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Toni Talks about PT Today

Let's All Be on the Same Page
by Toni Patt

Last week as I was preparing to do an evaluation, I overheard one of our case managers talking to a family member of one of my patients. Nearly everything the case manager said started with, "Rehab will take care of that." They were discussing gait training and preparing the patient for discharge home. That would have been wonderful except for one small problem.

The patient's chart was talking about end-of-life issues. The patient was not expected to survive long enough to be discharged and if she did, it would be to another care facility due to vent dependence and dialysis. There was a palliative care consult in the chart. Everything I read implied the patient wasn't going home.

Now, I can understand the family asking those questions. Patients and families always believe they will be the one out of a million who gets better. What I don't understand is why the case manager, who should have also read the chart, wasn't redirecting the conversation somewhere else. At least she could have prefaced her responses with, "If the patient improves" or "If the patient goes home." Give them hope but try to be realistic.

Now I, meaning therapy, will be the bad guy here. I'm not going to be doing what the family expects because the patient won't tolerate it. Someone with a resting heart rate over 120 isn't going to jump out of bed and walk to the bathroom. She didn't even tolerate transitioning to sitting.

It isn't that I don't want to progress the patient. Walking to the bathroom would be great. It just isn't going to happen any time soon, if at all. However, since the case manager talked about therapy walking the patient to the bathroom, the family probably thinks it is possible. Sooner or later, I'm going to be explaining why I'm not doing something with a patient who couldn't do it in the first place, because someone thinks it should be done.

I wish the case manager would have limited what she said to, "If that happens" or included a timeline to keep the expectations in line with reality.

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HIPAA Violations Can Be Overheard Too
by Toni Patt

The other day, I was sitting at a nursing station and overheard a conversation between a patient and a physician. I wasn't trying to eavesdrop. The patient was very hard of hearing and the doctor had to yell to be heard. The patient was yelling back. I realized I was overhearing a major HIPAA violation. Between the two of them, they were broadcasting protected information down the hall.

First of all, the doctor should have closed the door. I still might have been able to hear but wouldn't have understood what was being said. A nurse walking by did almost immediately after the conversation started.

With the onset of electronic charting, facilities have been stressing precautions to protect the data. I think everyone knows to limit exposure to printed information and throw it in the shred box when finished. Passwords must be changed every few months. We go out of our way to not say patient names in hallways, elevators and the like.

What about the patients who can't hear us unless we yell? I can talk loud enough that even those with the poorest hearing can understand me. I have to remember to close doors and have conversations is relative privacy. It just dawned on me how much protected information I've been given at full volume.

Doctors seem to be the worst. They have conversations in the hall. They see people in the rehab gym doing therapy. One had a conversation with a patient in the bathroom. I know this because I was in the bathroom with the patient. That was seriously wrong. He should have asked the patient's permission for me to be present. It wasn't anything I didn't already know, but that isn't the point.

Patients forget this a lot. Many of them yell information into the phone. Either they speak loudly, the other person can't hear or both. I've noticed there is no privacy during phone conversations. They'll share everything.

There isn't too much we can do about patients with loud voices but we can be aware of what we're doing. We can also close the door when the doctor forgets.

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She Loves Her Job
by Toni Patt

I always enjoy talking to the therapists who come to my course. Last week I met a PT I'll call Dottie. I don't want to use her real name, but she reminds me of someone named Dottie. Dottie has been a therapist since back in the day. She graduated years before I even thought about PT school and is still going strong.

Dottie is a home health therapist and has been for many years. She beams when she talks about her work and patients. She prides herself on always doing the most she can for them. Currently every patient on her caseload is someone who she'd seen previously and specifically asked for Dottie to be the treating therapist.

The thing that struck me most about her was how happy she was. She loves talking about her work. A friend accompanied her to my course because he sometimes translates for her. He wanted to know what she was learning so he could be more help to her. I found out later he also teaches boxing to handicapped children in his spare time.

