A dog is a rat is a doctor is a vet

I want to return briefly to a point made in a hard-hitting post from Canadian blogger Blazingcatfur about the awful treatment his mother received:

With barely contained anger I informed the nurse that keeping an ill, 84 year old woman in a hospital corridor for 18 hours was not the type of care that anyone should be expected to tolerate. In fact my cat receives better treatment from his vet.
This is not the first time I've seen the point raised about veterinary care being better than health care for humans. And you don't have to compare veterinary care to health care under socialized medicine to see the difference, although it becomes particularly glaring if you do.

Under our "system" of veterinary health care, there's generally little or no wait, they're invariably friendly (because you could always grab your dog or cat and take it to another vet), and as to the prices?

Let me give a personal example. My old dog Puff once swallowed half a tennis ball he had flattened, and it opened up like a parachute inside his small intestine. This formed an insurmountable blockage, and necrosis set in. Without immediate emergency surgery, Puff (by that time in horrible agony) would have been dead in a day or so. He was cut open, the foreign object removed along with a three foot section of intestine (the two severed ends being anastomized together) and after a couple of days at the vet I took him home, where he fully recovered without complication.

The bill for all of this? Nine hundred and fifty dollars.

$950.00

Now, this was some time ago, and today it would be more. Probably close to a couple of grand.

But imagine how much it would cost if a boy were to swallow something he shouldn't have and it lodged in his small intestine and had to be removed. I shudder to think of the possible bill for emergency surgery and two days in the hospital, but I think you'd be lucky if it cost less than $20,000.

Why?

The instruments, the drugs, the surgical techniques, sterile hygiene, intravenous lines, and post-operative support, all of these things are basically the same. True, the boy would not be placed in a four by six cage during his stay in the hospital, but a bed in a room is not all that complicated.

What accounts for the huge difference in price? A lot of people say it's the liability insurance, but is that all there is to it? It's not as if there's much difference in the degree of education between an MD and a DVM. (And it's actually harder to get into vet school than it is to get into med school, so if there's an issue involving brains, the vets might win.)

It strikes me that there is a giant, overarching difference between veterinary care and regular medical care, and that is that the former is barely regulated by the government, while the latter is so regulated that even now -- without socialized health care -- many doctors feel as if they spent most of their time being bureaucrats. Is that it? I'm sure my vet kept records for Puff, but I'd be willing to bet they consisted of little more than a couple of paragraphs summarizing the diagnosis, the procedure, and his recovery. And I'd also be willing to bet that for the same procedure on a boy, if all of the records were all printed out they'd be a stack of documents inches thick.

I realize that people will say I am silly and comparing apples and oranges, but it wasn't that long ago that the complex education and licensing as we know it simply did not exist. When they weren't cutting people open, "barber surgeons" cut hair and shaved faces.

But you don't have to go back to the 18th century. A close friend who died a few years ago had a copy of a bill she received for the birth of her son in the late 1940s. Including delivery, hospitalization, and maternity care, it came to just over two hundred dollars. Even if we correct for inflation, there is simply no comparison between the prices then and the prices now for medical care.

While I realize technology has added many tools to the medical arsenal since the 1940s, the same tools have been added to the veterinary arsenal, so that can't be all there is to it. I have not seen any vet bills from the 1940s, but I am sure that a cursory examination would reveal that the rate of increase has risen in a normal manner that we would expect, while the rate of increase for human medical care has skyrocketed. (Of course, in those days, far fewer people had health insurance. Might the "blank check" from the big pocket have something to do with it?)

Should we allow vets to treat humans? Why not? If a woman can consent to an abortion, why can't I consent to having a veterinarian cut a tennis ball out of my intestines?

Why can't we be consenting adults?

UPDATE: My thanks to Glenn Reynolds for the link and a warm welcome to all.

Your comments are invited -- agree or disagree.

posted by Eric on 09.19.09 at 10:26 AM










Comments

JVDeLong   ·  September 19, 2009 1:36 PM

I have nothing but admiration for the veterinary clinic that treats my cats. I believe every aspiring human doctor should be *required* to do a long rotation with a veterinary clinic in order to get a license to practice medicine on humans.
Vets are constantly treating hysterical, fully-armed patients who are trying to scratch and bite them during treatment. Yet I've never seen a vet who wasn't patient, gentle, and compassionate. On the other hand, I've had *plenty* of doctors who were jaw-dropping jerks. There must be something very different in the way veterinarians are trained- there just aren't as many arrogant creeps. It must be something in the philosophy.

