Practice hours journal
In this section, “Reflective Journaling” you will respond to the following:
-Select a couple key learning experiences (2-3). Reflect on your practice learning experiences. Why were these practice experiences meaningful to you?
-Summarize application of course content to your key learning experiences.
-Relate practice experiences to your professional learning and its potential impact on your professional nursing practice.
-Articulate achievement of your course Practice Experience Student Learning Outcomes.
-Cite references in APA format. Include professional nursing journal articles in support of your analysis as outlined in the Practice Experiences Grading Rubric.
Reflective Journaling: (Write your reflective journaling here including items 1-4.)
References (In APA format)
-Please use Family medicine article,Nurse mentoring article and Infection control article for my PE 2, 3, 4.
Your Reaction to this Practice Experience:
In this section, “Reflective Journaling” you will respond to the following:
1. Select a couple key learning experiences (2-3). Reflect on your practice learning experiences. Why were these practice experiences meaningful to you?
2. Summarize application of course content to your key learning experiences.
3. Relate practice experiences to your professional learning and its potential impact on your professional nursing practice.
4. Articulate achievement of your course Practice Experience Student Learning Outcomes.
5. Cite references in APA format. Include professional nursing journal articles in support of your analysis as outlined in the Practice Experiences Grading Rubric.
Reflective Journaling: (Write your reflective journaling here including items 1-4.)
References (In APA format)
*Description of the proposed Practice experience
1. Spend a day with a nurse leader- Kayla Merrit,RN : How she applies nursing research into her daily work, discuss nursing research articles( The Military Health System) this nurse leader is currently reviewing in order to make practice changes. (1.5pages)
2. Analyze use of nursing research in Family Medicine(Any family medicine practice research paper will be fine) – Evidence based practice in family medicine practice, journal findings and critical reflections of this experience & application to family medicine practice. (1.5 pages)
3. Spend time with a master’s prepared nurse(Ingelin Leslie, Nurse practitioner) to explore their participation in nursing research to create understanding of this provider’s contribution to changing nursing practice outcomes. (Shadowing ‘Ingelin Leslie, Nurse practitioner, her focused research is mentoring Nurses). (1 page)
4. Spend time with a nurse(StephaniLovitt, RN) to explore their role as a researcher(Infection control) to create understanding of this provider‘s contribution to changing nursing practice outcomes. (1page)
*Grading Rubric-Just for your information
Student completes Practice Experiences Plan on time and submits within online course. Student completes Practice Experiences Plan on time and submits within online course.
Student completes Practice Experiences hours as required for course and submits documentation within online course. Student completes Practice Experiences hours as required for course and submits documentation within online course.
Student completes a paragraph summary of practice experiences. Student completes a paragraph summary of practice experiences.
Student completes Practice Experiences Self-Reflection demonstrating understanding of theory to practice application. Student completes Practice Experiences Self-Reflection demonstrating understanding of theory to practice application.
Student’s completed Practice Experiences Self-Reflection includes at least 3 external scholarly references informing, supporting or refuting knowledge gained through this assignment. Student’s completed Practice Experiences Self-Reflection includes at least 3 external scholarly references informing, supporting or refuting knowledge gained through this assignment.
The Military Health System: A Community of
Solutions for Medical Education, Health Care
Delivery, and Public Health
Robert P. Lennon, MD, JD, Aaron Saguil, MD, Dean A. Seehusen, MD,
Brian V. Reamy, MD, and Mark B. Stephens, MD, MS
Multiple strategies have been proposed to improve health care in the United States. These include the
development of communities of solution (COSs), implementation of patient-centered medical homes
(PCMHs), and lengthening family medicine residency training. There is scant literature on how to build
and integrate these ideal models of care, and no literature about how to build a model of care integrating all 3 strategies is available. The Military Health System has adopted the PCMH model and will offer
some 4-year family medicine residency positions starting in 2013. Lengthening residency training to 4
years represents an unprecedented opportunity to weave experiential COS instruction throughout a family physician’s graduate medical education, providing future family physicians the skills needed to foster
a COS in their future practice. This article describes our COS effort to synergize 3 aspects of modern
military medicine: self-defined community populations, the transition to the PCMH model, and the initiation of the 4-year length of training pilot program in family medicine residency training. In this way we
provide a starting point and general how-to guide that can be used to create a COS integrated with other
current concepts in medicine. (J Am Board Fam Med 2013;26:264 –270.)
