2-year Programme Research Articles

Foundation doctors’ perspectives on the impact of the COVID-19 pandemic and lessons for the future

The foundation programme is a 2-year training programme for newly qualified doctors and aims to bridge the gap between medical school and specialty training. The pandemic led to some major disruptions to foundation training. As foundation trainees, we encountered new challenges: there were reduced learning opportunities and our future paths became uncertain with changes to specialty training applications and membership exams. However, it is said that every crisis creates new opportunities and is a test of our resilience and innovativeness. There was the adoption of novel teaching methods, new research opportunities, increased importance given to teamwork and support for our wellbeing and mental health. We learnt lessons from this crisis that we should take forward to improve foundation training for the future.

Academic springboard: The chief resident position correlates with career path in emergency medicine.

The chief resident role often includes additional administrative and educational experiences beyond those of nonchief senior residents. It is unclear to what extent these experiences influence the postresidency career path of those selected as chief residents. The objective of this study was to evaluate the association of chief resident status on immediate postresidency career characteristicsrelative to nonchief residents in emergency medicine (EM). We retrospectively analyzed graduate data from 2016 to 2020 at six accredited EM residency programs. Participating sites were geographically diverse and included 3- and 4-year training formats. Each site abstracted data using a standardized form including program, year of graduation, chief resident status, publications during residency, and immediate postresidency position (academic vs. nonacademic). We calculated descriptive statistics and performed logistic regression to explore differences between the chief resident cohort and other graduates. We gathered information on 365 total graduates (45.8% from 3-year programs and 54.2% from 4-year programs) including 93 (25.5%) chief residents. A total of 129 (35%) graduates assumed an academic position immediately following residency. Fifty-six (60%) of 93 chief residents assumed an academic position immediately following residency, compared to 74 (27%) of 272 other graduates. After program, year of graduation, and number of publications completed during residency were controlled for, chief resident status was a significant predictor of immediate postresidency academic career (odds ratio for a chief resident assuming an academic job= 5.36, 95% confidence interval= 3.10 to 9.27). The chief resident role within EM is significantly associated with pursuit of an academic position immediately following residency compared to nonchiefs.

The enlightenment of foreign MD-MPH double degree program to the cultivation of high-level applied public health talents in China

Objective: To understand the current status of foreign dual-degree programs of Medical Doctor (MD) and Master of Public Health (MPH) and provide evidence-based decision-making reference for promoting the education of high-level applied public health talents in China. Methods: The list of involved institutions and information of foreign MD-MPH dual-degree programs was collected through literature retrieval, online information searching, and additional survey of key figures. We extracted the details of each project regarding professional fields, core competence, length of schooling, teaching and learning arrangement, internship eligibility, and graduation assessment. Python 3.8.0 was used for data cleaning, and the occurrence frequency of related items in each dimension was calculated. Results: A total of 99 MD-MPH programs from 104 foreign institutions were included, among which 97.1% of them were implemented in universities from the United States. The School of Public Health provided 42.4% (42/99) of the programs. Epidemiology was the major discipline set up among most programs, accounting for 12.0% (29/241) of all the specialties involved. Epidemiological research methods, health policy management and practice, and public health practice were the top 3 core competencies to be mastered. Of the 99 programs, 87 gave information on the length of the program, of which 74.7% (65/87) were five years, 6.9% (6/87) were four years, and 18.4% (16/87) included both 4-year and 5-year programs. Conclusions: The international MD-MPH programs were sophisticated and mainly organized by the School of Public Health alone or in conjunction with the School of Medicine. Epidemiology is the core course and competence objective, with a length of 4-5 years. Through learning experience from international MD-MPH programs and the Chinese unique medical development background, China should optimize its medical education system to develop a suitable talent training strategy for MD-MPH dual-degree programs in the new era.

How culture affects validity: understanding Japanese residents’ sense-making of evaluating clinical teachers

ObjectivesTraditionally, evaluation is considered a measurement process that can be performed independently of the cultural context. However, more recently the importance of considering raters’ sense-making, that is, the process by...

