Becoming a Researcher in Academic Medicine: An Autoethnography of Research Faculty Development

Abstract

In the literature, research education is insufficiently addressed. Existing studies often document pre-/post-educational interventions. Accounts of individual scholars colored by their views and experience are rarely considered. This study describes the research experience of a faculty member in academic medicine and examines the values and practices that make up the subculture of research. Drawing on Hafler’s conceptual framework and autoethnography as a method, professional experiences related to research education are described and analyzed. Data were collected through the author’s journaled self-reflections. The findings were organized according to Hafler’s three suggested areas of faculty development. The first was the experience of formal professional development activities. There was a dearth of research education activities provided to faculty. The second was the experience of informal mentorship. Despite the tapestry of mentors, the types of relationships involved were unclear. The third theme is the experience of the culture surrounding promotion and funding. The quality of the research was challenged by the lack of funding. Current research education for faculty members are, in the author’s experience, modest. The research subculture encourages tacit strategies that orient faculty toward producing research on their own and influence scholarship decisions that produce works that do not necessarily have value and may not be considered impactful. A clearer purpose and more structured professional development that takes into consideration the three levels of faculty development—formal, informal, and cultural—are needed to help faculty fully realize their roles as researchers.

Keywords

faculty development academic medicine research education continuous professional development health professions education

Introduction

Research education is an integral part of a faculty member’s continuous professional development (CPD). Medical schools strive to provide ideal environments in which faculty members are encouraged to engage in scholarly activities and research production. A supportive environment would include access to resources and grants, training in research theory and processes, and the allocation of protected research time (Back et al., 2011; Cable et al., 2013; Gill et al., 2001). While a supportive scholarly environment is necessary to produce quality research that enhances medical practice, it is not usually the setting in which faculty find themselves (Hebert et al., 2003). Due to the competing roles that a medical faculty member is expected to take on, a counterproductive research culture often develops within academic medicine, ultimately influencing research education and the way faculty come to learn about research and its methodologies.

An example of the contending roles a physician must assume appears in the CanMEDS framework (Frank & Danoff, 2007). Of the seven competencies that comprise the CanMEDS framework, medical expert takes a central position. The remaining six competencies—communicator, scholar, collaborator, professional, manager, and health advocate—surround the medical expert role as petals of a greater floral shape that illustrates the complex interconnectedness between each role as well as the overlap between them. The purpose of the CanMEDS framework is to provide a standard for local, national, and global medical education and practice. More specifically, the interest of this paper—the scholar role, in the terms of the CanMEDS framework—is described as “…demonstrat[ing] a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship” (Richardson et al., 2015, p. 24). This is representative of current conceptualizations of scholarship in the medical education literature. This qualitative study aimed to critically analyze such conceptualizations of scholarship and research education by drawing on the lived experience of the author as a faculty member. The article discusses the influence of such conceptualizations on educational initiatives that target the research skills of faculty members and how they are situated and approached in schools of medicine.

More specifically, by drawing on Hafler et al.’s (2011) conceptual framework of faculty development and autoethnography as a methodological approach, I begin by asking, What is my experience as a researcher of faculty development addressing research competencies? Through this query, issues of contention in research education and overall culture are examined, including the formal activities, informal activities, and tacit cultural elements that shape learning, promotion, and funding. More deeply, the findings of this study suggest that these different factors—which are integral in the design and execution of research CPD activities, are aimed at developing faculty members as scholars, and enable them to practice evidence-based medicine—may collectively create a counterproductive culture that perpetuates poor research values, beliefs, and practices. Finally, some of the important implications for research, education, and practice in CPD are presented.

Defining Research Education

In the academic medicine literature, definitions of research education are broad and varied. This lack of clarity may be due, in part, to the universality of research education as a central component of higher education (Chan Fong Yee, 2014). Moreover, research theory, practice, and training have evolved as components of nearly every field, both in the humanities and sciences, which has led to the proliferation of different research ideals and best practices. In medical education specifically, conceptions of research education vary. When regarded as a practical action signifying methods of performing and executing, authorship and readership are interpreted as means to an end—namely, publication—rather than having clearly defined philosophical and theoretical frameworks that emphasize conceptual understanding (C. Rees et al., 2023; Reeves et al., 2008).