Lynne   ·  September 19, 2009 2:43 PM

I'm waiting for doctors and hospitals to step up to the plate and apologize for the health insurance monster they created.

Doctors and hospitals operated on the free market system, until Blue Cross/Blue Shield was "invented" as a convenient way for them to be paid more money.

Now, that in itself is not a bad thing, but it sure has come back to bite them and their patients.

Next, government needs to realize that wage freezes have consequences, like employers figuring out other ways to compensate employees. Government encouraged, then mandated that employers provide insurance.

And unions? uh... don't get me started!!

Anyway, back in them good ole days when I first had health insurance, I paid the doctor up front and he gave me a piece of paper saying what I had, what he did about it, and what he charged me. Then I sent that off the insurance company to be re-imbursed.

Hospitals worked a little differently. They would file the claims for me, but I still got a copy of the bill because I owed them a percentage of it.

I was not disconnected from what I was getting and paying for.

Now? I have no idea.

Donna B.   ·  September 19, 2009 6:11 PM

Call me anytime . After all, I can castrate a cat in eight seconds.

dr kill   ·  September 20, 2009 12:40 PM

Actually, there's a big difference in DVM vs. MD skillsets. The DVM is dealing with more than one species, and frequently more than one class (though generally only one phylum). Also, the DVM will often personally handle treatments that a GP would refer to a specialist. So, the vet needs a much broader range of skills.

Now, there is something to be said for specialization... but there's also overhead involved in passing a patient among various specialists, as opposed to having a generalist who deals directly with most of the common ailments and treatments.

Another fun question to ask: why does medical school cost so much? What with all the new doctors starting out with huge debts, wouldn't it be worth looking at the true cost of providing a medical education?

Eric Wilner   ·  September 20, 2009 1:42 PM

>Another fun question to ask: why does medical school cost so much? What with all the new doctors starting out with huge debts, wouldn't it be worth looking at the true cost of providing a medical education?

That's a government-subsidized cost; the "true cost" would be higher. Med students take a lot of valuable time and resources while adding liability.

JoelP   ·  September 21, 2009 9:21 AM

I agree.

However, remember: When one of my patients doesn't do well, I can't barbeque them.

Howard Bowman, MD   ·  September 21, 2009 9:35 AM

One reason vet care is cheaper is simply if the cost is too much, the owner can choose to put the animal down rather than the surgery.

This is not a main reason but it does keep the costs down since the alternnative is considered.

I had to do that last December. My dog had a large tumor. It was too close to the spleen. I had little money and the surgery was too expensive. The dog was already going blind and was not young so I chose to put him to sleep

RAH   ·  September 21, 2009 9:38 AM

Doctors make a lot more than vets because the medical establishment controls the number of people admitted to medical school, and has the power of the government behind it with regard to licenses to practice. I'm sure that the vet surgeon that treated Puff could, with an absolute minimum re-training, have successfully done the same procedure on a human. (Afterward, of course, the vet would then have gone to jail for the illegal practice of medicine.)

D. Ch.   ·  September 21, 2009 9:40 AM

In the US, the cost difference between animal and human care is due to lawyers. The cost is both monetary and emotional. A doctor knows, whatever he does or doesn't do, he WILL eventually be sued by someone.

My wife's a nurse. She once saw a child drowning at a beach and rescued him. She saved his life. She never followed up or wanted anyone to know. She treats it as a guilty secret. She spent years in fear that the kid would have some brain damage, and they would find her and sue her.

Once a friend of mine needed a complicated procedure on his dog. He wondered about what was necessary, costs, and who to go to. So, I emailed another friend who was a vet living too far away to be the right doctor in this case.

The email that came back was interesting. She concurred on what the dog needed, recommended the vet he was seeing, and outlined the costs. She noted that the needs were identical to the same operation on humans, including having a licensed anesthetist. According to her, the reason the human operation cost more was entirely due to the cost of malpractice insurance.

Lewis   ·  September 21, 2009 9:47 AM

Even apart from the question of insurance and lawsuits, the standards for human surgery will be higher and more expensive than for dog surgery because we insist that the risk of death must be made lower for humans.

