E32 Omar Farooq On International Medical Graduates

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it. On the podcast today, we have the privilege of chatting with Dr. Omar Farooq. Omar is much more than Ameer’s dad. His story of immigration, medical training, and raising a family in a new country is both inspiring and motivational. The aim of this podcast was to discuss some of the challenges that international medical graduates face. More specifically, Dr. Farooq provides insight on how to potentially navigate many of these hurdles, maintain a productive mental outlook and ultimately to succeed. We’ll let Dr. Farooq tell you his story. So, Dr. Farooq, thank you very much for joining us on Cold Steel. It’s an absolute pleasure to have you. This is a really special edition, I think of the podcast and something we’ve been thinking about for a long, very long period of time. And we’re really privileged to have you participate and help us out with it. Our goal really was to was to understand in a more nuanced way the international medical graduate experience within the surgical world and not only what that was like, but also how we can improve and how we can help the pathway of some folks. To start us off, I was wondering if you could tell us about where you grew up? When did you come to Canada and what your particular training pathway was like?

Omar Farooq  02:02

Chad, thanks very much for for having me on the program. And I really believe that the privilege is actually mine, that I could be invited to such a forum because, you know, I feel that the pathway that I have taken, I’m sure lots of other people are going to be taking. So I think if I can facilitate that, through your forum, I think it’s a big honor for me. Anyways, I grew up in Pakistan, which is in Southeast Asia. I was in the States so they would ask me, where did you come from and I would say oh, Pakistan. And they would always say, oh you know, that’s that state close to Pennsylvania. I said oh no, that’s in Southeast Asia. So I grew up in Asia. I did my medical school from there. And in 1988, I decided to come in here and I’ll never forget that I landed on the 14th of February. It was a cold day. And you know, when we were coming on the plane, that’s why I remembered the date. So they were handing out flowers. So you know, my wife who, you know, has lived all of her life in Canada said why are they passing flowers out on the plane. And you know, they told me it’s Valentine’s Day. So that was my introduction to Canada. And I landed in your city Chad, and it was just all snow and I was wondering, you know what, what is going to be my next step? The only thing I could see from up on the sky was snow. I then went ahead and did what most IMGs do: upgraded myself, wrote my exams. Went to Cleveland actually, because initially I wanted to do surgery, but I thought you know, the Achilles tendon for a surgeon is always medicine, as you know. Double blind studies, two surgeons looking at an EKG.  So I thought I might as well go and learn a little bit of medicine. So I got lucky enough and had the privilege of being in a very good hospital in Cleveland, did a year there and got a breakthrough and came to Saskatoon, Saskatchewan. Did my five years of general surgery there, went back to the US because I wanted to go back to Pakistan to do cardiac surgery there. So I actually went to South Carolina, Medical University of South Carolina and did about nine months of of cardiac surgery. And after doing a few pumps, I knew this was not for me. Came back, did one year of laparoscopic fellowship at McMaster with Dr. Anvari and then came to to Fort Saskatchewan as a community surgeon and have been there for about 22 years. Never looked back.

Chad Ball  05:06

Wow, that’s an amazing voyage. Just broadly speaking, and then maybe specifically, if you think it’s helpful, what were some of the dominant obstacles, maybe both in terms of, you know, your initial medical training, as well as just potentially, psychologically and socially when you first came over. And then in particular, as you pursued that really complex and high level training career path?

