6
THE WAY 1HEY 130 IT Teaching Interpersonal Skills in Physician Assistant Programmes Increasing awareness that the technical competence of health professionals must be complemented by a well developed set of interpersonal skills (IPS) has resulted in the rapid growth of the formal teaching of IPS in training programmes for an important group of new health professionals in the United States-physician assistants (PAS). This is a report of a national survey which was part of a study designed to determine the extent and characteristics of IPS teaching. Most PA programmes have a specific course or a section of a large course for the teaching of IPS. Psychologists, physician assistants, and psychiatrists serve as teachers for most of these programmes. The majority of pro- grammes teach process skills (for example, listening, responding), information-gathering skills, and psycho- logical intervention skills (for example, demonstrating empathy). Less than half the programmes report the provision of instructioh in one-to+ne patient edu- cation, team membership skills, sexual and family counselling and self-care for health professionals. Most of the programmes which responded to the survey use videotechnology in teaching or assessing IPS. This report examines the teaching of interpersonal skills in physician assistant training programmes. The first such programme was developed in 1975 in the United States in response to the general agreement that the nation faced a shortage of physicians. It was originally believed that these new health professionals would alleviate the physician shortage by performing some of their tasks thereby saving the physician time and effort Jane Wcstberg, PH D. is currently Associate Director, National Center for Faculty Development, University of Miami, School of Medicine, Room 900A, 1320 S. Dixie Highway, Coral Gables, Florida 33146, USA. At the time of the project she was Assistant Professor of lIealth Care Sciences, George Washington University. Gary Kahn, MMD. is Corporate Director, Division of Health Promotion, Samaritan Health Services. Phoenix, Arizona. At the time of the project he was Project Officer, National Medical Audiovisual Center. Barry Cohen, P1I.D. is Project Director, Carkhuff Associates, Inc., Amherst, Massachusetts. Theodore Friel, PH is Vice President. Carkhuff Associates, Inc. 136 (Pellegrino 1977). Physician assistants (PAS) were to work under the close supervision of a physician, generally in a highly structured hospital or other clinical setting. In their clinical roles, PA's major responsibilities are: establishing and analysing the health status data base and formulating, implementing and monitoring the health management plan. Establishing the health status data base can involve such tasks as eliciting a pertinent medical and psychosocial history and performing a per ~ tinent physical examination. Analysing the health status data base can involve differentiating between normal and abnormal findings and interpreting raw data from screening and diagnostic tests. Formulating the health management plan can include determining priorities for problems to be managed and selecting therapeutic measures. Implementing the health plan can include contacting selected supportive services to be involved in patient care. Monitoring the plan can include assessing patient cooperation and assessing progress towards the desired result. At about the same time, the public and the govern- ment became aware of the pressing need for com- prehe'nsive primary care which was accessible, available and affordable. There was increasing recognition of the rights of patients to be treated as whole persons, not as mere disease states. Crowing attention was paid to the quality of the relationship between health professionals and patients and the importance not only of respecting the feelings and perspectives of those who are seeking help, but also of promoting their collaboration in decision making (Barnlund 1976). One by one, neglected areas of concern were identified: chronic illness, prevention, patient education, health promotion and health maintenance. It became evident that the health personnel shortage was aggravated by the geographic maldistribution of physicians (the tendency of physicians to cluster in cities and regions populated by people with moderate or high incomes) and by the specialty maldistribtuion (the tendency of growing proportions of physicians to enter specialties) resulting in a decrease in the number of primary care physicians. In the early Medical Teacher Vvl2 No 3 1980 Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 11/11/14 For personal use only.

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Page 1: Teaching Interpersonal Skills in Physician Assistant Programmes

THE WAY 1HEY 130 IT

Teaching Interpersonal Skills in Physician Assistant Programmes

Increasing awareness that the technical competence of health professionals must be complemented by a well developed set of interpersonal skills (IPS) has resulted i n the rapid growth of the formal teaching of IPS in training programmes for an important group of new health professionals in the United States-physician assistants (PAS). This is a report of a national survey which was part of a study designed to determine the extent and characteristics of IPS teaching. Most PA programmes have a specific course or a section of a large course for the teaching of IPS. Psychologists, physician assistants, and psychiatrists serve as teachers for most of these programmes. The majority of pro- grammes teach process skills (for example, listening, responding), information-gathering skills, and psycho- logical intervention skills (for example, demonstrating empathy). Less than half the programmes report the provision of instructioh in one-to+ne patient edu- cation, team membership skills, sexual and family counselling and self-care for health professionals. Most of the programmes which responded to the survey use videotechnology in teaching or assessing IPS.

