Friday, April 10, 2009

Medical Education and Houseman Training

Houseman training is the most crucial part of the medical training. However, this is often poorly structured and it is very dependent on their immediate senior MOs, registrars and consultants and finally, the houseman’s own initiatives and commitment.

The standard of medical education has dropped dramatically over the last 20 years and this is due to host of reasons. Parental pressure for their children to do medicine is always there. Just a week ago, I received a call from an educated parents who was very insistent on his son doing medical course, either in India or even in Russia as long as he is a medical doctor. The reason is that medical profession is a money churning profession. I told him frankly this might be the case 30 years ago but not now anymore. If his son has no interest or passion to look after the sick, he would soon be sick of the profession and he will be a failure as a medical doctor. He was equally shocked to hear that in the Malaysia context on the average, about 5% of the houseman is not signed up because of poor competence and total lack of interest and commitment. Some just opted out to pursue other  job that they have interest, ranging from being a chef to medical sales representatives. I just hope that parents should have more confidence in their children to allow them to choose their own profession.

Over the years, MMC have recognized more than 300 over medical degrees all over the world. I did call for a review of all the degrees recognized by the MMC so that the list of recognition could be updated. Some of the universities have obviously passed their prime of life, for example the university of Iraq is also recognized for medical training. I generally support that there should be a total review of medical degree from Indonesia, Middle-East countries, Russia and  Ukranian countries.

Medical training requires you to take patience’s history and sending our students to foreign countries when English is hardly spoken, for example in Prague and Russia, Malaysia students have to struggle like hell to learn the language and then communicate with the patients. Back home, they have to translate these into Bahasa and English and local dialect and this is not going to be easy. Often, the student becomes an incompetent houseman. A lot of these houseman are often clueless about the pattern of medical diseases in a tropical country like Malaysia. A lot do not even know how to take proper medical history. Even a simple medical examination of a pregnant woman is beyond some of these young interns.

I used to hear how incompetent the housemen could be from senior doctors. When I was a minister, I decided to pay a surprise visit to the General Hospital KL. I had the opportunity to directly question 3 different housemen about 3 different patients under their care. Initially, I was hesitant since I had not practice actively since 1990. I left the ward convinced they were not up to mark. They just do not know how to manage a patient under their care from history taking, physical examination and further examination. They were too dependent on their senior doctors. What I asked was very basic question since I myself cannot claim to be updated about medical knowledge. I was shocked after my interaction with the 3 housemen.

Subsequently, I had the opportunity to talk to first year MOs that is one year after their internship in Sabah and Penang. That’s when I started further discussion with senior doctors and DG who is also the chairman of MMC that the time has come for the housemanship to be extended to 2 years. The 2nd year of the housemanship, they will be paid as MOs and also regarded as part of the compulsory service so that they would not lose out in their seniority. Hopefully, with the one additional year of supervision, they become more competent doctors. Of course a lot of parents and housemen were highly critical of my decision then.

There’s a need for more hospitals to be gazetted as training centre for houseman. This may not be easy since the hospitals selected for houseman training must have adequate basic specialty services, adequate mixture of cases, and enough specialists to ensure proper supervision. Otherwise, we will be training incompetent doctors. Private hospitals would be most unwilling to be used as training for houseman. As part of the training, houseman needs to undertake procedure and this often become not practical in paying patients in private hospitals. They are also legal complications when houseman under government service undergoes training in private hospitals.

The MMC need to totally review and update:

1)   The list of medical universities recognized currently. It should be brave enough to recommend to the Minister of Health to deregister some of these as I did to the Crimea Medical University.

2)   The program training for housemen should be more structured with adequate supervision.

3)   Signing up housemen at the end of their two years should not be “fait acompli” so that housemen become more committed in undergoing 2 years of vigorous training.

I have to admit that the housemanship training everywhere in the world is the most frustrating, the most difficult period of training before one is allowed to practice as a doctor independently.

Parents should not have the impression and the public should not perpetuate erroneous impression that the medical profession is a highly lucrative profession. A frustrated doctor is a danger to his patient and the society. I have the unfortunate experience in meeting some of them and I can only sympathize with the patients under their care.

27 comments:

supergoh said...

I think you should advise the Health Minister to deregister some overseas medical universities immediately before Malaysia is flooded with incompetent doctors.

