Pharmacy Training Research Articles

Motivational factors for early option choice by laboratory medicine residents in France

In France, both students from medicine and pharmacy background can have access to the residency in laboratory medicine (LM). The current curriculum of LM residency includes an early choice of option after the first two years of residency, which subsequently guides the rest of the training. This study aimed to analyze these choice and motivational factors, since its implementation in 2017. A national survey was conducted among LM residents and former residents who underwent the early option choice process. A questionnaire was developed and sent to residents via Google Forms. Several groups of items corresponding to potential motivational factors were included and rated on a 5-point Likert scale. A psychometric analysis allowed to identify the main motivational factors. A total of 178 responses from 24 residency regions were recorded. The median age was 28 years, with a slight female predominance (52%), and three-quarters of the participants had a pharmacy training background. The "hematology and immunology" option was the most chosen (35%). The psychometric analysis enabled to identify 7 motivational factors, and the most important is the training during the residency, which weights approximately 21% in the choice. Several associations have been observed between the motivational factors and the background training, origin, the chosen option and the planned career. Several factors influence the choice of early option among LM residents, and some of these factors are associated with the background training, origin, chosen option and planned career.

Introduction of antimicrobial resistance education in pharmacy curricula in India: Lessons learned and future direction

IntroductionInsufficient training in antimicrobial resistance (AMR) and antimicrobial stewardship (AMS) in the pharmacy curricula limits pharmacists’ participation in AMS activities in India. We explored the potential impact of an AMR curriculum implemented as part of a research project in one of the pharmacy colleges in Kerala, India. MethodsData were collected using documentary analysis (minutes of meetings and the AMR curriculum developed) and semi-structured qualitative interviews with key informants face-to-face or via the Zoom platform at the participant's convenience. Anonymized interview transcripts were thematically analyzed aided by NVivo 12 software. ResultsWe interviewed faculty (n = 4), clinical pharmacists (n = 3), and students (n = 6) involved in the design, implementation, and use of the new curriculum. The development and implementation of the new curriculum was conducted through strategically planned and established methodology with equal involvement from the pharmacy college and the research project team. Challenges in this process included a lack of human resources to take classes, time, limited interactions, and motivation of students during the online classes. Despite this, students who attended the classes agreed that the curriculum introduced them to AMS and AMR concepts which helped them during their clinical postings. They agreed that it would be beneficial if a similar curriculum was implemented in other pharmacy colleges. ConclusionLearnings from this study would be beneficial for other pharmacy colleges to implement a similar AMR curriculum for training pharmacy students to take key roles in AMS, especially in countries like India where postgraduate training for pharmacists remains limited.

Implementation and evaluation of a learner-driven leadership initiative for pharmacy students and pharmacy residents.

Introduction: Leadership training is a crucial component of the pharmacy education curriculum. The Accreditation Council for Pharmacy Education (ACPE) emphasizes and encourages the use of different leadership initiatives, and universities employ tactics with varying levels of success to implement these initiatives. "Leadership theory" debates if leadership can be learned or if it is a natural-born skill. This article explores learned leadership and describes a small study deployed to different levels of pharmacy learners to foster leadership confidence and self-awareness. Educational Context and Methods: Second- and third-year didactic students in a leadership elective, voluntary fourth-year Advanced Pharmacy Practice Experience (APPE) students on an ambulatory care rotation, and first postgraduate year (PGY1) pharmacy residents were included in this initiative. Each cohort facilitated a leadership book club discussion and completed professional development activities over the course of their experience. Learners' perspectives on leadership were surveyed utilizing a pre-post survey study, administered prior to beginning the initiative and after completing the initiative. Findings and Discussion: Results demonstrated learners' perceived confidence and self-awareness in their leadership skills increased from pre-survey to post-survey. Evaluation of qualitative responses exhibited that participants found value in adding more leadership development to their pharmacy training. Most participants noted leadership book discussion facilitation as the most valuable part of the initiative and posited they would utilize skills gained through these discussions nearly every day in their careers. Results suggest PGY1 pharmacy residents showed the most significant increase in their scores from pre- to post-study, while didactic students showed the least significant increase. Implications: Our findings suggest learner-driven leadership initiatives, specifically learner-facilitated book club discussions, are beneficial to incorporate into both didactic and experiential coursework. Implementation of these discussions could be applied in many aspects of the curriculum with minimal resources and a reasonable expectation of perceived benefit to student leadership development.

