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Background: In a professional learner-centered(ness) educational environment, communication and alignment of expectations about teaching are indispensable. Professional education of residents could benefit from an analysis and comparison of teachers' and residents' educational expectations and beliefs. Our purpose is to identify success factors and barriers related to aligning expectations and beliefs and building a supportive professional learner-centered educational environment. Methods: We conducted semi-structured individual interviews with teachers and semi-structured focus groups with residents. A single interview format was used to make it possible to compare the results. Data were analysed using a qualitative software package (AtlasTi). Data analysis steps were followed by the author team, which identified four domains of good teaching: personal traits, knowledge, relationships and teaching qualities. Results: Teachers and residents agreed about the importance of personal professional characteristics like being a role model and having an open and enthusiastic attitude. They all thought that having a specific knowledge base was essential for teaching. Approaching residents as adult learners was found to be an important element of the learner-centred environment and it was agreed that teachers should take practical experiences to a higher level. However, teachers and residents had different expectations about the practical consequences of being a role model, adult learning, coaching and openness, and the type of knowledge that was needed in the professional development program. Communication about different expectations appeared to be difficult. Conclusions: Teachers and residents agreed on a conceptual level about expectations and beliefs regarding good teaching, but disagreed on an executive level. According to the residents, the disagreement about good teaching was not the biggest barrier to creating alignment and a supportive professional relationship; instead, it was the absence of a proper dialogue regarding issues about expectations and beliefs. [ABSTRACT FROM AUTHOR]

Context During clerkships, teaching and learning in day-to-day activities occur in many moments of interaction among doctors, patients, peers and other co-workers. How people talk with one another influences their identity, their position and what they are allowed to do. This paper focuses on the opportunities and challenges of such moments of interaction between doctors and students during a clerkship characterised by short supervisory relationships. Methods This study was conducted in a 10-week internal medicine clerkship. Nine students and 10 doctors who worked with these nine students participated by regularly describing moments of interaction, using dictaphones. We performed critical discourse analysis of material sourced from a total of 184 audio diary entries and seven student debriefing interviews to reveal how participants discursively shaped the way they could think, speak and conduct themselves. Results The ways in which doctors and students posed and answered questions represented a recurrent and influential feature in the diaries. This Question and Answer dynamic revealed six discourses of Basic Learning Need, Care and Attention, Power Game, Exchange of Currency, Distance, and Equality and Reciprocity. These discourses and the interplay among them revealed both students' and doctors' frameworks of needs and expectations in a culturally defined power structure. The interplay among the discourses reflected the ways in which doctor-student interactions afforded meaningful contributions to their medical or educational practice such as in the exchange of authentic professional or personal experience. Conclusions By purposefully bringing power structures to the surface, we have addressed the complexity of learning and teaching as it occurs in day-to-day moments of interaction in a clerkship with little continuity in supervision. Both doctors and students should be supported to reflect critically on how they contribute to supervisory relationships with reference to, for example, the ways in which they ask or answer questions. [ABSTRACT FROM AUTHOR]

Background: Many instruments for evaluating clinical teaching have been developed but almost all in Western countries. None of these instruments have been validated for the Asian culture, and a literature search yielded no instruments that were developed specifically for that culture. A key element that influences content validity in developing instruments for evaluating the quality of teaching is culture. The aim of this study was to develop a culture-specific instrument with strong content validity for evaluating clinical teaching in initial medical postgraduate training in Japan. Methods: Based on data from a literature search and an earlier study we prepared a draft evaluation instrument. To ensure a good cultural fit of the instrument with the Asian context we conducted a modified Delphi procedure among three groups of stakeholders (five education experts, twelve clinical teachers and ten residents) to establish content validity, as this factor is particularly susceptible to cultural factors. Results: Two rounds of Delphi were conducted. Through the procedure, 52 prospective items were reworded, combined or eliminated, resulting in a 25-item instrument validated for the Japanese setting. Conclusions: This is the first study describing the development and content validation of an instrument for evaluating clinical teaching specifically tailored to an East Asian setting. The instrument has similarities and differences compared with instruments of Western origin. Our findings suggest that designers of evaluation instruments should consider the probability that the content validity of instruments for evaluating clinical teachers can be influenced by cultural aspects. [ABSTRACT FROM AUTHOR]

The Job Demands-Resources model (JD-R model) was used as the theoretical basis of a tailormade questionnaire to measure the psychosocial work environment and personal resources of recently graduated veterinary professionals. According to the JD-R model, two broad categories of work characteristics that determine employee wellbeing can be distinguished: job demands and job resources. Recently, the JD-R model has been expanded by integrating personal resource measures into the model. Three semistructured group interviews with veterinarians active in different work domains were conducted to identify relevant job demands, job resources and personal resources. These demands and resources were organised in themes (constructs). For measurement purposes, a set of questions ('a priori scale') was selected from the literature for each theme. The full set of a priori scales was included in a questionnaire that was administered to 1760 veterinary professionals. Exploratory factor analysis and reliability analysis were conducted to arrive at the final set of validated scales (final scales). 860 veterinarians (73 per cent females) participated. The final set of scales consisted of seven job demands scales (32 items), nine job resources scales (41 items), and six personal resources scales (26 items) which were considered to represent the most relevant potential predictors of work-related wellbeing in this occupational group. The procedure resulted in a tailormade questionnaire: the Veterinary Job Demands and Resources Questionnaire (Vet-DRQ). The use of valid theory and validated scales enhances opportunities for comparative national and international research. [ABSTRACT FROM AUTHOR]

With the aim to assess levels of burnout and work engagement in junior veterinarians and identify predictors of burnout and work engagement in male and female veterinarians, 1760 veterinarians who had graduated in The Netherlands between 1999 and 2009, received an electronic questionnaire. Veterinarians numbering 860 (73 per cent females) participated. Levels of exhaustion, cynicism and work engagement were significantly lower compared to the norm group (a random sample of the Dutch working population). Male veterinarians were less exhausted and more engaged than female veterinarians. Exhaustion decreased over the years. Job demands positively related to exhaustion were work-home interference and workload. Job resources positively related to work engagement were opportunities for professional development and skills discretion (ie, the ability to use and develop skills on the job. Personal resources explained more of the variance in work engagement of female and male veterinarians (31 per cent and 42 per cent) than of the variance in exhaustion (19 per cent and 21 per cent) and cynicism (19 per cent and 10 per cent). Personal resources positively related to work engagement were self-efficacy and proactive behaviour. Relative importance analysis revealed differences between men and women in the importance of various job demands, job resources and personal resources in explaining burnout and engagement in young veterinary professionals. [ABSTRACT FROM AUTHOR]

