Formation Of Large Groups Research Articles

Parrots live in smaller groups on islands.

Species living on islands are predictably different from their mainland counterparts in morphology and behaviour, but the source of these differences is still debated. Islands, in particular, are characterized by depauperate predator communities. Relaxed predation pressure might explain why living in groups, a common anti-predator adaptation in animals, is considered less likely on islands. However, the empirical evidence for this effect is scant and alternative explanations have been overlooked. For instance, smaller groups might be more common because island species are less studied, because a more stable food supply associated with benign climate on islands favours territoriality, or because the population density is too low to allow the formation of larger groups. I examined the determinants of foraging group size in parrots, a large worldwide avian order with many island populations. Using a multivariable phylogenetic framework, I found that foraging group size was smaller on islands than on the continents controlling for ecological variables known to influence group size such as diet and body size. In addition, the island effect persisted after controlling for research effort, climate variables and population density, suggesting that impoverished predator communities are an important driver of group size on islands.

Development and validity evidence for the resident-led large group teaching assessment instrument in the United States: a methodological study.

Despite educational mandates to assess resident teaching competence, limited instruments with validity evidence exist for this purpose. Existing instruments do not allow faculty to assess resident-led teaching in a large group format or whether teaching was interactive. This study gathers validity evidence on the use of the Resident-led Large Group Teaching Assessment Instrument (Relate), an instrument used by faculty to assess resident teaching competency. Relate comprises 23 behaviors divided into six elements: learning environment, goals and objectives, content of talk, promotion of understanding and retention, session management, and closure. Messick's unified validity framework was used for this study. Investigators used video recordings of resident-led teaching from three pediatric residency programs to develop Relate and a rater guidebook. Faculty were trained on instrument use through frame-of-reference training. Resident teaching at all sites was video-recorded during 2018-2019. Two trained faculty raters assessed each video. Descriptive statistics on performance were obtained. Validity evidence sources include: rater training effect (response process), reliability and variability (internal structure), and impact on Milestones assessment (relations to other variables). Forty-eight videos, from 16 residents, were analyzed. Rater training improved inter-rater reliability from 0.04 to 0.64. The Φ-coefficient reliability was 0.50. There was a significant correlation between overall Relate performance and the pediatric teaching Milestone, r = 0.34, P = .019. Relate provides validity evidence with sufficient reliability to measure resident-led large-group teaching competence.

Pharmacology of Sedating and Anesthetic Agents: A Case-Based Flipped Classroom Exercise for Preclinical Medical Students.

Sedating and anesthetic drugs are widely used in clinical practice; however, relevant teaching remains underrepresented in undergraduate medical education. We developed a 2-hour flipped classroom activity integrating foundational science topics, evidence-based medicine, and clinical reasoning on anesthetic pharmacology for preclinical medical students. Presession, second-year medical students reviewed a study guide and completed a readiness assessment. The flipped classroom session was facilitated in a large-group format with learners in small groups. At session end, students completed a consolidation quiz. Two case-relevant questions were included on the midterm and one on the final exam. Student satisfaction was assessed through an anonymous postsession survey. One hundred ten students participated in the session. Mean performance on the readiness assessment was 96%. Mean performance on the postsession quiz was also 96%. Mean performance on the three midterm and final exam questions was higher than the national mean (94% vs.72%, p < .005). Seventy-six students (69%) completed the survey, with mean satisfaction of 4.6 (SD = 0.7) on a 5-point Likert scale (1 = Strongly Disagree, 5 = Strongly Agree). We developed a flipped classroom session teaching pharmacology of sedating and anesthetic drugs for preclinical medical students. Students performed well on pre- and postsession assessments and above the national mean on National Board of Medical Examiners questions, suggesting adequate knowledge acquisition. This session was found to be a highly satisfactory and effective teaching tool requiring students to integrate foundational and clinical science knowledge.

