Handle with Care: Transformative Learning as Pedagogy in an Under-Resourced Health Care Context

Abstract

Issue: A significant component of health professions education is focussed on students’ exposure to the social determinants of health and the challenges that patients within the health care system face. An appropriate way to provide such exposure is through distributed clinical training. This usually entails students training in smaller groups along the continuum of care, away from tertiary academic hospitals. This also means students are away from their existing academic and social support systems. It is evident that knowledge and clinical skills alone are not sufficient to prepare students, they also need to be taught to critically reflect on how their own values and attitudes traverse their knowledge and skills to influence their practice as healthcare professionals. This process of critical reflection should aim to provide a transformative learning experience for students and requires active facilitation. In under-resourced health care contexts where clinicians responsible for student training are facing high patient load, lack of resources, inequitable health care services and high levels of burn-out, the facilitation of student learning may be compromised. Evidence: Clinical learning opportunities that are considered transformative, frequently challenge students’ sense of self and sense of belonging. This experience can have detrimental effects if the processes of transformative learning pedagogy are not adequately facilitated. The provision of support staff, lecturers and clinical facilitators on the distributed training platform is challenged by the remote nature of some of the sites and the cost of recruiting and capacitating additional on-site staff. The potential for what has been termed “transformative trauma” and the subsequent halted transformative learning experience, has ethical implications in terms of student wellness and the educational responsibility institutions carry. Implications: The authors suggest considerations in facilitating an ethical transformative learning process. These include making the transformative learning pedagogy explicit to students and clinical facilitators and using the ‘brave spaces’ framework to help students with individuation and provide them with the tools to understand how emotion influences behavior. Strategies to improve relationship development and communities of support, as well as ideas for faculty development are offered.

Keywords:

• Transformative learning pedagogy
• transformative trauma
• distributed training
• health professions education

Introduction

For more than a decade there has been a global move to optimize health professions education (HPE) curricula so that they address the needs of society and cultivate responsive health care professionals for the twenty first century.¹ This has led to a shift in focus from informative to transformative education to produce graduates who are life-long learners, are able to adapt to contextual health care challenges, and act as change agents.^2,3 Reconceptualizing HPE to help address issues of inequality and the health, social and environmental challenges has also been prioritized by institutions of higher education.⁴,⁵ Barrdell² argues that HPE for the twenty first century requires more than competency and proficiency but should also focus on promoting adaptability, advocacy, change agency and stewardship.² Training students to become graduates who can adapt to diverse populations, reflect critically, and tackle the challenges of a variety of health care contexts is necessary with the increasing global migration of health professionals.¹,⁶ This is especially true to ensure global citizenship education that promotes lifelong learning.

Transformative learning (TL) theory is recognized as one of the ways to enable graduates to continuously adapt and respond to the needs of society and act as agents of change.³,⁷ It is characterized as a consensual internal process of reflection,⁸ adaptation and integration after facing a disorienting dilemma.⁹,¹⁰

The disorienting dilemma that initiates the phases of transformation as detailed by Mezirow⁹ (Table 1) is likely to be facilitated when students are confronted with uncomfortable situations that challenge their worldview.³,¹⁰

Table 1. The ten phases of transformation as detailed by Mezirow9.

A disorienting dilemma Self-examination with feelings of fear, anger, guilt or shame A critical assessment of assumptions Recognition that one’s discontent and the process of transformation are shared Exploration of options for new roles, relationships and actions Planning a course of action Acquiring knowledge and skills for implementing one’s plans Provisional trying new roles Building competence and self-confidence in new roles and relationships A reintegration into one’s life on the basis of conditions dictated by one’s new perspectives

Scoping reviews exploring TL in HPE indicate the value of using TL theory as a framework to guide clinical and experiential learning.³,¹¹,¹² TL as a pedagogy (method of teaching) where educators follow Mezirow’s ten phases to promote behavioral change and agency has been widely adopted as a teaching pedagogy in HPE at both undergraduate and post graduate level.³,¹¹,¹² TL can influence cognitive, affective and behavioral change, with a resultant sustained change in action,¹⁰ but it does require a student’s willingness to change⁹.

