IN September, I had the privilege of sitting on a panel with leaders in general practice, including the Presidents of the Royal Australian College of General Practitioners (RACGP), the Australian College of Rural and Remote Medicine and the General Practice Registrars Association, at the General Practice Training and Education Conference (GPTEC) Future Forum to discuss the evolving landscape of their profession. The forum aimed to decipher what the future of general practice holds and what is needed to prepare for it, with topics ranging from the progress of Indigenous health in primary care to the support structure for GP registrars.

And of course, the question that was foremost in everyone’s minds: why are medical students losing interest in general practice?

Last week, Australian Doctor published the dramatically titled article Medical students shun general practice, highlighting figures from a Medical Deans of Australia and New Zealand survey which put only 15.4% of graduating medical students choosing general practice as their first-choice specialty, a decline from 17.8% in 2015. It’s worth noting that general practice remains third on that list, behind only adult medicine/internal medicine/physician (19.1%) and surgery (15.5%). Perhaps it should be asked why only two graduating students were interested in pain medicine, and why only one was interested in addiction medicine.

Looking past the mild clickbait, I’d like to expand on the reality of these numbers and reflect on the teaching of general practice I have received over the years.

Medical students are told from day one that primary care is the front line of health care, and prevention is better than cure. However, this is hugely incongruent with what we are taught, especially in a clinical setting. The majority of our clinical time is spent in hospital, not in primary care settings. In my own 3 years of clinical study, I will spend approximately 10 weeks of compulsory teaching at a GP clinic. Anything more than that, and I would have to actively seek out interest groups such as the General Practice Students Network or via RACGP student initiatives. Even in pre-clinical teaching, general practice is siloed as its own under-represented topic in separate lectures, as if a patient and their body systems in a general practice clinic is an alien compared with the same patient in a hospital.

How much opportunity do medical students have to have positive exposure to general practice if it is being offered as a 5-week supplement to our 40-odd weeks in hospital?

Madeleine Goss, a final year student from Deakin University, recently wrote:

“I completed a longitudinal program in regional Western Victoria, with fantastic GPs who also staffed the local hospital and nursing homes. Nineteen other students in my cohort were placed in similar sites across the state. We came together every six weeks for formalised teaching and exposure to specialties we may not see in our towns. The most common opening line of a specialist who would come to teach was ‘oh, you’re just going to be GPs; I’ll change what I was going to do’.”

This was frustrating to us, because, as medical students, we should be receiving standardised teaching.

However, it was much more insulting to GPs.

It is true that the minutiae of some topics are not relevant to general practice, but this detail is not taught at the medical student level, so why were our teachers changing their lessons? These types of interactions insinuated to my peers and me that doctors choose general practice because they “couldn’t make it” elsewhere and because we were going to follow that path, we needed to know less. As we know, those in the medical profession are often perfectionists and enjoy challenging themselves, so once this idea of “settling” for general practice has been planted, it is difficult to uproot.

Perhaps we would not have such a loss of interest in general practice if this career choice was not looked upon as a “consolation prize”.

When primary and preventive care should be the forefront of what we teach and learn, why are we in an environment where those who want to pursue general practice must defend or justify their decision?

Of course, it would be facetious to lay all blame on how we are taught; we must also consider how we, as students, are looking at our choices. The common misconception that general practice is not a specialty, or is “a consolation prize”, may be planted by others but then is perpetuated by us. I can think of too many times when I have heard from my peers: “What specialty do you want to do? Or do you just want to be a GP?” In a culture of increasing competitiveness to get on to training programs, we are pressured to choose early and then invest in a sunk-cost fallacy to try and pursue that pathway. Switching specialties or looking at generalism no longer seems like a viable pathway once you’ve poured time and energy into CV-buffing from day one of medical school.

I have been lucky enough to have two excellent general practice placements with GP supervisors who were keen to teach and loved by their patients, one of whom sparked my own interest in addiction medicine. It is important that medical students celebrate positive role models in general practice and encourage our peers who are pursuing the field.

Jessica Yang is the President of the Australian Medical Students’ Association, the peak representative body for Australia’s 17 000 medical students. She is a medical student at Western Sydney University. She can be found on Twitter at @YourAMSA and @JessHYang.

