Scenario Analysis: This scenario presents a common challenge in advanced surgical practice where the translation of research findings into tangible quality improvement initiatives requires careful navigation of ethical, regulatory, and practical considerations. The professional challenge lies in balancing the imperative to improve patient care through evidence-based practice with the need for rigorous validation, patient safety, and adherence to institutional and professional guidelines. Missteps can lead to compromised patient outcomes, regulatory non-compliance, and erosion of trust. Correct Approach Analysis: The best professional practice involves a systematic and evidence-based approach to simulation and quality improvement, directly informed by research translation. This begins with identifying a specific, measurable gap in minimally invasive foregut surgery outcomes or processes, ideally supported by emerging research or established best practices from peer-reviewed literature. The next step is to design and implement a simulation-based training program that directly addresses this identified gap. Crucially, this program must be rigorously evaluated for its effectiveness in improving surgical skills, reducing errors, and ultimately enhancing patient outcomes. This evaluation should involve objective metrics and potentially prospective data collection, aligning with principles of continuous quality improvement and research translation. The findings from this evaluation should then be disseminated within the institution and potentially to the wider surgical community, contributing to the ongoing body of knowledge and further refinement of best practices. This approach is ethically sound as it prioritizes patient safety and evidence-based care, and it aligns with professional expectations for surgeons to engage in lifelong learning and contribute to the advancement of their field. Incorrect Approaches Analysis: One incorrect approach involves implementing a simulation-based training program based solely on anecdotal evidence or personal experience without a clear, data-driven identification of a specific quality improvement need. This fails to demonstrate a commitment to evidence-based practice and may divert resources from areas where improvement is genuinely needed, potentially impacting patient care indirectly. It also bypasses the critical step of research translation, as it doesn’t systematically integrate findings from the broader scientific community. Another unacceptable approach is to conduct simulation training without any formal evaluation of its effectiveness. This represents a failure in quality improvement and research translation, as it does not provide data to confirm whether the training is achieving its intended goals or if it is even beneficial. Without evaluation, it is impossible to justify the resources expended or to demonstrate a positive impact on patient care, and it neglects the professional responsibility to validate interventions. A third flawed approach is to adopt simulation technologies or protocols based purely on their novelty or availability, without a clear link to specific patient care improvements or research findings relevant to minimally invasive foregut surgery. This prioritizes technology over evidence and patient benefit, failing to adhere to the principles of judicious resource allocation and evidence-based practice. It also misses the opportunity to translate meaningful research into actionable improvements. Professional Reasoning: Professionals should employ a decision-making framework that prioritizes patient safety and evidence-based practice. This involves: 1) Identifying a specific, measurable problem or opportunity for improvement in patient care, supported by data or relevant research. 2) Designing interventions, such as simulation-based training, that directly address the identified problem. 3) Rigorously evaluating the effectiveness of these interventions using objective metrics. 4) Translating successful interventions into practice and disseminating findings to contribute to the collective knowledge base. This iterative process ensures that efforts are focused, effective, and ethically sound.

Scenario Analysis: This scenario presents a professional challenge related to understanding the foundational purpose and eligibility criteria for advanced practice examinations in a specialized surgical field. Misinterpreting these requirements can lead to wasted time, resources, and potentially hinder career progression. Careful judgment is required to align individual qualifications and career aspirations with the stated objectives and prerequisites of the examination. Correct Approach Analysis: The best professional practice involves a thorough review of the official examination handbook and relevant governing body publications to ascertain the precise purpose and eligibility requirements. This approach is correct because it directly addresses the need for accurate information from the authoritative source. The purpose of the Advanced North American Minimally Invasive Foregut Surgery Advanced Practice Examination is to validate the advanced knowledge, skills, and competency of experienced practitioners