Keywords: Community Medicine, Delivery of Health Care, Medical Education, Military Medicine, Public Health
Communities of Solution: Why Now?
Radical changes in the structure of American society during the early part of the 20th century led to
the need to propose changes in health care delivery.
The Folsom Report advocated for creating communities of solution (COSs) as one framework to
integrate delivery of health care.1,2 COSs are partnerships designed to match seamlessly and efﬁciently local health needs with available health services. Early adoption of the COS concept, however,
This article was externally peer reviewed.
Submitted 25 July 2012; revised 6 November 2012; accepted 16 November 2012.
From the Naval Hospital Jacksonville Family Medicine Residency Program, Jacksonville, FL (RPL); the National Capital
Consortium Family Medicine Residency, Fort Belvoir Community Hospital, Fort Belvoir, VA (AS, DAS); the Department
of Family Medicine, F. Edward He´bert School of Medicine,
Uniformed Services University, Bethesda, MD (BVR, MBS).
Conﬂict of interest: none declared.
Corresponding author: Robert P Lennon, MD, JD, Naval
Hospital Jacksonville Family Medicine Residency Program,
Jacksonville, FL 32214 (E-mail: email@example.com).
264 JABFM May–June 2013
Vol. 26 No. 3
was slow and incomplete.2,3 In the wake of World
War II the U.S. health care system began to travel
down a path of increasing fragmentation and subspecialization. As medical care has continued to
expand exponentially in the latter half of the 20th
century (without proportionate improvements in
health outcomes), the original Folsom Report was
revisited by policy makers to encourage once again
COSs as a means to develop and sustain community-speciﬁc health programs. The vision outlined
in the Folsom Report lacks a deﬁned roadmap for
how to create a COS. One of the few available
models for developing a COS is from Vermont.4 It
describes that state’s prescribed method for developing state-funded COS. Although it is a valuable
resource, it does not integrate other current medical concepts, and its speciﬁcity makes it difﬁcult to
generalize. This articles serves in part to act as a
how-to guide for developing a COS using the vision outlined by the Folsom Report.
Two other current movements in primary care
address the complexities of modern health care and
Figure 1. Old-school isolation (stakeholders are
Old School Isolation
the improvement of patient outcomes. These are the
patient-centered medical home (PCMH)5 and the
examination of different models for length of training
during family medicine residency.6 The PCMH is a
team-based model that coordinates all elements of
medical care for patients, their families, and, potentially, communities. Early outcome-based data from
practices implementing PCMH-based care suggest
an improvement in preventive care, high patient satisfaction, and lower cost.7
Over the past decade, restrictions on work-duty
hours have been implemented by the Accreditation
Council for Graduate Medical Education to improve patient safety. A collateral impact of restricted duty hours is that physicians in residency
training programs must contend with the need to
integrate an increased fund of medical knowledge
in a functionally reduced time frame. To address
this, the Length of Training (LoT) Pilot Program,
sponsored by the Accreditation Council for Graduate Medical Education, seeks to determine how to
best provide the intellectual, procedural, and administrative skills new physicians need to lead
PCMH practices upon graduation. In family medicine, it is anticipated that physicians trained in a
4-year residency will be better able to implement
the PCMH in a COS framework to improve population health care outcomes. Speciﬁc areas of focus in the LoT pilot include building healthy living
environments, increasing health literacy, and motivating patients and communities to “take ownership” of individual and community health needs.
We describe the Military Health System (MHS) as
one example of a COS. Our model speciﬁcally
integrates PCMH and LoT concepts designed to
improve health care and educational outcomes.
What Makes a “Community”?
The classic model of medical care (represented
visually in Figure 1) has changed little since antiquity. Patients seek advice about and treatment for a
perceived disease. This episodic model of acute
care has created multiple problems in the current
high-cost, procedurally-based environment of U.S.
health care. To begin, most patients do not understand the cost of health care delivery.8 The complexities of billing, reimbursement, and insurance
leaves most patients with limited moral hazard in
terms of knowing exactly what any given test, procedure, or visit really costs. In addition, health care
is often widely distributed across multiple medical
entities, with poor communication between providers. This fragmentation often leaves patients and
families in charge of coordinating care across increasingly complex systems. Furthermore, today’s
highly global and interconnected world makes it
such that individual health decisions (such as
choosing or declining vaccination, accepting or declining recommended preventive health services)
can have disproportionate effects on population
health and the societal cost of health care delivery.
