Abortion education in Canadian family medicine residency programs

Abortion education in Canadian family medicine residency programs Background: Abortion has been decriminalized in Canada since 1988 and is considered an essential medical service. There is concern that decreasing numbers of abortion providers may impair access to abortion. This study examined the quantity of exposure and education that Canadian family medicine residents receive on abortion during training and their preparation to provide abortions. In addition, the study assessed residents’ attitudes, intention and expressed competency to provide abortion in future practice and the association between medical training and changes in these factors. Methods: The authors developed a 21-item survey in consultation with experts in medical education. The survey was distributed online in 2016. A total of 1517 family medicine residents in their first, second and third year of training attending 8 English language schools across Canada were invited to participate. Associations between attitudes, education, exposure and intention were assessed using relative risks based on bivariate analysis of self-reported measures and odds ratios from ordered logistic regression. Results: The response rate was 28.7% (436/1517). The majority of residents, 79%, reported never observing or assisting with an abortion during training. Similarly, 80% of residents reported receiving less than 1 hour of formal education on abortion. Residents strongly supported receiving abortion education. Self reported exposure to a single abortion during training was associated with an increase in residents’ intention (RR = 1.95, 95% CI 1.54–2.47) and self- rated competency to provide a medical abortion (RR = 2.16, 95% CI 1.60–2.93). Twenty five percent of residents were unaware of ethical and legal requirements towards abortion provision and referral. Conclusions: Canadian family medicine residents receive little education or exposure to abortion during training most do not feel competent to provide abortion services. Residents expressed strong support for receiving abortion training. The Canadian College of Family Physicians curriculum does not currently include abortion as a training objective. The authors argue there is a need for family medicine training programs to increase education and exposure to abortion during residency, while respecting residents’ rights to opt out of such training. Failure to do so may impair future access to abortion provision. Keywords: Abortion training, Medical education, Family medicine residency, Medical abortion, Theory of planned behaviour Background However, women seeking access to abortion continue to Therapeutic abortion (TA), the intentional termination face several challenges including: lack of trained providers of a pregnancy, is a common procedure in Canada, with and participating hospitals, regional disparities in access 28 abortions performed per 100 live births [1]. Approxi- requiring long distance travel, inadequate provider and mately one in three Canadian women will have an abor- patient knowledge, and ongoing stigma towards abortion tion during her lifetime [2]. Abortion was decriminalized provision [3–5]. Similar trends of residual barriers to abor- in 1988, and is fully covered under provincial and terri- tion access despite decriminalization or legalization have torial health insurance as an essential health service [3]. been observed across the developed world [6]. A consist- ent finding has been that low numbers of providers and * Correspondence: Dmyra088@uottawa.ca Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Myran et al. BMC Medical Education (2018) 18:121 Page 2 of 8 lack of training opportunities significantly decrease the used in the prediction of future behaviour, to address the availability of abortion [6]. following objectives: [17, 18]. While there is no national information on the number and trends of abortion providers in Canada, data from 1) To examine the amount of education and exposure British Columbia (BC) shows a general decline in the residents receive on abortion number of providers, with up to a 50% reduction in rural 2) To assess learner attitudes, intentions, and providers in the past two decades [7]. The geographic anticipated-competency around the provision of accessibility of abortion is related to the number of pro- abortion care in their training and in practice viders. In 2006, only 15.9% of Canadian hospitals offered 3) To examine the association between attitudes, abortion services, the majority of which were in urban perceived social norms, and perceived logistical areas [8] and until February 2017 the province of Prince difficulty on residents’ intention to provide abortion. Edward Island had no abortion providers [4]. A study of 4) To examine the association between education and women seeking an abortion at a clinic in a major urban exposure on residents’ competency and intention center in Canada found that more than 15% of women towards abortion provision travelled between 101 and 1000 km to access an abortion provider. Indigenous, socioeconomically disadvantaged, and Methods younger women were disproportionately impacted [5]. Study setting Exposure to abortion during medical education is likely To answer our research questions, we designed a 21-item associated with whether physicians provide abortion later survey. Ethics approval was provided by the University of in practice [9–11]. One study of practicing American obste- Ottawa and the University of Alberta Research Ethics tricians found that exposure to abortion during training Boards (REB). We approached the departments of family strongly predicted whether obstetricians provided abortion medicine at all English language family medicine residency during practice [9]. Two studies, one of Canadian obstetrics programs in Canada that also had reciprocal REB agree- and gynecology residents, and one study of American ments with the University of Alberta and the University of family medicine residents, found that exposure to abor- Ottawa for permission to distribute our survey. Universities tion during training was positively associated with resi- that did not respond to invitations to participate or grant dents’ expressed intention to provide abortions in future permission to distributethesurveywerenot included practice [10, 11]. However, Canadian family medicine and in the study. In total, the University of Ottawa, University obstetrics residents may not be receiving exposure during of Toronto, Queen’s University, Western University, the training. A 2002 study found that the majority of Ontario Northern Ontario School of Medicine, University of family medicine residents and practicing physicians did Saskatchewan, University of Alberta, and University not feel adequately trained to offer medical or surgical of British Columbia participated in the study. See (procedural) abortions to their patients [12]. A recent Additional file 1: Appendix 1 for further details on study of Canadian Obstetrics and Gynecology residents exemption. found that 15% had received no training on abortion at all during residency, with an additional 34% reporting that Study population and sampling procedures abortion training occurred in their program only on a A total of 1517 family medicine residents currently enrolled voluntary opt-in basis [13]. Similarly, two recent studies in postgraduate year one, two and, three were eligible for that surveyed medical school classes in Ontario and BC study participation. Collectively the schools that partici- found that respondents had limited knowledge of abortion pated enrolled 46.5% (1517 / 3265) of the country’sfamily [14] and relatively few expressed intention to provide medicine residents. The survey was administered online abortion in future practice [15]. using the survey platform ‘Fluid Surveys™’. Participation Family