This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed wishes and the clinician’s medical judgment, compounded by the potential for significant harm if the patient’s wishes are followed without due consideration. The advanced practice clinician must navigate complex ethical principles, including patient autonomy, beneficence, non-maleficence, and justice, within the framework of Pacific Rim healthcare regulations and advanced practice guidelines. Careful judgment is required to balance these competing interests while ensuring the patient receives the best possible care. The best professional approach involves a comprehensive, multi-faceted discussion with the patient and their family, involving a multidisciplinary team, to thoroughly explore the patient’s understanding of their condition, the rationale behind the recommended treatment, and the potential consequences of refusing it. This approach prioritizes shared decision-making, ensuring the patient’s autonomy is respected while also fulfilling the clinician’s duty of beneficence. It involves clearly documenting the patient’s capacity to make decisions, the information provided, and the patient’s final informed choice. This aligns with ethical principles that mandate respecting a competent patient’s right to refuse treatment, even if that refusal may lead to adverse outcomes, provided the patient is fully informed of the risks and benefits. An incorrect approach would be to unilaterally override the patient’s wishes based solely on the clinician’s perceived superior medical knowledge, without engaging in a thorough discussion about the patient’s values, beliefs, and understanding of their prognosis. This fails to uphold the principle of patient autonomy and can lead to a breakdown of trust. Another incorrect approach would be to proceed with a treatment the patient has explicitly refused, even if it is considered the standard of care, without re-evaluating the patient’s capacity or exploring alternative treatment options that might be more acceptable to the patient. This constitutes a violation of patient consent and can lead to legal and ethical repercussions. Finally, abandoning the patient due to a disagreement over treatment, without ensuring continuity of care through referral to another provider, would be ethically unacceptable and a failure to uphold the duty of care. Professional decision-making in such situations requires a structured process: first, assess the patient’s decision-making capacity; second, ensure the patient has received all relevant information in an understandable manner; third, explore the patient’s values, goals, and concerns; fourth, involve a multidisciplinary team for consultation and support; fifth, document all discussions and decisions meticulously; and finally, if disagreement persists and the patient remains capacitated, respect their informed decision, facilitating appropriate care transitions if necessary.

The performance metrics show a concerning trend in patient outcomes for stroke prevention in the Pacific Rim region, highlighting the critical need for advanced practitioners to demonstrate specialized knowledge and skills. This scenario is professionally challenging because it requires balancing the desire to advance one’s career and contribute to improved patient care with the strict requirements for eligibility for advanced practice examinations. Careful judgment is required to ensure that all prerequisites are met before seeking admission, thereby upholding the integrity of the certification process and patient safety. The approach that represents best professional practice involves meticulously reviewing the examination’s stated purpose and eligibility criteria, ensuring all academic, clinical, and professional requirements are demonstrably met, and then submitting a complete and accurate application. This is correct because the purpose of the Critical Pacific Rim Stroke Prevention Medicine Advanced Practice Examination is to validate a high level of expertise and competence in a specialized field. Eligibility criteria are designed to ensure that only those practitioners who have undergone appropriate training and possess the necessary experience can sit for the exam, thereby safeguarding the public and maintaining professional standards. Adhering strictly to these requirements demonstrates professional integrity and respect for the examination’s objectives. An incorrect approach involves assuming that a broad range of clinical experience in general cardiology or neurology is sufficient, without specifically verifying if it aligns with the specialized focus on stroke prevention and the advanced practice level required by the examination. This fails to acknowledge the specific nature of the certification, which is designed to assess expertise in a niche area. Another incorrect approach is to submit an application with incomplete documentation or to misrepresent qualifications, hoping for leniency or a later review. This directly violates ethical principles of honesty and integrity in professional practice and undermines the examination’s validation process. Furthermore, relying solely on informal advice from colleagues about eligibility, without consulting the official examination guidelines, is professionally unsound. This can lead to significant misunderstandings of the requirements and ultimately result in disqualification, wasting valuable time and resources. Professionals should employ a systematic decision-making process when considering advanced practice examinations. This involves: 1) Clearly identifying the examination’s purpose and target audience. 2) Thoroughly reading and understanding all published eligibility criteria, including academic prerequisites, clinical experience requirements (type, duration, and specialization), and any required certifications or licenses. 3) Honestly self-assessing one’s qualifications against these criteria. 4) Seeking clarification from the examination board or governing body for any ambiguities. 5) Gathering all necessary documentation well in advance of application deadlines. 6) Submitting a complete and accurate application.

