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I interview approximately 60 prospective physicians for medical school over the course of the year and 40 physicians who are applying for the residency program. The pre-med students (almost all of whom are the age of my children) tend to have pretty good interview skills and are trying very hard to get into medical school (“I’ve wanted to be a doctor for as long as I can remember”) so the interviews tend to be somewhat predictable. Every so often I’ll get one who considers ObamaCare to be the devil’s work but for the most part they are good but non-controversial interviews.

The resident interviews are more fun for me. These are physicians-to-be who want to be in Family Medicine, want to see what our program has to offer, and have at least a passing understanding of the advantages our program might have over our competition. These are interviews with much more substance. The three on Friday were especially enjoyable.

One of the candidates was from Louisiana and grew up in a part of the state that my family is from as well. After a discussion regarding Cajun territory, the conversation veered towards Family Medicine and why he wanted to become a Family Physician. The candidate had done most of his clinical work in Lafayette, a regional clinical site where Family Medicine is taught. Like all good clinicians-to-be, on every clinical rotation the instructors not only focused on his clinical learning but also on his career choice. “Why Family Medicine” they would ask. He worried about the prestige factor as he was choosing a specialty. His decision was cemented, though, by a decision LSU made to place him with a rural Family Physician for an extended period. He saw this physician as a mentor and it was this relationship that cemented his decision to go into Family Medicine. He said “At the (teaching) hospital in Lafayette, the Family Medicine team is down here and the specialists are up here. Out in the community it is completely reversed.”

The second candidate was a student who had come for an interview the previous year. I remember the interview from last year very well. I was very surprised when I heard that this student selected Pediatrics instead of Family Medicine. She came back to re-interview because she said she had discovered her mistake and wanted to be a “Family Doc.” She said she was admitting a very young patient to the inpatient service for failure-to-thrive. It is uncommon for infants to fail to thrive and it is almost always a parenting problem and not an infant problem. In this case the mother seemed to the resident to be suffering from post-partum depression. Unfortunately, she was told that it was not her place to treat the depression, only the poorly fed infant. She said to me “I want to be able to treat the whole family.”

The third was a non-traditional candidate who was originally from Mobile. He left Mobile almost 18 years ago and after a roundabout life course ended up in medical school. He told me “I want to take care of people who are underserved in a holistic way and I want to do it here at home.” The fact that he was of African-American descent was meaningful. Traditionally we have had trouble attracting African-American candidates from Mobile into primary care, as have others, in part because there is a tradition in the community to encourage minority medical students to pursue limited specialty choices. I suspect this is a reminder of our racist past in this region, where African-American physicians were excluded from specialty training. Having Family Medicine seen as a “specialty” by this student is clearly a victory.

So three candidates and three conversations that give me hope for our specialty and the future of medicine.

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When I was a student at Tulane, there was a story (possibly apocryphal) that illustrates how medical education used to occur. The Endocrine Clinic (a training clinic for Internal Medicine residents) at Tulane used to take care of a lot of patients with overactive thyroids. They would place them on medication (Propylthiouracil, expensive, had to take three times a day) and monitor them roughly every 2 months from signs of worsening or problems with the medication. One Christmas break, the surgery residents broke into the clinic, pulled the charts of all of the patients on this medication, and called them to ask if they were interested in having an operation that would eliminate the need for this medication (but possibly lead to the need for thyroid replacement therapy). After the clinics reopened, many of these patients came back for their follow-up with a fresh scar from their thyroidectomy. The chairman of Medicine, a clinical giant named C. Thorpe Ray, went into the Dean’s office and proceeded to rant loudly about the surgeons. The chairman of Surgery, called in special for the occasion, let Dr. Ray rant. When asked for his response, he answered simply: “The boys need thyroids.”

This had been the training philosophy in medicine since the model for modern medical training was established following the Flexner Report. Learners were placed in large hospitals and practiced on folks who needed care. Folks in need went to the large hospitals to get care. Some folks might get care they didn’t need or want but… the boys needed thyroids.

Medical training, though, is changing.

