An AMSA Report: John Flynn Placement Program Scholars

JF PP

AN AMSA REPORT: JOHN FLYNN PLACEMENT PROGRAM SCHOLARS

2021

TABLE OF CONTENTS 01 02 03 05 08 11 13 16 17 18

Executive Summary Background Demographics John Flynn Placement Program Experience - Drivers for Participation - Placement Benefits - Barriers to Completion Rural Clinical School Experience - RCS Participation - Commitment to Extended Placements Concerns Raised with Rural Experiences - JFPP Placements Key Issues - University Rural Placements Key Issues Rural Retention - Inspirations for Rural Career - Rural Intent - Rural Workforce Perspectives on the Future of JFPP Limitations, Conclusion and Acknowledgements References

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EXECUTIVE SUMMARY

The John Flynn Placement Program (JFPP) is a program run since 1997 providing thousands of students each year with a short-term rural placement opportunity. With clinical and community aspects, JFPP aims to create high-quality experiences for students to foster rural interest and invest in future workforce retention. The JFPP program was ceased in the 2021-22 Federal Budget citing reasons of high attrition rates and redundancy due to expanding rural university placements.

The Australian Medical Students Association and its Rural Health Committee advocates for greater accessibility to clinical placements for all students. Medical students and junior doctors who are current or former JFPP scholars were surveyed to explore their JFPP experience and draw comparison with any university-based rural placement. During the survey period, 172 responses were collected across Australia. 86% of respondents had undertaken clinical placements at university, and 71% have experienced some form of university rural placement. 47% of participants completed their JFPP, 44% are in progress, and 3% exited before completion. 58% disagreed with the cessation of JFPP, and 90% would like to see this model of rural placement return in future budgets.

Participants cited reasons for participating in JFPP including clinical experience, exposure to rural health and future aspirations to work in rural or remote areas. There was almost ubiquitous agreement that clinical experiences were valuable. Additionally, more than half of the participants developed mentorship connections, enjoyed exploring the local region, and were involved in community activities.

Primary concerns about the program included feelings of isolation and several cases of administrative mismanagement. Only 3% of participants exited the program prior to completion. However, a large majority of survey participants currently involved in the JFPP expressed an inability to complete the program before 31st December, 2021 (the initial deadline which has since been revised to 28th February 2022), largely due to COVID-19’s ongoing border restrictions and conflicts with university placement scheduling.

From those who had also undertaken rural placement at university under the Rural Health Multidisciplinary Training (RHMT) funding, 52% spent more than 12 months on rural rotation, and 51% completed one rural placement 6 months or longer. 47% of all participants were uncertain about or unable to commit to longer rural placements. The most common reasons were lack of support structures, financial stress, no availability of longer placements from university, and concerns about poor teaching.

Problems with university rural placements more broadly centred around the authenticity of rural experiences and lack of academic support.

When asked about motivators for future rural career intent, similar factors were noted by participants.

These included diverse clinical experiences, appreciation for rural lifestyle, and community integration.

More than 70% of participants wished to practice rurally as a consultant, however less than 50% wished to complete vocational training in a rural setting. Most notably, 80% of participants believed that JFPP contributed significantly to their intent to practice rurally. This rate of influence is similar to originating from a rural background. JFPP was more frequently reported to be an influence than university rural placements, which was considered impactful for 65% of participants. The impact of the program on rural retention was unable to be assessed, despite being an important indicator for all rural workforce programs and is a potential area for future analysis.

Alastair Weng - AMSA Rural Health (Vice Chair External)

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BACKGROUND The John Flynn Placement Program was established in 1997 and has since provided thousands of students with a taste of rural medicine. The key objective of the program is to provide an experience of rural practice while creating lasting connections with the community. Scholars spend their placements working alongside a rural doctor (clinical mentor), reside with a host and are provided a contact who provides insight into the community life. From July 2019 until 30 June 2020, 708 scholars from universities across Australia undertook rural placement funded under the JFPP and the majority of these were in the primary care setting (1).