In the CanMEDS physician competency framework, the encompassing role of scholar recalls the role described in the literature. However, in the literature, it is addressed with more specificity as the researcher role, and specific aspects of research education and training are elaborated, such as critical synthesis and analysis (Branson, 2004; Cumbie et al., 2005), academic writing (Cable et al., 2013; Derish & Eastwood, 2008), and the roles of supervisors or mentors (Alwazzan & Al-Angari, 2020; Gillespie, 2010). Some scholars call for sound pedagogical approaches to building robust and inclusive outcome-based research curricula (Hebert et al., 2003; Jackson, 2009), defying the longstanding assumption that most physicians should know how to read research and put it into clinical practice while a select few innovators produce it (Duley & Milne, 1994).

Furthermore, research education is often referred to as scientific training, and separate graduate work in master’s and PhD programs is advocated for those who wish to be researchers (Back et al., 2011). Others, however, advocate incorporating research education into clinical graduate programs (Byrnes et al., 2007; Moreau et al., 2014). Finally, emphasis is often placed on the responsibilities pertaining to research education at different levels—individual, departmental, and institutional. Some scholars emphasize individual efforts and self-directed learning to meet scholarly duties (L. Pololi et al., 2004), while many others call for action at the departmental and institutional levels and the creation of a scholarship community of practice (Cumbie et al., 2005; D’Eon et al., 2000; Kramer & Libhaber, 2016; Moses et al., 2009).

Conceptual Framework

A growing literature urges a close evaluation of faculty development initiatives and the overall socialization process that medical school faculty members must go through to be deemed “good” faculty (Hafler et al., 2011; Steinert, 2014). This study draws on the work of Hafler et al. (2011), which highlights the complexity of the learning process and identifies three types of effects on faculty development, to further explore this point of view:

(1) Formally structured, deliberate CPD activities—e.g., faculty development workshops

(2) Informal, unplanned, and unscripted CPD activities—e.g., mentorship

(3) Influences such as organizational culture and place, which are more invisible and ethereal in their presence and impact (p. 440)—e.g., promotional standards.

Hafler et al. (2011) contend that the latter two points together make up the hidden curriculum and that faculty development programs cannot be enhanced without first recognizing the tacit institutional culture and connections between the hidden curriculum, faculty, and learners (such as medical students and residents). In other words, the way research education is approached in undergraduate and graduate medical education and how medical learners perceive it are influenced by the ongoing professional development of faculty members. In this study, research education is seen as a component of faculty development. In the field of academic medicine, faculty development is often approached with a holistic approach (Richardson et al., 2015) That is, faculty development programs often target competencies that enable physicians to perform in their roles mentioned earlier in the CanMeds framework: the role of the medical expert, communicator, scholar, collaborator, professional, manager, and health advocate. The scholar role is further subdivided into the teacher role and the researcher role. The availability of workshops that cater to each role is subject to various factors including availability of experts, physical space, and institutional needs for human development overall (Steinert et al., 2016). Research education may target competencies that prepare faculty for conducting medical research or teaching and learning research depending on the needs of the faculty.

Methods

Study Design

Autoethnography is a qualitative, observational method of research that draws on and analyzes the lived experience of the practicing scholar and links their insights to self-identity, cultural values, interpersonal communication, traditions and symbols, shared meanings, and broader sociocultural issues (Atkinson, 2007; Rashid et al., 2019; Reeves, Albert et al., 2008). Autoethnography draws deeply on reflexivity; careful self-reflection is the main method of inquiry (Reeves, Peller et al., 2013), and active, reflexive writing is used to reveal the contours of sociocultural life (Richerdson, & St. Pierre, 2005).

Ethical Considerations

The author was the site of the inquiry and no other participants took part in this study. The proposed study is of very low risk to cause harm to the participant (the researcher) and the consent is inherently given by conducting and writing the manuscript. The study does not mention others directly. However, there remains a degree of indirect involvement. The author was reflexive throughout and took every precaution not to divulge potential identifying information about individuals or entities. These steps have been taken to address relational concerns prevalent within the autoethnographic type of research conducted by Ellis et al. (2011).