A new report from the AAMC provides the results of a 2010 survey of member institutions to determine how attributes of the patient-centered medical home are being incorporated into the clinical education environment.  While few studies have examined how medical homes have been integrated into teaching settings, “Moving the Medical Home Forward: Innovations in Primary Care Training and Delivery,” offers examples of seven medical schools successfully delivering patient-centered care to their communities.  The report also discusses the challenges and opportunities in the post-health care reform era for medical schools and teaching hospitals to develop new ways to train physicians and improve the health of the public.

And now Tulane offers community-based training at several Federally Qualified Community Health Centers across the city (from the AAMC report)

While training in an NCQA-recognized patient-centered medical home has profoundly affected the resident ambulatory experience, (there is currently a waiting list of residents who wish to train at Covenant House) their exposure to innovation extends outside the health center walls. The team has partnered with numerous local nonprofit civic and religious groups in efforts to “get our tentacles into the community,” and allow faculty, residents, and medical students to train community health workers through culturally sensitive care management programs. Faculty have noted the quick ability with which residents become “savvy” with the resources available to the community, and, as indicated by Dr. Price Haywood: “Residents play a key role in helping patients negotiate the community.”

A far cry from the boys needing thyroids.

The rules for creating a Teaching Health Center (which I discussed before here and here) have been posted. If you are thinking about applying, note that the deadline for submission is December 30, 2010 at 8:00 pm ET.  Here is a link to the application page. Below are some excerpts from their announcement with my commentary. 

The government is willing to pay for direct expenses associated with sponsoring an approved graduate medical education training program and indirect expenses associated with the additional costs relating to teaching residents in such programs out of this money. This money will go directly to the THC instead of being filtered through a hospital. Although the program period is one year, it is HRSA’s intent to fund qualified THCs for the entire five year THCGME program period pending satisfactory performance of awardees and availability of federal funds (putting the THC at risk if congress changes its mind but also putting the THC on notice that they may not take advantage of this progrma to continue to create traditional residency training programs). Funding can only be used for the costs of new residents in a newly-established THC or an expanded number of residents in a pre-existing THC (this is not to pay for residency slots currently being paid for but to try and create new slots which is a problem because many current slots are underfunded). These payments will be as much as $150,000 per resident per year (which shows you how much it costs to train residents).

Payments must directly support the THC ambulatory training site (to try to keep hospitals from taking the money and re-purposing it). If a THC-affiliated teaching hospital receives GME funding from Medicare or other sources for the new THC residents, the THC cannot claim that portion of the time for HRSA GME payments (you can’t double dip).

 Corporate Eligibility

Eligible entities include community-based ambulatory patient care centers that operate a primary care residency program in high-need, underserved communities. (This will move training into the community where it belongs).  

 Training Program Eligibility

Only specific residency training programs program (family medicine, internal medicine, pediatrics, internal medicine-pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry, and geriatrics) are eligible (Hospitals can’t use it to create radiology residencies).

 Funding Limitations

Successful THCs have common elements, foremost of which is an institutional commitment to a dual mission of medical education and service to an underserved patient population, including underrepresented minority and other high risk populations.  In addition, there is significant patient- and community-based input into THC operation and management; and THCs have also demonstrated progress toward innovative models of patient care delivery such as the patient-centered medical home, implementation of electronic health records, population-based care management, and use of interdisciplinary team-based care (HRSA is not interested in funding the same old stuff)

Measureable outcomes

Measureable outcomes will include practice patterns of graduates such as whether they are providing primary care, and whether they are serving in safety net settings one and five years after completion.  It may also include outcomes such as creation of interprofessional teams that provide person-centered care, improvement in quality parameters, improvement in patient outcomes, and improvement in use of electronic medical technology. Not only does the successful applicant have to say they are going to do good things, they have to actually do them.

I look forward to seeing the applicants and how they propose to change our training…

The faculty at the college of medicine were asked along by the College of Medicine “blogger” to share what we thought were the top three advances in medicine. I named two drugs (H2 blockers like Tagamet because they practically eliminated a type of surgery and statin drugs like Zocor because they have altered the course of heart disease dramatically) and one process (outcomes measurement because it forces physicians to consider how they are in aggregate and look at an individual patient’s improvement or lack thereof). I was not asked what has changed Family Medicine training for the worse but I am certain in my top three would be the “Teaching Rules”.

