Residency Training Experience Research Articles

Single-surgeon training of 14 novice surgeons in robotic cholecystectomy: a study of 300 consecutive cases, assessing training outcomes and surgical performance.

Robotic-assisted surgery (RAS) is a rapidly evolving field, requiring comprehensive training for widespread adoption. The aim of this study was to analyze the effectiveness of RAS cholecystectomy training in improving the technical skills and confidence of novice surgeons. Furthermore, the study examined the transferability of RAS skills to laparoscopic skills, the role of RAS cholecystectomies in reducing errors and improving patient outcomes, and identified factors that predict a successful transition from traditional laparoscopic surgery to RAS surgery. The RAST curriculum includes multimodal learning content delivered through a cloud-based platform, with three steps: basic training, simulation exercises, and structured on-patient training in the operating room. One general surgeon was trained on the Intuitive Surgical da Vinci system and assisted in performing 10 da Vinci-assisted laparoscopic cholecystectomies. In the first 300 patients who underwent robotic cholecystectomy, there were no major complications, conversions to laparoscopy, or open surgeries. The RAST curriculum demonstrates feasibility in providing a comprehensive and effective RAS training experience for surgical residents, reducing the need for extensive travel and high costs. The RAST curriculum is a promising solution for training surgical residents in RAS, with potential for widespread adoption and scalability.

A qualitative and quantitative cross-sectional study on the past, present, and future of vaginal delivery: Turkey.

The current study focused on predicting future trends in obstetrics by examining obstetricians' approaches to specific challenging vaginal delivery that require special experience, such as breech presentation, macrosomic fetus, twin pregnancy, and vacuum use, compared with their residency training experience. The cross-sectional study was conducted in two phases. The first phase was qualitative and the second phase was quantitative. The "interview" and "survey" techniques served as data collection tools. In total, 20 obstetricians participated in the interviews, and 400 obstetricians took part in the survey. Data from the interviews were analyzed using the Maxqda 2020 qualitative data analysis program, and survey data were analyzed using SPSS version 25.0. Over the past 2 decades, there has been a gradual shift from vaginal deliveries to cesarean deliveries in cases involving breech presentation, macrosomic fetus, twin pregnancy, and vacuum use. While medicolegal concerns are undeniable, the prevalent belief among obstetricians that cesarean delivery is safer than vaginal delivery significantly influences this trend. Comparatively, young obstetricians often complete their residency training without acquiring sufficient knowledge and skills in vaginal delivery. Young obstetricians currently lack adequate experience in managing vaginal deliveries for breech presentation, macrosomic fetus, twin pregnancy, and vacuum use. This experience is at risk of disappearing entirely within the next decade as senior obstetricians retire. Policymakers should take this into consideration when shaping future healthcare policies.

A Survey on Quality of Services, Training, and Attitude of Dermatology Trainee Residents About Sexually Transmitted Infections in Teaching Hospitals Across India.

The incidence of sexually transmitted infections (STIs) has increased disproportionately to STI services. It is uncertain how many residents trained in STI services continue them. This study assessed the self-rated quality of training and attitudes about STI services amongst residents of Indian teaching hospitals. In this descriptive cross-sectional survey study, opinions from Indian postgraduate trainee residents were sought in three domains of STIs- institutional STI management practices, quality and satisfaction with training, and attitude towards STI services. A total of 225 responses were included. There was no separate area for STI services at centers of 51.6% of residents, and among those with separate STI posting, the duration was ≤2 months for 34.7%, with 59.6% wishing for its increase. Easily available bedside tests were used regularly when indicated by only 41.8%. Only 58.2% of respondents strictly ensured contact tracing and partner treatment. Only 65.8% of centers had provision of benzathine penicillin. Under-confidence in managing STIs independently was reported by 19.6%. Inadequate training was the second reason for wishing to discontinue STI services upon completion of training; with 71.5% wishing to continue STI practice. In univariate analysis, frequent point-of-care testing (P < 0.001), and >2 months of separate STI posting (P = 0.018) were associated with good satisfaction with STI training. Frequent point-of-care testing (P < 0.001), and male gender (P < 0.001) were associated with good confidence in independently managing STIs. Male gender (P = 0.038), having less reluctance in dealing with STI patients (P = 0.003), and good confidence in independently managing STIs (P = 0.008), was associated with willingness to continue STI practice. STI care is associated with reluctance. Current STI training in Indian teaching hospitals is less than desired and can lead to unwillingness amongst residents to practice STI services in the future. Having >2 months of separate STI posting, frequent point-of-care tests, and efforts to reduce reluctance when dealing with STI patients are steps that can improve the STI training experience of residents.