SP said...

One of your best articles. As a layperson who is very interested in the future of the Malaysian health care system, I am very concerned about the big variation in the quality of the medical students who join the houseman programme since they come from all sorts of medical schools both at home and abroad.

Perhaps, we should introduce a common unified exam for all medical graduates regardless of the university they come from. In the USA, all students including those from top schools like Harvard, Yale etc, have to pass the USMLE Step 1 and Step 2 exams before they are allowed into their internship programs.

The other big problem is the shortage of senior doctors and specialists who can train the junior doctors and houseman. Many of them have migrated to the private sector. this is largely due to the Mahathir regime's policy of encouraging the growth of private hospitals.

Subramaniam Pillay, GMPPK

SaPPhiRe DraGoN said...

Yeah, i think too many students are pursuing medicine just for the sake of it. For example, most of my circle of friends applied for medicine in the JPA scholarship. But the cold hard fact is I can see they are just choosing it juz because they are science students. They lack the confidence to venture into other more exciting challenging careers.

chong said...

you and KJ can make a good team now.

kenny said...

Some doctors want to be politician. So they dont care about the quality of their medical education.

Prachai said...

In other parts of the world like China, their best students study mathematics, computer science and biology. The fast moving field of genomics provide ample opportunities for smart people to make a difference. It's a tremendously challenging field that requires people with multidisciplinary training.

It is true as you said, one should not choose to become a doctor simple because one's STPM/matrikulasi results are sterling; one must also be strongly motivated by concern for the well-being of another person.

朱刚明 said...

The new cabinet must immediately proceed with the remedial actions for the Queen Elizabeth Hospital (QEH) if PM's "People First" is truly honoured.

People's life is at stake with the resources splitting up into several locations which heavily affecting the performance of doctors and supporting staffs.

Coupling with the likely "incompetency" situation of the hospital personnel, public are reluctant and yet have no choice but to take on the risks of visiting government hospital.

The public are suffering because of this.

Shan said...

I'm a medical student studying in Russia. I know the reputation of the medical schools here are not at their best but can you please not lump us all together in the same bunch? I know there have been housemen that have been less than competent in their duties but I've known also plenty of housemen who had achieved distinctions academically and are mostly currently working as interns mainly in Sabah and Sarawak.

We came to Russia to study because we lack the funds to pay for more expensive private universities in Malaysia. Also the places for non-bumiputra students for medicine in our own country are extremely limited. All of us really want to study in Malaysia, but we were not even given the chance to do so.

I can assure you that the education system here is more than adequate to prepare us for our future profession. It is discouraging to know that we are treated as second class citizens even by our ministers after six years of hard work just to qualify for our degree.

Ik said...

我认为你的意见有欠公道,难道大马大学就是完美的吗? 我觉得大马政府以及有关部门(MMC)应该解决自家的问题先, 问问自己为何大马的医疗水平不及国外, 甚至邻国.

毕竟俄罗斯在医学这方面有着非常长远的历史, 它们的医疗水平及结构也远远的超越大马,更加的完善. 它们的医疗水平在这世界上是不可忽视的.

在俄罗斯念书的大马医学生, 也有是因为真正兴趣而来的, 也不排除有大部分的学生是因别的因素才来.

象您这篇看扁我们的文章到处都是, 数不清. 我们也已经看惯, 也麻木了. 我们也想做一位好医生, 为人名服务.

难道大马的医生们就不能把他们的有色眼镜放下, 把他们的骄傲放在脑后, 给我们一丝丝机会. 当你们的面前隔着一层有色眼镜, 不管我们做得多出色, 在你们眼里, 永远是不对的.

我们当初也不知来这儿会带给我们如此不堪的后果, 会遭人看扁, 我们也很努力啊!

既然我们已选择来了, 难不成要我们放弃学业, 回去当个社会的寄生虫? 读一些我们没有兴趣的课程? 还是倾家荡产去私营大学完成我们的梦想?

把你们的有色眼镜和骄傲放下吧...

-在俄罗斯的学生-

supergoh said...

You should also look into the deteriorating standards of medical education in Malaysian public universities,not just pointing finger to overseas medical universities only.

Mike said...