Beyond Cultural Humility – South Asian Cultural Specificity Training Garners Reform in Medical Curricula: A Workshop for Medical Students of Free Community Clinics

Background: Cultural humility is the notion of keeping an open mind towards learning about various cultural backgrounds of patients to improve health-care quality. Although medical curricula regarding cultural competency exist, a lack of integration creates disparities in culturally-appropriate healthcare. These disparities can be attributed to a lack of medical training to illuminate nuances among patient populations of interest. Educational material on cultural perspectives of the South Asian diaspora is especially limited. This article describes the implementation of a cultural humility workshop that addresses disparities preventing healthcare providers from delivering culturally appropriate care for members of the South Asian population. Methods: A new educational workshop on South Asian cultural humility was virtually presented to 40 medical student volunteers at a free clinic. The workshop was presented in a large-group format, followed by interactive case-based discussions with student facilitators. Cases reinforced participants’ understanding of cultural humility. Student volunteers assessed the workshop with qualitative and quantitative pre- and post-surveys. Results: Paired-sample t-tests across four of five domains of cultural humility reported statistically significant results. Content and thematic analysis showed participant interest in additional training and belief that the case studies solidified their understanding of the topics presented. Conclusions: These results highlight the utility of cultural humility training based on common clinical situations with patients of South Asian origin. It also displays a method to improve patient-provider relationships and to provide patient-centered care. Future endeavors include integrating this workshop into student clinic onboarding programs and optimizing its curriculum placement.

Divergent patterns of meiotic double strand breaks and synapsis initiation dynamics suggest an evolutionary shift in the meiosis program between American and Australian marsupials.

In eutherian mammals, hundreds of programmed DNA double-strand breaks (DSBs) are generated at the onset of meiosis. The DNA damage response is then triggered. Although the dynamics of this response is well studied in eutherian mammals, recent findings have revealed different patterns of DNA damage signaling and repair in marsupial mammals. To better characterize these differences, here we analyzed synapsis and the chromosomal distribution of meiotic DSBs markers in three different marsupial species (Thylamys elegans, Dromiciops gliorides, and Macropus eugenii) that represent South American and Australian Orders. Our results revealed inter-specific differences in the chromosomal distribution of DNA damage and repair proteins, which were associated with differing synapsis patterns. In the American species T. elegans and D. gliroides, chromosomal ends were conspicuously polarized in a bouquet configuration and synapsis progressed exclusively from the telomeres towards interstitial regions. This was accompanied by sparse H2AX phosphorylation, mainly accumulating at chromosomal ends. Accordingly, RAD51 and RPA were mainly localized at chromosomal ends throughout prophase I in both American marsupials, likely resulting in reduced recombination rates at interstitial positions. In sharp contrast, synapsis initiated at both interstitial and distal chromosomal regions in the Australian representative M. eugenii, the bouquet polarization was incomplete and ephemeral, γH2AX had a broad nuclear distribution, and RAD51 and RPA foci displayed an even chromosomal distribution. Given the basal evolutionary position of T. elegans, it is likely that the meiotic features reported in this species represent an ancestral pattern in marsupials and that a shift in the meiotic program occurred after the split of D. gliroides and the Australian marsupial clade. Our results open intriguing questions about the regulation and homeostasis of meiotic DSBs in marsupials. The low recombination rates observed at the interstitial chromosomal regions in American marsupials can result in the formation of large linkage groups, thus having an impact in the evolution of their genomes.

Need of the hour: Student-centered Learning in undergraduate Medical Curriculum

Background: Student-centered learning is becoming more prevalent in medical education, especially during large-group lectures. The variety and abundance of active learning techniques used in first-year MBBS large group format were investigated. Aim: To investigate the relationships between student-centered learning and the characteristics and distribution of student-centered teaching approaches in large group settings. Methods: This was a descriptive exploratory study in which by means of purposive sampling 25 faculty members who were involved in teaching in large and small groups were identified, out of these 25 faculty members, 15 members were chosen for interviews by convenient sampling. Retrospective curriculum evaluations and semi-structured interviews were used to collect the data. The authors tested a taxonomy of student-centered learning strategies and linked those strategies to the characteristics of education. Results: Over the course of six modules in the first year, teachers used 13 different strategies for active learning. 996 out of 1190 hours of large group teaching included a minimum of one active learning element. 83% of the curriculum's hours in the first year of MBBS had an active learning component. Practical implications: Many small group-learning approaches are included in active learning, and they may help undergraduate students achieve a higher level of cognitive skills through group engagement. Different kinds of small-group learning have been shown to be successful in fostering higher academic accomplishment, more positive attitudes toward learning, and enhanced persistence. Conclusions: The frequency and diversity of active learning elements incorporated into the first-year MBBS curriculum show how acquainted faculty are with these techniques and how supportive they are of interactive teaching culture. This research has stimulated discussion about instructional strategies and aided the transition from teacher-centered to learner-centered teaching. Keywords: Student-centered learning, active learning, interactive studies, critical thinking, game-based.

