Quality communication has been described as essential for safe health care.1 In the context of internal medicine (IM) clinical teaching teams in the inpatient setting, this emphasis has given rise to numerous interventions for improving communication performance, such as closed-loop communications and handover tools.2,3 Practice variability also has been the focus of calls for improvement,4 with interventions including the development of standardized protocols and guidelines for patient care.5 Such instrumental approaches pay little attention to the underlying assumptions or philosophies driving decision making, however. They assume that care plans are based on an agreed-upon set of goals that have been developed in collaboration with patients and families. They also assume that all members of the team understand and share the same overarching goals when it comes to patient care.
Our recent research suggests that this may not be the case.6 Rather, attending physicians (attendings) appear to hold different perspectives about the purpose of hospital admission. Some attendings view their role as dominantly discharge focused (i.e., manage acute problem and discharge patient), while others view their role as monitoring and management focused (i.e., manage acute problem and monitor and manage chronic active conditions) or optimization focused (i.e., manage acute problem and identify opportunities to improve overall health status).6 How these differences in perspective are enacted in practice is unknown. Also unknown is how trainees on clinical teaching teams navigate the perspectives held by the constantly changing roster of attendings and negotiate tensions between attendings’ perspectives and their own potentially different perspectives. Understanding how these different perspectives are enacted may offer novel insights into ways of improving patient safety and clinical teaching.
One of the greatest threats to patient safety during a hospital admission may be failing to attend to a patient’s chronic but active medical problems.7–9 Yet attending to chronic issues, both during hospitalization and in discharge planning, may be an issue of perspective.6 While individual attendings may not hold the same perspective on purpose of admission, they share similar challenges in relation to balancing competing demands. In the role of attending, they must balance providing safe, high-quality care for their patients with effective learning for their trainees.10,11 On IM inpatient teaching units, achieving this balance is further challenged by a combination of factors including large volumes of patients with high acuity and multimorbidity,12,13 system pressures to cut costs and shorten lengths of stay,12,14 and large teams of medical trainees who all need to be supervised and actively taught as they provide patient care.15
Our prior findings on attendings’ perspectives on purpose of admission were limited to interview data and observations of the admission case review.6 As a result, our findings were largely centered on attendings and did not span the entire hospital stay or take into account how these physicians navigate their perspectives in relation to the competing demands inherent in the day-to-day practice of supervising.16,17 In this study, we aimed to bridge the gaps by exploring several key issues, including how purpose of admission is signaled by the attending to the trainees, how trainees take up and enact the attending’s perspective (and their own perspectives), and how the purpose of admission changes (or remains the same) across patients, time, and attending changeover. We also explored whether individual attendings hold consistent, stable perspectives or whether their perspectives vary based on patient need. Through this study, we strove to explore how the different perspectives on purpose of admission affect collaborative teamwork and the team’s ability to refine progressively, over the course of a patient’s stay, their approach to best meet the needs of their patients.18
We used a constructivist grounded theory approach19 to structure our data collection and analysis. Purpose of admission6 was used as a sensitizing concept to allow us to explore how IM teams identified and enacted a hospitalization purpose for each of their patients. The term enact refers to individuals and teams taking actions to achieve their purposes. Consistent with a constructivist grounded theory approach, our data collection took place in iterative cycles where findings from one cycle were used to inform data collection in the subsequent cycle.19 The study was approved by the University of Western Ontario Health Sciences Research Ethics Board.
The research took place in 2017 in 2 IM teaching units, located at 2 teaching hospitals affiliated with a large academic health sciences center in Ontario, Canada. In each unit, there were 3 teaching teams. Each team was led by a group of attendings, with the attending rotating every 2 weeks. In addition to the attending, each team consisted of 2 senior medical residents (second- or third-year residents), 3 to 4 first-year residents (all rotating every 4 to 8 weeks), and 3 to 4 third- and fourth-year medical students (with third-year students rotating every 6 weeks and fourth-year students every 2 weeks). We conducted the research in the summer because medical students are more senior in their training, while training years for residents roll over in July, allowing us to observe residents at the beginning and end of the year. During a few of the observation periods, a fourth- or fifth-year resident in the general IM program served in the capacity of junior attending and was included in our analysis in the role of the attending. On average, each team admitted 3 to 5 new patients per 24-hour period. These patients were medically complex, often with multiple chronic diseases such as congestive heart failure, chronic obstructive pulmonary disease, and substance abuse disorder.
