Ethics Curriculum Research Articles

Designing an Ethics Curriculum in Obstetrics and Gynecology.

In developing an ethics curriculum in obstetrics and gynecology, educators should allow an open exchange of ideas in a nonthreatening setting, engage trainees by providing direct patient contact or small-group discussions, and tailor the program to the institution.

An ethics training specific for European public health.

Training in public health ethics is not at the core of public health programmes in Europe. The fruitful progress of the United States could stimulate the European schools of public health and other academic institutions to develop specifically European teaching programmes for ethics that embrace both transatlantic innovations and some adaptations based on the evolution of moral values in European societies. This paper reviews the arguments for a European public health ethics curriculum and recommends the main features of such a programme. Europe shares common values and, above all, the three major ethical principles that were socially and politically crystallized by the French Revolution: liberty, equality, and fraternity. Fraternity, otherwise known as solidarity, although rarely mentioned in the literature on ethical issues, is the moral value that best defines the European concept of public health expressed as a common good, mutual aid, and a collective or shared responsibility for health of the population. Specific political motivations were responsible for the origin of European health systems and for current policy proposals led by the European Union, such as Europe’s commitments, at least in theory, to: reduce social inequities in health and to develop the health in all policies approach. These and other initiatives, albeit not exclusively European, have political and legal repercussions that pose unique ethical challenges. Europe combines homogeneity in social determinants of health with heterogeneity in public health approaches and interventions. It is therefore necessary to develop training in ethics and good government for all public health workers in Europe, especially since a large segment of the population’s health depends on actions and decisions adopted by the European Commission and its regulatory agencies as well as for non EU European Region countries. Based on these arguments, the paper concludes with several recommendations for a common nucleus for the ethics curriculum in Europe.

Whatever Ought Not To Be Spoken Of Abroad: Formation (of Medical Students) and Information (of Patients)

Confidentiality has a pre-eminent status in the medical curriculum for ethics, law, and professionalism because it does not depend on prior clinical learning or scientific knowledge, and it provides students with the opportunity to engage in the work of self-formation in professional practice from the very beginning. The historical tendency to romanticise medical professionalism, and confidentiality in particular as a symbol for this, was able to thrive in previous eras as a result of uncertainty around the boundaries of disclosure. To some extent echoes of this romanticism can still be heard today in rhetorical appeals to the Hippocratic tradition despite the development of detailed clarification in frameworks of law, standards, codes, professional regulation, and guidance from the second half of the 20th century. This paper considers two iconic portrayals of medical professionalism from the romantic period of the Victorian past, contrasting that era with the present-day environment of normative codifications. While ethics is commonly approached in an intellectual mode as a discussion of theory, a purely cognitive understanding is deficient on its own since learning in professional ethics must by definition be reified as sets of practices. The shift to the clinical accountability of today means that practices are of central importance to the undergraduate medical curriculum, not least in the area of confidentiality, for which the General Medical Council guidance sets the UK agenda for medical educational approaches to teaching, learning, and assessment, before students repeat the Hippocratic Oath at graduation as they embark on their future careers as doctors.

Ethical issues identified by obstetrics and gynecology learners through a novel ethics curriculum

Obstetrics and gynecology (ob/gyn) is fraught with bioethical issues, the professional significance of which may vary based on clinical experience. Our objective was to utilize our novel ethics curriculum to identify ethics and professionalism issues highlighted by ob/gyn learners and to compare responses between learner levels to further inform curricular development. We introduced an integrated and dynamic ob/gyn ethics and professionalism curriculum and mixed methods analysis of 181 resulting written reflections (case observation and assessments) from third-year medical students and from first- to fourth-year ob/gyn residents. Content was compared by learner level using basic thematic analysis and summary statistics. Within the 7 major ethics and professionalism domains, learners wrote most frequently about miscellaneous ob/gyn issues such as periviability and abortion (22% of students, 20% of residents) and problematic treatment decisions (20% of students, 19% of residents) rather than professional duty, communication, justice, student-/resident-specific issues, or quality of care. The most commonly discussed ob/gyn area by both learner groups was obstetrics rather than gynecology, gynecologic oncology, or reproductive endocrinology and infertility, although residents were more likely to discuss obstetrics-related concerns than students (65% vs 48%; P = .04) and students wrote about gynecologic oncology-related concerns more frequently than residents (25% vs 6%; P = .002). In their reflections, sources of ethical value (eg, the 4 classic ethics principles, professional guidelines, and consequentialism) were cited more frequently and in greater number by students than by residents (82% of students cited at least 1 source of ethical value vs 65% of residents; P = .01). Residents disagreed more frequently with the ethical propriety of clinical management than did students (67% vs 43%; P = .005). Our study introduces an innovative and dynamic approach to an ob/gyn ethics and professionalism curriculum that highlights important learner-identified ethics and professionalism issues both specific to ob/gyn and common to clinical medicine. Findings will help ob/gyn educators best utilize and refine this flexible curriculum such that it is appropriately focused on topics relevant to each learner level.

