Women Surgeons’ Experiences of Interprofessional Workplace Conflict | Health Disparities | JAMA Network Open | JAMA Network
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Table 1.  Participant Demographic, Training, and Practice Characteristics
Participant Demographic, Training, and Practice Characteristics
Table 2.  Circumstances of Reported Conflicts
Circumstances of Reported Conflicts
Table 3.  Implications of Conflict
Implications of Conflict
Table 4.  Strategies for Navigating Conflict
Strategies for Navigating Conflict
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    1 Comment for this article
    EXPAND ALL
    Increasing Evidence of Structural and Systemic Barriers to Women Surgeon’s Academic Success Demands a Coherent Response from Surgical Leader
    Sabina Siddiqui, MD | Medical College of Wisconsin
    I would like to start by commending the authors on their success in capturing a very complex, challenging and salient issue.

    This work is very timely as academic surgery is scrambling to become more representative of the populations it serves. However, success in the pipeline does not translate into successful retention in the workforce. While the number of women entering surgery has increased, the attrition for women surgeons remains high2,3. This attrition rate will not change until there is a significant acknowledgement and change in the systemic misogyny within academic surgery.

    The explicit and implicit
    bias within our larger culture and surgical subculture has to be acknowledged by our surgical leadership. Despite the accumulating data, there is continual denial by surgical leadership as to the daily struggles of the delicate balance between gender schema and normative surgical leadership behaviors4. Multiple studies continue to show that not only our male colleagues5, but our evaluation, promotion and adjudication systems carry over our societal gender biases to the detriment of our female colleagues1,6,7.

    Once we recognize our underrepresented members as a particularly vulnerable population7, it’s easy to understand the need for a transparent and an equitable adjudication system. It is ironic that the ‘anonymous’ reporting systems that do not require specific dates or validated factual information can be weaponized against female leaders for not appropriately fulfilling gender norms, but a complaint filed with Human Resources for gender discrimination requires full disclosure and concrete data with a high burden of proof. Validated, transparent and concrete rubrics must be created not only for management of interprofessional conflict, but for other important aspects of academics- such as trainee evaluation and promotion.

    While the authors do a phenomenal job of capturing data that impacts the wellness, retention and success of women surgeons, there's an urgent need to highlight the continuing structural and systematic failures that persist in academic surgery. While as a woman surgeon, I am more than capable of grace and baking cookies, it’s high time we hold our colleagues and leadership culpable for a system inherently built to limit the success of women in the field. As scientists this data demands we re-evaluate our systems to create a more equitable environment that allows all our surgeons to focus on the shared primary goal of the best patient care possible.



    References:
    (1) Dossett LA, Vitous CA, Lindquist K, Jagsi R, Telem DA. Women Surgeons’ Experiences of Interprofessional Workplace Conflict. JAMA Netw Open. 2020;3(10):e2019843. doi:10.1001/jamanetworkopen.2020.19843
    (2) Khoushhal Z, Hussain MA, Greco E, et al. Prevalence and Causes of Attrition Among Surgical Residents: A Systematic Review and Meta-analysis. JAMA Surg. 2017;152(3):265–272. doi:10.1001/jamasurg.2016.4086
    (3) Heather C. Brod, Stanley Lemeshow, Philip F. Binkley, Determinants of Faculty Departure in an Academic Medical Center: A Time to Event Analysis, The American Journal of Medicine,
    Volume 130, Issue 4, 2017, Pages 488-493, ISSN 0002-9343,
    (4) Lemons M, Parzinger M (2007) Gender schemas: a cognitive explanation of discrimination of women in technology. J Bus Psychol 22(1):91–98
    (5) Ross, S.B., Jadick, M.F., Spence, J. et al. Men surgeons’ perceptions of women surgeons: is there a bias against women in surgery?. Surg Endosc 34, 5122–5131 (2020).
    (6) Ahmadiyeh N, Cho NL, Kellogg KC, Lipsitz SR, Moore FD, Jr., Ashley SW, Zinner MJ, Bre
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Original Investigation
    Surgery
    October 8, 2020

    Women Surgeons’ Experiences of Interprofessional Workplace Conflict

    Author Affiliations
    • 1Center for Health Outcomes and Policy, University of Michigan Institute for Health Policy and Innovation, Ann Arbor
    • 2Department of Surgery, Michigan Medicine, Ann Arbor
    • 3University of Michigan Medical School, Ann Arbor
    • 4Department of Radiation Oncology, University of Michigan, Ann Arbor
    JAMA Netw Open. 2020;3(10):e2019843. doi:10.1001/jamanetworkopen.2020.19843
    Key Points

    Question  What is the nature of interprofessional workplace conflicts experienced by women surgeons?

