American Medical Association
Encyclopedia
The American Medical Association (AMA), founded in 1847 and incorporated in 1897, is the largest association of medical doctors (M.D. and D.O.) and medical student
Medical Student
Medical Student may refer to:*Someone studying at medical school*Medical Student Newspaper, a UK publication...

s in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...

.

Scope and operations

The AMA's stated mission is to promote the art and science of medicine for the betterment of the public health, to advance the interests of physicians and their patients, to promote public health
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...

, to lobby
Lobbying
Lobbying is the act of attempting to influence decisions made by officials in the government, most often legislators or members of regulatory agencies. Lobbying is done by various people or groups, from private-sector individuals or corporations, fellow legislators or government officials, or...

 for legislation favorable to physicians and patients, and to raise money for medical education. The Association also publishes the Journal of the American Medical Association
Journal of the American Medical Association
The Journal of the American Medical Association is a weekly, peer-reviewed, medical journal, published by the American Medical Association. Beginning in July 2011, the editor in chief will be Howard C. Bauchner, vice chairman of pediatrics at Boston University’s School of Medicine, replacing ...

(JAMA), which has the largest circulation of any weekly medical journal in the world. The AMA also publishes a list of Physician Specialty Codes which are the standard method in the U.S. for identifying physician and practice specialties.

While its membership has declined in recent years, the AMA claims approximately 22% of US physicians and medical students as members.

The AMA's political positions through its history have often been controversial. In the 1930s, the AMA attempted to prohibit its members from working for the then-primitive health maintenance organization
Health maintenance organization
A health maintenance organization is an organization that provides managed care for health insurance contracts in the United States as a liaison with health care providers...

s that sprung up during the Great Depression
Great Depression
The Great Depression was a severe worldwide economic depression in the decade preceding World War II. The timing of the Great Depression varied across nations, but in most countries it started in about 1929 and lasted until the late 1930s or early 1940s...

, which violated the Sherman Antitrust Act
Sherman Antitrust Act
The Sherman Antitrust Act requires the United States federal government to investigate and pursue trusts, companies, and organizations suspected of violating the Act. It was the first Federal statute to limit cartels and monopolies, and today still forms the basis for most antitrust litigation by...

 and resulted in a conviction ultimately affirmed by the US Supreme Court
Supreme Court of the United States
The Supreme Court of the United States is the highest court in the United States. It has ultimate appellate jurisdiction over all state and federal courts, and original jurisdiction over a small range of cases...

. The AMA's vehement campaign against Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...

 in the 1950s and 1960s included the Operation Coffee Cup
Operation Coffee Cup
Operation Coffee Cup was a campaign conducted by the American Medical Association during the late 1950s and early 1960s in opposition to the Democrats' plans to extend Social Security to include health insurance for the elderly, later known as Medicare...

 supported by Ronald Reagan
Ronald Reagan
Ronald Wilson Reagan was the 40th President of the United States , the 33rd Governor of California and, prior to that, a radio, film and television actor....

. Since the enactment of Medicare, the AMA reversed its position and now opposes any "cut to Medicare funding or shift [of] increased costs to beneficiaries at the expense of the quality or accessibility of care" — and it also "strongly supports subsidization of prescription drugs for Medicare patients based on means testing". However, the AMA remains opposed to any single-payer health care
Single-payer health care
Single-payer health care is medical care funded from a single insurance pool, run by the state. Under a single-payer system, universal health care for an entire population can be financed from a pool to which many parties employees, employers, and the state have contributed...

 plan that might enact a National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...

 in the United States, such as the United States National Health Care Act. In the 1990s, the organization was part of the coalition that defeated the health care reform advanced by Hillary
Hillary Rodham Clinton
Hillary Diane Rodham Clinton is the 67th United States Secretary of State, serving in the administration of President Barack Obama. She was a United States Senator for New York from 2001 to 2009. As the wife of the 42nd President of the United States, Bill Clinton, she was the First Lady of the...

 and Bill Clinton
Bill Clinton
William Jefferson "Bill" Clinton is an American politician who served as the 42nd President of the United States from 1993 to 2001. Inaugurated at age 46, he was the third-youngest president. He took office at the end of the Cold War, and was the first president of the baby boomer generation...