Omar Farooq  05:34

Okay, Chad I think you hit it. That one word is so important. The psychological part; even the mindset was my biggest obstacle. For me, there were two transitions. One is, I was moving from one part of the world, which was very different from the other parts of the world, which may not be true for all attendees, you know. Some IMDs are actually in Canada, they go and train and then come back. Mine was a different scenario. I had two things to become familiar with. It’s just like anatomy, right? If, you know, you have to know about a little bit of brain and a little bit of abdominal surgery, both at the same time, within a limited period of time. So for me, I came up with a perfectionist mindset. And, you know, it was obvious that when you are in a new place, perfection as a mindset doesn’t work. You have to have a growth mindset. So if I had to say what was my biggest obstacle, the biggest obstacle was myself. I’ll give you a small example. You know, just to get into a residency, I didn’t have people telling me that you have to actually apply into a program. And I passed my exams. I thought, yeah, you know, what, why don’t I just go and try out things as we do in Southeast Asia. If you wanted to do something, you just go after it. So I actually got a ticket from Greyhound and drove into US without an interview. So the first guy looked at me, he’s like, are you crazy? What do you think you’re doing? You’re looking for an interview. But the second place, I landed an interview. And that was my home for a year. So I think mindset is the real thing, which was my most dominant obstacle. I myself was the biggest obstacle. And then also put me in a mindset, that in order for me to do better and to contribute. The biggest obstacle is also going to be me. Because as soon as I got into a training program, the language was different. You know, right now the language is dude, at that time, it was different different words, and I couldn’t understand. So my thing was Chad, I would call my wife and I said, you know, this guy’s saying this to me, what does it really mean, in this terminology. So the language aspect of it. And I’ll give you a small example, you know, when I go for my rounds in the morning. In Pakistan, when you go, you shake hands with everybody. And so here, the residents were nice enough, but after about five rounds, they were like, “we don’t shake hands, let’s get to work”. So it was a little bit of adjustment of a culture. The language barrier, like I said. The most important part for an IMG who’s actually migrating, the key has to sort of leave that cultural package behind. Not that there’s anything wrong with that. But you know, in order for a person to do well, he has to understand the norms of where he’s operating on. Whether it’s in the abdomen, or whether it’s in a society. He has to constantly find out what. So, you know, in a very generic way, that was the problem. In a specific way. I was not used to computers at that time. So I had to learn that.

Ameer Farooq  09:07

Sometimes I think being an IMG, contrary to what most people think, actually conveys some benefits. Like I think it allows you to maybe see things differently than other people see it. And then, there’s also a certain sense of family that you see among IMGs. Like when I see all the Pakistani residents, they’re tight. Like their families are tight, they’re tight. And they have a different sense of having kind of gone through this journey and this whole uphill struggle that no one else will really understand except for them. So do you think there’s been any benefits for having come from Pakistan and then started training here? And do you think there’s a special kind of camaraderie that links other IMGs together?

Omar Farooq  10:02

I mean, that’s a great question. But you know, retrospective scope, as you know, is perfect. You know, when you do an appendectomy, you can always say, well I could have done it differently. But when you’re actually going to somebody who’s got a BMI of 46, that’s what it seems like at that time. That you’re operating on somebody who’s got a BMI of 46, you know, you’re going to easily get lost in the momentum there somewhere. At that time, it doesn’t feel like camaraderie, or it doesn’t feel like you have a definite advantage. Your mindset is very different when you come in as an IMG because there is a lot of stress. A lot of stress because people from where you’re coming in and joining in have expectations, so stress management. So you know that your successes on the other part, on the other end of stress. So one thing that one doesn’t realize that for an IMG, stress management is actually a very important part because, you know, he has to manage stress, he’s sometimes coming from a background that everything looks new to him. You know, you take somebody’s language away, and you bring him down to a zero. And this camaraderie among residents, you know, you find camaraderie only when it’s a change in attitude that just came to my mind. It’s like, if there is one goat, and there are 10 lines going after it, you know, you have to figure out, are you the goat? Or are you the lion? It becomes very different. So, it’s like, 10 IMGs going into one residency spot. Only one person is going to get one. As soon as kill is over, everybody comes and joins in. So, you know, when you saw me, it was you, all of us were residents at that time, that struggle that went in. So the camaraderie among IMGs is because, again, the mindset. I believe in a different mindset, the mindset is progressive. Also, it is the economic mindset of scarcity, where we have limited resources, and you know, there are only a few spots, and only a lucky few are going to get it. So it takes you into a mindset that becomes very competitive. So rather than helping people and using those two years of your life or one year of your life, to get into a program to help each other, it becomes like you’re in a jungle trying to make a kill. So afterwards, like I said, it’s a very serene kind of atmosphere, and everybody’s nice. But you know, that’s the tip of the iceberg. An enemy, that’s something that only an IMG can experience. The guy who did not get that job, who’s still driving a cab or still selling a pizza, and still filling up gas, he has very different emotions about the camaraderie. He still thinks of himself as… he basically loses his own self dignity. So he not only, of course, loses his skills. If you don’t operate, you lose those motor skills. So he loses on many different ends. He loses his skills of whatever he’s trained in. But more importantly, he loses his confidence. And you know, when you lose your confidence, that strain that holds everything together, it’s an integration. So I would say that camaraderie, that international medical graduates experience after they have done residency and before they have done residency, are two very different things. So it’s not all rosy when you are going to work. Once you are beyond that threshold, it’s very different.

