Pedagogy Rules: Open Mindset in Adopting Fit-for-Purpose Educational Tools in Teaching Dispersed Medical Students

Abstract

Students in the Rural Clinical School of Western Australia (RCSWA) spend one year of clinical study learning in small groups while embedded in rural or remote communities. This aims to increase the locally trained rural medical workforce. Their learning environment, the clinical context of their learning, and their rural doctor-teachers all contrast with the more traditional learning setting in city hospitals. The RCSWA has succeeded in its outcomes for students and in rural medical workforce impact; it has grown from 4 pilot sites to 14 in 12 years. This reflective piece assimilates observations of the formation of the RCSWA pedagogy and of the strategic alignment of education technologies with learning environment and pedagogy over a seven-year period. Internal and external influences, driving change in the RCSWA, were considered from three observer perspectives in a naturalistic setting. Flexibility in both education technologies and organizational governance enabled education management to actively follow pedagogy. Peter Senge's learning organization (LO) theory was overlaid on the strategies for change response in the RCSWA; these aligned with those of known LOs as well with LO disciplines and the archetypal systems thinking. We contend that the successful RCSWA paradigm is that of an LO.

Introduction

In large, longstanding education organizations, the way that pedagogy and technology align has mostly followed a convention set for a standard learning environment. Medicine is no exception. In contrast, an alternative clinical study year during a medicine degree where students complete the same traditional curriculum while dispersed in a different learning environment requires the de novo alignment of pedagogy, environment, and technology. The Rural Clinical School of Western Australia (RCSWA) is one such example. It trains a cohort of 85 medical students in their penultimate clinical year in small groups of 3–11 students dispersed over Western Australia's 2.5 million square kilometers. This design maximizes students' learning by embedding them for the academic year in a remote/rural context where generalist practice predominates. Such placements are termed longitudinal integrated clerkships (LICs); they vary in format worldwide ¹ and have had universally successful learning outcomes for students. ² In Australia, LICs are part of a strategy to improve recruitment and retention of a locally trained medical workforce in rural practice. Students apply to participate.

From its inception, the RCSWA adapted its implementation of the clinical curriculum and education technologies to the students' unique learning environment. ³ The RCSWA program based on clinical learning embedded in rural communities (CLERC; detailed in Ref. 1) is proven. It stays current by selectively adopting emerging technologies that enhance its rural pedagogy and honing these in a context-sensitive manner. The ongoing successful student outcomes, coupled with confirmed rural medical workforce impact, ⁴ has led to an increase in the number of remote sites from 4 in the initial pilot to 14 in total. As the school grew, its community of new rural doctor-teachers learned together, gaining new competencies both as academics and educators. ⁵

Even amidst this significant expansion, the school has remained a cogent synergy of its parts (the remote sites). Although in principle the governance of each site is lifted from the conventional academy, as a whole it outperforms that blueprint. ⁶ With the current pressure on opportunities for clinical experience in the traditional undergraduate setting, perhaps the RCSWA's underlying paradigm indicates the future of medical education. But what is that paradigm?

This study collates a longitudinal series of observations of change inside the school and correlates their incidence pattern with learning organization (LO) theory (Fig. 1). ⁷

Figure 1.

Location of RCSWA sites in Western Australia. The map illustrates the scale of the dispersed learning context of the rural/remote sites at which groups of 3–11 students spend their penultimate year of study in the RCSWA. An approximate scale overlay of Australia's outline onto continental Europe is provided for comparison.

Process and Methods of Analysis

This scholarly work is written from a naturalistic perspective; ⁸ the data were collected using sociological field observation methodology. ⁹ The authors/observers are academic clinical teachers (KAA, SJM, HMW) and a medical education academic (MALM) who were members of the RCSWA during the study period, 2007–2014. Each had a distinct role within the school and viewed events from that perspective, these being of a rural doctor teaching inside a rural site (SJM), of a specialist coach who was either based at a rural site (KAA) or in a city tertiary hospital (HMW) but teaching all sites, and of a medical education technology academic based at a site but interacting with all sites (MALM). Effectively, they observed as field participants in the role of complete participant ⁹ gathering data in a naturalistic setting. ⁸ The data sources were (1) the configuration and performance of education technologies used in the school, (2) peer group discussions between rural doctor-teachers quarterly at all-school face-to-face meetings, (3) de-identified student feedback report summaries, and (4) ad hoc personal communications. All diary notes from group discussions and personal communications were de-identified to assure confidentiality.