In the 2021-22 Federal Budget, JFPP for medical students was ceased in favour of the new John Flynn Pre-Vocational Doctor Program (JFPDP) for junior doctors, with cited reasons being that the JFPP program was outdated in the context of the co-existing Rural Health Multidisciplinary Training program, in addition to a high attrition rate. In 2020, the rate of those who had withdrawn or ended their engagement with the program prior to completing the 8 weeks of placement was 4%, compared to the figure of 30% cited by the Department of Health (2).

Despite its longevity, little evidence has been collected regarding the influence of the JFPP on future rural practice. Further, although placement quality was rated a mean 86/100 in 2020-21 evaluation surveys, there is also no research into delineating what is anecdotally referred to as the “John Flynn magic”, the unique factors which students attribute to the high quality of placement experiences within the JFPP (1).

To address these questions, the Australian Medical Students Association (AMSA) Rural Health Committee developed and distributed a survey to medical students and junior doctors who have participated in the John Flynn Placement Program. The aim of this survey was to explore current and recent past scholars’ perceptions of the program and its contribution to rural intent and practice. It also collected information about participants’ university rural clinical placements in order to compare their experiences. The survey was created by the AMSA Rural Health team and distributed through social media channels to all universities across Australia. The survey remained open for one month during June - July 2021, and completed responses were used in the following analysis.

Established in 1997, the John Flynn Placement Program has provided thousands of students with a taste of rural medicine.

Image courtesy of State Library of Queensland

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DEMOGRAPHICS During the survey period (28/06/21 - 25/07/21), 172 valid responses from current and past JFPP scholars were received. 77% of respondents were female and 22% male. 56% of respondents were undertaking their clinical years at university, and a further 30% had graduated from medical school, see Figure 1. Most participants attended university in Victoria, NSW or Queensland, and close to two-thirds of scholars were offered JFPP placements in a state different from their university, see Figure 2. 71% of our cohort have also undertaken rural placement as part of their university studies.

Figure 1: Number of respondents by degree stage

Figure 2: JFPP state or territory aligned with respondents' medical school home-state

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2 in 3

respondents were offered JFPP placements in a different state to which they attended university

Figure 3: Respondents' current stage of program progression

Of the cohort, 7% were awaiting their first placement, with 44% in progress, 47% completed, and notably only 3% exited the program prior to completion, see Figure 3. Almost 70% of respondents had undertaken at least two JFPP placements, corresponding to a minimum of four weeks, see Figure 4.

Figure 4: Current number of placements completed by JFPP respondents

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JOHN FLYNN PLACEMENT PROGRAM EXPERIENCE

DRIVERS FOR PARTICIPATION

Respondents had the opportunity to share their motivations for applying to the JFPP program in the survey. There were a wide variety of drivers for participation, with the survey identifying several recurring themes.

Gaining clinical exposure, having additional placement opportunities and clinical experience were major motivators for participation. Many respondents who applied during pre-clinical years of their medical degrees were eager to obtain clinical experience earlier in their degree. The unique experience of “[being] in an environment where I was the only medical student” and the increased “one-on-one teaching”, clinical exposure and the close supervision provided were other factors that attracted respondents to the program. Additionally, the degree to which scholars could be practically involved and gain “hands-on experience” during their placement was appealing and motivated them to apply for the JFPP. The other major theme driving participation in the JFPP was the opportunity to gain rural experience and exposure to healthcare in a rural or remote setting. This was very commonly reported by respondents, many of whom had a keen interest in rural health. One participant stated that the placement provided by the JFPP was unique and it would have been “essentially impossible to organise such placements [themselves] or even through [their] university”.

Respondents from rural backgrounds who were based in a metropolitan area for university viewed the program as a way to stay connected to rural health and as an “opportunity to give back to the rural community”. Respondents from metropolitan backgrounds were motivated to apply for the program to gain rural experience, especially if they were unable to access or commit to longer medical school rural rotations and without “the pressures and expectations of [postgraduate] training”. Those who were part of the Bonded Medical Program (BMP) had a unique motivation for applying. They viewed the JFPP as an opportunity to “gain confidence and understanding of what rural life entails” and to enable them to “work effectively in rural communities in the future”.

