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Mid-Level Encroachment

Osteoth

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    So I searched to try and find something specific to dermatology, but this is kind of the age-old question.

    Why is dermatology safe from mid-level encroachment considering the relative acuity of a good deal of daily dermatology?
     
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    MOHS_01

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      Ummm. It's not? I have personally watched wait times decline precipitously and follow up intervals shorten as a result of the influx of providers, both mid level and MD/DO, into dermatology. It's not a regional trend, either -- all one has to do is look at the MC expenditures over time for various CPT codes and contrast that to actual disease burden taken from the same codes. The number of biopsies and local destructions have gone up relative to the actual incidence of malignant disease (which has also increased, probably for a variety of not always intellectually honest or good reasons), visits are up, etc.

      In medicine, supply drives demand to a large degree. It's a fundamental flaw of the current payment system.
       
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      doctalaughs

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        So I searched to try and find something specific to dermatology, but this is kind of the age-old question.

        Why is dermatology safe from mid-level encroachment considering the relative acuity of a good deal of daily dermatology?

        Mohs01 is correct. Derm, like all other medical fields is not immune to midlevel encroachment. However, it is a bit better (so far) than many specialties for several reasons.

        1. Acuity means nothing. High acuity means it's more likely a hospital-based specialty. If the hospital controls or influences the provider mix in any way (zero for derm) then the patient has decreased leverage in who they see, especially for an emergent issue (ie anesthesia, emergency medicine).

        2. Derm has traditionally trained PAs and not NPs who are generally more militant and independence-seeking. Not to say there aren't exceptions and this won't change in the future, but 99% of midlevels in derm are employed by a dermatologist.

        3. Derm is NOT really an algorithm/protocol driven field which is what nurses excel at. It's more visual and experience based. The visual is sorta like path/rads which midlevels have made very scant inroads. And aside from the 75% bread-butter skin ca, skin check, warts, acne etc -- there are hundreds of infrequent-to-rare diagnoses that you might manage based on scattered case series and the dozen patients you've seen from residency at a tertiary referral center.

        4. Any specialty where (often picky/cosmetically inclined) patients choose their "provider" months ahead, and any specialty where the results are immediately apparent in the mirror will heavily favor doctors over midlevels.


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        Osteoth

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          Ummm. It's not? I have personally watched wait times decline precipitously and follow up intervals shorten as a result of the influx of providers, both mid level and MD/DO, into dermatology. It's not a regional trend, either -- all one has to do is look at the MC expenditures over time for various CPT codes and contrast that to actual disease burden taken from the same codes. The number of biopsies and local destructions have gone up relative to the actual incidence of malignant disease (which has also increased, probably for a variety of not always intellectually honest or good reasons), visits are up, etc.

          In medicine, supply drives demand to a large degree. It's a fundamental flaw of the current payment system.

          Please translate the bolded sentence into MS3.

          Do you have any other points to add in terms of reasons why Dermatology would be decreasingly likely to be over-run by mid-levels?

          Mohs01 is correct. Derm, like all other medical fields is not immune to midlevel encroachment. However, it is a bit better (so far) than many specialties for several reasons.

          1. Acuity means nothing. High acuity means it's more likely a hospital-based specialty. If the hospital controls or influences the provider mix in any way (zero for derm) then the patient has decreased leverage in who they see, especially for an emergent issue (ie anesthesia, emergency medicine).

          2. Derm has traditionally trained PAs and not NPs who are generally more militant and independence-seeking. Not to say there aren't exceptions and this won't change in the future, but 99% of midlevels in derm are employed by a dermatologist.

          3. Derm is NOT really an algorithm/protocol driven field which is what nurses excel at. It's more visual and experience based. The visual is sorta like path/rads which midlevels have made very scant inroads. And aside from the 75% bread-butter skin ca, skin check, warts, acne etc -- there are hundreds of infrequent-to-rare diagnoses that you might manage based on scattered case series and the dozen patients you've seen from residency at a tertiary referral center.

          4. Any specialty where (often picky/cosmetically inclined) patients choose their "provider" months ahead, and any specialty where the results are immediately apparent in the mirror will heavily favor doctors over midlevels.

          2. At the same point wouldn't that cause an increased emphasis by NPs to invade the specialty? What leverage have they traditionally used to incorporate themselves into specialties that don't want them, other than legislative mechanisms?

