In Defense of Pediatricians … (And a Few Words of Advice For Doctors and Other Public Health Types)


Allow me to share a few select comments from Twitter with you.

“You people are awful.”

“This is just sick,” wrote another.

“All this to enrich yourselves. DISGUSTING!!”

“You endanger KIDS LIVES for a $400,000 a year salary and a Lexus???”

“This is just terrible, horrible behavior!!!”

Wow. What’s going on? What are these people talking about?

They’re taking me and my fellow pediatricians to task because of the perceived role pediatricians play in perpetuating the conspiracy that pediatricians, public health officials and greedy pharmaceutical companies encourage vaccinations in order to make money and are therefore willing to endanger the lives of children everywhere.

The anger toward pediatricians is real. How did things end up this way?

How did a medical specialty most people associate with sniffles and sore throats, reach the point where labels are thrown at us that are more commonly used to describe axe murderers and third world dictators?

Allow me to defend myself and my fellow pediatricians, most of whom are relatively reluctant to engage belligerent people on social media.

I do not have that problem.

In a way, I understand the anger. It makes sense to me.  I deal with parents every single day. These people are worried about the safety of their children. They’ve run across a very disturbing story on the internet and are worried by what they’re reading.

But these people do all seem to have one thing in common.

They seem to be operating with a mental image of doctors that got lodged in their brains about twenty five years ago.  Or might they have acquired it by binge watching too many medical dramas on Netflix? (I prefer to blame Hollywood scriptwriters, whose portrayal of the glamorous lives doctors lead is equally detached from reality, however I will save that for another time.)

As for the idea that I’m living a life of luxury? I’ve heard this one from enough people and enough times that I feel the time has come to address it.

The financial windfall I am supposedly reaping by vaccinating the kiddos in my care? Let me break it down for you. For the last 15 years, I have been paid $6 per immunization by the various insurers. With the ushering in of “value-based care,” the reimbursement rate is up to a whopping $17-22 as of this year. This is the princely sum for which I am supposedly willing to sell out my principals and commit the crime of keeping a child healthy.

Let me point out one little detail many people may not be aware of. The vaccinations that people are getting so worked up about? Fifty years ago they were administered by physicians or nurses only. In recent years, thanks to structural and legislative changes in the healthcare system,  the vast majority of immunizations are being administered by medical assistants, pharmacists, and other healthcare workers, many of whom have completed a single 20-hour training course. Could playing it ‘fast and loose’ with vaccinations have something to do with some of the uptick in complication rates?

Perhaps we should consult a statistician?

Here’s a study I’d like to see.  I’d like to see research that looks at the complication rates for vaccinations given by nonphysicians and compare them to the complication rates back in the days when pediatricians and nurses gave the immunizations.

I wouldn’t be surprised if the numbers tell a very interesting story.

Just ask Lou Ferrigno –otherwise known as “The Incredible Hulk”– about how he ended up in the hospital after receiving an immunization for pneumonia at his local pharmacy. His tweet said it all, “Went in for a pneumonia shot and landed up here [in the hospital] with fluid in my bicep.” He tells his followers that “it’s important you keep an eye on who’s giving the shot and make sure they not only swab the spot correctly but that you watch the needle come out of the package.”

The problem is that while pharmacists, medical assistants and health center employees are considered adequately qualified to roll up somebody’s shirt sleeve and jab a needle into their arm after a 20 hour crash course, they have little or no training to evaluate the health status of their patients. Many have never seen the patient before the day they walk through the door.

Which brings us back to those terrible stories on the Internet.  

It’s natural for parents to be upset. Especially when they raise their hands to ask questions and get shouted down by an angry mob. That’s because the stories they’re hearing sound plausible.  The vast majority of people who are being converted to the anti-vaxx camp are intelligent, rational people. Most are are highly educated, and they are good parents. They are aware enough to search for scientific evidence to answer their questions after being dismissed by the CDC.

If you’re like me, you may have noticed that the conspiracy theories that are floating around keep gaining strength. These ideas incense public health officials and scientists, but it turns out that on social media, the more we try to suppress ideas we dislike, the more they spread.  At this point it’s become obvious that things aren’t getting better. They’re getting worse. Pretty soon, the entire system is going to break down.