Another driver of participation included future career aspirations of working in a rural or remote area, as well as interest in training as a rural generalist or general practitioner. Respondents felt the JFPP was an opportunity “to learn what the expectation of working rural is” and investigate whether a career in rural medicine was a good fit for them.

Being able to engage whilst “consistently returning” to a community and integrate better with local groups was another motivating factor. Respondents also viewed the program as a way of creating connections with “mentors who are well ingrained within communities and have years of experience with the challenges and benefits of rural medicine” and as a way to build their networks within rural medicine.

Other motivations for applying for the JFPP included wanting to travel to rural areas, the reputation of the program, encouragement from peers and exposure to Indigenous health. Most respondents listed multiple reasons for applying, suggesting a multifactorial appeal to this program.

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PLACEMENT BENEFITS Our respondents expressed overall satisfaction with placement quality, both clinically and socially. From 159 respondents, 91% cited clinical experiences as a highlight of their placement, whilst 54% built mentor and professional relationships and 44% advanced their professional communication skills. Cultural awareness training was found to be helpful by 26% of respondents, indicating an area of improvement for the program.

With regards to social aspects, 71% enjoyed exploring the local region, and 54% were satisfied with their community integration and participating in local activities. This is expected due to the strong focus in community activities, with the assignment of a non-clinical local contact for JFPP scholars to assist with community integration.

There were various other benefits reported by respondents. One such benefit was gaining insight into local indigenous communities and their culture, as well witnessing how Aboriginal and Torres Strait Islanders are impacted by social determinants of health. Respondents who were placed in a different state benefited from seeing how other state health services operated. Finally, lasting friendships and connection with host families, mentors and the community were other notable benefits.

BARRIERS TO COMPLETION

100%

of accepted scholars yet to commence the program indicated it would not be possible for them to graduate JFPP

Placement in progress The cessation of JFPP in the 2021-22 budget has placed significant pressure on students to complete their eight weeks of placement in a shorter period of time. Out of 87 participants who had not completed their placement or formally exited the program, 76% did not expect that they could complete their placement by 31st December 2021, and a further 17% Placement yet to commence were uncertain. 100% of the accepted scholars that are yet to commence their placement indicated that they would not be able to complete the 8-weeks required to graduate from the program, see Figure 5.

The placement deadline extension to 28th February 2022 may allow a larger number of current scholars to complete their scholarship, but a significant proportion are unlikely to fulfil their eight weeks’ Figure 5: JFPP scholar expectations agreement. to complete placement by 31/12/21

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81 of the cohort of 87 who have not yet completed their placement discussed obstacles to program completion. COVID-19 was a concern for a large proportion of students, with 62% identifying travel and border restrictions as a barrier to completing their placement. The same proportion also explained that they had too many weeks of placement remaining. Interestingly, 36% stated that their university placements conflicted with their JFPP planning, and for 11% supervisors were unavailable, see Figure 6. Whilst not all current JFPP scholars are expected to complete their placement requirements, the effect of COVID-19 and competing university requirements have denied a large number a planned final JFPP visits.

Figure 6: Barriers to completion for current JFPP scholars

EARLY EXIT FROM THE PROGRAM Five participants exited the program prior to completion, corresponding to an

attrition rate of 3% amongst those surveyed. Reasons for non-completion varied, however factors include poor community support and changes in personal circumstances. Only one participant believed that their clinical experience was not worthwhile when compared to university rural placements. Despite the small sample size, this is consistent with Health Workforce Queensland figures of 4%, far lower than attrition rates of previous years at approximately 30% (2). Regardless, there may be a future need to address withdrawals and to investigate how negative experiences can be prevented.

