The accord amid able clinician–patient advice and accommodating outcomes is able-bodied authentic in the literature.1–3 Able advice is abnormally important for patients who are accountable to bloom disparities, such as African Americans,4 or at authentic medical risk, such as beforehand patients with assorted bloom problems and circuitous medical regimens.5,6 Empathy—one actuality aing with accession person’s affecting state—is an important aspect of able communication.7 Medical advisers accept affiliated it to added accommodating satisfaction, beneath abuse suits, bigger adherence, and bigger bloom outcomes.8,9
Given the benign aftereffect of affinity on capital outcomes, it is important to ascertain methods that will enhance clinicians’ accommodation to chronicle empathetically to their patients. One empathy-enhancing adjustment that assay in added fields has apparent to be acknowledged is perspective-taking, a action in which one actuality strives to apprehend what accession actuality is cerebration and feeling.
Researchers—principally in the fields of amusing attitude and neurobiology—have advised perspective-taking abundantly and accept accustomed it to be a awful able adjustment of acceptable affinity in a ample ambit of nonmedical contexts.10–13 These advisers about actuate the action by allurement participants to brainstorm accession person’s bearings and to put themselves “in that person’s shoes.” Advisers accept accustomed that perspective-taking improves communication, facilitates altruism, banned assumed aggression,10,13–15 produces added able agreements in business negotiations,16 and decreases stereotyping and prejudice.13,17,18 In addition, perspective-taking decreases stereotyping of aged people,12 increases alertness to advice a actuality in trouble,10 and decreases advancing responses to exact aggression.12,15
Ruby and Decety19 acclimated positron discharge tomography studies to annotate how perspective-taking induces empathy. Engaging in a perspective-taking exercise activated abstraction participants’ affecting processing centers. It additionally activated cerebral processing centers: a aggregate neural arrangement amid representations of cocky and added as able-bodied as a set of regions in the academician amenable for advancement a acumen amid and preventing abashing about cocky and other.19 This assignment provides a neurophysiologic base for perspective-taking-induced affinity in which both cerebral and affecting apparatus are capital parts.
In the ambience of anesthetic or medical education, advisers accept explored several approaches to abet empathy. One such access is experiential: Medical professionals “live” the acquaintance of actuality a patient.20 A added access is didactic: Medical professionals accept training in interpersonal,21 alive listening,22 and communication3 skills. Such training has led to increases in achievement on assorted affinity scales9 and, in some cases, bigger accommodating satisfaction.23 Although perspective-taking is sometimes absolute in such medical communications training, to the best of our knowledge, it has never afore been absolutely explored as a abandoned action to advance accommodating achievement in medical encounters. In this article, we appraise the aftereffect of perspective-taking in a medical ambience through the use of connected patients (SPs) in analytic abilities examinations (CSEs).
We conducted three randomized, controlled abstracts in which we acclimated SP achievement with student–clinicians as the primary aftereffect of our perspective-taking intervention. Accustomed perspective-taking’s capability in inducing affinity in nonmedical settings, we predicted that it would additionally be acknowledged in inducing affinity in a medical ambience and absolutely access SP satisfaction. SP alternation provides an able and achievable adjustment for assessing the appulse of perspective-taking in a controlled setting: Advisers accept authentic alternation with SPs in the appraisal of interpersonal abilities and accommodating satisfaction.24–28
For all three studies, our primary cold was to actuate whether student–clinicians apparent to a perspective-taking action would accept college accommodating achievement array than would controls. In addition, in Studies 2 and 3, we explored the aftereffect of perspective-taking on altered subgroups: African American SPs and medical acceptance with baseline differences in perspective-taking tendency.
Prior assay has apparent that perspective-taking is a able agency to abatement stereotyping, but has not explored how perspective-taking affects the achievement of banal accumulation members.11,13 Because African Americans are about accountable to stereotyping and disparate assay in bloom care,29 in Abstraction 2 we focused on whether the action would accept an appulse on the achievement of African American SPs.
We explored in Abstraction 3 whether acceptance who are added artlessly absorbed or afraid against perspective-taking (characterized by altered baseline tendencies) would be differentially afflicted by the perspective-taking intervention. We acclimated a well-validated check to ascertain acceptance with aerial and low baseline tendencies. We accepted that such a baseline adapted could accept a potentially able aftereffect on outcomes and, if demonstrated, could accept important educational implications. Identifying individuals who do and do not accede to the intervention, for example, could advice medical educators clothier their teaching of communications abilities to the admiration of their students.
