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RESEARCH ARTICLES

Effects of Healthcare Organization Actions and Policies Related to COVID-19 on Perceived Organizational Support Among U.S. Internists: A National Study

Sonis, Jeffrey MD; Pathman, Donald E. MD; Read, Susan PhD; Gaynes, Bradley N. MD; Canter, Courtney; Curran, Patrick PhD; Jones, Cheryl B. PhD, RN; Miller, Thomas MD

Author Information
Journal of Healthcare Management: May-June 2022 - Volume 67 - Issue 3 - p 192-205
doi: 10.1097/JHM-D-21-00208

Abstract

INTRODUCTION

Studies have reported elevated rates of anxiety, depression, post-traumatic stress disorder (PTSD), and burnout among healthcare workers (HCWs) during the COVID-19 pandemic (Li et al., 2021), although studies that used more rigorous sampling approaches have reported somewhat lower prevalence (Li et al., 2021; Sonis et al., 2021). Some studies have identified individual characteristics of HCWs that are associated with lower rates of adverse mental health during the pandemic (Sun et al., 2021), while others have focused on the impact of policies and actions of healthcare organizations on mental health (Giorgi et al., 2020; Khajuria et al., 2021), which is the aim of this study.

Perceived organizational support (POS) has been defined as a worker’s global belief in “the extent to which the organization that employs them values their contributions and cares about their well-being” (Eisenberger et al., 1986, p. 501). A systematic review found an inverse association between POS and perceived stress at work, burnout, and employee attrition across a wide variety of occupations (Kurtessis et al., 2017). During the COVID-19 pandemic, five studies reported inverse associations between POS and adverse mental health among HCWs, specifically two with anxiety (Labrague & De los Santos, 2020; Zhang et al., 2020), one with PTSD (Zhou et al., 2021), one with “work-related stress” (Zandi et al., 2020), and one with general psychological distress (Meese et al., 2021). However, three of those studies (Labrague & De los Santos, 2020; Zandi et al., 2020; Zhou et al., 2021) are based on small convenience samples. One study (Meese et al., 2021) was conducted in the United States but it was based on a single-institution sample, raising concerns about generalizability to the entire United States.

None of the five extant studies of the effect of POS on mental health of HCWs during the COVID-19 pandemic identified specific tangible actions or policies that healthcare organizations can implement to foster POS and reduce adverse mental health outcomes. A meta-analysis of predictors of POS among workers in many fields prior to the COVID-19 pandemic identified abstract general factors that foster POS, such as “leader member exchange,” “consideration and initiating structure,” and “transformational and transactional leadership” (Kurtessis et al., 2017, p. 1859). However, knowledge of these abstract factors does not provide practical guidance to healthcare leaders on the specific policies that they can implement to support their workers more effectively during the pandemic and beyond. Finally, no study has identified actions that healthcare organizations should avoid to prevent reductions in POS among their workers.

Websites (American Medical Association, 2020) and journal editorials and reviews (Rangachari & Woods, 2020; Shanafelt et al., 2020) on HCW mental health have recommended actions to reduce pandemic-related adverse mental health, but their impacts on POS have not been assessed empirically. Multiple healthcare organizations have described their multifaceted interventions to help their workers during the pandemic (Buselli et al., 2021), but most have not evaluated effectiveness.

The goals of this study were to identify healthcare organizations’ actions and policies that were associated—positively and negatively—with POS among physicians during the COVID-19 pandemic and to evaluate the associations between POS and (1) adverse mental health outcomes (generalized anxiety, depression, PTSD); (2) burnout; and (3) intention to leave clinical practice. To address these questions, we conducted a national survey in September and October 2020 of internal medicine physicians (internists) who are members of an online panel maintained by the American College of Physicians (ACP), the largest medical specialty organization in the United States. Internists are an important group to assess because of their central role during the pandemic.

METHODS

Participants and Procedures for Survey Administration

This study was part of a larger cross- sectional study that assessed the prevalence of anxiety, depression, and PTSD among ACP members (Sonis et al., 2021).

Internists were eligible to participate in the study if they were members of the ACP Insider Research Panel and provided patient care in at least 10% of their work hours. The panel consists of members who agree to consider completing occasional online surveys and is intended to be representative of ACP membership. In 2020, 36% of U.S. ACP physician members were women, 57% were White, 6% were Black, and the mean age was 49 years, while 40% of panel members were women, 56% were White, 6% were Black, and the mean age was 46.2 years.