in this subspecialty, ensuring a high standard of patient care. Eligibility typically requires a specific level of postgraduate training, board certification in a relevant surgical specialty (e.g., general surgery, cardiothoracic surgery), and a defined period of supervised or independent practice focused on minimally invasive foregut surgery. Adhering to these documented requirements ensures that candidates are appropriately prepared and that the examination serves its intended function of credentialing expertise. Incorrect Approaches Analysis: Relying solely on anecdotal information from colleagues or informal online discussions about the examination’s purpose and eligibility is professionally unacceptable. This approach risks propagating misinformation, as individual experiences may be outdated, incomplete, or inaccurate. It fails to meet the ethical obligation of ensuring one’s qualifications are demonstrably met according to established standards. Assuming eligibility based on general surgical experience without verifying specific foregut surgery practice requirements is also professionally flawed. While general surgical experience is a prerequisite, the advanced nature of this examination necessitates a focused and documented history within the foregut subspecialty. This assumption bypasses the critical step of confirming specialized practice, potentially leading to an application that does not meet the examination’s intent. Focusing exclusively on the perceived difficulty or prestige of the examination without understanding its defined purpose and eligibility criteria is an inappropriate approach. This perspective prioritizes personal ambition over meeting the objective standards set for credentialing. It fails to acknowledge that the examination is designed to assess specific competencies and experience, not merely to be a challenging hurdle. Professional Reasoning: Professionals seeking advanced certification should adopt a systematic approach. First, identify the official governing body or examination committee responsible for the credential. Second, locate and meticulously review all official documentation, including examination handbooks, candidate guides, and published eligibility criteria. Third, compare one’s own qualifications, training, and practice experience against these documented requirements. If any ambiguity exists, proactively seek clarification directly from the examination administrators. This ensures a clear understanding of the examination’s purpose and one’s suitability for candidacy, promoting ethical and efficient professional development.

This scenario presents a professional challenge due to the inherent risks associated with minimally invasive foregut surgery and the critical need for patient safety and informed consent, especially when considering novel techniques or modifications. Careful judgment is required to balance potential benefits with established protocols and patient well-being. The approach that represents best professional practice involves a thorough, multidisciplinary review of the proposed modification, including a detailed risk-benefit analysis, comparison with existing evidence-based techniques, and a clear plan for patient selection and post-operative monitoring. This approach is correct because it aligns with fundamental ethical principles of beneficence and non-maleficence, ensuring that any deviation from standard practice is rigorously evaluated to maximize patient safety and potential positive outcomes. It also adheres to professional guidelines that mandate evidence-based decision-making and a commitment to continuous quality improvement through careful assessment of new or modified procedures. An incorrect approach would be to proceed with the modification based solely on the surgeon’s experience or anecdotal success in a limited number of cases without formal institutional review or robust data collection. This fails to uphold the ethical obligation to protect patients from potentially unproven or inadequately assessed risks. Another incorrect approach is to implement the modification without a clear plan for data collection and outcome assessment, thereby hindering the ability to learn from the experience and contribute to the broader surgical knowledge base. This neglects the professional responsibility to advance the field through systematic evaluation. Finally, adopting the modification without transparently discussing the experimental nature and potential uncertainties with the patient and obtaining truly informed consent would be a significant ethical and regulatory failure, violating the patient’s autonomy and right to make decisions based on complete information. Professionals should employ a decision-making framework that prioritizes patient safety, evidence-based practice, and ethical considerations. This involves seeking peer review, consulting relevant institutional review boards or ethics committees, and ensuring that any proposed innovation is subjected to a structured evaluation process before widespread adoption. Transparency with patients about the rationale, risks, and benefits of any surgical approach, especially those that deviate from standard care, is paramount.