.

Also, the AMA has given high priority to supporting changes in medical malpractice
Medical malpractice
Medical malpractice is professional negligence by act or omission by a health care provider in which the treatment provided falls below the accepted standard of practice in the medical community and causes injury or death to the patient, with most cases involving medical error. Standards and...

 law to limit damage awards, which, it contends, makes it difficult for patients to find appropriate medical care. In many states, high risk specialists have moved to other states that have enacted reform. For example, in 2004, all neurosurgeons had relocated out of the entire southern half of Illinois
Illinois
Illinois is the fifth-most populous state of the United States of America, and is often noted for being a microcosm of the entire country. With Chicago in the northeast, small industrial cities and great agricultural productivity in central and northern Illinois, and natural resources like coal,...

. The main legislative emphasis in multiple states has been to effect caps on the amount that patients can receive for pain and suffering
Pain and suffering
Pain and suffering is the legal term for the physical and emotional stress caused from an injury .Some damages that might be under this category would be: aches, temporary and permanent limitations on activity, potential shortening of life, depression or scarring...

. These costs for pain and suffering are only those that exceed the actual costs of healthcare and lost income. Multiple states have found that limiting pain and suffering costs has dramatically slowed increases in the cost of medical malpractice insurance. Texas
Texas
Texas is the second largest U.S. state by both area and population, and the largest state by area in the contiguous United States.The name, based on the Caddo word "Tejas" meaning "friends" or "allies", was applied by the Spanish to the Caddo themselves and to the region of their settlement in...

, having recently enacted such reforms, reported that all major malpractice insurers in 2005 were able to offer either no increase or a decrease in premiums to physicians. At the same time however, states without caps also experienced similar results; suggesting that other market factors may have contributed to the decreases. Some economic studies have found that caps have historically had an uncertain effect on premium rates. Nevertheless, the AMA believes the caps may alleviate what is often perceived as an excessively litigious environment for many doctors. A recent report by the AMA found that in a 12 month period, five percent of physicians had claims filed against them.

Claims that the AMA generates $70 million in revenue through its stewardship of Current Procedural Terminology
Current Procedural Terminology
The Current Procedural Terminology code set is maintained by the American Medical Association through the CPT Editorial Panel. The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among...

 (CPT) codes appear to be a mischaracterization. The estimate is based on a distortion of the transparent financial information the AMA voluntarily offers in its Annual Report. The AMA has publicly reported this figure represents income from its complete line of books and products, which include more than 100 items, not just CPT.

The AMA sponsors the Specialty Society Relative Value Scale Update Committee
Specialty Society Relative Value Scale Update Committee
The Specialty Society Relative Value Scale Update Committee or Relative Value Update Committee, is a private group of 29 mostly specialist physicians who have made highly influential recommendations on how to value a physician's work when computing health care prices in the United States' public...

 which is influential group of 29 physicians, mostly specialists, who help determine the value of different physician's labor in Medicare prices.

Charitable activities

  • The AMA Foundation provides approximately $1,000,000 annually in tuition assistance to financially needy students. This has to be seen on the background that in 2007, graduating medical students carried a mean debt load of $140,000 which rose to $220,000 after 4 yrs of negative amortization
    Negative amortization
    In finance, negative amortization, also known as NegAm, deferred interest or graduated payment mortgage, occurs whenever the loan payment for any period is less than the interest charged over that period so that the outstanding balance of the loan increases...

     during residency medical student debt has increased by 7% each successive year.
  • Funds awareness projects about health literacy
  • Funds community service, community health, and healthcare education events held by local medical societies and student chapters
  • Supports research funding for students and fellows around the U.S.
  • Provides grants to community projects designed to encourage healthy lifestyles (of diet and exercise, good sleep habits, etc.).
  • The Worldscopes project is a collaboration with the medical community to collect stethoscopes and the funds to buy them. The stethoscopes are then distributed to those in the global medical community who normally lack the resources to obtain the instruments. Thousands of stethoscopes have been sent to physicians and others in the medical community around the world who lack access to this medical instrument.