    Findings  The results of this qualitative study of 30 US women surgeons suggest that the circumstances leading to interprofessional conflicts were primarily associated with breakdowns in communication, performance-related disputes, or breaches of protocols. Women surgeons perceived (1) a double standard related to these conflicts, (2) the expectation that they conform to gender over professional norms, and (3) that these conflicts have negative consequences on their personal well-being and professional reputation.

    Meaning  These data support the need for systematic changes to prevent interprofessional workplace conflict and to ensure more equitable adjudication when conflicts arise.

    Abstract

    Importance  Gender differences in interprofessional conflict may exist and precipitate differential achievement, wellness, and attrition in medicine.

    Objective  Although substantial attention and research has been directed toward improving gender equity in surgery and addressing overall physician wellness, research on the role of interprofessional conflict has been limited. The objective of this study was to understand scenarios driving interprofessional conflict involving women surgeons, the implications of the conflict on personal, professional, and patient outcomes, and how women surgeons navigate conflict adjudication.

    Design, Setting, and Participants  A qualitative approach was used to explore the nature, implications, and ways of navigating interprofessional workplace conflict experienced by women surgeons. The setting was a national sample of US women surgeons. Purposive and snowball sampling were used to recruit women surgeons in training or practice from annual surgical society meetings. Participants were eligible if they were currently in a surgical training program or surgical practice. Nearly all participants had experienced at least 1 workplace conflict with a nonphysician staff member resulting in a formal write-up.

    Exposures  A workplace conflict was defined as any conflict resulting in the nonphysician staff member taking action such as confronting the woman surgeon, reporting the event to supervisors, or filing a formal report.

    Main Outcomes and Measures  Interviews were conducted between February 19, 2019, and June 21, 2019. Recordings were transcribed and deidentified. Inductive thematic analysis was used to examine data in relation to the research questions.

    Results  Thirty US women surgeons (8 [27%] age 25-34 years, 16 [53%] age 35-44 years, 5 [17%] age 45-54 years, and 1 [3%] age 55-64 years) of varying surgical specialties were interviewed. Conflicts were often reported as due to a breakdown in communication or from performance-related disputes. Participants perceived personal and professional implications including self-doubt, depression, frustration, anxiety, loss of sleep, reputational harms, and delays to advancement. Participants also described potential patient safety implications primarily due to decreased communication resulting from some surgeons being hesitant to engage in subsequent interactions. Participants described a variety of navigation strategies including relationship management, rapport building, and social capital. The success of these processes tended to vary by individual circumstances, including the details of the conflict, practice setting, level of support of leadership, and individual personality of the surgeon.

    Conclusions and Relevance  This qualitative study highlights women surgeons’ experiences with interprofessional workplace conflict. Interprofessional culture building, broader dissemination of implicit bias training, and transparent and equitable adjudication systems are potential strategies for avoiding or mitigating the implications of these conflicts.

    Introduction

    Women surgeons experience less achievement, are more dissatisfied, and have higher levels of burnout compared with their male colleagues.1-4 Substantial work has focused on improving gender-based achievement through increased implicit bias training, mentorship and sponsorship, and work-life integration policies.2,5-8 Despite this work, little has been done to explore the role that interprofessional relationships and conflict may have in gender-based achievement and satisfaction gaps for women surgeons.

