Postgraduate Training Research Articles

Evaluation of user experience and satisfaction with workplace-based assessments (WPBAs) in dental postgraduate programmes.

To explore the experience of and satisfaction with workplace-based assessment tools among dental postgraduate trainees. The cross-sectional study was conducted from March to October 2022 at the Aga Khan University Hospital, Karachi, and comprised all Operative Dentistry, Prosthodontics and Orthodontics postgraduate trainees. A questionnaire with both open-ended and closed-ended questions was used to record the experiences and satisfaction level of the dental residents who had earlier been subjected to workplace-based assessment. Data was analysed using SPSS 20, while thematic analysis was used for open-ended questions. Of the 20 Subjects, 15(75%) were females. Also, 11(55%) participants had received prior training for workplacebased assessment. There were 16(80%) residents who were satisfied with workplace-based assessment tools in the dental residency programme, 15(75%) agreed that the tools improved their clinical skills and helped them identify their weak areas, all the 20(100%) participants said the feedback given to them was constructive, 18(90%) reported that they were allowed to put in their views. However, 7(35%) participants reported that being observed adversely affected their performance. Dental residents generally gave positive feedback related to workplace-based assessment tools in a clinical setting.

Enabling and inhibiting doctors transitions: introducing the social identity resource and belonginess model (SIRB).

The transition into postgraduate medical training is complex, requiring an integration into the workplace, adjustment to new identities, and understanding of the social and organisational structure of healthcare. Studies suggest that social resources, including a sense of belonging, inclusivity from social groups, and having strong social identities can facilitate positive transitions. However, little is known about the role these resources play in junior doctors' transitions into the healthcare community. This study aimed to explore the implications of having access to social resources for junior doctors. This study undertook secondary analysis from a longitudinal qualitative study which followed 19 junior doctors (residents within two years of qualification) for nine months. Data were thematically analysed using an abductive approach, with the social identity resource and belongingness (SIRB) model as a conceptual lens to explore how social networks of support act as identity resources (IRs) for junior doctors as they experience transitions. The doctors narrated that having accessible IRs in the form of supportive workplace relationships enabled an integration and a sense of belonging into healthcare practice, supported the construction of new professional identities, and strengthened career intentions. Those with inaccessible IRs (i.e. poor workplace relationships) expressed a lack of belonging, and casted doubt on their identity as a doctor and their career intentions. Our study indicates that SIRB model would be beneficial for medical educators, supervisors, and managers to help them understand the importance and implications of having IRs within the workplace environment and the consequences of their accessibility for healthcare staff experiencing transitions.

Resuscitation following trauma & role of trauma training programmes in emergency settings: A literature review & survey.

Background & objectives Traumatic injuries, especially in low- and middle- income countries (LMICs), present significant challenges in patient resuscitation and healthcare delivery. This study explores the role of trauma training programmes in improving patient outcomes and reducing preventable trauma-related deaths. Methods A dual approach was adopted, first a literature review of trauma training in LMICs over the past decade, along with a situational assessment survey. For the review of literature, we searched the PubMed database to identify key challenges and innovative practices in trauma training programmes in LMIC's. The survey, conducted among healthcare professionals in various LMICs, collected direct insights into the challenges and the status of trauma training programmes in these countries. Results The literature review analysed 68 articles, with a significant focus on the African subcontinent (36 studies), underscoring the region's emphasis on research on trauma training programmes. These studies mainly targeted physicians, clinicians, postgraduate trainees in surgical or anaesthesia fields and medical students (86.8%), highlighting innovations like simulation-based training and the cascading training model. In our survey, we received 34 responses from healthcare professionals in India, Belarus, Azerbaijan, Nepal and Pakistan. Around 52.9 per cent reported the absence of established trauma training programmes in their settings. The majority of respondents advocated for hands-on, simulation-based training (94.1%) and emphasised the need for structured training programmes (85.3%), feedback sessions (70.6%) and updated protocols (61.8%). This combined data underlined the critical gaps and potential improvements in trauma training programmes and resuscitation practices in LMICs. Interpretation & conclusions Effective trauma care in LMICs requires the establishment of comprehensive, tailored training programmes. Key interventions should include subsidization of pre-existing trauma courses and the adoption of World Health Organization Guidelines for essential trauma care, implementation of trauma quality improvement and review processes and the incorporation of focused assessment with sonography in trauma (FAST) in emergency departments. These steps are crucial for equipping healthcare workers with vital skills and knowledge, fostering a culture of continuous learning and improvement in the realm of trauma care.

