This scenario presents a significant professional challenge due to the inherent risks associated with complex urologic oncology surgery and the potential for serious patient harm from intraoperative complications. The surgeon’s immediate and accurate management of such an event is critical for patient outcomes and requires a blend of technical skill, ethical responsibility, and adherence to established practice guidelines. Careful judgment is paramount to ensure patient safety, maintain professional integrity, and comply with regulatory expectations regarding patient care and adverse event reporting. The best approach involves immediate, clear, and concise communication with the surgical team to assess the situation, stabilize the patient, and implement necessary corrective measures. This includes promptly identifying the source of bleeding, utilizing appropriate surgical techniques to control it, and ensuring hemodynamic stability. Following stabilization, a thorough intraoperative assessment of the extent of injury and a discussion with the patient’s family about the complication and the management plan are essential. This aligns with ethical principles of beneficence, non-maleficence, and patient autonomy, as well as professional standards for managing surgical adverse events. An incorrect approach would be to attempt to conceal the complication or downplay its severity to the patient or family. This violates the ethical principle of honesty and transparency, erodes patient trust, and could lead to legal repercussions. Furthermore, failing to document the complication accurately and comprehensively in the patient’s medical record is a breach of professional responsibility and regulatory requirements for record-keeping. Another unacceptable approach is to delay definitive management of the bleeding or to proceed with the planned procedure without adequately addressing the intraoperative complication. This demonstrates a failure to prioritize patient safety and can lead to severe morbidity or mortality, constituting a significant deviation from accepted surgical practice and potentially violating professional conduct standards. Finally, an approach that involves blaming other members of the surgical team without a thorough, objective assessment of the event is unprofessional and counterproductive. This undermines team cohesion and distracts from the primary goal of patient care. Professionals should employ a structured decision-making process that prioritizes patient safety, involves clear communication, adheres to established protocols for managing surgical complications, and maintains transparency with the patient and their family. This includes a commitment to continuous learning and improvement by analyzing adverse events to prevent future occurrences.

This scenario is professionally challenging because it requires balancing the immediate needs of a patient with the established protocols for assessing surgical competency, particularly in a specialized field like urologic oncology. The core tension lies between the urgency of a potentially life-saving procedure and the imperative to ensure the surgeon performing it possesses the requisite skills and qualifications to minimize patient risk. Careful judgment is required to avoid both unnecessary delays that could harm the patient and premature delegation that could compromise patient safety and professional standards. The best approach involves a thorough, documented review of the surgeon’s credentials and experience specifically within the context of the proposed complex urologic oncology surgery. This includes verifying their training, board certification, previous case logs for similar procedures, and any relevant peer reviews or performance evaluations. This systematic verification ensures that the surgeon’s qualifications directly align with the demands of the specific procedure, adhering to the principles of patient safety and due diligence mandated by professional medical bodies and institutional credentialing policies. Such a process upholds the ethical obligation to provide care only by competent practitioners and aligns with the regulatory framework that governs surgical practice and hospital privileging. An incorrect approach would be to proceed with the surgery based solely on the surgeon’s general reputation or a broad statement of their experience without specific validation for the complex urologic oncology procedure. This fails to meet the rigorous standards for assessing competency for specialized interventions and could expose the patient to undue risk. It disregards the ethical principle of ensuring competence for the specific task at hand and violates regulatory requirements for credentialing and privileging, which demand specific evidence of skill for particular procedures. Another incorrect approach would be to defer the decision entirely to the referring physician without independent verification of the operating surgeon’s qualifications. While collaboration is important, the ultimate responsibility for ensuring surgical competency rests with the hospital’s credentialing body and the surgical leadership. Relying solely on another physician’s recommendation, without due diligence, bypasses critical oversight mechanisms designed to protect patients and maintain professional standards. This approach neglects the ethical duty of the institution to ensure all practitioners meet established competency benchmarks. A further incorrect approach would be to approve the surgery based on the surgeon’s willingness to perform it, assuming their confidence equates to competence. This is a dangerous assumption that prioritizes expediency over patient safety. Professional judgment requires objective assessment of skills and experience, not subjective confidence. This approach fails to adhere to the ethical imperative of evidence-based practice and the regulatory necessity of demonstrable competency, potentially leading to adverse patient outcomes and professional liability. Professionals should employ a structured decision-making process that prioritizes patient safety through rigorous credentialing and privileging. This involves establishing clear criteria for assessing surgical competency for specific procedures, conducting thorough and documented reviews of surgeon qualifications, and maintaining an ongoing process for performance monitoring. When faced with complex cases, a multidisciplinary approach involving surgical leadership, credentialing committees, and relevant specialists is crucial to ensure that all decisions are evidence-based and ethically sound, thereby upholding the highest standards of patient care.

