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Nine STEPS to create the organizational structures that can result in more satisfied and productive physicians and other health professionals.
Answers to commonly asked questions.
Tools to guide the executive leadership team in creating a joyful practice environment and thriving workforce.
A more engaged, satisfied workforce will provide better, safer, more compassionate care to patients, which will, in turn, reduce the total costs of care. The Triple Aim of better care for individuals, better health for populations and at lower costs has been updated to the Quadruple Aim, with the fourth aim of clinician well-being.
The costs of burnout are widely under-recognized. Health professional burnout poses a significant threat to the clinical, financial and reputational success of an institution. But burnout can be prevented with intentional organizational initiatives. The return on investment for organizations that address burnout can be substantial.
Key drivers of burnout and engagement in physicians
How many physicians experience burnout?
Quiz Ref IDMore than half of US physicians experience some sign of burnout, a condition that impacts all specialties and all practice settings.1
Is burnout limited to physicians?
While burnout appears to impact all caregivers, it is especially prevalent among physicians.
What drives burnout?
The predominant drivers of burnout are systems-level factors rather than individual physician-level factors. Burnout is driven by high workloads; workflow inefficiencies, especially those related to the design and implementation of electronic health records (EHRs); increased time spent in documentation; loss of meaning in work; social isolation at work; loss of control over the work environment and a cultural shift from health values to corporate values.2
Why should an organization care about burnout?
Quiz Ref IDQuality reasons: Burnout negatively impacts quality of care, patient safety, patient satisfaction and productivity. For example, each 1-point increase in burnout correlates with a 3-10% increase in the likelihood of physicians reporting major medical errors.3
Humanitarian reasons: Burnout impacts the personal lives of individual healthcare professionals, and is associated with greater rates of dissatisfaction, divorce, drug and alcohol abuse, depression and death by suicide.4,5
Financial reasons: Burnout results in higher levels of physician turnover and reductions in professional work effort.6 For example, physicians who are burned out are more likely to leave their current practice or reduce to part-time as those who are not burned out. Replacement costs attributable to burnout are significant for organizations (see calculator). For example, consider an organization with 450 physicians with an annual turnover rate of 7.5% and typical replacement costs of $500,000 per physician. This organization would be expected to incur costs of over $5 million annually related to burnout-associated physician turnover.7
The aim is to go beyond reducing burnout to increasing professional fulfillment—to create the organization environment that allows clinicians to thrive.
What, then, are the organizational foundations that can foster joy, purpose and meaning in work and reduce the risk of burnout for clinicians?
Quiz Ref IDThe nine steps to creating the organizational foundation for Joy in Medicine™ are presented within the three domains of the Stanford Wellness Framework: Culture of Wellness, Efficiency of Practice, and Personal Resilience.
The Reciprocal Domains of Physician Well-Being
Defined as the creation of a work environment with a set of normative values, attitudes and behaviors that promote self-care, personal and professional growth, and compassion for colleagues, patients and self.
Engage senior leadership
Track the business case for well-being
Resource a wellness infrastructure
Measure wellness and the predictors of burnout longitudinally
Strengthen local leadership
Develop and evaluate interventions
Defined as the value-added clinical work accomplished, divided by time and energy spent. Factors that contribute to physicians' efficiency of practice include workplace systems, processes and practices that help physicians and their teams provide compassionate, evidence-based care for their patients.
7. Improve workflow efficiency and maximize the power of team-based care
8. Reduce clerical burden and tame the EHR
Defined as the set of individual skills, behaviors and attitudes that contribute to personal physical, emotional and social well-being, including the prevention of burnout.
9. Support the physical and psychosocial health of the workforce
Leadership should define professional wellness as a core organizational priority and dedicate appropriate resources toward it. Establish workforce wellness as a key leadership responsibility, with shared accountability across all domains of leadership. Include the efforts made toward improving professional well-being in the organization's annual strategic plan.
How can our organization manifest professional satisfaction as a core priority?