For example, we don't generally accept that a person will have a 1% chance of death by anesthesia, so we have highly trained MD-anesthesiologists (the exceptions which prove the rule, such as some non-hospital clinics as for plastic surgery, do have higher rates of death from anesthesia). We don't routinely do this for dog surgery. Call me crazy, but I'm insisting on an anesthesiologist for major surgery on me or my kids; on a dog, no way, and the difference isn't the insurance.

DWPittelli   ·  September 21, 2009 9:49 AM

Maybe I need to be corrected on the anesthetist! At any rate, I do not claim that the higher standards for human medicine are all the cause of the cost difference either. Just some.

I also do not claim that the higher standards for human medicine will always be better. Long slow death in an ICU may be worse than dying quickly. (But I wouldn't want the federal government making either decision.)

DWPittelli   ·  September 21, 2009 9:54 AM

D. Ch. -

I'm sure that the vet surgeon that treated Puff could, with an absolute minimum re-training, have successfully done the same procedure on a human.

Actually, I had an OB/Gyn I loved who delivered my first child by C-section. She had been a researcher before becoming and MD. I asked her once what prompted her to go into Obstetrics and female surgery. She said she had spent years doing laparoscopies on twenty monkeys a day, and it wasn't a big jump to doing them on humans. She liked that her human patients were usually better conversationalists than her monkeys, as well.

MathMom   ·  September 21, 2009 9:58 AM

A few years ago, I had sinusitis and was prescribed an antibiotic. Not penicillin, but something much like, and generic. My wife at the time looked at the bottle and said, "Wow, my horse is getting the same thing."

We checked. He was, right down to the markings on the pills.

"His" cost? Not 10% of mine.

Yeah.

Peter Buxton   ·  September 21, 2009 10:00 AM

JVDeLong wrote: Vets are constantly treating hysterical, fully-armed patients who are trying to scratch and bite them during treatment. Yet I've never seen a vet who wasn't patient, gentle, and compassionate. On the other hand, I've had *plenty* of doctors who were jaw-dropping jerks.



An armed society is a polite society.

steve   ·  September 21, 2009 10:03 AM

While I appreciate the vote of confidence, I assure you I don't need to add another species to my list of potential patients!
One of the big reasons for increased costs for treating people is the increased staffing costs. A hospital has a large number of trained and licensed nurses, lab techs, radiology techs, orderlies, etc. While I have a lot of confidence in myself and my staff, and we treat every patient conscientiously, I don't presume to think that I am as skilled at clin path and radiology as those who specialize in these areas. When a member of my family is seriously ill, I really want that flock of highly trained and licensed nurses, med techs, etc. supporting the doctor.

JeanE   ·  September 21, 2009 10:13 AM

Another difference is that when Puff was sick you didn't have to pay the bill for Fido and Rex down the street.

It should probably also be noted that we are supposedly paying to make sure that care never falls below a certain standard with humans. If we were willing to accept a little more variation in that regard then the price could be lowered a great deal without care really being any worse in most situations. For instance, in some countries you don't need an MD to prescribe certain medications.

When certain sorts of scans first came out it was easier and quicker to get one for your pet than to get one yourself. The hospitals were able to charge what it actually cost for pets but not for humans so the cost equation works out both way.

To Hayek With You   ·  September 21, 2009 10:25 AM

An obvious difference between veterinary and human medical practice is that veterinarians' patients (well, their owners) usually pay out of pocket for treatment (though pet insurance is becoming more common) and therefore usually know exactly what the treatment will cost. Veterinarians therefore compete with one another based on price. Most people, on the other hand, except for the uninsured, have no idea what their medical care is really costing. If their insurance is provided in whole or part by their employer, they most likely don't even know what the insurance costs! There is little or no cost-based competition in human medicine as a result. We don't make medical decisions for ourselves based on the cost of the treatment, and many of us are convulsed with rage right now at the idea that anyone, anywhere, should ever have to take cost into account in deciding which medical treatments to have and which not to have. This is one of the reasons -- perhaps a primary reason -- for the skyrocketing cost of medical care.