Scenario Analysis: This scenario is professionally challenging because it requires a urologic surgeon to balance the immediate need for specialized oncology surgical expertise with the established protocols for credentialing and privileging within a healthcare institution. The urgency of a patient’s condition can create pressure to bypass standard procedures, but doing so carries significant risks to patient safety, institutional integrity, and regulatory compliance. Careful judgment is required to ensure that patient care is not compromised while upholding the rigorous standards necessary for safe surgical practice. Correct Approach Analysis: The best professional practice involves initiating an expedited credentialing and privileging process that adheres to the institution’s established policies for urgent situations. This approach involves a thorough review of the surgeon’s qualifications, including verification of their board certification in urologic oncology, review of their surgical experience and outcomes, and consultation with relevant medical staff leadership. The process must be transparent and documented, ensuring that the surgeon meets the necessary standards for performing the complex oncology surgery, even under time constraints. This aligns with regulatory requirements for ensuring that only qualified practitioners provide care and upholds ethical obligations to patient safety. Incorrect Approaches Analysis: One incorrect approach involves allowing the surgeon to operate based solely on a verbal assurance of their qualifications without completing any formal credentialing or privileging, even on an expedited basis. This fails to meet regulatory mandates for verifying physician competence and poses a direct risk to patient safety by allowing an unvetted practitioner to perform a complex procedure. It also undermines the institution’s quality assurance framework. Another incorrect approach is to delay the surgery until the full, standard credentialing process is completed, even if the patient’s condition is deteriorating. While adherence to process is important, this approach neglects the ethical imperative to provide timely care when medically indicated and may lead to suboptimal patient outcomes, potentially violating the duty of care. A further incorrect approach is to grant temporary privileges based on a colleague’s informal recommendation without any independent verification of the surgeon’s credentials or surgical competency in urologic oncology. This relies on subjective endorsement rather than objective evidence of qualification, which is insufficient for ensuring patient safety and does not meet the standards for privileging set by regulatory bodies. Professional Reasoning: Professionals should employ a decision-making framework that prioritizes patient safety while respecting institutional policies and regulatory requirements. In urgent situations, this involves understanding the institution’s established protocols for expedited credentialing and privileging. The process should always include verification of qualifications, assessment of competency for the specific procedure, and appropriate oversight. When in doubt, consulting with medical staff leadership and legal counsel is advisable to navigate complex situations ethically and compliantly.

This scenario presents a professionally challenging situation due to the immediate life-threatening nature of the patient’s condition and the need for rapid, coordinated intervention. The urologist, as the most senior clinician with direct responsibility for the patient’s urologic trauma, must make critical decisions under extreme pressure, balancing immediate resuscitation needs with the specific requirements of urologic management. Careful judgment is required to ensure patient safety, optimize outcomes, and adhere to established protocols. The best professional approach involves prioritizing immediate life-saving interventions while simultaneously initiating the necessary urologic assessment and management. This includes ensuring adequate airway, breathing, and circulation (ABC) support, controlling external hemorrhage, and initiating broad-spectrum antibiotic coverage as per trauma guidelines. Concurrently, a rapid urologic assessment, including imaging to identify the extent of injury and potential for ongoing bleeding or organ damage, is crucial. This approach is correct because it aligns with established trauma resuscitation principles, emphasizing the ABCs as the absolute priority, and integrates urologic expertise at the earliest possible stage to address the specific organ system involved. This adheres to ethical principles of beneficence and non-maleficence by acting swiftly to save life and prevent further harm, and implicitly follows professional guidelines for trauma management that advocate for a systematic, multi-disciplinary approach. An incorrect approach would be to solely focus on the urologic injury without ensuring the patient is hemodynamically stable. This fails to address the immediate life threats posed by hypovolemic shock and potential airway compromise, violating the fundamental principles of trauma care. Ethically, this prioritizes a specific organ system over the patient’s overall survival, which is unacceptable. Another incorrect approach would be to delay urologic consultation or intervention until the patient is stabilized by