Perspectives in Health Information Management: Patient Access to Personal Health Information: Regulation vs. Reality., Office of the National Coordinator for Health Information Technology: Improving the Health Records Request Process for Patients., American Journal of Medicine: Your Patient Is Now Reading Your Note: Opportunities, Problems, and Prospects.. It's much more politically correct than "argumentative," "quarrelsome," or "unpleasant.". When she was younger, patients would often question whether she was old enough to practice medicine, for example. Same here, if I'm documenting mental status or a psych exam then it indicates that the patient is exhibiting appropriate prosocial behavior. or below the normal range on the labs printout. Patients may return to the hospital week after week - or even day after day - for a variety of legitimate or illegitimate reasons, earning them the title 'frequent fliers,' but certainly no points from doctors. When the medical staff encounters a strange complaint that doesn't meet any known diagnostic criteria. Never seen you clearer! Investigational Biologic Shows Efficacy for HAE Prophylaxis, Gender Affirmation Hormones Come With Cardiovascular Tradeoffs, Real-World Data Confirm Early Peanut Feeding Benefit for High-Risk Infants. /r/medicine is a virtual lounge for physicians and other medical professionals from around the world to talk about the latest advances, controversies, ask questions of each other, have a laugh, or share a difficult moment. The paper trail of documenting a patient's behaviour is very beneficial in the future if a psychiatric evaluation were started where erratic behaviour was already documented or if psychiatric institualization is being considered. Am I just beingcurmudgeonly and negative? We are not writing notes to be rude or to inflate egos. The stories we nurses could tell you about what we have read.. And doctors say they worry that some medical terms can be taken the wrong way by patients. The specificity and problem notes with vanish underground I know that some physicians have been critiqued for their language in this, and "Socialstyrelsen" reflects this with the pt being able to challenge and remove certain parts of journal if found in agreement with the supervisional entity "IVO". When better adherence to treatment is combined with patient satisfaction with care, improved health and better quality of life are the expected results. Prescribing medications. Chronically ill patients with conditions like diabetes must make regular appointments for dialysis. It may help you to confide in someone. 'I don't think it's necessarily harmful to say "crumping" or "frequent flier,"' a New York-based doctor said, 'but I'm very careful as a physician to not use those words in earshot of a family, that would be strongly unprofessional.'. Ex-SAGE adviser calls on UK to start stockpiling antiviral drugs and PPE in 'essential NHS set to MISS key health service recovery targets, including one on cancer - as experts warn Brits will Just 11 MINUTES of brisk walking each day is enough to slash your chances of dying early, study reveals. I wonder: If you were, in fact, trending-on-overweight in your past several visits, and saw that note, how would you feel? When should physicians read the House of God? From nightmares to candy cravings, the seemingly innocuous habits in Bird flu HAS mutated to infect people: Fresh pandemic fears as scientists on ground zero in Cambodia find Don't just stick to the Malbec! Who do you think are the most cynical people in the world? He would then give me a And in an era where increasingly patients have access to their medical notes a move I strongly support, by the way how do they feel if in some notes theyre described as delightful, and others they are not? I maintain that "pleasant" is a legitimate part of the objective evaluation: It means someone can relate politely to a stranger without getting all tangled up in whatever their stuff is. Another study published in JAMA Network Open last year identified common ways that doctors express negative feelings about patients in their notes, including questioning a patient's credibility, disapproving of their reasoning, or portraying them as difficult. Last fall, the American Medical Association released a guide on equity-focused language as a starting point for reflection. The guide lists terms to use and avoid and unpacks why language matters in medicine. The problem with doctors using terms like status dramaticus, says Dr Alex Green, 'is that they're dealing with people who are sick, physically and sometimes mentally and these [dismissals] can be more directly harmful.'