To access generalizability, we adjourned perspective-taking in as abounding settings as achievable aural the constraints of our institutions. During 2006–2007, as allotment of our anniversary CSEs, we conducted three abstracts beyond two disciplines, with acceptance from two medical schools—the George Washington University School of Anesthetic and Bloom Sciences (GW) and the Howard University College of Anesthetic (Howard)—and with SPs of altered ethnicities (Table 1). The instruments acclimated in the three experiments, although different, all absolute agnate items to admeasurement patients’ achievement with their clinician. We acclimated altered instruments because of alien contingencies—for example, the Baltimore–Washington Bunch of Medical Schools, to which GW and Howard belong, adapted medical schools to use a altered apparatus in 2007 than it had in 2006.
We conducted Abstraction 1 in 2006 with third-year medical acceptance from GW and Howard. In Abstraction 2, conducted in 2006–2007, we acclimated first- and second-year physician abettor (PA) acceptance from GW and African American SPs. In Abstraction 3, conducted in 2007, we afresh acclimated third-year medical acceptance from GW and Howard. All studies were conducted at GW; Howard acceptance took their exams in GW’s simulation center.
GW has an ethnically assorted apprentice population, but the majority of acceptance are white; Howard is a historically atramentous university. We call demographic characteristics of the accommodating acceptance in Table 2.
We conducted all three abstracts as randomized, controlled assessments in which we compared the achievement of student–clinicians who were accustomed a perspective-taking action with those who were accustomed aloof instructions above-mentioned to a CSE application SPs. For anniversary study, we randomized students, application a computer-generated schedule, to an action or ascendancy group. We stratified the randomization by gender and chase (and, as appropriate, university [Study 1, Abstraction 3] and diplomacy year [Study 2]) to accomplish almost antithesis amid the action and ascendancy groups. Differences amid the ascendancy and action groups in anniversary abstraction are about small. In Abstraction 1, there were added African American acceptance in the ascendancy accumulation than in the action group. (Stratification in Abstraction 1 was amiss because of scheduling issues.) All acceptance aural a abstraction accustomed the aforementioned cases. In all studies, the SPs were dark as to whether the acceptance were in the ascendancy or action group.
We recruited SPs through the university and from bounded communities. They accustomed six hours of training from an accomplished trainer. We did not formally appraise the interrater believability of the SPs.
Each abstraction was accustomed by the institutional assay lath of the university whose acceptance participated. For Studies 1 and 3, both the GW and Howard IRBs classified the abstraction as exempt, so students’ accord was not required. For Abstraction 2, which was accustomed by the GW IRB, acceptance active an a accord anatomy to acquiesce their abstracts to be acclimated in a “study of apprentice and SP interactions,” but they were blind of the attributes of the action and the purpose of the study.
The appointment amid the student–clinician and the SP was the assemblage of assay for testing beggarly differences amid the action and ascendancy altitude on the primary aftereffect variables. Because array were not absolute beyond encounters, we based hypotheses tests on mixed-model assay of about-face (ANOVA), area SP and case were included as accidental effects, and abstraction group, as able-bodied as university for Abstraction 1 and Abstraction 3, were included as anchored effects. We conducted these analyses with SAS Proc Mixed adaptation 9.1.3,30 application best likelihood estimation. For Abstraction 3, a added ANOVA archetypal was adapted by abacus a accumulation × perspective-taking addiction alternation appellation to the model. Perspective-taking addiction was based on a average breach of that calibration account for the analysis.
To facilitate comparisons beyond the three studies (which acclimated altered measures of accommodating satisfaction), we abbreviated action furnishings as connected aftereffect sizes (mean aberration disconnected by accepted aberration [SD]). This admeasurement indicates the about consequence of a beggarly aberration back the basal metric of the admeasurement is arbitrary. A aphorism of deride suggests that an aftereffect admeasurement of 0.10 to 0.20 is “small,” 0.50 is “medium,” and 0.80 or greater is “large.”
The absolute third-year classes of medical acceptance at GW and Howard alternate (N = 245: GW, n = 157; Howard, n = 88). SPs represented a ambit of indigenous backgrounds.
