Scenario Analysis: This scenario is professionally challenging because it involves a critical incident with a suboptimal outcome, requiring a thorough and unbiased review. The pressure to identify systemic issues without assigning blame, while also ensuring patient safety and learning from the event, is immense. The team must navigate potential defensiveness, fear of repercussions, and the inherent complexity of surgical complications. A robust quality assurance process is essential to prevent recurrence and improve future patient care. Correct Approach Analysis: The best approach involves a structured, multidisciplinary morbidity and mortality (M&M) review that prioritizes a systems-based analysis and the identification of human factors contributing to the adverse event. This process should begin with a comprehensive data gathering phase, including a review of the patient’s chart, operative reports, imaging, and relevant nursing notes. The M&M conference itself should be a safe space for open discussion, focusing on the sequence of events, decision-making at critical junctures, and potential system vulnerabilities (e.g., communication breakdowns, equipment issues, workflow inefficiencies, team dynamics). Human factors such as fatigue, cognitive biases, and stress should be explored objectively, not to assign blame, but to understand their impact on performance. The outcome of this review should be actionable recommendations for system improvements, educational initiatives, or policy changes, with clear accountability for implementation and follow-up. This aligns with the principles of continuous quality improvement mandated by regulatory bodies and professional ethical standards that emphasize patient safety and learning from errors. Incorrect Approaches Analysis: Focusing solely on individual surgeon error without exploring contributing systemic factors is professionally unacceptable. This approach fails to address the root causes of the adverse event and can lead to a culture of fear and blame, hindering open reporting and learning. It neglects the significant role that human factors and system design play in surgical outcomes. Attributing the complication solely to an unavoidable intraoperative technical difficulty without further investigation is also professionally inadequate. While some complications may be technically challenging, a thorough review should still explore whether pre-operative planning, team communication, or resource availability could have mitigated the risk or improved the management of the difficulty. This approach bypasses the opportunity for learning and system improvement. Dismissing the event as an unfortunate but isolated incident without a formal review process is a significant ethical and regulatory failure. This approach abandons the core tenets of quality assurance and patient safety, which require systematic analysis of adverse events to identify patterns and implement preventative measures. It fails to uphold the professional responsibility to learn from every patient outcome, good or bad. Professional Reasoning: Professionals should approach such situations by first activating a formal quality assurance process, such as an M&M review. This process should be guided by a framework that emphasizes a non-punitive, systems-based investigation. Key steps include: 1) objective data collection, 2) multidisciplinary discussion focused on events and decision-making, 3) identification of human factors and system vulnerabilities, and 4) development of specific, actionable recommendations for improvement with mechanisms for follow-up. This systematic approach ensures that learning occurs, patient safety is enhanced, and professional accountability is met through a commitment to continuous improvement.

The analysis reveals a scenario where a surgeon’s eligibility for an Advanced Global Acute Care Surgery Competency Assessment is in question due to a recent, significant professional development. This situation is professionally challenging because it requires a nuanced understanding of the assessment’s purpose and eligibility criteria, balancing the need for rigorous competency validation with the recognition of ongoing professional growth. Misinterpreting the assessment’s intent or the surgeon’s current standing could lead to either an unfair exclusion from a valuable developmental opportunity or an inappropriate assessment of readiness. The correct approach involves a thorough review of the surgeon’s current professional standing in light of the assessment’s stated purpose and eligibility requirements. This means understanding that the Advanced Global Acute Care Surgery Competency Assessment is designed to evaluate a surgeon’s advanced skills and decision-making capabilities in complex acute care surgical scenarios, often in resource-limited or global settings. Eligibility typically hinges on demonstrated experience, foundational competencies, and a commitment to the principles of acute care surgery. In this case, the recent completion of a specialized fellowship directly addresses and enhances the very skills and knowledge the assessment aims to evaluate. Therefore, acknowledging this advanced training as a positive indicator of readiness, rather than a disqualifier, aligns with the assessment’s goal of identifying and validating high-level expertise. This approach is ethically sound as it promotes professional development and recognizes the evolving nature of surgical practice. An incorrect approach would be to rigidly interpret eligibility based solely on a pre-defined tenure of practice without