尽管新出炉的内阁被普遍上认为依旧臃肿,不过马华总会长翁诗杰今日指出,这已经算是一种“瘦身”。

You see this so-called leaders of the 3rd largest Chinese Parties in the world, apparently never been to a supermarket sale and his math is just plain lousy. The minister posts reduced 2 but deputy minister posts add 3 and you end up being? You do that math.

When US has 15 department, UK 17, Australia 16 and Japan 12, Malaysia boleh actually has 25 Ministry and we are damn proud of it and both you and OTK said is streamlining….

询及其副手,即署理总会长蔡细历为何没入阁,翁诗杰反要记者先做功课,去翻阅宪法。

本来看似心情不错的翁诗杰,在听到这个问题后马上严正指出:“这是一个老问题,其实我在过去数天也已经回答。你应该先做功课,请你看一看宪法,宪法有提到,只有国会议员或者上议员才能受委为部长。”

He can appoint CMF through the back door to become a Senator but not you a more qualified Candidate. Why?

tanht1949 said...

JPA students with SPM results after attending a short 3 months' course in Malaysia can go straight to Year 1 in Russia. Some SPM students went to study Higher School Certificate in Indonesia (strictly speaking enjoy themselves for 3 months in Indo) can also go for Year 1 in Russia. Without a good Form Six foundation I wonder how these students can be good doctors.

However, to be fair, there are quite a number of good SPM students (e.g. 9A1 & 1 A2) graduated from Russia are doing very well as housemen.

So, the question is should the government set a higher standard to allow only these students to study medicine? In the past many had voiced and told the government not to send average students to study medicine but only landed to deaf ears. The government has its own agenda to do so. This is one of the reasons that has lead to its downfall.

Dr.Chua is not totally clear that there are English & Russian medium medical study in Russia and the differences in the standard of Russian Medical Universities.

So, when they enrolled for housemen, the Healthy Ministry should pay particular attention to those with poor entry qualifications when they entered medical universities. Generally, these are the students who damaged the whole image.

Lim said...

I read your comment with full agreement about the standard of young drs we have now. i'm now at my 7th year in gov service and as the years go by, i feel the standards of my fellow junior drs have really deteriorated. the most troublesome issue is there are now so many HOs in the wards and responsibility have dwindled.imagine a ward of 24 beds being managed by 6 HOs..this is never heard of in my days.things got settled with 2 HOs at the most but now with 6 HOs, things get left out and patient care declines.i just wonder why some of them bother to join this profession when in the first place the attitude is wrong and they just don't care..just punch out at 5pm and finish rounds.patients deteriorate and 'collapse" and we need to "invite" the jr drs to join in resuscitation.what has gone wrong with the system?and best of all, parents (of jr drs) come into the picture threatening senior MO/specialist for "preferential" treatment of their children when in the first place should not even be admitted to a medical school....even worse is when the jr drs. don;t realise their mistake/repent even after being told/informed/counselled by senior MOs/specilaist/consultants...my 2 cents

ChiaKC said...

rarely I read Dr Chua's post in full, but today I am grateful I did.

it is commendable, as you were frank enough to comment on some of the weakness of our health care system. some readers took it out of context , and they would not able to see the bigger picture like you.

I am a MLT by training, used to work with gov research lab, then private lab and overseas. Though I am not practicing right now, but speaking solely and based on my experience I am afraid Dr Chua is not worrying for the unreasonable. This is not intend to hit anyone but just some indication that things are falling apart, somehow.

you may already have a fairly good idea on how to revamp the whole system, but one thing: stop privatizing our hospital, just as starter.

I did a gathering with some MLT old folks recently and let me share a small story with you, Dr.

One guy working in privatized hospital turn out and said, he is asking for promotion, and will elevate him as a perfusionist to become senior MLT of a dialysis team. so for him better pay, less work and easier life and flexibility to handle heart-lung machine for private case, too.

Here I am not to judge it's right or wrong, but if I say it is profound, then I am abusing the language.

This is the mentality Dr Chua must see. There are a great number of fellow out there, took up critical position in our health care system and yet refuse to take their responsibility. There are good number of people considering being a member of our health care system means fortune, quicker social mobility and higher up in social class. How discouraging to be part of the team, I say.

supergoh said...

