Scenario Analysis: This scenario is professionally challenging because it requires balancing the need for consistent competency assessment with the potential impact of assessment outcomes on a critical care professional’s career and patient care. The pressure to maintain high standards must be weighed against fairness and support for individuals undergoing assessment. Careful judgment is required to ensure the retake policy is applied equitably and effectively, promoting continuous improvement without undue punitive measures. Correct Approach Analysis: The best professional practice involves a structured and supportive approach to retakes, emphasizing learning and development. This includes clearly communicating the rationale behind the blueprint weighting and scoring, providing targeted feedback based on the assessment results, and offering resources or remediation opportunities before a retake. This approach aligns with the ethical principle of promoting professional competence and patient safety, as it aims to identify and address knowledge or skill gaps constructively. It also fosters a culture of continuous learning, which is vital in the dynamic field of critical surgical critical care. Incorrect Approaches Analysis: One incorrect approach involves immediate disqualification or a lengthy waiting period for a retake without offering any supportive measures. This fails to acknowledge that assessments are tools for identifying areas for improvement, not solely for punitive action. It can be ethically problematic as it may not provide a fair opportunity for the individual to demonstrate their retained or improved competency, potentially impacting patient care if a capable professional is sidelined unnecessarily. It also undermines the principle of professional development. Another incorrect approach is to arbitrarily change the scoring or weighting for a retake without a clear, documented rationale tied to the original blueprint. This lacks transparency and fairness. It deviates from the established assessment framework, making it difficult to objectively measure improvement and potentially leading to perceptions of bias. This undermines the integrity of the assessment process and the credibility of the competency framework. A further incorrect approach is to allow retakes without any review of the original assessment or identification of the specific areas of weakness. This treats the retake as a simple re-administration of the test rather than an opportunity to address identified deficiencies. It fails to leverage the assessment data to guide learning and improvement, making the retake process less effective in ensuring genuine competency enhancement. This approach neglects the diagnostic value of the initial assessment. Professional Reasoning: Professionals should utilize a decision-making framework that prioritizes transparency, fairness, and continuous improvement. This involves: 1) Understanding and clearly communicating the assessment blueprint, weighting, and scoring methodology. 2) Establishing a clear, documented, and consistently applied retake policy that includes provisions for feedback and remediation. 3) Ensuring that retake opportunities are designed to assess the same core competencies, with feedback focused on areas of weakness identified in the initial assessment. 4) Fostering an environment where assessments are viewed as developmental tools, encouraging learning and professional growth.

Scenario Analysis: This scenario presents a professional challenge centered on ensuring patient safety and maintaining the integrity of surgical critical care standards. The core difficulty lies in balancing the need for experienced practitioners to contribute to patient care with the absolute requirement that all individuals performing critical surgical critical care interventions possess the necessary, formally assessed competencies. Failure to adhere to this principle risks patient harm due to inadequate skill or knowledge, and undermines the credibility of the competency assessment framework. Careful judgment is required to distinguish between valuable experience and formally validated competence. Correct Approach Analysis: The best professional practice involves ensuring that any individual, regardless of their prior experience or perceived expertise, must undergo the formal Critical Surgical Critical Care Competency Assessment if they are to perform procedures or provide care within that domain. This approach prioritizes patient safety by establishing a clear, objective standard for competence. Regulatory frameworks and professional guidelines for surgical critical care universally mandate that individuals must demonstrate proficiency through approved assessment processes before undertaking critical responsibilities. This ensures that all practitioners meet a defined level of knowledge, skill, and judgment, thereby minimizing risks associated with unqualified practice. The purpose of the assessment is precisely to validate these capabilities, making it an indispensable step for eligibility. Incorrect Approaches Analysis: One incorrect approach is to permit individuals with extensive prior experience in surgical critical care, even if from a different institution or prior to the implementation of the current assessment, to practice without undergoing the formal competency assessment. This fails to acknowledge that standards and specific procedural requirements can evolve, and that institutional or regional variations in practice may exist. Ethically, it bypasses the established process designed to protect patients and professionally, it disregards the regulatory imperative for validated competence. Another incorrect approach is to rely solely on the recommendation of a senior colleague or department head as sufficient evidence of competence. While such recommendations can be valuable indicators, they are subjective and do not replace the objective, standardized evaluation required by the competency assessment. This approach risks personal bias influencing critical decisions about patient care and violates the principle of transparent and verifiable competence. A further incorrect approach is to assume that holding a general surgical qualification automatically confers competence in surgical critical care. Surgical critical care is a specialized field with distinct knowledge bases and skill sets that go beyond general surgical training. Without specific assessment, there is no guarantee that an individual possesses the advanced diagnostic, management, and procedural skills required for this high-acuity environment. This approach is a direct contravention of the purpose of specialized competency assessments. Professional Reasoning: Professionals should adopt a decision-making framework that begins with identifying the specific role and responsibilities involved. If these fall within the scope of surgical critical care, the next step is to determine the regulatory and institutional requirements for performing those duties. This invariably leads to the Critical Surgical Critical Care Competency Assessment. The framework should then prioritize patient safety and adherence to established standards above all else. Any deviation from the formal assessment process, even for individuals with perceived expertise, should be immediately recognized as a potential risk and a breach of professional and regulatory obligations. The decision-making process must be guided by a commitment to objective validation of competence.

