Author	Affiliation
Emily C. Cleveland Manchanda, MD, MPH	Massachusetts General and Brigham and Women’s Hospitals, Boston Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts; Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
Anita N. Chary, MD, PhD	Massachusetts General and Brigham and Women’s Hospitals, Boston Harvard Affiliated Emergency Medicine Residency, Boston, Massachusetts; Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
Noor Zanial, MSc	Harvard Medical School, Program in Global Surgery & Social Change, Boston, Massachusetts
Lauren Nadeau, RN	Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
Jennifer Verstreken, MSN, MBA/MHCA, RN	Brigham and Women’s Hospital, Department of Emergency Medicine, Boston, Massachusetts
Eric Shappell, MD, MHPE	Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts; Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
Wendy Macias-Konstantopoulos, MD, MPH	Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts; Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
Valerie Dobiesz, MD, MPH	Brigham and Women’s Hospital, Department of Emergency Medicine, Boston, Massachusetts; Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts

Background
Methods
Results
Discussion
Limitations
Conclusion

BACKGROUND

The importance of teamwork and interprofessional collaborative practice in clinical care cannot be overstated. Evidence suggests that gender has effects on the culture, practice, and organization of medicine for both nurses and physicians at all levels of training; these effects intersect with perceptions of power dynamics, professional hierarchies, and spheres of practice.^1-4 The quality of nurse-physician interactions affects provider wellness in the workplace.⁵ Studies demonstrate that physicians’ and nurses’ perspectives differ with regard to both the quality of their interactions and the degree of interprofessional collaboration and respect.^4-8 Further-more, evidence suggests that among medical students and resident physicians the perceived importance of collaborative interprofessional care may decrease over time.⁹ Interactions between female resident physicians and female nurses may be particularly challenging, as the intersection of gender and professional identities can lead to dysfunctional communication patterns.¹⁰

Effective communication and collaborative decision-making between nurses and physicians contributes to high-quality care, while poor team dynamics, disrespect, and miscommunication adversely affect patient safety^8,11-16 and length of stay.¹⁷ Patient care “mishaps” may result from communication failures between nurses and residents.¹⁸ Developing strong interprofessional relationships may be particularly challenging for students² and resident physicians,¹⁰ as they are by nature of their roles only transient members of clinical teams. While a clinician’s years of experience play a role in establishing positive interprofessional relationships,¹² less is known regarding the role of gender, particularly for interprofessional relationships.

Gender disparities persist within the medical field for both nurses and physicians, with studies documenting continued salary disparities for both professions.^19-21 There is also evidence of significant differences in faculty evaluation of female and male trainees with respect to milestone achievements during residency,^22,23 which may be attributable to unconscious gender bias. Similarly, female gender is associated with more negative nursing evaluations of resident physicians;^24,25 however, limited data exist to explain factors that contribute to this disparity.²⁶ Research on the intersection of gender on resident/nursing interactions and leadership styles during resuscitations reveals that female residents express higher stress levels and discomfort when exhibiting directive leadership styles, despite this often being perceived as the most effective style; furthermore, female residents report needing to negotiate interactions, “gain trust,” or choose less assertive behaviors during interprofessional interactions than their male counterparts.^10,27-29

However, the impact of gender bias on interprofessional relationships is not as well studied,^10,30,31 in particular the extent to which gender bias occurs in interactions between resident physicians and nurses. During residency, physicians develop behavioral practice patterns that may last throughout their careers. The aim of this study was to explore and understand perceptions and experiences of gender bias in the context of interprofessional relationships between emergency medicine (EM) residents and nurses. This study builds on emerging literature exploring the ways in which gender shapes interactions between nurses and physicians during residency training.¹⁰ Our findings can inform strategies for improved interprofessional collaborative practice during residency training.

 

Population Health Research Capsule

What do we already know about this issue?

Gender disparities persist in emergency medicine (EM). Gender shapes the culture, practice, and organization of medicine for both nurses and physicians.

What was the research question?

How does gender affect interprofessional interactions between EM resident physicians and nurses?

What was the major finding of the study?

Perceived interprofessional gender bias negatively impacts personal wellbeing and workplace satisfaction, particularly among female residents.