Commitment to professional well-being can be realized in a variety of ways:
Develop a mission and vision statement that includes professional wellness.
Educate the governing board about the positive impact that improving clinician joy, purpose and meaning in work can have on the mission of the organization, including quality of care, patient experience, physician retention and a healthy financial bottom line. Use the calculator below to calculate the costs of burnout (Step 2).
Implement shared accountability for workforce wellness.
How can we implement shared accountability for workforce wellness?
A powerful tool to drive change is to link leadership performance review to improvement in clinician well-being. This prevents sub-optimization around a narrow domain of responsibility, where one division optimizes the organization around its particular goals (e.g., data security or compliance) at the cost to other organizational goals (e.g., patient satisfaction, productivity or workforce well-being).
As one example, the Chief Executive Officer (CEO), Chief Medical Information Officer (CMIO), Chief Compliance Officer and others on the executive leadership team can be assessed on improvement in the well-being for the entire institution as part of their annual performance review.
Once structures for shared accountability are in place, it is helpful to create opportunities for administrators and department and division leaders to collaborate with each other in the development of plans for improving workforce wellness.
Shared accountability for wellness across multiple domains of leadership also helps establish trust among the workforce.
How can leadership facilitate effective change?
At the highest level, it can be helpful to identify trust, courage and empowering front-line workers as keys to success.
When creative, committed physicians and others feel powerless or subject to excessive top-down controls or decisions based on fear, change is resisted and drag is added to the system. In contrast, when physicians and their teams are trusted and empowered to solve problems locally, with strong change management support and a light regulatory touch, the innate professionalism of the workforce is allowed to flourish and everyone gains.
Leadership should regularly estimate and report the organizational costs of burnout. Calculate the costs of burnout using the calculator below.
Physician burnout is expensive to an organization. It contributes to direct costs of recruitment and replacement when physicians leave or reduce their clinical work effort to part-time. Costs can range from $500,000 to over a million dollars per physician. This estimate includes the costs of recruitment, sign-on bonuses, lost billings and ramp-up costs for replacement physicians.
The costs of burnout also include the indirect costs of medical errors, higher malpractice risk, reduced patient satisfaction and damage to the organization's reputation and patients' loyalty. These are not factored into the calculator below.
Organizational Cost of Physician Burnout
Projected cost of physician burnout in terms of turnover. (Other costs of burnout, in terms of medical errors, malpractice liability, patient satisfaction, productivity and organizational reputation, are not included.)
How does physician burnout impact work effort?
Physicians who are burned out are more likely to reduce their work effort to part-time as their only coping strategy. Studies have shown that every one-point increase in burnout (on a seven-point scale) is associated with a 30-40 percent increase in the likelihood that physicians will reduce their professional work effort in the next two years.8
Medical errors are expensive to our organization, both through malpractice claims and through our global payment contracts. How does physician burnout impact cost and medical errors?
Burned out physicians may make more medical errors. A one-point increase in one domain of burnout has been shown to increase the risk of medical errors by 11 percent.3,9,10 Burned out physicians order more referrals, tests and prescriptions. For an emotionally exhausted physician, this may be a socially acceptable way to end a patient visit.
Our organization is increasingly financially rewarded/penalized for our patient satisfaction scores. How does physician burnout impact patient satisfaction?
Patients are more satisfied with their care and more adherent to their physician's treatment recommendations when their physicians have higher rates of satisfaction.11- 13
How does physician satisfaction impact patient health-related behaviors?
Physicians who are happier in their careers are more effective in working with patients on behaviors that improve health, which has the potential to lower the overall costs of care. For example, patients of satisfied physicians are more likely to adhere to their physician's medication, diet and exercise recommendations.13
We are entering into more capitated contracts. How can we help our physicians and our patients while at the same time be financially successful?
Highly satisfied physicians are able to contribute more to their organizations in a myriad of ways: going the extra mile for patients, engaging in quality improvement projects and simply providing safer, higher quality, more personalized care.