considering the qualitative advancements in a surgeon’s skill set. For instance, assuming that only surgeons with a specific number of years in general practice are eligible, and overlooking the advanced, specialized training received, fails to acknowledge the purpose of an *advanced* competency assessment. This approach is ethically problematic as it may unfairly exclude highly qualified individuals who have accelerated their development through specialized training. Another incorrect approach would be to assume that any recent, intensive training automatically confers eligibility without verifying if that training aligns with the specific competencies being assessed. While the fellowship is advanced, if its focus is entirely outside the scope of acute care surgery, it would not satisfy the assessment’s prerequisites. This approach is flawed because it prioritizes the recency of training over its relevance to the assessment’s objectives, potentially leading to an inappropriate assessment of readiness. Finally, an incorrect approach would be to require the surgeon to undergo the assessment without first confirming their eligibility based on the established criteria. This could lead to a wasted effort for both the surgeon and the assessment body, and potentially create a negative experience that discourages future engagement with professional development opportunities. It fails to uphold the principle of fair and transparent assessment processes. The professional reasoning framework for such situations should involve a multi-faceted evaluation: 1. Understand the explicit purpose and stated eligibility criteria of the competency assessment. 2. Assess the applicant’s current professional profile, including experience, training, and any recent significant developments. 3. Determine how the applicant’s profile aligns with the assessment’s objectives and prerequisites, considering both quantitative and qualitative aspects. 4. Consult relevant professional guidelines or governing bodies if ambiguity exists. 5. Make a decision based on a holistic and fair interpretation of the criteria, prioritizing the assessment’s integrity and the professional development of the surgeon.

Scenario Analysis: This scenario presents a professional challenge due to the inherent risks associated with operative instrumentation and energy device usage in acute care surgery. The surgeon must balance the need for effective surgical intervention with the paramount duty to minimize patient harm, which includes preventing unintended tissue damage or device malfunction. This requires a meticulous approach to instrument selection, preparation, and intraoperative management, informed by an understanding of device limitations and potential complications. The complexity is amplified by the acute nature of the patient’s condition, which may necessitate rapid decision-making under pressure. Correct Approach Analysis: The best professional practice involves a comprehensive pre-operative assessment of the patient’s condition and the specific surgical requirements, followed by the selection of appropriate, well-maintained instrumentation and energy devices. This includes confirming device functionality, ensuring adequate power supply, and having backup options readily available. Intraoperatively, the surgeon must maintain constant vigilance regarding device application, tissue interaction, and potential for collateral damage, adhering strictly to manufacturer guidelines and established surgical safety protocols. This approach aligns with the fundamental ethical principles of beneficence and non-maleficence, as well as regulatory expectations for patient safety and quality of care. Incorrect Approaches Analysis: One incorrect approach involves proceeding with instrumentation and energy devices without a thorough pre-operative check of their functionality and suitability for the specific procedure and patient anatomy. This disregards the principle of due diligence and increases the risk of intraoperative complications, such as device failure or unintended tissue injury, which could lead to patient harm and potential regulatory scrutiny for substandard care. Another unacceptable approach is the reliance on outdated or poorly maintained instrumentation, or the use of energy devices without understanding their specific settings and limitations. This demonstrates a failure to uphold professional standards of care and a disregard for patient safety, potentially violating regulations concerning the use of medical equipment and the provision of competent surgical services. A further professionally unsound approach is the failure to have contingency plans or backup instrumentation readily available when using specialized energy devices. This can lead to significant delays or compromises in surgical technique if the primary device malfunctions, placing the patient at undue risk and failing to meet the expected standard of preparedness in acute care surgery. Professional Reasoning: Professionals should employ a systematic decision-making framework that prioritizes patient safety. This involves: 1) Thorough pre-operative assessment of patient factors and surgical needs. 2) Careful selection and verification of all necessary instrumentation and energy devices, including confirmation of functionality and appropriate settings. 3) Proactive identification and mitigation of potential risks associated with device use. 4) Maintaining situational awareness throughout the procedure, adapting as necessary while adhering to safety protocols. 5) Ensuring availability of backup equipment and personnel.

