Editorial
Postgraduate medical education: the same, but different Tim Swanwick There is a tendency in medical education at the moment to bring together the postgraduate and the undergraduate into a set of unified frameworks. We see examples in regulatory standard setting—for instance, the UK’s General Medical Council has recently released a single framework for the approval of trainers1 and is developing a unified set of training standards2—and in curriculum design where CanMeds 2015 aims to service the continuum of medical education from undergraduate years to continuing professional development and beyond.3 Despite this comforting homogeneity there are some issues, challenges and practices that, although not absolutely unique to postgraduate medical education, arise from a particular set of relationships between trainee, trainer, the training institution, employer, commissioner, regulators (both those of service and education) and, of course, patients and carers. At the heart of the matter is a managed tension between service and training with the learner as employee. Unlike undergraduate students, postgraduate trainees are registered professionals carrying a particular set of expectations on their shoulders while necessarily performing at the limits of their competence. Including learners within the workforce raises some complex issues about workforce planning, recruitment and selection as well as the construction of training programmes. Training ‘in-service’ brings with it a concern for patient safety, so there is a need for supervision and a particular set of educational approaches. In addition, the learner’s employed status brings into play some thorny human resource issues as well as a complex triangular relationship with those who ‘own’ the training. All of this is played out within a set of organisational structures that, because of their proximity to politics, are subject to regular review and reform. The purpose of postgraduate medical training is to provide a particular geography with a workforce that will serve the future health needs of its population, and it’s the ‘future’ bit that’s difficult. Although Correspondence to Dr Tim Swanwick, Health Education North Central and East London, Stewart House, 32 Russell Square, London WC1B 5DN, UK; [email protected]
there may be reasonable certainty about demographic changes—an increasingly elderly population or a boom in birth rates —advances in medicine can quickly make one discipline obsolete and another in short supply; witness the virtual ‘eradication’ of stomach surgery for peptic ulcers by the discovery of Helicobacter pylori. This lack of certainty is a problem because of the length of time it takes to train a medical specialist and the need to predict workforce requirements more than a decade out. The issue is compounded by the politicisation of healthcare, questions over its resourcing, and the fact that there is rarely consensus about just how it should be structured or delivered. Adjusting training inputs and outputs is therefore a major preoccupation for those who manage postgraduate training and the availability of specific training programmes subject to considerable public scrutiny. In recent years a more long-term, holistic and integrated approach to workforce planning has been attempted through organisations with an avowedly multiprofessonal remit such as Healthcare Workforce Australia (and its successor body)4 and Health Education England.5 A related preoccupation in the postgraduate arena is the nature of the pipeline itself, both the shape and content of training programmes. In recent battles for curricular supremacy the generic professional curriculum is in the ascendancy, with communication skills, team working, research awareness, quality and safety improvement and clinical leadership topping the bill, reinforced by the recent rediscovery that the patient is at the centre of care.6 Beyond that, doctors are being led to realise that they have a societal responsibility that extends out of their consulting room into the wider population and health system.7 The tendency, however, for repeated restructuring of programmes is relatively unique to the postgraduate arena and policies such as the UK’s Shape of Training8 are a consummate example of what is arguably a legitimate political concern to ensure that training programmes are tailored to the needs of patients, not the other way round. One of the areas where postgraduate medical education has made significant strides in recent years is in recruitment and Swanwick T. Postgrad Med J April 2015 Vol 91 No 1074
