Blog do Curso de Medicina da Universidade Estadual de Maringá para a discussão de temas de Educação Médica, Educação das Profissões da Saúde e áreas correlatas.
Blog of University of Maringá Medical School for the discussion of issues of Medical Education, Health Professions Education and related areas.
Medicina da UEM desenvolve ações de desenvolvimento docente do Curso e da Universidade
O Conselho Acadêmico e o Núcleo Docente Estruturante do Curso de Medicina da UEM participará nos próximos dias de ações de desenvolvimento docente.
O primeiro evento, um curso de extensão voltado aos professores dos 11 departamentos que oferecem componentes curriculares para o Curso, terá o seu primeiro encontro no dia 29 de agosto de 2019 à noite. O objetivo principal será a avaliação do projeto pedagógico do Curso à luz das atuais Diretrizes Curriculares Nacionais (DCN, 2014) e um estudo comparativo com outros modelos curriculares.
Nos dias 02 e 03 de setembro de 2019, participaremos de uma mesa-redonda sobre o ensino de graduação na UEM onde coordenadores apresentarão experiências exitosas e desafios de seus Cursos.
Estas discussões visam embasar mudanças que valorizem o ensino de graduação e estimulem a sua integração com a extensão, pesquisa e pós-graduação.
Simulação Realística Aplicada à Educação. Este é o tema de um dos workshops do I Congresso do Hospital Universitário Regional de Maringá (HUM), que ocorre entre os dias 11 e 13 de outubro, juntamente com o Congresso Médico de Maringá. Os eventos comemoram os 30 anos do curso de medicina da Universidade Estadual de Maringá (UEM) e do Hospital Universitário. As inscrições estão abertas e a programação é de interesse de médicos, estudantes de medicina e servidores da área da saúde, especialmente, do HUM.
Estar em uma sala de emergência lotada diante de um paciente que não responde bem ao tratamento; isto é, que se comporta de maneira diferente do padrão descrito nos livros é um desafio. “Ainda mais quando nos deparamos com a falta de materiais ou equipamentos. Nesses casos, é preciso pensar rápido! Mas há algumas dicas que podem ser importantes. São elas que serão apresentadas no workshop de simulação realística”, explica Lucas Gremaschi, um dos estudantes que estão organizando os eventos científicos. Ele ainda destaca que o curso será ministrado no dia 13, pelos integrantes do Projeto Medicina, do Instituto Iavante, de Málaga, Espanha: o doutor Félix Plaza Moreno e o médico David Carrilo Atero.
Ainda são de interesse dos servidores e alunos do HUM outros dois cursos. O primeiro é Avaliação de Tecnologias em Saúde, que será nos dias 11 e 12, e tem como objetivo a criação do futuro Núcleo de Avaliação de Tecnologias em Saúde (NATS) dentro do HUM. A ideia é capacitar as equipes para elaboração de Pareceres Técnicos baseados em evidências técnico-científicas.
O segundo será de Segurança do Paciente. Neste caso, as atividades serão no dia 13 e têm como objetivo treinar as equipes do HUM para adotarem novas práticas de segurança dos usuários do hospital”, explicou a professora Elza Kimura, uma das organizadoras do evento. Ela ainda chamou atenção para o fato de que já foi solicitada a inclusão dos cursos no Plano de Capacitação dos Agentes Universitário junto à Divisão de Treinamento da Universidade Estadual de Maringá (TDE/UEM), o que vai permitir que sejam utilizados para avanço na carreira técnica.
A inscrição deve realizada via boleto emitido sistema da UEM, o Gescomp. Ali deve ser emitida uma guia de recolhimento, com o código 5412, no valor de R$ 230,00. A taxa para os funcionários do HUM permanecerá fixa até a data do evento.
“Além da programação científica, após a cerimônia de abertura haverá um coquetel, já incluso na taxa de inscrição. Caso tenham mais alguma dúvida, por favor, liguem para o ramal 9202 e falem comigo, professora Elza Kimura”. Os Congressos serão realizados no centro de eventos do Hotel Nobile Suites, em Maringá.
O Centro Acadêmico de Medicina de Maringá - UEM, com o apoio do Curso
de Medicina, Departamento de Medicina e Hospital Universitário Regional
de Maringá, promoverá nos dias 11 a 13 de outubro de 2018 o Congresso Médico de Maringá 2018.