          3. It seems to my uninitiated brain that every specialty requires experience to practice to an extent. How does this explain the rise of PAs/NPs in other specialties?

          4. Very very interesting.
           

          MOHS_01

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            Please translate the bolded sentence into MS3.

            Do you have any other points to add in terms of reasons why Dermatology would be decreasingly likely to be over-run by mid-levels?



            2. At the same point wouldn't that cause an increased emphasis by NPs to invade the specialty? What leverage have they traditionally used to incorporate themselves into specialties that don't want them, other than legislative mechanisms?

            3. It seems to my uninitiated brain that every specialty requires experience to practice to an extent. How does this explain the rise of PAs/NPs in other specialties?

            4. Very very interesting.

            Sadly, SDN does not allow me to draw stick figure cartoons. I could have had fun with that. Heh.

            Readers Digest version: people are doing a whole lot more "stuff" than would be predicted as necessary from a rise in "real" disease. Basically, people are freezing off lots of things, doing PDT, superficial radiation, "unnecessary" surgeries, and performing biopsies (and subsequent excisions) for every mole on a person. The increased supply of providers is driving the increased demand without a commiserate level of "bad" disease increase. You could argue that increased surveillance is capturing earlier disease, etc, save the fact that "bad" disease has stayed pretty damn steady with little influence by all the added activity.

            You're not paying attention if you do not believe that mid-levels have exploded in dermatology.

            Derm does not lend itself as handily to teaching / learning from a book, online course, etc, and the treatments are not so well defined and uniform as to make algorithm heavy approaches very useful. There is a reason is remains more cottage industry than most of medicine.
             
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            doctalaughs

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              You're not paying attention if you do not believe that mid-levels have exploded in dermatology.

              Yes and I want to emphasize that I agree with mohs01 that midlevels are more prevalent over time in dermatology just like every specialty -- it's just that (unlike for, say, CRNAs in anesthesia) the midlevels are largely still under our control, for now. The reasons for that are less influence of 3rd party "overlords" in dermatology (hospitals, c-suite, venture capital, mega-groups) in comparison to other specialties where they pretty much increasingly dominate the market.



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              Osteoth

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                Yes and I want to emphasize that I agree with mohs01 that midlevels are more prevalent over time in dermatology just like every specialty -- it's just that (unlike for, say, CRNAs in anesthesia) the midlevels are largely still under our control, for now. The reasons for that are less influence of 3rd party "overlords" in dermatology (hospitals, c-suite, venture capital, mega-groups) in comparison to other specialties where they pretty much increasingly dominate the market.

                So considering the margins are still very good in derm from what I understand, why haven't VC funds or big hospital groups tried to commodify the field? Is it simply due to lack of supply?
                 

                MilkIsGood

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                  So considering the margins are still very good in derm from what I understand, why haven't VC funds or big hospital groups tried to commodify the field? Is it simply due to lack of supply?

                  they already are. private equity groups are buying up derm practices. big hospitals are hiring all specialties, including derm, to be employees of their group practice
                   
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                  doctalaughs

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                    So considering the margins are still very good in derm from what I understand, why haven't VC funds or big hospital groups tried to commodify the field? Is it simply due to lack of supply?

                    Yea, they are buying derm practices but it's still a small proportion of the market. We are still 20 years behind other specialties--- mainly I suspect because the barrier to opening a practice is lower. You can still hang a shingle and compete with the venture-capital bought mega-group of 10-15 derms next door, to some extent, and take their patients. Not so at all for, say anesthesia, radiology or EM (and many others) where the big hospital contracts may be dominated by 1-2 mega groups in town as the only gig available (which are then often scooped up by venture capital, because they are essentially monopolies or close).


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                    exeunt

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                      i'm a resident so please chime in if you've had a different experience in practice, but what i have heard from my attendings is that mid level encroachment is a huge problem. midlevels are under supervision (for now, but are lobbying hard for independence) and even while supervised they are driving reimbursement down for MDs. many practices will prefer to hire midlevels to additional MDs because midlevels bill 80% of what a MD bills, but are paid 50% or less of the salary, so it's a huge profit margin for the practice. it's also favorable for insurance companies to have a midlevel see patients because they are reimbursed less. truthfully, midlevels are also capable of doing most of bread and butter dermatology. people take offense to this, but midlevels are (generally) fully capable of handling acne follow ups, moderate psoriasis, TBSEs, botox/filler... and there is so much variability in management even amongst dermatology attendings that it's difficult to demonstrate a difference in outcomes between midlevels vs physicians.

                      it's a big problem that our field is going to have to address to protect our current job market and reimbursement rates.
                       