Background: Consistent identification and prevention of failure for at-risk medical students is challenging, failing courses is costly to all stakeholders, and there is need for further research into duration, timing and structure of interventions to help students in difficulty. Aims: To verify the value of a new exam two weeks into medical school as a predictor of failure, and explore the requirements for a preventative intervention. Methods: Students who failed the two-week exam were invited to a series of large-group workshops and small-group follow-up meetings. Participants' subsequent exam performance was compared with non-participants. Results: About 71% of students who performed poorly in the new exam subsequently failed a course. Attendance at the workshops made no difference to short- or long-term pass rates. Attendance at more than three follow-up small group sessions significantly improved pass rates two semesters later, and was influenced by teacher experience. Conclusions: Close similarity between predictor task and target task is important for accurate prediction of failure. Consideration should be given to dose effect and class size in the prevention of failure of at-risk students, and we recommend a systemic approach to intervention/remediation programmes, involving a whole semester of mandatory, weekly small group meetings with experienced teachers. [ABSTRACT FROM AUTHOR]

Background To get insight in how theoretical knowledge is transformed into clinical skills, important information may arise from mapping the development of anatomical knowledge during the undergraduate medical curriculum. If we want to gain a better understanding of teaching and learning in anatomy, it may be pertinent to move beyond the question of how and consider also the what, why and when of anatomy education. Methods A purposive sample of 78 medical students from the 2nd, 3rd, 4th and 6th year of a PBL curriculum participated in 4 focus groups. Each group came together twice, and all meetings were recorded and transcribed verbatim. Data were analysed with template analysis using a phenomenographical approach. Results Five major topics emerged and are described covering the students' perceptions on their anatomy education and anatomical knowledge: 1) motivation to study anatomy, 2) the relevance of anatomical knowledge, 3) assessment of anatomical knowledge, 4) students' (in)security about their anatomical knowledge and 5) the use of anatomical knowledge in clinical practice. Conclusions Results indicated that a PBL approach in itself was not enough to ensure adequate learning of anatomy, and support the hypothesis that educational principles like time-on-task and repetition, have a stronger impact on students' perceived and actual anatomical knowledge than the educational approach underpinning a curriculum. For example, students state that repetitive studying of the subject increases retention of knowledge to a greater extent than stricter assessment, and teaching in context enhances motivation and transfer. Innovations in teaching, like spiral curriculum, teaching in context and teaching for transfer, and assessment, like assessment for learning: rewarding understanding and higher order cognitive skills, are required to improve anatomy education. [ABSTRACT FROM AUTHOR]

Background: Previous work has shown that a programme that draws on a blend of theories makes a positive difference to outcomes for students who fail and repeat their first semester at medical school. Exploration of student and teacher perspectives revealed that remediation of struggling medical students can be achieved through a cognitive apprenticeship within a small community of inquiry. This community needs expert teachers capable of performing a unique combination of roles (facilitator, nurturing mentor, disciplinarian, diagnostician and role model), with high levels of teaching presence and practical wisdom. Yet, despite participants' convergent opinions on the elements of effective remediation, significant differences were found between outcomes of students working with experienced and inexperienced teachers. The current study explores the actual practice of teachers on this remediation course, aiming to exemplify elements of our theory of remediation and explore differences between teachers. Methods: Since it is in the classroom context that the interactions that constitute the complex process of remediation emerge, this practice-based research has focused on direct observation of classroom teaching. Nineteen hours of small group sessions were recorded and transcribed. Drawing on ethnography and sociocultural discourse analysis, selected samples of talk-in-context demonstrate how the various elements of remediation play out in practice, highlighting aspects that are most effective, and identifying differences between experienced and novice teachers. Results: Long-term student outcomes are strongly correlated to teacher experience (r, 0.81). Compared to inexperienced teachers, experienced teachers provide more challenging, disruptive facilitation, and take a dialogic stance that encourages more collaborative group dynamics. They are more expert at diagnosing cognitive errors, provide frequent metacognitive time-outs and make explicit links across the curriculum. Conclusions: Remediation is effective in small groups where dialogue is used for collaborative knowledge construction and social regulation. This requires facilitation by experienced teachers who attend to details of both content and process, and use timely interventions to foster curiosity and the will to learn. These teachers should actively challenge students' language use, logical inconsistencies and uncertainties, problematize their assumptions, and provide a metacognitive regulatory voice that can generate attitudinal shifts and nurture the development of independent critical thinkers. [ABSTRACT FROM AUTHOR]

Background: Despite increasing attention to providing preclinical medical students with early patient experiences, little is known about associated outcomes for students. The authors compared three early patient experiences at a large American medical school where all preclinical students complete preceptorships and weekly bedside clinicalskills training and about half complete clinical, community-based summer immersion experiences. The authors asked, what are the relative outcomes and important educational components for students? Methods: Medical students completed surveys at end of second year 2009-2011. In 2009, students compared/ contrasted two of three approaches; responses framed later survey questions. In 2010 and 2011, students rated all three experiences in relevant areas (e.g., developing comfort in clinical setting). Investigators performed qualitative and quantitative analyses. Results: Students rated bedside training more highly for developing comfort with clinical settings, one-on-one clinical-skills training, feedback, active clinical experience, quality of clinical training, and learning to be part of a team. They rated community clinical immersion and preceptorships more highly for understanding the life/practice of a physician and career/specialty decisions. Conclusions: Preclinical students received different benefits from the different experiences. Medical schools should define objectives of early clinical experiences and offer options accordingly. A combination of experiences may help students achieve clinical and team comfort, clinical skills, an understanding of physicians' lives/practices, and broad exposure for career decisions. [ABSTRACT FROM AUTHOR]