the trauma team, without any initial urologic assessment. While the trauma team’s role is vital, delaying urologic input can lead to missed opportunities for early diagnosis and management of specific urologic injuries, potentially worsening outcomes or leading to complications. This approach fails to leverage the specialized knowledge of the urologist in the critical initial phase. A further incorrect approach would be to proceed with definitive urologic surgery before adequate resuscitation and stabilization have been achieved, unless the surgical intervention itself is deemed life-saving and directly addresses the immediate hemodynamic instability. Performing complex urologic procedures in a critically unstable patient significantly increases the risk of complications, further hemorrhage, and mortality. This violates the principle of non-maleficence. Professionals should employ a structured decision-making process that begins with a rapid assessment of the patient’s airway, breathing, and circulation. Simultaneously, a brief but focused history and physical examination should identify obvious external bleeding or signs of specific organ injury. Based on this initial assessment, immediate life-saving interventions should be initiated. Concurrently, a low threshold for involving relevant specialists, such as urology in this case, should be maintained. Communication and coordination among the trauma team and specialists are paramount to ensure a seamless and effective management plan. The decision to proceed with specific interventions, including surgical ones, should be guided by the patient’s physiological status and the potential benefit versus risk.

Scenario Analysis: This scenario is professionally challenging because it requires a urologic surgeon to navigate the specific eligibility criteria for a specialized qualification without compromising patient care or professional integrity. The core challenge lies in accurately interpreting and applying the qualification’s purpose and eligibility requirements, which are designed to ensure a high standard of expertise in a critical area of oncology surgery. Misinterpreting these requirements could lead to either an unjustified denial of a deserving candidate or the acceptance of an unqualified individual, both with significant ethical and professional repercussions. Correct Approach Analysis: The best professional practice involves a thorough review of the candidate’s documented surgical experience, focusing on the volume and complexity of urologic oncology cases performed, alongside evidence of specialized training and continuous professional development in the field. This approach directly aligns with the stated purpose of the Critical Caribbean Urologic Oncology Surgery Practice Qualification, which is to recognize surgeons who have demonstrated advanced proficiency and commitment to this subspecialty. Eligibility is typically predicated on a combination of hands-on experience, formal education, and ongoing engagement with the latest advancements in urologic oncology. Adhering to these documented criteria ensures a fair and objective assessment, upholding the integrity of the qualification and patient safety. Incorrect Approaches Analysis: One incorrect approach involves prioritizing the candidate’s general reputation or years in practice over specific urologic oncology experience. While reputation and experience are valuable, they do not inherently guarantee specialized competence in urologic oncology. This approach fails to meet the qualification’s purpose of assessing specific expertise in this critical area and could lead to the acceptance of a surgeon lacking the necessary advanced skills. Another unacceptable approach is to rely solely on the recommendation of a colleague without independent verification of the candidate’s qualifications against the stated eligibility criteria. Recommendations are important but are subjective. The qualification’s framework is designed for objective assessment, and bypassing this by relying solely on a personal endorsement undermines the rigorous standards required for specialized practice. Finally, an incorrect approach would be to interpret the eligibility requirements loosely, assuming that a broad surgical background is sufficient. The “Critical Caribbean Urologic Oncology Surgery Practice Qualification” implies a specific focus and a higher level of specialized knowledge and skill than general urology. A loose interpretation disregards the intent of the qualification to identify surgeons with dedicated expertise in this demanding field, potentially leading to unqualified individuals being certified. Professional Reasoning: Professionals should approach qualification assessments by first meticulously understanding the stated purpose and eligibility criteria of the qualification. This involves identifying the specific knowledge, skills, and experience required. Subsequently, they must gather objective evidence that directly addresses each criterion. This evidence should be reviewed impartially, comparing it against the established benchmarks. Any ambiguities should be clarified by referring to the official guidelines or seeking clarification from the awarding body. The decision-making process should prioritize adherence to the established framework, ensuring fairness, transparency, and ultimately, the highest standard of patient care.