I have discussed peripherally how we pay for physicians-in-training here and a little more detail about the agency that pays for them here and here, but I’ve not yet attempted to describe the disconnect between the payment process and the training process that currently exists. Partly that is because the story starts in 1965. It seems that from its inception, Medicare was expected to pay for some training but did not want to pay for all training. From testimony before the Practicing Physicians Advisory Council by the AAMC:

There is a 35 year history of Medicare requirements that a teaching physician is obligated to comply with when he or she submits a bill for a service in which a resident is involved. At issue over the years has been the extent to which a teaching physician must be present during a service in which a resident is involved, and the documentation that must be provided to support the level of a bill submitted to Medicare. Starting in 1967, The Centers for Medicare and Medicaid Services (CMS) and its predecessor organizations have issued a number of regulations, intermediary letters, memoranda and other documents that attempted to clarify the requirements. These efforts were not successful, and, in 1995, HCFA issued a new rule that superceded the old pronouncements. It became effective as of July 1, 1996.

Over the years, the Academic Health Centers had rationalized accepting payment for care provided by residents.  T he discussion around the development of this rule made it clear that Medicare felt that they were paying for the care delivered by the learner already and so the additional payment for care delivery seemed to be “double-dipping.” The 1996 “clarification” created a set of regulations which were well-intentioned but had several consequences, intended and unintended. First, it resulted in an immediate loss of revenue for the care of those patients who were insured through Medicare which was anticipated. Secondly, every other insurance followed Medicare’s lead (even though they do not pay us through any other method for training residents) resulting in additional loss of revenue which was unintended.

The response of Academic Medicine could have been to provide free care and charge learners tuition to make up the difference. Instead we decided to work within the new rules to maximize revenue generated as a consequence of patient care. For most hospital based specialties this meant the Teaching Physician needed to be present for certain aspects of care (such as a surgery performed by a resident, for example). The rules posed a particular challenge in Family Medicine, where most training took place in the office and involved thinking more often than the performance of a procedure. The thought process is more difficult to supervise than the removal of a gall bladder. Initially it looked like the rules would lead to the death of primary care training. The rules eventually  included an exception for primary care training to mitigate some of the potential difficulties. Unfortunately, as the rules were interpreted and reinterpreted, it seems that lost in the process was the intent of preserving primary care training.

As I said before, Family Medicine training tends to be different. Here at South Alabama we want our learners, by the time they finish their residency, to know how to take responsibility for patients over time. This includes caring for their acute illness, chronic illness, and facilitating their use of preventive services regardless of their insurance. The only way I know of to do this is to begin with heavy supervision and offer learners the opportunity to gradually practice independently over the course of the training program. We wish for our learners, when they graduate, to care for underserved populations so we would like to offer them the opportunity to provide care for patients with Medicare and other insurances while in training.

When the new rules were enacted we could (and did) request a “primary care exception” to allow us to not have to directly supervise the care delivered by every resident who had Medicare insurance. To obtain this we had to have one faculty for every four residents (which we were already doing) and the residents couldn’t bill for “higher level” codes. Although this sounds fairly simple, the rules have been interpreted and  re-interpreted.  So if a resident sees a patient who is “not complicated” but becomes complicated, what should the teaching physician do? Regarding the 1-4 ration, what if there are 7 residents and 2 teaching physicians? Under such circumstances, must each faculty member supervise a designated 3 or 4 of the 7 residents, or can they essentially provide “cross-coverage” of the entire 7 residents between them? If one of the teaching physicians takes a phone call, is he capable of supervising or does he have to call in a back-up supervisor while he’s on the phone? Each of these circumstances is open to interpretation, and unfortunately the audit is typically 2-3 years behind so we are required to keep records and detailed notes on what happened.

Part of the problem is that the rules are interpreted by intermediaries and are different in different locations and at different times.  What I can do is not what my colleagues in the northeast are able to do so we can’t offer best practices to our colleagues. Another problem is that the interpretations of the rules  are colored by “consultants” who have no more knowledge than most about the interpretation of the rules but as a consequence of their status can cause great disruption.  Because of the teaching rules we focus on style over substance, documentation over instruction, and worry all too much about payment for a particular activity. Our Family Medicine Center went from being marginally profitable prior to the Teaching Rules to being $700,000 in the red.

