How I Educate Series: Jacob Avila, MD

This week’s How I Educate post features Dr. Jacob (Jailyn) Avila, core faculty at Southwest Healthcare EM Residency and creator of Core Ultrasound. Dr. Avila spends approximately 70% of his shifts with learners which include emergency medicine residents, off-service residents, and medical students. He describes his practice environment as a hybrid academic/community practice that is about to start its 3rd year of EM residents. Below he shares with us his approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Focused, contentious, applicable.

What delivery methods do use when teaching on shift?

Mostly verbal, with supplementary images/media usually pulled up on my computer/phone. Occasional hand-drawn illustrations and gestures.

What learning theory best describes your approach to teaching?

My learning theory is that I should match whatever learning theory best fits the person I’m trying to teach.

What is one thing (if nothing else) that you hope to instill in those you teach?

There are always things to learn and there are patients attached to the diseases.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

The amount that I teach definitely depends on patient volume. I live to teach, but I don’t sacrifice patient care in the moment to orate. That being said, on shift, I try to give at least one teaching pearl to the learner assigned to me per patient. If I’m able to give more thorough teaching that’s a great thing!

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

I usually text them if it’s after shift, or talk to them on shift about their documentation.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Definitely. Since I work at a hybrid academic/community shop, I have to be diligent of overall ED flow (although I could also argue this is important in a purely academic shop). When it’s busy, I teach less. When it’s normal/less busy I teach more to make up for those times I can’t teach as much. Also, I make sure to acknowledge/apologize to the resident/learner when it’s one of those busy days.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

I rarely take over early, but if I do it’s because the patient is at high risk for an imminent bad outcome. If that happens, after the fact I will try to have the resident run through what they would’ve done to try and salvage the learning opportunity. That being said I believe that slight discomfort can go a long way to help the resident/student learn and solidify their knowledge. I never do this in an antagonistic way, but rather to make sure I hold the resident accountable (in a kind way!) for the knowledge I think they should know. However, I try to never let that discomfort progress into a zone in which it is counterproductive to learning.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

Develop on shift, most of the time. I think about it like surfing a wave. I know I’m catching a wave, but until I paddle into I don’t know exactly what the best way to approach the wave is.

Do you typically see patients before or after they are presented to you?

Either or both, depending on ED volume, patient acuity, and resident speed.

How do you boost morale amongst learners on shift?

Acknowledging tough patients, feeling associated with good/bad patient encounters. Additionally, I try to always maintain a cheerful and kind attitude on shift even when everything is burning down. You can’t help that it rains, but you can definitely carry an umbrella with you.

How do you provide learners feedback?

Verbal on shift if positive, phone call/debrief after the shift, and written feedback.

What tips would you give a resident or student to excel on their shift?

Write down one thing you learned per patient on an electronic document and add to it as residency/your career progresses. I started writing documents on specific topics (like heart failure treatments, common pediatric medication dosing, etc) that I still use and add to now.

Are there any resources you use regularly with learners to educate during a shift?

ALiEM of course! Some other sources: EMRAP HD for procedures, EMdocs EMCrit, Rebel EM. Core Ultrasound :) and POCUS atlas for ultrasound stuff.

What are your three favorite topics to teach during a shift?

EVERYTHING. I love critical care topics, procedures, and of course ultrasound. I have recently developed an interest in MSK topics that traditionally aren’t focused on in emergency medicine, such as arthritis, carpal tunnel, etc.

What techniques do you employ when teaching on shift?

Just-in-time learning, asynchronous (tell the learner to look up certain topics after shift and to tell me about it next time we see each other), at the bedside.

What is your favorite book or article on teaching?

How to change your mind.

Who are three other educators you’d like to answer these questions?

Michael Macias, Ben Smith, Arun Nagdev.
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Read other How I Educate posts for more tips on how to approach on-shift teaching.

How I Educate Series: Sara Dimeo, MD

This week’s How I Educate post features Dr. Sara Dimeo, the Program Director at East Valley Emergency Medicine. Dr. Dimeo spends approximately 70% of her shifts with learners which include emergency medicine residents, off-service residents, and medical students. She describes her practice environment as a busy, level 1 trauma center in the East Valley of Phoenix, Arizona with an annual patient volume of ~70K. Our sister hospital Mercy Gilbert has a new Women’s and Children’s pavilion where a pediatric ED will be opening in conjunction with Phoenix Children’s hospital. The program is a community-based EM program with all of the bells and whistles of an academic program, and the culture of the hospital makes it a great place to work. Below she shares with us her approach to teaching learners on shift.

What delivery methods do use when teaching on shift?

