Clinical Years Of Medical Education Research Articles

Bringing back the core concepts of physiology in an advanced medical school senior elective.

Integrating physiology core concepts into the clinical years of medical education has been challenging despite efforts. This article describes a fourth-year medical school elective, Advanced Physiology in Critical Care Medicine, that focused on integrating physiology core concepts in a case-based learning approach. The elective used interdisciplinary faculty in a virtual forum. Senior students were asked to generate mechanism of disease (MOD) maps, highlight the physiology core concepts associated with paper cases of critically ill patients, and discuss with faculty the relevance of the underlying basic science. The weekly footprint consisted of a student-led session presenting MOD maps for three cases, which examined aspects of core physiology concepts, and, later in the same week, student presentation of order sets for the management of the cases. Students ended the 4-wk elective with a mini-grand rounds presentation on a topic of their choice incorporating the core concept paradigm. Student perception data and faculty reflections of the elective course are included. Student data and faculty observations suggest that students appreciate and can apply physiological core concepts to patient care. Faculty experience in the course suggests that this senior elective helped them better approach all preclinical teaching with the Core Concepts framework in mind.NEW & NOTEWORTHY This article presents an innovative approach to integration of physiology core concepts with clinical management using cases of critically ill patients in an online senior elective for medical students. It uses a multidisciplinary faculty conducting a course primarily using case-based learning led by student presentations and discussions of concept maps and order sets.

Assessment of Preferred Learning Styles of Medical Students at Wah Medical College Using VARK Questionnaire

Objective: To assess the distribution of different learning styles and modalities among medical students and to identify any underlying association of socio-demographic characteristics of students with their preferred learning styles. Study design and setting: This is a cross-sectional survey which was conducted among medical students of Wah Medical College, Wah Cantt, for a duration of three months i.e. May 15th, 2023 to August 15th, 2023. Methodology: 271 students meeting the inclusion criteria were selected using the convenience sampling technique. Our data collection instrument was a questionnaire which consisted of two portions. The first portion was about the sociodemographic profile of the participants and the second portion consisted of the VARK questionnaire. Data was analysed using SPSS (version 23). The chi-square test was applied to determine the associations. A p-value less than 0.05 was considered significant. Results: A total of 271 students submitted the questionnaire with a mean age of 20 ± 1.7 years. The majority were female (62.4%). Kinesthetic learning was opted by 60.5% of students while quad-modal, tri-modal and bi-modal learning was opted by 35.1%, 33.2% and 31.7% of students respectively. The difference in learning styles used by students of varied clinical exposure was established (p=0.01). Conclusion: The most preferred learning style was kinesthetic and the majority of the students used quad-modal learning. It is also concluded that there is a difference in learning styles used by students in the pre-clinical and clinical years of medical education.

Breast Cancer And Self Breast Examination Awareness Amongst Pakistani Female Medical Students and Hospital Employees: Assessing Shortcomings in Health Literacy

Objective: To assess the knowledge, attitudes, and practices related to breast cancer and breast cancer screening among female medical students, healthcare workers, and hospital employees. Methodology: This cross-sectional study was conducted from September 1, 2021, to October 30, 2021. A questionnaire on breast cancer awareness and self-breast examination was distributed to female medical students across all five years at Fatimah Jinnah Medical University, Lahore, and to female hospital employees at Sir Ganga Ram Hospital, Lahore. A total of 404 women participated and were included in the study. Results: Out of the respondents, 71.2% were medical students, and 26.7% were doctors. Approximately 24% reported a family history of breast cancer. Media was identified as the primary source of information on breast cancer by 79.2% of women. Only 64.9% of respondents practiced self-breast examination, with merely 23.8% performing it monthly. Furthermore, only 37.1% correctly identified all the essential steps for conducting a breast self-examination. Conclusion: While the knowledge of breast cancer is satisfactory among healthcare workers and hospital employees, there is room for improvement in attitudes and practices related to early detection and screening. Initiatives should be undertaken by medical undergraduate curriculum coordinators to incorporate breast self-examination, clinical breast examination, and screening guidelines in both pre-clinical and clinical years of medical education. Additionally, information dissemination programs should be implemented in hospitals for all employees.