Clearly there are competing demands on the system and even under the current oppressive set of rules it is cheaper to use residents than any other labor source for many types of care delivery in Academic Health Centers. In Family Medicine it is more expensive to provide such care in the context of training. I believe we continue to do so because we realize the importance of our training mission and understand that there are no alternative training methods. As a consequence we react to continual reinterpretation with coping (like the frog in the boiling water) rather than saying “to heck with it.” I hope that the value of high quality subsidized training for Family Physicians is understood by Dr Berwick and he will work with the leaders in Family Medicine training to make the rules less difficult to interpret and follow. On my wish list for the primary care exception as it relates to the Teaching Rules are the following:

  • Changing the direct  payment structure such that the money follows the trainee instead of going through the Academic Health Center. This would allow me to hire the appropriate team members to transform the Family Medicine Center into a true Patient Centered Medical Home
  • Changing the rules such that the resident can deliver care for his or her patient without having to with hold documentation so that he or she can remain in compliance with the teaching rules. This means eliminating the restrictions on the codes that can be billed in the residents name if the Primary Care exception is followed
  • Use the PQRI process as a method to document the reception of value for care rather than focus on how residents are supervised as a metric. If we are able to deliver good care, does the minutia of supervision matter?

Are there more? Maybe Dr Berwick is open to suggestions…

I was pleased to read a student impression of the National Conference for Family Medicine Residents and Medical Students. I go almost every year and am impressed by the student interest and the efforts of those of us in Family Medicine to get students to the conference. This year South Alabama sent 11 students to the conference and they all seemed to come away with good knowledge about the specialty and an excitement about Family Medicine. The Medical RNinja reported on one session on the Patient Centered Medical Home where prospective residents were given a list of questions to ask prospective programs when interviewing. It is a very good list, so good that I will reproduce it below and encourage anyone applying for Family Medicine residencies to look at it before your interviews…

Access to Care

1. How does your practice provide patient-centered enhanced access (e.g., evening or weekend hours, open-access (same day) scheduling, e-visits)?

Electronic Health Records

1. What aspects of your medical home are electronic (e.g., medical records, order entry, e-prescriptions)?

2. Does your practice use a Personal Health Record that allows patients to communicate their medical history from home to the healthcare team?

Population Management

1. Do you use patient registries to track your patients with chronic diseases and monitor for preventive services that are due?

2. Does your practice use reminder systems to let patients know when they are due for periodic testing (e.g., screening colonoscopy, PAP smear, mammogram) or office visits (e.g., annual exam)?

Team-Based Care

1. Who comprises your medical home team and how do they work together to deliver comprehensive care to your patients?

2. What services can non-physician members of the team (nurse practitioners, medical assistants, social workers, etc.) provide for patients (e.g., diabetic education, asthma education)? How do you train them and ensure competency?

Continuous Quality Improvement

1. How do you monitor and work to improve the quality of care provided in your medical home?

2. How do you monitor your ability to meet patients’ expectations (e.g., patient satisfaction surveys)?

3. Are residents involved in helping to enhance practice quality and improve systems innovations?

Care Coordination

1. How does your practice ensure care coordination with specialists and other providers?

2. How does your practice ensure seamless transitions between the hospital and outpatient environment?

Innovative Services

1. What procedural services are offered in your medical home (e.g., obstetrical ultrasound, treadmill stress testing, x-rays)?

2. Does your medical home provide group visits (e.g., prenatal group visit)?

As I was driving back from a very nice long week-end with my extended family (fireworks, festivals, baseball, wings, and art in a gritty urban setting) in metro Atlanta, I heard an NPR story on “the July effect.”  This effect is a suspicion (now with some evidence behind it) that health care in teaching hospitals is worse in July because of the inexperience of the new learners (or as I tell my residents “You are moving from a very experienced physicians at one level to a very inexperienced physician at the next level”). The report cites an increase in deaths in counties with teaching hospitals and  lack of a similar effect in counties with non-teaching hospitals in July as evidence for this effect. It only finds the effect with medical errors. I am grateful to Dr Carol Motley who traded calls with me so I could be with my family and she could work with the newly promoted physicians on this worst weekend of the worst month of the year.