Context

The context of this study was the College of Medicine (COM) at Name of University (City, Country) between 2019 and 2023. The COM has 19 departments with an average of 120 faculty members, and in this period, 1,200 medical students matriculated into the Bachelor’s of Medicine and Surgery (MBBS) program, a 6-year program with an internship year. The author is an assistant professor of medical education. As a practicing medical educator, she leads the development of the MBBS curriculum and assessment policies, processes, and procedures. As a researcher, she focuses on the continuous professional development of the health practitioner, leadership, and leadership development in medical education and healthcare more broadly.

Data Collection, Management, and Analysis

The data were written journal entries that belonged to the author and were written over a Four-year period between March 2019 and March 2023. As a faculty member at a medical school, the author completed free-form written reflections using a physical journal on a monthly basis, although not rigidly. The journal entries were then digitized. Using Atlas.Ti (Germany, 2020) a qualitative analysis tool, thematic analysis was used to describe and analyze the author’s experiences. According to Ayash et al. (2001), a theme captures something important in the data set, it might be the prevalence of a certain theme within the data set or it might be an answer to the research question. In all cases, themes or patterns should address the research question. the author read through the transcripts and highlighted certain texts and gave them descriptions. Later the descriptions were refined and categorized according to Hafler’s conceptual framework. The ultimate purpose was to describe and interpret experiences of research education as a faculty member and research professional development activities as the fulcrum for actual scholarship in medical education and practice. The reflections and analysis were sent to two fellow scholars to appraise their general readability. The results section is organized according to Hafler et al.’s (2011) three levels of faculty development: (1) formal research CPD activities; (2) informal activities, that is, the role of mentorship; and (3) research culture—tacit learning, promotion, and funding. In the following section, short excerpts from the self-reflections are presented followed by a discussion that links the findings a previous work.

Results

Formal Research CPD Activities

For faculty members, medical schools offer ongoing professional development. Such activities ought to help members perform their jobs and responsibilities. Yet closer examination reveals a hierarchy of priorities in which these activities are addressed, with the quantity of research CPD activities outweighed by teaching CPD activities. The medical school where I work focuses primarily on the Bachelor’s of Medicine and Surgery degree (in a spiral integrated curriculum). Faculty development activities occur mostly in response to a program intended to transform traditional educational practices—e.g., lecture-based teaching—into more interactive teaching methodologies, such as problem-based learning. Activities that focus on research are few and far between. (Excerpt 1: Experiencing faculty development workshops, 2019)

When reviewing the literature, I found a few explanations of my experience. A common misconception is that faculty members can conduct research based on their previous training and, as a result, are not in need of continuous training; this may perpetuate the lack of explicit research education (Derish & Eastwood, 2008). Another viewpoint is that research education should be addressed primarily through self-directed learning. By contrast, faculty development that targets the teacher role, which is more interpersonal and thus necessitates more in-person instruction (Clark et al., 2004), are more more prevalent (Hartford et al., 2017; Hendry et al., 2005; Steinert et al., 2016). Moreover, the attention to other professional roles are also given substantial attention such as the role of physician as manager, many leadership and management programs are reported according to a systematic review by Steinert et al. (2012). Most likely, research activities are just the most prominent casualty of the lack of structure in CPD for health professionals more generally.

Larger medical schools provide more CPD activities for their faculty members, and they encourage health professionals belonging to other universities to attend. Although such CPD activities were beneficial, they did not address my needs. I attended a workshop entitled “How to conduct a literature review” and another called “The differences between systematic, scoping, and narrative reviews.” These workshops seemed to be a review of previous lessons I received in my graduate training. Moreover, I felt that they introduced me to local institutional procedures rather than enhancing my actual competencies in ethical practice and literature reviews. (Excerpt 2: Research CPD beyond medical school, 2020)

CPD activities frequently cover topics such as ethical approval and literature review construction, presenting these activities as procedural in nature. While ethics applications and literature reviews are important, research theory and methodology are thereby granted less weight (Reader et al., 2015). This focus may reflect what faculty believe they need, which would indicate a lack of knowledge of the essential research competencies. At this juncture, it is important to consider the hidden curriculum of research education within academic medicine. Rendering research as procedural and research education as how-to workshop might condition faculty to think of research as a means-to-an-end activity. For example, it is not uncommon for faculty to conceptualize research as a criterion for career advancement (Brandenburg et al., 2021). That is, to be promoted one must adhere to specific types of research and topics to collect points and get promoted. The audiences of such workshop are strictly healthcare professionals with an interprofessional blend including physicians, nurses, dentists etc. Being relatively unsophisticated, the available CPD activities influenced how I saw my self as a researcher, that one had to be more self-reliant to learn and conduct research.