The investigation demonstrates a scenario where a candidate for the Advanced North American Minimally Invasive Foregut Surgery Advanced Practice Examination has failed the examination twice. This situation presents a professional challenge due to the need to balance the candidate’s career progression and potential with the paramount importance of patient safety and maintaining the integrity of the certification process. Careful judgment is required to ensure that any decision made is fair, consistent, and upholds the high standards expected of advanced practitioners in this specialized surgical field. The best approach involves a thorough review of the candidate’s performance data from both examinations, consultation with the examination committee, and adherence to the established retake policies. This process ensures that the decision regarding further examination attempts is based on objective evidence of competency and aligns with the documented guidelines for candidates who do not achieve a passing score. The regulatory framework for professional certification typically mandates clear, objective criteria for progression and remediation, emphasizing that continued access to examination is contingent upon demonstrating mastery of the required competencies. This approach upholds the principle of accountability and ensures that only qualified individuals are certified, thereby protecting the public. An incorrect approach would be to allow the candidate to retake the examination immediately without a formal review process. This fails to acknowledge the repeated demonstration of insufficient competency and bypasses the established procedural safeguards designed to ensure adequate preparation and performance. Ethically, this undermines the principle of fairness to other candidates who adhere to the established policies and could potentially compromise patient safety by certifying an individual who has not yet met the required standards. Another incorrect approach would be to deny any further examination opportunities without providing specific feedback or outlining a clear remediation plan. While patient safety is critical, professional certification bodies also have an ethical obligation to provide candidates with clear pathways for improvement and opportunities to demonstrate competence if they are willing and able to meet the required standards. This approach lacks transparency and due process, potentially hindering a candidate’s professional development without a justifiable basis. A further incorrect approach would be to modify the examination content or scoring criteria for this specific candidate. This would violate the principle of standardization and fairness, creating an inequitable testing environment. It would also compromise the validity and reliability of the examination itself, making it impossible to compare candidate performance objectively and potentially lowering the overall standard of certification. The professional decision-making process in such situations should involve a systematic evaluation of the candidate’s performance against established criteria, a clear understanding and application of the governing retake and remediation policies, and open communication with the candidate regarding their progress and available options. Professionals must prioritize patient safety and the integrity of the certification process while also striving for fairness and providing opportunities for remediation when appropriate and supported by policy.

Scenario Analysis: This scenario presents a professionally challenging situation due to the rapid deterioration of a critically ill patient with a foregut pathology requiring emergent intervention. The challenge lies in balancing the immediate need for surgical intervention with the imperative to optimize the patient’s physiological status through effective resuscitation, all while adhering to established protocols and ensuring patient safety. The pressure of time, limited resources, and the potential for rapid decompensation necessitate a structured and evidence-based approach. Correct Approach Analysis: The best professional practice involves initiating a structured resuscitation protocol guided by Advanced Trauma Life Support (ATLS) principles, adapted for a critically ill surgical patient. This includes rapid assessment of airway, breathing, circulation, disability, and exposure (ABCDE), followed by aggressive fluid resuscitation, blood product transfusion if indicated, and correction of coagulopathy and electrolyte imbalances. Simultaneously, a multidisciplinary team, including surgical, anesthesia, and critical care specialists, should be convened to rapidly assess the need for and timing of surgical intervention, considering the patient’s hemodynamic stability and the potential benefits versus risks of delaying surgery. This approach is ethically justified by the principle of beneficence, aiming to provide the best possible care to improve patient outcomes, and is supported by established critical care guidelines that prioritize physiological stabilization before invasive procedures when feasible. Incorrect Approaches Analysis: Initiating immediate surgery without adequate resuscitation, despite hemodynamic instability, fails to address the underlying physiological derangements that would likely exacerbate surgical risks and potentially lead to intraoperative or postoperative complications. This approach neglects the ethical principle of non-maleficence by potentially causing harm through an unprepared surgical intervention. Delaying surgical intervention indefinitely to achieve complete physiological normalization, even when the patient is clearly deteriorating and surgery is indicated to address the underlying pathology, is also professionally unacceptable. This approach can be seen as a failure to act decisively when intervention is clearly required, potentially violating the principle of beneficence by allowing the patient’s condition to worsen due to inaction. Focusing solely on aggressive fluid resuscitation without a concurrent assessment of the need for surgical intervention, or without involving the surgical team, represents a fragmented approach. While resuscitation is critical, it must be integrated with the definitive management plan, which in this case includes surgery. This can lead to suboptimal patient care by not addressing the root cause of the patient’s instability in a timely manner. Professional Reasoning: Professionals should employ a systematic decision-making process that begins with a rapid primary survey (ABCDE) to identify life threats. This is followed by a secondary survey and targeted investigations. The core of the decision-making process in this context is the dynamic assessment of the patient’s physiological status in conjunction with the urgency of the surgical pathology. A multidisciplinary team approach is paramount, facilitating shared decision-making and ensuring all aspects of patient care are addressed concurrently. The decision to proceed to surgery should be based on a risk-benefit analysis, considering the patient’s current stability, the potential for improvement with resuscitation, and the risks associated with delaying definitive surgical management.

