Outpatient Education Research Articles

Pediatric Outpatient Teaching Clinics in Healthcare Networks: Enhancing Medical Education and Patient Care

Pediatric Outpatient Teaching Clinics in Healthcare Networks: Enhancing Medical Education and Patient Care

What Happened to Simulation-Based Education in Outpatient Setting in The 21st Century: A Scoping Review.

Simulation-based education (SBE) is an instructional approach that aims to accurately recreate real-life scenarios and engage learners in the practical application of lesson content. By replicating critical elements of clinical situations, SBE facilitates a deeper understanding and better preparation for managing such conditions in actual clinical practice. SBE offers promising prospects for improving medical education and patient care in various settings, such as outpatient clinics. Therefore, this scoping review aims to determine to what extent the most effective components and standards of the simulation have been considered in outpatient education. The present scoping review adheres to the guidelines outlined in the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist" and the "Joanna Briggs Institute (JBI) Reviewers' Manual". This review focused on articles that specifically focused on the use of simulation in outpatient education. Google Scholar, PubMed, Scopus, Embase, and ERIC were searched for keywords related to simulation, ambulatory care, outpatient clinics, and medical education from January 1, 2001, to August 12, 2023. The search indicated 513 articles, which were narrowed down by title and abstract relatedness. Twenty-nine articles entered the study's second phase, and after reviewing their full text, nine articles that explicitly reported simulation use in outpatient education remained. Based on the findings of eligible articles, the ten most frequent components of SBE that should be considered and followed discussed. These features were training facilitators, pre-briefing sessions, the type of simulation techniques, the site of simulation participation, the simulation duration, unit of participation, extent of direct participation, Simulation fidelity, feedback, and debriefing and reflection. SBE is a contemporary method of practical training for medical students that involves realistic modeling or simulation of clinical situations. It enhances learning effectiveness and provides a safe, educational atmosphere for teaching and learning. Designing simulations adhering to established standards and carefully considering essential components improves efficiency and effectiveness.

MITE Monthly Tip January 2024 Letting the Learner Lead: Utilizing the SNAPPS method for outpatient teaching

MITE Monthly Tip January 2024 Letting the Learner Lead: Utilizing the SNAPPS method for outpatient teaching

The Impact of Palliative Care on Mitigating Pain and Its Associated Effects in Determining Quality of Life among Colon Cancer Outpatients.

Pain continues to be a significant problem for cancer patients, and the impact of a population-based strategy on their experiences is not completely understood. Our study aimed to determine the impact of palliative care on mitigating pain and its associated effects in determining the quality of life (QoL) among colon cancer outpatients. Six collection databases were used to perform a structured systematic review of the available literature, considering all papers published between the year 2000 and February 2023. PRISMA guidelines were adopted in our study, and a total of 9792 papers were evaluated. However, only 126 articles met the inclusion criteria. A precise diagnosis of disruptive colorectal cancer (CRC) pain disorders among patients under palliative care is necessary to mitigate it and its associated effects, enhance health, promote life expectancy, increase therapeutic responsiveness, and decrease comorbidity complications. Physical activities, the use of validated pain assessment tools, remote outpatient education and monitoring, chemotherapeutic pain reduction strategies, music and massage therapies, and bridging social isolation gaps are essential in enhancing QoL. We recommend and place a strong emphasis on the adoption of online training/or coaching programs and the integration of formal and informal palliative care systems for maximum QoL benefits among CRC outpatients.

Awareness of high and pathological myopia among myopic patients in China: A cross‐sectional multicenter survey

AbstractThis study aimed to investigate the awareness of high and pathological myopia among patients with high myopia. A cross‐sectional multicenter survey involving both physicians and patients was conducted between February and April 2021. The outpatient education status, doctors' expectations toward patient education, patients' awareness of high/pathological myopia, and their access to relevant knowledge were inquired, and the proportions of patients with myopia, including high and pathological myopia, were assessed. In total, the survey involved 6975 physicians and patients with myopia from 161 medical institutions in China. The prevalence of high myopia among patients was 11.3%, with 22.59% having pathological myopia. Among those with pathological myopia, 22.45% experienced high myopia complications. Approximately 48.7% of the physicians believed that patients had only a vague idea about high/pathological myopia, with certain misconceptions. Additionally, most outpatients (61.4%) had no access to specialized staff for patient education. Patients' preferences and requirements for online ophthalmology information varied based on family background, medical history, and cognition toward myopia. This study demonstrated that the awareness level among patients with myopia regarding high and pathological myopia is currently insufficient. Therefore, it is important to enhance education efforts to reduce the incidence of adverse outcomes.