Informal Activities: The Role of Mentorship

I was fortunate to have a variety of research mentors. As grateful as I was for the time spent and lessons learned, I always felt the need to be concise so as not to waste the mentor’s time. I also felt a need to fit into each mentor’s world—that is, to adapt my research interests and needs to their interests and needs. I am, to this moment, unsure whether my feelings were ever merited. (Excerpt 3: Mentorship experience, 2021)

In the literature, mentors play a pivotal role (Cain et al., 2001). Whether formally or informally, junior faculty typically gravitate toward senior faculty members (Byrnes et al., 2007; L. Pololi & Knight, 2005; Pound et al., 2015). Senior faculty are presumed to be qualified as researchers and capable of mentoring. To examine this assumption, I draw on a definition of mentoring commonly cited in the academic medicine literature: “Mentoring is a collaborative learning relationship that proceeds through purposeful stages over time and has the primary goal of helping a mentee to acquire the essential competencies for success in a (research) career” (Powell, 2014, p. 551). In this definition, there is a clear emphasis on the collaborative learning relationship between mentor and mentee, where both engage in a learning process. As I mention in the excerpt, I did not find my learning experience with mentees to be a collaborative one as defined in the literature. This leads me to believe competence as a mentor in research must be given special attention, as not anyone can do it.

I learned from my mentors many lessons. More senior mentors offered sage advice on what topics to tackle and how to go about addressing certain research questions but certainly didn’t have the time to help me design instruments or address issues in questionnaire design after having collected and analyzed the data. More junior mentors, often, whom I considered peers had more technical advice to offer and solved issues I would face. (Excerpt 4: Mentorship experience, 2021)

The definition shared earlier does not tell us whether mentorship focuses on learning about research subject matter (e.g., ulcerative colitis disease in male patients) or the research process (e.g., questionnaire design). Mentees often seek out mentors according to content expertise rather than process expertise, potentially causing issues for mentees down the line. For mentoring relationships to be successful, there needs to be an explicit identification of the knowledge, skills, and attitudes that qualify a researcher to become a mentor. Research experience does not necessarily reflect the ability to mentor (Steinert et al., 2008).

Mentor qualifications in research and medical education are ambiguous, which often leads to less qualified individuals taking on the role, whether through formal mentoring programs or informal mentoring (Cruess, et al., 2008; Pololi & Knight, 2005). Mentors may be considered unqualified in two instances: first, by being incompetent as researchers, whether because of a limited understanding of research theory (C. E. Rees & Monrouxe, 2010), inexperience with research methodology (Cain et al., 2001), or an inability to navigate the research world by, for example, getting grants and networking (Gruppen et al., 2003); and second, because of poor teaching skills, such as not setting outcomes based on the mentee’s needs or providing appropriate feedback (Clark et al., 2004).

Research Culture: Learning, Promotion, and Funding

Protected time and structure are necessary for a researcher to be able to write. In reading the literature, I found that my experience lacked some of the activities reported, such as writing clinics and retreats, but I also found that such activities were severely critiqued as methods of achieving organizational performance rather than impactful individual research. (Excerpt 3: Writing for promotion, 2023)

Success in an academic setting is based on scholarly publication. Research published in peer-reviewed journals is the main determinant of promotion in higher education institutes. Research education initiatives reported in the literature are overwhelmingly approached functionally. In other words, CPD initiatives are motivated by the short-term gains of publishing. Writing clinics (Derish & Eastwood, 2008), retreats (Cable et al., 2013; Jackson, 2009), and workshops (Steinert et al., 2008) are catalysts used by faculties of medicine to ensure that their members are producing research papers. In a general sense, writing workshops are necessary for many scholars to write, both in and beyond medical education. However, the rampant nature of workshops and retreats aimed at writing and producing research in medicine sheds light on the pressure to produce.

Issues regarding scholarly production in faculties of medicine are twofold. First, competing clinical, teaching, administrative, and research demands force physicians to prioritize; usually, scholarly activities end up being neglected (Cull et al., 2003). Second, physicians are often ill-equipped for the researcher role (Gill et al., 2001; Hebert et al., 2003).

