According to the Graduate Medical Education Directory, published
by the American Medical Association, "the mission of the Accreditation
Council for Graduate Medical Education is to improve health care in the United
States by ensuring and improving the quality of graduate medical education
experience for physicians in training. The Accreditation Council for Graduate
Medical Education establishes national standards for graduate medical
education by which it approves and continually assesses educational
programs."1
The Directory also states that "the Accreditation Council
for Graduate Medical Education is a separately incorporated organization,
responsible for the accreditation of approximately 8,000 allopathic graduate
medical education programs. It has five member organizations: the American
Board of Medical Specialties, American Hospital Association, American Medical
Association, Association of American Medical Colleges, and Council of Medical
Specialty Societies. Each member organization nominates four individuals to
the Accreditation Council for Graduate Medical Education's Board of Directors.
In addition, the Board of Directors includes three public representatives, a
resident representative, and the chair of the Residency Review Committee
Council. A representative for the federal government and the chair of the
Residency Review Committee Resident Council also serve on the Board in a
non-voting
capacity."1
The accreditation of graduate medical education programs is carried out by
twenty-seven residency review committees. The orthopaedic surgery Residency
Review Committee has ten members; nine are appointed for six-year terms each
from three organizations (the American Board of Orthopaedic Surgery, the
American Medical Association, and the American Academy of Orthopaedic
Surgeons), and one resident is selected for a two-year term.
Through the accreditation process, the objective of the Accreditation
Council for Graduate Medical Education (ACGME) is to assure the public of the
high-quality education and training of physicians for improving health care in
the United States. It would be implicit in its mandate that, if physician
education and training are to remain outside direct governmental regulation,
the accrediting organization must act in the best interests of the public and
put aside the personal biases and viewpoints of the member organizations. It
is in this context that the Residency Review Committee members need to think
about the accreditation process.
A major initiative across all medical, graduate medical, and continuing
medical education is to ensure that physicians, including residents and
medical students, achieve competence in six areas: patient care, medical
knowledge, practice-based learning and improvement, interpersonal and
communication skills, professionalism, and systems-based practice. Organized
medicine has measured medical knowledge by standardized testing for many
decades, but knowledge has proved to be only a part of the skills and
attitudes of a competent physician. Likewise, surgical skills are only one
component of one competency, patient care, but this is very important for
surgeons, patients, and the public. In this context, this symposium tries to
address a critical issue: Should there be a minimal surgical experience for a
graduating orthopaedic surgery resident?
The orthopaedic surgery residency consists of five years of graduate
medical education. Postgraduate year (PGY)-1 has recently been well defined,
but the clinical curriculum for PGY-2 through PGY-5 has not. The
specialty-specific requirements for orthopaedic surgery education "must
include at least three years of rotations on orthopaedic
services,"1
and "the residents' clinical experience must include adult orthopaedics,
including joint reconstruction; pediatric orthopaedics, including pediatric
trauma; trauma, including multisystems trauma; surgery of the spine, including
disc surgery, spinal trauma, and spine deformities; hand surgery; foot surgery
in adults and children; athletic injuries including arthroscopy; metastatic
disease; and orthopaedic rehabilitation, including amputations and
post-amputation
care."1 This
is the only description of the clinical education in an orthopaedic surgery
residency program by the special requirements, and it is very limited.
In addition, the orthopaedic program requirements do not address the
surgical experience necessary for educating and training an orthopaedic
surgery resident. In the past five to ten years, many surgical and procedural
specialties, including orthopaedic surgery, have started to collect, by
resident self-reporting, surgical and procedural data. These data now are
collected through the Internet by the ACGME.
Some Residency Review Committees in surgical specialties have explicit
special requirements as to the type and volume of the surgical experience.
Plastic surgery requires "experience in all twelve specialties,"
and thoracic surgery requires "125 major operations" with
"adequate
distribution."1
The range in general surgery is 500 to 1000 major cases over five years and
150 to 300 major cases in the chief year. Neurosurgery requires 500 major
cases per finishing resident. Some surgical Residency Review Committees
require individual residents to have performed at least one standard deviation
below the mean of certain sentinel surgical procedures. These standards are
not a part of their special requirements, but they are nevertheless used by
their pertinent committees to make accreditation decisions. For making
accreditation decisions concerning surgical volume, there must be objective
standards.