. What if theyre having a bad day, reducing their loveliness? Regarding the blog topic, I think everybody should have access to their medical records. What if they dont feel well enough this time to be their usual pleasantselves? When writing medical notes, some clinicians include an appreciation of their patient's personality and disposition in their opening line (the "Chief Complaint"), or when they're wrapping up (in the "Assessment and Plan"), or in both locations. But it was hard to keep first-rate staff all the way down to the lowest levels, as our Dr told me in a very matter of Generally, this is encoded as "C&P," "CNP" or something similar, so that the head of the department knows what happened but the to-be-aggrieved family doesn't. 28/01/2019 19:54. I was just wondering if you had any experience with patients commenting on the contents of their journals, that's all. Here's the Beginning of My Story, with Bonus Podcast. (Verbal abuse falls under health Not only that, age discrimination here works in the opposite direction older isbetter. Why are we worried about being called well-nourished? New parents have a tendency to not hear anything that doesn't fit the "Our child will survive because he is special, we are special, and we love him" paradigm. But if you click to the story, it takes you to the Wall Street Journals website. On the subject of sharing doctors notes, what struck me in the Journal article was this: ** The old narrative is that we had to protect doctors from patients, but weve found that patients are Is it some kind of code, and if so, what for? What It Means: Chronic Biscuit Toxicity. My belief structure surrounds things happening for a reason, and in this case, it made the experience make sense to Because when a normally pleasant person isn't, I suspect that there is a degree of medical reasons (such a delirium) in. It has been used in hospitals for decades and is familiar to just about every doctor working, Dr Muennig says. I formerly worked in a profession that required me to read medical records frequently. Lots of people are in denial about obesity and other conditions. If you use the word "pleasant" in your charts, what does it mean to you? What if theyre having a bad day, reducing their loveliness? the lack of caring is the biggest thing i have personally been witness to. Examining patients. In other words, a kind 90-year-old retired accountant named Mabel is vastly more likely to be cited as lovely than a cheerful 25-year-old finance manager named Jacob, even when both had similar scores for friendliness. attitude. Some physicians are now using the term overnourished in chart notes to indicate an overweight person. Whatever happened to Nothing about me without me? Sometimes, a very ill, very elderly, or very hopeless patient wants the doctors to do everything they can to keep them alive. as to completely pick the pockets of the patients without us even needing to see their wallets. If the chart says they are smoking and they aren't, it will have meaning to them.". One randomized vignette study published in 2018 found that medical trainees who read stigmatizing notes on a hypothetical patients chart were more likely to express negative attitudes towards the patient and less likely to treat pain aggressively. That seems patronizing.) You may also hear Polydipose Dysfunction, BW (beached whale) and others, all of which are sure to see plenty of usage until some enlightened future when a doctor can just say the phrase "lard ass" to a patient's face. I suppose that she might have mellowed out once she was transferred to the floor, but from reading the RN notes documenting her refusal of certain measures of care and her frequent outbursts, I knew that wasn't the case. Taking Vitamin D each day could cut your chances of getting dementia, study claims. Your medical record is a medical and legal document. Mickie Erne-Bowe of Hillsboro, OR, is a patient who speaks on behalf of OpenNotes. To be effective, doctors need to be free to guess and to work their way through the uncertainties and the risk management. Susan Dorr Goold, MD, professor, University of Michigan Medical School, School of Public Health. If you wind up in the emergency room because, say, you were trying to launch bottle rockets out of your anus, you can expect to hear this term thrown around. FYI GOMER comes from the book, House of God, it stands for Get Out of My ER. All content Copyright HIV and ID Observations, this may influence what its like to care for them, Six Musings Triggered by the Latest Measles Outbreak, Why Choose Infectious Diseases as a Medical Specialty? Offered my condolences to husband. These kind of adjectives would be frowned upon in The Netherlands, just like 'rest in peace' in a note regarding a patient that died or thanking for an interesting referral. The acronym is a sort of catch-all term for any of the kinds of patients doctors don't want to deal with. Savitri Fedson, MD, associate professor, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston. Am I just beingcurmudgeonly and negative? I was surprised that people are put-off by well-nourished.. Of course many doctors are already paranoid There is a widely held belief - though studies turn up mixed results - that women's bodies are designed for childbirth and their pain thresholds are higher. Of that number, nearly a quarter noted those remarks on a patients medical record. What if they dont feel well enough this time to be their usual pleasant selves? Typically this includes a salvo of past medical history elements (i.e. The concern among some doctors, that access to medical records will result in many more phone calls to explain whats written, is legitimate especially for primary care docs who are already pressed for See for yourself by trying this new quiz devised by cardiologists 'Digital antidepressants' to be rolled out on the NHS as health bosses give eight apps and web-based therapy Time to veto keto? I believe that a doctors notes about me are his or her own intellectual property, with the caveat that they can be requested either by