Finally, individuals frequently are unable to control
many of the external determinants of health such as
public safety, access to healthy foods, and walkable/
bikeable communities. Faced with these challenges,
the need for a holistic, population-oriented COS
comes into sharp focus.
The PCMH model provides a sound central
platform around which to organize such a COS
(Figure 2). We speciﬁcally deﬁne “local partnership” from a community-based perspective. As deﬁned by Nutting,9 the term community can be unFigure 2. Community of solution with a foundation of
the patient-centered medical home (stakeholders are
Community of Solution
with a Foundation of the Patient-Centered Medical Home
Patient-Centered Medical Home
Touches All Stakeholders
Primary Care Manager
A COS for the Military Health System
derstood from 3 perspectives: (1) territories or
space, (2) group memberships, and (3) sets of social
structures and organization. Such an approach allows for a layered deﬁnition of community. When
resource utilization is not limited by geographic
proximity, global COSs such as the World Health
Organization are necessary. When there are geographical or political breaks in societies, regional
COSs such as the Western Africa Regional Health
Network become important. Our MHS COS
model speciﬁcally addresses local communities.
This represents a local COS based on the PCMH
physically located within hospitals on individual
military bases and encompassing locally assigned
The MHS has a strong motive to adopt the COS
model. While bases are bound tightly by common
devotion to the speciﬁc unit’s military mission, the
health care delivery system is often fragmented
between on-base care and “in-town” civilian care,
with no central organizing focus or center of communication. This has been exacerbated by more
than a decade of high operational tempo, with frequent deployments of medical personnel. While
the current MHS health care model includes support from public health ofﬁcers, occupational
health ofﬁcers, physicians, nurses, and medical support staff, frequent manpower shortages exacerbated by deployments limit the workforce available
to implement a COS. To ensure an adequate COS
workforce we are, therefore, implementing this
model at resident training sites. Residents are not
able to be deployed, and by coordinating implementation with 4-year residency slots we can build
dedicated COS support time into resident schedules. This residency-based COS model provides for
organized community needs assessments and a centralized communication hub.
In and of itself, a local COS is a relatively simple
concept. Considering the global interconnectedness of modern society, however, reality becomes
more complex. This raises the question, What is
the effective size limit of a local COS? The answer
is best deﬁned by the Swedish term lagom. While
there is no direct English translation, lagom essentially means “just the right amount.” The creation
of a local COS is important in concept, but not only
is it impossible to deﬁne the limits of a local COS
applicable to all scenarios, it is not necessary. The
local COS is an organic entity that will expand and
contract in scope until it reaches the right size for
266 JABFM May–June 2013
Vol. 26 No. 3
the patient community it serves, as measured by the
outcomes it chooses to achieve.
The organic nature of the COS within the MHS
is exempliﬁed by our approach to traumatic brain
injury (TBI).10 Before the current wars in Iraq and
Afghanistan, the military medical TBI research and
practitioner community was similar to that of the
civilian world, dominated by neurologists, psychiatrists, and emergency department physicians. As
TBI has become the dominant mechanism of injury
to our deployed troops, that COS has expanded to
include a TBI research center in theater, active
participation in TBI research and treatment within
all primary care specialties, and regular TBI briefings to all medical personnel. The TBI COS has
organically reshaped itself to meet situational
Our approach is to deﬁne clearly the boundary
parameters of an effective COS, provide a model
for execution of the COS, and educate new primary
care providers about how to create and maintain a
COS by having them actively participate in the
creation and management of a COS throughout
Communities of Solutions and Military Health Care:
A Generalizable Model
The populations for which we are developing
COSs are those served by the 5 family medicine
residency programs sponsored by the U.S. Navy.
These programs are located at Naval Hospital Jacksonville, FL; Naval Hospital Pensacola, FL; Camp
Pendleton, CA; Camp LeJeune, NC; and Naval
Hospital Bremerton, WA. Each site cares for active-duty members, their families, and eligible military retirees. Health care providers structured in
PCMH teams are responsible for managing health
care from preconception counseling through endof-life care. All 5 sites share signiﬁcant structural
and philosophical similarities, which allow us to
build an overarching COS framework that can be
applied generically across sites.