Of the 2,164 members of the panel, 2,145 devoted at least 10% of their time to direct patient care (based on membership data) and were invited to participate in the survey via an e-mail from the ACP research office with a link to the online survey. They were offered points redeemable for a $15 Amazon gift card. The survey was open from September 15, 2021, to October 8, 2021, near the beginning of the third surge in COVID-19 in the United States. The study was deemed exempt from further review by the University of North Carolina at Chapel Hill Institutional Review Board study 20-0881.

KEY MEASURES

Perceived Organizational Support

We measured perceived organizational support with a 4-item, 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) that included three items from the unidimensional POS scale (Eisenberger et al., 1986), adapted for the pandemic (e.g., “I have felt appreciated by my organization for my contributions during the pandemic”) and one item adapted from a study of the effect on HCWs of the SARS epidemic in Toronto (Maunder, 2004).

Potential Predictors of Perceived Organizational Support

Tangible organizational support that might predict POS was defined as policies offered and actions taken by healthcare organizations to support their workers’ physical and psychological safety (Rangachari & Woods, 2020), health, and ability to do their job during the pandemic. We developed a list of 12 items based on policies/actions recommended in: (1) information and guidance from the American Medical Association (2020); (2) reviews and editorials on organizational support of workers during COVID-19 (Rangachari & Woods, 2020; Shanafelt et al., 2020), one of which offered recommendations based on listening sessions with clinicians and nurses (N = 69) about support they believed would be most helpful (Shanafelt et al., 2020); and (3) items from a scale of COVID-19 organizational support developed in South America (Zhang et al., 2020). Following feedback from clinicians who had provided direct patient care during the pandemic, this list was narrowed to seven items. The questionnaire asked respondents whether their organization offered the actions or policies.

We included two other items of tangible organizational support that used different response categories: (1) availability of adequate personal protective equipment (PPE) during the 2 worst weeks of the pandemic in the respondent’s local community (5-point response scale, from 1, seldom or never to 5, all or almost all of the time, and (2) the query “Leaders in my organization have listened to the concerns raised by healthcare workers regarding COVID-19” (Likert-scaled response, from 1, strongly disagree to 5, strongly agree).

One item on organizational warnings and sanctions (i.e., a punitive organizational approach) was also included: “Do you know of any workers at your organization who have been warned or sanctioned for refusing assigned deployment or speaking up about worker/patient safety related to the COVID-19 pandemic?”

An index of tangible organizational support was created. The index was defined as the total number of items offered at the respondent’s healthcare organization plus the items regarding availability of PPE and perceptions of the degree to which the leaders listened to concerns regarding COVID-19, both of which were collapsed into two categories, high (1) and low (0), for inclusion in the index. We conceptualized tangible support as an index, not a scale, and did not expect any correlation among the different organizational policies or actions included in the index (DeVellis, 2017).

Potential Outcomes of Perceived Organizational Support

Three mental health outcomes (generalized anxiety, depression, PTSD) were measured with short screening scales indicating probable disorders but not confirmed diagnoses. Positive anxiety screening was defined as a score of 3 or greater on the Generalized Anxiety Disorder tool (GAD)-2 (range 0–6), a cutoff with a sensitivity of 86% and specificity of 83% for diagnosis of GAD (Kroenke et al., 2007). Positive screening for depression was defined as a score of 3 on the Patient Health Questionnaire (PHQ)-2 (range, 0–6), a cutoff with a sensitivity of 83% and specificity of 92% for diagnosis (Kroenke et al., 2003). Positive screening for PTSD was defined as a score of 6 or greater on a 4-item scale based on the Post-Traumatic Stress Disorder Checklist (PCL)-5 (range, 0–16), a cutoff with a sensitivity and specificity of 97% (Zuromski et al., 2019).

Burnout was measured with the single-item measure of emotional exhaustion, which performs similarly to the 22-item Maslach Burnout Inventory (West et al., 2012). High burnout was defined, as in other studies, as feeling burned out from work once a week or more often (i.e., 4 or greater response value, range 0–6) (West et al., 2012).

