Reducing training will diminish the status of physicians

If Dr. Ezekiel Emanuel gets his wish, tomorrow’s physicians won’t deserve to be paid as well as physicians today because they won’t be as well trained.

Dr. Emanuel, a brother of Chicago Mayor Rahm Emanuel and a chief apologist for the Affordable Care Act, is the lead author of a startling opinion column in the March 21 Journal of the American Medical Association.  He argues that there is “substantial waste” in the current medical education system, and—in a time when medicine gets more complex every day—advocates cutting the training period for young physicians by no less than 30 percent.

Dr. Emanuel’s plan would reduce both the time spent in medical school and in residency training, which (as every physician knows) is the period of three to seven years that a new graduate physician spends learning to practice a specialty.

Many people don’t realize that residents already receive less training than they used to, because stringent limits have been set on the amount they are permitted to work.  Since the duty hour rules were rewritten in 2003, residents are limited to 80 hours a week in the hospital, which includes overnights on call when they may be asleep (what the rules refer to as “strategic napping”).  First-year residents, or interns, as of 2011 aren’t allowed to work more than 16 hours at a stretch.

Many senior physicians are concerned that today’s residents aren’t seeing enough patients. Evidence suggests that board examination scores are on the decline in fields from neurosurgery to pediatrics, as reported in the Accreditation Council for Graduate Medical Education (ACGME) Bulletin in 2009.  The American Board of Internal Medicine reports that the passing rate for first-time exam takers slipped from 94 percent in 2007 to 87 percent in 2010.  Unfortunately there’s no evidence that patient care has improved now that residents get more sleep, or that medical errors are fewer.

Now Dr. Emanuel thinks that even this amount of training is too much.

“For internal medicine, pediatrics, and similar 3-year residencies,” his article claims, “the third year is not essential to ensure competent physicians.”  And in surgery, “subspecialist surgeons could be trained to achieve clinical competence without spending several years performing general surgery”.

What’s the real agenda here?  If you believe that a young surgeon doesn’t need to learn to tie a perfect surgical knot on a simple wound before moving on to brain surgery, then no argument can convince you otherwise.  But what Dr. Emanuel really wants to do is cut down drastically on the amount of money that the federal government spends on Medicare support of teaching hospitals—about $6.4 billion in 2011.  The easiest way to do that is to reduce the length of medical training, whether or not that’s good for physicians and patients.

This threat to professional standards in medicine makes sense, in a perverse way—if we diminish the status of physicians by training them less, then we can justify slashing their payments from Medicare or government-run insurance exchanges.  And that’s exactly what Dr. Emanuel and his co-author would like to do.  In their words, less education would “enable physicians to recognize their limitations as well as their competencies”, and no doubt agree meekly to pay cuts.

If new physicians have less training, Dr. Emanuel argues, they will “become comfortable with group decision making, standardization of practices, task shifting to nonphysician providers”—in other words, they’ll lack confidence in their own judgment.  They won’t have the scientific background to inform their decisions.  They’ll like the protection of the herd.  The new physicians will be content to practice medicine by cookbook, which is a sure path toward having the federal government write the recipes for everyone’s health care.

Every physician practices as part of a care team, whether we work in offices, clinics, intensive care units, or operating rooms.  The point is that every team needs leadership.  Excellent physicians help the whole team to excel and take pride in their work. This is the opposite of the Emanuel vision, which is best described as a planned descent into mediocrity.

While the process of medical education warrants critical review, the Emanuel prescription for cutting it by 30 percent would downgrade the profession of medicine.  Instead, the prescription should be to support medical education at every level, and uphold the practice of medicine so that the brightest young students will always aspire to be physicians.

Karen S. Sibert is an Associate Professor of Anesthesiology, Cedars-Sinai Medical Center.  She blogs at A Penned Point.

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  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    what i can’t understand is this ridiculous quest by regulators to cut MD salaries. They only represent less than 10 percent of total healthcare costs. I wanted the little girl in my picture one day take over my practice but now I don’t think there will be much to take over. MD training should not be cut at all, perhaps the monstrous amount of liberal arts classes an american medica student is subjected to prior. Do we not want the best and brightest among us to go into the healthcare field. Must every top student go into finance to make a great living or be an internet entrepeneur to make a great living? What do financial professionals really contribute to society?? 

    • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

      6 billion on training residents. Think about it, what is that in the grand scheme of things, 6 b2 bombers. Less than the annual revenue of lipitor. I can’t believe they would cut that. Medicare fraud is 40billion. Get rid of that, leave the training alone. Does Dr. Zeke realize the importance of medical residents in poor areas where hospitals are barely staying open. I have no doubt that a physician can be trained in internal medicine in 2 years, but the fact is that a lot of a residents time is spent in service/scut work, and it isn’t all teaching.  The care that the residents give cannot be replaced by hosptalists because hospitals can’t afford to pay the salary. The(relatively) free labor is a staple of many struggling community hospitals. Think of an intern, endlessly disrespected but he is a medical transporter, a phelbotomist, a nurse, as well as a doctor, in my first year i carried 12 patients, the PA(making 90K a year) carried 5). All for a lowsy salary of 7 bucks an hour(maybe 10/hr nowadays). Seems like a decent investment in public health

  • http://www.mywhitecoatisonfire.com/ Lumi St. Claire

    This is truly frightening.  The revenue saved from cutting 30% of MD training costs is miniscule compared to the fallout from doing so.  Clearly, Dr Emanuel has forgotten his own training and what he did the final year of his general residency.  Traditionally, the third year of residency is the year that a physician hones his/her supervisory skills, and actively supervise and support younger residents and lead a care team.  According to Dr Emanuel’s plan, we will be creating a new generation of physicians who will have even less knowledge and skill in bringing up future generations of doctors.  We don’t learn medicine simply from being in a hospital for a few years – we learn it from modeling upon our inspiring and skilled veteran colleagues.  Dr Emanuel is calling not only for a diminished status of physicians, but a diminished capability, and that isn’t good for anyone.

    ~Lumi St. Claire
      http://mywhitecoatisonfire.com

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    It is time to stop dumbing down the education of medical doctors to suit the needs of economists, insurance companies, employers and academic and medical surgical programs. Practicing medicine is a calling and it is hard, arduous , stressful but fulfilling work. its time to start recruiting students who are willing to make the sacrifices the public and profession need.
    There is an explosion of knowledge and technology. If anything the training needs to be lengthened with medical school graduates enrolling in a one year rotating general internship which exposes them to all the different specialties. At least this way our future doctors will have a chance to understand what it is their colleagues actually do, how they think and make decisions and what a procedure entails. Today’s medical students get this broad exposure only in their third year. Is it any wonder that despite cell phones, emails , text messages and computers communication between doctors caring for the same patient is at an all time low. Its because the right hand doesnt really understand what the left hand is doing and because of no common or shared experiences in caring for this problem has forgotten that they do bear responsibility for a successful and positive outcome.
    The responsibility for our future doctors needs a change in how we select medical school candidates and who we select. In a NY Times op ed piece in 2011 Dr Silbert discussed the unusually high attrition rate of experienced and trained female physicians from the profession. Why then are we still reserving 50% or more of medical school classes for women if there is a physician manpower shortage?  We additionally hear about today’s doctors wanting a more balanced life and not wanting to put in the hours and bear the responsibilities of past generations of doctors. Maybe we should be biasing our medical school selections for students who realize this profession requires individuals who think a 40 -60 hour work week is the norm and may actually be longer?   We already make exceptions and lower the MCAT scores and standards to obtain diversity in our medical school classes?  Why not select caring , compulsive individuals looking to work hard and  long for the better health of their patients?
    Last month a peer journal ran an article about the difficulty primary care doctors are having interpreting scientific statistics and the real meaning of what data reveals. Does Dr Ezekiel really believe eliminating research requirements for post graduate fellows and others will rectify this problem?
    Yes increase the time spent training. In fact I propose racketeering by the Federal government in terms of giving funding for programs that train doctors in areas we need extra practitioners and limit funding and grants for training in over subscribed specialties.  Make every new doctor and nurse serve a year in a Public  Health National Service Corps before they can complete their specialty training. Then pay for their entire education and leave them debt free if they agree to go out into the community and practice that needed specialty for the next twenty years !!!! 