Scenario Analysis: This scenario presents a significant professional challenge due to the inherent risks associated with surgical instrumentation and energy device use. The critical nature of the procedure, coupled with the potential for unforeseen complications arising from equipment malfunction or improper application, demands meticulous attention to detail and adherence to established safety protocols. The surgeon’s responsibility extends beyond technical skill to encompass a comprehensive understanding of the tools employed and their safe deployment, directly impacting patient outcomes and the integrity of the surgical field. Correct Approach Analysis: The best professional practice involves a systematic pre-operative verification of all surgical instruments and energy devices. This includes a thorough visual inspection for any damage, ensuring all components are present and functional, and confirming compatibility with the planned procedure. For energy devices, this extends to verifying the integrity of the insulation, the proper connection of accessories, and a brief functional test (e.g., audible tone, visual indicator) in a safe environment, such as a sterile saline bath, to confirm activation and output. This approach is correct because it proactively identifies potential hazards before they can affect the patient. It aligns with fundamental principles of patient safety, risk management, and the ethical obligation to provide care that minimizes harm. Regulatory bodies and professional organizations consistently emphasize the importance of equipment readiness and safety checks as a cornerstone of surgical practice. Incorrect Approaches Analysis: Relying solely on the scrub nurse’s prior experience without independent verification by the surgeon is professionally unacceptable. While experienced scrub nurses are invaluable, the ultimate responsibility for patient safety rests with the surgeon. This approach fails to acknowledge the surgeon’s direct accountability and introduces a potential point of failure if the scrub nurse overlooks a subtle defect or has a lapse in concentration. It deviates from the principle of shared responsibility and robust verification. Assuming all instruments and energy devices are functional simply because they were used successfully in previous surgeries is also professionally unsound. Surgical equipment can degrade over time, sustain damage during sterilization or handling, or develop latent defects. This assumption bypasses essential safety checks and introduces an unacceptable level of risk. It neglects the dynamic nature of equipment integrity and the need for ongoing vigilance. Performing a cursory visual check of instruments but neglecting specific functional testing of energy devices, particularly their insulation and activation, is inadequate. While visual inspection is a component of safety, it does not guarantee the safe delivery of energy. Damaged insulation on an energy device, for instance, can lead to unintended thermal injury to surrounding tissues, a critical failure that a simple visual check might miss. This approach fails to address the unique risks associated with energy modalities. Professional Reasoning: Professionals should adopt a systematic, multi-layered approach to ensuring surgical safety. This begins with a comprehensive understanding of the planned procedure and the specific instrumentation and energy devices required. A pre-operative checklist, encompassing both visual inspection and functional testing of all critical equipment, should be rigorously followed. This process should be a collaborative effort between the surgeon and the surgical team, with clear lines of accountability. In situations involving energy devices, specific attention must be paid to insulation integrity and activation confirmation. When in doubt about the functionality or safety of any piece of equipment, it should be replaced or tested further before use. This decision-making framework prioritizes patient well-being, adheres to regulatory mandates for safe practice, and upholds the ethical imperative to avoid harm.