This scenario presents a professional challenge due to the inherent uncertainty in assessing the true acuity and potential trajectory of a patient presenting with complex symptoms in an acute care setting. The critical need for timely and effective intervention, balanced against the risk of overtreatment or delayed definitive care, requires a robust decision-making framework. Careful judgment is paramount to ensure patient safety and optimal resource utilization. The best professional approach involves a systematic, evidence-based assessment that prioritizes immediate life threats while concurrently gathering information to refine the differential diagnosis and guide subsequent management. This includes a thorough history, physical examination, and judicious use of diagnostic investigations tailored to the patient’s presentation and risk factors. The goal is to establish a working diagnosis and initiate appropriate interventions promptly, while remaining open to revising the plan as new information emerges. This aligns with the ethical principles of beneficence and non-maleficence, ensuring that patient care is both beneficial and avoids harm, and adheres to professional guidelines that emphasize a structured and iterative approach to patient management in acute settings. An incorrect approach would be to solely rely on initial impressions without a systematic evaluation, potentially leading to premature closure of the diagnostic process. This could result in overlooking critical diagnoses or initiating inappropriate treatments, thereby failing to uphold the duty of care. Another incorrect approach would be to delay definitive management due to excessive caution or an inability to synthesize available information, which could lead to patient deterioration and adverse outcomes, violating the principle of timely intervention. Finally, an approach that prioritizes resource conservation over immediate patient needs, without a clear clinical justification, would be ethically unsound and professionally unacceptable. Professionals should employ a decision-making framework that begins with identifying and addressing immediate life threats (ABCs), followed by a structured diagnostic workup. This involves formulating a differential diagnosis, prioritizing investigations based on likelihood and impact, and reassessing the patient’s status regularly. The framework should encourage critical thinking, collaboration with colleagues when necessary, and a willingness to adapt the management plan based on evolving clinical data.

Scenario Analysis: This scenario presents a professionally challenging situation due to the immediate life-threatening nature of the trauma, the need for rapid decision-making under pressure, and the potential for significant patient harm if protocols are not followed precisely. The complexity arises from the dynamic physiological state of the patient, the limited time available for assessment and intervention, and the critical importance of accurate and timely resuscitation to prevent irreversible organ damage and death. The ethical imperative to provide the highest standard of care, coupled with the regulatory requirement to adhere to established trauma protocols, necessitates a systematic and evidence-based approach. Correct Approach Analysis: The best professional practice involves immediate initiation of the Advanced Trauma Life Support (ATLS) primary survey, focusing on Airway, Breathing, Circulation, Disability, and Exposure (ABCDE). This systematic approach ensures that life-threatening injuries are identified and managed in order of priority. The ATLS protocol is a globally recognized standard of care for trauma patients, designed to provide a structured framework for assessment and management, thereby minimizing delays in critical interventions. Adherence to ATLS is often mandated by institutional policies and professional guidelines, reflecting a commitment to evidence-based practice and patient safety. This approach prioritizes immediate threats to life, ensuring that resuscitation efforts are directed towards the most critical physiological derangements first, which is ethically sound and aligns with regulatory expectations for trauma care. Incorrect Approaches Analysis: Focusing solely on a single suspected injury without completing the primary survey is professionally unacceptable. This approach risks overlooking other, potentially more immediately life-threatening injuries, leading to delayed or absent critical interventions. Such a deviation from established protocols represents a failure to adhere to best practices in trauma management and could be considered a breach of professional duty of care, potentially violating institutional policies and regulatory standards that mandate systematic assessment. Delaying definitive resuscitation measures to obtain extensive diagnostic imaging before stabilizing the patient is also professionally unsound. While imaging is crucial, it should be integrated into the resuscitation process, not used as a prerequisite for essential interventions like hemorrhage control or airway management. This approach can lead to critical delays in life-saving treatments, increasing the risk of patient deterioration and death, and failing to meet the expected standard of care in a time-sensitive trauma situation. This deviates from the principles of ATLS and could be seen as a failure to act with appropriate urgency. Relying on anecdotal experience or intuition rather than established protocols for resuscitation is ethically and professionally problematic. While experience is valuable, it should complement, not replace, evidence-based guidelines. Trauma resuscitation is a complex field with well-defined protocols designed to optimize outcomes. Deviating from these established standards without a clear, evidence-based rationale introduces an unacceptable level of risk and can lead to suboptimal patient care, potentially violating professional standards and institutional guidelines. Professional Reasoning: Professionals should employ a systematic, protocol-driven approach to trauma resuscitation. The decision-making process should begin with a rapid, structured assessment using a recognized framework like ATLS. This involves prioritizing interventions based on immediate threats to life (ABCDE). If the initial assessment reveals a critical issue, immediate management should commence. Diagnostic investigations should be integrated into the resuscitation process, ordered strategically to guide further management without causing undue delay to life-saving interventions. Continuous reassessment of the patient’s physiological status is paramount, allowing for adjustments to the resuscitation plan as needed. Ethical considerations, such as beneficence and non-maleficence, dictate that care must be delivered in a manner that maximizes benefit and minimizes harm, which is best achieved through adherence to established, evidence-based protocols.

