Dokter Blog: from the desk of Rahajeng Tunjungputri

Medicine et cetera by @ajengmd

The Journal Club, Faculty of Medicine Diponegoro University

Earlier this year, together with the tremendous support and enthusiasm from a group of our medical students, I initiated The Journal Club, where its activities now are maintained by the students themselves.

It is essentially a club where we come together and discuss journal articles. The idea is to learn how to read english journal articles, discuss and share ideas.  The most distinguishing aspect of this club is that all the discussion are conducted in english, and we encourage students to improve their own english level as we go along.

At the moment, this program is an extracurricular activity, although heavily stressing on having immediate impact on the students academic skills.

Before every meeting, the students have the chance to read the journal articles. During the meeting, they will have focus group discussion regarding several questions that I ask them in relation to the journal.

Below are the discussion points from our previous 3 meetings so far with the links to the respective journal articles.

For now, our main goal is to continue to improve and reach out to more students who are interested in improving their academic english skills.

First meeting

Second meeting

Third meeting

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Teachers can bully students too: are you part of the problem?

Teaching is what most doctors do during the period of their training or throughout their career as they encounter medical students or even patients. In fact, the origin of the word doctor, came from the word docere, which means “to teach”.

With regards to a post by Wids about teaching, I was prompt to think about other things that may happen in teaching. Regardless of the teaching and learning environment, in whatever context and level of education, bullying can happen; and the worse part is that the teacher can be the bully. Bullying by teacher happen at the lowest level of primary school education up to the university level.

I have no expertise in discussing the matter. However, I’d still like to point out some important resources about bullying by teachers.

WebMD gives an overview about teachers who bully in http://www.webmd.com/parenting/features/teachers-who-bully while another document by Allan McEvoy provides a more comprehensive information at the site ‘Stop Bullying Now’.

According to McEvoy,

bullying by teachers (or other staff, including coaches,

who have supervisory control over students) is defined as

a pattern of conduct, rooted in a power differential,

that threatens, harms, humiliates, induces fear, or

causes students substantial emotional distress.

Regarding the nature of bullying, the author stated the following:

it is an abuse of power that tends to be chronic

and often is expressed in a public manner.

It is a form of humiliation that generates attention

while it degrades a student in front of others.

In effect, the bullying can be a public degradation ceremony

in which the victim’s capabilities are debased

and his or her identity is ridiculed.

This explanation implies that regardless of the chosen method of bullying or intimidation, the effect on the students is what shows that certain behaviour of a teacher as an act of bullying.

Bullying is not a part of proper teaching. 

Let me repeat this: bullying is not a part of proper teaching.

A set of references about bullying in medicine is provided by Wikipedia here. An anonymous site even regularly posts about academic bullying.

Professional attention bring light to the matter. The British Medical Association (BMA) has a complete guidance for medical students on harassment, intimidation and bullying which aims to provide help when students face bullying by peers or teachers. The British Medical Journal (BMJ) published an article by Tim Field entitled “Those who can, do; those who can’t bully”.

Teaching and learning, as any other aspect of culture, can vary between different settings and countries. Most of the time, in a culture where hierarchy is rigidly maintained, students have to accept bullying without ever having the chance to fight it, or even to consider that they shouldn’t accept such treatment by their teacher. Most will never even realize that they are victims of bullying which may lead them to think that intimidation and humiliation is an acceptable form of teaching and academic life. Well, they are not:  bullying is not a part of proper teaching.

The act of bullying can be continuously practiced freely in academics, and so many are unaware that they themselves are part of the problem. In university, even, there are situations that keep alive the vicious cycle of bullying: when there is no knowledge by the staff and students about bullying; when there is no stance against bullying; when acts of bullying are culturally accepted as normal; when acts of bullying are considered as a part of a teacher’s personality and habit instead of abusive behavior towards students; when acts of bullying are considered as part of educating and teaching professionally; when as a teacher you see fellow teacher who bully students but do nothing to stop it; when the students themselves, not being able to fight back anyway, refuse to see intimidation and verbal abuse as form of bullying by teacher.

