Policy responses to increasing workforce supply: IMGs, policy failure and continued reliance
Dr Ayman Shenouda Over the coming weeks I’d like to start a discussion to support planning around a future Australian medical training model. The first starts here with IMGs and our continued reliance on them and what’s next in the context of national self-sufficiency planning. A rural workforce reality: IMGs remain a key part of the rural medical workforce despite increasing graduate supply. Whether described as policy failure or policy still in motion, it is clear we are yet to harness our increased domestic supply as intended. Our planned approach for less reliance on IMGs towards self-sufficiency has clearly not met its objective. We’ve seen an increase in domestic supply of 2.7 per cent per year and above population growth. The raw numbers show an overall increase of 5.3 per cent per year, from 59,359 in 2005 to just under 94,000 in 2017.[i] But, despite these results, we just haven’t effectively utilised gains from increased supply to improve distribution. It is a lack of a coordinated national planning approach which has seen a strong policy response in increasing local medical workforce supply fail at both the prevocational and vocational training points. This has made workforce supplementation through migration less of a temporary fix and more of a permanent policy fixture. Visa reform Despite slow gains in workforce planning we’re starting to see some key shifts coinciding with changes to the visa system and a broader commitment towards a national workforce strategy. Policy announced earlier this year through the Commonwealth’s Visas for GPs initiative sees a reduction in IMG intake over the next four years. This remains a short-term measure. The wider medical workforce maldistribution problem in rural Australia needs a stronger national medical workforce plan and approach as discussed in newsGP when the policy was announced. This strategy brings rural workforce planning into alignment with the broader skilled migration policy changes with the introduction of the Temporary Skill Shortage visa (subclass 482) replacing the former 457 visa. In facilitating targeted use of overseas workers to address temporary skill shortages – it provides stronger policy controls to direct these doctors to where they are needed the most. Getting this policy lever to work for us and towards national workforce planning objectives is an important step in the right direction. This should always have been the aim and is more policy realignment than reform but represents an important first step. Policy implications Workforce distribution through migration can lead to unintended policy consequences in the absence of a national medical workforce plan. Workforce supplementation through migration is a divisive issue: many will say the most obvious solution is forced distribution of our domestic supply. But we know forced policies just don’t work. We already have one, in the form of the 10-year moratorium, and this has seen most IMGs return to urban settings once they’ve satisfied the regulatory requirements. Broader than policy, and putting cultural isolation issues aside, there are still plenty of negatives for the IMG. Often described as a two-tiered system, we place limits on their professional development and career opportunities while placing them in an unsupported and clinically complex environment. Our failure to nurture rural retention just makes it so much harder for those wanting to stay. This makes this forced distribution scheme just flawed policy working against retention aims. It has led to a constant stream of IMGs leaving rural areas once they obtain their unrestricted licenses. So, despite considerable policy efforts, the issue we started with nearly two decades ago remains. We still don’t have enough doctors in the areas where we need them the most. In fact, forced measures like these have just make rural practice less viable and appealing. More broadly though, it is a lack of coordinated national medical workforce planning has led us here. The recent COAG Health Ministers commitment towards a national medical workforce planning strategy will enable a much stronger needs-based approach providing a way forward towards self-sufficiency. Self-sufficiency planning Important to self-sufficiency planning, a recent review on the reliance of our IMG workforce highlights our obligation to consider global maldistribution and not just our own in workforce planning.[ii] The review led by O’Sullivan et al. 2019 states that our ability to minimise our reliance on IMGs is important for equitable global workforce distribution. It highlights a key role in workforce planning, specifically in developing national workforce data capacity to help inform sustainable medical health workforce planning. For Australia, in achieving the right balance of locally trained doctors, this review states policy to reduce our reliance on IMGs has to be mindful of the flow on effects to developing countries. This is an important point that often gets lost in the urgency to fill local positions. And, while I think more recent shifts to our visa controls brings us closer to meeting our moral obligations here, we still need to fully utilise the significant data and associate studies to support a national plan. In working through this aim, this review skilfully demonstrates how the available data, in this case from the MABEL study findings can be used to consolidate the best available national evidence to inform self-sufficiency planning. New stratified analyses of MABEL data have been captured to identify IMG work location patterns. Results show the proportion of IMGs among rural GPs and other specialists increases for each cohort of doctors entering medicine since 1970 peaking for entrants