Scenario Analysis: This scenario is professionally challenging because it involves a critical decision with potentially life-altering consequences for a patient, requiring the surgeon to balance immediate clinical needs with the ethical imperative of informed consent and patient autonomy. The pressure of an acute surgical situation can sometimes lead to a desire for rapid action, but this must be tempered by a thorough understanding of patient rights and legal obligations. Careful judgment is required to ensure that any intervention is both clinically appropriate and ethically sound, respecting the patient’s capacity and right to make decisions about their own body. Correct Approach Analysis: The best professional practice involves clearly and comprehensively explaining the proposed surgical intervention, including its risks, benefits, and alternatives, to the patient in a manner they can understand. This approach is correct because it directly upholds the fundamental ethical and legal principle of informed consent. Regulatory frameworks and professional guidelines universally mandate that patients have the right to be fully informed before agreeing to any medical procedure. This ensures patient autonomy, allowing them to make a decision aligned with their values and preferences, even in an acute setting, provided they have the capacity to do so. The surgeon’s duty of care includes ensuring the patient comprehends the information provided, which may necessitate using interpreters or simplified language. Incorrect Approaches Analysis: One incorrect approach involves proceeding with the surgery based on the assumption that the patient’s consent is implied due to the emergent nature of their condition, without attempting to obtain explicit consent or assess their capacity. This fails to meet the regulatory requirement for informed consent and violates the patient’s right to autonomy. Even in emergencies, consent is generally required unless the patient is incapacitated and no surrogate decision-maker is available, and even then, the intervention should be limited to what is necessary to preserve life or limb. Another incorrect approach is to proceed with a less invasive procedure than is clinically indicated, out of concern for potential patient anxiety or perceived lack of understanding, without discussing this alternative and its limitations with the patient. This undermines the surgeon’s professional responsibility to provide the most appropriate care and deprives the patient of the opportunity to make a fully informed choice about the best course of treatment for their condition. It is paternalistic and does not respect the patient’s right to accept or refuse even potentially risky treatments. A third incorrect approach is to delegate the responsibility of obtaining consent to a junior member of the surgical team without adequate supervision or ensuring that the junior member possesses the necessary knowledge and communication skills to convey the complex information accurately. This can lead to incomplete or inaccurate information being provided to the patient, rendering any subsequent consent invalid. It also represents a failure in the senior surgeon’s supervisory duty and commitment to ensuring ethical patient care. Professional Reasoning: Professionals should employ a structured decision-making process that prioritizes patient autonomy and informed consent. This involves: 1) Assessing the patient’s capacity to make decisions. 2) Clearly and comprehensively communicating all relevant information about the proposed treatment, including risks, benefits, and alternatives, in an understandable manner. 3) Actively listening to the patient’s concerns and answering their questions. 4) Documenting the consent process thoroughly. In emergent situations, the process must be adapted to obtain consent as quickly as possible while still respecting these core principles, or proceeding under established emergency exceptions with clear justification.