Education and Career Advancement Opportunities in Polish and English Nursing-A Comparative Study of Intensive Care Unit Nurses.

The aim of this study was to comparatively investigate education, job, and professional development satisfaction among intensive care unit nurses in Poland and England. A total of 258 ICU nurses from both countries were interviewed (72 Polish nurses working in Poland and 186 of various national backgrounds in England, including 50 of Polish origin). We used an 11-item structured survey followed by an open-ended qualitative interview retrospectively coded for statistical analysis. Regardless of national origin, nurses in England report significantly higher education satisfaction, attributed to better theoretical knowledge gain but not to other dimensions (such as practical knowledge or personal satisfaction). They also express greater satisfaction with job conditions regarding professional development, a state-of-the-art work environment, teamwork, and finance. The UK system is also considered significantly superior in promotion opportunities and participation in post-graduation training. In conclusion, systemic factors play a crucial role in career satisfaction and advancement in nursing, with the British band system having a clear advantage over the Polish one.

Implications of the shift from GP-centred to multidisciplinary models on postgraduate GP training in the UK.

Implications of the shift from GP-centred to multidisciplinary models on postgraduate GP training in the UK.

Isolation and identification of primary cells: A comprehensive primary cell culture experiment for graduate students.

Experimental teaching is an important part of postgraduate training in basic and clinical medicine. While primary cell isolation and identification are among the most important research techniques for medical graduate students, most graduate students do not understand and master these techniques before starting their research experience. In particular, many students lack training in this field, and high-quality teaching and learning materials are still very sparse. Here, we designed a practical experiment course for graduate students engaged in research. The target students usually have research projects involving primary cell culture in their future research, making the course highly applicable for the students. The lab exercise focused on the methods of primary cell isolation (including mechanical grinding method, explant culture method and enzymatic digestion method) and identification (including flow cytometry, immunofluorescence, and periodic acid-Schiff (PAS) staining). It aimed to help students master the conceptual, principle, technical, operation, and analytical skills related to primary cell culture and contributed to their foundation for future research. Students generally reflect that they have initially mastered the isolation and identification of primary cell culture as a result of the course. Student feedback also indicates significantly increased confidence in the practical application of primary cell culture in the future. Here, we provide our experience for others who may want to implement similar courses.

Current and future workforce of general internal medicine in Switzerland: a cross-sectional study.

General internal medicine is a crucial element in healthcare systems. Understanding how many people are and will be working in this field is important to maintain and improve quality for patients in healthcare systems. This can provide a basis for political decisions. We conducted a cross-sectional study to analyse the current and future workforce of generalists (general practitioners and internists in hospitals) in Switzerland. The Swiss Society of General Internal Medicine (SSGIM) distributed a survey to all members. Respondents were asked about their current average workload in 2023 and planned workload in 2033. The responses were used to calculate full-time equivalent (FTE) for the current and future workforce of generalists and to extrapolate FTE for all active SSGIM members. To model the demand by 2033, we derived different scenarios. Of all 6,232 active SSGIM members, 2,030 (33%) participated: 46% female, 25% (largest age group) 56-65 years old, 19% still in postgraduate training. The average workload in 2023 was 78% for female and 87% for male generalists; the FTE extrapolated to all active SSGIM members in 2023 was 5,246. By 2033, 1,935 FTEs (36%) will retire, 502 FTEs (10%) will reduce their workload, 116 FTEs (2%) will increase their workload and 2,800 FTEs (53%) will remain in the workforce with the same workload as in 2023. To maintain the same workforce as in 2023, 2,321 new FTEs (44%) will be needed by 2033. To fill this gap of 232 FTE new generalists per year, we modelled different scenarios with assumptions of interest, workload, migration and dropouts. Within only one decade, 44% of the current workforce of generalists will disappear, mainly due to retirement and decreased workload. To fill this gap, various scenarios need to be incorporated. Politicians are called upon to create the political framework to create attractive training and working conditions for generalists to address the future demand for healthcare services.

Appraisal of AI-generated dermatology literature reviews.

