MD Course Descriptions
At NYU Grossman Long Island School of Medicine, we offer various courses, clerkships, and learning experiences to complete your medical degree, helping you become a leader in primary care medicine.
Longitudinal Courses
Longitudinal learning courses take place throughout all phases of our curriculum and are integrated with our basic and clinical science courses and clerkships. Our longitudinal courses include the following:
- Practice of Medicine
- Health Systems Science
- Continuity Ambulatory Practice Experience
- Learning Community
Practice of Medicine
The Practice of Medicine (POM) course is a longitudinal course that takes place during phase one of our curriculum that is designed to bridge the foundational and clinical sciences. The key components of bedside diagnosis are instituted in conjunction with each foundational science module in the first academic year. Students build upon core clinical skills that include the following:
- medical interviewing, motivational interviewing, and communication skills that reinforce patient-centered care, establish the doctor–patient relationship, and gather information
- adult and child physical examinations
- verbal and written documentation of all elements gathered from history-taking and physical examinations
- clinical reasoning to formulate an assessment from gathered data and generate a tiered differential diagnosis
- interprofessional skills and building effective working relationship
The POM course begins with an intensive focus on developing communication skills. Students apply the information learned in foundational science sessions via problem-based learning exercises each morning to clinical cases they encounter in the afternoon. The POM course includes interactive large group conferences, small group skills workshops, panel discussions, simulated patient exercises, and bedside sessions with real patients, as well as Objective Structured Clinical Examinations (OSCEs).
Students attend bedside sessions to practice clinical skills in small groups with an attending preceptor. They also gain experience with medical interviewing, physical examination, and diagnostic reasoning skills during twice monthly Continuity Ambulatory Practice Experience (CAPE) courses. Issues in population health and health systems science, particularly those pertinent to primary care physicians, are also explored during POM, the Language Acquisition course and organ systems courses.
For more information about POM, contact Ralph K. Della Ratta, MD, course director, at ralph.dellaratta@nyulangone.org or 516-663-7210.
Health Systems Science
During the Health Systems Science longitudinal course, students build foundational knowledge in six core health systems science domains: healthcare structure and processes; healthcare policy, economics, and management; population and public health; epidemiology and biostatistics; value-based care; and health system improvement and patient safety.
These learning experiences highlight how health systems influence patient care and incorporate principles of leadership, teamwork, professionalism, ethics, and evidence-based practice throughout our broader medical school curriculum.
For more information about Health Systems Science, contact Maria L. Quintos-Alagheband, MD, program director, at maria.quintos-alagheband@nyulangone.org; or Ranjith Kamity, MD, assistant director, at ranjith.kamity@nyulangone.org; or Stacy Zhang, PhD, assistant director, at donglan.zhang@nyulangone.org.
Continuity Ambulatory Practice Experience
Continuity Ambulatory Practice Experience Course (CAPE) is a longitudinal ambulatory experience that spans all three years of medical school. Students gain experience taking patient histories, performing physical examinations, and assessing and managing patients. CAPE encourages students to transition from the role of being an observer to being able to conduct and perform a thorough history and physical examination and form an appropriate assessment and management plan for patients. This experience demonstrates how to use problem solving skills related to medical thinking and reasoning for patient care.
During the first year of medical school, CAPE is divided into two blocks. Initially, each student is assigned to one of two ambulatory settings: general medicine (which includes family medicine, geriatrics, or internal medicine) or pediatrics. Each student then rotates through the other setting to complete the academic year. Students participate in CAPE approximately once a month.
For more information about CAPE, contact Francis L. Faustino, MD, program director, at francis.faustino@nyulangone.org.
Learning Community: Social Sciences, Humanities, Ethics and Professionalism
During the Learning Community: Social Sciences, Humanities, Ethics and Professionalism (SHEP) longitudinal course, students learn about forming a professional identity and developing ethics and professionalism, along with further exploration of the medical humanities and social sciences. This course spans all three years of medical school.
Students develop the skills needed to engage in self-reflection, moral reasoning, and ethical analysis and prepare to capably negotiate the complexities of clinical care and medicine in society. Each two-hour Learning Community session is divided between a structured small group reflective discourse centered on particular topics and skills and semi-structured peer-to-peer and faculty-to-peer support and mentoring.
