Implicit Bias in Healthcare

Special guest Stephen Carek, MD, CAQSM, DipABLM, Program Director for the Prisma Health/USC School of Medicine Greenville Family Medicine Residency Program and Clinical Associate Professor at the University of South Carolina School of Medicine, Greenville, joins us to talk about implicit bias in healthcare.

Listen in as we discuss the differences between implicit and explicit bias and how biases can lead to disparities in healthcare.

None of the speakers have anything to disclose. 

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

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00:00:07 Stephen Carek 

I think that healthcare is incredibly complex. We are all incredibly busy. We all have, a lot of at times, very high stakes decisions to make with limited information. When you try to throw in the pressure of time on that, we may make decisions pretty quickly. 

00:00:20 Stephen Carek 

We don't have the opportunity to reflect and maybe collect as much information as we want, and that lends itself to potentially being influenced by bias, for better or for worse.  

00:00:33 Stephen Carek 

I know that one thing for me personally is when you feel that the pressures on that's when some of those mistakes can be made. 

00:00:45 NARRATOR 

Welcome to Medication Talk, the official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, RxAdvanced, and the most trusted clinical resources. 

00:00:56 NARRATOR 

On today’s episode, we’ll listen in as we review the differences between implicit and explicit bias and how biases can lead to disparities in healthcare.   

00:01:06 NARRATOR 

Our guest today is Dr. Stephen Carek from the USC School of Medicine Greenville. 

00:01:11 NARRATOR 

This podcast is an excerpt from one of TRC’s monthly live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers. 

00:01:25 NARRATOR 

The full webinar originally aired on September 19, 2024. 

00:01:30 NARRATOR 

And now the CE information. 

00:01:34 NARRATOR 

This podcast offers continuing education credit for pharmacists, physicians and nurses. 

00:01:40 NARRATOR 

This podcast offers Continuing Education credit for pharmacists, physicians, and nurses. Please log in to your Pharmacist’s Letter or Prescriber Insights account and look for the title of this podcast in the list of available CE courses. 

00:01:47 NARRATOR 

None of the speakers have anything to disclose. 

00:01:51 NARRATOR 

Now, let’s join TRC Editor, Dr. Sara Klockars, and start our discussion! 

00:01:57 Sara Klockars 

Implicit bias is a bias that is unintended or unconscious. It's sometimes called unconscious bias. 

00:02:05 Sara Klockars 

It's a normal human behavior that we learn throughout our lifetime from recognizing patterns in the environment around us. 

00:02:12 Sara Klockars 

Historically, this learned behavior helped humans determine friend from foe, as our mind creates automatic associations about a particular person or group of people, however. 

00:02:24 Sara Klockars 

It can manifest into stereotypes, prejudice and discrimination. 

00:02:29 Sara Klockars 

These biases kick in automatically and can subtly influence the way we behave or make decisions. Sometimes without us even being aware of it. 

00:02:38 Sara Klockars 

Implicit bias can actually go against what we say or value. 

00:02:43 Sara Klockars 

So even if we see ourselves as fair and unbiased, these hidden biases can still affect our actions and decisions. And this is different than explicit. 

00:02:52 Sara Klockars 

Yes, this is more conscious, more deliberate and explicit biases. When we're aware of our preferences and beliefs, and we may even act on them. And this can manifest in ways like excluding someone from a conversation or a decision making process. Or it can be more extreme through physical or verbal harassment. 

00:03:12 Sara Klockars 

So for today's discussion, we're going to focus in on implicit bias. 

00:03:17 Sara Klockars 

Since it's present in everyday assumptions are verbal and nonverbal communications, actions, attitudes, even the decisions we make. 

00:03:26 Sara Klockars 

So for example. 

00:03:28 Sara Klockars 

You may assume that older patients are typically sedentary or you may give a little extra time and attention to a patient that you relate well to. Or maybe you'll speak to some patients in a certain way because of your beliefs about their perceived social class. So these actions happen automatically. 

00:03:48 Sara Klockars 

Based on the snap judgments, our brains make about people just based on our own past experiences. 

00:03:57 Sara Klockars 

An implicit bias can be associated with a wide range of factors, age, marital status, level of education, and parents spiritual beliefs, just to name a few. And all of these traits make us unique. They shape our worldview and influence our interactions and impact the way we perceive and. 