Perhaps the first step to prevent bullying by teachers is to be willing to admit that there are teachers who bully their students. Perhaps the first step is to understand that students should not accept the unacceptable behaviour of their teachers towards them: students have to be aware that as long as they respect teachers, they also deserve respect from their teachers.

When this is a matter involving power differential, as stated by McEvoy, then students generally will not have the power, authority nor capacity to fight back on their own. The BMA in United Kingdom for example, has acknowledged the issue of bullying in medical teaching, and has a list of counselors and help line that students can contact to seek help when they experience bullying.

Unfortunately, such help is an unobtainable privilege for most students in other countries. The act of bullying is dismissively considered “normal” and “educative”. The perpetrator keep doing it, and the students are intimidated to accept it.

I will end this by asking some questions I don’t have answers to. To what extent can we apply a universal definition of bullying? Does culture play a prominent role in determining whether a teacher’s actions (and verbal statements) are a form of bullying students? Are certain actions and words by teachers seen as bullying by a certain culture (or country), while being perceived as a normal thing by (students and teachers of) other cultures/countries? To what extent students have the right to be respected by the teachers, and to what extent the teachers acknowledge their obligation to respect students?

But one thing we should know. Bullying is not a part of proper teaching. 

23 June 2011.

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“The real world of medicine”

A discussion about teaching and learning medicine was brought up in doc2doc, and this is quoted from Odysseus, in http://doc2doc.bmj.com/blogs/doctorsblog/_expect-teachers

If your students were your soldiers in boot camp and you were the drill sergeant you are responsible for their success or failure as a soldier up to a point and thus responsible for their death or survival. But no matter how hard you ride the recruit, whether or not he or she takes on board all you have told them, is still their own responsibility.

Indeed it is your responsibility as an examiner (teacher) to ensure they jump as high as the bar you set and if they fail, they will not stand the pressure of the real world and must repeat or drop out.

The real world of medicine is life and death and coronial inquests and court cases and even jail if you get it badly wrong, so raising the bar to a high level and exhorting them to jump is essential.

"The real world of medicine is life and death and coronial inquests and court cases and even jail if you get it badly wrong"

I just thought that this is a good piece to start a lecture with.

I’d also like to introduce the professional values for medical students from the General Medical Council UK, http://www.gmc-uk.org/education/undergraduate/professional_behaviour.asp . I’d expect all my students to read this during their preclinical years.

-Rahajeng, Semarang 30 October 2010

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Investing in young Indonesian Researchers

Last week the article I submitted for The Jakarta Post was published on 22 August 2010. The issue was something dear to my life and work: that we need more young Indonesian researchers; and to accomplish that we need to invest in them.

The article was inspired by my experience with a mentor. He has always taken the time and energy to foster new generations of clinician-scientists. I recently realized, that to “produce” excellent scientists in Indonesia, a senior researcher has to be willing to make an investment. The mentor will have to invest his or her time, energy, patience and guidance, for years, in his or her students. There is no instant process of turning an average student into a leading scientist. Everyone must take part in investing in Indonesian young researchers.

http://www.thejakartapost.com/news/2010/08/22/investing-young-indonesian-researchers.html

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Announcement for Lectures of Prof. Cremers, 2010

Center for Biomedical Research (CEBIOR) Faculty of Medicine Diponegoro University, Semarang Indonesia in collaboration with Department of Human Genetics Radboud University Nijmegen Medical Centre, The Netherlands is announcing a lecture and presentation event by Prof. dr. Frans P.M. Cremers, PhD.
Below is short introduction of Prof. Frans Cremers:
In 1984, he finished his master Biology at the Radboud University Nijmegen (main subject: molecular biology). He performed his PhD study at the Department of Human Genetics, in the Radboud University Nijmegen Medical Centre and received a cum laude PhD in 1991 on the thesis entitled: ‘Positional cloning of a candidate gene for choroideremia’. In 2004 he was appointed full professor Molecular Biology of Inherited Eye Diseases, and in 2009, he was also appointed Adjunct Honorary Professor in Comsats Institute of Information Technology, Islamabad, Pakistan. In 2005 he was appointed Programme Director of the topmaster ‘Molecular Mechanisms of Disease’. From 1992 – 2010, he supervised 12 PhD students and numerous BSc and MSc students. He was awarded the ‘Internationalizations Award 2010 of the Radboud University Nijmegen’ for his continued efforts to facilitate MSc and PhD students to study in the Netherlands,and to foster international collaborations.
Lectures and presentation will be held 21-23 July 2010, from 08.30 a.m. in 3rd floor of Faculty building, Faculty of Medicine Diponegoro University Semarang.
(Please click image for full poster)