For more information about Learning Community sessions, contact program directors, Jeffrey T. Berger, MD, at jeffreyt.berger@nyulangone.org; or Dana Ribeiro Miller, MDiv, LCSW, ACHP-SW at Dana.Miller@NYULangone.org.
Preclerkship Courses
Preclerkship courses provide comprehensive introductions to physiology, embryology, histology, and anatomy, as well as pathophysiology, pathology, and pharmacology. Our courses weave key basic science concepts into clinical case studies and teach students how to diagnose diseases and treat patients in the neonatal, pediatric, adolescent, adult, geriatric, and end-of-life stages. All courses consist of case-based activities supplemented with small and large group sessions to encourage active learning.
- Language Acquisition
- Cardiology System
- Pulmonary System
- Renal System
- Gastrointestinal System
- Endocrine–Reproductive System
- Musculoskeletal, Rheumatology, and Dermatology Multisystem
- Brain, Mind, and Behavior
- Hematology–Oncology System
- Morphology of Medicine: Anatomy, Histology, Pathology, and Radiology
Bill Miyawaki, MD, is the director of organ system modules for all courses. For more information about organ system modules, contact him at nobuyuki.miyawaki@nyulangone.org or 516-663-2171.
Language Acquisition
The Language Acquisition course integrates core concepts in molecular biology, genetics, biochemistry, cell biology, pathology, pathophysiology, microbiology, immunology, and pharmacology. All students must master this eight-week overview of basic science material before advancing to organ system courses.
For more information, contact Louis Ragolia, PhD, course director, at louis.ragolia@nyulangone.org or 516-663-2028.
Cardiology System
This four-week course provides an introduction to the cardiovascular system. Topics covered include normal cardiovascular physiology, heart failure, hypertension, myocardial infarction, cardiac arrest, bacterial endocarditis, heart murmurs, heart valve disease, hyperlipidemia, preventive cardiology, and electrocardiogram.
Each morning, students take part in seminars that further integrate concepts from disciplines including infectious disease, pharmacology, genetics, and embryology. Morphology of Medicine laboratory sessions that focus on anatomy, histology, pathology, and radiology take place on Monday and Thursday mornings.
CAPEs and POM emphasize cardiovascular conditions. Patient encounters and bedside teaching experiences focus on history taking and physical examination for patients with cardiovascular conditions.
To learn more, contact Kevin P. Marzo, MD, co-course director, at kevin.marzo@nyulangone.org or 516-663-4480; or Mallory P. Barnett, MD, at mallory.barnett@nyulangone.org or 516-663-4480.
Pulmonary System
This four-week course provides an introduction to the pulmonary system. Key topics include pulmonary physiology, acute respiratory distress syndrome, asthma, bronchiolitis, chronic dyspnea, chronic obstructive pulmonary disease, pneumonia, pulmonary hypertension, and tuberculosis.
Learning activities integrate concepts from disciplines including infectious disease, pharmacology, genetics, and embryology. Morphology of Medicine laboratory sessions, which cover anatomy, histology, pathology, and radiology, take place on Monday and Thursday mornings.
CAPEs and POM emphasize treatment and management of chronic and acute asthma. Patient encounters and bedside teaching experiences focus on history taking and physical examination for patients who have chronic obstructive pulmonary disease.
To learn more, contact Mangalore Amith Shenoy, MD, or Shilpa A. DeSouza, MD, course co-directors, at mangalore.shenoy@nyulangone.org or shilpa.desouza@nyulangone.org or 516-663-3897.
Renal System
This three-week course provides an introduction to the renal system. Topics covered include normal renal physiology, acid–base balance, electrolyte imbalance, and kidney diseases.
Daily sessions integrate concepts from disciplines including infectious disease, pharmacology, genetics, and embryology. Morphology of Medicine laboratory sessions, which focus on anatomy, pathology, and radiology, take place on Monday and Thursday mornings.
CAPEs emphasize the impact of kidney disease on medical care. Patient encounters and bedside teaching experiences focus on history taking and physical examination for patients who have kidney disease.
For more information, contact Bill Miyawaki, MD, course director, at nobuyuki.miyawaki@nyulangone.org or 516-663-2171.