00:04:16 Sara Klockars 

Are perceived by others when it comes to health care. These traits also play a significant role in how patients experience care, and how they might be affected by implicit bias. So for example. 

00:04:31 Sara Klockars 

A patient socioeconomic status might influence assumptions about their health, literacy or access to resources. 

00:04:39 Sara Klockars 

Or a refugees background might lead to biases related to their language proficiency or trust in the healthcare system. 

00:04:47 Sara Klockars 

Even a patient's spiritual beliefs might affect the way their health choices are perceived by healthcare providers. So just recognizing that the broad range of factors can contribute to this implicit bias and acknowledging these diverse traits allows us to better tailor our approach to meet each patient's unique needs. 

00:05:07 Sara Klockars 

So, Stephen, what are some patient specific factors that you've seen in your tenure that have impacted a patients health and can you provide some examples of either positive or negative effects on patient care? 

00:05:21 Stephen Carek 

Yes, I think there's there's probably an extensive list we probably don't have time to go through during this session. But the things that come to mind, I think race, age, gender, socioeconomic status, those tend to be the most common. 

00:05:34 Stephen Carek 

The ones that we probably experience on a day-to-day basis probably will have our own stories about patient interactions that we have had where we have either observed or even been directly involved in some of those biases that may have influenced care for the patients that we provide care for. I think of examples of encounters that have been. 

00:05:55 Stephen Carek 

This is your poor outcomes. I mean, I think definitely social determinants and and seeing patients who don't have economic means. Transportation means educational means to understand the healthcare they're receiving the decisions or the the gravity of the decisions that they have to make. 

00:06:11 Stephen Carek 

Things like how or even how they're able to take care of for themselves, being able to afford medications, afford treatments, afford therapies, get to a doctor's appointments. I think of age and and how, for example, pediatric patients not having necessarily the ability to choose if they would like vaccinations or certain therapies just because of the nature of maybe their education or the influence of their parents or guardians. 

00:06:34 Stephen Carek 

They have on that decision for elderly, especially those that may have limited resources, limited family dementia, other decision making, limitations that definitely influences their care, and then our ability to provide for. 

00:06:46 Stephen Carek 

Them. 

00:06:47 Stephen Carek 

There are opportunities, too, where it it has, I think resulted in in good outcomes. I think through things like individuals, faith systems and the communities that they're able to build through a common network, whether they're from a similar nationality, speaking similar languages, practicing similar belief systems. And I think that builds a sense of community, a sense of support for patients that at times may empower them. It may allow them to. 

00:07:09 Stephen Carek 

Seek guidance to seek understanding and seek support and what may be challenging decisions. 

00:07:16 Sara Klockars 

Awesome. Thank you for sharing your perspective, Stephen. And those were some really helpful examples. 

00:07:21 Sara Klockars 

Now let's move on, and I'd love to get your thoughts on this question. Have you or one of your residents or a colleague unconsciously made an assumption about a patient based on their appearance, behavior or background? And then how did that assumption impact the interaction with the patient? 

00:07:40 Stephen Carek 

Oh yeah. I mean, I I definitely, I know that I personally have. I've made this error before and continue to try to learn and grow from these. I mean, I think we get so busy sometimes trying to provide patient care that you go into a room and you immediately turn on those system one thinking you kind of just operate on quick fire, you walk into your room, you see a patient you. 

00:08:00 Stephen Carek 

Make a lot of presumptions based on their appearance, and with that you may ask specific questions you may have specific biases you may have already come to a conclusion about what your diagnosis, what your treatment plan may be. You may assume that just by the way a patient looks that may not understand what a medicine does, or understand what a procedure may be, or have the level of healthcare literacy. 

00:08:20 Stephen Carek 

You know, I've had examples of that where it's I've interacted some of that, it turns out they were actually professionals in the healthcare field and knew lots about what I was talking about. And I completely misjudged that opportunity and then came across as being someone who was not well informed and did not do a very good job meeting the patient where they were at. 

00:08:36 Stephen Carek 

So those are definitely, definitely plenty of opportunities. And that think the best thing we can do from those is just try to learn from that. 