This scenario is professionally challenging because it requires balancing the immediate need for surgical intervention with the potential for significant patient harm due to unforeseen complications. The surgeon must make a critical judgment call under pressure, considering not only technical skill but also the ethical imperative to ensure patient safety and informed consent, all within the framework of established surgical best practices and institutional guidelines. The best approach involves a comprehensive, multi-faceted risk assessment that extends beyond the immediate operative field. This includes a thorough pre-operative evaluation of the patient’s comorbidities, a detailed discussion of potential risks and benefits with the patient and their family, and the development of contingency plans for anticipated complications. This structured operative planning, emphasizing proactive risk mitigation through open communication and preparedness, aligns with the ethical principles of beneficence, non-maleficence, and patient autonomy. It also reflects the professional responsibility to uphold the highest standards of care, as often mandated by professional bodies and institutional policies that emphasize patient safety and informed decision-making. An approach that focuses solely on the technical aspects of the surgery without adequately addressing patient-specific risks or involving the patient in the decision-making process is professionally unacceptable. This failure to conduct a thorough pre-operative assessment and engage in meaningful informed consent discussions violates the ethical duty to respect patient autonomy and can lead to inadequate preparation for potential adverse events. Another professionally unacceptable approach is to proceed with surgery without a clear understanding of the patient’s baseline physiological status and potential for perioperative instability. This oversight can result in unexpected complications that are not adequately anticipated or managed, potentially leading to suboptimal outcomes and increased patient morbidity or mortality. Finally, an approach that neglects to establish clear communication channels with the patient and their family regarding the risks, benefits, and alternatives to surgery, as well as potential complications, is ethically flawed. This lack of transparency undermines the principle of informed consent and can lead to mistrust and dissatisfaction, even if the surgical outcome is technically successful. Professionals should employ a systematic decision-making process that begins with a comprehensive patient assessment, followed by a detailed risk-benefit analysis. This should be coupled with open and honest communication with the patient and their family to ensure informed consent. The development of a detailed operative plan, including contingency strategies for anticipated complications, is crucial. Regular team briefings and a commitment to continuous learning and adaptation based on emerging information are also vital components of sound professional judgment in acute care surgery.

The evaluation methodology shows that managing complications in subspecialty acute care surgery requires a nuanced approach that balances immediate patient needs with established professional standards and ethical obligations. This scenario is professionally challenging due to the inherent unpredictability of surgical outcomes, the potential for rapid patient deterioration, and the need for swift, informed decision-making under pressure. The surgeon must not only possess advanced technical skills but also demonstrate sound judgment in assessing risks, communicating effectively with the patient and family, and adhering to ethical principles of beneficence, non-maleficence, and autonomy. The best approach involves immediate, transparent communication with the patient and their family regarding the unexpected complication, its potential implications, and the proposed management plan. This includes clearly outlining the risks and benefits of further intervention, exploring alternative options, and actively involving the patient (or their surrogate decision-maker) in the decision-making process. This aligns with the ethical imperative of informed consent and patient autonomy, ensuring that the patient’s values and preferences are respected. Furthermore, prompt consultation with relevant subspecialists ensures that the most expert care is brought to bear on the complex situation, reflecting the principle of beneficence by seeking the best possible outcome for the patient. This approach also implicitly adheres to professional guidelines that emphasize open communication and shared decision-making in complex medical scenarios. An incorrect approach would be to proceed with a secondary procedure without fully informing the patient or their family about the complication and the rationale for the intervention. This failure to obtain informed consent violates the patient’s right to autonomy and can lead to mistrust and ethical breaches. It also neglects the principle of transparency, which is fundamental to the patient-physician relationship. Another professionally unacceptable approach would be to delay definitive management or consultation with subspecialists due to concerns about personal liability or administrative hurdles. Such delays can directly harm the patient by exacerbating the complication and compromising their prognosis, thus violating the principle of non-maleficence. This demonstrates a failure to prioritize patient well-being over personal or institutional concerns. A further incorrect approach would be to unilaterally decide on a course of action without adequately considering the patient’s wishes or the input of other members of the surgical team. This paternalistic approach undermines patient autonomy and can lead to suboptimal care if the chosen intervention does not align with the patient’s goals or if other critical perspectives are overlooked. The professional reasoning framework for such situations should involve a systematic assessment of the complication, a thorough understanding of the patient’s condition and preferences, open and honest communication with all stakeholders, collaborative decision-making with the patient and the healthcare team, and a commitment to evidence-based practice and ethical principles. Prioritizing patient safety and autonomy should always guide the decision-making process.