How does this improve population health?

Understanding how gender and gender bias affect interprofessional dynamics in EM creates opportunities to improve teamwork and patient care.

 

Study Objective

Our goal was to explore the effects of gender on interprofessional interactions between EM resident physicians and nurses.

METHODS

This sequential mixed-methods study gathered qualitative data, which informed the development of a quantitative survey. The study was conducted at two urban, academic, Level I trauma centers with annual ED censuses of approximately 63,000 and 115,000. Spanning these two EDs is a single, four-year EM residency program that matches 15 residents per year.

Phase I: Qualitative Study

We recruited EM nurses and resident physicians to participate in qualitative interviews and focus groups. We limited recruitment of resident physicians to second-, third-, and fourth-year residents given their longitudinal experiences with nursing colleagues. Similarly, nurses recruited for participation in the qualitative portion of this study were limited to those with more than two years of institutional experience. The research team’s resident members [EC, AC] contacted eligible participants from a roster of 42 residents, while the research team’s nurse members [JV, LN] contacted a convenience sample of 31 nurses from both institutions who were eligible and who had indicated in informal conversations that they would be willing to participate. After an individual expressed their willingness to participate, scheduling was taken over by the team’s social scientist [NZ], who conducted interviews and focus groups.

Semi-structured interviews were piloted with three individuals (one female nurse and two residents, one male and one female) to refine interview and focus group guides. Subsequently, focus groups were conducted with residents, separated by gender. Due to scheduling challenges, five nurses from two different institutions opted to participate in individual interviews rather than as part of a focus group. Between June–October 2019 interviews and focus groups were conducted by a trained interviewer [NZ] with no professional role in the residency or either ED. Questions focused on providers’ perceptions and experiences of how gender affects interprofessional interactions (Appendix 1). Interviews ranged from 20–40 minutes; focus groups lasted 90 minutes. Interviews and focus groups were recorded with consent of participants and transcribed verbatim using a transcription service (TranscribeMe, Inc., Oakland, CA).

We analyzed using inductive and thematic content analysis,³² allowing dominant themes to emerge. Free-text responses from the electronic survey (see below) were also coded and included in qualitative analysis. The research team developed a codebook from successive rounds of reviewing transcripts. Each transcript was coded for themes independently by two of four authors [EC, LN, JV, NZ] using a web-based, qualitative data analysis tool (Saturate, Jonathan Sillito, Brigham Young University, Provo, UT). An experienced qualitative researcher [AC] led resolution of coding discrepancies with research team input.

Reflexivity

Reflexivity in qualitative research refers to researchers’ consideration of how their sociocultural values and experiences influence study design and analysis. Qualitative data was collected by a social scientist [NZ] who does not have clinical EM experience. Analysts were all female, and included senior EM nurses [LN, JV], emergency physicians [AC, EC; both senior residents], and social scientists [AC, NZ]. Coding pairs were intentionally grouped across professions (nurse/MD, MD/social scientist or nurse/social scientist). Results were additionally presented to healthcare providers at three local and national conferences for feedback on interpretation of the major themes identified. To protect participant identity, transcripts are not publicly available. The study codebook is available in Appendix 2.

Phase II: Quantitative Study

An anonymous electronic survey, developed through an inductive-deductive approach informed by the interviews and focus groups, was administered via Research Electronic Data Capture (REDCap, Vanderbilt University, Nashville, TN) and distributed via institutional email to all EM residents (60 individuals) and EM nurses at both hospitals (159 at one facility and 203 at the other), regardless of experience level. Up to two reminders of the invitation to participate were sent over the course of one week. Respondents were asked about the perceived frequency with which gender affects both their personal and witnessed interactions with colleagues across professions. Participants were also asked about how interprofessional gender bias affects the workplace with regard to job satisfaction, patient care, personal wellness, burnout, self-doubt, and patient safety. We collected basic demographic and professional experience data. Complete survey questions are available (Appendix 3).