Scenario Analysis: This scenario presents a professional challenge due to the inherent uncertainty in interpreting complex imaging findings in a time-sensitive stroke prevention context. The physician must balance the need for timely intervention with the ethical imperative to avoid unnecessary or potentially harmful procedures based on uncertain diagnostic information. The potential for misinterpretation carries significant consequences for patient outcomes and resource allocation. Correct Approach Analysis: The best professional practice involves a systematic, multi-modal approach to imaging interpretation, prioritizing established diagnostic pathways and seeking expert consensus when ambiguity exists. This includes correlating findings from initial non-contrast CT with subsequent advanced imaging modalities like CT angiography (CTA) and CT perfusion (CTP) to delineate the extent and nature of vascular compromise. Crucially, if interpretation remains equivocal or if findings suggest a complex or rare etiology, consultation with a neuroradiologist or stroke specialist is paramount. This collaborative approach ensures that diagnostic decisions are grounded in the highest level of expertise, minimizing the risk of misdiagnosis and guiding appropriate, evidence-based treatment strategies. This aligns with the ethical principle of beneficence, ensuring the patient receives the most accurate diagnosis and appropriate care, and non-maleficence, by avoiding interventions based on potentially flawed interpretations. Incorrect Approaches Analysis: Proceeding with definitive treatment based solely on the initial, equivocal non-contrast CT findings without further advanced imaging or specialist consultation is professionally unacceptable. This approach fails to adhere to established diagnostic protocols for stroke evaluation, potentially leading to inappropriate interventions that could cause harm without clear benefit. It also disregards the ethical obligation to obtain the most accurate diagnosis possible before committing a patient to significant medical or surgical treatment. Relying exclusively on a single advanced imaging modality, such as CTA, without considering the complementary information provided by other techniques like CTP or even MRI in select cases, represents a failure to utilize the full diagnostic armamentarium. This can lead to an incomplete understanding of the pathophysiology, such as failing to identify areas of salvageable brain tissue (penumbra) that CTP can reveal, thus hindering optimal treatment decisions. Delaying further investigation or treatment indefinitely due to persistent uncertainty, without actively seeking expert opinion or exploring alternative diagnostic avenues, is also professionally unacceptable. While caution is warranted, prolonged indecision can lead to irreversible neurological damage, violating the principle of timely intervention in acute stroke scenarios. Professional Reasoning: Professionals should employ a structured diagnostic reasoning process that begins with a thorough clinical assessment, followed by a stepwise approach to imaging. This involves selecting the most appropriate imaging modality based on the clinical presentation and suspected pathology, and critically interpreting the findings in the context of other available data. When faced with diagnostic uncertainty, particularly in high-stakes situations like stroke, the professional decision-making framework must include seeking consultation from specialists, reviewing relevant literature, and engaging in collaborative decision-making with the patient and their family. This iterative process of assessment, investigation, interpretation, and consultation ensures that patient care is guided by the best available evidence and ethical principles.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed wishes and the clinician’s assessment of their best interests, particularly when the patient’s capacity to make informed decisions is in question. Navigating this requires a delicate balance of respecting patient autonomy while fulfilling the duty of care, all within the established legal and ethical frameworks governing medical practice in the Pacific Rim region. The advanced practice nurse must consider the nuances of evidence-based stroke prevention, the patient’s specific clinical context, and the potential consequences of different management strategies. Correct Approach Analysis: The best professional approach involves a comprehensive assessment of the patient’s capacity to understand their condition, the proposed treatment options, and the potential risks and benefits of each. This assessment should be documented thoroughly and, if capacity is deemed impaired, involve consultation with the patient’s designated healthcare proxy or legal guardian, adhering strictly to the principles of informed consent and patient advocacy as outlined in regional healthcare ethics guidelines. If capacity is confirmed, the patient’s informed decision, even if it deviates from the clinician’s preferred evidence-based recommendation, must be respected, provided it does not pose an immediate and severe risk of harm that overrides autonomy. The focus remains on shared decision-making and respecting the patient’s values and preferences. Incorrect Approaches Analysis: One incorrect approach would be to