BACKGROUND AND PURPOSE
Cultural competence is defined as “acceptance and respect for difference, continuing self-assessment regarding culture, vigilance towards the dynamics of differences, ongoing expansion of cultural knowledge and resources, and adaptations to services.”1(p13) As the United States (US) population diversifies,2 there is an increasing need for health care providers who can provide culturally competent care. The promotion of cultural competence in physical therapist (PT) curricula is integral in preparing physical therapists to provide care that “reflects consideration of individual and cultural differences,” as endorsed by the American Physical Therapy Association (APTA).3(p1) One way to facilitate cultural competence is the inclusion of experiential learning opportunities in physical therapist education curricula. An important form of experiential learning is service-learning, defined as a “structured learning experience that provides community service with explicit learning objectives, preparation, and reflection.”4(p274) Key components of servicelearning include community collaboration and focused, meaningful reflection. Specifically, service-learning responds to community concerns and is developed, implemented, and evaluated in active collaboration with a community partner. Reflection allows for a more meaningful learning experience when it is carefully connected to content and theory acquired in didactic coursework.5
Two specific types of experiential learning take place outside of the country where the physical therapist program is located: international service-learning (ISL) and international clinical education (ICE).6,7 The literature reports a number of positive outcomes from international learning experiences. These include a positive impact on cross-cultural competency, improved personal development of students, and increased global awareness.6,7 Cultural immersion experiences (where students live and work within communities in another country) appear to be particularly effective in increasing cultural competence in health profession students,8–18 including physical therapist students.16,19–22 Such improvements do not seem to require long periods of time spent in the different culture. Positive effects have been noted in experiences as short as 1 week.16
Recognizing the value of international experiential learning experiences, a large percentage of physical therapist education programs have incorporated some type of international experience into their curricula.6,7 This trend has resulted in the need to determine best practice.23 The inclusion of international opportunities comes with a responsibility to consider the effect of the experience on all stakeholders, including students, the university/program, and the host community.24,25 In addition to measuring outcomes, emphasis must be placed on ensuring ethical practice, minimizing potential risks, and ensuring the safety of participating students and faculty members.24–26
The literature reveals several recommendations for effectively structuring international experiences. Lattanzi and Pechak24 propose a model that includes cultural competency training, community coordination and communication, and a comprehensive assessment program. Pechak and Cleaver25 suggest that institutions must critically examine their programs to ensure ethical and culturally appropriate practice, and emphasize the need to research best ISL practices. This would include the identification and analysis of common structures and processes.25 Similarly, Landry et al26 describe the importance of careful selection of students, the need to establish formal relationships with host institutions, and the need to develop specific ISL objectives. The authors also argue for the importance of risk management on the part of physical therapist education programs.24–26
In an effort to encourage best practice, Pechak and Thompson23 developed a conceptual model that describes 5 phases necessary for an optimal ISL experience: development, design, implementation, evaluation, and enhancement. Throughout these 5 phases, 4 major themes (structure, reciprocity, relationship, and sustainability) are identified (Figure 1).23 As stated by the authors, this conceptual model provides a guideline for developing new ISL experiences and can also be utilized to improve existing ISL programs.23
The purpose of this paper is to describe the development, design, implementation, evaluation, and planned enhancement of a combination ISL/ICE experience based on Pechak and Thompson's conceptual model.23 At our institution, the international experience was embedded within an existing 3-week pediatric clinical course that took place in rural Nicaragua. The authors believe this is the first time an ISL/ICE experience in a physical therapist program's curriculum has been evaluated utilizing the Pechak and Thompson model.23 The case report may serve as a useful method of assessment for other physical therapist programs as they critically review their own international experiences.
