Improving Situation Awareness in Clinical Practice
Situation Awareness—Bridging Neuroscientific and Human Factors/Ergonomics Perspectives and Implications for Clinical Practice
Stavros Prineas
- Department of Anaesthetics and Pain Management, Nepean Hospital, Sydney, Australia
OPEN ACCESS
PUBLISHED: 30 April 2025
CITATION: Prineas, S., 2025. Situation Awareness and Bridging Neuroscientific and Human Factors/Ergonomics Perspectives and Implications for Clinical Practice. Medical Research Archives, [online] 13(4).
https://doi.org/10.18103/mra.v1 3i5.6457
COPYRIGHT: © 2025 European Society of Medicine. This is an open- access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
DOI https://doi.org/10.18103/mra.v1 3i5.6457
ISSN 2375-1924
ABSTRACT
A key challenge for clinicians is to make sufficient sense of what is happening around them to anticipate what might happen next and take timely action. This review article examines the theoretical basis of Situation Awareness (SA) – defined by Endsley as “the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and a projection of their status in the near future” (SA Levels I, II and III respectively) – and its relevance to clinical practice. SA is fundamental to good decision-making, and in turn to safe and effective human performance. Traditional models of clinical history taking / examination / investigation / diagnosis / prognosis align with the basic components of SA and can be further refined when viewed through the prism of SA, and its scope further extended by incorporating psychological, neurocognitive and statistical (Bayesian) perspectives.
Stress, fatigue and environmental noise/distractions can significantly impair SA, while other factors can significantly improve it. Experts experience a different perceptual world to novices, and techniques that may accelerate the acquisition of expert clinical SA (e.g. deliberate reflection, simulation, ergonomic environmental design etc.) could be beneficial to clinical practice. Moreover one can distinguish individual SA from ‘shared’ or ‘team’ SA, where specific communication, teamwork and leadership skills become relevant. Clinical emergencies and crises usually entail greater urgency, ambiguity, volatility and uncertainty, and impose a greater challenge on clinicians to form adequate SA in real time. Examples of SA in everyday clinical practice and the extent to which SA can be improved by adapting the clinician (through training) and/or adapting the work environment (through workplace/organisational design) are discussed.
Keywords: Situation Awareness, Neuroscience, Cognition, Human Factors, Ergonomics, Medical Education, Patient Safety
Introduction and Rationale
A key challenge for clinicians is to make sufficient sense of what is happening around them to anticipate what might happen next and take timely action, and for clinical teams similarly to function under a shared mental model. Situation awareness (SA) is an important human factors/ergonomics (HF/E) concept which arguably underpins all other non-technical skills such as perception of risk, communication, teamwork, leadership and managing automation.
This review article seeks to define SA and examine its counter-intuitively plastic and dynamic nature from several perspectives, in order to show the links between our current neuroscientific understanding of how the brain processes information and the practical aspects of the applied cognitive psychology underpinning the concept. The article will then explore more directly how SA relates to clinical practice, the factors that affect SA in healthcare environments, the differences between novice and expert SA, the extended concepts of team, shared and distributed SA, and finally the implications of SA for medical education and the design of healthcare systems more generally. Examples will be taken from anaesthetics and critical care (the author’s field of clinical expertise) however the concepts can in principle be readily extrapolated to other healthcare domains.
Definition of Situation Awareness
The roots of SA can be found in classical writings of military strategists such as Sun-Tzu (“know your enemy”)¹ and von Clausewitz (“knowledge of circumstances”)², emphasising recurrent themes of gathering intelligence and understanding/anticipating your opponent. Endsley defined SA formally as “the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and a projection of their status in the near future”.³˒⁴ SA can be deconstructed into three levels: Perception, Comprehension and Projection.
Level I Situation Awareness – Perception
The first level of SA relates to perception of the status, attributes and dynamics of elements in an environment. It corresponds to the traditional framework of clinical assessment – reviewing a patient’s chart, taking a history, examining the patient, observing monitors, ordering investigations, consulting/conferring with colleagues etc. The ability to ask the right questions, to examine methodically and to navigate electronic medical record systems are all learned skills. Even when proficiency is gained, other factors can impair the ability to perceive key elements of a clinical situation (see below).