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The Tobacco Epidemic: Problems, Conflicts, Solutions

Dear all,

I mentioned before that I was asked to speak about tobacco for a group of medical students few weeks ago. I wrote a more comprehensive review of the tobacco epidemic in Indonesia into my blog in doc2doc, “The Cure of The Tobacco Epidemic”.

At the event I brought up the issue of the tobacco epidemic; the problems, conflicts and solutions. This presentation is aimed to highlight the importance of consumer perception, the tobacco and anti-tobacco campaign “wars”, the socio-economic context of the tobacco epidemic in Indonesia and how physicians can contribute in curing this epidemic.

I have uploaded the presentation from that event to Slideshare.

For further reading, please do check the last slide with a list of great reference sites.

Regards,

Rahajeng

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Semester Exam of Genetic Counseling

I had the semester exam this week in my Master Programme of Genetic Counseling FMDU. I really had to focus on these exams, because as you can see, within 6 days I had 19 different exam subjects, and not much time, energy nor interest in anything else other than preparing myself for these exams.

And the menu for those 6 long days were:

  1. Psychiatry – Grief and bad news, Counseling in children with congenital or genetic abnormalities
  2. Psychology – Helping theory, Development of helping relationship, Genetic Counseling
  3. Obgyn – Psychosocial aspect of fetomaternal cases, Prenatal diagnosis
  4. Endocrinology – Genetics of Diabetes Melitus
  5. Neurology – Myotonic dystrophy, Parkinson Disease, Spinal Muscular Atrophy, Ataxia
  6. Mitochondrial medicine
  7. Immunogenetics – Blood group and HLA
  8. Molecular biology – Gonadal development, Molecular basic, Sexual development disorder
  9. Medical ethics – Bioethics, Professional ethics
  10. Pediatric endocrinology – Basic physical measurement, Cytogenetics, Genetic screening, Genetic disorders
  11. Endocrinology – Genetics of thyroid diseases (congenital hypothyroidism, autoimmune disease, malignancy)
  12. Pediatric urology – Congenital adrenal hypertrophy, Androgen insensitivity syndrome
  13. Pediatric neurology – Epilepsy, Myasthenia gravis, Muscular dystrophy
  14. Embryology – Genetics of embryology, teratology
  15. Immunogenetics – Immunodeficiency, Genetics of immune system
  16. Cancer genetics
  17. Biomolecular aspect of thalassemia
  18. Inborn error of metabolism

*Reenactment of my exam preparation by a model (image is not mine)

And the exam week was particularly challenging because I had what looked almost identical to this (WARNING: This is NOT my picture), the cause I presumed was psychological stress which leads to immune dysregulation (due to exam and several other things… such as my passport issues -Not to be discussed here):

*Reenactment of my canker sores (image is not mine)

Note that it was a large and deep ulcer, heavily inflammed and located on the side of the tongue. When I talk the tongue (and ulcer) is hitting my lips and my teeth, when I sleep the tongue dried and sticked to my palate, and OUCH!!! Basically, the ulcer made eating, drinking, speaking, studying, answering my exam, sleeping, and living, in general, very difficult and extremely painful, each and every minute.

I guess we’ll see the result of the exam in the next few weeks, but generally I’m content and satisfied realizing how broad my studies were in the past 6 months. Considering that my main interest is infectious disease, the opportunity of learning genetics and psychology has been a privilege. I explored the subjects I never really thought about learning before (psychology, counseling, embryology) and I even enjoy them!

And what I truly love from the master programme is: you have this whole new world of knowledge and science opening up, and you are free to explore it for yourself!