Both of them are of an age where they don't have to be doing anything. Yet here they are. I've never done home health but I can't imagine it would be easy. Unlike most settings, the home health therapist has limited access to things we take for granted in the clinic. Plus, that seminar was in Los Angeles. The traffic was terrible. Dottie drives in it every time she goes to work.

It was refreshing to see someone who loves what she does. I hope I'm the same way when I reach that point in my career.

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Just Do What the Family Wants
by Toni Patt

Earlier today I had a conflict with a demented, agitated patient's wife. She wanted me to get the man out of bed with a gait belt and hoist him over into the chair. I declined, stating I didn't feel comfortable doing that and it wasn't very therapeutic. She insisted. I apologized and told her I would assign the patient to someone else tomorrow who was strong enough to complete the transfer. She was still upset.

I spent the rest of the morning defending why I didn't want to "fling" a patient into a chair who didn't want to go there. He might have been confused but he knew he didn't want to get out of bed. Somewhere along the line, one of my OT coworkers told me I need to learn better customer service. Just do what the family wanted to keep them happy. I was too proud and pride comes before the fall.

There is nothing therapeutic or safe about flinging a person into a chair. Sitting up in a chair might have been therapeutic except for the fall risk from his restlessness. I used my clinical judgment and decided getting him into a chair wasn't a great idea. Being told to do it anyway is wrong on so many levels. Being told to do something simply because the family wants it without consideration of therapeutic value or skill is ridiculous.

We are supposed to be providing skilled therapies. There was nothing skilled about flinging someone into a chair. Charging a service as skilled when it isn't is a form of fraud. Doing something contraindicated because the wife wants it is not only unsafe but wrong. It also eliminates any chance of transfer training, neuromuscular reeducation and motor learning.

When did keeping the family happy become more important than providing therapy? More and more, PTs are being asked to bypass the skills we worked so hard to master and become lifting services. There's so much more to what we do. In this case, standing up for myself and my profession made me the bad guy.

There's more to good customer service than simply doing whatever the family demands. All that does is encourage them to become more demanding. Not only will those people never be happy, but all the other patients who aren't seen will also be unhappy. How does that help patient satisfaction?

In this case, I think the man is deteriorating mentally and physically and his wife is refusing to see it. She isn't going to be happy unless he does whatever he was doing before he was hospitalized and that isn't going to happen. I was wrong because I put safety first. I was wrong because I stood up for my profession.

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Selection for Recognition
by Toni Patt

Driving home from work today, I was listening to a podcast of a morning radio show. They were making fun of a man who had been given some awards because he had been contributing regularly to the organizations. Because it's a local show, I knew who they were talking about. I had to agree there was no reason other than money that the man was being recognized.

That got me thinking about all the people I know who should be recognized but aren't. One of the greatest unsung heroines I know works as a palliative care nurse for the "evil empire." Everyone knows how great she is, but she has never been formally recognized. I doubt she has ever been nominated.

There is nothing spectacular about doing a good job or being good at your job. You know who I mean. They never call in sick. They do whatever is asked of them. They manage impossible caseloads of complex patients. They don't talk about it, they do it. I've been at my current job for almost a year. I've yet to hear a thank you or a job well done from anyone.

True, you must be nominated to win. From what I can tell, there are two reasons people get awards. The process has become a popularity contest or there's a political reason. Why else would doctors who never set foot in the building win employee of the year? I worked with a male OT who was the only male in the department. He regularly won recognition awards because his was the only name anyone could remember.

There's no correlation between likeability and job skill. Yet job recognition awards count toward promotions, raises and other perks. At the evil empire, it counted on the annual evaluation. Friendly employees got bigger raises.

I don't think there is a PT out there doing this simply to win an award. I do think there are lots of PTs out there who should be recognized for the hard work they do. I suppose getting your name on a plaque is nice. I'd be happy with being told I did a good job.

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Blatant Rudeness
by Toni Patt

Usually when I go on a teaching trip, I have wonderful students. For the most part they pay attention. I get good questions. Some have fallen asleep because they drove three hours to get there. Others are obviously there for the CEUs. Last week I had someone who disrupted the class.