And one day soon there may be a real epidemic. Not a flare up. Not a scare. A real epidemic that kills thousands of people and brings life as we know it in this country to a halt.

And I’ll tell you one thing. If it happens, it’s going to be our fault.

Yes, you read that correctly.

If you want to blame somebody for the vaccine crisis, blame the pediatricians. Why?

Because we know better. We let government bureaucrats and health insurance bean counters push us around, even though this puts the health and welfare of children at risk. We let others who are far less qualified than we are take the lead and take up the challenge of explaining the vaccine story to the world.

How did we let that happen? I’ll tell you what happened. We gave up.

We got sick and tired of beating our heads against a wall. Tired of explaining to public health officials that it’s a bad idea to tell people that vaccines just work. Period.  Tired of fighting with insurers and employers, who don’t see the value of paying twenty dollars more for a physician to administer immunizations directly. Tired of arguing with our government, which believes vaccinations are so ‘harmless’ that in 1993, U.S. Secretary of Health and Human Services Donna Shalala (currently serving in the US Congress) asked the American Pharmacists Association (APha) to help define the role of pharmacists in the national vaccine program for children.  They jumped at the opportunity when millions in revenue was at stake.

We’ve known since the beginning that vaccines have risk. All medicines have risks. They have trade offs and rewards. In an age when scientific information is widely available on the Internet, it makes absolutely no sense for public health officials and scientists to dodge the hard questions by telling people that “vaccines work”.

In a world where opinion is shaped through social media, a public health strategy based on trying to “educate people” by shoving “facts” in their face when the facts are in dispute is not going to work very well.  In reality, it may backfire and produce exactly the opposite result from the one you intended. And that is exactly what is happening here.

The people who are revolting and opting out of the vaccination system? They’re not going anywhere. They’re not going to be shamed into submission. They’re not going to sit back down and shut up. You can try to “educate them.” They’ll go out and get different books.  You can bar their kids from schools. They’ll build new schools.

It’s pretty clear that it’s time for a new approach.  We need to have a national conversation about the risks and benefits of vaccination. We need to respect the power of immunizations and their side effects.  And it’s time to take vaccinations out of the hands of people who know nothing about the risks involved and give them back to the physicians.

And lastly, it’s time for somebody to have a long hard talk with Big Pharma about the role they are playing here.  What data do they have? To quote one of Hollywood’s favorite conspiracy movies: What do they know and when did they first know it?

Many of the questions that are being raised by the people who are challenging the current system are fair.  Parents deserve answers to their questions and full disclosure. Then and only then, will the controversy subside and allow pediatricians to go back to the peace and quiet of their glamorous lives treating runny noses and all that other stuff.

In reality, physicians are the only group of healthcare professionals with the ability to turn the anti-immunization debacle on its head.  Pediatricians, especially, must reclaim the responsibility for talking openly and honestly with our patients about the risks, benefits, and alternatives of immunizations. After all, look at where relying on the CDC, WHO or even the US Government has gotten us?

Oh and one last thing? For the record.

$400,000 is a pipe dream and my Lexus is a minivan made by someone else.

Niran Al-Agba, MD is a pediatrician based in Washington State. She is an associate editor for The Deductible. Follow her on Twitter at @silverdalepeds

20 thoughts on “In Defense of Pediatricians … (And a Few Words of Advice For Doctors and Other Public Health Types)

  1. “In a world where opinion is shaped through social media, a public health strategy based on trying to “educate people” by shoving “facts” in their face when the facts are in dispute is not going to work very well. In reality, it may backfire and produce exactly the opposite result from the one you intended. And that is exactly what is happening here”.

    Yup. The arrogance of the intelligentsia is a large part of the problem. It’s how the political discourse in the country has become so rigid and how public health issues have taken on this kind of tenor. ‘I am the expert, you only know what you read on the internet and are uneducated, so trust me’. People involved in the fields of communication and shaping others’ opinions (marketers, politicians, etc) talk about how decisions are not made only on ‘facts’ but on emotion. The fastest way to create resistance and bring out the worse emotions is to be dismissive of someone’s fears/feelings and to ram ‘facts’ down their throat.

    As Dr Al-Agba points out, facts can be cherry picked depending on one’s perspective.

  2. I personally believe the trade offs involved with vaccines are well worth it. But I get there are risks. And I accept them. In my view, the public health challenge here is about how those risks are explained to patients and how we deal with people who ask uncomfortable questions we know the answers.