This scenario presents a professional challenge due to the inherent risks associated with urologic oncology surgery, particularly the need for precise and timely intervention to optimize patient outcomes. The surgeon must balance the urgency of the situation with the imperative to ensure all necessary pre-operative assessments and patient consents are meticulously handled, adhering to the highest standards of patient care and ethical practice. The critical nature of the surgery demands a robust and efficient pre-operative process that leaves no room for compromise on safety or informed consent. The best approach involves a comprehensive pre-operative assessment that includes a thorough review of all diagnostic imaging, pathology reports, and patient medical history, followed by a detailed discussion with the patient regarding the surgical plan, potential risks, benefits, and alternatives. This discussion must culminate in obtaining fully informed consent, ensuring the patient understands the procedure and has had all their questions answered. This approach is correct because it directly aligns with the fundamental ethical principles of patient autonomy and beneficence, as well as the regulatory requirements for informed consent in medical practice. It ensures that the patient is an active participant in their care and that the surgical team is proceeding with a clear understanding of the patient’s wishes and medical status. Proceeding with surgery without confirming the availability of all necessary surgical equipment and ensuring the operating room is adequately prepared represents a significant ethical and regulatory failure. This oversight could lead to delays, compromised surgical technique, and potentially adverse patient outcomes, violating the duty of care owed to the patient. Similarly, initiating the surgical procedure before the final pathology report is reviewed and integrated into the surgical plan is professionally unacceptable. This failure to consider all available diagnostic information could lead to an inappropriate surgical approach, potentially missing critical details that would influence the extent or nature of the surgery, thereby failing to provide the best possible care and potentially causing harm. Finally, relying solely on a junior colleague’s assessment without independent verification by the lead surgeon demonstrates a lapse in professional responsibility and oversight. This could lead to the perpetuation of errors or oversights in the pre-operative assessment, directly impacting patient safety and the quality of care delivered. Professionals should employ a structured decision-making process that prioritizes patient safety and adherence to established protocols. This involves a systematic checklist approach to pre-operative preparation, ensuring all diagnostic information is reviewed, informed consent is unequivocally obtained, and all logistical and personnel requirements for the surgery are confirmed. Regular team briefings and a culture of open communication are essential to identify and mitigate potential risks before they impact patient care.

Scenario Analysis: This scenario is professionally challenging because it requires balancing the immediate need for surgical intervention with the imperative to ensure patient safety and informed consent, especially when dealing with complex oncologic cases. The pressure to proceed quickly can sometimes overshadow the meticulous steps necessary for comprehensive risk assessment and mitigation, potentially leading to suboptimal outcomes or ethical breaches. Careful judgment is required to navigate the inherent uncertainties of cancer surgery and the diverse needs and understanding of the patient. Correct Approach Analysis: The best professional practice involves a structured operative planning process that prioritizes a thorough pre-operative assessment, including detailed imaging review, multidisciplinary team consultation, and a comprehensive discussion with the patient about all potential risks, benefits, and alternatives. This approach ensures that all available information is considered, potential complications are anticipated, and the patient is fully informed and empowered to participate in decision-making. This aligns with ethical principles of beneficence, non-maleficence, and patient autonomy, and is implicitly supported by professional guidelines emphasizing evidence-based practice and patient-centered care within the Caribbean’s healthcare framework, which generally adheres to international standards of medical ethics and professional conduct. Incorrect Approaches Analysis: Proceeding with surgery based solely on the surgeon’s experience without formal multidisciplinary input or detailed patient discussion fails to leverage collective expertise and can overlook critical factors influencing risk. This approach neglects the ethical duty to ensure comprehensive patient understanding and consent, potentially violating principles of autonomy. Relying primarily on the patient’s immediate verbal consent without documenting a detailed discussion of risks, benefits, and alternatives is insufficient. While verbal consent is a component, the absence of thorough documentation and a clear understanding of the patient’s comprehension leaves room for misinterpretation and can be ethically problematic, particularly in complex procedures. Delaying surgery indefinitely due to a minor, non-urgent imaging discrepancy without further investigation or consultation risks patient deterioration. This approach fails the principle of beneficence by not acting in the patient’s best interest when a reasonable course of action exists to address the discrepancy and proceed safely. Professional Reasoning: Professionals should adopt a systematic approach to operative planning. This involves: 1) Thoroughly reviewing all diagnostic data and consulting with relevant specialists (e.g., radiologists, pathologists, medical oncologists). 2) Engaging in open and honest communication with the patient, explaining the diagnosis, proposed procedure, potential risks and benefits, and alternative treatment options in a manner they can understand. 3) Documenting all discussions and decisions meticulously. 4) Developing a detailed operative plan that anticipates potential complications and outlines strategies for mitigation. 5) Regularly reassessing the plan based on new information or patient status.