TL is not simply an introspective process in a challenging environment, it requires competencies related to high-level communication, such as empathic and receptive listening as well as the ability to engage in rational and reflective discussions with others.³ Furthermore, TL requires additional skills of conflict resolution, a commitment to lifelong learning and the willingness to collaborate with others.¹³ van Schalkwyk et al.³, recommend that educators and clinical facilitators, who are clinicians tasked with the facilitation of students clinical skills in the workplace develop these same competencies to ensure students’ progress from knowledge assimilation to transformation. The scoping reviews on TL question the degree to which learning activities followed Mezirow’s 10 phases and how transformation can be attributed specifically to transformative learning practices.

Responsive health professions education

In response to the call for the adaptation of HPE curricula to promote skills development so as to address population healthcare needs in various contexts, training students along the continuum of care has become more common.⁴,¹⁴,¹⁵ Training students outside the traditional academic hospitals is a well-established practice across many parts of the world,¹⁵ variously referred to as community-based training, distributed or decentralized training. In this paper such training is referred to as distributed training, meaning that training occurs across all levels of health care and health service contexts. This type of training includes exposure to primary health care, diverse communities and cultures, and a variety of patient conditions as well as the experience of working in multiprofessional settings¹⁶. There is evidence that training students on the distributed training platform (DTP) can foster TL and the development of social responsibility.³,¹⁶ This is especially true when students are immersed within the communities they serve for extended periods of time such as during international health electives¹⁷ and longitudinal models of training.¹⁸ Longitudinal training is loosely defined as a situation where students, through the continuity of learning and relationship development are able to become legitimate contributors to the health care system.¹⁹ The perceived reciprocal benefit that exists for both health services (improved patient satisfaction, quality of care, professional development and accountability) and students (clinical exposure, sense of responsibility and feeling part of a team) is reported in relation to long-term student placement at a distributed health care site.^20–22

Using South Africa (SA) as a case study, this paper explores some of the implications and ethical considerations of adopting TL as a pedagogy during distributed clinical training where students are placed far from their academic and social support systems in resource constrained environments.

The disorientation of an inequitable healthcare system

Distributed training in SA, which is encouraged as part of the reconceptualization of HPE in SA⁴,¹⁴,¹⁵ has become an integral part of clinical training in the country during the past 20 years.²³ This is driven by the need both to expose students to the complexities of health along the continuum and to accommodate the increasing number of students needing to be trained.²³,²⁴

Immersing health professions students in their patients’ environments during distributed training exposes them to varying health care services, socio-political and cultural contexts. This can result in them being confronted with the sometimes-disorienting reality of their patients’ health care experiences, which can be different from, or all too similar to their own personal experiences.²⁵ This process of individuation during which students come to an awareness of who they are and how they relate to the world can trigger unconscious issues that create an emotional response.²⁶ In addition, students placed in distributed under-resourced settings not only face the reality of inequitable health care but they are removed from their academic and social support systems.²⁷,²⁸

SA is ranked as one of the most inequitable countries in the world, based on income inequality,²⁹ which is strongly associated with health poverty in Sub-Saharan countries.³⁰ Poverty and inequality play a role in disease patterns experienced by local populations,³¹ which face a quadruple burden of disease including communicable and non-communicable diseases, maternal and child mortality as well as injury and trauma.³² SA also has a well-documented inequitable distribution of healthcare services between the private and public sector³³,³⁴ and the number of health professionals employed by the public sector has not kept pace with the population growth and rural areas are worse affected by shortages in staff.³⁵

A systematic review of burn-out in sub-Saharan Africa reports 40–80% prevalence in health care professionals.³⁶ High levels of burnout (59%–81%) have been reported in doctors working in both the metropolitan and district state health care services of SA reportedly due to high clinical workload, long working hours, emotional exhaustion and lack of resources and support from senior staff.^37–39 Students placed at distributed training sites face similar challenges related to the burden of disease and available resources and support. They are also required to adapt their patient management based on the limited human and physical resources available to them.⁴,⁴⁰

These factors, along with the complexity of having 12 official languages in SA and a diaspora of cultures across nine provinces.⁴¹ can contribute to the disorientation of working in an inequitable health care system. Students and clinicians from under-resourced and richly diverse countries like SA are likely to face additional disorientations when one considers that they would normally process context driven challenges based on their own cultural identity⁴²,⁴³. Students who study in environments where they are unrepresented in either gender, language, culture or race may face the disorientation of how to present themselves in order to conform to the professional identity dictated by the institution, clinicians or patients in that context.¹¹,⁴³