I have not any received any grants to this day, mainly because I don’t know where to apply. I often think grants are sparse, but I’m not sure. It is difficult to conduct certain projects especially now with publication fees being so high. (Excerpt 21: Funding, 2022)

There are many avenues for receiving research grants in medical faculties. Junior faculty regularly face issues in securing research funding. They may not have the skills necessary to apply for research grants, such as seeking out potential funding sources and writing grant proposals (Bauer, 2003). Of the various topics mentees discuss with their mentors—including professional/personal life balance, promotion, clinical duties, and gaining access to research funding—funding-related skills have been identified as the most frequent (Feldman et al., 2010). This study found that a great deal of pressure is put on the individual mentor to teach a mentee. That this is the most discussed topic might alert us to the fact that such skills are not addressed as part of a formal research curriculum in medical education.

Another reason for funding being a popular topic of discussion between mentors and mentees is the difficulty associated with gaining access to it, even for senior faculty. Sizable grants are typically granted to well-established researchers, who then create small, nearly closed circles that are difficult to gain access to (Ebadi & Schiffauerova, 2015). In light of this, mentors do not necessarily teach practical techniques for securing funding (e.g., proposal writing); instead, they may act as gatekeepers to elite research communities.

Many faculty members are considered incompetent in research competencies, including framing research questions, choosing a proper methodology, analyzing and interpreting data in both quantitative and qualitative research, and reporting findings. As a result, both researchers and their institutions often hire specialists and delegate much of the research process (Kramer & Libhaber, 2016)—for example, outsourcing data analysis to methodology experts, such as biostatisticians (Péron et al., 2013).

Generally, recruiting methodology experts is considered an ideal approach because it is perceived to increase the quality of research and encourage collaboration among faculty members. Péron et al. (2013) examined the influence of statisticians’ involvement on randomized clinical trials and found that including them as coauthors of manuscripts had no influence on the quality of the resulting papers. However, this does not tell us how such collaborations influenced the researchers themselves and whether, by collaborating, their research skills improved at all. It is assumed in an alarming number of current research CPD initiatives that research is supposed to be performed by delegating crucial tasks (Back et al., 2011; Byrnes et al., 2007; Cain et al., 2001; Derish & Eastwood, 2008). In other words, physicians are taught to delegate rather than engage in the research process. This is not surprising, given the lack of protected time that faculties of medicine are willing to give faculty members to perform research (Gill et al., 2001).

Discussion

Much of research education lies in the informal and ephemeral. Through my autoethnography, I realized that what I learned about research can be broken down into the three themes outlined by Hafler et al. (2011): formally structured activities, informal activities, and organizational influences, such as culture—the last being imperceptible. My own learning involved explicit exercises and implicit lessons, governed by a complex interplay of the training that was available, the requirements for career advancement, and my personal desire to produce valuable research.

As previously discussed, separate graduate work is often recommended to become a physician/scientist by some (Back et al., 2011), while others advocate self-directed learning, others yet advocate action at the departmental and institutional levels (Byrnes et al., 2007; Moreau et al., 2014). Based on the findings of this study, improving research education seems to require a multi-pronged intervention at the individual, institutional, and perhaps the policy level. Institutes, namely universities must take a proactive role in the development of faculty as researchers through structured programs taking into considerations the interests of the researchers themselves.

Overall, my conceptualization of scholarship became more nuanced as I progressed in my career, drawing on the three themes mentioned and demonstrating more complexity in my understanding as I mixed with other scholars I considered mentors. Defining research education on the basis of the literature was helpful. Early on, the main influence on my understanding of research education was the literature on research CPD presented in this study—partly because of an interest in the subject. However, at a later stage, the informal interactions and the culture of research greatly shaped my experience.

My identity as a scholar was forged by complexity, and in many instances, I endured challenges, such as a lack of experience and funding. As I completed my graduate training and matriculated into the work environment as an assistant professor, accounts of formal CPD activities were relatively unsophisticated, failing to provide the catalyst I anticipated for my research. This seemed different from one institute to another, as I sought other places for professional development opportunities and found that medical schools affiliated with research centers and tertiary hospitals had more opportunities.