Outpatient education, a momentous in clinical education: a qualitative study of medical students’, faculty members’, and residents’ perspectives

BackgroundEven though a lot of scholars have been looking at outpatient education lately because it has become more popular and they want to know about its successes, failures, and problems, we have not been able to find a complete study. Therefore, our study aims to gain a deeper understanding of the various aspects of outpatient education based on the actual experiences of medical students, faculty, and residents.MethodsFace-to-face and semi-structured interviews were used to collect data for this qualitative study. Until data saturation was reached, the interviews continued. A total of 21 participants from Shiraz University of Medical Sciences, including medical students, residents, and teachers, were enrolled. The Guba and Lincoln-first written standards for scientific accuracy in qualitative research were used to figure out how reliable the data were.ResultsFourteen categories were extracted from four main themes. The results show that four categories: “physical space and equipment,” “prerequisites related to the curriculum,” “teaching skills development,” and “near-peer teachers” should be considered for outpatient education preparation. Theme 2, “implementation requirements,” included “student dimension,” “faculty’s commitment to planning,” and “program supervision.” Theme 3, “challenges of outpatient education,” was described by five related categories, including “curriculum implementation challenges,” “student challenges,” “faculty challenges,” “system-related challenges,” and “patient-related challenges.” Finally, two categories emerged about facilitators of outpatient education: internal and external facilitators.ConclusionOutpatient clinics represent a crucial aspect of medical practice. To effectively leverage this resource, preliminary planning, considering all the prerequisites, paying attention to the implementation requirements, getting to know the challenges, and trying to solve them, especially with incentives, are essential.

Near-Peer Supervision in Primary Care: Bringing Teaching Teams From the Wards to the Clinic.

Teaching near-peers yields numerous benefits to residents. Opportunities for near-peer teaching are typically restricted to hospital settings. Little is known about the educational potential of outpatient near-peer teaching. To describe Primary Care Teaching (PC Teach), a novel outpatient near-peer teaching experience for residents in a large, urban, internal medicine residency program; characterize its feasibility and acceptability; and evaluate changes in residents' self-reported confidence in outpatient teaching and attitudes toward teaching and primary care/outpatient medicine. In 2020-2021, following a didactic workshop, 43 postgraduate year 3 (PGY-3) residents at continuity clinics assigned to PC Teach completed a series of half-day sessions acting as preceptor to interns under attending supervision. Worksheets facilitated post-session feedback for residents and interns. Eighteen PGY-3s at nonparticipating clinics, who also completed the workshop, served as controls. We assessed process measures for feasibility and acceptability and analyzed resident attitudes using pre-post surveys. Participating residents completed 2 to 8 sessions each. Post-intervention scores for confidence in outpatient teaching and attitudes toward teaching were greater, relative to pre-intervention group means, for intervention residents (median pre-post changes +0.60 [IQR 0.26, 1.26] and +0.46 [-0.04, 0.46], respectively) vs controls (-0.15 [-0.48, 0.85] and -0.36 [-0.86, 0.39]; between-group differences +0.75 [P=.03] and +0.82 [P=.02]). Changes in attitudes toward primary care/outpatient medicine did not differ significantly between intervention and control groups (+0.43 [-0.07, 0.68] and 0.04 [-0.58, 0.42]; between-group difference +0.39 [P=.12]). In multivariable analyses, odds of gains in confidence in outpatient teaching remained significantly larger for intervention residents vs controls. Implementing PC Teach with existing resources was feasible and acceptable, with program flexibility highlighted as a strength. Resident participation was associated with greater confidence in outpatient teaching.