Chad Ball  14:20

That’s such a profound series of comments. Dr. Farooq, you know, it’s an interesting time, of course. Maybe we’ll get into it towards the end. But, you know, as a now middle aged white male who certainly would be described as privileged growing up in Canada. Certainly, on a personal note, my family was in the lower socio economic side of things. I am aware of some of the struggles that you speak of, you know, that I never have to deal with or had to deal with at any point. But certainly not all of them. And it’s remarkable to hear that point of view. I guess as a greater country and a medical community and in particular surgical community, of course now that you’ve been part of for a number of decades, how do we make that experience better for an international medical graduate trying to navigate that pathway within Alberta, within Canada? How do we gain more insight? How do we show more insight? How do we be more helpful for those particular folks who, you know, maybe have that aptitude and that drive and are going to be wonderful contributors to our medical landscape?

Omar Farooq  15:33

Chad first of all, I think the most important part is having a mentor.  First of all, the criteria of who can or cannot come in has to be as stringent as possible. You are now up there in training residents. And, you know, we always feel proud saying, I’m only going to let that resident go who can operate on my mother or my wife. So you know, that criteria always has to be there. It doesn’t matter whether you’re an international medical graduate, that you’re trying to help, the bottom line is that the criteria has to be met. That this person is smart enough and trustworthy enough that you can let one of your loved ones get operated on. So that formula that the Canadian surgeons apply, and I think surgeons apply that all over the world, is the Golden Grail. There is no question about it. That has to be met. Having said that, you know what I didn’t know Chad, was the research aspect of things. So you know, if I would have come in, and somebody would have said, you know what, you have this one year to start trying to figure out what the next step is. If somebody would have just taken mentorship out there, if there was a program in which… I know what an avid researcher you are, for example. And if there was an avenue I could connect with you. I think that would have been very helpful. The second thing is, now that I’ve been a certain…when I would go into the operating room initially, there is a very different perception. If a surgeon would shout at me, for example, or was throwing a temper tantrum, to me, it really didn’t affect me. And I thought this was normal. And, you know, if a foreign medical graduate or an international medical graduate that comes through, if he is sort of educated in this, that this is not normal, that, you know, he could, he actually has to be nurtured like a small little tree. Because he comes on with his own background of complexes. He sort of thinks of himself a little bit less than everybody. And then the reason then becomes important Dr. Ball, because then he cannot contribute as much as his potential is. And that’s the biggest thing in my mind. That if our community as surgeons can take all the small obstacles or the big hurdles away from a path of such a person, and let him just nurture, we both know that human potential is limitless. There is no such thing as impossible. But that person has to realize that himself or herself. So in a more generic fashion, if a program director or the surgeons who are involved can nurture a person and especially an IMG, and just take the obstacles out of the way and concentrate on those things which he or she may not have enough exposure, which I think is a research mindset. I think it will go a long way.

Ameer Farooq  19:29

One of the things that people widely perceive as potentially getting a foot in the door is to become a clinical associate. And just for context for our listeners, the clinical Associate Program in Alberta is a program by which often IMGs are employed within a particular specialty, often surgical specialty, but also internal medicine as well, where they can practice as almost like, as a resident, looking after a particular service. What are your thoughts on being a clinical associate? You and I both know kind of sometimes how clinical associates can be treated. But on the flip side, sometimes it does seem like it may be a foot in the door for people. What do you think? What are your thoughts on the Clinical Associate Program? Do you think that’s something that is good? Or is it kind of exploitative for IMGs?