    This is about something much bigger than people asking questions that challenge accepted science. This is about the democratization of knowledge.

    Remember back when people thought the Internet was going to usher in a Golden Age for Science and Medicine? Well, it has. It just happens that the Golden Age doesn’t looking anything like we expected. It turns out that when you give people access to information and data they do unexpected things with it. Some good / some bad.

    Everywhere you look, people are challenging the “experts” and making their own decisions. In most cases the experts are unhappy about this, which is understandable. Nobody likes being challenged.

    In a way, it’s kinda ironic that public health people are getting twisted by the all the questions and the challenges, doctors are getting the same thing all day every day.

    People are walking into their office waving Google search results and asking annoying, stupid (and completely brilliant questions). I’d say to the public health folks what I say to doctors, you’re going to have to change the way you do your job, otherwise life is going to suck.

    The old days when people accepted the answer “trust me, I’m an expert.” are over.

    I think a lot of people are having trouble wrapping their minds around that fact. Like it or not, this is how the process works now. It’s ugly. But there are benefits. We’re going to answer a lot of questions. And we’re eventually going to figure out how to talk to each other, if we don’t kill each other first. Until then, there are going to be a lot of heated arguments. A lot of hurt feelings.

    And a lot of conspiracy theories.

  3. Read a quote today; from 1896; something like, science is not data, science is not information, science is knowing how to use the data and information. Giving data was never the intent, the intent was to teach the public to fish, use the data, but we let them down. That, too, will change. Then we will see where we stand ….. or sit.

    1. From my perspective it’s as though the FCC’s Fairness Doctrine was extended to truth. First it was, “here’s one opinion and here’s another.” Now people seem to think that “here’s your facts and here’s my facts.” As Moynihan said, you can have your own opinion but you cannot have your own facts.

      The benefits of vaccines are based on empiric facts. Yes, there are risks but they are smaller than the risks faced by all of us when we go out in the world. There will always be those that live in an alternative universe and don’t recognize truth. And, that’s their right and they can refuse vaccines and act (or not act) on their ignorance. But, that doesn’t include the right not to vaccinate their kids who deserve the opportunity to triumph over genetics and wind up sane. Jimmy Kimmel had the final word. (See link to hilarious public service message below.)


  4. Niran,

    Thanks for the piece. Are there any studies or reports that show that the public cares who administers an immunization (e.g. physician/nurse versus other health care workers)?

    Also, if you’re saying that cost isn’t the issue (given your reimbursement rates), there must be some reason that public health officials have to for broadening the scope of who can provide immunizations to other HCWs. Isn’t part of the problem that we have too many specialists and not enough primary care physicians?
    If so, who is to blame for this and who can rectify the situation?


    1. Jason, I am so glad you asked these questions. There are no studies or reports about what the public cares about on this subject. In my opinion, it is because no one has bothered to ask them. And we should. If you ask my patients (especially those who have been coming to my office for three generations) they would say me (or my father) were the ONLY people who have ever given them a shot in their lives. My patients unequivocally like that fact. I have a record of working closely with vaccine hesitant parents and the fact I give them, understand them and can answer many questions about immunizations is quite helpful anecdotally.

      Public health officials have broadened the scope for who can provide immunizations because they can. They are so out of touch with the American people that they believe getting immunized is more about “convenience” than trust. In fact, CVS and their minute clinic believes the same thing. It won’t be any better. They won’t provide more comprehensive care than little ‘ol me but they will use up millions (just like the public health people have) until they realize they just don’t get it.

      I know I sound like a broken record, but I invite you to spend just one day in my clinic. Your entire perspective will be turned on its head. You just can’t understand what a primary care doc on the front lines does until you see it. A good relationship between a doctor and patient is simply magical. More than that, it is unbelievably cost-effective, high quality and all those other things the public health people are still scratching their heads and trying to figure out.

      Now as for the shortage, that is on Congress and the ACGME funding they pulled away years ago. We need more primary care residency positions and we need to pay primary care docs more to do their very difficult jobs. If you pay a specialist 400k and a PCP 100k, then more people will choose the former rather than the latter. I have written on this topic ad nauseum over the past few years, but no one seems to be listening.