O Congresso fará parte das comemorações
pelos 30 anos da criação do Curso de Medicina da UEM e pretende
congregar as comunidades médica e acadêmica da cidade e região em torno
da sua programação científica.
In this issue, Weiss and Fiester's (2018) “From ‘Longshot’ to ‘Fantasy’: Obligations to Patients and Families When Last-Ditch Medical Efforts Fail” calls attention to the weight of clinician word choice when discussing interventions in the pediatric population. Their work focuses on communication in a highly narrow slice of intervention options, from unlikely to work therapies to impossible ones. Regardless of a therapy's low probability of success, physicians and parents suffer from forms of misconception: physicians tend to be overly optimistic in both their prognostic estimates and in their disclosure of illness severity [Soliman 2017Soliman, I. W., O. L. Cremer, D. W. de Lange, A. J. C. Slooter, J. H. J. M. van Delden, D. van Dijk, and L. M. Peelen. (September 6, 2017). The ability of intensive care unit physicians to estimate Long-Term prognosis in survivors of critical illness. Journal of Critical Care 43:148–55. doi:10.1016/j.jcrc.2017.09.007.[Crossref], [PubMed], [Web of Science ®],[Google Scholar]], and parents tend to be highly likely to believe that their child is the one of many who will benefit from therapy [Mack 2007Mack, J. W., E. Francis Cook, J. Wolfe, H. E. Grier, P. D. Cleary, and J. C. Weeks. 2007, April 10. Understanding of prognosis among parents of children with cancer: Parental optimism and the parent-physician interaction. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology 25 (11):1357–62. doi:JCO.2006.08.3170.[Crossref], [PubMed], [Web of Science ®],[Google Scholar]]. For Weiss and Fiester's proposal to work, clinicians must realize and acknowledge early on that a “longshot” therapy is unlikely to work. This insight allows the team to share this understanding with the family and for the family to then, the authors assume, process the information. Adequate communication is a core clinical skill, yet not one innate to the best clinicians and few evidence based resources exist to support clinicians in achieving mastery in this arena. (One notable exception is Vital Talk [www.vitaltalk.org], however, the program is not specifically geared towards pediatric providers.)
The authors advocate for expectation management at its finest: clear, highly specific communication that empowers parents to understand their child's illness better and to come to terms with narrowing treatment options. They propose a four-step process in which clinicians may build a series of signposts for parents, connecting an already unlikely cure to an unrealistic one. As the clinical picture evolves, parents are aware that forks in the road lie ahead. Presumably, this helps parents and clinicians build a stronger relationship while working in tandem to manage expectations of success and failure.
We have some concerns about whether this proposal would be workable or even desirable in practice. There are several ambiguities and assumptions that need to be explored. First, Weiss and Fiester make no distinction between highly innovative “longshot” therapies and routine “longshot” intensive care. Commonly, tertiary care children's hospitals accept referrals of patients previously declined by other centers. Often times, there may only be one center that offers a specific therapy, and such centers are willing to accept a high failure risk for a slim possibility of reward for patients and families. For example, there may be few surgeons who offer an innovative procedure and one that has evidence that her outcomes are better than other surgeons in the field. This may present a child's best and only hope for disease modifying treatment, even if the chances of cure are low.
This is significantly different from a patient who has languished in the intensive care unit, failing to improve despite high quality standard therapy (ventilator, antibiotics, pressors, etc.), who slips from care that's likely to work (a point upstream from the 4 stages presented) to care highly unlikely to work. In the case of a highly innovative therapy, the lines may be easier to draw, when families have been specifically referred to a tertiary care pediatric hospital for a “longshot” therapy, providing a starting point to clearly lay out the path(s) that may lie ahead. It is much trickier to do so for patients who have crept into the realm of “fantasy” care during their hospitalization. As a result, we are skeptical that the approach will work in these types of cases.