In addition, a more engaged, satisfied workforce, whose workflow has been optimized, is more effective at controlling population health costs. One study estimated that if all practices adopted the workflows and professional attitudes of those in high-performing practices, health care costs would be reduced by 12.5 percent.14
Our physicians report that they are under-staffed and thus doing work that doesn't require their training, and yet staffing costs are one of our largest expenses. How can we afford additional staff?
Most industries recognize the importance of maximally leveraging the skills of their highest trained workers. Healthcare has been an exception. Yet, by reassessing current assumptions about having minimal staff support, and factoring in the costs of burnout and of replacing physicians who cut back or leave, organizations have an opportunity for a triple win: a win for the patient, a win for the care team and a win for the organization.
Consider a hypothetical population of 6000 patients.
Clinic A has a 1:1 physician: medical assistant (MA) staffing ratio and a panel size of 1500, and thus requires 4 physicians and 4 MAs to manage the population, at a total salary cost of $1.2 million.*
Clinic B has a 1:2 physician: MA staffing ratio and a panel size of 2000, and thus requires 3 physicians and 6 MAs at a total salary cost of $1.05 million.*
Create an executive-level champion position, such as a Chief Wellness Officer, who reports directly to the CEO, on par with other leaders such as the Chief Operating Officer (COO) and Chief Medical Officer (CMO), and is resourced accordingly. This leader should ensure all leadership decisions consider the potential effect on workforce wellness.
Establish a sufficiently resourced Well-being/Clinical Transformation Center responsible for improving clinician well-being, improving clinical workflows and EMR performance and enhancing a sense of community among physicians and other health professionals in the organization.
How much shall we invest in our wellness infrastructure?
Leaders are often unaware of the costs their organizations incur due to physician burnout. You can estimate the costs related to burnout using the calculator above.
Establish physician wellness/burnout as a critical quality metric on the organization's data dashboard. Assess burnout, its drivers and the costs to the organization at least annually and report the results regularly to the organization's governing board.
What survey instruments are available to assess physician well-being?
Quiz Ref IDAvailable measurement instruments include:
Maslach Burnout InventoryMayo Well-being IndexMini-Z 2.0†Oldenburg Burnout Inventory
Maslach Burnout Inventory
Mayo Well-being Index
Oldenburg Burnout Inventory
The EHR is a major source of stress for our health professionals. What tools are available to assess EHR inefficiencies?
Many EHR vendors have the capacity to generate EHR-use data. This data can provide insight into practice inefficiencies that can be targeted for improvement. For example, an organization can assess the time their providers spend on inbox work, and then institute in-basket management changes to reduce this. Pre- and post-intervention measurements can demonstrate the impact such changes have made and help spread change throughout the organization.
EHR-use data can identify efficient physicians from whom others can learn best practices. Such data can also identify physicians at high risk for burnout (e.g., because they are spending two hours of their personal time each night doing EHR documentation). This data can also identify physicians who would benefit from new workflows or improved task delegation among their team. For example, a physician who spends considerably more time on orders than their peers will benefit from process re-engineering assistance to delegate some of this work to team members.
Your organization may want to track additional metrics15 regarding EHR use. Some of these can be measured behind the scenes with programs supplied by the EHR vendor, others may require direct observation through time-motion studies or diaries.
Work after Clinic (WAC): time spent on EHR when not scheduled with patients
Work on Vacation (WOV): time spent on the EHR while on vacation
Total work hours: Both direct patient care time as well as after-hours work, which is a better measure of clinical effort than scheduled patient care hours
Face-to-face (F2F)/EHR: Direct face-to-face time with patient versus EHR/deskwork time
EHR stress: See Mini-Z, above
The leadership skills of a physician's direct supervisor have a powerful impact on physician burnout. For example, one study of several thousand physicians found that every one-point increase in leadership score (on a 60-point scale) for a physician's immediate supervisor was associated with a 3.5 percent decrease in the likelihood of burnout and a 9.1 percent increase in physician satisfaction.16
For this reason, it is important to regularly assess the leadership performance of division chiefs, department heads and other direct supervisors of physicians. This can be done directly, by surveying the individuals they lead, and indirectly, by evaluating the well-being scores of those under their leadership.
