{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T16:59:55Z","timestamp":1785517195726,"version":"3.56.0"},"reference-count":44,"publisher":"Springer Science and Business Media LLC","issue":"10","license":[{"start":{"date-parts":[[2025,12,2]],"date-time":"2025-12-02T00:00:00Z","timestamp":1764633600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.springernature.com\/gp\/researchers\/text-and-data-mining"},{"start":{"date-parts":[[2025,12,2]],"date-time":"2025-12-02T00:00:00Z","timestamp":1764633600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/www.springernature.com\/gp\/researchers\/text-and-data-mining"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["J GEN INTERN MED"],"published-print":{"date-parts":[[2026,8]]},"DOI":"10.1007\/s11606-025-10065-z","type":"journal-article","created":{"date-parts":[[2025,12,2]],"date-time":"2025-12-02T18:18:35Z","timestamp":1764699515000},"page":"2711-2716","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Are Difficult Inpatients Also Difficult Primary Care Patients?"],"prefix":"10.1007","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9820-5834","authenticated-orcid":false,"given":"Jeffrey L.","family":"Jackson","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Akira","family":"Kuriyama","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,12,2]]},"reference":[{"issue":"6","key":"10065_CR1","doi-asserted-by":"publisher","first-page":"647","DOI":"10.1016\/0895-4356(94)90212-7","volume":"47","author":"SR Hahn","year":"1994","unstructured":"Hahn SR, Thompson KS, Wills TA, Stern V, Budner NS. The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol. Jun 1994;47(6):647\u201357. https:\/\/doi.org\/10.1016\/0895-4356(94)90212-7","journal-title":"J Clin Epidemiol."},{"issue":"6","key":"10065_CR2","doi-asserted-by":"publisher","first-page":"588","DOI":"10.1007\/s11606-010-1620-6","volume":"26","author":"SA Hinchey","year":"2011","unstructured":"Hinchey SA, Jackson JL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med. Jun 2011;26(6):588\u201394. https:\/\/doi.org\/10.1007\/s11606-010-1620-6","journal-title":"J Gen Intern Med."},{"issue":"10","key":"10065_CR3","doi-asserted-by":"publisher","first-page":"1069","DOI":"10.1001\/archinte.159.10.1069","volume":"159","author":"JL Jackson","year":"1999","unstructured":"Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med. May 24 1999;159(10):1069\u201375. https:\/\/doi.org\/10.1001\/archinte.159.10.1069","journal-title":"Arch Intern Med."},{"key":"10065_CR4","doi-asserted-by":"publisher","unstructured":"Mota P, Selby K, Gouveia A, et al. Difficult patient-doctor encounters in a Swiss university outpatient clinic: cross-sectional study. BMJ Open. Jan 25 2019;9(1):e025569. https:\/\/doi.org\/10.1136\/bmjopen-2018-025569","DOI":"10.1136\/bmjopen-2018-025569"},{"issue":"4","key":"10065_CR5","doi-asserted-by":"publisher","first-page":"533","DOI":"10.2169\/internalmedicine.0085-22","volume":"62","author":"K Shikino","year":"2023","unstructured":"Shikino K, Mito T, Ohira Y, et al. Frequency of Difficult Patient Encounters in a Japanese University Hospital and Community Hospitals: A Cross-sectional Study. Intern Med. Feb 15 2023;62(4):533\u2013537. https:\/\/doi.org\/10.2169\/internalmedicine.0085-22","journal-title":"Intern Med."},{"issue":"8","key":"10065_CR6","doi-asserted-by":"publisher","first-page":"1843","DOI":"10.1007\/s11606-022-07936-0","volume":"38","author":"H Tamura","year":"2023","unstructured":"Tamura H, Shikino K, Sogai D, et al. Association Between Physician Empathy and Difficult Patient Encounters: a Cross-Sectional Study. J Gen Intern Med. Jun 2023;38(8):1843\u20131847. https:\/\/doi.org\/10.1007\/s11606-022-07936-0","journal-title":"J Gen Intern Med."