  • http://www.facebook.com/abcsofra Deborah Murphy

    OK, from a strictly consumers view as I consume the medical output as needed with a chronic illness. If funding for such hospitals was taken off the back of medicare and such hospitals reduced their charges to consumers, wouldn’t this be a win win situation? I refer to other educational driven consumer industries such as hair, massage, and such. When one uses these “schools” there is a substantially reduced charge to the consumer with the understanding that the service provider is a student in training. Do these hospitals currently charge less for medical students working on patients? I lived near a major study hospital UMDNJ and yes, they provided a sliding scale if one couldn’t afford it but I never saw a difference on my insurance bills…meaning we could afford it. Unfortunately until this country either gets on board with a government supported healthcare system these are the types of “solutions” we will be offered.  With the current political push, medicare will be drastically anyway and thus these hospitals too. Personally I feel we need to revamp our healthcare system. And no one can convince me otherwise as unfortunately corporations are NOT humans and operate strictly on a bottom line driven mentality – profit rather then on the cost efficiency in relation to quality. When we are dealing with life, this just shouldn’t fly. And that of course is my opinion.

    And I so agree with Vikas about cutting the liberal arts classes all together….say at least 30-45 credits in just the first four years of college.  They are just a rehash of high school anyway. A complete waste of time for those that are beyond them in the first place (can pass the basic college entrance test in the first place). Having a 20, 30 and 40 year old I have seen this waste of money, time and energy these classes take and do not give back towards the major unless it is in english or history or gym, etc. That alone would reduce their education by 1 year and I am sure there are other classes that could be cut out.

    And perhaps another thought…apprenticeship. Why not offer this much earlier on and partner “to be” doctors with current practices or form local clinics close to where the patients are (and yes in underserved areas in particular) and use these are training places. Hospitals are only one link in our healthcare system. Why aren’t we utilizing private practices as well and clinics?  

    And just one last departing sentence…this week I had to rush my daughter to the er. They mandated that all blood workup had to be redone at the hospital even though two other doctors (a gp and one specialist) had just run the same d$#%  # tests the day before!!! Basic thinks like CBC, etc. Why is this? Why duplicate costs like this. I have found this problem rampant in our medical society. I try as a consumer to cut costs every possible way because I do it with my household budget and thus feel as a medical consumer I should be watching my spending in that field as well. I can’t tell you the bull stories I have been given as to why the same exact test MUST be run even though another doctor just ran it and I have those results in my hands too. I believe that “need” like I believe I have a hole in my head.

    I so appreciate your blog because you get people thinking which is exactly what we need right now! All brains on board :-) to solve this complex, diversified issue.

  • Marc Frager

     Perhaps Dr. Emanuel’s status will be diminished with the upcoming election. The only waste I see is mandatory maintenance of certification which only goes to maintain the status, and salary, of effete academics.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      Agree with Dr Frager. Another ACP ABIM money making ineffective control tool

  • http://www.facebook.com/timrichpt Charles Timothy Richardson

    I agree physicians need confidence to make life-or-death decisions quickly and I further agree that teams need leaders.

    However, I think these features of physician training miss the point of Dr. Emanuel’s article.

    No physician can keep up with the massively expanding universe of medical information and more training will not help. Fortunately, we have NEW ways of exploring medicine, called Clinical Decision Support, that puts patient-specific information at the physician’s fingertips. The generalist physician will disrupt the specialist while non-physician providers will disrupt general physicians.

    Camden, New Jersey’s Hot Spotters showed us that teams of unlicensed “health coaches” provided better care than highly trained emergency room doctors for the most expensive 1% of patients that were driving 30% of the costs.

    We’ll still need specialists who have 12-16 years of medical school, residency and sub-specialty training. We just won’t need as MANY of them.

    They’ll still be high-status doctors in our society – although healthcare reform shouldn’t be about preserving physicians’ prestige and social status.

    It should be about the patient and preserving healthcare for all Americans.

    Tim Richardson, PT
    http://www.PhysicalTherapyDiagnosis.com

     

  • Craig Koniver, MD

    Thanks for sharing this. You make some excellent points and I agree whole-heartedly with you.