unilaterally override the patient’s stated preference for a less aggressive treatment plan, solely based on the clinician’s interpretation of evidence-based guidelines, without a thorough capacity assessment or engagement with the patient’s support system. This fails to uphold the principle of patient autonomy and can lead to a breakdown of trust and potential legal challenges. Another incorrect approach would be to proceed with a treatment plan that the patient has explicitly refused, even if the patient’s capacity is questionable, without first exhausting all avenues to clarify their wishes, assess their understanding, and involve appropriate surrogates or legal counsel. This constitutes a violation of the patient’s right to refuse treatment and could be considered battery. A third incorrect approach would be to delay or refuse to offer any treatment options due to the patient’s expressed ambivalence or perceived difficulty in decision-making, thereby failing to provide timely and appropriate evidence-based care. This neglects the duty to treat and can lead to adverse outcomes for the patient, contravening the core tenets of professional responsibility. Professional Reasoning: Professionals should employ a structured decision-making process that prioritizes patient-centered care. This involves: 1) Thoroughly assessing the patient’s clinical condition and understanding the evidence-based management options. 2) Evaluating the patient’s capacity to make informed decisions, employing validated tools and seeking multidisciplinary input if necessary. 3) Engaging in open and honest communication with the patient, explaining all options, risks, and benefits in a clear and understandable manner, and exploring their values and preferences. 4) If capacity is impaired, identifying and involving the appropriate surrogate decision-maker, ensuring they are informed and acting in the patient’s best interests. 5) Documenting all assessments, discussions, and decisions meticulously. 6) Respecting the patient’s informed choices, even if they differ from the clinician’s recommendations, unless there is a clear and present danger that necessitates overriding autonomy within legal and ethical boundaries.

The scenario presents a professional challenge related to the examination’s blueprint weighting, scoring, and retake policies. Specifically, it involves a candidate who believes their performance was unfairly assessed due to perceived inconsistencies in the examination’s structure and scoring, leading to a retake. This situation requires careful judgment to balance the candidate’s concerns with the integrity and established procedures of the examination. The best professional approach involves a thorough and objective review of the candidate’s examination performance against the established blueprint weighting and scoring criteria, while also considering the examination’s stated retake policies. This approach prioritizes fairness and adherence to established procedures. It requires the examination board to: 1) verify the candidate’s score against the blueprint’s weighting for each section, ensuring no miscalculation or misapplication of scoring rubrics occurred; 2) confirm that the retake policy was applied correctly based on the candidate’s initial performance and the examination’s guidelines; and 3) communicate the findings transparently to the candidate, explaining how their score was determined and the rationale behind the retake decision, referencing the official blueprint and policy documents. This upholds the principles of procedural fairness and accountability inherent in professional examinations. An incorrect approach would be to dismiss the candidate’s concerns without a formal review, citing the finality of the examination results. This fails to acknowledge the possibility of administrative error and disregards the candidate’s right to a fair assessment process. It also undermines trust in the examination’s credibility. Another incorrect approach would be to offer a special accommodation or a revised scoring solely based on the candidate’s subjective perception of unfairness, without objective evidence of a discrepancy with the blueprint or scoring. This compromises the standardization and validity of the examination, potentially creating a precedent for preferential treatment and eroding the equal application of rules for all candidates. A further incorrect approach would be to focus solely on the retake policy without addressing the candidate’s specific concerns about the initial scoring and blueprint weighting. While the retake policy is relevant, it does not resolve the underlying issue of whether the initial assessment was accurate and fair according to the established criteria. Professionals should employ a decision-making framework that emphasizes due process, transparency, and adherence to established policies. This involves: 1) actively listening to and documenting candidate concerns; 2) initiating an objective review process that aligns with the examination’s governing documents (blueprint, scoring rubrics, retake policies); 3) seeking clarification or verification from relevant examination administrators if needed; 4) making a decision based on evidence and established procedures; and 5) communicating the decision and its rationale clearly and respectfully to the candidate.