},{"key":"10065_CR7","doi-asserted-by":"publisher","unstructured":"Jackson JL, Murphy MG, Fletcher KE. The difficult inpatient, prevalence and characteristics. Patient Educ Couns. Apr 25 2025;137:108785. https:\/\/doi.org\/10.1016\/j.pec.2025.108785","DOI":"10.1016\/j.pec.2025.108785"},{"issue":"9 Pt 2","key":"10065_CR8","doi-asserted-by":"publisher","first-page":"897","DOI":"10.7326\/0003-4819-134-9_part_2-200105011-00014","volume":"134","author":"SR Hahn","year":"2001","unstructured":"Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. May 1 2001;134(9 Pt 2):897\u2013904. https:\/\/doi.org\/10.7326\/0003-4819-134-9_part_2-200105011-00014","journal-title":"Ann Intern Med."},{"issue":"1","key":"10065_CR9","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/bf02603477","volume":"11","author":"SR Hahn","year":"1996","unstructured":"Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med. Jan 1996;11(1):1\u20138. https:\/\/doi.org\/10.1007\/bf02603477","journal-title":"J Gen Intern Med."},{"issue":"1","key":"10065_CR10","first-page":"24","volume":"62","author":"PG An","year":"2013","unstructured":"An PG, Manwell LB, Williams ES, et al. Does a higher frequency of difficult patient encounters lead to lower quality care? J Fam Pract. Jan 2013;62(1):24\u20139.","journal-title":"J Fam Pract."},{"key":"10065_CR11","doi-asserted-by":"publisher","unstructured":"Du J, Wang Y, Wu A, et al. The validity and IRT psychometric analysis of Chinese version of Difficult Doctor-Patient Relationship Questionnaire (DDPRQ-10). BMC Psychiatry. Dec 1 2023;23(1):900. https:\/\/doi.org\/10.1186\/s12888-023-05385-5","DOI":"10.1186\/s12888-023-05385-5"},{"issue":"5","key":"10065_CR12","first-page":"698","volume":"47","author":"R Han","year":"2018","unstructured":"Han R, Wei L, Li J, Zhang D, Li H. The Mediating Effects of Job Satisfaction on the Association between Doctor-patient Relationship and OCB among Physicians in China. Iran J Public Health. May 2018;47(5):698\u2013705.","journal-title":"Iran J Public Health."},{"issue":"395","key":"10065_CR13","first-page":"293","volume":"45","author":"N Mathers","year":"1995","unstructured":"Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. Br J Gen Pract. Jun 1995;45(395):293\u20136.","journal-title":"Br J Gen Pract."},{"issue":"5","key":"10065_CR14","doi-asserted-by":"publisher","first-page":"1209","DOI":"10.1016\/j.pec.2021.08.023","volume":"105","author":"L Fosnot","year":"2022","unstructured":"Fosnot L, Jones CD, Keniston A, Burden M, Indovina KA, Patel H. Hospitalists' perspectives on challenging patient encounters and physician well-being: A qualitative study. Patient Educ Couns. May 2022;105(5):1209\u20131215. https:\/\/doi.org\/10.1016\/j.pec.2021.08.023","journal-title":"Patient Educ Couns."},{"issue":"10","key":"10065_CR15","doi-asserted-by":"publisher","first-page":"1858","DOI":"10.1007\/s11606-024-08802-x","volume":"39","author":"JL Jackson","year":"2024","unstructured":"Jackson JL, Murphy MG, Fletcher KE. The \"Difficult\" Inpatient, a Qualitative Study of Physician Perspectives. J Gen Intern Med. Aug 2024;39(10):1858\u20131869. https:\/\/doi.org\/10.1007\/s11606-024-08802-x","journal-title":"J Gen Intern Med."},{"issue":"9","key":"10065_CR16","doi-asserted-by":"publisher","first-page":"606","DOI":"10.1046\/j.1525-1497.2001.016009606.x","volume":"16","author":"K Kroenke","year":"2001","unstructured":"Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. Sep 2001;16(9):606\u201313. https:\/\/doi.org\/10.1046\/j.1525-1497.2001.016009606.x","journal-title":"J Gen Intern Med."},{"issue":"6","key":"10065_CR17","doi-asserted-by":"publisher","first-page":"489","DOI":"10.1002\/jts.22059","volume":"28","author":"CA Blevins","year":"2015","unstructured":"Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation. J Trauma Stress. Dec 2015;28(6):489\u201398. https:\/\/doi.org\/10.1002\/jts.22059","journal-title":"J Trauma Stress."},{"issue":"3","key":"10065_CR18","doi-asserted-by":"publisher","first-page":"448","DOI":"10.1097\/01.alc.0000117836.38108.38","volume":"28","author":"KA Bradley","year":"2004","unstructured":"Bradley KA, Kivlahan DR, Zhou XH, et al. Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients. Alcohol Clin Exp Res. Mar 2004;28(3):448\u201355. https:\/\/doi.org\/10.1097\/01.alc.0000117836.38108.38","journal-title":"Alcohol Clin Exp Res."},{"issue":"5","key":"10065_CR19","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1016\/0021-9681(87)90171-8","volume":"40","author":"ME Charlson","year":"1987","unstructured":"Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373\u201383. https:\/\/doi.org\/10.1016\/0021-9681(87)90171-8","journal-title":"J Chronic Dis."},{"key":"10065_CR20","doi-asserted-by":"publisher","unstructured":"Seal K, Becker W, Tighe J, Li Y, Rife T. Managing Chronic Pain in Primary Care: It Really Does Take a Village. Journal of General Internal Medicine. 2017\/08\/01 2017;32(8):931\u2013934. https:\/\/doi.org\/10.1007\/s11606-017-4047-5","DOI":"10.1007\/s11606-017-4047-5"},{"key":"10065_CR21","unstructured":"Jackson JL, Kuriyama A, Whittle J, et al. The Prevalence and Characteristics of Difficult Patients, a systematic review and meta-analysis. Annals of Internal Medicine. 2025;In Press"},{"key":"10065_CR22","doi-asserted-by":"publisher","unstructured":"Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE. Interventions to improve provider diagnosis and treatment of mental disorders in primary care. A critical review of the literature. Psychosomatics. Jan\u2013Feb 2000;41(1):39\u201352. https:\/\/doi.org\/10.1016\/s0033-3182(00)71172-8","DOI":"10.1016\/s0033-3182(00)71172-8"},{"key":"10065_CR23","doi-asserted-by":"publisher","unstructured":"Keeley RD, West DR, Tutt B, Nutting PA. A qualitative comparison of primary care clinicians\u2019 and their patients\u2019 perspectives on achieving depression care: implications for improving outcomes. BMC Family Practice. 2014\/01\/15 2014;15(1):13. https:\/\/doi.org\/10.1186\/1471-2296-15-13","DOI":"10.1186\/1471-2296-15-13"},{"key":"10065_CR24","doi-asserted-by":"publisher","unstructured":"Loeb DF, Bayliss EA, Candrian C, deGruy FV, Binswanger IA. Primary care providers\u2019 experiences caring for complex patients in primary care: a qualitative study. BMC Family Practice. 2016\/03\/22 2016;17(1):34. https:\/\/doi.org\/10.1186\/s12875-016-0433-z","DOI":"10.1186\/s12875-016-0433-z"},{"issue":"4","key":"10065_CR25","doi-asserted-by":"publisher","first-page":"404","DOI":"10.1007\/s11606-017-4300-y","volume":"33","author":"JL Jackson","year":"2018","unstructured":"Jackson JL. A Randomized Trial to Improve Communication between Patients and Providers in a Primary Care Walk-In Clinic. J Gen Intern Med. Apr 2018;33(4):404\u2013405. https:\/\/doi.org\/10.1007\/s11606-017-4300-y","journal-title":"J Gen Intern Med."},{"issue":"2","key":"10065_CR26","doi-asserted-by":"publisher","first-page":"549","DOI":"10.1007\/s11606-020-06013-8","volume":"36","author":"JL Jackson","year":"2021","unstructured":"Jackson JL, Kay C, Scholcoff C, Becher D, O'Malley PG. Capturing the Complexities of \"Difficult\" Patient Encounters Using a Structural Equation Model. J Gen Intern Med. Feb 2021;36(2):549\u2013551. https:\/\/doi.org\/10.1007\/s11606-020-06013-8","journal-title":"J Gen Intern Med."},{"issue":"8","key":"10065_CR27","first-page":"530","volume":"14","author":"SV Pakhomov","year":"2008","unstructured":"Pakhomov SV, Jacobsen SJ, Chute CG, Roger VL. Agreement between patient-reported symptoms and their documentation in the medical record. Am J Manag Care. Aug 2008;14(8):530\u20139.","journal-title":"Am J Manag Care."},{"issue":"4","key":"10065_CR28","doi-asserted-by":"publisher","first-page":"430","DOI":"10.1097\/PSY.0b013e31816aa0ee","volume":"70","author":"JL Jackson","year":"2008","unstructured":"Jackson JL, Kroenke K. Prevalence, impact, and prognosis of multisomatoform disorder in primary care: a 5-year follow-up study. Psychosom Med. May 2008;70(4):430\u20134. https:\/\/doi.org\/10.1097\/PSY.0b013e31816aa0ee","journal-title":"Psychosom Med."