      The answer is right under our noses. Pay physicians adequately and you will begin to have more of them entering the field and staying in practice longer than they are now. If you don’t, then we will have more measles outbreaks, mumps, or even polio will return. What a stupid way to go to prove a point.

      And I ask anyone commenting on this thread if they gave anyone immunizations today? I sure did. Why not pay attention to the one who is actually doing this work on actual human beings every single day?

      1. Hi Niran,

        I appreciate your points. I also think it’d be great for a study to conducted as to what level patients value their relationship with their doctor RE: immunizations versus getting them from the most convenient health care worker source.

        I’m a little more conflicted on this one that you are. I certainly appreciate what primary care docs deal with but I’m thinking from a patient perspective. Personally, from where I sit as an educated non-parent, I’m comfortable with treatment or shots from non-physicians/nurses as long as I’m given the right sources to follow up with. So, from that perspective, I can understand the value of convenience (and potential cost savings) of going with the nearest qualified health care worker as opposed to physicians/nurses.

        That being said, I think when it comes to childhood vaccinations, I tend to agree with you that there should be a different standard. Many doctors I know, particularly pediatricians, tell me that they can overcome much vaccine hesitancy and vaccine skepticism simply by being a trusted source for information for young parents. So, perhaps the answers lie in treating children and adults differently as patient populations, as well as the funding that goes along with it.

        As for the shortage of primary care physicians, I’m going to be a little controversial here and say that I’m not entirely sure that Congress is the villain here. It says a lot of the collective health care industry that wages between specialists and PCPs are so out of whack. And frankly, I’m not sure that the political will is there for Congress to seriously advocate that PCPs getting another six figures to keep up with their medical joneses.

        No one will be happy with this, but has the time come for doctors to engage in a little proactive wealth redistribution?

  5. It’s our fault (the public). We don’t teach science well enough in our schools, and our health care journalism has been limited to stories about early trials that promise cancer cures in mice and diet fads. Hyperbole and bias prevail. Dr. Sanjay Gupta does only the most extreme stories. How are parents supposed to get trustworthy information? It’s not like it used to be when families had the same pediatrician fo years. Now if you change jobs you change doctors. Of course there is no trust. Every doctor is a stranger.

    Am I an anti-vaxxer? Never, because kids in my youth got polio, measles and mumps. Some of them were sterile and paralyzed and blind from childhood diseases. We were desperate for vaccines. BUT even I am suspicious of the.shingles vaccine, which has made many people sick and is only 10 % more effective than the old one that I’ve already had. We need much better public information for public health.

    1. Actually Francine, in response to your statement:
      “It’s not like it used to be when families had the same pediatrician for years. Now if you change jobs you change doctors. Of course there is no trust. Every doctor is a stranger.”

      This is not true for docs like me. My practice is on third generation patients. I KNOW these people just like doctors did 150 years ago. It is possible and it is amazing. It can be done.

    2. That’s precisely the point. People don’t have first hand memories of the plague, or the ravages of polio or other lesser epidemics. We are the victims of our success and this should have been anticipated. You look around and see no danger to your brand new baby. So why take a risk no matter how small? You may even understand that other people are taking that risk with their babies and maybe you think that you don’t have to, that you can protect your own baby, as unfair as that may sound. Fairness is not a consideration when it comes to your own kids.

      So yeah, it’s awful, but it’s also human behavior. It’s one thing to vaccinate and take a small risk to protect from a big risk, and quite another thing to expose your baby to even a tiny risk when there is no clear and present danger.

      And before you all start yelling at me, I vaccinated all my kids because as a kid I did have the measles, and the mumps and whooping cough and every goddamn virus. And like Francine I’ve seen what these things can do to kids. I never had to be in the mental place I described above….and I had a pediatrician who was my personal friend and lived two doors down the street, so there you go….

      1. All true, Margalit.

        But, in addition to lack of direct experience with epidemics, there has been a change in the public mindset. Those that remember the pre-LBJ era will recall that there a completely different attitude toward authority. The Americans of the 50s universally took smallpox vaccine even though few had ever seen a case.