Data-driven approach for tailoring facilitation strategies to overcome implementation barriers in community pharmacy

BackgroundImplementation research has delved into barriers to implementing change and interventions for the implementation of innovation in practice. There remains a gap, however, that fails to connect implementation barriers to the most effective implementation strategies and provide a more tailored approach during implementation. This study aimed to explore barriers for the implementation of professional services in community pharmacies and to predict the effectiveness of facilitation strategies to overcome implementation barriers using machine learning techniques.MethodsSix change facilitators facilitated a 2-year change programme aimed at implementing professional services across community pharmacies in Australia. A mixed methods approach was used where barriers were identified by change facilitators during the implementation study. Change facilitators trialled and recorded tailored facilitation strategies delivered to overcome identified barriers. Barriers were coded according to implementation factors derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Tailored facilitation strategies were coded into 16 facilitation categories. To predict the effectiveness of these strategies, data mining with random forest was used to provide the highest level of accuracy. A predictive resolution percentage was established for each implementation strategy in relation to the barriers that were resolved by that particular strategy.ResultsDuring the 2-year programme, 1131 barriers and facilitation strategies were recorded by change facilitators. The most frequently identified barriers were a ‘lack of ability to plan for change’, ‘lack of internal supporters for the change’, ‘lack of knowledge and experience’, ‘lack of monitoring and feedback’, ‘lack of individual alignment with the change’, ‘undefined change objectives’, ‘lack of objective feedback’ and ‘lack of time’. The random forest algorithm used was able to provide 96.9% prediction accuracy. The strategy category with the highest predicted resolution rate across the most number of implementation barriers was ‘to empower stakeholders to develop objectives and solve problems’.ConclusionsResults from this study have provided a better understanding of implementation barriers in community pharmacy and how data-driven approaches can be used to predict the effectiveness of facilitation strategies to overcome implementation barriers. Tailored facilitation strategies such as these can increase the rate of real-time implementation of innovations in healthcare, leading to an industry that can confidently and efficiently adapt to continuous change.

Audiovisual Content for a Radiology Fellowship Selection Process During the COVID-19 Pandemic: Pilot Web-Based Questionnaire Study.

BackgroundTraditional radiology fellowships are usually 1- or 2-year clinical training programs in a specific area after completion of a 4-year residency program.ObjectiveThis study aimed to investigate the experience of fellowship applicants in answering radiology questions in an audiovisual format using their own smartphones after answering radiology questions in a traditional printed text format as part of the application process during the COVID-19 pandemic. We hypothesized that fellowship applicants would find that recorded audiovisual radiology content adds value to the conventional selection process, may increase engagement by using their own smartphone device, and facilitate the understanding of imaging findings of radiology-based questions, while maintaining social distancing.MethodsOne senior staff radiologist of each subspecialty prepared 4 audiovisual radiology questions for each subspecialty. We conducted a survey using web-based questionnaires for 123 fellowship applications for musculoskeletal (n=39), internal medicine (n=61), and neuroradiology (n=23) programs to evaluate the experience of using audiovisual radiology content as a substitute for the conventional text evaluation.ResultsMost of the applicants (n=122, 99%) answered positively (with responses of agree or strongly agree) that images in digital forms are of superior quality to those printed on paper. In total, 101 (82%) applicants agreed with the statement that the presentation of cases in audiovisual format facilitates the understanding of the findings. Furthermore, 81 (65%) candidates agreed or strongly agreed that answering digital forms is more practical than conventional paper forms.ConclusionsThe use of audiovisual content as part of the selection process for radiology fellowships is a new approach to evaluate the potential to enhance the applicants experience during this process. This technology also allows for the evaluation of candidates without the need for in-person interaction. Further studies could streamline these methods to minimize work redundancy with traditional text assessments or even evaluate the acceptance of using only audiovisual content on smartphones.

Using Learning Analytics to Examine Achievement of Graduation Targets for Systems-Based Practice and Practice-Based Learning and Improvement: A National Cohort of Vascular Surgery Fellows