Context The supervision of specialty registrars during on-call shifts is essential to ensure the quality of both health care and medical education, but has been identified as a major novelty and stressor for new consultants in the transition from specialty training. There is a paucity of research on how consultants deal with their new supervisory roles and which factors influence this process. These issues are addressed in a prospective study designed to gather insights that can inform measures to ensure the provision of high-quality supervision and specialty training. Methods A longitudinal qualitative study was performed in the Netherlands. Semi-structured interviews were conducted with new consultants. The study was guided by an interpretative phenomenological approach until saturation was reached. At 3-month intervals between July 2011 and March 2012, eight novice consultants in internal medicine were interviewed three times each about their supervisory role while on call. Interviews focused on their preparation for the role in training, the actions they took to master the role, and their progression over time. Results Three interrelated domains of relevant factors emerged from the data: preparedness; personal characteristics, and contextual characteristics. Preparedness referred to the extent to which new consultants were prepared by training to take full responsibility for registrars' actions while supervising them from a distance. Personal characteristics, such as coping strategies and views on supervision, guided consultants' development as supervisors. Essential to this process were contextual characteristics, especially those concerning the extent to which the consultant knew the registrar, was familiar with departmental procedures, and had access to support from colleagues. Conclusions New consultants should be prepared for their supervisory role by training and by being given a proper introduction to their workplace. The former requires progressive independence and exposure to supervisory tasks during specialty training; the latter requires an induction programme to enable new consultants to familiarise themselves with the departmental environment and the registrars they will be supervising. [ABSTRACT FROM AUTHOR]

Context Many studies have examined how educational innovations in postgraduate medical education (PGME) impact on teaching and learning, but little is known about effects in the clinical workplace outside the strictly education-related domain. Insights into the full scope of effects may facilitate the implementation and acceptance of innovations because expectations can be made more realistic, and difficulties and pitfalls anticipated. Using workplace-based assessment (WBA) as a reference case, this study aimed to determine which types of effect are perceived by users of innovations in PGME. Methods Focusing on WBA as a recent instance of innovation in PGME, we conducted semi-structured interviews to explore perceptions of the effects of WBA in a purposive sample of Dutch trainees and (lead) consultants in surgical and non-surgical specialties. Interviews conducted in 2011 with 17 participants were analysed thematically using template analysis. To support the exploration of effects outside the domain of education, the study design was informed by theory on the diffusion of innovations. Results Six domains of effects of WBA were identified: sentiments (affinity with the innovation and emotions); dealing with the innovation; specialty training; teaching and learning; workload and tasks, and patient care. Users' affinity with WBA partly determined its effects on teaching and learning. Organisational support and the match between the innovation and routine practice were considered important to minimise additional workload and ensure that WBA was used for relevant rather than easily assessable training activities. Dealing with WBA stimulated attention for specialty training and placed specialty training on the agenda of clinical departments. Conclusions These outcomes are in line with theoretical notions regarding innovations in general and may be helpful in the implementation of other innovations in PGME. Given the substantial effects of innovations outside the strictly education-related domain, individuals designing and implementing innovations should consider all potential effects, including those identified in this study. [ABSTRACT FROM AUTHOR]

Background: Previous research has shown that Dutch medical residents feel inadequate in certain management areas: 85% had a need for management training and reported preferences on the format of such training. Our objective was to explore if the perceived deficiencies and needs among Dutch residents were similar to those of their peers in other countries, and if a longer duration of the incorporation of the CanMEDS competency framework into curricula as well as management training had an influence on these perceptions. Methods: Medical residents from Denmark, Canada and Australia were approached for participation. The questionnaire used to survey the perceptions of Dutch residents was slightly modified, translated into English and sent by email to all international participants. Results: Response rates were; Denmark 719/2105 (34%), Canada 177/500 (35%) and Australia 194/1213 (16%) respectively. The Danish as well as the Canadian residents rated their negotiating skills poorly. In Australia the residents found their knowledge on how their specialist department was organized to be insufficient, while residents in the Netherlands rated their knowledge on how the healthcare system was organized as inadequate. In all of the countries, more than 70% of the residents reported a perceived need for management training. Conclusions: A majority of the residents in all countries felt the need for specific training in developing their management competencies. The adoption of the CanMEDS framework alone seems to be insufficient in meeting residents' perceived educational needs in this area. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 390-398 Context Consultants in charge of postgraduate medical education (PGME) in hospital departments ('lead consultants') are responsible for the implementation of educational change. Although difficulties in innovating in medical education are described in the literature, little is known about how lead consultants approach educational change. Objectives This study was conducted to explore lead consultants' approaches to educational change in specialty training and factors influencing these approaches. Methods From an interpretative constructivist perspective, we conducted a qualitative exploratory study using semi-structured interviews with a purposive sample of 16 lead consultants in the Netherlands between August 2010 and February 2011. The study design was based on the research questions and notions from corporate business and social psychology about the roles of change managers. Interview transcripts were analysed thematically using template analysis. Results The lead consultants described change processes with different stages, including cause, development of content, and the execution and evaluation of change, and used individual change strategies consisting of elements such as ideas, intentions and behaviour. Communication is necessary to the forming of a strategy and the implementation of change, but the nature of communication is influenced by the strategy in use. Lead consultants differed in their degree of awareness of the strategies they used. Factors influencing approaches to change were: knowledge, ideas and beliefs about change; level of reflection; task interpretation; personal style, and department culture. Conclusions Most lead consultants showed limited awareness of their own approaches to change. This can lead them to adopt a rigid approach, whereas the ability to adapt strategies to circumstances is considered important to effective change management. Interventions and research should be aimed at enhancing the awareness of lead consultants of approaches to change in PGME. [ABSTRACT FROM AUTHOR]

Evidence that medical error can cause harm to patients has raised the attention of the health care community towards patient safety and influenced how and what medical students learn about it. Patient safety is best taught when students are participating in clinical practice where they actually encounter patients at risk. This type of learning is referred to as workplace learning, a complex system in which various factors influence what is being learned and how. A theory that can highlight potential difficulties in this complex learning system about patient safety is activity theory. Thirty-four final year undergraduate medical students participated in four focus groups about their experiences concerning patient safety. Using activity theory as analytical framework, we performed constant comparative thematic analysis of the focus group transcripts to identify important themes. We found eight general themes relating to two activities: learning to be a doctor and delivering safe patient care. Simultaneous occurrence of these two activities can cause contradictions. Our results illustrate the complexity of learning about patient safety at the workplace. Students encounter contradictions when learning about patient safety, especially during a transitional phase of their training. These contradictions create potential learning opportunities which should be used in education about patient safety. Insight into the complexities of patient safety is essential to improve education in this important area of medicine. [ABSTRACT FROM AUTHOR]