Even nonsurgical specialties have some specific objective requirements
regarding the number of patients or procedures for an acceptable program or an
acceptable resident clinical experience. Physical medicine and rehabilitation
requires approximately 200 electrodiagnostic consultations per resident. For
radiation oncology, 600 patients must receive external beam radiation in the
parent institution, and each resident must treat at least 150 patients per
year, with a maximum of 450 patients per year. Pathology requires all
residents to perform fifty autopsies, examine 1500 cytology specimens, sign
out at least 2000 surgical specimens, and examine 200 frozen sections.
Diagnostic radiology specifies at least 7000 radiographic examinations per
year per resident. All of these requirements have numbers.
Orthopaedic surgery has shied away from requiring residents to have an
explicit or objective procedural experience. In the past, one justification
was that orthopaedic surgery is so diverse a surgical field that it is too
difficult to set minimal standards. Another valid concern is that some
residents need less surgical experience than do others to learn a particular
technique. Also, some faculty members are better teachers or allow more
surgical independence for a resident than others do, so that a quantitive
minimal standard is somewhat arbitrary.
An argument could be made that other clinical and didactic experiences and
curricula are just as necessary as surgical experience for acquiring the
knowledge, attitudes, and skills for preventing and treating musculoskeletal
diseases, disorders, and injuries by medical, surgical, and physical methods.
Surgical skill is just a part of one component of the six competencies.
However, besides medical knowledge, this is the only other competency that we
presently document. The other four competencies are difficult to teach,
document, and evaluate. Furthermore, the Residency Review Committee already
has data on the surgical experiences of each program and resident. The
documentation of evaluation and management activity could be measured in the
future as part of the case log system. What must also be part of the
curriculum is the teaching and assessment of the application of medical
knowledge, ethics and professionalism, practice-based learning, interpersonal
and communication skills, and systems-based practice. But until methods for
teaching and assessing these competencies can be developed, one can measure
surgical technical competence by at least a surrogate, the surgical
experience. Just because we are not measuring other important competencies, we
cannot deny that surgical skills are important to document, for fear that too
much emphasis will be placed on technical skills. After all, we are surgeons;
that is, orthopaedic surgery is the name of our specialty. The Residency
Review Committee has the data that can be used. Along with the rest of
medicine, we must develop methods to track and evaluate other
competencies.
In view of these concerns, it seems to be in the best interest of the
specialty, the public, and the residents that the Residency Review Committee
requires minimal objective numerical procedural experiences for the most
common surgical procedures carried out by each orthopaedic resident. The most
common surgical procedures performed in practice are known through data
collected by national databases, the American Academy of Orthopaedic Surgeons,
and the American Board of Orthopaedic Surgery Part-II oral examinations. These
include knee and shoulder arthroscopy, knee and hip replacement, hip fracture
repair, and carpal tunnel release. The Residency Review Committee, in
consultation with the American Board of Orthopaedic Surgery, could set minimal
standards for the number of surgical experiences per resident in these common
procedures that would be required for a program to be accredited. The
standards could also include a minimal number of the common surgical
procedures that are believed to be sentinel in proving a specific clinical
experience, e.g., amputation and the treatment of supracondylar fractures of
the distal aspect of the humerus in children.
The Residency Review Committee should publish the median, mean, and
standard deviation of key surgical procedures performed per resident across
all accredited programs. These data would provide a powerful incentive for the
individual programs to adjust their residents' surgical experience. Now that
the Residency Review Committee has the data, they can be used to substantiate
the surgical education and experience of each resident and assure the public
and our specialty that each resident has minimal surgical experience in the
commonly performed orthopaedic surgical procedures.
Before the symposium, we conducted a relatively unscientific survey of
PGY-4 orthopaedic surgery residents, program directors, and chairs or chiefs
of orthopaedic surgery residency programs through the American Orthopaedic
Association, an organization of academic leadership comprising 219 program
directors and chairs or chiefs of orthopaedic surgery. A total of 106 (48%) of
the 219 program directors and chiefs or chairs replied. Of the 101 PGY-4
residents selected by the chairs or chiefs to attend the 2005 American
Orthopaedic Association Resident Leadership Forum, forty-five (45%) replied.