Anonymous   ·  September 21, 2009 10:25 AM

The reason vets are better docs than MDs is they really like their patients and want them to be well. Most vets give a more thorough physical exam on either a routine or emergency visit than MDs. Vet school costs as much as med school and the pay is less so you don't go into the profession for financial security. My wife is a vet 12 years out and still paying off loans and will be for the foreseeable future.

tom   ·  September 21, 2009 10:32 AM

"One reason vet care is cheaper is simply if the cost is too much, the owner can choose to put the animal down rather than the surgery.

This is not a main reason but it does keep the costs down since the alternnative is considered."

Now I understand what Obama's reform is.

Dmitry   ·  September 21, 2009 11:23 AM

As a vet, I think my insight may be useful. We are less expensive and more available for several reasons.

1) Lower liability coverage. Many MD's pay more annually than I make, so I'm not as big a target for those who wish to win the "insurance lottery". Also we rarely settle out of court, so such claims merely cost their lawyer. I have been threatened three times in 17 years, and always said "bring it on". Never heard from them again. So we also have less "defensive" medicine.

2) The customer is always right. The customer is the one paying the bill. Therefore in human medicine, you are NOT the customer, the insurer or the government are. For every case, I have to explain what the treatment is, and what it costs to the client, and get their approval. The client is the one who knows the patient best, and loves them. But to the government or the insurers, the patient is not personally beloved, or even known, just a number.

3) Vets are almost exclusively in small business. We are acutely aware that clients can take their trade down the road if our customer service and pricing are not competitive.

4) Because we are "fee for service" medicine, and not insurance driven, we have to be very aware of cost benefit of new equipment and therapies. So no, I don't have an MRI in my back pocket, or a hyperbaric chamber. If needed, there are referral centers full of specialists.

The Grey Man   ·  September 21, 2009 11:41 AM

Just to add in but one of my dogs came down with diabetes about 2 years ago. Diabetes is very difficult to treat in animals. After about $1200 in treatment over around 5 months she wasn't responding and was suffering so she went to doggy heaven. But there were no transfusions or treatment beyond diagnosis and insulin treatment. She was a wonderful and beautiful Siberian but the responsible and humane thing was to have ehr euthanized. She was 11 and continuing her end of life treatment wasn't going to be what you would do with a human. There's no big conspiracy.

bandit   ·  September 21, 2009 11:53 AM

Eric-

If you swallow half a tennis ball, I'd chip in $25 toward your vet bill. If enough people chip in, you could even make a nice profit.

Come one everyone, let's see how much we can raise!

Ignorance is Bliss   ·  September 21, 2009 11:58 AM

My father, may he rest in peace, was a veterinarian for over 40 years and president of the regional veterinary association. He was frequently consulted by MDs and after his funeral one of the region's leading human medicine surgeons told me that my dad "was the best diagnostician in Detroit, period".

Veterinarians have patients that cannot tell them what hurts, where it hurts or what their symptoms are.

Ronnie Schreiber   ·  September 21, 2009 12:08 PM

What's missing here and in all discussions of health care expense that I have seen is a detailed breakdown and explanation of the costs. It probably wouldn't be too hard to get that data for the vet bill, but next to impossible to get for the ball swallowing boy. You could see the hospital bill, but I've never seen an honest elaboration on the details.
"Follow the money" they say, but it's as if that's not allowed in the case of medical costs.

Rabel   ·  September 21, 2009 12:33 PM

If 'a boy is a dog is a rat' why do they always choose the rat over the boy?

murph   ·  September 21, 2009 12:36 PM

Hi Dr. Bowman,

When we get socialized medicine, putting people to sleep because they cost too much to keep alive will quickly become SOP.

And even with that, we won't get lower costs.

The increasing regulation of our lives is all about government power, nothing more.

Patrick Carroll   ·  September 21, 2009 1:02 PM

Having worked at a veterinary hospital and with horses, I would be perfectly happy to have a vet provide medical services for me (and I have). I'm just another large animal, after all, and one that can conveniently indicate where exactly it hurts and give myself pills.

The difference, as has been stated before, is the visibility of cost in veterinary service. I have a similar situation with my high-deductible insurance. I have very good coverage in the event of a catastrophic problem, but for the little things its in my best interest to take control of costs/benefits of treatments. I startle the heck out of my doctors when I ask them what the costs of various treatments are. They're not used to someone making decisions based on price... which is the problem.