in 2005-2009. In our efforts to build a locally trained workforce for rural Australia, the review also confirms recent domestic graduates are less likely to work either as GPs or in rural communities. This study helps to identify the key drivers to successfully growing a local rural medical workforce - what we’ve done well and where we now need to focus our efforts. These are the broader reforms with many initiatives already in train. These key policy enablers, important to recruitment and retention, will be the focus of my next blog in this series. They include the required focus on generalism in ensuring the right balance of skills in moving closer to the National Rural Generalist Pathway. In addition, the more recent work towards an Integrated Rural Training Pipeline to support high quality rural medical training and as a key component of reform to ensure growth in graduates flows through to gains for rural Australia. A more supportive approach Distribution policies which can allow for self-sufficiency remain our key objective but benefits from increasing domestic supply will take time. However, it is clear that IMGs continue to address critical shortages in rural and remote areas and we need to continue to support them. The focus should include a mix of retention strategies and education supports toward Fellowship which encourage a permanent place in the community they’ve served. The recently announced More Doctors for Rural Australia Program (MDRAP) will provide targeted support for non-VR doctors providing GP services towards attaining Fellowship. A further positive shift in the new RACGP Practice Experience Program (PEP) Specialist Stream, replacing the current Specialist Recognition Program (SRP) from September, will allow doctors to access the highest Medicare benefits while working towards Fellowship. The PEP Stream encompasses educational modules as well as a workplace-based assessment with a core aim is to support professional development providing feedback on individual progress towards Fellowship. newsGP Importantly, the O’Sullivan led study[iii] also highlights the need for continued support. The authors conclude that IMGs are a key part of ongoing rural medical workforce planning and while we need to monitor our reliance, we also need to continue to support them. The positive is that we are now starting to see recognised our continued reliance on IMGs and the fact that they remain a key part of rural medical workforce. Importantly, we are seeing a strengthening of the data-policy link in national medical workforce planning leading to greater support. My message has always been: If you don’t need them – don’t get them. But if you need them then you must support them. It’s clear we need them and they must be continued to be supported in policy. [i] Scott A.(2019) Health Sector Report The future of the medical workforce. ANZ Melbourne Institute: Applied Economic & Social Research, The University of Melbourne. [ii] O'Sullivan, Belinda, Russell, Deborah J., McGrail, Matthew R. and Scott, Anthony (2019) Reviewing reliance on overseas-trained doctors in rural Australia and planning for self-sufficiency: applying 10 years' MABEL evidence. Human Resources for Health, 17 1: 8. doi:10.1186/s12960-018-0339-z [iii] Ibid.
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Future GP workforce: The strategies needed to get ahead of the crisis curve
Dr Ayman Shenouda A recent GP workforce discussion in the Herald Sun has warned supply is set to worsen over the next decade due to recruitment failures and broader impacts brought about by casualisation. There are some key issues impacting here and at this point in the election cycle, it is a good time to highlight precisely what has led us to these recruitment failures and how to fix them. We know what the path to a sustainable health system looks like and it involves a solid commitment to properly fund general practice and primary care. If we want to design a system around patient needs then it is in primary care where we must focus our health reforms. We have strong evidence to support this. We know that general practitioner supply is significantly associated with better population health. Countless studies have confirmed this – the most notable being those from Starfield and Shi – yet successive governments have failed to put in place an action plan to realise these benefits. Getting ahead of the crisis curve In order to get ourselves ahead of the GP workforce crisis curve, a cohesive national strategy is now required. It will certainly require a much stronger national policy focus to both recruitment and retention planning than we’ve seen in the past in order to build the GP workforce of the future. A longer-term vision is what is required: half promises set within short-term electoral cycles will not build the health system our patients deserve. At the heart of the issue is valuing general practice as a specialist discipline. The fact is that there is a lot of devaluing happening. Professional negativism exposure during training, which seems firmly entrenched within the hospital-based specialties, is very much part of the problem. We have to find a way to ensure general practice is high on the list in junior doctor’s specialisation choices. To do this, we need to work on the perception of primary as distinct from, and of lower status than, secondary care. When to direct our efforts Medical career decision making is complex and much of that occurs during the early postgraduate years. This is one or two years after graduation and for most their influences or role models will be from within the hospital system. This is the time that doctors are making important career decisions and where positive exposure to general practice needs to occur. Understanding the career choice determinants is