The abstraction took abode during a determinative CSE that we conducted at the end of the students’ third year (2006). The Baltimore–Washington Bunch of Medical Schools chose the CSE’s six cases—to be acclimated by all affiliate schools—to assay basal analytic abilities apery the spectrum of third-year analytic experiences. The bunch called the cases from a array of case books developed at a cardinal of altered institutions and consortiums. The cases depicted patients presenting with astute conciseness of breath, astute aerial belly pain, astute lower belly pain, anxiety, stroke, or pediatric ing/diarrhea.
All acceptance abounding preexamination acclimatization sessions in baby groups; acceptance were assigned to groups according to their action status. We gave all acceptance a accepted acclimatization anatomy that was additionally apprehend aloud to them by the administrator of the GW simulation center. This anatomy adumbrated that, like the National Lath CSE, the assay would account them on history-taking, concrete exam, accommodating communication, and accounting notes.
In addition, we gave and apprehend aloud altered added apprenticeship forms to acceptance in the action and ascendancy groups. We gave the perspective-taking action accumulation the afterward appropriate instructions:
When you see your patient, brainstorm what the accommodating is experiencing as if you were that person, attractive at the apple through the patient’s eyes and walking through the apple in the patient’s shoes.
We additionally instructed the action accumulation to address a abrupt agenda (10 curve or less) afterwards commutual anniversary case, anecdotic what they absurd the accommodating was experiencing. We included the afterward archetype of a postcase note:
Sherry Jenkins, a 23 year old secretary with appropriate bottom swelling: If I were Sherry, I would be absolutely affronted that this happened to me.… I couldn’t run in the Marine Corps chase that I had been training for the accomplished year.… I abhorrence my job, and my circadian run is what gets me through the day … and additionally actuality afflicted is absolutely black … at the age of 23 I am bruised about like an old woman!
We gave the ascendancy accumulation altered appropriate instructions:
We are absorbed in alive how able-bodied your third-year clerkships able you for anniversary of the cases in this exam. During anniversary appointment amuse accumulate this in mind.
We additionally instructed the ascendancy accumulation to address a abrupt agenda (10 curve or less) afterwards commutual anniversary case, anecdotic how their third-year acquaintance had able them for that authentic case. We provided the afterward example:
My anesthetic accessory at GW helped me a lot in advancing for this affectionate of case. She accomplished me how to do a absolutely acceptable affection babble exam. She is a absolutely accomplished cardiologist, who alike took the time to accept to affection murmurs with me application the Harvey affection complete simulator.
After every appointment with a medical student, SPs completed two appraisal checklists: (1) medical skills, which was specific to anniversary case, to appraise history-taking and concrete assay behaviors, and (2) accommodating satisfaction, which was identical for all cases. The Baltimore–Washington Bunch of Medical Schools created the accommodating achievement account based on arise belief that the National Lath of Medical Examiners acclimated to assemble the advice account for its analytic abilities licensure assay (Step 2 CS).31 The account acclimated in this abstraction consisted of bristles items—listening skills, caring, adopting accommodating accord in care, trust, and all-embracing satisfaction—that are rated on a five-point calibration (very annoyed to absolute satisfied).
The absolute first- and second-year PA classes at GW alternate (N = 105: aboriginal year, n = 55; added year, n = 50). All SPs were African American.
We conducted Abstraction 2 in the ambience of a determinative CSE amid through bookish year 2006–2007. Anniversary apprentice alternate in three SP encounters—medical cases involving asthma, endocarditis, or diabetes.
All PA acceptance abounding preexamination acclimatization sessions in baby groups; acceptance were assigned to groups according to their action status. The aforementioned PA adroitness affiliate (S.F.L.) gave all instructions verbally above-mentioned to the aboriginal SP interaction. All acceptance accustomed accepted CSE instructions. The action accumulation additionally accustomed two appropriate instructions. First, we asked the acceptance to “put themselves in the shoes” of the patients they were about to encounter. Then, to rehearse perspective-taking, we asked them to anamnesis a contempo claimed interaction:
One aspect of the appraisal in your assay is your alternation with the patient, and a way to advance that alternation is to put yourself in the patient’s shoes; that is, as you are talking with the patient, anticipate about how you would feel if you were in their position and try to brainstorm their feelings. Booty a moment now and anticipate about a memorable accommodating you afresh saw on your rotation. Put yourself in that patient’s position and brainstorm how you would feel.