},{"key":"10065_CR29","doi-asserted-by":"publisher","unstructured":"van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence. 2013\/07\/01\/ 2013;131(1):23\u201335. https:\/\/doi.org\/10.1016\/j.drugalcdep.2013.02.018","DOI":"10.1016\/j.drugalcdep.2013.02.018"},{"key":"10065_CR30","doi-asserted-by":"publisher","unstructured":"Parish CL, Feaster DJ, Pollack HA, et al. Healthcare provider stigma toward patients with substance use disorders. Addiction. Jul 23 2025; https:\/\/doi.org\/10.1111\/add.70122","DOI":"10.1111\/add.70122"},{"issue":"11","key":"10065_CR31","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0277538","volume":"17","author":"AK Byrne","year":"2022","unstructured":"Byrne AK, Scantlebury A, Jones K, Doherty L, Torgerson DJ. Communication interventions for medically unexplained symptom conditions in general practice: A systematic review and meta-analysis of randomised controlled trials. PLoS One. 2022;17(11):e0277538. https:\/\/doi.org\/10.1371\/journal.pone.0277538","journal-title":"PLoS One."},{"issue":"10","key":"10065_CR32","doi-asserted-by":"publisher","first-page":"1092","DOI":"10.1001\/archinte.166.10.1092","volume":"166","author":"RL Spitzer","year":"2006","unstructured":"Spitzer RL, Kroenke K, Williams JB, L\u00f6we B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. May 22 2006;166(10):1092\u20137. https:\/\/doi.org\/10.1001\/archinte.166.10.1092","journal-title":"Arch Intern Med."},{"issue":"9","key":"10065_CR33","doi-asserted-by":"publisher","first-page":"2519","DOI":"10.1007\/s11606-020-05816-z","volume":"35","author":"JL Jackson","year":"2020","unstructured":"Jackson JL, Choi A. From the Editors Desk: the Quandary of Difficult Patients. J Gen Intern Med. Sep 2020;35(9):2519\u20132520. https:\/\/doi.org\/10.1007\/s11606-020-05816-z","journal-title":"J Gen Intern Med."},{"key":"10065_CR34","unstructured":"Kennedy C. Personality DIsorders Step by Step: A structured guide to diagnosing, understanding and managing cluster A,B and C personality disorders. tagvault; 2025."},{"key":"10065_CR35","doi-asserted-by":"publisher","unstructured":"Yoshida S, Matsushima M, Wakabayashi H, et al. Correlation of patient complexity with the burden for health-related professions, and differences in the burden between the professions at a Japanese regional hospital: a prospective cohort study. BMJ OPEN. 2019;9(2)e025176. https:\/\/doi.org\/10.1136\/bmjopen-2018-025176","DOI":"10.1136\/bmjopen-2018-025176"},{"issue":"4","key":"10065_CR36","doi-asserted-by":"publisher","first-page":"410","DOI":"10.1001\/archinternmed.2008.549","volume":"169","author":"PG An","year":"2009","unstructured":"An PG, Rabatin JS, Manwell LB, et al. Burden of Difficult Encounters in Primary Care: Data From the Minimizing Error, Maximizing Outcomes Study. Archives of Internal Medicine. 2009;169(4):410\u2013414. https:\/\/doi.org\/10.1001\/archinternmed.2008.549","journal-title":"Archives of Internal Medicine."},{"issue":"5","key":"10065_CR37","doi-asserted-by":"publisher","first-page":"943","DOI":"10.1093\/fampra\/cmab180","volume":"39","author":"X Shen","year":"2022","unstructured":"Shen X, Xu H, Feng J, Ye J, Lu Z, Gan Y. The global prevalence of burnout among general practitioners: a systematic review and meta-analysis. Fam Pract. Sep 24 2022;39(5):943\u2013950. https:\/\/doi.org\/10.1093\/fampra\/cmab180","journal-title":"Fam Pract."},{"issue":"3","key":"10065_CR38","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1007\/s11606-023-08514-8","volume":"39","author":"JL Jackson","year":"2024","unstructured":"Jackson JL, Kuriyama A, Muramatsu K. A Model of Burnout Among Healthcare Professionals. J Gen Intern Med. Feb 2024;39(3):373\u2013376. https:\/\/doi.org\/10.1007\/s11606-023-08514-8","journal-title":"J Gen Intern Med."