Scenario Analysis: This scenario presents a common yet critical challenge in trauma care: the rapid deterioration of a patient’s condition during resuscitation. The professional challenge lies in balancing the immediate need for life-saving interventions with the requirement for accurate and timely diagnostic information, all while adhering to established protocols and ethical considerations. The pressure of a critical situation can lead to rushed decisions, potentially compromising patient safety and the quality of care. Careful judgment is required to prioritize actions and ensure that interventions are both effective and appropriate. Correct Approach Analysis: The best professional practice involves a systematic and evidence-based approach to resuscitation, prioritizing airway, breathing, and circulation (ABCDE) while concurrently initiating a focused history and physical examination to guide further management. This approach ensures that immediate life threats are addressed without delay, while also gathering essential information to tailor subsequent interventions. Adherence to established trauma resuscitation protocols, such as those outlined by the Advanced Trauma Life Support (ATLS) guidelines, is ethically mandated to provide the highest standard of care and is a cornerstone of professional competence in critical surgical care. This systematic method ensures that no critical step is missed and that interventions are guided by the patient’s evolving physiological status. Incorrect Approaches Analysis: Initiating extensive diagnostic imaging, such as a full-body CT scan, before securing a patent airway and establishing adequate circulation is a significant ethical and regulatory failure. This approach prioritizes diagnostic information over immediate life support, potentially leading to irreversible harm or death due to delayed resuscitation. It deviates from established trauma protocols that emphasize the ABCDE approach as the primary determinant of immediate action. Delaying definitive airway management to obtain a detailed patient history from family members, while important for context, is professionally unacceptable when the patient exhibits signs of airway compromise. The immediate need to ensure oxygenation and ventilation supersedes the collection of non-emergent historical data. This failure to prioritize life-saving interventions violates the ethical duty to act in the patient’s best interest and contravenes standard resuscitation protocols. Administering broad-spectrum antibiotics and intravenous fluids without a clear indication or assessment of the patient’s hemodynamic status, before addressing airway and breathing, represents a failure to follow a structured resuscitation pathway. While fluid resuscitation is a critical component of trauma management, its timing and type must be guided by the patient’s physiological state and the ABCDE assessment. This approach risks exacerbating potential complications or masking critical signs if not integrated into a comprehensive resuscitation plan. Professional Reasoning: Professionals should employ a structured decision-making framework that begins with a rapid primary survey (ABCDE) to identify and manage immediate life threats. Concurrent with this, a focused secondary survey and history should be initiated as the patient’s condition allows. This iterative process allows for the continuous reassessment of the patient’s status and the adjustment of interventions based on evolving clinical data. Adherence to established protocols provides a reliable roadmap, while critical thinking and clinical judgment are essential to adapt these protocols to individual patient needs in complex and dynamic situations.

Scenario Analysis: This scenario is professionally challenging because it involves a critical surgical complication requiring immediate, expert intervention. The surgeon must balance the urgency of the situation with the need for clear, documented communication and adherence to established protocols for managing adverse events. The potential for patient harm, the need for multidisciplinary team coordination, and the medico-legal implications all demand careful judgment. Correct Approach Analysis: The best professional practice involves immediate, direct communication with the attending surgeon regarding the identified complication, followed by a structured handover to the critical care team. This approach ensures that the most experienced clinician is immediately aware and can direct the management plan. Subsequently, a thorough documentation of the event, the intervention, and the patient’s response in the medical record is crucial for continuity of care, medico-legal protection, and quality improvement. This aligns with ethical principles of beneficence (acting in the patient’s best interest), non-maleficence (avoiding harm), and professional accountability. Regulatory frameworks often mandate clear communication pathways and accurate record-keeping for patient safety and adverse event reporting. Incorrect Approaches Analysis: Delaying communication with the attending surgeon to first consult with a junior colleague or to complete non-urgent administrative tasks would be a significant ethical and professional failure. Such delays could lead to delayed or suboptimal management of a life-threatening complication, directly violating the principle of beneficence. Failing to document the complication and the management plan thoroughly in the patient’s medical record is a regulatory and ethical breach. Accurate and timely documentation is essential for continuity of care, is often a legal requirement, and is vital for any subsequent review or audit of patient care. Attempting to manage the complication without involving the attending surgeon or the critical care team, or by delegating responsibility inappropriately, would also constitute a failure to adhere to established protocols and professional standards, potentially leading to patient harm and professional misconduct. Professional Reasoning: Professionals should employ a structured approach to managing critical surgical complications. This involves: 1. Immediate recognition and assessment of the complication. 2. Prompt and direct communication with the most senior responsible clinician. 3. Collaborative development and implementation of a management plan, involving the appropriate multidisciplinary team. 4. Meticulous and timely documentation of all events, decisions, and actions. 5. Post-event review for learning and quality improvement.