“What if”…I like to pose hypothetical situations to mentally prepare learners when a critical patient is arriving. For example, a patient who is in cardiac arrest is due to arrive; “What if they just had an orthopedic surgery recently?” “What if they are in refractory v-fib?” “What if the nurses are struggling to get a line?”

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

It can be difficult to provide note feedback while on shift, depending on the shift. I like to open an email while I sign my charts and take notes to send to learners; particularly if I notice a pattern of difficulty with documentation.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

I aim to be somewhere in the upper end of the middle of the pack in regards to patients per hour, etc. I think that choosing opportune times to teach, and running the list with residents frequently to divide and conquer between myself and them which tasks need to be done helps a lot. For example, if we have a sign out list of 3 patients and there are 2 new patients to be seen, I’ll “take” the sign out patients and have the resident go see the 2 new ones.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

YES- this can be so hard! I was once given the advice that everyone will know you’re an attending if you stand at the foot of the bed to guide the resuscitation. I try to guide my learners to assume this position and encourage them to consciously lead the team. I physically will stand next to them or at the side of the room and put my hands in my pockets. I try to speak up only if I see a patient safety issue or if the learner truly needs help.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

I think that the entire idea of developing an objective to learn before a shift can be flawed because often you will see very different presentations of patients than what you desire. However, making sure your learners know how you work is important. Also, creating broad objectives such as: “I want to work on completing my notes in real-time”, or “I want to try to see every patient in the pod” is a sure way to go.

Do you typically see patients before or after they are presented to you?

Depends. If possible, I like to see them before because I can synthesize their presentation and give them better real-time feedback. I also like to directly observe learners because it gives me the best insight into their H&P and decision-making skills, and also kills two birds with one stone (where I don’t have to see the patient later). It also allows you to model certain behaviors or add focused questions, though I think this is best done at the end of the learner’s questioning because otherwise, I’d feel I was interrupting them.

How do you boost morale amongst learners on shift?

Residency is really hard. Medical school is hard but in different ways. For students, involving them as much as possible so they feel they are truly part of the team, and showing them my enthusiasm for learning and discovering is my approach. With residents, I encourage them to get food, coffee, etc. and just try to be a supportive ally in what they’re going through.

How do you provide learners feedback?

I used to struggle a lot with giving feedback, so I made an effort to practice it often and now I don’t think it’s such a big deal. It pains me so much when a resident receives a scathing evaluation and they tell me no one has discussed it with them. It really takes a toll on their mental health. I think the cool thing about residents is that they want to improve, and they usually are the hardest on themselves. I always start with an open-ended question such as “How do you think that went?”, which gives me the opportunity to clarify their thought process about their performance.

What tips would you give a resident or student to excel on their shift?

(1) Put in your orders, then dictate your HPI and PE of your note right after seeing a patient
(2) Run your patient list frequently
(3) Try not to put off procedures or difficult cognitive decisions to the end of your shift….it will just make you stay over!

Are there any resources you use regularly with learners to educate during a shift?

Life in the Fast Lane for EKGs, EMRAP procedural videos, EMRA guides

What are your three favorite topics to teach during a shift?

(1) Love eye stuff! it’s an often neglected topic
(2) STEMI equivalents (though now the guidelines are finally catching up!)
(3) How to give a death notification/difficult patient encounter approaches

What is your favorite book or article on teaching?

If you haven’t read the original Dunning-Kruger paper, I found it to be really fascinating.

Who are three other educators you’d like to answer these questions?

Christina Shenvi, Andy Little, and Molly Estes.

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Read other How I Educate posts for more tips on how to approach on-shift teaching.

By |2023-03-22T07:41:13-07:00Mar 22, 2023|How I Educate, Medical Education|

How I Educate Series: Whitney Johnson, MD

This week’s How I Educate post features Dr. Whitney Johnson, the Director of Education at UHS SoCal Medical Education Consortium. Dr. Johnson spends approximately 50-60% of her shifts with learners which include emergency medicine residents, off-service residents, and medical students. She describes her practice environment as two high-volume community hospitals. Below she shares with us her approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Cerebral, practical, inquisitive.

What delivery methods do use when teaching on shift?

Open discussion.

What learning theory best describes your approach to teaching?

Deliberate practice primarily, but also aspects of constructivism and socio-constructivism.

What is one thing (if nothing else) that you hope to instill in those you teach?