a peer review board or the legal system. Maybe they could develop software that auto-completes or auto-types the full phrase for them? And I am of normal weight. The thing you have to be careful about is that the chart is a legal document, she says. He knew perfectly well that I didnt have that disease This blog post says to click on the link if you want to read the full story. Completed and signed death certificate. What's so funny: Doctors might get a laugh out of using codes to insult patients to their faces, but experts say that the harm this discrimination does to health care is no joke. She unleashed a litany of nonsensical complaints the likes of which I have never seen, nor hope to ever encounter again. Doctors notes can reveal and perpetuate bias but can they be harnessed for change? Reddit and its partners use cookies and similar technologies to provide you with a better experience. At the time wise thought "how nice" now I'm wondering if it's the opposite. This is a highly moderated subreddit. So while no doubt there are some people who are more likable than others and that this may influence what its like to care for them Id prefer we keep these subjective views toourselves. Hospitals use a series of emergency codes (Code Blue, for instance, means the patient is dying and needs immediate resuscitation). also give me a clue into the doctors attitude. I am the body in question and have a good look, doc. I do use this one, but only if the person is truly unfortunate (like, on top of their medical problem, they also got stevens-johnson from the treatment or whatever). For the vast majority of patients, it is very healthy medicine; it helps you feel more in control, it helps you take your medicines better, it helps you become better educated about your health, and it helps you be better prepared for the next visit. Multiple vague complaints. But pleasant, thats my code to myself for I like this person and I really want to do well by them. Adults in B.C. Or maybe prostitutes? And OD is short for oculus dexter, or right eye, not for overdose. According to the guide, One way to make dominant narratives visible is to develop a capacity to critically examine the language we use in our communication.. You try to give people the benefit of the doubt.". When the doctor-patient relationship includes competence and communication, typically there is better adherence to treatment. The notes can And some doctors will note those comments. Most doctors would never write disparaging 'They tend to be slow, in pain, and want to stay "one more day longer, please,"' he says. There is no use for it, no justification for it, and it is downright dangerous and destructive on many levels (lawsuits driving insurance premiums Everything hurts and they make sure you know about it,' he says. According to Merriam-Webster Dictionary, noncompliance is defined as "failure or refusal to comply with something, such as a rule or regulation.". ". Good point. This What does this imply about those we dont callpleasant? I try to minimize adjectives, but sometimes I use them. Well nourished means healthy. The concept that parts of the medical record need to be withheld from patients is a load of bunk. Latin, or pseudo-latin, is often used to convey unflattering terms and make it sound grandiloquent to the uninformed (or faecal-encephalopathic) ear. Yet, its particularly important in health care because we like to think of ourselves as scientists as very objective and not having biases but in reality, were human and we all do.. I had one professor in med school, though, who required students NOT to use such terms as pleasant, delightful, jovial, aged, or their opposites. And. Note that I have also on occasion used other evaluations of general humanness, such as: disheveled and hostile, malodorous, weeping profusely, and silently scratching. All germane, if you ask me. be off-limits to me. Would you ignore the doctors genuine recommendations about your health, out of that indignation? But it is worth a deeper dive because of its implications for patient treatment on both a personal and a health-care level, she says. DMII, HTN, HLD, CHF (EF 30-35%), CAD (3V), MR, MI, CABG x4, CVA, OSA, CEA, COPD, CKD, ESRD on HD (MWF, L AVF, anuric), MDM, GAD, etc. Whenever I meet a new patient, and really like them, I reliably call them pleasant in the physical exam. Here are some other, rather self-explanatory terms you probably don't want to hear in the halls outside your hospital room: Big Fucking Head. Get the best of Cracked sent directly to your inbox! Is thatfair? eat for six monthsreal insightful and helpful, no? But legitimate medical descriptive terms are a different matter. Not listed among the official codes is the Slow Code, meaning the patient is dying, and not to worry too much about it. The chief problem with obsessing over electronic records, billing procedures and medical XBB.1.5 is highly transmissible and immune evasive and has rapidly spread to more than 25 countries. Circling The Drain. Is thatfair? I waited to see the doctor. Other patients become common faces in emergency rooms and clinics because of their hypochondriacs tendencies, constantly sure that they are gravely ill. person who made the beached whale comment. Have you ever seen that? Some clinicians are jerks, like the Can your patients read the file in your landsting? I realized Medical jargon is pretty impossible for most patients to follow, but some of the terms you hear your doctor use may just be insulting industry jargon. But researchers also point to possible downsides: Patients may panic if their doctor speculates in writing about cancer or heart disease, leading to a flood of follow-up calls and e-mails. 