Data collection consisted of field observations and field interviews. The observations took place over a 3-month time frame (June–August 2017) and were conducted by K.B., a medical student with no prior relationship with any of the participants. Observations were staggered between 2 of the 3 teams at each hospital and targeted to observe 3 to 4 days during each attending’s 2-week rotation on the IM teaching unit. Observations were limited to 2 teams at any given time to allow sufficient coverage of each. Observation periods lasted 5 to 7 hours and included all consenting members of the team. Two-thirds of the observations took place at one site at the beginning of the study period, and one-third took place at the second site toward the end of the study period. During and between observation periods, dedicated time was taken for writing field notes, memoing, and iteratively analyzing the existing data.
Observations typically began during morning admission case review, where the postcall junior trainee (first-year resident or medical student) presented each patient they had admitted. At this time, the interactions between the attending, the senior medical residents, and the junior trainees were observed as the team deliberated on each admitted patient. Following case review, either a junior trainee or a senior medical resident was followed on their rounds for the day. Toward the end of the day, teams were observed during afternoon team rounds, where each patient was discussed in turn, and daily management decisions were reviewed with the attending. Field interviews were also conducted by K.B. as time permitted. Field interviews were audio-recorded and transcribed. Interviews were used to inform the observational data and at times to explore broader issues, such as trainee experiences working with different attendings. Individuals interviewed were also asked about discharge pressures and how they saw themselves and others responding to those pressures.
A combination of purposive and theoretical sampling was used. Sampling was purposive about the timing of observations to target periods before and after attending changeover, to follow management decisions around admitted patients, and to observe residents at the start and end of the training year.
The 2 teaching hospitals were selected purposively for known differences in their patient populations. One had a younger, less affluent population with a higher rate of homelessness, and the other had an older, more affluent population. Each site had a completely different set of attending physicians. The 2 sites were similar in terms of the number of patients per team, the number of medical members of the team, and the structure of the team and rounding, as described above. Medical students and residents did not generally attend interdisciplinary rounds at one site but did at the other. One site had a team dedicated to geriatric patients, which we did not observe.
Purposive sampling was employed in selecting which trainees to observe during their daily patient care activities: Trainees were selected based on level of training and which patients they were responsible for during the day. As our theory of the phenomena evolved, theoretical sampling was employed to target field observations on patient care–related management decisions and tensions arising as a result of these decisions.
Data collection and analysis proceeded in an iterative fashion. Field notes and field interview transcripts were analyzed using a constant comparative approach, and analytic codes were developed based on the data.20 The research team met at least weekly during the observation period, and more often early on, to discuss study findings and inform analysis for the next iteration of data collection. These meetings resulted in the frequent writing of research memos and analytic summaries.
The 3 perspectives on purpose of admission were derived from our prior study6 and reassessed in this study. All other codes and analyses were derived from the present study. K.B. developed the initial codes. This initial list of codes was refined, and a final list was developed through consensus by K.B. and M.G. All transcribed field interviews were coded using this final list of codes. Also, participants were stratified based on their perspectives to explore perspective stability within and across participants over the observation period. NVivo 11 (QSR International, Doncaster, Australia) was used to facilitate coding of the data.
In total, 150 hours were spent observing teams on 2 IM inpatient units at 2 teaching hospitals, over 28 separate observation periods. Management decisions across 185 different patients were identified and followed during the observation periods.
The 54 participants included 8 attendings, 2 junior attendings, 10 senior medical residents, 31 junior trainees (15 first-year residents and 16 medical students), and 3 patient care facilitators (whose role was to facilitate interprofessional collaboration and discharge). Each attending was observed on an average of 3 occasions (range: 1–5).
All 3 perspectives on the purpose of admission were identified among the attendings and trainees, and no additional perspectives were found. Four participants (1 attending, 3 senior medical residents) were identified as holding a discharge-focused perspective. Eight participants (3 attendings, 1 junior attending, 4 senior medical residents) held a monitoring and management–focused perspective. Seven participants (3 attendings, 1 junior attending, 2 senior medical residents, 1 first-year resident [who was at the end of the training year]) held an optimization-focused perspective. Two participants (1 attending, 1 senior medical resident) were difficult to characterize because of limited observation periods but were felt to be between the monitoring and management–focused and the optimization-focused perspectives.
