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Integrative Medicine: “Patient-Centered Care” is the new Medical Paternalism

Integrative Pitchmen

Several of us have written about how contemporary quacks have artfully pitched their wares to a higherbrow market than their predecessors were accustomed to, back in the day. Through clever packaging,* quacks today can reasonably hope to become professors at prestigious medical schools, to control and receive substantial grant money from the NIH, to preside over reviews for the Cochrane Collaboration, to be featured as guests and even as hosts on mainstream television networks and on PBS, to issue opinions in the name of the National Academy of Sciences, to be patronized by powerful politicians, and even to be chosen by U.S. presidents to chair influential government commissions.

The most successful pitch so far, and the one that the fattest quack-cats of all have apparently decided to bet the farm on, is “integrative medicine” (IM). Good call: the term avoids any direct mention of the only thing that distinguishes it from plain medicine. Its proponents, unsurprisingly, have increasingly come to understand that when they are asked to explain what IM is, it is prudent to leave some things to the imagination. They’re more likely to get a warm reception if they lead people to believe that IM has to do with reaching goals that almost everyone agrees are worthy: compassionate, affordable health care for all, for example.

In that vein, the two most consistent IM pitches in recent years—seen repeatedly in statements found in links from this post—are that IM is “preventive medicine” and that it involves “patient-centered care.” I demolished the “preventive” claim a couple of years ago, as did Drs. Lipson, Gorski, and probably others. Today I’ll explain why the “patient-centered care” claim is worse than fatuous.

Patient-Centered Care and Respect for Autonomy

“Patient-centered” is a term of recent vintage, used in legitmate contexts to emphasize the modern view that patients (or their competent surrogates) are free agents who are entitled to make their own health care decisions. Thus “patient-centered” is to be contrasted with “paternalistic,” the bad old style in which physicians merely told patients what to do, with explanations varying from none to fanciful (“take this [placebo], it’ll help”).

Physicians are now, ideally, expert consultants whose job is to give patients the information that they need to make rational decisions (even if patients don’t always make rational decisions). The formal ethical basis for this new “patient-centered” practice is the principle of Respect for Autonomy. This is also the ethical basis for the requirement of informed consent—both in trials and in medical practice. Thus informed consent is the sine qua non of patient-centered practice.

Integrative Medicine: “Patient-Centered Care” is the new Medical Paternalism

Do IM practitioners inform patients adequately? Let’s find out. Here are the first five M.D. practices that appear in the Google search, “Integrative Medicine Ontario” (can you guess why I chose Ontario?):

  1. Integrative Medicine Consultants Inc.
  2. Integrative Medicine Clinic
  3. Seekers Centre for Integrative Medicine
  4. Markham Integrative Medicine
  5. Toronto Clinic for Preventive Medicine

Rather than spend my usual many hours copying, pasting, and explaining lengthy quotations from those sites, in order to demonstrate the wellspring of misinformation that each of them is, I’ll simply guarantee you that I am correct in that assertion. As difficult as it is to be fighting this uphill battle against modern quackery, one thing is utterly predictable: between the nature of the claims and the apparently irresistible urge that all quacks have to make them, you will almost always find whatever flim-flam you’re looking for. I’ve perused those sites just enough to see that the stuff is rampant, but I confess that I’m too tired to do the busywork now; perhaps I’ll add it piecemeal over the weekend. Alternatively, if any of you is moved to cull a juicy passage or two, I’ll be happy to heap praise upon you in the comment section.

Yes, there are vast deficits of informed consent in integrative medicine. Hence, when an integrative medicine advocate uses the term “patient-centered,” he actually means its historical opposite: medical paternalism. Now take another look at Andrew Weil, and you’ll see him in a whole, new, er, make that old, light. He doesn’t just pine for the days of pre-scientific treatments; he pines for the days of doctor-as-mystical-priest-figure. That, of course, is what IM advocates really mean by “patient-centered”: “my patients want me to be a shaman who can weave magic, damn it, and I really get a kick out of that ego trip myself!”

QED

…………………..

*A sampling from our 4 years of speaking truth to packaging:

Misleading Language: the Common Currency of “CAM” Characterizations Part II

Why would medical schools associate with quackery? Or, How we did it.