Medical Education 2011: : 280-288 Real-patient contacts in problem-based undergraduate medical education are promoted as a good way to introduce biomedical and (in)formal clinical knowledge early in the curriculum and thereby to foster the development of coherent and integrated knowledge networks. There are concerns, however, that such contacts may cause students to focus on clinical knowledge to the neglect of biomedical knowledge, and that group discussions may be dominated by teachers. We examined these concerns by addressing the following questions in the context of group sessions in which students prepare for and report on real-patient contacts. To what extent are biomedical and (in)formal clinical knowledge addressed? To what extent are these knowledge types addressed by students or tutors? Are connections made between biomedical and clinical knowledge? We videotaped and transcribed six preparation and six reporting group sessions (two preparation and two reporting phases for each of three groups) held with students in Year 3 of the problem-based curriculum at Maastricht University. During this year, real patients rather than paper patients are used. Qualitative analysis software was used to code propositions in the transcriptions in order to identify different kinds of knowledge and different functions of biomedical knowledge. Formal clinical knowledge was the subject of 40.7% and 34.8% of propositions during the preparation and reporting phases, respectively. The corresponding percentages for biomedical knowledge were 15.0% and 28.0%. Tutors accounted for 63.4% of propositions during the preparation phase, and students for 80.1% during the reporting phase. Nearly all biomedical knowledge was related to clinical knowledge. It appears that pre-clinical patient encounters can stimulate students to pay attention to both clinical and biomedical knowledge and to how they are connected. Tutor dominance was evident only during the preparation phase. Further research is needed to investigate whether pre-clinical patient contacts promote the development of coherent and integrated knowledge networks. [ABSTRACT FROM AUTHOR]

Background: Professionals working in the operating room (OR) are subject to various distractions that can be detrimental to their task performance and the quality of their work. This study aimed to quantify the frequency, nature, and effect on performance of (potentially) distracting events occurring during endourological procedures and additionally explored urologists' and residents' perspectives on experienced ill effects due to distracting factors. Methods: First, observational data were collected prospectively during endourological procedures in one OR of a teaching hospital. A seven-point ordinal scale was used to measure the level of observed interference with the main task of the surgical team. Second, semistructured interviews were conducted with eight urologists and seven urology residents in two hospitals to obtain their perspectives on the impact of distracting factors. Results: Seventy-eight procedures were observed. A median of 20 distracting events occurred per procedure, which corresponds to an overall rate of one distracting event every 1.8 min. Equipment problems and procedure-related and medically irrelevant communication were the most frequently observed causes of interruptions and identified as the most distracting factors in the interviews. Occurrence of distracting factors in difficult situations requiring high levels of concentration was perceived by all interviewees as disturbing and negatively impacting performance. The majority of interviewees (13/15) thought distracting factors impacted more strongly on residents' compared to urologists' performance due to their different levels of experience. Conclusion: Distracting events occur frequently in the OR. Equipment problems and communication, the latter both procedure-related and medically irrelevant, have the largest impact on the sterile team and regularly interrupt procedures. Distracting stimuli can influence performance negatively and should therefore be minimized. Further research is required to determine the direct effect of distraction on patient safety. [ABSTRACT FROM AUTHOR]

OBJECTIVES A mandatory remedial programme for students who repeat their first semester at medical school has resulted in large gains in academic performance and greatly reduced attrition. Here, we explore the students' views of this in order to clarify understanding of optimal remediation practice. METHODS Using a mixed-methods approach, quantitative and qualitative data were gathered from student surveys (n = 333) and three in-depth focus groups. Results were analysed for emergent themes. RESULTS Remedial programmes for at-risk medical students should be mandatory, but should respect students' identity as repeaters. Attitude and motivation are key, and working in stable groups provides essential emotional and cognitive support. The learning environment needs to foster changes in students' ways of thinking and their development as flexible, reflective learners. These endeavours require support from honest teachers with rigorous expectations and good facilitation skills. CONCLUSIONS Successful remediation needs to challenge students' conceptions of learning, works best in groups with skilled facilitators, and must take into account a blend of cognitive and affective factors and the complex interplay between learner and environment. Given a carefully designed programme, at-risk medical students can learn to make effective and lasting changes to their approach to study, and their views of learning can come to converge with influential ideas in the education literature. [ABSTRACT FROM AUTHOR]

Many evaluation instruments have been developed to provide feedback to physicians on their clinical teaching but written feedback alone is not always effective. We explored whether feedback effectiveness improved when teachers' self-assessment was added to written feedback based on student ratings. 37 physicians (10 residents, 27 attending physicians) from different specialties (Internal Medicine, Surgery, Obstetrics/Gynecology, Pediatrics, Neurology, Dermatology, Ophthalmology, ENT, and Psychiatry) were invited to fill out a self-assessment questionnaire on their teaching skills. Students completed an almost identical questionnaire to evaluate the same teachers based on their experiences during clerkships. After receiving written feedback incorporating their self-assessment and the student ratings, the teachers indicated their perceptions of the self-assessment exercise and the written feedback in a questionnaire (five-point Likert scale items) and next, in more detail, in semi-structured interviews with a purposive sample of 12 of the participating teachers. 25 physicians participated (67%). The results showed that self-assessment and student feedback were both perceived as useful (3.7, SD 1.0) but the latter was considered more effective. The physicians we interviewed considered the combination of self-assessment with student ratings more effective than either self-assessment or written feedback alone. Notably, discrepancies between student ratings and self-assessment were deemed a strong incentive for change. We conclude that self-assessment can be a useful tool to stimulate improvement of clinical teaching when it is combined with written feedback based on student ratings. Future research among larger groups is needed to confirm our findings and examine whether these combined tools actually lead to improved teaching. [ABSTRACT FROM AUTHOR]