After a abeyance to acquiesce the acceptance time to reflect, the investigator asked them to “take a few moments and briefly address your patient’s animosity down, seeing yourself in his or her position.” A few moments later, the investigator calm the students’ writings and instructed them: “Now, back you see your patient, try to appoint in this aforementioned process.” We did not ask the PA students, clashing the medical students, to address postencounter notes.
We did not accord either accumulation any added instructions during the alternation of SP encounters.
We acclimated the Apprenticeship Commission for Foreign Medical Graduates’ interpersonal abilities check (IPS), which educators developed to appraise all-embracing medical graduates (IMGs) on SP interactions.32,33 The IPS has been adjourned for believability in added than 37,000 IMGs, with Cronbach alpha alignment from 0.80 to 0.90.32 It consists of 17 questions in four areas—interviewing, counseling, rapport, and claimed manner— evaluated on a four-point calibration anchored by examples. For this study, we computed accommodating achievement as the beggarly account over the 17 items.
The absolute third-year classes of medical acceptance at GW and Howard alternate (N = 258: GW, n = 157; Howard, n = 101). SPs represented a ambit of indigenous backgrounds.
As in Abstraction 1, we conducted this abstraction during a determinative CSE at the end of the students’ third year (2007). We acclimated agnate cases and the aforementioned abstraction architecture and action as in Abstraction 1.
After every appointment with a medical student, SPs completed two appraisal checklists: (1) medical skills, which was specific to anniversary case, for history-taking and concrete assay behaviors, and (2) accommodating satisfaction, which was identical for all cases. This accommodating achievement account was altered from the account acclimated in Abstraction 1. For the 2007 bunch exam, the Baltimore–Washington Bunch of Medical Schools adopted to acclimate the East Tennessee State University Accepted Arena Rating Form.34 It uses a six-point calibration (unacceptable to outstanding) to appraise eight items: actualization of able competence, advice acquisition skills, alert skills, affinity building, assay of patient’s perspective, acclamation feelings, affair patient’s needs, and all-embracing satisfaction.
At the end of the examination, acceptance completed the perspective-taking subscale of the Interpersonal Reactivity Index (IRI), a authentic check that assesses basal perspective-taking tendencies. The IRI asks acceptance to announce the amount to which seven statements call them, application a five-point scale.35–39 Two sample items arise below:
I sometimes try to accept my accompany bigger by apperception how things attending from their perspective.
Before criticizing somebody, I try to brainstorm how I would feel if I were in their place.
We abridge accommodating achievement ratings for anniversary of the three studies in Table 3. We affected Cronbach alpha for the achievement array alone for anniversary case in anniversary study. Coefficient alpha values, averaged beyond cases, were 0.87, 0.85, and 0.94 for Studies 1, 2, and 3, respectively.
In Abstraction 1, we begin a statistically cogent aberration amid the ascendancy and the action groups. Third-year medical acceptance apparent to a perspective-taking action accomplished a beggarly accommodating achievement account of 4.04 (SD 0.62) on a five-point scale, compared with a beggarly account of 3.94 (SD 0.63) for the ascendancy accumulation (P = .01); aftereffect admeasurement = 0.16. As we acclaimed earlier, the aftereffect admeasurement enables us to analyze the after-effects beyond the three studies, which acclimated altered achievement instruments.
In Abstraction 2, the action accumulation showed a statistically cogent college beggarly accommodating achievement account than did the ascendancy group. Those first- and second-year PA acceptance who were apparent to a perspective-taking action accomplished a beggarly accommodating achievement account from the African American SPs of 3.38 (SD 0.35) on a four-point scale, compared with 3.26 (SD 0.42) for the ascendancy accumulation (P = .001); aftereffect admeasurement = 0.31.
In Abstraction 3, the action accumulation additionally outperformed the ascendancy accumulation on accommodating satisfaction, with after-effects agnate to those of Abstraction 1: 3.43 (SD 0.69) against 3.34 (SD 0.68) on a six-point calibration (P = .009); aftereffect admeasurement = 0.13.
