Acute care surgery’s role in expanding the surgical workforce in Latin America

In the April issue of the Bulletin, “Using global surgical indicators to improve trauma care in Latin America” introduced readers to the relationship between The Lancet Commission on Global Surgery’s (LCoGS) core surgical indicators and specific components of trauma program and systems development in Latin America.¹ An article in the July issue of this publication centered on prehospital care using a trauma systems application of LCoGS indicator 1 (LCoGS I-1).² This month, the authors explore the link between LCoGS indicator 2 (LCoGS I-2), workforce and acute care surgery education and training, as well as acute care surgery’s role in responding to World Health Assembly (WHA) Resolution 68.15.

Global preparedness for surgical care delivery

Access to surgical care is paramount to improving health care systems in resource-poor settings. Mounting evidence highlights the health, economic, and welfare inequities that result from inadequate access to surgical care. The LCoGS created indicators to track progress toward surgical care equity and universal access to surgery, and those indicators fall into three categories: preparedness, delivery, and impact (see Table 1).³

Table 1. LCoGS core indicators and associated trauma program/system elements

Category	LCoGS indicator	Description	Proposed trauma program/ system element focus
Preparedness	1	The geographic accessibility of surgical facilities	Prehospital system and integration with hospital registry
	2*	The density of specialist surgical providers	Acute care surgeon/fellowships; trauma program manager
Delivery	3*	The number of surgical procedures provided per 100,000 population	Trauma and emergent/essential hospital/societal registries
	4	30-day perioperative mortality rates	Trauma and emergent/essential hospital/societal registries, formal trauma performance improvement and patient safety, and trauma morbidity/mortality review process
Impact	5*	The risk of impoverishing expenditure when surgery is required	Future work—ministries of health/education/finance and trauma/acute care surgery divisional business administration
	6*	The risk of catastrophic expenditure when surgery is required	Future work—ministries of health/education/finance and trauma/acute care surgery divisional business administration

*World development indicators

At the 2015 68th WHA—the meeting during which the World Health Organization (WHO) established its top health policy priorities—strengthening emergency and essential surgical care was highlighted as a critically important component of universal health coverage through the passage of WHA Resolution 68.15.⁴ The resolution urged both member states and national-level leadership to prioritize emergency and essential surgery services by enacting significant improvements to the provision, access, monitoring, and policies regarding surgical care (see Table 2). With the increased role of global surgery in public health, the challenge will now be to accurately characterize the surgical capability—or capacity—of individual regions to provide universal coverage. One of the first steps toward addressing the capacity limitations in Latin America is to provide access to education and training opportunities that augment the surgical workforce. The LCoGS attempted to address the capacity issue first by suggesting a framework to strengthen national surgical systems. Its recommendations resulted in the six indicators in the aforementioned three categories.

Table 2. Highlights of the WHA Resolution 68.15 recommendations to member states and requests to the director-general

Member states

Identify, prioritize, and implement methods to foster universal accessibility

Promote capacity and accessibility in first-referral facilities

Promote collaboration and a leadership role for health ministries in strengthening the provision

Promote access to effective and affordable medication, antibiotics, and diagnostics

Consistently evaluate capacity to identify gaps in infrastructure, resources, and training

Collect reliable data, including outcomes

Strengthen infection control

Develop policies that ensure minimum standards in workforce, equipment, infrastructure, supplies, and quality improvement

Create interdisciplinary education and training programs consistent with relevant core competencies

Director-general

Facilitate multidisciplinary collaboration in developing science-based approaches to prevention, screening, and implementation

Facilitate collaboration among member states to exchange information and technology

Promote cost-effective solutions to improve morbidity/mortality outcomes

Collect reliable data to better understand gaps in care and improve capacity

Establish safe access to care and consistent risk adjustment

Collect reliable cost data to assess economic impact

Support member states in policy development, and delivery of medicine, devices, and diagnostics

Support member states developing legislation mitigating misuse, diversion, and trafficking of medicines

Work with international organizations to established balanced control of controlled medicines

Work with international organizations to develop strategies to estimate the availability of medicines

Support member states in improving skills of the health workforce

Set aside adequate resources for the secretariat to strengthen care

Support member states designing strategies to mobilize adequate resources

Report to 70th WHA

The first two indicators are in the preparedness category: LCoGS I-1, timely access to care, and LCoGS I-2, the workforce density of surgery, anesthesia, and obstetrics (SAO) providers per 100,000 national population. The discussion that follows focuses on strengthening Latin America’s emergent and essential surgical workforce. To accomplish this, the proposed strategy is to expand the role of acute care surgery—an evolving specialty that includes three essential components: trauma, critical care, and emergency surgical care. We show that the workforce can be buttressed through an emphasis on education and training to scale up sustainable infrastructure with respect to preparedness LCoGS I-2 2030 targets.