Politics

Throughout its history, the AMA has been actively involved in a variety of medical policy issues, from Medicare
Medicare (United States)
Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...

 and HMOs
HMOS
Depletion-load nMOS/NMOS is a form of nMOS logic family which uses depletion-mode n-type MOSFETs as load transistors as a method to enable single voltage operation and achieve greater speed than possible with pure enhancement-load devices...

 to public health
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...

, and climate change
Climate change
Climate change is a significant and lasting change in the statistical distribution of weather patterns over periods ranging from decades to millions of years. It may be a change in average weather conditions or the distribution of events around that average...

.
  • In the 1930s, the AMA attempted to prohibit its members from working for the primitive health maintenance organization
    Health maintenance organization
    A health maintenance organization is an organization that provides managed care for health insurance contracts in the United States as a liaison with health care providers...

    s that sprung up during the Great Depression
    Great Depression
    The Great Depression was a severe worldwide economic depression in the decade preceding World War II. The timing of the Great Depression varied across nations, but in most countries it started in about 1929 and lasted until the late 1930s or early 1940s...

    . The AMA's subsequent conviction for violating the Sherman Antitrust Act
    Sherman Antitrust Act
    The Sherman Antitrust Act requires the United States federal government to investigate and pursue trusts, companies, and organizations suspected of violating the Act. It was the first Federal statute to limit cartels and monopolies, and today still forms the basis for most antitrust litigation by...

     was affirmed by the U.S. Supreme Court
    Supreme Court of the United States
    The Supreme Court of the United States is the highest court in the United States. It has ultimate appellate jurisdiction over all state and federal courts, and original jurisdiction over a small range of cases...

    . American Medical Ass'n. v. United States, .
  • The AMA's vehement campaign against Medicare
    Medicare (United States)
    Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other...

     in the 1950s and 1960s included the Operation Coffee Cup
    Operation Coffee Cup
    Operation Coffee Cup was a campaign conducted by the American Medical Association during the late 1950s and early 1960s in opposition to the Democrats' plans to extend Social Security to include health insurance for the elderly, later known as Medicare...

     supported by Ronald Reagan
    Ronald Reagan
    Ronald Wilson Reagan was the 40th President of the United States , the 33rd Governor of California and, prior to that, a radio, film and television actor....

    . Before Medicare passed, according to Steven Schroeder, Wilbur Cohen inserted "usual, customary and reasonable" charges into the Social Security Act of 1965
    Social Security Act of 1965
    The Social Security Amendments of 1965 was legislation in the United States whose most important provisions resulted in creation of two programs: Medicare and Medicaid. The legislation initially provided federal health insurance for the elderly and for poor families. While President Lyndon B...

     "in an unsuccessful attempt to placate" the AMA. Since the enactment of Medicare, the AMA stated that it "continues to oppose attempts to cut Medicare funding or shift increased costs to beneficiaries at the expense of the quality or accessibility of care" and "strongly supports subsidization of prescription drugs for Medicare patients based on means testing". The AMA also campaigns to raise Medicare payments to physicians, arguing that increases will protect seniors' access to health care. In the 1990s, it was part of the coalition that defeated the health care reform proposed by President Bill Clinton.
  • The AMA has given high priority to supporting changes in medical malpractice law to limit damage awards, which, it contends, makes it difficult for patients to find appropriate medical care. In many states, high-risk specialists have moved to other states with such limits. For example, in 2004, not a single neurosurgeon remained in the entire southern half of Illinois. The main legislative emphasis in multiple states has been to effect caps on the amount that patients can receive for pain and suffering. These costs for pain and suffering are only those that exceed the actual costs of health care and lost income. Multiple states found that limiting pain and suffering costs has actually dramatically slowed increases in the cost of medical malpractice insurance. Texas, having recently enacted such reforms, reported that all major malpractice insurers in 2005 were able to offer either no increase or a decrease in premiums to physicians. At the same time however, states without caps also experienced similar results; this suggests the cyclical nature of insurance markets may have actually been responsible. Some economic studies have found that caps have historically had a dubious effect on premium rates. Nevertheless, the AMA believes the caps may alleviate what is often perceived as an excessively litigious environment for many doctors.
  • Another top priority of the AMA is to lobby for change to the federal tax codes to allow the current health insurance system (based on employment) to be purchased by individuals. Such changes could possibly allow millions of currently uninsured Americans to be able to afford insurance through a series of refundable tax credits based on income (for example, the lower one's income, the greater your credit).
  • The AMA has made efforts to respond to health care disparities.
    • As such, the AMA created an advisory committee to assess the nature of disparities within different racial and ethnic groups. One such committee focuses on the health of the Gay, Lesbian Bisexual and Transgender community. In 2005, the AMA president Edward Hill
      Edward Hill (physician)
      Born in Omaha, Neb., Dr. Edward J. Hill was educated in the public schools of Vicksburg, Miss., and received both his BS and MD degrees from the University of Mississippi. He completed his internship while serving four years as a commissioned officer in the U.S. Navy, in addition to serving as a...