We also identified how purpose-of-admission perspectives are signaled by attendings and senior medical residents and taken up in a team setting. As not all members of the team necessarily held the same perspective as the attending, this could involve enacting different and, at times, competing perspectives. We did not observe any instances of an explicit discussion taking place between the attending and the team about the purpose of a hospital admission or why the attending held a particular perspective.
The 3 perspectives and their stability
All attending physicians and trainees in the study appeared cognizant of the risks of hospitalization and system pressures, but their responses to these pressures were different. Table 1 provides examples of how attendings and trainees signaled and attendings enforced their perspectives across a range of discussion topics and situations. As shown in Table 1, attendings’ enforcement strategies could include the use of authority and redirection to shut down unwanted dialogue.
Senior medical residents and junior trainees appeared able to identify the perspectives of individual attendings. Neither the attendings nor the senior medical residents were observed to deviate much from their perspectives. For example, discharge-focused attendings might be observed to monitor and manage chronic medical conditions, but they would not engage in the optimization of overall patient health. Optimization-focused attendings might downgrade their tendency toward optimization and simply monitor and manage chronic active conditions, but they would not focus on discharge as the main goal. Those attendings we identified as enacting a monitoring and management–focused perspective appeared more flexible in their approach and could be observed incorporating elements of discharge-focused or optimization-focused perspectives. Junior trainees, by contrast, appeared to be more flexible than other participants, mostly taking on the perspectives they were directed to by a senior medical resident or an attending.
Discharge-focused attendings and senior medical residents emphasized workload, placing “the list”—the roster of all patients on their service—at the forefront of their thinking. The list, therefore, represented something to be maintained in the interest of the team. Discharge-focused attendings and trainees frequently spoke of the number of patients on their service and attributed multiple benefits to a smaller list. For example, to them, a smaller list meant increasing teaching time, improving patient safety, and/or creating a more relaxed environment for the team.
And keeping the list short helps the senior as well as all the junior residents because you’re done sooner, you can discuss patients, you can teach. It creates a more relaxed . . . environment. (Field Interview 8, First-Year Resident 1)
Individuals were observed shortening the list in other ways, such as by removing—crossing out—patients who did not need to be seen by the team because of their stability or who were ready for discharge.
Individual patients thus took a less central position in this mode of thinking and were seen as components of an aggregate (i.e., the list). Discharge-focused physicians encouraged discharge planning early in the course of hospitalization and drew attention to issues that might result in return to the hospital, linking readmission to increased workload for the team.
Optimization-focused attendings and senior medical residents emphasized optimizing the overall health of each individual patient. They frequently described to the team and acted on overarching principles they held, such as harm reduction and medication optimization. Each patient was viewed through this lens of optimization, with even straightforward patients being assessed thoroughly with respect to both acute and chronic issues.
The attending that I’m working with now, I find that she’s very good at balancing the acute issue but also not forgetting that these people have other issues as well. So again, one of my patients, you know, her acute issue might be an infection, but she also has blood pressure issues that we’re trying to fix. (Field Interview 4, Medical Student 17)
Teams led by an optimization-focused attending appeared to have somewhat longer days (not explicitly measured) as these physicians used the hospital stay to address more issues. At discharge, optimization-focused attendings and senior medical residents instructed junior trainees to attend to patient follow-up in the community for discharge planning and prevention of readmission, including calling community physicians and pharmacists with updates.
Monitoring and management–focused perspective.
Monitoring and management–focused physicians directed the team to address issues that were within their sphere of influence—the set of circumstances with which the attending or senior medical resident was directly involved on the IM unit. Individual patients on their service were referred to in terms of what brought them into the hospital, with chronic issues managed as they related to the admission, but not beyond this.
The three aspirations [referring to a patient with three admissions for aspiration pneumonia] in a month was “not an ideal situation.” Senior Medical Resident 14 had wanted to set up a family meeting. However, he then dismissed the case and said it “was not our problem anymore,” referring to a transfer to another unit. (Field Note 20)
Issues beyond the sphere of influence, such as harm reduction, medication optimization, and overall list size, were less of a consideration for monitoring and management–focused attendings and senior medical residents. They attended to discharge issues as they related to what the team could accomplish while the patient was still within the sphere of influence.