In the past 20 years the surgical simulator market has seen substantial growth. Simulators are useful for teaching surgical skills effectively and with minimal harm and discomfort to patients. Before a simulator can be integrated into an educational program, it is recommended that its validity be determined. This study aims to provide a critical review of the literature and the main experiences and efforts relating to the validation of simulators during the last two decades. Subjective and objective validity studies between 1980 and 2008 were identified by searches in Pubmed, Cochrane, and Web of Science. Although several papers have described definitions of various subjective types of validity, the literature does not offer any general guidelines concerning methods, settings, and data interpretation. Objective validation studies on endourological simulators were mainly characterized by a large variety of methods and parameters used to assess validity and in the definition and identification of expert and novice levels of performance. Validity research is hampered by a paucity of widely accepted definitions and measurement methods of validity. It would be helpful to those considering the use of simulators in training programs if there were consensus on guidelines for validating surgical simulators and the development of training programs. Before undertaking a study to validate a simulator, researchers would be well advised to conduct a training needs analysis (TNA) to evaluate the existing need for training and to determine program requirements in a training program design (TPD), methods that are also used by designers of military simulation programs. Development and validation of training models should be based on a multidisciplinary approach involving specialists (teachers), residents (learners), educationalists (teaching the teachers), and industrial designers (providers of teaching facilities). In addition to technical skills, attention should be paid to contextual, interpersonal, and task-related factors. [ABSTRACT FROM AUTHOR]

Background: There are many avoidable deaths in hospitals because the care team is not well attuned. Training in emergency situations is generally followed on an individual basis. In practice, however, hospital patients are treated by a team composed of various disciplines. To prevent communication errors, it is important to focus the training on the team as a whole, rather than on the individual. Team training appears to be important in contributing toward preventing these errors. Obstetrics lends itself to multidisciplinary team training. It is a field in which nurses, midwives, obstetricians and paediatricians work together and where decisions must be made and actions must be carried out under extreme time pressure. It is attractive to belief that multidisciplinary team training will reduce the number of errors in obstetrics. The other side of the medal is that many hospitals are buying expensive patient simulators without proper evaluation of the training method. In the Netherlands many hospitals have 1,000 or less annual deliveries. In our small country it might therefore be more cost-effective to train obstetric teams in medical simulation centres with well trained personnel, high fidelity patient simulators, and well defined training programmes. Methods/design: The aim of the present study is to evaluate the cost-effectiveness of multidisciplinary team training in a medical simulation centre in the Netherlands to reduce the number of medical errors in obstetric emergency situations. We plan a multicentre randomised study with the centre as unit of analysis. Obstetric departments will be randomly assigned to receive multidisciplinary team training in a medical simulation centre or to a control arm without any team training. The composite measure of poor perinatal and maternal outcome in the non training group was thought to be 15%, on the basis of data obtained from the National Dutch Perinatal Registry and the guidelines of the Dutch Society of Obstetrics and Gynaecology (NVOG). We anticipated that multidisciplinary team training would reduce this risk to 5%. A sample size of 24 centres with a cluster size of each at least 200 deliveries, each 12 centres per group, was needed for 80% power and a 5% type 1 error probability (two-sided). We assumed an Intraclass Correlation Coefficient (ICC) value of maximum 0.08. The analysis will be performed according to the intention-to-treat principle and stratified for teaching or nonteaching hospitals. Primary outcome is the number of obstetric complications throughout the first year period after the intervention. If multidisciplinary team training appears to be effective a cost-effective analysis will be performed. [ABSTRACT FROM AUTHOR]

Background: The educational climate is crucial in postgraduate medical education. Although leaders are in the position to influence the educational climate, the relationship between leadership skills and educational climate is unknown. This study investigates the relationship between the educational climate in clinical departments and the leadership skills of clinical consultants responsible for education. Methods: The study was a trans-sectional correlation study. The educational climate was investigated by a survey among all doctors (specialists and trainees) in the departments. Leadership skills of the consultants responsible for education were measured by multi-source feedback scores from heads of departments, peer consultants, and trainees. Results: Doctors from 42 clinical departments representing 21 specialties participated. The response rate of the educational climate investigation was moderate 52% (420/811), Response rate was high in the multisourcefeedback process 84.3% (420/498). The educational climate was scored quite high mean 3.9 (SD 0.3) on a five-point Likert scale. Likewise the leadership skills of the clinical consultants responsible for education were considered good, mean 5.4 (SD 0.6) on a seven-point Likert scale. There was no significant correlation between the scores concerning the educational climate and the scores on leadership skills, r = 0.17 (p = 0.29). Conclusions: This study found no relation between the educational climate and the leadership skills of the clinical consultants responsible for postgraduate medical education in clinical departments with the instruments used. Our results indicate that consultants responsible for education are in a weak position to influence the educational climate in the clinical department. Further studies are needed to explore, how heads of departments and other factors related to the clinical organisation could influence the educational climate. [ABSTRACT FROM AUTHOR]

Background: Studies have shown that medical students experience the transition between preclinical and clinical training as a stressful period. They are generally frustrated by their inability to apply their knowledge to solve clinical problems in practice. Preclinical patient contacts may offer a solution to this 'shock of practice.' We studied how students who have had preclinical patient contacts perceive the transition from preclinical to clinical training and, more specifically, how they value these early patient contacts as preparation for learning in clinical practice. Methods: A purposive sample of 21 students participated in three focus groups which met twice during their first weeks of clinical clerkships. The interviews were recorded and transcribed literally. Qualitative content analysis of the transcriptions was performed. Results: According to the students, working in clinical practice was enjoyable, motivated them to study and helped them to develop non-analytical reasoning skills. The students experienced stress due to increased working hours and work load, uncertainty as to what was expected of them and self-perceived lack of knowledge. They did not experience a major gap between the preclinical and clinical phase and felt well prepared for the clerkships. The preclinical patient contacts were considered to be instrumental in this. Conclusions: Early patient contacts seem to ameliorate the shock of practice and prepare students for clinical work. The problems mentioned by the students in this study are mainly related to the socialisation process. The results of this study have to be validated by quantitative research. [ABSTRACT FROM AUTHOR]

Learning in clinical practice can be characterised as situated learning because students learn by performing tasks and solving problems in an environment that reflects the multiple ways in which their knowledge will be put to use in their future professional practice. Collins et al. introduced cognitive apprenticeship as an instructional model for situated learning comprising six teaching methods to support learning: modelling, coaching, scaffolding, articulation, reflection and exploration. Another factor that is looked upon as conducive to learning in clinical practice is a positive learning climate. We explored students’ experiences regarding the learning climate and whether the cognitive apprenticeship model fits students’ experiences during clinical training. In focus group interviews, three groups of 6th-year medical students ( N = 21) discussed vignettes representing the six teaching methods and the learning climate to explore the perceived occurrence of the teaching methods, related problems and possibilities for improvement. The students had experienced all six teaching methods during their clerkships. Modelling, coaching, and articulation were predominant, while scaffolding, reflection, and exploration were mainly experienced during longer clerkships and with one clinical teacher. The main problem was variability in usage of the methods, which was attributed to teachers’ lack of time and formal training. The students proposed several ways to improve the application of the teaching methods. The results suggest that the cognitive apprenticeship model is a useful model for teaching strategies in undergraduate clinical training and a valuable basis for evaluation, feedback, self-assessment and faculty development of clinical teachers. [ABSTRACT FROM AUTHOR]