},{"issue":"2","key":"10065_CR39","doi-asserted-by":"publisher","first-page":"262","DOI":"10.1513\/AnnalsATS.202201-029OC","volume":"20","author":"A Kuriyama","year":"2023","unstructured":"Kuriyama A, Sakuraya M, Kinjo M, et al. Burnout and Turnover Intention in Critical Care Professionals During the COVID-19 Pandemic in Japan: A Cross-sectional Survey. Ann Am Thorac Soc. Feb 2023;20(2):262\u2013268. https:\/\/doi.org\/10.1513\/AnnalsATS.202201-029OC","journal-title":"Ann Am Thorac Soc."},{"key":"10065_CR40","doi-asserted-by":"publisher","unstructured":"Hodkinson A, Zhou A, Johnson J, et al. Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis. BMJ. Sep 14 2022;378:e070442. https:\/\/doi.org\/10.1136\/bmj-2022-070442","DOI":"10.1136\/bmj-2022-070442"},{"issue":"3","key":"10065_CR41","doi-asserted-by":"publisher","first-page":"249","DOI":"10.1016\/j.amjmed.2023.10.003","volume":"137","author":"A Haslam","year":"2024","unstructured":"Haslam A, Tuia J, Miller SL, Prasad V. Systematic Review and Meta-Analysis of Randomized Trials Testing Interventions to Reduce Physician Burnout. Am J Med. Mar 2024;137(3):249\u2013257.e1. https:\/\/doi.org\/10.1016\/j.amjmed.2023.10.003","journal-title":"Am J Med."},{"issue":"6","key":"10065_CR42","doi-asserted-by":"publisher","first-page":"1143","DOI":"10.1093\/jamia\/ocw021","volume":"23","author":"JM Madden","year":"2016","unstructured":"Madden JM, Lakoma MD, Rusinak D, Lu CY, Soumerai SB. Missing clinical and behavioral health data in a large electronic health record (EHR) system. Journal of the American Medical Informatics Association. 2016;23(6):1143\u20131149. https:\/\/doi.org\/10.1093\/jamia\/ocw021","journal-title":"Journal of the American Medical Informatics Association."},{"issue":"2","key":"10065_CR43","doi-asserted-by":"publisher","first-page":"69","DOI":"10.1192\/bjp.2019.166","volume":"216","author":"C Winsper","year":"2020","unstructured":"Winsper C, Bilgin A, Thompson A, et al. The prevalence of personality disorders in the community: a global systematic review and meta-analysis. The British Journal of Psychiatry. 2020;216(2):69\u201378. https:\/\/doi.org\/10.1192\/bjp.2019.166","journal-title":"The British Journal of Psychiatry."},{"issue":"16","key":"10065_CR44","doi-asserted-by":"publisher","first-page":"279","DOI":"10.3238\/arztebl.2015.0279","volume":"112","author":"H Haller","year":"2015","unstructured":"Haller H, Cramer H, Lauche R, Dobos G. Somatoform disorders and medically unexplained symptoms in primary care. Dtsch Arztebl Int. Apr 17 2015;112(16):279\u201387. https:\/\/doi.org\/10.3238\/arztebl.2015.0279","journal-title":"Dtsch Arztebl Int."}],"container-title":["Journal of General Internal Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11606-025-10065-z.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11606-025-10065-z","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11606-025-10065-z.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T16:08:31Z","timestamp":1785514111000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s11606-025-10065-z"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,2]]},"references-count":44,"journal-issue":{"issue":"10","published-print":{"date-parts":[[2026,8]]}},"alternative-id":["10065"],"URL":"https:\/\/doi.org\/10.1007\/s11606-025-10065-z","relation":{},"ISSN":["0884-8734","1525-1497"],"issn-type":[{"value":"0884-8734","type":"print"},{"value":"1525-1497","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,2]]},"assertion":[{"value":"6 March 2025","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"19 November 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"2 December 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"This study was approved by our local IRB. Written consent from survey participants was waived as participation was voluntary and anonymous.","order":1,"name":"Ethics","label":"Ethics Approval and Consent to Participate","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors declare that they do not have a conflict of interest.","order":2,"name":"Ethics","label":"Conflict of Interest","group":{"name":"EthicsHeading","label":"Declarations"}}]}}