selection. The UK in particular has introduced a number of significant innovations including a national portal for applications launched this year, centralised and standardised selection episodes, selection centre methodologies based on detailed job analyses and values-based selection methods such as situational judgement tests.9 This mixture of human resource and educational practices has also been subject to significant research and evaluation and, with the advent in the UK of a single regulator across undergraduate, postgraduate and continuing professional development, analysis of large longitudinal datasets is now possible in pursuit of the ‘holy grail’ of selection, predictive validity—that is, how well or badly scores on selection predict a future outcome or criterion.10 Postgraduate medical education itself is founded on a particular set of relationships between learning and work. This in turn requires a particular set of educational practices and ways of thinking about teaching and learning. Supervision—both of professional development and professional performance—and the supervisory relationship are at the heart of training, and considerable efforts have been made to clarify roles and activities. A distinction commonly made is between clinical supervision—the act of looking over the learner’s shoulder ‘in the moment’ with an eye to ensuring safety and quality of care—and educational supervision where the focus is on the developmental trajectory of the learner over the course of a placement or programme of placements.11 Both activities have elements in common with the related developmental practices of appraisal, performance management, mentoring and coaching. Specific ways of thinking about learning are also found in postgraduate practice, although these may not be immediately apparent to either trainees or trainers. There is an underlying tension here too between the explicit and the implicit— between what Anna Sfard calls two metaphors for learning: learning as acquisition versus learning through participation.12 Learning as acquisition is, according to Sfard, “so strongly entrenched in our minds that we would probably never become aware of its existence if another alternative metaphor did not start to develop” ( p6). Learning here is seen in terms of the trainee’s accumulation of knowledge and skills and, when operating within this metaphor, educators and educational systems typically emphasise the importance of structure and defined objectives, the need to build upon prior knowledge and the value of learning from talk. 179
Editorial Learning through participation is construed as a process by which one becomes a member of a particular community of practice—a surgeon, a teacher, an academic. To some degree this could be described as ‘apprenticeship’, as fundamental processes at work within this metaphor include learners increasing engagement in the day-to-day work of the community, the social formation of professional identities and the development of ‘the ability to communicate in the language of the community and act according to its particular norms’ ( p6). In this way, learning is seen as part of social practice, it is embedded in everyday activities and is no longer seen as being ‘necessarily or directly dependent on pedagogical goals or official agenda’ ( p113).13 The situated nature of learning means that the workplace itself is not neutral in all of this and key is the way that the workplace ‘affords’—provides, permits or invites—access to activities from which learning can arise.14 As a result, and on account of the need to protect both patients and learners, considerable time and resource in the postgraduate arena is consumed in patrolling and managing the quality of the educational environment. Concerns over patient safety have also led to a huge rise in the use of simulation in medical education based on the (as yet weakly evidenced) assumption that simulated practice accelerates the learning curve and provides a safe place to rehearse skills and learn from error. Considerable investment has been made in simulation both for the skills development of individuals and in interprofessional team-based training and, as a companion to work-based learning, simulation looks set to become a core delivery vehicle in the majority of postgraduate specialty curricula.15 Another area in which postgraduate medical education has developed a set of relatively unique practices is assessment, notably in the area of work-based assessment and reviews of competence progression. Over the course of history the seductiveness of standardised testing has led medical education to rely on externally administered assessments delivered at the end of programmes of training. The problem is that what doctors do in controlled assessment situations correlates poorly with their actual performance in professional practice.16 Assessment of competence in a contextual vacuum is all very well, but how can we know what happens in the messiness of real professional practice—or what the doctor actually ‘does’? This is where workplace-based assessment comes into its own, offering an 180
opportunity to integrate teaching, learning and assessment by using tools for gathering information about aspects of trainee work which are then employed as vehicles for offering direct, timely and relevant feedback. The collection of workplace-based assessment data is learner-led and brought together, usually in a portfolio of evidence, to inform judgements about the trainee’s overall progress. Professional performance is of such complexity that there will always be ‘judgements’ to be made no matter how reliable the assessment tools. Like clinical diagnoses, such judgements in postgraduate medical education are based on a range of data, from the narrative to the numerical. To ensure validity, defensibility and fairness, such judgements should always be made by a well-trained panel. In the UK, summative