Emergent and essential surgery workforce in Latin America

LCoGS I-2 is the most intuitive indicator—that is, national surgical capacity is reliant on the number of providers with operative and anesthetic capabilities. The LCoGS recommends that low- and middle-income countries (LMICs) set a target of 20 to 40 SAO providers per 100,000 people. The combined efforts of the LCoGS and the WHO have led to an assessment of SAO workforce density in 31 Latin American and Caribbean countries (176 countries total).⁵ The surgical workforce is commonly assessed via national data banks that document registered SAOs and/or extrapolation from survey studies. These methods include a mixture of subjective and objective sources, such as health care facility capacity surveys (for example, personnel, infrastructure, procedures, equipment, and supplies [PIPES]), and records from licensing boards, health departments, professional societies, and ministries.

These survey methods frequently fall short of capturing location-specific complexities that can significantly augment the surgical workforce. For example, regional dispersion tends to be heterogeneous within countries; in effect, the misdistribution of capable surgeons and educators only becomes apparent when assessing rural and urban areas separately. Scheffer and colleagues showed that although Brazil has an overall surgical workforce density of 46.55/100,000 population, a tremendous disparity exists between the northern (20.21/100,000), southern (60.31/100,000), and the Amazonian (< 1/100,000) regions.⁶

Another consideration is how countries use midlevel and other allied health care professionals. Several LMICs have incorporated models in which midlevel providers deliver varying amounts of surgical care—task sharing—that may include basic operative services. Some nonclinical examples also include the acute care teams that address emergent and essential surgical disease in Colombia, and a newer consideration for the role trauma nursing managers may play in strengthening trauma program management.⁷ Ultimately, for many LMICs, it will be impossible to meet the goals of WHA resolution 68.15 without considering comprehensive, interprofessional data on LCoGS I-2, and more specifically, how these data relate to a region’s ability and outcomes in addressing emergency surgical disease within its population.

Until now, we have considered a region’s surgical capacity as a raw number or density, which, of course, runs the risk of missing what provider capacity means. Use of provider density as a measure of capacity is both a quantitative and qualitative issue. Studies should begin characterizing the types of providers within a region to better determine the demand for specialized care and how implementation of prerequisite education, training, background, and experience can best occur within its own health system. The salient information regarding the surgical workforce then is not only the number of surgical care providers who are available, but also, and perhaps more importantly, details that potentiate the infrastructure and surgical system administrative leadership that generates the emergent and essential surgery preparedness. Indeed, a large proportion of surgical disease and death in many Latin American and other resource-limited countries is due to injury, which is promulgated by deficient trauma systems. Addressing this problem prompted a recent rise in acute care surgery development in Latin America, and stems from the historical vision and mission of the Panamerican Trauma Society (PTS).

Acute care surgery in North America

Implementing and expanding an acute care surgery specialty in North America was in response to an identified workforce crisis in on-call emergent and essential surgery coverage, and specifically to address “hospital-based emergency care at its breaking point,” a “worsening workforce in general surgery,” and “insufficient number of surgeons in emergency call
panels.”^8-12 Major North American trauma organizations, including the American College of Surgeons (ACS) Committee on Trauma (COT), the Western Trauma Association (WEST), the Eastern Association for the Surgery of Trauma (EAST), and the American Association for the Surgery of Trauma (AAST), joined forces and formed an ad hoc committee under AAST’s aegis in 2003, which ultimately led to the development of the reorganized curriculum of critical care, trauma, and emergency surgery, and formalized education and training for an acute care surgery specialty.¹³ Almost two decades later, the AAST Acute Care Surgery Committee recently guided education and training innovation in 2015 by approving the first global surgery electives in which North American acute care surgery fellows acquire concentrated short-term training under the direction of recognized Colombian and South African acute care surgeons in their care settings.