Level II Situation Awareness – Comprehension
Level II corresponds to the forming of a mental model that makes sense of clinical findings – a clinical impression, a working diagnosis plus differential etc. History and examination often suggest a range of likely conditions; there may be atypical presentations of less likely conditions. The ability to assign differential weight to a range of possible diagnoses and to adapt in the light of new information is learned over time through conscious reflection of aggregated experiences. Understanding how a range of contextual and environmental factors (clinical urgency, remote location, limited resources, operating in the middle of the night, interpersonal conflict etc.) can impact on human performance is part of Level II SA.
Level III Situation Awareness – Projection
The “brass ring” of SA is the ability to use one’s clinical understanding of a situation to predict what will happen in the future and to act on that prognosis in a timely manner – not only to manage complications, but ideally to prevent them from happening. Pilots are taught to make sure ‘the brain is always five minutes ahead of the plane’; anaesthetists are taught to ‘think five minutes ahead of the vapour’. Examples of effective Level III SA strategies in clinical practice include the “Between The Flags” system of vital signs monitoring to alert staff to trends of patient deterioration⁵ and the evolution of Cardiac Arrest Teams to Medical Emergency Teams (MET), designed nowadays to manage not only arrested patients, but also deteriorating patients pre-arrest, thereby reducing overall mortality.⁶
The Dynamics of Situation Awareness
The serial logic underpinning this model (perception → comprehension → prediction) is intuitively appealing but serves only as the foundation of a network of more complex cognitive processes as observed in the real world (see Fig. 1). The next few paragraphs take a deeper dive into the neural basis of cognition seeking further insight into how SA is generated and maintained.
Figure 1. Situation Awareness
SYNAPTIC PLASTICITY
Information in biological brains is not held in binary digital packets the way it is stored in computers. Humans are born with a rudimentary ‘firmware’ of neuroanatomical connections but the ability to process, retain and recall information relies upon activation dependent synaptic plasticity (ADSP)⁷ occurring not just in infancy but throughout our lifetime. New experiences result in firing of neurons along a myriad of pathways; repeated stimulation along the same pathway within a critical timeframe results in an increase in the number of synaptic connections between activated neurons as well as a lowering of the neurotransmitter threshold for future stimulation. These make it more likely that subsequent stimulation will trigger the same pattern of firing. This biasing or synaptic weighting is fundamental to Hebbian learning, colloquially summarised as ‘neurons that fire together wire together’.⁸
Synaptic plasticity is how the brain codes information about the world. Studies of taxi drivers demonstrated that subjects trained in ‘The Knowledge’ of navigating London streets over a period of years acquired significantly larger posterior hippocampi than controls, postulated to be as a direct result of ADSP.⁹ This plasticity occurs not only in the hippocampus but wherever multipolar interneurons connect and interact throughout the brain; so most of the experiential ‘biasing’ of processed information about the world that the brain retains occurs beneath the level of consciousness. Synaptic weighting is happening all the time, even while we sleep.¹⁰ Thus
the organ we use to experience and understand the world is constantly, often imperceptibly changing. to paraphrase Heraclitus, “No person can enter the same river twice, for it is not the same river and they are not the same person”.¹¹
MENTAL MODELS AND SCHEMATA
The challenge for any brain is to discern meaning from the chaos of information about the self and the world around it in real time with only the limited processing power at its disposal. Through natural selection it appears that early neural networks acquired the ability to filter and ‘chunk’ aggregate neural activity into crude summary packets of that activity. These mental ‘models’ – precursors of ‘meaning’ – are refined by the hierarchical winnowing of information through intense competition between activated neural pathways in the midbrain, limbic system, hypothalamus, thalamus and ultimately the cerebral cortex.
The statistician George Box made the famous observation that “all models are wrong, but some are useful”.¹² All the models created by the brain are ‘wrong’ in so far as they are at best rough approximations; however many prove useful through the outcomes they produce. Useful models are retained, refined and become schemata,¹³ repertoires of thinking patterns and behaviour that run in the background or are activated by specific triggers. Collectively these subconscious ‘best guesses’ can be thought of as the brain’s ‘autopilot’, traditionally assigned to the basal ganglia but, like most higher order cognitive functions, now thought to be distributed across a much wider “default mode network” of brain structures.¹⁴
The increasing sophistication of information processing and modelling by central nervous systems can be tracked across species through key evolutionary steps from early metazoans to modern-day humans over hundreds of millions of years:¹⁵˒¹⁶ from the ability to focus attention by enhancing certain neural inputs while inhibiting others, to learning through physical trial and error (pavlovian conditioning), to the ability to imagine future states, abstracted learning through imagined trial and error (counterfactual or ‘what if’ learning), to modelling one’s own state of attention and that of others,¹⁷ and ultimately to the rich, ‘meaningful’ subjective experience that is human consciousness.