judgements are made in relation to training progression from one year to the next, but an interesting way of thinking about this process has been developed in the Netherlands in the form of ‘entrustable professional activities’—tasks that are of high importance for daily practice, high-risk or error-prone or exemplary of certain competencies. The resident collects evidence, requests entrustment, evidence is assessed and responsibility awarded, or not.17 Despite their status as learners, doctors in postgraduate training are also employed professionals. This comes with a number of responsibilities in terms of the doctor’s accountability to society, professional bodies and their employer. Again, there is a managed tension here between the developmental needs of the individual, the profession and that of the institution. This is played out in negotiations over study leave, access to specific placements and attendance at, and funding for, courses, and the fact that continuing professional accreditation is inextricably interwoven within the fabric of training programmes. This complex set of relationships is also seen in relation to the ‘trainee in difficulty’ where there is shared but often contested responsibility between the training organisation, employer and professional body. Unlike its undergraduate cousin which has functioned in much the same way for the last 100 years or so, postgraduate medical education is a comparatively young discipline that has yet to be privileged in quite the same way. There are very few professors or departments of postgraduate medical education and the discipline has yet to find an academic voice. There are, however, a set of preoccupations, pedagogies and practices that can be described as peculiarly ‘postgraduate’ in
their provenance, and a growing number of faculties with a deep understanding of what it means to learn at, from and through work. But we are not there yet, and there is much to do in delivering a workforce that reflects the future needs of society in constructing meaningful programmes delivered by well-motivated and skilled clinical educators, in addressing the curricula balance of the specialist and the systemic and in responding to the increasing recognition that, as care is delivered by clinical teams, a major component of postgraduate training delivery should be interprofessional. However, postgraduate medical education has in the last decade or so finally come out of the shadows and is now recognised as absolutely fundamental to safe and high quality care, both for today’s patients and tomorrow’s. Twitter Follow Tim Swanwick at @tswanwickncel Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Swanwick T. Postgrad Med J 2015;91:179– 181. Received 24 August 2014 Revised 22 March 2015 Accepted 25 March 2015 Postgrad Med J 2015;91:179–181. doi:10.1136/postgradmedj-2014-132805
REFERENCES 1
2
3
4 5 6 7 8
9
10
General Medical Council. Recognition and approval of trainers. http://www.gmc-uk.org/education/10264. asp (accessed 24 Aug 2014). General Medical Council. Standards for medical education and training (draft). http://www.gmc-uk. org/education/26040.asp (accessed 22 Mar 2015). Royal College of Physicians and Surgeons of Canada. CanMEDS 2015 (draft). http://www.royalcollege.ca/ portal/page/portal/rc/canmeds/canmeds2015 (accessed 22 Mar 2015). Health Workforce Australia. https://www.hwa.gov.au (accessed 24 Aug 2014). Health Education England. http://hee.nhs.uk (accessed 24 Aug 2014). Health Foundation. Person-centred care. http:// personcentredcare.health.org.uk/ (accessed 22 Mar 2015). Brook RH. Medical leadership in an increasingly complex world. JAMA 2010;304:465–6. Greenway D. Shape of training. Securing the future of excellent patient care. Final report of the independent review. http://www.shapeoftraining.co.uk/static/ documents/content/Shape_of_training_FINAL_ Report.pdf_53977887.pdf (accessed 24 Aug 2014). Patterson F, Ferguson E, Knight AL. Selection into medical education and training. In: Swanwick T, ed. Understanding medical education. Evidence, theory and practice. Oxford: Wiley Blackwell, 2013:403– 420. General Medical Council. Evidence: reports, surveys and other data. http://www.gmc-uk.org/education/ evidence_reports_and_surveys.asp (accessed 22 Mar 2015).
Swanwick T. Postgrad Med J April 2015 Vol 91 No 1074
Editorial 11
12 13
Kilminster S, Cottrell D, Grant J, et al. AMEE Guide No. 27: effective educational and clinical supervision. Med Teach 2007;29:2–19. Sfard A. On two metaphors for learning and the dangers of choosing just one. Educ Res 1998;27:4–13. Lave J, Wenger E. Situated learning. Legitimate peripheral participation. Cambridge: University of Cambridge Press, 1991:113–14.
Swanwick T. Postgrad Med J April 2015 Vol 91 No 1074
14
15
Billett S. Learning through work. Workplace participatory practices. In: Rainbird H, Fuller L, Munro A, eds. Workplace learning in practice. London: Routledge, 2004:109–125. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27:10–28.
16
17
Rethans J, Norcini J, Baron-Maldonado M, et al. The relationship between competence and performance: implications for assessing practice performance. Med Educ 2002;36:901–9. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and practice? Acad Med 2007;82:542–7.