This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed wishes and the clinician’s assessment of their best interests, particularly when the patient’s capacity to make informed decisions is in question. The advanced practice clinician must navigate complex ethical principles, including patient autonomy, beneficence, and non-maleficence, while adhering to professional standards and legal requirements for capacity assessment and decision-making. The correct approach involves a thorough and documented assessment of the patient’s capacity to make decisions regarding their stroke prevention medication. This includes ensuring the patient understands the nature of their condition, the proposed treatment, the risks and benefits of the medication, and the alternatives, including no treatment. If the patient is deemed to have capacity, their decision, even if it contradicts the clinician’s recommendation, must be respected, provided it is informed and voluntary. This aligns with the ethical principle of patient autonomy, which is paramount in healthcare decision-making. Professional guidelines emphasize the importance of respecting a patient’s right to self-determination, even when their choices may seem unwise to others, as long as they possess the requisite capacity. An incorrect approach would be to unilaterally override the patient’s decision based solely on the clinician’s judgment of what is best, without a formal capacity assessment. This disregards the principle of patient autonomy and could constitute a breach of professional duty. Another incorrect approach would be to proceed with treatment without obtaining informed consent, even if the patient verbally agrees, as this fails to meet the legal and ethical standards for valid consent. Furthermore, pressuring or coercing the patient into accepting the medication, or making assumptions about their understanding without verification, are also ethically and professionally unacceptable, as they undermine the voluntary nature of informed consent and respect for the individual. Professionals should employ a structured decision-making process when faced with such dilemmas. This begins with a comprehensive assessment of the patient’s capacity, involving clear communication and exploration of their understanding. If capacity is present, the patient’s informed decision should be respected. If capacity is lacking, the clinician must then consider established legal and ethical frameworks for substitute decision-making, which may involve consulting with family members or legal guardians, always acting in the patient’s best interests. Documentation of all assessments, discussions, and decisions is crucial throughout this process.

The efficiency study reveals a critical need for advanced practitioners to optimize their preparation for the Critical Pacific Rim Stroke Prevention Medicine Advanced Practice Examination. This scenario is professionally challenging because it requires balancing the immediate demands of clinical practice with the long-term investment in specialized knowledge acquisition. The pressure to maintain patient care standards while dedicating sufficient time to rigorous study can lead to ethical dilemmas regarding resource allocation and personal well-being. Careful judgment is required to ensure that preparation is both effective and sustainable, without compromising patient safety or professional integrity. The best approach involves a structured, proactive, and evidence-based preparation strategy. This includes identifying high-yield topics through syllabus analysis, consulting recommended reading lists from reputable professional bodies such as the Pacific Rim Stroke Society, and utilizing a combination of established textbooks, peer-reviewed journals, and accredited online learning modules. A realistic timeline should be established, breaking down the material into manageable study blocks, incorporating regular review sessions, and scheduling practice questions to assess comprehension and identify areas needing further attention. This method aligns with ethical principles of professional competence and lifelong learning, ensuring that practitioners are adequately prepared to provide optimal patient care. An incorrect approach would be to rely solely on informal discussions with colleagues or to cram material in the weeks immediately preceding the examination. This fails to meet the ethical obligation to achieve a deep and comprehensive understanding of the subject matter. It also risks superficial knowledge acquisition, which can lead to errors in clinical judgment and patient management, thereby violating the principle of non-maleficence. Another incorrect approach is to delegate preparation entirely to junior staff or to assume that prior experience in general stroke care is sufficient without dedicated study of the specific advanced topics covered in the examination. This demonstrates a lack of personal responsibility for professional development and can lead to a deficit in specialized knowledge, potentially compromising the quality of care for complex stroke cases. A further incorrect approach is to prioritize personal leisure activities over dedicated study time, leading to an inadequate and rushed preparation. This neglects the professional duty to maintain and enhance one’s skills and knowledge base, which is essential for providing safe and effective advanced practice care. Professionals should adopt a decision-making framework that prioritizes a systematic and comprehensive approach to examination preparation. This involves self-assessment of knowledge gaps, strategic resource selection based on expert recommendations, and the development of a realistic study schedule that integrates learning with clinical responsibilities. Regular evaluation of progress and adaptation of the study plan are crucial to ensure mastery of the material and to uphold the highest standards of professional competence.