Psychometric properties of the Persian version of System for Evaluation of Teaching Qualities by students: A tool for assessing clinical tutors from students’ viewpoint

BACKGROUND:Effective clinical teaching is crucially important for patient care in future. Therefore, proper clinical training is essential to make physicians capable of delivering high-quality health care.MATERIALS AND METHODS:The present study was a cross-sectional research. After translating the questionnaire into Persian, it was distributed among medical students in the clinical years of medical education in teaching hospitals affiliated to Ahvaz Jundishapur University of Medical Sciences in 2018. The System for Evaluation of Teaching Qualities (SETQ) has 25 questions in a 6-scale Likert scale that evaluates clinical tutors in five dimensions of teaching and learning environment, professional attitude toward students, transferring of goals, evaluation of students, feedback, and promoting self-directed learning. Instrument reliability was assessed by calculating the Cronbach's alpha coefficient, whereas questionnaire content validity was evaluated by relative content validity ratio (CVR) and content validity index (CVI). To evaluate the structural validity, an exploratory factor analysis was conducted.RESULTS:The SETQ was completed by 127 medical students. Cronbach's alpha coefficient of the total questionnaire was estimated as 0.908. The factor analysis showed that the questionnaire was composed of six factors, explaining 66.14% of the total variance. The CVI and CVR indices of the individual items were also acceptable.CONCLUSION:The findings of our study showed that the Persian version of SETQ questionnaire had the acceptable reliability and validity to be used in assessing clinical tutors in different hospitals in Iran.

The short- and long-term effects of a course on rational drug use: A comparative study between prefinal- and final-year undergraduate medical students who attended the course in different clinical years.

BACKGROUND:Rational pharmacology use and appropriate prescribing are among the key learning outcomes in medical education. Some medical faculties include rational pharmacotherapy course in their education programs at different years of education in Turkey. The aims of this study were to investigate the differences in effect of rational pharmacotherapy course on short- and long-terms by comparing two cohorts who attended the course in different clinical years of medical education by identifying which parameters of prescription items are different among groups.MATERIALS AND METHODS:This quasi-experimental study was conducted in School of Medicine. Participants consisted of 157 students who attended the course in Grade 4 (n = 110, Group A) and Grade 5 (n = 47, Group B). Students were asked to complete a prescribing task both upon completion of the course and 1 year after. The performance in prescribing was determined by prescription scoring form. Repeated measures ANOVA was employed to test the intervention effect between two periods. McNemar test was employed to measure the change in each item on the prescription. Point-biserial correlations between each item on the prescription and their scores on the test as a whole were calculated.RESULTS:The mean score of Group A dropped to 59.41 (standard deviation [SD] = 14.06) from 90.43 (SD = 8.90), and the mean score of Group B dropped to 73.37 (SD = 12.56) from 83.91 (SD = 10.03). All the prescription components in the scripts of the Group A students worsened significantly, except the “name of drug,” whereas Group B students maintained most of them after 1 year.CONCLUSIONS:This study shows that the long-term retention effect of rational pharmacotherapy course conducted in later years of education is better than the course conducted in earlier years of education, which may be related to the fact that students in later years are more likely to take on responsibility for patient therapy process in clinical education.