Scenario Analysis: This scenario presents a common yet challenging situation in advanced minimally invasive foregut surgery. The professional challenge lies in the immediate need to identify and manage a potentially life-threatening complication (esophageal perforation) while balancing the patient’s critical status with the need for definitive diagnosis and treatment. The surgeon must act decisively, leveraging their procedural knowledge and understanding of post-operative care protocols, all within the context of established surgical ethics and patient safety guidelines. The pressure to act quickly, the uncertainty of the exact extent of the injury, and the potential for rapid patient deterioration necessitate careful judgment. Correct Approach Analysis: The best professional practice involves immediate, direct visualization of the operative field to confirm the suspected perforation and assess its extent. This approach is correct because it aligns with the fundamental principle of surgical patient safety: direct assessment of the operative site is paramount when a complication is suspected. Prompt identification allows for immediate intraoperative repair, minimizing the risk of mediastinitis, sepsis, and further patient morbidity. This is ethically mandated by the principle of beneficence (acting in the patient’s best interest) and non-maleficence (avoiding harm). Regulatory frameworks, such as those governing surgical practice and patient safety, implicitly support this direct investigative approach as the primary response to intraoperative complications. Incorrect Approaches Analysis: Delaying direct visualization to await imaging studies, such as a contrast esophagram, is professionally unacceptable. While imaging can be useful, it introduces a delay in diagnosis and treatment when a perforation is strongly suspected intraoperatively. This delay violates the principle of beneficence by prolonging the patient’s exposure to a serious injury and increases the risk of harm. It also fails to meet the standard of care for immediate intraoperative complication management. Initiating empirical antibiotic therapy and close observation without confirming the perforation is also professionally unacceptable. While antibiotics are crucial for managing potential infection, they do not address the source of the problem. Relying solely on observation without direct confirmation of the perforation can lead to a critical delay in definitive management, allowing the perforation to worsen and leading to severe complications. This approach neglects the immediate need for surgical intervention and risks patient harm. Proceeding with the planned closure of the abdomen and deferring investigation until the post-operative period is the most egregious failure. This approach completely disregards the intraoperative suspicion of a life-threatening complication. It directly violates the principles of beneficence and non-maleficence by knowingly leaving a potentially catastrophic injury unaddressed, leading to severe, preventable morbidity and mortality. This would constitute a significant breach of professional duty and surgical standards. Professional Reasoning: Professionals facing such a scenario should employ a structured decision-making process. First, recognize the immediate signs and symptoms suggestive of a complication. Second, prioritize direct intraoperative assessment to confirm the suspicion. Third, if a complication is confirmed, immediately initiate appropriate management, which in this case is direct repair. Fourth, consider adjunctive measures like imaging or antibiotics only after the primary issue is addressed or if direct visualization is not immediately feasible and a controlled delay is deemed necessary for diagnostic clarity, which is not the case here. Always err on the side of direct visualization and immediate intervention when a critical intraoperative complication is suspected.

Scenario Analysis: This scenario is professionally challenging because it requires a candidate to critically evaluate their own learning process and resource utilization for a highly specialized and advanced examination. The pressure to perform well, coupled with the vastness of potential preparation materials, necessitates a strategic and evidence-based approach to ensure optimal readiness without wasting valuable time or resources. Misjudging the effectiveness of preparation strategies can lead to under-preparedness or burnout, both detrimental to exam success. Correct Approach Analysis: The best approach involves a structured, multi-modal preparation strategy that prioritizes foundational knowledge reinforcement, targeted practice with high-fidelity simulation and case-based scenarios, and engagement with current literature and expert consensus guidelines. This approach is correct because it aligns with established principles of adult learning and professional development in medicine. Specifically, it emphasizes active recall, spaced repetition, and application of knowledge in realistic clinical contexts, which are proven methods for long-term retention and skill development. Regulatory and ethical considerations in advanced medical practice demand a commitment to lifelong learning and evidence-based practice. Therefore, a preparation strategy that mirrors these principles, focusing on deep understanding and practical application rather than rote memorization, is ethically sound and professionally responsible. This approach directly addresses the need for mastery in advanced minimally invasive foregut surgery, ensuring the candidate is not only knowledgeable but also capable of applying that knowledge effectively. Incorrect Approaches Analysis: Relying solely on a single textbook or online resource, even