Offices and Clinics of Doctors of Medicine

SIC 8011

Companies in this industry

Industry report:

This industry consists of offices and clinics of licensed medical doctors, excluding doctors of osteopathic medicine (covered in SIC 8031: Clinics of Doctors of Osteopathy). These establishments are engaged in general or specialized medicine or surgery. This category includes the offices of the following types of medical specialists: anesthesiologists, dermatologists, gynecologists, neurologists, obstetricians, oculists, ophthalmologists, orthopedic physicians, pathologists, pediatricians, plastic surgeons, psychiatrists, psychoanalysts, radiologists, medical surgeons, and urologists. Clinics covered in this category are free-standing--not associated with hospitals--such as ambulatory surgical centers, freestanding emergency medical centers, primary care medical clinics, and outpatient psychotherapy and women's health clinics.

Industry Snapshot

According to the U.S. Department of Labor, there were 7.5 million people serving as healthcare practitioners and technicians in 2010, including 101,800 family and general physicians; 42,340 surgeons; 46,980 general internists; 33,310 anesthesiologists; 29,640 general pediatricians; and 20,540 obstetricians and gynecologists. A physician saw an average of more than 100 patients each week, with general and family physicians averaging slightly more than specialists.

The operation of office- and clinic-based physician practices has been strongly influenced by ongoing changes in the entire healthcare industry. Increased healthcare costs, coupled with decreased federal funding, has pushed practitioners to closely evaluate their practices and patient base. During the first decade of the 2000s, physicians also adjusted to new options in technology that could finally convert multiple filing tasks into automated computerized systems that, although expensive to install, provided better quality-of-care and overall cost savings. At the beginning of the twenty-first century, a shortage of physicians challenged the United States as the baby boomer generation moved into retirement and increasing numbers of medical graduates bypassed primary care for a more lucrative career in specialty medication. In addition, healthcare reform was at the top of the national political agenda and Medicare reimbursements were expected to be cut drastically.

Organization and Structure

This industry is organized primarily according to the type of practice or medical specialty performed at an establishment. In the past, most physicians were self-employed and ran their offices in a partnership or group, sharing office help and medical assistants. During the 1980s, some physicians started to franchise, which involved paying a franchiser to handle administration, such as billing and insurance claims. According to a 1999 survey by the American Medical Association, 62 percent of physicians were self-employed, 9 percent were employed in a physician-owned practice, and 29 percent were employed in an institutional setting, such as hospitals, universities and medical schools, and HMOs. However, according to data from the Bureau of Labor Statistics, by the second half of the first decade of the 2000s, just 15 percent of physicians were self-employed. Of the wage-and-salary physicians, about 50 percent worked in an office with a group of physicians, 18 percent worked for a hospital, and the remainder were employed in other settings like the state/federal government, universities, medical schools, and outpatient clinics.

Doctors' offices and clinics play an important role in the overall operation of the health care industry. Doctors usually work with one hospital and refer patients to that hospital for tests and treatment. For this reason, the relationship between doctors and hospitals is often regarded as a buyer-seller relationship, in which hospitals approach local doctors for their patients. In addition, doctors are buyers in their relationship with pharmaceutical companies.

Background and Development

While the convention of doctors working in some institutional or hospital-like establishment dates back to ancient Egypt, doctors' offices as independent establishments emerged in the Middle Ages with barber-surgeons. These independently employed doctors worked in their offices or in patients' homes and received payment for their services as they were provided. Doctors who cared for patients in hospitals received no payment from their patients or the hospital. In the nineteenth century, however, hospitals began paying doctors, and the profession grew rapidly.

During the twentieth century, the role of the physician changed with economic, government, and societal pressures, along with technological advances. In the early part of the century, doctors in the United States were a highly autonomous group that was held accountable to the standards defined by the profession itself and not the general public, according to Harold M. Swartz and Ann Barry Flood in Money, Power, and Health Care.

The gap in salaries between primary care physicians and specialists grew significantly in the twentieth century. As a result, there was a general shift from primary care physicians to specialists. The use of HMOs and provider networks to cut medical costs also changed this profession from wholly self-employed doctors to those working on salaries for hospitals, HMOs, and provider networks. By 1995 the average share of physicians' revenues from managed care rose from 11 to 27 percent, with a higher proportion going to primary care physicians.