A situational analysis is made annually of the internal and external change influences on the learning and teaching in the RCSWA during the period, internal factors being from within the RCSWA, eg, its students and staff, and external factors being from host institution(s) ethos and governance, Funding source expectations, and other industry stakeholders.

The indicators of change influence were at two levels: at a granular level, eg an alteration in the configuration of an education technology for the next period as a result of feedback, and at a more macro level, eg, an agreed change in rural site policy relating to either an educational or lifestyle rationale underpinning the RCSWA pedagogy.

In terms of analysis, these observations and the subsequent change event outcomes are revisited using the management philosophy of LOs. ⁷ A reflective analysis is made from overlaying the LO framework on the change observations, and conclusions are drawn.

RCSWA Pedagogy

Learners and their environment

During their RCSWA year, the educating agents for students included the local community and its networks; the local health professionals and their networks; and the networks formed by the wider RCSWA community (other sites), including specialist coaches in pediatrics, cancer medicine, ophthalmology, and Aboriginal health. Paramount was the mentoring from the local rural doctor-teacher(s).

Context of clinical experience

Students' clinical experience was gained primarily in an integrated practice setting, and the yearlong placement more often enabled longitudinal follow-up of patients where they lived. Accordingly, the students were highly visible in the community; this drew their attention to aspects of professionalism and their own personal development.

Range of clinical experience

The contrasting demographics of the 14 sites naturally delivered a varied spectrum of clinical experience between sites and across the school. Education technologies were used to balance these variations.

Learner acculturation

The RCSWA placement blended personal experiential learning with challenging academic learning and new professional skills development. ¹⁰ Students relocated from their city homes and so were separated from their previous personal and study norms and value systems. At each site, they were housed as a group, comfortably and safely for the year. Naturally, the stressors of displacement were initially disorienting, akin to a culture shock of varying impacts on different individuals. ¹¹ In the new setting, their acculturation personally and as learners may have made them more accepting of new education technologies. Individual determinants such as mindset and personal resilience must affect learning outcomes, an area of increasing enquiry. ¹²

Their teachers

One or more medical practitioners practicing locally in the rural town were appointed as medical coordinators (MCs) part-time; their role was not only to teach but also to network locally for access to preceptors in other general practices and to the local hospital. Some were experienced in postgraduate teaching but mostly they were new to undergraduate teaching and unfamiliar with an undergraduate curriculum. MCs were often international medical graduates, giving a richness of perspective to the students. ¹³ A Graduate Certificate in Rural and Remote Medicine with a strong education component was created by RCSWA education academics; most MCs have since achieved this qualification. Collectively, they constitute a highly skilled clinician teacher workforce committed to excellence in rural medical education and scholarship; each one, like a new student, has undergone a personal/professional transformation inside the school.

Developments Underlying RCSWA Education Technologies

A key feature of the education technologies that were selected to support students was that they captured the intrinsic attributes of the students' learning environment (as described above). Some initial development was required to facilitate this.

Logging—overview of eLog

In response to the dissonance from applying a city curriculum approach into the generalist rural context, a thinking template was distilled from the pratique of a rural doctor academic with a lifetime's experience in rural practice; he was the organization's leader at that time. A database resource matching that thinking template was developed (the eLog tool) and trialed for a year and reviewed.

eLog's instructional design focus was to facilitate longitudinal reflection on learning and to identify further learning needs from clinical encounters; this was the core of rural practice. Importantly, eLog was searchable on all its fields.

In eLog, the student assigned the underlying clinical disciplines as he/she saw them for each case, including instances of personal and professional development (PPD). As a PPD portfolio equivalent, students were encouraged to write reflections when an experience had personal impact (in at least 10% of total cases) as well as to allocate specific PPD portfolio areas by check box. Students could upload de-identified files to store with any log. eLog was a private space but shared with a local clinical mentor at that student's regular case-based discussions on their eLogged cases (“log-based discussions”).

eLog spanned the learning domains ^a of knowledge, attitudes, and dialectic skills (eg, formulation), and all curriculum theme elements were mapped to its caselog interface. The eLog outcome for students was to show increasingly mature clinical thinking from patient encounters and fluent written clinical conversation as the year progressed.