important and there is an abundance of literature around this. I would like to see a strategy that prioritises general practice and primary care with targeted attraction policies that trigger at those key decision points for junior doctors. We need to work with other specialties to address professional negativism and find ways to provide more GP role models at these critical points in career decision making. Other factors at play Beyond recognition, it is important to highlight that there are other factors impacting significantly on our profession. These not only limit our ability to attract doctors to our specialty but are adding to professional dissatisfaction among the current GP workforce. Whether it is in its financing, remuneration or barriers to integration with the broader health system these are key capacity issues which persistently impact on our specialty. We can already see that the Medicare Review Taskforce’s proposed revamp of GP items is set to place a whole new set of restrictions. This combined with the impacts from the Medicare freeze and a persistent lack of investment in primary care is what makes our specialty a less attractive choice. These all contribute to the pressures of working in the current health system and places restrictions on the value of care we can provide as specialists. GP workforce action plan It is clear that GP workforce reform would need to see more funding to strengthen primary care. It would need less bureaucracy and significantly more funding to support patients with complex care needs for a system aligned with the multimorbidity in the community. It would require a sustained effort to lift the profile and prioritise supports to encourage junior doctors towards careers in general practice. We’re doing more to ensure the training occurs in primary care but that effort is diminished if all they see is a system in crisis. There is a need to include a targeted strategy which financially incentivises GPs into training and practices where they are most needed. But overall, we need to strengthen the role of generalist within the health system. A high-performing health system built on integrated models of care must prioritise primary care and GP leadership. We need to see a comprehensive GP workforce action plan prioritised by the major parties at the 2019 federal election. Rural maternity services: It takes a team to make it work
Dr Ayman Shenouda Timing is everything - this is particularly true in healthcare - and in birthing services right now, it’s actually getting quite critical for GP obstetrics. For the rural GP obstetrician, the discussion is no longer about a rebirth of rural obstetric services for rural areas but in has moved rapidly to the preservation of this critical role. Two key discussions are occurring in obstetric care in Australia at the moment both lacking one vital component and that is valuing the key role of the GP obstetrician in providing this care. The first, occurring at the national level, in setting national directions for maternity services prioritises access yet omits GPs almost entirely despite their reliance in rural and remote areas. The other discussion involves a state-led shift in WA towards a new model of care which seems to locks GP obstetricians out completely. We are seeing spot fires right around the country including in northern NSW but on a slightly different front in resistance of midwifery units to GP involvement. Combined these are worrying developments and it is clear that major change looms unless we can work to reframe the discussion. We have the solution The vital role of the GP obstetrician has to now dominate the national discussion and the National Rural Generalist Pathway is the connecting policy thread here. We are now at a critical point in building a future rural workforce which offers a single solution by factoring together all the required enablers in one. The vital work done over the last twenty years has shown us solutions which brought together in one pathway will offer a sustainable way to address rural health needs. It’s a model that will work – one that prioritises the skills needed – which are reflective of local health needs with the required training supports embedded. . This is a model that brings flexible models of care bridging the primary care and hospital care continuum – it’s based on community need. And it provides a way to keep it sustainable by enabling a highly skilled GP workforce integrating primary, secondary and tertiary care skills. But it is reliant on enabling infrastructure too and in keeping it sustainable and so much is connected to a town’s capacity to preserve procedural services like birthing. State of play Here’s a brief outline of the current state of play. Round 2 of the National Strategic Approach to Maternity Services Consultation has just closed (20 November). The Australian Health Ministers’ Advisory Council’s consultation draft Strategic Directions for Australian Maternity Services is structured around four values — respect, access, choice, and safety. Enabling access to services for rural and remote women is emphasised. Our College has advocated strongly for the federal government to acknowledge the role of GPs when this strategy is finally released next year having previously outlined concerns about the marginalisation of general practitioners out of obstetric care. Meanwhile, in Western Australia, the debate continues to heat up on hospital led changes to the obstetric care model in that State which is seeing GP obstetricians increasingly locked out. The WA shifts In WA we are hearing that this shift has been occurring gradually over a five-year period. The move to a hospital system with very little GP involvement and reliant on the fly in fly out specialist with onsite junior staff is becoming more prevalent. Local