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Klitgaard TL, Gjessing S, Skipper M, Nøhr SB. Becoming a doctor-The potential of a change laboratory intervention. MEDICAL TEACHER 2022; 44:1376-1384. [PMID: 35862640 DOI: 10.1080/0142159x.2022.2098099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In a previous ethnographic field study, we found that newly graduated doctors (NGDs) found their first months of practice challenging and overwhelming. By including an organisational perspective (Cultural Historical Activity Theory), we were able to identify contextual factors within the hospital organisation, which influence the NGDs' challenges. This raised the question: What can be done about it? To address this, we designed a Change Laboratory intervention (CL), consisting of six sessions, involving NGDs, junior doctors, and consultants across eight departments (on average, 18 doctors participated in each session). Through the CL, the participants were able to get a mutual understanding across departments and develop two initiatives to support the NGDs: An NGD introduction day with a 'need-to-know' focus, where the NGDs meet their future collaborators, and are introduced to important work procedures, and are given the opportunity to establish a peer network. This is followed up by a monthly NGD forum with a 'nice-to-know' focus, where new topics are introduced, allowing time for reflections, and supporting the further strengthening of a peer community. The CL approach promoted agency among participants and the results show how CL offers a unique opportunity for stakeholders to challenge and rethink their work practices within the hospital organisation.
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Affiliation(s)
- Tine Lass Klitgaard
- Department of Postgraduate Medical Education, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Sofie Gjessing
- Department of Postgraduate Medical Education, Aalborg University Hospital, Aalborg, Denmark
- Center for General Practice, Aalborg University, Aalborg, Denmark
| | - Mads Skipper
- Postgraduate Medical Educational Region North, Viborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Susanne Backman Nøhr
- Department of Postgraduate Medical Education, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Yardley S, Francis SA, Dean Franklin B, Ogden M, Kajamaa A, Mattick K. Getting palliative medications right across the contexts of homes, hospitals and hospices: protocol to synthesise scoping review and ethnographic methods in an activity theory analysis. BMJ Open 2022; 12:e061754. [PMID: 35301215 PMCID: PMC8932278 DOI: 10.1136/bmjopen-2022-061754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Prescribing and medication use in palliative care is a multistep process. It requires systems coordination and is enacted through activities of patients, informal carers and professionals. This study compares practice to idealised descriptions of what should happen; identifying when, how and why process disturbances impact on quality and safety. Our objectives are to:Document an intended model (phase 1, scoping review).Refine the model with study of practice (phase 2, ethnography).Use the model to pinpoint 'hot' (viewed as problematic by participants) and 'cold' spots (observed as problematic by researchers) within or when patients move across three contexts-hospice, hospital and community (home).Create learning recommendations for quality and safety targeted at underlying themes and contributing factors. METHODS AND ANALYSIS The review will scope Ovid Medline, CINAHL and Embase, Google Scholar and Images-no date limits, English language only. The Population (palliative), Concept (medication use), Context (home, hospice, hospital) framework defines inclusion/exclusion criteria. Data will be extracted to create a model illustrating how processes ideally occur, incorporating multiple steps of typical episodes of prescribing and medication use for symptom control. Direct observations, informal conversations around acts of prescribing and medication use, and semistructured interviews will be conducted with a purposive sample of patients, carers and professionals. Drawing on activity theory, we will synthesise analysis of both phases. The analysis will identify when, how and why activities affect patient safety and experience. Generating a rich multivoiced understanding of the process will help identify meaningful targets for improvement. ETHICS AND DISSEMINATION Ethical approval granted by the Camden & Kings Cross NHS Regional Ethics Committee (21/LO/0459). A patient and public involvement (PPI) coinvestigator, a multiprofessional steering group and a PPI engagement group are working with the research team. Dissemination of findings is planned through peer-reviewed publications and a stakeholder (policymakers, commissioners, clinicians, researchers, public) report/dissemination event.