Artificial intelligence (AI) tools have the potential to revolutionize many facets of medicine and medical sciences research. Numerous AI tools have been developed and are in continuous states of iterative improvement in their functionality. This study aimed to assess the performance of three AI tools: The Literature, Microsoft's Copilot and Google's Gemini in performing literature reviews on a range of dermatology topics. Each tool was asked to write a literature review on five topics. The topics chosen have recently had peer-reviewed systematic reviews published. The outputs of each took were graded on their evidence and analysis, conclusions and references on a 5-point Likert scale by three dermatologists who are working in clinical practice, have completed the UK dermatology postgraduate training examination and are partaking in continued professional development. Across all five topics chosen, the literature reviews written by Gemini scored the highest. The mean score for Gemini for each review was 10.53, significantly higher than the mean scores achieved by The Literature (7.73) and Copilot (7.4) (p < 0.001). This paper shows that AI-generated literature reviews can provide real-time summaries of medical literature across a range of dermatology topics, but limitations to their comprehensiveness and accuracy are apparent.

Learning of Intimate Area Examination Amongst Pakistani Medical Students: Knowledge, Attitudes, and Practices Study

Background: Intimate area examination (IAE) is an integral part of clinical examination skills and must be mastered by medical students before they start their careers. This study explores the experiences of Pakistani medical students regarding learning of IAE, the associated barriers and their effects on students’ learning. Methods: This cross-sectional study, based on a self-designed questionnaire, was conducted at two Pakistani medical colleges, which included final year students and postgraduate trainees. Results: During their undergraduate training, 74.9% of the respondents had not conducted a female pelvic examination, 51.9% had not examined a female groin, 79.7% had not examined a female rectum, and 72.7% had not examined a male rectum. From the 65 postgraduate doctors, 48.4% reported that they were not prepared to perform an IAE at the start of their clinical career. Regarding barriers to IAE learning, more than half of the respondents felt that the opposite gender of the patient (64.7%) and patient’s refusal (63.1%) had a strong negative effect on IAE learning. A high percentage of respondents reports that they were not taught IAE during their undergraduate years. Among the currently used pedagogical techniques, 71.1% of the respondents opted for real patient-based learning, followed by clinical simulations (21.9%), and videos (7.0%). No one thought examination should be taught theoretically. A significant difference between male and female experience in IAE learning was also observed. Conclusion: Learning of IAE remains unsatisfactory and poses a major challenge for the Pakistani Medical Students in the institutes included in this study.

Optometrists’ perspectives on speciality programme development in South Africa

Background: South Africa (SA) has postgraduate research-based master’s and doctorate qualifications in optometry with no clinical coursework qualifications in special interest fields. As a result, it hinders professional growth and career path for optometrists and further limits patients’ access to various care pathways from would-be upskilled optometrists.Aim: To explore optometrists’ perspectives on postgraduate programme development in special interest fields of optometry for SA.Setting: Study population of practicing optometrists registered with the Health Professions Council of South Africa (HPCSA).Methods: A quantitative cross-sectional descriptive design was employed, utilising an online questionnaire developed with the Evasys survey system v8.2. Non-probability sampling was used to access eligible participants.Results: From 424 survey responses, 83.5% had undergraduate qualifications and 95.5% worked in patient-facing environments. Participants responded positively (88%) to this need for educational expansion. Educational needs in Ocular Disease (75.6%), Paediatric Optometry (66.4%), Binocular Vision (65.1%) and sub-specialties of myopia control (41.2%) and Specialised Contact Lens Fitting (31%) were reported. With combined ‘highly important’ and ‘likely important’ responses, participants indicated that obtaining professional recognition (94.9%) and to improve patient care (98.8%) were the main drivers for pursuing additional education and training.Conclusion: A notable demand was found for coursework postgraduate programmes by the study populations from which professional recognition can be awarded in various special interest fields of optometry. The benefit of improved patient care from upskilled optometrists was expressed.Contribution: The findings would contribute towards the development of a conceptual framework for postgraduate education and training for optometrists in SA.

