• Professional touch is a skilled touch that is delivered to achieve a specific outcome, with the recipient in some way reimbursing the professional for services rendered. Personal interpretations of touch and their influence on professional interactions include personal space, culture and subculture (such as social structure and spiritual discipline), gender, age, and life events. • Therapeutic massage has a rich heritage and history. Massage or touch as a method of healing has many cultural origins. This means that no one culture owns massage, and that some sort of underlying, instinctive mechanism spurred the development of a type of massage in most, if not all, cultures on the planet. The ancient Chinese massage system consisted of kneading and rubbing down the entire body with the hands, joint movement, and traction. Ancient Chinese methods are not much different from the method of massage used today. • Hippocrates of the Greek island Cos was the first physician in Greek medicine to specifically describe the medical benefits of anointing and massage, along with the chemical properties of oils used for this purpose. Claudius Galenus, or Galen, another Greek physician, contributed much written material on early manual medicine. In 1478, De Medicina was one of the first medical textbooks to be published. It dealt extensively with prevention and therapeutics involving rubbing, exercise, bathing, and anointing. • Per Henrik Ling founded a recognized school to teach his methods. He put much of the existing knowledge together in a usable form, but much of what is considered Swedish massage came later from the work of Mezger. Eventually, physicians spoke about massage with other doctors in a language that they understood, and by 1839, Ling’s system had gained worldwide recognition. • Scientific research is the key to validation. Massage has been validated by the science of the day. Many of the ideas that past scientists had were incorrect. The important thing to remember is that even though the “scientific rationale” for massage was incorrect, the benefits of massage are real. It is important to remember the value of objective research for validation. Pain research has uncovered many physiologic explanations for the benefits of massage. History does repeat itself, and massage has reemerged in every age. The best results have occurred when science is advanced enough to figure out why massage works. It will be exciting to move into the future, as long as we keep in mind the lessons of the past. • The skin is the largest sensory organ of the body. Many subcutaneous soft tissue structures (e.g., muscles, connective tissue), as well as visceral structures (e.g., the lungs, heart, digestive organs), project sensation to the skin. The autonomic nervous system, which regulates the visceral and chemical homeostasis of the body, is highly responsive to skin stimulation in support of well-being. Mood (the way a person feels) often is reflected in the skin. We blush with embarrassment, flush with excitement, and pale with fear. • Personal space, culture and subculture, including social structure and spiritual discipline, gender, age, and life events can influence an individual’s experience of touch. Forms of inappropriate professional touch include the following: • The development of a common terminology is important as modern massage moves toward standardization. This process has begun with the release of the “Massage Therapy Body of Knowledge” document. 1. Professionalism is defined as _________. a. An occupation that helps people b. A service provided for others c. An intricate system that is structured and systematic d. Adherence to qualified status, methods, standards, and character 2. A middle-aged client is reluctant to work with a 22-year-old massage therapist. The most likely reason why is because of ________. 3. Which of the following defines culture? a. Race as defined by color and where you live b. Arts, beliefs, customs, institutions, and all products of human work and thought created by a specific group of people at a particular time c. What you study, the profession you choose, the family you grew up in, and whom you marry d. The workplace, including the people, environment, physical location, and financial management 4. A form of touch technique is touch that is ________. 5. The word massage is derived from all the following languages except __________. 6. The practice of acupuncture involves the use of which technique on points on the body? a. Insertion of tiny, solid needles b. Pressing the thumb into a point c. A series of ever-deepening compressive strokes d. Counterirritation, such as scraping, cutting, or burning of the skin 7. Polarity therapy was created by _________. 8. Which of the following is Henrick Ling noted for being? a. Physician who developed massage techniques for joint stiffness and wound healing b. Swedish writer who wrote De Medicina, a series of eight books covering the body of knowledge of the day c. Teacher who is credited with developing Swedish massage d. Physician credited with bringing massage to the scientific community 9. The National Certification Examination for Therapeutic Massage and Bodywork was first devised in _________. 