181
Copyright of Postgraduate Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Postgraduate medical education: the same, but different Tim Swanwick There is a tendency in medical education at the moment to bring together the postgraduate and the undergraduate into a set of unified frameworks. We see examples in regulatory standard setting—for instance, the UK’s General Medical Council has recently released a single framework for the approval of trainers1 and is developing a unified set of training standards2—and in curriculum design where CanMeds 2015 aims to service the continuum of medical education from undergraduate years to continuing professional development and beyond.3 Despite this comforting homogeneity there are some issues, challenges and practices that, although not absolutely unique to postgraduate medical education, arise from a particular set of relationships between trainee, trainer, the training institution, employer, commissioner, regulators (both those of service and education) and, of course, patients and carers. At the heart of the matter is a managed tension between service and training with the learner as employee. Unlike undergraduate students, postgraduate trainees are registered professionals carrying a particular set of expectations on their shoulders while necessarily performing at the limits of their competence. Including learners within the workforce raises some complex issues about workforce planning, recruitment and selection as well as the construction of training programmes. Training ‘in-service’ brings with it a concern for patient safety, so there is a need for supervision and a particular set of educational approaches. In addition, the learner’s employed status brings into play some thorny human resource issues as well as a complex triangular relationship with those who ‘own’ the training. All of this is played out within a set of organisational structures that, because of their proximity to politics, are subject to regular review and reform. The purpose of postgraduate medical training is to provide a particular geography with a workforce that will serve the future health needs of its population, and it’s the ‘future’ bit that’s difficult. Although Correspondence to Dr Tim Swanwick, Health Education North Central and East London, Stewart House, 32 Russell Square, London WC1B 5DN, UK; [email protected]
there may be reasonable certainty about demographic changes—an increasingly elderly population or a boom in birth rates —advances in medicine can quickly make one discipline obsolete and another in short supply; witness the virtual ‘eradication’ of stomach surgery for peptic ulcers by the discovery of Helicobacter pylori. This lack of certainty is a problem because of the length of time it takes to train a medical specialist and the need to predict workforce requirements more than a decade out. The issue is compounded by the politicisation of healthcare, questions over its resourcing, and the fact that there is rarely consensus about just how it should be structured or delivered. Adjusting training inputs and outputs is therefore a major preoccupation for those who manage postgraduate training and the availability of specific training programmes subject to considerable public scrutiny. In recent years a more long-term, holistic and integrated approach to workforce planning has been attempted through organisations with an avowedly multiprofessonal remit such as Healthcare Workforce Australia (and its successor body)4 and Health Education England.5 A related preoccupation in the postgraduate arena is the nature of the pipeline itself, both the shape and content of training programmes. In recent battles for curricular supremacy the generic professional curriculum is in the ascendancy, with communication skills, team working, research awareness, quality and safety improvement and clinical leadership topping the bill, reinforced by the recent rediscovery that the patient is at the centre of care.6 Beyond that, doctors are being led to realise that they have a societal responsibility that extends out of their consulting room into the wider population and health system.7 The tendency, however, for repeated restructuring of programmes is relatively unique to the postgraduate arena and policies such as the UK’s Shape of Training8 are a consummate example of what is arguably a legitimate political concern to ensure that training programmes are tailored to the needs of patients, not the other way round. One of the areas where postgraduate medical education has made significant strides in recent years is in recruitment and Swanwick T. Postgrad Med J April 2015 Vol 91 No 1074
selection. The UK in particular has introduced a number of significant innovations including a national portal for applications launched this year, centralised and standardised selection episodes, selection centre methodologies based on detailed job analyses and values-based selection methods such as situational judgement tests.9 This mixture of human resource and educational practices has also been subject to significant research and evaluation and, with the advent in the UK of a single regulator across undergraduate, postgraduate and continuing professional development, analysis of large longitudinal datasets is now possible in pursuit of the ‘holy grail’ of selection, predictive validity—that is, how well or badly scores on selection predict a future outcome or criterion.10 Postgraduate medical education itself is founded on a particular set of relationships between learning and work. This in turn requires a particular set of educational practices and ways of thinking about teaching and learning. Supervision—both of professional development and professional performance—and the supervisory relationship are at the heart of training, and considerable efforts have been made to clarify roles and activities. A distinction commonly made is between clinical supervision—the act of looking over the learner’s shoulder ‘in the moment’ with an eye to ensuring safety and quality of care—and educational supervision where the focus is on the developmental trajectory of the learner over the course of a placement or programme of placements.11 Both activities have elements in common with the related developmental practices of appraisal, performance management, mentoring and coaching. Specific ways of thinking about learning are also found in postgraduate practice, although these may not be immediately apparent to either trainees or trainers. There is an underlying tension here too between the explicit and the implicit— between what Anna Sfard calls two metaphors for learning: learning as acquisition versus learning through participation.12 Learning as acquisition is, according to Sfard, “so strongly entrenched in our minds that we would probably never become aware of its existence if another alternative metaphor did not start to develop” ( p6). Learning here is seen in terms of the trainee’s accumulation of knowledge and skills and, when operating within this metaphor, educators and educational systems typically emphasise the importance of structure and defined objectives, the need to build upon prior knowledge and the value of learning from talk. 179