The university27 and PT program28 mission statements support service to the church, community, and the world, and encourage the development of an international experience within our curriculum. With university support, the authors began a partnership between the physical therapist education program and a medical clinic located in the rural community of El Viejo, Nicaragua. The clinic is operated by a missionary nurse from the US whose work is sponsored by a local church. During the summer of 2009, the primary author visited the medical clinic to further investigate the feasibility of developing a partnership with the nurse and the organization that she founded, known as the Circle of Empowerment.29
Rehabilitation services have never been provided in El Viejo previously, and the nurse was enthusiastic about the opportunity to partner with PTs to expand her medical program. The missionary nurse's program includes a medical clinic housed on her property which is staffed by herself and another nurse from the community. In addition, Nicaraguan physicians in training for rural medicine complete a rotation in the clinic. Any type of medical or psychological issue is evaluated at the clinic. The patient is then either provided with education and medication, or referred to a local physician or hospital. Problems with parasites, malaria, dengue, urinary tract infections, pregnancy and family planning, and respiratory issues are frequently treated. Although rehabilitation services for children with disabilities are available for free through a local organization called Los Pipitos, the cost of transportation to and from the local organization from the rural areas is a barrier to receipt of services. Therefore, the ability to offer these services in the rural areas would be extremely beneficial for the community.
The missionary nurse has established a health clinic, an education program with a library, and is actively working on economic development plans for the people in the 8 rural villages for which she provides medical service. Her philosophy is to empower the people in her community to enable them to continue to care for one another. One way in which this is accomplished is through services provided by brigadistas. These are members of the local community, chosen by the villagers, who are then trained to provide follow-up patient care including monitoring blood pressure or pregnancy, and patient status after recent surgery. The brigadistas also assess compliance with recommendations and home programs provided by visiting medical professionals. The medical and educational programs available through the leadership of the missionary nurse provided an appropriate community partner with which to develop an international experience for PT students. Following the visit, a tentative plan was made to return with students for 3 weeks in January 2010 during the students’ pediatric clinical experience time.
Methods for keeping the team safe and healthy at the site were already in place. Housing for the visiting team was available in a retreat center designated for those providing services to the clinic and the community. The missionary nurse was very competent in medical differential diagnosis and had access to both a nearby smaller hospital as well as to a larger hospital to provide for any medical issues that might arise with the team. Because medications are on the premises, a rural Nicaraguan guard is present to contribute to the safety of the medical clinic.
A required 3-week pediatric clinical experience is completed by all students following the third semester in the 3-year Doctor of Physical Therapy program provided at the university. The primary author developed a proposal to offer the Nicaraguan site as an option for this clinical experience for up to 4 students from a cohort of 24 students each year. The course syllabus, which included objectives for the clinical course, was reviewed with the director of clinical education (DCE). The DCE determined that, with some revision, the objectives could serve all students in the course, those going to Nicaragua as well as those students assigned to clinics and schools in the US. Objectives for the clinical course include performing a physical therapy examination of a pediatric client, implementing a physical therapy plan of care, demonstrating the use of age-appropriate play and language in therapeutic interactions, and teaching home or classroom activities to those involved with the care of the child.
Clinical performance was assessed for all students using a clinical skills list as well as the Generic Abilities Assessment.30 All students were also required to complete the APTA Physical Therapist Student Evaluation: Clinical Experience and Clinical Instruction Form.31 In addition, students going to Nicaragua kept a daily reflection journal. Four students expressed interest in the site and were approved by faculty to complete the clinical experience in Nicaragua in 2010. Students’ financial needs were partially supported by global education grants through the university.
All students were asked to complete a questionnaire called the Civic Attitudes and Skills Questionnaire32 (CASQ) before and after the 3-week clinical experience in order to compare the 2 groups of students and determine if there were any differences between students who chose an international clinical site versus a clinical site in the US. The questionnaire itself is composed of 6 scales (civic action, interpersonal and problem-solving skills, political awareness, leadership skills, social justice attitudes, and diversity attitudes) and was developed to assess college students’ skills, behavioral intentions, and attitudes which might be affected through service-learning participation. Reliability and validity for the 6 scales have been established.32
In preparation for the Nicaragua clinical placement, the 4 students were instructed to obtain a passport, an up-to-date tetanus shot, and anti-malarial medication. In addition, they began the process of locating and constructing pediatric supplies and coordinating donated medical supplies. Prior to the trip, the missionary nurse provided a 2-hour orientation to the students at the university related to her medical services, education provided to area children, and general information on the Nicaraguan culture. In the first year, the primary author and the students also attended medical Spanish classes for 10 weeks through the university prior to going to Nicaragua to improve their ability to communicate.