Virtual Classrooms and Their Challenge of Interaction-An Evaluation of Chat Activities and Logs in an Online Course about Digital Medicine with Heterogeneous Participants.

Learning digital competencies can be successful if the information is also tried out immediately using interactive elements. However, interactive teaching poses a particular challenge, especially in large group formats. Various strategies are used to promote interaction, but there is little known about the results. This article shows different strategies and evaluates their influence on the interaction rate in a large group course over two terms that teaches digital medicine. Log files and participation in surveys as well as participation in chat were quantitatively evaluated. In addition, the chat messages themselves were evaluated qualitatively. For the evaluation, relation to the total number of participants was particularly relevant in order to be able to determine an interaction rate in the individual course sessions. A maximum average interaction rate of 90.97% could be determined over the entire term while the participants wrote an average of 3.96 comments during a session in the chat. In summary, this research could show that interactive elements should be well planned and used at regular intervals in order to reap the benefits.

Digital Dissection with CT Scans Enhances Anatomy Education: First‐year Medical Students’ Perception of Radiology Teaching During the Covid‐19 Pandemic

OBJECTIVEThe aim of this study was to evaluate students’ perceptions of the educational value of online, interactive anatomy radiology laboratories.HYPOTHESISDigital dissection is performed with computed tomography (CT) scans on near life‐size anatomy visualization tables and has been used to teach radiology anatomy at our institution. These sessions were pivoted to online delivery in response to COVID‐19. With the ongoing movement towards technology integration in medical education, if home access to these online laboratories is made available then we hypothesize the perceived learning experience should be preserved.METHODS290 first‐year medical students participated in 10 weekly digital radiology anatomy laboratories, which employed 3D CT scans to emphasize the clinical applications of anatomy. Students reviewed the cases at home prior to the lab on a mobile platform and labs were delivered synchronously via the Zoom platform in a facilitated large‐group format. After the course, a voluntary anonymous online survey was distributed assessing learner satisfaction, task value, emotional achievement, and cognitive load.RESULTSSurvey response rate was 44%. Most participants reported the labs improved their knowledge of anatomy (82%), disease (81%) and clinical decision making (65%), including surgical knowledge (76%). The large group, synchronous learning format was found to be the most effective (68%). Positive emotional achievement was reported (mean 2.98). The extraneous cognitive load of the at‐home mobile technology and lack of time were perceived as the greatest programmatic challenges.CONCLUSIONSynchronous digital dissection labs were perceived as a valuable addition to the first‐year medical curriculum, enhancing learners’ clinical decision making and preparation for medical sub‐specialties. This format of radiology anatomy education can be integrated into blended learning environments to provide students with additional learning opportunities.

Taking the VITALS to Interrupt Microaggressions.

IntroductionMicroaggressions are subtle statements or actions that reinforce stereotypes. Medical students, residents, and faculty report experiences of microaggressions, with higher incidences among women and marginalized groups. An educational tool utilizing the acronym VITALS (validate, inquire, take time, assume, leave opportunities, speak up) provided a framework for processing and addressing microaggressions encountered in the academic health center environment.MethodsWe developed a 60-minute workshop designed to raise awareness of microaggressions encountered by medical students and trainees. The workshop consisted of a didactic presentation and multiple interactive exercises shared in small- and large-group formats. Participants also completed pre- and postsurvey instruments to assess changes in their knowledge and attitudes about promoting an environment that prevents microaggressions from occurring.ResultsThere were 176 participants who completed our workshop. In comparing anonymized pre- and postworkshop responses submitted by attendees, an increase in recognition of one's own potential stereotypical beliefs about social identity groups was observed. Participants also expressed a greater sense of empowerment to foster mutual respect in health care settings. After completing the workshop, attendees indicated a greater likelihood to engage in difficult conversations, including responding to microaggressions, which both peers and superiors encountered in both academic and clinical environments.DiscussionThe workshop provided an interactive format for medical students and trainees to gain awareness, knowledge, and tools for addressing microaggressions encountered in health care settings.