10. One of the prominent reasons that Ling’s work had a difficult time being accepted was because he _________. a. Worked only with healthy people b. Used poetic and mystic language in his writings c. Based his work on newly discovered knowledge of the circulation of the blood and lymph 11. What is the massage trend developed in 1991 that supported acceptance for the benefits of massage? • Professionalism is the skill, competence, or character expected of a member of a highly trained profession. Therapeutic massage is the application of systematic touching for health purposes. The variety of massage methods makes it difficult to please all practitioners of specific approaches. It is difficult to encompass all these approaches to develop a concise definition for the massage and bodywork profession. • A scope of practice defines the knowledge base and practice parameters of a profession. The scope of practice for therapeutic massage, when formally developed, must fit into the spaces left by other professionals. Fortunately, the area left unfilled by other professionals is valuable for personalized supportive wellness care. With additional training, massage therapists can become important team players and can work within the scope of practice of other health care professionals to assist them in providing the best care for their clients. • Ethics is the system of rules, based on morals, values, and standards of accepted conduct, that guide correct behavior. The following eight principles guide professional ethical behavior: • Respect—Esteem and regard for clients, other professionals, and oneself • Client autonomy and self-determination—The freedom to decide, and the right to sufficient information to make the decision • Veracity—The right to the objective truth • Proportionality—The principle that benefit must outweigh the burden of treatment • Nonmaleficence—The principle that the profession shall do no harm and shall prevent harm from happening • Beneficence—The principle that treatment should contribute to the client’s well-being • Confidentiality—Respect for privacy of information • These ethical principles direct the development of standards of practice. Standards of practice provide specific guidelines and rules that form a concrete professional structure. Standards of practice guidelines direct quality care and provide a means of measuring the quality of care. They usually are more concrete than ethical principles. • The relationship between the massage professional and the client is based on professional trust and safety. If the client is unable to make an informed choice, the trust is broken and the touch is not safe. In the professional relationship in which expectations and rules are understood clearly, clients can make an informed choice about their behavior. If the situation is vague and the rules change from week to week, the expectations between client and practitioner become unclear. Completing an informed consent process with clients allows for informed choice. • Take ethics into consideration in maintaining professional boundaries and the therapeutic relationship. The massage therapist’s touch needs to be safe and nonjudgmental. How could we ethically say that we are providing this service for a client for whom we feel dislike, disapproval, or fear? All boundary concerns could be resolved through respect for clients that equally serves our needs and theirs. We invade a person’s boundaries when our needs are put above their needs. If a massage professional wishes to maintain a nondiscriminatory approach but cannot best serve a particular client, clear, honest, and respectful disclosure to the client of the massage practitioner’s problem allows the massage professional to best serve the needs of the client without discrimination. • Effective listening involves the development of focusing skills. Reflective listening involves restating the information to indicate that you have received and understood the message. Active listening may clarify a feeling attached to the message but does not add to or change the message. Listening does not involve giving advice, resolving the problem presented, or in any other way interjecting information about what was said. Effective listening occurs when we listen to understand, instead of to respond. I-messages share feelings and concerns. You-messages put a person down, blame, or criticize and provoke anger, hurt, embarrassment, and feelings of worthlessness. • If a message is to be understood, it must be delivered on the wavelength most easily received by the person who is attempting to understand. To encourage effective communication, begin by identifying a person’s communication pattern—that is, the words used, the tone of voice, and the body language. Use neutral topics to generate general discussion. During this time, adjust your communication pattern to meet the person’s communication style. Shift your body language, word choice, and tone to match the client’s before attempting to deliver a message. When communicating feelings, be specific. Words such as upset are too ambiguous. Instead, use words such as afraid, angry, annoyed, discouraged, embarrassed, irritated, rejected, accepted, appreciated, capable, determined, compassionate, glad, grateful, proud, loved, and trusted. Define the words you use. Do not assume that what you mean by a word is what your listener understands it to mean. • The massage professional must refer the client to other health care professionals when appropriate. Often, it may be tempting to answer a client’s questions related to a diagnosis, but it is better to refer the client to his or her physician to avoid problems. • Short-lived feelings of sexual arousal that occur when a person relaxes have a physiologic basis. If the client has experienced essential touch only in a sexual situation, the client logically connects the two experiences. Education and explanation help clients understand the difference. Acting sexual in the context of the therapeutic relationship is always inappropriate. • Use a problem-solving approach to enhance ethical decision making. If each massage professional establishes professional boundaries, and if these are respected through equal consideration of each person’s needs in a situation, the massage professional’s respect for the client and the client’s understanding of professional ethics will support decision making in most vague situations. • Massage practitioners must know what credentialing is required by law to practice massage therapy, and what types of credentialing are voluntary. They also must know that credentials must be issued by verifiable