Omar Farooq  20:36

I mean, again, when you are looking for light, and you even see a little glimmer, you hold on tight, right? So Clinical Associate Program, I think, is definitely a big benefit. But you know, how you always judge a program by what the end result is; what the end result is. For listeners, we are in Alberta. In Alberta, the end goal is to get a Clinical Associate to a point in which he or she can apply for residency. I think it’s a great idea, right. On an average, I don’t know whether you’re aware or not, a Clinical Associate gets paid 30 bucks an hour, which they’ve really cut down on it. And so clinical associate, for a person who’s getting in, if that’s the end of his career, that he is going to die as a clinical associate, obviously I don’t think that’s right. For that person, that may not be a fulfillment of his or her dream. But if there was a pathway in which clinical associate could get into this program, and then has the ability to really shine and other people can see that this person has potential, and then apply into a residency program, I think that would be good. So, I think it’s better than having nothing. But I think the goals have to be defined very clearly. So you know, in Quebec, for example, as you know, there is COVID. They have asked people to come in and apply for jobs, which are only going to be there till the COVID ends. And it doesn’t take a rocket scientist to figure out what that clinical associate going to be doing, you know. That’s a step in the door for him, but at what cost? That person has to decide. But, you know, the analogy that comes to my mind, again, you know, the Mughals used to have those big knives, which were very carved and had emeralds on them and lots of jewels on it. But you know, if you use that knife to cut onions, it’s not really a smart idea. Right? So if the clinical associate thinks of himself, this is it for me, it’s like using that knife that could do lots of things. And here he is, cutting onions with it. So, I think the end goal of this Clinical Associate Program for people like Dr. Ball is very important. Because they look at it as, here is a stream of fresh minds, and smart people coming through. But then people higher up who are in residency programs are actually looking for these people and saying, okay, you know, this guy can help Canada and can help progress the art of searching.

Chad Ball  23:55

That’s really interesting. You know, we think, as you do, I think a lot about the clinical Associate Program here in Alberta and the delivery of it. I think your points are just so dead on. I think that program probably is just like, all the rest of life, you know, in and outside of medicine. Life is sort of a bell curve. And folks at the very top end of it who utilize that platform, and that exposure to people are real stars, they tend to walk into residency programs as you’re saying. There’s a small cohort at the bottom of the bell curve, really, that maybe are a long, long way away from being able to contribute in that way. Even in the near to mid future in the country. But I do worry about that program and that concept. You’re sort of highlighting it for them, you know, the bulk of the bell curve. And I always sort of reflect on my connection with South Africa. You know, I credit Cape down in the trauma world and South Africa with a lot of my training. In that old school British system that, as you probably know, it’s quite interesting because you can be stuck as a senior resident for many years and not progress. When I first went down there as a resident to train for an elective, I had never seen that system and I was sort of blown away that it even existed. Because certainly, you know, in North America and certainly in Canada, you move forward. You have attainable goals, you make them, you don’t make them but you know where you sit. And I do worry that that same sort of mentality or maybe reality applies to the bulk of the bell curve for folks in a Clinical Associate Program. To the point that I wonder, you know, exactly how much we are helping them or inhibiting them at all. So I guess my question after droning on about that is, the psychology of that: of feeling stuck in one place must be like my South African friends. Just terribly demoralizing and difficult to deal with. How do you –  not that you’ve maybe ever personally experienced that aspect of it, because you’re clearly a star from the beginning – but how do you deal with that? How do they deal with that? And how can they break out of it potentially?

Omar Farooq  26:19

You know, you’re dead on again, Dr. Ball. But you know, it’s the same thing as Viktor Frankl while he was living in Auschwitz. It’s your mindset. First of all, he knew that this was going to be a long struggle, but he only concentrated on those things which he could change. Because you’re right, once the hope is gone, you as a person sort of disintegrate in many different levels. Some do it in a big way. And some people just, you know, if you lose your dreams, you lose everything. And you’re absolutely right, Chad. Sometimes, like you mentioned about South Africa, and I know in Pakistan, also, the system just helps a few people and for other people, there’s just total loss of their dreams, and they are just stuck in that system. Now, what is the solution for that? I think the solution for that, again, is that those people…there has to be a program for those people who are in there and not able to get up, or get off there. There has to be. And again, I believe in research so much, that I think, first of all, we don’t want to use the word study. But you know, we actually get those people involved and say, okay what are the other areas that you can contribute? So, you know, not everybody can become a star trauma surgeon. But everybody can write the economics of medicine. So you know, those people who are there, maybe medicine was just a foot in the door for them, and you know, now they are in Canada. Because, again, if you go in a mind of an IMG, there is a lot more social aspects of how and why that person became a doctor in the first place. Because I really believe that if you love something, you will get to the top of it. That’s the passion that drives.