In accession to acknowledging the allegation in Abstraction 1, the after-effects of Abstraction 3 advance that the capability of the perspective-taking action depends in allotment on the preexisting perspective-taking tendencies of the medical students. We conducted abstracted analyses in Abstraction 3, adding acceptance according to whether they denticulate aloft or beneath the average on the IRI perspective-taking subscale (Table 4). We articular a absolute action aftereffect (effect admeasurement = 0.25) amid acceptance who denticulate aloft the average on the scale. A assay of the alternation of perspective-taking addiction by the action action was statistically cogent (P = .0004). However, we did not acquisition a aberration amid the ascendancy and action groups amid acceptance who denticulate beneath the median.
In three randomized, controlled studies (N = 608), student–clinicians who were accustomed a perspective-taking action accustomed decidedly bigger accommodating achievement array from SPs than did controls. Although the aftereffect admeasurement was small, these after-effects advance that our perspective-taking action may be an able and generalizable action to advance accommodating satisfaction, accustomed its constant capability beyond two medical schools, two analytic disciplines, and beyond SPs’ ancestral groups. To the best of our knowledge, the abstracts appear actuality represent the aboriginal studies of perspective-taking as a abandoned action in a medical context. Our after-effects are constant with allegation acquired from altered populations in the amusing attitude literature,10–13 which provides added affirmation for the intervention’s generalizability and validity.
Studies 2 and 3 body on and analyze the after-effects of Abstraction 1. In Abstraction 2, PA acceptance interacted alone with African American SPs. The action not alone succeeded, but the aftereffect admeasurement (0.31), admitting still small, was greater than that in Studies 1 and 3 (0.16 and 0.13, respectively). Added acuteness on the allotment of African American SPs to the accommodating focus displayed by their analyst may accept contributed to this difference. This achievability is authentic by Beach and colleagues’4 award that patient-centeredness bigger the accommodating achievement array of student–clinicians interacting with African American SPs but not with European American SPs. The greater aftereffect admeasurement may additionally be accompanying to a adeptness cogwheel amid PA and medical students. In analytic practice, PAs are acceptable to accept beneath power, authentic as the adeptness to ascendancy important resources, than physicians do. Galinsky and colleagues’40 assignment indicates that those with lower adeptness are added acceptable to finer booty the angle of others. It seems possible, therefore, that amid student–clinicians, PA acceptance will be added acceptable than medical acceptance to accept aerial perspective-taking tendencies.
The added aftereffect admeasurement in Abstraction 2 may additionally accept been afflicted by the added action apprenticeship that the PA acceptance received. Both medical acceptance and PA acceptance were asked to brainstorm themselves in the patients’ shoes. However, PA acceptance were additionally instructed to rehearse this process—prior to the encounter—by autograph about a contempo claimed interaction, anecdotic what they believed the added actuality was cerebration or feeling. This footfall may accept created a added able action and may accept contributed to the stronger effect.
In Abstraction 3, we disconnected student–clinicians into those with aerial and low perspective-taking tendencies, as adumbrated by their responses to the IRI questionnaire, to analyze the access of baseline characteristics on the aftereffect of the intervention. The arrangement of SP achievement after-effects suggests that high-tendency acceptance responded to the action admitting low-tendency acceptance did not. Abstraction 3 supports a axiom that is able-bodied accustomed in the diplomacy appraisal literature: Baseline predisposition to accomplishing account from an action may apply a ample access on the intervention’s effectiveness.41 We did not admeasurement predisposition to perspective-taking in Studies 1 and 2, but it may accept additionally afflicted those results. Accustomed that low-tendency acceptance seemed not to accede to the intervention, Abstraction 3 additionally supports the altercation that educators should adapt training methods to access such students’ perspective-taking tendencies or advance atypical interventions to which they ability respond.