Scenario Analysis: This scenario presents a professional and ethical challenge involving a patient’s autonomy, the clinician’s duty of care, and the complexities of health systems science in resource-limited settings. The core conflict lies in balancing the patient’s expressed wishes with the clinician’s assessment of their best interests and the practical limitations of the healthcare system. The advanced practice clinician must navigate these competing demands while upholding professional standards and ethical principles. Correct Approach Analysis: The best professional approach involves a multi-faceted strategy that prioritizes patient autonomy while acknowledging systemic constraints. This includes engaging in a thorough and empathetic discussion with the patient to understand the underlying reasons for their refusal of the recommended medication, exploring their concerns, and providing comprehensive information about the risks and benefits of both treatment and non-treatment. Simultaneously, the clinician must advocate for the patient within the health system, seeking alternative solutions, exploring cost-effective options, or escalating the case for further review if necessary. This approach respects the patient’s right to make informed decisions about their care, even if those decisions differ from the clinician’s recommendation, and demonstrates a commitment to patient-centered care and health systems advocacy. This aligns with the ethical principles of autonomy and beneficence, and the professional responsibility to act in the patient’s best interest while respecting their rights. Incorrect Approaches Analysis: One incorrect approach involves overriding the patient’s decision based solely on the clinician’s judgment of what is medically best, without further exploration of the patient’s reasoning or systemic barriers. This fails to uphold the principle of patient autonomy and informed consent, potentially leading to a breakdown in the patient-clinician relationship and a feeling of coercion. It also neglects the health systems science aspect by not considering the practicalities of accessing and affording the medication. Another incorrect approach is to simply accept the patient’s refusal without attempting to understand the reasons or explore alternatives, and then documenting the refusal without further action. This could be interpreted as a failure to provide adequate care and a lack of due diligence, especially if the patient’s refusal is based on misinformation or a misunderstanding of the condition’s severity. It also fails to engage with the health systems science component by not seeking solutions to overcome barriers. A third incorrect approach is to pressure the patient into accepting the medication through guilt or fear-mongering tactics. This is ethically unacceptable, violates the principles of respect for persons and autonomy, and can cause significant psychological distress to the patient. It also undermines the trust essential for effective healthcare. Professional Reasoning: Professionals should employ a decision-making process that begins with a comprehensive assessment of the patient’s clinical condition and their understanding of it. This is followed by an open and honest dialogue to explore the patient’s values, preferences, and concerns, particularly regarding treatment options and their perceived barriers. The clinician should then clearly articulate the recommended treatment, its rationale, potential benefits, and risks, as well as the consequences of non-treatment. Crucially, the clinician must then explore the patient’s capacity to make decisions and their willingness to engage in shared decision-making. If the patient’s decision conflicts with the clinician’s recommendation, the clinician should investigate the underlying reasons for the conflict, which may involve exploring financial, social, or cultural factors, and then work collaboratively with the patient and the healthcare system to find mutually acceptable solutions or to ensure the patient’s decision is truly informed and voluntary.

This scenario presents a professional challenge due to the inherent tension between resource allocation, population health goals, and the ethical imperative to address health inequities. The monitoring system’s findings highlight a disparity in stroke prevention medication access, which directly impacts the health outcomes of a specific demographic within the Pacific Rim region. Careful judgment is required to balance the immediate needs of the identified underserved group with broader public health strategies and the principles of equitable healthcare delivery. The best approach involves a multi-faceted strategy that prioritizes immediate outreach and tailored support for the identified underserved population while simultaneously advocating for systemic changes to address the root causes of inequity. This includes actively engaging with community leaders and healthcare providers within the affected areas to understand specific barriers, developing culturally sensitive educational materials, and exploring flexible prescription and delivery models. This approach is correct because it directly addresses the observed health inequity by providing targeted interventions, aligning with the ethical principles of justice and beneficence in public health. It also demonstrates a commitment to understanding and mitigating social determinants of health, which is crucial for sustainable improvements in population health. Furthermore, it aligns with the principles of advanced practice in recognizing the broader societal factors influencing health outcomes. An incorrect approach would be to solely focus on increasing general public awareness campaigns about stroke prevention without specific targeting or resource allocation for the identified underserved group. This fails to acknowledge the specific barriers faced by this population, such as access to healthcare facilities, transportation, or culturally appropriate information, and