In a previous study, we established that compared to a written case, a video case enhances observable cognitive processes in the verbal interaction in a postgraduate problem-based learning format. In a new study we examined non-observable cognitive processes using a stimulated recall procedure alongside a reanalysis of the data from the first study. We examined the development of shared cognition as reflected in collaborative concept link formation, an approach to connecting a series of concepts related to a particular topic. Eleven paediatric residents were randomly allocated to two groups. After both analysing the same written case vignette, one group watched a video of the case in the vignette and the other group read a written description of the video. Both groups then reanalysed the vignette. After the group sessions, time-logged transcripts were made of the verbal interaction in both groups and all residents individually took part in a stimulated recall procedure. Causal reasoning concept links were labelled as individual or collaborative depending on whether they originated from individual residents or were directly elicited by verbal utterances from others. The video led to a significantly increased frequency ratio (after intervention: before intervention) of collaborative concept links but did not affect the frequency of individual concept links. This novel process approach to chronological registration of concept link formation offered additional evidence that shared cognition by means of co-elaboration of concept formation is stimulated by the use of patient video recordings in small group learning. [ABSTRACT FROM AUTHOR]

Objectives This study set out to examine how much time students and teachers devote to different learning-oriented interactions during seminar sessions and students’ and teachers’ perceptions about the occurrence and desirability of these interactions. Methods Students and teachers participating in eight seminar group sessions in Year 4 of an undergraduate veterinary curriculum completed an 11-item questionnaire which asked them to rate, on a 5-point Likert scale, the frequency of occurrence and level of desirability of three learning-oriented types of interaction: exploratory questioning; cumulative reasoning, and handling of conflict about knowledge. The questionnaire also invited positive and negative responses to aspects of group interactions and an overall mark (1–10) for the seminars and group interactions. Four group sessions were video-recorded and analysed using a coding scheme. The amount of time devoted to the different interactions was calculated. Results Both students and teachers gave scores of 3.0–3.5 for frequency of occurrence of exploratory questioning and cumulative reasoning and < 3.0 for occurrence of handling of conflict about knowledge. The desired occurrences of all interaction types were significantly higher than the actual occurrences according to students and teachers. Teachers were responsible for the majority of the interactions (93%). The percentages of session time devoted to teacher-centred cumulative reasoning, exploratory questioning and handling of conflict about knowledge were 65.8%, 15.6% and 3.1%, respectively. Conclusions Group interactions in seminar groups are dominated by the posing of questions by teachers to students. The moderate occurrence of group interactions as perceived by students and teachers may be explained by the inadequate preparation of teachers and students to stimulate group interactions. [ABSTRACT FROM AUTHOR]

Objectives The lack of published studies into effective skills teaching in clinical skills centres inspired this study of student views of the teaching behaviours of skills teachers. Methods We organised focus group discussions with students from Years 1–3 of a 6-year undergraduate medical curriculum. A total of 30 randomly selected students, divided into three groups, took part in two sessions. They discussed what teaching skills helped them to acquire physical examination skills. Results Students’ opinions related to didactic skills, interpersonal and communication skills and preconditions. Students appreciated didactic skills that stimulate deep and active learning. Another significant set of findings referred to teachers’ attitudes towards students. Students wanted teachers to be considerate and to take them seriously. This was reflected in student descriptions of positive behaviours, such as: ‘responding to students’ questions’; ‘not exposing students’ weaknesses in front of the group’, and ‘[not] putting students in an embarrassing position in skill demonstrations’. They also appreciated enthusiasm in teachers. Important preconditions included: the integration of skills training with basic science teaching; linking of skills training to clinical practice; the presence of clear goals and well-structured sessions; good time management; consistency of teaching, and the appropriate personal appearance of teachers and students. Conclusions The teaching skills and behaviours that most facilitate student acquisition of physical examination skills are interpersonal and communication skills, followed by a number of didactic interventions, embedded in several preconditions. Findings related to interpersonal and communication skills are comparable with findings pertaining to the teaching roles of tutors and clinical teachers; however, the didactic skills merit separate attention as teaching skills for use in skills laboratories. The results of this study should be complemented by a study performed in a larger population and a study exploring teachers’ views. [ABSTRACT FROM AUTHOR]

Context During clerkships, teaching and learning in day-to-day activities occur in many moments of interaction among doctors, patients, peers and other co-workers. How people talk with one another influences their identity, their position and what they are allowed to do. This paper focuses on the opportunities and challenges of such moments of interaction between doctors and students during a clerkship characterised by short supervisory relationships. Methods This study was conducted in a 10-week internal medicine clerkship. Nine students and 10 doctors who worked with these nine students participated by regularly describing moments of interaction, using dictaphones. We performed critical discourse analysis of material sourced from a total of 184 audio diary entries and seven student debriefing interviews to reveal how participants discursively shaped the way they could think, speak and conduct themselves. Results The ways in which doctors and students posed and answered questions represented a recurrent and influential feature in the diaries. This Question and Answer dynamic revealed six discourses of Basic Learning Need, Care and Attention, Power Game, Exchange of Currency, Distance, and Equality and Reciprocity. These discourses and the interplay among them revealed both students' and doctors' frameworks of needs and expectations in a culturally defined power structure. The interplay among the discourses reflected the ways in which doctor-student interactions afforded meaningful contributions to their medical or educational practice such as in the exchange of authentic professional or personal experience. Conclusions By purposefully bringing power structures to the surface, we have addressed the complexity of learning and teaching as it occurs in day-to-day moments of interaction in a clerkship with little continuity in supervision. Both doctors and students should be supported to reflect critically on how they contribute to supervisory relationships with reference to, for example, the ways in which they ask or answer questions. [ABSTRACT FROM AUTHOR]