    The type of thinking exhibited by Dr. Emanuel should be very scary for ALL doctors. Once you start to decrease the amount of training, thereby decreasing our very high level of professional development, you slowly but surely start to create a model where we as physicians get lumped into the group of everyone else. We are just a little bit more trained. Why go see your doctor when this other practicioner can do just the same. 

    Doctors need to stand on guard against this. Do not settle for mediocrity. Mediocrity arises when the value of what we do declines. And I think it starts with us being the system’s pawn.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Thank you for writing this article. Dr. Emanuel is not an outlier in his opinion, and I believe this suggestion is part of the relentless march towards assembly line medicine for the masses, which is viewed as the solution of choice for reducing costs of medical care, based on previous experiences in the manufacturing and retail industry.

    The master physician, in this theory, is as obsolete as the master cobbler was a few hundred years ago, because the cheaper way to make affordable shoes is to have dozens of illiterate people, each stitching one area, preferably with a machine programmed somewhere else, in this case presumably at the academic centers, by the few physicians chosen to receive this type of additional education.

    I think the vision is, again based on manufacturing, similar to how the Engineering profession has evolved. The few who stay in academia, conduct all the research, define standards, etc., while most engineers are employed in large corporations to implement this body of knowledge, in a standardized, predictable manner.

    If you share the belief that medicine is at a point where large parts of it can be automated, or at least protocolized, then having the majority of workers specialized in their own station task only, with a few supervisors to oversee that all lines are moving smoothly, is probably the most cost-efficient way of fixing people.

    The people may differ though…..

  • buzzkillersmith

    Dr. Emanuel is in the vanguard of an attempt to de-professionalize medicine. He thinks it would help society.  Maybe he is right, maybe not.  I doubt it would be good for doctors.  

  • SidewaysShrink

    We do not to shorten physician training but to double down on paying for the 2 key health care provider groups educations: physicians and nurses. Nursing schools get no extra federal finding for clinicals for ARNPs who are becoming a big part of the solution. If the government paid on the front end, we could afford to serve the under served. As it is, slices to Medicare fees will kill that program in 10 years due to the student loan debt of those of who are supposed to serve the Boomer’s in their 30 year retirements on Medicare. There must also be loan repayment for the rest of us who took out massive debt already. It can’t just apply to new students .
    Otherwise, NONE. of these affordable care acts will be affordable to the providers. We are not individually mandated to participate in any of this reform since we have not been consulted on what amounts to impending servitude unless for some reason agree to it. I have opted out of Medicare and failing debt restructuring for medical providers I will stay opted out.

  • dsblanchard

    I was always appalled that NP’s (nurse practitioners with 18 months post baccalaureate degree, if they had one) and PA’s were technically becoming the primary care providers in our country. I wanted their education increased to the level of the family practice physician (if they were going to fill that slot in the system) and have all physicians be specialists. Well, this article sets that thought straight into the pipe dream category. Ah, well, what else can you expect from government officials who come from families with philosophies of life such as E. J.  Emanuel has. Together with some colleagues, Ezekiel Emanuel devised the “Complete Lives System” stating that in an era of scarce resources society will have to weed out the weak, starting with those on the extreme ends of life–those newborns and elderly that just sap the system.1

    1 Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions, Lancet (373) 423-431.

    It’s time for me to retire, Folks!
    Dawn PhD, RN

    • militarymedical

      I agree it may be time for you to retire, Dawn.  Show me a certified NP program that accepts RNs with less than a baccalaureate degree and please, climb down from your high horse.  NPs and PAs are becoming de facto primary care providers (more akin to older GPs than BC/BCE family practice physicians) not because of delusions of grandeur, but because fewer and fewer physicians enter the primary care/family practice field.  Otherwise, I agree with your comments.

  • http://twitter.com/sarasteinmd Sara Stein MD

    Zeke, what are you doing!! This is a sure way to overload the high tiered specialists who would wind up taking the “medium” acuity cases that primary care adeptly treats in the current system. Which would, of course, lead to overloading specialists…(like you Zeke, oncology)… who would then have less time and energy for the “high” acuity cases.

    I do favor cutting out one or two years of undergraduate education to speed the process for some students. And maybe medical school could be adjusted to a full-time year round experience starting year 1, which would shorten educational time, but not quantity. But residency?

