Abstract
In a primary care health clinic, providers before, after, and throughout their shifts retrieve archival patient information and document new empirical data from each patient encounter into an electronic medical record (EMR). This documentation, called charting, contributes to ever increasing workload and provider burnout. While a provider may not perceive it to be, “charting” is writing work, and the clinic is a writing space. In this article, we use the concept of writing stewardship to examine a needs analysis of workflow in a family health center. We argue that the addition of writing stewards would shift the burden of documentation practices to distribute writing throughout the clinic, not primarily on providers. The implications of this are twofold: first, that writing studies researchers can help clinics write more efficiently and, second, that patient outcomes improve as a result of improved clinical communication.
Keywords
Introduction: Chronic Illness and the Primary Care Clinic
Half of the U.S. population as of 2012 suffers from one or more chronic health problems (Ward, Schiller, & Goodman, 2014). These conditions account for 70% of deaths in the United States (Centers for Disease Control and Prevention, 2015) and 86% of the costs of delivering health services (Gerteis et al., 2014). And, according to a team led by former Assistant Secretary of Health & Human Services Howard Koh, care for chronic illness presents, primarily, as a “literacy” problem (2013). Koh, Brach, Harris, and Parchman (2013) proposed a framework for chronic illness care and prevention called the health literate care model in 2012. This model centers complex acts of communication including patient-provider shared decision making, patient self-management, and evidence-based clinical practice as key drivers of improved outcomes for chronic illness at the population level in the United States and around the world. It also calls upon health care organizations to recognize and work to improve what Koh et al. (2013) call “literate practice,” recognizing the demands of delivering primary care, for instance, and the need to transform to a “health-literate organization.” The definition of “literate” in the health literate care model is focused, however, on strategies to improve the health literacy of patients, assuming a deficit in patients that providers need to address through improved patient-centered care and shared decision-making. For this reason, the term “literacy” in the context of health care institutions is fraught with value-laden considerations about patients that obfuscate the financial interests and power differentials of payers and health care systems in the outcomes and delivery of health care (Opel, 2018). Furthermore, it complicates an understanding of what “literacy” might mean for a health and medical professional acting separate and apart from patients.
Medical rhetorician Judy Z. Segal (2005) argues that the health policy debate in the United States is framed primarily as an economic one—a health care system in “crisis.” Patients with chronic conditions put additional strain on the system; therefore, improving their health literacy would alleviate that strain. That being said, health care in the United States today is a three-trillion-dollar, for-profit industry, and the “crisis” of the economic model—to which patients with chronic conditions increasingly contribute—does not exist in the same way elsewhere. As Elisabeth Rosenthal (2017), editor of Kaiser Health News, argues, “Every other developed country in the world delivers health care for a fraction of what it costs here. They use a wide range of tools and strategies that line up with each country’s values, political realities, and medical traditions” (p. 243). These tools and strategies can include various government-negotiated rates and payments for products, payments, and services, and transparency in pricing structures (Rosenthal, 2017, pp. 243-244).
This crisis in the American health care system is the backdrop for the study of health care delivery in a primary care clinic that we report on in this article (Opel, Abbott, & Hart-Davidson, 2018). Although both authors are writing studies researchers, we never imagined that writing would be the focus of this study. We were initially engaged, rather, by a clinical practice to conduct a needs assessment to improve the patient experience more broadly. Originally, issues such as design of clinical space, waiting room procedures, and others were brought to us by the clinicians seeking practice improvement. Both authors had experience as writing studies researchers working in health care settings prior to working together on this project (Olomu, Hart-Davidson, Luo, Kelly-Blake, & Holmes-Rovner, 2016; Opel, 2018). We draw on prior and concurrent experience working as embedded writing researchers to offer an expansive set of evidence to support our own framing of health services delivery for chronic care as a problem for our colleagues in rhetoric and writing students to engage. We see the role of writing studies research, particularly in light of the ambiguous discussion of provider literacy offered in the health literate care model, as crucial—primary rather than secondary—if we are to see population-level improvement in chronic illness in the near future. Writing studies researchers have a role to play in revealing writing process problems (broadly conceived) that complicate or undermine the delivery of care. We also have an opportunity to develop, test, and help to implement writing-based interventions in care delivery contexts that can lead to improved health outcomes for patients (Olomu et al., 2016) and better working conditions for providers.
These are bold claims, and we acknowledge these go beyond what Koh and his colleagues argued or anticipated in 2012. So why do we see writing as central to treating chronic illness?
A body seeking treatment for chronic illness never presents itself in real time. It must be assembled from a corpus of texts that precedes its arrival, a patient-provider dialogue about the historical body, and another set of texts to be interpreted that result from examining the body that arrives for a clinical encounter. These texts—lab reports of test results, office notes from prior visits, hospital charts documenting acute care episodes, pharmaceutical information, health coverage plan information, among others—are often individually quite sophisticated, requiring not merely advanced reading ability but also scientific and mathematical reasoning skills, and visual interpretive skills. When we consider that no single text is sufficient, that the body/corpus is assembled over time from many such texts and represented in others, a picture of primary care as demanding, distributed writing activity begins to come into focus. Our aim in this project is to detail that picture for our colleagues in rhetoric and writing studies in a way that opens dialogue about where our expertise might contribute to saving lives.
Writing in Clinical Settings
Early in the second chapter of Laboratory Life: The Construction of Scientific Facts, Latour and Woolgar (1979) use a composite character—“the anthropologist”—to convey a seemingly counterintuitive finding from their ethnographic study of the Jonas Salk Laboratory. Through the eyes of this observer, they describe the physical space of the lab with the aid of a floorplan diagram, noting that the space is divided into two areas: the “bench” and the “office.” The bench side has scientific equipment and looks like the anthropologist character expects a science lab to look. The office side looks like, well, an office, evidenced by stacks of paperwork, as one might expect. The counterintuitive discovery for the anthropologist comes when he attends for some time to the activity in each space. After careful observation, the anthropologist concludes that the action happens at the desk on the office side. And that action consists of drafting and revising scientific papers.
But what happens on the bench side? Latour and Woolgar (1979) write that “after several further excursions into the bench space,” the anthropologist is surprised to learn that “its inhabitants are compulsive and almost manic writers” (p. 42). Indeed, as they go on to elaborate, “Our anthropological observer is thus confronted with a strange tribe who spend the greatest part of their day coding, marking, altering, correcting, reading and writing” (p. 43). The science lab, then, is a writing space, every bit as much as the office.