00:08:44 Stephen Carek 

I know that unfortunately, we will make mistakes and we'll continue to make these mistakes but always being, you know, trying to approach every patient with an open mind, with an open heart, being curious, being non-judgmental and trying to do what you feel is best for the patient in the situation that you are given. 

00:09:02 Sara Klockars 

Thank you. 

00:09:03 Sara Klockars 

Now let's explore a case to illustrate how bias can impact patient care. 

00:09:09 Sara Klockars 

Here we have Michelle, a 45-year-old customer service manager. She started experiencing persistent abdominal pain, bloating, unexplained weight gain and feeling full quickly when eating. 

00:09:21 Sara Klockars 

Despite her concerns, her doctor kept attributing these symptoms to her weight, suggesting she just needs to lose a few pounds, manage her diet better and increase her activity. 

00:09:31 Sara Klockars 

No further tests were done and her symptoms were largely dismissed. 

00:09:36 Sara Klockars 

As time went on and her symptoms got worse, Michelle decided to get a second opinion. 

00:09:41 Sara Klockars 

And that's when she found out she had advanced ovarian cancer, which already spread beyond her ovaries. 

00:09:48 Sara Klockars 

Implicit bias may be subtle, but its impact in health care is significant and very real. 

00:09:55 Sara Klockars 

Let's expand a bit more on the impact of implicit bias in healthcare when healthcare providers unconsciously allow biases to influence their clinical judgment, it can lead to incorrect or misdiagnosis. For example, in Michele's case, if a provider makes assumptions based on a patient's weight. 

00:10:14 Sara Klockars 

They may overlook certain symptoms or underestimate the severity of the patient's condition, and this can result in a delayed diagnosis. 

00:10:24 Sara Klockars 

Unfortunately, such delays can lead to critical treatment being postponed, potentially worsening the patients outcome. 

00:10:33 Sara Klockars 

These biases can subtly influence clinical decisions. 

00:10:37 Sara Klockars 

For instance, the provider might unconsciously assume that a patient from a lower socioeconomic background is less likely to adhere to medication regimens and therefore perhaps they don't prescribe the most effective treatment. And these assumptions can lead to suboptimal care and perpetuate negative health outcomes. 

00:10:58 Sara Klockars 

Implicit bias also plays a role in the persistent health disparities we see across different racial, ethnic, and socioeconomic groups. So, for example, minority populations often experience higher rates of chronic conditions, lower life expectancy, and higher infant mortality rates. 

00:11:17 Sara Klockars 

And another serious consequence of implicit bias is the erosion of trust between patients and healthcare providers. When patients perceive bias during their interactions, they may feel misunderstood or judged, and this may make them less likely to provide pertinent details. Follow medical advice, seek timely care. 

00:11:34 Sara Klockars 

For return for follow up appointments and over time, this lack of trust can worsen health conditions and create a reluctance to engage with healthcare providers in the future. 

00:11:46 Sara Klockars 

The psychological impact of implicit bias on patients cannot be overlooked either. Experiences of bias can lead to feelings of alienation, stress, anxiety, and this can worsen overall well-being and mental health. This is particularly concerning for patients from marginalized communities who may already face multiple sources of stress and discrimination in their daily lives. 

00:12:09 Sara Klockars 

Beyond the clinical and relational consequences, implicit bias also has financial implications. 

00:12:17 Sara Klockars 

So we saw this with Michelle, when biases lead to misdiagnosis, delayed treatment, suboptimal care. The result is often higher healthcare costs because patients may require more extensive and expensive treatments down the line, more frequent hospitalizations or perhaps prolonged care due to complications from inadequate initial treatment. 

00:12:38 Sara Klockars 

This not only increases the financial burden on patients, but also strains the healthcare system. 

00:12:44 Sara Klockars 

The bottom line is that certain groups might end up receiving lower quality care, not because we as providers intend to, but because these unconscious biases are at play. 

00:12:56 Sara Klockars 

Even when we have the best of intentions and I want to pause here, Stephen, do you have any thoughts to share here? 

00:13:05 Stephen Carek 

I think again, it kind of goes back to there's multiple factors to it, but I think that Healthcare is incredibly complex. We are all incredibly busy. We all have a lot of at times, very high stakes decisions to make with limited information. And when you try to throw in the pressure of time on that, we may make decisions pretty quickly.  