Perspective tension and individual agency
Teams appeared to vary considerably with regard to the mix of perspectives held by individual members. Differences in perspectives became most noticeable at the 2 extremes (i.e., discharge focused vs optimization focused) and when differences existed between a senior medical resident and the attending. Many of the junior trainees described being more likely to mirror the expectations of the attending or senior medical resident than to try to enact their own perspective.
I try and now present my cases [matching the medications to chronic diseases] . . . to make sure their [the patients’] medications are either optimized, in that they’re on all the medications they should be as well as addressing polypharmacy . . . for the physicians who are you know, really active-issues centered, they don’t want to hear about the medications, because they assume the medications were optimized at the time of admission. And, hopefully, most of the time they are, but sometimes they certainly aren’t. (Field Interview 1, Medical Student 5)
Medical Students 16 and 5 also mentioned after the interview that they find they mirror the attendings on the team, especially towards the end of the [attending’s] rotation as they become used to what is expected from them by that attending. (Field Note 1)
At times, however, conflict between a senior medical resident and the attending could lead to confusion for the junior trainees.
First-Year Resident 24 said if “the boss” wanted it, she could be discharged today, but Senior Medical Resident 21 was wanting her to stay for another day to transition to the oral Lasix . . . Medical Student 16 said this case was tricky because “Attending 7 was so discharge focused, that’s where my mind was at.” (Field Note 2)
This did not, however, mean junior trainees did not also have their own perspectives that created tensions. Observed strategies for handling perspective tensions included direct advocacy, acceptance, passive avoidance, and active workarounds. In the few instances where direct advocacy was observed, the junior trainees were not successful at resolving differences in perspectives in favor of their own.
Medical Student 8 told me his legs were still quite edematous and said, “Ideally, we would keep him here until we’d diuresed all the fluid off, and I was just on cardio and I know they would do that. I tried to advocate for that for this patient, but they always need beds. . . .” (Field Note 4)
Passive avoidance-based strategies such as “forgetting” to complete a task—for instance, avoiding reviewing diabetes medication (Field Note 17)—were also observed. However, it was unclear to what extent these strategies were deliberate.
Senior medical residents, on the other hand, were more likely than junior trainees to uphold their own perspectives on purpose of admission. Attending changeover appeared to be a threat or an important opportunity for a workaround.
Senior Medical Resident 19 told me the staff was changing tomorrow so she wanted to get as many discharges done as possible because new staff don’t like discharging people they don’t know. (Field Note 28)
Senior Medical Resident 21 suggested consulting geri-psych, and Attending 7 said he didn’t like consulting geriatrics because they delay discharge. Senior Medical Resident 21 replied laughingly that they would consult them tomorrow . . . as Attending 7 was switching over. (Field Note 3)
For the most part, attendings were not explicit about their expectations regarding purpose of admission, which could result in uncertainty and disjointed teamwork.
Sometimes attendings . . . may do one thing and their senior [medical resident] is doing another, and they’re not in sync. So that makes it very difficult because that’s where a lot of the miscommunication can come from. (Field Interview 6, Patient Care Facilitator 2)
I’ve been with a physician that . . . didn’t mind if the patient stayed in the hospital . . . just in case if things were getting set up at home. And that’s very different from the preceptor I had before her, who was very, “they don’t need to be in hospital, they don’t need to tax the health system any more than they need to.” (Field Interview 10, Medical Student 3)
Trainee development of perspectives
Despite a lack of explicit dialogue by the attendings on purpose of admission, trainees were clearly aware of differences between attendings regarding their perspectives. Trainees worked through perspective differences both independently via self-reflection (as described in field interviews) and collaboratively with their peers. For example, one medical student was observed whispering to another over lunch: “Do you think Attending 7 is pushing people out a little?” (Field Note 1). This remark spurred a discussion between the students over whether the discharges were safe, the risk of patients being readmitted, and comparison with the perspectives of other attendings they had.
Trainees clearly developed, over time, a sense of how they were expected to practice with one attending and could then find the subsequent attending actively discouraging this approach. Despite potential tensions, trainees at all levels indicated, during field interviews, that they valued different styles in attendings and felt that the exposure to different perspectives helped them develop their own.