If we sent an anthropologist to the family medicine clinic where our own observations occurred, she might well draw similar conclusions as Latour and Woolgar’s observer. The inhabitants of the primary care clinic write. Often they do so in what might appear to an outsider to be compulsive and obsessive ways. But unlike the Salk laboratory, there is not a clear division between the examination room and the office when it comes to the scenes of writing activity.
As writing studies researchers, we knew to expect to see writing activity when we entered the clinical space. The most important precedent study that informed our work was conducted by Schryer (1993) in a veterinary medicine clinic. There, she observed and interviewed students and instructors using problem-oriented veterinary medical records (POVMR) as a scaffold for working as clinicians. The structure provided by the POVMR genre acted to scaffold decision-making during a clinical encounter, but it also played a larger role according to Schryer, influencing other types of writing such as the composing of scientific articles, course materials and evaluations, among others. The POVMR genre represented routinized writing behaviors associated with clinical practice and rendered others less common, with both immediate practical and further-reaching ideological consequences. For example, the use of POVMR terms tended to make it more difficult for veterinary clinicians to talk to their clients because these were more aligned with epidemiological accounts. The result was that they used different, more distinctly scientific language than the people who brought their animals in for care.
Schryer’s analysis is important and compelling for us in the way it centers writing and the conscious adoption of a particular form of medical record keeping as central to clinical practice. This account maintains an implicit understanding of record keeping as secondary or perhaps parallel to providing care that we came to question during our own study in the primary care clinic. It is worth noting, however, that Schryer’s work as an ethnographer is undertaken for different purposes than our own. While her work, like many ethnographers, advances our theoretical understanding of a social construct (here, actions that give rise to genres), we entered the clinic not as ethnographers, but with a narrower goal of identifying possible interventions that could improve the patient experience in this (and other) primary care clinics. For Schryer, genres are the routinized behavior that give rise to writing activity, and the texts that result are the traces of that behavior, not necessarily the focus of it. For us, the texts offered clues for potential interventions to improve writing practices in the clinic.
We returned to Schryer’s work time and again, though, to help contextualize what we believed we were seeing in the clinic. In 1994, Schryer wrote about the contrasts and tensions she observed between clinical record keeping and research writing connected to the POVMR study. In that piece, Schryer’s account gave us another foothold on our own observations. She noted that scientists are aware that they are writing, while the writing of clinicians stays in the background. This happens, moreover, even when a single individual plays a dual role as scientist and veterinary care provider! A later study by Schryer and Spoel (2005) involving medical students helped us to name another dynamic we observed in the primary care clinic. In their account, the researchers describe how learning to do case presentations is deeply intertwined with clinicians’ emergent sense of professional identity (p. 262). Providers can be so enmeshed in the routinized behavior of a writing practice that it becomes something they cannot reflect on as a discourse practice. It is simply what they do and, over time, who they are professionally.
That writing can be so pervasive in one’s professional life and even central to one’s professional identity while also being nearly invisible is one of the true revelations of our small study. But as our results indicate, this lack of visibility has material consequences for clinicians. Most obvious, perhaps, is that because they do not name writing as a thing they do, they may not make a concerted attempt to improve their writing ability. They may not see that better writing may help them to help their patients. Studies such as those by Campbell (2017), however, are encouraging in that they show when writing becomes focal. Campbell, studying nursing students working in a simulated EMR system, reported that students drew upon genre knowledge gained in clinical experiences such as internships to design novel forms of reporting in the EMR simulation. For these students, written genres were tools and writing itself was a modality for improving the patient experience.
To summarize, we knew that we were looking to study the clinical space as writing space and to think about how writing might be improved to improve patient experiences in the clinic. We knew from prior research that writing genres in clinical spaces were influenced by the roles that are performed there and the ways that writing may or may not be a part of a clinician’s understood professional identity. From this context, we formulated the following research questions:
Research Question 1: What professional roles exist in the Family Health Center?
Research Question 2: Where and when specifically are discoordinations, contradictions, and breakdowns of communication occurring?
Research Question 3: What strategies can we recommend to intervene and improve clinical practice in the Family Health Center?
In the following sections, we lay out our method, with special attention to how activity theory (AT) and other AT-grounded studies guided this workplace study. We then offer analysis and results, outlining key themes. We offer a suggestion for intervention, the writing stewardship model, and conclude with four main implications for writing studies researchers interested in working with health care professionals.
Method
In the summer of 2016, we were invited to join an initiative at Michigan State University’s Family Health Center called the Clinic Transformation Project. The Clinic Transformation Project came about because health care providers were feeling frustrated with the level of care provided in the clinic, which they attributed to many disparate factors, from physical space to front desk procedures to billing and documentation practices. As a result, they were unsure how to proceed with changes to clinical practice, and so, an initiative was formed between health care administrators, providers, and other health care professionals. To participate, we employed Spinuzzi’s (2013) Topsight as a set of methods for structuring our inquiry in this project. As Spinuzzi describes, a needs analysis is a qualitative workplace study that culminates in a set of recommendations to the client to inform an intervention that might be tested for practice improvement (p. 261). This set of methods presented clear boundaries for our project, as we wanted to ethically and pragmatically bound what we could recommend based on our observation and analysis.
There are many ways to evaluate workflow processes in organizations. The Topsight framework has methodological roots in AT as interpreted by writing studies scholars, and as such affords an analytic focus on writing as social behavior understood to evolve, over time, to suit context-specific motives and goals (see, e.g., Bazerman, 1994; Russell, 1995; Winsor, 1996; Witte, 1992). Spinuzzi (2015) offers a detailed examination of these affordances, arguing that because AT-grounded studies frequently focus on outlier activities rather than more stable routines, researchers can miss the chance to examine internal contradictions that occur within those routines. This argument relies on a typology of activity inherited from Leont’ev’s (1978) hierarchy of activity, action, and operation as they correspond to human actors’ motives, goals, and habits, respectively.
Activities are motivated human behaviors that operate at the level of a social group. The motivated aims of an activity are shared among participant actors and, importantly, this motivation is not determined by any one person. In a primary care clinic, patient care is an example of an activity. The clinic and all the people who work there are motivated to take care of patients that come into the clinic. Moreover, this is not up for debate. The social structure of the clinic means that people who work there subscribe, consciously or not, to the motive of patient care. Most of their actions and operational moves work toward this end. Where they do not, it could be because they are part of a different activity. For instance, we might see a person writing on a clipboard in the clinic and assume she is a health care provider engaged in patient care. But upon talking to the person, we might learn she is a contractor inspecting the electrical wiring in the building. The same action—writing on a clipboard—could be part of two distinct activities.