Surgeons provide patient care in complex health care systems and must be able to participate in improving both personal performance and the performance of the system. The Accreditation Council for Graduate Medical Education (ACGME) Vascular Surgery Milestones are utilized to assess vascular surgery fellows' (VSF) achievement of graduation targets in the competencies of Systems Based Practice (SBP) and Practice Based Learning and Improvement (PBLI). We investigate the predictive value of semiannual milestones ratings for final achievement within these competencies at the time of graduation. National ACGME milestones data were utilized for analysis. All trainees entering the 2-year vascular surgery fellowship programs in July 2016 were included in the analysis (n = 122). Predictive probability values (PPVs) were obtained for each SBP and PBLI sub-competencies by biannual review periods, to estimate the probability of VSFs not reaching the recommended graduation target based on their previous milestones ratings. The rate of nonachievement of the graduation target level 4.0 on the SBP and PBLI sub-competencies at the time of graduation for VSFs was 13.1-25.4%. At the first time point of assessment, 6 months into the fellowship program, the PPV of the SBP and PBLI milestones for nonachievement of level 4.0 upon graduation ranged from 16.3-60.2%. Six months prior to graduation, the PPVs across the 6 sub-competencies ranged from 14.6-82.9%. A significant percentage of VSFs do not achieve the ACGME Vascular Surgery Milestone targets for graduation in the competencies of SBP and PBLI, suggesting a need to improve curricula and assessment strategies in these domains across vascular surgery fellowship programs. Reported milestones levels across all time point are predictive of ultimate achievement upon graduation and should be utilized to provide targeted feedback and individualized learning plans to ensure graduates are prepared to engage in personal and health care system improvement once in unsupervised practice.

Financial Considerations Associated With a Fourth Year of Residency Training in Family Medicine: Findings From the Length of Training Pilot Study.

The feasibility of funding an additional year of residency training is unknown, as are perspectives of residents regarding related financial considerations. We examined these issues in the Family Medicine Length of Training Pilot. Between 2013 and 2019, we collected data on matched 3-year and 4-year programs using annual surveys, focus groups, and in-person and telephone interviews. We analyzed survey quantitative data using descriptive statistics, independent samples t test, Fisher's Exact Test and χ2. Qualitative analyses involved identifying emergent themes, defining them and presenting exemplars. Postgraduate year (PGY)-4 residents in 4-year programs were more likely to moonlight to supplement their resident salaries compared to PGY-3 residents in three-year programs (41.6% vs 23.0%; P=.002), though their student debt load was similar. We found no differences in enrollment in loan repayment programs or pretax income. Programs' descriptions of financing a fourth year as reported by the program director were limited and budget numbers could not be obtained. However, programs that required a fourth year typically reported extensive planning to determine how to fund the additional year. Programs with an optional fourth year were budget neutral because few residents chose to undertake an additional year of training. Resources needed for a required fourth year included resident salaries for the fourth year, one additional faculty, and one staff member to assist with more complex scheduling. Residents' concerns about financial issues varied widely. Adding a fourth year of training was financially feasible but details are local and programs could not be compared directly. For programs that had a required rather than optional fourth year much more financial planning was needed.

A nationwide survey of emergency medicine resident workflow efficiency: Are training programs teaching residents to be efficient?

Workflow efficiency (WFE) is essential to the practice of emergency medicine (EM), but a standardized approach to measuring and teaching it during residency is lacking. In this study we sought to describe how EM residency programs in the United States currently measure and teach WFE and to assess the relative importance of WFE teaching to EM residency program leaders. We conducted a cross-sectional survey of all accredited EM residency training programs in the United States in Fall 2019. We invited all allopathic EM residency programs to participate in the study by directly emailing program directors and assistant/associate program directors. We conducted the study and performed descriptive statistics using SurveyMonkey software. We received a total of 133 responses out of 190 total programs (70%) with proportionate representation from 3- and 4-year programs and all regions of the United States. When asked to what extent teaching efficiency should be a priority compared to other educational goals, 65% of program leaders responded with "significant" or "moderate" priority. Most EM programs collect WFE data on their residents, either by tracking patients per hour (78%) or by written evaluations (59%). Common methods for providing WFE data to residents were: "individual data provided along with deidentified rank" (35%), "data provided only during private feedback meetings" (26%), and "no data or rank provided to residents" (16%). Regarding targeted WFE teaching to residents, 88% reported utilizing general on-shift teaching, 48% reported teaching WFE during formal didactics, and 45% during dedicated private feedback sessions. This national study of allopathic U.S. EM programs suggests that most EM program leaders do value WFE teaching. However, we found no consistent approach among programs for tracking or distributing resident WFE data, and many programs lack a formalized way to teach efficiency to their residents.