Seventy-one percent of the leadership and 89% of the residents said that an
"orthopaedic surgery resident should have a minimal surgical experience
for some common orthopaedic procedures." The cohort of program directors
and chairs favored the program directors, the American Board of Orthopaedic
Surgery, and the Residency Review Committee as the organizations that always
should set the standards. Of the common surgical procedures performed in the
United States, knee arthroscopy and total hip and knee arthroplasty had the
support of >90% of the academic leadership for inclusion as minimal
standard requirements. Open reduction and internal fixation of a hip fracture,
hemiarthroplasty for a hip fracture, carpal tunnel release, and open reduction
and internal fixation of fractures of the femur, ankle, and tibia had the
support of between 80% and 90% of the orthopaedic leadership for inclusion as
minimal surgical requirements. Operative fixation of supracondylar fractures
in children and fractures of the distal aspect of the radius in adults had the
support of between 70% and 80% of the leadership for inclusion as minimal
surgical standards. Lastly, below-the-knee amputation and lumbar laminectomy
received the support of only about 50% of the leadership for inclusion as a
minimal surgical standard. The replies of the residents to these standards
were similar to those of the orthopaedic leadership except that even fewer
residents thought that carpal tunnel release was as important as the
orthopaedic leadership did. Notably, residents likewise rated lumbar
laminectomy lowest and below-the-knee amputation second lowest for setting
common surgical standards.
Eighty-seven percent of the orthopaedic leadership and 79% of the residents
desired the Residency Review Committee to publish the median and standard
deviation of common surgical procedures performed per resident in all
accredited programs, whereas 67% of the program directors or chairs and 64% of
the residents thought that the American Board of Orthopaedic Surgery should
require a minimal surgical experience for each resident to qualify for Part I
of the certification examination.
During the five years of an orthopaedic residency, the recently graduated
medical students are expected to become orthopaedic surgeons. Their education
is not expected to be completed after only five years, but they are expected
to have mastered sufficient knowledge, skills, and attitudes so that they can
practice competently and independently. Does an orthopaedic surgeon need to
have done every operation in a residency before doing it in practice? This is
not possible, much less practical. So, what are the operations that must be
done during a residency to prepare the resident for independent practice? How
many total hip replacements does a resident need to do before he or she is
competent? Is there a number that reliably assures a basic level of
competence? It is apparent that some residents master surgical skills quickly
with limited repetition, whereas others struggle even after doing an operation
numerous times. Simply continuing the number of surgeries provides only a very
approximate measure of competence, especially because residents are almost
always supervised.
There are other competencies the resident must learn and master before the
end of the residency. What nonoperative skills are required? Are we devoting
so much time to these skills that we can spare some more time to attend to the
surgical aspects of the residency? How much of the nonoperative education must
be obtained during the residency, and how much is obtained before the
residency? Do we expect residents to have sufficient education in the ethics
of being a surgeon before the residency so that we do not need to teach
ethics? Are residents expected to have sufficient communication skills before
they enter the residency so that we do not need to teach communication skills?
How much time should a resident spend reading? How many patients need to be
evaluated in an outpatient setting before a resident has developed the skills
necessary to come adequately to a management plan or an accurate diagnosis?
Under what conditions do residents learn best how to evaluate, how to
communicate, and how to advise patients about their condition and the
potential treatment options, including, but not exclusively, surgical
options?
The answers to these questions are debatable. Everyone has a different view
of the correct answers. Each resident needs a different amount of experience
for each skill. Some residents start a residency with good operative skills,
some with good communication skills, a few with reasonable diagnostic skills,
but very few, if any, with them all. Each of us is still developing our own
skills in all of these areas. It is, after all, called the practice of
medicine.
Currently, the orthopaedic Residency Review Committee's specific
quantitative requirements are minimal. There must be a minimum of four hours
per week of conference—four out of eighty hours.
"Conference" is not specifically defined, and a review of
overnight patients seen in the emergency room during the night qualifies as a
conference. One half-day of outpatient experience per week with at least ten
patients is required. This requirement is only for PGY-2 and PGY-5. Therefore,
a resident could finish an accredited residency having seen fewer than 2000
patients in an outpatient setting. It is implied that there is faculty
supervision, but there is no specific requirement that any of these patients
be presented to a faculty member. None of the patients are required to have
preoperative evaluations. They all could be postoperative patients. The
requirement for "continuity of care" and seeing
"preoperative patients" is now often fulfilled by an assessment by
the resident in the anesthesia holding area immediately prior to surgery.