Improving third-year medical students' competency in clinical moral reasoning: Two interventions

ABSTRACTBackground: This article reports on the impact of two ethics interventions implemented for third-year medical students. Previous research validated our institution's model for assessing medical students' competency in medical ethics. Confident in our assessment model, the bioethics faculty sought to improve student performance. Methods: We designed and implemented two additions to the third-year medical ethics curriculum: a written ethics project with faculty feedback, and a standardized glossary of the bioethical concepts addressed by our curriculum. To measure the impact of the written ethics project, we compared students' scores on their comprehensive ethics assessment in 2011, prior to the curricular additions, to the 2013 scores of students who only received the written ethics assignment supplement. To measure the impact of the glossary we distributed it to half of the students sitting for the ethics assessment in 2013, and compared their scores with their classmates' who had not received the glossary. Results: The 2013 students who only received the written ethics project scored 12.5% higher than the 2011 students, and they displayed significant improvement in justifying a resolution of a clinical ethical dilemma. The 2013 students who received the glossary were significantly better at recognizing which principles and concepts of biomedical ethics were relevant to a clinical case and explaining how they created a conflict. Conclusions: Medical student competency in clinical moral reasoning is enhanced by written ethics projects, a faculty feedback component, and access to a glossary of ethical terms.

Catholic Schools Can Be Catholic

Loyola High School is a private Jesuit high school for boys, which was founded in 1848 in Montreal, Quebec, Canada. Until the 1990s, schools in Quebec were confessional schools, either Protestant or Roman Catholic. When the schools were deconfessionalized through a constitutional amendment in 1997, the religious education component of the curriculum was replaced by a neutral Ethics and Religious Culture (ERC) curriculum.1 Loyola High School applied for an exemption from the ERC, which, under legislation, the Minister of Education, Recreation, and Sports could grant if there was an alternative, equivalent course. The Minister refused the exemption on the basis that the proposed alternative was to be taught from a Catholic, rather than a secular, perspective. Loyola applied for judicial review of that decision. The judge at first instance ruled that the Minister infringed section 2(a) of the Charter of Rights and Freedoms (Charter) that guarantees freedom of religion. He overturned the Minister’s decision. The Quebec Court of Appeal overturned this decision on two bases. First, the standard of review. The court’s interpretation of the administrative standard of review of a discretionary decision maker was ‘reasonableness’. Second, the court ruled that the ECR program did not interfere with religious freedom in a substantial manner. The court therefore ruled that the Minister’s decision was reasonable.

Education research: a case-based bioethics curriculum for neurology residents.

In 2012, the American Academy of Neurology (AAN) updated and expanded its ethics curriculum into Practical Ethics in Clinical Neurology, a case-based ethics curriculum for neurologists. We piloted a case-based bioethics curriculum for neurology residents using the framework and topics recommended by the AAN, matched to clinical cases drawn from Columbia's neurologic services. Our primary outcome was residents' ability to analyze and manage ethically complex cases as measured on precurriculum and postcurriculum multiple-choice quizzes. Secondary outcomes included precurriculum and postcurriculum self-assessed comfort in discussing and managing ethically complex cases, as well as attendance at ethics discussion sessions as compared to attendance at other didactic sessions. Resident performance on quizzes improved from 75.8% to 86.7% (p = 0.02). Comfort in discussing ethically complex cases improved from 6.4 to 7.4 on a 10-point scale (p = 0.03). Comfort in managing such cases trended toward improvement but did not reach statistical significance. Attendance was significantly better at ethics discussions (73.5%) than at other didactic sessions (61.7%, p = 0.04). Our formal case-based ethics curriculum for neurology residents, based on core topics drawn from the AAN's published curricula, was successfully piloted. Our study showed a statistically significant improvement in residents' ability to analyze and manage ethically complex cases as measured by multiple-choice tests and self-assessments.