Ideals, passion, and courage

Dear MJM:Helping a fellow human being is likely the most common reason why students enter the medical profession. The immense satisfaction that we experience by helping another person motivates us to devote our lives to a profession that proclaims this as its raison d’être. However, as we enter the clinical years of medical education, it becomes evident that to achieve this in the context of medicine is indeed a challenge.Why is it that we have the ideals, yet still fail to help others the way we hoped to? On June 19th, 2000, the McGill Chapter of Phi Delta Epsilon medical fraternity had the honor of hosting Dr. Miguel N. Burnier Jr., Chairman of the Department of Ophthalmology, McGill University, as the Aaron Brown Lecturer. Dr. Burnier gave a lecture titled “A Story”, through which he communicated an inspiring message, and answered this unasked question. “What makes a good physician is not the knowledge one possesses, but three things: ideals, passion, and courage.”Ideals give direction to our lives. It is the ideal of wanting to help the sick that brought most of us to the doors of the medical profession. Through medicine we hoped to cure disease and thus alleviate suffering. However, the suffering of a patient is more than the symptoms of the disease, it is the consequences of the disease – physical, emotional, psychological, and social consequences. Only if we are able to recognize the distinction between disease and illness and address the full impact of both can we alleviate the suffering.Passion empowers ideals. The practice of medicine in the 21st century is a foreboding challenge. Physicians are inundated with increased numbers of patients and concomitant decreased availability of support staff and health care funding. These factors not only compromise patient care directly but they also affect the physician’s interactions with patients. Physicians, when working in stressful situations, rarely have enough time to spend with their patients. They are unable to provide the holistic care that is needed to alleviate the suffering. Furthermore, these behaviors and stressors are passed down to the residents and the medical students. The passion that we have as young medical students starts to decline as we face the similar challenges of worsening working conditions. The small, yet frequent difficulties we encounter on the way to becoming the “good doctors” we set out to become, make us question the realism of such an entity. Passion empowers us to practice our ideals and the loss of passion allows us to compromise our ideals.It is courage that will carry us through the difficult times that we may encounter as health care professionals. Courage is the capacity to suffer in the name of our ideals. When in situations that challenge our ideals and dampen our passion, it is courage that sustains us. Courage transforms the challenges we experience into opportunities to grow through suffering. As medical students develop courage, they give depth to their passion and ideals, and thus mature to become the role models they once followed. Thus, young medical professionals need to remember their ideals, sustain their passion, and harness their courage to achieve their goal.

CLASSIE teaching \u2013 using virtual reality to incorporate medical ethics into clinical decision making

BackgroundTeaching medical ethics (ME) in the clinical environment is often difficult, uncalibrated and medical students get variable exposure to skilled educators. Explicit discussion of ethical dimensions of patient management is often neglected, as clinical teachers may feel inadequately skilled to do this.MethodsWe developed a suite of online modules. Each consisted of a clinical scenario filmed using virtual reality (VR) technology, linked to an adaptive, interactive, online tutorial which explicitly discussed the relevant ethical issues and guidelines. These were embedded in clinical placements of students to encourage the transfer of knowledge from these modules to clinical skill competency.We conducted a pilot study to evaluate these modules which examined student engagement, knowledge gains (self-perceived and measured) and user experience. We also reviewed reflections to assess the incorporation of these modules and transfer of knowledge into the clinical learning and skill development of the students.ResultsEngagement and self-perceived knowledge gains were extremely high. Students found these modules realistic, interesting and helpful. The measured knowledge gains (module exit quiz) were moderate. User experience was positive overall, although students were intolerant of any technical glitches. There was mixed feedback on whether the VR aspect of the clinical scenarios added value. Student reflections showed high level incorporation of these modules into clinical practice of the students and evidence of knowledge transfer (level 3 Kirkpatrick model of evaluation) in over ¾ of students.ConclusionsThis study showed that the use VR clinical scenarios combined with interactive online learning modules resulted in demonstrable high-level student engagement and learning gains in medical ethics and transfer of knowledge to clinical application. It standardised and ensured the student experience of high-quality educational deliverables in clinical years of medical education. This use of VR and online technology can be adapted for use in many areas of the medical curricula where we need to ensure the delivery of well calibrated, high quality, educational deliverables at scale for students.

Teaching models in the clinical years of medical education.

Teaching models in the clinical years of medical education Anmol Bipin Patel, Harkaran Singh KalkatDepartment of Undergraduate Medicine, Faculty of Medicine, Imperial College London, London, UK Students are exposed to a range of teachingmethods during the pre-clinical and clinical years of medical school. At Imperial College London, the pre-clinical years involve a predominantly lecture-based approach, with the aim of efficiently disseminating large volumes of knowledge to a large cohort. As clinical years approach, there is a swift move towards hospital-based teaching, where students have the independence to make the most of learning opportunities during placements. As learning objectives during medical studies, a corresponding change in teaching method is necessary. However, a sudden transition between teaching models or an overreliance on any one can be detrimental.