Technical advances in this industry were abundant during the twentieth century. From 1900 to the 1950s, the development of antibiotics and public health initiatives, such as water treatment, increased physician effectiveness in many parts of the country and simultaneously decreased the need for doctors in many respects. Wars and increases in population and fatal crimes offset this pattern, however.

During the second half of the twentieth century, technical developments increased doctors' roles in health care. Many diseases, such as Hodgkin's disease and leukemia, were treated with chemotherapy. Moreover, detecting disease was increasingly helped by new technologies for diagnosis. The development and use of these technologies, however, was regulated by governmental bodies and insurance companies.

Freestanding clinics increased in the second half of the twentieth century. By the end of the 1980s, there were 23,000 licensed clinics in the United States, according to the General Accounting Office (GAO). These included outpatient ambulatory care facilities, outpatient surgical centers, psychiatric and psychotherapy clinics, and obstetric/gynecological clinics.

The rapid proliferation of clinics posed problems for state regulators of these facilities. According to a 1989 GAO report, state health regulators were concerned about the complex appeals systems between patients and clinics and were disturbed to find that roughly one-half of the states did not have any means of resolving patient complaints against clinics.

The government acknowledged the growing need for psychiatric outpatient care in 1989 when it increased its coverage for such care under Medicare. The program opted to provide more types of psychiatric and psychotherapy care and to increase the caps on payments.

In the 1980s, physicians broke with a long-held tradition by advertising their services. This new practice was the focus of much debate within the profession and was initially regarded by many physicians and other health care providers as unprofessional. By the end of the 1980s, however, advertising in newspapers, on television, and on radio became common. By 1992 doctors' offices and clinics spent roughly $50 million annually in advertising, with 13.7 percent growth in advertising expenditures.

Plastic surgeons spent an estimated $30 million on advertising in 1990, which represented a 400 percent increase from 1985. In large part the increase was due to societal changes that made plastic surgery in general more acceptable. According to the American Society of Plastic and Reconstructive Surgeons, in 1987 nearly 50 percent of all Americans found plastic surgery acceptable, compared with 35 percent in 1982. In addition, advertising by plastic surgeons increased because a larger number of doctors went into plastic surgery and had consequently increased competition.

Due to increased health care costs and rising competition among doctors seeking business, during the late 1980s the number of consumers seeking medical information outside doctors' offices surged. Nurse-call lines, self-help medical books, and educational videotapes started to compete with doctors' offices. Some offices and clinics, however, adapted to this trend by showing videotaped programs as a way of educating patients about available procedures and treatment options.

Company Clinics.
By the end of the 1980s, large companies in a variety of businesses greatly expanded their company clinics in response to rising health care costs. By 1990 several employers sponsored clinics for their employees. Many of these clinics were operated by the companies themselves, while others were operated by medical management companies. One of the primary ways in which these clinics brought down medical costs was through the hiring of doctors on salaries on the assumption that salaried physicians did not have incentives to perform unnecessary tests.

In 1992 John Deere was the first company in the United States to set up a primary care clinic for its employees in conjunction with a third-party hospital, the Mayo Clinic of Rochester, Minnesota. The largest company clinic in the country was operated by Southern California Edison Company, which had 10 medical clinics and first-aid stations, employed a staff of 70, and facilitated more than 100,000 patient visits annually. Similarly, the Gillette Company and Goodyear Tire & Rubber Company sponsored corporate primary care clinics and offered incentives for employees to use them.

Medicare and Medicaid.
Medicare and Medicaid are government programs providing financial assistance for medical treatment. The Medicare program is designed for individuals at least 65 years old and for the disabled, while Medicaid helps families with low incomes. Government funds for these programs come from both federal and state sources and primarily through Social Security payroll taxes.

In 1997 more than 55 million people received Medicare and Medicaid payments. Medicare payments for doctors, clinics, laboratory services, end-stage renal disease treatments, and continuous-use medical equipment, such as wheelchairs, totaled $51.7 billion in 1997, with $38.2 billion going to physicians. Medicaid payments going to both hospitals and doctors and other health care facilities and providers totaled $123.6 billion in 1997.

Although Medicaid expenditures nearly doubled between 1990 and 1997, growth dropped to 2.8 percent from 1995 to 1997. In 1997 Medicare paid for 20.7 percent of the 787.4 million patient visits to office-based physicians, while Medicaid financed another 8.1 percent of total visits. Private insurance covered 53.1 percent of 1997 visits to office-based physicians.