Building locally relevant ethics curricula for nursing education in Botswana

Aim The goal of this multi-institutional collaboration was to develop an innovative, locally relevant ethics curriculum for nurses in Botswana. Background Nurses in Botswana face ethical challenges that are compounded by lack of resources, pressures to handle tasks beyond training or professional levels, workplace stress and professional isolation. Capacity to teach nursing ethics in the classroom and in professional practice settings has been limited. Methods A pilot curriculum, including cases set in local contexts, was tested with nursing faculty in Botswana in 2012. Results Thirty-three per cent of the faculty members indicated they would be more comfortable teaching ethics. A substantial number of faculty members were more likely to introduce the International Council of Nurses Code of Ethics in teaching, practice and mentoring as a result of the training. Based on evaluation data, curricular materials were developed using the Code and the regulatory requirements for nursing practice in Botswana. A web-based repository of sample lectures, discussion cases and evaluation rubrics was created to support the use of the materials. Discussion A new master degree course, Nursing Ethics in Practice, has been proposed for fall 2015 at the University of Botswana. The modular nature of the materials and the availability of cases set within the context of clinical nurse practice in Botswana make them readily adaptable to various student academic levels and continuing professional development programmes. Conclusion The ICN Code of Ethics for Nursing is a valuable teaching tool in developing countries when taught using locally relevant case materials and problem-based teaching methods. Implications for Nursing The approach used in the development of a locally relevant nursing ethics curriculum in Botswana can serve as a model for nursing education and continuing professional development programmes in other sub-Saharan African countries to enhance use of the ICN Code of Ethics in nursing practice.

Research ethics training of trainers: Developing capacity of Bolivian health science and civil society leaders

Program/Project Purpose: The University of San Andres, Faculty of Medicine in La Paz, Bolivia in collaboration with Touro University California, Public Health Program was awarded a NIH Research Ethics Planning Grant in June, 2013 to develop strategies and processes for implementation of a comprehensive national research ethics program for Bolivia. Although the importance of scientific research based on ethical principles is highlighted in the Bolivian constitution and national health legislation, few Bolivian academics, researchers and health professionals have received formal training in the principles and practices of research ethics. A principle aim of the Planning Grant is to develop and implement a Research Ethics Train the Trainers (TOT) course with the goal of training faculty for future implementation of a national research ethics program. Structure/Method/Design: A Project Directors Committee representing public health science universities from four participating Bolivian Departments/States (La Paz; Santa Cruz, Cochabamba & Chuquisaca) was formed to oversee all project activities including implementation of a three day in-personTOT followed by a 10week online training. Training modules utilized materials developed by Bolivian academics and scientists and international research ethics programs at PAHO (PanAmerican Health Organization) and CITI (Collaborative Institutional Training Initiative), University of Miami. TOT University and civil society representatives were selected from each participating Department/State for a total of 26 participants. Upon completion of the training, participants were asked to implement educational research ethics activities in their local communities and institutions. Outcomes & Evaluation: A pre-test/post-test study design was used to assess change in participant knowledge related to research ethics principles and practices. The mean score improved from 73% correct at baseline and 84% at course completion. Participants completed a course evaluation after the in-person and virtual components of the course. Participants highlighted the most useful topics in the course as respect for persons and human rights, principles of bioethics, informed consent and the function of research ethics committees. The most positive aspects of the inperson component of the course were the high level of participation, group work, communication and debate among participants representing different academic disciplines and social sectors. Eighty percent of participants completed the course with five dropping out during the virtual component. Most students reported that the instructions for using the virtual platform were clear and they received sufficient support from the Course Coordinator, however, most stated that some of the teachers provided insufficient academic support. Going Forward: Integrating the group interaction strengths of the inperson TOT component with the flexibility of the virtual component recommends using a mixed methods approach while providing additional training to teachers related to virtual teaching methodologies. Funding: NIH/FIC, International Research Ethics Education and Curriculum Development Award (R25). Abstract #: 01ETC001