*

– Rahajeng

https://dokterblog.wordpress.com

PS: And YES, as the exam finishes, my stomatitis is healing.

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I’m now blogging on doc2doc.bmj.com

I have been writing since 2005, so 5 years until now. I started with a variety of topics, and now I mostly blog about medicine. And I think by now I know that my writing can reach more audience, more than just my local peers or medical students. It’s a good time to “go international“.

And I was recently accepted and published as a blogger on a British Medical Journal (BMJ) group website, doc2doc, http://doc2doc.bmj.com/blogslist.html (as AjengMD).

For my first post, click here http://bit.ly/bgU1YL

Doc2doc is an international online community for doctors worldwide. And from the website, “doc2doc is a free of charge service offered by the BMJ Group. The BMJ Group is a trusted global medical publisher that provides a wide range of products and services to improve the decisions doctors make every day. On a day to day basis, doc2doc is run by its community manager, community clinical editor, and the editor of bmj.com, all of whom are based at BMJ Group’s London office.”

Doc2doc.bmj.com does not offer blog hosting. Interested blogging doctors/students have to apply with our own ideas and writings in order to blog there, and new bloggers will be reviewed based on the content of their blog posts. I don’t have my own URL on doc2doc, so my writing are published on doc2doc blog page. I was so excited that when I was accepted, it wasn’t just doc2doc who twittered me, but also BMJ Group.

This is the frontpage of the bloglist.

Another look on the summaries,


And, I’m really excited about this one:

So, maybe it’s time to take the blogging one step higher.

–Rahajeng

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What do you expect from your teachers?

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I’ve always loved writing. It hasn’t always brought me positive result. Sometimes I envy people in other countries where they have a little bit more freedom of speech in medicine. And that you don’t have to be old first to share your experience and opinions.

I found a blog of a medical student:

http://blogs.medscape.com/thedifferential with a post titled as “The Deal” by Lucia Li.

She basically states what the medical students expect from the doctors, and what they are willing to give back to the doctors who teach them. Some points there, from a student perspective they ask the followings from the doctors who teach them:

“Don’t ignore us — no-one likes to be ignored. We’re here to learn, we want to learn. show some interest in our education and we’ll likely love you forever.

Remember who we’re going to be — doctors. That means, however many years down the line, we’re going to be your house-officers, your registrars. It’s in your interest to teach us and contribute to our elevation from ignorance/ incompetency.

Remember who we currently are — students. We want to learn. About lots of different things.

Challenge us — ask us questions to get us thinking. It helps us to identify the important things to learn. It also may spark a lasting interest in that specialty…

But, hey, this is a two-way bargain. What can we, the students, offer in return?

And then they offer the teachers what they can do in return

What should we, the students, do?

Mind our manners — We will appreciate the fact that you have given time out of your busy schedule for us.

We’ll make use of your efforts — If I’m going to be taught by someone who I know will ask me questions and challenge me, I will certainly try to do some reading beforehand so I understand more of what you’re teaching. In short, it is only right that we reciprocate the interest you have taken in our education with an interest in improving our own.

Give feedback — if you have taught me well, I will make try to show my appreciation by thanking you when I leave clinic or telling the course organisers. But, the best feedback we can give you…

Be excellent doctors — being taught well by a good doctor has two benefits. The first being the imparting of medical wisdom. The second being the setting of a role model; a good doctor, explaining things as they go along, engaging with me as well as their work, always inspires me to do that same. Learn more, try harder.”


And here, I’d like to make my own personal points. I am still a student, and as a doctor I know I will continue being a student for a very long time (for my residency, for my research). On the other hand, I also teach, which I only started very recently, which gives me great pleasure and a fresh perspective on students and teaching.

From what I experience, I know that still being a student can help me learn how to be a good teacher. I observe my own teachers, learn what is for me an exciting and great learning experience. I love it when my teachers stimulate me to think and answer questions in the class instead of just bombarding me with information because it helped me form my pattern of thinking in a logical way. I love it when they can capture my interest and award me with extra information. I love it when I realize that after a class I gain new knowledge and insight. I love it when the teachers engage personally with us and interested in what we have learned so far. I love it when the teachers give feedback about our assignments and our efforts in working on those assignments. I love it when the ultimate goal is to help us understand the subjects. I love it when they have time to teach us even though they are very busy, and focused on us during the class. I love it when they are interested and enthusiastic about what they teach, because it makes us understand the importance of learning them. I love it when they appreciate me and my efforts. I love it when they inspire!