I encourage questions and discussion with attendees. This time I got something different. We were talking about pushers. She didn't agree with what I said. Instead of a discussion, she tried to argue with me. It was more of a, "I'm right, you're wrong," exchange instead of mutual agreement both options could work. I changed the topic as quickly as possible so the class could move forward.

Wouldn't you know that on my course reviews I got comments about not being open to discussion with the class. What bothered me most was up until that exchange, she seemed more interested in the crossword from the newspaper than what I was saying. I guess she didn't think I could see what she was doing.

I don't mind if someone doesn't pay attention. I try my best but still get paid whether someone pays attention or sleeps the entire time. Maybe she was already familiar with what I was saying. I'm sure there are others just as skilled as I am with stroke patients. God knows I've sat through classes in utter boredom for that reason. That just happened at CSM during the stroke course. Instead of being rude and argumentative, I kept quiet and tried to appear to be paying attention even when my mind was drifting.

I never said she was wrong. Instead I said I had tried what she suggested and it didn't work. But that didn't mean it wouldn't work for someone else. I only have so much time and a lot of information to cover. If she felt that strongly, she should have come to me at lunch or on a break.

Yes, I probably could have handled that better. Maybe if she hadn't been so interested in the crossword, I might have taken her more seriously.

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Why I Became a PT
by Toni Patt

I was asked this question on Sunday by someone who doesn't know me very well. I had to stop and think a minute before replying. The answer is I don't remember. I remember applying to PT school. I remember PT school. I remember deciding I liked acute care the best. Yet I don't remember why I made a decision that has shaped my life for many years.

Now I'm wondering if I would give the same answer if asked today why I am a PT. I don't think so because so much as changed over the years. I'm no longer idealistic nor do I believe I can help everyone. There are some people I would avoid having as patients at all costs. I also realize there are limits to what can be accomplished.

If I had to choose all over again today, I don't think I would choose physical therapy school. This is partially due to how difficult it has become to get into and how onerous the education has become. If I base the choice on my experiences, I would consider neurology. If I base the choice on horses, it would be nursing because there are many more opportunities for a nurse than a physical therapist.

That's one of the big problems with our field. Where do the older PTs go if they aren't ready to retire? A few go into teaching. I know a few who started working in schools. I can see where some would choose outpatient. What about the rest of us? I have no idea what I'm going to do when I can't keep up physically.

The older I get, the more I think about that. I joke that I'll be working as long as I want to own a horse. That's true. But I don't know what I'll be working as. I thought I would teach, which meant a PhD. I've since discovered if you want a PhD, it has to be the only thing you want. And you must want it badly. I want horses more.

I need to remember why I became a PT. Maybe that will help me decide what I want to do next.

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Request for Submissions
by Toni Patt

It's that time of year again. The company that I teach for is requesting submissions for an education summit next year. I'm supposed to select a topic, describe what it is and why I think people would be interested. Then I submit that and five references no more than a year or two old. They try to present newer information.

The problem is I can't think of topics. Each presentation is two hours. I teach a six-hour class. Two hours is nothing. I've already been told pretty much anything I submit will be accepted because I'm the neuro person. With one exception, everyone else who teaches is either an orthopedic person or pediatric person.

Naturally I want to fall back on stroke-related topics. All the newer stuff in stroke research is medical in nature, not related to physical therapy. That won't work. It's time to broaden my horizons. I'm an NCS. I should have a good grasp of neurological therapy in general. But it has to be interesting to me. So far I haven't thought of much.

There's another problem. I like acute and subacute stuff. Most of the research is done with chronic patients, particularly with stroke. So there isn't much research to support anything. There has been work with acute brain injuries but I'm not sure if I can make that interesting for two hours. That would entail breaking down what the lines and wires are for, which I think is common knowledge.

A lot of what I do is based on anecdotal work I've done. I try things and see what happens. I know it works. I have research that supports the theory I started from. I've considered submitting two case studies that support things I do, which would then be literature. That's difficult because few publications will publish case studies.

I have a week to figure this out, pull articles and write descriptions. That would be challenging if I knew which topics to research. This is going to be an interesting week.