From an observational perspective, activities look different from one another because of the differences in motive, not necessarily because of differences in the sequences of actions that comprise them (Bracewell & Witte, 2003). And as Spinuzzi (2015) notes, workplace writing researchers like ourselves are often drawn to the distinctions at this level of typology because writing in a primary care clinic is part of an activity that can be quite distinct from writing that is part of a different activity, say writing in an engineering division of a large farm-implement manufacturer. Documenting these differences is interesting and valuable as a way to understand the myriad ways writing operates in the world.
But where writing tends to live within these activity contexts is interesting too. It lives, as the example illustrates, at the action level. At this level, human actors undertake their work with purpose, with a goal, but are not necessarily motivated to perform a specific action in order to achieve the motivated aim of the activity. So they might write. Or they might place a phone call. And they might do one of those things one time, and then the very next time choose to do the other. They will consciously choose one, but if we were to interrupt a person in the middle of one or the other of these actions to ask what they were doing, we wouldn’t hear a rationale based on the action. They would likely answer with a reference to the motivated activity they were engaged in. For example, we might hear something like “I’m making sure the patient’s most recent chart data from the hospital is included in our EMR.” The motivated activity here is patient care. One or more actions involving written communication might be part of this activity. And where this string of actions is part of a stable routine—e.g., prepping charts for patient encounters—an observer might see it happen many times during a typical day but also observe slight variations each time. Maybe one care provider uses an iPad one time and a sticky note another time, maybe another provider sends text messages to her medical assistant rather than jotting things down on sticky notes.
Spinuzzi suggests that tuning in to the differences at the action level in otherwise stable activity routines are interesting and important sites for intervention. There are two important reasons for this. One is that some of the actions may introduce inconsistencies with the immediate goal and the broader motive. Spinuzzi calls these inconsistencies “contradictions” in the Topsight framework because the action, especially if repeated over time, can be a disruption to a group’s effort to achieve its motivated aim. For example, one clinician may need a verbal or written authorization from another to execute a patient care task. One way to signal this need is to write a message down on a sticky note. This solves an immediate need to remember a bit of detail. But sticky notes are ephemeral and can quickly lose their meaning when they are moved from one place to another. Sending a text message might work better but could introduce risks to patient confidentiality. None of the actors want to put patients at further risk—either by their important data getting lost or by confidentiality being breached—because it goes against their motivation to take care of patients.
Contradictions are therefore valuable because they mark possible interventions that can improve the overall outcomes that participants work toward while also stabilizing their existing routines. A new writing practice that responds to participants’ needs while aligning with the overarching motive is likely to be adopted if these alignments can be made obvious to participants. This is why we structured our observation time in the primary care clinic to focus on stable routines at the action level of the AT hierarchy. We wanted to document what Spinuzzi (2015) calls “the steady pulse” of activity in the clinic (p. 17), with an eye toward the internal variations and especially those that introduced contradictions, in the action sequences that made up the steady pulse of patient care.
We also chose relational coordination as a complementary framework to look at how employees communicate and relate for the purpose of task integration. This framework focuses on helping researchers identify specific communication and relationship ties needed to drive coordination and performance in an organization (Relational Coordination Research Collaborative [RCRS], 2017). With this framework, researchers learn what communication takes place across what roles in an organization, and what relationships with what roles are valued most. Rather than trying to distinguish specific individuals’ performances, researchers who study through the lens of relational coordination look at organizations by role, deidentifying the individual and aggregating communication tasks. This framework has been used in industries as far ranging as automotive, higher education, banking, and now health care (RCRS, 2017).
We used a combination of Topsight methods and relational coordination specifically to study the clinic’s practices by role with specific emphasis on locating discoordinations, contradictions, and breakdowns in day-to-day, mission-critical work routines. Discoordinations are not usually big problems when they occur—more often just small problems in routine practice. But patterns of them shift the focus of work to solving these rather than working on what workers understand to be their “real work.” Contradictions are moments when an issue seems at odds with the mission or goals of the clinic. These can be felt as personal disruptions (e.g., “this isn’t what I’m supposed to be spending my time doing”) or as shared ones (e.g., “we are not getting the job done”). Breakdowns are moments when patient expectations are not met. These may result from patterns of discoordination or moments of contradiction (see Table 1).
Topsight Rubric for Observation.
In our initial meetings with the Clinic Transformation group, we had been told about several breakdowns that patients were seeing and experiencing negatively in the Family Health Center (e.g., long wait times). Our goal was to observe the Family Health Center’s workflow to find patterns of upset or difficulty that contributed to these visible breakdowns and identify a means to intervene for improved patient experience.
Field Site: The Family Health Center
The Family Health Center is a clinical practice on Michigan State University’s campus that provides primary care services for adults and children in the mid-Michigan area. It is also a federally qualified health center, which means that it provides medically necessary services regardless of ability to pay. The 14 providers in the clinic (medical doctors [MDs], (doctors of osteopathic medicine) [DOs], and (physician assistants) [PAs]) all hold faculty positions at Michigan State, so they work approximately one to two days per week in the clinic. While on rotation in the clinic, they not only see patients, but also supervise medical students who also rotate through the clinic. Meanwhile, nurses and medical assistants work full-time to staff the clinic on a day-to-day basis.
It is also important to note that while we were on-site at the Family Health Center, the entire clinical center at Michigan State was undergoing a transition to a new electronic medical record (EMR) system, AthenaHealth. While it was not the intent to conduct research about this transition, this was a major part of the day-to-day operations of the clinic during this time, and significantly affected the trajectory of the project. We see the stories that circulated about the EMR transition, from the varying perspectives of administration, clinician, and staff, as critical to an understanding of organizational communication in the clinic. For that reason, we employ Brenton Faber’s (2002) critical, “empirical yet activist” framework for reading organizational communication and change through story. We offer context for the “meso-level” results reported here by taking an institutional critique approach to the “macro-level” conditions that can help to explain why the workflows and challenges we saw exist. To do this, we report on our interactions with the clinic staff sharing data in two group meetings. These conversations—the stories of change that were told to us—taught us more about the power dynamics and role-based conflicts that animate the clinic as a research site and reflect our commitment to reciprocity in meaning making for engaged research.