A Novel Longitudinal Training Experience in Obesity Medicine for Internal Medicine Residents.

Background Treatment of obesity is a public health priority. However, little training in obesity medicine is currently integrated into residency programs. We integrated a 12-month obesity medicine training experience within a New York internal medicine residency program. Objective We describe the structure, feasibility and acceptability, resident assessments, and patient weight loss outcomes of an optional longitudinal obesity medicine training experience for internal medicine residents. Methods Between July 2016 and June 2021, 26 second-year residents participated in the 12-month program, which comprised 10 educational/clinical sessions overseen by obesity medicine attendings. Residents completed baseline and post-program 5-point surveys of knowledge, competence, and attitudes. Differences at 12 months were analyzed using paired t tests. Resident patient weight loss was analyzed using the Wilcoxon signed rank test. Results The training experience was successfully integrated over the study period and remains ongoing at present, demonstrating feasibility and acceptability. Fourteen of 26 (54%) residents completed post-program surveys. Significant improvements in all measures of knowledge and competence were seen. The greatest improvements were in comfort discussing weight loss with patients (+1.1; 95% CI 0.8-1.5; P<.001) and prescribing weight loss medications (+1.4; 95% CI 1.1-1.6; P<.001). The 98 patients seen by residents lost an average of 4.5 kilograms (95% CI 3.0-6.0; P<.001). Conclusions The training experience was feasible and acceptable, and demonstrated improvements in resident outcomes and patient weight.

Evaluating the Realism of a Task Trainer and the Impact on Residents' Confidence in Managing Massive Upper Gastrointestinal Bleeding Among Emergency Medicine Residents.

Objective Hemodynamically unstable upper gastrointestinal bleeding (UGIB) represents a life-threatening emergency that often lacks adequate high-fidelity training in the insertion of balloon tamponade devices. To address this gap, we developed an affordable task trainer that provides real-time feedback to enhance the training experience for emergency medicine residents. This study aims to evaluate the realism of the task trainer and its impact on residents' confidence in managing massive UGIB. Methods Constructed from low-cost, readily available materials, the task trainer was utilized in a training session attended by 28 emergency medicine residents. Following the review of an instructional video, participants were timed during the insertion of the balloon tamponade device. Subsequently, they completed a paper survey to assess their experiences and confidence levels. Results All 28 residents completed both the pre- and post-session surveys. The average time for inserting the balloon tamponade device was 3 minutes and 49 seconds. Sixteen participants strongly agreed, 11 agreed, and one felt neutral regarding the task trainer's realism in teaching the procedure. Additionally, all residents rated the simulation average or above average compared to previous educational experiences. Fourteen residents reported feeling significantly more confident in managing massive UGIB, while 13 felt slightly more confident, and one noted no change in confidence. Participants provided several positive remarks regarding the training session. Conclusions The balloon tamponade device task trainer proved beneficial in enhancing emergency medicine residents' confidence in managing patients with massive UGIB. Furthermore, the task trainer was perceived as realistic and superior to other educational modalities.

Left-handed cardiac surgery and training: a survey-based assessment.

There is a lack of guidance and scant learning resources for left-handed (LH) cardiac surgery residents and surgeons. No objective data exists to evaluate the reality of the training experience of LH cardiac surgeons and residents. A 32-question survey was designed for LH cardiac surgeons and residents. The survey questions were aimed towards understanding the experiences of LH cardiac surgeons and residents in order to identify and determine where the challenges of LH in cardiac surgery lie. The survey was disseminated by the European Association for Cardio-thoracic Surgery (EACTS) through online platforms, social media and the EACTS website. 74 total responses were gathered from the survey; 73% were true LH operators. During residency, 78.1% of LH cardiac surgery residents had no access to LH faculty. Of those with LH mentors, only 53.3% were supportive and helped teach LH techniques. As trainees, 49.3% considered coronary artery bypass grafting anastomosis to be the most difficult portion of LH technique. Upon initiating independent practice, LH cardiac surgeons consider being LH an advantage in comparison to residency. In LH cardiac surgery, there is a lack of tailored surgical exposure, training guidance, standardization, learning tools and teaching resources. Training resources for LH cardiac surgeons and residents should be developed.