    To test Zeke’s platform, I think he should only have junior residents treat his entire family for the next 5 years. Let us know how that goes!

  • cheeryble

    Surprise surprise
    doctors here don’t think economies should be made if it affects their status, regardless of pursestrings.
    “Let them eat cake” becomes “Let them go broke to pay for our perfection”.
    I have a solution which would really be a solution if only…..yes…..physicians would enact it.
    As Europe is so measurably superior to the US not only in the cost but in the quality of healthcare how about all US physicians demand their government simply copy the best on offer from Europe with all it’s real innovations with a view to bringing the healthcare budget down to a non-ruinous figure whilst covering all.
    Cheeryble

  • http://www.facebook.com/timrichpt Charles Timothy Richardson

    “…building more hospitals or training more doctors is not the solution…” – Jason Hwang, MD co-author of The Innovator’s Prescription.

    I’d also segue off of cheeryble’s post and point out that Family Practice doctors in Europe earn comparable to US $200,000. My Family Practice friends back in Florida only earn a median $165,000 – they’re the most underpaid doctors in medicine.

    Tim Richardson, PT
    http://www.PhysicalTherapyDiagnosis.com

  • jeffmchpn

    This is most certainly an advocacy piece which distorts the well-stated aims of the Patient Protection and Affordable Care Act. It is essential that physicians engage in collaborative patient care, and in doing so their role is not diminished, it is enhanced and more effective. Team-based health care is not some new assault on the perceived status of physicians — it has been demonstrated to be the most efficient, effective, and safe means of providing holistic, health promoting care. I commend to you seminal articles such as the “Sounding Board” article by Dr. Eric Cassel in the NE Journal in 1982, entitled “Suffering and the Goals of Medicine.” In opinion and clinical experience our interventions are most effective when we address “persons”, not diseases, syndromes, or conditions.

    As a semi-retired hospice RN manager and director, I know that interdisciplinary — not multidisciplinary — care is dynamic, even synergistic, and is by far the most cost-effective, and above all, patient-centered care we can provide. There is utterly no reason ALL clinicians cannot do so, once we leave our egos and titles at the door. Dr. Emmanuel is quite correct to challenge the assumptions and realities involved in Federal government support of medical education. This very substantial contribution of taxpayer underwriting of medical training is not providing the substantial numbers of primary care physicians, and most importantly geriatricians, that we clearly need. And finally, this ridiculously expensive so-called “system” is the least cost-effective among industrialized countries. By all relevant measures and comparisons the “corporatizing” of health care in our country is outrageous. I live in a “high quality — low cost” healthcare region, one of several around the US, which includes Oregon, Minnesota (near the Mayo Clinic), and greater Cleveland (near the Cleveland Clinic). The hallmark of these islands of effective and efficient care is collaborative, evidence-based provision of care in team-based systems — systems which focus upon patient and family needs. We do not have a broken system. We have many independent systems for reimbursements. We have never had a health care system. The VA, Indian Health Service, and our military hospitals and clinics represent the only true healthcare systems in the US. That is pathetic!

  • PMD1234

    The third year is when you get thrown more cases with less supervision. That is what real practice is all about. Our hospitalists right out of training have little experience or gut sense that a case is a little odd, or that the multiple things going on require closer watch, not turfing blindly to the specialists. Specialists are also getting narrower and narrower- and may or may not have read they med list before they add something else.
    I needed surgery at a big teaching hospital- the pre-op I got was- I swear – by a PA in the conference room, because I needed this relatively urgently. The exam consisted of listening to my heart and lungs over my shirt.I had the requisite labs and ekg- and the rest of the (wrong) history was taken from the EHR. The (wrong) history was why I needed the surgery urgently.
    I see my job as an internist as to take advice from the specialists. If it doesn’t make sense or was by the cookbook, I need to question further. I already read the cookbook.I have to know enough and where to look it up or ask for further thought or find another specialist. I have to know enough to know the difference- and out of courtesy to the specialist the patient should arrive with the studies he/she will ask for, so we can skip that step and go for meaningful thought.I need to know enough  that when a radiology report makes no sense, to call.
    If I am going to manage physician extenders, I need to know if what they are doing is medically sound- the person in charge ( I hope) has to be a resource- otherwise all patients will increase cost because they will go to specialists. On  three occasions in 20 years I have finally said to a cardiologist “If you don’t cath them, I will find someone who will. Two went to immediate bypass, one needed emergent PTCA.The difference- I know the patient.
    Dr Emanuel is assuming all internists will practice within referral distance to an academic center.
    WIth the rise of ACO ( and I’m not sure I see the difference between this and capitated care- which meant no specialist wanted to see the patient) internists will need to know more, not less.