doctors currently perform the majority of abor- was anonymous and voluntary, with survey completion tions in Canada, with the percentage of abortions provided implying consent. Eligible participants were recruited by this group increasing over time [16]. In 2014–2015, fam- by email, in-class announcements and social media posts. ily doctors provided 75.5% of the 86,824 reported TAs [16]. University specific recruitment emails were sent on behalf Consequently, the training and exposure that family medi- of the researchers by the family medicine departments at cine residents receive during residency may be of consider- each university, with the exception of the University of able importance to future access to abortion. Toronto which posted an invitation to the survey in their To our knowledge, this is the first study to examine monthly newsletter. Universities sent up to two follow up national education, exposure, intention and self-expressed emails reminding residents to participate in the survey. Fur- competency of Canadian family medicine residents with ther details on study recruitment can be seen in Additional regards to abortion. We used the Theory of Planned file 1: Appendix 1. Participants were entered into a draw to Behaviour (TPB), a well-validated social psychology theory win one of three $20 gift certificates. Myran et al. BMC Medical Education (2018) 18:121 Page 3 of 8 Survey development and data collection results, was made to divide intention responses into We used the Theory of Planned Behaviour (TPB) as a “intenders” and “non-intenders” with intenders answering 6 framework for survey design [17, 18]. The theory holds or 7 on the Likert scale and non-intenders answering 1–5 that intentions to engage in a behaviour are the strongest on the Likert scale when conducting bivariate analysis predictor of that future behaviour. Individual intention is between exposure and intention and the components of best predicted by personal attitudes, how an individual per- the TRA and intention. We created a binary variable for ceives their community social norms, and the degree that a exposure (yes/no), where residents who observed, assisted person feels they are able to perform the behaviour of inter- with or performed one or more medical or surgical abor- est. The TPB is accepted as being a strong predictor of tions were considered exposed. We used Chi-square tests future behaviour, including health and physician-related be- to examine the relationships between exposure to abortion havior [19, 20]. Questions from previous surveys examining and intention and self expressed competency. We calcu- abortion education were adapted with the aid of content lated the Relative Risk (RR) based on the self-reported experts in medical education and reproductive health to de- measures. We fit ordered logistic regressions to assess the termineexposuretoabortion in Canadian family medicine association between education, exposure, and intention to programs [9, 10, 15, 21]. The survey was piloted with five provide medical abortions and included interaction terms family medicine residents for feedback and administered to test for effect measure modification. between April 26th and June 26th, 2016. Results Measures of interest Response rate and respondent characteristics The main measures in our study were as follows (see We received 436 responses for an overall response rate Additional file 2: Appendix 2 for a copy of the survey of 28.7%. Twenty-two participants were excluded for with all measures including attitudes, social norms and completing less than 50% of the survey, one individual perceived behavioral control): who had indicated they attended a school which had not consented to participation was also excluded, with – Education: Education was assessed with two a final 413 (27.2%) responses retained for data analysis. questions: “In your residency so far, how many See Additional file 1: Appendix 1 for the response rate hours of teaching on abortion provision did you by school. We report characteristics of our respondents have in A) a formal academic setting (lecture, in Table 1. The gender breakdown and mean age of academic day presentation, online learning module participants in our study were comparable to the etc) B) an informal setting (case discussions, bedside reported national averages for family medicine residents or in clinic teaching, informal presentations)”. in 2014–2015 [22, 23]. Respondents were also presented with a short case with multiple choice responses to assess their knowledge of professional requirements. – Exposure: Exposure to abortion was measured with Table 1 Respondent characteristics the question “During your family medicine residency N (%)/Mean training have you assisted with or performed a Age 29.62 (SD 3.95) medical or surgical abortion?” Residents were Gender considered exposed if they answered yes. Male 123 (29.9%) – Intention to provide medical and surgical abortion: Female 289 70.1%) Intention was assessed using a 7-point Likert scale Planned future practice size: with the following questions “I intend to provide medical abortions in my future practice” and “I intend Rural population 9999 or less 64 (15.5%) to provide surgical abortions in my future practice.” Small town/city between 10,000 and 99,999) 138 (60.9%) – Self-reported competency: This measure was assessed Urban population greater than 100,000 187 (23.6%) using a 7-point Likert scale with the following three Year of Training questions “By the end of residency, I expect to be PGY-1 201 (48.6%) competent to: A) Counsel women about abortion B) PGY-2 202 (48.7%) Perform medical abortions C) Perform at least one method of surgical abortions. PGY-3 11 (2.7%) Religious/moral objections to abortion Analysis of data Yes 73 (17.9%) All analyses were conducted using SPSS Statistics version No 334 (82.1%) 24. An a priori decision, to simplify interpretation of the Myran et al. BMC Medical Education (2018) 18:121 Page 4 of 8 Education and exposure to abortion during residency required to refer to another provider if the physician was Fifty-seven percent of residents reported receiving no personally opposed to abortion provision. formal education on abortion and 80.2% received less than 1 hour during training. Twenty-seven percent of Exposure to abortion during residency and intention and residents reported receiving no informal education on self-expressed competency to provide abortion abortion and 64.2% received less than 1 hour. Twenty-two Exposure to abortion during residency was significantly percent of residents reported receiving no education, for- associated with positive intentions to provide medical and mal or informal, during their training, and 45.7% reported surgical abortion, belief that abortion was within the scope receiving less than 1 hour. of practice of family doctors and residents’ self-expressed We report the amount of exposure to abortion by competence to counsel on and provide abortions, see university in Fig. 1. Twenty-one percent of residents re- Table 3 and Table 4. Students who were exposed to ported being exposed to one or more abortions during abortion during a routine or elective rotation did not residency. Of those exposed, 63.1% reported that their differ significantly in their intention to provide medical experiences occurred during a routine, scheduled rota- abortion (54.8% elective, vs 50% routine, Pearson tion. The remainder reported that exposure to abortion chisquare = 0.1821 p = 0.670) or their anticipated compe- occurred during an elective rotation. tency to provide medical abortion (48.39% elective vs 46.15% routine, Pearsons chisquare = 0.0389 Pr = 0.844). Attitudes towards abortion and medical education on Education on abortion during residency and intention abortion and intention to provide abortion and self-expressed competency to provide abortion Sixty-one percent of residents in our survey