Intention to leave clinical practice was assessed using the single item, “What is the likelihood you will leave direct patient care in the next 5 years,” rated on a scale from 1, very low to 5, very high (Williams et al., 2001).

Potential Confounders

We measured three categories of potential confounders of the relationship between organizational actions/policies and POS and between POS and the principal outcomes: (1) physician demographics; (2) factors associated with greater exposure to patients with COVID-19; and (3) characteristics of the health organizations, as reported by physicians who responded to the survey.

The following demographic characteristics were measured: age category (measured in six increments, from 25–34 to 75 and above), gender, race, and Latinx ethnicity.

Factors associated with risk of exposure to patients with COVID-19 that were measured included perceived risk of developing COVID-19 at work, perceived risk of dying if infected, physician estimate of local rate of COVID-19 in the previous 2 weeks compared to the United States as a whole (lower, about the same, higher), primary practice location (outpatient only, outpatient and inpatient, inpatient only), clinical subspecialty (recoded into high risk of exposure to COVID-19 [hospital medicine, infectious disease, pulmonary medicine, critical care medicine, emergency medicine] vs. all other subspecialties), number of patients with suspected or confirmed COVID-19 seen face-to-face in the previous 2 weeks, and total clinical hours in the previous week.

Organization characteristics measured were type of setting of clinical practice (hospital, outpatient facility, other [emergency department, long-term care facility, setting devoted to care for medically underserved]), and state where the primary clinical practice is located.

DATA ANALYSIS

Weighting of Sample Data

The demographic characteristics of the respondents differed slightly from those of the ACP Insider Research Panel. For instance, 21.5% of the panel but 16.9% of the unweighted sample were Asian physicians under the age of 45, and 15.7% of the panel but 17.8% of the unweighted sample were women aged 45 years or older. Poststratification weighting (Gelman & Carlin, 2002) and raking (Dal Grande et al., 2015) were used to make the age–gender and age–race-ethnicity composition of the sample similar to the panel (Sonis et al., 2021). The analyses in this study were all weighted, with the sum of the weights equal to the total sample (N = 810).

Missing Data

Most items on the survey had less than 1% missing data. However, three covariates had nontrivial missing data: risk of COVID-19 infection (13.6%), risk of death if infected, and availability of PPE (5.1%). Descriptive characteristics of the sample are reported based on nonmissing responses. We used full information maximum likelihood (Collins et al., 2001) as the method of estimation in Mplus 8.5 for all regressions to address missing data in covariates (Muthén & Muthén, 2017).

Analyses of the Research Questions

To assess associations between tangible organizational actions/policies and POS, we assessed the difference in means of POS in respondents who reported that the action/policy was offered at their organization and those who reported that it was not. Both bivariate differences and differences adjusted for potential confounders are reported using multiple linear regression, with associated 95% confidence intervals.

To assess the associations between each of the organizational actions/policies and POS, independent of all other organizational actions/policies, we fitted a multiple linear regression model, with POS as the dependent variable, that included all 10 of the tangible policies/actions (i.e., the nine tangible support items and the item on warnings/sanctions). We ran one model with only the actions/policies and a second model that included the actions/policies as well as potential confounding factors.

To evaluate the associations between POS and screening positive for anxiety, depression, PTSD, burnout, and intention to leave direct patient care, we dichotomized perceived support at its median and used bivariate and multivariable logistic regression, controlling for potential confounding, to determine crude and adjusted odds ratios. Separate models were fitted for each outcome. Intention to leave direct patient care was dichotomized into two categories—high and very high versus moderate, low, or very low. The same covariates were used in all models.

RESULTS

Sample Characteristics

Among the 2,145 eligible panel members, 810 (37.8%) responded to the survey. About half (55%) of the respondents were under the age of 45; 40% were women. General internal medicine was the most common subspecialty (45%); 29% were in specialties at particularly high risk of exposure to COVID-19, such as hospital medicine. The mean number of patients with suspected or confirmed COVID-19 who were seen face-to-face in the previous 2 weeks was 7.4 (95% CI [6.2, 8.6]).

Effect of Tangible Organizational Actions/Policies Related to COVID-19 on POS

Internal reliability of the 4-item POS scale was very high, Cronbach’s alpha 0.92 (95% CI [0.91, 0.93]). The mean POS score was 15.3 (95% CI [15.1, 15.5]), range 4–20. The item-mean score was 3.8, indicating that respondents nearly agreed, but not strongly, that their organization cared about and supported them during the pandemic.