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


Poll

Other specialties do not show general practice enough respect
  • Strongly agree (60%, 125 Votes)
  • Agree (25%, 52 Votes)
  • Neutral (6%, 13 Votes)
  • Disagree (5%, 11 Votes)
  • Strongly disagree (4%, 8 Votes)

Total Voters: 209

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26 thoughts on “Why are students not pursuing general practice?

  1. Debbie Scholem says:

    I commend Ms Yang on a thoughtfully written and insightful article. However to not mention the current Medicare rebate structure for GP services is not giving the full picture. My husband has clocked in 38 years of comprehensive and dedicated patient care and I have been his ‘ever loyal’ Practice Manager for that time. Over these years we have witnessed the slow erosion of adequate remuneration for the thorough expertise that he gives day in and day out. He has successfully run a solo general practice because we had the surgery area as a separated part of our home (read no rent). Over the past ten years he enjoyed and was reenergized by teaching many students. He was often trying to convince them that general practice was as rewarding as he had found it. The variety of medical problems being just one of the reasons. My husband is retiring at the end of the year with a deep sense of satisfaction that his dream, from a very young age, of being a good family GP was the best choice he could have made.

  2. Andrew Pennington says:

    Jess – I think your article nails it well. It is well thought out and reasoned.
    When one considers that the training in medical school is increasingly done by more and more sub-specialised partialist specialists, it is not surprising that the General Practice speciality looks more dull and boring.
    Preventive medicine takes time to be seen. Interventional specialist procedures are short term gratification that can be appreciated quickly.
    There are so many other complexities in the equation, but thank you for highlighting some.
    For my part I think General Practice is the best medical job in the world and would love to see more medical students considering it as a career.

  3. Anonymous says:

    The elephant in the room. No one is crass enough to mention it but if the pay differential between procedural specialists and GP were reversed I doubt there be a lack of students pursuing G.P.
    Otherwise we can talk till we are blue in the face about the ‘reasons’ for this unexpected phenomena.
    LOL.

  4. Anonymous says:

    Unfortunately, ever since the introduction of Medicare, the standing of GP’s has been increasingly undervalued (disrespected and constrained in breadth of legitimate clinical competencies) by society, governments, and the wider profession itself. Modern GP’s know way more but do far less (procedural things including obstetrics, anesthetics, and minor surgery) except for boring and burdensome paperwork, and burgeoning social work demands driven by deteriorating bureaucratic and community “needs” unrelated to clinical matters; and primary prevention is in reality undervalued too. These changes over the last few decades have undercut scientific GP resourcing to be replaced by a plethora of dubious arts including palm reading, iridology, homeopathy, chiropractopathy, astrology, etcetera. Sadly, I doubt whether the future for GP will be very bright except for Dr Google.
    Maybe future governance will conscript all new Medical Practitioners to a year or two of GP before allowing them to move forward. Probably safer than relying on the best efforts of variously competent OMG’s particularly into country areas. In the meantime, GP is no longer a 24/7 calling, so probably okay for part-time and intermittent careers, and better family-work balance.

  5. Anonymous says:

    Sad to say, but having recently retired, and reviewing my financial position as it now is – compared to what I expected it to be after 40 odd years dedicated to GP, I must agree with anonymous above. Unless, and until, the woeful remuneration of GP, and by that I mean not only the financial returns, but the whole system by which GP is funded, is completely revamped, the speciality will continue to wither on the vine. Until ultimately I fear, virtually the entire GP workforce will be via IMGs, who are largely prevented from doing anything else, and even GP is made hard enough for them as things stand.
    Another ‘anonymous’ now ex-GP

  6. MJS says:

    I agree with Dr Yang’s comments in all but one area. General Practice should not be viewed as just another specialty. It is and should be viewed as the core specialty. There should be 30-40% of new graduates applying for General Practice , not 15%.
    There has been over the years a greater disparity in the incomes of GP’s and the other specialists. I have been told by the older doctor in our practice that when medicare first came , Specialists earned between 20-30% more than GP’s. Now the disparity is closer to 300-400% more. I would think that given the effort required to now become a GP, why not put the same effort in to becoming a Specialist, restrict your knowledge to one area only and earn more money.
    Yes we must give our students more exposure to General Practice, but one of the reasons we are treated as plebs is that we are paid as plebs.