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RURAL CLINICAL SCHOOL EXPERIENCE

Rural Clinical Schools (RCS) were established in 2000 to support the rural placement of medical students throughout their clinical years. Currently, RCSs are funded by the Rural Health Multidisciplinary Training Program (RHMT), an arm of the Stronger Rural Health Strategy (3, 4).

RHMT funding covers many facets of the rural student experience including education, community engagement, research, financial support and rural selection (3). The approach and use of RHMT funding currently varies between universities, with some RCSs providing accommodation for students, travel support, links with community programs and/or support in finding health services.

There are currently no guidelines regarding placement quality or support provision under the RHMT which must be met by universities, nor universal evaluation systems for student experience and long-term career intent.

In 2018, approximately 2,500 graduating students had completed a placement at an RCS: 997 completed a year or more at an RCS. 2,411 completed a short rural medical placement (4).

There is a trend away from short-term to long-term rural placements due to policy change and the reduction in the short rural clinical placement target from 100% to 50% of Commonwealth Supported Places nation-wide (3).

In 2018, RCSs provided a total 6,384 rural placements, 25% of which were long placements (6-12 months), and 75% were short-term (average 5 weeks).

Approximately two-thirds of the long-term placements are in the hospital setting, and the other one-third in primary care (4).

The RHMT Program is therefore responsible for a majority of rural experience opportunities in medical school; however, the current parameters and intent of the program is around percentages of students and “rural placement weeks”, rather than necessarily using quality of placement or rural retention rate measures. As the RHMT Program was described as an adequate substitute for the JFPP, it was evaluated alongside this program in the survey.

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RCS PARTICIPATION From our cohort of 172 participants, 122 completed rural placements with their university in addition to the JFPP, see Figure 7. Half of these students spent more than 12 months on rural rotations, and approximately the same proportion attended a single rotation longer than six months, see Figure 8. Notably, the distribution of length per placement is bimodal, suggesting that students either spend less than six weeks or more than six months on rural rotations.This may be due to university rural program structures.

Figure 7: Total university rural placement

Figure 8: Length of longest university rural placement

COMMITTMENT TO EXTENDED PLACEMENTS Slightly over half (53%) of our respondents indicated that they were able to commit to rural placements longer than six months. An additional quarter were unable to partake in these extended placements and the remaining respondents were uncertain, see Figure 9. 76 participants provided reasons for their inability to take on a rural placement for extended periods, see Figure 10. 50% of these students were concerned for a lack of social and family support, with 14% having carer duties for someone in a metropolitan centre.

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Further barriers include financial difficulties and access to medical care, affecting 24% and 11% of students respectively. Notably, only 9% of students said they were not interested in an extended placement. In 34% of cases their university was unable to provide them with extended rural placement opportunities. Furthermore, 22% of students expressed concern that they would not receive adequate teaching on extended rural placements.

Figure 9: Ability to commit to >6 months rural placement

This data suggests that, as expected, for the majority of students, inability to complete long-term rural placements stems from personal rather than professional issues, and that there may be space for improvement with regards to ensuring social, financial, and medical service support.

Figure 10: Barriers to attending extended rural placements

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CONCERNS RAISED WITH RURAL EXPERIENCES

Thematic analysis was performed to identify key issues faced by students on university and JFPP placements. The survey data revealed several issues across both university and JFPP placement experiences. These issues are summarised below.

JFPP PLACEMENTS – KEY ISSUES ADMINISTRATIVE ISSUES A major concern expressed by a number within the JFPP cohort was organisational challenges. Reported issues such as “poor communication”, “late cancellations”, “admin issues” and “unresponsive and disorganised staff” were consistent themes. While several students also brought up administrative issues with university placements, it was notably a more prevalent idea within the JFPP cohort. This is likely explainable given that universities have significantly more funding, administrative staff, and organisational mechanisms to ensure due process. However, administrative issues may be addressed through appropriate student feedback and closed-loop communication.

ISOLATION AND FACILITIES A second major theme of concern across the JFPP cohort was the sense of isolation.