Participants: Clinicians and Staff in the Family Health Clinic
The participants in the study were all clinical professionals in the Family Health Center at Michigan State University. After agreeing to participate and signing a consent form pursuant to our IRB-approved protocol, the authors conducted observations of two health care providers (an MD and a PA), five medical assistants (MAs), two nurses, and one front desk receptionist.
Data Collection and Analysis
Our data collection process focused on observation-based methods inside of the clinic. We spent over 20 hours in the clinic, shadowing the roles of providers, MAs, nurses, and the front desk receptionist one-on-one as they went about their routine workflow processes. In total, we conducted seven observations of duration between two and five hours each, and shadowed two providers, five MAs, two nurses, and one front desk receptionist. Each professional shadowed signed a participant informed consent form pursuant to our IRB-approved protocol. The duration of each observation was determined by length of shifts for each role and also the ebb and flow of practice that day (for instance, if there was a lull or repetitive procedures that we had observed several times on one shift, we would choose to return another day).
For this project, we did not observe inside of the treatment room or record any patient data. Each observation included contextual inquiry, a method developed by Beyer and Holtzblatt (1998) to study workplace activities—actual use of workplace technologies—alongside the user in the context of the work being performed. This method allowed us to ask questions from time to time of the clinician to guide our observation of their work on a specific task. For observation itself, we created a form that allowed us to record all routine communicative practices chronologically by phase (pre–delivery of care, during care, post–delivery of care) throughout our time visiting for that day.
Our observation form (see the appendix) allowed us to focus on the Topsight mesoscopic categories, and as a consequence highlight routine, goal-oriented activities. A useful shorthand for this observational approach is “role, goal, actions, outcomes.” Our observation form allowed us to track a specific role’s work as it unfolds for a given activity. Routine activity such as a patient encounters in the clinic involve multiple roles, but each observer can typically follow only one at a time. As we observed and took notes over multiple days, we assembled role sheets that allowed us to understand the sequential and simultaneous actions across roles. As an activity developed over time, our notes gave us details about mediating communication genres and technologies and, importantly, where complications or problems arose. Because we have the activity accounts stratified by role this way, we could distinguish one-off glitches from problems that recur, notice how issues might affect actions performed by others “downstream,” and compare how one encounter team may have evolved tactics to deal with a challenge that could be useful for others to adopt. As our accounts accumulated, we synthesized across “levels of scope” (or the multiple focuses of human activity that can be observed by a field researcher) that Spinuzzi (2002) recommends. (p. 3). We aligned multiple accounts of the same routine activity at different levels of scope to note where problems may reflect three kinds of addressable concerns: contradictions (macro), discoordinations (meso), and breakdowns (micro).
We also collected consent forms and photographs of artifacts relevant to our observation. These included photographs of physical documentation and communication (e.g., a patient room door flag, blank screening forms, the vertical file housing documentation for patient encounters, the documents at each MA station, shift schedules, a whiteboard with general notes for patients, and a handout for patients about the new EMR system).
Finally, we conducted post-observational focus group meetings and feedback sessions, in which we met with MAs, nurses, and providers (MAs and nurses in one session, providers in another) to discuss what we had observed and what artifacts we had collected. They also confirmed or added additional insights into events we had observed in our time in the clinic. We geared these sessions toward two questions: (a) Does the picture we are assembling make sense to you? and (b) Is it something you can use to take action?
After all data were collected, we entered observational forms, field notes, and images of artifacts into a Google Drive folder, with a separate file for each observation. We also uploaded and added detail to notes and paraphrased discussions from focus group meetings and feedback sessions. From here, each author made consistent interpretative passes for each to create a fuller picture of what patient encounters and communicative genres looked like. Our goal was to locate challenges that might be targets for successful interventions, or improvements to work routines in the clinic.
We triangulated the data by looking across data types at the same incident, using observations, artifacts, and focus group data. We also triangulated across participants (was the same communicative event perceived across role?) and across visits (on different days and weeks, could the communicative event be observed?). Last, we shared our interpretative passes with participants and with the Clinic Transformation Project team intermittently, to facilitate a process of participatory data analysis.
Analysis and Results
The people who work in primary care clinics must write, together. But the clinicians we worked with did not understand themselves to be writers, and they did not organize their work together as a team of writing professionals in other kinds of workplaces might do. When we presented our initial results to our participants in a meeting to discuss implications and action steps they could take to improve patient care, the providers were eager to implement a team-based approach. Our primary contact in the clinic, Dr. Cathy Abbott, coauthored an article with us about this intervention—a shift to Agile-style team-based project management with a focus on improved communication (Opel et al., 2018). We worked with Dr. Abbott to detail the kinds of writing processes associated with each role in the clinic.
Providers—that is, physicians and nurse practitioners—assume the primary responsibility for most of the research-oriented writing in the clinic as depicted in Figure 1. Providers spent the most time in the clinic gathering data and evidence, examining patients and searching for records, before, during, and after the patient encounter. For example, in two different observations of providers, providers left the examination room eight times, leaving patients to go to their computer terminals and look up records or literature. We observed five MAs working in the clinic, but only recorded four instances where they did similar work to the providers. Providers spent more time entering data that the other roles that we observed as well. We had expected MAs, nurses, and front desk personnel to do more of this work than we observed. Writing was frequent within the time frame of a specific encounter for providers as well. We observed the two providers composing the “office note” and/or writing in the EMR 11 times during our observations. For the five MAs we observed, we only saw them writing in these spaces four times. Providers routinely fell behind with their writing tasks as well. They had more writing to do than an encounter would allow time for in nearly each visit. They would complete their documentation after their service shift, and as a result we were not able to observe all the post-encounter “charting.”
Model of clinic as writing space.
In contrast with providers, the MAs we observed spent more time interacting orally or seeking written communications (including signatures) from providers (Table 2). We recorded over 20 instances of MAs writing Post-it notes to providers and placing them at their workstation to facilitate charting work, asking clarifying questions to providers, and seeking signatures for forms or correspondence. MAs also spent time doing routine task work associated with providing care such as preparing rooms for patient encounters, preparing equipment, rooming patients, exiting with patients, etc. We also noted some instances where there were discoordinations or breakdowns involving MAs. The most common were moderate discoordinations such as when MAs were unable to continue with an assigned task because they were waiting for instruction or clarification from providers (e.g., documents that could not be signed or approved sitting in piles at workstations).