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My Worlds are Colliding
by Toni Patt

Anyone who knows me is aware that I have two lives. One is my professional life. The other is my horses. Thanks to planning and a little luck, I've always been able to avoid scheduling conflicts. Sure there's been the occasional afternoon scramble to leave work in time to make a lesson. And obviously one of the reasons I work as much as I do is to support my hobby.

Next month will be the first time there's a conflict with an either/or choice. The last Saturday of the month I need to be in two places at the same time. Both are supposed to be optional.

The first option is to travel to Austin, Texas, for a legislative activity with my leadership training group. I'm a member of a leadership development program to prepare individuals to assume larger roles in the Texas Physical Therapy Association and, if desired, on the national level. I believe we're attending that session in support of some legislation that is pro-physical therapy. I would leave Friday after work and return Saturday after the session ends. Austin is a 2- to 3-hour drive from Houston, which is doable.

The other option is a horse show. Only one of my horses, the younger one, would attend. It's being held in a facility just outside of Houston and is a practice show. The purpose is to give my horse more experience in the show ring at a lower cost. It's scheduled for the same Saturday and because it's local, I would drive there, ride, and come home.

The cost for both is about the same. I had already made arrangements to be off from my weekend job. One has a greater time commitment than the other. One will probably be more fun. Only some of us in the leadership program are attending. The show will be small and doesn't count for anything. I truly don't know what to do.

What do you think? I don't have to commit to either one until mid-April. Should I develop my leadership skills or my horse?

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‘We're All Gonna Need Physical Therapy Soon'
by Toni Patt

I spent last weekend at a horse show in San Antonio. Even though I had both show horses with me, there was still a lot of down time. Since everything is close quarters it's easy to overhear conversations. While I was waiting I was surprised to hear someone in the barn next to us say, "We're all gonna need physical therapy soon."

I wasn't surprised to hear he was sore. I was surprised to hear he knew what physical therapy was. My first thought was the efforts of the APTA must be paying off. People are starting to know what physical therapy is and what we do. I took this as a good sign since a horse show is a good sample of the general population. We have everything from engineers to teachers to truckers in our midst.

My bubble was quickly burst. His very next words were, "I need a good massage." The message hasn't gotten out as clearly as we'd like. I guess this is progress of a sort. He knew that physical therapy existed and treated muscle problems. He just has no clue as to what we can do. I bet this is someone who goes to the chiropractor for a backache.

No, I didn't correct him. It was neither the time nor the place for a teachable moment. I felt the same way at the time anyway, only I was thinking hot shower.

Besides, I have a bigger problem in my barn. One of the show mothers is also a PT. She treats menstrual cramps and stomach aches with who knows what. I'd be thrilled if she would limit herself to massages and muscle spasms.

Guess we have a little more work to do on brand identification.

In case anyone is curious, Flame aced his sport horse classes and Allie managed to beat seasoned horses at only her second show.

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You Can't Discharge Her, the Family Will Complain
by Toni Patt

We've all had patients we've kept on caseload longer than necessary. Sometimes it's just one more day until discharge. I've occasionally kept patients on caseload because they wouldn't get out of bed unless I did it. When I worked in the ICU, I'd keep patients because I thought they were waking up.

I can't say I've ever kept someone on caseload because the family demanded it. I have of one those right now. The patient and her husband have learned the louder they complain, the more a facility will acquiesce to their demands. At least it's understandable when a family wants to continue therapy because they're convinced the loved one will get better. This couple simply likes being in control.

Yes, getting out of bed is therapeutic. She gets up twice daily with a sling lift, which nursing can do without us and therefore is not a skilled service. She refuses to exercise and will never ambulate due to orthopedic problems. A slide board is out of the question due to sacral wounds. She's been doing this more than two weeks so orthostasis isn't a problem. Yet she's still on caseload and we are still charging for the service.

I brought this up with the other therapists. They have no problem with keeping her on caseload because the couple is difficult to deal with. Difficult to deal with or not, by keeping her on caseload we're charging for a skilled service that isn't skilled. And that's the problem. I don't care about getting her out of bed. I care that we're calling it a skilled service when it isn't.