THE BAYESIAN BRAIN
In the traditional SA model, clinicians learn to evaluate complex clinical information from a range of sources (Level I SA) to arrive at probable diagnoses (Level II SA) and prognoses (Level III SA). This can be seen as a ‘bottom-up’ approach to cognitive processing – sensory inputs drive initial conscious perceptions, which are serially processed by higher cognitive centres. However, a wealth of research on various optical, sensory and cognitive illusions¹⁸˒¹⁹˒²⁰˒²¹ suggests that there is much more to how the brain forms conscious perceptions.
In the ‘Bayesian Brain Hypothesis’ (BBH)²²˒²³ the brain is treated as ‘statistical inference engine’²⁴ which is constantly and unconsciously trying to predict future states on the basis of past experience. Clinicians are most familiar with Bayesian theory when evaluating medical investigations and their predictive value based on specificity, sensitivity, false positives and negatives etc.²⁵ The effect of prior knowledge on probabilistic predictive power is often counterintuitive, shown most elegantly by the ‘Monte Hall Problem’²⁶ and other cognitive paradoxes. BBH is often described as a ‘top-down’ theory of cognition – our conscious perceptions of the world are to a large extent shaped by context and prior knowledge. The eyes are more than mere cameras; they ‘see’ what brain predicts they should see, calibrated as needed by salient sensory inputs (e.g. see Fig. 2).
Figure 2. The Cat Sat on the Mat
BBH has implications for more traditional models for SA predicated on ‘bottom-up’ cognitive processes. ‘Top-down’ elements better explain how with time and reflected experience, the serial hierarchy of perception-comprehension-projection becomes less distinct; prior diagnoses and prognoses shape future perceptions and perceived likelihoods, and the three levels of SA tend to coalesce into a single gestalt which form the basis of expert SA (see below).
SYNTHESIS
In summary, several relevant threads emerge. First, our picture of the world is built and maintained through patterns of synaptic weights reinforced by prior experiences which bias information processing from the perceptual level upwards. Second, parts of the brain are constantly competing with each other – some win, some lose (often for reasons not consciously apparent to us) but they all nevertheless effect plastic changes across the brain whenever they are active, even when we sleep. Third, what we understand as ‘consciousness’ represents only a fraction of the massive amount of biased information about the world that the brain has already stored and continues to process throughout our lifetime. Next, the models formed by the brain are fundamentally crude ‘executive summaries’ of complex neuronal activity whose sophistication and utility in humans are the culmination of millions of years of evolution. Finally, our sense of reality in any given moment lies somewhere between perception, memory and prediction: consciousness is not just driven from the ‘bottom up’ by our senses but also from the ‘top-down’ by our subconscious ‘schemata’ and ‘autopilot’. The world we ‘see’ is framed by an often arcane mix of what we have seen before and what we hope to see, as the Bayesian brain’s ‘best guess’ of reality. All of these elements have implications for how SA is elaborated and susceptible to a range of biological and non-biological factors.
Inattentional Blindness and Manipulating Perceptions
Under certain circumstances our senses do not render faithfully what is in front of us. Entertaining examples of ‘inattentional blindness’ are Simons and Chabris’ notorious Basketball Video²⁷˒²⁸ and Wiseman’s ‘Amazing Colour Changing Card Trick’.²⁹ These videos illustrate how perception itself can be altered and indeed misdirected by distractions or other cognitive activities such as focusing intently on a task. Medical hypnosis, a technique which allows a patient’s past memories of joyful or pleasant sensations to be experienced vividly as if they were in the present, has been shown to relieve anxiety and pain in a range of invasive procedures under local anaesthetic.³⁰˒³¹˒³² This is not only evidence of the manipulability of SA, but also an indicator of the practical benefits of understanding the plastic nature of SA in clinical environments.