In many ways the participating military bases
mirror civilian metropolitan areas. Each base has
embedded infrastructures to support work, housing, and recreation. Speciﬁc agencies dedicated to
health, public works, housing, and resource management exist locally to keep the base in a fully
operational status. Each base, therefore, represents
a self-contained “city” in many ways. Military bases
also have a deﬁned command structure that is sim-
ilar to city or county governments. Base leadership
interacts with local civilian community leaders the
same way that government leaders from any other
pair of metropolitan areas in close geographic proximity would. Since many military families also live
in areas surrounding the base, by necessity an inclusive COS includes these civilian partners.
Creating Local Communities of Solution: The
As part of the LoT pilot program we are creating
4-year family medicine residency tracks at 5 U.S.
naval hospital family medicine residencies. Each
program includes a longitudinal curriculum covering cognitive and procedural skill sets that will
allow family physician graduates to coordinate, implement, and lead a PCMH-centered COS within
the MHS. Each site has a speciﬁc curriculum that
leverages local strengths and focuses on physician
leadership and the full scope of practice. To create
COSs that best meet local needs, we will be using
the strategy outlined in Figure 3, an adaptation of
the Plan, Do, Check, Act cycle.
Step 1: Identify Key Stakeholders
When developing a local COS it is important to
recognize that PCMH physician leaders cannot always predict which of the stakeholders will choose
to be involved. This necessitates an open solicitation for stakeholders. An expanded list of likely
COS stakeholders is provided in Table 1. We empirically presume that common and indispensible
stakeholders are the patient, their resident PCMH
physician-leader, and the faculty mentor. Depending on local goals and needs, additional early stake-
Figure 3. Community of solution methods.
Table 1. List of Likely Communities of Solution (COS)
● Primary care physicians
● Base commanders
● Public health ofﬁcers
● Businesses/business associations (on and off base)
● Schools (on and off base)
● Policy makers (base command, similar to a city government)
● Regulatory bodies
● Service providers†
● Food providers‡
● Branch clinics
● Unit physicians§
● Managers of recreational spaces¶
*Most base housing is a mix of apartment and single-family
Emergency medical services, police, ﬁre, water, sanitation (a
mix of on- and off-base providers).
Restaurants, grocery stores, convenience stores on base.
Many military units have a dedicated physician to provide their
Military bases offer an array of recreation, from golf courses to
holders within the hospital and base community
can be identiﬁed to help shape objectives and desired health outcomes.
Step 2: Convene the Stakeholders
Once stakeholder groups are identiﬁed, key representatives will be invited to participate in a series of
focus groups designed to shape goals and objectives
for the local COS. This invitation is not exclusive
because there are likely additional stakeholders that
have not yet been identiﬁed. During initial meetings, representatives from each stakeholder group
will describe their role in the health of the population, the outcome measures they would like to
track, challenges they currently face, and what
health-related outcomes they believe would improve with collaborative help.
Step 3: Identify and Prioritize the Goals of the COS
After initial stakeholder meetings, the next step is
to prioritize action items for each local COS to
address. We anticipate that each site will begin with
1 or 2 of the most pressing local community health
issues and expand as needed over time. Starting
A COS for the Military Health System
with small projects will facilitate early success and
allow the newly formed COS to build momentum
for larger and longer-term projects.
Three baseline goals of any MHS COS would
be (1) improve public safety in homes, neighborhoods, schools, and places of work and recreation;
(2) improve preventive health by maintaining a
COS that integrates public health services into
work, school, and recreational areas; and (3) track
commonly agreed upon public health metrics to
promote better community health and public safety
(eg, safe water, safe buildings, safe neighborhoods).
Other goals will be identiﬁed locally. Table 2 represents an example of goals generated using a
brainstorming model. Prioritizing individual COS
goals will take time and collaboration to develop
trust and ensure that selected goals are achievable,
have measurable outcomes, and do not represent a
threat to other stakeholders. We will prioritize reported data when available and rely on the COS
members’ intuitive sense of high versus low values
(seen in much of the early literature on cost-effectiveness evaluation) to create a low-resolution, doable action list for interventions that do not have
data readily available.