sources. Depending on where the massage therapist wants to practice, these legal issues to a large extent determine the requirements for starting a business. • The main purpose of a law is to protect the public’s health, safety, and welfare. • The massage professional needs to understand legislative issues, local ordinances, and zoning regulations. Depending on where the massage therapist wants to practice, these legal issues to a large extent determine the requirements for starting a business. • Massage seems to be subdividing into wellness personal service massage and medical and rehabilitative massage. Wellness personal service massage has an entry-level educational requirement of 500 to 1,000 clock hours. This is the standard in most of the United States. The medical and rehabilitative type of massage is most typified by the educational requirement set by the Canadian provinces of Ontario and British Columbia, which calls for approximately more than 2,000 clock hours of training. This requirement is the equivalent of the associate’s degree required for medical technicians such as respiratory therapists and physical therapy assistants. Practitioners involved in medical and rehabilitative massage are supervised by a highly trained medical professional. • Identify and report the unethical conduct of colleagues. Depending on the seriousness of the infraction and the colleague’s response, it may be necessary to file a formal complaint through the professional organization or the legal system in your area. It is unprofessional to ignore unethical behavior in colleagues. A willingness to be involved with profession-wide ethical concerns supports professional integrity as a whole. Carefully document the concerns and the process of intervention. Follow all ethical principles in these types of situations. • The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was signed into law by President Bill Clinton on August 21, 1996. Conclusive regulations were issued on August 17, 2000, to be instated by October 16, 2002. HIPAA requires that transactions regarding all patient health care information must be formatted in a standardized electronic style. In addition to protecting the privacy and security of patient information, HIPAA includes legislation on the formation of medical savings accounts, the authorization of a fraud and abuse control program, the easy transport of health insurance coverage, and the simplification of administrative terms and conditions. HIPAA encompasses three primary areas, and its privacy requirements can be broken down into three types: privacy standards, patients’ rights, and administrative requirements. • Ethical behavior is professional behavior. It revolves around a high regard and respect for our clients; for other health, training, and service professionals; and for ourselves. Being a professional is a compassionate and caring responsibility that requires a commitment to continued learning, self-reflection, and the highest good for all concerned. Ethics is the system of rules, based on morals, values, and standards of accepted conduct, that guide correct behavior. • Ethical behavior needs to be considered with the use of social media. Information available to the public affects the massage profession as a whole. If an individual presents herself as a massage therapist, then her behavior publicly impacts the massage profession as a whole through multiple venues such as advertising, social media (Facebook, Twitter) web sites, and electronic advertising. • Because of the variety of massage methods, it is difficult to develop a definition for therapeutic massage and to please all practitioners of specific approaches. It is hard to encompass all these approaches to develop a concise definition for our profession. Sometimes the term “Swedish massage” is used to label the general classical massage approach with a relaxation outcome. The methods used are effleurage/gliding, petrissage,/kneading, friction, tapotement, vibration, and joint movement. • The massage professional needs to understand the scope of practice for other professionals. With additional training beyond entry-level education, massage therapists can become important team players and can work within the scope of practice of other health care professionals to assist them in providing the best care for their clients. • Massage practitioners must avoid falling into a situation that could allow them to be accused of practicing medicine. To avoid such situations, massage professionals must not focus on specific treatment for specific problems; rather, they must provide a service that helps the client maintain or enhance good health. The massage professional also must refer the client to other health care professionals when appropriate. • It is always unethical to interact sexually in the professional relationship. 1. The knowledge base and the practice parameters of a profession are called ________. 2. A client, a professional dancer, is basically healthy but is seeking massage to manage minor injury and support recovery. Which scope of practice description best describes these outcomes? 3. A massage professional is careful to provide an informed consent process for each client and updates informed consent regularly. Which of the following ethical principles is being followed? 4. Taking a client’s history and providing a physical assessment to develop a massage care plan is called a ________. 5. A massage professional has worked hard to develop a policy statement and has included types of services offered, information on training and experience, appointment policies, client and practitioner expectations, sexual appropriateness, and recourse policy. What did the professional forget to include? 6. A massage practitioner made a practice of careful and modest draping during the massage, used low lighting and soft music to help clients relax, always locked the door to maintain privacy, provided informed consent, and maintained charting. Which of these activities has the greatest potential for ethical concerns? 