To Ik,

本人同意大马政府大学的教学水平江河日下,令人担忧。本地医学生的素质差强人意,参差不齐。可是,政府依然置之不理。可见政府重量不重质。

没错,俄罗斯的医学水平应该比马来西亚好。俄罗斯有很多世界顶尖的教授。不过,这只限于以俄语作为教学媒介语的大学科目。

不是大马医生要给你们脸色看。只是有些俄罗斯医科毕业生的素质太令人失望。

本人劝你发奋图强,毕业后到美国修读专科。这样,本地医生就再也不敢瞧不起你们。



前程似锦

Voices Of Taiping said...

http://www.sinchew.com.my/node/109904?tid=1
看來你的"好夥伴"還不懂民意,連鄉下的小孩都懂.
看來巫統不會改變

呉 和豪 said...

Dear Comrade Dr.Chua Soi Lek

Your's tough and uncomproising stand on important issues pertaining to the interest of rakyat prooved that you are one of the excellent leaders and ministers , hope that whatever you suggested will be accepted by relevant authorities as part of our effort to implement culture of excellence

呉 和豪 said...

蔡细历同志
蛋糕应该被扩大, 政府大学的医学学额要增加, 我们要确保在马来西亚的每一个地方的马来西亚人,都可以感到及看到光明。每一个有潜能成为医生成为医生。增加政府大学的医学学额对于来自低收入家庭的优秀学生非常重要。增加政府大学的医学学额对于马来西亚的医药旅游发展也非常重要。

Mike said...

The turmoil in Thailand clearly demonstrated what happens when a democracy process is upset. This is what happened when the outcome of a democratic election process is not respected by the minority. When the minority group used unpopular means to unseat the democratically elected government, the society is polarized and the whole democratic system breakdown.

In a democratic society no 100% of everyone get what they wanted. However the minority has to respect the decision of the majority no matter how marginally it is (even by 50.0001%).

We in Malaysia should look at situation unfolding in Thailand with great caution and learn a valuable lesson from. The incident in Perak is extremely similar. The ruling government must have a long-term vision and must not be focus on the short term gain. Because you may win the battle but end up losing the war.

I still strongly believe a re-election in Perak is the best justifiable mean to end this mess peacefully

Chin Yit said...

Dr Chua,

Hi. i find it interesting to read your post about the medical education.

i am currently a first year medical student. Here, we have exams every six weeks.

After we graduate, we are expected to pass MRCP within some 18 months.

Since there are already too many examinations, i don't mind sitting for an additional unified medical examination in Malaysia, as long as it can be fairly conducted.

If a fair unified medical licensening examination can solve all doubts on standards, i would be supportive.

Best regards,

chin yit

MD Moscow Medical Academy said...

Actually,I see your point but the thing I can say is not to generalised the medical graduates from these country especially russia!

The thing I have to say is russian medical school is not a bad destination for medical education because the key of becoming a competent doctor depends on learning attitude!

Not all the incompetent medical graduates come from these country,there are still some competent one!

Indeed,the medical school may have a poor grading and examination system but part of the responsibility should be carried by the students itself!

Some rich spoiled kids going there is just playing around but not try to garner as much knowledge and skill as possible.That why they come out as an incompetent houseman!

The most important thing is to make sure the student they take in is not substandard in order to avoid the substandard doctors is being produced!

MD Moscow Medical Academy said...

Please don't be generalized the medical graduates from these country because there are competent doctors graduated from these country's medical school also!

The key factor of incompetent is mostly due to the student's learning attitude.

Some rich spoiled kid is being sending there just to play but not to learn or garner a good medical knowledge and skills.

The"easy pass"grading system have made these spoiled kids even worse at last come out as incompetent doctor.

I think a better students enrollment requirement should be set up to a adequate level,as example spm result for entering Pre-medical course in russia should be set to at least 2A for all sciences and maths subjects.

This can easily make sure the student take in is not sub-standard,so substandard doctor will not being produced!

dHarjma said...

Dear Dr Chua,

I am surprised by this article. Having been Health Minister for a while, I would have expected more insight and useful solutions into the problems in dealing with new graduates. None of the solutions you offered are new or useful. Recognising graduates of Oxford doesnt mean that we rid outselves of 'incompetant' doctors.

I am a Penang Medical College graduate. I worked a year in Ireland - and observed many inherent flaws of its system. I then moved on to Cleveland for my Internal Medicine residency. I think we malaysians can learn a thing or two about educating new graduates from other established systems.