In Nicaragua, students provided physical therapy to children and adults in the villages, in the medical clinic, and at a local organization/clinic in nearby Chinandega (Los Pipitos).33 Patients treated by occupational, physical, or speech therapists have included adults with cerebrovascular accidents, diabetes mellitus, and spinal pain, and children with Down syndrome, hydrocephalus, spina bifida, cerebral palsy, congenital scoliosis, developmental delay, and vision or hearing impairments. Children with disabilities were also seen for treatment in their homes, and family members were educated in activities they could carry out after the team left. The team provided the instruction in both written (including pictures) and verbal formats. Interpreters were often utilized to facilitate more effective oral and written communication. The examination and interventions were documented in the patient's record and kept at the mission clinical site.
To assist in the implementation of physical therapy activities, the team constructed various pieces of equipment such as walkers, parallel bars, and tire swings, or brought equipment from the US. Additional therapeutic supplies were purchased in Nicaragua, including exercise balls, soccer balls for eyehand and eye-foot activities, drawing, writing, and coloring supplies, tires for swings, and shoes for foot support.
Students recorded their daily reflections in a journal. Guided questions for reflection included what went well or could have been improved during the examination, evaluation, and intervention with each child; what things did not go as planned during the interactions with each child; if the child was comfortable with what was done with them; or should anything be done differently the next time to improve or change the session? Students also were encouraged to write about any emotions experienced during their stay in Nicaragua. Informal debriefing and reflection, often led by the missionary nurse, on these same topics occurred almost every day during meal times.
The evaluation phase involves assessment of outcomes. Three areas were chosen for assessment, including student, community, and departmental outcomes.23
Student outcomes assessment. The authors assessed student outcomes in 2 ways, by achievement of learning objectives described in the clinical course syllabus, and the Civic Attitudes and Skills Questionnaire (CASQ).32 All students in both settings successfully met the learning objectives for the clinical course as evidenced by the clinical skills list and the Generic Abilities Assessment Tool.30 In the Nicaragua group, additional student outcomes were informally assessed via the reflection journals and through verbal feedback provided by the missionary nurse to both the individual student and the primary author. Comments from the reflection journals were categorized by the first author (clinical instructor while in Nicaragua) under the areas of language issues, the cultural system, service and giving, and cultural learning (Table 1).
The nonparametric Mann-Whitney U test34 was used to compare the results from the 6 scales of the CASQ for the students participating in Nicaragua compared with students participating in the United States. All of the students in the Nicaragua group completed the questionnaire, but only 6 out of 19 students in the United States cohort completed it. No significant difference (P = .05) was found between the 2 groups, pre- or post-test. Possible reasons for this lack of difference may be the short length of the clinical experience, the self-selected sample participating in Nicaragua, the small sample size, and the fact that all physical therapist students likely value the ability to provide service to people with physical disabilities.
Community outcomes assessment. The authors assessed community outcomes through observation of the children's progress. Each time the primary author made subsequent visits to the country, she visited each of the families. During these visits, the primary author observed that the families were able to properly demonstrate the interventions. In addition, the primary author and each family observed improved function in the children. This often included the new ability for some children to attend school due to improved gross motor function.
Departmental outcomes assessment. The authors assessed departmental outcomes by examining the university-wide outcomes adopted by the university,35 and the physical therapist program student learning outcomes,36 core values, and strategic plan. The authors determined that the international experience contributed to the university outcome related to global citizenship. In addition, the experience provided support for physical therapist program core values of Christian stewardship (using gifts and abilities) and global mindedness (the willingness to work with people around the globe). The experience also contributed to goals in the physical therapist strategic plan related to integrating global health into the curriculum, and providing opportunities to students for service.
The enhancement phase focuses on improving and expanding the existing program. Initial assessment of the experience in Nicaragua following the first year supported the practice of offering the program as an optional, international, clinical site for the pediatric clinical experience. The authors completed the more recent comprehensive evaluation of the Nicaraguan experience, both to identify strengths and areas for improvement, as well as to determine if the program was properly positioned within the curriculum. The evaluation is organized using Pechak and Thompson's 4 themes of structure, reciprocity, relationship, and sustainability.23
Structure. Pechak and Thompson23 describe the need for clearly organized structure among all key players in any ISL experience. A total of 4 student groups have participated in the Nicaragua experience from 2010 to 2013. Three cohorts of 4 students and 1 cohort of 2 students participated in similar experiences with no obvious differences found in participation, learning, or interactions with the children and families while in Nicaragua. All 4 groups of students have described the experience as positive and life changing as evidenced by entries in the reflection journals (Table 1).