In all three studies, we acclimated accommodating achievement as the end point. This was authentic by the advanced “real-world” use of accommodating achievement as a admeasurement for free the capability of the doctor–patient interaction42 and the articulation amid accommodating achievement and absolute bloom affliction outcomes (e.g., bigger medication and dialysis adherence).43–45
As we acclaimed above, the aftereffect sizes of the action are not large. This may be due in allotment to the ambience of the studies. The participants were acceptance on their best assay behavior encountering “patients” who presented with accepted medical problems but who were not interpersonally challenging. It is additionally accessible that in the assay setting, added factors (test achievement anxiety, poor analytic skills) may predominate over the action for some students. Further, if alone acceptance with aerial baseline perspective-taking tendencies are affected to the action (as appropriate by Abstraction 3), acceptance with low tendencies may accept beneath the all-embracing aftereffect size. Finally, it is account acquainted that baby aftereffect admeasurement does not necessarily aftereffect in atomic consequences, as assay has apparent in added fields.46,47
We accept that perspective-taking will become an important accession to the communications class for analytic professions. Accommodating achievement is important to acquiescence and bloom outcomes, so alike baby increases in achievement can accomplish ample differences. Further, perspective-taking is achievable to absorb into the class because it takes basal time and amount to implement.
The assignment appear actuality credibility to avenues for added exploration. One of our studies suggests that perspective-taking could access achievement amid African American SPs, but the cardinal of cases was baby and the abstraction did not accommodate white SPs to serve as controls. The admeasurement to which perspective-taking can access achievement amid African Americans and added high-risk and underserved populations needs added study. In addition, board should appraise the abeyant of perspective-taking to abate stereotyping of these populations, accustomed the role bent and stereotyping comedy in bloom affliction disparities.48 Perspective-taking studies in added fields accept apparent reductions in stereotyping,12 advertence that the action ability prove decidedly accessible in acceptable clinicians as they advance to arch differences amid themselves and demographically assorted patients.
More assignment needs to be done to ascertain how to administrate the action for best effect. To reinforce perspective-taking, participants in Studies 1 and 3 wrote abbreviate essays anecdotic the patient’s angle afterwards anniversary accommodating encounter, admitting participants in Abstraction 2 accustomed alone abrupt instructions at the alpha of the assay with no reinforcement. These modes were acknowledged in our studies, but advisers should analyze agency to addition the aftereffect of the action while befitting it durable, simple, and able to implement. Added issues important to assay accommodate the optimal way to accommodate perspective-taking into communications abilities teaching, the backbone of the furnishings of perspective-taking training, and the appulse of perspective-taking on convalescent clinician–patient advice in real-world analytic practice. Perspective-taking in analytic convenance should prove advantageous beyond all specialties because compassionate advice is universally important back architecture affirmation amid analyst and patient. As with student–clinicians, however, alone physicians and PAs with aerial baseline perspective-taking tendencies may accede to interventions.
These studies accept several limitations. First, we conducted them with medical and PA acceptance in apish situations; perspective-taking may be added or beneath able with physicians, residents, and PAs in absolute analytic practice. Second, we alone looked at one of abounding important outcomes—patient satisfaction. We chose accommodating achievement because it is acclimated in abounding studies as an important aftereffect of the doctor–patient interaction, it is a reasonable affinity indicator43–45 with which to admeasurement the aftereffect of perspective-taking, and it is achievable to use in a apish analytic context. Third, these studies, admitting performed with acceptance and SPs of altered contest and beyond two medical schools and two disciplines, were nonetheless bound to clandestine institutions in the District of Columbia and may not generalize to added populations in added geographic areas. Finally, we abstinent accommodating achievement as an aftereffect of the aftereffect of perspective-taking-induced empathy, but we did not anon admeasurement compassionate behavior through assay of video recordings of the encounters.
In conclusion, our three studies accommodate affirmation that absolute abrupt apprenticeship in perspective-taking—a adjustment of acceptable empathy—may comedy a admired role in architecture the clinician–patient relationship. As analyst affinity is important to accommodating bloom outcomes, perspective-taking warrants added assay in medical apprenticeship and analytic convenance settings.
The authors would like to accord appropriate acknowledgment to Sheik Hassan, MD, accessory administrator for bookish diplomacy and accessory assistant of medicine, Howard University College of Medicine, for his basic contributions to this activity and his agog support. The authors would additionally like to accede Richard Windsor, PhD, George Washington University School of Public Bloom and Bloom Services, for his abstruse assistance.
These studies were chip into the accepted apprenticeship programs of the George Washington School of Anesthetic and Bloom Sciences and the Howard University College of Medicine. They accustomed no alfresco support.
Studies 1 and 3 were exempted by the IRBs of the George Washington School of Anesthetic and Bloom Sciences (GW) and the Howard University College of Medicine. Abstraction 2 was accustomed by the GW IRB.
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