The first formal North American AAST/ACS-developed acute care fellowship was offered in 2008 at the University of Nevada School of Medicine, Las Vegas, and has since expanded to more than 20 fully accredited programs with more in the certification pipeline.^9,14 After completion of a two-year acute care surgery fellowship, candidates are double boarded by the American Board of Surgery (ABS) in general surgery and surgical critical care, possess both a trauma training certificate and an AAST acute care surgery fellowship certificate (if AAST-accredited program), and have an educational foundation in the extensive processes and maintenance required for continued trauma center verification by the ACS COT.

Training in acute care surgery covers a spectrum of surgical disciplines, including elective general surgery and emergency surgery in trauma, critical care, orthopaedic, neurosurgical, thoracic, vascular, and soft-tissue surgery. Importantly, training focuses not only on the technical aspects of multiple organ surgery, but also emphasizes the education and training to expand the workforce in emergent and essential care through a systems-based regional inclusive approach to surgical disease management. In other words, care is coordinated through close collaboration between multiple components, including tiered-level surgical care centers within a defined region. As a result, ACS COT-verified trauma programs demonstrate a capacity to collectively optimize care at the state and/or national level across the continuum of care from the prehospital setting to discharge and rehabilitation. Learning the ins and outs of this capacity is valuable to the young surgeon entering today’s local and global surgical workforce.

Education and training in Latin America

A lack of access and provider shortages in emergent and essential surgery (including trauma) have recently stimulated the development of a Latin American acute care surgery practice model, as well as the need for formal education and training programs. Acute care surgeons have helped to strengthen emergent and essential surgery education and training in Latin America since the PTS was established 30 years ago.15 Past-presidents and executives of the PTS have held simultaneous leadership roles in major North American academic surgical societies, like the ACS and AAST, and provided great synergy for an Americas acute care surgery professional roadmap. An acute care surgery curriculum that is standardized across North, Central, and South American academic institutions could engender interest among young surgeons in surgical specialties that bridge the existing surgical workforce gaps in resource-poor settings through reciprocal transnational rotations and shared curriculum structure.

The first two-year Latin American acute care surgery fellowship of which the authors are aware was initiated in 2013 in Cali, Colombia. A core group of leaders in several countries have focused on multidisciplinary efforts to strengthen the North, Central, and South American emergent and essential surgery workforce, education, and training through such examples of an acute care surgery academic implementation. Bidirectional and transnational efforts to better support growth and capacity as it relates to formalizing such programs has scaled up in recent years, perhaps partly as a result of the global surgery movement, but certainly through sustainable acute care surgery partnerships between the Americas.

Despite the establishment of newer fellowships, competency-based goals and objectives in emergent and essential surgery education and training programs at the graduate level still need development. In fact, formalization of surgical underrepresented and/or underreported in Latin America, perhaps because of the overwhelming emergent and essential clinical demand or workforce shortage of local educators and incomplete integration of Latin America trauma/acute care surgical societies with other specialty surgical societies at the national level. For example, the Brazilian Medical Association recognizes neither trauma nor acute care surgery as a surgical specialty, even though the Brazilian Trauma Society has sought to improve awareness of these practice areas. This lack of recognition is not due to a lack of regional interest, as the Brazilian College of Surgeons’ annual congress comprises several panel discussions on emergent and essential surgery, and attendance at these sessions is high among general surgeons and residents. A full spectrum of young persons’ interest exists, and in fact, the medical student involvement represented by the work of the Brazilian trauma leagues in emergent and essential surgery education is exemplary.

