrome (PICS), with one or more domains impaired. Among patients with PICS, 28 (47%; 95% CI, 35-59%) were impaired in at least 2 domains, and 12 (20%; 95% CI, 12-32%) impaired in all three domains. Significant symptoms of post-traumatic stress were present in 20 patients (33%; 95% CI, 23-46%), anxiety in 23 (38%; 95% CI, 27-51%), and depression in 25 (42%; 95% CI, 30-54%). Thirty-three patients (55%; 95% CI, 42-67%) had impairments in physical activity; 25 patients (42%; 95% CI, 30-54%) demonstrated cognitive impairment. CONCLUSIONS: Eighty percent of COVID-19 survivors who required mechanical ventilation demonstrated PICS 6 months after hospital discharge. Patients were commonly impaired in multiple PICS domains as well as coexisting mental health domains.

Assessment of a Crisis Standards of Care Scoring System for Resource Prioritization and Estimated Excess Mortality by Race, Ethnicity, and Socially Vulnerable Area During a Regional Surge in COVID-19.

Importance: Crisis standards of care (CSOC) scores designed to allocate scarce resources during the COVID-19 pandemic could exacerbate racial disparities in health care. Objective: To analyze the association of a CSOC scoring system with resource prioritization and estimated excess mortality by race, ethnicity, and residence in a socially vulnerable area. Design, Setting, and Participants: This retrospective cohort analysis included adult patients in the intensive care unit during a regional COVID-19 surge from April 13 to May 22, 2020, at 6 hospitals in a health care network in greater Boston, Massachusetts. Participants were scored by acute severity of illness using the Sequential Organ Failure Assessment score and chronic severity of illness using comorbidity and life expectancy scores, and only participants with complete scores were included. The score was ordinal, with cutoff points suggested by the Massachusetts guidelines. Exposures: Race, ethnicity, Social Vulnerability Index. Main Outcomes and Measures: The primary outcome was proportion of patients in the lowest priority score category stratified by self-reported race. Secondary outcomes were discrimination and calibration of the score overall and by race, ethnicity, and neighborhood Social Vulnerability Index. Projected excess deaths were modeled by race, using the priority scoring system and a random lottery. Results: Of 608 patients in the intensive care unit during the study period, 498 had complete data and were included in the analysis; this population had a median (IQR) age of 67 (56-75) years, 191 (38.4%) female participants, 79 (15.9%) Black participants, and 225 patients (45.7%) with COVID-19. The area under the receiver operating characteristic curve for the priority score was 0.79 and was similar across racial groups. Black patients were more likely than others to be in the lowest priority group (12 [15.2%] vs 34 [8.1%]; P = .046). In an exploratory simulation model using the score for ventilator allocation, with only those in the highest priority group receiving ventilators, there were 43.9% excess deaths among Black patients (18 of 41 patients) and 28.6% (58 of 203 patients among all others (P = .05); when the highest and intermediate priority groups received ventilators, there were 4.9% (2 of 41 patients) excess deaths among Black patients and 3.0% (6 of 203) among all others (P = .53). A random lottery resulted in more excess deaths than the score. Conclusions and Relevance: In this study, a CSOC priority score resulted in lower prioritization of Black patients to receive scarce resources. A model using a random lottery resulted in more estimated excess deaths overall without improving equity by race. CSOC policies must be evaluated for their potential association with racial disparities in health care.

Peri-arrest bolus epinephrine practices amongst pediatric resuscitation experts.

AIM: To describe current practices of peri-arrest bolus epinephrine use amongst pediatric resuscitation experts in a multinational survey. METHODS: A 9-question survey was developed and electronically distributed to pediatric critical care physicians who are site investigators for the Pediatric Resuscitation Quality Collaborative (pediRES-Q) network. Institutional demographics were collected through the American Hospital Association 2018 Annual Survey and linked to responses. Descriptive statistics were used to characterize closed-ended responses, and qualitative content analysis to analyze open-ended responses. RESULTS: Of the 63 collaborative members invited to participate, 49 (78%) responded, representing 35 institutions in 9 countries. Forty-six of the 49 respondents (94%) reported that they would consider using peri-arrest bolus epinephrine during critical situations in patients not requiring cardiopulmonary resuscitation. Initial dosing strategies ranged from 0.1mcg/kg to 10mcg/kg, with the most commonly reported initial dose of 1mcg/kg by 25 of the 37 (68%) respondents who answered this question. Three of the 49 (6%) participants indicated that they would generally avoid using peri-arrest bolus epinephrine, citing lack of evidence to support its use. CONCLUSIONS: In this multinational survey of pediatric resuscitation experts, endorsement of peri-arrest bolus epinephrine use was nearly universal, though a few clinicians cited lack of evidence to support this practice. There was a 100-fold difference in the range of initial weight-based doses reported, as well as a minority of clinicians who reported using non-weight-based dosing. Further research is needed to determine best practices, standardization of initial dosing, clinical factors that may warrant dosing modifications and associations with clinically important outcomes.