Knowledge, Attitudes and Practice of Burns Prevention and First Aid among Medical Students of King Khalid University, Saudi Arabia

Background: Burn prevention and first aid knowledge amongst medical students is a neglected subject.Objectives: 1.Assess the knowledge, attitudes and practices of medical students regarding burn prevention and first aid 2. Identify their sources of knowledge.Materials and Methods: This cross-sectional survey of KKU medical students documented their sociodemographic data, knowledge, attitudes and practices of burn prevention and first aid, and their sources of information. Data was analysed using SPSS 17. Descriptive information was presented as frequency and percentages, while Chi square test was used to find association of knowledge with sociodemographic factors.Results: A total of 273 students, from preclinical and clinical level were enrolled in the study. With an average of 9.3 correct responses, the median score of knowledge regarding burn prevention and first aid was 56.2 %. About half of the respondents (50.9%) achieved a fair knowledge score i.e. between 50-75%.College curriculum emerged as the major source of information for burn prevention (34.06%) and first aid (25.27%). About 42 % students suggested that inclusion in college curriculum would be the best way to increase awareness. YouTube emerged as the most common extra-curricular learning method (67.7%). Students in clinical years of medical education demonstrated significantly higher knowledge than those in pre-clinical years (p=0.01, COR=1.82). Fire prevention practices were not widely in place; however students revealed a positive attitude towards the same.Conclusion: Medical students have a fair knowledge in burn prevention and first aid and carry a positive attitude towards training. Incorporating social media for health awareness shows promise.Bangladesh Journal of Medical Science Vol.17(4) 2018 p.537-544

Vertical Integration in Clinical Years of Medical Education

Background: Integration is one of the main principles of contemporary medical education. Horizontal integration necessitates the coordination of teaching and learning activities within a year or a block, while vertical integration can be achieved by the contribution of basic and clinical sciences in all phases of medical education. Although vertical integration is achieved in many programs during the first 2-3 years (pre-clinical years), it is usually disregarded in clinical clerkships.Methods: A clinical-basic science integration (CBSI) program was implemented at Alfaisal University College of Medicine during 4th year clerkships of Surgery, Obstetrics-Gynecology and Internal Medicine and the topics discussed were related to those clerkships. The basic sciences disciplines involved were: microbiology, pathology and pharmacology.Results: A five points Likert scale questionnaire was used to collect the results of the students. There was a satisfaction level of over 80% for most of the questions and topics.Conclusion: Basic and clinical science integration (correlation) sessions are the way to complement vertical integration in clinical years. Integrated sessions should be planned and implemented in all clerkships with appropriate basic science topics. In order to ensure complete integration, these sessions should be coordinated by a team of basic scientists and clinicians.

Self-perceived versus objectively measured competence in performing clinical practical procedures by final year medical students.

ObjectivesTo determine and compare the self-perceived and objectively measured competence in performing 14 core-clinical practical procedures by Final Year Medical Students of the University of Zambia.MethodsThe study included 56 out of 60 graduating University of Zambia Medical Students of the 2012/2013 academic year. Self-perceived competence: students rated their competence on 14 core- clinical practical procedures using a self-administered questionnaire on a 5-point Likert scale. Objective competence: it was measured by Objective Structured Clinical Examination (OSCE) by faculty using predetermined rating scales. Rank order correlation test was performed for self-perceived and objectively measured competence.ResultsTwo thirds 36 (66.7%) of the participants perceived themselves as moderately competent, 15 (27.8%) rated themselves as highly competent while 3 (5.6%) had low self-perception. With objective competence, the majority 52 (92.8%) were barely competent while 4 (7.2%) were absolutely competent. When overall self-perception was compared to objectively measured competence, there was a discordance which was demonstrated by a negative correlation (Spearman rho -.123).ConclusionsSignificant numbers of students reported low self-competence in performing procedures such as endotracheal intubation, gastric lavage and cardiopulmonary resuscitation which most never performed during the clinical years of medical education. In addition, the negative correlation between self-perceived and objectively measured competence demonstrated the inability of students to assess and rate themselves objectively due to fear that others may know their weaknesses and realize that they are not as competent as expected at a specific level of training.

Student Perceived Value of Anatomy Pedagogy, Part I: Prosection or Dissection?