Medicare and Medicaid greatly affected this industry by increasing administrative duties involved in handling paperwork and by setting costs for medical services. Since the late 1980s, lawmakers have tried to reduce Medicare and Medicaid financing by shifting coverage to promote outpatient treatment over extended hospital care.

In 1991 the Medicare program was reduced $43 billion as part of the federal government's economic budget changes. In 1992 the Health Care Financing Administration, which managed Medicare, started a plan to change how doctors were paid by the government. Under the new plan, doctors' fees were based on resources and the doctors' time in consultations rather than on procedures performed by the physicians. This arrangement was set up to attract primary care physicians who felt the old system was unfair. The American Medical Association (AMA) opposed total use of this system, pointing out that some unfairness to specialty doctors needed to be worked out of the system before private insurers adopted it for their payment plans. At the end of the 1990s, the cost of Medicare was still a hot topic for political debate pertaining to the goal to balance the budget and create health care reform, and by the end of the first decade of the 2000s, Medicare funds were cut more every year.

The Insurance Information Institute (III) reported that the number of medical malpractice claims filed against doctors peaked in 1985 at 17.8 per 100 doctors, then fell for the rest of the decade, dropping to 8 claims per 100 doctors by 1989. During the 1990s, the rate of increase in the number and size of claims tended to fluctuate, according to the III. The malpractice insurance market attracted new entrants in many states, increasing competition and holding down rates.

Due to the proliferation of malpractice suits, the practice of defensive medicine increased considerably. Defensive medicine refers to excessive precautions doctors take in order to safeguard themselves against possible malpractice suits. Precautions that doctors often took in treating patients included ordering duplicate tests, requesting additional diagnostic procedures, and using consultants. According to the AMA, in 1992 defensive medicine added $15 billion to the cost of health care nationwide. In 1991 medical malpractice represented $9.1 billion of total tort costs in the United States, 58 percent of which was incurred by physicians. In 1993 the number of malpractice claims had been reduced by state health regulators imposing caps on suit awards and by the insurance industry and medical profession, which was represented by more than 30 medical associations, together advocating tort system reforms.

Obstetricians and gynecologists were among the doctors most commonly sued for medical malpractice in the early 1990s. According to a study conducted by the American College of Obstetricians and Gynecologists, in 1992 about 27 percent of all claims against gynecologists were for failure to diagnose a medical condition, usually breast cancer. The average payment for claims won against gynecologists was reported to be $92,500 in 1990. Approximately 33 percent of all obstetric complaints were for infant brain damage. The average payment for obstetric claims was $311,400 in 1990. Given the frequency and costs of these claims against obstetricians and gynecologists, their average insurance premiums were $36,946 in 1991, while the average for all physicians was $15,900. Insurance payments and claims awards, however, varied considerably from state to state.

Malpractice cases also strained the relationship between physicians and hospitals. Hospitals had higher insurance coverage and more general funds to cover malpractice cases; consequently, many claims involving doctors were directed at hospitals in order to receive higher awards.

According to a 1993 study by the Health Research Group of Public Citizens, the most common complaints against doctors were for negligence, misprescribing drugs, and substance abuse by the physicians. The study also found that 150,000 to 300,000 medical negligence cases were not disciplined by such measures as revoking or suspending licenses. The AMA responded to this study by pointing out that physicians as a group acted as a self-correcting organization whereby doctors did not refer patients to doctors with reputations for such practices. Moreover, many states did not have the funds to investigate the many claims against doctors.

One measure taken to protect patients from consulting with negligent doctors began in 1990 with the establishment of the National Practitioners Data Bank. Owned by the federal government, this computer data bank stored and provided information about physicians who had their licenses suspended or who faced disciplinary action for negligence and helped to prevent these physicians from setting up new offices.

Other ways of dealing with malpractice cases and the costs they placed on health care included placing caps on the size of awards for personal suffering. This system began to be used in California in the late 1970s. Under health care reform programs discussed at the federal level in 1993, most of the cost of malpractice awards would be paid by HMOs and other health management organizations.