Gastrointestinal System
This four-week course introduces students to the gastrointestinal system. Topics covered include congenital multi-organ motility disorder, Crohn’s disease, acute biliary pancreatitis, gastroesophageal reflux disease, colon cancer, gastrointestinal complications in immunocompromised patients, abnormal results on liver-related tests, jaundice, and chronic liver disease.
Daily morning sessions integrate concepts from disciplines including infectious disease, pharmacology, genetics, and embryology. Morphology of Medicine laboratory sessions, which focus on anatomy, histology, and pathology, take place on Monday and Thursday mornings.
CAPEs and POM emphasize treatment and management of gastrointestinal disease. Patient encounters and bedside teaching experiences focus on history taking and physical examination for patients with liver diseases.
For more information, contact Rani Modayil, MD, at rani.modayil@nyulangone.org.
Endocrine–Reproductive System
This five-week course provides an introduction to the endocrine–reproductive system. Topics covered include normal endocrine and reproductive systems; pituitary diseases; growth disorders; thyroid disease; calcium disorders; diabetes, obesity, puberty, and the menstrual cycle; pregnancy and its complications; and benign and malignant conditions of the male and female reproductive tracts, including the breast, and genital tract infections.
Daily morning sessions integrate concepts from disciplines including infectious disease, pharmacology, genetics, and embryology. Morphology of Medicine laboratory sessions, which focus on anatomy, histology, and pathology, take place on Monday and Thursday mornings.
CAPEs and POM emphasize treatments for diabetes and reproductive issues. Patient encounters and bedside teaching experiences focus on history taking and physical examinations for patients who have endocrine issues.
For more information, contact Stanislaw Klek, MD, course co-director, at stanislaw.klek@nyulangone.org or 516-663-1654; or Wendy L. Kinzler, MD, course co-director, at wendy.kinzler@nyulangone.org.
Musculoskeletal, Rheumatology, and Dermatology Multisystem
This five-week course provides an introduction to the musculoskeletal, rheumatology, allergy, and dermatology systems. Topics covered include medication allergies, osteoarthritis, rheumatoid arthritis, sacroiliitis, systemic lupus erythematosus, and granulomatosis with polyangiitis.
Daily morning sessions integrate concepts from disciplines that include infectious disease, pharmacology, genetics, and embryology. Morphology of Medicine laboratory sessions, which focus on anatomy, histology, and pathology, take place on Monday and Thursday mornings.
CAPEs and POM emphasize treatments for dermatological and other vasculitis disorders. Patient encounters and bedside teaching experiences focus on history taking and physical examinations for patients who have musculoskeletal issues.
For more information, contact Elise Belilos, MD, rheumatology course director, at elise.belilos@nyulangone.org or 516-663-4755.
Brain, Mind, and Behavior
This six-week course provides a comprehensive introduction to the neuroscience and behavioral systems. Topics include the normal neurobehavioral system, acute ischemic stroke, panic disorder, seizures and migraines, bipolar disorder, schizophrenia, opioid use disorder, meningitis, Guillain-Barré syndrome, Alzheimer’s disease, multiple sclerosis, amyotrophic lateral sclerosis, and sleep disorders in patients who have Parkinson’s disease.
Daily morning sessions integrate concepts from disciplines including infectious disease, pharmacology, genetics, and embryology. Morphology of Medicine laboratory sessions, which focus on anatomy, histology, and pathology, take place on Monday and Thursday mornings.
CAPEs and POM emphasize recognizing and treating neurological and behavioral conditions. Patient encounters and bedside teaching experiences focus on history taking and physical examination for patients who have neurological illnesses.
For more information, contact Sok W. Lee, MD, course co-director, at sok.lee@nyulangone.org or 516-663-2691; Matthew A. Bokhari, MD, course co-director, at matthew.bokhari@nyulangone.org, or call 516-324-7500; Daniel B. Cucco, MD, course co-director at daniel.cucco@nyulangone.org; or Orla O’Donoghue, PhD, course co-director, at orla.o'donoghue@nyulangone.org.
Hematology–Oncology System
This two-week course provides an introduction to the hematology–oncology system. Topics covered include the hematological system, anemia, thrombocytopenia, and bone marrow disorders including malignant hematologic conditions such as leukemias and lymphomas.
Daily morning sessions integrate concepts from disciplines including infectious disease, pharmacology, genetics, and embryology. Morphology of Medicine laboratory sessions, which focus on anatomy, histology, pathology, and radiology, take place on Monday and Thursday mornings.