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Affiliation(s)
- Sarah Yardley
- Marie Curie Palliative Care Research Department, University College London, London, UK
- Central & North West London NHS Foundation Trust, London, London
| | - Sally-Anne Francis
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Bryony Dean Franklin
- University College London School of Pharmacy, London, UK
- Pharmacy Department, Imperial College Healthcare NHS Trust, London, UK
| | - Margaret Ogden
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Anu Kajamaa
- Faculty of Education, University of Oulu, Oulu, Finland
| | - Karen Mattick
- College of Medicine & Health, University of Exeter, Exeter, UK
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Qureshi SP. Cultural Historical Activity Theory for Studying Practice-Based Learning and Change in Medical Education. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2021; 12:923-935. [PMID: 34456600 PMCID: PMC8390886 DOI: 10.2147/amep.s313250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/28/2021] [Indexed: 06/13/2023]
Abstract
Cultural historical activity theory (CHAT) is a social theory which is useful as a methodological framework for the vital task of studying practice-based learning in complex learning environments. CHAT is an apparatus considering learning as occurring through practice, through collective activity, and mediated by culturally specific instruments. Because CHAT is increasingly drawn upon in medical education academia, it is necessary for medical educationalists to be familiar with this theory. This methodology article explains how CHAT theorizes learning in dynamic workplaces within an activity system comprising multiple practitioners engaged in activity, which is collaborative, multi-voiced, and bounded by a shared intended object. It provides an accessible overview of the central concepts within CHAT and a description of a methodological strategy (activity system analysis) to incorporate CHAT into one's own work. CHAT also theorizes where tensions lie within and between activity systems, causing difficulties in achieving the intended object, defining such tensions as contradictions. It is through the overcoming of past contradictions that activity has come to exist in its current form, abiding by social norms of the present time, and CHAT allows consideration of how practice within a system may be changed through resolution of contradictions. For example, the Change Laboratory is a contrived intervention where practitioners consciously contribute to developing and embedding new, improved ways of practicing using CHAT principles. This allows practitioners to have agency in improving their own areas of learning and practice. Throughout this article, examples are provided of how CHAT has been usefully applied to various aspects of medical education research, including undergraduate education, postgraduate education, and continuous professional development. By building on the introduction to CHAT provided in this article, the reader can start to use CHAT methodologically to describe complexity, identify practice-based contradictions, and develop improved forms of practice-based learning, in his/her own context.
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Affiliation(s)
- Shaun Peter Qureshi
- Palliative Medicine, NHS Greater Glasgow and Clyde, Glasgow, UK
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
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Abstract
This article introduces key concepts of activity theory and expansive learning. Expansive learning builds on the foundational ideas of the cultural-historical activity theory (CHAT). It is a research approach designed for studying the complexities and contradictions in authentic workplace environments. Change Laboratory is a formative intervention method developed for studying workplaces in transition and for stimulating collaborative efforts to design improved patterns of activity. We present concrete examples of formative interventions in healthcare, where good patient care was compromised by the fragmentation of care and disturbances in collaboration between the healthcare experts. This implies that physicians are challenged to develop collaborative and transformative expertise. We present three spearheads into a zone of proximal development, representing opportunities for change of medical expertise: (1) reconceptualizing expertise as object-oriented and contradiction-driven activity systems, (2) pursuing expertise as negotiated knotworking, and (3) building expertise as expansive learning. While medical expertise needs to expand, medical education must also look for ways to evolve and meet the challenges of the surrounding society. We call for adopting an interventionist approach for developing medical education and intensifying collaboration with the practitioners in healthcare units, their patients, and target communities.