Health professions educators have to consider equipping students and graduates with tools to meet challenges like these and navigate obstacles in the healthcare system,² especially when students are placed away from their academic home and support systems. Cox and John⁴⁴ suggest the use of TL as an appropriate adult educational strategy to empower students with the capabilities required to work in the difficult socioeconomic contexts that exist in SA, capitalizing on the disorienting dilemma.⁴⁴

A closer look at transformative learning

Uncomfortable and often distressing emotions are common during HPE⁴⁵ and should not have a negative influence on learning if managed and processed correctly.⁴⁶ In fact, neurobiologically it is evident that some emotional discord is crucial during the process of reflection to result in TL at an implicit level and not just consciously.¹³ At the same time clinical facilitators need to be cognizant of emotional dysregulation that can potentially trigger defence mechanisms.⁴⁷ Emotional dysregulation includes psychological defenses, such as dissociation, denial, withdrawal, and emotional blunting which impede students’ capacity for higher order thinking which is required for critical reflection,¹⁰,⁴⁸,⁴⁹ therefore limiting capacity for TL. The disorienting experiences of working on the DTP in under-resourced settings with the lack of academic support may trigger these responses. Students, who are influenced by their prior knowledge and experiences, are central to their own TL experience and thus require support and facilitation through the process of feeling, thinking and reasoning until they are capable of critical self-reflection.¹⁰ In order for TL to take place students have to be receptive to other peoples’ worldviews, emotionally capable of being vulnerable and open to new disorienting experiences.³

Critical reflection is made possible when learning opportunities are emancipatory and empowering, and not only threatening. This can be facilitated when reflection takes place with peers and is guided by an experienced clinical facilitator.⁵⁰ This is not always possible on the DTP due to the lack of human-resources and students’ distance from their academic and social support systems. Having a sense of community or belonging in which to reflect and learn is considered a valuable tool in helping students traverse the continuum of TL.⁵¹ Opportunities for students to connect socially, share relevant knowledge, skills and attitudes, reflect critically and to access the required support to do so are necessary to facilitate TL. One could argue that communities of practice (CoPs) in the workplace may offer such an environment. As health profession educators we explore some of the challenges students may face in accessing these important opportunities.

Community of practice and transformative learning

CoP is defined by the domain of interest that brings people together, the interactions and deliberations of group members and participation to develop shared resources.⁵² CoPs may prove to be a space in which students can access the required skills and support needed for the TL process. Wenger⁵² however acknowledges the complexity of establishing membership in a CoP, which occurs within larger historical, social, cultural and institutional contexts’. Productive communities develop over a period of time through the ‘sustained pursuit of a shared enterprise’.^52(pg4) This implies that it may take time for students to ‘access’ existing CoPs, which would be difficult during short rotation placements. Students may, however, encounter various CoP’s during their training each with its own set of ‘rules’ by which membership is recognized. The boundaries that exist between these CoPs may add an additional layer of complexity for the students⁵³ who originate from various socio-economic, cultural and historical backgrounds. Wenger⁵² cautions educators against the potential consequences when individuals do not find their CoP. Students may feel isolated and unsupported, and have fewer opportunities to learn and share knowledge, resulting in a stagnation of thinking and reasoning.⁵² It is also possible that individuals without a CoP may remain stuck in a loop of inefficient problem solving or self-reflection. A lack of feedback or affirmation may pose a threat to their professional identity.⁵² These consequences could potentially be catalysts of ineffective TL.

An interruption of the transformative learning process

As previously mentioned when students are confronted with emotionally provocative situations they may experience strong uncomfortable emotions that precipitate psychological defenses which can hamper TL.⁴⁷,⁵⁴,⁵⁵ If students do not have time, space, or skills to reflect on and integrate these experiences they may disengage due to the defenses that are in place during their emotional dysregulation.¹³ The TL process is interrupted and rather than being transformative, the new experience is traumatic. Yacek⁵⁶ refers to this as ‘transformative trauma’ and emphasizes the need to have adequate resources in place to help students transition through a place of negating their prior understanding of the world to a point where they adopt a compelling alternative.⁵⁶