For the purpose of exploring the impact of seniority on perceptions of gender bias, postgraduate year (PGY)-1 and -2 residents are considered “junior,” while PGY-3 and -4 residents are considered “senior.” Nurses with >4 years of experience were considered “senior,” while those with fewer years of experience were considered “junior.” We analyzed data in Stata 15.0 (StataCorp, LLC, College Station, TX), and included descriptive statistics and between-group comparisons using Student’s t-tests for continuous data and two-sample Wilcoxon rank-sum test for ordinal data.

Ethics

This study was reviewed by the local institutional review board and determined to be exempt from further review (Protocol #2019P000147). Funding to support this research was provided by the Massachusetts chapter of the American College of Emergency Physicians 2018 Resident Research Grant. We report qualitative findings following the Standards for Reporting Qualitative Research guidelines.³³

RESULTS

This study included 20 participants in the first, qualitative phase, and 134 respondents to the quantitative survey. The findings from each phase are described below, and in Tables 1–5.

Qualitative Data

A total of 20 individuals participated in the qualitative portions of this study (see Table 1). Individual interviews were conducted with eight participants: six nurses (three female and three male, two from one institution and four from the other), and two residents (one female and one male). Focus groups were gender-specific with seven male residents in one group and five female residents in the other. Four themes emerged from qualitative data: communication in interprofessional relationships; specific examples of gender bias toward nurses; specific examples of gender bias toward residents; and responses to interprofessional gender bias. Representative quotes from each of these themes are listed in Table 2.

I. Communication

The theme of how gender shapes communication in interprofessional relationships emerged from data collected from both residents and nurses, particularly among females of each group. Examples of how gender shapes interprofessional communication significantly differed between nurses and residents. Female residents perceived questions from nurses about patient care as a threat to their decision-making and expertise. Female nurses identified feeling that female residents are more approachable about patient care questions and are more collaborative in their language and behavior than male residents.

II. Examples of Gender Bias toward Nurses

Nurses offered two major examples of witnessed or experienced interprofessional gender bias. They described male residents dismissing female nurses’ perspectives about patient care and emphasized that this occurs much more frequently than with female residents. Dismissive behaviors included residents not being willing to engage in conversation about nurses’ concerns about orders, lab values, or plans of care. The second example centered on the perception that male nurses receive more respect than female nurses. Both female and male nurses perceived that resident physicians, irrespective of the physician’s gender, take male nurses’ input about patient care more seriously.

III. Examples of Gender Bias toward Residents

When residents were asked for specific examples of witnessed or experienced gender bias toward residents, two major examples were described. First, female and male residents alike perceived that female residents receive more “pushback” from nurses of both genders. This included nurses questioning residents about orders and plans, disregarding residents’ plans, or not supporting residents in performing procedures. While residents held these perceptions regarding patient care in general, some reported the dynamics as more obvious and upsetting to female residents when they occurred during trauma and critical care resuscitations. Secondly, both female and male residents perceived that male residents have greater ease establishing friendly and collegial relationships with female nurses. With the exception of a few female nurses with whom male residents had difficult interactions, male and female residents perceived female nurses to be more friendly with male residents and interested in socializing with them outside the hospital. Female residents felt that they had to work harder and be more deferential toward female nurses to build relationships with them over time.

Participants from both professions recognized that gender alone did not account for their or others’ experiences of being dismissed or questioned. Rather, residents reported that gender had a lesser impact on interprofessional interactions as they progressed through training and gained more institutional experience.

IV. Responses to Gender Bias

Several suggestions emerged within the theme of responses to interprofessional gender bias. Both residents and nurses identified filing “safety reports,” the institutional standard for addressing quality concerns, as a potential course of action. However, residents identified their lack of anonymity as a major deterrent to pursuing this option. Nurses identified filing a complaint with the human resources department as an alternative. However, no respondents reported having taken these steps. Both nurses and residents gave examples of discussing biased interactions with their same-profession colleagues, including the emotional impact of these problematic experiences.

Quantitative Survey

In total, 134 individuals (32% response rate) completed the survey, including 104 nurses (28.7% response rate) and 30 residents (52.6% response rate) (Table 1). Participating nurses were 84.6% female, while 36.7% of resident respondents were female. The gender balance of respondents roughly reflected that of each of these groups (approximately 80% female nurses at each institution; 38.5% of residents identified as female, yielding a 47.8% response rate among female EM residents). None of the respondents identified as non-binary. Among nurses, four individuals preferred not to indicate their gender, and their data were omitted from between-gender comparisons. The mean age of nurse respondents was significantly older than residents (36.7 vs 29.4 years, P <0.001). Most (80.6%) respondents self-identified as White, although the resident cohort had greater racial diversity (Table 1).