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Affiliation(s)
- Yrjö Engeström
- Center for Research on Activity, Development and Learning, University of Helsinki, Helsinki, Finland
| | - Eeva Pyörälä
- Center for University Teaching and Learning, University of Helsinki, Helsinki, Finland
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Skipper M, Nøhr SB, Engeström Y. The change laboratory in medical education: Two examples of tackling contradictory challenges. MEDICAL EDUCATION 2021; 55:93-100. [PMID: 32722852 DOI: 10.1111/medu.14298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 07/08/2020] [Accepted: 07/20/2020] [Indexed: 06/11/2023]
Abstract
CONTEXT Medical education and workplace learning is bound to develop through tensions between providing high quality patient care and providing training of the future specialist healthcare workforce. This paper on the Change Laboratory and the theoretical framework supporting it, shows examples on how to explore inherent and contradictory tensions in medical education and healthcare and use them as a driving force for change. We argue that the traditional tools and theories for change and fixing tensions are inadequate and therefore suggest an alternative strategy found in Cultural-Historical Activity Theory (CHAT) and the Change Laboratory method. METHODS The Change Laboratory intervention method builds on the theoretical framework of CHAT and specifically the theory of expansive learning. The Change Laboratory intervention method uses well-defined steps for participants in collaboration with researchers/facilitators to co-construct and develop new ways of going about their work practice. RESULTS Drawing on our own research on implementing the Change Laboratory intervention method we present two case examples of interventions in respectively a Finnish surgical unit and a Danish paediatric outpatient clinic. CONCLUSIONS The Change Laboratory intervention offers ways to systematically leverage tensions in medical education and thus could be effective in developing and designing organisational and professional change. It is not a quick fix solution as participators must be motivated and engaged in uncovering inherent contradictions in their activity systems (workplace) and get familiar with the concepts and theory underlying the intervention and its procedures. Profound knowledge and transformative agency emerges when participants and facilitators/researchers are given the time and opportunity to analyse both historical practice, current data on practice, and organisational issues collaboratively in order to envision and redesign their practice and learning environment.
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Affiliation(s)
- Mads Skipper
- Ringgold Standard Institution, Centre for Health Sciences Education, Aarhus University, Aarhus, Denmark
- Postgraduate Medical Education Region North, Viborg, Denmark
| | - Susanne Backman Nøhr
- Ringgold Standard Institution, Centre for Health Sciences Education, Aarhus University, Aarhus, Denmark
- Department for Postgraduate Education, Ringgold Standard Institution, Aalborg University Hospital, Aalborg, Denmark
| | - Yrjö Engeström
- Faculty of Educational Sciences, Ringgold Standard Institution, CRADLE, University of Helsinki, Helsinki, Finland
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Diniz CSG, Bussadori JCDC, Lemes LB, Moisés ECD, Prado CADC, McCourt C. A change laboratory for maternity care in Brazil: Pilot implementation of Mother Baby Friendly Birthing Initiative. MEDICAL TEACHER 2021; 43:19-26. [PMID: 32672483 DOI: 10.1080/0142159x.2020.1791319] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Disrespectful and abusive treatment of women during childbirth is a worldwide problem. This research aimed to develop and implement a Mother Baby-Friendly Hospital Initiative (MBFHI) in an academic maternity hospital in Brazil and evaluate how change could be sustained. Change Laboratory principles guided a process of action research, which was conducted between 2017 and 2019. Clinicians and managers joined the researchers in discussion sessions to redesign routines and care pathways. Observation, interviews, focus groups, and historical and documentary analysis provided information about the existing activity system, which we analysed qualitatively using MBFHI criteria to identify themes. Evidence of inappropriate obstetric interventions and impersonal interactions between clinicians and patients stimulated us to devise innovative solutions. The challenges identified by this exercise included: poor infrastructure and ambience; difficulty adhering to evidence-based protocols; social and professional hierarchies; and clinicians being poorly educated about women's rights. Although challenges remained, positive changes included a friendlier environment, improved patient privacy, and fewer unnecessary procedures. Resources released by these changes allowed us, collaboratively, to track the further implementation and sustainability of change. We conclude that the Change Laboratory can help motivated clinicians and managers humanise patients' experiences, make care more evidence-based, and expand learning of mother-friendly maternity care. Tensions and contradictions between education and patient care reported here may resonate in settings other than maternity care.