This scenario presents a professional challenge due to the inherent conflict between immediate patient needs and the established protocols for resource allocation in a critical care setting. The pressure to act swiftly for a critically ill patient must be balanced against the ethical imperative of fairness and the professional duty to adhere to established guidelines, ensuring equitable access to limited resources. Careful judgment is required to navigate these competing demands without compromising patient care or professional integrity. The best approach involves a structured, transparent, and collaborative decision-making process. This entails immediately escalating the situation to the multidisciplinary critical care team, including senior medical staff and the ethics committee if necessary, to review the patient’s case against established admission criteria. This approach is correct because it upholds the principles of clinical governance, patient safety, and ethical resource allocation. It ensures that decisions are made based on objective clinical need and established protocols, rather than on individual bias or external pressure. This aligns with professional codes of conduct that emphasize accountability, transparency, and the fair distribution of healthcare resources. An incorrect approach would be to bypass established protocols and admit the patient directly based on the family’s influence or perceived urgency without a formal review. This fails to uphold the principle of fairness and could undermine the trust in the critical care unit’s admission process. It also neglects the professional responsibility to adhere to institutional policies designed to ensure equitable access to scarce resources. Another incorrect approach would be to delay the decision-making process by solely focusing on administrative hurdles or documentation, thereby potentially compromising the patient’s critical condition. This demonstrates a failure in prioritizing patient well-being and a lack of proactive engagement with the clinical team responsible for resource allocation. A further incorrect approach would be to unilaterally decide against admission without a thorough, multidisciplinary review, even if the patient’s condition appears borderline. This could lead to a missed opportunity for life-saving intervention and fails to demonstrate due diligence in assessing the patient’s needs against available capacity and established criteria. Professionals should employ a decision-making framework that prioritizes patient safety and ethical considerations. This involves: 1) Rapid assessment of the patient’s clinical status. 2) Immediate consultation with the critical care team and adherence to established admission protocols. 3) Transparent communication with the patient’s family regarding the process and criteria. 4) Escalation to senior leadership or ethics committees when complex ethical dilemmas arise. This systematic approach ensures that decisions are clinically sound, ethically defensible, and professionally responsible.

The efficiency study reveals that a significant number of candidates preparing for the Critical Surgical Critical Care Competency Assessment are struggling to achieve optimal performance due to inadequate preparation strategies. This scenario is professionally challenging because the assessment directly impacts patient safety and the quality of critical care provided. Inadequate preparation can lead to a deficit in essential knowledge and skills, potentially resulting in suboptimal clinical decision-making and patient outcomes. Careful judgment is required to guide candidates towards effective and compliant preparation methods. The best approach involves a structured, evidence-based preparation plan that integrates comprehensive review of core surgical critical care principles, simulation-based practice, and engagement with current clinical guidelines and research. This method is correct because it aligns with the ethical imperative to ensure competence and patient safety, as well as the professional responsibility to maintain up-to-date knowledge and skills. Regulatory frameworks, such as those governing medical practice and professional development, implicitly or explicitly require practitioners to be adequately prepared and competent. This proactive and thorough preparation minimizes the risk of knowledge gaps and skill deficiencies, directly contributing to better patient care. An incorrect approach involves relying solely on passive learning methods, such as reading textbooks without practical application or simulation. This is professionally unacceptable because it fails to adequately develop the practical skills and critical thinking necessary for high-stakes surgical critical care scenarios. While reading is a component of learning, it does not replicate the dynamic and often stressful environment of the ICU, where rapid assessment and intervention are crucial. This approach risks creating a disconnect between theoretical knowledge and practical application, potentially leading to errors in judgment. Another incorrect approach is to focus preparation only on the perceived format of the assessment without a deep understanding of the underlying principles. This is professionally unacceptable as it promotes rote memorization and test-taking strategies over genuine competency. The assessment is designed to evaluate a candidate’s ability to apply knowledge and skills in complex situations, not merely to pass a specific test. Over-reliance on superficial preparation can lead to a candidate who can pass the assessment but lacks the robust understanding required for safe and effective patient care. A further incorrect approach is to delay intensive preparation until immediately before the assessment. This is professionally unacceptable because it does not allow for sufficient assimilation of complex information, skill development, or remediation of identified weaknesses. Effective preparation for a competency assessment in a specialized field like surgical critical care requires a sustained and progressive effort over a considerable period to build a strong foundation and refine practical abilities. Cramming can lead to superficial learning and increased anxiety, hindering true competency development. Professionals should adopt a decision-making framework that prioritizes a comprehensive, multi-modal, and sustained preparation strategy. This involves: 1) identifying core competencies and knowledge domains required for the assessment and for safe practice; 2) allocating sufficient time for structured learning, including active recall, problem-based learning, and simulation; 3) seeking feedback and engaging in self-assessment to identify areas needing improvement; and 4) staying abreast of current best practices and guidelines. This framework ensures that preparation is not just about passing an exam, but about developing and maintaining the highest standards of patient care.