Perceptions of Gender Bias in Interprofessional Interactions

Perceptions of the frequency with which respondents both experienced and witnessed interprofessional gender bias were evaluated on a 100-point scale, labeled from “never” (0) to “always” (100) (Table 3). Among all respondents, females more frequently reported experiencing interprofessional gender bias than males (mean frequency 30.9, 95% confidence interval [CI], 25.6, 36.2 vs 17.6, 95% CI, 10.3, 24.9). This difference was noted both among female nurses (mean frequency 26.4, 95% CI 21.3, 31.4) vs 9.9 (95% CI, 2.5, 17.3] among male nurses, as well as among female residents (mean frequency 66.9 (95% CI 53.8, 80.0]) vs 22.5 (95% CI, 11.6, 33.4) for male residents. Female residents more frequently experienced interprofessional gender bias than their female nursing colleagues (mean frequency 66.9 [95% CI 53.8, 80.0] for female residents vs 26.4 [95% CI, 21.3, 31.4] for female nurses), but no significant difference was noted between male nurses and male residents.

Overall, significant between-profession differences emerged in the reported frequency of witnessing interprofessional gender bias. Resident physicians reported witnessing this bias more frequently than nurses [mean 58.7 (95% CI, 48.6, 68.7) among residents vs 23.9 (95% CI, 19.4, 28.4) among nurses [see Table 3]). This held true across both genders, such that female residents reported witnessing interprofessional gender bias more frequently than female nurses (mean 73.5 [95% CI, 57.3, 89.8] vs 23.4 [95% CI, 18.6, 28.3]), and male residents more frequently reported this than male nurses (50.1 [95% CI, 38.0, 62.1] vs 17.8 [95% CI, 3.6, 31.9]).

Perceived Manifestations of Interprofessional Gender Bias

Several questions explored the perceived manifestations of interprofessional gender bias that emerged from qualitative data, including the following: having a concern raised about oneself to a superior; having an order ignored; being given less trust; having one’s role confused by a cross-professional colleague; and being called a term of endearment by a cross-professional colleague. With the exception of having orders ignored, resident physicians reported experiencing each of these manifestations of gender bias significantly more frequently than their nursing colleagues (Table 4). No significant differences were identified between female and male nurses; however, female residents experienced each of these significantly more frequently than their male resident colleagues.

Impact of Gender Bias in Interprofessional Interactions

Respondents were asked about the frequency with which interprofessional gender bias affected several aspects of their work experience and patient care. Residents, when compared with nurses, more frequently felt gender bias negatively affected job satisfaction (P = 0.002), patient care (P = 0.001), personal wellness (P = 0.003), burnout (P = 0.002), and self-doubt (P = 0.017). Female residents felt gender bias affected these areas more frequently than their male colleagues, and more frequently than female nurses (Table 5). No significant between-gender differences were found among nurses on these factors, nor between male nurses and male residents.

Seniority did not modify any of the aforementioned relationships. The perceived negative impact of gender bias on job satisfaction increased with seniority among female residents (P = 0.01), but seniority was not otherwise associated with significant differences in the perceived impact of interprofessional gender bias.

DISCUSSION

Gender shapes the professional experiences of healthcare providers, including medical students,² resident physicians,^10,28 and nurses.^20,21 The extent to which gender bias shapes interprofessional interactions between residents and nurses remains incompletely described, although existing literature suggests that female gender identity may complicate interprofessional interactions.¹⁰ Power and privilege are created and justified through multiple social identities: Gender operates not alone but in conjunction with sexuality, race, ability, and other social identities to advantage some and disempower others.³⁴ By design, this study focused specifically on the ways in which gender affects interprofessional interactions between resident physicians and nurses in the emergency department (ED).