Activities of clinical pharmacologists across Europe: A survey by the European association of clinical pharmacology and therapeutics.

In order to explore clinical pharmacology and therapeutics (CPT) teaching and practices across continental Europe, the European Association of Clinical Pharmacology and Therapeutics (EACPT) made a survey in 2022 amongst its 27 affiliated societies. The survey was made available online to EACPT representatives, and 47 filled-in questionnaires were received from 25 countries (one to five per country), representing all geographic areas of Europe. Clinical pharmacologists (CPs) spend 25%, 30%, 15%, and 25% of their time in teaching, hospital activities, committees, and research, respectively, with large variations across and within countries. CPT courses are given at Schools of Medicine in all the countries except one, mostly organized and taught by medical doctors (MDs). In Central, Western, and Southern Europe, the teachers may have medicine or pharmacy training. Therapeutic drug monitoring and pharmacovigilance were the hospital activities most frequently reported, and clinical/forensic toxicology, rounds of visits, and pharmacogenetics the least. Two-thirds of the panel think CPs should be MDs. However, the transversal nature of CPT was underlined, with patients/diseases and drugs as gravity centres, thus calling for the complementary skills of MDs and PharmDs. Besides, most respondents reported that clinical pharmacists in their country are involved in rounds of visits, pharmacovigilance, TDM, and/or pharmacogenetic testing and that collaborations with them would be beneficial. CPT comes with a plurality of backgrounds and activities, all required to embrace the different pathologies and the whole lifecycle of medicinal products, but all of them being rarely performed in any given country. The willingness to use common CPT teaching material and prescribing exams at the European level is a good sign of increasing harmonisation of our discipline Europewide.

Evaluating the role of intern pharmacists in pharmaceutical care in hospitals in Uganda.

In Uganda, there is limited adoption of pharmaceutical care in hospitals due to pharmacist shortages and limited collaboration among healthcare professionals. Intern pharmacists are deployed annually to assist in patient care to address pharmacist shortages. Evaluate intern pharmacist's extent of involvement in pharmaceutical care activities, assess facilitators and barriers, and explore healthcare professionals' perceptions, attitudes, and opinions on implementation of pharmaceutical care. A mixed-method concurrent study was carried out for four months. We conducted an online survey among 107 intern pharmacists from 26 hospitals, including National Referral, Regional Referral, Private Not-For-Profit, and General hospitals; predictors of extent of involvement were identified using linear regression models, using STATA 14. 24 key informants (nurses, prescribers, pharmacists) from five hospitals were interviewed; themes were developed using a deductive thematic analysis approach. Intern pharmacists had a median (Interquartile range[IQR]) age of 25 years (25-27) and 74.7% were male. About half (54.1%) of key informants were female and had a median (IQR) of 10 years (4.0-15.5) of professional experience. Interns focused on patient counseling, lacked documentation, and showed positive attitudes, and knowledge. Key informants supported implementation, but prescribers expressed dissatisfaction with interns' performance. Enhancing pharmacy internship and training through developing policies and guidelines on pharmaceutical care practice, improving working conditions, and mentorship can address gaps impeding pharmaceutical care implementation by intern pharmacists.

Toward inclusive health care: Pharmacists’ perceptions on academic preparedness and health care provision for the LGBTQIA+ community

BackgroundThe community of lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other identities (LGBTQIA+), comprising sexual and gender minorities, frequently encounters violence, discrimination, and numerous obstacles in accessing health care services. Pharmacists have the potential to significantly contribute to the health care provision for this community. ObjectiveTo assess pharmacists’ perceptions regarding academic preparedness and health care provision for the LGBTQIA+ community in Brazil. MethodsAn online cross-sectional survey was conducted from August 2022 to February 2023, focusing on the academic training of pharmacists and the provision of health care to the LGBTQIA+ community in Brazil. Data collection was achieved through a 28-question online questionnaire, comprising both closed-ended questions, and Likert-type items. The study variables were subjected to an exploratory descriptive analysis. ResultsWe received 261 complete and valid responses. A majority of pharmacists indicated that they provided health care to the LGBTQIA+ community (n = 161, 61.7%); however, they lacked formal education on LGBTQIA+ health care during their pharmacy program (n = 256, 98.1%). Most participants strongly agreed that pharmacists play a crucial role in promoting health care for this community (n = 213, 81.6%). However, only a small percentage felt confident in addressing issues related to the effectiveness and safety of hormone use for transgender patients (n = 38, 14.6%). Furthermore, less than a third believed that the health care provided by pharmacists should be differentiated for patients within and outside of the LGBTQIA+ community (n = 76, 29.1%). ConclusionThe results of this study underscore the necessity and significance of incorporating this topic both in pharmacy training and continuing education. This approach is crucial to enhance and bolster the clinical practice of pharmacists.