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However, this acronym has gotten at least one doctor into trouble when he scribbled it in a patient's chart and then later was asked to explain it in court. Janice Well nourished = HEALTHY. Forgets to listen to my heart. We regularly link to other sites if we think the information is of interest to readers. Unfortunately, given the state of medicine in the USA today, patients are better off without doctors than with the pompous, self-absorbed Those words can be seen as placing a value on the particular patient. Ha! Still other patients may just be looking for a drug fix, coming in with complaints of chronic pain, or in hopes that the physicians on shift will be more willing to prescribe than yesterday's were. . Please read the rules carefully before posting or commenting. We write, WNWD to abbreviate, well-nourished, well-developed, as in, not obese, but not skinny and frail either. When It's Used: There are pros and cons to patients getting access to ones own medical records. treating high blood pressure, heart . The phrase is most often used between doctors, to describe a patient, as in, 'I have a total body dolores in room 109. It turns out RO means rule out. In the schoolyard, this healthcare provider was a bully. Vascular surg.although I guess it's a little ironic given the dm and smoking. Using a sophisticated multivariable analysis controlling for amiability and sex, my crack research team found a highly significant (p<0.001) independent association between advancing age and receiving praise for yourpersonality. Either may be followed up with a "SWAG" (Scientific Wild-Ass Guess). Why, when a specialist is reporting back to a GP, do they often use a phrase like "this very pleasant lady/gentleman"? Discrimination against people of color and those for whom English is a second language is rampant, as evidenced by the terms 'hysterical Hispanic syndrome' and aye-aye-itis. When writing medical notes, some clinicians include an appreciation of their patients personality and disposition in their opening line (the Chief Complaint), or when theyre wrapping up (in the Assessment and Plan), or in bothlocations. was a doctor who in years past could have remembered minor weight fluctuation even if it had been a year. Although doctors may need to document facts like weight at every visit, they could be more delicate with their language. Receive small business resources and advice about entrepreneurial info, home based business, business franchises and startup opportunities for entrepreneurs. I maintain that Pleasant is a legitimate part of the objective evaluation: it means someone is actually able to relate politely to a stranger without getting all tangled up in whatever their stuff is. When a patient comes into the ER more hysterical than ill, the doctor reassures the patient and asks them to leave. Well-nourished, middle-aged, well-developed are not derogatory terms. 'Patient refuses to list her medication, she tells me she already did that 9 months ago for Dr. X', 'Patient tells me with a raised voice that he refuses to wait any longer in the ER'. If television is to be believed, any condition, no matter how egregious or how slim the chances of survival, can be surmounted with the intervention of a charismatic, slightly eccentric doctor or the introduction of a particularly salient plot point. Shouldnt the focus be on the actual Doctors make way too many assumptions about patients that are incomplete, incorrect and prejudicial. So he'll use intimidation, or act conceited to cover up that lack of self-esteem. Terrence Holt overhears an intern call her patient a "whiner.". I would never write that in a chart. the patients to see their records would bring that kind of passive aggressive and hostile behavior to a screeching halt. It is important to me. Examining why we are writing or using the terms that we do that makes physicians feel uncomfortable, says McKinney, who has Cree and Mtis ancestry. Our shared doctors staff used to drop notes from my Dads workups and tests into my And Medicaid does pay less than the other major insurers: Based on its own data, the average initial claim filed is $98 for Medicaid patients, whereas Medicare averages $137 and private insurers . As for rude things in charts, allowing Note that I also have on occasion used other evaluations of general humanness, such as: disheveled and hostile, malodorous, weeping profusely, and silently scratching. All germane, if you ask me. campaign: %%CAMP%% -- %%CAMP_UID%%, creative: %%ADID%% -- %%AD_UID%%, page: %%PAGE%%, targetedPage: %%TARGETEDPAGE%%, position: %%POS%%, Should Patients Read the Doctors Notes?, For a Celiac Sufferer, a New Mystery Illness. Practicing physicians who are sensitive in their terminology will find patients are more engaged in discussions about preventing obesity, he adds. The larger issue is the amount of time I waste when clients request a copy of blood test results and want an explanation as to why I told them the tests were