Our study is situated in an understanding of gender through gender socialization theory,³⁵ which posits that humans learn femininity and masculinity through social interactions, primarily with their families, peers, and groups. We become socialized into traditionally binary gender roles and identities, which create differential societal expectations for males’ and females’ behaviors. These expectations of gender roles permeate all environments, from the household to the workplace. In medicine, for example, women are expected to display caregiving and communicative capacities, while men are expected to display leadership and decision-making capacities, stemming from traditional gender roles within the household and society at large. Particularly early in residency, informal learning occurs in interprofessional relationships.³ This learning may shape long-standing behaviors and can affect professional identity development. As women now make up almost half of resident physicians across specialties,³⁶ it is more important than ever to understand the ways that gender and gender bias affect interprofessional relationships.

This study reveals that both nurses and residents view gender as an important factor influencing interprofessional interactions; however, the perceived manifestations and impact of gender differed sharply between the two professional groups. This was most notable in qualitative data revealing how gender shapes communications between EM nurses and residents. While EM nurses expressed frustration with male residents, who were viewed as more dismissive and less collaborative when approached with a patient care question, female residents felt that frequent questioning of their clinical plans by nursing colleagues, and particularly from female nurses, reflected a lack of trust of female physicians. These starkly different perceptions of the same interactions build on prior literature demonstrating that physicians and nurses have disparate experiences of their interprofessional interactions with regards to communication and collaboration.^4-8,10,12 While the intent behind nursing-initiated communication with residents is to improve patient care, this study revealed that for female residents in particular such interactions may increase self-doubt and insecurity. Understanding these differing perspectives highlights the need for further collaborative and longitudinal discussions between the two groups, particularly among females early in residency training, in order to bridge this gap and find ways to both mitigate problematic interactions and clarify the intent and goals of such conversations.²⁶

Examples of gender bias shared by both residents and nurses reveal persistent and stark differences in how male and female health professionals experience the workplace. While males were more willing to attribute negative interprofessional interactions to personality differences, females more often identified gender as a defining factor in shaping these relationships. These findings were further underscored in the survey findings, as females of both professions reported experiencing interprofessional gender bias more frequently than their male counterparts (among female vs male nurses, mean frequency 26.4 [95% CI, 21.3, 31.4] vs 9.9 [95% CI, 2.5, 17.3] and among female vs male residents, 66.9 [95% CI, 53.8, 80.0] vs 22.5 [95% CI, 11.6, 33.4)]). Female residents reported both experiencing and witnessing interprofessional gender bias to a much greater degree. Female residents more frequently reported perceiving the various manifestations of gender bias in their cross-professional interactions (Table 4), and similarly were far more likely to report that this adversely affected their experiences in the workplace (Table 5).

The perceived negative impact of interprofessional gender bias on female residents in the ED may in part result from female residents taking on stereotypically gender-discordant professional roles,^26,37-39 through which they are expected or encouraged to take on more typically male characteristics. The persistent and pervasive negative effects of gender bias in interprofessional interactions may have implications for patient care and patient safety. Effective communication across professional lines is a key component in the delivery of high-quality care; there is ample evidence that disrespect and poor team dynamics can harm patients.^8,11-16

Across both professions, participants in the qualitative study expressed a sense of limited agency in addressing instances of perceived gender bias, which translated into a sense of apathy, frustration, or both. Both residents and nurses felt that additional years of experience may mitigate challenges in interprofessional interactions. Although the study was not primarily designed to explore the interaction between seniority and the various manifestations of interprofessional gender bias explored in this study, in quantitative analysis no such correlation emerged. Further investigation into the relationship between years of professional experience and the ways in which gender shapes interprofessional interactions may prove fruitful.

Educators and leaders within medicine may find it useful to look to the business world for examples of how gender shapes workplace interactions. Much has been written about gender and leadership in business, including the ways in which stereotypically female leadership styles, which in some sectors may be more democratic and participatory, rely more on communication and relationship building.^40,41 Men may benefit from adopting some of these collaborative styles in business,⁴² and this may be true for clinicians of both genders in medicine. Relational coordination, a “mutually reinforcing process of communicating and relating for the purposes of task integration” described by Gittell et al, has proven effective in healthcare settings both for improving quality of care and job satisfaction among clinicians.⁴³ Fostering strong interprofessional relationships between early-career physicians and nurses, particularly between females, may increase job satisfaction and mitigate perceptions of gender bias.