Step 4: Identify the Stakeholder Accountable for
Each Action Item, the Method of Tracking Cost and
Outcome, and the Timeline for Implementation
The following narrative serves as a “before” example of how a military community medical problem
was addressed and allows us to highlight the importance of clearly identifying stakeholders and
tracking costs and timelines.
A military primary care clinic had an inﬂux of
young adults presenting with symptoms of allergic
rhinitis during a month when pollen levels were
high. Some, but not all, had a history of seasonal
allergies. This rise in allergic rhinitis initially was
attributed to the season, but it soon emerged that
Table 2. Brainstormed Goals Created During
Communities of Solution (COS) Meetings
● Have ﬂu vaccines available at major command events
● Widen all base roads to include bike lanes
● Fix existing sidewalks to promote walking
● Increase police presence in off-base neighborhoods with
● Tax unhealthy foods at point of purchase
● Require providers to provide care in patient homes
268 JABFM May–June 2013
Vol. 26 No. 3
all these patients lived in the same building, and
many of their families were affected by similar
symptoms. This was not initially obvious because
the clinic was seeing primarily spouses while the
active-duty service members had gone to their unit
physicians and their school-aged children went to
their school nurses. The unit and school providers
also had noticed an increase in allergic rhinitis, but
there was no system in place for collaborative communication or sharing data.
Eventually an investigation by a public health
ofﬁcer revealed that 1 month earlier a water main
broke in the apartment building the patients
shared. The damage was minimal, but the basement walls had become overgrown with mold. The
basement areas were for storage and not considered
to impact the living spaces and therefore were given
a low priority on the housing authorities’ agenda.
As each involved party began to communicate—an
impromptu COS—the problem was reprioritized,
the mold was removed, and the patients’ symptoms
If a COS had been in place at the time of the
water main break, the public health ofﬁcer might
have been able to identify the potential health hazard immediately. This would have allowed for an
immediate tasking by the base commander to the
housing authority to address what seemed to them
to be a relatively innocuous water leak. Because the
cost of ﬁxing the leak would have been identical
regardless of when it was ﬁxed, any savings realized
by ﬁxing the leak sooner rather than later would be
of value. While the public health ofﬁcer might not
have been able to quantify an exact cost of delay (it
would be difﬁcult to predict the extent of mold
growth and the effect of lost work time), the potential for signiﬁcant increased costs of delay would
likely prompt immediate action. In this case the
timeline could be based on a risk-beneﬁt analysis of
other housing authority projects. Table 3 lists possible outcome metrics that could be tailored for
Step 5: Review Outcome Metrics
As goals are being implemented, progress will be
shared through an interactive COS portal (website). This portal allows stakeholders to comment and
act as a social network to strengthen ties within the
COS. This portal also allows for the identiﬁcation of
previously unrecognized stakeholders and adapts action items based on real-time feedback. Regularly
updated data allows all invested parties to evaluate
each goal or action item from their own perspective.
Local media portals (school bulletins, neighborhood
listservs) will describe projects and results in terms
that are readily understandable to the lay public. The
goal is to improve the education, health, and safety of
the ultimate stakeholder: the patient.
One beneﬁt to implementation within the military setting is access to universal communication
networks between all stakeholders. At the base
commander’s order, information can be disseminated to all potential stakeholders within the military system through direct mail to beneﬁciaries,
written and verbal contact through the chain of
command to all military personnel, bulletins distributed at all base facilities (from grocery stores
and gas stations to schools), and radio and television advertisement through the Armed Forces Network (often the only or primary source of mass
media for personnel stationed overseas). Users of
the MHS are solicited for feedback actively
through direct mail surveys and paper feedback
forms after every visit and passively through electronic kiosks at most MHS point of care sites that
offer users the option of providing anonymous or
personal feedback. This level of communication is
admittedly not as readily available in civilian communities, but it might be approximated by expanding current Public Health Service educational announcements through mass media and Internet
Interventions with immediate, measurable, and
positive results might be expanded. Interventions
with detrimental results (in terms of either patient
outcomes or costs) might be eliminated. Intermediate items can be modiﬁed based on the data. The
longer outcome metrics (Table 3) are tracked, the
greater the ability to identify signiﬁcant relationships and make meaningful process improvements.