A day-to-day management model improves patient compliance to treatment for Helicobacter pylori infection: a prospective, randomized controlled study

BackgroundThe day-to-day (DTD) management model encourages patients to actively participate in their healthcare by setting goals. We determined the effectiveness of the DTD model in the treatment of Helicobacter pylori (H. pylori) infection, as compared with conventional outpatient education (OE).MethodsWe randomized 254 H. pylori-positive patients into a DTD group (127 patients) and an OE group (127 patients) prior to primary treatment with 14-day bismuth-containing quadruple therapy, including esomeprazole, amoxicillin, and clarithromycin. Both groups received consistent medication instructions. Patients in the DTD group recorded daily attendance after completing their daily medication plan from day 1 to day 14. The medication compliance, follow-up compliance, H. pylori eradication rates, and adverse events (AEs) were evaluated.ResultsIn the modified intention-to-treat (MITT) and per-protocol (PP) analyses, the DTD group showed significantly higher medication compliance than the OE group (P = 0.001 and P = 0.031, respectively). Both the MITT and PP analyses showed significant differences in follow-up compliance (P < 0.001 and P = 0.003, respectively) and timing of the review urea breath test (P < 0.001 and P = 0.001, respectively) between the two groups. However, no significant differences were observed in the H. pylori eradication rates (95.8% vs. 93.8%, P = 0.529) in the PP analysis, or AEs incidence (25.4% vs. 28.3%, P = 0.603) between the two groups.ConclusionThis study demonstrated the novel application of the DTD model in the treatment of H. pylori infection, which enabled patients to develop habitual medication-taking behaviors without physician intervention.

The Early Effects of the Coronavirus Disease-19 Pandemic on Pediatric Resident Education: A National Assessment.

Residency programs must ensure resident competence for independent practice. The coronavirus disease-19 (COVID-19) pandemic disrupted health care delivery, impacting pediatric residencies. This study examines the impact on pediatric resident education. The authors conducted a mixed methods national survey of pediatric residency program directors (PDs) from May 2020 to July 2020. Data analysis included descriptive statistics, chi-square, and Wilcoxon rank sum tests. Multivariable modeling identified factors associated with resident preparation for more senior roles. Thematic analysis was performed on open-ended questions about PD COVID-19 pandemic recommendations to peers, Accreditation Council for Graduate Medical Education and American Board of Pediatrics. Response rate was 55% (110/199). PDs reported the COVID-19 pandemic negatively affected inpatient (n=86, 78.2%), and outpatient education (n=104, 94.5%), procedural competence (n=64; 58.2%), and resident preparation for more senior roles (n=50, 45.5%). In bivariate analyses, increasingly negative impacts on inpatient and outpatient education were associated with an increasingly negative impact on resident preparation for more senior roles (P=.03, P=.008), these relationships held true in multivariable analysis. Qualitative analysis identified 4 themes from PD recommendations: 1) Clear communication from governing bodies and other leaders; 2) Flexibility within programs and from governing bodies; 3) Clinical exposure is key for competency development; 4) Online platforms are important for education, communication, and support. The COVID-19 pandemic negatively impacted inpatient and outpatient education. When these were more negatively impacted, resident preparation for more senior roles was worse, highlighting the importance of competency based medical education to tailor experiences ensuring each resident is competent for independent practice.

1038-P: Evaluation of an Outpatient Pathway for Management of Pediatric Patients with New-Onset Diabetes

Background: Education and management for new onset diabetes (NOD) does not always require hospitalization. A pathway for outpatient management of pediatric NOD patients after initial evaluation and long-acting insulin dose in the emergency department was developed at a tertiary academic medical center. Methods: A multidisciplinary team identified key initial eligibility criteria for outpatient NOD management including absence of DKA, age ≥3 years, and beta-hydroxybutyrate (BOHB) &amp;lt;1 mmol/L. Data tracking, chart review, and endocrine provider surveys determined reasons for exclusion or non-participation. Control charts tracked and analyzed monthly utilization. Refinement of the pathway occurred through iterative PDSA cycles. Results: The pathway launched in September 2020. To date, 58 eligible children (33%) have completed the pathway (monthly median 33%). One patient was hospitalized after newly identified social concerns. Increase of BOHB cut-off to 1.5 mmol/L and option of rapid-acting insulin bolus for borderline BOHB resulted in significant shift in utilization from mean 23% to 41%. Barriers to participation include limited space availability, weekend presentation, and patient/family refusal. Conclusion: Data suggest that outpatient management is feasible for select patients with NOD but requires flexible resources and supportive patient messaging regarding outpatient education. Disclosure S.Azova: None. E.Rhodes: None. C.Baskaran: None. S.Einis: None. J.A.Fortin: None. M.Silva: None. K.Aamodt: None. B.G.Ethier: None. S.Nanavati: None. K.Garvey: None.