Novice vs Expert Situation Awareness
Abundant research into Naturalistic Recognition Primed Decision Making (NDM or RPDM) has demonstrated that highly attuned SA is fundamental
to how experts make decisions.³³˒³⁴ Novices and experts, looking at exactly the same clinical situation, have very different perceptual and cognitive experiences. The novice may ask fifty system review questions and examine a patient thoroughly, gathering a wealth of clinical information, but struggle to integrate them into a diagnosis. The expert will also interrogate and examine the patient diligently, but having ‘eyeballed’ the patient will have already made a (usually correct) working diagnosis and management plan based on only a few targeted questions and signs specifically sought on examination. This is due to the large bank of iterative and reflected experiences influencing synaptic weighting and ‘Bayesian Brain’ logic, prefacing what they see and look for. Cues in the immediate environment trigger simultaneous intuitive perceptions, comprehensions and projections. All three levels of SA merge into a single gestalt, in what Klein describes as ‘seeing the past, present and future as one’.³⁵ This principle lies at the heart of RPDM. Experts have an enhanced faculty to simulate mentally the outcomes of potential courses of action i.e. they have more highly developed Level III SA. Beyond a certain point experts exhibit tacit knowledge in their area of expertise – they may find it difficult to articulate how or why they know what they know – also known as ‘unconscious competence’.³⁶
Experts are more adept at modifying their mental models in the light of new information and are more sensitive to context and changes in detail.³⁷ Trainees are frequently taught ‘if you hear hooves, it’s a horse, not a zebra’ – an entirely appropriate heuristic in many situations; a person with expert SA is more likely to think ‘if you hear hooves, it’s a horse… unless you’re in the Serengeti, then it probably is a zebra’.
Experts are often more attuned to their own emotions, intuitions and ‘gut-feelings’ (reflecting subconscious information processing) such as unease or discomfort, which trigger further conscious enquiry and information gathering. Surgeons frequently refer to their comfort level when deciding on whether or not to proceed with laparoscopic procedures.³⁸
The ‘10000-hour rule’ for acquiring expertise popularised by Gladwell³⁹ based on the work of Ericsson⁴⁰ has gained attention in the medical education literature, but there has been a growing counter-commentary reminding readers that clocking hours of experience alone is not enough;⁴¹˒⁴² rather it is the quality of reflection on those hours of experience (‘deliberate practice’) that better determines the level of expertise,⁴³˒⁴⁴ a point made in the original literature but often missed.⁴⁵
Inadequate Situation Awareness
In adverse event analysis reports it is common to read of practitioners ‘losing situation awareness’ leading to an incident. However, as Flach has asserted, “SA exists only in the mind of the researcher, not as an object in the mind being studied”.⁴⁶ Unless consciousness itself is impaired or lost, SA is not something that can be ‘lost’; rather it is a dynamic state of mind that is always active but may or may not be appropriate/adequate for the requirements of the task at hand. Endsley proposed a simple taxonomy of SA errors based on the three levels (see Table 1).⁴⁷ Schulz et al. used this classification to analyse 200 anaesthetic and critical care adverse events and found SA errors in 81.5% of cases, the majority of errors being related to failures of perception and comprehension.⁴⁸
Table 1. A Taxonomy of SA Errors with Clinical Examples
The adequacy of clinical SA needs to be actively monitored, maintained and calibrated in real time, not just because clinical situations often change rapidly, but also because human cognition itself is vulnerable to range of performance shaping factors (PSFs). These are summarised in Reason’s ‘Three Buckets’ (see Fig.3).⁴⁹ For example, fatigue and sleep deprivation (e.g. in night shift work) are known to significantly impair cognition and clinical decision-making,⁵⁰˒⁵¹ while stress is recognised as a major PSF that impairs diagnostic accuracy, reaction time, attention and memory, leading to poorer safety outcomes such as medication errors and hospital acquired infections.⁵² Distractions are a significant cause of impaired cognitive clinical performance.⁵³ Disorientation and lack of familiarity with the work environment is a significant PSF for new employees⁵⁴ and locum doctors/agency nurses.⁵⁵ PSFs apply to experts and novices alike. Practitioners are advised to ‘HALT’ (i.e. pause and reflect/confer) if they are ‘Hungry Angry Late or Tired’.⁵⁶ In susceptible mental states, where signals are vague or ambiguous the balance of perception is more likely to be tipped toward subconscious schemata than sensory inputs, and practitioners are more likely to ‘see’ a memory of what had been seen, or what they projected they would see, rather than what is actually there, clouding subsequent SA.