North, Central, and South American acute care surgeons and nurses in the ACS and the PTS have conducted various emergent and essential training courses and programs in Latin America. PTS members annually host Advanced Trauma Life Support (ATLS^®), Advanced Trauma Operative Management (ATOM^®), Advanced Surgical Skills for Exposure in Trauma (ASSET^®), and Definitive Surgical Trauma Care courses, as well as additional programs listed in Table 3. Lowering or eliminating financial barriers for trainees, physicians, and surgeons in LMICs to attend such courses has been a primary focus of PTS collaborations and is a response to insufficient government action to scale up local education and training. In Ecuador, an ATLS course may be cost-prohibitive at upward of 80 percent of the monthly salary for a trauma surgeon in Quito working within the public/government hospital, with no cost offset despite the surgeon and hospital owning the bulk of its societal trauma volume burden for the capital city. The PTS therefore has forgone fees associated with initiating nursing courses, for example,⁷ sharing with the ACS spirit of waived registration fees and donated teaching materials for medical student-level courses such as the Trauma Evaluation and Management (TEAM) course for Cuba. In fact, the Advanced Medical Response to Disasters course, as well as the Ultrasound in Emergency and Trauma and the Trauma Nursing courses, became a part of the Fourth International Symposium on Trauma hosted by the Cuban Society of Surgery-Trauma Section, in Havana, May 2017. The positive didactic impact of these experiences was presented at the 2017 ACS COT International Injury Care Committee meeting in Washington, DC. This was a particularly important statement for Cuba given its long tradition of training medical students and residents from many different LMICs throughout Latin America, Africa, and Asia, and because Cuba is home to the largest medical school in the world, ELAM (Escuela Latinoamericana de Medicina), the Latin American School of Medicine, specifically dedicated to a tuition-free mission of expansion of the global workforce. In light of the fact that nearly 30 percent of the student body enrolled in the first TEAM course at the Faculty of Medical Sciences in Havana were from other countries (Angola, South Africa, Colombia, and Germany, among others), the ACS is ensuring the dissemination of high-quality emergency and essential surgery education and training propelled by such international students, as well as the Cuban graduates who participate in international medical missions. Recent education and training activities that are applicable to emergent and essential surgical care workforce at the citizen level include the ACS Stop the Bleed^® course, which is delivered collaboratively by Latin American colleagues who serve on the ACS COT international committees.

Table 3. PTS Multidisciplinary Training Courses

Advanced disaster medical response: Train multidisciplinary medical personnel in the basics of disaster medical management of specific disaster scenarios Essential trauma course: Deliver a systematic approach to the management of patients who sustain traumatic injuries in resource-limited areas Burn management: Review guidelines for burn management according to local facilities Transthoracic echocardiography course: Teach technique of echocardiogram for the evaluation of the fluid status and cardiac function of critically ill patients Surgical skills: Discuss and practice the diverse surgical techniques used in trauma using live animal models Trauma nursing: Train hospital nurses to classify, monitor, care for, and supervise the management of injured patients Trauma quality improvement (QI): Promote a better understanding of QI, provide training in straightforward and practical techniques, such as preventable death reviews, and discuss ideas for future development of trauma QI Ultrasound in emergency and trauma basic: Train staff who manage patients needing trauma and other emergency care in management of emergency ultrasound

Call to action

Measuring and meeting a projected workforce estimate will require better characterization of the specific local education and training paradigms that exist, as well as their matriculation and program output. The WHO global surgery workforce database is an example of an effort to understand present and projected needs to train emergent and essential care professionals.¹⁶ A 2017 PTS Education Committee survey aims to identify the specific and ongoing need from individual Latin American countries for formal emergent and essential education and training. For a meaningful way forward, the PTS is referring to the LCoGS Workforce, Education, and Training Working Group to provide an overview for emergent and essential surgery in Latin America (see Table 4). The 2015 LCoGS terms of reference document outlines the current state of the surgical workforce and sets out to describe how to ensure a continuous supply of health care professionals and to determine how to maintain high standards of care regardless of the location or time of day. To appropriately expand the surgical workforce in Latin America, the following key stakeholders must form partnerships with both private and public entities to champion a balance between the costs of education and training and the safeguarding of universal access to health care that is not profit-driven:

• Governments (Ministries of Health, Finance, Education, and Labor)
• WHO
• Multilateral/bilateral organizations (World Bank, U.S. Agency for International Development)
• Private foundations
• Education bodies (training colleges, societies, congresses, and so on)
• Academic and professional entities
• Industry