Among tangible organizational support policies and actions related to COVID-19 (Table 1), relatively few organizations offered free healthcare for their workers with COVID-19 (17.9%) or free lodging if quarantined (24.8%); much higher percentages offered rapid COVID-19 testing (61.3%) and stress management resources (70.0%). Most respondents (81.6%) reported that they had adequate PPE available most or all of the time when the pandemic was at its most severe, and most (70.1%) agreed or strongly agreed that leaders in their organization listened to concerns raised by HCWs regarding COVID-19. Approximately 1 in 10 respondents (10.1%) reported that they knew of HCWs at their organization who had been sanctioned or warned for refusing pandemic deployment or speaking up about safety related to the COVID-19 pandemic.

TABLE 1 - Tangible Support Actions and Policies Related to COVID-19 Offered by Respondents’ Health Organizationsa
Weighted percent (95% CI)
Free healthcare for HCWs infected with COVID-19 17.9 (15.2–20.5)
Free lodging during quarantine for HCWs who develop COVID-19 24.8 (21.8–27.8)
Opportunities for reassignment to low-risk areas for HCWs at high risk if infected with COVID-19 32.5 (29.3–35.7)
Opportunities to discuss ethical questions in caring for patients with COVID-19 45.6 (42.1–49.0)
Appropriate training for HCWs deployed to new areas 48.0 (44.6–51.5)
Rapid results for COVID-19 tests of HCWs 61.3 (57.9–64.6)
Stress management services or resources 70.0 (66.8–73.1)
Leaders in respondents’ health organization listened to HCW concerns re: COVID-19 (agree or strongly agree) 70.1 (66.9–73.2)
Adequate personal protective equipment available during the two most severe weeks of the pandemic in the local community (most or all of the time) 81.6 (78.9–84.3)
Note. HCW = healthcare worker.
aBased on respondent report.

The median number of actions/policies offered, out of 9 listed on the survey questionnaire, was 4.5, interquartile range 3.0. There was a strong correlation between the 9-item index of tangible organizational actions/policies and perceived organizational support, rp = 0.47, (95% CI [0.42, 0.52], p < .001.

Each of the organizational actions/policies was associated with POS, in both crude and adjusted analyses (See Table S1, published as Supplemental Digital Content at https://links.lww.com/JHM/A75.), though the magnitude of the effect differed substantially across items. The smallest effects were for the policies of offering HCWs free lodging during quarantine and rapid COVID-19 testing. The largest effects were for leadership listening to concerns regarding COVID-19, availability of adequate PPE, and opportunities to discuss ethical questions in caring for patients with COVID-19 (4.6-, 2.8-, and 2.1-point differences in adjusted mean POS, respectively). Respondents who reported that their organization had sanctioned or warned HCWs for refusing redeployment or speaking up about COVID-19 safety had adjusted mean POS scores that were 3.9 points lower (95% CI [3.0, 4.8], p < .001) than those who did not.

In the multiple linear regression in which POS was regressed simultaneously on all 9 of the tangible organizational support actions/policies plus the item about whether the respondent knew of HCWs at their organization who had been sanctioned or warned, the R2 = .45, indicating that 45% of the variance in POS was explained by the 10 organizational actions/policies. When potential confounding factors were added to the model—in addition to all of the organizational actions and policies (Table 2)—3 actions/policies were found to be significantly associated with higher POS: opportunities to discuss ethical questions in caring for patients with COVID-19 (β = 0.74, p = .001), adequate access to PPE (β = 1.00, p = .005), and leadership that listened to concerns regarding COVID-19 (β = 3.58, p < .001). The one punitive organizational action assessed (threatening or sanctioning workers) was associated with significantly lower POS (β = –2.06, p < .001). All assumptions of multiple linear regression were met (See Table S2, published as Supplemental Digital Content at https://links.lww.com/JHM/XXX)