Chad Ball  28:27

Yeah, that’s perfect. And you preempted a concept that I really wanted to talk about, which is exactly that. When things aren’t going well, how do you reintegrate and rekindle your passion or your movement forward? You know, one of our listeners who’s who’s a close friend of mine, who’s an HPB surgeon, who most of the HPB community knows quite well, and I won’t say his name, but you know, he came over from his from his country as an IMG and he was literally the janitorial staff in the hospital. That was his entry point. And work and work and work. And then he hooked up with an HPB surgeon who ran a lab, sort of befriended that HPB surgeon who had been in that facility for a long time. Ended up transitioning into the lab. Ended up transitioning and redoing medical school, residency, fellowship. And then, you know, now obviously, is a very successful and really great guy in that field. I look at him and I’m amazed by the story and impressed by it and he’s such a beautiful human being. But I do also recognize, a guy with that kind of drive and that kind of hidden talent, at least hidden initially to people around him. He’s going to do great, he’s going to be a star because he has the same qualities that you do. But I do continue to worry about the folks who aren’t as driven or optimistic or talented in these programs. And I worry about it, quite honestly.

Omar Farooq  30:01

Chad again, that speaks more about what your perspective on life is. And you know, in the end, it comes on to, you know, what percentage of your own internal aspects. I don’t think that there’s any shortcuts I took.

Ameer Farooq  30:28

One of my favorite stories growing up is the story that we would always hear about when you first came to the US and to Canada. Where you have to write the LMCC exams. Or sorry, maybe the USMLEs that you had to write. In any case, you met another Pakistani who had been living in Cleveland for years, where you were doing your internship, and you told him well, I’m planning to write both my USMLEs in the next year, in one sitting. And he said, oh you’re crazy. Like, you know, I’ve been studying and trying to do this exam for years. And I’ve failed. And you told mom that, you know what, I’m going to give it one shot. Otherwise, that’s it. I’m going back. How much do you think the fact that you had us and you had a family kind of changed your motivation? And obviously, you’re not unique in that lots of IMGs come to Canada with a with a family. And that’s often I think the reason why many IMGs come to Canada, is looking for better opportunities for their family and for their children. But how do you think that knowing that you had five of us to look after and to think about, how do you think that changed your perspective? How do you think that motivated you in a different way? And what advice do you have to other IMGs, who have families and are trying to raise their families in a new country, while at the same time themselves going through this tremendous journey?

Omar Farooq  32:19

You know, as far as family is concerned, of course, in medicine, I really believe that you need to have a partner in life, that can take care of your kids. Just because it becomes exponentially hard. Or the person has to be so motivated that he or she can do surgery or do medicine and then come back and take care of the kids. Both aspects have to be there. For us as IMGs you know, the first thing I think for an IMG who is going through – remember what I was telling you. There’s always that stress component that happens. So, the most important thing that I thought that I was never going to think about myself as a victim. That mentality that, you know, whatever I have to do, if I have five, well two or three kids at that time, I really felt that was a strong point for me. That motivated me to go out and do things. And again, at that time, family becomes important. Because it’s not really about medicine and researching at that time. It’s how you control your stress that goes with it, because you’re not getting anywhere, at least for initial period of time. And when you come home, you know, it may sound very cliché or like a movie scene, but you see your kids laying there and you’re thinking like, using, like, you know, how am I going to feed them or what’s gonna happen? So, you know, it becomes a reality at that time. It’s not really a movie scene, it really does happen that you see your kids and you get motivated every day. You know, one other way that we can connect together with international medical graduates is having their families integrate themselves because you know, the struggles are the same. In residency, you always have a grant room, you know, in which you complain against people like your professors like Dr. Ballinger, like he did this to me. And you know, you can all get together and say, somehow once you release that struggle, somehow you feel like you have vented everything and you’re ready for the next day. So I think meeting together with families, having a clear goal. Most important thing is: not get into that victim mode that you know, man, I have these kids, what’s going to happen to me. You just can’t. Use this as a motivation, not as an obstacle.