The more recent comprehensive evaluation of the experience revealed positive outcomes for 2 stakeholders involved in the experience—the students and the host community. Students benefitted from the learning opportunities offered by the site as evidenced by their reflection journals and their evaluation of the clinical experience and clinical instruction. The Nicaraguan people benefitted from the services they received during the clinical course as evidenced by verbal reports from them, the brigadistas, and the missionary nurse, as well as by the improved levels of function noted from year to year by the primary author. The use of student reflection journals appears to be a valuable way to assess affective aspects of student learning. As evidenced by entries in the reflection journals, and informal discussions with students during and after the experience, students consistently reported positive perceived value for the experience. This value related to enhancement of their clinical skills, and growth in their ability to work in a culture different from their own.
Although the clinical course objectives were achieved by all students, there were obvious differences between the experiences of the students in the US as compared to those who went to Nicaragua. This led to a more formal evaluation of the experience to determine if it was appropriate to maintain as a clinical site for the pediatric clinical experience. To further assist in this process, the authors asked all students in the 2012 cohort to create a table that provided the following information about the children for whom they provided physical therapy services: number of children seen, age, diagnosis, number of visits, and equipment used. This allowed the faculty members to better compare elements of the 2 clinical experiences, which were not reflected in the course objectives (Table 2).
The authors determined that there was strong communication and coordination between the program and the host community. There was consistent student interest in choosing the Nicaraguan site as a placement for the pediatric clinical each year, and the students participated in some pre-trip activities designed to prepare them for the experience. The missionary nurse met at the university with the students for 2 hours in the semester prior to the experience to educate them about the services provided in Nicaragua and Nicaraguan culture. In addition, the supervising faculty member reviewed the required and recommended vaccinations/medications and required travel documents with the students. The program strongly recommended, but did not require, that the students complete some sort of medical Spanish review prior to the experience.
The ethical concepts of beneficence and nonmaleficence, related to the balance between students doing good works and practicing within the realm of training, were also considered. Concerns related to quality of patient care might arise in a situation where 1 faculty member supervises 4 students. However, in Nicaragua, the faculty member worked directly with 1 student, and 1 patient at a time. In this model, the patient benefitted from the faculty member's expertise and full attention, as well as the student's participation in their care. Therefore, this was considered to be a strength of the experience and an example of ethical practice.
Consideration for the cultural values of the host community is essential when planning any international experience. Evidence for this can be found through the role of the brigadistas, who consistently communicate to the missionary nurse any concerns they have related to the interactions between the US team and patients. The nurse then addresses the concerns with the US team. This helps to facilitate provision of care within acceptable cultural norms.
Relationship. The primary author established a long-term personal and professional relationship between the program and the host community through effective and ongoing communication and coordination with the missionary nurse in Nicaragua. This communication occurs before, during, and after each trip made to the country. The university's support for the experience, and this faculty member's ongoing interest in returning each year with a student group, further strengthens this relationship.
Reciprocity. The development of a strong reciprocal and collaborative relationship between the program and the host community is evidenced by both parties collaborating in the identification of the focus of the physical therapy services to be provided in the community, and in the development of the plan for implementing those services. The role of physical therapy in the community was clearly defined prior to the faculty/student team's arrival and a plan is consistently in place for them to maximize the provision of services to the community during their time in the country.
Sustainability. The ability of the international experience to remain in long-term existence within the program is one aspect of sustainability. The possibility for services to be continued in the community once the faculty/student team leaves the host country and returns to the US is a second aspect of sustainability. The international experience in Nicaragua exhibits both aspects of sustainability. The university and the physical therapist program remain supportive of the experience, and student/faculty interest remains high, thereby ensuring long-term existence within the curriculum. In the host community, the brigadistas, the missionary nurse, and family members, who are trained during the visits, demonstrate the ability to carry out exercises or activities with the children after the faculty/student team has left. In an effort to provide greater rehabilitation services to those with disabilities, additional physical, occupational, and speech services have been provided by therapists (including the primary author) visiting in June, 6 months following the physical therapist student visits. Regular communication also occurs between the primary author and the missionary nurse throughout the year regarding various programs provided to the children or adults.