Self-Directed Learning in Medical Education: Training for a Lifetime of Discovery.

Issue: Life-long learning is a skill that is central to competent health professionals, and medical educators have sought to understand how adult professionals learn, adapt to new information, and independently seek to learn more. Accrediting bodies now mandate that training programs teach in ways that promote self-directed learning (SDL) but do not provide adequate guidance on how to address this requirement. Evidence: The model for the SDL mandate in physician training is based mostly on early childhood and secondary education evidence and literature, and may not capture the unique environment of medical training and clinical education. Furthermore, there is uncertainty about how medical schools and postgraduate training programs should implement and evaluate SDL educational interventions. The Shapiro Institute for Education and Research, in conjunction with the Association of American Medical Colleges, convened teams from eight medical schools from North America to address the challenge of defining, implementing, and evaluating SDL and the structures needed to nurture and support its development in health professional training. Implications: In this commentary, the authors describe SDL in Medical Education, (SDL-ME), which is a construct of learning and pedagogy specific to medical students and physicians in training. SDL-ME builds on the foundations of SDL and self-regulated learning theory, but is specifically contextualized for the unique responsibilities of physicians to patients, inter-professional teams, and society. Through consensus, the authors offer suggestions for training programs to teach and evaluate SDL-ME. To teach self-directed learning requires placing the construct in the context of patient care and of an obligation to society at large. The SDL-ME construct builds upon SDL and SRL frameworks and suggests SDL as foundational to health professional identity formation.KEYWORDSself-directed learning; graduate medical education; undergraduate medical education; theoretical frameworksSupplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1938074 .

Critical care leadership during the COVID-19 pandemic.

The COVID-19 pandemic taxed critical care and its leaders in unprecedented ways. Medical directors, nursing directors, division chiefs and department chairs were forced to lead their staff through a pandemic wrought with personal and professional safety concerns, uncertainty, and more death than most critical care practitioners had ever seen. No leader was fully prepared for the COVID-19 pandemic. Herein, we describe what we believe are the three most important qualities of a leader in times of crisis: presence, transparency, and empathy.

ATS Core Curriculum 2021. Pediatric Pulmonary Medicine: Pulmonary Infections.

The following is a concise review of the Pediatric Pulmonary Medicine Core reviewing pediatric pulmonary infections, diagnostic assays, and imaging techniques presented at the 2021 American Thoracic Society Core Curriculum. Molecular methods have revolutionized microbiology. We highlight the need to collect appropriate samples for detection of specific pathogens or for panels and understand the limitations of the assays. Considerable progress has been made in imaging modalities for detecting pediatric pulmonary infections. Specifically, lung ultrasound and lung magnetic resonance imaging are promising radiation-free diagnostic tools, with results comparable with their radiation-exposing counterparts, for the evaluation and management of pulmonary infections. Clinicians caring for children with pulmonary disease should ensure that patients at risk for nontuberculous mycobacteria disease are identified and receive appropriate nontuberculous mycobacteria screening, monitoring, and treatment. Children with coronavirus disease (COVID-19) typically present with mild symptoms, but some may develop severe disease. Treatment is mainly supportive care, and most patients make a full recovery. Anticipatory guidance and appropriate counseling from pediatricians on social distancing and diagnostic testing remain vital to curbing the pandemic. The pediatric immunocompromised patient is at risk for invasive and opportunistic pulmonary infections. Prompt recognition of predisposing risk factors, combined with knowledge of clinical characteristics of microbial pathogens, can assist in the diagnosis and treatment of specific bacterial, viral, or fungal diseases.