Tom Harkin’s War on Science (or, “meet the new boss…”)

Lies, Damned Lies, and ‘Integrative Medicine’

Integrative Obfuscation

“Integrative medicine”: A brand, not a specialty

………….

The Misleading Language and Weekly Waluation of the Weasel Words of Woo series:

  1. Lies, Damned Lies, and ‘Integrative Medicine’
  2. Integrative Medicine: “Patient-Centered Care” is the new Medical Paternalism

 

Posted in: Health Fraud, History, Medical Ethics, Politics and Regulation, Science and Medicine

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32 thoughts on “Integrative Medicine: “Patient-Centered Care” is the new Medical Paternalism

  1. Quill says:

    “Rather than spend my usual many hours copying, pasting, and explaining lengthy quotations from those sites, in order to demonstrate the wellspring of misinformation that each of them is, I’ll simply guarantee you that I am correct in that assertion. ”

    I like that a lot. :-) Posting an unconditional, personal guarantee that the pursuit of hubris in those other places will pan out is a nice touch, as is letting others find the paternalism that is rampant at those places instead of restricting the field to quotes already harvested.

    You also mentioned the Count of Cam, Andrew Weil, and suggest taking another look at him. But has anyone actually -looked- in the first place? The fact he bears more than a little resemblance to Rasputin in his more manic phases may provide hard evidence for reincarnation.

    One thing on language. I quickly scanned the sites listed and it amazes me how many offer not just the usual “energy balancing,” homeopathy and the like but also chelation therapy and “life coaching.” On one site they don’t stop there but offer their own guarantee of sorts:

    “No matter what symptoms you have or what diagnosis you have been given, we can probably help.”

    Really? Even with pages of legal disclaimers, how can a medical practice front-page such a statement? Do they have futuristic psychic powers to know all possible presentations and even if so, do they also know, in a precognitive way, that they can help most of them? Did they beam down Dr. McCoy or Dr. Beverly Crusher from “Star Trek” complete with their sick bays? Just boggles the mind that an apparently licensed medical practice in an otherwise civilized country can get away with such marketing madness.

  2. daijiyobu says:

    Re: “doctor-as-mystical-priest-figure”…

    aka “ye old secret knowledge”, therein “just trust me, you won’t or can’t understand.”

    Paternalistic, dictatorial, condescending: a knowledge-type mud pie blending claims that are subjectively pulled out of a certain orifice that you have to take your pants of to access and those objectively posed, and that doesn’t care for vetting former against reality.

    Well, one of the links, to Dr. Konigsberg, states “”therapies that are supported by scientific evidence” and then another page talks of her “Primordial Sound Meditation Course” [Deepak Inc.!!!!].

    I imagine the narration:

    “this is scientific primordial sound, the sound of knowledge as it lies foundering in the integrative primordial soup-that-dare-not-actually-be-scientific.”

    The brochure says PSM leads to one being “less judgmental”.

    Which is therein a very helpful state of gullibility highly desired by the IM types: judgement is probably inversely related to their commerce, and without a doubt inversely related to scientific analysis of their claims.

    Regarding informed consent, the PSM is stated as “mantra” based. I’m wondering if “Hinduism” is ever mentioned in the promotional material on the good doctor’s site.

    Remember when the Maharishi was also Hinduizing TM people surreptitiously?

    -r.c.

  3. maus says:

    @daijiyobu “The brochure says PSM leads to one being “less judgmental”.”

    It’s sad that to them, such an attitude is a virtue.

  4. cervantes says:

    I like this, from the Integrative Medicine Clinic: “Mind and Body are one unit – although we tend to think of mind and body as being separate, in reality each cell communicates with every other cell. Therefore what you think is transmitted throughout your body; and what happens in your body is transmitted to your mind.”

    So I take it then when I think the above is horseshit, the neurons that form that thought communicate it to every cell in my body, with unspecified but no doubt dastardly consequences, which are then transmitted back to my mind which is malignly influenced into continuing to think it is horseshit. Is there no escape from this vicious cycle?

  5. nybgrus says:

    From link #2, Dr. Edward Leyton:

    Many treatment modalities are utilised – the Clinic is not an ‘alternative’ to orthodox treatments, but combines the best of both orthodox and complementary therapies. The latter include nutrition, stress reduction, exercise, and replacement of unhealthy behaviours with health enhancing behaviours. Nutrition, herbs, supplements, massage, Homeopathic Treatments, Acupuncture, relaxation and psychotherapy may all be used in treatment.