Weiss and Fiester's plan hinges on eventual “universal clinical agreement” and a zero probability of success. Critical care occurs along a continuum, and is not easily dissected into artificially and nebulously defined stages. Two clinicians may believe they are in different stages at the same time, making it impossible to achieve the consensus the authors expect. Therefore, clinicians never make it to step four, no matter how poor the outcome. At any point along this continuum, clinicians might advise parents against a longshot therapy, or alternatively, parents might decide to withdraw treatment because the risks of therapy do not outweigh the suffering caused. The idea that zero probability of success is the bright line at which clinicians should argue for redirection of treatment is deeply troubling. It is not clear that a true zero probability is ever reached. Almost every pediatrician has at least one story of a patient for whom they felt there was no hope for survival, who persisted and survived none the less. With a bar set so high, most critically ill children will experience unnecessary suffering for no benefit. In fact, by the time clinicians find themselves in widespread agreement about clinical “fantasy,” innumerable communication opportunities that focus on whether continued critical care interventions make sense will have been missed.
Finally, based on our extensive experience talking to families dealing with serious illness, we are skeptical that the words “longshot” and “fantasy” are uniquely suited to convey precise meaning, and are worried families may find the term “fantasy” offensive and confusing. Certainly, anyone who has been involved in clinical ethics has had families hope for or even demand miracles. As many of the OPC's point out, the word “fantasy” will likely not save us from the pitfalls of “futility,” and any individual word risks suffering the same lack of uniform interpretation. We should ask the empirical question: what language works with what families? Communication is complicated, even between two people who are already on the same page.
Weiss and Fiester raise questions vital to quality pediatric care, as clinicians struggle to determine how to communicate complex information to parents in a palatable manner. James Tulsky and colleagues (2017) have called for research into communication practices and proposed an agenda to include formal evaluation of both verbal and non-verbal communication. Studies in adults are helpful, but we need to know more about parents and children. What is the best way to deliver the worst news to parents and children? Are specific words particularly helpful when explaining small to miniscule probabilities of success? Are words or phrases equally effective for communication between each clinician, child, and parent? How can clinicians move a family towards understanding a poor prognosis in a compassionate and honest way? Unfortunately, neither the authors’ framework or the choice of language is based in empirical evidence. The development of a four-stage approach to communication is intriguing, although untested and atheoretical. Such a proposal may provide clinicians with an organizational framework for their thoughts on a case, but without methodical exploration, we won't know if it actually helps clinicians and families.
REFERENCES
Mack, J. W., E. Francis Cook, J. Wolfe, H. E. Grier, P. D. Cleary, and J. C. Weeks. 2007, April 10. Understanding of prognosis among parents of children with cancer: Parental optimism and the parent-physician interaction. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology 25 (11):1357–62. doi:JCO.2006.08.3170.
Porter, K., M. Danis, H. Taylor, M. Cho, and B. Wilfond. 2018. The emergence of clinical research ethics consultation: Insights from a national collaborative. American Journal of Bioethics 18 (1):39–45.
Soliman, I. W., O. L. Cremer, D. W. de Lange, A. J. C. Slooter, J. H. J. M. van Delden, D. van Dijk, and L. M. Peelen. (September 6, 2017). The ability of intensive care unit physicians to estimate Long-Term prognosis in survivors of critical illness. Journal of Critical Care 43:148–55. doi:10.1016/j.jcrc.2017.09.007.
Tulsky, J. A., M. Catherine Beach, P. N. Butow, S. E. Hickman, J. W. Mack, R. S. Morrison, R. L. Street, R. L. Sudore, D. B. White, and K. I. Pollak. 2017, September 1. A research agenda for communication between health care professionals and patients living with serious illness. JAMA Internal Medicine 177 (9):1361–66. doi:10.1001/jamainternmed.2017.2005.
Weiss, E., and A. Fiester. 2018. From “longshot” to “fantasy”: Obligations to patients and families when last-ditch medical efforts fail. American Journal of Bioethics 18 (1):3–11.
Prédio da Faculdade de Medicina de Ribeirão Preto, com os prédios do Hospital das Clínicas ao fundo – Foto: Divulgação/FMRP
Oferecer oportunidades para o desenvolvimento e capacitação do professor e, assim, melhorar o processo de aprendizagem de seus alunos levou à criação do Centro de Desenvolvimento Docente para o Ensino (CDDE) na Faculdade de Medicina de Ribeirão Preto (FMRP) da USP.
De acordo com o professor Valdes Roberto Bollela, um dos coordenadores do CDDE, esse trabalho vai impactar positivamente na qualidade da experiência educacional dos estudantes da FMRP. “Especialmente porque teremos professores mais bem preparados para o desafio de auxiliar jovens estudantes na sua trajetória de formação enquanto profissionais e cidadãos”, afirma.