SentWest   ·  September 21, 2009 1:08 PM

As another data point, we didn't have maternity coverage when my daughter was born in 1987. The delivery cost us about $3k, and I don't believe our obstetrician ever showed up; we just had the hospital's on-duty nurses and doctor.

wheels   ·  September 21, 2009 1:21 PM

Amen!!! We already do home steep tests for the kids - next time one of them gets a broken bone we're off to the vet. Maybe I'll need to become friends with them first. . . :)

Steve Adams   ·  September 21, 2009 2:01 PM

JeanE hit on the most significant difference, apart from liability insurance costs, specialization, and equipment: the fact that vets aren't compelled by law to treat everyone who walks in, regardless of their ability to pay. So yes, your bill for Puff is a bill for Puff, not one that comprehends what a hospital loses for every ER "self-pay" (code for "cannot pay and will never pay" admit, of which there are hundreds every day in every hospital of any size -- and Medicare/Medicaid covers only a fraction of the incurred costs of dealing with each of those admits. (Disclosure: I'm an ambulance medic.)

Megaera   ·  September 21, 2009 2:05 PM

Seconding Peter Buxton's point: I spoke to my vet a while ago. She had cancer patients taking chemo drugs. She had to get those drugs from the local hospital pharmacy. One dog in particular was about 120 pounds, and so was getting the same dose as a human would. The hospital pharmacy charged her $300 for the same number of pills that would cost a human $3000. (They told her this.)

Anthony   ·  September 21, 2009 2:09 PM

The Friday after Labor Day, 1976, one of our two dogs, a mutt we'd found abandoned at a nearby state park on Sept. 21, 1971, made the perhaps pardonable mistake of chasing the city's mowing machine, which was sent around periodically to cut the grass beside streets without sidewalks. It was one of those long cutter-bar arrangements run by a tractor, the kind with the oscillating teeth . . . a hay mowing attachment, in fact. She stepped over the bar with her front legs, with predictable results. The ligaments on the left were clipped, but the right front foot was hanging literally by a shred of skin. So we packed her into the car and my brother, the human tourniquet, clamped down while my poor mother drove faster than she ever had before (or has since, come to think of it) all the way to the city, to our vet. They were able to fix the left leg pretty easily, and made a yeoman effort to save the right one, but she lost it in the end. Some weeks later my grandfather, who taught orthopaedic surgery at Vanderbilt for about 184 years or so, and who hated, in that order, lawyers and vets, kept nattering at my mother to know how much it cost. My mother, being a good Midwestern German girl who wasn't well acqainted with backing down from anyone, even someone who ruled like an Old Testament patriarch, finally shut him down with, "Well, let's just say he charged a great deal less than you would have for the same procedure." Game. Set. Match. Maggie went on to live almost another ten years, dying on Feb. 26, 1986; about the only thing she couldn't do was shake hands (a sight both funny and pathetic at the same time). I'll let others argue the economics of it, but if nobility lies in helping those who cannot do for themselves, then vets, whatever they charge, are setting a pretty ferocious pace. Just my two.

Countrylawyer   ·  September 21, 2009 2:25 PM

One other thing- the US Army recognizes the parallels. My dog's vet is a former Army med officer. He enlisted, the Army sent him through vet school on the condition that he serve x number of years active duty as an Army doc.

Yep- our servicepeople on the battlefield are often treated by veterinarians. Why? Because it is the same job, roughly the same training. In many sense, the vet's diagnostic job is harder because the patient doesn't answer questions very well. But the treatments and procedures are roughly the same. I'd go to my vet for care in a heartbeat.

Kurmudge   ·  September 21, 2009 2:30 PM

One other thing- the US Army recognizes the parallels. My dog's vet is a former Army med officer. He enlisted, the Army sent him through vet school on the condition that he serve x number of years active duty as an Army doc.

Yep- our servicepeople on the battlefield are often treated by veterinarians. Why? Because it is the same job, roughly the same training. In many sense, the vet's diagnostic job is harder because the patient doesn't answer questions very well. But the treatments and procedures are roughly the same. I'd go to my vet for care in a heartbeat.

Kurmudge   ·  September 21, 2009 2:31 PM

For a comparison: My hip replacement at a University hospital was $38K plus change at menu price, about $26K insurance co. price. My St. Bernard's hip replacement at a university vet hospital $3500 plus 4 days room and board cash price.