When I joined residency in the USA, I was shocked at the ability of residents in training programs here. Doctors who just graduated 12 months ago from medical school are routinely running codes, adjusting ventilator settings, initiating BiPAP based on arterial gas results and making decisions on transferring patients in and out of the ICU. Their competance is not measured by their ability to insert a urinary catheter - rather they are analysing results of pulmonary artery catheters and adjusting afterload medications in people with severe valvular heart disease.

I am by no means suggesting they learnt all this in 12 months by themselves. Instead, a well oiled system of mentorship has already been in place for over 100 years, where senior residents spend 1 on 1 time with new houseman, allowing houseman to make decisions very early on while keeping a close eye on things. Senior residents in turn are then evaluated by Consultants of the team to see if they have well developed mentorship and clinical skills.

The system here does not differentiate whether you graduated from Zimbabwe or Harvard, rather everyone who plugs into the system has to sit for a common entry exam. Based on the results of the exam and your CV, you apply to hospitals you want to work in. Hospitals make themselves more attractive to applicants by improving their medical education programs. A system has been created that rewards hard working people regardless of background with more expidited and thorough training. Competition for residency can be stiff, despite the fact that the annual salary is low and work hours are long. People are willing to put in the hours if they have good reason to.

Once you are in residency, residents frequently work hard in order to score a coveted fellowship. In short - a system has been created to pick good doctors early on and provide them incentive to care for patients better. The system did not limit itself to picking graduates of a certain country / language preference / background - it simply chooses the best it can - without having to dish out bigger salaries for it. Many that contribute significantly to the medical field here are trained in countries like Bahrain, Sweden, Zambia, Kenya, Egypt etc. Many of these did not even have English as their first language.

I dont think we need to come up with a new system from scratch - we have plenty of systems around the world we can emulate. Instead of limiting the numbers of universities we recognise, why not recognise more? Let any Malaysian who wants to be a doctor leave our shores and get his/her training wherever he wants- for as long as they are good and can pass a well designied entrance exam, they can return and care for Malaysians in our hospitals. Dont waste our time convincing the world that being a doctor isnt a lucrative profession, that isnt our job. Instead, lets allow adults to make their own decisions based on whatever motivation they have - and concentrate on hiring the best. If we are serious about quality, we should create a quality system that creates incentive for good doctors to work with us.

In short, what I propose is:

1. A common series entrance exams for all graduates (whether local or foreign graduates). This exam should be strict, fair, well structured, and unlike the CLP exams for Law graduates - scandal free. We can use exams like the USMLE as example, and modify according to our needs.


2. once in the system, housemen should be encouraged to work hard for good letters of recommendation for further applications for subspecialty training, senior positions, or desired locations. If they are good, we should not deprive them of the opportunity regardless of allocated quota spots.

3. We should come up with a way to reward competitive candidates - such as provide training opportunities very early on, allow them to make management decisions with proper guidance, limiting unnecessary scut work like chasing scans, filling up forms, drawing blood from 40 patients each morning - we have ancillary staff for these jobs. Instead we should concentrate on 'front loading' decisions to new graduates while consultants in our hospitals concentrate on research etc. Ofcourse, there should be good supervision throughout this time.

Currently it is not difficult to get disheartened as a houseman in Malaysia. I have myself seen many reasons why this is the case during my clinical training in Penang. Housemanship can be difficult, lonely, demanding, and with the wrong consultant degrading, demoralising and painful. We have a system in place currently that can sometimes be quite autocratic, racist and unfair. While I am not justifying the incompetance you saw in housemen in HKL, I think there are many things we can do that go beyond telling people to choose medicine for the right reasons and recognising a select bunch from certain countries. Lets concentrate on picking good graduates instead, and give them good reasons to join the ministry. Malaysians are a smart bunch - I dont see why we cannot create a system that works.

Dhssraj Singh
dhssraj@hotmail.com

dHarjma said...

Dear Dr Chua,

I am surprised by this article. Having been Health Minister for a while, I would have expected more insight and useful solutions into the problems in dealing with new graduates. None of the solutions you offered are new or useful. Recognising graduates of Oxford doesnt mean that we rid outselves of 'incompetant' doctors.