Teaching business ethics in the global South: control, resistance, and phronesis

We explore academic literature on business ethics education and critically compare the themes emerging from different contexts. Outlining guidelines for analysis based on Southern Theory, we conduct a content analysis on a selection of English, peer-reviewed articles and then critically compare emergent themes from across the ‘Northern'–Southern’ divide. The results suggest commonality but also substantive nuances. One key difference concerns a concerted effort from the South to decipher daily business experiences in relation to prevalent business ethics frameworks focused on the North. Furthermore, using notion of phronetic science, we critically discuss our findings to highlight inherent dynamics of control and resistance. The paper concludes by suggesting future directions for business ethics curriculum development that is more sensitive to these dynamics and by suggesting an adoption of notions related to practical wisdom.

Ethics is not rocket science: how to have ethical discussions in your science class.

The Rutland Institute for Ethics at Clemson University seeks to encourage discussion on campus, in businesses, and in the community about how ethical decision-making can be the basis of both personal and professional success. In the last 15 years, our fellows have, among other things, served as Co-PI’s on a wide range of grants, produced Responsible Conduct of Research training for science and engineering graduate students and faculty, managed the ethics curriculum at a medical school, and produced video lectures on ethical thinking for undergraduate Biology majors. The crown jewel of our efforts to-date is our Ethics Across the Curriculum program, affectionately known as “ethics boot camp.” Each year, we bring faculty from all corners of the disciplinary spectrum together to show them how to have rich ethical discussions in their own classes with the students from their majors. The program has been extremely successful and over the past 15 years has touched the lives of hundreds of faculty and thousands of students. The purpose of this paper is to provide a very abbreviated version of the Rutland Ethics Across the Curriculum material to a wider audience of science educators. It is our hope that this will motivate more faculty to introduce ethics into their classes as well as provide them the basic tools they will need to make this experience fruitful for all concerned.

Building locally relevant ethics curricula for nursing education in Botswana.

The goal of this multi-institutional collaboration was to develop an innovative, locally relevant ethics curriculum for nurses in Botswana. Nurses in Botswana face ethical challenges that are compounded by lack of resources, pressures to handle tasks beyond training or professional levels, workplace stress and professional isolation. Capacity to teach nursing ethics in the classroom and in professional practice settings has been limited. A pilot curriculum, including cases set in local contexts, was tested with nursing faculty in Botswana in 2012. Thirty-three per cent of the faculty members indicated they would be more comfortable teaching ethics. A substantial number of faculty members were more likely to introduce the International Council of Nurses Code of Ethics in teaching, practice and mentoring as a result of the training. Based on evaluation data, curricular materials were developed using the Code and the regulatory requirements for nursing practice in Botswana. A web-based repository of sample lectures, discussion cases and evaluation rubrics was created to support the use of the materials. A new master degree course, Nursing Ethics in Practice, has been proposed for fall 2015 at the University of Botswana. The modular nature of the materials and the availability of cases set within the context of clinical nurse practice in Botswana make them readily adaptable to various student academic levels and continuing professional development programmes. The ICN Code of Ethics for Nursing is a valuable teaching tool in developing countries when taught using locally relevant case materials and problem-based teaching methods. The approach used in the development of a locally relevant nursing ethics curriculum in Botswana can serve as a model for nursing education and continuing professional development programmes in other sub-Saharan African countries to enhance use of the ICN Code of Ethics in nursing practice.

Establishing the need and identifying goals for a curriculum in medical business ethics: a survey of students and residents at two medical centers in Missouri.

BackgroundIn recent years, issues in medical business ethics (MBE), such as conflicts of interest (COI), Medicare fraud and abuse, and the structure and functioning of reimbursement systems, have received significant attention from the media and professional associations in the United States. As a result of highly publicized instances of financial interests altering physician decision-making, major professional organizations and government bodies have produced reports and guidelines to encourage self-regulation and impose rules to limit physician relationships with for-profit entities. Nevertheless, no published curricula exist in the area of MBE. This study aimed to establish a baseline level of knowledge and the educational goals medical students and residents prioritize in the area of MBE.Methods732 medical students and 380 residents at two academic medical centers in the state of Missouri, USA, completed a brief survey indicating their awareness of major MBE guidance documents, knowledge of key MBE research, beliefs about the goals of an education in MBE, and the areas of MBE they were most interested in learning more about.ResultsMedical students and residents had little awareness of recent and major reports on MBE topics, and had minimal knowledge of basic MBE facts. Residents scored statistically better than medical students in both of these areas. Medical students and residents were in close agreement regarding the goals of an MBE curriculum. Both groups showed significant interest in learning more about MBE topics with an emphasis on background topics such as “the business aspects of medicine” and “health care delivery systems”.ConclusionsThe content of major reports by professional associations and expert bodies has not trickled down to medical students and residents, yet both groups are interested in learning more about MBE topics. Our survey suggests potentially beneficial ways to frame and embed MBE topics into the larger framework of medical education.