O professor comemora os resultados do primeiro ano de implementação do CDDE, em especial do Módulo Básico para a Educação nas Profissões da Saúde (MB-EPS). “Ao término de dois módulos básicos em 2017, somamos 51 propostas de intervenção educacional e esperamos que sejam implantadas já em 2018.”
Prof. Valdes Roberto Bollela – Foto: Vladimir Tasca
Para o professor Bollela, mesmo com uma sólida formação na área profissional as universidades não têm muitas ações voltadas ao professor que ensina na graduação, ou seja, que atua como educador no meio universitário.
“Na verdade ensinar é uma prática profissional como qualquer outra e na área da saúde, em especial na medicina, existe uma ideia equivocada de que, se você é um bom médico ou um bom pesquisador, automaticamente será também um bom professor”, conta.
Bollela diz que muito do que o professor faz em sua prática educacional é baseado em sua própria experiência, enquanto estudante, se espelhando em modelos prévios que são ajustados na medida em que acumula tempo ensinando.
“Sem dúvida essa é uma forma de se aprender a ser professor, mas, como nas outras áreas, existem meios mais efetivos e rápidos para que esse objetivo seja alcançado.” O coordenador lembra que muitos têm dúvidas sobre o que significam conceitos básicos como avaliação programática, princípios para o desenho curricular, aprendizagem de adultos, aprendizagem com pares e sala de aula invertida.
A FMRP, segundo Bollela, tem ciência dessa necessidade e, através da criação do CDDE, busca atender também ao Artigo 34 das novas Diretrizes Curriculares dos cursos de graduação em Medicina de 2014, que deixa explícita a necessidade desses cursos manterem permanentemente um Programa de Formação e Desenvolvimento da Docência em Saúde, seguindo uma tendência já presente nas melhores instituições de ensino do mundo.
Prof.ª Margaret de Castro, diretora da FMRP – Foto: Gabriel Soares
Criar um centro de desenvolvimento docente já era uma das propostas do plano de gestão dos professores Margaret de Castro, diretora, e Rui Alberto Ferriani, vice-diretor da FMRP, que contaram com as sugestões e propostas dos professores Luiz Ernesto de Almeida Troncon e Bollela, ambos da FMRP.
Em janeiro do ano passado, os professores Margaret, Eduardo Ferriolli, presidente da Comissão de Graduação, Troncon e Bollela compuseram um grupo de trabalho que viabilizou a criação do CDDE.
“A maior parte das universidades de prestígio do mundo já dispõe, há décadas, de centros de capacitação e desenvolvimento docente, que procuram oferecer oportunidades para que seus professores aprendam conceitos e métodos que possam tornar mais efetiva a sua atuação como educadores e, com isso, os estudantes aprendam mais e melhor”, enfatiza a professora Margaret.
Resultados
Atualmente, a FMRP conta com 337 professores e 600 preceptores (profissionais de saúde não ligados diretamente à USP), que atuam em sete cursos de graduação, com um total de 1.430 alunos matriculados.
Durante o primeiro ano de atividades do centro, foram priorizados os professores mais novos da faculdade, mas houve participação de professores mais antigos e de alguns preceptores da prática profissional. Foram oferecidos dois módulos básicos, um em cada semestre, que contaram com encontros presenciais semanais e atividades a distância.
Ao término do módulo básico, os participantes fizeram propostas de intervenção que envolveram, principalmente, estratégias de ensino e aprendizagem, como a sala de aula invertida (quando o professor divide com o aluno o processo de ensino e aprendizagem), o team-based learning, estudo dirigido, técnicas de aprendizagem em pequenos grupos, aprendizagem com os pares e avaliação formativa.
Além disso, o CDDE ofereceu oficinas com temas voltados às avaliações dos estudantes, como as boas práticas na elaboração de testes de múltipla escolha, com a participação de 60 professores e preceptores ligados à FMRP e ao Hospital das Clínicas (HCFMRP).
O centro expandiu suas ações e os membros da equipe participaram de eventos organizados por outras entidades que tratam de temas relacionados à educação nas profissões da saúde. As expectativas do grupo coordenador são muitas, segundo Margaret. “Entre elas a realização de um módulo básico específico para os profissionais das unidades que compõem o complexo HCFMRP e manter os encontros presenciais periódicos entre participantes dos módulos básicos e os facilitadores, para fomentar uma comunidade de práticas que está se iniciando na FMRP”, enfatiza a diretora.