00:13:26 Stephen Carek 

And I think that's that Type 1 thinking where we don't have the opportunity to reflect and maybe collect as much information as we want that lends itself to potentially being influenced by bias, for better or for worse. And I know that that's one thing for me personally is when those when you feel that the pressures on that's when sometimes some of those mistakes can be made. 

00:13:44 Sara Klockars 

Thank you. 

00:13:46 Sara Klockars 

So now we know what implicit bias is and how it impacts patient care. How can we recognize and help address implicit bias? It's difficult as committed healthcare professionals or helpers, we spend our time helping patients optimize their health and medication therapy, and this dedication to patients makes it especially hard. 

00:14:08 Sara Klockars 

To consider the possibility that we may have implicit attitudes and stereotypes that may be having negative effects on patient care. 

00:14:17 Sara Klockars 

In fact, research has found that levels of implicit bias in healthcare professionals is about the same that's found in the general population. 

00:14:27 Sara Klockars 

It's also important to note that while healthcare professionals who work with certain groups, such as patients with mental illness, may have a lower level of implicit bias, attitudes towards that group than those who don't studies show they still have bias. 

00:14:44 Sara Klockars 

So to address implicit bias and effectively reduce the negative effects of implicit bias in healthcare, two key actions are essential. 

00:14:53 Sara Klockars 

1st we need to increase our awareness of our own implicit biases, and this involves recognizing that everyone has biases. 

00:15:03 Sara Klockars 

Often unconsciously, and understanding how these biases can influence our decisions and actions, particularly in a healthcare setting. 

00:15:13 Sara Klockars 

2nd we must make a conscious effort to reduce these biases, and this requires not just acknowledging their existence, but actively working to counteract their influence in our daily practices. And this is much more difficult than it sounds. 

00:15:30 Sara Klockars 

So now we're going to explore some effective evidence based strategies that can help us achieve these goals and move towards more equitable bias free care for all patients. 

00:15:42 Sara Klockars 

Uncovering your own implicit bias through reflection and self-awareness is the first step on the path to cultural competency. Many healthcare professionals are aware of the importance of cultural competency, but many are less aware of their own implicit biases. 

00:15:58 Sara Klockars 

Self-awareness involves discovering implicit thoughts and feelings about your interactions that are unconscious and automatic. 

00:16:06 Sara Klockars 

And uncovering these biases can be particularly difficult, since many of us will not admit that we have biased opinions or viewpoints that are stereotypical. 

00:16:17 Sara Klockars 

And it may be particularly helpful to use objective testing methods to discover and measure implicit bias. 

00:16:25 Sara Klockars 

So Steven, I have a question for you. What resources have you used in your training to help residents or students become aware of their own implicit biases? 

00:16:38 Stephen Carek 

Yeah, if you've never done implicit bias training, there's lots of good resource. I think there's really one through Harvard. I mean, that's one place to start that can help you understand your own biases as a residency program director. The ACG Me also has really good resources, CME videos, scenarios to go through on the topic of implicit bias. 

00:16:58 Stephen Carek 

Especially in healthcare education, I thought I've done that and that was really, really helpful for me as well. 

00:17:03 Stephen Carek 

Well, and then the other part of it too is just if you are in a position, if you're working on a team, talking with your team, you know, understand their perspective, have they ever felt if you don't have systems in place for people to assess the environment, assess their team, like how do they feel they are being perceived or being active there, are there people of of certain gender certain races that feel they're being? 

00:17:23 Stephen Carek 

Interact with or perceive differently than others. I think you have to understand what the pulse of your culture is and to know where you might want to go from there and if the culture is strong, great, keep doing what you're doing. If the culture though, there are opportunities with it, you know, trying to figure out what those are and create actionable next steps is really important. 

00:17:43 Sara Klockars 

Great. Thank you. Stephen, you mentioned the resource from Harvard to objectively identify implicit bias, and I just want to spend a couple minutes on that. 

00:17:51 Sara Klockars 

It's called Project Implicit, and it's a research initiative that offers tests that can help you discover and measure your own implicit biases. 