Roles, Prevalent Activities, and Evidence in the Clinic.
One of the most interesting communicative roles in the clinic was that played by nurses. Nurses took primary responsibility for asynchronous care, handling incoming calls via the phone triage system or calling patients for follow-up care. Though nurses are situated inside of the clinic and are integrated into the routine work of patient encounters, the nurse phone triage role operates outside of the boundaries of in-person patient encounters (appointments). The nurse’s schedule is largely based on when in-bound calls from patients are returned. For a nurse, an “encounter” is the patient phone call. These might last, based on our observations, anywhere from 5 seconds to 20 minutes. During our observation session with a nurse in phone triage, we noted that she performed a wide range of actions before, during, and after these calls, and did so at a consistent rate. In one session, we saw three instances of data collection, five of data entry, six of oral communication (outbound phone calls to specialists or other professionals), and three of written communication to others (prescription forms, etc.). These numbered instances helped us to understand the variety and frequency of communicative acts that the nurse role performs in phone triage.
Providers, MAs, and nurses all contribute to the writing work of the clinic. But the roles they play and both the formal and informal habits associated with those roles meant their writing work was frequently uncoordinated and, in some cases, fragmented and incoherent. In our first round of analysis, with the clinical staff as our primary audience, we sought to bring conceptual coherence to their work by searching for alignments in goals. We then turned to the contradictions, discoordinations, and breakdowns we saw in order to identify potential areas for improvement.
We next present the areas for improvement that emerged from our analysis with an eye toward the ways writing studies concepts make these issues visible and tractable problems. We highlight two major thematic sections of importance to written communication in the clinic. First, we discuss charting (or documentation processes in the EMR) as a form of writing and describe the work we saw in our observations as evidence to support this claim. Second, we describe and interpret the challenges for clinicians as writers, with particular focus on the contradictions, discoordinations, and breakdowns that occur as a result of these challenges, and some more institutional context for why these may occur.
Charting Is Writing
When providers in the primary care clinic were writing, they did not call the activity “writing.” They called the more formal writing they did in the EMR system “charting.” Other, less formal forms of writing occurred routinely as well. Clinical staff in all roles took a lot of handwritten notes and made annotations on other documents such as printed test results. They also used a whiteboard to indicate which providers and MAs would be using which exam rooms for a given day. These usually did not register as writing either.
But charting is writing. And while it is strongly guided by the EMR and the predefined fields that clinicians were required to use to document a patient encounter, charting is really part of a complex but rather familiar routine of research-oriented writing. The routine is one we, ourselves, used to write this article. It involves moves like gathering observational evidence, gathering archival material, and producing a written account that synthesizes and interprets these two forms of evidence.
To draw the analogy to Latour and Woolgar’s (1979) observations in laboratory life, clinic life is focused on writing. Most of what goes on in the clinic is done to produce writing within the broader activity of facilitating patient care. For patients receiving care for chronic conditions, the writing enables a series of other actions that could lead to better health. But these actions—interventions and tests to understand if the interventions are working—do not happen during an encounter. We argue in this section that patient care in the primary clinic is mostly about writing a report that provides the basis for a number of actors—providers in that same clinic, other providers such as specialists, pharmacists, home health aides, family members, and the patient herself—to help the chronic-care patient.
Figure 1 reflects our understanding of how encounter teams routinely gathered evidence and produced accounts of the chronic-care patient body. We will use an example of one provider, Dr. B, that we observed in this study. Though we do not present it here in the form of the AT extended triangle, we see that a “patient encounter” nonetheless exhibits the characteristics of routine, even cyclical activity well suited to the AT-inflected analysis methods described by Spinuzzi in Topsight. But our account of Dr. B seeing patients in the clinic comes with what may be an unexpected twist when it comes to the object, in AT terms, of her goal-oriented action.
Dr. B’s work involves assembling evidence and writing a detailed report of each patient she sees on a given day. The black arrows show that there are two very different sources of evidence that both contribute to the office notes during a patient encounter. Most, but not all, of the evidence Dr. B will need for the report is assembled prior to and during the patient visit. Occasionally Dr. B will need to assemble additional evidence after the visit as well, usually from records that were not available or not yet authorized for viewing in the clinic EMR system at the time of the visit. Prior to the patient’s scheduled visit, the report she will produce does not exist anywhere in coherent form. There are prior records that may include previous reports, but each new version of this genre that Dr. B calls “office notes” is a new report that the care provider creates.
The aim of the report is to make a persuasive case for diagnosis and treatment. Who is Dr. B trying to persuade? Representatives of the agencies and groups who will provide payment for medical services. Much of the work of assembling evidence happens concurrent with another important activity—providing care during the patient encounter. Ideally, at least some if not all of the work of writing the report happens during the visit as well, but this is actually fairly uncommon for Dr. B. The demands of the two activities—creating a report and being present in the encounter and engaged with the patient to whom she is providing care—clash for Dr. B. When they do, providing care takes precedent for her in the moment. The work of writing is postponed until after the visit. But it must be done. Often Dr. B stays late or begins the next day early to complete her reporting work.
We began to see this reporting work as primary rather than secondary when we observed a contradiction—a moment when Dr. B’s goals and the clinic’s writing-related requirements of her seemed to clash. We observed Dr. B asking an MA to search for and print out something to give to a patient she had just finished examining. After the encounter, we asked Dr. B what the printed material was and why she asked for it. It turned out to be a self-care guide, something she had given to patients in the past but could not locate quickly in the exam room because it had been moved in a recent update of the clinic’s website. But we were especially interested in the reason why she wanted to provide the guide. It was not because the patient was doing anything wrong. In fact, the encounter confirmed that she was doing well after a recent surgery. So well, Dr. B had no other advice and no prescriptions for this patient. But she noted, “I hate to send them away with nothing.”
From our point of view, the encounter was routine. It allowed Dr. B and the clinic to update the patient’s status. They had data for their report—a chart from the hospital where the surgery was performed contained test results and vital signs as well as an account of the procedure, and on the empirical side, an MA had taken vital signs and Dr. B’s examination produced observational data. All was well. But neither Dr. B nor the patient understood the primary goal of the encounter to be these acts of writing. Dr. B created a transaction as a result—a largely symbolic gesture to give the patient some self-care information—to supplement the writing work of the clinic.