Individualized care is the best way to serve our patients/communities. We are all working to improve daily and avoid cook book medicine, anchoring bias, and premature closure that can contribute to healthcare disparities.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

I care a lot about on-shift teaching so that typically means slowing down my own workflow (likely seeing a few fewer patients to focus on the residents’ growth/learning). It definitely comes at the expense of my documentation but I haven’t found a way to improve that yet.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

My review is post-shift. Formal feedback is provided by written surveys, but I also try to follow up with the resident the next day or shift if there are significant areas that need improvement.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

It can adversely affect teaching because many of these metrics are behind trends in clinical practice and EM literature. My approach is to acknowledge departmental flow and metrics but also review with the resident any of our own growing EM literature that might provide further insight as to where the standard of care and state of practice is moving.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

This is very hard for me because I don’t want my residents to feel like I’m leaving them hanging but there is also just as much learning in our struggles as there is in our successes. If it does not compromise patient or staff safety I give them a chance to troubleshoot. Residents also have to be humble enough to know their limitations and when they should reach out for help. It’s a balancing act that I’m still working on. The residents I know well and have worked with I have generally grown aware of their limitations and am comfortable waiting for their nonverbal cues of struggle.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

I ask the resident what they would like to work on for the given shift and try to look for opportunities to fold that into our day-to-day grind

Do you typically see patients before or after they are presented to you?

For stable patients, I will wait for the resident to present. Any unstable patient or patient an RN has expressed concerns about I will see earlier, often just taking the resident with me

How do you boost morale amongst learners on shift?

I try to encourage clinical autonomy so they feel like the smart physicians they truly are.

How do you provide learners feedback?

Verbal on shift and a more summative written assessment post shift.

What tips would you give a resident or student to excel on their shift?

First, have a goal for each shift for your own personal growth. It will make it more engaging for you as a learner. Second, be a steward of your own education. Don’t expect EM knowledge to be spoon-fed to you by your attendings. Third, don’t be afraid to ask your attending questions about their clinical practice or decisions, in a professional manner. Some residents feel like they have to just order what the attending wants, but know that there is practice variation in our specialty and more than one way to work up a complaint. Consider picking your attending’s brain on what made them choose a given workup or what they saw in the patient that made them change your plan. Bring your own readings and insights into the discussion. Attendings learn from residents just as residents learn from us. Last, have a few go-to resources that you like, and don’t be afraid to pull them up on a shift. No one expects you to remember all the information, but know where to find it on shift.

Are there any resources you use regularly with learners to educate during a shift?

CorePendium!

What are your three favorite topics to teach during a shift?

Post-ROSC care, approach to orthopedic imaging, high yield DDx “worst first”.

What techniques do you employ when teaching on shift?

Deliberate practice primarily.

What is your favorite book or article on teaching?

Who are three other educators you’d like to answer these questions?

Dr. Xian Li, Dr. Jacob Avila, and Dr. Leah Bauer.
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Read other How I Educate posts for more tips on how to approach on-shift teaching.

How I Educate Series: Tarlan Hedayati, MD

This week’s How I Educate post features Dr. Tarlan Hedayati, the Chair of Education at Cook County Hospital. Dr. Hedayati spends approximately 90% of her shifts with learners, including emergency medicine residents, off-service residents, and medical students. She describes her practice environment as a large, public, urban, Level 1 trauma center. Below she shares with us her approach to teaching learners on shift.

What delivery methods do use when teaching on shift?

Some of the other attendings joke that they know when I’ve been working because the garbage can is full of paper towels I’ve used to write on when I teach on shift.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

Post shift. I usually send an email to the resident if there is something in the charting that can be improved upon or if the documentation is especially excellent.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Flow and metrics absolutely impact teaching and learning. If it’s too slow, the experiential component of education is lost. Too fast, and there isn’t time to make sure concepts and ideas are properly recognized and absorbed by learners. I try to verbally summarize things we have seen and learned toward the end of the shift as a recap so that learners are reminded of topics they should investigate further when they go home. I also incorporate specific cases in my written feedback so the resident can read it and remember notable pearls.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

As long as there is no risk to the patient, I let things play out. I am pretty confident that I can bail out of a bad situation and know that I need to let them practice. Learners have to figure out how to troubleshoot, how to think on the fly, how to correct their own errors, and how to learn from mistakes. I have to remind myself that the safest place for them to make mistakes is while I am by their side.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

Both. I look ahead to see who I am working with and which areas I am covering. That way I can figure out whether I need to mentally access more fast-track topics, more critical care topics, or more bread-and-butter EM topics. I also look to see what year the resident is that I am working with so I can tailor my teaching to the appropriate level. Ultimately bedside teaching is dynamic though so I also need to be prepared to improvise on the fly.

Do you typically see patients before or after they are presented to you?

Before. It helps me organize my thoughts so I can drive the teaching in a more organized meaningful way.

How do you boost morale amongst learners on shift?