A Four-Year Longitudinal Curriculum to Improve Feedback-Seeking Behaviors for Medical Students

Introduction: Feedback is essential for performance improvement and plays a pivotal role in competency-based medical education. Medical learners need training to acquire skills to effectively seek feedback for their unique situations. Methods: We developed a 4-year longitudinal curriculum designed to encourage feedback-seeking by medical students. The 4.5-hour curriculum consisted of interactive lectures, feedback-seeking surveys, trigger videotapes, and peer-group discussions in small- and large-group formats. A volunteer study cohort (n = 14/37, 38%) was interviewed in 4 separate waves in individual and focus-group formats to explore perceptions about feedback-seeking and effectiveness of the curriculum. Results: Themes and student quotes related to the learning objectives were summarized. The students expressed appreciation for the value of seeking feedback. They appreciated the techniques they learned and the frequent reminders. They particularly appreciated the opportunities to share successes and failures related to feedback-seeking with their peers. Discussion: Our novel feedback-seeking curriculum supported students’ understanding of the importance of feedback and their effective use of multiple feedback-seeking techniques. The longitudinal component supports greater opportunity for building space in the curriculum, incorporating reflection and reinforcement, and creating capacity for student application and technique refinement. Conclusions: Teaching students feedback-seeking through various techniques tailored for their unique situations, rather than waiting to potentially receive feedback, is important for their professional development and overall medical education.

A Proposed Systematic Approach to the Cognitive Autopsy for Internists.

The cognitive autopsy has been a proposed tool for physicians to evaluate misdiagnosis. However, prior iterations of this tool are cumbersome, not designed for the internist, and may cause users to isolate cognition from systems issues. A 10-point tool was created to be utilized individually or by a group when evaluating an adverse event. This could be used with Croskerry’s 2020 “cognitive autopsy” or as a standalone tool for internists. We trialed this tool in large group formats and with individual residents; all reported an improved appreciation of the factors leading to poor outcomes and medical errors.

Developing Poetry as a Research Methodology with Rarer Forms of Dementia: Four Research Protocols

People living with rarer forms of dementia tend to have progressive cognitive symptoms affecting skills other than memory and/or onset before the age of 65 years. They are often misdiagnosed and due to symptom profile or age of onset, do not usually fit well with care pathways designed for older people with typical Alzheimer’s disease or vascular dementia. Although the arts have been increasingly used as interventions to support people with dementia, there is very little attention given to rarer dementia forms in arts and health research or practice. The objective of the present international study seeks to systematically explore four diverse forms of poetry writing within this population through virtual and in-person small and large group formats. Our approach includes investigating poetic processes as methodology through the lens of an arts-based methodological approach in order to explore how poems construct knowledge and a felt experience. We will also use more traditional qualitative approaches to understand the experience of writing, reading and listening to poetry as an intervention that can be used with different rarer forms of dementia. To the best of our knowledge, this will be the first study to explore poetry using multiple research protocols. The results will have implications for methodology development, co-constructed poetic inquiry and multiple opportunities for involving poetry in supporting people with dementia and family members.

Use of the Delphi method to develop a guideline-based geriatric oncology gap assessment.

236 Background: Older adults are more likely to be diagnosed with cancer than their younger counterparts. Because the underlying health status of older adults with cancer is generally heterogeneous, geriatric assessment (GA) is helpful for uncovering age-related vulnerabilities and guiding subsequent care planning. GA provides multidimensional, multidisciplinary evaluations of pertinent health domains. When used to evaluate an older adult with cancer prior to initiating therapy, GA and screening tools can help oncologists differentiate between fit and frail patients and tailor their treatment accordingly. Methods: The Association of Community Cancer Centers (ACCC) conducted a 4-round Delphi method to achieve expert consensus (≥75%) related to 9 domains of geriatric oncology care from a multidisciplinary perspective. A survey was conducted with 70 international clinicians working in geriatric oncology to assess perspectives on guideline-recommended GA tools in clinical practice. Facilitator led focus groups were conducted to review the results in a large group format and come to consensus. Aggregated results were shared back with the group to ensure effective capture of group discussion regarding validated clinical practice tools to include as resources in the gap assessment instrument. Results: A 32 question geriatric oncology gap assessment was developed in an online survey platform. This tool was beta tested by 30 individuals at cancer programs of various types and regions across the US. A final version was published and made accessible for multidisciplinary teams to self-assess care delivery for older adults with cancer in 9 domains: Functional Status; Cognition; Comorbidities; Decision Making: Screening, Life Expectancy, Chemo Toxicity; Pharmacy/Medication Management; Psychological Health; Nutrition; Patient Goals and Needs; and Communication and Workforce Training. Within each domain, respondents select the level (see Table) that most closely represents the practice(s) at their institution. A personalized report is generated. Sample Question. Conclusions: The ACCC geriatric oncology gap assessment offers cancer programs a validated way to evaluate care delivery for older adults with cancer. To optimize workflow, cancer programs should consider utilizing gap assessment results to develop and advance scalable quality improvement programs at their institution, taking into consideration resource level and infrastructure.[Table: see text]