CAPEs and POM emphasize hematological issues. Patient encounters and bedside teaching experiences focus on history taking and physical examination for patients with hematological and oncological conditions.
To learn more, contact Marc J. Braunstein, MD, PhD, course co-director, at marc.braunstein@nyulangone.org or 516-663-9500; or Chana Glasser, MD, course co-director, at 516-663-9400.
Morphology of Medicine: Anatomy, Histology, Pathology, and Radiology
This longitudinally integrated educational thread, also called M4, provides foundational knowledge of the four morphological sciences: anatomy, histology, pathology, and radiology. This module takes place over the course of 38 learning sessions that occur within the organ systems and language acquisition courses during phase one of our curriculum.
Studying the morphology of medicine is similar to acquiring a new language—students literally learn thousands of new words throughout the course. Instructors use both regional and systemic approaches to teach the structures of anatomy and their relationships to one another and to describe the major systems of the body. Success comes from understanding medical terminology, visualizing the structures of disease three dimensionally, and applying this knowledge to solve clinical problems.
Students participate in M4 laboratories with collaborative and integrative instruction from pathologists, anatomists, and radiologist. Through active learning approaches, students gain exposure to human anatomy and pathology from plastinated anatomy models, articulated and disarticulated skeletal models, surgical and autopsy specimens, and by performing autopsies.
For more information, contact Brian M. Shearer, PhD, course co-director, at brian.shearer@nyulangone.org; or Suparna A. Sarkar, MD, PhD, course co-director, at suparna.sarkar@nyulangone.org or 516-663-2721.
Clerkships
During phase two of the NYU Grossman Long Island School of Medicine curriculum, students participate in clerkships. Our clerkships are competency based and follow Core Entrustable Professional Activities, or Core EPAs, guidelines from the Association of American Medical Colleges, which establish expectations for activities that all medical students should be able to perform upon entering residency.
We offer the following clerkships:
- Pediatric Clerkship
- Internal Medicine Clerkship
- Primary Care Clerkship
- Neurology and Rehabilitation Clerkship
- Psychiatry Clerkship
- Obstetrics and Gynecology Clerkship
- Surgery Clerkship
Pediatric Clerkship
This six-week, phase two rotation at NYU Langone Hospital—Long Island includes a comprehensive introduction to general pediatric medicine through patient encounters, case presentations, and record keeping using an electronic medical record (EPIC). Students take thorough and focused patient histories and physical examinations for children from the newborn period to adolescence and perform common pediatric procedures.
Learning experiences are delivered in a variety of formats such as case-based learning sessions, lectures, observed structured clinical exams (OSCEs), and simulations. Students have the opportunity to work with a variety of faculty, resident preceptors, and other inter-professional staff both in the inpatient and outpatient units. They learn to provide humanistic and comprehensive care to children who are well, acutely ill, and chronically ill.
Our curriculum is based on recommendations put forth by the Council on Medical Student Education in Pediatrics (COMSEP). Each student is assigned to a faculty preceptor, who they meet with on a weekly basis, and a teaching resident during their inpatient unit rotation.
For more information, contact Asif Noor, MD, clerkship director, at asif.noor@nyulangone.org; Manju M. Chandra, MD, clerkship associate director, at manju.chandra@nyulangone.org; or Susan Sinisi, clerkship coordinator, at susan.sinisi@nyulangone.org.
Internal Medicine Clerkship
During this eight-week, phase two rotation, students gain experience caring for adult patients at NYU Langone Hospital—Long Island and participate in educational sessions about internal medicine topics. Students are assigned to an inpatient house-staff team and an attending preceptor small group. Students benefit from close working relationships with house staff team and participate in an educational program that has been carefully and specifically designed for medical students.
Preceptor sessions, active learning sessions, and the core curriculum complement the clinical experience on the medical inpatient units. It is this total experience—which involves clinical patient care, preceptor sessions, conferences, and core curriculum—that comprises the rotation period. Students are required to attend all preceptor, case discussion, and simulation sessions. In addition to didactic sessions, students participate in simulated learning focused on evaluating patients with cardiac complaints, sepsis, and pneumonia.
If you have questions, contact Jamie C. Yedowitz-Freeman, DO, clerkship director, at jaime.yedowitz-freeman@nyulangone.org; or Lily Gonzalez, clerkship coordinator, at liliana.gonzalez@nyulangone.org or 516-663-2494.