reports state that GP obstetricians are being excluded from being involved in intrapartum care with the new model using a salaried medical workforce and shift to midwifery-led care. This model has resulted in a significant disconnect between the hospital staff and the local primary care workforce. This being at odds with what the federal government is trying to achieve nationally through the NRGP in building a resilient rural GP workforce. Choice for women But perhaps the most important point is that with a new maternity model which favours salaried medical staff over GP obstetricians it is the patient that loses most of all. With GP obstetricians unable to care for public obstetric patients’ the choice for women is now much limited as a result. In these towns, the continuity of care role sits with GP obstetricians and carving this off piece by piece to a fly in fly out service model will come at a significant cost. In other towns we are seeing services close - women and their families have to travel significant distances to access care for pregnancy and birth. We know the risks that come with increased distance as well as the associated financial burden on already struggling rural families. Delivering care close to the patient is what works. Rural communities depend on their GP obstetrician with more babies delivered by GP-obstetricians than specialists in rural areas. A collaborative model What is missing in these discussions is a real understanding of team care and what it takes to address patient need in small rural towns. That is, what it actually takes to sustain a rural maternity service and those interconnective factors for why it matters so much for other services. We know that it takes a collaborative approach and advanced clinical skills encompassing medicine, midwifery, nursing, Aboriginal health and allied health. What’s important is understanding the role of the team and scope of practice enabling all to work together without comprising quality. It takes the whole team to make this work. A sustainable model involves a coordinated team involving the obstetrician, GP obstetrician and midwives and a roster divided among all of them. This is how the service is maintained and we only have to look at the success of places like Albury Wodonga to see how this model sustains their service – sharing on call and the prenatal and antenatal. We also know the other sustaining factor here – that the maternity service often opens up ways for other procedural services to develop. A vital skill set GP obstetricians skilled in childbirth require support, not barriers, in retaining such a vital skill set. At a national level, procedural training grants ensure they can maintain their skills yet on a state-level, at least in parts, this is not sustainable when access is denied. These latest developments not only risk the provision of obstetric services in rural areas becoming even more of a rarity but there will be some very real flow-on effects for our discipline. The attraction and retention of GPs to the region is closely tied to the GPO model and it is a skill set we need to nurture to preserve through the National Rural Generalist Framework. It is about getting the right skilled workforce in place, supporting a collaborative team structure to secure and sustain birthing services across rural Australia. The rural generalist model offers a way forward which will make a difference for rural patients - ensuring safe, affordable and accessible healthcare. MHR – It’s time for a policy reset
Dr Ayman Shenouda It’s a particularly hectic Monday morning and first up I have a 70-year-old male patient who has just been discharged from hospital. It will be no surprise that there is no information from the hospital. He’s had some blood tests though and his potassium is very high. This is why he was admitted - that along with some kidney problems. He’s accompanied by his son who is not aware of any previous conditions and not forthcoming about much at all. There’s some patchy interpretation offered of what was conveyed to them in hospital – but too cryptic to work through and the confusion was just making this patient more anxious. But what we do have is all his medication in a bag – a complication mix of current and old meds to sift through – so with that, the usual diagnostic challenge begins. Looking through I find Spironolactone – a potassium-sparing diuretic – and an obvious issue for a patient admitted with high potassium if he continue on this meds it can be life-threatening. He also had a very severe itch and swollen legs and few other chronic disease including renal failure This mixed bag of medications alongside some troubling symptoms makes for a very complicated patient. It took half a day to sort this patient out. More blood tests, phone calls and inquiry in order to reassure that all issues were adequately covered. It is when you have to deal with this spaghetti of information around a patient that access to their record in real time would have been helpful. Particularly when combined with the lack of discharge summary and the fact that both patient and son had little to no health literacy. It is those times when patients are moving between doctors, during emergencies and for post-acute episode follow-up that having this information to hand really counts. This is where My Health Record (MHR) would support better healthcare decisions and enable GPs to find information quickly. MHR Implementation The crisis of progress – in terms of resistance and technology – is something we’ve come to expect when introducing significant change. People resist change and with technology, this is intensified commensurate with risk, perceived or otherwise, which is precisely what we’ve just seen with MHR implementation. Expecting resistance to change and planning for it is something good policy planners do. But with this one, the MHR, really from its outset, there have been problems really from the early policy development to now in attempting implementation. There were problems on a number of fronts in working through the opt-in then opt-out rather than compulsion. But these are just your usual pain points in working through complex policy implementation. There were issues during the design phase and a seeming reluctance to take technical advice at critical points. With the focus now of course predominantly on the risks: the risks to privacy, cybersecurity and hacking with minimal success in lessening privacy concerns. From the very first day of the opt-out period, those opposed were stating that it is an ‘uncontrolled’ data dump.