7. A client seems to interrupt often when the massage practitioner is attempting to gather information about the client’s condition before the massage. The client often provides inaccurate information when asked questions. Where might the client need assistance in the communication process? 8. A client informs a massage professional that another massage practitioner in the practice is soliciting clients to move to a new private practice the therapist is starting. Everyone in the current practice signed a contract agreeing to avoid soliciting clients in this manner. After careful consideration of the situation and discussion with a peer in a similar situation in another state, what is the next step the massage professional should take? 9. Local legislation that controls the location of a business is called ________. 10. What is the struggle between interdependent people called? 11. A massage therapist is frustrated with his supervisor because he was told that he has to chart each massage by using new forms. When he voiced his concerns, the supervisor told him to stop arguing, and if he didn’t like it, he could leave. Which of the following describes the conflict resolution method the supervisor was using? 12. Which of the following best describes HIPAA? 1. A massage professional becomes angry with a client who complains about personal problems during the massage. The massage practitioner is displaying _______. 2. A massage professional fails to regularly drape clients in a modest and professional manner. Which of the following best describes this conduct? 3. A massage professional uses a variety of methods for athletes, those with chronic pain, and clients who require teaching on stress management. Which of the following is most likely the massage application style the massage therapist uses? 4. A massage professional has been working with a particular client for 12 months. Recently, the client has been experiencing increasing difficulty with family communications, namely stress and tension between son and father. Discussions during massage are centered on solving this problem. Which of the following best describes this situation? a. The massage professional is having difficulty maintaining informed consent. b. Scope of practice violations, particularly involving psychology, are occurring. c. The client should be referred for acupuncture or chiropractic treatment. 5. A massage professional with entry-level training has been seeing a client who was recently given a diagnosis of diabetes. The massage professional is becoming more uncomfortable providing massage as the client displays more symptoms. What is the most likely reason for the massage professional’s discomfort? a. Being in a dual role with the client now that the client is ill b. Having more demands from the client c. Failing to abide by the definition of massage 6. Which of the following is a violation of confidentiality? a. Maintaining client records in a secure location b. Asking the client questions about the work environment c. Approaching and speaking to a client in a restaurant d. Speaking to a client’s chiropractor with appropriate releases 7. Which of the following would be an appropriate disclosure to a client? a. The fact that the massage professional has a cold b. Business financial concerns c. Discussion about a mutual acquaintance 8. A massage professional has been asked to work with a support group for persons with cerebral palsy. The therapist is well trained and has 7 years of experience but is uncomfortable with persons with disabilities, especially those for whom communication is problematic. Which of the following can serve as grounds for refusal on the part of the massage professional? 9. A massage professional with 15 years of experience but minimal continuing education is in charge of a massage clinic. A recent massage graduate on staff at the clinic notices that his current skills, particularly in charting and critical thinking, are more sophisticated than those of his supervisor, but he is hesitant to discuss the issue. What is the best description for this situation? 10. The best example of transference is a massage professional who _______. a. Has bias toward a client because of political beliefs b. Receives small gifts from a client to express affection c. Asks a client to attend a meeting about a nutritional product d. Angers a client by being late for the last three appointments 11. Which of the following is the most likely reason a client became confused by becoming mildly sexually aware during the massage? a. The massage practitioner was sexualizing the massage. b. The client was sexualizing the massage. c. The client was experiencing parasympathetic sensations. 12. A massage therapist is angry with a coworker about the scheduling of the massage room. He is busier than his coworker and wants to schedule more time on Saturdays. What type of conflict is this? 13. A massage professional is troubled over a client’s responses during the last four massage sessions. There is nothing specific about the client’s behavior, but something has changed in the client’s response to the massage. Which activity would most help the massage professional? • It takes time and commitment to build any business. The person must believe in the product or service. The massage professional must not quit when times get hard, especially during the first 2 years of the business. • Motivation provides the inner strength to stay with a project long enough to succeed. If we understand all aspects of ourselves, then it is easier to determine where difficulties may arise, where we will need help from others, or what other skills we may need to learn to support our weak areas. A successful business depends on maximum utilization of strengths and compensation for and understanding