Resident and supervisor perceptions of gaining obstetrical competency in Family Medicine: a qualitative descriptive study.

Canadian Family Medicine (FM) residents, upon graduation, are disinclined to provide intrapartum care. The FM resident experience with obstetrical training has not been studied in over a decade while the FM landscape has changed. This study explored the FM resident experience in working towards their obstetrical competencies as one of the chief influences on their career decision to provide intrapartum care or not. Using a qualitative descriptive design, we conducted semi-structured interviews with second-year FM residents (n = 7) and obstetrical supervisors (n = 8) from one Ontario FM program. We coded and interpreted the transcripts for common themes. FM residents working towards their intrapartum skills are influenced by the following themes: the learners' unique and individual experience and expectations; opportunities in the training environment; and learning obstetrics in the changing FM landscape. Notably, the influence of FM maternity care role models permeated all themes. This study offers insight into potential areas of intervention to improve the FM residency training experience in intrapartum care. Investment in FM maternity education, in the undergraduate and postgraduate medical curricula, with continued support in practice, is critical to maintain comprehensive education and patient care, especially while Canada faces a maternity care crisis.

Cosmetic Gynecology: Is There Enough Exposure in the Obstetrics and Gynecology Residency?

Introduction While cosmetic gynecology has gained popularity, the training experience for obstetrics and gynecology residents in this area is limited and not standardized. The primary objective was to investigate the exposure of obstetrics and gynecology residents to cosmetic gynecologic procedures including hymenoplasty, labia majora reduction, vaginoplasty, G-spot amplification, labiaplasty, clitoral hood reduction, and vaginal laser therapy. The secondary objective was to assess their comfort in performing the procedures after graduation. Methods This is a non-validated cross-sectional survey of obstetrics and gynecology residents and their exposure to cosmetic gynecology procedures. Using the Fellowship and Residency Electronic Interactive Database Access System, the Accreditation Council for Graduate Medical Education-accredited Obstetrics and Gynecology residency programs in the United States were identified, and the residency program coordinators were asked to distribute the survey. Data regarding demographics, program-specific characteristics, and exposure to certain cosmetic gynecology procedures were obtained and reviewed. Participants' reported comfort with the independent practice of certain cosmetic gynecology procedures after graduation was also obtained. Descriptive statistics were completed. Results A total of 96 responses were received. Approximately 50% of participants were exposed to cosmetic gynecology during training. Moreover, 70.9% of residents disagreed that they would feel confident in defining the included procedures. Furthermore, 87.5% disagreed that they would feel comfortable performing the procedures independently. A minority of participants were also unsure of the indication for cosmetic gynecology procedures, with 15.4%, 7.1%, 5.7%, and 4% unaware of the surgical indication for hymenoplasty, vaginoplasty, labiaplasty, and labia majora reduction, respectively. No participant knew the indication of surgery for vaginal laser therapy or clitoral hood reduction. Conclusions In the setting of current cosmetic gynecology training, nearly 90% of residents were not comfortable with these surgeries after graduation. Exposure to cosmetic gynecology for obstetrics and gynecology residents was limited. Without adequate exposure, residents may face difficulty performing procedures and managing complications after graduation. Therefore, standardizing resident training for cosmetic gynecology should be considered.

Early career family physician perspectives on their residency experience and practice choices in Canada: a qualitative study.

Though there are more family physicians in Canada than ever before, and residency programs are expanding, gaps in access to comprehensive care remain. This study aimed to describe and understand the role residency training experiences played in shaping practice choices, including the provision of comprehensive community-based care, among early career family physicians. A secondary analysis of sixty-three (63) qualitative interviews was conducted on data from a larger mixed method study on practice patterns and choices of early career Canadian family physicians. We utilized Braun and Clarke's six phases of reflexive thematic analysis on portions of transcripts concerning residency training experiences. Participants described positive residency training experiences that shaped practice choice with respect to preceptors and mentorship, experiences of longitudinal care, breadth of exposure, and preparedness for comprehensive clinical practice. Woven through these four domains were "points of tension" and "hidden truths". Points of tension included: i) the promotion of an idealized professional identity and practice that was difficult to uphold, ii) lack of representation among faculty/preceptors with respect to age and gender, at some sites, and iii) frustration about the lack of opportunities for interprofessional collaborative practices that reflected training experiences. Hidden truths included: i) lack of preparation to run a business, ii) high administrative workload, iii) realities of payment models, and iv) the range of roles available for family physicians beyond the provision of comprehensive care. Findings highlight opportunities for educational reform supporting the transition from residency to practice alongside the importance of addressing systemic factors beyond training which impact physicians' choices regarding comprehensive care.