[i] Right up to the penultimate day as the deadline to opt-out loomed yesterday the movement in the Senate called for a delay for a further 12 months. This last-hour intervention was made while Australians were rushing to opt-out causing system overload with both website and phone line were being reported as down. I’m pleased to see Minister Hunt has decided to extend the opt-out period to 31 January 2019 which should enable some time to work through the many issues and hopefully reassure the public. Where to next? Our entire lives, it seems, are already in a databank of sorts and this lack of control is precisely why consumers needed that reassurance around privacy in this rollout. A centralised database with widespread access is of course problematic. It required precision in design and diligence around patient privacy concerns and effective responsive communication to implement. This needed a framework of trust and any attempt to implement without it was always going to lead to this point. From the lack of informed consent, privacy and security challenges and limited protections around these - some have suggested the MHR is the health sector’s NBN and there are certain similarities here. The risks are high and the right to privacy in the digital age relies on good laws and the lack of privacy and security provisions made it not ready in my view. These are complex technical and privacy concerns and this is where the problem lies. These risks are poorly understood and the fact that we’ve only just reached some consensus around some new protections through recent RACGP-led negotiations this makes for a good time for a policy reset. The extension to the end of January provides some time to work through the Senate Standing Committee on Community Affairs Report (which doesn’t recommend the abandonment of the system). The benefits of the MHR or any redesign can only be realised through regular use so that it becomes a routine part of healthcare and only then will its full benefits be realised. Broader take up can only eventuate once trust has been restored and there’s still quite a journey ahead before we get even close to this level given the policy implementation failures to date. [i] Zhou N. Media Article: My Health Record: privacy, cybersecurity and the hacking risk. 16 Jul 2018. Available at: https://amp.theguardian.com/australia-news/2018/jul/16/my-health-record-privacy-cybersecurity-and-the-hacking-risk New models of care: making integrated out-of-hospital care a reality
Dr Ayman Shenouda As the cost and need for care rise – with an ageing population and increasing disease burden - we will need new models of care to meet the healthcare needs of our communities. Improving the ability of healthcare systems to respond to the demands of patients in acute care and particularly for older patients presents a significant system and funding challenge. We need to define and fund new ways of working to better support our patients through a preventive strategy to reduce hospital admissions. We also need to ensure those receiving acute care actually require hospitalisation and for those who don’t we need new ways to transition from hospital to less costly, more appropriate settings. For our system to be sustainable we need to ensure our patients receive care in the most appropriate, least expensive setting. But an admission avoidance – hospital avoidance strategy requires integration of acute care with preventive and primary care something our funders resist despite the obvious efficiencies. It requires better integration of acute care within local and nationally funded health systems. This represents a paradigm shift that provides an acute service but that can be referred to across primary, secondary and tertiary care. It is about bringing teams together consolidating different points of access to care and providing that care in the home. This is already being by providing short home-based acute care to public hospital patients through a Hospital in the Home (HITH) model. A model tested and proven to be a viable alternative to hospital admission providing same or better patient outcomes and service delivery. Hospital in the Home Recently I met a doctor who is working hard to realise this vision for his community in Townsville. Dr Michael Young is a rural GP with advanced skills in ED and currently working as a Senior Medical Officer with the Hospital in the Home Service (HIHS) in the Townsville Hospital. For the last 4.5 years, he has been developing a team to run the acute HITH service in Townsville. Funded by the Queensland Government since 2014, Dr Young says it is an exceptionally efficient service which has equal or better length of stay and readmission criteria than that of an inpatient stay across a number of different diagnosis-related groups. These models are often state-led and funded and have been around for some time. An early investment in Victoria more than 25 years ago means we now have good evidence validating the model. Recent studies have shown significant