It’s good to get an exposure of different attendings, because . . . they bring different values and it’s good as a learner to see the style that one attending has, and it gives you an opportunity to question your own values, why you have them, why are they not the same as this person’s, and then go through this process of questioning yourself, which is important. (Field Interview 2, Medical Student 16)
Because you get to work with so many different attendings, a lot of it is just taking in everybody’s perspective. . . . So, I think a lot of it is just trying to get as much exposure as possible from the different attending styles, consolidate it, decide what you feel comfortable doing. (Field Interview 3, Senior Medical Resident 21)
We set out to explore the stability of attendings’ perspectives on purpose of admission to the hospital and how these perspectives were signaled to and taken up by their trainees. In so doing, we also identified and explored a complex social construct around purpose of admission, as different team members held and enacted different perspectives. Participating attendings, who faced similar resource constraints and system pressures, were observed to hold fairly consistent but different perspectives regarding purpose of admission. While it is possible that attendings might adjust their perspectives based on patient needs, we did not observe that to be the case. Similar to our prior study on purpose of admission,6 we observed multiple strategies used by attendings across all teams for implicitly signaling and enforcing their perspectives without actively negotiating or debating them. These included using their authority to shut down or redirect discussion. Explicit dialogue around possible purpose of an admission and why one direction was chosen over another was not observed. This lack of dialogue was observed to lead to tensions within the team when members held divergent perspectives and, at times, to more covert approaches to handling these tensions (i.e., passive avoidance, active workarounds), with implications for trust within the team, patient care, and trainee development.
Within-team collaborative tensions have been subject to little scrutiny in the literature. The majority of collaborative tension research on colocalized physician teams is focused on patient safety,21–25 ethical disagreements,26,27 or mistreatment of trainees.23,28,29 While our findings share some similarities with this existing literature, there is a noticeable difference: The attending behaviors observed in our study are not inherently unsafe or unethical, nor do they involve trainee mistreatment. Rather, they represent an undebated topic in the care of acutely unwell patients with multimorbidity. While we believe that holding that debate is important, we have already written about the topic.6 Here, we will focus on why it is essential for teams to explicitly label and negotiate purpose(s) of admission.
Attendings did not appear to be cognizant of the extent to which their perspective on purpose of admission was a matter of concern for their trainees. For attendings, perspective on purpose of admission appeared to be held as a matter of fact—an ostensibly objective detail taken for granted and requiring neither reflection nor explicit dialogue.30 For trainees, who were new to the practice of medicine and early into their own professional identity formation, perspective on purpose of admission appeared to be a matter of concern—something forcing a pause, reflection, and dialogue.30 Junior trainees were aware of perspective differences between themselves and their attendings, between their attendings and their senior medical residents, and between different attendings. Junior trainees and senior medical residents also participated in maneuvers to enact their desired perspective, ranging from direct advocacy to covert manipulation of the clinical scenario. Our results thus point to a previously uncharacterized point of tension within the training environment and the efforts individuals take to resolve it. We would argue that, at times, these resolution efforts both reflected a lack of trust in more senior members of the team and represented a reason why trainees should not themselves be fully trusted.
The power of practice-based learning to shape future practice should not be underestimated. Similar to other studies,4,24,31,32 junior trainees in our study were aware of perspective differences in practice, and most chose to mirror the way the attending or senior medical resident practiced to avoid conflict. This did not always work when attendings and senior medical residents were at cross-purposes. Other trainees, especially senior medical residents, did not simply mirror. Through experiences in clinical settings, trainees are continuously forming and reforming their developing professional identities, and these identities are influenced by trainees’ trust in each other, their attendings, and the health care system itself.33–36 In this context, perspective on purpose of admission must be a matter of concern for medical educators. We observed gaps in communication around what each member of the team wanted to do and what they felt was right for the patient and the team.
Setting aside for the moment the patient safety concerns,37–40 we would like to focus on our findings’ implications for professional identity formation and trust. Our interpretation of the observed phenomena is that by the time a trainee becomes a senior medical resident, the trainee already appears to hold a set perspective on purpose of admission. We also found that trainees are learning, fairly early on, that explicit advocacy is ineffective and that contentious issues, such as those involving differing perspectives around purpose of admission, can only be resolved by accepting external authority or through workarounds.24,41,42 Neither approach represents espoused ideals for the medical profession.