Evaluation of a Teaching Assistant Program in Online Education

Online student success is determined by several factors, including learning effectiveness, access (academic, technical, and administrative support), faculty satisfaction, and student satisfaction. These factors are part of the Online Learning Consortium’s Pillars of Quality Online Education, which were established to ensure all students are provided a quality education, with high levels of student engagement, instructor feedback and interaction, and experiential learning opportunities. Using Teaching Assistants (TAs) in the virtual classroom is not a traditional practice for most online institutions, but is a strategy that can have a positive impact on these factors. This exploratory research study discusses a TA program that was developed, implemented, and evaluated over 3 years. Fifteen (<em>n</em> = 15) doctoral students were hired to provide teaching support to high-risk courses in the undergraduate programs. Background, recruitment, onboarding, division of course responsibilities, data, and outcomes of the 3-year TA programs are discussed in alignment with the five pillars. Findings suggest the addition of TAs in online education is a potentially useful strategy to improve student learning outcomes, scale, access, and faculty and student satisfaction.

Evaluation of a Teaching Assistant Program in Online Education

Online student success is determined by several factors, including learning effectiveness, access (academic, technical, and administrative support), faculty satisfaction, and student satisfaction. These factors are part of the Online Learning Consortium’s Pillars of Quality Online Education, which were established to ensure all students are provided a quality education, with high levels of student engagement, instructor feedback and interaction, and experiential learning opportunities. Using Teaching Assistants (TAs) in the virtual classroom is not a traditional practice for most online institutions, but is a strategy that can have a positive impact on these factors. This exploratory research study discusses a TA program that was developed, implemented, and evaluated over 3 years. Fifteen (<em>n</em> = 15) doctoral students were hired to provide teaching support to high-risk courses in the undergraduate programs. Background, recruitment, onboarding, division of course responsibilities, data, and outcomes of the 3-year TA programs are discussed in alignment with the five pillars. Findings suggest the addition of TAs in online education is a potentially useful strategy to improve student learning outcomes, scale, access, and faculty and student satisfaction.

Workplace Skills and Teacher Competency from Culinary Arts Students’ Perspectives

Workplace skills are essential skills needed by graduates today to fulfill the demands of employers. Employers in the hospitality industry are looking for well-prepared Culinary Arts graduates that possess adequate training and are equipped with workplace skills to fill up positions in the job market. Apart from skills, teacher competency impacts the acquisition of knowledge and workplace skills among Culinary Arts students and contributes to the issue of unemployment. This study aims to differentiate workplace skills and teacher competency based on gender, socio-economic status, as well as academic and vocational achievements of Culinary Arts students. Furthermore, the relationship between workplace skills and teacher competency is assessed. This correlational study was conducted at Malaysian vocational colleges offering 2-year Culinary Arts programs involving 198 final year students. A 5-point Likert-scale questionnaire was used for data collection. The findings demonstrated that the students’ workplace skills and perception of teacher competency were at a moderate level. No significant differences were noted based on gender, socioeconomic status, as well as academic and vocational achievements. Teacher competency and workplace skills were correlated moderately and positively. This study provides a basis and serves as a reference to the Technical and Vocational Education and Training practitioners to design a curriculum for vocational college students in improving the acquisition of students’ workplace skills. Teachers are recommended to play an active role in efficiently integrating workplace skills in the learning process to enhance their competencies.

Financing the Fourth Year: Experiences of Required 4-Year Family Medicine Residency Programs.

The optimal length of family medicine training has been debated since the specialty's inception. Currently there are four residency programs in the United States that require 4 years of training for all residents through participation in the Accreditation Council for Graduate Medical Education Length of Training Pilot. Financing the additional year of training has been perceived as a barrier to broader dissemination of this educational innovation. Utilizing varied approaches, the family medicine residency programs at Middlesex Health, Greater Lawrence Health Center, Oregon Health and Science University, and MidMichigan Medical Center all demonstrated successful implementation of a required 4-year curricular model. Total resident complement increased in all programs, and the number of residents per class increased in half of the programs. All programs maintained or improved their contribution margins to their sponsoring institutions through additional revenue generation from sources including endowment funding, family medicine center professional fees, institutional collaborations, and Health Resources and Services Administration Teaching Health Center funding. Operating expense per resident remained stable or decreased. These findings demonstrate that extension of training in family medicine to 4 years is financially feasible, and can be funded through a variety of models.