TABLE 2 - Multiple Linear Regression Associations Between Tangible Organizational Actions/Policies Related to COVID-19 and Perceived Organizational Support
Perceived Organizational Support, Base Modela Perceived Organizational Support, Adjusted Modelb
Action/Policy Related to COVID-19 Coefficient Estimatec Standard Error p Coefficient Estimatec Standard Error p
Free healthcare for HCWs infected with COVID-19 0.52 0.30 .08 0.46 0.28 .10
Free lodging during quarantine –0.14 0.26 .58 –0.03 0.25 .92
Opportunities for reassignment to low-risk areas for HCWs at high risk 0.25 0.25 .30 0.21 0.24 .39
Opportunities to discuss ethical questions regarding patients with COVID-19 0.66 0.24 .01 0.74 0.23 .001
Training for deployment to new areas 0.67 0.25 .01 0.48 0.25 .06
Rapid results for COVID-19 tests of HCWs –0.60 0.23 .81 –0.06 0.23 .79
Stress management resources 0.18 0.28 .50 0.28 0.275 .31
Leaders listened to HCW concerns regarding COVID-19 3.75 0.28 < .001 3.58 0.26 < .001
Adequate PPE availability 1.11 0.33 .001 1.00 0.36 .005
Warning or sanction for HCWs who refuse redeployment or speak out on safety related to COVID-19 –2.08 0.41 < .001 –2.06 0.40 < .001
Note. HCW = healthcare worker; PPE = personal protective equipment.
aThe base linear regression model included all of the healthcare organization’s actions/policies related to COVID-19 shown and poststratification weights but no other potential confounders.
bThe adjusted linear regression model included all of the actions/policies related to COVID-19 shown, poststratification weights, and the following potential confounders: age category, gender, race-ethnicity, perceived risk of developing COVID-19 at work, perceived risk of dying if infected with COVID-19, respondent estimate of local rate of COVID-19 in the previous 2 weeks compared to the United States as a whole, work setting (outpatient only, outpatient and inpatient, inpatient only), clinical subspecialty (high risk of exposure to COVID-19 vs other), total clinical hours in previous week, number of patients with suspected or confirmed COVID-19 seen in previous 2 weeks, type of healthcare setting (hospital, outpatient setting, other).
cCoefficients can be interpreted as the difference in the mean perceived organizational support score between respondents who reported that their organization offered a policy and those who reported that their organization did not offer that policy.

Effect of POS on Mental Health, Burnout, and Intention to Leave Patient Care

The prevalence of screening positive for the mental health outcomes was reported in Sonis et al. (2021). The prevalence of burnout was 28.4% (95% CI [26.8%, 30.0%]). About 1 in 5 respondents (20.2%; 95% CI [17.4%, 23.0%]) reported high or very high intention to leave patient care in the next 5 years.

High POS was associated with lower odds (by approximately one half to two thirds) of screening positive for generalized anxiety, depression, PTSD, burnout, and high or very high intention to leave direct patient care in the next 5 years in multivariable logistic regression models. Figure 1 shows the adjusted odds ratios for those associations; Table S3, published as Supplemental Digital Content at https://links.lww.com/JHM/XXX shows the crude (unadjusted) and adjusted odds ratios.

F1
Figure 1:
Multiple Logistic Regression Adjusted Associations Between High Perceived Organization Support and Mental Health, Burnout, and Intention to Leave Patient Care

DISCUSSION

The results from this national study of U.S. internists reveal four major findings. First, the item-mean POS score of 3.8 on a scale ranging from 1–5 indicates that they nearly agreed, but not strongly, that their organizations value their contributions and care about their well-being. It is unknown whether the level of POS among internists in this study is different than prior to the pandemic because there are no data from physician ratings of POS in national samples prior to the pandemic. This moderate level of POS (Labrague & De los Santos, 2020) suggests that organizations could improve their support of physicians.

Second, there is a substantial difference in the frequency with which each specific tangible support has been offered to HCWs by their organizations. Policies that require funding for services that were not offered prior to the pandemic, such as free healthcare for those infected and lodging for those quarantined, have been offered less often than services that could be easily incorporated, such as rapid testing for COVID-19 and appropriate training for pandemic redeployment. More than 80% of internists in this survey reported adequate PPE most or all of the time during the worst 2 weeks in their local community. This means that 1 in 5 internists reported adequate PPE only half of the time or less.