  7. Anonymous says:

    Pursuing general practice as a career also assumes you can actually get a place on the training program …

  8. Anonymous says:

    I retired from Practice four years ago after 54 years as a GP. I graduated in the era when, as Medical students we received a lot of practical medical training. We had to deliver at least 21 babies, one of which had to be a breech and another a forceps delivery. As a first year resident I performed 14 appendices and gave dozens of anaesthetics.. As a result when we chose to be GP’s we had a good level of competence in practical procedures, The result was a high level of satisfaction in our work. We were highly respected by our patients. Unfortunately with the development of specialties and sub-specialties, delineation of privileges in hospitals and introduction of differential rebates by Medicare we became second class citizens and slowly but surely our skills were lost. If I was graduating today, I would not seek to enter General Practice to become a provider of prescriptions and referral certificates with little opportunity to become a “proceduralist” because of the prohibitive indemnity costs and low GP fee structure. I am not at all surprised Students are not opting for General Practice today.

  9. Anonymous says:

    no doubt there are some excellent GPs, but unfortunately there are too many who simply push people out the door after 5 – 7 mins either with an inappropriate antibiotic script or a lazy referral to the nearest hospital Emergency department where all too often we are left scratching our heads as to why on earth has this patient been sent to an Emergency department, and often at a hospital that does not have the outpatient nor inpatient specialist service ( ENT, Gynae, Vascular etc ) that is obviously required, rather than the other hospital down the road in a different suburb of Melbourne. it seems many GPs do not know or care what services are available at which hospitals.
    and don’t get me started on the nursing home demented patients with documented NFR status being referred in by GPs to hospital Emergency departments rather than being managed conservatively or palliated in their nursing home.
    do those GPs deserve to be paid as much as specialists for an inappropriate hospital referral ?
    I realize that a lot of this is related to Medicare funding, but….

  10. Saratchandran says:

    Medical students are intelligent human beings! They realise that General Practice has been dumbed down and pushed to the lowest level of health profession in Australia. It offers neither a great esteem nor appropriate reward for the work value. All this happens after eleven tedious years of going through training. They chose anything but General Practice, and can you blame them!?

  11. Norman Saunders says:

    I was a clinical student at University College Hospital Medical School in the mid 1960s. There was NO component of general practice in the 3-year course. General practice was consistently rubbished by the consultants (most of whom were incompetent psychopaths). If my classmates were asked what career they might pursue the consistent answer was “don’t know but definitely not general practice”. In those days young doctors who fell off the consultant god pyramid could emigrate to Australia, Canada, New Zealand or the US. This together with the poor standing of general practice led to a crisis at least as great as the present one in Australia. It was solved in large measure by a substantial increase in remuneration of general practitioners and general practice has gradually crept into the curriculum; but given that many doctors in training are likely to work in general practice it is bizarre that the curriculum remains dominated by hospital medicine.
    Sad but not surprising that so many of the comments are anonymous.

  12. David B says:

    Many years ago Kenneth Robinson, retired UK minister of health said the Government was only prepared to put sufficient money into health to stave off total collapse. In Australia our Governments pay lip service to General practice and mental health while screwing both services into the ground. They regularly emphasise how each year these services have increased budgets without reference as to how much the services should receive to maintain standards. The procedural people earn so much more because they can get away with it and somehow patients find the money but few patients are prepared to pay for time , judgement and thought. This is hard to fit into ten minutes anyway. Compared to almost all professions those of us who talk and think are underpaid. General Practice and Psychiatry are joining school teaching as professions that lack value and respect.

  13. Dr Lou Lewis says:

    A true fairytale story for all you nasty critics about the demise of General Practice entitled , especially those that blame the demise of General Practice on bulk billing .
    “ A current fairytale ( or not!) story about our current health minister.”
    Dated 14/10/2019
    Hypothetically, I was having dinner with the health minister the other night and I asked him this hypothetical question: “Minister, if you or a member of your family were choking on your steak and there were two doctors present, one who bulk bills and one who private bills, which one would you prefer to attend to your emergency?”

    He would, as I assume any rational person would, say to me: “Lou, that is an irrelevant question because either doctor is equally qualified,” and I would say to him, “Minister, then why are you trying to destroy the livelihood of the doctor who bulk bills?”