Editorial Learning through participation is construed as a process by which one becomes a member of a particular community of practice—a surgeon, a teacher, an academic. To some degree this could be described as ‘apprenticeship’, as fundamental processes at work within this metaphor include learners increasing engagement in the day-to-day work of the community, the social formation of professional identities and the development of ‘the ability to communicate in the language of the community and act according to its particular norms’ ( p6). In this way, learning is seen as part of social practice, it is embedded in everyday activities and is no longer seen as being ‘necessarily or directly dependent on pedagogical goals or official agenda’ ( p113).13 The situated nature of learning means that the workplace itself is not neutral in all of this and key is the way that the workplace ‘affords’—provides, permits or invites—access to activities from which learning can arise.14 As a result, and on account of the need to protect both patients and learners, considerable time and resource in the postgraduate arena is consumed in patrolling and managing the quality of the educational environment. Concerns over patient safety have also led to a huge rise in the use of simulation in medical education based on the (as yet weakly evidenced) assumption that simulated practice accelerates the learning curve and provides a safe place to rehearse skills and learn from error. Considerable investment has been made in simulation both for the skills development of individuals and in interprofessional team-based training and, as a companion to work-based learning, simulation looks set to become a core delivery vehicle in the majority of postgraduate specialty curricula.15 Another area in which postgraduate medical education has developed a set of relatively unique practices is assessment, notably in the area of work-based assessment and reviews of competence progression. Over the course of history the seductiveness of standardised testing has led medical education to rely on externally administered assessments delivered at the end of programmes of training. The problem is that what doctors do in controlled assessment situations correlates poorly with their actual performance in professional practice.16 Assessment of competence in a contextual vacuum is all very well, but how can we know what happens in the messiness of real professional practice—or what the doctor actually ‘does’? This is where workplace-based assessment comes into its own, offering an 180
opportunity to integrate teaching, learning and assessment by using tools for gathering information about aspects of trainee work which are then employed as vehicles for offering direct, timely and relevant feedback. The collection of workplace-based assessment data is learner-led and brought together, usually in a portfolio of evidence, to inform judgements about the trainee’s overall progress. Professional performance is of such complexity that there will always be ‘judgements’ to be made no matter how reliable the assessment tools. Like clinical diagnoses, such judgements in postgraduate medical education are based on a range of data, from the narrative to the numerical. To ensure validity, defensibility and fairness, such judgements should always be made by a well-trained panel. In the UK, summative judgements are made in relation to training progression from one year to the next, but an interesting way of thinking about this process has been developed in the Netherlands in the form of ‘entrustable professional activities’—tasks that are of high importance for daily practice, high-risk or error-prone or exemplary of certain competencies. The resident collects evidence, requests entrustment, evidence is assessed and responsibility awarded, or not.17 Despite their status as learners, doctors in postgraduate training are also employed professionals. This comes with a number of responsibilities in terms of the doctor’s accountability to society, professional bodies and their employer. Again, there is a managed tension here between the developmental needs of the individual, the profession and that of the institution. This is played out in negotiations over study leave, access to specific placements and attendance at, and funding for, courses, and the fact that continuing professional accreditation is inextricably interwoven within the fabric of training programmes. This complex set of relationships is also seen in relation to the ‘trainee in difficulty’ where there is shared but often contested responsibility between the training organisation, employer and professional body. Unlike its undergraduate cousin which has functioned in much the same way for the last 100 years or so, postgraduate medical education is a comparatively young discipline that has yet to be privileged in quite the same way. There are very few professors or departments of postgraduate medical education and the discipline has yet to find an academic voice. There are, however, a set of preoccupations, pedagogies and practices that can be described as peculiarly ‘postgraduate’ in
their provenance, and a growing number of faculties with a deep understanding of what it means to learn at, from and through work. But we are not there yet, and there is much to do in delivering a workforce that reflects the future needs of society in constructing meaningful programmes delivered by well-motivated and skilled clinical educators, in addressing the curricula balance of the specialist and the systemic and in responding to the increasing recognition that, as care is delivered by clinical teams, a major component of postgraduate training delivery should be interprofessional. However, postgraduate medical education has in the last decade or so finally come out of the shadows and is now recognised as absolutely fundamental to safe and high quality care, both for today’s patients and tomorrow’s. Twitter Follow Tim Swanwick at @tswanwickncel Competing interests None. Provenance and peer review Commissioned; internally peer reviewed.