    Apparently Dr. Leyton has also practiced complimentary medicine for 25 years and accepts referrals.

    Also note that “alternative” is nutrition, stress reduction, excercise and the the replacement of “unhealthy behaviors” with “health enhancing” ones. Oh yeah, and Homeopathy and Acupuncture. And then closed out by relaxation and psychotherapy.

    There was an old rule I learned in writing, back in high school if I recall. People are struck most by and remember most the first and last thing in what they read. Note that the claim goes from perfectly reasonable (and in fact science based and having nothing “alternative” about it) to outright quackery and then back to reasonable again.

    And of course, based on the rest of the site, the “best” of both “orthodox and complimentary therapies” undoubtedly means “the stuff that works” and “the stuff we can charge you for because we feel like it,” respectively. That seems to be a good gimmick to run – here, take this real medicine and if you add on [woo of choice] (for a nominal additional fee, of course) it will help the real stuff work better. Then, of course, it was the woo that fixed the problem

  6. Pman says:

    Why the Katz hating? He’s a good man.

  7. daijiyobu says:

    @Pman:

    I see no reference in the post to a Katz.

    Katz who?

    -r.c.

  8. DrRobert says:

    If any docs out there are bored, I setup up a little challenge for CAM practitioners. I gave them a hypothetical case with real imaging and asked for their input on how to manage this patient. It’s gotten hundreds of views, but only one taker so far.

    http://www.skepticalhealth.com/2011/12/09/cam-challenge-1/

  9. DKlein says:

    From “The Seekers”, where there was so much to choose from:

    “Patients must be seekers too. In the age of the internet, information is no longer the domain of a privileged elite. It is freely accessible to all. To get the best care, many people with serious illness no longer solely rely on their doctors for information – they are taking responsibility for their own health – for their own lives.

    However, a little information can be a dangerous thing. Without a background of medical training and clinical experience, patients can often spend time and money pursuing therapies that are less likely to be effective. Our Centre aims to offer training and guidance to doctors and patients who consider themselves Seekers.”

    This bit is all quite contradictory. Not relying solely on their doctors for information is “taking responsibility” but without a medical background, one can end up wasting time and money on “therapies” that aren’t effective but which they offer (like acupuncture, NLP and Ayurvedic nutrition). This practice claims to take IM beyond the typical IM practice and will even train other physicians.

  10. Why the Katz hating? He’s a good man.

    I see no reference in the post to a Katz.

    Here’s the reference in the post:

    …quacks today can reasonably hope to become professors at
    prestigious medical schools…

    Here are posts demonstrating that Katz is not an ethical physician and is surprisingly naive about scientific evidence and implausible health claims, although he claims to be “recognized internationally as an authority on evidence-based, integrative medicine”:

    Science, Reason, Ethics, and Modern Medicine, Part 2: the Tortured Logic of David Katz

    The 2nd Yale Research Symposium on Complementary and Integrative Medicine, part II

  11. Mark P says:

    Why the Katz hating? He’s a good man.

    Good men can be wrong.

    The saying “the road to Hell is paved with good intentions” isn’t heard so much these days, but still has merit.

  12. daijiyobu says:

    @ KA and Pman:

    OK, rather a ‘Katz dog whistle’ type reference!

    Of course, if people have knowledge of the good Dr. and his positions, fine.

    I, personally, can only say this:

    he was my instructor at Yale Medical School.

    Which is quite odd, really, since I was after all studying NATUROPATHY quite innocently enough

    at a different university until I realized that what naturopathy is all about isn’t at all “innocent”

    or ethical.

    Did I mention too that my homeopathy instructor was ND Howard Fine”:

    “Paging Doctor Howard, paging Doctor Fine, paging Doctor Howard.”

    Really. Can’t make this stuff up.

    [If you aren't getting it, the Three Stooges' last names were Howard and Fine].

    -r.c.

  13. daijiyobu says:

    By the way, we need some kind of algorithm which measures ‘vegetable soup pseudogravitas’.

    [Andy Lewis, anyone? The Soupometer...].