00:18:01 Sara Klockars 

And the tests work by measuring your reaction time when matching different factors like race or gender with positive or negative words. 

00:18:10 Sara Klockars 

And many are surprised at what biases are uncovered with these tools, and this is normal and unavoidable, since we all have implicit biases, but becoming aware of your own biases can help us prevent them from affecting patient care, or allowing us to, you know, act based on rational assessment of the clinical situation rather than implicit stereotypes or prejudices, so that's what this tool is. 

00:18:40 Sara Klockars 

So Stephen, have another question for you. What are some ways you recognize implicit bias when it's affecting a patient interaction and how can we hold each other accountable? 

00:18:54 Stephen Carek 

Yes, see people just using interacting with people sometimes tone is different. Sometimes body language is different, sometimes just the terminology that you're using is different. Being able to acknowledge that in some extreme cases it's utilizing sexist or racist language. 

00:19:10 Stephen Carek 

If you hear that or see that acknowledge it and call that person out on the spot, have the confidence have the self-belief. Have the awareness, or at least give that feedback in some context. And then especially if it's the language that is abusive, sexist, racist, escalating that to their superiors and let people know utilizing your systems to make sure that that behavior is stopped immediately. 

00:19:33 Stephen Carek 

Some of it's not so obvious too. Some of it may be not witnessed once, but there may be a series of events that maybe allow you to build evidence or builds your own perceptions that maybe this an individual is demonstrating bias or demonstrating favoritism in some way, in which case it's a lot of talking with an individual talking with your superiors. 

00:19:54 Stephen Carek 

And trying to seek understanding about your perception of the situation and then hopefully bringing people together to talk through some of these more challenging issues in these situations, your own bias could be coming out about other people's biases. 

00:20:06 Stephen Carek 

So it can be very complex, very challenging, but I think ultimately it's coming together as a team, making sure as the support team, especially with a hierarchy of leadership, for example, with residents bringing people together, bringing maybe if there's resident conflict, bringing people together, mediating that conversation, making sure that for me as a leader, seeking more understanding, seeking their perspectives. 

00:20:27 Stephen Carek 

And trying to approach it in an unbiased way, making sure that I have the information. If I don't, where can I find that information to obtain that and then if I do feel that there is potentially favoritism bias really helping guide our learners in ways that they can understand their own biases, and then through someone, since that we talked about before, hopefully finally, so that they can improve that and hopefully prevent that from being a tendency or being something that repeats itself in the future. 

00:20:57 Sara Klockars 

Those are some really great practical tips, Steven, thank you for sharing. 

00:21:04 Sara Klockars 

So now let's dive into some practical strategies we can use to break a habit of bias. The first strategy is stereotype replacement, and this involves recognizing when an action or thought is based on a stereotype and making a conscious effort to change it. 

00:21:20 Sara Klockars 

Next we have counter stereotypic imaging. 

00:21:24 Sara Klockars 

This technique involves imagining the patient as the opposite of the stereotype. You might unconsciously hold. So, for instance, if you automatically associate a certain demographic with being non-compliant, visualize the patient as highly engaged and motivated in their care, and this helps to disrupt the stereotype and replace it with a more balanced perspective. 

00:21:46 Sara Klockars 

Finally, we have the perspective shift strategy, and this encourages us to consider the patient's point of view, essentially putting ourselves in their shoes. So just ask yourself, how might this patient be feeling? What challenges might they be facing? And by empathizing with their experience, we can better understand their needs and then respond with greater compassion and accuracy. 

00:22:08 Sara Klockars 

So let's walk through an example of how to apply the stereotype replacement strategy. 

00:22:15 Sara Klockars 

This approach involves several steps to help us recognize, reflect on, and ultimately replace biased thoughts with more accurate, individualized understanding. 

00:22:25 Sara Klockars 

Imagine you catch yourself thinking. 

00:22:28 Sara Klockars 

I just assumed she might not care about her health because of how she looks. 

00:22:32 Sara Klockars 

This is the first step acknowledging that a stereotype has influenced your perception. 

00:22:40 Sara Klockars 

So next you reflect on where the assumption comes from. You might think I realized that I've associated tattoos and casual dress with a lack of interest in health, but this is a generalization that doesn't consider her as an individual. 