AntibiogramDSM: a combined local antibiogram and educational intervention.

To describe the development of a combined local antibiogram and assess its utility in an educational intervention. Retrospective analysis of a combined, multi-healthcare system antibiogram with an educational intervention and pre-post analysis. Creation of the combined antibiogram included all health systems in Des Moines, Iowa. The educational intervention was delivered live via webinar and remained available on demand for one year. The combined antibiogram participants included four health systems representing eight hospitals. The educational intervention included 45 healthcare providers (15 live, 30 on demand) who elected to participate. Yearly antibiograms were collected from four health systems for 2017 and 2018 and from three health systems for 2019 and 2020. Each was aggregated into a single antibiogram, posted online, and analyzed retrospectively. In 2021, an educational intervention took place, which included pre-educational assessments, a one-hour presentation on local resistance rates and impact on common infections, and post-education assessments. The educational session was available online for one year. Correct responses before and after education were compared using NcNemar's test. Over 4 yr, 123,168 isolates were included in the antibiogram, representing 57 species and 46 tested antibiotics. Before education, prediction of local resistance rates for E. coli and S. pneumoniae was poor. After the education session, there was improvement in the proportion of correct responses to case-based questions: pneumonia (31.8% vs 58.8%, P = 0.022), UTI (47.7% vs 85.3%, P < 0.001), sinusitis (75% vs 91.2%, P = 0.109), and diverticulitis (43.2% vs 88.2%, P = 0.002). A combined local antibiogram was useful in supporting an outpatient education program.

Advantages and Challenges of Virtual Outpatient Education: A Review Article

This study reviews articles published in the last two decades to determine the pros and cons of virtual outpatient education for undergraduate medical students and residents. A review of articles published between 2001 and 2021 in PubMed, Scopus, ERIC, and google scholar databases. Keywords for this search were: Ambulatory care/Outpatient clinics and education, and medical/internship and residency. The emphasis of this study was on the implementation of any kind of E-learning in outpatient clinics. Out of 5100 in the initial monitoring, 168 articles were reviewed based on the full text. Finally, information on 11 articles was extracted. Results were summarized in 4 areas: methods and tools used in e-learning, benefits of e-learning, challenges and limitations of e-learning, and student support. The main methods used were telemedicine via video conferencing and telephone calls, especially for residents. Other were virtual clinics with a simulated patient, as well as online educational modules. The main preponderances were: increasing knowledge and skills of telemedicine, improving medical knowledge and skills, access to educational resources even during patients visit, the possibility of learning at any time and place, and betterment of the quality of care. The main challenges were lack of technological literacy and lack of Internet access for some patients, time-consuming entry of patient information for students, reduction of clinical experiences, the unfeasibility of acquiring full skills in performing physical examinations, or some technical and procedural skills and hardware/software technological problems. Regarding student support, the main activity includes holding orientation sessions on new approaches for trainees. Due to the urgency of using virtual outpatient education in the corona era, it is predicted that in the post-corona era, we will see a tendency to use this method by stakeholders. Certainly, citing the results of original articles and reviewing them, similar to the present study, can make it possible to implement qualified E-learning innovation in clinics with quality in the future.

Using Learning Analytics to Examine Differences in Assessment Forms From Continuous Versus Episodic Supervisors of Family Medicine Residents.