    And he would say, ” Lou, you are so wrong, my government and I are totally committed to general practice and believe that the general practitioner should be rewarded for using their skills many times a day to keep people well and out of hospital.”

    I then say, “Minister, what price do you put on the service of a general practitioner, especially the one who saved your life tonight?”

    And he would reply, ” My God, Lou, you cant put a monetary value on such a service, it is priceless, and I assure you, Lou, that me and my two best mates, Scott Morrison and the Minister for Financial Affairs, are doing our best to acknowledge the great work that you GPs are doing, and our government is committed to ensuring that you and your colleagues will have these ‘priceless’ services adequately acknowledged and rewarded, and by our recent proposals for the future of General Practice in the Budget we are getting closer to achieving this goal, and, hopefully, within a few years, the value of a general practice visit will be truly priceless!”

    And I say, “Minister, that is fantastic news and I can’t wait to log onto the doctor’s forums on AusDoc and The Medical Republic and tell the good news to my colleagues. They will be overjoyed and will take back all the nasty things they have said and thought about you and your government. Thank you, thank you, thank you!”

    The next day the headline story in the SMH or the Daily Telegraph reads: ‘ Doctors agree with the Morrison government in acknowledging that a price cannot be put on a general practice encounter and their spokesman and the health minister are pleased to announce that they are working together in achieving this goal, and within three years their goal would have been reached and the general practice rebate will be zero dollars, thus bringing satisfaction to both the selfless doctors and the government by not putting a figure on saving people’s lives and as such it is with great satisfaction that the minister announces the new item number for a GP consultation:
    Item 00, Description of service : standard priceless or worthless consultation, in either (sic) the doctors place of residence, place of business, or anywhere the doctor may be.”
    And my colleagues and I will live under the benevolence of the Morrison government, happily and contented, for many years.
    Bless you, Minister Hunt
    Your new sycophant and greatest admirer
    Dr Lou Lewis

  14. Richard Newman says:

    In 1988 as a second year Resident in a tertiary care hospital I resolved to become a county/ rural General Practitioner. Having grown up in the country it seemed natural to go back and “do something useful”. It seemed to offer a higher degree of self-sufficiency and professional challenge ( not frustration …. the two are quite different and sometimes confused).
    My year of undergraduate Medicine were about the last to be able to organise our own training prior to proceeding into General Practice. I approached the RACGP in any case and was rejected out of hand with no explanation offered.
    Quite disheartened I reassessed my position and opted for Physician Training. This was a long hard slog ( for me at least) but I opted for General Medicine and in due course finally prevailed.
    During the training program some of my colleagues wondered why I would choose Internal Medicine
    (then the American descriptor for General Medicine but somehow carrying a bit more gravitas) over a “real specialty.”
    My senior colleagues felt obliged to warn me that the discipline was in decline and I once again became discouraged especially since much of what I was doing on the face of it could have been best handled by the patient’s General Practitioner.
    I still wanted to be a generalist professionally (and in my personal pursuits) and turned towards Intensive Care Medicine.
    Twenty years later I returned to General Medicine as a consultant in private practice travelling mostly to regional and rural areas.
    Full circle?…. not quite

  15. David Penington - a forner Daen of Medicine at University of Melbourne says:

    I agree that GP is the core of primary health care and plays a hugely important role through practicing family medicine, preventive advice, advising on relevant specialist referrals as necessary and and in rehabilitation after hospital care. It is a challenging field but a critically important on in our national health network.

  16. Bill McKay says:

    Many factors involved. Lack of exposure as students and JMO’s. Attitude of those in the hospital environment that those doctors not becoming specialists are “Just a GP”. Bulk billing expectation when the majority of consultations are children and the elderly. My haircut costs $34 for 10 minutes. The barber has very little overhead costs. No receptionists, practice nurses, computers, ongoing CPD, medical indemnity insurance. Yet, after at least 10 years of training, a GP is expected to accept $38.20 for a 15 minute consult. Increasingly medical students are already graduates. A physiotherapist can charge $85 for a 20 minute consult. I suspect many physiotherapists, who complete a medical degree, do so to be a sports physician or orthopaedic surgeon. If they do not obtain placement on a specialty training scheme they are not going to be “Just a GP” and work for $38.20 per consult. If the government was serious about preserving bulk-billing for children and pensioners, then they would increase the fee of items 10990 and 10991 to at least $40.00 to truly reflect the value of the service provided and the cost of providing it. As in all aspects in life “You get what you pay for and you pay for what you get”.