What to consider when preparing a model core curriculum for GIS ethics: objectives, methods, and a sketch of content

The purpose of this article is to provide a summary of what is known about teaching ethics in engineering, science, and related disciplines. Such a summary should provide a useful starting point for preparation of a detailed curriculum for teaching the ethics of geo-coded information systems broadly understood (“GIS ethics” for short). It attempts to answer the following questions: What is “ethics” for the purpose of GIS? What is teaching ethics? What objectives should teaching ethics have in a technical curriculum? What methods should be used? How should student work in ethics be assessed? How should the teaching of ethics be assessed?

Telemedicine as an ethics teaching tool for medical students within the nephrology curriculum.

A novel patient-centered approach was used to deliver ethics curriculum to medical students. Two medical school clinicians designed a telemedicine session linking their facilities (across 2 continents). The session, Exploring the Patient Experience Through Telemedicine: Dialysis and End-Stage Renal Disease, allowed second-year medical students to explore various parameters of quality of life experienced by dialysis patients. A panel of 4 medical students interviewed a dialysis patient via Skype video connection between the medical school and the hospital's dialysis unit. Interview questions were adapted from the Kidney Disease Quality of Life instrument. During the live video-streamed interview, the remaining 23 second-year medical students observed the session. Afterward, the 23 were offered a voluntary anonymous online feedback survey (15 responded). The 4 panelists submitted narrative responses to 2 open-ended questions about their experience. All 15 responding students "Strongly agreed" or "Agreed" that the session was an aid to their professionalism skills and behaviors; 14 of 15 "Strongly agreed" or "Agreed" that telemedicine technology contributed to their understanding of the topic; 12 of 15 "Strongly agreed" that the session improved their understanding of the psychosocial burdens of dialysis, quality of life, and human suffering, and increased their empathy toward patients; and 12 of 15 "Strongly agreed" or "Agreed" that the session encouraged reflective thinking and was an aid to improving their communication skills. Telemedicine can be an effective and feasible method to deliver an ethics curriculum with a patient-centered approach. Additionally, the cross-cultural experience exposes students to additional contextual features of medicine.

Ethics Skills Laboratory Experience for Surgery Interns

Ethics curricula are nearly universal in residency training programs, but the content and delivery methods are not well described, and there is still a relative paucity of literature evaluating the effect of ethics curricula. Several commentators have called for more ethics curriculum development at the postgraduate level, and specifically in surgery training. We detail our development and implementation of a clinical ethics curriculum for surgery interns. We developed curricula and simulated patient cases for 2 core clinical ethics skills--breaking bad news and obtaining informed consent. Educational sessions for each topic included (1) framework development (discussion of interns' current experience, development of a consensus framework for ethical practice, and comparison with established frameworks) and (2) practice with simulated patient followed by peer and faculty feedback. At the beginning and end of each session, we administered a test of confidence and knowledge about the topics to assess the effect of the sessions. A total of 98 surgical interns participated in the ethics skills laboratory from Spring 2008 to Spring 2011. We identified significant improvement in confidence regarding the appropriate content of informed consent (<0.001) and capacity to break bad news (<0.001). We also identified significant improvement in overall knowledge regarding informed consent (<0.01), capacity assessment (<0.05), and breaking bad news (0.001). Regarding specific components of informed consent, capacity assessment, and breaking bad news, significant improvement was shown in some areas, while we failed to improve knowledge in others. Through faculty-facilitated small group discussion, surgery interns were able to develop frameworks for ethical practice that paralleled established frameworks. Skills-based training in clinical ethics resulted in an increase in knowledge scores and self-reported confidence. Evaluation of 4 annual cohorts of surgery interns demonstrates significant successes and some areas for improvement in this educational intervention.