Site collaboration—network infrastructure

A key strategy was to include all the school's dispersed sites on a level playing field for communications technology. To facilitate collaboration by videoLearning, a wider area network (WAN) was commissioned connecting all sites; each site was a template local area network. The layered network architecture (Surak Enterprises, www.surak.com.au) prioritized video; the modest, uncontended, 1.5 MB symmetrical service proved to meet the consolidated communication needs of the rural site offices. For video, the multipoint control unit connecting the sites was configured for self-serve into virtual rooms to allow ad hoc multiple-participant meetings. Desktop telepresence (CISCO Jabber client) was integrated with virtual room access, which enabled students or staff who were remote from their site but with internet connectivity to join virtual meetings.

The RCSWA Education Technologies

Five principal tools were selected and/or developed to support students and teachers in the RCSWA. These are summarized in the text below and itemised in Table 1.

Table 1.

Attribution matrix of the RCSWA pedagogy focus addressed by the education technologies (top row) and the education management strategy served by the education technologies (bottom row).

RCSWA PEDAGOGY FOCUS / TOOL	LONGITUDINAL REFLECTION ON CLINICAL LEARNING (EXPERIENTIAL)	IDENTIFICATION OF DISCIPLINE COMPONENTS OF CLINICAL EXPERIENCE (RECOGNIZE INTEGRATION)	REFLECTION ON PERSONAL AND PROFESSIONAL LEARNING FROM EXPERIENCE	COMPETENT ADVOCACY FOR RURAL COMMUNITIES	OPEN, INCLUSIVE DIALECTIC ETHOS
Learning domain	Knowledge	Knowledge	Attitudes	Attitudes/skills	Attitudes/skills
Student eLog	✓	✓	✓	✓	✓
Virtual patients	✓		✓	✓	✓
Video learning	✓		✓	✓	✓
Open blog			✓	✓	✓
miniCEX	✓	✓	✓		✓
EDUCATION MANAGEMENT FOCUS / TOOL	EVIDENCE CLINICAL EXPERIENCE ACCESSED ACROSS THE SCHOOL	EVIDENCE COMPLEXITY OF AVAILABLE CLINICAL EXPERIENCE	DEMONSTRATE IMPACT ON LEARNER AS A REFLECTIVE PRACTITIONER	HIGHLIGHT CURRENT RURAL SPECIFIC ASPECTS OF HEALTH CARE PROVISION	NETWORKING FOR SCHOOL WIDE AWARENESS

Table 1 is a matrix showing the correlation of RCSWA pedagogy and educational management achieved through appropriate implementation of tools over the life of the RCSWA to the present.

1. 1.

   RCS Student eLog, a web-based database resource for the longitudinal logging of and reflection on their clinical learning. A minimum number of quality logs per core discipline were required from each student by the end of the year as a barrier assessment item. Throughout the year the logs were used as discussion points during face-to-face meetings between student and MC (log-based discussions). MCs could review their local students' logs at any time (time line: 2006–2014).

   The pedagogy was to share clinical thinking and reflect on their learning.

2. 2.

   Virtual patient (VP) content packages, created in house, either

3. 3.

   Group videoLearning sessions, either large group (whole of school) or small group inter-site sessions (time line: 2010–2014), and with eClicker ^b integration, eg, as hinge questions during videoLearning (time line: 2013–2014).

   These were led by either

4. 4.

   RCS videoLearning blog, a WordPress blog installation serving as a platform for in-session synchronous eClicker polling and also for school wide asynchronous discussion on the learning from videoLearning sessions and beyond (time line: 2012–2014).

   The pedagogy was for shared, open, asynchronous discussion about learning.

5. 5.

   Mini Clinical EXaminations (miniCEX) in the core disciplines. Students invited these clinical skills appraisals from nominated local clinicians who completed a paper assessment form. A minimum number per core discipline was a summative assessment requirement. ¹⁴ The form was transposed by the local administrative staff into a school-wide web-based database (HIWA) for central collation. The students could then view their own miniCEX scores through their eLog interface, and similarly, the local MC could view those for his/her students. The technology best practice rationale was for accurate transposing of data, impartial calculation of scores, and transparency of stored assessment information (time line: 2008–2014).