    After clicking on the above Katz link, I realize that such long practically farcical

    accolades-in-the-place-of-possible-professional-psychological-integrity

    are quite the sign of sCAM proponentry.

    -r.c.

  14. DevoutCatalyst says:

    @ 大丈夫
    Cotton!

  15. GLaDOS says:

    Its proponents, unsurprisingly, have increasingly come to understand that when they are asked to explain what IM is, it is prudent to leave some things to the imagination.

    Very nice.

  16. DrRobert says:

    Dear SBM,

    Would you possibly consider adding a forum? It’s extremely simple. The makers of WordPress (the software you run) also make a forum software called bbPress: http://bbpress.org/

    It’s literally a 1 click install (search plugins for “bbpress”), and then add a new item to your menus up top. It’s not the most sophisticated software in the world, but it integrates perfectly, and all of us with accounts here could start posting immediately. I run it on my site (link in username, click on “Community” at top.)

    As someone new to the SBM online community, I have a ton of questions and I feel horrible emailing people directly (although you have been amazing). Also it would be great to be able to solicit opinions from people like WTU, Dr. Hall, Dr. Gorski, etc. There’s a lot of questions that would be great to be able to ask. For example, I’m looking up data on the success of chiropractors with treating scoliosis, and I found an article… published by a chiropractor in “Musculoskeletal Disorders.” I have no idea if this is a quack journal, or what.

    It seems like it would be a great way to spread information around.

  17. lilady says:

    @ Dr. Robert: I keyed in NIH NCCAM scoliosis chiropractic treatment and found no studies at that site. I did locate an interesting extensive article at the NIH NIAMS (National Institute of Arthritis and Musculoskeletal and Skin Diseases) website under “Scoliosis”.

    It brought back memories of the “Milwaukee” brace used by my friend’s daughter from age 12 until age 15. Surprisingly, the “Milwaukee” brace is still used for most cases of scoliosis.

  18. ABS says:

    I am a family physician and teacher of family medicine. Patient-centered care is a serious area of teaching and practice. This stealing of a very fine concept to sell all sorts of woo leaves me furious. Patient-centered care is anything but paternalistic, and yet it doesn’t have to bend to nonsense. We are very careful to explain to students that being “holistic”, “comprehensive” and, yes, “patient-centered” has nothing to do with pseudoscientific fantasy. In fact this method stresses the physician’s duty to be extremely clear when explaining different approaches to health and illness.

    There is a relatively new concept – quaternary prevention – that has been gathering momentum among general practitioners around the world. Its definition reads as follows: “Action taken to identify a patient or a population at risk of overmedicalisation, to protect them from invasive medical interventions and provide for them care procedures which are scientifically and medically acceptable.” Link this to patient-centered care and you have nonsense-free science-based medicine.

  19. DrRobert says:

    That brace was one heck of a medieval looking device!

    You know, I almost feel bad for chiropractors. They go to school for 4 years and they get out and basically their entire practice boils down to being as effective as a Tylenol for a couple of types of back pain. They could have been trained over a weekend at a massage school. That has to be one of the driving forces for the cognitive dissonance that lets them lie to themselves and believe most of the woo they purport.

    I saw an extremely severe case of scoliosis that will be my next CAM challenge. 40′ curvature with a 38′ compensatory curve. Poor girl’s family never brought her back for treatment after she was diagnosed at age 12. Now she’s an adult, growth plates closed, and would need severe surgery.

    Speaking of growth plates. A 12 year old patient was brought in by his parents because he had been told by his chiropractor he had bilateral fractures of his femoral heads with “bone fragments” spread down to his lesser trochanter. We repeat the Xray. Perfectly normal. The chiropractor had apparently never seen growth plates before. Wow. Was it a harmless misdiagnosis? Well, patient was needlessly exposed to radiation in his pelvic region twice, and his parents had been distraught for weeks trying to figure out who may have been abusing him at school or elsewhere.

    I could go on and on about chiropractic misdiagnosis of xrays. My wife had been told she had scoliosis and and bones spurs on her spine at age 25 (before we met!) She had a strange musculoskeletal pain so we ended up taking an xray of her back. Spine was as straight as can be and obviously no bone spurs. I’ve seen dozens of people with “chiropractor scoliosis” with spines straighter than Rick Perry. (bad joke)

    (rant over)

  20. DevoutCatalyst says:

    >They could have been trained over a weekend at a massage school.