benefits from an active HITH program affiliated with an acute tertiary hospital. What makes the model work? Firstly, the Townsville HITH Service runs as an acute facilitation service with a state-based tertiary hospital. The nature of the services places it as an extension to an acute care setting. Clearly, the model can be adapted to function from other funded tiers - including primary care and residential aged care – and applying to these models is expanded on later in the discussion. Secondly, team structure and success in part is reliant on having a doctor-facilitated referral service. This helps to build the required trust between referrers. It is also well recognised that having a medical officer improves the scope of what you can reasonably treat in the home. The Townsville experience sees 80 percent of patients come directly from ED while the other 20 percent are step down referred by surgeons, physicians, oncologist. These patients are usually referred to the HITH service for ongoing care for three or four days to complete their course of antibiotics or other treatment. The Townsville model operates leveraging three disciplines –infectious diseases physicians; general physicians and gerontologists; and general practitioners. The GPs involved are usually rural generalists with skills in acute inpatient management and some hospitalist skills. This brings a solid skillset to the team with GPs having familiarity with community medicine, acute medicine and with good knowledge on what can reasonably be treated in the community setting. Thirdly, for the model to work, it needs to focus on select conditions and an agreed patient cohort that are HITH amendable services. Hospital in the Nursing Home (HINH) I believe a step-up approach within nursing homes is another way to apply this model. The HITH model is currently predominantly step downs taking patients straight out of the ED and off the ward and back to the RACF to complete their treatment course or for additional care. However, the model can flex and pilots should be encouraged particularly for HINH and in primary care as an expanded healthcare home model. We need to focus on different models of nursing home care that can support general practitioner decisions. A step-up approach to support interventions and reduce acute hospitalisations from nursing homes. Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support. It would also work as a model to deliver end-of-life care. This could direct state investment in better quality end of life care facilitated by the GP out-of-hospital. It would certainly save the $2000 on average per night for a stay in ICU for what is often considered futile treatments. Tech platforms and monitoring through biometric devices also offer hope particularly in monitoring chronic disease in the home. Placing the technology into healthcare homes model would help to recognise acute deterioration early. GP can step in early to prevent deterioration and avoid hospital admission. But technology is only an enabler and we need to focus on investing in the model that underpins that technology. Getting started In summary some key enablers for getting the model to work. Firstly, the communication framework is really important and a lack of engagement with the referring doctor is where these models have tended to fail in the past. Whether referral is directly from private rooms or RACF the primary GP has been involved in the diagnosis and finding ways for those lines of communication to stay open is key. It is important when transferring that care back that a thorough yet succinct discharge summary is transmitted to the GP (and provided to the patient). A shared medical platform would be the ideal to ensure GPs have that window into the acute treatment base. Another key point, expanding on the discussion earlier, is getting the patient selection correct. That is to clearly design the scope of what you do - clinical or disease pathways – and how you do it based on need. Finally, in bringing together the required team – doctors, nurses and allied health professionals - to enable treatment to be administered safely and effectively in the home or RACF. Key barriers The current funding model is a key barrier in shifting resources to the community - primary care which is federally funded against state-funded tertiary care model makes this difficult. This is the lingering elephant in the room which sees a state-funded system that cannot always see the value of investing in primary care. This is then often set against a federal funder hesitant to top up what it already sees as a large investment in tertiary care. It’s a discussion we’ve had before and it comes down to valuing primary care and preventative work. But this investment is surely better than building larger hospitals and funding costly stays for patients that just don’t need to be there. Whole care continuum The ideal model is one that supports the whole care continuum so that a patient can achieve acute care whether referred from hospital or GP. Facilitating direct admissions from the GP is where the funding discussion now needs to occur as an extension of this model. But also looking beyond acute care to enable us to broaden the services we offer such as treating chemotherapy in the home. As we’ve discussed throughout, this model needs the right clinical and corporate governance framework around it. The right service parameters –patient selection and disease selection. It also needs volume to realise cost benefits and feeding that data back. We already have enough evidence around the HITH model but we need to do more measuring to ensure our funders start to tangibly realise those benefits. This is the only way we can make integrated out-of-hospital care a reality. |
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