Factors Influencing Primary Care Career Choice: A Multi-Institutional Cross-sectional Survey of Internal Medicine Primary Care Residency Graduates.

Although primary care is associated with population health benefits, the supply of primary care physicians continues to decline. Internal medicine (IM) primary care residency programs have produced graduates that pursue primary care; however, it is uncertain what characteristics and training factors most affect primary care career choice. To assess factors that influenced IM primary care residents to pursue a career in primary care versus a non-primary care career. Multi-institutional cross-sectional study. IM primary care residency graduates from seven residency programs from 2014 to 2019. Descriptive analyses of respondent characteristics, residency training experiences, and graduate outcomes were performed. Bivariate logistic regression analyses were used to assess associations between primary care career choice with both graduate characteristics and training experiences. There were 256/314 (82%) residents completing the survey. Sixty-six percent of respondents (n = 169) practiced primary care or primary care with a specialized focus such as geriatrics, HIV primary care, or women's health. Respondents who pursued a primary care career were more likely to report the following as positive influences on their career choice: resident continuity clinic experience, nature of the PCP-patient relationship, ability to care for a broad spectrum of patient pathology, breadth of knowledge and skills, relationship with primary care mentors during residency training, relationship with fellow primary care residents during training, and lifestyle/work hours (all p < 0.05). Respondents who did not pursue a primary care career were more likely to agree that the following factors detracted them from a primary care career: excessive administrative burden, demanding clinical work, and concern about burnout in a primary care career (all p < 0.05). Efforts to optimize the outpatient continuity clinic experience for residents, cultivate a supportive learning community of primary care mentors and residents, and decrease administrative burden in primary care may promote primary care career choice.

Postresidency Practice Setting and Clinical Care Features According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Pilot Study.

Factors associated with physician practice choice include residency location, training experiences, and financial incentives. How length of training affects practice setting and clinical care features postgraduation is unknown. In this Length of Training Pilot (LoTP) study, we surveyed 366 graduates of 3-year (3YR) and 434 graduates of 4-year (4YR) programs 1 year after completion of training between 2013 and 2021. Variables assessed included reasons for practice setting choice, practice type, location, practice and community size, specialty mix, and clinical care delivery features (eg, integrated behavioral health, risk stratified care management). We compared different length of training models using χ2 or Fisher's exact tests for categorical variables and independent samples, and t test (unequal variances) for continuous variables. Response rates ranged from 50% to 88% for 3YR graduates and 68% to 95% for 4YR graduates. Scope of practice was a predominant reason for graduates choosing their eventual practice, and salary was a less likely reason for those completing 4 years versus 3 years of training (scope, 72% vs 55%, P=.001; salary, 15% vs 22%, P=.028). Community size, practice size, practice type, specialty mix, and practice in a federally designated underserved site did not differ between the two groups. We found no differences in patient-centered medical home features when comparing the practices of 3YR to 4YR graduates. Training length did not affect practice setting or practice features for graduates of LoTP programs. Future LoTP analyses will examine how length of training affects scope of practice and clinical preparedness, which may elucidate other elements associated with practice choice.

A Multi-aim Redesign of the Residency Training Experience in Outpatient Psychiatry.

A Multi-aim Redesign of the Residency Training Experience in Outpatient Psychiatry.

Clinical Care of Patients with Neurocognitive Disorders: A Qualitative Study of the Psychiatric Residency Training Experience.