Food! Seriously though, I firmly believe there is a boomerang effect to outlook, mindset, and mood. Good morale has to start with me.

How do you provide learners feedback?

Verbal in real time on shift, written after shift

What tips would you give a resident or student to excel on their shift?

Stay curious–keep asking questions of your patients, co-workers, and attendings.

Are there any resources you use regularly with learners to educate during a shift?

LITFL (ECGs), YouTube and EM:RAP HD (for procedures), Google images (rashes)

What are your three favorite topics to teach during a shift?

ECGs, chest pain, and rashes.

Who are three other educators you’d like to answer these questions?

Anna Kalantari, George Willis, and Jenny Beck-Esmay.
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Read other How I Educate posts for more tips on how to approach on-shift teaching.

By |2023-03-22T12:12:57-07:00Feb 1, 2023|How I Educate, Medical Education|

52 Articles in 52 Weeks, 3rd edition (2022)

How can I keep up with so many landmark articles in Emergency Medicine (EM)? This is an often asked question we hear from interns and residents. Published in 2013 (1st edition) and 2016 (2nd edition), the “52 Articles in 52 Weeks” compendium is a compilation of 52 journal articles provided interns a list to read over a 52-week period, at an average pace of 1 journal article per week. We present the updated 2022 compilation.

Methodology for Article Selection

We primarily build off of the original list from 2016. These 52 articles were refreshed such that newer landmark articles replaced those on the same topic.  Additional publications were considered if they were cited on MDCalc’s site or reviewed on clinical EM websites like REBEL EM, Wiki Journal Club, and The Bottom Line during 2016-2022. A panel of 7 EM faculty with a niche in graduate medical education could also add publications for consideration. A total of 71 articles were scored by these 7 faculty using the Best Evidence in Emergency Medicine (BEEM) score with an EM intern audience in mind.

Best Evidence in Emergency Medicine (BEEM) Scoring [1]

Question for reviewer: Assuming that the results of this article are valid, how much does this article impact on EM clinical practice?

BEEM ScoreDescription (revised for EM intern audience)
1Useless information
2Not really interest, not really new, changes nothing
3Interesting and new, but doesn’t change practice
4Interesting and new, has the potential to change practice
5New and important: this would probably change practice for some EM interns
6New and important: this would change practice for most EM interns
7This is a “must know for EM interns

Results

The final list of the top 52 articles, based on the mean BEEM scores, are presented below in descending rank order. A bonus 53rd article is also listed because there was a 4-way tie for articles #50-53. Feel free to copy-paste this list into your own Google Sheets or Excel spreadsheet for list sortability.

Project Lead

  • Nicholas Dulin, MD (EM Resident, Department of Emergency Medicine, Einstein Medical Center; Captain, Medical Corps, United States Air Force)

Faculty Raters

  1. Claire Abramoff, MD (Assistant Residency Program Director, Department of Emergency Medicine, Einstein Medical Center)
  2. Layla Abubshait, MD (Associate Residency Program Director, Department of Emergency Medicine, Einstein Medical Center Montgomery)
  3. Jacqueline Dash, MS, DO (Core Faculty, Department of Emergency Medicine, Einstein Medical Center)
  4. Joseph Herres, DO (Research Director, Department of Emergency Medicine, Einstein Medical Center)
  5. Jessica Parsons, MD (Associate Program Director, Department of Emergency Medicine, Einstein Medical Center)
  6. Anthony Sielicki, MD (Assistant Program Director, Department of Emergency Medicine, Einstein Medical Center)
  7. Steven J. Walsh, MD (Medical Toxicology Faculty, Einstein Medical Center)

Reference

  1. Worster A, Kulasegaram K, Carpenter C, et al. Consensus conference follow-up: inter-rater reliability assessment of the Best Evidence in Emergency Medicine (BEEM) rater scale, a medical literature rating tool for emergency physicians. Acad Emerg Med. 2011;18(11):1193-1200. [PubMed]

How I Educate Series: Christina Shenvi, MD

Christina ShenviThis week’s How I Educate post features Dr. Christina Shenvi, the Director of the Office of Academic Excellence and former Associate Residency Director at the University of North Carolina, Chapel Hill. Dr. Shevani spends approximately 80% of her shifts with learners, including emergency medicine residents, off-service residents, and medical students. She describes her practice environment as tertiary care academic center. Below she shares with us her approach to teaching learners on shift.

Name 3 words that describe a teaching shift with you.

Interactive, team-based, and collaborative.

What delivery methods do use when teaching on shift?