       gave a keynote address to the Gay and Lesbian Medical Association
      Gay and Lesbian Medical Association
      The Gay and Lesbian Medical Association works to ensure equality in health care for lesbian, gay, bisexual and transgender individuals and health care professionals...

       at its annual conference. Since that time, the AMA has worked closely with GLMA to develop AMA policy towards better health care access for LGBT patients and better working environments for LGBT physicians and medical students.
    • The AMA responded to the government estimate that more than 35 million Americans live in underserved areas by stating it would take 16,000 doctors to immediately fill that need, and the gap is expected to widen due to rising population and aging work force. "And that will mostly be felt in rural America," said Sen. Kent Conrad
      Kent Conrad
      Kent Conrad is the senior United States Senator from North Dakota. He is a member of the North Dakota Democratic-NPL Party, the North Dakota affiliate of the Democratic Party...

      , D-N.D., adding, "We're facing a real crisis." Fueling the shortage are the restrictions on allowing foreign physicians to work in the U.S. after the September 11, 2001 attack, and may become more restrictive after the attempted terrorist bombings June 2007 in Britain, still under investigation, linked to foreign doctors.
  • In June 2007, at its annual meeting, the AMA discussed its opposition to a fast-spreading nationwide trend for medical clinics to open up in supermarkets and drugstores. The AMA identified at least two problems with in-store clinics: potential conflict of interest, and potential jeopardized quality of care. The AMA went on to rally state and federal agencies to investigate the relationship between the operating clinics and the pharmacy chains to decide if this practice should be prohibited or regulated. Dr. Peter Carmel, neurosurgeon and AMA board member asked, "If you own both sides of the operation, shouldn't people look at that?" The AMA also noted some employers reduce or waive the co-payment if an employee goes to the retail clinic instead of the doctor's office, inferring that this practice might negatively affect quality of care.
  • In 2008, the AMA issued a policy statement on global climate change declaring that they "support the findings of the latest Intergovernmental Panel on Climate Change
    Intergovernmental Panel on Climate Change
    The Intergovernmental Panel on Climate Change is a scientific intergovernmental body which provides comprehensive assessments of current scientific, technical and socio-economic information worldwide about the risk of climate change caused by human activity, its potential environmental and...

     report, which states that the Earth is undergoing adverse global climate change and that these changes will negatively affect public health." They also "support educating the medical community on the potential adverse public health effects of global climate change, including topics such as population displacement, flooding, infectious
    Infectious disease
    Infectious diseases, also known as communicable diseases, contagious diseases or transmissible diseases comprise clinically evident illness resulting from the infection, presence and growth of pathogenic biological agents in an individual host organism...