    Interprofessional teamwork is critical to success in medicine, particularly in intense work environments such as the operating room, trauma resuscitation bay, and critical care units.9,10 Interprofessional conflict is known to contribute to workplace dissatisfaction and stress, and existing data suggest women are more likely to experience these conflicts.11 For example, surgical technologists file complaints against women more than men and exhibit sex-based discrimination.12 Moreover, a study of operating room behaviors demonstrated complex differences related not simply to the sex of the attending surgeon but also the sex of others present, including greater cooperation when the attending surgeon’s sex differed from the majority of other team members. These gender-based differences in interprofessional conflict in surgical settings may partially explain why women surgeons experience a higher stress index.13,14

    The purpose of this study is to understand interprofessional conflict involving women surgeons for the purpose of identifying strategies to prevent or more quickly resolve these conflicts. Our specific questions were: (1) what are the circumstances leading to interprofessional conflicts involving women surgeons, (2) what are the personal, professional, and patient safety implications of these conflicts, and (3) how do women surgeons navigate these conflicts and the resulting adjudication process?

    Methods
    Study Design and Setting

    In order to broadly explore interprofessional conflicts experienced by women surgeons, we selected a qualitative descriptive study design utilizing semistructured interviews with a national sample of US women surgeons. The interviews sought to obtain a broad understanding of the nature of interprofessional conflicts experienced by women surgeons, the personal and professional implications of those conflicts, and strategies for navigating these conflicts. This study was approved by the University of Michigan Institutional Review Board and is reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline (eAppendixes 1-3 in the Supplement).15

    Interview Participants

    Participants were recruited by email (eAppendixes 1-3 in the Supplement) and in person at the annual meetings of national surgical societies. Purposive and snowball sampling were used to ensure participants were diverse with respect to age, surgical specialty, and years in practice (Table 1). Women surgeons were eligible if they were currently in a surgical training program or surgical practice. Nearly all participants had experienced at least 1 workplace conflict with a nonphysician staff member resulting in a formal write-up. Participants were not compensated for their participation. We continued to interview until thematic saturation was reached (ie, new themes emerged infrequently, and the code definitions remained stable), resulting in a total of 30 interviews.16

    Interview Procedures

    All participants received a written informed consent statement and verbally consented before their interview. Participants agreed to having their responses published, and quotations were shared with all participants to ensure accuracy. Interviews were conducted in person or over the phone between February 19 to June 21, 2019, by a coinvestigator (C.A.V.), a woman anthropologist with significant expertise in qualitative interviewing. The interviewer had no previous relationship established with participants before the interview. An interview topic guide (eAppendix 2 in the Supplement) was designed to explore experiences of workplace conflict resulting in reporting action by a nonphysician (eg, nurse, scrub tech, or circulator). A workplace conflict was defined as any event or conflict leading the staff member to take action such as directly confronting the woman surgeon, reporting the event to a supervisor, or filing a formal report. The domains included in the guide were workplace culture, descriptions of workplace conflict, implications of workplace conflict, and how participants would have preferred conflicts be handled. Several iterations of the interview guide were generated based on content validity, face validity, ability of participants to interpret essential information, and ability to complete the interview within the anticipated time. Two pilot interviews were completed with subsequent slight modification to the interview guide. The interviews were digitally recorded and lasted an average of 32 minutes (range, 13-53 minutes). Observations about each interview (ie, field notes) were documented afterward.

    Analysis

    Audiotapes were transcribed verbatim and deidentified. Once data were collected, we began an iterative process of analyzing the data using inductive thematic analysis. The initial codebook was created by having 2 team members (C.A.V. and K.L.) read the transcripts and collate ideas, mapping them to a coding schema. Once the initial codebook was agreed upon, each transcript was then coded using NVivo software, version 12.5.0 (QSR International) by 2 members of the research team (C.A.V. and K.L.), blinded to each other’s work. In areas where disagreement was found, consensus was met between C.A.V. and K.L. Once all data were coded, the entire research team met to reach consensus on the most salient themes.16 Validity was established through investigator triangulation and member checking, which was accomplished by sharing study findings with participants to ensure the findings represented their viewpoints.13

    Results

    We interviewed 30 women surgeons (8 [27%] age 25-34 years, 16 [53%] age 35-44 years, 5 [17%] age 45-54 years, and 1 [3%] age 55-64 years) from the United States from a variety of surgical specialties (Table 1). The majority of participants were younger than 45 years and had been in practice for less than 10 years, consistent with the distribution of age and experience level among women surgeons in the United States.17 Inductive thematic analysis of the narratives of the women surgeons in this study revealed 3 major themes in relation to circumstances of interprofessional workplace conflict:

    1. Circumstances of reported conflicts: the context surrounding the conflict events (eg, performance-related issues, lack of professionalism, breaches of policies or protocol)

    2. Implications of conflict: the perceived effects of the conflict events on the women surgeons (eg, personal, professional, patient outcomes)

    3. Strategies for navigating conflict: the approaches described by women surgeons as being helpful in navigating interprofessional conflicts (eg, relationship management, rapport building, social capital)

    Circumstances of Reported Conflicts

    Circumstances leading to reported interprofessional conflicts were described by the participants as due to (1) the surgeon’s response to perceived performance-related issues on behalf of the staff member, (2) the interprofessional staff perceiving the women surgeons as unprofessional, (3) breaches of protocols, or (4) a combination of these circumstances (Table 2). In addition, participants described the role of double standards and difficulty in taking orders from a woman as factors mediating these circumstances.

    Performance-related issues included a failure of the staff member to obtain proper equipment for cases, schedule or prioritize clinical work, carry out clinical care, or communicate about a patient’s status. Participants described how when they attempted to correct these issues with the involved staff, they were regularly perceived as being unprofessional. Often, these events or complaints were escalated to leadership, with the surgeon having limited knowledge of whom, or in some instances what specific event, led to the write-up. In the majority of cases, the conflict occurred when the women surgeons addressed the performance issue in a way that the staff perceived as unprofessional behavior. These responses were characterized as “sarcastic” or “mean” by the staff member (occasionally the women surgeons agreed with these characterizations). Notably, the women surgeons believed their responses were in line with those they had witnessed from male mentors or colleagues.

    Other conflicts resulted from breaches of institutional policies or protocols by the women surgeons (policies for booking urgent cases, wearing nail polish, wearing incorrect operating room attire, etc), most often occurring in the operating room suite. Many of these conflicts related to nursing-derived policies the women surgeons believed were not supported by evidence (eg, rules against the use of cloth scrub caps or scrub jackets). Participants further described a double standard in enforcing a policy when a woman surgeon was involved while allowing male surgeons to breach the same policy.

    Participants described events involving other women interprofessional staff and often speculated that these staff members are unaccustomed to or uncomfortable with taking direction or being led by other women. For many participants, these processes were difficult to tease out against other aspects possibly at play—such as tension between nursing and surgical culture, being a person of color, or the particular place in their career (ie, early in their career). The participants further believed that this led to interprofessional staff having a double standard with regard to how behavior was accepted, reported, or adjudicated. This occurred at the level in which the event was happening as well as how leadership responded to it. Importantly, in many examples, the reporting came as a surprise to the women surgeons, as they had not perceived a significant conflict with the interprofessional staff member. Participants often further clarified that they did not perceive a malicious intent on the part of the staff but rather acknowledged many of these interactions reflected the bias and gender scripts present in society at large.

    Implications of Conflict

    Participants described a number of implications arising from interprofessional workplace conflict, falling under the domains of personal, professional, and patient outcomes (Table 3). Personal implications included both emotional and physical components. From an emotional standpoint, participants described feelings of self-doubt, depression, frustration, devastation, humiliation, and anxiety. Though not as common, participants asserted a number of physical symptoms including gastrointestinal distress, loss of appetite, insomnia, burnout, and exhaustion. Participants described how they perceived these responses to affect their mood and influenced the way they felt both in the hospital and at home. There was also variation in how these responses were experienced, in both duration and intensity.

    Professional implications included perceived harms to professional reputation, a reluctance to pursue leadership positions, and a perceived detrimental effect on promotion and career trajectory. Because of the lack of transparency and consistency in how these events were recorded in employee files, participants described how the exact implications of these events were often difficult to assess. Although some participants were able to cite explicit examples, many others described the subtle ways in which they came to realize how both colleagues and mentors perceived them.

    Implications for patient outcomes included nonphysician staff questioning guidelines or orders from women surgeons resulting in delays in care, as well as some surgeons avoiding interprofessional engagement regarding patient issues owing to fear of conflict. Specifically, participants described impaired collaboration with potential patient outcome implications after a conflict, manifest in their own avoidance of further interactions with the staff member or tense and ineffective communication. Although the participants did not describe specific negative patient outcomes, they often referenced the belief that patient outcomes were improved when interprofessional communication and collaboration were optimal.