A series of three annual surveys of David Geffen School of Medicine (DGSOM) at UCLA students and UCR/UCLA Thomas Haider Program in Biomedical Sciences students were administered from 2010 to 2012 to ascertain student perceptions of which anatomy pedagogy—prosection or dissection—was most valuable to them during the first year of preclinical medical education and for the entire medical school experience in general. Students were asked, “What value does gross anatomy education have in preclinical medical education?” We further asked the students who participated in both prosection and dissection pedagogies, “Would you have preferred an anatomy curriculum like the Summer Anatomy Dissection during your first year in medical school instead of prosection?” All students who responded to the survey viewed anatomy as a highly valued part of the medical curriculum, specifically referring to four major themes: Anatomy is (1) the basis for medical understanding, (2) part of the overall medical school experience, (3) a bridge to understanding pathology and physiology, and (4) the foundation for clinical skills. Students who participated in both prosection and dissection pedagogies surprisingly and overwhelmingly advocated for a prosection curriculum for the first year of medical school, not a dissection curriculum. Time efficiency was the dominant theme in survey responses from students who learned anatomy through prosection and then dissection. Students, regardless of whether interested in surgery/radiology or not, appreciated both pedagogies but commented that prosection was sufficient for learning basic anatomy, while dissection was a necessary experience in preparation for the anatomical medical specialties. This suggests that anatomy instruction should be integrated into the clinical years of medical education.

Can patient simulator scenarios be utilized to improve teamwork and communication skills in first year medical students taking Medical Physiology?

Communication (Com) skills, as well as decision making/clinical problem solving, are on the list of LCME “hot topics”. Additionally, there has been a recent push to improve patient safety which most commonly revolves around miscommunication. Development of these skills occurs most often during the clinical years of medical education and studies focused on incorporation of these skills during the preclinical years are few. The aim of the current study is to determine if Com and teamwork skills can be improved during the preclinical years by using patient simulator (SIM) scenarios based upon physiology concepts. We used a modified version of the Anesthetists’ Non‐Technical Skills Behavorial (ANTS) marker system. This focused on 4 major categories: task management(TM), team working (TW), situation awareness (SA), and decision making (DM). 100 1st medical students participated in two SIM activities (#1: heat exhaustion, #2: Heart failure) in which faculty rated 4 categories on a 1–4 scale (poor to good). Students were debriefed in 2–3 groups on basic science concepts, and teamwork/Com skills. Average scores decreased in all four categories between SIM 1 and 2. TM = 3.2 to 3.1, TW = 3.6 to 3.0, SA = 3.3 to 2.9, and DM = 3.4 to 3.00. Interestingly, verbal feedback and actions from the students as well as faculty observations of the students appears to show the opposite and that the students appear to be discussing and group assessing to a greater degree. Additionally, the complexity of the SIM may play a role in these skills as SIM 2 is a more complex case than SIM 1. In conclusion, more data is needed and additional analysis measurements are needed to address how to assess student behavior regarding Com and teamwork skills. However, the fact that these are vital life‐long skills which could improve patient safety long term makes it a noteworthy focus of medical institutions.

Using a high-fidelity patient simulator with first-year medical students to facilitate learning of cardiovascular function curves

Students are relying on technology for learning more than ever, and educators need to adapt to facilitate student learning. High-fidelity patient simulators (HFPS) are usually reserved for the clinical years of medical education and are geared to improve clinical decision skills, teamwork, and patient safety. Finding ways to incorporate HFPS into preclinical medical education represents more of a challenge, and there is limited literature regarding its implementation. The main objective of this study was to implement a HFPS activity into a problem-based curriculum to enhance the learning of basic sciences. More specifically, the focus was to aid in student learning of cardiovascular function curves and help students develop heart failure treatment strategies based on basic cardiovascular physiology concepts. Pretests and posttests, along with student surveys, were used to determine student knowledge and perception of learning in two first-year medical school classes. There was an increase of 21% and 22% in the percentage of students achieving correct answers on a posttest compared with their pretest score. The median number of correct questions increased from pretest scores of 2 and 2.5 to posttest scores of 4 and 5 of a possible total of 6 in each respective year. Student survey data showed agreement that the activity aided in learning. This study suggests that a HFPS activity can be implemented during the preclinical years of medical education to address basic science concepts. Additionally, it suggests that student learning of cardiovascular function curves and heart failure strategies are facilitated.