very strongly We compared the self-reported competency of first and or strongly supported receiving abortion training during second year residents to provide a medical abortion by residency. Table 2 shows a bivariate analysis of residents’ the end of residency. Residents in their second year of attitudes, social norms and perceived behavioural control, training (19.1%) were significantly less likely to report factors outlined in the TPB, stratified by intention to feeling competent to provide a medical abortion com- provide a medical abortion in future practice. Having pared to first year residents (36%) (Pearsons chi-square positive attitudes, perceiving positive social norms, and 14.83 p = 0.001). anticipating relative ease of providing an abortion were all We fit ordinal logistic regressions to examine the asso- significantly associated with increased resident intention ciation between formal education, informal education, to provide medical abortion in future practice. When gender, and exposure on intention to provide medical presented with a short case addressing professional abortion by the end of residency (measured on a 7-point requirements of abortion provision and referral, 25.6% of Likert scale). See Table 4 for model details. We found a residents incorrectly responded that a physician was not trend towards increased intention to provide medical Fig. 1 Exposure to abortion in residency training programs in Canada Myran et al. BMC Medical Education (2018) 18:121 Page 5 of 8 Table 2 Mean scores of attitudes and demographics of residents stratified by intention to provide medical abortion Intender (148) Non-Intender (249) Mean (SD) Mean (SD) Positive attitudes towards abortion 6.39 (0.84) 4.28 (1.95) p < 0.001 Positive perceived social norms towards abortion provision 4.92 (1.16) 3.00 (1.48) p < 0.001 Anticipated ease of providing abortion 4.11 (1.52) 3.21 (1.46) p < 0.001 We defined positive intention as agree or strongly agree (6 or 7) on a 7 point Likert scale. There were 17 missing responses for intention abortion at the end of residency with increased amount during residency may be partially explained by its of formal education but no significant association. Each absence from the College of Family Physicians of Canada one-hour increase in informal education was associated (CFPC) list of 99 priority topics and the Medical Council with a 22% increase in the odds of expressing more of Canada (MCC) objectives for licensure [24, 25]. While positive intentions to provide medical abortion (p =0.014). we find the low levels of education and exposure to abortion concerning, we are further alarmed by the Discussion finding that one-quarter of respondents in our survey This study found that Canadian family medicine residents were unaware of ethical and legal requirements towards receive little education on, or exposure to abortion during abortion referral for non-providers. This finding suggests their family medicine training. However, respondents to that a substantial portion of graduating family medicine our survey generally held positive attitudes towards the residents may not provide the legally required standard provision of abortion and supported the inclusion of abor- of care. tion training in their post-graduate programs. Residents The positive association between exposure to abortion who received formal education on abortion showed a during training and self-expressed competency and non-significant trend towards increased intention to pro- intention to provide abortion is consistent with the litera- vide medical abortion in future practice, while increased ture. Previous studies of residents found that the number informal education was significantly associated with in- of manual vacuum aspirations performed in residency was creased intention to provide medical abortion. Residents positively correlated with intention to provide abor- who reported exposure to abortion during training were tions in future practice [11]. The association between more likely to intend to provide medical abortions, believe higher self-reported competency and intention to pro- that abortion should be part of postgraduate training and vide abortion for residents did not differ for residents believe that abortion provision was within the scope of who were exposed to abortion on an elective or on a practice for family physicians. regularly scheduled rotation. This comparison controls Our data on limited education and exposure are con- for selection bias, where individuals voluntarily ex- sistent with a 2002 study of family medicine residents in posed to abortion may differ from individuals who did Thunder Bay and Hamilton, Ontario, which found that not volunteer, and suggests that exposure may result in only 39.1% of residents reported education on abortion increased intention and competency in abortion provision, during residency [12]. The lack of abortion education regardless of initial interest. Table 3 Positive intention, scope of practice and competency by exposure to abortion during residency Exposed Not Exposed Relative Risk N =88 N = 325 Intend to provide: Medical abortion in future practice 61.7% (50/81) 31.7% (97/306) 1.95 (1.54–2.47) Surgical abortion in future practice 13.3% (11/83) 3.3% (10/304) 4.04 (1.78–9.22) Within scope of practice for family doctor: Medical abortion 93% (80/86) 76.9% (240/312) 1.21 (1.11–1.32) Surgical abortion 41.9% (36/86) 21.5% (67/312) 1.95 (1.40–2.70) Competency to: Counsel on abortion 83.7% (72/86) 70.6% (221/313) 1.19 (1.05–1.33) Provide a medical abortion 47.4% (41/86) 22% (69/313) 2.16 (1.60–2.93) Provide a surgical abortion 12.8% (11/86) 5.8% (18/310) 2.22 (1.09–4.53) We defined exposure as being exposed to 1 or more abortions during residency We defined positive intention, within scope of practice, and competent, as agree or strongly agree (6 or 7) on a 7 point Likert scale Myran et al. BMC Medical Education (2018) 18:121 Page 6 of 8 Table 4 Five ordinal logistic regression models fitting residents that the current lack of resident education on abortion intention to provide medical abortion in future practice with could limit potential improvements to abortion access in the amount of formal and informal education received on Canada from mifepristone. abortion, exposure to abortion, gender, and interaction Implementing abortion training in academic family between informal education and exposure medicine units is possible. Two studies have described the Odds Ratio (95% CI) P successful integration of abortion provision at Beth Israel Model 1. Formal education 1.07 (0.86–1.34) 0.512 Residency Program in New York, and at the University of Model 2. Informal education 1.22 (1.04–1.42) 0.014 New Mexico (UNM) despite facing cultural, logistic, finan- cial and political barriers. At UNM the authors credited the Model 3. Exposed 3.58 (2.29–5.60) < 0.0001 following elements for the program success; adding mife- Model 4. Female 2.00 (1.36–2.94) < 0.0001 pristone to the hospital formulary, normalizing manual vac- Model 5. Fully adjusted model with formal and informal education, uum aspiration by first introducing it for use in incomplete exposure, gender and interaction term. and missed spontaneous abortions, holding a values work- Exposed 5.52 (2.09–14.53) 0.001 shops emphasizing and patient-centred care, and reassur- Informal education 1.026 (0.81–1.28) 0.823 ance that staff with moral objections were not obligated to Female 1.84 (1.24–2.72) 0.002 participate [30]. Exposed * informal education 0.81 (0.54–1.21) 0.306 The results of the positive association between attitudes, Intention to provide medical abortion was measured on a 7-point likert scale perceived social norms and anticipated ease of provision with 7 being strongly intend to provide and 1 being strongly do not intend with intention to provide medical abortion is consistent to provide with predictions of the TPB. These results