During residency, physicians not only learn medical knowledge and procedural skills, but also develop leadership styles and other patterns of behavior that can persist throughout their careers. Strong inter-professional relationships are integral to providing excellent patient care.^11-15,17,18 Fostering collaborative interprofessional communication and strong nurse-physician relationships while in residency may result in attending physicians who promote and model more collaborative behaviors throughout their careers. Support from nursing leadership in EDs to foster positive, gender-informed interactions between EM nurses and the residents who work alongside them is equally important to fostering a collegial and respectful work environment for all healthcare providers. Educators and administrators – physicians and nurses alike – must consider and endeavor to understand the ways in which gender affects these interactions.³⁸

Several strategies for improving interprofessional communication between residents and nurses have been explored by others, including structured “huddles,”⁴⁴ simulation exercises,⁴⁵ and collaborative “time-outs” prior to patient discharge,⁴⁶ with variable efficacy. Further work is needed to understand, develop, and implement strategies for mitigating the negative impact of gender bias in interprofessional interactions; study participants suggested several possible interventions, which may warrant additional exploration through future research. Most of our study participants perceived gender bias in the clinical environment but demonstrated a reluctance to report this bias. Effective and safe mechanisms to report incidents and to ensure accountability and follow up of these occurrences should be explored.

In this study we identified a variety of suggestions for improving other aspects of interprofessional interactions. One interesting recommendation for improving cross-professional female allyship was to establish mentoring pairs between a female nurse and incoming female resident during intern orientation. Other means of increasing awareness could include workshops, video learning, and simulation exercises. At a local level, the findings from this study have led to the formation of a working group at one of our institutions, through which nurses and residents are exploring strategies for improving communication and assuring mutually respectful interactions. Further study of the effect of gender bias in interprofessional interactions between resident physicians and nursing colleagues should include the ways in which this occurs across specialties and throughout the career cycle of clinicians.

LIMITATIONS

This study has several limitations. First, it was conducted only at large, urban, training hospitals hosting a single residency training program. Findings may not be transferrable to other training environments. The qualitative data was gathered by a social scientist unaffiliated with either the residency program or the hospitals; however, her gender (female) may have influenced the information shared by participants. Similarly, the qualitative analysis team included only female researchers, which inevitably shaped our interpretation of this data. Nursing perspectives were proportionally less represented in the qualitative portion of this study due to logistical challenges in recruitment. Similarly, response bias may have influenced our findings, particularly for the quantitative portion of this study. While the gender balance of respondents was similar to that of eligible participants in both professions, the opinions of study participants may differ significantly from those who chose not to respond to invitations for either interviews/focus groups or the emailed survey.

Lastly, our study included few participants whose backgrounds are historically and contemporarily under-represented in medicine. The intersection of race and sexuality with gender identity inevitably affected our findings; further study is warranted to understand the ways in which other forms of social identity influence interprofessional relationships.

CONCLUSION

Gender shapes interprofessional interactions between resident physicians and nurses. The perception of gender bias contributes to dissatisfaction in the workplace, the effects of which are felt by both male and female nurses and residents, but disproportionately more by females of both professions. Female residents more frequently report experiencing the negative impacts of gender bias in their interprofessional relationships, raising concerns for their residency training and overall wellbeing. Key institutional stakeholders including residency, nursing, and hospital leadership should invest the resources necessary to develop and integrate evidence-based strategies to improve interprofessional relationships that will ultimately enhance residency training, work climate, and patient care.

Footnotes

Section Editor: Danya Khoujah, MBBS

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Address for Correspondence: Emily C. Cleveland Manchanda, MD, MPH, Boston Medical Center, Department of Emergency Medicine, 800 Harrison Ave, BCD Building, 2nd Floor, Boston, MA 02118. Email: emily.cleveland@bmc.org 7 / 2021; 22:919 – 930

Submission history: Revision received September 9, 2020; Submitted March 16, 2021; Accepted March 16, 2021

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

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