To cite Swanwick T. Postgrad Med J 2015;91:179– 181. Received 24 August 2014 Revised 22 March 2015 Accepted 25 March 2015 Postgrad Med J 2015;91:179–181. doi:10.1136/postgradmedj-2014-132805
REFERENCES 1
2
3
4 5 6 7 8
9
10
General Medical Council. Recognition and approval of trainers. http://www.gmc-uk.org/education/10264. asp (accessed 24 Aug 2014). General Medical Council. Standards for medical education and training (draft). http://www.gmc-uk. org/education/26040.asp (accessed 22 Mar 2015). Royal College of Physicians and Surgeons of Canada. CanMEDS 2015 (draft). http://www.royalcollege.ca/ portal/page/portal/rc/canmeds/canmeds2015 (accessed 22 Mar 2015). Health Workforce Australia. https://www.hwa.gov.au (accessed 24 Aug 2014). Health Education England. http://hee.nhs.uk (accessed 24 Aug 2014). Health Foundation. Person-centred care. http:// personcentredcare.health.org.uk/ (accessed 22 Mar 2015). Brook RH. Medical leadership in an increasingly complex world. JAMA 2010;304:465–6. Greenway D. Shape of training. Securing the future of excellent patient care. Final report of the independent review. http://www.shapeoftraining.co.uk/static/ documents/content/Shape_of_training_FINAL_ Report.pdf_53977887.pdf (accessed 24 Aug 2014). Patterson F, Ferguson E, Knight AL. Selection into medical education and training. In: Swanwick T, ed. Understanding medical education. Evidence, theory and practice. Oxford: Wiley Blackwell, 2013:403– 420. General Medical Council. Evidence: reports, surveys and other data. http://www.gmc-uk.org/education/ evidence_reports_and_surveys.asp (accessed 22 Mar 2015).
Swanwick T. Postgrad Med J April 2015 Vol 91 No 1074
Editorial 11
12 13
Kilminster S, Cottrell D, Grant J, et al. AMEE Guide No. 27: effective educational and clinical supervision. Med Teach 2007;29:2–19. Sfard A. On two metaphors for learning and the dangers of choosing just one. Educ Res 1998;27:4–13. Lave J, Wenger E. Situated learning. Legitimate peripheral participation. Cambridge: University of Cambridge Press, 1991:113–14.
Swanwick T. Postgrad Med J April 2015 Vol 91 No 1074
14
15
Billett S. Learning through work. Workplace participatory practices. In: Rainbird H, Fuller L, Munro A, eds. Workplace learning in practice. London: Routledge, 2004:109–125. Issenberg SB, McGaghie WC, Petrusa ER, et al. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27:10–28.
16
17
Rethans J, Norcini J, Baron-Maldonado M, et al. The relationship between competence and performance: implications for assessing practice performance. Med Educ 2002;36:901–9. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and practice? Acad Med 2007;82:542–7.
181
Copyright of Postgraduate Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