It is assumed that there is a need for continuity of supervision within competency-based medical education, despite most evidence coming from the undergraduate medical education rather than the graduate medical education (GME) context. This evidence gap must be addressed to justify the time and effort needed to redesign GME programs to support continuity of supervision. To examine differences in assessment behaviors of continuous supervisors (CS) versus episodic supervisors (ES), using completed formative assessment forms, FieldNotes, as a proxy. The FieldNotes CS- and ES-entered for family medicine residents (N=186) across 3 outpatient teaching sites over 3 academic years (2015-2016, 2016-2017, 2017-2018) were examined using 2-sample proportion z-tests to determine differences on 3 FieldNote elements: competency (Sentinel Habit [SH]), Clinical Domain (CD), and Progress Level (PL). Sixty-nine percent (6104 of 8909) of total FieldNotes were analyzed. Higher proportions of CS-entered FieldNotes indicated SH3 (Managing patients with best practices), z=-3.631, P<.0001; CD2 (Care of adults), z=-8.659, P<.0001; CD3 (Care of the elderly), z=-4.592, P<.0001; and PL3 (Carry on, got it), z=-4.482, P<.0001. Higher proportions of ES-entered FieldNotes indicated SH7 (Communication skills), z=4.268, P<.0001; SH8 (Helping others learn), z=20.136, P<.0001; CD1 (Doctor-patient relationship/ethics), z=14.888, P<.0001; CD9 (Not applicable), z=7.180, P<.0001; and PL2 (In progress), z=5.117, P<.0001. The type of supervisory relationship impacts assessment: there is variability in which competencies are paid attention to, which contexts or populations are included, and which progress levels are chosen.

The positive and negative impacts of the COVID-19 pandemic on the European Council on Chiropractic Education accredited programs: A mixed methods audit and thematic analysis.

The objectives of this study were to: (1) determine the impact of COVID-19 on the operations within the 9 sections of the European Council on Chiropractic Education (ECCE) 'Standards'; (2) identify specific rapid changes to the programs; and (3) identify positive changes that will continue post-pandemic. This was a mixed methods audit and thematic analysis of data from interviews conducted via a cloud-based video conferencing tool with program leaders of the ECCE accredited institutions. A validated questionnaire designed around ECCE's "Standards" was used, consisting of 3 sections: (1) Severity of the COVID-19 impact on each ECCE Standard section; (2) Description of program changes made for each section; (3) Identification of positive changes continuing post-pandemic. Descriptive statistics were calculated for Part 1 and compared for significant differences via the Kruskal-Wallis test. Verbal responses to Parts 2 and 3 were evaluated independently by 3 researchers using a modified "thematic analysis" approach. Final thematic categories and themes were agreed upon by the researchers. There was a 100% response rate. Outpatient teaching clinics were most severely affected, followed by teaching chiropractic technique courses. Curricular structure and duration and program management were least affected (p =.033). Four thematic categories were identified: Extreme Stress, Courses Most Severely Affected, Integrity of Examinations and Assessments, and Positive Changes That Will Continue. Final-year students were most negatively impacted due to restricted opportunities in outpatient clinics. Integrity of examinations was also a problem. Positive, innovative teaching materials and methods were quickly developed and should continue.

Management of Type 1 Diabetes in Children in the Outpatient Setting.

Management of Type 1 Diabetes in Children in the Outpatient Setting.

Stakeholder Engagement In a Comparative Effectiveness/Implementation Study to Prevent Staphylococcus Aureus Infection Recurrence: CA-MRSA Project (CAMP2).

Methicillin-resistant or methicillin-sensitive Staphylococcus aureus skin and soft tissue infections pose serious clinical and public health challenges. Few protocols exist for outpatient education, decolonization and decontamination. This trial implemented infection prevention protocols in homes via community health workers/Promotoras. We engaged clinicians, patient stakeholders, clinical and laboratory researchers, New York-based federally qualified health centers and community hospital emergency departments. The Clinician and Patient Stakeholder Advisory Committee (CPSAC) convened in person and remotely for shared decision-making and trial oversight. The intervention trial consented participants with skin and soft tissue infections from Methicillin-resistant Staphylococcus aureus or methicillin-sensitive Staphylococcus aureus, completed home visits, obtained surveillance cultures from index patients and household members and sampled household environmental surfaces at baseline and three months. The retention of the CPSAC during the trial demonstrated high levels of engagement. CPSAC was highly effective throughout design and execution by troubleshooting recruitment and home visit challenges.

Service quality in outpatient teaching hospital pharmacies based on the SERVQUAL model: An assessment in the south of Iran.