From experience I will agree that the learning curve for a newly promoted physician is steep. I unfortunately know of no better method of training physicians. The author of the study in his interview cited a lack of surgical effect as evidence that surgical training is superior. I would argue that this suggests a certain randomness to his findings and we probably need to look more closely before discarding the entire training process. It does point out the need for close supervision of neophyte learners and the importance of good processes coupled with an assessment of outcomes to determine if the desired effect is being achieved.

It also identifies a need for continuation of an extensively supervised period of learning prior to neophyte physicians being transitioned into the “real world”. This process (known as residency training) is labor intensive if done correctly. It involves ongoing assessment of the learners progress towards achieving  six types of competence which the prototypical physician is expected to demonstrate in practice. We do this in part through close supervision of the learner in hopes of detecting potential errors before they are made. We also do this by collating thousands of individual observations on each of our learners and using them to assess progress towards achieving these competencies. This process is time consuming and expensive.

The current way of paying for this instruction is for the payor (usually Medicare)  to give money to the hospitals and hope that they pass this money on to those of us providing the instruction. The hospitals tend to see the cost of training residents as including a lot of costs not involving direct supervision and assessment residents by attending physicians (in part because we can bill for the service which covers a small part of the total cost). Consequently, we don’t see much of that money. Perhaps if more people are aware of the “July problem” the allocation of money to pay  for supervision of neophyte residents will be seen as important.

Dr Lamar Duffy had an article published in one of our more prestigious specialty journals this past week. Several years back, we made a decision as a practice to use “e-prescribing” for all of our prescriptions (took away the pads). Lamar and Angela Yiu (among others but they were the main ones) had the vision to begin collecting data before, during , and after this transition. They found a decline in the number of after hours phone calls. Not an earth shattering finding but it proved that we can study the process of care with enough rigor to get papers published. This is important because a lot of our health care mess is due to a broken process that needs to be described and improved in a systematic fashion. Also, it showed that even in a small department like ours we can occasionally keep up with the big boys.

Writing a grant is all about trying to convince an agency/not-for-profit/rich person that their money will make a difference in the activities of your organization. Being in a medical school, I typically look to several federal agencies who are looking to improve medical education when I’m asking for money. This money typically cannot go towards “operating expenses” but must go towards changing the activities of the applying organization to bring them more in line with the goals of the granting agency. This is why it is important that the agency shares the goals of the person or group requesting the money.

The agency that typically funds family medicine education is the Health Resources Services Adminstration (HRSA). This agency has been charged with “improving access to health care services for people who are uninsured, isolated or medically vulnerable.” Over the years that I have been involved with this agency, I have sought and acquired funding for Community Oriented Primary Care, care of victims of domestic abuse, care of underserved rural Americans, and care of underserved urban Americans. Fortunately, the goals of this agency dovetail with my interests and the interests of the department.

The Patient Protection and Affordability Act has outlined what the primary care priorities are going to be for HRSA this year (listed below). Wish me luck:

  • Programs that develop programs between academic administrative units of primary care;
  • Programs that Propose innovative approaches to clinical teaching using models of primary care, such as the patient centered medical home, team management of chronic disease, and interprofessional integrated models of health care that incorporate transitions in health care settings and integration of physical and mental health provision;
  • Programs that have a record of training the greatest percentage of providers, or that have demonstrated significant improvements in the percentage of providers trained, who enter and remain in primary care practice;
  • Programs that have a record of training individuals who are from underrepresented minority groups or from a rural or disadvantaged background;
  • Programs that provide training in the care of vulnerable populations such as children, older adults, homeless individuals, victims of abuse or trauma, individuals with mental health or substance-related disorders, individuals with HIV/AIDS, and individuals with disabilities;
  • Programs that establish formal relationships and submit joint applications with federally qualified health centers, rural health clinics, area health education centers, or clinics located in underserved areas or that serve underserved populations
  • Programs that teach trainees the skills to provide interprofessional, integrated care through collaboration among health professionals;
  • Programs that provide training in enhanced communication with patients, evidence-based practice, chronic disease management, preventive care, health information technology, or other competencies as recommended by the Advisory Committee on Training in Primary Care Medicine and Dentistry and the National Health Care Workforce Commission established in section 5101 of the Patient Protection and Affordable Care Act; or
  • Programs that provide training in cultural competency and health literacy.