if comprehensive, is an insufficient approach. This fails to account for the diverse learning styles of individuals and the limitations of any single source to cover the breadth and depth of advanced surgical techniques and their associated evidence base. Ethically, this can lead to a superficial understanding and a lack of exposure to alternative perspectives or emerging techniques, potentially compromising patient care. Focusing exclusively on memorizing surgical steps without understanding the underlying pathophysiology, anatomical variations, or potential complications represents another failure. This approach neglects the critical thinking and problem-solving skills essential for advanced surgical practice. It is ethically problematic as it prioritizes procedural execution over patient safety and individualized treatment planning. Engaging in extensive, unstructured reading of unrelated surgical literature without a clear focus on the examination syllabus or areas of personal weakness is inefficient and unlikely to yield optimal results. This approach lacks strategic direction and can lead to information overload and a diluted understanding of core competencies. It represents a failure in professional resource management and a potential ethical lapse in dedicating time that could be more effectively used for targeted preparation. Professional Reasoning: Professionals preparing for advanced examinations should adopt a systematic and self-aware approach. This involves: 1) Thoroughly understanding the examination blueprint and learning objectives. 2) Identifying personal knowledge gaps through self-assessment or practice questions. 3) Selecting a diverse range of high-quality preparation resources, including textbooks, peer-reviewed journals, online modules, and simulation tools. 4) Developing a realistic study schedule that incorporates spaced repetition and active learning techniques. 5) Regularly assessing progress and adjusting the study plan as needed. 6) Seeking feedback from mentors or peers. This iterative process ensures comprehensive preparation and fosters the critical thinking and adaptive learning skills necessary for advanced practice.

Scenario Analysis: This scenario presents a common challenge in minimally invasive foregut surgery: selecting the most appropriate energy device for tissue dissection and hemostasis. The professional challenge lies in balancing efficacy, safety, and patient outcomes while adhering to established best practices and manufacturer guidelines. Misapplication of energy devices can lead to thermal injury, increased operative time, and potential complications, necessitating careful consideration of the specific surgical task and the characteristics of available devices. Correct Approach Analysis: The best professional practice involves utilizing an energy device specifically designed for precise dissection and effective hemostasis in delicate foregut tissues, such as a bipolar energy device with integrated sealing capabilities. This approach is correct because bipolar energy devices offer controlled energy delivery, minimizing collateral thermal spread compared to monopolar devices. Devices with integrated sealing technology further enhance hemostasis by coagulating and fusing small vessels, reducing operative bleeding and the need for additional hemostatic maneuvers. Adherence to manufacturer guidelines for the specific device’s intended use and power settings is paramount for safety and efficacy. This aligns with the ethical principle of beneficence, ensuring the patient receives the safest and most effective treatment, and the principle of non-maleficence, by minimizing the risk of iatrogenic injury. Regulatory bodies and professional surgical societies emphasize the importance of understanding and appropriately using surgical energy devices to optimize patient care. Incorrect Approaches Analysis: Employing a monopolar energy device with a fine tip for extensive tissue dissection and primary hemostasis in this context is professionally unacceptable. Monopolar devices have a wider zone of thermal spread, increasing the risk of unintended thermal injury to adjacent structures, such as nerves or the esophagus itself. The current returning pad also introduces a risk of thermal injury at the pad site if not properly applied. Using a high power setting on any energy device for delicate dissection increases the likelihood of charring and inefficient cutting, prolonging operative time and potentially compromising tissue integrity. Relying solely on electrocautery without considering the specific tissue characteristics and the limitations of the energy modality constitutes a failure to apply evidence-based practice and may violate professional standards of care. Furthermore, using a device outside its manufacturer-recommended parameters or for an indication not supported by evidence represents a deviation from safe surgical practice. Professional Reasoning: Professionals should approach energy device selection by first identifying the primary surgical objective (e.g., dissection, hemostasis, division). They must then consider the specific tissue type and its proximity to critical structures. A thorough understanding of the principles of operation, advantages, and limitations of each available energy device is essential. Consulting manufacturer guidelines and institutional protocols for safe and effective use is a non-negotiable step. In cases of uncertainty, seeking guidance from experienced colleagues or attending relevant continuing education on surgical energy device safety is prudent. The decision-making process should always prioritize patient safety and optimal surgical outcomes, guided by ethical principles and regulatory expectations.