Kilgore and Bloom⁵⁷ argue that when students are in a context of crisis the process of TL can be interrupted or halted.⁵⁷ A context of crisis may include students facing external demands on them during the learning programme that lead to financial, social, spiritual or learning poverty and students being in a learning programme involuntarily or under personal duress.⁵⁸ Facing the additional complexity of students’ cultural, racial or gender identity being perceived as unprofessional by educators, clinicians or patients can also contribute to external demands placed on underrepresented student populations.¹¹,⁴³,⁵⁹

Yacek⁵⁶ argues that although there is value in providing opportunities for transformative education there has been a disregard for the possible ethical issues that arise from confronting students with experiences that drive them to change.⁵⁶

Implications: Handle with care

There is a possibility that not all clinicians who facilitate student learning are aware of TL pedagogy and the steps needed to facilitate this. In an under-resourced setting where clinicians’ capacity for training may be limited, they may not be prepared or skilled to facilitate critical reflection. The risks of transformative trauma and a halted transformation need to be considered when preparing to place students on a DTP where access to emotional, social and academic support systems may be limited. We explore considerations for students, clinical facilitators, the clinical platform and faculty that may facilitate ethical TL during distributed training.

Make the TL pedagogy explicit

An explicit understanding by students and clinical facilitators of the TL pedagogy, contextual challenges and the educational interventions to facilitate students’ transformative development is essential.¹¹ This means disclosing the fact that many of the disorienting dilemmas students face during training are inevitable because of the context in which they are placed. This is not only true for distributed training but can occur across any health care context. Conscientizing students and facilitators on the DTP to the value of discomfort and emotion in adult learning is important, because educators are often unable to be present on site due to the challenges of distance.⁶⁰ Difficult conversations are necessary and specific skills development (e.g. emotional regulation and reflection) prior to clinical placement may help students prepare for and manage affect and cognitive dissonance. In this way students and clinical facilitators may understand what they are getting themselves into and that disorientation, emotion and intentional critical reflection are normal and important aspects of the TL process. We acknowledge that not all students would be willing to engage in the processes required for TL and clinical facilitators would need to be trained by institutions how to manage such students while remaining nonjudgmental.

Ideas for consideration when facilitating students and clinicians’ skills development are explored below.

Recognizing emotions

Providing students with alternative frameworks of understanding and preparing them to be aware of and to know how to process affective discomfort, with skills such empathy, self-awareness and management of ones emotions,⁸ may facilitate their engagement in critical reflection.⁹

Mentalisation is a psychological process that entails the ability to understand and interpret the thoughts, feelings, intentions and beliefs of oneself and others and the influences this has on behavior.⁵⁴ Mentalisation plays an important role in social interactions, communication, empathy, forming and maintaining relationships, and enabling self-reflection and personal growth.⁵⁴ The concept of mentalisation, although psychoanalytic in its origins, is considered to be integral to adaptive functioning, personal transformation and understanding oneself and one’s position in the world of emotions.⁵⁴ Exploring and identifying strategies to recognize and name emotions, share these with others, and have empathy for others yet be self-aware are concepts that are only recently becoming more common in health professions education.⁵⁵,^61–63

Defenses that healthcare workers or students exhibit as a result of stressful situations include depersonalization, emotional dysregulation, denial and dissociation from their care giver role.⁴⁷,⁵⁴,⁵⁵ Among health care workers there appears to be a relationship between the incapacity to mentalise (as assessed by the Reflective Functioning Questionnaire of 8 items (RFQ-8)) and defenses such as burn-out and depersonalization, leading researchers to conclude that mentalisation is a positive predictor of health care worker mental health and empathic patient care.⁶¹

Safiye⁵⁵ suggests incorporating mentalising skills and knowledge into interpersonal skill training,⁵⁵ which can be considered during curricular reform to ensure students are prepared for TL. Interpersonal skills training and mentalisation can be done during the earlier years of undergraduate training. Since the psychosocial dynamics and context of the work environment may affect an individual’s capacity to mentalise, there should be a greater emphasis on self-care, programmes aimed at understanding emotional dysregulation including strategies to recognize and regulate ones emotions through personal or group therapy.⁴⁷,⁶³,⁶⁴ Dirkx²⁵ supports this notion when encouraging adult learners to take seriously the responsibility of learning about who they are and how the world around them affects them. Understanding where our feelings are coming from and why they can lead to ‘a profoundly transformative, life-changing process’.^56(p21) Dirkx²⁵ recommends using emotionally charged images in small groups to help adult learners conscientize themselves to who they are as individuals.²⁵