     and vector-borne diseases, and healthy water supplies."
  • In July 2008, the AMA focused its energy on blocking cuts to Medicare. Through advocacy efforts and communications campaigns, the AMA and all the specialty societies and state medical societies it comprises came out with a temporary victory. Despite a presidential veto, H.R. 6331, the “Medicare Improvements for Patients and Providers Act of 2008”, passed with wide, bi-partisan majorities in both the U.S. House of Representatives and the U.S. Senate.
  • The AMA has affirmed, through continual policy statement (policies H-460.957, H-460.974, H-460.964, and H-460.991 for example), its support for appropriate and compassionate use of animals in biomedical research programs, and its opposition to the actions of other groups that impede such research, such as some actions from animal rights groups, and its opposition to legislation that unduly restricts such research.
  • The AMA's Office of Alcohol and Other Drug Abuse
    Office of Alcohol and Other Drug Abuse
    The Office of Alcohol and Other Drug Abuse at the American Medical Association was established by the temperance-oriented Robert Wood Johnson Foundation with an initial grant of $5 million, followed by more substantial funding....

     promotes temperance and lobbies for a reduction of alcoholic beverage advertising and an increase in alcoholic beverage taxes, among other activities.
  • The AMA supported the Patient Protection and Affordable Care Act as a step toward providing coverage to all Americans and improving the nation’s health system. See AMA news release at: http://www.ama-assn.org/ama/pub/health-system-reform/ama-supports-reform-passage.shtml
  • The AMA is completely against the death penalty and does not allow any of its members to partake in part of an execution process.

Criticisms

  • Critics of the American Medical Association, including economist Milton Friedman
    Milton Friedman
    Milton Friedman was an American economist, statistician, academic, and author who taught at the University of Chicago for more than three decades...

    , have asserted that the organization acts as a guild
    Guild
    A guild is an association of craftsmen in a particular trade. The earliest types of guild were formed as confraternities of workers. They were organized in a manner something between a trade union, a cartel, and a secret society...

     and has attempted to increase physicians' wages and fees by influencing limitations on the supply of physicians and non-physician competition. In Free to Choose
    Free to Choose
    Free to Choose is a book and a ten-part television series broadcast on public television by economists Milton and Rose D...

    , Friedman said "the AMA has engaged in extensive litigation charging chiropractors and osteopathic physicians with the unlicensed practice of medicine, in an attempt to restrict them to as narrow an area as possible."
  • Profession and Monopoly, a book published in 1975, is critical of the AMA for limiting the supply of physicians and inflating the cost of medical care in the United States. The book claims that physician supply is kept low by the AMA to ensure high pay for practicing physicians. It states that in the United States the number, curriculum, and size of medical schools are restricted by state licensing boards controlled by representatives of state medical societies associated with the AMA. The book is also critical of the ethical rules adopted by the AMA which restrict advertisement and other types of competition between professionals. It points out that advertising and bargaining can result in expulsion from the AMA and legal revocation of licenses. Restrictions against advertising that is not false or deceptive were dropped from the AMA Code of Medical Ethics in 1980 (AMA Ethical Policy E-5.02). The book also states that before 1912 the AMA included uniform fees for specific medical procedures in its official code of ethics. The AMA's influence on hospital regulation was also criticized in the book.
  • The AMA and other industry groups predicted an over-supply of doctors, and worked to limit the number of new doctors. But recently, the AMA has changed its position, predicting a doctor shortage
    Doctor shortage
    Physician supply refers to the number of trained physicians working in a health care system or active in the labour market. The supply depends primarily on the number of graduates of medical schools in a country or jurisdiction, but also on the number who continue to practice medicine as a career...

     instead.
  • It has been argued that the AMA's CPT monopoly has been created by the government and makes the organization subject to government influence; further, the restricted access to CPT codes may not be in the interest of its constituents.