This report examines the teaching of interpersonal skills in physician assistant training programmes. The first such programme was developed in 1975 in the United States in response to the general agreement that the nation faced a shortage of physicians. I t was originally believed that these new health professionals would alleviate the physician shortage by performing some of their tasks thereby saving the physician time and effort

Jane Wcstberg, PH D. is currently Associate Director, National Center for Faculty Development, University of Miami, School of Medicine, Room 900A, 1320 S. Dixie Highway, Coral Gables, Florida 33146, USA. At the time of the project she was Assistant Professor of lIealth Care Sciences, George Washington University. Gary Kahn, MMD. is Corporate Director, Division of Health Promotion, Samaritan Health Services. Phoenix, Arizona. At the time of the project he was Project Officer, National Medical Audiovisual Center. Barry Cohen, P1I.D. is Project Director, Carkhuff Associates, Inc., Amherst, Massachusetts. Theodore Friel, PH is Vice President. Carkhuff Associates, Inc.

136

(Pellegrino 1977). Physician assistants (PAS) were to work under the close supervision of a physician, generally in a highly structured hospital or other clinical setting.

In their clinical roles, PA's major responsibilities are: establishing and analysing the health status data base and formulating, implementing and monitoring the health management plan. Establishing the health status data base can involve such tasks as eliciting a pertinent medical and psychosocial history and performing a per ~

tinent physical examination. Analysing the health status data base can involve differentiating between normal and abnormal findings and interpreting raw data from screening and diagnostic tests. Formulating the health management plan can include determining priorities for problems to be managed and selecting therapeutic measures. Implementing the health plan can include contacting selected supportive services to be involved in patient care. Monitoring the plan can include assessing patient cooperation and assessing progress towards the desired result.

At about the same time, the public and the govern- ment became aware of the pressing need for com- prehe'nsive primary care which was accessible, available and affordable. There was increasing recognition of the rights of patients to be treated as whole persons, not as mere disease states. Crowing attention was paid to the quality of the relationship between health professionals and patients and the importance not only of respecting the feelings and perspectives of those who are seeking help, but also of promoting their collaboration in decision making (Barnlund 1976). One by one, neglected areas of concern were identified: chronic illness, prevention, patient education, health promotion and health maintenance. I t became evident that the health personnel shortage was aggravated by the geographic maldistribution of physicians (the tendency of physicians to cluster in cities and regions populated by people with moderate or high incomes) and by the specialty maldistribtuion (the tendency of growing proportions of physicians to enter specialties) resulting in a decrease in the number of primary care physicians. In the early

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Page 2: Teaching Interpersonal Skills in Physician Assistant Programmes

197Os, there were 22,000 generalists and 8,000 specialists (Beeson 1974).

Physician assistants have been responsive to health care needs in the United States. An unpublished report by the Association of Physician Assistant Programs states that 70 per cent of PA graduates are providing primary care, of xhom 47 per cent arc in family practice. Almost 40 per cent of PAS are practising in rural areas. The real ztossibility that PAS will function increasingly indepen - dently is reflected in the fact that 17 per cent of graduates are working in satellite centres where physicians serve m l y part time.

A clue to the success of these new health professionals is :he rapid growth of the profession. Fourteen years after :he establishment of the first training programme, there Ire more than 50 accredited programmes producing

,500 graduates annually.