Primary Care Clerkship
This four-week, phase two clinical rotation takes place at NYU Langone Hospital—Long Island’s ambulatory primary care sites. Students provide acute care, manage chronic conditions, engage in preventive care visits, and gain a better understanding of the physician–patient relationship in outpatient settings with guidance from an attending preceptor.
During the rotation, students encounter patients with a range of common primary care complaints, formulate comprehensive patient histories, perform relevant physical exams, and develop appropriate patient assessment and management plans. This is a unique opportunity for students to work one-on-one, for an extended period of time, with a preceptor in the outpatient setting. This clerkship enables students to witness the full spectrum of disease and the gratification that the establishment of long-term physician–patient relationships brings to the practice of medicine. Structured didactic learning sessions, home visits in hospice care settings, dental, and ophthalmology are also part of the clinical experience.
For more information, contact Niti Rajpal, MD, clerkship co-director, at niti.rajpal@nyulangone.org; or Joel A. Attard, DO, clerkship co-director, at joel.attard@nyulangone.org.
Neurology and Rehabilitation Clerkship
During this four-week, phase two clerkship, students learn the underlying principles and skills necessary to recognize and manage common neurologic diseases.
There are two primary goals of this clerkship: first, to become proficient at obtaining a neurologic history and performing a neurologic exam; and, second, to become familiar with basic neurologic disease processes, their presentation, work-up, and treatment. Students also become familiar with the psychosocial impact of chronic and acute neurologic disease on patients and their families.
If you have questions, contact Sok W. Lee, MD, clerkship co-director, at sok.lee@nyulangone.org; Matthew A. Bokhari, MD, clerkship co-director, at matthew.bokhari@nyulangone.org; or Ashley Kirk, clerkship coordinator, at ashley.kirk@nyulangone.org or 516-663-4771.
Psychiatry Clerkship
During this six-week, phase two clinical clerkship, students gain a range of clinical experience treating common psychiatric and substance use–related disorders in hospital- and office-based outpatient settings.
Students accompany attending psychiatrists, psychologist, or clinical social workers—or a combination thereof—on initial patient assessments, as well as on follow-up visits, and are encouraged to actively participate in each patient encounter, including conducting patient evaluations with supervision. Behavioral health patient encounters occur throughout the hospital, as well as in an office-based outpatient psychiatric setting. Students also assess acute psychiatric patients at an adult emergency setting with an assigned attending psychiatrist.
If you have questions, contact Daniel B. Cucco, MD, clerkship director, at daniel.cucco@nyulangone.org, or Violeta Safadi, clerkship coordinator, at violeta.safadi@nyulangone.org.
Obstetrics and Gynecology Clerkship
This six-week, phase two clinical rotation exposes students to the breadth and depth of obstetrics and gynecology services at a major academic medical center. In addition to clinical experience, students participate in didactic learning sessions that include lectures, clinical skills workshops, and seminars. Students work closely with residents, fellows, house officers, and faculty members, many of whom are top experts in the field of obstetrics and gynecology.
All inpatient experiences take place at NYU Langone Hospital—Long Island. Outpatient clinical experiences take place within our ambulatory offices for general obstetrics and gynecology, maternal–fetal medicine, urogynecology, reproductive endocrinology, and gynecologic oncology.
For more information, contact Nadia B. Kunzier, DO, clerkship director, at nadia.kunzier@nyulangone.org; or Georgea Sergeant, clerkship coordinator, at georgea.sergeant@nyulangone.org.
Surgery Clerkship
This six-week, phase two clerkship in surgery is designed to provide the student with a broad experience in the general surgical disciplines. This experience is designed to emphasize direct patient contact, including all phases of evaluation, diagnosis, and treatment, and is based on the recommendation of the Curriculum Committee of the Association for Surgical Education.
Students spend three weeks on a general surgical service, during which they are given the opportunity to follow patients from initial presentation and evaluation, participate in the patient's surgical therapy, and provide care during the postoperative recovery period until discharge from the hospital.
During the remainder of the surgical clerkship, students gain broad experience in the other surgical disciplines, including exposure to bariatrics, surgical oncology, and robotic surgery. Each student is assigned to a preceptor for the entirety of the six-week surgical ambulatory experience. The student is expected to function as a member of the surgical team with supervision from residents and attending physicians.