I’m writing to ask the federal government for some money to train more primary care physicians and to train them in better and different ways. More on grants and their role in training physicians later. Turns out that after 10 years of thinking the market would provide us with the right mix of health care professionals, we awake to find that we are able to image any part of the human body and make it more physically attractive but no one is available to keep folks in good health. They say that “ObamaCare” will correct some of these problems. Looks like there are going to be some winners and some sore losers.

In this country we have an odd way of doing workforce planning for physicians. Many years ago medical schools in this country were optional, set up to supplement the apprenticeship system that functioned in the seventeenth and eighteenth centuries. As described by Abraham Flexner in 1910 “The likely youth of that period, destined to a medical career, was at an early age indentured to some reputable practitioner, to whom his service was successively menial, pharmaceutical, and professional; he ran his master’s errands, washed the bottles, mixed the drugs, spread the plasters, and finally, as the stipulated term drew toward its close, actually took part in the daily practice of his preceptor,—bleeding his patients, pulling their teeth, and obeying a hurried summons in the night.” Students who desired to learn a more rigorous practice could supplement this apprenticeship with medical study in the larger towns in America. Mobile had medical schools early in its history and a very good one (Medical College of Alabama in Mobile) was established in 1859 to “supply physicians to rural Alabama, to reverse the economic and cultural drain among Alabamians that out-of-state education implied, and to educate medical students regarding the unique health care requirements of a predominantly rural Alabama populace.” Medical schools were commonly established near hospitals to expose students to people with various ailments with the Hospital Physician charged with oversight of these students.

The additional training of doctors freshly out of medical school in hospitals became popular in the 1870s and the City Hospital of Mobile had such a training program prior to 1895. The emphasis was on personalized instruction, use of laboratory to make diagnoses, and (after antisepsis became widespread) the use of surgery to cure illnesses such as appendicitis. Beginning in the late 1800’s but accelerating after WWII, physician specialization required additional training in a hospital after medical school. Where such training took place often dictated where one could practice following training (and still does to some extent) so there were not as many coveted positions as there were medical students. Medical students would go on interviews and were lucky enough to receive an offer would be given as little as several hours to think it over. This was not conducive to good medical student mental hygiene.

In 1952 a group of medical students got together and determined a method that internships (and further training  called residencies) could be announced using a computer to match the medical student choices with the hospital choices. That process is now known as  the match. In 1952, when the match was created, the money to pay for internships and residencies was put up by the hospitals. There were no work restrictions and the job became an apprenticeship type experience with some education provided. The book “House of God” is a good description of the training from that era.

Over the ensuing 50 years, much has changed regarding residency training. beginning in 1965 the federal government began paying for medical education through the Medicare program. Hospitals took advantage of this opportunity to add a number of training programs. These programs benefitted the hospitals by allowing them to provide more extensive care but did not necessarily lead to good training and the programs offered had no relationship to the needs of the community. In addition, physicians from other countries were encouraged to train here (and ultimately the system came to depend on these 5,000 physicians brought over every year) but were offered training that they could not use in their country for the most part because of a lack of available technology. Beginning in the 1980s efforts were made to control both the quality of the training programs and the importation of physicians from other countries, with mixed results.

What does this have to do with workforce? Graduating medical students select a specialty based on what they think they might like to do, where they might want to live, and (some more than others) how much money they anticipate making. Hospitals, who have little skin in the game when it comes to training residents and actually make money for having residents, want to be successful in attracting residents so they tend to offer training programs that are desirable to prospective residents. In an odd coincidence, those programs that graduates think will allow them to make a lot of money tend to fill first, before those that are needed to provide care for the poor and underserved (primary care). In the annual ritual, we offer more specialty care positions than we need as a country to provide optimum care, celebrate all of our bright students getting into these programs, and then bemoan the waste that comes from doing too many cardiac catheterizations. After all, a cardiologist has to eat.

After all was said and done, this years match actually ended on an optimistic note for my specialty. Although only reflecting an improvement of about 100 students, there were more US graduates going into Family Medicine than in previous years. Doctors in our specialty may not make as much as some of our limited specialty colleagues but I hope that one of the results of tomorrow’s vote will be to eliminate some of the stresses that contribute to professional dissatisfaction. It appears that at least some US students are anticipating this. Maybe next year will continue the trend…

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