One of the biggest complaints PTs have is being referred to as a lifting service. Nursing calls therapy to get up anyone who's somewhat difficult or overweight. The only skill required is body mechanics to prevent ourselves from getting injured in the process. We might complain but still get the patients up, thus becoming a lifting service.

Thus we come full circle. We're not providing a skilled service. She should not be on caseload. This doesn't mean therapy won't help with getting her up if needed. That both the patient and her husband complain loudly shouldn't enter into the equation.

I don't care if we've been doing it this long so what will a few more days matter. In theory we're providing skilled services, not simply lifting patients. In reality she'll remain on caseload because I need to pick my battles and won't win this one. What's disappointing is that my coworkers don't see anything wrong with the situation.

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Are Groups the Answer?
by Toni Patt

One of the take-home messages from the APTA Combined Sections Meeting last month was that more therapy is better. I think everyone agrees with that. What we can't agree on, or even figure out for that matter, is how to squeeze more therapy into an already overcrowded day. One suggestion was to utilize group therapy in addition to what we're already doing.

On the surface that sounds like a great idea. You can work with more patients with less staff. Group is even billable, although not for very much. When performed in addition to regular therapy, there would be a net increase in revenue. At least that's how it sounds. If a couple of groups were incorporated into the weekly schedule, we'd have more therapy.

I see two problems with the idea. First, who is going to staff the group? Generally everyone will have a full caseload. I don't know of one facility that allows overtime. Nobody has time in their schedule for extra therapy. Bringing in an extra person probably isn't feasible. Even with some revenue generated, the influx will not cover the salary of the staff needed to have the group.

The second problem is reimbursement, as in who will pay for it? Even if you somehow find the time and the staff, someone still has to pay for it. One suggestion was to have patients private pay for the group when provided on an outpatient basis. I don't know about everyone else, but at any given time at least one-third of my patients are non-funded. Many others are on a fixed income. Even if they want the therapy, they can't afford it.

You would need to have the group meet at least three times a week for it to have any meaningful impact. Multiply that by a few weeks and the cost rises quickly. If the cost is kept low, larger groups will be needed to offset expenses. Larger groups mean more staff. If you limit the number in the group, the cost will need to be higher. Many patients grumble about outpatient therapy copays. I can't see this going over any better on a large scale.

So we have a reasonable suggestion but no feasible way to implement it at this time. Obviously increasing the amount of reimbursement for our services would be a big help, but that isn't going to happen.

Until someone on the payer side realizes all the benefits of therapy on keeping costs down and decreasing length of stay, nothing will change. The same studies that say more is better also show how increasing the therapy actually decreases the bill and length of stay. Maybe they don't want to see it. Maybe they don't believe it. One reason our system is dysfunctional is because of the numerous groups and entities invested in keeping it the way it is.

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Customer Service
by Toni Patt

I don't think you can work in healthcare for any length of time without attending the mandatory customer service inservice. It usually includes a segment on making upset customers happy. In our case, that would be patients and families. One strategy is to listen, verbalize back and then address each complaint.

I'm skeptical when I hear that. It might prevent that customer from having a bad experience, but what about the ones waiting in line while the service is being provided? When I was in South Dakota waiting to check in, a man was complaining loudly. The registration person spent 5 minutes resolving the issues. I know this because I, and eventually four others, stood in line that long. That man was happy but five other people had a bad experience.

Last weekend I had to go in on a Saturday to do an evaluation. I was told there were a lot of problems when the patient was admitted, so everyone was trying to make the family happy. Normally the facility doesn't staff for rehab on the weekend but because the family wanted therapy to start immediately and the physician ordered it, someone had to provide the service. I work in an LTAC. Evaluating the man on Saturday instead of Monday wasn't going to make any difference in the outcome.

Everywhere I've worked, facilities have practically bent over backward to make a complaint go away. They'll do anything to prevent a bad experience. Those same facilities never think about the patients who aren't being cared for, call bells that aren't being answered and therapy not provided because everyone is trying to make one person happy.