Areas for Improvement
Structure. There were differences between the experiences of the students in the US compared to those who went to Nicaragua. The most obvious differences related to the number of children seen, variety of diagnoses seen, equipment encountered, and the student experience with different systems of health care delivery (Table 2). Differences related to the health care system were also reflected in the APTA Physical Therapist Student Evaluation: Clinical Experience and Clinical Instruction Form.31 This prompted further assessment related to the suitability of the site being offered as a clinical site for the pediatric clinical course.
During the Nicaraguan experience, the students also saw adult patients in the medical clinic for various neurological and musculoskeletal conditions. The students’ level of preparedness to provide examination and intervention to the adult population was limited because they had not yet completed all of the orthopedic and adult neurologic coursework. This led to further consideration as to whether or not this experience was correctly placed within the curriculum.
As a part of the assessment process, several components of the experience were identified for modification, including the student selection process, pre-departure and post-trip activities, and risk management. The process by which students were selected for the Nicaraguan clinical site was not consistent with the procedure used by the DCE for other clinical site selections. Students were instructed to let the DCE know of their interest in the Nicaraguan site for the pediatric clinical and were then formally approved by the faculty as a whole. Conversely, the students completing the clinical experience in US sites were required to submit clinical paperwork justifying their clinical choice to their advisor prior to being assigned to a particular site. In addition, given the unique nature of the Nicaraguan site, there was no specific information shared with students related to student characteristics that might lead to the best fit of a student to the site, as is done with other unique clinical sites.
Although the students received some pretrip preparation, this did not include formal training related to Nicaraguan culture. Upon returning from the trip, the supervising faculty member met one time with the student group to generally reflect back on the experience. She also encouraged them to continue to share aspects of the experience with others as needed, including family, friends, clergy, etc. However, there was no formal post-trip debriefing completed to reconcile conflicted feelings that may have resulted from participation in the experience and the subsequent return to US culture. Finally, students were not required to purchase international health and medical evacuation insurance prior to departing for Nicaragua. Therefore, there was not a formal plan in place should any member of the team require significant medical assistance or evacuation while in Nicaragua.
Relationship. Faculty recommended that participating students possess some knowledge of Spanish, but this was not a requirement for the experience. In some years, this resulted in only 1 member of the university team being somewhat fluent in the native language. As a result, the team needed to rely on interpreters to help them communicate with their Nicaraguan patients. This may impact the ability to develop stronger personal and professional relationships when providing physical therapy services.
Reciprocity. Each year, the returning faculty member performs informal community assessment of the impact of physical therapy services by observing caregiver abilities to correctly demonstrate the physical therapy techniques they had been taught, and by noting the functional progress in the children. However, in a truly reciprocal and collaborative relationship, this assessment would seek more formal participation from the host community in assessing these outcomes with appropriate modifications, thus better meeting identified community needs.
Sustainability. The current rehabilitation services being provided by the US team has provided a beginning framework of care to the rural people of Nicaragua. However, there are several opportunities for improvement in the area of sustainability of services in the absence of the US team. The brigadistas receive a basic level of training in rehabilitation activities and could benefit from expanded training to increase their role in monitoring established rehabilitation programs. There has not been significant communication to date between the US team and the PTs at Los Pipitos. Increased collaboration may help to improve access to physical therapy services for the rural population when the US team is not in the country. Finally, there have been no efforts to link the PTs at Los Pipitos with the World Confederation for Physical Therapy. Connecting with a larger professional body such as this would facilitate the move to more sustainable practice.
International service-learning and international clinical education experiences have become prevalent in physical therapist education.6,7 Pechak and Cleaver have advocated for the evaluation of these experiences to facilitate their positive impact and limit the potential risks associated with them.25 The authors completed a formal evaluation of a current international service-learning, clinical education (ISL/ICE) experience. The evaluation revealed many positive features that should be maintained. However, there were several areas identified for improvement. These are described below with some ideas of how to strengthen each area (Table 3).
The Commission on Accreditation in Physical Therapy Education (CAPTE) indicates that international clinical education experiences need to be equivalent to domestic clinical education.37 The authors’ evaluation of the current ISL/ICE revealed that although the students in both groups (US sites and the Nicaraguan site) met the established course objectives, the experiences did vary related to the practice environment in which students made clinical decisions. The students in the Nicaraguan group did not have the opportunity to practice in a clinical environment regulated by the Individuals with Disabilities Education Improvement Act (IDEIA).38 The authors determined this exposure to be an important aspect of developing generalist entry-level practitioners proficient in providing physical therapy across the continuum of care, including pediatrics. Since the Nicaraguan site did not provide this exposure, the authors determined that Nicaragua was not an appropriate site for a pediatric clinical education experience.