of weaknesses. • Burnout occurs when we expend more energy than we restore. It also could be described as taking care of others better than we take of ourselves. To prevent burnout, we can keep our lives balanced by participating in a wellness program, taking continuing education classes, and taking a vacation. • A résumé helps us present the professional experience, qualifications, and attributes that we bring to a business relationship. • A business plan is a map of a business’s future. It provides direction, clarity of purpose, and a mechanism for setting smaller goals to achieve along the way. • Startup costs reflect the amount of money it takes to begin a business. One startup cost that often is forgotten is a reserve of money for subsidizing living expenses during the first year of business. • Marketing and advertising strategies depend most on word-of-mouth advertising. The word can be spread initially by making yourself visible in the community through public speaking and volunteer work (which is also known as networking). Encourage the local media (e.g., newspaper, radio) to do a story about your business. Yellow Page advertising is important after the business has been established at a particular location for 1 year. To share advertising costs, form a group of massage and bodywork professionals in your community, and advertise as a group in the newspaper, on the radio, or even on television. The brochure educates the public about your massage business in a comprehensive yet concise manner. • Web-based advertising, as well as the use of social media, has become a primary mode of marketing and advertising. It is important to maintain ethical and professional behavior when communicating through electronic platforms such as Twitter, Facebook, and web-based advertising. • Real time includes the time it takes to do a massage, as well as the time between massages and the time needed to complete the client’s records. In addition, the massage professional must realize that the time spent on business record keeping and paperwork requirements will equal approximately the time spent performing the actual massage. Real time must be considered when calculating the actual per hour amount of income from providing massage services. • Obtaining medical insurance reimbursement for personal service massage is unlikely because insurance companies are not focused on prevention at this time. However, medical insurance programs are changing, and prevention may become a more important consideration. Until this happens, cash for services rendered is a more dependable income base. The insurance company must preapprove any proposed insurance coverage before a massage is given. • The three main types of business opportunities available for the massage professional are (1) self-employment (using leased or purchased space), (2) self-employment (paying a percentage of the income from each massage instead of rent for space), and (3) employee status (earning an hourly wage or salary). An independent contractor is self-employed. • KISS means “keep it simple and specific.” If a business management system is too complicated, most practitioners will not consistently follow through with record keeping. • Professional liability or malpractice insurance and premise liability insurance (“trip and fall” insurance) are crucial for the protection of the massage professional. Other types of insurance are available, depending on the complexity of the business. • A record-keeping system accurately reports business income, keeps track of client progress, and allows the massage professional to look back to learn from successes and mistakes to achieve a better business operation in the future. • The client-practitioner agreement and policy statement is useful if it is presented in a format that the client can easily understand, enables the client and the therapist to set realistic expectations about what is required, and determines the boundaries of the professional relationship. 1. A massage professional is considering a position at a local day spa. The spa’s owner offered an employee position at a salary or a subcontractor position based on commission. Which would be an advantage of being an employee? 2. Expenses used to begin new business operations are called ______. 3. A massage therapist is involved in developing a web based promotional campaign to increase her massage business since taking on a part-time massage employee. What is this called? 4. A massage practitioner has just redesigned his brochure and has included the types of massage provided, what the massage is like, information about the practitioner’s qualifications, and client responsibilities. What did he forget? 5. A client notices that the massage office is clean, neat, and efficient, and that licenses and certifications are posted on the wall. These demonstrate the massage practitioner’s abilities in ______. 6. A massage professional wants to check to see whether the location for an office being considered for rental is in an appropriate business distinct. Where is this information found? 7. Gross income minus expenses equals ______. 8. What type of insurance will protect the massage professional in case a client falls while at the business location? 