Fig 3. Performance Shaping Factors – Reason’s ‘Three Buckets’.
Gaba’s triad of fixation errors⁵⁷˒⁵⁸ rates a special mention in the context of deteriorating patients not responding to resuscitation efforts. The triad refers to cognitive behaviours commonly observed during simulated medical crises: “This And Only This” refers to the tendency to fixate on a particular diagnosis and a refusal to entertain any other differential diagnosis; “Anything But This” is a fixation of exclusion; the practitioner is convinced a particular diagnosis cannot be the cause of ongoing deterioration; “Everything’s Fine” is a state of abject denial, a refusal to acknowledge the patient is deteriorating. All three conditions reflect a relative inability under stress to review one’s mental model in the light of existing and/or new information. A healthy state of shared SA can help ‘reboot’ individual team members out of fixation states and help them achieve adequate Level II/III SA.
Failure to perceive the passage of time while focused on a critical technical task (e.g. attempting to intubate) can have disastrous results.⁵⁹ Time perception is highly subjective and affected by a surprising range of factors beyond task-focus and distractions, including state of emotional arousal and how fast things are changing in the background,⁶⁰ factors common in many clinical emergencies. Untrained humans are generally poor at judging timeframes of exponential/non-linear processes⁶¹, a feature often seen in trauma resuscitations⁶² and in deteriorating patients more generally.
An emerging problem in highly automated systems is the ‘Out-Of-The-Loop performance problem’,⁶³ where of much of the clinical information processing underpinning adequate SA resides more in automated devices than in the operator. This problem was first noticed in aviation⁶⁴ but will manifest itself increasingly in health care settings as the preponderance of intelligent monitors, smart pumps, multimodal ventilators and AI-driven medical equipment grows.⁶⁵
Team and Shared Situation Awareness
The next dimension of complexity arises when teams perform. The individual SAs of each team member related to a given task will be different but must somehow be brought into functional concordance, i.e. they must get ‘on the same page’.
A distinction is made between team SA (the task-specific SA required of each member in the complex execution of a team task e.g. their particular skills, roles and responsibilities, when each must play their part etc.) and shared SA (knowledge and mental models that must be made common to all members of the team to ensure coordinated team performance – e.g. correctly identifying the patient, agreed procedure to be performed, level of urgency etc.).⁶⁶ Both elements have been identified as essential to effective team performance.⁶⁷ In both team and shared SA, two broad HF/E elements become critical: communication (briefings, handovers, controlled vocabulary, assertiveness, debriefing) and leadership (creating psychological safety, framing the mission, facilitating a shared mental model distributing workload, managing conflict).
Situational leadership (knowing when to be instructive/autocratic vs facilitative/consultative)⁶⁸ utilises Level I Team SA to clarify and adapt to the available skills and knowledge within the team; ‘Lighthouse leadership’ (where the MET team leader is clinically ‘hands-off’ to oversee and direct team activity)⁶⁹ aims to enhance Level II and Level III Shared SA by affording the leader the cognitive freedom to see and articulate to the rest of the team the bigger picture of what is happening and where things are heading.
Weller et al.⁷⁰ identified team/shared SA as a critical component of patient safety and proposed three key improvement measures: building respectful relationships within teams to promote an atmosphere of psychological safety, allowing even junior members to raise and escalate concerns; clear, concise communication strategies to improve shared SA; and development of AI-guided monitor displays that integrate disparate sources of information and offer trend projections of the state of a patient.
Distributed Situation Awareness and Ergonomics
Fioratou et al. proposed an evolution of the traditional SA model applied to anaesthesia called distributed situation awareness (DSA) where knowledge and meaning about the world is seen to reside not just in the minds of the individual human agents but also in the operating theatre environment itself, and in the interplay between the environment and the human agents⁷¹. The patient, the physiology, the monitors, the surgical field, drugs and equipment, the clock, all the clinicians etc. are in interactive flux, each with information competing for our attention and our cognitive modelling faculties. DSA emerges from appreciating, understanding and anticipating these interactions in real time.