The scenario of preparing for an advanced competency assessment in Global Acute Care Surgery presents a significant professional challenge due to the high stakes involved. Success directly impacts patient care capabilities, career progression, and the reputation of the institution. The complexity of global acute care surgery demands a comprehensive and well-structured preparation strategy, necessitating careful judgment in selecting appropriate resources and timelines. The best approach involves a structured, multi-faceted preparation strategy that integrates diverse learning modalities and realistic timelines. This includes dedicating specific blocks of time for theoretical review of core surgical principles, evidence-based guidelines relevant to global acute care settings, and case-based learning. It also necessitates active engagement with practice questions, simulation exercises, and potentially peer review or mentorship. This comprehensive strategy aligns with the ethical imperative to maintain the highest standards of patient care and professional competence, ensuring readiness for diverse and often resource-limited environments. It also implicitly adheres to professional development guidelines that emphasize continuous learning and skill validation. An approach that relies solely on passively reviewing textbooks without active application or practice is professionally deficient. This fails to adequately prepare for the practical and decision-making aspects of acute care surgery, potentially leading to suboptimal patient outcomes. It neglects the ethical responsibility to be demonstrably competent and prepared for the challenges of the assessment. Another inadequate approach is to cram material in the final days before the assessment. This superficial engagement with the subject matter is unlikely to foster deep understanding or retention, increasing the risk of errors and demonstrating a lack of commitment to professional development. It falls short of the ethical standard of diligent preparation required for a role with such critical responsibilities. Finally, an approach that focuses exclusively on memorizing facts without understanding the underlying principles or their application in varied clinical scenarios is also flawed. Acute care surgery demands critical thinking and adaptability, which cannot be achieved through rote memorization alone. This approach risks superficial knowledge that is insufficient for real-world complex surgical decision-making. Professionals should adopt a systematic decision-making process that prioritizes a deep understanding of the assessment’s scope, identifies knowledge gaps, and then strategically allocates time and resources for targeted learning and practice. This involves setting realistic goals, utilizing a variety of validated preparation materials, and incorporating self-assessment mechanisms to gauge progress and identify areas requiring further attention.

Scenario Analysis: This scenario presents a professional challenge due to the inherent tension between immediate patient needs in an acute care setting and the requirement for thorough, documented consent, especially when dealing with potentially life-saving interventions that carry significant risks. The urgency of the situation can create pressure to bypass standard procedures, but failing to do so can lead to suboptimal patient outcomes or legal/ethical repercussions. Careful judgment is required to balance the imperative to act with the patient’s right to informed decision-making. Correct Approach Analysis: The best professional practice involves obtaining informed consent as expeditiously as possible, even in emergent situations, by clearly and concisely communicating the critical information necessary for the patient (or their surrogate) to make a decision. This includes explaining the nature of the life-threatening condition, the proposed intervention, its benefits, risks, and alternatives, and confirming understanding. This approach is correct because it upholds the fundamental ethical principle of patient autonomy and respects their right to self-determination, even under duress. Regulatory frameworks and ethical guidelines universally emphasize the importance of informed consent as a cornerstone of patient care, ensuring that medical interventions are not performed without the patient’s agreement, except in very narrowly defined circumstances where consent is implied by the emergency itself and the patient is unable to consent. Incorrect Approaches Analysis: One incorrect approach is to proceed with the surgery without any attempt to obtain consent, relying solely on the presumed emergency. While implied consent may apply in certain life-threatening situations where a patient is incapacitated, a proactive effort to obtain explicit consent from the patient or their surrogate, even if brief, is ethically and often legally superior. Failing to make this attempt can be seen as a violation of patient autonomy and could lead to legal challenges if the outcome is not as desired. Another incorrect approach is to delay the surgery significantly to conduct a lengthy and detailed consent process that is not feasible given the patient’s critical condition. This prioritizes procedural formality over immediate patient well-being, potentially leading to irreversible harm or death. While thoroughness is important, it must be balanced with the urgency of the clinical situation. A third incorrect approach is to obtain consent from a family member who is not the legally designated surrogate decision-maker without a diligent and documented effort to locate the appropriate surrogate or, if none is available, to seek judicial intervention or consult hospital ethics committees. This bypasses the established hierarchy of decision-making and can lead to disputes and legal complications. Professional Reasoning: Professionals should employ a decision-making framework that prioritizes patient safety and autonomy. In emergent situations, this involves a rapid assessment of the patient’s condition and decision-making capacity. If the patient is incapacitated, the immediate priority is to identify and involve the legally authorized surrogate decision-maker. Communication should be clear, concise, and focused on the essential elements of informed consent relevant to the emergency. Documentation of the consent process, including the information provided and the decision made, is crucial. If there is any ambiguity or lack of a clear surrogate, seeking guidance from hospital ethics committees or legal counsel should be considered.