In the mid-1980s, consumer groups drew attention to physicians who referred patients to laboratories totally or partially owned by the doctors, a practice known as "self-referrals." In 1992 a study conducted by the Health Care Financing Administration estimated that at least 25 percent of independent laboratories were financially tied to individual physicians. The same study reported that Medicare patients who were referred by physicians to laboratories they owned received 45 percent more lab tests than other Medicare patients. Some sources estimated that the annual excess in costs as a result of self-referrals was roughly $140 million, while others estimated the costs in the tens of billions.

Federal legislation was eventually drafted that prohibited physicians from making self-referrals for Medicare patients. State legislators adopted similar laws to cover patients on private insurance.

Doctors' Offices Dispensing Medicine.
Since the early 1900s, when licensed physicians gained the legal right to prescribe drugs, doctors' offices and clinics had dispensed drugs in limited numbers to patients. Originally, this practice was not done for profit, but during the 1980s and into the 1990s drug dispensation began to increase rapidly. This increase was prompted by high profits and persuasive marketing by the pharmaceutical repackaging industry. Pharmaceutical repackagers purchase drugs in bulk and repackage them in small units, allowing doctors to maintain a stock of a large variety of drugs at their offices. In 1987 about 5 percent of doctors' offices and clinics routinely dispensed these repackaged drugs. By 1993 nearly 50 percent of doctors' offices and clinics were dispensing repackaged drugs.

The dispensing of drugs out of doctors' offices and clinics caused friction between medical doctors and the pharmaceutical industry. Moreover, this practice raised ethical issues within the medical community. Health care professionals disagreed as to whether doctors should engage in competition with pharmacists and whether doctors, who were generally not as well trained in medicines as pharmacists were, had the qualifications to routinely dispense drugs.

In 1988 the federal government tried to amend the Food, Drug, and Cosmetic Act to restrict doctors from selling drugs from their offices, with the exceptions of emergencies or cases in which patients would have difficulties getting to a pharmacist. The amendment did not pass, and the federal government has since prohibited states from passing similar laws that restrict doctors from dispensing drugs.

According to the National Center for Health Statistics, the number of people who used the services of doctors' offices and clinics gradually increased throughout the 1980s, with the largest increases occurring in cities. This industry also benefited from the aging population, which was reflected in the growth in geriatric medicine and the offices of ophthalmologists, where technical innovations provided eye surgery for the elderly.

In the 1990s, the organizational structure of the industry and its means of making a profit were challenged. The economic needs of employers and expected government reforms changed the industry's structure from individual practices to group care. Rising costs of health care resulted in the introduction of new ways to price services provided by doctors. In addition to the new system adopted by Medicare, which attempted to establish salary parity between primary care doctors and specialists, private insurers and health provider networks imposed caps on the costs of doctors' services.

Organizational changes also occurred as health care moved from inpatient to outpatient surgery. Ambulatory surgical centers, ophthalmology clinics, and gynecology clinics were the fastest growing of these outpatient centers, estimated at nearly 1,500 in 1991. The growth of managed care has promoted the trend toward practice consolidation and significantly reduced the number of self-employed, solo practice physicians.

This industry experienced a shortage of primary care physicians, particularly in rural areas. The more lucrative specialists' salaries drove medical students away from primary care. Rural areas were even less desirable for primary care physicians because salaries were generally smaller than those offered in cities, and physicians preferred to live in metropolitan areas. From 1985 to 1994, the number of physicians in relation to the population increased 11 percent in nonmetropolitan areas compared to 16 percent in large metropolitan areas (populations over 1 million) and 19 percent in small metropolitan areas. Rural hospitals attempted to attract more primary care physicians by offering income guarantees for doctors who joined local practices, and state governments helped rural practices in recruiting new doctors.

As in the entire health care industry, changing government regulations and funding made a deep impact on the manner in which office- and clinic-based physicians practice and conduct business. According to a 2002 study by the American Academy of Family Physicians, nearly 22 percent of family physicians surveyed said they no longer accept new Medicare patients, a 28-percent increase from a similar study done the previous year. The paperwork hassles combined with a decreasing pay schedule, which dropped 5.4 percent in 2002 and another 4.4 percent in 2003, meant that Medicare patients were too much work for too little return. Of those physicians who were not outright refusing Medicare patients, nearly 25 percent placed limits on the number of Medicare patients they would retain on their books. According to doctors, reimbursements simply did not cover their overhead, making Medicare billing for many a money-losing endeavor.