However, there was no question that the Nicaraguan experience was valuable to both the students and the Nicaraguan people served. This consideration led the authors to retain the option of the Nicaraguan experience by transitioning it from a clinical education experience to an elective global health course that occurs later in the curriculum. As a global health course, the experience will continue to allow students to provide examination and intervention to children with disabilities in the rural Nicaraguan community, as well as provide care in the medical clinic. Leadership, logistics, and the university's support would not change.
The global health course will occur later in the curriculum, providing the students with a greater depth and breadth of didactic knowledge, including additional orthopedic and adult neurologic concepts of examination and intervention. Additionally, students will have completed a 3-week pediatric clinical. The additional didactic information, along with clinical time with children, will give the students more experience with problem solving and determining appropriate interventions required with the pediatric and adult populations seen in Nicaragua. Although the physical therapist program does not currently have a global health course in the curriculum, there are plans to develop one in the next year.
The literature describes several strategies to strengthen global health experiences and encourage responsible actions related to them. Landry et al26 recommend the development and implementation of specific student selection criteria to clarify expectations, maximize student learning, and minimize risk. Suggested criteria include identification of specific student characteristics, skill sets, previous travel experience to resource-poor settings, and language skills to match the setting.
Taking this into consideration, prior to the 2012 cohort going to Nicaragua, the authors developed a more formal student selection process for the January 2012 trip. Students were still able to indicate their interest in the Nicaraguan site, but were then required to complete an application form (similar to other clinical placements) in which they describe how this particular placement will contribute to the achievement of their professional goals. Preference was given to students who spoke some Spanish and had previous international travel or mission experience. In addition, students were asked to self-assess themselves related to several characteristics that have been identified by others as being important in student success on international experiences.39 Faculty members also completed this assessment on each student and were then able to indicate their approval or disapproval of the student being placed at the Nicaraguan site for the clinical experience. A similar process could be implemented for the global health course.
Pre-departure planning which includes more formal preparation for the social structure, culture, and language can also assist in minimizing risk. In addition to the missionary nurse meeting with students at the university prior to the trip to introduce them to the medical system and culture of the region, more comprehensive pre-departure preparation of students will be developed. This will include more formal training related to Nicaraguan health care practices and beliefs, cultural values, cultural understanding of disability, and appropriate ways to enhance rehabilitative services in the country. Additional Spanish language study, especially related to health care terminology, will be strongly recommended. Students will also be required to purchase international health and medical evacuation insurance. Post-trip activities will be expanded as well, to allow more formal and comprehensive debriefing between the students and instructor to assist the team in processing the experience more fully.
The development of more effective personal and professional relationships between the faculty/student team and the Nicaraguan people can be enhanced by the change in the student selection procedure which gives preference to students who speak Spanish. Additionally, the recommendation of further Spanish language study can improve the faculty/student team interaction with the Nicaraguan people.
In order to strengthen the reciprocal nature of the relationship between the university and the host community, a more formal method of assessing the impact of the services provided to the Nicaraguan people should be developed. Assessment tools have been designed by others for this purpose40 and could be adapted for use in assessing how well the services provided meet the needs of the community.
Efforts to improve sustainability of physical therapy services could include providing advanced training for the brigadistas, facilitating increased collaboration with the PTs at Los Pipitos to determine ways to improve access to their services for the people in the rural regions, and linking the PTs at Los Pipitos to the North American or Caribbean representative of the World Confederation for Physical Therapy to improve utilization of available resources.
Evaluation of curricular content is an important aspect of educational assessment. This case report describes the process utilized by a physical therapist education program to evaluate an ISL/ICE experience in rural Nicaragua using Pechak and Thompson's conceptual model of optimal ISL.23 Based on the evaluation, the decision has been made to transition the experience from a clinical education course to a global health course which occurs later in the curriculum. Components identified as strengths will be maintained, while planned modifications to address areas for improvement will be implemented to further enhance the learning experience. The authors found the conceptual model developed by Pechak and Thompson23 to be a useful guide in this process.
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