  17. Anonymous says:

    Two anaesthetists with whom I work ( I am a surgeon), have been rural GPs prior to turning to anaesthetics. They both alleged to have loved their couple of decades but it “wore them out” they said.
    Both of them have nothing but a superb knowledge of medicine and are brilliant anaesthetists as well. Perhaps 5 or even 10 years of general practice should be compulsory prior to narrower specialisation.

  18. Max Kamien says:

    Sadly, this is a perennial topic. Two medical students and I wrote about it i20 years ago. Aust Fam Physician. 1999 Jun;28(6):576-9.
    Doctors badmouthing each other. Does it affect medical students’ career choices?
    Kamien BA, Bassiri M, Kamien M.
    The paper continues to be cited so the subject, as Jessica Lang demonstrates, remains topical.

    My other comments, while not as logical or as entertaining as Lou Lewis’s , still apply:

    2. Specialists know a lot about a little. They are highly critical of GPs who don’t know a lot about their little.

    3. Prof Richard Hays – observed that in some medical student examinations the care-based clinical scenarios began with a patient, misdiagnosed or inadequately treated by their GP, who now presents to the Teaching Hospital for management by the exam candidate.

    4. Ed Bateman Maximise Medicare income

    4a Many, especially young patients use GPs the same way as they use a free 7Eleven store.
    The joy and usefulness of continuity of family care has become less common.
    In my last decade of medical practice I spent a lot of time with the elderly whose multiple pathologies were each under the care of a specialist who was disinterested in the patient’s other problems. These patients rarely had a GP who co-ordinated their care. The patient and their carers were effectively abandoned and will cost the health system a lot more than it would if GP was properly financed and supported.

    5. Minister Michael Wooldridge – Shortage of Australian University graduates becoming rural GPs Open the flood gates to OTD doctors –who go to the city as soon as they pass the FRACGP.

    6. Difficulty in getting skills training eg obstetrics for rural GPs
    and fear of litigation.

    7. Student attachments to disillusioned GPs who advise students against doing GP.

    8. Highly trained bright doctors suffocated by mindless bureaucracy. That was one of the main reasons that after 58 years I stopped practice.

    9. Medicare rebates. The shorter the consultation the more the income.
    Complicated 45 min GP consultation = $105 Medicare
    Initial 3 min consultation procedural specialist = $200 private

    10. RACGP happy when Freeze ended and level B consult increased by 60c.

    11. Government scared of hospital specialists. They can go on strike eg 1984 NSW Doctors’ Strike. GPs could never agree or organise to strike.

    12. Part of solution: RACGP, ACRRM, get together with AMA and patient advocacy groups and keep talking to the Hon Greg Hunt. By his own statement he is the Minister for General Practice.

  19. John R says:

    A well kept secret by specialists is that it it much easier to be a good specialist than a good GP .
    41 years as GPO, GPA, GPS = Rural GP (anything) -confirms that is very true – but such rewards !!

  20. Anonymous says:

    In this day and age of increasing Medical Specialty, the knowing more and more about less and less NECESSITATES the gate-keeping role of good General Medical Practitioners -if only to constrain cost blow-outs. We run the risk of going the way of America, where patients self-refer to the Specialist they THINK they need to see, and care becomes fragmented, whether in hospital or in the community – unless they cannot afford it. And then the whole systrem begins to break down.
    Having worked in rural General Practice for 40 years, where Specialist access was usually remote, we had to carefully assess before referring to tertiary hospitals – for the sake of the patients, their family, and the finances of the local hospital. Quality care given was rewarded by community respect, if not unfortunately by equal financial reward.

  21. Ian Hargreaves says:

    When my son was doing medicine our family GP advised him not to become a GP, because of all the ever-increasing impositions of government, colleges etc. The paperwork was expanding exponentially, as opposed to the enjoyable work of actually treating people. Money was not a major issue, he explained, because a good GP who does not bulk bill everybody can still make a very good living.