Health Professionals Need Interpersonal Skills

I t is becoming clear that PAS and other health professionals cannot provide comprehensive care if their cechnical competence is not complemented by a well developed set of interpersonal skills (IPS). The health professional’s success in gathering accurate, complete data from a patient and in guiding a successful plan of aanagement can depend upon skills in relating and communicating effectively. Health professionals who ask leading questions of their patients, for instance, can elicit inaccurate histories. Those who do not give patients the opportunity to verbalize fully their concerns can miss significant clues to an accurate diagnosis. Even physical Iindings can be affected by interpersonal skills. A health xofessional who does not help the patient feel at ease, for sample, can mistake ‘tenseness’ for ‘guarding’ in the abdominal examination. Recent studies indicate that ?atient cooperation and even positive treatment out- comes are linked with effective communication between xovider and patient (Davis 1966; Francis et al. 1969; Gillum and Barsky 1974; Bertakis 1977).

Both provider and patient gain satisfaction from relationships characterized by good rapport (Doyle 1968). Conversely, patient discontent is associated with poor communication in provider-patient relationships. Patients who feel they have received inadequate in- formation, or that their dignity, privacy and/or comfort :lave been violated consider, or even take, legal action against health professionals (Reeder 1972).

Traditionally, it was assumed that IPS did not need to 3e taught; that a mature, bright student would learn the required skills through experience. Studies indicate, however, that mere exposure to patients does not xecessarily improve a student’s skills. Indeed, Barbee and Feldman (1970) observed that the interviewing skills of zlinical students who had received no specific instruction m interviewing actually decreased or remained the same. Helfer and Ealy (1976) found that a student’s in- rerviewing skills did not improve with increasing clinical xactice in the absence of specific instruction. It has been jemonstrated, however, that students who do not receive ivtruction in IPS are able to improve these skills (Enelow Medical Teacher V o l 2 No 3 1980

et al. 1970; Werner and Schneider 1974; Grayson et al. 1977). Hutter and colleagues (1977) showed that this improvement was most dramatic in students who demonstrated major defects early in the programme.

Surveying Different Health Professionals

When the decision was made to study the extent and characteristics of IPS instruction in training programmes for health professionals in the United States, it was agreed that because PAS are making an important contribution to primary care, they would be an important population to include in the study. Other professionals studied were nurse practitioners and physicians (medical students and family practice residents). The following questions were explored in a national survey of all these programmes: 1. To what extent are interpersonal’skills taught in the health professions? 2. What specific interpersonal skills are taught? 3. Who does the teaching? 4. What instructional methods are used? 5 . What evaluation methods are used? 6. To what extent is video technology used in the teaching/evaluation of interpersonal skills? The full study included four elements: the national surveys; a review of the literature; site visits to selected institutions; and informal input from selected professionals in the field. This report focuses on the instructional and evaluation methods, and some of the findings for physician assistant programmes. The find- ings of the other components of the study are reported elsewhere (Kahn et al. 1979a, 1979b).

T h e Survey Design

The study was conducted in three phases. In Phase 1 the relevant study populations were determined. Teachers of interpersonal skills had to be identified before questions could be asked of them, so we wrote to the directors of the 44 PA programmes listed in the National New Health Practitioner Programs: Profile 1976-1977 as having received approval (accreditation) from the Council on Medical Education of the American Medical Association. The programmes were also members of the Association of Physician Assistant Programs. The study was explained to the directors who were asked to answer these questions: “Does your programme teach interpersonal skills in a formal course?” “Would you please identify people who teach such a course(s)?”. The self-reply postcard on which these questions were asked was completed and returned by people representing 30 of the 44 PA programmes. All of the respondents indicated that interpersonal skills were being taught.

Phase 2 had three goals: 1. To confirm that individuals identified in Phase 1 did, in fact, have responsibility for teaching interpersonal skills. 2. To determine whether they would be willing to respond to a detailed questionnaire.

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Oxford University Press 138

3. To determine whether video technology was used in their teaching programmes. Fifty-eight people who served as instructors for 28 PA programmes completed Phase 2 questionnaires. People from 26 programmes indicated that they used videotape. The detailed Phase 3 questionnaire (requesting 30 to 45 minutes to complete) was sent to people representing the 26 programmes in which IPS are taught and videotaping is used in the teaching of those skills. The questionnaire contained 17 major items (for example: skills taught, evaluation and teaching methods used, use made of video technology, types of student and programme duration), each item including several sub-items. For example, 37 specific skills were listed as possible content for IPS programmes. Respondents were asked to select ap- plicable items from listed options, and provided space for them to add “other” categories. When appropriate, quantification was requested (for example, the number of students taking a course). Usable responses were received from people representing 19 of the 26 PA programmes using video - a 73 per cent response rate.