Iniciativa pioneira
O professor Bollela lembra que a Pró-Reitoria de Graduação (PRG) da USP vem investindo há muito tempo na qualificação do trabalho do docente como educador e que essa iniciativa vem se somar ao esforço da Universidade. “Acreditamos que o trabalho de capacitação e desenvolvimento docente para o ensino deva ser feito respeitando as particularidades de cada unidade e do seu corpo de professores. E, ainda, que os melhores resultados são obtidos quando se propõe oportunidades de contato muito próximo entre os professores que participam aprendendo e aqueles que atuam como facilitadores desse aprendizado.”
Assim, diz o professor, “acreditamos que a proposta do CDDE da FMRP e as atividades desenvolvidas em 2017 constituam uma experiência pioneira na Universidade”. Para Bollela, o caráter inovador da proposta decorre exatamente do modo como as atividades de capacitação e desenvolvimento vêm sendo oferecidas, que está criando uma ‘comunidade de práticas’ na faculdade, composta de pessoas interessadas em qualificar melhor o ensino.
“Comunidade de práticas é a designação dada a um grupo de pessoas com interesses comuns, que se ajudam e se apoiam mutuamente, para contribuir com o crescimento de sua área de interesse e amplificar o impacto das suas ações”, finaliza.
1New York Presbyterian, New York, New York 2New York Presbyterian, Weill Cornell Medicine, New York, New York
JAMA. Published online November 27, 2017. doi:10.1001/jama.2017.17094
Medicine has seen a
proliferation of specialties over the last 50 years, as scientific
discovery and care delivery advanced. Diagnoses and treatments have
become more complex, so the need for formal training for specialty
competence in cognitive and surgical disciplines has become clear. There
are currently 860 000 physicians with active certifications through the
American Board of Medical Specialties and 34 000 through the American
Osteopathic Association.1
Drivers of Specialty Expansion
Specialty development has been driven by advances in
technology and expansion of knowledge in care delivery. Physician-led
teams leverage technology and new knowledge into a structured approach
for a medical discipline, which gains a momentum of its own with
adoption. For instance, critical care was not a unique specialty until
30 years ago. The refinement in ventilator techniques, cardiac
monitoring and intervention, anesthesia, and surgical advancements drove
the development of the specialty and certification, with subsequent
subspecialization (eg, neurological intensive care). The development of
laparoscopic and robotic surgical equipment, with advanced imaging,
spawned new specialty and subspecialty categories including colon and
rectal surgery, general surgical oncology, interventional radiology, and
electrophysiology.
In nonprocedural areas, unique certification was
established for geriatrics and palliative care. Additional new
specialties include hospitalists, laborists, and extensivists, to name a
few. These clinical areas do not yet have formal training programs or
certification but are specific disciplines with core competencies and
measures of performance that might be likely recognized in the future.
Telemedicine and Medical Care
Telemedicine is the delivery of health care services
remotely by the use of various telecommunications modalities. The
expansion of web-based services, use of videoconferencing in daily
communication, and social media coupled with the demand for convenience
by consumers of health care are all factors driving exponential growth
in telehealth.2
According to one estimate, the global telehealth market
is projected to increase at an annual compounded rate of 30% between
2017 and 2022, achieving an estimated value of $12.1 billion.2 Some recent market surveys show that more than 70% of consumers would consider a virtual health care service.3
A preponderance of higher income and privately insured consumers
indicate a preference for telehealth, particularly when reassured of the
quality of the care and the appropriate scope of the virtual visit.3
Telemedicine is being used to provide health care to some traditionally
underserved and rural areas across the United States and increased
shortages of primary care and specialty physicians are anticipated in
those areas.4
A New Specialty
Digital advances within health care and patients acting
more like consumers have resulted in more physicians and other
clinicians delivering virtual care in almost every medical discipline.
Second-opinion services, emergency department express care, virtual
intensive care units (ICUs), telestroke with mobile stroke units,
telepsychiatry, and remote services for postacute care are some
examples.
In the traditional physician office, answering services
and web-based portals focused on telephone and email communication. The
advent of telehealth has resulted in incremental growth of video
face-to-face communication with patients by mobile phone, tablet, or
other computer devices.2,3,5
In larger enterprises or commercial ventures, the scale is sufficient
to “make or buy” centralized telehealth command centers to service
functions across broad geographic areas including international.