suggest that Education was measured as zero hours, less than one hour, one to two hours, two to three hours, and more than three hours efforts to promote positive social norms and reduce perceived logistic difficulties of abortion provision would The absence of a significant association between resi- result in increases intention by residents to provide abor- dents’ formal education and intention to provide abor- tion. We argue that departments of family medicine could tion was unexpected and merits further investigation. create positive social norms, decrease stigma associated One speculation is the majority of the limited formal with abortion provision, and increase abortion related education that residents receive may focus on ethical competency, by creating opportunities for routine clinical considerations of abortion rather than actual details of exposure to abortion for all residents. Evidence from pro- abortion provision. Prior work examining education on grams that have integrated abortion provision into resi- abortion in the medical school curriculum has found a dency training have found a shift towards more positive disproportionate focus on ethics over clinical knowledge social norms and attitudes regarding abortion [30, 31]. [26]. Further research is needed to examine the type of Academic programs would be more likely to educate and education on abortion that residents are receiving and expose residents to abortion if the Canadian College of how to better deliver impactful education on this topic. Family Medicine added abortion to their list of “99 priority Canadian women face several barriers to receiving abor- topics” as these topics form the backbone of the compe- tion care. The absence of trained providers in non-urban tency based curriculum in family medicine residency. communities limits access to this essential health service Further studies would be needed to see if education (3,4,5). Given that family physicians provide approximately and exposure interventions increased the actual number three in four therapeutic abortions in Canada and that the of abortion providers in Canada. number of Canadian providers may be declining [3, 7, 8] there is a need to train new family physicians to provide Limitations abortions. It is hoped that the recent Health Canada ap- Our study has several limitations including the proval of mifepristone will streamline the provision of cross-sectional design, low overall response rate, and medical terminations thus improving access to abortion self-report outcomes. While we found positive associa- [7, 27]. However, studies examining the introduction of tions between variables such as exposure and intentions mifepristone in the United States found that although to provide abortion as well as expressed competency to do rates of medical abortion increase, overall access did not so, we are unable to establish causal relationships given improve [28, 29]. While there are substantial cultural, the cross-sectional nature of the study. Future studies funding, and health systems differences between Canada could follow family medicine residents longitudinally and the United States with regards to abortion, lack of through training to better examine the impact of educa- education for providers appears to be a shared factor. In a tion and exposure on abortion related measures. study of New Mexico physicians, lack of training in The overall response rate of 28.7% and the lack of data medical abortion was the most commonly reported barrier from French language and Maritime programs were limita- to abortion provision [29]. We are similarly concerned tions to our study. Despite the low response rate, we believe Myran et al. BMC Medical Education (2018) 18:121 Page 7 of 8 that several factors support the validity of our findings. First, Availability of data and materials The datasets used and/or analysed during the current study are available overall trends did not differ from those observed at the from the corresponding author on reasonable request. University of Ottawa, which had over a 60% response rate, and other programs. Second, measures such as reported Authors’ contributions education and exposure reflect objective aspects of residency DM thought up the concept and methodology for the project, applied to REBs, co-conducted the background literature review, co-collected the data, participated programs and are thus less likelytobeimpactedby response in data analysis and interpretation, and co-wrote the final manuscript. JB assisted bias.Third,our respondents’ rate of religious or moral ob- with the development of the study concept and methodology, applied jections to abortion was consistent with previously reported REBs, co-conducted the background literature review, co-collected that data, participated in data analysis and interpretation and co-wrote the rates suggesting a representative sample [11, 14]. manuscript. TE participated in survey design by reviewing and editing survey Finally, all measures in the survey, including competency questions, participated in data analysis and interpretation and helped draft and which can be measured objectively, were self-reported. As review the final manuscript. KW participated in survey design by reviewing and editing survey questions, participated in REB application, and helped draft and residents may not be good judges or their own competency, review the final manuscript. All authors read and approved the final manuscript. and could be subject to social desirability bias, further research could focus on objective measurements of compe- Ethics approval and consent to participate tency for abortion provision. Participants were provided with a letter of information detailing that participation in survey was anonymous and voluntary and that completing the survey would indicate consent to participate in the study. The following Conclusions Research Ethics Boards granted approval for the study. Ottawa Health Science Network Research Ethics Board. Protocol # 20160173. Despite residents holding strongly positive views on University of Alberta Research Ethics Board. Study ID: Pro00063436. abortion family medicine training programs in Canada University of Saskatchewan REB File number 16–170. provide little education and exposure to abortion. The majority of family medicine residents do not feel competent Competing interests to provide abortion services. These findings are concerning The authors declare that they have no competing interests. given studies highlighting existing difficulties accessing abortion services in Canada. Multiple examples of success- Publisher’sNote ful integration of abortion training into family medicine Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. residency have been documented in the United States. 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Canada:Health Canada; 2015 [cited 2017 February 24]. Available from: https://srhr.org/abortion-policies/documents/countries/04-REGULATORY- DECISION-SUMMARY-MIFEGYMISO-2015.pdf. 28. Finer LB, Wei J. Effect of mifepristone on abortion access in the United States. Obstet Gynecol. 2009 Sept;114(3):623–30. 29. Espey E, Leeman L, Ogburn T, Skipper B, Eyman C, North M. Has mifepristone medical abortion expanded abortion access in New Mexico? A survey of OB- GYN and family medicine physicians. Contraception. 2011 Aug;84(2):178–83. 30. Leeman L, Espey E. You can’t do that 'round here;' a case study of the introduction of medical abortion care at a university medical center. Contraception. 2005 Feb;71(2):84–8. 31. Prine L, Lesnewski R, Bregman R. Integrating medical abortion into a residency practice. Fam Med. 2003 July-Aug;35(7):469–71. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Medical Education Springer Journals

Abortion education in Canadian family medicine residency programs

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Education; Medical Education; Theory of Medicine/Bioethics