Faith-based pharmaceutical supply chains and their role in African pharmaceutical systems: a qualitative systematic review

For the health system to function well, the population must have equitable access to quality, affordable pharmaceutical supplies; however, pharmaceutical systems in Africa are challenged by inadequate funding, drug stock outs and irregular supplies, a shortage of trained pharmacy personnel, and a lack of systems for drug regulation and quality. Faith-based health providers, as private, not-for-profit actors, have long complemented public sector efforts in the supply of pharmaceuticals in Africa. However, the contribution of faith-based health providers in pharmaceutical systems has not been formally studied. This study examines the nature and function of faith-based healthcare providers in improving access to pharmaceutical supplies in Africa. To do so, we conducted an exploratory qualitative systematic review to identify documents that contain information on faith-based involvement in pharmaceutical supply in Africa. The review identified 20 articles for inclusion. These articles were analyzed using thematic, narrative analysis. The analysis revealed a significant evidence gap relating to the contribution of private-not-for-profit, faith-based providers to African pharmaceutical systems. The review suggests that while faith-based drug supply organizations have existed for a long time and contribute significantly to national pharmaceutical systems, there is very little known about the nature of faith-based pharmaceutical providers and how they complement public sector pharmaceutical systems. In many contexts, faith-based involvement in pharmaceutical systems improved access for the general population and increased the supply of pharmaceuticals in national systems. Faith-based drug supply organizations also often provide pharmaceutical supplies to both rural and urban areas, often targeting rural and remote areas particularly. The review also indicates that faith-based drug supply organizations improved access to medicines and related commodities and, despite a lack of regulation in many contexts, have the potential to make a positive contribution to quality assurance of pharmaceuticals. In summary, the analysis confirmed that faith-based involvement in pharmaceutical supply chains contributes to strengthening the national health system by complementing the public pharmaceutical system through improved access to medicines and related commodities in Africa. These conclusions corroborate the need to continually document and acknowledge faith-based healthcare providers’ efforts which could guide the formulation of stringent, evidence-based strategies.

An analysis of the intention of female pharmacy students to work in community pharmacy settings in Saudi Arabia using the theory of planned behavior

ObjectiveThis study aimed to determine the intention of female Saudi pharmacy students to work in community pharmacies and the factors associated with this intention. MethodsThis cross-sectional study was conducted between April 2022 and June 2022 and included female students from pharmacy colleges in Saudi Arabia. The survey was created based on the Theory of Planned Behavior. It included items that measure student intentions, attitudes, subjective norms, and perceived behavioral control regarding working in community pharmacies in Saudi Arabia. The study also included items that assessed sociodemographic characteristics, pharmacy program degrees, training, and job preferences of students. ResultsA total of 407 participants completed the survey. The average age was 21.8 (±1.6) years, and most participants were Saudi nationals (97.79 %). The intention of participants to work in community pharmacies after graduation was low (mean = 3.2 ± 1.8; range: 1–7). Slightly positive attitudes toward working in a community pharmacy after graduation were revealed as participants showed an overall attitude mean of 4.5 ± 1.6 (range: 1–7). Furthermore, the participants perceived a low social pressure toward working in a community pharmacy after graduation (mean of 3.3 ± 1.9; range: 1–7). The intention of female pharmacy students to work in community pharmacies was significantly predicted by attitudes (p-value < 0.0001), perceived behavioral control (p-value = 0.0017), nationality (p-value = 0.0151), residence in the Saudi Arabian region (p-value = 0.0013), monthly income (p-value = 0.0231), pharmacy degree program (p-value = 0.0035), training received in community pharmacies (p-value = 0.0145), had a relative working in a community pharmacy (p-value = 0.0257), and preference to work in community pharmacies after graduation (p-value = 0.0001). ConclusionFemale pharmacy students in Saudi Arabia had a low intention to work in community pharmacies, a positive attitude toward working in community pharmacies, and perceived no social pressure to work in them. A positive attitude and behavioral perception of control toward working in community pharmacies were demonstrated among pharmacy students who study at a university outside Riyadh, undertaking a bachelor’s degree in pharmacy, have a monthly income higher than 5000 Saudi riyals (USD 1,333.3), previously received training in community pharmacies, having a relative working in a community pharmacy, prefer to work in community pharmacies after graduation.