After I return from teaching, I complete an evaluation of each facility. The one in South Dakota got a bad one because of my experience. Because I worked on a Saturday for something ridiculous, I'm much less likely to do it again. It accomplished nothing. The family was just as unhappy when I left as when I arrived. The ordering physician probably forgot about it as soon as he wrote the order, so isn't any happier either.

Maybe we need to change how we think of customer service. Facilities create much more ill will when they inconvenience one person to make another happy. The inconvenienced one might not complain but won't return either.

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Bariatric Patients are Nationwide
by Toni Patt

One of the benefits I get from traveling is talking to therapists in different parts of the country. Things are not the same all over the country but there are a few recurring themes. We all agree that our patients are getting bigger. I started including trunk exercises for the obese patient because I was asked that question in every seminar.

Whenever the topic of large patients comes up, it's always followed by the words "and we aren't equipped to treat them." Sometimes the problem is inadequate staffing. It takes more people to mobilize an obese patient. This is a problem when staffing is cut to the bare minimum. An even bigger problem is lack of adequate equipment. Bariatric wheelchairs, beds and walkers are a must for this population.

This morning, I had an order to find a wheelchair large enough to fit a patient so she could get out of bed for 30 minutes. She wasn't comfortable in our 30-inch chair. Plus we don't have elevating leg rests for that chair. Nor do we have a large enough cushion to accommodate her and her wound.

Equipment is another area feeling the brunt of cost-cutting. Anything bariatric is almost twice as expensive as its normal-sized counterpart. Facilities might buy some bariatric equipment. Problems develop when there are more plus-size patients than plus-size equipment. I have four decent cushions. To accommodate my large lady, I will need to take some away from other patients.

Meanwhile both the patient and her doctor will be complaining. The doctor will write orders for a bariatric cushion, wheelchair etc. Despite the obvious need, the facility will not allow me to purchase anything. Rather than spending some money to solve the problem, we'll be told to make do. We might save a little money but the stress will escalate.

I've heard similar stories many times. The research is showing early mobilization of stroke patients improves outcomes. Facilities say they want good outcomes but stop short of spending the money. I don't have any answers. There is no substitute for getting someone out of bed.

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Agitation or Aggression?
by Toni Patt

Recently we had an elderly man on caseload with a diagnosis of advanced dementia. It was obvious he was in the later stages of the process. He couldn't follow commands. His swallow was diminished. He was disoriented times three and demonstrated poor motor planning with any voluntary movement. However, he could still move and verbalize spontaneously.

Unless disturbed, he laid quietly in bed. The problem arose when we tried to get him out of bed. He didn't want to be disturbed. As soon as we started to move him, he told us no and began cursing. This was followed by swinging.

Anyone who works with the elderly knows there are two kinds of swings. Some are ineffectual. These may be taps. There may be a little force. Patients with brain injury frequently flail in bed during the restless state. The intent isn't to strike someone so much as to move. These people might be described as agitated. Restlessness while in bed is certainly agitated.

Then there is the man I described above. He wasn't agitated. He was aiming for us. He didn't want to be moved and was resisting it. On a few occasions, his wife was present when we attempted to get him out of bed. She told us to ignore him. He didn't mean it. Mean it or not, he was trying very hard to hit someone.

Patients have the right to refuse therapy. That statement is made with the assumption the patient understands what he is refusing. In cases of dementia and confusion, we often have to rely on family members to give consent for treatment. This man was clearly refusing despite his wife's statement to the contrary. He knew he didn't want to get out of bed.

After a couple of days of struggling, I discharged him from therapy. Someone was going to get injured if things continued. One of our PRN PTAs knew him from previous interactions. She said this was normal behavior for him and they got him up anyway. He was just agitated. Obviously I don't agree with that. Despite the benefits of being out of bed, there is the real risk of injury to either himself or a caregiver. This went beyond any level of agitation. He was aggressively trying to strike someone.

He has since discharged to a SNF. I don't know if it's the one he came from or a different one. For his sake, I hope a different one that recognizes the difference between agitation and aggression.

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