Choey   ·  September 21, 2009 2:38 PM

One reason vet care is cheaper is simply if the cost is too much, the owner can choose to put the animal down rather than the surgery.

This is not a main reason but it does keep the costs down since the alternnative is considered.

Hmmm... So you're saying that Obamacare really COULD reduce medical costs?

Barry D   ·  September 21, 2009 2:53 PM

Well this article screams at me "TORT REFORM AND FREE CHOICE ACROSS STATE LINE FOR HEALTH INSURANCE". I wonder if Obambi is listening.

kenny komodo   ·  September 21, 2009 3:04 PM

"Call me anytime . After all, I can castrate a cat in eight seconds."

As conversation starters go, that one must really clean out the deadwood in the singles bars...

richard mcenroe   ·  September 21, 2009 3:04 PM

There's a lot of valid points raised above, but most come down to the point that vets deal in an actual market, while human medical care does not and can not operate on strict market principles. Vets have patients who will be allowed to die if the treatment is too expensive or onerous, doctors/hospitals know that their patients will pay. If my cat has something terminal and expensive, Fluffy's going to die. If I get a sucking chestwound, I'm going to the hospital regardless of how expensive it is. The ability to not only shop around for a better price but to walk away from the transaction completly is a necessary component in the free market. Basic Econ 101 will tell you what happens when you have universally high demand, regardless of supply the cost stays relatively high. Thats why most adverts try and convince people a luxury is actually a necessity ("can't live without it"). That's also why when you artificially increase the demand by adding people outside of market motivation (subsidies and grants) you increase the cost (see tuition and housing).

Mauther   ·  September 21, 2009 5:12 PM

There's a second, large component to human medical costs that hasn't been mentioned, and that's the cost of unreimbursed government coverage.

Doctors/hospitals know that a large percentage of medicaid and medicare payments are either going to be late, incomplete, or simply never coming in at all. As partial compensation for this, they price all medical procedures extremely high. Private insurance, of course, always pays on time (so long as the work is covered by the policy). People with good, private insurance, thus, wind up cross-subsidizing people relying on government coverage.

I've even heard large numbers of stories of doctors--especially GPs in private practice--who no longer even bother submitting the paperwork for government reimbursement for relatively minor stuff like office visits & general check-ups. It's not worth the time involved, and they're not going to get paid back anyway. Now imagine what it would be like if the government were to move up to a Canadian style universe health care system.

Beck   ·  September 21, 2009 5:37 PM

In principle I agree that reducing the regulation of the human medical industry would be the best reform for medicine. I'd like to point out that a huge part of the disparity in cost between human and animal medicine, is that the consumers in the veterinary setting often self-ration care. I'm an animal lover, and have had pets for my entire life (I'm pushing 50). When my first dog Sonny, a Gordon Setter that I rescued from a breeder when I was 13 years old because he had a recessive gene, began to have seizures when he was around one year old, I decided that his quality of life was so poor that keeping him alive would be against his best interests ... and would only serve to salve my conscience and sorrow (heavy thoughts for a 13 year old, even in 1972).

I would not (want to) use the same moral approach with my Mom or Dad, or my wife, or one of my children. They are people not pets. But realistically, I think if we are ever going to reform human medicine, without significantly de-regulating it, there will be some form of rationing. I'm not advocating this, but I'm acknowledging its inevitability.

An Average American   ·  September 22, 2009 8:32 PM

You know, Milton Friedman once made the argument for abolishing the licensing of doctors. He reasoned thusly:

1) The market will take care of it (always point number one with Friedman)
2) Licensing doesn't stop quacks
3) Licensing creates mandarins (the AMA, medical schools, the MCAT, etc)
4) Alternatives exist
5) The market will take care of it. Really.

While I'm not going to advocate abandoning the licensing of doctors, I would definitely suggest that massive deregulation would bring costs down by a much much greater percentage than it would bring down the standard of care (which might, potentially, actually, just dare to think about it, go UP).

Beck   ·  September 24, 2009 12:21 AM

If a woman can consent to an abortion, why can't I consent to having a veterinarian cut a tennis ball out of my intestines?

Why can't we be consenting adults?

THANK YOU. It's not that one doesn't want people to be safe, healthy, and happy--it's that the only way for them to be that way is to decide for themselves how to get there.

Zandra   ·  September 29, 2009 11:19 PM

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