More than 50% of students reported feeling “alone”, having limited “community contact”, “minimal social opportunities” and being placed in single accommodation houses. This is largely a consequence of the individual nature of the JFPP. In contrast, major rural sites in university organised placements have upwards of 20 students, increasing social contact and the sense of a medical student community. Furthermore, university-organised placements often provide joint accommodation, hostel-type living and shared houses which would further increase connectivity. This was reflected in the relatively low number of students on university-organised placements identifying isolation as a major issue. Along a similar theme, JFPP students reported facility issues including having “dodgy internet”, “unsafe accommodation”, “no air-conditioning”, and "no telephone communication for days”. Servicing more remote locations, a lack of preexisting university infrastructure and fewer in-person support staff are likely reasons behind this concern.

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UNIVERSITY RURAL PLACEMENTS – KEY ISSUES THE RURAL EXPERIENCE Those on university placements experienced frustration regarding the lack of flexibility and sites available for placement. Students often reported being placed at sites they “hated” and not at their “preferred” location. Furthermore, a major concern was identified regarding the “rurality” of clinical sites. Many sites were reported as being “not really” rural, often less than an hour away from metropolitan hubs. In contrast, the greater flexibility and rurality of the JFPP, alongside the opportunity for interstate placements provided a significantly enhanced experience. In particular, a number of JFPP students noted the “amazing” opportunity to be placed in rural and remote communities within the Northern Territory – an experience that most university-organised placements could simply not provide.

THE ACADEMIC EXPERIENCE A second major concern raised by those on university placements was the culture and quality of education. With the majority of teaching in university medical curriculums dictated through metropolitan sites, rural students often felt “neglected” and “forgotten” by faculty and “lacking” academic support. The academic and placement experience reported by students on the JFPP was consistently more positive and enriching. This likely reflects one of the primary benefits of the JFPP – that is, the JFPP is a voluntary program where students and clinicians want to experience rural environments and education, and have a desire to immerse themselves within the community. In contrast, some students perceived rural university placements as being “forced” upon them and having the primary purpose of preparing students for end-of-year examinations and meeting national quotas rather than true engagement within local rural communities. The prevalence of these sentiments amongst rural clinical students remains unknown.

The universities and JFPP offer distinctly different placements, each having their own strengths and weaknesses.

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RURAL RETENTION

INSPIRATIONS FOR A RURAL CAREER

154 JFPP scholars and 118 university rural placement students outlined their inspirations for a rural career. Comparing both groups, there were no substantial differences in their clinical experience, with over 80% in both groups indicating the diverse mix of clinical experiences contributed to rural interest, see Figure 11. The effects of JFPP seem greater than RCS placements with respect to rural generalism role-modelling and appreciation of rural health, perhaps due to the often more intimate professional relationships.

Furthermore, students favoured community integration through JFPP over RCS, a commendation for its community contact system. However, JFPP placements tended to provide sub-optimal work-life balance, possibly attributed to the compressed nature of short-term placements. Interestingly, whilst JFPP mentors may have had greater effects on role-modelling, students preferred mentorship through RCS rather than JFPP, perhaps due to the longer-term placements and non-clinical university roles of educators in rural areas.

Rural Clinical School Experience

RURAL INTENT

JFPP Experience

Figure 11: Inspirations for a rural career

Our survey participants were asked about their rural intentions at different stages of their career, namely as a pre-vocational doctor, doctor in training, and consultant, see Figure 12. As expected for this cohort, a large majority wished to practice rurally in early postgraduate years and after vocational training, but this rural intent decreased to 48% for specialist training. This may be due to a lack of available and established non-GP vocational training pathways in rural Australia, as well as an ongoing perception that specialist training should be conducted in tertiary metropolitan settings.

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Figure 12: Rural intentions at different career stages

When questioned about factors that affect one’s decision to practice rurally, almost 80% agreed that JFPP played a significant role, on par with coming from a rural background, for expressing intent to work rurally. Compared with university rural placements, a figure which is approximately 65%, and marginally trails factors such as other rural clinical or research experiences, see Figure 13.