In 2003 physicians also were working to keep ahead of the technology learning curve as computer-based programming and Internet-related technology began to transform the way doctors conducted their businesses. In the 1980s, few physicians' offices had a computer, and all offices kept track of the paperwork associated with their patients and a handful of insurance companies in a manual filing system. By the beginning of the twenty-first century, a doctor's office might have over 1,000 insurance claims on file, each with specific rules for filing and reimbursement. New programming and technology allowed for computerized patient records, as well as online insurance claims. These changes resulted in better care as patients' files become more quickly accessible and updateable. Doctors also benefited from cost-savings related to increased efficiency and quicker reimbursement. According to a Modern Physician survey conducted in 2000, over 63 percent of physicians surveyed said that they would be using computer-based medical records systems within three years, up from just 21 percent in 2000.

During the first half of the first decade of the 2000s, the entire health care industry faced a growing crisis as health care cost spiraled upward. Balancing rising costs with public demands for better care in a complex system of a growing number of specialized doctors was a clear challenge throughout the middle of the decade.

According to a report issued by Merritt Hawkins, a national physician recruiting company, published by the American Academy of Family Physicians (AAFP), family physicians continued to play an unprecedented, centralized role in the nation's health care system. However, the total number of family physicians refusing new Medicare patients continued to grow, placing a larger burden on physicians who still accepted Medicare patients. According to The New York Times, many doctors opted out of Medicare because the paperwork was a hassle and the reimbursement was too low. For example, a 2008 survey by the Texas Medical Association found that only 38 percent of the state's primary care physicians accepted new Medicare patients.

Also placing pressure on the nation's doctors' offices was the growing number of aging Americans, a shortage of primary care physicians, and the discrepancy between the number of primary care physicians and specialty physicians. According to a 2009 report by the Robert Johnson Wood Foundation published in U.S. News & World Report Online, 78 million American baby boomers were moving into retirement, as were many of the country's healthcare providers. For example, according to the study, 60 percent of Virginia's public health workers were eligible for retirement on or before 2014. In addition, Nebraska, Wisconsin, and New Hampshire had projected retirement rates of 50 percent or higher. The Association of American Medical Colleges projected a shortage of as many as 150,000 physicians by 2025. Along with the concern over the number of general practitioners, the Institute of Medicine forecasted that the country will not have enough geriatricians to meet the needs of the country's aging population.

Part of the problem is that general practice and geriatrics are commonly the most complex yet least financially rewarding career choices for medical students. Specialists tend to treat select conditions and their relationship with the patient is often limited. Conversely, general practitioners and geriatricians must track the overall health and well-being of their patients, who often come to the office with complicated histories and medical needs. In addition, older patients are more likely to be on Medicare. Faced with a higher patient load, more paperwork, and less pay (a specialist's income can more than double a general practitioner's pay), many emerging medical graduates are foregoing a career in primary care to pursue specialty medicine.

Doctors were also facing financial pressures on many sides at the end of the first decade of the 2000s. Insurance companies placed increasing restrictions on the tests and drugs that it would cover and under what circumstances. Some insurers even made the move to attempt to penalize providers if they sent patients to out-of-network services like labs, threatening to charge the physician a fee for each out-of-network referral. President Obama's healthcare reform initiative, a hotly debated topic, made universal healthcare, a public option for medical insurance, and payout for Medicare payments political issues.

Current Conditions

According to the U.S. Census Bureau, there were 191,473 offices of physicians in 2010. A majority of these employed fewer than four people. Other statistics from the Centers for Disease Control and Prevention showed that Americans made 956 million trips to physicians' offices in 2010, 60.5 percent of which were primary care physicians.

In the early 2010s, the industry was dealing with multiple challenges, one of which was a shortage of medical doctors. According to Modern Healthcare, "The nation's healthcare system is said to be facing a physician shortage just as 30 million uninsured individuals are about to enter the patient pool and threaten to overload an already stressed system." One of the possible solutions was to utilize more physicians assistants and nurse practitioners for routine medical care, leaving physicians to deal with more new patients and patients with complicated conditions. According to the American Academy of Physicians Assistants, about 75,000 physicians assistants were practicing in the United States in 2010, with another 14,000 licensed to do so. The American Academy of Nurse Practitioners reported approximately 140,000 nurse practitioners in practice. Many of these worked through retail clinics, which made it difficult to coordinate care among the different providers. Donald Fisher, president and CEO of the American Medical Group Association, said, "It's appropriate if it works for the patient. The problem is when they're not connected and there's not a built-in referral system and oversight."