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Abstract

Background: Abortion has been decriminalized in Canada since 1988 and is considered an essential medical service. There is concern that decreasing numbers of abortion providers may impair access to abortion. This study examined the quantity of exposure and education that Canadian family medicine residents receive on abortion during training and their preparation to provide abortions. In addition, the study assessed residents’ attitudes, intention and expressed competency to provide abortion in future practice and the association between medical training and changes in these factors. Methods: The authors developed a 21-item survey in consultation with experts in medical education. The survey was distributed online in 2016. A total of 1517 family medicine residents in their first, second and third year of training attending 8 English language schools across Canada were invited to participate. Associations between attitudes, education, exposure and intention were assessed using relative risks based on bivariate analysis of self-reported measures and odds ratios from ordered logistic regression. Results: The response rate was 28.7% (436/1517). The majority of residents, 79%, reported never observing or assisting with an abortion during training. Similarly, 80% of residents reported receiving less than 1 hour of formal education on abortion. Residents strongly supported receiving abortion education. Self reported exposure to a single abortion during training was associated with an increase in residents’ intention (RR = 1.95, 95% CI 1.54–2.47) and self- rated competency to provide a medical abortion (RR = 2.16, 95% CI 1.60–2.93). Twenty five percent of residents were unaware of ethical and legal requirements towards abortion provision and referral. Conclusions: Canadian family medicine residents receive little education or exposure to abortion during training most do not feel competent to provide abortion services. Residents expressed strong support for receiving abortion training. The Canadian College of Family Physicians curriculum does not currently include abortion as a training objective. The authors argue there is a need for family medicine training programs to increase education and exposure to abortion during residency, while respecting residents’ rights to opt out of such training. Failure to do so may impair future access to abortion provision. Keywords: Abortion training, Medical education, Family medicine residency, Medical abortion, Theory of planned behaviour Background However, women seeking access to abortion continue to Therapeutic abortion (TA), the intentional termination face several challenges including: lack of trained providers of a pregnancy, is a common procedure in Canada, with and participating hospitals, regional disparities in access 28 abortions performed per 100 live births [1]. Approxi- requiring long distance travel, inadequate provider and mately one in three Canadian women will have an abor- patient knowledge, and ongoing stigma towards abortion tion during her lifetime [2]. Abortion was decriminalized provision [3–5]. Similar trends of residual barriers to abor- in 1988, and is fully covered under provincial and terri- tion access despite decriminalization or legalization have torial health insurance as an essential health service [3]. been observed across the developed world [6]. A consist- ent finding has been that low numbers of providers and * Correspondence: Dmyra088@uottawa.ca Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Myran et al. BMC Medical Education (2018) 18:121 Page 2 of 8 lack of training opportunities significantly decrease the used in the prediction of future behaviour, to address the availability of abortion [6]. following objectives: [17, 18]. While there is no national information on the number and trends of abortion providers in Canada, data from 1) To examine the amount of education and exposure British Columbia (BC) shows a general decline in the residents receive on abortion number of providers, with up to a 50% reduction in rural 2) To assess learner attitudes, intentions, and providers in the past two decades [7]. The geographic anticipated-competency around the provision of accessibility of abortion is related to the number of pro- abortion care in their training and in practice viders. In 2006, only 15.9% of Canadian hospitals offered 3) To examine the association between attitudes, abortion services, the majority of which were in urban perceived social norms, and perceived logistical areas [8] and until February 2017 the province of Prince difficulty on residents’ intention to provide abortion. Edward Island had no abortion providers [4]. A study of 4) To examine the association between education and women seeking an abortion at a clinic in a major urban exposure on residents’ competency and intention center in Canada found that more than 15% of women towards abortion provision travelled between 101 and 1000 km to access an abortion provider. Indigenous, socioeconomically disadvantaged, and Methods younger women were disproportionately impacted [5]. Study setting Exposure to abortion during medical education is likely To answer our research questions, we designed a 21-item associated with whether physicians provide abortion later survey. Ethics approval was provided by the University of in practice [9–11]. One study of practicing American obste- Ottawa and the University of Alberta Research Ethics tricians found that exposure to abortion during training Boards (REB). We approached the departments of family strongly predicted whether obstetricians provided abortion medicine at all English language family medicine residency during practice [9]. Two studies, one of Canadian obstetrics programs in Canada that also had reciprocal REB agree- and gynecology residents, and one study of American ments with the University of Alberta and the University of family medicine residents, found that exposure to abor- Ottawa for permission to distribute our survey. Universities tion during training was positively associated with resi- that did not respond to invitations to participate or grant dents’ expressed intention to provide abortions in future permission to distributethesurveywerenot included practice [10, 11]. However, Canadian family medicine and in the study. In total, the University of Ottawa, University obstetrics residents may not be receiving exposure during of Toronto, Queen’s University, Western University, the training. A 2002 study found that the majority of Ontario Northern Ontario School of Medicine, University of family medicine residents and practicing physicians did Saskatchewan, University of Alberta, and University not feel adequately trained to offer medical or surgical of British Columbia participated in the study. See (procedural) abortions to their patients [12]. A recent Additional file 1: Appendix 1 for further details on study of Canadian Obstetrics and Gynecology residents exemption. found that 15% had received no training on abortion at all during residency, with an additional 34% reporting that Study population and sampling procedures abortion training occurred in their program only on a A total of 1517 family medicine residents currently enrolled voluntary opt-in basis [13]. Similarly, two recent studies in postgraduate year one, two and, three were eligible for that surveyed medical school classes in Ontario and BC study participation. Collectively the schools that partici- found that respondents had limited knowledge of abortion pated enrolled 46.5% (1517 / 3265) of the country’sfamily [14] and relatively few expressed intention to provide medicine residents. The survey was administered online abortion in future practice [15]. using the survey platform ‘Fluid Surveys™’. Participation Family doctors currently perform the majority