If you have questions, contact Adam E. Stright, MD, co-clerkship director, at adam.stright@nyulangone.org; Matthew Symer, MD, co-clerkship director, at matthew.symer@nyulangone.org; or Kelly Sillifant, clerkship coordinator, at kelly.sillifant@nyulangone.org.
Advanced Clinical Experiences
During phase three of the NYU Grossman Long Island School of Medicine curriculum, students participate in advanced clerkships and clinical experiences. Our advanced clerkships and required rotations are based on Core Entrustable Professional Activities, or Core EPAs, guidelines from the Association of American Medical Colleges, which establish expectations for activities that all medical students should be able to perform upon entering residency. Students also participate in various elective courses to round out their education and prepare them for residency.
Advanced Emergency Medicine Clerkship
During this four-week, phase three advanced emergency medicine rotation at NYU Langone Hospital—Long Island, students gain a comprehensive introduction to adult and pediatric emergency medicine from a variety of faculty, preceptors, and midlevel care providers, including nursing and other interprofessional staff in the emergency department.
Clinical experiences include a comprehensive introduction to emergency medicine through patient encounters; focused, complaint-driven history and physical exam of adults; common emergency procedures; and medical record keeping. Students participate in case presentations, common emergency procedures, didactic lectures, and simulated patient cases. Students also take part in the stabilization and resuscitation of patients, complete history taking and physical examinations, and the process of disposition for emergency department patients, which includes admissions, transfers, and discharges.
If you have questions, contact Sunil George, MD, clerkship director, at sunil.george@nyulangone.org; or Rita Francique, clerkship coordinator, at rita.francique@nyulangone.org or 516-663-2496.
Critical Care Clerkship
During the four-week, phase three critical care clerkship at NYU Langone Hospital—Long Island, students develop the knowledge, skills, and experience needed to care for critically ill patients. Students have the option to rotate in a specialty intensive care unit (medical, neonatal, pediatric, surgical) aligned with their career choice.
For more information about each specialty area, contact the director or coordinator:
- medical ICU—Shalinee Chawla, MD, director at shalinee.chawla@nyulangone.org, or Jennifer Fermin-Solon, coordinator, at jennifer.fermin-solon@nyulangone.org
- neonatal ICU—Amrita Nayak, MD, director at amrita.nayak@nyulangone.org, or Esther Mangum, coordinator, at esther.mangum@nyulangone.org
- pediatric ICU—Marguerite Canter, MD, director, at marguerite.canter@nyulangone.org, or Esther Mangum, coordinator, at esther.mangum@nyulangone.org
- surgical ICU—Ricardo Jacquez, MD, director, at ricardo.jacquez@nyulangone.org, or Kelly Sillifant, coordinator, at kelly.sillifant@nyulangone.org
Critical care clerkship responsibilities include daily teaching rounds and following, assessing, and treating critically ill patients and be an active member of the care team. This rotation also includes didactic sessions on important critical care topics.
Subinternships
During four-week, phase three subinternships at NYU Langone Hospital—Long Island, students complete rotations in four areas of primary care: medicine, surgery, pediatrics, and obstetrics and gynecology. Students have the option to choose a specialty aligned with their career choice and take on patient-care responsibilities that exceed those of the core clerkships. These experiences help prepare you to excel during the internship year of your upcoming residency.
For more information about each specialty area, contact the director or coordinator:
- medicine—Stephanie Mawhirt, DO, director at stephanie.mawhirt@nyulangone.org, or Barbara Cohen, coordinator at barbara.cohen@nyulangone.org
- pediatrics—Alena Connelly, MD, director at alena.connelly@nyulangone.org, or Esther Mangum, coordinator, at esther.mangum@nyulangone.org
- obstetrics and gynecology—Elana Kastner, MD, director at elana.kastner@nyulangone.org, or Georgea Sergeant, coordinator at georgea.sergeant@nyulangone.org
- surgery—Adam Stright, MD, director at adam.stright@nyulangone.org, or Kelly Sillifant, coordinator, at kelly.sillifant@nyulangone.org
Subinternship responsibilities may include taking extended night calls, night floats admitting patients, and entering orders, being an active member of the care team and attending didactic sessions.