According to the U.S. Department of Labor, Bureau of Labor Statistics, there were 7.5 million people working as healthcare practitioners and in related technical occupations in 2010. The mean annual salary of a family or general practitioner was $161,490. Surgeons $206,770 in salary, and anesthesiologists made an average of $197,570. There were 2.54 million registered who earned an annual mean salary of $65,130. An additional 475,950 people were medical assistants earning a mean annual salary of $29,060. Job prospects for the medical field were considered very good through 2014. Physicians and surgeons were expected to be needed to replace a retiring workforce, particularly in the fields of general practice, especially in rural areas; geriatrics; and obstetrics/gynecology.

Registered nurses working in doctors' offices and clinics assist physicians by administering medications and treatments and performing routine laboratory and office work. They receive their training through bachelor and associate degree programs in nursing or through three-year diploma programs in hospitals. They must pass a licensing examination to obtain a nursing license. In the early 2010s, the entire healthcare industry continued to suffer from an overall lack of registered nurses.

Physician assistants support physicians and provide routine diagnostic, therapeutic, and preventive health care services under the supervision of a physician. Physician assistants take medical histories, examine patients, order and interpret laboratory tests and X-rays, make preliminary diagnoses, and treat minor injuries. Physician assistants must complete an accredited, formal education program. Most states require physician assistants to pass a certifying exam. In 2010, 83,540 physician assistants earned a median annual salary of $89,470.

Medical laboratory technologists work under the direction of a pathologist. The three types of medical laboratory technologists with different levels of training are medical technologists, with four years of specialized training; medical laboratory technicians, with two years training; and medical laboratory assistants, with one year of training. Of these three, only the medical technologist carries out supervisory and administrative duties. In 2010 the median salary for the 165,220 medical technologists in the United States was $58,120, while the 156,860 medical laboratory technicians earned an average of $38,960 annually.

Jobs for physicians and other positions in doctors' offices and clinics were generally expected to grow in the 2010s, along with the overall growth in the health care industry and the aging population. Government reforms, however, were expected to address the shortage of medical doctors in primary care by reducing the demand for and income of specialists. Moreover, due to cost controls enforced by HMOs and government programs, physicians' incomes began to level off, curtailing their considerable annual growth rate. Under government reforms, the need for medical support staff, such as nurses and medical assistants, was expected to increase, while the number of secretaries would be reduced as reforms reduced paperwork and doctors left their individual practices to join group practices.

America and the World

Foreign doctors who want to practice medicine in the United States must be licensed in the United States. By the end of the first decade of the 2000s, nearly one-quarter of America's doctors were foreign born. Some were trained in their home countries and came to the United States for their residency or employment, and others attended a U.S. medical school. To qualify for entrance to a U.S. institution, a foreign-born student must be highly academically qualified. While the United States continued to fill its sagging physician rosters with international physicians, competition was increasing for the world's best and brightest from other countries who were also experiencing doctor shortages, including Australia and Great Britain.

Research and Technology

At the beginning of the twenty-first century, new technology fueled the shift from inpatient hospital care to outpatient surgical clinics. Technologies like laser surgery decreased the invasiveness of many medical procedures, allowing them to be performed in outpatient facilities. Technological advances also decreased complications related to the administering of anesthesia, which often required overnight hospitalization.

The trend away from prolonged hospitalization also gave rise to the development of in-home monitoring devices. These devices were used by patients who left hospitals for financial reasons but had conditions requiring observation, such as congestive heart failure. The monitoring devices electronically linked the patient's home with a doctor's office or health care agency.

Advances in information technology were becoming increasingly important as the health care industry pushed forward to update patient record keeping. Doctors' offices modernized their record keeping equipment, switching from paper to computerized records. Many doctors equipped their exam rooms with computers so patient information could be called up directly and entered immediately. Other offices outfitted their doctors with tablet PCs with writable touch-screens. Health care systems began linking their doctors into one main database so a patient's records were centralized and updated for each visit to every doctor with the system.

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