I only very recently started as assistant lecturer. And when I have discussion with my students, I know that I ask them to do “at least” the followings. I want them to be focused in class. I want them to be prepared before meeting me, because then we can engage more in the discussions. I want them to understand the fundamentals: why we think in certain ways, why certain things are very important, what is the “big picture”, what’s the underlying principle and philosophy of the things we learn, what I want them to learn specifically for the exams and also what they still have to remember for the rest of their lives as doctors. I want them to be able to learn how to think, and what to think about. I want them to start a class with focus and attention because there’s new information I’d like to share with them. I want them to do their assignments and do them well because I also prepare myself to give feedback on their assignments. I want them to read, because I also read and there are items in the reading material that I’d love to discuss with them. I want to share new things with them, because I don’t want them to be bored with the learning session. I want them to share their opinions, their questions and answers. I want them to be interested and to always want to do better.

So, what do you expect from your teachers?

— Rahajeng

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Keep Reading, Keep Learning

First I’d like to apologize for not updating this blog. Apparently many of you Dearest Readers manage to stumble your way to this blog and kindly submit your comments and questions.

I left for PTT few months ago, and internet connection was rather problematic. But now that I’m back to the world of internet connection, I hope I can maintain this blog better.

One thing, keep reading, keep learning.

I recently found a strange, almost mystical attraction to this book in an english book store. It was put under a display table, the only copy left in the store. A bit pricey, but what english book isn’t. The back cover only mentions this one quote from the book:

“What’s terrible is to pretend that the second-rate is the first-rate. To pretend that you don’t need love when you do; or you like your work when you know quite well you’re capable of better.”

A statement that boldly shows ambition and determination for achieving the best from yourself.

This book is The Golden Notebook, by Doris Lessing.

I’m lucky to have found this book (although “accidentally”), and I just started reading it. I’m sure to share my thoughts about this book after I read it (the whole 635 pages).

Whether you’re a book lover, or a doctor, please keep reading, keep learning. You’ll enrich your life.

dr. Rahajeng

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Dokter Muda/ Coass di RS Pendidikan: Aset atau Liabilitas?

Sebuah artikel di koran lokal beberapa hari yang lalu  (Radar Semarang) memuat judul “Dilematika Dokter Coass: Dinilai Repotkan Pasien, Demi Regenerasi Dokter”. Pada intinya artikel tersebut memuat keluhan pasien tentang dokter muda di rumah sakit pendidikan, “saya ogah dijadikan bahan praktik”.

Kemudian muncul pertanyaan setelah keluhan ini; dokter muda/ coass merupakan aset atau justru liabilitas sebuah rumah sakit?

Tentu saja sebagai seorang dokter yang telah menyelesaikan pendidikan, saya menyadari betapa pentingnya kegiatan belajar di fakultas kedokteran. 3,5 tahun di bangku kuliah, dilanjutkan dengan setengah tahun berlatih di laboratorium skill, sebelum akhirnya memulai kegiatan kepaniteraan klinik di rumah sakit selama hampir 2 tahun sebagai dokter muda atau coass. Untuk yang tidak familier dengan pendidikan dokter, kepaniteraan klinik adalah pendidikan profesi, sehingga semua dokter muda yang menjalani kepaniteraan klinik semuanya adalah sarjana lulusan S1. Selain itu, di Fakultas Kedokteran Universitas Diponegoro kami juga masih menjalani pendidikan tambahan selama 2 bulan di RS Daerah dan Puskesmas di wilayah Jawa Tengah sebelum lulus sebagai dokter.

Di rumah sakit pendidikan tidak ada keputusan medis yang dibuat dan dijalankan sendiri oleh dokter muda/coass. Semua tindakan yang dilakukan oleh dokter muda telah sepengetahuan dan pengawasan dokter yang berwenang, dan telah dilakukan atas persetujuan pasien.