^beClickers are a web-based version of physical clickers applied as a classroom aggregation technology or polling software; we used Pinnion (http://www.pinnion.com/).

Pedagogy and Education Management

The real wealth of the RCSWA placement stemmed from the opportunities for longitudinal, experiential learning in integrated practice settings alongside reflective practitioner role models. The MCs were committed to rural practice and its inherent, innovative, team heuristic; ¹⁵ this was the RCSWA pedagogy.

After the initial proof of concept in the RCSWA pilot year, ¹⁶ a set of city-equivalent benchmarks had to be evidenced to retain Funding. These included a range of clinical experience of adequate complexity and the reflective engagement of learners in those clinical encounters. So implementing education tools that confirmed these outcomes was integral to the educational framework, ie, this was appropriate educational management.

Aligning to Environment—Perpetual Change in Education Technologies

eLog was modified in some way annually in response to observed student and teacher behaviors and their feedback. The modifications mostly reflected progressive alignments toward the students' honest/naive clinical thinking. For example:

• •

  At first, only nine disciplines were offered for identifying integration; these were the taught/assessed disciplines (Fig. 2). Students then wanted to know how they could declare all the other learning they recognized, ie, outside those disciplines. In response, the MC group then agreed on 30 disciplines, which were covered in rural practice, as well as the care contexts in which patients were seen (Fig. 3). This meta tagging or subcategorization by the students of case material enabled interrogation of eLog for missing (ie, perceived as) experience. The missed learning opportunities were then transformed into VP content packages.

  Figure 2.

  Clinical disciplines in the pilot eLog. The pilot version of eLog offered the disciplines that were assessed as ones that students encountered while at their RCSWA site.

  
  Figure 3.

  Clinical disciplines/care contexts in the revised eLog. Feedback from students who used the pilot eLog showed that they needed a broad selection of disciplines from which to attribute the learning from their clinical experiences at their RCSWA site. The care contexts were added to further situate the experience.

• •

  So as to proffer related VPs from within eLog as just-in-time learning related to their real case, a field was added for students to propose keywords for their real case, and on submission, eLog then listed VPs that shared any of those keywords.

The transition of the RCSWA from proven concept to optimally enriched learning environment also required changes in eLog's behavior for both students and teachers. For example:

• •

  Originally, the management strategy had anticipated a need for a future audit to verify claimed clinical encounters, so eLog required data in all fields on log submission. Later on, at student request, this stringency was relaxed and a link was provided to a list of incomplete logs for completion.

• •

  In previewing students' logs before a log-based discussion, the MCs wanted to see students' learning issue entries adjacent to their differential diagnosis/formulation entries, so that they could follow the students' thinking. This adjustment was made to the MC summary interface of eLog.

Likewise, the videoLearning program evolved from urban specialist centered to be delivered by RCSWA specialist coaches and MCs with special expertise and their local colleagues (Fig. 4). New teaching practices were tried such that a mix of all of school didactic, half of school, or smaller group sessions focused more on dialog and discussion among individuals. This widening of uptake accompanied increased skills and confidence of the RCSWA teachers (evidenced from their discussions at quarterly meetings and by network use).

Figure 4.

Inter-site networking via video infrastructure. The extent of inter-site networking changed as teachers trusted video network infrastructure. (A) Prior to group video Learning, shared workshop groupings by site visits. (B) A different balance of inter-site groupings using video Learning. (C) Whole of school video Learning from a rural site. (D) A clinicopathological conference format with two sites co-presenting a whole school session.

Good network reliability underpinned the early and innovative adoption of new practices and tools. The examples were clinicopathological conference style dual-site presenter sessions (Fig. 4D) with strategic inclusion of in-session hinge questions via eClicker technology and asynchronous blog discussion (RCS videoLearning blog). In turn, this role modeling inspired students to lead videoLearning sessions themselves, both in large group presentations and between small groups where they compared their clinical experiences.

The HIWA resource for miniCEX recording was progressively modified to reflect assessment policy changes relating to, for example, the intervals in the rating scale, the balance of required formative to summative assessments, and the clinical rank of assessors. Progressive deadlines for submission of paper forms were imposed after a few years; the students would stockpile their best minCEXs and submit them in one bolus near year end, instead of as a trickle throughout the year as they were completed.

The overarching flexibility of the tools and their active management almost in an ongoing action research mode meant that misalignments between RCSWA pedagogy (on the ground) and technology performance could be resolved quickly.