The Politics of Language in Constructing Civil Identity: Case of Bosnia and Herzegovina

Civil identity is one of the most significant factors in modern political practice. Today’s identity formation and development of large national groups is less based on a cultural and historical foundation and increasingly depends on political technologies. Among them, the construction of new languages plays an important role. The article studies the Bosnian language policy, which, contrary to forming a common civil identity, as a result of the politicization of linguistic norms becomes a factor in creating a “forge of hatred”. Drawing on constructivist social theories, the author summarizes Bosnian linguistic practices and examines them through the prism of symbolic interactionism and negative feedback systems. Particular attention is paid to situations when the desire for effective communication motivates speakers to abandon ethnically colored linguistic markers and situations in which the language acts as a defense against the internal “other.” Applying the criteria for distinguishing between language and dialects, the author concludes that the phonetic principle of the Serbo-Croatian language formation made it possible, after the destruction of Yugoslavia, to turn this linguistic continuum into an identification weapon to delimit the citizens of one country. This experience helps analyze the politicization of literary interpretations and linguistic norms in other regions of the world, where there are also examples of the growth of xenophobia, nationalism, and intolerance resulting from a differentiating language policy.

Instructional Coaching Cycles and Career and Technical Educators’ TPACK

Most professional development occurs in a large group format. In most cases, there is little to no application or continued support for teachers. All teachers, particularly those in career and technical schools, struggle to implement newly learned strategies related to technology, pedagogy, and content knowledge (TPACK) with this type of support. A review of the literature proves that through the support of instructional coaches, teachers can improve their practice through sustained professional learning with a coaching peer. The study followed six, secondary teachers from a comprehensive career and technical school who participated in instructional coaching cycles to improve technology, pedagogy, and content knowledge (TPACK) in their classrooms. Results from the study suggest the utility of instructional coaching as a means of helping educators develop enhanced TPACK.

Groepsidentificatie en cognitie

Abstract Group-identification and cognition: Why trivial conventions are more important than we think In existing (evolutionary) explanations for group formation and -identification, the function of cultural conventions such as social etiquette and dress codes is limited to providing group-markers. Group formation and identification itself is explained in terms of less arbitrary and more substantial phenomena such as shared norms and institutions. In this paper I will argue that, however trivial and arbitrary, cultural conventions fulfil an important cognitive function that makes them essential to the formation of and identification with large groups. Complex role-division, both informal and institutional, is important in the functioning of any large group of people. Shared conventions enable a virtually automatic understanding of signals, scripts and rules that regulate the interaction of divided roles. They provide a cultural infrastructure within which we perceive e.g. specific behavior and clothing as a range of social-cultural affordances for role-interactions. Shared familiarity with this infrastructure is the foundation for the basic kind of trust of in-group strangers that is a requirement for the formation of large groups. This non-intellectualist view on group formation and group identification can contribute to new ways of dealing with problems in multicultural societies.

Structures Virtual Review Sessions in a Large‐Group, Interactive Format: a creative solution born from COVID‐19 restrictions.