Scenario Analysis: This scenario presents a professional challenge due to the inherent conflict between immediate patient needs and the established protocols for resource allocation in a critical surgical setting. The surgeon faces pressure to act decisively to save a life, but must also consider the broader implications for patient safety, fairness, and the efficient use of limited critical care resources. Careful judgment is required to balance these competing demands, ensuring that decisions are ethically sound and compliant with institutional policies. Correct Approach Analysis: The best professional practice involves a structured approach that prioritizes immediate life-saving interventions while simultaneously initiating the formal process for escalating resource requests. This approach involves the surgeon directly assessing the patient’s critical condition and initiating necessary life-saving measures within their immediate purview. Concurrently, they must immediately notify the critical care team and relevant hospital administration to formally request the transfer of the patient to the intensive care unit, providing all necessary clinical information to justify the urgent need. This dual action ensures that the patient receives immediate attention while adhering to established procedures for critical care bed allocation, thereby upholding principles of patient safety and equitable resource distribution. This aligns with the ethical imperative to provide care while also respecting the systemic requirements for managing scarce resources. Incorrect Approaches Analysis: One incorrect approach involves bypassing formal escalation procedures entirely and unilaterally admitting the patient to an already occupied critical care bed, based solely on the surgeon’s assessment of urgency. This fails to respect the established protocols for critical care bed management, potentially jeopardizing the care of patients already in the unit and undermining the fairness of the allocation system. It disregards the need for a coordinated response and the input of the critical care team, who are responsible for ongoing patient management in that environment. Another incorrect approach is to delay initiating life-saving measures until a formal critical care bed is confirmed and allocated. This is ethically unacceptable as it prioritizes administrative process over immediate patient well-being in a life-threatening situation. While adherence to protocols is important, it should not impede the provision of urgent, life-saving care when indicated. A further incorrect approach is to solely rely on the critical care team to assess the patient’s need for admission without the surgeon providing a clear, urgent clinical justification and initiating the request. While collaboration is key, the surgeon’s direct assessment and advocacy for the patient are crucial in conveying the immediate severity of the surgical patient’s condition and the necessity for critical care intervention. Professional Reasoning: Professionals in this situation should employ a decision-making framework that integrates immediate clinical assessment with adherence to established institutional policies. The framework involves: 1) Rapidly assessing the patient’s immediate life threat and initiating appropriate surgical interventions. 2) Simultaneously and clearly communicating the critical need for critical care admission to the appropriate channels (e.g., critical care physician, bed management). 3) Providing concise, accurate clinical data to support the urgency of the request. 4) Collaborating with the critical care team to ensure a smooth and safe transition of care. This process balances the imperative to save a life with the responsibility to maintain an organized and equitable system for critical care resource allocation.