        Vietnam and Watergate destroyed the public faith that authority can be trusted to work for the general welfare. And, there is nothing on the horizon to restore that faith. Unfortunately, some of that mistrust extends to the authority of others who are seen as “establishment” including physicians. Perhaps that wariness of authority is a good thing overall. But, after having taken a bite out of that apple there appears to be no going back to innocence, for good or not…

      2. Agree on the timeline Daniel, but I’m not sure it’s authority that lost its appeal. I don’t think Americans at any point had a tradition of being especially deferential to authority. I think its trust in expertise and a sense of allegiance to the group to the point of sacrifice. Americans in the 50s just had huge accomplishments under their belts. They were very patriotic still…. I don’t want to get into politics, but these things go together. If anyone dares say today what JFK said about what you can do for your country, that person would be labeled a fascist. I don’t think we have that mindset of doing whatever it takes to keep our “group” safe, at least not to the same degree. And yes, I agree, it started in the 60s and it is getting really bad (or good?) now.

        And then there is expertise, which is losing its charm by the minute, with Wikipedia and Google and the sewer known as The Internet in general. It’s sort of funny how the larger and more complex the human body of knowledge becomes, the more folks think they can be experts at everything, or at least know enough to make informed decisions.
        We are democratizing vapidity, superficiality, mediocrity, selfishness and foolishness, I’m afraid…..

      3. Bless you, Margaiit….especially for that last line: “We are democratizing vapidity, superficiality, mediocrity, selfishness and foolishness, I’m afraid…..”

        But, there is, I would argue, a more sinister force beyond “vapidity, superficiality, mediocrity, selfishness and foolishness.” There is an almost systematic attack on science and knowledge — the sewer from which this nonsense emerges. Just as with climate science deniers, the Right presents the ratio of 1 “scientist” vs 3,000,000 scientists as a balanced debate….so the sewer of the internet is used to promote anti-vaxxers as reasonable.

        Ditto “creation science” and all the other nonsense that is now presented as alternative truth….err truth.

        It may be a sewer, but it’s being nurtured and nourished by rich people with bad intent (and also by poor people who ain’t so moral either but just don’t have the same resources… no invidious distinctions intended on that axis).

        Also, I’d be remiss if I failed to mention the remnants of the KGB etc.

      4. Good afternoon, all

        I am no Luddite, let alone a science basher. In fact, much of my research career had me at the bench as a physical-biochemist – a context far more scientifically elegant and comforting than that offered when I wear my other hat as a clinical epidemiologist.

        I am convinced that the endless American vaccine kerfuffle is the result of dueling disinformation dating back to colonial times. If it weren’t for Reverend Cotton Mather and Doctor Zabdiel Boylston piercing the miasma of prevailing opinion, 18th C Boston would have been decimated by smallpox. The disinformation is more invidious today because profitability confounds preconception, but the disinformation is not less harmful. Furthermore, the disinformation today has many sources, not all of which are members of the flat earth guild.

        Wakefield’s shameful, egregious sophistry has a life of its own despite compelling science regarding the safety of thimerosal in the vehicle and of the DPT and MMR epitopes. It reverberates, nonetheless, in the popular press and the vast literature of “the world is a minefield” that attracts so many mothers who don’t know whether their child should be allowed to sleep prone or drink from a plastic bottle.

        Nonetheless, the long term safety of some vaccines is supported by far less compelling science and the effectiveness of others far less incontrovertible. Such an assertion borders on the “politically incorrect” but not the scientifically irrelevant:

        The long-term consequences of varicella and HPV vaccination wait for the “long term” to be clarified. There is theoretical reason for worrying about the former so that some could argue that “chicken pox” is nearly always a childhood passage rather than a disaster demanding uncertainties of prevention. As for vaccinating to prevent shingles, have you looked at the NNT for a severe infection? As for HPV, the European and Canadian data on untoward consequences thwarts reflexive reassurance.
        MMR makes sense except for the middle-M which very rarely leaves important residua. But why not? Or is it why?

        Then there’s the annual epidemic of influenza fears and disinformation, followed by soft statements about whether the last round of vaccinating actually had a meaningful or valid NNT.

        We are so busy medicalizing life in America, that we bridle at any discussion of de-medicalizing life in America. When it comes to vaccination, in childhood or adulthood, we all deserve a conversation with a physician who has prepared for such and who is willing to prepare us. I suspect we’ll end up with far less anxiety regardless of which vaccination we acquiesce to.

  6. Jason you misunderstood my point about Congress entirely.

    They decreased funding for residency spots. It is killing our profession.