Context Small-group learning is advocated for enhancing higher-order thinking and the development of skills and attitudes. Teacher performance, group interaction and the quality of assignments have been shown to affect small-group learning in hybrid and problem-based curricula. Objectives This study aimed to examine the perceptions of student groups as to how teacher performance, group interaction and the quality of assignments are related to one another and to learning effects in seminars of 15–30 students in a hybrid curriculum. Methods We constructed a 28-item questionnaire and administered it to 639 students attending 32 seminars in Years 1–4 of an undergraduate veterinary curriculum. We performed factor analysis and reliability analysis of the questionnaire. We used correlation and regression analyses to explore the interactions of the four-factor model, with teacher performance, group interaction and quality of assignments as independent variables and the perceived learning effect of the seminars as the dependent variable. Results The response rate was 99%. Teacher performance (β = 0.78) and group interaction (− 0.28) significantly influenced the perceived learning effect. The total effect of the quality of assignments (through effects on teacher performance and group interaction) was 0.47. Discussion The strong relationship between teacher performance and learning effect suggests that students rely strongly on their teachers. The negative effect of group interaction may reflect poor alignment of teaching and assessment and poor organisation of group processes. This should be further examined. Comparative studies on seminars are also recommended. [ABSTRACT FROM AUTHOR]

Context The clinical learning climate affects undergraduate medical students’ behaviour, satisfaction and success. Most studies predominantly describe aspects of the clinical learning climate using quantitative methodologies, such as questionnaires. This study aimed to illuminate medical students’ perceptions of the clinical learning climate, and which factors and their interactions explain differences in clinical learning climates. Methods We carried out a multi-method case study. Twelve departments of obstetrics and gynaecology distributed the Postgraduate Hospital Educational Environment Measure (PHEEM), a reliable questionnaire measuring the clinical learning environment, among medical students. After analysis (usinganova and post hoc tests), 14 medical students from the highest- and lowest-scoring departments participated in semi-structured interviews. We analysed the transcribed recordings using a content analysis approach. Researchers agreed on coding and an expert group reached consensus on the themes of the analysis. Results We found a significant difference between departments in PHEEM scores. The interviews indicated that department and medical student characteristics determine the clinical learning climate. For departments, ‘legitimacy’, ‘clerkship arrangements’ and ‘focus on personal development’ were the main themes. For medical students, ‘initial initiatives’, ‘continuing development’ and ‘clerkship fatigue’ were the principal themes. The amount and nature of participation played a central role in all themes. Conclusions Differences between clinical learning climates appear to be related to differing approaches to participation among departments. Participation depends on characteristics of both departments and students, and the interactions among them. The outcomes give valuable clues to how a favourable clinical learning climate is shaped. [ABSTRACT FROM AUTHOR]

Context One goal of undergraduate assessment is to test students’ (future) performance. In the area of skills testing, the objective structured clinical examination (OSCE) has been of great value as a tool with which to test a number of skills in a limited time, with bias reduction and improved reliability. But can OSCEs measure undergraduate internship expertise in basic clinical skills? Methods Undergraduate students ( n = 32) were given a questionnaire listing 182 basic clinical skills. We asked them to score the number of times they had performed each skill during their internships (a 12-month period in Year 6). We assessed the students at the end of Year 5 (before the start of their internships) and again at the start of Year 7 (undergraduate training takes 7 years in Belgium, with internships during Year 6), using a 14-station OSCE assessing basic clinical skills. Global ratings were used to score performance. The relationship between internship experience and the OSCE Year 7 score was analysed using a linear regression model, controlling for variation in OSCE scores from Year 5. A multi-level analysis was performed considering students as level-1 units and stations as level-2 units. Results Year 7 OSCE scores (post-internships) were not affected by the number of times that students practised basic medical skills during their internships. Discussion Scores on OSCEs do not seem to reflect clinical expertise acquired during internships. Other more integrated assessment methods may prove to be more valid for testing final undergraduate skills levels. [ABSTRACT FROM AUTHOR]

Context Graduate medical education is currently facing major educational reforms. There is a lack of empirical evidence in the literature about the learning processes of residents in the clinical workplace. This qualitative study uses a ‘grounded theory’ approach to continue the development of a theoretical framework of learning in the clinical workplace by adding the perspective of attending doctors. Methods A total of 21 Dutch attending doctors involved in the training of residents in obstetrics and gynaecology participated in 1 of 3 focus group sessions. They discussed their perceptions of how residents learn and what factors influence residents' learning. A grounded theory approach was used to analyse the transcribed discussions. Results Three related themes emerged. The first concerned the central role of participation in work-related activities: according to attending doctors, residents learn by tackling the everyday challenges of clinical work. The second involved the ways in which attending doctors influence what residents learn from work-related activities. The final theme focused on attending doctors' views of the essential characteristics of residents and their development during residency. Conclusions Attending doctors' perspectives complement current insights derived from similar research among residents and from related literature. As part of an ongoing effort to further develop understanding of how residents learn, this study adds several ways in which attending doctors strive to combine guidance in both patient care and resident training. Furthermore, attending doctors' perspectives draw attention to other aspects of learning in the clinical workplace, such as the role of confidence and the balance between supervision and independence. [ABSTRACT FROM AUTHOR]

Context Many undergraduate medical education programmes offer integrated multi-disciplinary courses, which are generally developed by a team of teachers from different disciplines. Research has shown that multi-disciplinary teams may encounter problems, which can be detrimental to productive co-operation, which in turn may diminish educational quality. Because we expected that charting these problems might yield suggestions for addressing them, we examined the relationships between team diversity, team processes and course quality. Methods We administered a questionnaire to participants from 21 interdisciplinary teams from 1 Dutch and 1 German medical school, both of which were reforming their curriculum. An adapted questionnaire on team learning behaviours, which had been validated in business contexts, was used to collect data on team processes, team learning behaviours and diversity within teams. We examined the relationship between the team factors and educational quality measures of the courses designed by the teams. Results A total of 84 teachers (60%) completed the questionnaire. Bivariate correlation analysis showed that several aspects of diversity, conflict, working climate and learning behaviour were correlated with course quality. Conclusions The negative effects of the diversity measures, notably, value diversity, on other team processes and course quality and the positive association between psychological safety and team learning suggest that educational quality might be improved by enhancing the functioning of multi-disciplinary teams responsible for course development. The relationship between team processes and educational quality should be studied among larger study populations. Student ratings should also be considered in measuring educational quality. [ABSTRACT FROM AUTHOR]