This scenario presents a professionally challenging situation due to the inherent risks associated with minimally invasive foregut surgery and the critical need for accurate pre-operative assessment to ensure patient safety and optimize surgical outcomes. The challenge lies in balancing the potential benefits of a less invasive approach with the identification of contraindications or factors that might increase perioperative morbidity. Careful judgment is required to select the most appropriate diagnostic pathway that is both effective and minimizes unnecessary patient burden. The best professional practice involves a systematic and evidence-based approach to risk stratification. This includes a thorough patient history, physical examination, and judicious use of diagnostic imaging and endoscopic evaluations tailored to the patient’s specific symptoms and risk factors. This approach is correct because it aligns with established principles of patient care, emphasizing a personalized and comprehensive assessment. Ethically, it upholds the principle of beneficence by seeking to provide the best possible care and non-maleficence by avoiding unnecessary interventions. Regulatory frameworks in North America, such as those guided by professional surgical societies and hospital accreditation bodies, mandate that pre-operative evaluations be thorough and individualized to ensure patient safety and informed consent. An incorrect approach would be to rely solely on a single diagnostic modality without considering the broader clinical picture. For example, proceeding with advanced imaging without a comprehensive initial assessment might lead to unnecessary costs, radiation exposure, and potential for incidental findings that cause patient anxiety without clinical relevance. This fails to adhere to the principle of proportionality in diagnostic workups. Another incorrect approach would be to defer definitive diagnosis to the intraoperative period. This is ethically unacceptable as it violates the principle of informed consent, as the patient would not have been fully apprised of the risks and benefits based on a complete pre-operative understanding. It also represents a failure in due diligence and risk management, potentially exposing the patient to unforeseen complications without adequate pre-planning. Professionals should employ a decision-making framework that prioritizes a stepwise, evidence-based diagnostic strategy. This involves starting with the least invasive and most informative tests, escalating to more complex investigations only when indicated by initial findings or persistent diagnostic uncertainty. This framework ensures that diagnostic resources are used efficiently, patient risk is minimized, and the diagnostic process is aligned with established clinical guidelines and ethical obligations.

Scenario Analysis: This scenario presents a professionally challenging situation due to the inherent risks associated with minimally invasive foregut surgery, particularly in a patient with complex comorbidities. Structured operative planning is paramount to mitigate these risks, ensuring patient safety and optimal outcomes. The challenge lies in balancing the benefits of a minimally invasive approach with the potential for unforeseen complications, requiring a meticulous and comprehensive pre-operative assessment and strategy. Correct Approach Analysis: The best professional practice involves a detailed, multi-disciplinary pre-operative assessment that includes a thorough review of the patient’s medical history, imaging studies, and physiological status. This assessment should inform a personalized operative plan that anticipates potential intraoperative challenges and outlines specific risk mitigation strategies. This approach aligns with the ethical principles of beneficence and non-maleficence, as well as the regulatory expectation for healthcare providers to deliver care that is safe, effective, and patient-centered. Specifically, it reflects the standards of care expected in advanced surgical practice, emphasizing proactive identification and management of risks. Incorrect Approaches Analysis: Relying solely on a standard, pre-defined operative protocol without significant customization for the patient’s specific comorbidities represents a failure to adequately address individual risk factors. This approach neglects the principle of personalized medicine and may lead to unexpected complications that were not adequately planned for, potentially violating the duty of care. Proceeding with surgery based on a general understanding of minimally invasive foregut procedures, without a detailed, structured plan that incorporates specific risk mitigation for this patient’s unique profile, is professionally unacceptable. This demonstrates a lack of due diligence and a disregard for the potential for adverse events, which is contrary to established ethical and regulatory standards for surgical practice. Focusing exclusively on the technical aspects of the minimally invasive approach while downplaying the significance of the patient’s comorbidities in the operative plan is also a critical failure. This oversight can lead to inadequate preparation for potential complications directly related to the patient’s underlying conditions, thereby compromising patient safety and failing to meet the expected standard of care. Professional Reasoning: Professionals should adopt a systematic approach to operative planning, beginning with a comprehensive patient assessment. This involves identifying all potential risks, both general to the procedure and specific to the patient’s condition. The next step is to develop a detailed operative strategy that directly addresses these identified risks, including contingency plans for foreseeable complications. This structured process ensures that the surgical team is well-prepared, minimizing the likelihood of adverse events and maximizing the potential for a successful outcome. Adherence to established ethical guidelines and regulatory frameworks for patient safety and quality of care should be the guiding principle throughout this process.