Our findings also likely have implications for competency-based medical education, a movement largely focused on assessing and entrusting trainees.11,43 We wonder, for example, about the extent to which the decision to trust and entrust a trainee might be influenced by shared perspective on purpose of admission, or how preexisting entrustment decisions might affect supervision on a team where the attending and senior medical resident may be working at cross-purposes.44 While the notion of a mismatch in supervisory and trainee expectations has been reported,45 we were unable to identify any published studies in medicine exploring the impact on patient care and training when trainees do not fully trust in the judgment of their supervisors. Some studies have suggested an impact in the supervisory relationship in psychotherapy trainees.46,47
Returning to the issue of patient safety, our study adds to the calls for improved communication within teams. While we would not argue with the importance of known safety improvement initiatives, such as closed-loop communication2,48,49 and handover tools,3,50 we would like to add to the list of communication practices requiring improvement. It is important that teams explicitly label and negotiate purpose of admission in ways that allow for divergent opinions to be openly expressed by trainees and that ensure that trainees’ opinions and individual patients’ needs have the potential to influence decision making. We would argue that a fixed perspective on purpose of admission held by the attending or a senior medical resident as a matter of fact hampers the team’s ability to tailor their approach to caring for the individual patient. A patient with no medical issues beyond the acute issue could be safely viewed through the lens of a discharge-focused perspective. However, a complex patient with a pattern of recurrent readmissions may be better served by taking an optimization-focused approach and recognizing that something new needs to be done. Patients with multimorbidity make up a growing population51 and require a unique approach to care.52–55 At the minimum, they need to have medication and other chronic active issues addressed to keep them safe while they are in the hospital.7,56,57 In the interest of reducing readmissions and increasing patient safety, a question for future research to explore would be “What influence does tailoring purpose of admission to the patient’s needs rather than the physician’s perspective have on medical errors and readmission rates?”
Making one’s perspective on purpose of admission explicit is not as simple as just talking about it, though. As we described in our prior study, for many attendings, this perspective does not feel like a choice.6 Rather, for some, it is a response to an overstressed system, a system where physicians perceive demanding work, low control, and insufficient resources to achieve the high quality of care they want to provide.34,58–60 There are frequently no or limited financial incentives for addressing more complex patient needs.61–64 Increasingly, however, there are incentives for reducing hospital length of stay.65–67 As in many contexts, on the IM teaching units we sampled, team size is not capped, which can lead to concerns about the potential for overly large and unwieldy team censuses; moreover, the introduction of scorecards tracking length of stay by physician can also place undue pressure on teams.68–71 With all of this in mind, in addition to supporting more explicit dialogue within teams, we urge hospitals, medical education leaders, and researchers to collaborate, explore, and study innovative approaches to configuring and resourcing teaching teams.
One of the strengths of our study is its constructivist nature, taking up our prior findings and exploring them in depth in the same setting from which they arose. This also represents a limitation of transferability. Many of the driving forces were contextually based. This setting had relatively high patient volumes, large numbers of learners, and no incentives for addressing patient complexity. For those wishing to build upon our findings, we would therefore encourage reflection and observation in their own settings to explore transferability. This study also could not answer the question of which perspective is “best.” While we have no data on the impact of purpose-of-admission perspective on cost or length of stay, we would argue that the best perspective is likely the one that best matches patient needs and so varies from patient to patient. As we do not have any data to confirm or refute our stance, we suggest that this question represents an area for future research.
The challenges that teaching teams face in coming up with a shared admission purpose tailored to the patient are not simply the result of ineffective communication. Rather, achieving shared purpose is hampered by collaborative tension, ineffective advocacy, and factors related to an overstressed health care system. For attendings, holding one perspective on purpose of admission as a matter of fact may impair the ability to adjust their approach patient by patient, to ensure that their team is functioning cohesively, and to safeguard against sending mixed messages to their trainees around how to advocate effectively for patients in their care. For trainees, not explicitly addressing purpose of admission as a team may lead to covert maneuvers to work through the tension between their perspectives and the attending’s, which has important implications for trainees’ professional identity development. As attendings play key roles in directing patient care, encouraging effective teamwork, and shaping trainees’ future practices, it is essential that they be explicit about purpose of admission and adopt an approach to practice characterized by openness to dialogue around the possible best purpose for each patient.
The authors wish to thank the study participants, all of whom were invaluable to the completion of this study. The authors would also like to thank Jennifer Campi for all of her support in editing the final manuscript. The article is a better read as a result of her efforts.
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