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Affiliation(s)
| | | | | | - Elaine Christine Dantas Moisés
- Department of Gynecology & Obstetrics, Ribeirão Preto School of Medicine (FMRP), University of São Paulo, Ribeirão Preto, Brazil
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Kajamaa A, de la Croix A, Mattick K. How to … use qualitative research to change practice. CLINICAL TEACHER 2019; 16:437-441. [PMID: 31486285 PMCID: PMC6851743 DOI: 10.1111/tct.13085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The ‘How to …’ series focuses on how to do qualitative research. But how can qualitative research enhance patient care? This paper aims to support health care practitioners, educators and researchers who are interested in bridging the gap between research and practice (both clinical and educational), to guide improvements that can ultimately benefit patients. We present action research and The Change Laboratory method as two approaches that typically involve qualitative research and have potential to change practice, blending scientific inquiry with social action. These approaches establish close research–practice partnerships and help answer tricky ‘why’ and ‘how’ questions that may unlock deep insights to enhance learning and patient care.
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Affiliation(s)
- Anu Kajamaa
- Faculty of Educational Sciences, University of Helsinki, Finland
| | - Anne de la Croix
- LEARN! Academy, Vrije Universiteit Amsterdam, the Netherlands.,Amsterdam UMC, VUmc School of Medical Sciences, Research in Education, the Netherlands
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, UK
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Kajamaa A, Mattick K, Parker H, Hilli A, Rees C. Trainee doctors' experiences of common problems in the antibiotic prescribing process: an activity theory analysis of narrative data from UK hospitals. BMJ Open 2019; 9:e028733. [PMID: 31189683 PMCID: PMC6576120 DOI: 10.1136/bmjopen-2018-028733] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/25/2019] [Accepted: 05/15/2019] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Prescribing antibiotics is an error-prone activity and one of the more challenging responsibilities for doctors in training. The nature and extent of challenges experienced by them at different stages of the antibiotic prescribing process are not well described, meaning that interventions may not target the most problematic areas. OBJECTIVES Our aim was to explore doctors in training experiences of common problems in the antibiotic prescribing process using cultural-historical activity theory (CHAT). Our research questions were as follows: What are the intended stages in the antibiotic prescribing process? What are the challenges and where in the prescribing process do these occur? METHODS We developed a process model based on how antibiotic prescribing is intended to occur in a 'typical' National Health Service hospital in the UK. The model was first informed by literature and refined through consultation with practising healthcare professionals and medical educators. Then, drawing on CHAT, we analysed 33 doctors in training narratives of their antibiotic prescribing experiences to identify and interpret common problems in the process. RESULTS Our analysis revealed five main disturbances commonly occurring during the antibiotic prescribing process: consultation challenges, lack of continuity, process variation, challenges in patient handover and partial loss of object. Our process model, with 31 stages and multiple practitioners, captures the complexity, inconsistency and unpredictability of the process. The model also highlights 'hot spots' in the process, which are the stages that doctors in training are most likely to have difficulty navigating. CONCLUSIONS Our study widens the understanding of doctors in training prescribing experiences and development needs regarding the prescribing process. Our process model, identifying the common disturbances and hot spots in the process, can facilitate the development of antibiotic prescribing activities and the optimal design of interventions to support doctors in training.