Investigation of Disparity of Urologic Fellowship Match Rates by Gender and US Versus International Medical Graduates Over the Past Decade

ObjectiveTo investigate the influence of postgraduate medical education (US vs. international) and gender on applicant matching for postgraduate training across different urologic sub-specialties. MethodsMatch statistics of five societies that participated in the AUA fellowship match between 2010-2024 were retrospectively reviewed. Societies included: Endourology Society (EUS), Society for Urological oncology (SUO), American Society of Andrology (ASA), Society of Genitourinary Reconstructive Surgeons (GURS), and Society of Pediatric Urology (SPU). Candidates were classified based on gender (male/female) and their postgraduate medical education: local graduates from the United States or Canada (US/Ca) and international medical graduates (IMG). The match odds were analyzed using the Chi-square test, while trends were assessed through the Mann-Kendall test. ResultsOverall, 2429 applicants applied for 1627 programs from 2010 to 2024, comprising 1998 males (81.8%), 399 females (16.4%), and 42 undisclosed (1.7%). There were 1486 US/Ca graduates (60.8%) and 953 IMGs (39.2%). 1471 (60.6%) applicants were matched with a program, compared to 958 (39.4%) unmatched. The likelihood of US/Ca graduates matching (83.8%) was significantly higher than IMGs (23.3%), OR = 17.5, 95% CI: (14.3, 21.5), p < 0.001. IMGs had the highest match rate with GURS (33.8%, 47/118) and the lowest with SPU (7%, 1/14). Female applicants had a significantly higher chance of matching 324/399 (81.2%) than male applicants 1139/1998 (57%), OR = 3.26, 95% CI: (2.5, 4.3), p < 0.001. US/Ca-to-IMGs ratios and the male-to-female ratios were stable throughout the match years. ConclusionsCompared to IMGs, U.S./Ca graduates had remarkably higher matching rates. Matching outcomes were also significantly better for female applicants. Further assessment of international involvement and diversity in urological subspecialty roles is warranted.

Best practice in psychoeducational assessment: beyond the manual

ABSTRACT Objective Psychologists have a responsibility to conduct standardised assessment according to instructions in test manuals and guidelines in assessment texts. In practice, circumstances arise that are not addressed in manuals and texts. The aim of this study was to explore the ways in which experienced psychologists manage some of these issues. Method The participants were 10 psychologists with postgraduate training in assessment and reputations as experts within the professional community. Years of experience ranged from 5 to more than 30 years. Most of the participants had specialist area of practice endorsement in educational and developmental psychology. Participants responded to survey questions about aspects of assessment for which ready answers could not be identified in test manuals or published texts. Each participant was asked to explain and justify their decisions. Results On some issues, participants tended to follow the way they had been taught. Other decisions were based on clinical experience, rather than on shared understandings or evidence from research. Conclusions The findings highlight the lack of empirical research about best practice in assessment, the importance of ongoing professional development, and the need for rigorous training that addresses the many issues that arise in assessment and encourages ongoing reflective practice.

Cultivating Inclusivity and Bridging Gaps Through Reverse Mentoring: A Feasibility Study Within the Royal College of Radiologists

AimThe Royal College of Radiologists (RCR) recognizes the importance of addressing differential attainment, bridging existing disparities, and fostering diversity and equity. Materials and methodsA joint-faculty reverse mentoring (RM) pilot launched from July 2023 to January 2024. Participation was voluntary, mentors (trainees) from ethnic minority backgrounds and mentees (RCR officers) were recruited across the UK. Mentoring pairs engaged in regular meetings focused on sharing lived experiences and informal discussions. Data were collected through prepilot and postpilot surveys, virtual question polls at induction meeting, and written reports. Data were analyzed using descriptive statistics and thematic analysis for quantitative and qualitative data, respectively. ResultsEight matched pairs met predominantly online, on average 4 times over 6 months. Discussions covered a wide range of topics exploring systemic biases and professional development. Expectations expressed were to learn from others' experiences and achieve personal and professional growth. The prepilot survey revealed that 50% of respondents had experienced or witnessed racial discrimination, with only 28.5% feeling capable of supporting colleagues facing challenges. By mid-pilot, meaningful connections were established, allowing mentors to share experiences, and foster safe spaces. The postpilot survey results indicated that 90% of respondents felt better equipped to support colleagues facing challenges related to protected characteristics. Key lessons included understanding cultural differences, resilience, and empowering participants to drive change. ConclusionsThe exchange of perspectives and experiences between individuals from diverse backgrounds and levels of expertise enhanced mutual understanding and inclusivity. This dynamic process has the potential to catalyze positive change across diverse domains, underlining its significance in shaping a more equitable postgraduate training landscape.