Few data describe how general psychiatry residencies prepare trainees to care for individuals with neurocognitive disorders (NCDs), despite increasing recognition of the need for psychiatrists to provide care for the growing numbers of patients with NCD. This study aims to identify training needs and approaches, as the resident experience is one important perspective that can be added to others, such as milestones developed by expert educators. The authors conducted three focus groups of third- and fourth-year general adult psychiatry residency trainees from three different training programs in May and June of 2021. Focus groups consisted of three to eight unique participants per group. Qualitative data analysis techniques derived in grounded theory were utilized to identify themes. Four main themes emerged from the focus groups: unique challenges of NCD care, intrinsic rewards of working with families, perceived gaps in educational experiences, and limited comfort in future practice. Participants expressed that aspects of NCD care were fundamentally different than care for other mental health conditions encountered in psychiatry residency. They found the progressive nature of the disease to be particularly challenging, and they also expressed challenges with clinical interviews and establishing rapport with individuals with NCDs. However, working with families was especially rewarding. Regardless of training program, participants expressed a need for additional longitudinal and diversified training opportunities to prepare them for future practice in this area.

The Role of Gender in Perceived Vascular Surgical and Cardiovascular Residency Training Experience

The Role of Gender in Perceived Vascular Surgical and Cardiovascular Residency Training Experience

Satisfaction With Abortion Training in an Abortion-Restrictive State.

Background With increasingly disparate patient access to abortion care and resident access to abortion training opportunities following the Dobbs v Jackson Women's Health Organization decision, educators must better understand how legal restrictions affect obstetrics and gynecology (OB/GYN) resident training experiences and residents' desire to provide abortions. Objective To characterize how resident perceptions of abortion restrictions affect satisfaction with training and intent to provide abortion. Methods We recruited OB/GYN residents training in Ohio, a state restrictive to abortion, to complete surveys capturing training experiences between 2019 and 2020. Logistic regression models were used to estimate associations between perception of the legal climate on training and satisfaction with training and intent to provide abortions. To provide additional context to survey responses, we reviewed open-ended responses to the effect of the legal climate on training. Results Of 343 eligible residents, 88 (26%) responded from 13 of 15 programs (87% of programs). Most (73%) felt that the legal climate affected their training, and these respondents were more likely to be unsatisfied with their training (adjusted odds ratio [aOR] 16.6; 95% CI 2.83-97.22). We found no association between perception of legal climate on training and intent to provide abortions. In open-ended responses, most residents described a desire for more abortion training and barriers to patient care. Some highlighted the positives of training in a restrictive environment, which allowed for an improved understanding of the skills required for patient advocacy. Conclusions Many residents felt that the legal climate in Ohio affected their abortion training, a perception that was associated with decreased satisfaction with training.

The Role of Gender in Perceived Vascular Surgical and Cardiovascular Residency Training Experience: A Canadian Experience

The Role of Gender in Perceived Vascular Surgical and Cardiovascular Residency Training Experience: A Canadian Experience

Assessing the Impact of Shifting Enfolded Neurosurgery Fellowships to Follow the Chief Resident Experience: National Survey of Program and Fellowship Directors

The neurosurgery chief resident year is traditionally completed during the final residency year; however, a recent directive decried that enfolded fellowships should be undertaken following completion of the chief experience for most fellowships. A national survey was distributed to U.S.-based neurosurgery residency/fellowship directors regarding these changes. We received 135 completed surveys (37% response rate). Respondents tended to feel the new post-chief enfolded fellowship mandate represented positive effects on residency training (58%) and chief experiences (54%)-overall, 47% agreed the changes are net positive, 17% neutral, and 36% negative. In addition, 66% respondents thought the enfolded fellowship was enhanced due to previous completion of the chief year. Most did not feel the directives had a negative impact on resident case minimums completion, total case volumes, or overall case mix during residency; but 64% felt it would reduce post-graduate training. Of those who said the mandate would reduce post-graduate training, 45% thought this would be positive. Throughout all questions, most respondents tended to feel strongly, although with little overall consensus across many of these questions. One area of relative agreement was a 60% preference to allow program discretion for chief/enfolded fellowship training timing-with 41% strongly supporting versus 15% strongly rejecting reversion to program-directed administration. Fervent bimodal opinions exist among residency program and fellowship directors regarding the directives for enfolded fellowships to follow successful completion of the chief resident experience. However, there was broad support for allowing greater program discretion for directing certain enfolded fellowship timing and structure.