Table 4. LCoGS Working Group terms of reference

Workforce	Numbers (surgical and anesthesia density)
	Distribution (for example, LMIC vs. HIC, rural vs. urban, public vs. private)
	Access and barriers
Education and training	Tools (curriculum, structure, education materials, accreditation of training programs, ethical HIC-LMIC relationships)
	Barriers and approaches to overcome
	Measure the efficacy of these programs
Supply and demand	Establish workforce numbers independently by discipline
	Dynamics that lead to shifts in supply and demand
	Remuneration: public vs. private
	Metrics to measure success and failure
Task shifting/sharing	Identify middle level providers
	Task shifting vs. task sharing
	Appropriate supervision/monitoring
	Barriers to care

It is anticipated that these efforts will result in the engagement of both public and private institutions that can take on the responsibility of funding acute care surgery education and training as a public health service, as well as cost-effectiveness. An investment in measuring the value of acute care surgery education and training to accomplish local, regional, and national acute care surgery recruitment and retention of quality emergent and essential providers at public and governmental entities is crucial. Advocacy efforts that promote not only universal access to care, but also universal access to education and training, are therefore critical. Stimulating an affordability of education/training (in Latin America, residents pay for residency training), salary improvement, professional satisfaction, data that reflect a profession’s clinical impact, and provision of tools to create work-life integration, also will help. The current landscape in education and training should be better defined so that the variability between countries can be elucidated and efforts consolidated (see Table 5). Then, the PTS and other national medical societies in the Americas will best identify collectively the desired workforce as it relates to emergent and essential surgery, what needs to be done, and how to do it (see Table 6).

Table 5. Education and training focus

Curriculum Structure Relevant education materials Availability/accessibility Continuing education and maintaining standards of care for those who are already trained Accreditation of training programs Financing of training Message to high-income countries regarding ethical partnerships in research, training, and care delivery

Table 6. Questions going forward for Latin America

If an increase in number of trainees is needed, what is the national system’s capacity to manage them? How do we create these management systems? What models from the ACS, PTS, and other societies have worked particularly well? How do we measure success/failure of an approach? What are the metrics going forward? Supply and demand (immigration, attrition) must be defined in our current situation, and quickly. Among different workforce members (nurses, physicians, and so on) in different countries, are there opportunities for nurses to share in the formal systems education and training management (SAO nursing)? Which countries have improved the situation and how have they done it? Can we describe the dynamics that lead to shifts in supply and demand (disaster relief; war; terrorism; narcotics trafficking; educational, personal, and financial opportunities; and misconceptions about these factors)? What is the remuneration and retention in public vs. private hospitals? Can we describe the desired outcome? How do we get there? What are the barriers to how we measure success/failure? What are the metrics?

Emergent and essential surgery is the focus of the 30th Annual Panamerican Congress of Trauma, Critical Care and Emergency Medicine in Mexico City, Mexico, November 27 to December 1. This annual congress has consistently demonstrated that leaders across numerous disciplines and organizations view this topic as a top health care priority. The emergence of surgical education and training is critical to the viability of reaching LCoGS I-2 targets and creation of national surgical plans that optimize emergency and essential care delivery.⁴ Current acute care surgery leaders in the Americas seek your help for support in working with individual Latin American surgical societies and national ministries to define the acute care surgery profession and its respective funding, policy, and legislation for the cross-disciplinary, interprofessional, population-based health care it provides as keys to meeting WHA Resolution 68.15. Consistent with the need for surgical system strengthening, especially regarding trauma national plans, acute care surgery can serve both as the approach to assess the surgical workforce and as a mechanism by which it can be improved. Herein we have highlighted scaling up the emergent and essential surgical workforce in Latin America. Importantly, we demonstrate the necessity of leveraging training and education—particularly focused on acute care surgery—as the cornerstone of our efforts.

Acknowledgements

The authors would like to thank the following individuals for their contributions to this article and the work described in it: Jorge Esteban Foianini, MD, FACS, secretary-treasurer of the Panamerican Trauma Society; Allissa Gerdes, MPH, global surgery program coordinator, Rutgers Robert Wood Johnson Medical School (RWJMS) acute care surgery division, New Brunswick, NJ; Carlos Morales, MD, professor of surgery, University of Antioquia, San Vicente Hospital, Medellin, Colombia; Rachel Nemoyer, MD, masters in public health dual degree epidemiology and global health, global surgery track, Rutgers RWJMS; Jose Cruvinel Neto, MD, Universidade Santo Amaro, Brazil; Carlos Ordonez, MD, FACS, professor of surgery, Universidad del Valle and Fundación Valle del Lili, Cali, Colombia; Juan Carlos Puyana, MD, FACS, professor of surgery, University of Pittsburgh Medical Center, Presbyterian Hospital, PA; Martha Quiodettis, MD, FACS, chief of trauma, Santo Tomas Hospital, Panama City, Panama; Deesha Sarma, chancellor global distinction scholar, Rutgers RWJMS; and Paul Truche, MD, general surgery resident, Rutgers RWJMS.