    Agreed. For what it’s worth, massage therapists are on the pointless training treadmill too these days, required to spend up to a 1000 hours in some states for something that was previously learnt by a hippie chick with a booklet and some hands-on in a few hours max.

  21. DrRobert says:

    @DevoutCatalyst – I totally agree. A friend of mine teaches at one. The MT schools earn big bucks between selling the students books, equipment, and artificially extended duration of classes. They also teach them all the woo – reflexology, basics of acupuncture, meridians, some energy healing, etc.

    It’s thought provoking, because most students passed high school, but have little if any college under their belts. So they go to this seemingly professional school, and in the school they’re taught that if you rub on a person’s foot in certain way you can cure constipation (“Hey, well, my teacher gave me this chart of the foot and said it worked!”) Do we blame the students for being scientifically illiterate? Or do we blame the teachers?

    One thing that I’ve never understood: they do learn some anatomy and physiology. But in those classes, they certainly aren’t ever shown a histological slide of an acupuncture point, nor or are they ever shown a dissection of a meridian. And they are never taught a neurological pathway that explains reflexology. So why isn’t there more often a disconnect where they realize that these CAMs aren’t biologically plausible?

  22. I was a bit worried that I hadn’t made it clear in the post that the term “patient-centered” has a legitimate use; it was not coined by quacks, but rather borrowed by them for purposes of misleading others about what they actually do (“holistic” has a similar history). I’ve made a slight change in the text above to clarify this point.
    KA

  23. DugganSC says:

    FWIW, one can get certified in a number of other areas from bartending to wine tasting to stock trading, all areas where it’s been shown that amateurs perform as effectively, if not better, than the trained professionals when it’s looked at objectively. Personally, I partly blame a generation raised that “you must go to college” to pursue one’s dreams. It comes from an understandable place, wanting your kids to do better than you did, and to reach their full potential, but it’s engendered a world where you can’t do anything without shelling out years of your life and thousands of dollars to reach an arbitrary benchmark.

  24. nybgrus says:

    flawed it certainly is, but I think the idea is (at least the idea I would agree with) is that there is some sort of verification that you actually possess the knowledge and skillset you claim to have.

    I can teach myself medicine – at least the theory part of it – without being in medical school. I could learn absolutely everything I need to know to pass (perhaps not excel at but certainly pass) my medical boards without every setting foot in or paying for med school.

    But the point is that something should inform people that I don’t just have the skills to pass an exam, but actually be a physician and have the knowledge necessary.

    Perhaps that sort of things breaks down more at professions that require less time and knowledge. But the way I see it, if I walk into a job interview and say “I have skills and knowledge [xxx]” how can I prove to the employer I have them?

    Of course, just having a degree means less and less these days – I know many of my undergrad colleagues have a degree but are dumb as doornails. But, to me at least, that is the principle behind the time and benchmark you are paying for.

    However, this is also why in many of the circles I frequent, the interest is not in just a degree but in what you can put forth. I know guys who have dropped out of PhD programs because they actually did work that was more worthwhile – i.e. it proved that they knew and had the experience necessary to succeed in their field. A PhD would have been less worthwhile to them.

  25. cyclelicious says:

    Speaking of ‘integrative medicine,” something I’ve been asking about is the University of Colorado’s Department of Integrative Physiology. It’s kind of a big deal for sports physiologists especially (where my interest lies), but I haven’t really been able to figure out if it’s integrative in the sense of woo, or if they really have an evidence-based approach to physiology.

    Opinions?

  26. nybgrus says:

    @cyclelicious:

    Just try and answer the question “What are they integrating?”

  27. Vera Montanum says:

    Very interesting comments above by DrRobert and DevoutCatalyst regarding massage therapy. You folks are absolutely clueless about the training received at legitimate schools and what LMTs actually do – nice bit of contempt prior to investigation. (And, no, I am not an LMT.)

    Same thing with the discussions about “Patient-Centered Care” that got off track. Sometimes many at this site get so carried away with lambasting anything that smacks the least bit of “Woo” (what a childish term!) that you start losing a sense of objectivity.