The prevalence and correlations of medical student burnout in the pre-clinical years: A cross-sectional study

Burnout is a psychological syndrome of emotional exhaustion, depersonalization, and impaired personal accomplishment induced by repeated workplace stressors. Current research suggests that physician burnout may have its origins in medical school. The consequences of medical student burnout include both personal and professional distress, loss of empathy, and poor health. We hypothesized that burnout occurs prior to the initiation of the clinical years of medical education. This was a cross-sectional survey administered to third‐year medical students at the Mount Sinai School of Medicine (MSSM) in New York, New York (a traditional-style medical school with a marked division between pre-clinical and clinical training occurring at the beginning of the third year). Survey included an instrument used to measure job burnout, a sleep deprivation screen, and questions related to demographic information, current rotation, psychiatric history, time spent working/studying, participation in extracurricular activities, social support network, autonomy and isolation. Of the 86 medical students who participated, 71% met criteria for burnout. Burnt out students were significantly more likely to suffer from sleep deprivation (p = 0.0359). They were also more likely to disagree with the following statements: “I have control over my daily schedule” (p = 0.0286) and “I am confident that I will have the knowledge and skills necessary to become an intern when I graduate” (p = 0.0263). Our findings show that burnout is present at the beginning of the third year of medical school, prior to the initiation of the clinical years of medical training. Medical student burnout is quite common, and early efforts should be made to empower medical students to both build the knowledge and skills necessary to become capable physicians, as well as withstand the emotional, mental, and physical challenges inherent to medical school.

Several Reasons Keep Clinicians From Reporting Child Abuse

Several Reasons Keep Clinicians From Reporting Child Abuse

Making Cents of Osirix: Workstation Class Medical Imaging in the Gross Lab

This seminar is a descriptive and illustrative session detailing an innovative approach to teaching anatomy in the medical school curriculum. Clinical medical imaging anatomy data is an important resource for the education of medical students that has been underutilized in the basic science and clinical years of medical education. In the past, this has been due to the cumbersome and expensive nature of film based archives not being readily available to students and teaching faculty. With the advent of Picture Archiving Communication Systems, the cost of bringing these complex imaging databases into use is declining since digital archiving is exponentially less costly than film‐based archiving. Expensive workstations from the clinical imaging industry have limited the use of imaging data for teaching purposes. Recent developments in open‐source DICOM‐based imaging software on the Mac OS have made consumer grade computer systems available for medical image processing. Three‐dimensional renderings of anatomy from this workstation‐class software and virtual dissection techniques will be performed. The involvement of teaching professionals from within the diagnostic radiology community as well as the gross anatomy department is critical to the success of such a program, but the capital cost of the cross‐disciplinary approach is now so small with this particular implementation that it can be easily justified in any budget.

Task-based learning programme for clinical years of medical education

Task-based learning (TBL) is an educational strategy recommended for the later years of the medical education programme. The TBL programme was adopted for clinical years in the 2000-2001 academic year in Dokuz Eylul University School of Medicine (DEUSM). The aim of this paper is to describe the TBL programme of DEUSM. DEUSM outlined 50 clinical tasks for fourth-year students and 37 for fifth-year students. The tasks were grouped into four and five blocks. Interdisciplinary practicals, lectures and patient visits were organised in each task's schedule. The tasks were the focus of learning and each discipline contributed its own learning opportunities to the attached tasks. Formative and summative methods were used to evaluate the programme. Based on the experience and feedback provided by the students and trainers, the authors considered TBL an applicable and advisable approach for the clinical years of medical education.

Integrating communication training into a required family medicine clerkship.

Persistent evidence suggests that the communication skills of practicing physicians do not achieve desired goals of enhancing patient satisfaction, strengthening health outcomes and decreasing malpractice litigation. Stronger communication skills training during the clinical years of medical education might make use of an underutilized window of opportunity-students' clinical years-to instill basic and important skills. The authors describe the implementation of a novel curriculum to teach patient-centered communication skills during a required third-year, six-week family medicine clerkship. Curriculum development and implementation across 24 training sites in a five-state region are detailed. A faculty development effort and strategies for embedding the curriculum within a diverse collection of training sites are presented. Student and preceptor feedback are summarized and the lessons learned from the curriculum development and implementation process are discussed.

Interactive videoconferencing system for rural health education: a preliminary report.

To establish a videoconferencing network in a new Rural Clinical School. A report on choosing hardware and connecting multiple sites simultaneously. Rural South Australia. Undergraduate medical, nursing and allied health students. None. Establishment of an effective multisite, dual mode videoconferencing system. The choice of hardware was simple, but acquiring adequate broadband connection between sites proved difficult. Multi-site meetings for academic and administrative purposes are now routine. Evaluation of the effectiveness of medical education delivery will occur throughout 2004.