of abor- was anonymous and voluntary, with survey completion tions in Canada, with the percentage of abortions provided implying consent. Eligible participants were recruited by this group increasing over time [16]. In 2014–2015, fam- by email, in-class announcements and social media posts. ily doctors provided 75.5% of the 86,824 reported TAs [16]. University specific recruitment emails were sent on behalf Consequently, the training and exposure that family medi- of the researchers by the family medicine departments at cine residents receive during residency may be of consider- each university, with the exception of the University of able importance to future access to abortion. Toronto which posted an invitation to the survey in their To our knowledge, this is the first study to examine monthly newsletter. Universities sent up to two follow up national education, exposure, intention and self-expressed emails reminding residents to participate in the survey. Fur- competency of Canadian family medicine residents with ther details on study recruitment can be seen in Additional regards to abortion. We used the Theory of Planned file 1: Appendix 1. Participants were entered into a draw to Behaviour (TPB), a well-validated social psychology theory win one of three $20 gift certificates. Myran et al. BMC Medical Education (2018) 18:121 Page 3 of 8 Survey development and data collection results, was made to divide intention responses into We used the Theory of Planned Behaviour (TPB) as a “intenders” and “non-intenders” with intenders answering 6 framework for survey design [17, 18]. The theory holds or 7 on the Likert scale and non-intenders answering 1–5 that intentions to engage in a behaviour are the strongest on the Likert scale when conducting bivariate analysis predictor of that future behaviour. Individual intention is between exposure and intention and the components of best predicted by personal attitudes, how an individual per- the TRA and intention. We created a binary variable for ceives their community social norms, and the degree that a exposure (yes/no), where residents who observed, assisted person feels they are able to perform the behaviour of inter- with or performed one or more medical or surgical abor- est. The TPB is accepted as being a strong predictor of tions were considered exposed. We used Chi-square tests future behaviour, including health and physician-related be- to examine the relationships between exposure to abortion havior [19, 20]. Questions from previous surveys examining and intention and self expressed competency. We calcu- abortion education were adapted with the aid of content lated the Relative Risk (RR) based on the self-reported experts in medical education and reproductive health to de- measures. We fit ordered logistic regressions to assess the termineexposuretoabortion in Canadian family medicine association between education, exposure, and intention to programs [9, 10, 15, 21]. The survey was piloted with five provide medical abortions and included interaction terms family medicine residents for feedback and administered to test for effect measure modification. between April 26th and June 26th, 2016. Results Measures of interest Response rate and respondent characteristics The main measures in our study were as follows (see We received 436 responses for an overall response rate Additional file 2: Appendix 2 for a copy of the survey of 28.7%. Twenty-two participants were excluded for with all measures including attitudes, social norms and completing less than 50% of the survey, one individual perceived behavioral control): who had indicated they attended a school which had not consented to participation was also excluded, with – Education: Education was assessed with two a final 413 (27.2%) responses retained for data analysis. questions: “In your residency so far, how many See Additional file 1: Appendix 1 for the response rate hours of teaching on abortion provision did you by school. We report characteristics of our respondents have in A) a formal academic setting (lecture, in Table 1. The gender breakdown and mean age of academic day presentation, online learning module participants in our study were comparable to the etc) B) an informal setting (case discussions, bedside reported national averages for family medicine residents or in clinic teaching, informal presentations)”. in 2014–2015 [22, 23]. Respondents were also presented with a short case with multiple choice responses to assess their knowledge of professional requirements. – Exposure: Exposure to abortion was measured with Table 1 Respondent characteristics the question “During your family medicine residency N (%)/Mean training have you assisted with or performed a Age 29.62 (SD 3.95) medical or surgical abortion?” Residents were Gender considered exposed if they answered yes. Male 123 (29.9%) – Intention to provide medical and surgical abortion: Female 289 70.1%) Intention was assessed using a 7-point Likert scale Planned future practice size: with the following questions “I intend to provide medical abortions in my future practice” and “I intend Rural population 9999 or less 64 (15.5%) to provide surgical abortions in my future practice.” Small town/city between 10,000 and 99,999) 138 (60.9%) – Self-reported competency: This measure was assessed Urban population greater than 100,000 187 (23.6%) using a 7-point Likert scale with the following three Year of Training questions “By the end of residency, I expect to be PGY-1 201 (48.6%) competent to: A) Counsel women about abortion B) PGY-2 202 (48.7%) Perform medical abortions C) Perform at least one method of surgical abortions. PGY-3 11 (2.7%) Religious/moral objections to abortion Analysis of data Yes 73 (17.9%) All analyses were conducted using SPSS Statistics version No 334 (82.1%) 24. An a priori decision, to simplify interpretation of the Myran et al. BMC Medical Education (2018) 18:121 Page 4 of 8 Education and exposure to abortion during residency required to refer to another provider if the physician was Fifty-seven percent of residents reported receiving no personally opposed to abortion provision. formal education on abortion and 80.2% received less than 1 hour during training. Twenty-seven percent of Exposure to abortion during residency and intention and residents reported receiving no informal education on self-expressed competency to provide abortion abortion and 64.2% received less than 1 hour. Twenty-two Exposure to abortion during residency was significantly percent of residents reported receiving no education, for- associated with positive intentions to provide medical and mal or informal, during their training, and 45.7% reported surgical abortion, belief that abortion was within the scope receiving less than 1 hour. of practice of family doctors and residents’ self-expressed We report the amount of exposure to abortion by competence to counsel on and provide abortions, see university in Fig. 1. Twenty-one percent of residents re- Table 3 and Table 4. Students who were exposed to ported being exposed to one or more abortions during abortion during a routine or elective rotation did not residency. Of those exposed, 63.1% reported that their differ significantly in their intention to provide medical experiences occurred during a routine, scheduled rota- abortion (54.8% elective, vs 50% routine, Pearson tion. The remainder reported that exposure to abortion chisquare = 0.1821 p = 0.670) or their anticipated compe- occurred during an elective rotation. tency to provide medical abortion (48.39% elective vs 46.15% routine, Pearsons chisquare = 0.0389 Pr = 0.844). Attitudes towards abortion and medical education on Education on abortion during residency and intention abortion and intention to provide abortion and self-expressed competency to provide abortion Sixty-one percent of residents in our survey very strongly We compared the self-reported