How to Train Pharmacy Students to Become Leaders in Healthcare – A Review of Four University Curricula

How to Train Pharmacy Students to Become Leaders in Healthcare – A Review of Four University Curricula

Communication skills-based training about medication switch encounters: pharmacy staff and patients' experiences.

Non-medical medication switches can lead to difficult conversations. To support pharmacy staff, a communication training has been developed based on two strategies: 'positive message framing' to emphasize positive elements of the message and 'breaking bad news model' to break the news immediately and address emotions. To assess how patients and trained pharmacy staff experience the application of communication strategies for non-medical medication switch conversations and which are barriers and facilitators for the application. The Kirkpatrick training evaluation model, level 3 'behavior', including barriers and facilitators and 4 'results' was used. Trained pharmacy staff registered switch conversation characteristics and asked patients to complete a questionnaire. Semi-structured interviews with trained pharmacy staff members were conducted. Quantitative data were analyzed descriptively and interview data were analyzed thematically. Of the 39 trained pharmacy staff members, 21 registered characteristics of 71 conversations and 13 were interviewed; 31 patients completed questionnaires. Level 3: trained pharmacy staff self-reported they applied aspects of the strategies, though indicated this was not yet a standard process. Interviewees indicated signs of increased patient contact and job satisfaction. Time, face-to-face conversations and colleague support were facilitators. Level 4: pharmacy staff members were satisfied with most switch conversations (89%), particularly with addressing emotions (74%). Patients were (very) positive (77%) about the communication, particularly about clear explanations about the switch. Pharmacy staff's learned behavior includes being able to apply aspects of the strategies. The training results show first signs of better patient-pharmacy staff relationships and increased job satisfaction.

Evaluating Sustainable Online Education: A Cross-Disciplinary Analysis of IT Device Utilization among Slovakian and Hungarian University Students

By the onset of the 21st century, online presence had become prevalent in higher education, with the COVID-19 pandemic further accelerating this trend. However, the success of online education and its assessment by students can differ significantly from region to region and according to the field of study. This can be influenced by students’ habits of using IT devices, but it can also occur the other way around. In this research, experiences related to online education were examined in the fields of Informatics, Agriculture and Pharmacy education at two higher-education institutions in Slovakia and one in Hungary, considering the environmental and social sustainability implications. In the study, in addition to simple statistical methods, a cross-tabulation analysis was carried out using Cramer’s V method. The results have shown that the students of the investigated institutions confidently navigate the online world; they are conscious users of IT tools without being addicted. A total of 74% of students in Mosonmagyaróvár believe they possess sufficient information about the risks associated with computers, mobile phones, and the Internet, whereas only 34% of students in Košice share the same sentiment. The reason for the differences between these characteristics can be attributed to the specialties of the different majors, and not to those arising from regional differences, raising important questions about the ecological sustainability of online education practices. A relatively great consistency can be observed in the assessment of online learning among students from the three institutions, with approximately 85% expressing overall satisfaction with the online learning experience. The easier availability of study materials and savings on travel are mentioned as advantages, contributing to economic sustainability. However, separation from their mates and the lack of practical training may be regarded as a disadvantage for them, as they seem to have a preference for face-to-face training. Overall, it may be concluded that purely online training in the fields of Informatics, Agriculture, and Pharmacy training is not feasible for the time being, necessitating a balanced and sustainable approach for the future.