PurposeFirst‐year medical students (M1s) at the Icahn School of Medicine at Mount Sinai begin their year with Structures course, which opens their medical education, covering gross anatomy, embryology, and histology. Second‐year medical students (M2s) serve as teaching assistants (TAs) for this course and their responsibilities include leading comprehensive review sessions prior to each set of exams. Historically, such reviews have taken place in small‐group classrooms, with groups of 10‐18 M1s rotating through a series of rooms, each hosting a rapid‐fire review of a specific topic, conducted by several TAs. In 2020, the virtual setting imposed by COVID‐19 restrictions demanded creativity to rethink the format of these review sessions, leading to the implementation of a large‐group, interactive format, with all M1s in the same remote video session, covering material at a slower pace. We here examine the effectiveness of this large‐group, interactive format. Methods: The first two review sessions of Structures 2020 mimicked the traditional style, with groups of M1s rotating through a series of 20‐minute Zoom sessions led by M2s TAs. For the last two review sessions, all students remained in one 3‐hour Zoom session, and TAs covered certain material at certain times, with more or less time allotted depending on the difficulty and amount of material. TAs also incorporated more interactivity with real time quizzes on high‐yield topics and direct practical questions through the review. We surveyed M1s regarding which format they preferred and also solicited qualitative feedback from M1s and TAs throughout Structures. Results: 55% of M1s preferred the large‐group format, with 23% preferring the traditional format and 23% expressing no preference. Many TAs also expressed preferences for the large‐group format. Qualitative feedback from M1s indicated that they appreciated the interactivity with quizzes and practical questions. Conclusion: In the remote environment, most students preferred a large‐group, interactive format over the small‐group rotation format. Main advantages observed were: 1) time flexibility: complex components of the session addressing challenging topics were covered more extensively and in‐depth; 2) In the large group, all M1s experience the session equally, including the answers to all questions from their classmates. Such interactivity is not compatible with the small group format and can be challenging in its compressed timeframe. 3) optimization of M2 TAs workforce: in the large session TAs are assigned with a section of the review and lead the review of their only once, for a short period of time, while in the small group format, TAs are required to repeat the review of their topic multiple times. The effectiveness of this format may have implications once in‐person instruction resumes; for example, review sessions could be conducted in a lecture hall, in an in‐person setting, or virtually, in a hybrid learning system, to facilitate the advantages of the large‐group interactive format.

Teaching Trauma-Informed Care: A Symposium for Medical Students.

A large body of evidence links exposure to childhood trauma with negative health outcomes. Training future physicians to recognize and respond to trauma is paramount, and engaging medical students in the preclinical years affords the opportunity to foster the development of a trauma-informed lens that can then be solidified during clinical clerkships. We developed and implemented a 4-hour trauma-informed care (TIC) symposium for 179 second-year medical students at the George Washington University School of Medicine and Health Sciences during the Patients, Populations, and Systems course. The symposium included three interactive didactic sessions focusing on the connection between trauma and health and TIC principles. A facilitated small-group discussion allowed students to apply TIC principles to a patient case, followed by reflection and evaluation. The overall rating of the TIC symposium was 4 out of 5. Strengths included integration of a small-group case with discussion on application of TIC in practice, experience of the lecturers and small-group facilitators, and review of research relating adversity to specific health outcomes. Suggestions for improvement included incorporating role-play and standardized patients. Content analysis of student reflections mapped to the domains of physician competency. A 4-hour symposium can affect student knowledge and understanding of TIC. Teaching TIC presents an opportunity to prepare medical students for a career in medicine through cultivation of required physician competencies. Next steps include enhanced opportunities to practice TIC and follow-up analysis of participants to determine behavior change during clinical years.

Mujeres en las composiciones de tierra en Zacatecas durante el siglo XVII

This article focuses on the participation of women in the formation of large territorial groups in Zacatecas during the seventeenth century. Investment in agro-livestock production could be managed by women with more ease than mining investments, reason why we found some examples of large owners who managed their investments in this sector very closely. &nbsp;

Scaling Up Behavioral Skills Training: Effectiveness of Large-Scale and Multiskill Trainings.

We used behavioral skills training (BST) to teach multiple skills to 2 cohorts of 18 participants. BST consisted of the standard 4 components: (a) didactic instruction, (b) modeling, (c) role-play, and (d) feedback, modified to be delivered in a large-group format. All components were provided by 1 trainer, simultaneously to all participants, with peers delivering feedback during role-plays. Across 4 targeted skills (e.g., discrete-trial teaching), the average performance of Cohort 1 improved from less than 60% correct implementation in baseline to a performance of between 85% and 100% correct, across participants, following BST. We used social validity data collected from Cohort 1 to modify the length of instruction across skills for Cohort 2. BST was similarly effective for Cohort 2, with a decrease in the additional training required for trainees to demonstrate the skill in a novel role-play scenario or with a client. Implications for effectively scaling up BST are discussed.