competency of first and or strongly supported receiving abortion training during second year residents to provide a medical abortion by residency. Table 2 shows a bivariate analysis of residents’ the end of residency. Residents in their second year of attitudes, social norms and perceived behavioural control, training (19.1%) were significantly less likely to report factors outlined in the TPB, stratified by intention to feeling competent to provide a medical abortion com- provide a medical abortion in future practice. Having pared to first year residents (36%) (Pearsons chi-square positive attitudes, perceiving positive social norms, and 14.83 p = 0.001). anticipating relative ease of providing an abortion were all We fit ordinal logistic regressions to examine the asso- significantly associated with increased resident intention ciation between formal education, informal education, to provide medical abortion in future practice. When gender, and exposure on intention to provide medical presented with a short case addressing professional abortion by the end of residency (measured on a 7-point requirements of abortion provision and referral, 25.6% of Likert scale). See Table 4 for model details. We found a residents incorrectly responded that a physician was not trend towards increased intention to provide medical Fig. 1 Exposure to abortion in residency training programs in Canada Myran et al. BMC Medical Education (2018) 18:121 Page 5 of 8 Table 2 Mean scores of attitudes and demographics of residents stratified by intention to provide medical abortion Intender (148) Non-Intender (249) Mean (SD) Mean (SD) Positive attitudes towards abortion 6.39 (0.84) 4.28 (1.95) p < 0.001 Positive perceived social norms towards abortion provision 4.92 (1.16) 3.00 (1.48) p < 0.001 Anticipated ease of providing abortion 4.11 (1.52) 3.21 (1.46) p < 0.001 We defined positive intention as agree or strongly agree (6 or 7) on a 7 point Likert scale. There were 17 missing responses for intention abortion at the end of residency with increased amount during residency may be partially explained by its of formal education but no significant association. Each absence from the College of Family Physicians of Canada one-hour increase in informal education was associated (CFPC) list of 99 priority topics and the Medical Council with a 22% increase in the odds of expressing more of Canada (MCC) objectives for licensure [24, 25]. While positive intentions to provide medical abortion (p =0.014). we find the low levels of education and exposure to abortion concerning, we are further alarmed by the Discussion finding that one-quarter of respondents in our survey This study found that Canadian family medicine residents were unaware of ethical and legal requirements towards receive little education on, or exposure to abortion during abortion referral for non-providers. This finding suggests their family medicine training. However, respondents to that a substantial portion of graduating family medicine our survey generally held positive attitudes towards the residents may not provide the legally required standard provision of abortion and supported the inclusion of abor- of care. tion training in their post-graduate programs. Residents The positive association between exposure to abortion who received formal education on abortion showed a during training and self-expressed competency and non-significant trend towards increased intention to pro- intention to provide abortion is consistent with the litera- vide medical abortion in future practice, while increased ture. Previous studies of residents found that the number informal education was significantly associated with in- of manual vacuum aspirations performed in residency was creased intention to provide medical abortion. Residents positively correlated with intention to provide abor- who reported exposure to abortion during training were tions in future practice [11]. The association between more likely to intend to provide medical abortions, believe higher self-reported competency and intention to pro- that abortion should be part of postgraduate training and vide abortion for residents did not differ for residents believe that abortion provision was within the scope of who were exposed to abortion on an elective or on a practice for family physicians. regularly scheduled rotation. This comparison controls Our data on limited education and exposure are con- for selection bias, where individuals voluntarily ex- sistent with a 2002 study of family medicine residents in posed to abortion may differ from individuals who did Thunder Bay and Hamilton, Ontario, which found that not volunteer, and suggests that exposure may result in only 39.1% of residents reported education on abortion increased intention and competency in abortion provision, during residency [12]. The lack of abortion education regardless of initial interest. Table 3 Positive intention, scope of practice and competency by exposure to abortion during residency Exposed Not Exposed Relative Risk N =88 N = 325 Intend to provide: Medical abortion in future practice 61.7% (50/81) 31.7% (97/306) 1.95 (1.54–2.47) Surgical abortion in future practice 13.3% (11/83) 3.3% (10/304) 4.04 (1.78–9.22) Within scope of practice for family doctor: Medical abortion 93% (80/86) 76.9% (240/312) 1.21 (1.11–1.32) Surgical abortion 41.9% (36/86) 21.5% (67/312) 1.95 (1.40–2.70) Competency to: Counsel on abortion 83.7% (72/86) 70.6% (221/313) 1.19 (1.05–1.33) Provide a medical abortion 47.4% (41/86) 22% (69/313) 2.16 (1.60–2.93) Provide a surgical abortion 12.8% (11/86) 5.8% (18/310) 2.22 (1.09–4.53) We defined exposure as being exposed to 1 or more abortions during residency We defined positive intention, within scope of practice, and competent, as agree or strongly agree (6 or 7) on a 7 point Likert scale Myran et al. BMC Medical Education (2018) 18:121 Page 6 of 8 Table 4 Five ordinal logistic regression models fitting residents that the current lack of resident education on abortion intention to provide medical abortion in future practice with could limit potential improvements to abortion access in the amount of formal and informal education received on Canada from mifepristone. abortion, exposure to abortion, gender, and interaction Implementing abortion training in academic family between informal education and exposure medicine units is possible. Two studies have described the Odds Ratio (95% CI) P successful integration of abortion provision at Beth Israel Model 1. Formal education 1.07 (0.86–1.34) 0.512 Residency Program in New York, and at the University of Model 2. Informal education 1.22 (1.04–1.42) 0.014 New Mexico (UNM) despite facing cultural, logistic, finan- cial and political barriers. At UNM the authors credited the Model 3. Exposed 3.58 (2.29–5.60) < 0.0001 following elements for the program success; adding mife- Model 4. Female 2.00 (1.36–2.94) < 0.0001 pristone to the hospital formulary, normalizing manual vac- Model 5. Fully adjusted model with formal and informal education, uum aspiration by first introducing it for use in incomplete exposure, gender and interaction term. and missed spontaneous abortions, holding a values work- Exposed 5.52 (2.09–14.53) 0.001 shops emphasizing and patient-centred care, and reassur- Informal education 1.026 (0.81–1.28) 0.823 ance that staff with moral objections were not obligated to Female 1.84 (1.24–2.72) 0.002 participate [30]. Exposed * informal education 0.81 (0.54–1.21) 0.306 The results of the positive association between attitudes, Intention to provide medical abortion was measured on a 7-point likert scale perceived social norms and anticipated ease of provision with 7 being strongly intend to provide and 1 being strongly do not intend with intention to provide medical abortion is consistent to provide with predictions of the TPB. These results suggest that Education was measured