The present study assessed the quality of services in the outpatient teaching hospital pharmacies affiliated to Shiraz University of Medical Sciences, Iran, in 2019 according to the SERVQUAL model to identify areas for improvement. The research was cross-sectional, descriptive and analytical. Patients referred to the outpatient teaching hospital pharmacies affiliated to Shiraz University of Medical Sciences formed the study population. The sample size was 300 people chosen through the stratified sampling method proportional to the size as well as the convenience sampling method. The modified SERVQUAL questionnaire developed by Mohammadi et al. (in Eftekhar Ardabili H, Akbari Haghighi F, Mahmoudi M, Poorreza A. Evaluation of service quality based on the patients' expectations and perceptions in Zanjan hospitals. J Sch Public Health Inst Public Health Res. 2003;2:71-84) was used for data collection. Data analysis was performed by SPSS 24.0 using statistical tests of paired t-test, independent t-test and ANOVA. A P-value of <0.05 showed statistical significance. Moreover, EXCEL 2013 was used to draw the graphs. The results showed that the participants had higher expectations regarding the quality of pharmacy services in all six dimensions compared to their perceptions (negative gaps) and the difference was statistically significant (P <0.05). The largest gap was in the 'access' dimension (G = -0.44 ± 1.15) and the smallest one was in the 'reliability' dimension (G = -0.21 ± 1.30). Also, the mean of overall quality gap, among the patients' demographic characteristics, had a significant relationship only with having supplementary health insurance coverage (P = 0.03). It seems that hospital managers and technical managers of pharmacies should make several interventions in the field of staff empowerment and training empathy and teamwork skills. Also, strengthening the system of receiving quick and easy feedback from patients and paying attention to the voice of customers can pave the way for hospital managers and technical managers of pharmacies to enhance the service quality with subsequence reduction of the existing gaps.

Outpatient teaching in specialist practices - a qualitative study with doctors about attitudes, influencing factors and specialist features.

The aim is to record existing attitudes, influencing factors and specialised requirements with regard to the training of medical students in specialist outpatient care with doctors working in outpatient care. Between September 2020 and May 2021, individual interviews with 15 specialists employed in outpatient care were held as part of this qualitative study. The recorded interviews were evaluated structurally in accordance with the Kuchartz method. Enhanced outpatient training for medical students in specialist teaching practices was considered as important by all participants. Among other things, motivational factors were pleasure in teaching, a feeling of duty, the desire to pass something on, the need to convey one's own ideas and to generate future talent for the field. A lack of time, greater organisational effort and legal concerns were stated as hurdles. Reducing organisational effort for teaching practices, appreciation of their teaching activity and financial considerations were in particular given as significant incentives for participating. The attitude of participants towards financial remuneration was heterogeneous. Different specialist features and requirements for student training were mapped out. This study provides, for the first time, findings about teaching in specialist outpatient establishments. They point to a great degree of willingness of specialist doctors to undertake teaching and provide starting points for creating concepts about producing teaching practices in specialist fields. Further quantitative investigation is required to substantiate the findings before us.

A review on the status quo and implementation methods of ethics education in standardized training for resident doctors in medical genetics department

Clinical practice of Medical Genetics involves application of various genetic techniques for the diagnosis of genetic disorders and subsequent genetic counseling and treatment. The principles of Medical Ethics must be fully taken into account when applying genetic knowledge for medical practice. Medical Ethics education is therefore essential for the standardized training of resident doctors in medical genetics department. With a basic system of Medical Genetics Physician Training established, our hospital has made a preliminary exploration for the development of Medical Ethics teaching in resident training through various teaching practices including seminar, network teaching, case study, scene teaching and outpatient teaching, with an aim to strengthen Medical Ethnics knowledge, professionalism and communication skills, and implement Medical Ethics principles throughout clinical practice.

Examining the impact of video-based outpatient education on patient demand for a rheumatology CNS service.

Patient demand for education and access to the clinical nurse specialists (CNSs) during the rheumatology clinic at one hospital in Ireland was increasing. Alternative methods of providing patient education had to be examined. To explore the efficacy of video-based outpatient education, and its impact on demand for the CNSs. A video was produced to play in a rheumatology outpatient department. A representative sample of 240 patients (120 non-exposed and 120 exposed to the video) attending the clinic was selected to complete a questionnaire exploring the effect of the video. Data were analysed using chi-square tests with Yates' continuity correction. Demand for the CNSs was six times higher in the non-exposed group compared with the exposed group (non-exposed: 25%, exposed: 4.8%) (χ2=15.7, P=0.00007), representing a significant decrease in resource demand. High-quality educational videos on view in the rheumatology outpatient department provide patients with information sufficient to meet their educational needs, thus releasing CNS resources.