Leaders can also combat physician burnout by ensuring that physicians have some control over their work environment and the nature of their work. For example, having control over the start and stop times of clinic, appointment length and task delegation among the physician's team will improve career satisfaction and retention.
In addition, it is important to allow time for physicians to pursue their passions. Research has shown that if work is structured so that physicians have 20 percent of their time dedicated to the professional activities they find most meaningful (quality improvement work, community outreach, mentorship, teaching, meeting needs of underserved, etc.) burnout is reduced.
What are the important attributes of leaders who support the professional satisfaction of others?
In the words of physicians, such a leader16:
Holds career development conversations with me
Inspires me to do my best
Empowers me to do my job
Is interested in my opinion
Encourages employees to suggest ideas for improvement
Treats me with respect and dignity
Provides helpful feedback and coaching on my performance
Recognizes me for a job well done
Keeps me informed about changes taking place at my organization
Encourages me to develop my talents and skills
Are there other ways leadership can improve communication and relationships with physicians?
Establish “co-creation” as the standard approach for organizational initiatives, including in the development of institutional policies and regulations. In a co-creation framework, policies are created with input from both organizational leaders and those who will be impacted by the policies.17
Choose an approach of “empower and encourage” rather than “design and deploy” or “command and control” in rolling out new initiatives. This requires allowing local customization within standard workflows. For example, rather than developing a standard template for daily huddles that is mandated for all practices, invite each practice to develop a template and create the time, location and content of daily huddles that fits best within their workflow. The template users know what is most helpful to them.
Quiz Ref IDDevelop a communication platform for physicians to address daily work challenges and rapidly accelerate sharing of key issues from the front lines to top-level leadership capable of addressing these issues.
We suggest creating a toolkit of interventions and the associated staff available to assist with their implementation, and then inviting individual units to choose where to start. If the organization has a Wellness Center, the Center's staff can track and report annually on the interventions implemented and their impact on well-being, along with other metrics, such as productivity and retention.
Workflow improvements are among the most powerful interventions to reduce burnout. In addition, combating professional isolation and increasing opportunities to build community within the workforce can improve satisfaction. In the Healthy Work Place trial, three types of interventions were successful: workflow redesign, communication improvements between provider groups, and quality improvement initiatives in chronic disease management in areas of clinician concern.18 Social isolation has become more prevalent, especially for physicians in ambulatory practice. Organizations can intentionally support collegiality and create community by re-examining how the physical space is designed, activities are scheduled and channels of communication are employed.
The University of Minnesota created “collaboration hallways” in its new ambulatory clinics building. These corridors of communal workspaces cut crossways through patient care hallways. An endocrinologist can walk down the collaboration hallway to easily consult with a dermatologist. A surgeon can walk over to talk with a general internist about their mutual patient.
At Beth Israel Deaconess Medical Center and Atrius Health, both in Boston, space is assigned to encourage people of different roles to cross paths with each other in the course of the day, increasing the possibilities for communication. For example, Atrius Health co-locates physicians with MAs and nurse practitioners in a common office, on a shared corridor with other teams. Other organizations have found that a provider lunchroom, physicians' lounge or other meeting space helps to combat isolation and build stronger working relationships. Visit the STEPS Forward™ module, Optimizing Space in Medical Practices for more information.
Schwartz Rounds/Empathy Forums
Supporting forums for health professionals to explicitly address the emotional and spiritual needs of patients and caregivers can build a sense of community within an organization. Visit the STEPS Forward™ module Listening with Empathy for more information.