Essential elements for a nationwide remote pharmacy trainee mentoring program: An opinion of the Ambulatory Care Practice and Research Network of the American College of Clinical Pharmacy

AbstractMentorship is vital for pharmacy trainees to develop professional skills and networks. This paper aims to share the development and implementation of a national remote mentorship program for pharmacy trainees within the American College of Clinical Pharmacy Ambulatory Care Practice and Research Network. We offer recommendations for developing a similar program within organizations emphasizing the program's framework as a resource for similar initiatives. The following key recommendations are proposed to enhance mentorship programs: (1) Program flexibility for tailored interactions; (2) Effective mentor–mentee matching through comprehensive data collection; and (3) Strong, early communication to maintain participant engagement. These strategies are crucial for successfully developing remote mentorship programs in professional pharmacy organizations, as evidenced by limited reports in the current literature.

Systematic Review And Meta-Analysis On The Gaps In Pharmacy Education System: A Prisma Compliant Study

Background:Pharmacy education is crucial in shaping the competencies and skills of future pharmacists. However, significant gaps in the current pharmacy education system have been reported globally. These gaps range from outdated curricula and insufficient clinical training to inadequate research opportunities and lack of mental health support for students. Identifying and evaluating these gaps is essential for improving the quality of pharmacy education. Objective:This systematic review and meta-analysis aim to identify and evaluate the gaps in the pharmacy education system worldwide. The study adheres to PRISMA guidelines to ensure transparency and reproducibility. Methods: A comprehensive literature search was conducted using PubMed, Scopus, and Google Scholar databases. Search terms included 'pharmacy education', 'curriculum gaps', 'clinical training in pharmacy', 'pharmacy education system', and 'mental health in pharmacy students'. The inclusion criteria were peer-reviewed articles focused on pharmacy education gaps, studies following PRISMA guidelines, and articles published in English between January 2000 and January 2024. Data were extracted using a standardized form, and the quality of included studies was assessed using the Newcastle-Ottawa Scale. A meta-analysis was performed using random-effects models to account for heterogeneity. Results:Out of 2,500 studies identified, 200 met the inclusion criteria. Key findings include significant gaps in curriculum content, particularly in emerging fields such as personalized medicine, pharmacogenomics, and digital health. Inadequate clinical training and exposure to real-world scenarios were major concerns. Limited research opportunities for undergraduate students and insufficient mental health support systems were also identified. Conclusion:This systematic review and meta-analysis highlight critical areas in pharmacy education that require immediate attention. Updating curricula to include emerging fields, enhancing clinical training, encouraging undergraduate research, and implementing robust mental health support programs are essential steps to address these gaps. The findings and recommendations can guide policymakers, educators, and stakeholders in improving the quality of pharmacy education globally.

Preparing for OSCEs in pharmacy training

Preparing for OSCEs in pharmacy training

Knowledge and perception of mHealth medication adherence applications among pharmacists and pharmacy students in Jazan, Kingdom of Saudi Arabia.

The advances in digital health, including mobile healthcare (mHealth) medication adherence applications (MApps), have been demonstrated to support medication adherence and improve health outcomes. This study aims to evaluate the knowledge and perception of the MApps among pharmacists and pharmacy students. An online cross-sectional survey was conducted among 223 pharmacists and pharmacy students in the Jazan region of Saudi Arabia between 1st and 30th April 2023. The survey collected information about the participants' socio-demographics, knowledge, and perception of the MApps. Among the 223 participants included in the study, 105 (47.1%) were pharmacists and 118 (52.9%) were pharmacy students. Most participants were females (72.6%) and aged 18-30 (70.4%). About half of the participants had poor knowledge of the MApps [pharmacists (48.0%) and students (42.0%)] and mainly encountered Medisafe (18.1%) or Pills (17.0%) MApps, respectively. Pharmacy students showed significantly higher knowledge of MApps (p = 0.048), especially the Pills (p = 0.022) than pharmacists. However, the pharmacists had significantly higher knowledge of MyMeds (p = 0.001) than pharmacy students. Most participants had a positive perception of the usefulness of the MApps (pharmacists, 79.0%; students 80.0%). Notably, over 85% of the participants expressed willingness to know and provide guidance on MApps, with over 50% willing to recommend it to the patients. There was no significant difference in perception between the pharmacists and pharmacy students (p>0.05). In conclusion, the study demonstrates limited knowledge with a positive perception of mHealth medication adherence applications among pharmacists and pharmacy students. Integrating digital adherence tools like the MApps into pharmacy training could significantly improve professional practice mHealth competencies, and optimize healthcare delivery and patient outcomes.