DSA is more consistent not only with our current understanding of how the brain models the world and the Bayesian factors that influence the fidelity of predicting future states and outcomes, but with a sociotechnical HF/E model of system performance. DSA is as much ‘in the world’ as it is ‘of the world’; to this extent appropriate ergonomic design of equipment and theatre environments can significantly improve SA. For example, the wider adoption of video technology in operating theatres⁷³ can enhance SA at several levels: live video displays of the operative site and the anaesthetic monitor gives ready and accessible information about the state of the patient and surgical progress to all members of the theatre team throughout the procedure, enhancing shared Level I SA; recording and playback of surgical procedures allows structured and deliberate reflection of skills and decisions, facilitating the acquisition of expert SA; the ability to teleconference operations live with senior specialist colleagues in remote sites permits access to their expert SA; finally the burgeoning use of artificial intelligence in clinical environments promises to create tools that support Level II and Level III SA.
The value of ergonomist input into healthcare workplace design⁷³˒⁷⁴ and medical equipment designs⁷⁵ remains largely under-recognised by clinicians and health care executives. The UK Chartered Institute for Human Factors and Ergonomics recently published a guide on integrating human-centred AI for clinical practice which included recommendations for improving individual and team SA.⁷⁶
At a more low-tech level, individual practitioners can modify their immediate work environment to facilitate SA. For example, anaesthetists routinely use syringes with colour-coded labels to readily distinguish medications; they can also arrange their workspace so that the patient, anaesthetic machine, monitoring displays, surgeon, drip stand, pumps, ventilator etc. are all within a single field of view to rapidly detect and assimilate changes in real time. Simple principles of ‘personal ergonomics’ to improve SA can easily be extrapolated to other clinical arenas.
Training Implications
Understanding SA levels and the factors that affect SA serves as a useful theoretical starting point for developing expert individual and team SA. Having said this true expert SA cannot per se be taught; it can only be cultivated over time and through deliberate iterative reflection on practice of every clinical exposure, linking perceptions to mental models to decisions, and ultimately to the outcomes of those decisions.Good communication is critical to both individual and team SA. Organisational training in structured briefings⁷⁷ and handovers using formalised tools such as SBAR/ISBAR⁷⁸ should be standard in any clinical team setting. Structured debriefing along SA levels (“What did you see/hear – What did you think was happening – What did you think was going to happen”) in both simulated and real-world environments facilitates the acquisition of expert SA in both individuals and teams over time.⁷⁹ Training practitioners in situational leadership skills may help adapt team/shared SA to different clinical situations.High-fidelity simulation offers a safe environment where practitioners and teams to experience and reflect on their cognitive performance in simulated scenarios, thereby shaping SA and modifying future thinking and behaviour.⁸⁰ Simulation also offers a more objective assessment of SA through the SA Global Assessment Technique (SAGAT),⁸¹ an established and widely used tool where representative tasks are simulated and scenarios are frozen at randomly selected times, allowing participants to answer brief questions about their current perceptions of the situation. SAGAT has been used to evaluate SA in a range of healthcare teams⁸²˒⁸³˒⁸⁴ and guide training.⁸⁵A novel low-tech technique for enhancing level I SA is to place clinicians a simulated nightmare clinical environment where participants are asked toidentify as many safety-critical errors as possible in a limited time period. Variants of this technique include the “Room of Horrors”⁸⁶ and the Patient Safety Escape Room.⁸⁷Orientation programmes for new graduates, employees and locum/agency staff are now standard practice in most public hospital environments. More work is required to identify the optimum period and content for orientation.
Conclusion
Situation awareness is fundamental to competent clinical decision making and clinical performance of individual practitioners and healthcare teams. Individual SA is the product of a complex interplay between events in the physical environment and competing modelling processes in the brain and is susceptible to a range of performance shaping factors. Expert SA is a skill that can be acquired over time through active reflection of past experiences, and can be accelerated through targeted training, especially medical simulation. Health authorities should seek formal input from professional ergonomists to develop work environments and equipment that can optimise individual and team/shared SA in a range of routine and emergency clinical settings.
Acknowledgements:
I would like to thank Kathleen Mosier, Steven Shorrock and Tim Suharto for their invaluable editorial input.
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