00:22:55 Sara Klockars 

And this step is crucial because it helps you understand the bias behind the stereotype. 

00:23:01 Sara Klockars 

The goal is to replace that stereotype with a more accurate, individualized approach. You can start by engaging with the patient directly. 

00:23:11 Sara Klockars 

Thinking something like, I'll start by asking her about her health goals and any challenges she's faced in maintaining her health and this will help me understand her needs better and provide the best care. 

00:23:23 Sara Klockars 

And then finally reinforce this new understanding by focusing on the facts, noting to yourself she's actually very committed to her fitness routine and is looking for advice on improving her diet. This reminds me that outward appearances don't provide enough information about someone's health priorities. 

00:23:41 Sara Klockars 

So by following these steps, recognizing the stereotype, reflecting on the bias, replacing the stereotype with the focus on the individual and then reinforcing the new perspective, we can disrupt our automatic assumptions and then provide more personalized effective care. 

00:24:04 Sara Klockars 

Another technique is counter stereotypic imaging. 

00:24:09 Sara Klockars 

So this is a mental exercise where you consciously visualize someone who contradicts a common stereotype. 

00:24:15 Sara Klockars 

So by frequently imagining individuals who do not fit into stereotypical categories, you can train your mind to associate positive and diverse characteristics with people from different backgrounds, while weakening those automatic biases. 

00:24:33 Sara Klockars 

The first step is to become aware of the stereotype. You might unconsciously hold. So, for example, you might realize you associate older adults with frailty or resistance to change. 

00:24:46 Sara Klockars 

The next step is to think of someone who breaks the stereotype. 

00:24:51 Sara Klockars 

So this could be a person you know, or a well known public figure. For example, imagine an older adult who runs marathons regularly, volunteers or as tech savvy. 

00:25:03 Sara Klockars 

And then spend some time regularly visualizing this person and their activities. Focus on their energy capabilities, positive traits that contradict the stereotype. 

00:25:15 Sara Klockars 

And the next time you interact with someone who fits that stereotyped group, recall the counter stereotypic image and let it guide your interactions, encouraging you to approach interactions with an open mind free from the bias associated with the stereotype. 

00:25:32 Sara Klockars 

And after interactions reflect back on how the use of the counter stereotypic imaging. 

00:25:39 Sara Klockars 

Influenced your behavior and the patient's response, and this reflection helps reinforce the positive impact that the exercise. 

00:25:47 Sara Klockars 

Counter stereotypic imaging is a great tool to help shift unconscious biases by regularly challenging and replacing stereotypical thoughts with more individualized and positive images, it helps create a mental framework where diversity and behavior, abilities and characteristics as normal. 

00:26:07 Sara Klockars 

So now that we've covered some strategies that we can work on individually to counteract implicit bias, Steven, I wanted to ask you, what are some strategies that you have found effective for helping your team, your institution or organization increase awareness and address biased behavior? 

00:26:29 Stephen Carek 

Our part of our team and every year we do implicit bias training. We even do some simulated workshops with our residents that address bias and how to acknowledge it in real world settings instead of a bystander be someone who actually can influence when you observe implicit bias in action and be a a model for change. And I think that's one that's been really well. 

00:26:52 Stephen Carek 

The second thing we do is that we kind of have a spin on the traditional M&M. The morbidity and Mortality Conference. But instead of thinking through outcomes of the medical operation and failing in and having either a near miss or a poor. 

00:27:05 Stephen Carek 

Come. We look at it through the lens of social determinants and have a social determinants M&M to where we look more at society and we look at sort of the institutions that we have that have ultimately potentially not benefited a patient in this, you know, things like transportation, education, jobs, patients who are immigrants, patients of certain races. 

00:27:25 Stephen Carek 

Gender discrepancies or disparities, all those things have allowed us to have a more open conversation and addresses our own biases, address our own misunderstandings or understandings of certain belief systems, and then talk about it as a group and how we can prevent that bias from influencing how we take care of our patients, and hopefully, hopefully too as well with like the social determinants of health and. 

00:27:46 Stephen Carek 

Create change be advocates for change that can hopefully improve, not the healthcare of individuals, but future patients that may have similar backgrounds. 

00:27:58 NARRATOR 

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