This scenario is professionally challenging because it requires balancing the need for continuous professional development and maintaining surgical competency with the practicalities of a busy urologic oncology practice. The urologist must adhere to the established qualification framework for the Critical Caribbean Urologic Oncology Surgery Practice, which includes specific guidelines on blueprint weighting, scoring, and retake policies, while also ensuring patient care is not compromised. Careful judgment is required to interpret and apply these policies fairly and effectively. The best approach involves a thorough review of the urologist’s performance against the established blueprint weighting and scoring criteria, followed by a clear communication of the results and the specific areas requiring improvement. This approach aligns with the principles of fair assessment and professional development mandated by qualification frameworks. It acknowledges that the blueprint weighting and scoring are the objective measures of competency, and retake policies are designed to provide a structured pathway for remediation. By focusing on the specific blueprint areas and providing targeted feedback, the urologist can be guided towards successful re-qualification, ensuring they meet the high standards of the Critical Caribbean Urologic Oncology Surgery Practice. This respects the integrity of the qualification process and prioritizes patient safety by ensuring only qualified surgeons practice. An approach that immediately suggests a retake without a detailed analysis of the scoring against the blueprint weighting is professionally unacceptable. This bypasses the fundamental assessment mechanism and can lead to unnecessary stress and resource expenditure for the urologist, while potentially failing to address the root cause of any performance gap. It also undermines the credibility of the scoring and weighting system. Another professionally unacceptable approach would be to disregard the established retake policies and allow for an informal or ad-hoc re-assessment. This deviates from the structured and transparent process designed to ensure consistent qualification standards across all practitioners. It introduces subjectivity and can create perceptions of unfairness or favoritism, eroding trust in the qualification body. Finally, an approach that focuses solely on the number of cases performed without reference to the blueprint weighting and scoring is also flawed. While case volume is important, the qualification framework emphasizes the quality and demonstrated competency in specific areas as defined by the blueprint. Ignoring these specific criteria means the assessment is not truly measuring against the defined standards of the Critical Caribbean Urologic Oncology Surgery Practice. Professionals should approach such situations by first understanding the governing qualification framework in its entirety, including the blueprint, scoring mechanisms, and retake policies. They should then objectively apply these criteria to the individual’s performance. Clear, evidence-based communication of the assessment outcomes and the rationale behind any remediation steps is crucial. This fosters a culture of accountability, continuous improvement, and upholds the integrity of the qualification process.

This scenario is professionally challenging because it requires balancing the candidate’s desire for efficient preparation with the stringent requirements for demonstrating competence in a specialized surgical field. The Critical Caribbean Urologic Oncology Surgery Practice Qualification demands a robust understanding of both theoretical knowledge and practical application, necessitating a structured and comprehensive approach to preparation. The pressure to qualify quickly can lead to shortcuts that compromise the depth of learning and ultimately patient safety. Careful judgment is required to ensure that preparation is thorough, evidence-based, and aligned with the qualification’s objectives. The best approach involves a structured, multi-faceted preparation strategy that integrates theoretical learning with practical skill development, guided by current best practices and regulatory expectations. This includes dedicating specific time blocks for reviewing foundational urologic oncology principles, engaging with peer-reviewed literature on advanced surgical techniques, and actively seeking mentorship from experienced practitioners. Furthermore, it necessitates the development of a realistic timeline that allows for iterative learning, skill refinement through simulation or observation, and adequate time for self-assessment and feedback. This comprehensive strategy directly addresses the qualification’s emphasis on both knowledge and practical competence, aligning with the ethical imperative to provide safe and effective patient care. Regulatory frameworks governing surgical qualifications typically emphasize a thorough and verifiable demonstration of skills and knowledge, which this approach facilitates. An approach that prioritizes rapid acquisition of theoretical knowledge through passive learning methods, such as solely relying on outdated textbooks or brief online summaries, without incorporating practical skill development or seeking expert feedback, is professionally unacceptable. This fails to meet the practical competency requirements inherent in surgical qualifications and neglects the ethical obligation to ensure proficiency before undertaking complex procedures. Such a method risks superficial understanding and inadequate preparation for the nuances of urologic oncology