    Strategies for Navigating Conflict

    Participants described a variety of ways in which they attempted to navigate these conflicts. Domains included relationship management, rapport building, and building social capital (Table 4). Specifically, participants described what could be collectively considered the unwritten rules of being a woman surgeon. For example, one participant remarked:

    “I’ve had conversations with my female counterparts, and it’s always the same conversation. If you want something done, bring cookies. If you get mad, don’t show it. If you have conflict, address it head on, apologize. Even if you don’t think you’ve done anything wrong you’re still at fault. It’s just kind of a theme.”

    From a relationship management perspective, participants discussed aspects such as personal accountability, gauging the emotional responses of others, and recalibrating their actions based on those responses. Often, participants described these processes as contributing to the emotional implications, as they were seen as a form of additional labor required of them. Participants also described the process of rapport building. Within this was the expectation to participate in events for nonphysician staff (ie, baby showers), to establish friendships, and the amount needed to invest in order to develop those relationships. For some, this process was natural and in line with how they would communicate with colleagues, but for others it felt contrived and was viewed as a form of performance needed to make things run smoother.

    Participants also described the various ways in which they established social support in these spaces. In the absence of having leadership effectively manage these situations, women surgeons would find other forms of support to alleviate the burden. This support was found in both formal and informal spaces and most often involved commiserating over shared experiences. The success of these processes varied by individual circumstances, including the details of the conflict, practice setting, level of support of leadership, and individual personality of the surgeon.

    Discussion

    This study has several key findings: (1) interprofessional conflict experienced by women surgeons was primarily due to a breakdown in communication, breaches of protocols, or the surgeons’ response to perceived performance-related issues; (2) women surgeons described various strategies for navigating these conflicts but ultimately expressed frustration regarding what they perceive as a double standard for behavior and a need to conform to gender over professional norms; and (3) women surgeons perceive these conflicts to have substantial personal and professional implications. These findings highlight opportunities for improvement in order to avoid conflict or more quickly and fairly adjudicate issues when they do arise.

    Many conflicts described by participants arose from performance- or systems-based issues identified by the women surgeons that led them to address the performance gap in a way that was deemed unprofessional. The women surgeons largely perceived their actions as mirroring those of their male surgeon mentors or peers. The majority of conflicts were with other women, leading many participants to speculate conflict resulted from staff members not being comfortable with actions violating gender stereotypes, such as assertive direction or correction from another woman. This notion is supported by the literature where studies note the prescriptive nature of gender stereotypes and the discordance of expectations for conforming to these stereotypes among physicians and nurses.18 For example, whereas occupation is viewed as secondary to gender by female nurses, for female physicians, gender is viewed as secondary to occupation.19 This leads women physicians to feel as if they must conform to gender norms and be more polite with nurses than their male colleagues, even when certain clinical circumstances may call for highly agentic and stereotypical male behaviors.20 This perception is further supported by data demonstrating that expression of anger in the workplace may heighten status for men but may lead to backlash or lessen the status of women. Furthermore, women’s anger is more likely to be attributed to internal personality characteristics, whereas men’s anger is attributed to external circumstances or stressors.21-24

    Although the number of women in surgery has increased in the past decade, the senior surgeons who train them remain predominately male. Some male surgeons continue to model behaviors projecting a patriarchal or dominant-subservient doctor-nurse relationship,19 which then leads to interprofessional conflict when expressed by women. Although a focus on professionalism, team building, a flattened hierarchy, and open communication25 has led to improvement in the accepted behavior in the operating room, there is undoubtedly room for continued improvement. Especially in training programs, hostile, uncivil, sarcastic, or bullying behavior should not be tolerated, whether from men or women. Second, interprofessional staff should consider their own explicit and implicit biases as a means of increasing awareness of differences in gender norms and expectations. Although implicit bias training has noted shortcomings, it is, at minimum, a means of addressing knowledge gaps that contribute to behavior.26 Finally, male leaders, when adjudicating conflict, should consider whether conflict with traditional gender schema could have perpetuated either the conflict or the conflict reporting. Just as a growing body of literature demonstrates female faculty are evaluated more harshly than their male peers,27 attention to whether a reported conflict is due to a particular behavior or a difference in reporting threshold should be considered.