Residents are required to record every activity associated with a Current
Procedural Terminology (CPT) code. They are not required or even asked to
keep track of how many times they discuss a new diagnosis with a patient, how
many times they help patients to decide whether surgery is what they need or
want, or how many times they talk to a family about a complication of a
treatment.
The responsibility of the Residency Review Committee is to ensure that
residency programs meet a minimally acceptable standard. Some would say that
the Residency Review Committee should make more requirements of residency
programs, but requiring a specific number of operations is not one of them.
There are a number of reasons for this.
First, there is no evidence that residents are inadequately educated in
surgical technique. The median number of procedures performed by an
orthopaedic resident during the residency was 1572 in 2003 to 2004. Is that
enough? Is it too many? Most residents seem to prefer the operating room to
the clinic, anatomy laboratory, research laboratory, conference room, and
library. Many faculty members often feel more comfortable teaching operative
skills than teaching any other aspect of the program. Lack of interest does
not seem to be an issue with education in surgical skills. We may not be
teaching residents the specific surgical skills necessary for them to become
the best surgeons, but simply requiring a specific number of operations will
not solve that problem, because residents have different rates of learning
technical skills. Some might say that in orthopaedic surgery the decision to
operate is more important than a perfectly performed operation.
Second, there is no reason to believe that lack of surgical-skills
education leads to poor performance on the American Board of Orthopaedic
Surgery (ABOS) examination. On Part II of the ABOS board examination, surgical
technique is infrequently a cause of failure. It is the orthopaedic surgeon
with the best surgical skills and little clinical decision-making experience
who gets into trouble trying to solve a problem by using a surgical solution
when a nonsurgical solution would be better.
Third, the evidence suggests that the majority of medical-legal problems
are related to nonsurgical aspects of practice except possibly in trauma
surgery, where the surgical-technique is often an important aspect of the
case. However, in other areas of practice, it is more likely to be a missed
diagnosis or a delay in diagnosis. The second edition of the American Academy
of Orthopaedic Surgeons publication entitled Managing Orthopaedic
Malpractice Risk, which was published in 2000, concludes, "In
summary... most [claims] continue to be based on errors or misjudgments of
principles well known to the orthopaedic
community."2
Fourth, other surgical Residency Review Committee requirements are not very
specific about the number of operations
required3. In
general surgery, a total of 500 to 1000 operations are required, with 150 to
300 done during the chief year. The requirements state that an excess of 1500
total cases, or more than 450 during the chief year, needs to be
"justified by the program
director."1
For neurosurgery, the requirement is the total number of cases done
"within the total clinical facilities available to the training
program."1 The
requirement is that 500 cases be done per year by each finishing resident, not
that the finishing resident does the cases, but that, if there are two
finishing residents, 1000 cases per year need to be done "within the
total clinical facilities available to the training
program."1 If
there are three residents, then 1500 cases need to be done; if four, then 2000
cases; and so forth. Otolaryngology requires that there should be cases
"sufficient in number and
variety..."1
Plastic surgery has no numbers. Urology requires the cases to be distributed
evenly among the residents.
Many other competencies are being neglected. A recently published
"Instructional Course Lecture" indicated that orthopaedic surgeons
are not good at communicating with
patients4.
Communication skills can be taught and learned. This takes practice and time.
This is an aspect of resident education that is for the most part being
ignored.
Approximately two-thirds of residents do fellowships. Maybe many do so
because they do not yet feel comfortable evaluating patients and selecting
candidates for surgery. They know that during a fellowship, they will have
more experience in an office setting.
There are a number of initiatives that should improve residency education
first. Academic orthopaedic surgery organizations should establish a
curriculum for at least the basic knowledge base that residents are expected
to master during the residency. The current orthopaedic Residency Review
Committee requirements regarding faculty and program director qualifications
are weak and should be strengthened. Orthopaedic surgery organizations should
provide more opportunities for faculty to learn how to be educators. The
Residency Review Committee should establish a specific minimum number of new
patients that a resident must see and present to a member of the faculty. The
Residency Review Committee should establish a minimum number of postoperative
patients that a resident needs to see with a faculty member. The program
director should be required to document the competency of each resident in a
specific list of skills at the end of each year of the residency. We should
assure the public that every resident who completes an orthopaedic residency
program has certain operative and nonoperative skills. Once competency
criteria have been established, the need to specify the number of surgeries
performed would become superfluous.