Memang dokter muda secara umum hanya “melakukan tugas sederhana”, seperti memeriksa pasien, belajar mengawasi pasien, memasang tensi dan mengukur suhu pasien. Namun selain tugas sederhana tersebut ada banyak kompetensi yang harus dipelajari dokter muda selama kepaniteraan klinik di rumah sakit.

Tentu saja semua dokter pernah merasakan betapa melelahkannya tugas-tugas ini saat pendidikan. Namun menyebut bahwa dokter muda melakukan hanya “tugas sederhana” di atas sepertinya pernyataan yang terlalu menyederhanakan realita. Dokter masa kini paham betul, bahwa saat lulus kita harus memiliki kompetensi yang memadai sebagaimana yang ditetapkan oleh Konsil Kedokteran Indonesia. Diantara “tugas sederhana” yang wajib kita kerjakan siang, malam, dini hari dalam keadaan lelah, mengantuk dan lapar, diantara kegiatan belajar, mempersiapkan ujian, dan mengerjakan tugas-tugas teori, kita memiliki kewajiban untuk mempelajari dan menguasai keterampilan klinis sesuai standar kompetensi dokter umum. Selalu diantara “tugas sederhana” ini dokter muda masih harus belajar untuk memiliki keterampilan klinis misalnya kegiatan bedah minor seperti menjahit luka, memasang infus, menyuntik obat, memasang pembalut luka, melakukan tindakan untuk keadaan-keadaan emergency.

RS Pendidikan harus mendidik mahasiswa kedokteran, sebagaimana sebagai RS mereka tetap harus melayani pasien. Kembali saya ingatkan bahwa para dokter muda telah mendapat pendidikan dan persiapan sebelum memasuki jenjang kepaniteraan klinik maupun selama menjalaninya. Di Indonesia, hal ini dilakukan di beberapa lingkup tertentu RS Pendidikan tersebut sesuai kebijakan RS yang bersangkutan, dalam pengawasan dokter yang berwenang. Harap diingat, hal semacam ini dilakukan oleh semua rumah sakit pendidikan di seluruh dunia termasuk di negara barat. Tidak ada tempat bagi dokter-dokter baru lulus yang hanya merupakan produk lulusan laboratorium dengan alat-alat peraga berupa boneka. Dokter adalah profesi dengan tanggung jawab kemanusiaan yang berat, yang harus dididik dan dilatih untuk dapat bekerja mandiri menghadapi pasien, situasi klinis dan problem kesehatan yang kompleks di masyarakat. Dokter-dokter baru ini yang nantinya akan menjadi petugas kesehatan, dan bahkan sebagian akan memilih untuk menjalani kegiatan pengabdian dan ditempatkan oleh Departemen Kesehatan di daerah terpencil dan sangat terpencil di seluruh pelosok Indonesia. Meningkatnya derajat kesehatan bangsa Indonesia dan tingginya kualitas dokter tidak bisa lepas dari peran RS Pendidikan dalam mempersiapkan dokter-dokter baru.

Untuk menjawab pertanyaan di atas, maka kehadiran coass di RS Pendidikan sebagai aset dan bukannya liabilitas membutuhkan kerja sama dan usaha keras dari semua pihak, baik RS Pendidikan, fakultas kedokteran, para coass sendiri dalam hubungannya dengan penyediaan layanan terhadap pasien.

Kegiatan supervisi yang selanjutnya harus ditingkatkan agar dokter muda dapat tetap menimba keterampilan dan pengalaman agar siap terjun di masyarakat, sementara pasien tetap mendapat penanganan yang optimal dari sebuah rumah sakit. Tentu saja hal ini harus dibarengi etika dan persiapan keterampilan yang matang dari dokter muda yang melayani pasien di rumah sakit.

Dr.Rahajeng Tunjung

Filed under: miscelaneous, , , , ,

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Disclaimer

Medicine is a growing field, and information presented here is reflective of the time of posting. Please refer to your physician for direct medical consultation. My views do not reflect those of my employers. --
Regards, Rahajeng

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