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References

1. Peck G, Saluja S, Blitzer D, et al. Using global surgical indicators to improve trauma care in Latin America. Bull Am Coll Surg. 2017;102(4):11-16. Available at: bulletin.facs.org/2017/04/using-global-surgical-indicators-improve-trauma-care-latin-america/. Accessed July 20, 2017.
2. Peck G, Blitzer D, Citron I, et al. Latin America Indicator Research Coalition examines prehospital care using a trauma systems application of LCoGS indicator 1. Bull Am Coll Surg. 2107;102(7):23-31. Available at: bulletin.facs.org/2017/07/latin-america-indicator-research-coalition-examines-prehospital-care-using-a-trauma-systems-application-of-lcogs-indicator-1/. Accessed August 18, 2017.
3. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
4. World Health Assembly. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. WHA68.15. Agenda item 17.1. May 26, 2015. Available at: apps.who.int/gb/ebwha/pdf_files/WHA68/A68_R15-en.pdf. Accessed March 15, 2017.
5. The Lancet Commission on Global Surgery. Data for sustainable development of surgical systems: A global collaboration. June–September 2015. Available at: media.wix.com/ugd/346076_26d4a927dc074b128be2e61f34e14018.pdf. Accessed July 20, 2017.
6. Scheffer MC, Guilloux A, Matijasevich A, et al. The state of the surgical workforce in Brazil. Surgery. 2017;161(2):556-561.
7. Muñiz SA, Lang RW, III, Falcon L, Garces-King J, Willard S, Peck GL. Preparing global trauma nurses for leadership roles in global trauma systems. J Trauma Nurs [In press 2017].
8. Davis KA, Jurkovich GJ. An update on acute care surgery: Emergence of acute care surgery. ACS Surgery News. June 11, 2015. Available at: www.mdedge.com/acssurgerynews/article/100409/update-acute-care-surgery. Accessed July 20, 2017.
9. The American Association for the Surgery of Trauma. Acute care surgery. Introduction. Available at: www.aast.org/AcuteCareSurgery.aspx. Accessed July 20, 2017.
10. Kutcher ME, Peitzman AB. A history of acute care surgery (emergency surgery). Acute Care Surgery Handbook. Pp 19-37. Available at: https://link.springer.com/chapter/10.1007/978-3-319-15341-4_2. Accessed on July 20, 2017.
11. Association of American Medical Colleges. The complexities of physician supply and demand: Projections from 2013 to 2025. March 2015. Available at: www.aamc.org/download/426242/data/ihsreportdownload.pdf?cm_mmc=AAMC-_-ScientificAffairs-_-PDF-_-ihsreport. Accessed July 20, 2017.
12. Committee on the Future of Emergency Care in the United States Health System. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press; 2006.
13. Davis KA, Jurkovich GJ. Fellowship training in acute care surgery: From inception to current state. Trauma Surgery & Acute Care Open. 2016;1:1-5. Available at: http://tsaco.bmj.com/content/1/1/e000004/. Accessed July 20, 2017.
14. Wu D. Graduate of the first acute care surgery fellowship program reflects on the experience. Bull Am Coll Surg. 2015;100(10):11-16. Available at: bulletin.facs.org/2015/10/graduate-of-the-first-acute-care-surgery-fellowship-program-reflects-on-the-experience/. Accessed July 20, 2017.
15. Ivatury RR, Aboutanos M. PanAmerican Trauma Society: The first three decades. J Trauma Acute Care Surg. 2017; 82(5):966-973.
16. World Health Organization. Emergency and essential surgical care. WHO EESC global database. Available at: http://who.int/surgery/eesc_database/en/. Accessed July 20, 2017.