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                      MOHS_01

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                        So considering the margins are still very good in derm from what I understand, why haven't VC funds or big hospital groups tried to commodify the field? Is it simply due to lack of supply?

                        FYI -- the margins are really not that outside of the norm, percentage wise at least, for the majority of practitioners. Want proof? Look at the compensation between single specialty employment settings and multi specialty groups. Want further proof? Look at MGMA income figures relative to MGMA revenue figures.

                        So many myths, so little time.....
                         
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                        MOHS_01

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                          Yea, they are buying derm practices but it's still a small proportion of the market. We are still 20 years behind other specialties--- mainly I suspect because the barrier to opening a practice is lower. You can still hang a shingle and compete with the venture-capital bought mega-group of 10-15 derms next door, to some extent, and take their patients. Not so at all for, say anesthesia, radiology or EM (and many others) where the big hospital contracts may be dominated by 1-2 mega groups in town as the only gig available (which are then often scooped up by venture capital, because they are essentially monopolies or close).


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                          Exactly -- it is still much easier to make of a go of it in derm than the cloistered specialities. People will actually take the initiative to pick up the phone and schedule a visit for their skin and, for now at least, we are not having to contend with favored nation clauses in managed care contracts that preferentially directs patients to certain provider groups.

                          I would not say 20 years, though. This is low hanging fruit, soon to be consumed by the parasitic horde if things continue on the path they're on. The proliferation of VC backed M&A megagroups is rather astounding... and they will seek out the above once they feel they have critical mass. They will first go after fully insured employer groups, then translate that into the commercial. MC and MA will not be open to such for a longer period of time (save MC Advantage, that is an interesting beast).
                           

                          Osteoth

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                            i'm a resident so please chime in if you've had a different experience in practice, but what i have heard from my attendings is that mid level encroachment is a huge problem. midlevels are under supervision (for now, but are lobbying hard for independence) and even while supervised they are driving reimbursement down for MDs. many practices will prefer to hire midlevels to additional MDs because midlevels bill 80% of what a MD bills, but are paid 50% or less of the salary, so it's a huge profit margin for the practice. it's also favorable for insurance companies to have a midlevel see patients because they are reimbursed less. truthfully, midlevels are also capable of doing most of bread and butter dermatology. people take offense to this, but midlevels are (generally) fully capable of handling acne follow ups, moderate psoriasis, TBSEs, botox/filler... and there is so much variability in management even amongst dermatology attendings that it's difficult to demonstrate a difference in outcomes between midlevels vs physicians.

                            it's a big problem that our field is going to have to address to protect our current job market and reimbursement rates.

                            So how does derm, or really any non-surgical field avoid going the way of anesthesiology? I know that many individuals on these boards have down-played the trouble with mid-level in gas but at the same time I've personally witnessed 1x3 MD/NP set-ups. Like it or not the money works and with the need for practitioners its really not going backwards.

                            Kinda begs the question: Since we're in this mess due to lack of increased residency spots, controlled by the government, can it be said that the government ****ed physicians? And due to the fact that the government is basically a publicly traded entity, how did the AMA and all the physician professional groups let this happen? In the golden age of medicine when doctors were making $1,000,000+ regularly. How were our lobbyists not in both ears of those in congress?

                            Or is it more so that the public need/population growth and demographic shift kind of overwhelmed everyone involved?

                            FYI -- the margins are really not that outside of the norm, percentage wise at least, for the majority of practitioners. Want proof? Look at the compensation between single specialty employment settings and multi specialty groups. Want further proof? Look at MGMA income figures relative to MGMA revenue figures.

                            So many myths, so little time.....

                            MGMA income & revenue data is pay-only, right?

                            Also, how does comparing single-specialty & multi-specialty groups allow you increased information about relative margins? Wouldn't the multi-specialty data be relatively diluted? Aka hard to tell where the money is actually coming from since "multi-specialty" could be a derm and a radiologist up to a series of surgical centers and FSEDs who keep all patients in-house.
                             