Critical reflection

A recent systematic review on TL for graduates found that commonly used methods to prompt critical reflection include using small group discussions to share stories, journalling, engaging in artistic practices and meditation.¹¹ Vipler et al.⁶⁵ used ‘comics’ during qualitative interviews to elicit emotion and disorientation prior to reflection on students’ understanding of the world⁶⁵. Participants of Viplers et al.’s⁶⁵ study expressed appreciation for the opportunity to reflect in such a way since they had engaged in little reflection prior to the time. Students unfamiliar with reflection may be ineffective in doing so and protected time for reflection should be considered as part of the curriculum.¹¹ Students should have ample experience with critical reflection prior to placement on the DTP as active facilitation thereof may not always be possible due to lack of available human resources.

Similar to reflection, one way to strengthen students’ capacity to mentalise is through facilitated small group discussions that provide space and time for processing new experiences and the emotions they evoke.⁵⁴ Spaces for mentalisation and reflection that enable connection can be purposively created by using ‘brave spaces’ during undergraduate education especially in the pre-clinical years to prepare students for their role in TL in under-resourced settings.

Create brave spaces

Creating spaces where students’ emotions can be acknowledged, and where there can be genuine discussions about dilemmas they may be facing while navigating the transformative potential of the curriculum is possible. Students’ active engagement in ‘brave spaces’ have been shown to provide environments that allow students to have challenging conversations in the context of learning.⁶⁶

Brave spaces are typically bound by five principles introduced to and discussed by all group members: (1) Everyone’s opinions are accepted as valid; (2) If the well-being of another person has been affected it is acknowledged and discussed; (3) Students can choose to be part of challenging conversations; (4) Respect for other people’s personhood should be maintained and (5) An agreement is made that no one will intentionally hurt another group member.⁶⁶

Although creating these spaces is important, they require intentionality and human resources. Wasserman and Browne⁶⁰ propose a brave spaces model that addresses teachers’ and learners’ intrapersonal, interpersonal and civic rights and responsibilities when creating and engaging in brave spaces. Acknowledgement of the right to intrapersonal experiences and feelings is followed by the responsibility to respect and respond to triggers in the interpersonal relationship which is inevitable with differences. Recognizing and responding to issues of inclusivity and diversity in the learning environment is considered a civic responsibility of both students and institution. Hierarchy between educator and student, and, in some cases, between students from different professions, need to be considered and addressed when creating ‘brave spaces’ for reflection.⁶⁷ The diversity of student backgrounds and experiences also need to be acknowledged, legitimized and valued.¹¹ Having a broader distribution of student ethnicities, cultures, religions, and professions may facilitate the value of ‘brave spaces’ and resultant TL by challenging students’ worldview and assumptions.

An understanding of the brave spaces framework and model by students and clinical facilitators may be of value prior to distributed training⁶⁰ to encourage them to actively create and engage in difficult conversations on the DTP.

Mentorship

Access to mentors has been considered crucial to facilitate transformative learning¹¹. Mentors can include clinicians, peers, academic staff, community members or patients who point out disorienting dilemmas, share their own stories, unpack prejudices and recognize emotion.¹¹ Mentors are encouraged to be physically present on the DTP because online reflection may be negatively influenced by technological problems and the impersonal nature, especially if the mentor and mentee have not yet met.⁶⁸ Intentional effort to ensure that mentorship is available to students should be a priority for the faculty.

It should be noted however, that not all disorienting dilemmas are professional in nature. Students social, cultural, and relational interactions are also an important aspect to consider during mentorship. when exploring TL pedagogy during distributed training.^8,51 The success of TL experiences may well depend on religious and/or socio-cultural communities of support where students feel seen and heard. Encouraging opportunities for socialization, access to religious organization, sports and culture to suit students’ needs should be considered in facilitating spaces where students feel comfortable with peers. Having an environment where students can engage in rational deliberation, transformative thinking, yet still belong to a significant cultural or social group is important and needs to be guided by mentors.⁶⁹ This does require that educators, mentors and clinical facilitators engage in introspection and move from supporter of diversity into action for diversity and inclusion.¹¹ As much as health care professionals are called upon to understand the culture of their patients, health profession educators, clinical facilitators and mentors are called to understand the cultures of their students to ensure inclusivity is the norm during their education.⁵⁹