Design Science and Best Practice

eLog's structure (ie, its data fields), the face-to-face discussion events linked to it, the interactive VP packages available from the same interface, and the keyword-linked VPs offered in response to students' real case keyword submission comprise the pedagogical pattern for RCSWA.

Adopting clicker or classroom aggregation technology ¹⁷ into our virtual classroom sessions for immediate feedback to the teacher on the current student understanding conforms to the best practice use of technologies for our dispersed context (see Table 12.1 in Ref. 18). Laurillard ¹⁸ has set four design science precepts that the teacher-scientist should follow: to keep improving their practice, to design and test principled improvements, to build on others' work, and to share their outcomes. The dissection of the pedagogical pattern of learning in the RCSWA and our strategy in the use of digital technologies to reflect that, illustrates our design science.

As an LO

We contend that its journey of inauguration and subsequent growth has identified the RCSWA as an LO, an organization that is “continually expanding its capacity to create its future,” according to the philosophy of Senge. ⁷ The focus on a public need, ie, to return doctors to the bush (for better health care in rural communities), was its spiritual foundation, a cornerstone of LOs. The protracted political issue of a rural health crisis required ongoing advocacy on behalf of underserved populations. This seeded a strong and consistent contextual base for the rural health cause and for student doctors being in rural areas.

Strategies typical of LOs

Over several phases in its lifetime thus far, the RCSWA has sequentially applied all eight of the strategies below, which have been formally assigned to exemplar diverse LOs. ⁷ This is illustrated as follows:

1. (1)

   Integrate learning and working—Our new MCs needed to study the art of teaching as they taught our students, so completed a teaching on the run courses. ¹⁹

2. (2)

   Start where you are with whoever is there—The first pilot site was run from a shop front in a mining town with a few local doctors teaching and a local person inexperienced with educational management as the administrator.

3. (3)

   Become bicultural—Understand the tenets of traditional clinical teaching by city specialists sufficiently so as to communicate the rural generalist equivalence effectively.

4. (4)

   Create practice fields—Carefully considered pilots in a changed or new teaching practice were welcomed, evaluated, and adopted.

5. (5)

   Connect with the core of the business—Each site's staff was asked to initiate and maintain active ongoing liaison with local community stakeholders; student community service projects were included in the curriculum; the school networked with national rural health lobby groups; the school's medical education practices had high visibility at international academic fora of high standing.

6. (6)

   Build learning communities—The site MCs rejoined as a group regularly in face-to-face meetings (including by video-participation) with a focus of learning from each other's practice; the school linked internationally with other like-minded medical schools; special interest groups formed on the basis of common topic interest, eg, Aboriginal health, virtual patients, etc.

7. (7)

   Work with the other—A sustained dialog was kept up with the main medical faculty in the city through presence on various faculty committees and active contributions into formal processes; administrative staff engaged with institutional governance initiatives, eg, occupational health and safety requirements; MCs networked with other rural health professional bodies.

8. (8)

   Develop learning infrastructures—RCSWA education staff created the Graduate Certificate in Rural and Remote Medicine so that MCs could achieve a formal academic qualification relevant to them; this established a community of practice (CoP) recognized beyond the RCSWA; the video network infrastructure facilitated the convening of special interest groups.

The LO disciplines

The RCSWA used strategies typical of LOs to ride each wave through its organizational life phases so far; it also practised the five defining LO disciplines intuitively.

According to Senge, ⁷ personal mastery is the discipline of continually clarifying and deepening personal vision, of focusing our energies, of developing patience, and of seeing reality differently. On joining the school, MCs already had mastery as rural doctors. They sought personal mastery as teachers, and that experiential learning was facilitated both by talking to more experienced MCs at the similar site and by the graduate certificate course. This relational space for MC collaboration is a hallmark of LOs. ²⁰ In contrast, students arrive at their RCSWA site as experienced learners who seek mastery of (rural) clinical practice. Each of mentor and mentee are engaging in transformative learning, so there is an attitudinal synergy.

The next of the five disciplines is mental models, these being deeply ingrained assumptions, generalizations, or even images that influence how we understand the world and how we take action. The students/doctors who choose to learn/practice in rural areas, particularly in regions with extensive Aboriginal health problems, get experience that challenges the mental models they formed from learning medicine in an urban setting. The PPD reflection in the eLogs of students showed that mental models were challenged. The log-based discussion between student and MC was the occasion for students to open their thinking for external comment.