The design of the questionnaires themselves followed conventional procedures. Guided by the survey goals, the staff, national advisers and consultants gathered a pool of items, revising and editing as necessary. Draft in- struments were devised, field tested and revised.

Findings

The major findings of the survey are summarized ac- cording to the six major questions which were the focus of the study.

Extent of Teaching

There is considerable activity in the teaching of IPS. It is conceivable that there is additional activity in programmes which did not respond to the survey. 1. In at least 30 out of 44 PA programmes there is a specific course or courses or a section of a large course for the teaching of IPS. 2. In at least 26 out of those 30 programmes video technology is used. 3. The number of courses offered seems to be increasing. In 22 of the PA programmes there are courses which are less than four years old, while in nine of the programmes there are courses which have been offered for one year or less.

Skills Taught

Table 1 presents the frequency with which various interpersonal skills are taught. Overall, most pro- grammes address the basic skills of interpersonal process, information gathering and psychological intervention. Less than half the programmes, however, provide in- struction in one-to-one patient education, team member- ship skills, sexual and family counselling and self-care for health professionals.

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Table 1. Interpersonal skills taught. Table 2. Most frequently used evaluation methods.

Percentage of Skills programmes

Interpersonal process skills Listening Observing Responding Ini tiating-questioning-challenging Self-awareness Self- assessment Information gathering skills (interviewing) History taking-medical content History taking - psychosocial content Interpersonal skills for physical examination Information-gimng/counselling skills Information giving- sharing diagnostic

Advice giving- explicit action recommended One-to-one patient education (e.g., self-care

Psycho logica 1 intervention skills Demonstrating empathy Providing psychological support Responding to patient feelings or helping a

Team membership skills Group problem-solving Case management - responsibility sharing Group interaction

SupeTvisory skills Providing feedback Supervision contracting (e.g., establishing a

contract or set of supervision objectives) ‘Interpersonal process recall’ Special application areas Working with the difficult patient Crisis intervention Death and dying counselling Suicide prevention Presurgical counselling Sexual counselling Family counselling (e.g., third party processes) Self-carc for health professionals

findings

instructions)

patient deal with hidher feelings

(e.g., self-awareness/personal growth)

84 90 84 84 79 69

74 89 79

58 63

37

84 74

74

32 32 42

47

16 26

63 53 47 37 21 37 26

32

Background of Teachers

Psychologists are instructors in 47 per cent of the programmes which responded to the in-depth questionnaire. In one third of the programmes PAS teach IPS, and in one third of them psychiatrists do so. Twenty-six per cent of the programmes utilize family practitioners and social workers for IPS teaching, while 16 per cent use paediatricians, medical sociologists and anthropologists. Other professionals involved in IPS teaching in PA programmes include family practice residents, internists, third- and fourth-year medical students, second-year PA students and political scientists.

Medical Teacher V o l 2 No 3 1980

Evaluation method used Percentage of programmes

Indirect assessment Self-report (student satisfaction, etc.) Multiple choice examination Patient management programmes Attendance Dzrect assessment (staff o bseruation) Global ratings Quantified behavioural indices Criterion referenced indices Outcomes indices Statement of patient satisfaction

68 74 42 26

63 32 21

26

Peer review Observation by untrained peers 62 Observation by trained peers 26

Instruction Methods

Fifty-eight instructors from 28 PA programmes com- pleted the Phase 2 questionnaire. Eighty-six per cent indicated that they use live lectures or videotapes of lectures for didactic presentations. For demonstrations of IPS the same percentage indicate that they prefer live simulation. Videotapes are used by 72 per cent of the respondents. For skills practice and feedback, videotape is used by 72 per cent of the respondents and audiotape by 35 per cent. Sixty-seven per cent of those reporting observe rheir students directly (use live observation).