Diagnostic Neuroradiology Subspecialty Training: 1 Versus 2 Years; the Canadian Perspective

Canada began a national reform of its post-graduate medical education training programs to a Competence By Design (CBD) model. Trends from accredited neuroradiology programs from the past 10 years were investigated to inform educators and stakeholders for this process. A 13-question electronic survey was sent to program directors of all 8 accredited neuroradiology training programs in Canada. Data was requested for each year on the 2008-2019 graduating classes. Questions pertained to program enrolment; program completion; post-training employment; and the sufficiency of 1-year training programs. Response rate was 100%. Over the timeframe studied, the 2-year programs increased in size (P = 0.007), while the 1-year programs remained steady (P = 0.27). 12.2% of trainees enrolled in the 2-year program dropped out after 1 year, and were considered 1-year trainees thereafter. A higher proportion of 2-year trainees obtain positions within academic institutions (89.5 vs 67.2%, P = 0.0007), whereas a higher proportion of 1-year trainees obtain positions within non-academic institutions (29.3 vs 8.1%, P = 0.0007). A higher proportion of those with Canadian board certification in diagnostic radiology who completed a 2-year program obtained a position within a Canadian academic institution compared to non-certified 2-year trainees (P < 0.001). 71.4% of program directors agreed that a 1-year program was sufficient for non-academic staff positions. The length of the training program has significant impact on employment in academic vs non-academic institutions. This information can be used to guide the upcoming CBD initiative for neuroradiology programs.

Are Esophagectomy Board Requirements Achievable? A Multi-Institutional Analysis

Duty-hour restrictions have implications on trainee operative exposure necessary to meet minimum case-volume requirements. We utilized a previously validated simulation model to evaluate the effect of program volume, trainee numbers and complement, and rotation schedule on the probability of achieving adequate esophagectomy case numbers for cardiothoracic surgery trainees. A ProModel simulator centered on probabilistic distributions of operative cases was utilized. Historical data from five 2-year cardiothoracic surgery training programs were obtained from 2016-2018 and used as inputs to the simulator that generated 10,000 "trainee 2-year periods" per program. Programs varied in annual average esophagectomy volume (12-91 per year), with 2-4 trainees graduating over a 2-year training period. If esophagectomy cases were distributed solely based on scheduling and institutional volume, only 60% of evaluated programs could adequately expose all trainees in esophagectomy to meet case requirements. The 3 programs with adequate esophagectomy volumes had averaged 3.3 times (range 3.0-3.6) the minimum number of board-required cases for their programs' trainees. The ability of programs to provide trainees with adequate esophagectomy volume is challenging based on institutional volume and scheduling. Through simulation, we demonstrate that programs need >2 times the expected minimum number of esophagectomies to ensure that >90% of trainees meet case-volume requirements. Programs may consider strategies such as allowing trainees to select cases based on personal need, train fewer fellows, or enable trainees to seek subspecialty exposure externally to achieve minimum esophagectomy case-load requirements.

The Importance of Place: Effects of Community Job Loss on College Enrollment and Attainment Across Rural and Metropolitan Regions

Youth living in remote rural communities face significant geographic barriers to college access. Even those living near to a postsecondary institution may not have the means for, or may not see the value of, pursuing a college degree within their local economy. This study uses 18 years of national county-level data to ask how local economic shocks affect the postsecondary enrollment and attainment of rural students, as compared to students in metropolitan and metropolitan-adjacent regions. Results from an instrumental variables analysis indicate that each 1 percentage point increase in local unemployment increases local college enrollment by 10.0% in remote rural areas, as compared to a 5.2% increase in metropolitan-adjacent areas and no detectable increase in metropolitan areas. The rise in rural college enrollment is driven primarily by students enrolling in or continuing in associate degree programs, and by students transferring from 2-year to 4-year programs.

Medical Education Reform in China: The Shanghai Medical Training Model.

Medical Education Reform in China: The Shanghai Medical Training Model.