Early telehealth focused on minor ailments such as
coughs, colds, and rashes, but now telehealth is being used in broader
applications, such as communicating imaging and laboratory results,
changing medication, and most significantly managing more complex
chronic disease.
The coordination of virtual care with home visits,
remote monitoring, and simultaneous family engagement is changing the
perception and reality of virtual health care. Commercialization is well
under way with numerous start-ups and more established companies. These
services are provided by the companies alone or in collaboration with
physician groups.
The Medical Virtualist
We propose the concept of a new specialty representing the medical virtualist.
This term could be used to describe physicians who will spend the
majority or all of their time caring for patients using a virtual
medium. A professional consensus will be needed on a set of core
competencies to be further developed over time.
Physicians now spend variable amounts of time delivering
care through a virtual medium without formal training. Training should
include techniques in achieving good webside manner.5
Some components of a physical examination can be conducted virtually
via patient or caregiver. Some commercial insurance carriers and
institutional groups have developed training courses.5
These are neither associated with a medical specialty board or society
consensus or oversight nor with an associated certification.
Contemporary care is multidisciplinary, including
nurses, medical students, nurse practitioners, physician assistants,
pharmacists, social workers, nutritionists, counselors, and educators.
All require formal training in virtual encounters to ensure a similar
quality outcome as is expected for in-person care.
It is possible that there could be a need for physicians
across multiple disciplines to become full-time medical virtualists
with subspecialty differentiation. Examples could be urgent care
virtualists, intensive care virtualists, neurological virtualists, and
psychiatric or behavioral virtualists. This shift would not preclude
virtual visits from becoming a totally integrated component of all
practices to varying extents.
Based on early experience in primary care, one estimate
suggests that 30% to 50% of visits could possibly be eligible for a
virtual encounter.4
This could be amplified when coupled with home care and remote
monitoring devices. There are varying data on the influence of
telehealth on total health care services utilization and that will be
determined with greater adoption. In addition, as the number of
emergency department visits continues to increase nationally, health
care systems must develop innovative ways to maximize efficiency and
maintain high-quality standards.6
However, complete replacement of the traditional
clinical encounter will not occur. “Bricks and clicks” will prevail for
patients’ convenience and value. Physicians will lead teams with both
in-office and remote monitoring resources at their disposal to deliver
care. This model could be enhanced in the future with digital assistants
or avatars.
In the surgical specialties, remote surgery has been
more focused on telementoring and guiding surgeons in remote locations.
There have been examples of true virtual surgeons who have operated
robotically on patients hundreds of miles away.7 This approach can be expected to develop further in the coming years.
Critical Success Factors
The success of technology-based services is not
determined by hardware and software alone but by ease of use, perceived
value, and workflow optimization.
Medical virtualists will need specific core competencies
and curricula that are beginning to develop at some institutions. In
addition to the medical training for a specific discipline, the
curriculum for certification should include knowledge of legal and
clinical limitations of virtual care, competencies in virtual
examination using the patient or families, “virtual visit presence
training,” inclusion of on-site clinical measurements, as well as
continuing education.
It will be necessary for early adopters, thought
leaders, medical specialty societies, and medical trade associations to
work with the certifying organizations to formalize curriculum,
training, and certification for medical virtualists. If advances in
technology continue and if rigorous evidence demonstrates that this
technology improves care and outcomes and reduces cost, medical
virtualists could be involved in a substantial proportion of health care
delivery for the next generation.
Article Information
Corresponding Author: Michael Nochomovitz, MD, Physician Services Division, New York Presbyterian, 525 E 68th St, PO Box 182, New York, NY 10021 (mnochomovitz@nyp.org).
Conflict of Interest Disclosures:
Both authors have completed and submitted the ICMJE Form for Disclosure
of Potential Conflicts of Interest and none were reported.
Additional Contributions:
We thank Risa Oliveto, Jonathon Monteiro, Shauna Coyne, and Laura
Forese, MD, MPH, New York Presbyterian; Jane Torres, Weill Cornell
Medicine; and Peter Fleishut, MD, New York Presbyterian-Weill Cornell
Medicine, for providing input on the manuscript, none of whom were
compensated for their help.