Membership

Physician membership in the group is thought to have decreased to less than 20% of practicing physicians. In 2004, the AMA reported membership totals of 244,569, which included retired and practicing physicians along with medical students, residents, and fellows. The medical school section (MSS) reported totals of 48,868 members, while the resident and fellow section (RFS) reported 24,069 members. Combined they account for almost 30% of AMA members. There are currently approximately 661,400 practicing physicians in America. However, MedPage Today estimates that the AMA only represents 135,300 "real, practicing physicians" as of 2005 (15.0% of the United States practicing physicians). When asked about this, Jeremy Lazarus, a speaker in the AMA House of Delegates, stated that membership was stable, avoiding commenting on the low overall numbers (2005 AMSA
American Medical Student Association
The American Medical Student Association , founded in 1950 and based in Washington, D.C., is the oldest and largest independent association of physicians-in-training in the United States. AMSA is a student-governed, national organization...

 annual meeting, AMA vs. PNHP
Physicians for a National Health Program
Physicians for a National Health Program , is an advocacy organization of some 17,000 American physicians, medical students, and health professionals founded by Quentin Young who support a single-payer system of national health insurance....

 healthcare debate, Arlington, Virginia).

See also

  • AMA Foundation Leadership Award
    AMA Foundation Leadership Award
    The Excellence in Medicine Awards are accolades presented annually by the American Medical Association Foundation to recognize excellence of a select group of physicians and medical students who exemplify the medical profession’s highest values: commitment to service, community involvement,...

  • AMA Manual of Style
    AMA Manual of Style
    AMA Manual of Style: A Guide for Authors and Editors is a style guide by the editors of JAMA and the Archives Journals, most recently published by Oxford University Press. It specifies the writing and citation styles for use in scholarly publications in medicine internationally, including JAMA...

  • AMA Scientific Achievement Award
    AMA Scientific Achievement Award
    The AMA Scientific Achievement Award is awarded by American Medical Association. It may be given to either physicians or non-physician scientists who have contributed significantly to the field of medical science...

  • American Association of Physicians and Surgeons
  • American College of Physicians
    American College of Physicians
    The American College of Physicians is a national organization of doctors of internal medicine —physicians who specialize in the prevention, detection, and treatment of illnesses in adults. With 130,000 members, ACP is the largest medical-specialty organization and second-largest physician group in...

  • American Dental Association
    American Dental Association
    The American Dental Association is an American professional association established in 1859 which has more than 155,000 members. Based in Chicago, the ADA is the world's largest and oldest national dental association and promotes good oral health to the public while representing the dental...

  • American Medical Student Association
    American Medical Student Association
    The American Medical Student Association , founded in 1950 and based in Washington, D.C., is the oldest and largest independent association of physicians-in-training in the United States. AMSA is a student-governed, national organization...

  • American Osteopathic Association
    American Osteopathic Association
    The American Osteopathic Association is the representative member organization for the over 78,000 osteopathic medical physicians in the United States...

  • List of journals published by the American Medical Association
  • National Physicians Alliance
    National Physicians Alliance
    The National Physicians Alliance is a national, multi-specialty medical organization founded in 2005 by former leaders of the American Medical Student Association...

  • Physicians for a National Health Program
    Physicians for a National Health Program
    Physicians for a National Health Program , is an advocacy organization of some 17,000 American physicians, medical students, and health professionals founded by Quentin Young who support a single-payer system of national health insurance....


Further reading

  • Burrow, James G. AMA: Voice of American Medicine. Baltimore: Johns Hopkins University Press
    Johns Hopkins University Press
    The Johns Hopkins University Press is the publishing division of the Johns Hopkins University. It was founded in 1878 and holds the distinction of being the oldest continuously running university press in the United States. The Press publishes books, journals, and electronic databases...

    , 1963.
  • Campion, Frank. The AMA and U.S. Health Policy Since 1940. Chicago: Chicago Review Press, 1984.
  • Fishbein, Morris. History of the American Medical Association, 1847–1947. Philadelphia: W. B. Saunders, 1947.
  • Numbers, Ronald. Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912–1920. Baltimore: Johns Hopkins University Press, 1978.
  • Poen, Monte. Harry S. Truman versus the Medical Lobby: The Genesis of Medicare. Columbia, MO: The University of Missouri Press, 1979.
  • Starr, Paul. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books, 1982.

External links

The source of this article is wikipedia, the free encyclopedia.  The text of this article is licensed under the GFDL.
 
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