The Impact of a Hands-On Interventional Radiology Training Course on Radiology Resident's Training: A Single Academic Institution Experience

Abstract Purpose The aim of this study was to investigate the outcomes of an instructional hands-on training course that introduces radiology residents to the essential tools and skills needed to perform basic interventional radiology (IR) procedures. Materials and Methods This study was performed over a single academic year at a single academic institution. A precourse survey was sent to all radiology residents to identify areas of weakness and potential opportunities for improvement. In view of the responses, a hands-on training course was designed to cover the basics of vascular and soft-tissue access, catheters, wires, embolics, and closure devices. The training was provided in a one-to-one setting by a single IR attending over a period of 45 minutes and was concluded with hands-on training on an ultrasound (US) vascular access phantom whenever possible. An anonymous postcourse survey was then distributed and the results were analyzed. Results The average reported comfort level with basic IR concepts prior to course attendance was 1.7 on a 5-point scale (1 = not comfortable, 5 = very comfortable). This increased to an average of 4 following the course. Ninety-three percent of residents reported they have more confidence getting into the IR suite and assisting in IR procedures following the course. Residents who had an opportunity to train on the US vascular access phantom gave an average response of 4.6 out of 5 to a question of how helpful the experience was in improving their US hand skills (1 = not helpful, 5 = extremely helpful). One hundred percent of responders reported that the course successfully met its goal. Finally, the overall responses were unanimously in favor of continuing the hands-on training course. Conclusion A personalized, cost-effective, hands-on training course can improve the IR training experience of radiology residents, especially in the early training phase. This model is of particular value for smaller to medium-sized academic institutions with limited financial and educational resources.

Predictors of intention to provide abortions after OB/GYN residency training.

Abortion is a common gynecological procedure and plays a central role in women's health and autonomy. To maintain accessibility to abortion, it is important that sufficient obstetrics and gynecology (Ob/Gyn) residents intend to provide abortion care after residency. This study identifies factors that influence a resident's intention to provide abortions (IPA) post-training. A multiple-choice survey, addressing demographics, religious background, residency program metrics, training experience and intent to provide abortions (IPA), was answered by 409 Ob/Gyn residents. Chi-square test was performed on descriptive statistics and continuous variables were tested with ANOVA with p<0.05 considered significant. Residents with IPA were predominantly female (p = 0.001), training in the Northeast and West (p<0.001), identifying either as non-religious, agnostic/atheist or Jewish (p<0.01), not actively practicing their religion (p<0.001) and leaning democrats (p<0.002). Those with IPA were more likely to train at hospitals without religious affiliation (p<0.008), to train at a Ryan Program (p<0.001), to place strong emphasis on choosing a program with family planning training (p<0.001), to join programs where a significant portion of the faculty performs abortions (p<0.001) and to have completed a higher number of first trimester medical and surgical abortion procedures during the last six months of training (p<0.001). These results suggest that factors influencing a physician's intention to provide abortions are multifactorial, involving personal and program factors. A model predicting IPA is derived. To maximize IPA, residency programs can increase abortion volume, facilitate additional training and build a supportive faculty.

Psikiyatri İhtisasında Psikoterapi Eğitiminin Yeri: Türkiye’den Bir Sunum

Objective: This study aimed to investigate the psychotherapy training experiences of psychiatry residents through a questionnaire, addressing the knowledge gap on standards and practices during psychiatry residency training in Türkiye. .&#x0D; Materials and Methods: The study was conducted via WhatsApp and e-mail groups specific to psychiatry residents in Türkiye.&#x0D; Results: In our study, 80.5% of psychiatry residents received psychotherapy training during their residency, whereas, especially in those who have been in residence for four years or more, 97% received theoretical training, and 68% received supervision training. Moreover, a substantial portion (90.3%) of residents expressed plans to pursue psychotherapy training after graduation. Of those who received training, 63.7% obtained it from their educational institution, while 89.0% obtained it from other centres. Furthermore, 47.8% of the psychotherapy training was provided by in-house faculty members. Cognitive Behavioral Therapy was the most preferred type of psychotherapy among the residents. The most commonly reported barrier to accessing psychotherapy training was its high cost..&#x0D; Conclusion: The study concluded that most psychiatry residents in Türkiye received psychotherapy training. Enhancing psychotherapy training in psychiatry residency, overcoming barriers, and improving supervision are critical issues to be addressed