Evaluation Methods

Table 2 presents the evaluation methods utilized in the 26 PA programmes in the Phase 3 study. Indirect assessment methods are used more than direct methods. Outcome indices, such as patient satisfaction, are used by only 26 per cent of the programmes. The following methods are used by even fewer programmes: written indices of patient satisfaction on predetermined outcome objectives (five per cent); rating of the specific skills by trained patients (16 per cent); and behavioural indices of patient compliance/adherence with student instruction (none).

Use of Videotechnology in Teaching/Evaluating IPS

These figures are based on the findings from Phase 3 of the study. Prerecorded videotapes are used in 53 per cent of the PA programmes as trigger tapes to stimulate class discussion. In 53 per cent, prerecorded programmes are used for evaluating students. In 42 per cent, they are used to give students a common learning experience, while in 32 per cent they are used in conjunction with self- instructional modules or units.

In 74 per cent of the programmes, learners are taped while practising interpersonal skills. In 84 per cent other students in the course are used as ‘patients’ for skill practice. In 58 per cent of the programmes, these

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Page 5: Teaching Interpersonal Skills in Physician Assistant Programmes

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'student-patients' present a simulated history, while in 21 per cent, 'student-patients' use real histories which have been modified for consistency. Actors and actresses with simulated histories are used in 27 per ceilt of the programmes as 'patients' for skill practice. In another 26 per cent, volunteer patients present their real histories.

Student-patient practice sessions are recorded in classrooms/conference rooms in 37 per cent of the programmes. In 32 per cent, special interviewing rooms are used and in 16 per cent, studios. The camera is visible, not concealed, in most instances. Students are not taped through a one-way mirror in any of the programmes.

Most students are not videotaped in real clinical set- tings. Students in only 5 per cent of the programmes are videotaped in ambulatory clinics, and none are taped in hospi ta I settings.

In more than half (53 per cent) of the programmes, recorded student-patient interviews are played back to help learners look at their own feelings: in 42 per cent, playbacks are used to stimulate learner awareness of patients' feelings. In 53 per cent of the programmes, playback is used to help learners rate their level of skill proficiency; in 32 per cent, it is used by instructors to rate learners.

The teacher is present during the playback session in 63 per cent of the programmes; the student is present in 6 3 per cent: the patient is present in 21 per cent and other students in 37 per cent of the programmes.

Discussion

One of the most striking findings of the survey is the high level of activity in the teaching of interpersonal skills. All persons who responded to Phase 1 report that these skills are taught in their programmes. An encouraging finding is the extent to which videotape is being used to teach IPS (93 per cent of the programmes responding to Phase 2 use i t ) . Seventy-two per cent of the teachers responding to Phase 2 use video technology for demonstration, and the same number use it for skill practice.

Training in basic IPS, for example, listening, ob- serving, responding, initiating/questioning/challenging is provided in most programmes responding to Phase 3. In a significant number of programmes, the psychosocial content of history taking is taught. In a high percentage, students are helped to demonstrate empathy to patients.

While these results are encouraging, it must be remembered that the data were elicited through a self- report questionnaire. This method tends to cause some inflation in the findings which, in some cases, means low figures are especially significant and merit further in- vestigation. The finding that only 37 per cent of the programmes provide training in one-to-one patient education, for instance, is a c a w for concern because it could mean that only a small number of programmes provide explicit training in a skill considered to be fundamental to the effectiveness of PAS. The apparent low level of teaching in the area of team membership skills also deserves further investigadon. Additionally, group problem-solving or responsibility-sharing in case

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Page 6: Teaching Interpersonal Skills in Physician Assistant Programmes

management is taught in only 32 per cent of the programmes. Since PAS usually work in conjunction with a physician or another provider, it would seem that attention needs to be paid to these important skills.

Information-gathering skills are basic for PAS who, typically, are expected to be able to elicit accurate histories and perform competent physical examinations. Yet, in 26 per cent of the programmes these skills are not addressed in teaching the medical content of history taking. In 42 per cent of the programmes, explicit training is not given to help students share diagnostic findings with patients and in 63 per cent, training is not provided in advice-giving skills.

Evaluation also appears to merit further investigation. If students are to improve their skills, it seems logical that they will need specific, constructive feedback based on actual observations of their interactions with patients. Multiple choice examinations, which do not allow the instructor to witness students’ process skills, are the most widely used form of assessment. Staff observations of students are chiefly reported in global, not specific, terms. While it is generally agreed that the goal of IPS training is improved patient care, few programmes measure results in this way. Even global statements of patient satisfaction, which are less than optimal, are used in only one quarter (26 per cent) of the programmes.