Step 6: Repeat the Cycle
Each COS is organic and by nature will change its
composition, scope, and action items over time. By
creating a circular model, we are inviting participants to join at any stage of the process. This may
include simple changes in personnel, broader
changes in scope, or the separation of a COS that
has become unwieldy into ⱖ2 COSs that can be
effective in their respective areas of focus. To integrate further the PCMH and the LoT pilot program, residents selected for 4-year residency training
Table 3. Outcome Metrics to be Tracked for Process
● Percentages of immunization
● Change in lost work days
● Morbidity and mortality (all cause or speciﬁc cause)
● Inpatient admissions
● Emergency department visits
● Teenage pregnancy
● Alcohol use
● Drug use
● Citizen satisfaction
● PCM satisfaction
● Community, PCP, specialist revenue
HEDIS, Healthcare Effectiveness Data and Information Set;
PCM, primary care manager; PCP, primary care physician.
will have longitudinal time dedicated to leadership and
research built into their schedules. This helps to provide
each site with a renewable stream of researchers to support tracking COS evolution and outcome data and
provides the community at large a stream of LoT residents trained and experienced in developing COS.
We see 3 primary barriers to generalizing the MHS
COS model. First and foremost, the military command structure allows for implementation by singular direction. The scope of this authority extends
to all stakeholders. There is no parallel in the civilian world. Government authorities have this
ability within their own structure, but their order
cannot compel participation by other stakeholders.
However, because COS systems are designed to
improve patient care, and all health care dollars
ultimately ﬂow from the patient (directly or indirectly through the political process), economic
forces will likely shape analogous COS in civilian
communities. Second, stakeholder communication
is much easier in the MHS. Finally, civilian systems
are more restricted by direct costs than is the military system. Within the MHS, collateral duties
such as COS development and participation can be
assigned without extra compensation to stakeholders. Optimizing COS in civilian communities will
likely require a change in compensation structures.
We believe, however, that if the value of COSs
A COS for the Military Health System
within the MHS can be demonstrated, civilian
communities will demand increased value within
their communities and that the MHS COS model
will serve as a template for success for civilian
health care systems.
COSs have the potential to radically improve population health outcomes. By integrating a new 4-year
family medicine residency LoT pilot program with
the implementation of a PCMH in the MHS, our
model represents a unique COS that spans medical
education, health care delivery, and public health.
The authors thank Ms. Linda G. Culp, Visual Information
Specialist, Uniformed Services University Media Services,
Rockville, MD, for her excellent images.
1. The Folsom Group. Communities of solution: the Folsom Report revisited. Ann Fam Med 2012;10:250–60.
4. Department of Vermont Health Access. Vermont
blueprint for health implementation manual. Available from https://hcr.vermont.gov/sites/hcr/ﬁles/
Accessed July 24, 2012.
5. National Committee for Quality Assurance. Patientcentered medical home. Available from https://www.
ncqa.org/tabid/631/default.aspx. Accessed May 23,
6. Accreditation Council for Graduate Medical Education. Call for proposals, family medicine length of
training pilot. Available from https://www.aafp.org/
acgmepilot.htm. Accessed May 23, 2012.
7. Grumbach K, Grundy P. Outcomes of implementing patient centered medical home intervention: a
review of the evidence from prospective evaluation
studies in the United States. Updated November 16,
2010. Available from https://www.pcpcc.net/ﬁles/
evidence_outcomes_in_pcmh.pdf. Accessed July 16,
8. Gaynor M, Polachek S, National Bureau of Economic Research. Measuring ignorance in the market:
a new method with an application to physician services. NBER working paper no. 3430. Available from
http://www.nber.org/papers/w3430. Accessed March
2. NCCHS. Health is a community affair–report of the
National Commission on Community Health Services
(NCCHS). Cambridge: Harvard University Press; 1967.
9. Nutting PA. Community-oriented primary care:
from principal to practice. Albuquerque: University
of New Mexico Press; 1987.
3. The American Board of Family Medicine Young
Leaders Advisory Group. Improving America’s
health requires community-level solutions: Folosom
revisited. Am Fam Physician 2012;86:1–2.
10. Cifu DX, Cohen SI, Lew HL, Jaffee M, Sigford B.
The history and evolution of traumatic brain injury
rehabilitation in military service members and veterans. Am J Phys Med Rehabil 2010;89:688 –94.
270 JABFM May–June 2013
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