Physician Engagement Groups
Mayo Clinic offers all of their physicians the opportunity to meet in small groups for dinner at a restaurant in town to discuss topics related to physicianhood every two to four weeks. A discussion question is provided to start the conversation. Mayo Clinic pays for the cost of these meals. Burnout has been shown to decrease in those who participate.19 (Check out case 2 “How's it going in Rochester” in the STEPS in practice section to learn more about the Mayo Clinic.)
Writing and Literature Groups
Other organizations have supported writing and literature groups among their workforce as a means of strengthening social connections. For example, The Stanford Literature & Medicine Dinner and Discussion series provides an opportunity for physicians to come together and share a meal while discussing works of literature. It is part of a national program to foster the medical humanities in partnership with participating academic organizations such as Harvard University and the University of Chicago.
Physicians spend nearly two hours on EHR and deskwork for every hour of direct clinical face time with patients.19 This is often not satisfying to patients or to physicians. Many practices can save several hours of physician and support staff time per day by strategically re-engineering the way the work is done, the way technology is used and the way care is shared according to ability within the team.
For example, some work, such as prescription renewal or results reporting, can be re-engineered out of the physician's workflow; other work, such as visit note documentation and order entry, can be shared with other members of the team.
Where can I learn more about improving workflow efficiency?
The STEPS Forward™ portfolio of toolkits can provide guidance and practical tools and actionable downloads, including sample policies, checklists and metrics for each intervention. A practice team or pilot group can use the Practice Assessment Tool to assess their organization's current state and guide their choice as to where to start. Many organizations have also found that including patients and families in the change process results in better outcomes.
STEPS Forward™ toolkits for improving teamwork and efficiency include:
Expanded rooming and discharge protocols
Implementing team-based care
Where can I learn more about leading change?
Change management techniques, such as Lean and PDSA cycles, can be helpful in empowering front-line workers to choose the problems they want to solve and to create and assess solutions themselves, with the support and guidance of organizational leaders. It is important that those doing the work have some control over how their work is done, both on a day-to-day basis and during times of significant process redesign.
STEPS Forward™ offers several toolkits for facilitating organizational change
Medical assistant professional development
Quality improvement using PDSA
Preparing your practice for change
Select sustainable change initiatives
The EHR is a significant source of stress and burnout for our physicians. Some of this relates to the design and regulation of EHRs, but much of the stress relates to organizational decisions made during implementation. Many of these decisions have pushed more work to the physician, work that may not require a medical education, and thus contributes to time pressure and demoralization.
What have organizations done to reduce the burden of the EHR?
Atrius Health has created a “Joy in Practice IT bundle” to improve physician efficiency and reduce stress. This bundle includes:
Wide screen monitors
Provide efficiency assessment through the use of Epic's EHR-use tool (Physician Efficiency Profile) to generate data on EHR-use and then target interventions to improve efficiency
Workflow assessment involving a comparison of a given unit's workflow to Atrius Health's ideal practice model, with change management assistance to transform toward the ideal model if desired
Electronic prescribing of controlled substances (EPCS) using a smartphone application. For more information, visit the Drug Enforcement Administration's Diversion Control Division website.
Clinical leadership and operations leadership engagement that encourages “teaming” between clinical and IT leadership.
Other organizations have implemented the following to reduce the clerical burden of EHRs
Tap and Go badge sign in
Voice recognition software with natural language processing
Our doctors report they spend too much time on data entry. What does it cost for physicians to perform data entry that others could do?
Asante Physicians Partners in Grants Pass, OR, calculated that it costs $8 per patient for the MA to record elements of the patient's history into the record, compared with $32 per patient if this same work is done by the physician.
Consider the costs of data entry performed by an MA versus a physician for visit note documentation, billing and order entry. An MA doing this work at 10 minutes per patient at $25/hour for 20 patients a day results in data entry costs of roughly $80/day. For the physician to do this same work at $150/hour costs the organization $500/day. In addition, there are the indirect costs of reduced professional satisfaction and retention when highly trained professionals perform repeated tasks that do not require their training.