Seeing that encounter helped us to realize that in the case of chronic care, all of the writing processes of the clinic happen as the primary reason for the visit. The patient encounter has a clear goal: to write about the body that requires care for a chronic condition. This is the work of charting.
Challenges for Clinicians as Writers
What prevents clinical professionals from perceiving themselves to be—and actually being—writers? The discoordinations with writing-related tasks discussed above reveal how workflow is not set up in the clinic for writing. Yet our needs analysis identified two central challenges to clinicians as writers, both related to professional identity and development. Clinicians do not see the work they do to be writing work, but rather, as the delivery of care through the face-to-face patient encounter. “Charting” is the drudgery associated with payment for services. This creates a contradiction between clinicians’ perceived professional identity and the task at hand—writing. Furthermore, clinicians are not trained to be writers in the same way that they are training to provide direct patient care, and this training deeply informs their identity. Both issues create moments for clinicians where they experience dissonance about what they feel they should be doing (direct patient care) and what needs to be done (charting/writing). In this section, we’ll discuss each challenge in turn, with an eye toward exploring how writing studies might address these challenges through an intervention grounded in writing studies theory and practice—the introduction of writing stewardship.
Professional identity
In our observations and feedback sessions with the three major roles in the clinic, providers, nurses, and MAs, all both explicitly described and performed their roles with an emphasis on the face-to-face patient encounter. In our study, we observed providers, nurses, and MAs alike, in a sustained pattern, prioritize interpersonal interaction with the patient as each was afforded an opportunity to provide direct, face-to-face care.
Similar to the medical students observed by Schryer and Spoel (2005), whose identities became tied to the genre of the case presentation, the work of charting in the Family Health Center was primarily viewed as the responsibility of the provider. However, even though it was seen as a provider responsibility, our providers viewed this work as administrative rather than clinical—primarily for billing, as the patient cannot be billed until the provider enters a billing code into the EMR (this act was viewed as the conclusion of “charting” in this study’s clinic). This is consistent with recent health services research, such as a recent study by Young, Burge, Kumar, Wilson, and Ortiz (2018) that indicated that primary care physicians during 982 patient encounters spent more time working with the EMR than they do with patients face-to-face. In our study, the provider indicated to us that the time charting was keeping them from their work of providing care to the patient at hand. MAs only entered certain data points (for example, vital signs) into the EMR, and even this was inconsistent. Repeatedly, MAs took notes on paper or on sticky notes, and these were handed to the provider before or after the patient encounter. The ultimate responsibility for ensuring that the record was fully entered with billing codes for patient processing fell on the provider. Providers noted that some MAs took more initiative for charting, but tended to see this as the result of more experience or skill. MAs, on the other hand, tended to await instruction, seeing their work as what is directly asked of them by providers or what was immediately necessary to ensure a smooth patient encounter (prepping exam rooms, for example). Responsibility for the chart ultimately fell to the provider.
Provider schedules reinforce this professional identity in the clinic. Each provider is given a schedule for a shift that is segmented in increments by patient and length of patient visit, which is dictated by billing code for the type of visit (new patient visit, established patient visit, annual exam, etc.). The presumption on the part of both the provider and the health care administration is that that length of time is face-to-face with the patient (and the provider can chart or not simultaneously). The charting work is left for after the shift, or before the next assigned shift, or at lunch. In our study, several MAs and nurses commented about the backlog of charting and the providers complained about their overwork as a result. In this way, the administrative structures and processes challenge the work of writing in the clinic, and thus, the ability of clinicians to assemble a report that more accurately and effectively aids in the treatment of patients, particularly chronic-care patients whose symptoms do not present themselves at every encounter.
Nurses in our study perform a phone triage role, and they are tasked with recording those calls into the EMR and updating the charts as necessary to reflect any updated patient data. However, one nurse stated during an observation that she much preferred direct patient care. Nurses in the clinic performed one such task—drawing blood to check medication dosing for patients with chronic illnesses. We observed this nurse drop everything in phone triage to run to perform this task when this patient arrived (these patients are set on a nurse schedule rather than on the main provider/MA schedule). Yet again, because the nurse’s identity appears to be deeply connected to seeing patients face-to-face, the phone triage and charting role is relegated to a later time when confronted with a direct patient encounter. This also contributes to the backlog of writing in the clinic.
Training
A lack of training in writing—both in their formative and continuing training—contributes to a disconnect between the professional identity of clinicians and the work of writing. Medical students are often taught a particular writing genre, the SOAP note (Subjective, Objective, Assessment, and Plan), to document a patient encounter (see e.g., Heifferon, 2005). However, this genre of writing reflects the primacy of the provider-patient relationship and encounter, and usually involves taking notes with paper and pen (although we observed providers taking these on word processing software on iPads in the encounter in our clinic, as well). As a result, this experience with writing is mainly seen in the aid of the patient encounter, and removed from both the EMR and the other clinical staff. It keeps intact the professional identity of the provider as that of providing care in the patient encounter.
Still, providers have had some exposure to a writing genre in their formal education. For nurses and MAs, this is not often the case. And certainly, it is not the case that many MAs and nurses working now received formal training in the kind of writing practices necessary for assembly of a record in an EMR. In our needs analysis, we saw hesitation to outright fear regarding the EMR. We also observed many instances of perceived technological inadequacy on the part of all roles in the clinic. One MA told us that she was afraid that that the new EMR in the clinic might have been designed to eliminate positions in the clinic such as hers. Her fears were in response to the design of the particular EMR system the clinic was testing, which was not customized to that clinic environment and running on templates in which individual roles in the clinic were siloed to inboxes with tasks related to a generic version of their role. This MA saw this as eliminating the work that she performed that was not reflected in this template. MAs, nurses, and front desk staff wanted to comply with new EMR processes, but were suspicious and afraid that their skills were inadequate to succeed in this new writing environment.
The training offered for clinical staff for the new EMR rollout in the clinic was not sufficiently adequate to support clinical professionals’ confidence in their use of the EMR. The training handbook that was provided to the clinic was systems-centered, immense, and technical in its language, such that clinicians found it all but unusable. The training sessions offered by the vendor were short and task-driven, removed from the complexities of the context of use. Again, all roles reported to us that these were not helpful in learning how to use the EMR.