Considering context

As much as having a DTP where students have enough time to engage and learn with one another is important. Evidence shows that students spending longer periods of time living and training on the DTP can foster sustained relationships with their peers,²⁷ and build relationships with clinical facilitators.¹⁹,⁷⁰ This is best achieved by students becoming part of a community of practice allowing for continuity of learning in a health care system and community. Relationship development with patients, peers, professionals, trainers and community members also becomes possible with sustained engagement during longitudinal training,⁷⁰,⁷¹ and has been shown to facilitate lasting behavioral changes.¹¹,⁷² In a study by Greenhill et al.⁷² in Australia students engaging in longitudinal distributed training developed an understanding of the health care system and their role in it, a tolerance for clinical uncertainty and an understanding of the complexity and importance of diversity.

Encouraging opportunities for socialization, access to religious organizations or sports and culture suited to students needs may also foster students’ active participation in their learning journey.²⁸ Alternatively access to online support for participation in mentorship programmes and existing support structures are essential if none are available on site.²⁸ Students need access to data and transport otherwise benefitting from the value of distributed training may only be possible for the privileged who have access to their own resources.²⁸

Faculty development

To ensure ethical and continuous TL during distributed training, a structured faculty development (FD) plan focussing on the benefits and risks of TL pedagogy and the value of diversity and emotion in adult learning should be developed. FD activities for educators and clinical facilitators can include workshops outlining Mezirow’s 10 steps to facilitate TL, teaching methods including critical reflection, mentorship and the value of cognitive and affective responses of students in the learning environment.³,¹² Programmes to assist educators and clinical facilitators to explore their own identities as teachers, and to equip them with the skills to mentalise their own emotions and engage in critical self-reflection are recommended.³ This can be guided by experts in the field who have a sensitivity to the local context.

Cultural awareness and understanding the interplay between culture and context in health professions education is important and can be driven by FD programmes that address diversity and faculty engagement in ‘brave spaces’.⁷³ The notion of the ‘brave spaces’ framework and the model to implement this can be facilitated through workshops that promote ‘brave spaces’ for clinical facilitators in the workplace.

In addition, the academic institution may need to identify part time student support personnel who can be trained to facilitate critical reflection and mentalisation remotely, using online resources. However, there would need to be specific effort to ensure the availably of the infrastructure required for online support.

The participation of students in identifying what they need to feel supported in their learning journey can drive both FD and the research agenda in the development of indigenous knowledge related to HPE.⁴²,⁵⁹

As part of the social accountability of academic institutions, workshops to support the empowerment and capacitation of clinicians at distributed training sites should be offered as part of their FD plans. Recommendations by Blitz et al.⁷⁴ on the capacity development of distributed platform clinical facilitators include providing faculty mentorship and helping establish CoP to facilitate training at distributed sites.

We recommend that academic institution’s delegate the responsibility of evaluating the readiness of both students and clinical facilitators prior to the placement of students on the DTP. Institutional guidelines should be developed when identifying and planning distributed clinical training sites in response to the challenges TL can face in under-resourced contexts.

Limitations

Although the authors of this paper are from diverse professional backgrounds, we are predominantly white. We acknowledge that this limits the insight we may have into the depth and breadth of challenges faced by health professions students training in SA. In response to this, a research study exploring students’ experiences of distributed clinical training using intersectionality as a theoretical lens is currently underway in collaboration with the study participants as part of JM’s PhD.

Conclusion

We understand and value the importance of TL during HPE in facilitating the development of agents of change in a complex world. We do however argue that the TL process cannot be taken lightly, especially when students are removed from their support systems to train at remote sites. In health care contexts where resources are limited, where patient mortality and morbidity are high and where disorientations abound, institutions of higher education should be cognizant of the additional responsibility they have in ensuring that students can access support and engage in brave conversations facilitated by competent personnel. One could argue that this is true for all TL, but in this article, we make the case specifically that TL demands a more ethical approach for distributed clinical training of students in under-resourced settings.

Disclosure statement

The authors have no relevant financial or competing interests to disclose. The corresponding author will submit this paper as part of her PhD degree (non-financial interests).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.