Attitude and perception of urology by fifth-year (GEMPIII) students at the end of their mixed block rotation at Wits Medical School

BackgroundThis University Medical School offers a 6-year MBBCh programme, of which the fifth year consists of seven blocks of 6 weeks each of which 2 weeks are mixed rotations in specialities such as ophthalmology, ear–nose–throat and urology. The purpose of the study was to assess the current urology knowledge and skills confidence amongst undergraduate medical students regarding urological diagnostic and therapeutic procedures, in order to evaluate the current curriculum for possible need of improvement.MethodsThis was a qualitative survey of 250 fifth-year medical students from September 2019 to February 2020. The survey was conducted by means of a questionnaire consisting of two parts: The first component covered the students perceptions of the urology rotation, and the second component contained the students self-evaluations. The aim of the study was to evaluate students perceptions of the current urology curriculum and to assess the possible need for improvement in urological knowledge and skill.ResultsOf 250 (100%) voluntary participants, 159 (63.6%) were female and 91(36.4%) were male. The majority of students considered their urology knowledge on lithiasis/stone disease and erectile dysfunction sufficient and were comfortable with male catheterisation. Voiding dysfunction, paediatric urology and uro-oncology were the subjects students commonly expressed a deficit in. There was a statistical significant difference in females having a more positive attitude to urology, than males (p = 0.02). No statistical significant difference in attitude to urology was found between students who rotated in one center opposed to students who rotated in another center. Indeed, the majority of students had a negative attitude to urology at the end of the mixed block rotations regardless of the training location. Unattractivity and lack of knowledge were the most common reasons for not choosing urology as a career.ConclusionThe study reveals a need for improvement in basic urological knowledge and skills during the mixed block rotation. A more practical curriculum, taking into account: bedside teachings, attendance of urological clinics and more exposure to urological patients, are some suggestions to be considered in improving the urological educational curriculum.

Challenges and satisfaction in Cardiothoracic Surgery Residency Programmes: insights from a Europe-wide survey.

The increasing complexity of surgical patients and working time constraints represent challenges for training. In this study, the European Association for Cardio-Thoracic Surgery Residents' Committee aimed to evaluate satisfaction with current training programmes across Europe. We conducted an online survey between October 2018 and April 2019, completed by a total of 219 participants from 24 countries. The average respondent was in the fourth or fifth year of training, mostly on a cardiac surgery pathway. Most trainees follow a 5-6-year programme, with a compulsory final certification exam, but no regular skills evaluation. Only a minority are expected to take the examination by the European Board of Cardiothoracic Surgery. Participants work on average 61.0 ± 13.1 h per week, including 27.1 ± 20.2 on-call. In total, only 19.7% confirmed the implementation of the European Working Time Directive, with 42.0% being unaware that European regulations existed. Having designated time for research was reported by 13.0%, despite 47.0% having a postgraduate degree. On average, respondents rated their satisfaction 7.9 out of 10, although 56.2% of participants were not satisfied with their training opportunities. We found an association between trainee satisfaction and regular skills evaluation, first operator experience and protected research time. On average, residents are satisfied with their training, despite significant disparities in the quality and structure of cardiothoracic surgery training across Europe. Areas for potential improvement include increasing structured feedback, research time integration and better working hours compliance. The development of European guidelines on training standards may support this.

The Relationship Between Accreditation Cycle and Licensing Examination Scores: A National Look.

Accreditation aims to ensure all training programs meet agreed-upon standards of quality. The process is complex, resource intensive, and costly. Its benefits are difficult to assess because contextual confounds obscure comparisons between systems that do and do not include accreditation. This study explores accreditation's influence "within system" by investigating the relationship between accreditation cycle and performance on a national licensing examination. Scores on the computer-based portion of the Medical Council of Canada Qualifying Examination Part I, from 1993 to 2017, were examined for all 17 Canadian medical schools. Typically completed upon graduation from medical school, results within each year were transformed for comparability across administrations and linked to timing within each school's accreditation cycle. ANOVAs were used to assess the relationship between accreditation timing and examination scores. Secondary analyses isolated 4-year from 3-year training programs and separated data generated before versus after implementation of a national midcycle informal review program. Performance on the licensing exam was highest during and shortly after an accreditation site visit, falling significantly until the midpoint in the accreditation cycle (d = 0.47) before rising again. This pattern disappeared after introduction of informal interim review, but too little data have accumulated post implementation to determine if interim review is sufficient to break the influence of accreditation cycle. Formal, externally driven, accreditation cycles appear associated with educational processes in ways that translated into student outcomes on a national licensing examination. Whether informal, internal, interim reviews can mediate this effect remains to be seen.