therefore perpetuates the existing inequity. It is ethically deficient as it does not actively work to correct a known disparity. Another incorrect approach would be to recommend a blanket policy change that mandates a specific medication for all patients without considering individual needs, potential contraindications, or the accessibility of that medication for the underserved population. This approach, while seemingly equitable on the surface, could inadvertently create new barriers or fail to address the unique challenges faced by the identified group, potentially leading to non-adherence or adverse outcomes. It neglects the principle of individualized care and the need for context-specific solutions. A further incorrect approach would be to dismiss the monitoring system’s findings as statistical anomalies or to delay action pending further, more extensive research without any interim measures. This inaction is ethically unacceptable when a clear health disparity has been identified, particularly in a critical area like stroke prevention. It violates the principle of acting in the best interest of the population and fails to uphold the responsibility to address preventable harm. Professionals should employ a decision-making framework that begins with data interpretation and identification of disparities. This should be followed by an assessment of the underlying causes of these disparities, considering social, economic, and cultural factors. Subsequently, interventions should be designed to be both targeted and systemic, ensuring that immediate needs are met while simultaneously working towards long-term equitable solutions. Continuous evaluation and adaptation of strategies based on ongoing monitoring and community feedback are essential components of this process.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between a patient’s expressed wishes and the clinician’s clinical judgment, particularly when those wishes might lead to suboptimal or potentially harmful outcomes. The advanced practice clinician must navigate the ethical principles of patient autonomy and beneficence, while also adhering to professional standards of care and the specific regulatory framework governing their practice. The “Pacific Rim” context, while not dictating specific regulations in this prompt, implies a diverse patient population and potentially varying cultural understandings of healthcare decisions, adding another layer of complexity to communication and shared decision-making. The core challenge lies in obtaining a comprehensive and accurate history that informs a hypothesis about the underlying cause of the patient’s symptoms, while simultaneously performing a focused physical examination that efficiently gathers high-yield data, all within the bounds of ethical and professional conduct. Correct Approach Analysis: The best professional practice involves a hypothesis-driven history taking and high-yield physical examination that prioritizes patient-centered care and informed consent. This approach begins with open-ended questions to understand the patient’s chief complaint and their perception of the problem, allowing for the generation of initial differential diagnoses. The clinician then systematically probes for specific symptoms, relevant past medical history, social history, and family history, all guided by the evolving hypotheses. The physical examination is then tailored to confirm or refute these hypotheses, focusing on the most likely causes and critical findings. This method ensures that the patient’s narrative is central, their autonomy is respected by involving them in the decision-making process, and the clinical investigation is efficient and targeted. This aligns with ethical principles of respect for persons and beneficence, and professional guidelines that emphasize thoroughness and patient involvement. Incorrect Approaches Analysis: One incorrect approach involves solely focusing on the patient’s stated preference for a specific diagnostic test without adequately exploring the underlying symptoms or the rationale behind their request. This fails to uphold the principle of beneficence, as it may lead to unnecessary investigations or delay in identifying the true cause of the patient’s condition. It also undermines the clinician’s professional responsibility to provide evidence-based care and to educate the patient about appropriate diagnostic pathways. Another incorrect approach is to conduct a rote, exhaustive physical examination without a clear hypothesis guiding the process. This is inefficient, time-consuming, and may lead to the clinician missing critical findings because their attention is not focused. It also fails to respect the patient’s time and comfort, and can be perceived as impersonal, potentially eroding trust. A third incorrect approach is to dismiss the patient’s concerns outright if they do not immediately align with the clinician’s initial hypothesis, without further exploration. This disregards patient autonomy and can lead to a breakdown in the therapeutic relationship. It also risks overlooking crucial information that the patient may possess but has not yet articulated effectively. Professional Reasoning: Professionals should employ a structured yet flexible approach to history taking and physical examination. This involves developing a systematic method for generating and testing hypotheses, starting with broad inquiries and progressively narrowing the focus based on patient responses and initial findings. Crucially, this process must be collaborative, involving open communication with the patient, active listening, and shared decision-making. Professionals should be mindful of their own biases and assumptions, and be prepared to revise their hypotheses as new information emerges. The ethical imperative is to balance patient autonomy with the clinician’s duty to provide competent and beneficial care, ensuring that all diagnostic and treatment decisions are well-informed and patient-centered.