    There were NO (zero) unmatched residents in the 1999 match and space left for FMGs. Today, unmatched applicants number in the thousands annually.
    Do you understand now? This means thousands who have successfully graduated from medical school cannot find a spot to finish their training in residency.

    They are 400k in debt and this travesty disproportionately affects women, African Americans, Native American and nontraditional physicians applicants.

    You bet your bottom dollar Congress is responsible for this aspect if the doctor shortage after not keeping up with training enough of us.

    It is shameful that our leaders are so stupid on both sides of the aisle.

    Sometimes this group acts like they are hearing this stuff for the first time. We all know Congress killed graduate education funding yet I can’t blame them. Who do I blame for this?

    1. Niran, I was referring to the pay issue and didn’t adequately address the residency spot issue.

      I do find it troubling that there has been a decrease in primary care residency spots. But is this contributory to the growing shortage of PCPs? And (I bring this up knowing I might get shouted down) there also appears to be a diversity of opinions when it comes to whether American will be dealing with a doctor shortage or not.

      Getting back to the point, even if even more residency slots existed, I’m not certain it would change the situation. After all, here’s what AJM commentary notes (

      “…the percent of 2017 applicants who entered these potential primary care residency programs increased by 43% from 2002 to 2017. How many of the physicians who entered these residency programs in 2017 will emerge as primary care physicians? Unfortunately, a minority of these physicians entering these residencies will enter practice as generalists.”

      1. Ahhhhh thank you for your comments Jason.
        Yes, it has hurt the numbers entering primary care.
        Yes, it is mostly a physician maldistribution issue. Nevertheless that is a functional shortage.

        And now you bring up the issue that once they are trained in primary care, they can’t actually afford to go into practice in primary care….

        Hmmm I wonder why someone with 400k of debt cannot accept a position with a 120-150k annual salary? Thoughts about this?

        I have some. First off, I am frugal. Just ask my kids. I make 100k working 24 hours per week and covering 3000 patients. Though that increased a bit after my dad died last year. 😔 I’m busier than the average pediatrician and can see more patients because of NO dreaded EHR. I’m on call 24/7 365 days per year. I finished school with 100k of debt (a pittance compared to nowadays) lived on peanut butter, Diet Coke and pizza to scrimp save and buy my first home for 169k in 2001.

        My patients give me their children’s clothes secondhand. Patients bring me food because I never have time to eat myself. I did purchase a larger home (2600 square feet on 88 Feet of waterfront) with four bedrooms for my husband and I and four children NOT because I’m a damn doctor but because I won 250k from a ‘defamation per se’ lawsuit last fall!! 🎉

        Seriously, someone needs to come and visit and see how medicine really works out here in a small underserved area. Some good ideas might come from broadened horizons. I think it would change your mind about what we’re worth as well.

      2. Hi Niran,

        I think we’re agreed on a number of points.

        1) We agree that there is a functional shortage.
        2) Compensation structures between primary care physicians and specialists make no sense.
        3) The imbalance is affecting those wishing to get into primary care who are burdened with massive debt (almost everyone at this point)

        The only point on where we have differed is whether Congress has stomach to step in. Politics aside, I don’t see much movement among the current crop of legislators. This isn’t because they shouldn’t necessarily do so, it’s just an assessment of where their head is at.

        But there is also room for re-examination within the medical community about pay structures and how it’s established (WaPo ran a good piece about how specialists gamed the system here: Sparking and pushing this conversation could do a lot of good.

        And, just to clarify in case it wasn’t absolutely clear, I’m not making a personal value judgment about the value or hard work of primary care physicians community-wise or compensation-wise. What I’m saying is that Congress is highly unlikely to favor any expansion of the pot to address pay disparities – they’re more likely to kick the issue back down to doctors (though I fully admit I stated that in a provocative way to test the reaction).

        On a personal note, as for residencies, a small background. I used to help with the Canadian Resident Matching Service at McGill Psych when I was in undergrad and I am super sympathetic to young graduates who don’t get matched. And it’s not just doctors suffering from a lack of places – many of my law school friends had to go far and wide to get matched into articling in Canada (legal residencies). Frankly, I don’t think we should be educating those if there’s no realistic pathway for them to go for mandatory licensing or address their debt.

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