Surgical Residency Review Committees have been gathering information on the
operative experience of individual residents for more than forty years, and,
during that time, most specialties have required residents to meet
quantitative minima in specified categories of procedures in order for them to
become eligible for certification. However, until the 1990s, when computer
tracking systems became available, those minima were set by Residency Review
Committees and/or Boards using professional judgment that was not necessarily
informed by quantitative data analysis.
Since 1999, when the ACGME introduced its Internet-based case log system,
Residency Review Committees have been given the opportunity to gather and
analyze the patient-care experience of residents much more efficiently and
effectively, which has resulted in the establishment of more quantitative
minima for residents in most specialties. Currently, eight surgical Residency
Review Committees (general surgery, thoracic surgery, plastic surgery,
ophthalmology, obstetrics-gynecology, urology, otolaryngology, and orthopaedic
surgery) and seven "non-surgical" specialties (allergy and
immunology, anesthesiology, dermatology, pediatrics, neurology, pathology, and
radiation oncology) require the use of the system as part of the accreditation
process. The system is adapted to each specialty, although it utilizes common
software to receive, store, and analyze data. Most of the Residency Review
Committees focus on the gathering and analysis of patient-care activities that
may be categorized by CPT and/or International Classification of Diseases,
Ninth Revision (ICD-9) codes. These data are then available for analysis
at the program and national levels. For example, during the 2003 to 2004
academic year, 3053 orthopaedic surgery residents entered data into the case
log system, which permitted the Residency Review Committee to project that a
typical resident would perform 1572 procedures (1324 in adults and 248 in
children) during the four years of orthopaedic surgery education in an
accredited residency. The case log system is not ideal. The system is based on
self-reporting. There is variability in resident compliance and in reporting
whether the resident is a primary surgeon or a first assistant.
As Residency Review Committees have gained experience with the statistics
made readily available by the case log system, six surgical committees
(general surgery, urology, thoracic surgery, plastic surgery, ophthalmology,
and obstetrics-gynecology) have established minimum numbers of procedures that
residents must perform in selected areas. For the most part, these minima fall
in the eighth or ninth decile of the national statistics for that specialty.
In contrast, orthopaedic surgery and otolaryngology have not set minima,
preferring to compare the experience of a program's residents with national
means, medians, and standard deviations. Following this approach, the
Residency Review Committees are not required to change minima as national
statistics vary over time. They are, however, able to maintain a reasonable
consistency in the evaluation of resident experience from program to
program.
As Residency Review Committees have gained experience with the capabilities
of the case log system, additional committees are having the system adapted to
their use. Next year, the colon and rectal surgery version of the system will
come into use, and several other Residency Review Committees are close to
requesting an adaptation for their use. In another recent initiative, the
ACGME computer staff and the orthopaedic surgery department at Tulane
University are developing software that will permit programs (from any
specialty) to extract data from local databases and transfer them in batches
to the case log system. Finally, as the system becomes generally accepted and
user-friendly, certifying boards and Residency Review Committees are working
together to design reports that may be used for both accreditation and
certification. Five surgical boards (general surgery, thoracic surgery,
obstetrics and gynecology, plastic surgery, and otolaryngology) already
require residents to submit case log system reports as part of the application
process for certification.
Ultimately, many specialties are interested in linking the statistical
analysis of resident experience data with faculty evaluations of resident
ability and experience. Because the quantitative component of such a system is
already in place, several specialties are in the process of developing online
faculty evaluation forms that would permit a more immediate linkage between
statistical indicators and faculty assessment of resident competence.