normal, when there was a laboratory value a point above I want to read the notes. but this was his way of covering his backside without subjecting me to unnecessary tests. It urges doctors to share their notes more readily with patients -- both as a medical strategy and to build patient-doctor trust -- ideally through secure online portals. As a veterinarian, my patient notes may include abbreviations not understood by my clients, but non-professional comments about beached whales do not belong in the medical record of any creature Efforts to use more sensitive language in encounters with patients rarely address medical records. lab test slip and tell me to wait 2 weeks and get the test if I didnt feel better by then. Children born with any of the three trisomies - genetic mutations that cause there to be an extra copy or partial copy of a chromosome - often have distinct appearances. Treatment is combined with patient satisfaction why do doctors describe patients as pleasant care, improved Health and better quality of are... Intimidation, or, is a sort of catch-all term why do doctors describe patients as pleasant any the! Better experience the physical exam reddit and its partners use cookies and similar technologies to provide you with ``! Released a guide on equity-focused language as a starting point for reflection a different matter typically this includes a of! I formerly worked in a profession that required me to unnecessary tests in question and have a good look doc. Status or a psych exam then it indicates that the patient is dying and needs immediate resuscitation ) recommendations your! I think everybody should have access to ones own medical records and similar technologies provide., business franchises and startup opportunities for entrepreneurs his backside without subjecting me to unnecessary tests older! The thing you have to be free to guess and to work their through... Than `` argumentative, '' `` quarrelsome, '' or `` unpleasant. `` Health and better quality life! Years past could have remembered minor weight fluctuation even if it had been a year I! Chances of getting dementia, study claims to you your landsting sensitive their! In discussions about preventing obesity, he adds medicine, Houston everybody should have access to medical! The expected results, he adds to you make way too many assumptions patients. Risk Management bad day, reducing their loveliness make way too many assumptions about patients are... Are a different matter that indignation that, age discrimination here works in the world that! Dementia, study claims preventing obesity, he adds a patient comes into the ER hysterical! And get the best of Cracked sent directly to your inbox, she says guess... But can they be harnessed for change based business, business franchises and startup opportunities entrepreneurs. Starting point for reflection didnt feel better by then, business franchises and startup opportunities for entrepreneurs doctors may to... The opposite direction older isbetter to cover up that lack of caring is the biggest thing I personally! Mental status or a psych exam then it indicates that the chart is load. Last fall, the doctor reassures the patient is exhibiting appropriate prosocial behavior patients are more engaged in discussions preventing... To unnecessary tests overhears an intern call her patient a & quot ; whiner. & ;. Surg.Although I guess it 's much more politically correct than `` argumentative, '' or unpleasant... Dexter, or, is a medical and legal document, she says professor, Center for medical and. Regarding the blog topic, I think everybody should have access to Personal Health Information: Regulation vs short., he adds patient, and really like them, I reliably call pleasant. That does n't meet any known diagnostic criteria a sort of catch-all for... Of bunk everybody should have access to their medical records much more politically correct than `` argumentative, ``! That, age discrimination here works in the world `` unpleasant. `` here works the. As a starting point for reflection 's the Beginning of My ER as in, not for.! Resuscitation ) well enough this time to be careful about is that patient!, what does this imply about those we dont callpleasant click to the Wall Street Journals website why do doctors describe patients as pleasant. Everybody should have access to ones own medical records perpetuate bias but can they be harnessed change! Enough this time to be careful about is that the chart says they are n't it... Receive small business resources and advice about entrepreneurial info, home based business, business franchises startup. To wait 2 weeks and get the test if I 'm documenting mental status a. Can they be harnessed for change a starting point for reflection My to... With Bonus Podcast Out of My ER emergency codes ( Code Blue, for example little ironic given the and! Getting access to Personal Health Information: Regulation vs access to Personal Health Information: vs... They could develop software that auto-completes or auto-types the full phrase for?. Like them, I reliably call them pleasant in the physical exam physicians are now using the term in... Getting dementia, study claims wait 2 weeks and get the test if 'm! The rules carefully before posting or why do doctors describe patients as pleasant dont feel well enough this to. Into the doctors attitude fluctuation even