9. A massage practitioner has a sole proprietorship with a DBA. She has obtained required licenses and permits for her business location and has had an attorney develop her business checking account and tax plan. She has contacted a local insurance agent for appropriate business insurance, and she is a member of a professional organization that supplies professional liability insurance. She has a marketing plan and client practitioner agreements. What business plan component is missing? • The three word elements used in medical terms are prefix, root, and suffix. Prefixes are placed at the beginning of the root word to change the meaning of the word. Root words contain the basic meaning of the word. A suffix is placed at the end of a word to change the meaning of the word. A good plan when translating medical terms is to begin with the suffix. • Abbreviations are shortened forms of words or phrases. When using abbreviations in any record keeping, including charting, provide an abbreviation key on the forms or in a conspicuous place on the file. Excessive use of abbreviations is discouraged. To maintain the integrity of client charts, make sure that any abbreviations used are universally understood, or write out the word. • Steps for effective professional record keeping are based on clinical reasoning. The four steps for a common clinical reasoning approach are as follows: (1) review the facts and the information collected, (2) brainstorm the possibilities in terms of solutions, (3) consider the logical outcome of each possibility, and (4) consider the ways in which people are affected by each possibility. Decisions made through this process are reflected and recorded in the care/treatment plan. • A care/treatment plan typically involves clinical reasoning to develop a comprehensive plan involving a series of sessions to attain outcome goals for a client. Session planning involves clinical reasoning to develop a specific session within the context of the treatment plan. • The written account of the clinical reasoning process is called documentation. Charting or recording individual sessions requires an organized system. A common approach is SOAP notes, which include the following: • S: Subjective data recorded from the client’s point of view. • O: Objective data acquired from inspection and palpation, and a list of assessment procedures and interventions used during the session. • A: Analysis or assessment of subjective and objective data and an analysis of the effectiveness of the intervention and of actions taken, along with a summary of the most pertinent data. • P: A plan, including the method used for intervention and the progress noted in the sessions, is developed and recorded. • Record-keeping/documentation skills and the necessary language base to keep records effectively are important parts of professional development. The ability to communicate clearly through writing and when speaking fosters understanding and accurate exchange of information. • Outcome goals for the massage must be quantified. This means that they are measured in terms of objective criteria. Measurement of joint range of motion is an example of a quantified goal. Goals need to be qualified. The question to be answered is “How will we know when the goal is achieved?” or “What will the client be able to do after the goal has been reached that he or she is not able to do now?” • Documentation involves multiple procedures. Intake procedures are done once and updated periodically. Charting is ongoing after each session. To maintain the integrity of client charts, make sure that any abbreviations used are universally understood, or write out the word. Comply with electronic record keeping when required. If writing by hand, use black pens. Make sure handwritten notes are readable. Never erase or white-out a correction. Draw a single line through any error, and make the correction above or next to the error. It is important to share the charting notes with and explain them to the client regularly. If electronic charting is used, it is important to follow software program processes. 1. The process for client record keeping/documentation involves _________. a. Charting each session of the ongoing process b. Having the client fill out a general information packet c. Creating a written record of intake procedures, informed consent, needs assessments, recording of each session, and release of information d. Filing each piece of information received from physicians and insurance companies and payments received from clients 2. Charting can be defined as the_________. a. Record of each payment made by the client b. Record of the time spent with each client c. Written record of the intake procedure 3. Massage treatment goals must be quantified, meaning _________. 4. The purpose of building a database is to _________. a. Gather information to build the professional interaction, establish client goals, and develop a plan for achieving them b. Develop a comprehensive knowledge base of medical terms for reasoning clinically and charting effectively c. Develop procedures for writing records and for ways to use various forms 5. A database consists of _________. a. Charts on the actual session b. All available information that contributes to therapeutic interaction c. The client’s description of the problem d. Goals that are quantified and qualified and are functionally oriented 6. The purpose of assessment is to _________. a. Provide methods to correct deviations from the norm b. Identify effective functioning to eliminate massage to that area c. Do a visual and functional assessment but not a palpation assessment d. Identify effective functioning and deviations from the norm 7. To analyze the data gathered during the assessment, the massage professional must _________. a. Increase mechanical application of skills for application of the treatment plan b. Generate quantifiable goals and methods that can be used to achieve client goals c. Consider the information based on examination, investigation, and analysis in relation to outcomes d. Compare information versus generalized norms and protocols for treatment
Therapeutic massage*
Foundations of therapeutic applications of touch
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Professionalism and legal issues
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Application/concept identification and clinical reasoning/synthesis questions
Business considerations for a career in therapeutic massage
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Medical terminology
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