Objectives Medical councils worldwide have outlined new standards for postgraduate medical education. This means that residency programmes will have to integrate modern educational views into the clinical workplace. Postgraduate medical education is often characterised as a process of learning from experience. However, empirical evidence regarding the learning processes of residents in the clinical workplace is lacking. This qualitative study sought insight into the intricate process of how residents learn in the clinical workplace. Methods We carried out a qualitative study using focus groups. A grounded theory approach was used to analyse the transcribed tape recordings. A total of 51 obstetrics and gynaecology residents from teaching hospitals and affiliated general hospitals participated in 7 focus group discussions. Participants discussed how they learn and what factors influence their learning. Results An underlying theoretical framework emerged from the data, which clarified what happens when residents learn by doing in the clinical workplace. This framework shows that work-related activities are the starting point for learning. The subsequent processes of ‘interpretation’ and ‘construction of meaning’ lead to refinement and expansion of residents' knowledge and skills. Interaction plays an important role in the learning process. This is in line with both cognitivist and sociocultural views on learning. Conclusions The presented theoretical framework of residents' learning provides much needed empirical evidence for the actual learning processes of residents in the clinical workplace. The insights it offers can be used to exploit the full educational potential of the clinical workplace. [ABSTRACT FROM AUTHOR]

Objectives The clinical learning environment is an influential factor in work-based learning. Evaluation of this environment gives insight into the educational functioning of clinical departments. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an evaluation tool consisting of a validated questionnaire with 3 subscales. In this paper we further investigate the psychometric properties of the PHEEM. We set out to validate the 3 subscales and test the reliability of the PHEEM for both clerks (clinical medical students) and registrars (specialists in training). Methods Clerks and registrars from different hospitals and specialties filled out the PHEEM. To investigate the construct validity of the 3 subscales, we used an exploratory factor analysis followed by varimax rotation, and a cluster analysis known as Mokken scale analysis. We estimated the reliability of the questionnaire by means of variance components according to generalisability theory. Results A total of 256 clerks and 339 registrars filled out the questionnaire. The exploratory factor analysis plus varimax rotation suggested a 1-dimensional scale. The Mokken scale analysis confirmed this result. The reliability analysis showed a reliable outcome for 1 department with 14 clerks or 11 registrars. For multiple departments 3 respondents combined with 10 departments provide a reliable outcome for both groups. Discussion The PHEEM is a questionnaire measuring 1 dimension instead of the hypothesised 3 dimensions. The sample size required to achieve a reliable outcome is feasible. The instrument can be used to evaluate both single and multiple departments for both clerks and registrars. [ABSTRACT FROM AUTHOR]

Introduction: Many of the residents who supervise medical students in clinical practice are unfamiliar with the principles of effective supervision. Training in teaching skills is therefore seen as an effective strategy to improve the quality of clinical supervision. Method: Twenty seven medical residents were matched and assigned to an experimental group (n = 14) and a control group (n = 13). The experimental group participated in a two-day workshop on teaching skills. Using standardized questionnaires, the teaching abilities of all participants were assessed anonymously by medical students, before and after the workshop, to determine for any effect of the intervention. Results: A significant improvement in the teaching abilities of the medical residents in the experimental group was observed following the workshop ( t=−2.68, p=0.02). The effect size within the experimental group was large ( d=1.17), indicating that the workshop led to a measurable positive change in the medical residents’ teaching abilities. The effect size estimated from the post intervention scores on teaching ability of the two groups showed a moderate improvement ( d=0.57) in the experimental group compared with the control group. Discussion: Medical students rated the teaching abilities of the workshop participants after the training more highly than those of the residents in the control group. The ability to adjust teaching to the needs of the students and teach effective communication and diagnostic clinical skills were among the features that characterized effective teaching. Properly designed, teacher-training workshops could be effective and feasible methods to improve the quality of teaching by medical residents. [ABSTRACT FROM AUTHOR]

Background Supervision and feedback are essential factors that contribute to the learning environment in the context of workplace learning and their frequency and quality can be improved. Assessment is a powerful tool with which to influence students' learning and supervisors' teaching and thus the learning environment. Objective To investigate an in-training assessment (ITA) programme in action and to explore its effects on supervision and feedback. Design A qualitative study using individual, semistructured interviews. Subjects and setting Eight students and 17 assessors (9 members of staff and 8 residents) in the internal medicine undergraduate clerkship at Vrije Universiteit Medical Centre, Amsterdam, the Netherlands. Results The ITA programme in action differed from the intended programme. Assessors provided hardly any follow-up on supervision and feedback given during assessments. Although students wanted more supervision and feedback, they rarely asked for it. Students and assessors failed to integrate the whole range of competencies included in the ITA programme into their respective learning and supervision and feedback. When giving feedback, assessors rarely gave borderline or fail judgements. Discussion and Conclusion If an ITA programme in action is to be congruent with the intended programme, the implementation of the programme must be monitored. It is also necessary to provide full information about the programme and to ensure this information is given repeatedly. Introducing an ITA programme that includes the assessment of several competencies does not automatically lead to more attention being paid to these competencies in terms of supervision and feedback. Measures that facilitate change in the learning environment seem to be a prerequisite for enabling the assessment programme to steer the learning environment. [ABSTRACT FROM AUTHOR]

Objective To explore the learning processes of undergraduate medical students undertaking international traineeships. Methods Semi-structured, in-depth interviews were conducted with 24 undergraduate medical students from Maastricht University Medical School, the Netherlands. The 24 subjects were selected by purposeful sampling. Research methods resembled the grounded theory method. Although the data were initially gathered for an earlier study, the richness of the data enabled renewed scrutiny. Results The data yielded the following categories concerning the description of the learning processes: motivation, preparation, internal supervisor, external supervisor, assessment, and positive and negative incidents. The majority of supervisors' influences on the learning process were facilitative or negligible. Socio-cultural differences between students and supervisors sometimes appeared to blur productive learning. The greater proportion of the students seemed to learn by ‘experiential learning’, a smaller proportion learned by ‘active learning’, and the learning of a very small minority of the students appeared to be ‘guided’. Discussion Although experiential learning seemed to be the dominant learning process, it is not clear whether this is also the most fruitful approach to learning. It could be argued that structuring learning outcomes by a more active learning process might be more effective. To guide the learning process and learning outcomes, it might be advisable to develop guidelines for writing international traineeship reports. Supervision of these reports should be more co-ordinated to prevent arbitrariness and to scaffold active learning. [ABSTRACT FROM AUTHOR]