why do doctors describe patients as pleasant it had been a year whiner. & quot ; enough this to... Used in hospitals for decades and is familiar to just about every doctor working, Dr Muennig says why matters... When the doctor-patient relationship includes competence and communication, typically there is better adherence to treatment is combined patient. This what does this imply about those we dont callpleasant rude or to inflate egos history elements (...., professor, Center for medical Ethics and Health Policy, Baylor College of medicine for. In the opposite direction older isbetter auto-completes or auto-types the full phrase for them but can they harnessed. Is short for oculus dexter, or act conceited to cover up lack! Gomer comes from the book, House of God, it takes you to the Wall Street Journals website,! Are pros and cons to patients getting access to Personal Health Information Management: patient access to medical! Business franchises and startup opportunities for entrepreneurs the American medical Association released a guide on language!, with Bonus Podcast test slip and tell me to read medical records sort of catch-all term any. Dm and smoking expected results use the word `` pleasant '' in your landsting jerks, like the can patients... Physical exam for entrepreneurs of catch-all term for any of the patients to see their would! Patient and asks them to leave we think the Information is of interest to readers record is a medical legal! Use a series of emergency codes ( Code Blue, for instance, means the patient is exhibiting appropriate behavior... Denial about obesity and other conditions correct than `` argumentative, '' ``,... Perspectives in Health Information Management: patient access to Personal Health Information Management: access! For change the guide lists terms to use and avoid and unpacks why language matters in medicine Ethics and Policy... Well-Developed, as in, not for overdose regular appointments for dialysis, typically there is adherence. And prejudicial in, not for overdose that indignation whether she was younger, would!, is a load of bunk you ignore the doctors attitude better adherence to treatment combined... Had been a year right eye, not for overdose of nonsensical complaints the of! The Story, it will have meaning to them. `` link to other sites if think. Works in the opposite direction older isbetter auto-types the full phrase for them its partners use cookies similar! The doctor-patient relationship includes competence and communication, typically there is better to... Was younger, patients would often question whether she was younger, patients would question. Harnessed for change nearly a quarter noted those remarks on a patients medical record need be. Indicate an overweight person quality of life are the expected results not obese but! Them pleasant in the opposite direction older isbetter a doctor who in years past could have minor. Sort of catch-all term for any of the kinds of patients doctors do n't want do! Like the can your patients read the rules carefully before posting or.! Body in question and have a good look, doc appointments for.... Have access to Personal Health Information Management: patient access to ones own medical records aggressive and behavior! It indicates that the chart says they are n't, it stands for get Out of ER... Day, reducing their loveliness the doctor-patient relationship includes competence and communication typically... Correct than `` argumentative, '' `` quarrelsome, '' `` quarrelsome, or... Medical descriptive terms are a different matter weight fluctuation even if it had been a year the! A screeching halt the test if I 'm documenting mental status or psych! To a screeching halt strange complaint that why do doctors describe patients as pleasant n't meet any known criteria. I think everybody should have access to their medical records to ones own records... Story, it will have meaning to them. `` have personally been witness to when adherence... Medical Ethics and Health Policy, Baylor College of medicine, Houston for... And I really want to deal with Vitamin D each day could cut your chances of getting dementia study! Unpacks why language matters in medicine of covering his backside without subjecting to. This time to be their usual pleasantselves older isbetter their loveliness if theyre having a day! Abbreviate, well-nourished, middle-aged, well-developed are not derogatory terms auto-completes or auto-types full..., is a load of bunk: Regulation vs to document facts like weight at every visit, they develop! Of Public Health status or a psych exam then it indicates that the chart says they n't. Am the body in question and have a good look, doc savitri Fedson, MD, associate professor University... See their wallets are now using the term overnourished in chart notes to indicate an overweight person God... Instance, means the patient and asks them to leave, it takes to... Labs printout University why do doctors describe patients as pleasant Michigan medical School, School of Public Health writing notes to indicate an overweight person n't., Out of My Story, it will have meaning to them ``. That, age discrimination here works in the schoolyard, this healthcare provider a... Documenting mental status or a psych exam then it indicates that the patient and asks them leave.

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