The third principal finding is that while all of the tangible support policies we evaluated were associated with POS individually, three were positively and independently associated with POS when controlling for all other support policies and for potential confounders: opportunities to discuss ethical questions in caring for patients with COVID-19, access to adequate PPE, and having leaders who listened to concerns raised by HCWs regarding COVID-19. Studies conducted during previous respiratory epidemics (Kisely et al., 2020) and during the COVID-19 pandemic have similarly reported the beneficial impact of access to adequate PPE and having leaders who listened to workers’ concerns (Muller et al., 2020). To our knowledge, ours is the first study to report the positive association between opportunities to discuss ethical questions related to the care of patients with COVID-19 and POS. This is not surprising, given the many ethical dilemmas that physicians have faced during the COVID-19 pandemic (The Hastings Center, 2020).

There also is a strong negative association between POS and warnings or sanctions for refusing assigned deployment or speaking up about safety issues during the pandemic. Increased absences early in the pandemic (Groenewold et al., 2020), coupled with surges in healthcare use, raised concerns that healthcare organizations might not have enough workers to provide direct care during an epidemic (Rafi et al., 2021; Spetz, 2020). Some organizations may have implemented punitive approaches to try to maintain a robust workforce (Scheiber & Rosenthal, 2020). Our study suggests that those approaches reduce POS and may actually increase attrition. Our findings are consistent with previous research that shows inverse associations between punitive human resource management approaches and POS (Kurtessis et al., 2017; Shanock et al., 2019) and research on psychological safety (Rangachari & Woods, 2020).

Fourth, our findings indicate an association between POS and lower odds of screening positive for anxiety, depression, PTSD, burnout, and intention to leave direct patient care in the next 5 years. These findings on mental health are consistent with results from studies conducted during previous respiratory epidemics (Maunder, 2004) and the few reported thus far in the COVID-19 pandemic (Labrague & De los Santos, 2020; Meese et al., 2021; Zandi et al., 2020; Zhang et al., 2020; Zhou et al., 2021) on the effect of POS.

Study Limitations

The response rate for our survey was 37.9%. However, unlike studies during the COVID-19 pandemic that used convenience sampling (Labrague & De los Santos, 2020; Zandi et al., 2020; Zhou et al., 2021), we were able to compare the demographic characteristics of the respondents to those of the nationally representative ACP Insider Research Panel. We used poststratification weights for age, gender, and race/ethnicity in the analyses, although other differences between the sample and the panel could have affected the findings.

Also, although we describe some factors as predictors of POS and others as outcomes of POS, the temporal relationships among variables cannot be determined based on data from this study alone because of the cross-sectional design. However, a large body of research on POS in many fields supports the temporal assumptions we make in this study (Eisenberger et al., 2020; Kurtessis et al., 2017; Shanock et al., 2019). In addition, respondents may not have reported accurately on the presence or absence of tangible support policies offered by their organizations. We believe that these reporting errors, when present, were most likely the results of respondents’ lack of knowledge of their organization’s policies, and therefore nondifferential with respect to POS. However, it is possible, because of the study’s cross-sectional design, that POS influenced reporting of tangible support policies. If present, this could lead to artifactually elevated associations between organizational actions/policies and POS. Finally, because our sample included only physicians, generalizability of the findings to other HCWs is unknown.

CONCLUSION

The findings from this study have practical implications for healthcare management during the COVID-19 pandemic. Our results suggest that healthcare organizations can increase physician POS by offering opportunities to discuss ethical concerns related to caring for patients with COVID-19, guaranteeing adequate PPE, and having leaders who listen to concerns about COVID-19. While healthcare organizations may consider implementing other policies and actions for the safety of staff or patients, implementation of the policies identified in this study are likely to have the largest positive impact on POS. Conversely, warning or sanctioning of workers who refuse pandemic deployment or speak up about worker/patient safety is associated with lower perceived support and should be avoided.

We also found that high POS was associated with lower adverse mental health, burnout, and intention to leave patient care. This suggests that, by implementing the tangible support policies identified here and avoiding punitive ones, healthcare organizations may reduce adverse mental health outcomes and attrition among their physicians during the COVID-19 pandemic by fostering POS. Supporting them is not only humane but also likely to help healthcare organizations during the COVID-19 pandemic and beyond.

ACKNOWLEDGMENT

The current study was supported by funding from the Office of Research, School of Medicine, University of North Carolina at Chapel Hill.

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