Verbal discussions usually with both residents and med students, where we take turns coming up with answers to things, and share ideas or resources. For example, if we are discussing the causes of falls in older adults, we go around in a circle coming up with things that contribute to the fall syndrome in older patients until none of us can think of any more. For questions with fewer options or answers, I will start with the med student and then move up to the intern and PGY3 to develop a progressively more nuanced or thorough discussion.

What learning theory best describes your approach to teaching?

Scaffolding; social constructivism.

What is one thing (if nothing else) that you hope to instill in those you teach?

A lifelong curiosity and love of learning.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

I look for times when there is either a natural learning opportunity, a lull in activity, or both. If there is an interesting CT or EKG, that is a good learning moment to gather the group and briefly discuss it. If there is a lull in activity, that is a good time to discuss a given topic related to a patient we have taken care of. It sometimes comes at the expense of documentation, but teaching is a priority.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

Usually, I review notes on shift if they are available and provide feedback.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

We do what we can with what we have. There is a joint mission in academic hospitals: to care for patients *and* to teach. If the pendulum swings too far one way or the other, then one of the missions will suffer. The goal is to keep both in mind and find moments for teaching, while making other tasks, such as documentation, as efficient as possible.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

I will usually ask: “Let me know if you need a hand or another set of eyes.” If it is a patient safety issue, then I will step in sooner, otherwise, there is usually time to let them try on their own.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

I will usually ask the residents or students what they want to work on that day, or what they would like feedback on. By honing in on their goals, I can pay more attention to the area that they are working on, whether it is ultrasound, EKG interpretation, department flow, communication, etc. That also focuses their attention on the area, so they can work on it.

Do you typically see patients before or after they are presented to you?

After – this allows the learner the chance to gather the information first and present it so that they are the primary caregiver.

How do you boost morale amongst learners on shift?

Staying positive myself is the first goal. Focusing our energy on what we can control vs what is outside of our control is key as well.

How do you provide learners feedback?

Verbal feedback during or at the end of the shift is often the most effective because it can lead to more reflection and discussion. I also provide written feedback online after the shift.

What tips would you give a resident or student to excel on their shift?

Let your attending know what you want to work on and get feedback on. This will help them give you better quality feedback at the end of the shift, rather than “good job” or “read more”. Take ownership of your own learning, making a reading or study schedule for yourself. Pick your favorite resources and podcasts, and make regular time to use them.

Are there any resources you use regularly with learners to educate during a shift?

I often use LITFL and other online resources to show examples of EKGs, procedures, or images.

What are your three favorite topics to teach during a shift?

My fellowship training is in geriatric EM, so I enjoy teaching specifically on geriatric syndromes and falls, ACS in older adults, as well as on EKGs.

What techniques do you employ when teaching on shift?

Discussion, Q&A, elaboration (ie. taking a given case or situation and expanding to other related cases to discuss and expand the learning opportunities).

What is your favorite book or article on teaching?

Books: Make it Stick

Who are three other educators you’d like to answer these questions?

Sara Dimeo; Megan Osborne; Guy Carmelli
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Read other How I Educate posts for more tips on how to approach on-shift teaching.

EM Match Advice 39: Mailbag Q&A as a Mid-Interview Season Check-In

The holiday season is soon ending, but the residency interview season is only at the half-way point. Based on your recently submitted questions, you are encountering unforeseen dilemmas about navigating the interview and post-interview season. Dr. Sara Krzyzaniak (EM program director at Stanford) hosts this quick Mailbag Q&A episode with Dr. Michelle Lin (ALiEM Founder/UCSF) and featuring the ever-wise Dr. Matt Pirotte (EM program director at Vanderbilt). We discuss the nuances around:

  • Preference signaling
  • Writing letters or emails of interest
  • Meaningfully connecting with busy program directors

We also answer the perennial question of “Really, how important IS the interview in my overall application?”

Thank you to EM program directors from Wisconsin, Northwestern, Denver, University of Virginia, University of Massachusetts, St. Johns Riverside, Loyola, St Joseph’s Regional Medical Center, Mount Sinai-Elmhurst, Maimonides, Brookdale, University of Chicago, and Hackensack, who also contributed their insights and answers to your questions.

Match Advice Podcast 39: Mailbag Q&A

 

Reference

Jewell C, David T, Kraut A, Hess J, Westergaard M, Schnapp BH. Post-interview Thank-you Communications Influence Both Applicant and Residency Program Rank Lists in Emergency Medicine. West J Emerg Med. 2019;21(1):96-101. 2019 Dec 9. doi:10.5811/westjem.2019.10.44031. [Open access link]

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

 

 

By |2022-12-29T22:55:52-08:00Dec 30, 2022|EM Match Advice|
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