I am a Penang Medical College graduate. I worked a year in Ireland - and observed many inherent flaws of its system. I then moved on to Cleveland for my Internal Medicine residency. I think we malaysians can learn a thing or two about educating new graduates from other established systems.

When I joined residency in the USA, I was shocked at the ability of residents in training programs here. Doctors who just graduated 12 months ago from medical school are routinely running codes, adjusting ventilator settings, initiating BiPAP based on arterial gas results and making decisions on transferring patients in and out of the ICU. Their competance is not measured by their ability to insert a urinary catheter - rather they are analysing results of pulmonary artery catheters and adjusting afterload medications in people with severe valvular heart disease.

I am by no means suggesting they learnt all this in 12 months by themselves. Instead, a well oiled system of mentorship has already been in place for over 100 years, where senior residents spend 1 on 1 time with new houseman, allowing houseman to make decisions very early on while keeping a close eye on things. Senior residents in turn are then evaluated by Consultants of the team to see if they have well developed mentorship and clinical skills.

The system here does not differentiate whether you graduated from Zimbabwe or Harvard, rather everyone who plugs into the system has to sit for a common entry exam. Based on the results of the exam and your CV, you apply to hospitals you want to work in. Hospitals make themselves more attractive to applicants by improving their medical education programs. A system has been created that rewards hard working people regardless of background with more expidited and thorough training. Competition for residency can be stiff, despite the fact that the annual salary is low and work hours are long. People are willing to put in the hours if they have good reason to.

Once you are in residency, residents frequently work hard in order to score a coveted fellowship. In short - a system has been created to pick good doctors early on and provide them incentive to care for patients better. The system did not limit itself to picking graduates of a certain country / language preference / background - it simply chooses the best it can - without having to dish out bigger salaries for it. Many that contribute significantly to the medical field here are trained in countries like Bahrain, Sweden, Zambia, Kenya, Egypt etc. Many of these did not even have English as their first language.

I dont think we need to come up with a new system from scratch - we have plenty of systems around the world we can emulate. Instead of limiting the numbers of universities we recognise, why not recognise more? Let any Malaysian who wants to be a doctor leave our shores and get his/her training wherever he wants- for as long as they are good and can pass a well designied entrance exam, they can return and care for Malaysians in our hospitals. Dont waste our time convincing the world that being a doctor isnt a lucrative profession, that isnt our job. Instead, lets allow adults to make their own decisions based on whatever motivation they have - and concentrate on hiring the best. If we are serious about quality, we should create a quality system that creates incentive for good doctors to work with us.

In short, what I propose is:

1. A common series entrance exams for all graduates (whether local or foreign graduates). This exam should be strict, fair, well structured, and unlike the CLP exams for Law graduates - scandal free. We can use exams like the USMLE as example, and modify according to our needs.


2. once in the system, housemen should be encouraged to work hard for good letters of recommendation for further applications for subspecialty training, senior positions, or desired locations. If they are good, we should not deprive them of the opportunity regardless of allocated quota spots.

3. We should come up with a way to reward competitive candidates - such as provide training opportunities very early on, allow them to make management decisions with proper guidance, limiting unnecessary scut work like chasing scans, filling up forms, drawing blood from 40 patients each morning - we have ancillary staff for these jobs. Instead we should concentrate on 'front loading' decisions to new graduates while consultants in our hospitals concentrate on research etc. Ofcourse, there should be good supervision throughout this time.

Currently it is not difficult to get disheartened as a houseman in Malaysia. I have myself seen many reasons why this is the case during my clinical training in Penang. Housemanship can be difficult, lonely, demanding, and with the wrong consultant degrading, demoralising and painful. We have a system in place currently that can sometimes be quite autocratic, racist and unfair. While I am not justifying the incompetance you saw in housemen in HKL, I think there are many things we can do that go beyond telling people to choose medicine for the right reasons and recognising a select bunch from certain countries. Lets concentrate on picking good graduates instead, and give them good reasons to join the ministry. Malaysians are a smart bunch - I dont see why we cannot create a system that works.

Dhssraj Singh

YM said...

I think MMC should look into the long hours that a houseman needs to go through in their training. It is ridiculous for any human beings (What more doctors where patients life lies in their hands) to be on their toes for 36 hours without any rest or sleep. This is what a houseman has to go through on alternate days to complete their on-call rotation. I can only sympathize with the houseman and what more the patients under their care.

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