A rapid response survey was administered after these presentations at the
Annual Meeting of the American Orthopaedic Association in Huntington Beach,
California, on June 25, 2005. A total of 135 individuals, including thirteen
residents (10%), fifty-two faculty members (39%), and seventy program
directors and/or chairs (52%), participated in the audience response. When
asked what the minimal number of surgical experiences as a surgeon or first
assistant for fourteen common orthopaedic procedures during a residency should
be, they had the following responses. Fifteen to twenty percent had a constant
response that no minimal standards should be set for all fourteen common
procedures. The recommended minimal range of operative experiences was one to
five below-the-knee amputations; six to twenty-five operations each of nine
procedures (shoulder arthroscopy; hemiarthroplasty for hip fracture; carpal
tunnel release; lumbar laminectomy; and internal fixation of a femoral shaft
fracture, pediatric supracondylar fracture of the humerus, ankle fracture,
tibial fracture, and distal radial fracture); and twenty-six to 100 operations
each of four procedures (total knee arthroplasty, total hip arthroplasty, knee
arthroscopy, and internal fixation of a hip fracture).
Given the experience of Residency Review Committees to date, it is
appropriate to conclude that quantitative criteria (whether expressed as
absolute minima or standard deviations above or below the means) have been and
will become crucial to accreditation decisions. Having quantitative data makes
it much easier for Residency Review Committees to be consistent in their
evaluation of programs. Furthermore, the setting of minima and/or the
publication of national statistics (means and standard deviations) make it
easier for programs and residents to understand what is expected of them.
However, neither Residency Review Committees nor certification boards would
base their accreditation and certification decisions on quantitative data
alone. No certification board would permit an individual to take an
examination without the recommendation of a program director, even if the
resident has met every quantitative standard. Nor would a Residency Review
Committee accredit a residency solely because it is able to provide evidence
of a satisfactory number of surgical procedures. In both cases, qualitative
evaluation is also required (e.g., a global assessment that the resident is
capable of performing surgery independently and competently). The use of
quantitative data to develop an overall, qualitative decision improves
results, but the decision is not based on numbers alone. Therefore, it seems
appropriate to conclude that quantitative minima are now necessary, but still
not sufficient, criteria for crucial decisions regarding the competence of
surgeons and the quality of residencies and fellowships. Minimal quantitative
criteria are just one more tool to address and assess competency.
The Residency Review Committee must strengthen the position of the program
director; more clearly separate and define the roles, responsibilities, and
relationship of residents and fellows; require (and objectively document) more
outpatient and continuity of care criteria; and, with the help of the ACGME,
develop curricula and tools to evaluate professionalism, practice-based
learning and improvement, interpersonal and communication skills, and
systems-based practice, in addition to developing quantitative data for
surgical experience.
Documenting residency surgical experience is starting to become a
credentialing issue between hospitals and individual surgeons. In the near
future, documentation is likely to have a role in applying for initial
hospital privileges. Program directors are now being asked to review resident
credentialing applications and to attest to their competence for certain
procedures. In the future, a global assessment will not satisfy the certifying
medical boards. Furthermore, residents know or will learn that they will need
to perform certain common orthopaedic surgical procedures to be credentialed.
They will then demand and ensure that they get experience in these procedures
to fulfill their initial request for hospital surgical procedures.
Our orthopaedic surgery Residency Review Committee is at a historic point
in time. Extrinsic pressures have put the Residency Review Committee in a
reactive posture. There have been no substantial changes in the special
program requirements pertaining to the education and training of orthopaedic
surgeons since 1998! There are many opportunities to be proactive in
strengthening education in orthopaedic surgery. Surgical skills provide just
one of these opportunities.
The Residency Review Committee must strengthen orthopaedic education by a
variety of changes in the special requirements, especially with more objective
and quantitative criteria. The Residency Review Committee and the American
Board of Orthopaedic Surgery are the only two organizations that can have a
direct impact on resident education. The American Orthopaedic Association and
the American Academy of Orthopaedic Surgeons have nominating and appointing
power and can only influence either by that process or by strong position
statements. Furthermore, the American Board of Orthopaedic Surgery and
hospitals could bypass the ACGME by requiring certain surgical minima for
certification and/or credentialing.
With the public drive toward accountability, medicine is moving or being
pushed toward more quantitative data to measure quality. While surgical volume
in clinical practice seems to be directly related to outcomes in many surgical
specialties, surgical volume during residency has not been studied and the
resident is almost always supervised.
American Medical Association.
Graduate medical education directory 2005-2006. Chicago:
American Medical Association; 2005. p 1,
161, 226, 229, 269, 505.1
2005
Committee on Professional Liability.
Managing orthopaedic malpractice risk. 2nd ed. Chicago:
American Academy of Orthopaedic Surgeons; 2000.
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