The “hidden curriculum” refers to the norms and values that are taught indirectly (Hafler et al., 2011). To that extent, in my experience, it offered lessons of exclusivity and the need to self-direct learning in research. Initially, this communicated an important message, namely, that research is secondary to teaching and thus not a priority. Indeed, the CanMEDS framework describes the role of the scholar as encompassing both teaching and research (Frank & Danoff, 2007). This unity may downplay the importance of the role of the researcher among physicians. However, a great deal of utility and prestige were attributed to research and research production. This juxtaposition left me with one explanation: research is an exclusive endeavor. Given advancement of the field, one might argue that overwhelming proliferation in research (as a result of the increase in the number of journals and ease of publication process) in all fields creates an overwhelming body of literature, some of which is not of great quality. As a result, it is too difficult to determine which articles are of good quality. Keeping this in mind, one might argue for exclusivity to maintain quality of scholarly work.

Implications for Research, Education, and Practice

Research education in CPD is fragmented and unstructured. A crucial next step is thus to give research education and training structure, clear objectives, and a sequence (Hebert et al., 2003). Using the CanMEDS framework as an example, schools of medicine can design CPD programs that are outcome-based. This would require taking into consideration what learners already know, what competencies they have yet to achieve, and how the latter can be presented in a sequential manner. This would allow learners to advance at a proper pace.

Moreover, given the broad and varied definitions of research education, it is vital to question these conceptualizations and explore their influence on the development of research CPD. Given the current functional nature of research CPD activities, a reconceptualization of research education should include theory, methodology, and methods of knowledge synthesis. Teaching and learning about research should also be contextualized within the researcher’s unique experience. By tailoring CPD initiatives to the needs of faculty and the available resources in their workplaces, research education activities can become more efficient (Moreau et al., 2014).

To further develop scholarly CPD programs in schools of medicine, it is necessary to explore how such programs are designed. Who designs them, and to what end? Hebert et al. (2003) began the debate on designing such programs, emphasizing the need to draw on sound educational theories and practices. However, their review of the literature was limited to residency education and did not include CPD. Moreover, while they applied curriculum design principles to the available literature, they failed to address who designs such programs, leaving a gap for future research to fill. It is important to assign qualified faculty, preferably those with educational training, to address the actual needs of faculty members.

Finally, it is crucial to identify the intentions underlying CPD program design by asking, To what end? Ultimately, research is meant to inform clinical practice and advance the medical humanities and sciences. If it fails to do so, then producing it is of little consequence. The quality of medical research is influenced by an array of factors (e.g., the availability of resources), but above all, research quality depends on the skills of researchers. Consequently, the impact of research depends on the quality of the training faculty receive.

Conclusion

Drawing on my experiences as a faculty member and researcher, I have argued that the position of research education among other CPD activities, the role of mentorship, the influence of authorship and publication, funding and access to resources, and lessons about the research process collectively form a hidden curriculum that is counterproductive to research education and continues to perpetuate unhealthy research ideologies and practices such as research being a self-directed activity and that it is in many cases an individual endeavors. Moreover, as Hebert et al. (2003) argued, research education lacks structure and direction; consequently, improving it requires drawing on sound curriculum design principles to develop robust CPD activities. However, many faculties of medicine do not have faculty members specializing in medical education, which limits their capacity to improve.

Given these tensions in research CPD activities, how can medical educators and faculties of medicine improve the current conditions? To begin with, as I have argued, the academic medicine community needs to examine the hidden curriculum and the culture associated with research education. The values, assumptions, and practices that make up the research culture, as well as the nuanced way certain practices are taught to junior researchers, inform the design of research CPD initiatives. From my experience, I found the lack of research-specific workshops and the ambiguity surrounding mentor-mentee relationships, as well as the lack of funding opportunities together form a hidden curriculum in academic medicine. That is, research is for a special few who may gain access to certain communities where teaching and learning take place, such elite communities will also facilitate access to research grants.

Dealing with issues of research education and training requires recognition of the implicit role we all play in perpetuating certain ideologies and practices. Furthermore, we must take part in a difficult dialog that aims to create supportive and sustainable research education programs. Addressing research education problems will not be solved by short, intensive workshops but by addressing the root of the problem and asking, Why don’t we give research CPD programs enough attention, and how are current CPD programs harming research education rather than helping it?

Footnotes

Acknowledgements

None

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Ethics Statement

Not applicable.

ORCID iD

Lulu Alwazzan

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