While the majority of physician well-being is driven by systems factors within the institution or the healthcare system at large, it is also important to support self-care efforts at the individual level.
To support wellness, some organizations provide assistance for physicians in accomplishing basic life tasks. For example, one organization has arranged for on-site dry-cleaning drop-off, another arranges for home delivery of healthy meals as a thank you for service on institutional committees, and another has an office that provides resources and referrals for physicians as they manage childcare or care for aging parents.
An organization may also choose to regularly assess physician self-care as part of an annual survey.
What are some additional measures that an organization can take to support personal wellness and resilience:
Provide access to healthy food and beverages.
Provide training in mindful eating and the time to mindfully eat.
Provide on-site exercise facilities.
Provide on-site showers (so that workers can bike or run to work or exercise during a work break).
Provide convenient opportunities for yoga, tai chi, mindfulness or other resiliency-oriented classes.
Establish a quiet “refresh and recharge” room for physicians to go to after a stressful event.
Provide peer support from physicians trained to listen to their peers undergoing trauma from lawsuit, medical error, career misgivings, etc.
Provide financial counseling via an annual review of financial health with a financial professional.
Include self-care in the institution's code of ethics.
Establish after-hours, off-site and confidential psychological counseling services.
Integrate presentations on personal resilience and well-being into the calendar of scheduled grand rounds or other organizational presentations.
Teach compassion and self-compassion20.
“Best practices to create an organizational structure to help clinicians thrive #STEPSforward”
At a time of dynamic change in medicine, improving the experience of the caregivers is essential, and is dependent on recognizing the costs of burnout and the value of a fulfilled professional workforce. Recognizing and quantifying the problem of burnout is the first step toward meaningful systematic change. Creating the organizational foundation for Joy in Medicine™ can be achieved by addressing issues within the three domains of physician well-being: efficiency of practice, culture of wellness and personal resiliency.
Executive leadership teams have an opportunity to improve the health and well-being of patients, and their organization's financial bottom line, by improving the health and well-being of physicians and their practices.
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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;
0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;
It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
AMA CME Accreditation Information
Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Target Audience: This activity is designed to meet the educational needs of physician leaders, senior leadership executives, organizational leaders, health professionals, practice managers and may also be interested in this activity.
*Disclaimer: Salary assumptions: physician $250K, MA $50K.
†Note: the AMA can survey your organization and provide customized, detailed feedback. Please contact us at email@example.com for more information.
Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.
Alejandro Aparicio, MD, CME Program Committee Advisor, AMA
Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, AMA
Bernadette Lim, Program Administrator, AMA
Samantha Leicht, Program Administrator, AMA
Christine Sinsky, MD, FACP, Vice President, Professional Satisfaction, American Medical Association; Tait Shanafelt, MD, Chief Wellness Officer, Stanford Medicine; Mary Lou Murphy, Administrative Director, Stanford Medicine WellMD Center; Patty de Vries, Director of Strategic Projects, Stanford Medicine WellMD Center; Bryan Bohman, MD, Chief Medical Officer, University Healthcare Alliance, Clinical Professor, Anesthesiology, Perioperative and Pain Medicine, Stanford Medicine; Kristine Olson, MD, MSc, Assistant Professor of Clinical Medicine, Yale School of Medicine; Ronald J. Vender, MD, Associate Dean for Clinical Affairs, Chief Medical Officer, Yale Medicine; Steven Strongwater, MD, President & CEO, Atrius Health; Mark Linzer, MD, FACP, Director, Office of Professional Worklife, Hennepin County Medical Center
Hunter L. McQuistion, MD, Chief, Department of Psychiatry and Behavioral health, Gouverneur Health / NYC Health and Hospitals; Russell S. Phillips, MD, Director, Center for Primary Care, William Applebaum Professor of Medicine, Professor of Global Health and Social Medicine, Harvard Medical School
About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,“ and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.
The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.
The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.
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