    The best of SBM at this site uses science to objectively assess and debunk that which is not supported by sound science. I would recommend that you stick to that and put the cutesy, snide emotionalism aside — surely it is beneath you.

  28. I had an occasion to visit a chiropracter’s office – he was interested in a used care I was selling, and I was able to swing by. So, I actually set foot in a chiropractic clinic.

    His practice had the atmosphere of a spa. Clients were coming and going, having pleasant chats with the counter staff as they bought whatever remedies were for sale like the way the products are displayed at the hair salon.

    This was a patient-focused place.

    Was anyone actually getting genuine therapeutic medical care? Probably not.

    But this place was patient-focused.

    Don’t get me started on health care delivery in the real world. Patient-focused billing – yes. Patient-focused care? More like Patient-Focused Where.

  29. DevoutCatalyst says:

    @ Vera Montanum

    Massage therapists are not doctors, but you’d hardly know it talking to some of them. That’s a change I’ve noticed with the new crop of therapists. Would like to know what the new massage therapists can do that the old schoolers could not, because the new training appears irrelevant from this client’s perspective. Masseuses and masseurs developed their chops perfectly well before legislation requiring classroom attendance, after all, you wouldn’t retain too many customers if you did not become good at it. What is the difference between a therapist who receives 300 hours of required schooling in one state, and the required 1000 hours in another? Interesting that cosmetology schools suddenly became experts in the field and stepped right up to meet the requirements of the legislation. My hippie chick reference is anecdotal, but not apocryphal. She had flaming red hair and too many cats, and gave the best damn massages of my life. She learned her skills through self-study, then honed her craft on the job. Suspect that’s how it was for many back in the 70s, early 80s. What I notice today is that some therapists want to switch you to another modality, but I’m paying good money for a massage, not zero balancing or some such. Patient centered NOT! I did once get a chance to look at the big massage bible that students were toting with them to class. My cursory impression was not favorable, seemed to me a case of extensive padding that would make any high schooler blush. If I am clueless, fill me in.

  30. Vera Montanum, I was an LMT (“R” for registered in Canada, actually, but whatever) and I have no quibble with anything that’s been said here about massage therapy by DevoutCatalyst or DrRobert. They do not seem “clueless” or offensive to me.

    Your comment, on the other hand, has no substance but a complaint about their tone and style. If you are aware of a single factual inaccuracy in their statements, you failed to point it out. That kind of reaction is typical of a defensive tone that I encountered so frequently among massage therapists and other CAM practitioners that I abandoned the profession in disgust.

    The training here is excellent, as CAM training goes: unusually high certification standards, lots of physiology and pathology. Nevertheless, here and everywhere else, pseudoscientific thinking and dubious claims and practices are alarmingly common in massage therapy. Some massage therapists are certainly trying to change that, but by no means are they in the majority, and they encounter a great deal of resistance. Massage therapy has a lot going for it, but it has a long way to go as a profession before it can be considered science-based or above criticism. See my review of the scientific case for and against massage therapy.

  31. DrRobert, you wrote:

    One thing that I’ve never understood: they do learn some anatomy and physiology. But in those classes, they certainly aren’t ever shown a histological slide of an acupuncture point, nor or are they ever shown a dissection of a meridian. And they are never taught a neurological pathway that explains reflexology. So why isn’t there more often a disconnect where they realize that these CAMs aren’t biologically plausible?

    I had ample opportunity to observe this phenomenon up close in my massage therapy training. For three years, I watched many of my student colleagues deftly avoid the more awkward clashes between their education and their beliefs, biases and sacred cows. There are many mechanisms, but it’s actually really easy to cherry pick facts from a curriculum, particularly when you’re in rote-learning mode and know little or nothing of the process of science or cognitive distortions. It is greatly facilitated by the presence of a few poorly qualified teachers with their own agendas. We could go from one class with an instructor who had a good science background to the next class taught by a chiropractor, for instance… so there was plenty of “spin” available.

    One of my favourite stories from school was the day that one of the phsyiology instructors, a hard science guy, tried to share the results of a study showing that massage doesn’t actually increase circulation. He was nearly lynched! There was actual shouting over this, immediately. What struck me most was that the students were defending a belief that they had only recently acquired from other instructors over the past few months. But it was already integrated into their vested interests, and they circled the wagons to defend against this “threat” with amazing ferocity.

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