75 lat polskiej medycyny i farmacji we Wrocławiu (1945–2020). Wybrane elementy historii wrocławskich wyższych uczelni. Część trzecia

75 years of Polish medicine and pharmacy in Wrocław (1945–2020). Selected elements from the history of higher education in Wrocław. Part tree Professional training in medicine and pharmacy had begun in Wrocław by the fall of 1945. The Faculty of Medicine was created within the structure of Wrocław University and Wrocław University of Science and Technology. Two departments were established within it: the Pharmaceutical and Dentistry departments. In 1950, a specialized medical school was developed from the University, functioning briefl y under the name of the Medical Academy (which was changed to the Academy of Medicine), already with an independent Faculty of Pharmacy. In 1979, the Medical Analytics Department was established within the Faculty of Pharmacy (which ceased its activities in 2020). In 1978, the Faculty of Nursing was created which was transformed into the Faculty of Public Health in 2001 and into the Faculty of Health Sciences in 2008. Starting in 1989, the school was called the Academy of Medicine in Wrocław (Akademia Medyczna im. Piastów Śląskich). In 1992, the Post-Graduate Faculty of Medicine (existing until the academic year 2019/2020) was distinguished from the Faculty of Medicine. In 2000, the Department of Dentistry was transformed into the Faculty of Medicine and Dentistry. As a part of the school, liberal arts and social studies connected with medicine were also developed in units located within the structure of various departments of the AM. The Academy of Medicine in Wrocław existed until 2011 when the decision was made to transform it into Wrocław Medical University (Uniwersytet Medyczny im. Piastów Śląskich), functioning until now. The article presents the major stages in the history of medical schools in Wroclaw after 1945, taking into consideration the external factors that had an effect on the changes occurring in them. It also presents their results. It consists of three parts. The fi rst one presents the most important aspects of the history of the Faculty of Medicine of Wrocław University and Wroclaw University of Science and Technology in the years 1945–1949. The second part discusses the history of the Academy of Medicine in the years 1950– 2011, and the third one of Wrocław Medical University in the years 2011–2020. The article contains an extensive bibliography of studies concerning the history of these schools as well as the system of public medicine in Poland in the years 1945–2020, providing the context for their activities.

NHS England to integrate genomic medicine into pharmacy education and training

NHS England to integrate genomic medicine into pharmacy education and training

Community pharmacy training sites without access to a prescribing supervisor advised to withdraw placements

Community pharmacy training sites without access to a prescribing supervisor advised to withdraw placements

Fall in uptake for funded mental health pharmacy training

Fall in uptake for funded mental health pharmacy training

The impact of Saudi Arabia – United States clinical pharmacy post-graduate training programs agreements on clinical pharmacy faculty in Saudi universities: A retrospective descriptive study focused on history and future recommendations

BackgroundThere has been a growing demand for clinical pharmacy services in the Kingdom of Saudi Arabia (KSA) in the past 3 decades. The Ministry of Education has established agreements with several institutions in the United States to secure clinical pharmacy residency and research fellowship programs opportunities for Saudi scholars. The aims of this study were to describe the Saudi scholars’ clinical pharmacy training pathways and their contribution to the pharmacy profession in KSA. MethodsThis is a retrospective, descriptive study conducted on clinical pharmacy faculty in governmental Saudi universities who graduated from the US until 2023. The study outcomes included the post-graduate year-1 (PGY-1) residency match rate, post-graduate year-2 (PGY-2) acceptance rate, the PGY-2 specialties of Saudi scholars, and the number of clinical pharmacy programs established in KSA. ResultsIn total, 115 Saudi scholars have pursued clinical pharmacy pathway in the US. The PGY-1 residency match rate was 80 % (92/115). In contrast, the PGY-2 acceptance rate was 60.9 % (70/115). The most common PGY-2 specialty was in infectious diseases (N = 17; 24 %). Two pharmacy colleges had established residency programs and 1 pharmacy college had established a research fellowship. ConclusionThe Ministry of Education's efforts for clinical pharmacy program agreements were fundamental for advancing clinical pharmacy in Saudi universities. A significant number of Saudi scholars returned to KSA with clinical pharmacy degrees. There are more opportunities for further development, including expanding the clinical pharmacy program collaboration in the US and increasing the number of residency and research fellowship positions in KSA.