                            ActinicKeratosis

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                              I'm applying into derm so I've been thinking about this a lot. First off, even though derm utilizes many midlevels, there are very few practicing independently. In fields that are overrun with midlevels (gas and primary care), doctors still make significantly more. Sure midlevels may be able to handle run of the mill acne, skin cancer, etc...but what about the diseases that stump even experienced derms? Aren't there enough of these patients to go around? The patient with psoriasis that can't be controlled even though they went to five different dermatologists is never going to let an NP/PA touch them. Plus Mohs and derm path are pretty safe. Can any practicing derms chime in?
                               

                              MOHS_01

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                                So how does derm, or really any non-surgical field avoid going the way of anesthesiology? I know that many individuals on these boards have down-played the trouble with mid-level in gas but at the same time I've personally witnessed 1x3 MD/NP set-ups. Like it or not the money works and with the need for practitioners its really not going backwards.

                                Kinda begs the question: Since we're in this mess due to lack of increased residency spots, controlled by the government, can it be said that the government ****ed [s=]physicians[/s] everyone? And due to the fact that the government is basically a publicly traded entity, how did the AMA and all the physician professional groups let this happen? In the golden age of medicine when doctors were making $1,000,000+ regularly. How were our lobbyists not in both ears of those in congress?

                                Or is it more so that the public need/population growth and demographic shift kind of overwhelmed everyone involved?


                                MGMA income & revenue data is pay-only, right?

                                Also, how does comparing single-specialty & multi-specialty groups allow you increased information about relative margins? Wouldn't the multi-specialty data be relatively diluted? Aka hard to tell where the money is actually coming from since "multi-specialty" could be a derm and a radiologist up to a series of surgical centers and FSEDs who keep all patients in-house.

                                One cannot insulate oneself from things that are entirely beyond the control of that individual; does not matter if we are talking about the ravages of inflation / monetary policy, militarism, or the fiscal solvency of the healthcare system. One can only choose a specialty, practice, practice mix, and geographic location that affords some semblance of protection and diversification of revenue streams. Dermatology is very pliable in that regard relative to other specialties.

                                Yes, the politicians screw damn near everything their whoring hands touch.

                                Regarding the rest: MGMA is a self reported survey, take it for what it is worth. If the discrepancy in pay between single specialty and multispecialty is large for a given volume of work, people will naturally flow to / away from the practice settings that create benefit. If you want another metric, look at the wRVU/comp relationship between different practice settings for same specialty. If you still believe derm is high margin, look at how low the $/wRVU is for derm relative to these "low margin" specialties. The picture is not always as clean as it is sold.
                                 
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                                doctalaughs

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                                  Sorry, if you are looking for reassurance, then as we said no specialty is completely safe from midlevel encroachment. Derm is probably safer than some (anesthesia, em, primary care) and less safe than others (surgery and surgical subspecialties). However no specialty has "enough doctor work" if you eliminate all the easy bread/butter cases because by definition this is where you make money. It's hard to make money on the complicated patient that takes a huge amount of time and effort. That is why midlevel encroachment is so annoying - they want to cherry pick the easy, lucrative stuff while leaving the complex poorly paying stuff to doctors, and at the same time have us take the liability for everything.


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                                  Osteoth

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                                    I'm applying into derm so I've been thinking about this a lot. First off, even though derm utilizes many midlevels, there are very few practicing independently. In fields that are overrun with midlevels (gas and primary care), doctors still make significantly more. Sure midlevels may be able to handle run of the mill acne, skin cancer, etc...but what about the diseases that stump even experienced derms? Aren't there enough of these patients to go around? The patient with psoriasis that can't be controlled even though they went to five different dermatologists is never going to let an NP/PA touch them. Plus Mohs and derm path are pretty safe. Can any practicing derms chime in?

                                    My question is, do doctors survive a 40 year career doing only the hardest, most complex or most acute cases their specialty has to offer? Sounds like a one way path to burn-out.

                                    One cannot insulate oneself from things that are entirely beyond the control of that individual; does not matter if we are talking about the ravages of inflation / monetary policy, militarism, or the fiscal solvency of the healthcare system. One can only choose a specialty, practice, practice mix, and geographic location that affords some semblance of protection and diversification of revenue streams. Dermatology is very pliable in that regard relative to other specialties.

                                    Yes, the politicians screw damn near everything their whoring hands touch.

                                    Regarding the rest: MGMA is a self reported survey, take it for what it is worth. If the discrepancy in pay between single specialty and multispecialty is large for a given volume of work, people will naturally flow to / away from the practice settings that create benefit. If you want another metric, look at the wRVU/comp relationship between different practice settings for same specialty. If you still believe derm is high margin, look at how low the $/wRVU is for derm relative to these "low margin" specialties. The picture is not always as clean as it is sold.