    The GP colleges were greedy enough to steal GP training away from the universities (leaving them with an increasingly esoteric specialisation emphasis) and naive enough to accept the government’s promises about bulk billing. The chiropractors/dentists/vets who stayed outside the Medicare system charge a decent fee for their service and do well.

    Max Kamien’s salient comments above hit the nail on the head, but his “Complicated 45 min GP consultation = $105 Medicare” is better than my experience today – complicated 60 min specialist consultation (4th opinion) = $75 Medicare. Fortunately my Hand Surgery/Orthopaedic Surgery mentors warned me of the danger of taking the Queen’s Shilling, and by following the AMA principle of setting fees appropriate to level of complexity/expertise, I charged a reasonable fee for my time. Patient gets good treatment, doctor doesn’t resent them for taking a long time to sort out.

  22. Ed says:

    First of all, I don’t think you can make that decision as a student. Most people make their decision to specialise usually during intern or resident years. That is, you should spend a few years rotating through the specialties and working on the job to make an informed decision. Some people choose to pursue a hospital specialty, and others choose to be community family GPs. Both are admirable and respectable, and either clinician is worth their weight in gold if you do your job well and whole heartedly, your patients and colleagues will appreciate who you are rather than the label attached to your occupation.

    I personally find that it is only amongst the arrogant and junior specialists that look down at GPs. Most specialists who have had time to mature and grow in the job, come to realise that to ensure the best patient care it is necessary both GPs and Specialists work together. We shouldn’t see it so much as a tribal discrepancy or barrier.

    That being said, there are financial and political and cultural issues that do not help the situation. As others have mentioned the Medicare freeze and renumeration of GPs is typically less when compared to other Specialists. Employment is uniquely in community private practice as opposed to tenured staff positions at teaching hospitals. And with this, there’s a lack of status and prestige less associated with this misconstrued image of a simple family GP compared to a hot shot hospital Specialist.

    In any case the sage advice is: Don’t worry about what so much other people think about you. Just strive do the best job you can for your patients whatever your Specialty. And you should choose a Specialty you enjoy intellectually and practically, not so much about the status and prestige.

  23. Robert Tucker says:

    Jessica,thank you for an interesting article and compliments to all who have entered replies ! Way-back,when I faced the decision of WHAT .TO.DO….I sought out “my own” Work-experiences…..!! Then 48 years later,with absolutely NO regrets,I retired….

  24. Anonymous says:

    As a general practice registrar in Qld about to finish I can tell you why I’m leaving General Practice, and I can’t wait to skip out the door.
    It’s the pay. We’re paid next to nothing.
    It’s the lack of respect. From colleagues to the general public.
    It’s the anxiety and time pressure. We’re rushed to see cases from a variety of all specialties and history take and provide examinations and plans all in 15mins before the next bulk-billing patient gets angry.
    It’s the litigation. >75% of cases are against GP’s – we pay APHRA each year to help vextacious litigious patients to chase us when they’re not happy.
    It’s the isolation. We’re locked in 3x3m rooms by ourself all day, little sunlight or interaction with anyone other than demanding patients.
    It’s the harassment. Practice managers, greedy owners, entitled patients who have done their research.
    It’s the funding – we get nothing for all this risk, we have to pay for our own holidays, pay our own super, college fees, ridiculous exams so far fetched from practice. The general trend of I should be bulk-bilked by Doctor is greedy encourages patients to treat us like dirt.
    Gone is the respect. Gone is the pay.
    You’d be crazy to start training.

  25. Sassy says:

    Disgruntled GPs- get a job as a hospital locum. There’s lots out there and the skills are there!
    Perhaps yet another reason it to be a Gp- medical school Gp Med school training is largely observing at times, which is sleep inducing. At least in the hospital students can do their own interviewing, examining etc without scrutiny and at their own pace.

  26. Yan Yu says:

    Thank you from Canada, Jessica. Your article strikes a cord and issues are similar here regarding general practice being undervalued as a profession. It’s important to speak up on the issue and call out the hidden curriculum when it happens. Also, although unfairly perhaps, important for us to be excellent GPs to prove all the doubters wrong. Sharing my opinions on this issue with you – https://www.kevinmd.com/blog/2015/08/yes-i-am-a-rhodes-scholar-who-is-just-a-family-doctor-heres-why.html

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