as zero hours, less than one hour, one to two hours, two to three hours, and more than three hours efforts to promote positive social norms and reduce perceived logistic difficulties of abortion provision would The absence of a significant association between resi- result in increases intention by residents to provide abor- dents’ formal education and intention to provide abor- tion. We argue that departments of family medicine could tion was unexpected and merits further investigation. create positive social norms, decrease stigma associated One speculation is the majority of the limited formal with abortion provision, and increase abortion related education that residents receive may focus on ethical competency, by creating opportunities for routine clinical considerations of abortion rather than actual details of exposure to abortion for all residents. Evidence from pro- abortion provision. Prior work examining education on grams that have integrated abortion provision into resi- abortion in the medical school curriculum has found a dency training have found a shift towards more positive disproportionate focus on ethics over clinical knowledge social norms and attitudes regarding abortion [30, 31]. [26]. Further research is needed to examine the type of Academic programs would be more likely to educate and education on abortion that residents are receiving and expose residents to abortion if the Canadian College of how to better deliver impactful education on this topic. Family Medicine added abortion to their list of “99 priority Canadian women face several barriers to receiving abor- topics” as these topics form the backbone of the compe- tion care. The absence of trained providers in non-urban tency based curriculum in family medicine residency. communities limits access to this essential health service Further studies would be needed to see if education (3,4,5). Given that family physicians provide approximately and exposure interventions increased the actual number three in four therapeutic abortions in Canada and that the of abortion providers in Canada. number of Canadian providers may be declining [3, 7, 8] there is a need to train new family physicians to provide Limitations abortions. It is hoped that the recent Health Canada ap- Our study has several limitations including the proval of mifepristone will streamline the provision of cross-sectional design, low overall response rate, and medical terminations thus improving access to abortion self-report outcomes. While we found positive associa- [7, 27]. However, studies examining the introduction of tions between variables such as exposure and intentions mifepristone in the United States found that although to provide abortion as well as expressed competency to do rates of medical abortion increase, overall access did not so, we are unable to establish causal relationships given improve [28, 29]. While there are substantial cultural, the cross-sectional nature of the study. Future studies funding, and health systems differences between Canada could follow family medicine residents longitudinally and the United States with regards to abortion, lack of through training to better examine the impact of educa- education for providers appears to be a shared factor. In a tion and exposure on abortion related measures. study of New Mexico physicians, lack of training in The overall response rate of 28.7% and the lack of data medical abortion was the most commonly reported barrier from French language and Maritime programs were limita- to abortion provision [29]. We are similarly concerned tions to our study. Despite the low response rate, we believe Myran et al. BMC Medical Education (2018) 18:121 Page 7 of 8 that several factors support the validity of our findings. First, Availability of data and materials The datasets used and/or analysed during the current study are available overall trends did not differ from those observed at the from the corresponding author on reasonable request. University of Ottawa, which had over a 60% response rate, and other programs. Second, measures such as reported Authors’ contributions education and exposure reflect objective aspects of residency DM thought up the concept and methodology for the project, applied to REBs, co-conducted the background literature review, co-collected the data, participated programs and are thus less likelytobeimpactedby response in data analysis and interpretation, and co-wrote the final manuscript. JB assisted bias.Third,our respondents’ rate of religious or moral ob- with the development of the study concept and methodology, applied jections to abortion was consistent with previously reported REBs, co-conducted the background literature review, co-collected that data, participated in data analysis and interpretation and co-wrote the rates suggesting a representative sample [11, 14]. manuscript. TE participated in survey design by reviewing and editing survey Finally, all measures in the survey, including competency questions, participated in data analysis and interpretation and helped draft and which can be measured objectively, were self-reported. As review the final manuscript. KW participated in survey design by reviewing and editing survey questions, participated in REB application, and helped draft and residents may not be good judges or their own competency, review the final manuscript. All authors read and approved the final manuscript. and could be subject to social desirability bias, further research could focus on objective measurements of compe- Ethics approval and consent to participate tency for abortion provision. Participants were provided with a letter of information detailing that participation in survey was anonymous and voluntary and that completing the survey would indicate consent to participate in the study. The following Conclusions Research Ethics Boards granted approval for the study. Ottawa Health Science Network Research Ethics Board. Protocol # 20160173. Despite residents holding strongly positive views on University of Alberta Research Ethics Board. Study ID: Pro00063436. abortion family medicine training programs in Canada University of Saskatchewan REB File number 16–170. provide little education and exposure to abortion. The majority of family medicine residents do not feel competent Competing interests to provide abortion services. These findings are concerning The authors declare that they have no competing interests. given studies highlighting existing difficulties accessing abortion services in Canada. Multiple examples of success- Publisher’sNote ful integration of abortion training into family medicine Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. residency have been documented in the United States. We argue that there is an urgent need for family medicine Received: 18 July 2017 Accepted: 23 May 2018 programs across the country to develop and integrate education and clinical exposure on abortion provision References into training. Medical education programs should focus 1. Statistics Canada. Induced abortions [Internet]. Canada: The Daily; 2008 on normalizing abortion provision through routine clinical [updated 2008 May 21; cited 2017 February 24]. Available from: exposure for family medicine residents, while respecting http://www.statcan.gc.ca/daily-quotidien/080521/dq080521c-eng.htm. 2. Norman WV. Induced abortion in Canada 1974-2005: trends over the first individual residents’ rights to opt out of training. generation with legal access. Contraception. 2012;85(2):185–91. 3. Sabourin JN, Burnett M. A review of therapeutic abortions and related areas Additional files of concern in Canada. J Obstet Gynaecol Can. 2012;34(6):532–42. 4. Norman WV, Guilbert ER, Okpaleke C, et al. 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BMC Medical EducationSpringer Journals

Published: Jun 1, 2018

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