    These data also support a potential to prevent conflict through interprofessional team building and training. Despite the critical nature of teamwork in the operating room, surgeons rarely have significant input in choosing their team members, regular opportunities for performance evaluation, or regular opportunities for team-based training. In this way, the traditional nature of physician and nursing leadership silos may create obstacles to optimal teamwork and accountability. Many conflicts reported by the participants occurred early in the tenure of the women surgeons, and relationships often improved after several years, after the staff became more familiar with the women surgeons. Given that many conflicts were related to perceived performance gaps, strategies such as assigning high-performing staff members to new surgeons may reduce interprofessional conflict by reducing the performance-based gaps surgeons may encounter when in a new system. For example, assigning a lower-performing or new staff member to a new surgeon who is under considerable cognitive load due to inexperience or a new environment may put a situation particularly at risk for conflict. Furthermore, simulated operating room team training28,29may improve teamwork and communication and prevent conflict in high-stress environments where a majority of these conflicts occurred.

    A final key finding is the implication that these conflicts have for wellness. Referring to prior data linking workplace conflict to insomnia, depression, and somatic symtpoms,30-32 these conflicts may have implications for retention, job satisfaction, and burnout for women surgeons. In order to be effective, comprehensive wellness efforts must aim to prevent burnout by addressing workplace conflict through the strategies noted previously or through more equitable adjudication processes.

    Limitations

    Our study has several limitations. We relied on women surgeons to self-identify workplace conflicts and did not interview interprofessional staff regarding their experience of conflict with women surgeons. This possibly creates bias in the reported circumstances and only represents one side of the conflict. We also did not interview male surgeons regarding their experience with interprofessional conflict; it is possible some themes are not unique to conflict involving women surgeons. These areas are the focus of ongoing investigations. Finally, we did not deeply explore intersectionality with regard to race/ethnicity, experience level, or other factors.

    Conclusions

    The results of this qualitative study of 30 US women surgeons suggest that the circumstances leading to interprofessional conflicts are primarily due to breakdowns in communication or performance-related disputes. Women surgeons perceive a double standard related to these conflicts and the expectation that they conform to gender over professional norms. Further research to elucidate drivers and outcomes of interprofessional conflict, including the role of gender, is necessary to inform policy and practice. Only by evidence-based intervention can patient care and professional wellness be optimized.

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    Article Information

    Accepted for Publication: July 29, 2020.

    Published: October 8, 2020. doi:10.1001/jamanetworkopen.2020.19843

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Dossett LA et al. JAMA Network Open.

    Corresponding Author: Lesly A. Dossett, MD, MPH, Assistant Professor, Department of Surgery, University of Michigan, 1500 E Medical Center Dr, 3310 Cancer Center, Ann Arbor, MI 48109 (ldossett@umich.edu).

    Author Contributions: Drs Dossett and Telem had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Dossett, Telem.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Dossett, Vitous, Lindquist.

    Critical revision of the manuscript for important intellectual content: All authors.

    Obtained funding: Telem.

    Administrative, technical, or material support: Vitous, Telem.

    Supervision: Dossett.

    Conflict of Interest Disclosures: Dr Dossett reported receiving grants from the Agency for Healthcare Research and Quality during the conduct of this study. Dr Telem reported receiving grants from the Agency for Healthcare Research and Quality, the National Institutes of Health, and Medtronic outside the submitted work. Dr Jagsi reported receiving grants from the National Institutes of Health, the Doris Duke Foundation, the Komen Foundation, Blue Cross Blue Shield of Michigan, and Genentech; grants and personal fees from the Greenwall Foundation; personal fees from Sherinian and Hasso, Dressman, Benziger, Lavelle, Amgen, Vizient, and Equity Quotient outside the submitted work. Dr Jagsi reported being an uncompensated founding member of TIME'S UP Healthcare and a member of the American Society of Clinical Oncology Board of Directors. No other disclosures were reported.

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