The training materials and sessions reinforced some lore offered by the MAs in feedback sessions. One MA expressed concern that the new EMR system was purchased in order to automate processes that MAs perform; in essence, to replace them. “Will we lose our jobs?” she asked of us, hoping that we might have insider information. This sentiment reflects greater cultural belief that the U.S. health care system (“in crisis”) is growing increasingly technological to cut costs. The tediousness of the manual and the training sessions only reinforced to the MAs that they were not supposed to learn to use the system because they might not be there at all.
The result of these difficulties with continuing technology/EMR training is that, in this clinic, it further removed the clinician’s identity from the work that is done in the EMR. Instead, the perception was that this work is put upon them by health care administrators (for the purposes of saving money or reducing labor costs), effectively pitting the writing work that may be mediated by the EMR against the care work that clinicians believe themselves to be responsible for. The breakdowns that result are significant and mission-critical. Patient care is negatively affected by the backlog of writing work (which leads to incomplete records, delayed processing of prescriptions and bills) and by the burnout and attrition of those providers to whom it is assigned (which leads to less capacity for patient care in the clinic; Arndt et al., 2017).
Suggestion for Intervention: Writing Steward Model
The needs analysis that we conducted for the Clinic Transformation Project led to a presentation that we provided to clinicians, administrators, and other interested stakeholders in which we presented our findings and made recommendations for potential interventions. These interventions ranged from very small and easy to implement to more extensive, requiring time and other resource commitments on the part of health care administration and the clinical professionals in the clinic. All suggestions were based on two concepts: (a) that the work of the clinic includes writing work and (b) that this writing work must be coordinated and distributed beyond the provider to all clinicians and staff who care for patients.
A suggestion for intervention that involves writing lies in the adoption of a writing stewardship model. Hart-Davidson (2013) has written that the shift in the North American economy to an information economy has ramifications for the work that technical communicators may do in workplaces. In fact, they will not be the only writers in a workplace: “Now, everybody in the information economy writes or contributes to an organization that must write, and write well, to stay competitive and fulfill its goals” (Hart-Davidson, 2013, p. 58). Writing stewardship involves recognizing the role and value of knowledge about writing practices as a key component of an organization’s central mission or goal. As Hart-Davidson (2013) wrote, “Even in the manufacture of traditional goods, it is often the information produced about and along with a product that is its most valuable commodity” (p. 57). Doing the work of the information economy requires expertise in writing and rhetoric; particularly, in how the conceptual and procedural knowledge that guides effective writing practice can help members of an organization better learn and work together. While Hart-Davidson envisioned technical communicators fulfilling the writing steward role in the workplace, thus adding value to the position of technical communicator in the workplace, the framework might be expanded in the health care context to that of providing training and coaches to clinicians to become their own writing stewards.
A health care organization is no different than any other workplace in the information economy. We argue that the most valuable thing that primary care clinicians produce is not point-of-contact care, but instead, information that forms a record of the body that can assist in caring for that body over time. If this is the case, the creation of the EMR, the chart, is actually what is being made by clinics all day long. EMR vendors already know this, as do large health care systems’ IT departments. But the clinical professionals are struggling to adapt to this, largely for the reasons we have outlined in our analysis above: their workflows and schedules are not designed for writing, and their identities and training are not reflected in writing. Returning to the institutional critique, empirical-yet-activist approach to this work, we see a connection between the discussion of the technical communicator’s role in the fast capitalism of the 1990s (Wilson & Wolford, 2017, citing Henry, 2006; Gee, Hull, & Lankshear, 1996) and our observation of a health care organization in the early 21st century. Namely, as health care systems have become privatized and profit-driven, work conditions have changed so as to destabilize prior hierarchical, slower work processes of the clinic.
In the information economy, the EMR is now the most valuable commodity and the central work product of the clinic. In much the same way that Hart-Davidson (2013) argued for the role of technical communicators to change to be stewards of the writing of others, so should the responsibilities of clinicians change in order for the clinic to succeed as an organization. In short, the writing overall must improve, and this means that all clinicians must learn to write and learn to coordinate the writing they do with one another. In the same way that MAs and providers see themselves in our study’s clinic as an encounter team, providing face-to-face patient care, they must also see themselves as a team that writes to support the care of that patient beyond the structure of the patient encounter in the clinic.
Care coordination, whether it be coordination within an encounter team, or coordination to other specialists, support services, and caregivers outside of the clinic, requires a communications strategy that if asynchronous must include writing, and furthermore, writing stewardship, to be successful. Coordination is a term loosely defined and represented in health care contexts, and often does not include the processes and platforms by which coordination takes place. For example, in the health literate care model, care coordination is visually represented by two ovals (community and clinic) that overlap for this purpose (see Figure 2). Yet, how this is to be done is left largely to interpretation. What do overlapping circles mean in terms of community and clinic communication and other activities? Training in writing stewardship by those with writing expertise can assist in defining and rendering visible the role and value of writing in coordination of care. But understanding where and how writing activity already figures into the clinics’ work, who writes, how, and when, is a preliminary step to specifying a strategy for writing stewardship. In this way, we see writing stewardship work for writing and rhetoric researchers and teachers to do on multiple levels: first in identifying what writing activity is or is not happening in a clinic (the needs analysis), then in devising a strategy for clinics to distribute writing activities across their teams of clinicians, and finally, in training and coaching clinicians to become writing stewards in their own right.
Health literate care model: A universal precautions approach.
Care coordination as an activity in health care is not unlike the kinds of coordination necessary to participate in distributed work, something that technical communication researchers have been studying for some time (see, e.g., Johnson-Eilola, 1996; Slattery, 2007; Spinuzzi, 2007). And in other workplace contexts, communications researchers such as Kellog, Orlikowski, and Yates (2006) have looked at how communication practices influence success of a workplace. “Boundary crossing” and “boundary spanning” were the theoretical frames that they employed to analyze how a web development firm transparently displayed, represented, and assembled information across organizations, creating a structure for coordination of information that allowed for exchange and transformation (Kellog et al., 2006). Such exchange and transformation will also be necessary for clinicians and other caregivers in multiple spaces to successfully coordinate the care of those patients managing chronic conditions.