The control framework reveals a scenario where a surgeon must make a critical decision regarding perioperative management based on evolving anatomical understanding. This situation is professionally challenging because it requires integrating real-time anatomical findings with established surgical principles and patient safety protocols, demanding a high degree of clinical judgment and adaptability. The potential for unexpected anatomical variations necessitates a proactive and informed approach to patient care. The best professional practice involves a comprehensive intraoperative assessment of the identified anatomical anomaly, followed by a collaborative discussion with the surgical team and a clear communication of the revised surgical plan to the patient or their representative, if feasible and appropriate, before proceeding. This approach is correct because it prioritizes patient safety by ensuring the surgical strategy directly addresses the discovered anatomical variation. It aligns with ethical principles of beneficence and non-maleficence, as well as professional guidelines emphasizing informed consent and shared decision-making where possible. Regulatory frameworks governing surgical practice mandate that care be tailored to individual patient anatomy and that deviations from the planned procedure be managed judiciously and with appropriate consultation. Proceeding with the original surgical plan without adequately assessing or addressing the identified anatomical anomaly represents a significant regulatory and ethical failure. It violates the principle of non-maleficence by potentially exposing the patient to unforeseen risks and complications due to a mismatch between the surgical intervention and their actual anatomy. This also constitutes a failure in professional duty of care and may contravene guidelines on intraoperative management of unexpected findings. Altering the surgical plan unilaterally without consulting relevant team members or considering the implications for patient recovery is also professionally unacceptable. This approach risks introducing new complications or compromising the effectiveness of the surgery due to a lack of multidisciplinary input and a failure to fully consider the physiological consequences of the anatomical variation. It undermines the collaborative nature of surgical care and can lead to suboptimal outcomes. A professional decision-making process in such situations should involve a systematic approach: first, recognize and acknowledge the unexpected finding; second, pause and thoroughly assess the anatomical variation and its potential impact on the planned procedure; third, consult with experienced colleagues or specialists if necessary; fourth, formulate a revised surgical plan that prioritizes patient safety and optimal outcomes; and fifth, communicate the revised plan and rationale to the patient or their representative, as appropriate, and document all decisions and actions meticulously.

Scenario Analysis: This scenario presents a common yet challenging situation in critical care where a preventable adverse event has occurred. The professional challenge lies in conducting a thorough and objective review that identifies systemic issues and human factors without resorting to blame, while simultaneously ensuring patient safety and fostering a culture of continuous improvement. Balancing the need for accountability with the imperative to learn from mistakes is paramount. Correct Approach Analysis: The best approach involves a structured, multidisciplinary morbidity and mortality (M&M) review that explicitly incorporates human factors analysis. This process begins with a comprehensive collection of all relevant patient data, team communications, and procedural details. The review team, comprising clinicians, nurses, and potentially administrators or quality improvement specialists, systematically analyzes the sequence of events leading to the adverse outcome. The focus is on identifying deviations from expected care, understanding the contributing factors (including system design, communication breakdowns, workload, fatigue, and cognitive biases), and determining the root causes. This approach aligns with the principles of quality assurance mandated by healthcare regulatory bodies, which emphasize proactive identification and mitigation of risks. Ethically, it upholds the duty to learn from errors to prevent future harm and promotes transparency and a just culture. Incorrect Approaches Analysis: One incorrect approach would be to focus solely on identifying individual clinician error without investigating the underlying systemic or human factors. This approach fails to address the root causes of the adverse event and can lead to a punitive environment, discouraging open reporting and learning. It violates the ethical principle of non-maleficence by not implementing measures to prevent recurrence and may contravene regulatory requirements for comprehensive root cause analysis. Another unacceptable approach is to dismiss the event as an unavoidable complication without a thorough investigation. This stance ignores the potential for learning and improvement, thereby failing to uphold the professional responsibility to enhance patient care. It represents a significant failure in quality assurance, as it allows potential systemic weaknesses or human factors to remain unaddressed, increasing the risk of future similar events. A third incorrect approach would be to conduct a superficial review that relies on anecdotal evidence or incomplete data. This lacks the rigor necessary for effective quality improvement. It fails to identify the true contributing factors and therefore cannot lead to meaningful interventions. This approach is ethically problematic as it does not fulfill the obligation to diligently investigate adverse events and may not meet the standards set by regulatory bodies for patient safety reviews. Professional Reasoning: Professionals should approach such situations by adopting a systematic, data-driven, and non-punitive framework. This involves: 1) immediate reporting of the adverse event; 2) initiating a formal M&M review process that includes a multidisciplinary team; 3) employing a structured methodology for root cause analysis that explicitly considers human factors; 4) focusing on system improvements and learning rather than individual blame; and 5) implementing and monitoring the effectiveness of any changes made. This process ensures adherence to regulatory mandates for quality assurance and upholds ethical obligations to patients and the profession.