Assessment of Professionalism among Postgraduate Medical Students: A Cross-Sectional Study from Patna, Bihar.

Professionalism is a core quality which has to be developed and imbibed by medical students. However, training in professionalism was not a part of the medical curriculum until recently when the Competency-Based Medical Education system was introduced for undergraduate medical students in India, by the National Medical Commission. However, there has been no formal training on professionalism, in the curriculum of postgraduate (PG) medical students in India. Therefore, in this study, we have done a quantitative assessment of the attitude towards professionalism among PG medical students. A cross-sectional study was conducted among 200 PG medical students of an autonomous institute in Patna, Bihar over a period of six months using the Learners' Attitudes on Medical Professionalism Scale (LAMPS) questionnaire. Data entry was done on Microsft Excel 2015 (Microsoft Corporation, Redmond, Washington, United States) and data analysis was done using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). Out of 200 study subjects, 55% (n=110) were PG students from clinical departments and 45% (n=90) were from pre-clinical and para-clinical departments; 25.5% (n=51) of them were from first year, 57% (n=114) of them were from second year, and 17.5% (n=35) were from third year PG training. The overall mean score for the LAMPS scale across all domains was found to be 2.78±0.178(mean±S.D). Clinical PG students (2.99 ± 0.217) received significantly higher scores than pre/paraclinical PG students (2.68 ± 0.176) (T-test value = 10.9262, p < 0.0001). This study highlights the disparity in professionalism scores between clinical and pre/para-clinical students, suggesting a tailored approach might be beneficial. In order to improve the attitude towards professionalism, structured courses/workshops should be inculcated into the PG training curriculum. Continuous evaluation of professionalism throughout medical training can lead to better preparedness for future professional roles.

Which is more effective? Porcine tendon or 3D- printed flexor tendon? A study of model realism and educational utility in a flexor tendon repair workshop

IntroductionAnimal models in orthopaedic surgical training have raised concerns about ethics and availability, prompting the search for non-animal alternatives. The 3D-printed silicone tendon model has emerged as a potential alternative due to its hygiene and reusability. This study aimed to compare the effectiveness of the two models for flexor tendon repair training. Materials and methodsA survey involved 25 postgraduate trainees with no prior experience in flexor tendon repair. Porcine tendon models and 3D-printed models were used, with participants evaluating accuracy, understanding of pulley systems, joint flexion, tissue feel, and model realism. Repairs were evaluated by experienced surgeons, and participants completed a survey. ResultsBoth models demonstrated satisfactory accuracy and realistic joint flexion. The porcine model scored higher in anatomical accuracy, while the 3D-printed model excelled in understanding pulley systems. The porcine model provided realistic tissue feel, while the 3D-printed model facilitated anatomy teaching. No significant difference was found in educational utility. The 3D-model was perceived as hygienic and odourless, whereas the porcine model offered better tendon handling. The 3D-model improved visualization of suture placement. Both models were equally accepted and recommended for training. ConclusionThe 3D-printed silicone tendon model is a cost-effective and reproducible alternative to porcine models in flexor tendon repair training. Although the 3D-printed model has limitations in mimicking human tendons, it was equally effective in teaching suturing techniques and improving repair skills. Combining the porcine model and 3D-printed model provides a comprehensive approach to flexor tendon repair training, addressing the limitations of each model and enhancing the educational experience.

An Analysis of Trainee Salaries Offered in Nurse Practitioner and Physician Assistant/Associate Postgraduate Residency and Fellowship Programs in the United States.