  • http://pulse.yahoo.com/_UDJTUH45CFUC6LKCBLB6FGRDKU Diane

    How many cartoons are already out there showing surgeons watching utube in the OR. Or, there could just be flowcharts on the walls of patient rooms, though maybe it’s easier to keep it in ” THE DIAGNOSTIC COOKBOOK”. Or all new docs can just google stuff, hey, it works for patients. Keep an ipad in every room, have the patients (hopefully they are conscious) type in their symptoms (gunshots wounds are obvious) into the google search, come up with their self diagnosis, and see if the doc thinks it’s correct. Really, this Dr. Emanuel may be on to something. I can see the savings adding up already. I wonder if he is head of the National Insurance Coalition of CEOs to line our pockets and make our stocks go higher organization. 

    25+ years ago, the PharmD was just coming into in own. I decided that was the right path for me b/c the extra year(s) of learning would not only reinforce the “book learning” but offer more opportunities in the workplace. This was back in the day when you could get away with 2 years of pre-pharm and didn’t need a degree  to get into pharmacy school. And I was the kid who changed career goals every quarter – photography, economics, prison social worker, anthropology, psychology, then decided pharmacy was a good job b/c they made the most money and I could set up my own dark room.
    Once in pharmacy school and all those silly classes during the 1st 2 years were out of the way, we settled into the “real” pharmacy classes our 3rd year with rotations in pharmacies and hospitals half a day. It wasn’t until my 4th year – the D part, where I was out in the real world doing rotations in clinical settings that I finally put all that book learning to use and it finally sunk in and made any sense at all. Most folks in pharmacy school at this time had graduated in 3 years and were out the door putting pills in a bottle and sending folks on their way. I knew this wasn’t for me but I still wasn’t exactly sure what I wanted to do so I did the next best thing, a general residency to learn even more. In 20+ years of working in the real world, I have worked in almost every setting imaginable. And I love the variety, the interaction and the learning that goes on. I never did set up that darkroom though I still love taking pictures. 

    I can’t imagine my doctor coming out of college with say a business degree, not liking his job and going to his true calling, medicine. But say he’s an average student and kind of needs that extra 30% of education for all the stuff in the classroom, on rotations, and in 80 hours (hey, how many studies have those medical type folks done over the years to PROVE SLEEP is better for memory retention, brain function, etc) a week of clinical work to actually sink in. Because remember, for every valedictorian, there’s someone in the middle or hey, maybe even near the bottom of the class. This doesn’t mean their heart doesn’t long to be a great and wonderful doctor, it just means their brain can’t retain all that book stuff without seeing and doing and seeing and doing to get it locked in. So what happens when he’s got real patients and his say is the final word. Sure you save on education costs, but does patient care go down? Do MD, ER, hospital visits increase? Malpractice insurance?

    And like PMD1234 said you can’t always count on EMR to help you out as great as they sound on paper. Funny, I was just telling my mom this last night- that with 50 (a wild guess) EMR programs out there, that information isn’t transferring from this doc’s office to this doc’s office to this hospital to this hospital to this state to that country, etc. So you can’t count on carrying that little credit card of electronic health any time soon. That is IF the info is even right. 

    I’ve had my own experience of watching a PA at my neuro grow in her knowledge of migraine info. A year ago, I thought, well she knows this med is used, but she doesn’t even know the dose???? Good grief. Why is she even here? A year later, she seems much better able to discuss meds used and in my case, with a complicated medical history, cognizant of other risk factors involving those meds too. Since my doc had left the practice and was unavailable, I was leary to see her. But it’s amazing how much difference a year of experience had made.

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