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Affiliation(s)
- Anu Kajamaa
- Faculty of Educational Sciences, University of Helsinki, Finland
| | - Karen Mattick
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Hazel Parker
- Pharmacy Department, Royal Devon & Exeter Hospital, Exeter, UK
| | - Angelique Hilli
- Centre for Research in Professional Learning, University of Exeter, Exeter, UK
| | - Charlotte Rees
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
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Jensen RD, Seyer-Hansen M, Cristancho SM, Christensen MK. Being a surgeon or doing surgery? A qualitative study of learning in the operating room. MEDICAL EDUCATION 2018; 52:861-876. [PMID: 29992693 DOI: 10.1111/medu.13619] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 12/12/2017] [Accepted: 04/05/2018] [Indexed: 06/08/2023]
Abstract
CONTEXT A key concern for surgical educators is to prepare students to perform in the operating room while ensuring patient safety. Recent years have seen a renewed discussion of medical education through practice theoretical and sociomaterial lenses. These lenses are introduced to understand and prepare the learner to perform in the given context. This paper takes its point of departure from practice theory by introducing a lens through which to understand learning environments in surgery. METHODS Using a multi-site ethnographic and practice-based design, this study investigates how aspiring surgical students are stirred into surgical practices and learn to engage as surgeons. During 70 hours of observations of medical students' participation in the operating room, we analysed how the phenomenon of surgical learning can be perceived as instances of transformation in and among social practices. RESULTS By applying an analytical perspective, this article highlights the use of practice theory in surgical education, which can help to establish a firmer understanding of the learning environment and thereby help educators to improve curricula and prepare students more effectively to enter surgical training. CONCLUSIONS The use of a practice theory adds the perspective that the education of surgeons needs to take the sayings, doings and relatings that constitute a surgical practice into account when preparing students to perform in their future workplace. In this way, surgical training can be perceived as a process of being stirred into practice. This means that one learns by participating in the practice of providing high-quality care, where the aim is to teach students to be surgeons instead of teaching them to perform surgery.
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Affiliation(s)
- Rune Dall Jensen
- Centre for Health Sciences Education, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Mikkel Seyer-Hansen
- Department of Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Demark
| | - Sayra M Cristancho
- Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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Kilty C, Wiese A, Bergin C, Flood P, Fu N, Horgan M, Higgins A, Maher B, O’Kane G, Prihodova L, Slattery D, Stoyanov S, Bennett D. A national stakeholder consensus study of challenges and priorities for clinical learning environments in postgraduate medical education. BMC MEDICAL EDUCATION 2017; 17:226. [PMID: 29166902 PMCID: PMC5700623 DOI: 10.1186/s12909-017-1065-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 11/07/2017] [Indexed: 05/10/2023]
Abstract
BACKGROUND High quality clinical learning environments (CLE) are critical to postgraduate medical education (PGME). The understaffed and overcrowded environments in which many residents work present a significant challenge to learning. The purpose of this study was to develop a national expert group consensus amongst stakeholders in PGME to; (i) identify important barriers and facilitators of learning in CLEs and (ii) indicate priority areas for improvement. Our objective was to provide information to focus efforts to provide high quality CLEs. METHODS Group Concept Mapping (GCM) is an integrated mixed methods approach to generating expert group consensus. A multi-disciplinary group of experts were invited to participate in the GCM process via an online platform. Multi-dimensional scaling and hierarchical cluster analysis were used to analyse participant inputs in regard to barriers, facilitators and priorities. RESULTS Participants identified facilitators and barriers in ten domains within clinical learning environments. Domains rated most important were those which related to residents' connection to and engagement with more senior doctors. Organisation and conditions of work and Time to learn with senior doctors during patient care were rated as the most difficult areas in which to make improvements. CONCLUSIONS High quality PGME requires that residents engage and connect with senior doctors during patient care, and that they are valued and supported both as learners and service providers. Academic medicine and health service managers must work together to protect these elements of CLEs, which not only shape learning, but impact quality of care and patient safety.
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Affiliation(s)
- Caroline Kilty
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | - Anel Wiese
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | | | - Patrick Flood
- Dublin City University Business School, Dublin, Ireland
| | - Na Fu
- Trinity College Dublin Business School, Dublin, Ireland
| | - Mary Horgan
- School of Medicine, University College Cork, Cork, Ireland
| | - Agnes Higgins
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Bridget Maher
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | | | | | | | - Slavi Stoyanov
- Open University of the Netherlands, Heerlen, Netherlands
| | - Deirdre Bennett
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
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