Building shared vision is the skill of unearthing shared pictures of the future that foster genuine commitment and enrollment rather than compliance. The founding leader of the school was charismatic in his projection of the mastery engendered by extended rural practice and of the urgency for increasing the rural medical workforce and the learning opportunities it offered. The leader following on has used the existing impetus and commitment to the concept, to strategically networked and lobbied to normalize being inclusive of the rural context.

Team learning starts with dialog, the capacity of members of a team to suspend assumptions and to enter a genuine thinking together. Since its inception, the school has had quarterly face-to-face meetings of the MC group where verbal site reports were given and special items discussed honestly and openly. MC dialogs continued on beyond this forum. Technology (video) has been used to make these meetings as inclusive as possible, ie, to keep a level playing field for all members and not to leave anyone behind. A similar pedagogy supports the network of site administrative officers.

The fifth discipline, systems thinking, results from the practice of the other four disciplines. In the RCSWA, this is evidenced by the responsiveness of the school to external requests and by its culture of routine reflection on performance at regular all-school face-to-face meetings of teachers and on listening to feedback from students. A formal structure for student representation and ongoing feedback at time points during the year has been part of the RCSWA from the beginning.

Conclusions

In assimilating the various perspectives of the authors/observers, the resonant concepts were those from management and education. Agreed key features of life inside the school were conveyed by these concepts: metanoia (mind shift), generative learning (that which enhances the ability to create), dialog (a discussion that has a trajectory of continuity), open (permission to share and experiment), networked (sustainable collaboration), and digital (instant/re-usable/sharable/updatable). Collectively, these mostly ascribe to systems thinking (management); they also form a hidden curriculum (education).

The teaching group (the MCs and coaches) might be considered an education technology in itself; we have previously reported ⁵ the MC group as a community of practice (CoP) ^c . ²¹ We now see this CoP as a single slice of the whole dynamic organization that includes students, education academics, administrative staff, and community networks. The collegiality and professionalism of the MC group and their craftsman-like approach ²² to teaching embodies the lifelong learning paradigm originally perceived as the key to safe rural practice, a discipline of systems thinking.

The quality of the student experience in the RCSWA yields, if not always, an immediate return to rural practice, then at least a mind shift in understanding what rural/remote is; ¹⁰ these intangible qualities remain undefined to outsiders, yet are respected for their delivery of tangible outcomes.

This naturalistic study sought to link sets of longitudinal observations of education technologies, teachers' practice and their professional development, with organizational pedagogy. Rather than focusing on technical aspects of the tools or on student performance, we have assimilated the observed patterns of change to the forces driving the school. In doing so, we have identified the best practice paradigm underlying the success of the RCSWA, ie, that of an LO. This relates to a generic approach in management rather than an off-the-shelf solution, ie, one technology does not fit all.

Future emerging themes for interdisciplinary education require technologies to support an open, digital, and networked approach. ²³ The RCSWA is a networked living system; in healthy living systems, control is distributed. As challenges arose, the RCSWA could think through a direct route to a solution and act. Early on, it correctly identified a good-fit rationale for learning in context. It could innovate and be flexible in its choice of educational instruments to support that rationale. These instruments were the means of executing its main business (education) and of its evolving as an LO. Into the future, we anticipate continuing to innovate with new mobile technologies to engage learners in ongoing dialog and to inform our learning as an organization.

^cCoP—members build relationships to learn from each other, share tacit knowledge, and develop resources that lead to improvement.

Perhaps this indicates that even within large established education institutions, there should be active support for defining the alignment of technology, environment, and pedagogy within different study areas. Large education institutions should focus more on being LOs themselves and allowing their parts to be.

Author Contributions

Conceived and designed the analysis: MALM. Analyzed the data: MALM and HMW. Wrote the first draft of the manuscript: MALM. Contributed to the writing of the manuscript: MALM, HMW, and SJM. Agreed with manuscript results and conclusions: SJM, HMW, and KAA. Jointly developed the structure and arguments for the paper: MALM and HMW. Made critical revisions and approved the final version: MALM, SJM, HMW, and KAA. All authors reviewed and approved the final manuscript.