Education in virtues as goal of business ethics instruction

The moral development paradigm underlying a particular business ethics curriculum design plays a significant role in determining the goals of business ethics instruction. Concretely, the view of moral development advanced by cognitive developmental psychology that dominates business ethics literature identifies moral development with cognitive processes, but disregards educating students in virtues. The aim of the present paper is to propose an alternative paradigm of moral development to that of cognitive developmental psychology and presents Aquinas’ view of moral development as a suitable framework for a curriculum design that focuses on virtues as a possible goal of business ethics instruction.Â

Teaching global health ethics using simulation: interprofessional training

<h2>Abstract</h2><h3>Background</h3> Many ethical dilemmas in global health fieldwork stem from cultural differences and limited resources, and trainees frequently report feeling ill-equipped to deal with such issues. A literature review shows a need for predeparture training that would enable participants to develop a strategy for recognising and resolving such problems. <h3>Methods</h3> After reviewing global health ethics education and predeparture training resources, we organised multidisciplinary focus groups with global-health experts at our institution. These sessions identified key ethical issues that our training should address: scope of practice, informed consent, privacy or confidentiality, professional ethics, harm and benefit, and corruption. We then developed four scenarios focusing on these ethical issues. Each scenario was followed by a debriefing session led by a faculty facilitator. We piloted the simulation training with a multidisciplinary cohort (n=27) of postgraduate trainees. All participants completed prestimulation and postsimulation evaluations that assessed their exposure to the scenarios' ethical issues and ability to deal with these ethical dilemmas and identify resources for help. <h3>Findings</h3> The results showed a significant knowledge gain in the above domains. Paired t-tests were used to compare participants' agreement scores with the statement "I have a strategy to deal with this ethical issue," which significantly increased (p<0·05) postsimulation for the following ethical issues: scope of practice, privacy, harm, and corruption. <h3>Interpretation</h3> Our preliminary results show that the simulation sessions accomplish our training's objectives. Further, our institution's ethics faculty expressed a keen interest in integrating these exercises into the mainstream ethics curriculum. <h3>Funding</h3> The Haile T Debas Academy of Medical Educators Innovations Funding Grant.

The importance of an ethics curriculum in surgical education.

The nature of surgical work provides fertile ground in which ethical problems can grow. The concept of what it means to be a "good surgeon" includes the ability to reason and deliberate about how the surgeon's unique technical capabilities integrate with larger society. Ethics education at the resident level is important for several reasons. It can ensure that care is delivered in a socially and ethically responsible manner through global and emergent effects on institutions and traditions. It will prepare residents for leadership positions. It can allow residents to confront issues, such as the scientific underdetermination of surgical practice, the application of new technologies to trusting patients that have been developed by for-profit companies, and a surgical environment that is becoming increasingly institutionalized. Resident ethics education provides the opportunity for a model of collective deliberation to be developed that can be used to make sense of ethical problems as they arise.

Teaching Ethics and Professionalism in Plastic Surgery

Maintenance of the highest ethical and professional standards in plastic surgery is in the best interests of our profession and the public whom we serve. Both the American Board of Medical Specialties and the Accreditation Council on Graduate Medical Education mandate training in ethics and professionalism for all residents. Presently there is no gold standard in ethics and professionalism education. A systematic review on teaching ethics and professionalism in plastic surgery was performed for all articles from inception to May 23, 2013 in MEDLINE, Scopus, EMBASE, CENTRAL, and ERIC. References of relevant publications were searched for additional papers. Key journals were hand searched and relevant conference proceedings were also reviewed. Duplicate and non-English articles were excluded. Inclusion and exclusion criteria were applied to find articles that described a curriculum in ethics and/or professionalism in plastic surgery. Two hundred twenty-seven relevant articles were identified. One hundred seventy-four did not meet inclusion criteria based on screening of the title, and 39 of those did not meet inclusion criteria based on screening of the abstract or introductory paragraph. Of the 14 identified for full text review, only 2 articles described a set curriculum in ethics and/or professionalism in plastic surgery training and reported outcomes. A paucity of data exists regarding the structure, content, or relevant measures that can be applied to assess outcomes of a curriculum to teach ethics and professionalism to plastic surgery trainees. Endeavors to teach ethics and professionalism to plastic surgery trainees must rigorously document the process and outcomes to facilitate the maintenance of our profession.