                                    Well I meant professionally in terms of politicians, but yes I agree.

                                    Sorry, if you are looking for reassurance, then as we said no specialty is completely safe from midlevel encroachment. Derm is probably safer than some (anesthesia, em, primary care) and less safe than others (surgery and surgical subspecialties). However no specialty has "enough doctor work" if you eliminate all the easy bread/butter cases because by definition this is where you make money. It's hard to make money on the complicated patient that takes a huge amount of time and effort. That is why midlevel encroachment is so annoying - they want to cherry pick the easy, lucrative stuff while leaving the complex poorly paying stuff to doctors, and at the same time have us take the liability for everything.

                                    Exactly. And then shove their "metrics" in everyone's face showing they're basically the same as MDs. I don't understand how people keep getting convinced by this... Then again, if congress people can't be damned to read a healthcare bill, I really doubt they actually read/listen to these people either.
                                     

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                                      3. Derm is NOT really an algorithm/protocol driven field which is what nurses excel at. It's more visual and experience based. The visual is sorta like path/rads which midlevels have made very scant inroads. And aside from the 75% bread-butter skin ca, skin check, warts, acne etc -- there are hundreds of infrequent-to-rare diagnoses that you might manage based on scattered case series and the dozen patients you've seen from residency at a tertiary referral center.

                                      I'm not sure that will stop a militant NP, many believe their online degree is better than our 6 years of clinical experience
                                       
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                                      DermADVISOR

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                                        I could see (and may be happening) in states where NPs have independent practice a clinic ran by NPs that specializes in treatment of skin problems. Midlevels are exploding in many specialties and dermatology seems like a prime one for it to continue. As physicians, regardless of specialty, we need to stick together and refer to other physicians.

                                        Part of the problem with medical organizations is the lack of political involvement by physicians. The current state is our fault. Physicians won't take days off clinic to visit the state capital or meet with lawmakers at the state level about these issues. Physicians do very little compared to NPs when it comes to advocating for the profession. Every physician should take two days off per year to meet with a lawmaker about these issues. I know from experience, midlevels lobby like this constantly.
                                         
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                                        MOHS_01

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                                          I could see (and may be happening) in states where NPs have independent practice a clinic ran by NPs that specializes in treatment of skin problems. Midlevels are exploding in many specialties and dermatology seems like a prime one for it to continue. As physicians, regardless of specialty, we need to stick together and refer to other physicians.

                                          Part of the problem with medical organizations is the lack of political involvement by physicians. The current state is our fault. Physicians won't take days off clinic to visit the state capital or meet with lawmakers at the state level about these issues. Physicians do very little compared to NPs when it comes to advocating for the profession. Every physician should take two days off per year to meet with a lawmaker about these issues. I know from experience, midlevels lobby like this constantly.

                                          This is true, but the big political selling point is the discount. Politicians by nature gleefully wrote checks with their mouths that their asses have no hope of cashing, and this allows for a bigger promise - or so they think.


                                          The problem with the whole of medicine is that we have far too many providers of all stripes who are blind to what they don't know. Then there are the self enriching jerkoffs who know enough to understand what is unnecessary - but defensible - and these guys really gore my ox...


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                                          username456789

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                                            This is true, but the big political selling point is the discount. Politicians by nature gleefully wrote checks with their mouths that their asses have no hope of cashing, and this allows for a bigger promise - or so they think.


                                            The problem with the whole of medicine is that we have far too many providers of all stripes who are blind to what they don't know. Then there are the self enriching jerkoffs who know enough to understand what is unnecessary - but defensible - and these guys really gore my ox...


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                                            I know it's only a small sliver of what you speak, but I frequently see patient records from their previous derm that include totally unnecessary "flaps" performed for what would otherwise be simple excisions on the back or lateral neck or wherever.
                                             
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                                            MOHS_01

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                                              I know it's only a small sliver of what you speak, but I frequently see patient records from their previous derm that include totally unnecessary "flaps" performed for what would otherwise be simple excisions on the back or lateral neck or wherever.
                                              Oh yeah... can't beat those needless O to Z's and transpositions that took all of 6, maybe even 8 :eek: closely placed 6-0 nylons #eyeroll
                                               
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