Further research is needed to determine where and how writing researchers’ knowledge and responsibility can find a home in primary care clinics. One area that has emerged from the current study which focused on patient encounters for chronic care, depicted in Figure 1, is explicit mapping of the patient encounter as part of a writing task, with attention to the sources of evidence—archival and empirical—that should be gathered to facilitate reporting. Many permutations are possible as to which roles are charged with looking after writing tasks in a primary care clinic and coordinating the teams necessary to write effectively there. The first step is to define this work as writing, to understand encounter teams as writing collaboratively, and to begin to expand organizational studies of writing and communication practices to include clinical practice. This step paves the way for writing stewardship in clinics—and serves as a means through which writing researchers can assist clinicians.
Implications and Conclusion
The major implication of our needs analysis is that researchers of writing have important contributions to make to help patients get healthier, through helping clinical professionals and patients write in a more coordinated and effective manner. In effect, the writing process needs to get better in order to better manage chronic conditions of patients in and out of the clinic and across the lifespan. As the momentum in the practice of primary care moves toward an acceptance of the health literate care model in order to manage chronic conditions more effectively (to drive down the costs of health care and improve health care outcomes), so must the clinic move to a distributed and collaborative writing model that challenges current professional education in health and medicine. These challenges—those involved in the move from writing as a solitary act to writing as a collaborative, networked, and distributed one—are not new to those who study workplace writing. Health care professionals need educational and professional development resources based on workplace writing studies.
In order to connect the expertise of writing professionals with that of clinical professionals, we propose four main implications of our needs analysis to inform work going forward:
Call It Writing: Terms Like Charting Disguise the Nature of the Problem and Potential Interventions
The conversation about the crisis in EMR documentation processes, providers’ time “charting,” and provider burnout (Arndt et al., 2017; Young et al., 2018) is currently not able to entertain writing as a foundational concept, due to the categorization of work performed. As a result, the frameworks that writing and technical communication researchers offer are not legible to the health and medical community. This must change if we are to recommend potential interventions such as writing stewardship models. In our needs analysis, we felt that by the time we presented our findings and recommendations to the Clinic Transformation Project, the clinicians had begun to recognize the value and importance of writing researchers in their clinic. A small cultural shift was then able to be made to entertain team-based writing interventions. This is the kind of cultural work needed to change the definition of work and the discussion of what is to be done to alleviate that work for providers.
Recognize the Patient Encounter as Part of an Inquiry Process That Is Part of a Writing Process, and Train and Resource the Clinic Accordingly
The primacy of the face-to-face patient encounter that we observed and were repeatedly reminded of by clinicians is only one small part of the process toward the health and wellness of a patient. The assembly of the patient record is a collaborative, asynchronous research and writing process. Clinics are not currently set up for this work—not physically, temporally, or in terms of human resources. Health care policy analysts are aware of this, and one area of the Affordable Care Act meant to address this is the incentivization of activities that move clinics like the Family Health Center (who accept patients with Medicaid or who are uninsured) from a cost-based fee structure to a value-based fee structure. With the latter, patient schedules and billing processes are not tied to the patient encounter (fee per visit, and more visits, more money), but instead, tied to activities known to boost patient outcomes (such as coordinating care and making care plans with social services agencies and other caregivers). Some of these incentives, implemented by the Centers for Medicare and Medicaid Services (CMS), involve training and resources for team-based approaches to care (CMS, 2017; CMS, 2016), and these may be a way to begin to consider team-based care models as collaborative, process-based writing teams.
Do Not Rely on the EMR to Distribute Writing Tasks. Mediating Technologies Like the EMR Contribute to Distributing Writing Work but Do Not Substitute for Expertise, Human Agency, or Strategy. In Fact, It May Black Box Processes (All Documented Issues by Writing Researchers)
The tagline of the EMR vendor AthenaHealth (the EMR vendor of the new system at the Family Health Center) is “Let’s free you up to focus on what matters most” (2018). They go on to say, in their promotional materials, “Our services automate, simplify, and even eliminate work that’s wasting your time. So you can spend more time on the higher-value work you went into healthcare to do.” These statements contribute to the notion that documentation is preventing providers from doing the work they should be doing instead, in the examination room. Furthermore, EMR systems like this pride themselves on black boxing and siloing tasks by role, so that the provider is less fettered by the backlog of documentation work. Unfortunately, by giving siloed tasks to other roles in the clinic, the EMR gives a perception of distributed, collaborative writing, but instead it further individuates work. In our study, we observed instances, particularly several by the front desk receptionist and MAs, where these roles could not see into the tasks of others, yet knew (mainly from yelling across the clinic at one another) that these tasks were being duplicated across roles. In this way, the workflows in the EMR by role contributed to less transparency in the documentation process, and less ability to work as a team. There is much work to be done by writing researchers to apply the theories and practices of networked, distributed writing in other contexts to the clinical context.
Care Coordination Requires Writing Stewardship Especially Given the Stresses and Uplifts Associated With Distributed Labor and Shared Decision Making
A complicated effect of letting go of control of the documentation process is that it may cause both stress and uplift for the provider. In a recent study by Arnetz, Zhdanova, and Arnetz (2016), they found that involving patients more actively in health care contributed to both hassles (negatives) and uplifts (positives) for clinicians. Our needs analysis reflected this in the different work patterns of the providers on various shifts. Particularly, one provider found it easier to do research tasks herself rather than delegate to MAs, and did this repeatedly throughout her shift, as her schedule on that shift moved steadily further and further behind. A provider like this one may find it stressful to give up control of the writing tasks, even though the backlog of writing is hurting her practice and ultimately, her patients. Again, this is why the role of writing stewardship is so critical, because there must be a role to supervise and coordinate the writing of others, especially when the divestment of this work may prove trying.
And trying is an apt term to conclude, although this piece is only the beginning of the nexus between the work of writing researchers, practitioners, and clinicians. Writing researchers can begin to explore the connections with health services researchers studying physician burnout and EMR use, or begin dialogues with clinicians to learn more about where their writing practices might be a factor in work quality or satisfaction. Writing courses in the health professions might be expanded to include collaborative writing activities designed by writing studies teachers. These are just a few suggestions that highlight some possible directions for research and intervention. Just as the health care debates in the U.S. Congress continue in stops and starts, so will the work of reforming health care clinical practices so that they may support the increasing numbers of chronically ill patients. Writing is a crucial component of this work. Let’s get started, together, to improve the health care system and the health and wellness of us all.
Footnotes
Appendix
Acknowledgements
We would like to thank our anonymous reviewers as well as Written Communication editor Chad Wickman for their very helpful feedback. We would also like to thank our colleague and collaborative partner, Dr. Cathy Abbott.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.