surgery, potentially jeopardizing patient outcomes. Another professionally unacceptable approach is to focus exclusively on memorizing surgical steps from procedural videos without a deep understanding of the underlying oncological principles, patient selection criteria, or potential complications. This narrow focus ignores the critical decision-making and problem-solving skills essential for a qualified surgeon. It also bypasses the need for understanding the evidence base that informs surgical choices, which is a cornerstone of modern medical practice and a likely implicit requirement of any rigorous qualification. Finally, an approach that relies heavily on anecdotal advice from colleagues without cross-referencing with established guidelines or seeking formal mentorship is also professionally deficient. While peer advice can be valuable, it lacks the systematic rigor and evidence-based foundation required for qualification in a specialized surgical field. This can lead to the adoption of suboptimal or outdated practices, failing to meet the standards expected of a qualified urologic oncology surgeon and potentially exposing patients to unnecessary risks. The professional decision-making process for similar situations should involve a systematic evaluation of the qualification’s requirements, an honest self-assessment of current knowledge and skills, and the development of a personalized preparation plan that is both comprehensive and realistic. This plan should prioritize evidence-based learning, active skill development, and seeking mentorship and feedback from qualified professionals. It is crucial to allocate sufficient time for each component, recognizing that mastery in a complex surgical discipline is a process, not an event. Adherence to ethical principles of patient safety and professional competence should guide all preparation activities.

Scenario Analysis: This scenario presents a professional challenge due to the inherent complexity of urologic oncology surgery, which demands precise anatomical knowledge and a thorough understanding of perioperative physiological responses. The challenge lies in integrating this scientific knowledge with the practicalities of patient care, ensuring optimal outcomes while minimizing risks. The need for continuous professional development and adaptation to evolving surgical techniques and scientific understanding adds another layer of complexity, requiring surgeons to critically evaluate their practice and seek evidence-based improvements. Correct Approach Analysis: The best professional practice involves a systematic review of recent peer-reviewed literature and established clinical guidelines specifically pertaining to advanced urologic oncology surgical techniques and their associated perioperative management. This approach is correct because it directly addresses the need for evidence-based practice, which is a cornerstone of modern medicine and a requirement for maintaining professional competence. Adhering to established guidelines and incorporating the latest research ensures that surgical decisions are informed by the most current and reliable scientific data, thereby maximizing patient safety and efficacy of treatment. This aligns with the ethical obligation to provide the highest standard of care and the professional responsibility to remain current in one’s field. Incorrect Approaches Analysis: Relying solely on personal experience without incorporating new evidence or guidelines is professionally unacceptable. While experience is valuable, it can lead to the perpetuation of outdated practices or the overlooking of significant advancements in surgical anatomy, physiology, or perioperative care. This approach fails to meet the ethical standard of providing the best possible care and can violate professional obligations to stay current. Adopting techniques based on anecdotal reports from colleagues without critical evaluation or independent verification is also professionally unsound. Anecdotal evidence, while sometimes a starting point for investigation, lacks the rigor of peer-reviewed research and may not be generalizable or safe for all patients. This approach risks introducing unproven or potentially harmful practices, violating the principle of “do no harm” and failing to adhere to evidence-based medicine. Implementing novel surgical approaches based on preliminary, unpublished research findings without robust validation or established consensus is premature and professionally risky. While innovation is important, patient safety must be paramount. Unvalidated techniques may not have undergone sufficient scrutiny regarding their anatomical accuracy, physiological implications, or long-term outcomes, potentially leading to adverse events and compromising patient well-being. This approach disregards the established process of scientific validation and ethical review necessary before widespread clinical adoption. Professional Reasoning: Professionals should adopt a decision-making framework that prioritizes evidence-based practice. This involves actively seeking out and critically appraising relevant scientific literature and clinical guidelines. When considering new techniques or approaches, a thorough understanding of the underlying applied surgical anatomy, physiology, and perioperative sciences is essential. This understanding should be informed by validated research and established best practices. A commitment to continuous learning, peer review, and a cautious approach to adopting unproven methods are crucial for ensuring patient safety and maintaining professional integrity in the field of urologic oncology surgery.