Figure 13: Factors influencing the decision to practice rurally

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RURAL WORKFORCE The 51 doctors who completed our survey were further questioned about whether or not they worked rurally for a period of longer than three months following graduation, see Figure 14. Due to the small sample size, little can be concluded when comparing those who have and have not worked in a rural area, and this data does not take into consideration intent to work rurally. Notably, there is a significantly larger number of registrars who have worked rurally than those who have not, which may be partially explained by the nature of some training programs rotating through rural hospitals.

Figure 14: Prevalence of JFPP scholars undertaking rural practice, post-graduation

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PERSPECTIVES ON THE FUTURE OF JFPP

Overall, our survey participants were against the withdrawal of funding for the JFPP medical student program and reallocating funds to the JFPDP junior doctor program. From 165 responses, 58% disagreed with the budgetary decision, and only 14% agreed, with a further 28% undecided, see Figure 15. Even more revealing, 90% of participants would like to see the return of this medical student program, or a similar one, to provide medical students the opportunity for voluntary short-term rural placements, see Figure 16.

Figure 15: Perspectives of respondents, ceasing JFPP in favour of JFPDP

Figure 16: Perspectives of respondents on recommencing a student rural placement program

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LIMITATIONS

There are limitations to this survey that should be considered. Participation in this survey was voluntary, and the survey was circulated via social media and other networks by AMSA and other rural health stakeholders. Not all JFPP participants were reached by this method of distribution.

Hence, there is likely to be some selection bias, as JFPP scholars who are engaged with rural health via social media and other networks were more likely to access the survey and respond.

The generalisability of the conclusions drawn from this survey may also be improved. As not all JFPP scholars were contacted and invited to participate, our sample may not be representative of the entire population of JFPP scholars, evidenced by female respondents making up 77% of total participants. This could be improved by inviting all current and past scholars to complete the survey via email or other recruitment measures.

This survey was distributed shortly after the announcement of the cancellation of the JFPP. This, along with how the survey was constructed may have introduced response bias and may have led to respondents to share more positive reflections of the JFPP. Positive responses may have been further influenced by survey structure. This survey was developed by the AMSA Rural Health Committee, who are passionate about rural health and medical student involvement in rural health. This may have introduced interviewer bias, and lead to acquiescence bias in responses, leading to a skew towards positive reviews of the JFPP. Finally, the data gathered by this survey was mostly categorical and qualitative. As such, no formal statistical analysis could be conducted. The conclusion of this survey may be further supported by statistical analysis and obtaining more quantitative data. The survey conclusions may also be better supported by increased power and larger sample size.

CONCLUSION

The results of this survey have illustrated that the John Flynn Placement Program has largely contributed to the rural career interest of participants. 90% of our cohort of 172 participants would like to see a short-term placement program similar to that of JFPP. It is a placement that offers a valuable insight into rural careers and community beyond what can be provided by university placements. JFPP inspires students to practice rurally through a reward-based program that is accessible to more students than placements under RHMT. As such, we believe that there is value in considering an independent short-term rural placement program for medical students, with a robust data collection and longitudinal evaluation system, in order to develop rural interest in order to impact rural workforce retention.

ACKNOWLEDGEMENTS Authors Alastair Weng Jasmine Elliott Anant Butala Madeline Green Laura Beaumont

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REFERENCES 1. Palanna K, Wellman D. John Flynn Placement Program National Post-Placement Report 1 July 2019 - 30 June 2020. Health Workforce Queensland. 2020.

2. Mitchell C. Rural Workforce Agency Network Chair. Personal communication. 8th July 2021.

3. Australian Government, Department of Health. Rural Health Multidisciplinary Training (RHMT) Program Framework 2019-2020. Australian Government. 2020.

4. Battye K, Sefton C, Thomas JM, Smith J, Springer S, Skinner I, Callander E, Butler S, Wilkins R, Gordon J, Kelly K. Independent Evaluation of the Rural Health Multidisciplinary Training Program: Final Report to the Commonwealth Department of Health. KBC Australia. 2020.

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