Background Although there has been steady growth in the number of postgraduate nurse practitioner (NP) and physician assistant/associate (PA) residency and fellowship programs in the United States, little is known about annual salaries paid to trainees across a national sample of postgraduate programs and specialties. We describe postgraduate program NP and PA trainee salaries and the relationship to specific variables. Methodology An electronic survey was distributed via email to 336 postgraduate NP, PA, and joint NP/PAresidency/fellowship programs between November 2023 and December 2023.Frequency tables (for categorical variables) and descriptive statistics (for continuous variables) were used to summarize the data. Chi-square tests of independence were used to determine the relationship between trainee salary and program type, geographical location, and clinical setting. Results There was a statistically significant association between trainee salary for primary care and clinical profession (χ2(6) = 13.993, p = 0.022). Over half of NP respondents(52.1%) reported that their trainees had an annual salary between $76000 and $86000. The majority of PA respondents (57.1%) reported that their trainees had an annual salary below $75000. Respondents who were non-clinical professionals(50.0%) reported that their trainees had an annual salary of over $86000. The single physician respondent also reported that their trainees' had an annual salary of over $86000.It appears that PA respondentswere more likely to report lower trainee salaries than respondents who were NPsand non-clinical professionals. Additionally, respondents associated with primary carejoint NP/PA cohorts were more likely to report higher trainee salaries than participants having NP-only cohorts. Lastly, there was a statistically significantly positive relationship between trainee salary and the number of postgraduate advanced practice provider (APP) trainees in psychiatric mental health (τb= 0.451, p = 0.006). Conclusion To the best of our knowledge, this national study is the first of its kind to examine and summarize APP postgraduate trainee annual salaries across multiple specialties. Additional studies are needed to clarify the relationships between trainee salaries and other variables.

Use of artificial intelligence (AI) in medical postgraduate training.

Use of artificial intelligence (AI) in medical postgraduate training.

Internship in the System of Postgraduate Training of Medical Specialists for Various Sectors of Healthcare, Including the Disaster Medicine Service of the Ministry of Health of Russia: the History of its Formation and Development, 1967–2017

Internship in the System of Postgraduate Training of Medical Specialists for Various Sectors of Healthcare, Including the Disaster Medicine Service of the Ministry of Health of Russia: the History of its Formation and Development, 1967–2017

Graduating resident and fellow readiness for general urologic practice during the COVID-19 pandemic A survey-based assessment of trainees and program directors.

Our goal was to compare the perceived readiness of graduating urologic residents and fellows to program directors (PDs) in U.S.-based postgraduate training programs. Additionally, we set out to assess the impact of COVID-19 on postgraduation plans to pursue fellowship training. Graduating residents, fellows, and PDs of accredited residency/fellowship programs in the U.S. were surveyed. The ranked preparedness of trainees to perform common urologic procedures was measured using a Likert scale from 1 (not comfortable) to 5 (fully proficient). The impact of COVID-19 was measured using a three-point Likert scale. Chi-squared and Kruskal-Wallis analyses were used to compare the groups. From 93 responders, 21 were residents, 19 were fellows, 24 were residency PDs, and 29 were fellowship PDs. The median levels of comfort for trans-urethral resection of the prostate, hydrocelectomy, vasectomy, and urethral sling were at or above (≥3) moderate for both PDs and trainees. PDs were more likely to report underperformance for hypospadias repair (60% vs. 39%), penile prosthesis implantation (39% vs. 26%), and orthotopic neobladder formation (57% vs. 18%) than the trainees. Fifty-three (57.0%) of the surveyors felt that COVID-19 did not impact the trainees' comfort in performing general urologic procedures. COVID-19 influenced trainees' decision to pursue a fellowship or opt to practice as general urologists (p=0.002). Our study suggests there may be a self-reported discrepancy between graduating trainees and their PDs regarding trainees' comfort levels performing general urologic procedures.

Acciones para establecer el esquema de certificación de Sistemas de Gestión de Organizaciones Educativas basado en NC-ISO 21001:2019 en Cuba

To demonstrate their quality, higher education institutions can be accredited by sectoral educational quality schemes or certify their management systems, following the approaches of the International Organization for Standardization. The objective of this work is to present the actions carried out in Cuba to establish the certification scheme, according to NC-ISO 21001:2019. To this end, a descriptive research was carried out, with a qualitative approach, supported by the analysis of scientific articles and other documents that substantiate the importance of the SGOE. The focus group technique was applied to know the experts' perceptions about the relevance of establishing this certification in the country. The necessary actions were planned to establish the scheme and it was designed with the University of Havana, as owner. The certification of Management Systems for Educational Organizations will allow institutions that provide higher-level and postgraduate training services to demonstrate the quality of their educational processes, through compliance with the NC-ISO 21001:2019 standard, by a third-party evaluation scheme, which includes educational organizations that are not governed by the sectoral accreditation system established in Cuba.