Almost all of the videotaping of students takes place in the classroom. Although this is important, it can be valuable for students to see themselves interacting with real patients in real patient care settings. Currently, only 5 per cent of the programmes videotape students in am- bulatory settings. No programmes reported taping in hospitals.

Conclusions

The high level of interest and activity in the teaching of interpersonal skills is encouraging. This could derive at least in part from a commitment to equip PAS to provide comprehensive care, responsive to the needs of the whole person.

Research in IPS teaching in schools of the health professions is young but it does support the ap- propriateness and importance of this kind of training. Hopefully, the study reported here can serve as a baseline against which future findings can be compared and also as a stimulus for further investigation.

Up to this point, PA programmes appear to be working done at the task of providing IPS instruction. It is hoped h a t future activities and research will include collaboration between PA programmes and training ?rogrammes for other health professionals.

Xeeferences

Sarbee, R. A. and Feldman, S . E., A Three-Year Longitudinal Study = Medical Interviewing and its Relationship to Student Performance in 3 c a l Medicine,,lournal of Medical Education, 1970, 45, 770. %dund, D. C., The Mystification of Meaning: Doctor-Patient En- .zmters, Journal of Medical Education, 1976, 51, 716. *n, P . , Some Good Features of the British National Health Service, k m a l of Medical Education, 1974, 49.43-49.

Medical Teacher V o l 2 No 3 I980

Bertakis, K.. The Communication of Information from Physician to Patient: A Method for Increasing Patient Retention and Satisfaction,

JournalofFamily Practice, 1977, 5 ,217. Davis, M. S . , Variation in Patients’ Compliance with Doctors’ Orders: Analysis of Congruence Between Survey Responses and Results of Empirical Investigations, Journal of Medical Education, 1966, 41, 1037. Doyle, M. S . , Attitudinal and Behavioral Aspects of the Doctor-Patient Relationship as Expressed and Exhibited by Medical Students and their Mentors, Journal of Medical Education, 1968, 43, 337. Enelow, A. J . Adler, L. M. and Wexler, M . , Programmed Instruction and Interview, Journal of the American Medical Association, 1970, 212, 1843. Francis, V . , Korsch, B. M. and Morris, M. J. Gaps in Doctor-Patient communication: Patients’ Responsr to Medical Advice., New England Journal of Medicine, 1969, 280, 535. Gillum, F. and Barsky, A,, Diagnostic and Management of Patient Non-Compliance, Journal of the American Medical Association, 1974, 228, 1563. Grayson. M., Nugent, C. and Oken, S . L., A Systematic and Com- prehensive Approach to Teaching and Evaluating Interpersonal Skills,

Journal of MedicalEducation, 1977, 52,906. Helfer, R.E. and Ealy, K. F., Observation of Pediatric Interviewing Studies, AmencanJournal ofDiseases of Childhood, 1976, 123, 556. Huttrr, M. J . , et al. Interviewing Skills: a Comprchcnsivc Approach to ‘Teaching and Evaluation, Journal ofMedical Education, 1877, 52, 328. Kahn, G., Cohen, B. and Jason, H., The Teaching of Interpersonal Skills in US Medical Schools, Journal of Medical Education, 1979a, 54, 29. Kahn G.. Cohen, B. and Jason, H.. Teaching lnterprrsonal Skills in Family Practice, J o u m l of Family F’ractice, 1979b. 8, 309. Pellcg~ino, E., in The New Health Professionab ’ Nurse Practitioners and Physicinni Assistants (I’Ass, A. A . and Cohen, E. D. , Eds), Aspen Systcms Corporation, Germantown, 1977. Reeder, L. C. , The Patient-Client as a Consumer: Some Observations in the Changing Professional-Client Relationship, Journal of Health and Social Behaviour, 1972, 13,406. Wrrnrr. A. and Schneidrr, 1. M., .l‘eaching Medical Students Inter- actional Skills, New EnglandJournaf of Medicine, 1974, 290, 1232.

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