Ameer Farooq  34:58

You’ve kind of touched on this a little bit already, and I think it’s so important to actually have a mentor and community. You know, I always think of that story that you tell when you came to Cleveland, and then we made friends or you made friends with other Pakistani doctors and someone just offered out of the blue to to edit your CV. Like they said, literally just send me your CV, and I’m going to go through it without you even asking them to do it. And they totally revamped your CV and made it possible for you to go and apply to surgical residency. So beyond having the reaching out and becoming part of the community, are there any specific resources that you think are important for IMGs to know about? And what would those be?

Omar Farooq  35:57

I think the most important resource is people. I really believe that for IMGs, connecting with people, you know, along with their community, is really important. But I think, for IMGs who are coming in now, the resources are all available on the net. If I may use that word. I think it’s not about the availability of resources, which is there. But I think there is a big distinction between knowing something and having knowledge of something. So although the resources are there, I really believe that it’s in small steps, how an IMG uses those resources, and gets to where he or she wants to get to. So I think it’s not about resources, it’s, again, being able to cultivate those resources in one subject that I think is important.

Chad Ball  37:11

You know, Dr. Farooq, I hear your insights and your humanity quite honestly, and your advice. We can’t thank you enough for it. I think this podcast is going to do, hopefully a lot, with our international medical graduates. You know, obviously Ameer and I have been doing this now for many months, and there’s been a few world events that have sort of occurred while we’ve been doing it. And we would probably be remiss if we didn’t touch on it. Certainly, the global call for, quote unquote, visible minority equity right now is clearly very front and centre. I guess I’d like to end the podcast with your views on that. It seems a little bit funny to apply this label to you because, of course, you you’ve been in Alberta as a staff surgeon for so many years, but I guess as a visible minority, as a surgeon, as a father, as a husband, as an international medical graduate and as a Canadian: how do you view the current equity discussion that’s going on? How do you process it? And what do you think about it going forward? You know, not only in the US where yourself and myself and a lot of us have lived, and it is a different place. But, in particular as applied to Canada and maybe even the medical surgical world?

Omar Farooq  38:35

We have forgotten as surgeons, our role for having this equity distribution. And you know, who better people to understand this than surgeons? When we cut a person, we know that the blood is always the same color. The gallbladder always looks the same. You know, when you’re doing transplants, you don’t match by color, you look at the HLA and you know, at that time, you don’t have that distinction. So we know as surgeons, that this is such an arbitrary division off coloured. You know, when you have a bleeding vessel, you deal with it very differently than how you deal with a chronic wound. And I find that this racism problem or this color problem is once you deal with it, at all aspects, just like surgeons, you know, operative way versus non operative…because, you know, life for me, being a surgeon, honestly has become so binary that it almost feels like, okay, what’s the operative way? What’s the non operative way? So, I would think, you know, if you just think of it as a preoperative assessment. As surgeons, even if you contribute…first of all, if we think of that problem, you know, just like we have given up hospital bed administration. I know I only complain about it, but don’t contribute towards it. Because I always feel like this is not my problem. So the first thing is realizing that it is a problem, and we have to deal with it. I think that in itself will go a long way. And who else can deal with it better than people who see blood every day, if you know what I mean? So even if we contribute, like, you know, $10, in an area that we decide, you know, First Nations come to mind, other minorities come to mind. We’re gonna support 10 kids in a year. The surgical community, I’m not talking about Canadians, specifically, but generally. And in that community, we are going to have pathways for these ten students. We are going to facilitate that these people have role models, and they can actually, all the hurdles that come for this specific background, are delicate. I think that’s the first thing. That we start at a very basic educational level. And then you know, that’s sort of the preoperative assessment. Intraoperatively, you know, sometimes, you have to stop, you have to put pressure on the blood vessels, and sometimes you have to tie it. Sometimes if the area’s gangrenous, you just have to take it off. So, that interoperative approach or the current approach that happens, you have to take it like this. And your discretion, your own biases come at that time. How you’re going to approach that particular thing. You know, basically remember, remember who we really are as human beings.

Ameer Farooq  42:18

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