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Teaching and Assessing Communication Skills in Pediatric Residents: How Do Parents Think We Are Doing?

Howell, Heather B; Desai, Purnahamsi V; Altshuler, Lisa; McGrath, Meaghan; Ramsey, Rachel; Vrablik, Lauren; Levy, Fiona H; Zabar, Sondra
OBJECTIVE:Curricula designed to teach and assess the communication skills of pediatric residents variably integrates the parent perspective. We compared pediatric residents' communication skills in an objective structured clinical exam (OSCE) case as assessed by Family Faculty (FF), parents of pediatric patients, versus standardized patients (SP). METHODS:Residents participated in an OSCE case with a SP acting as a patient's parent. We compared resident performance as assessed by FF and SP with a behaviorally-anchored checklist. Items were rated as not done, partly done or well done, with well-done indicating mastery. The residents evaluated the experience. RESULTS:42 residents consented to study participation. FF assessed a lower percentage of residents as demonstrating skill mastery as compared to SP in 19 of the 23 behaviors. There was a significant difference between FF and SP for Total Mastery Score and Mastery of the Competency Scores in three domains (Respect and Value, Information Sharing and Participation in Care and Decision Making). The majority of residents evaluated the experience favorably. CONCLUSION/CONCLUSIONS:Involving parents of pediatric patients in the instructive and assessment components of a communication curriculum for pediatric residents adds a unique perspective and integrates the true stakeholders in parent-physician communication.
PMID: 34186252
ISSN: 1876-2867
CID: 5003712

A Novel Method of Assessing Clinical Preparedness for COVID-19 and Other Disasters

Fisher, Harriet; Re, Cherilyn; Wilhite, Jeffery A; Hanley, Kathleen; Altshuler, Lisa; Schmidtberger, James; Gagliardi, Morris; Zabar, Sondra
QUALITY ISSUE:The emergence of COVID-19 highlights the necessity of rapidly identifying and isolating potentially infected individuals. Evaluating this preparedness requires an assessment of the full clinical system, from intake to isolation. INITIAL ASSESSMENT:Unannounced Standardized Patients (USPs) present a nimble, sensitive methodology for assessing this readiness. CHOICE OF SOLUTION:Pilot the Unannounced Standardized Patient methodology, which employs an actor trained to present as a standardized, incognito potentially infected patient, to assess clinical readiness for potential COVID-19 patients at an urban, community safety-net clinic. IMPLEMENTATION:The Unannounced Standardized Patient was trained to present at each team's front desk with the complaint of feeling unwell (reporting a fever of 101 degrees Fahrenheit in the past 24 hours) and exposure to a roommate recently returned from Beijing. The Unannounced Standardized Patient was trained to complete a behaviorally-anchored assessment of the care she received from the clinical system. EVALUATION:There was clear variation in care Unannounced Standardized Patients received; some frontline clerical staff followed best practices; others did not. Signage and information on disease spread prevention publicly available was inconsistent. Qualitative comments shared by the Unannounced Standardized Patients and those gathered during group debrief reinforced the experiences of the Unannounced Standardized Patients and hospital leadership. LESSONS LEARNED:Unannounced Standardized Patients revealed significant variation in care practices within a clinical system. Utilization of this assessment methodology can provide just-in-time clinical information about readiness and safety practices, particularly during emerging outbreaks. Unannounced Standardized Patients will prove especially powerful as clinicians and systems return to outpatient visits while remaining vigilant about potentially infected individuals.
PMCID:7543447
PMID: 32991675
ISSN: 1464-3677
CID: 4677192

What did you say?: Assessing a virtualgoscetotrain RAS who recruit older adults to clinical trials [Meeting Abstract]

Fisher, H; Altshuler, L; Langford, A; Chodosh, J; Zabar, S
LEARNINGOBJECTIVES 1: Interpersonal /Communication Skill: 1) Identify communication skills needed to recruit older adults LEARNING OBJECTIVES 2: 2) Assess feasibility of GOSCEs to enhance recruitment skills in RAs. SETTING AND PARTICIPANTS: Convenience sample of 18 (5 male, 13 female) Research Assistants (RAs) at an urban hospital who recruit older adults for clinical trials. DESCRIPTION: Increasing older adults' participation in clinical trials is urgently needed. We developed a remote, three station simulation (Group Objective Structured Clinical Exam - GOSCE) to teach RAs communication skills. This 2-hour course included a discussion of challenges in recruiting older adults; skills practice with Standardized Participants (SPs); and a debrief to review experiences, highlight best practices. After discussion, RAs rotated (3 per group) through the stations, each with SP and faculty observer who provided immediate feedback. Thus, learners had opportunities for active and observational learning.Scenarios were: 1) an older white woman with hearing impairment; 2) an older white woman and family member together; and 3) an older Black man mistrustful due to history of racism in medical research. SPs completed behaviorally anchored checklists (11 communication skills across all cases, and 5-7 case-specific questions). Learners completed a 36- item survey of self-assessed change in skill after the workshop; insights on recruitment practice; and educational value. EVALUATION: The communication checklist across all cases included: relationship development (5 items, mean of 58% well done (range: 50-75%), patient education (3 items, 44% (42-58%)), patient satisfaction (2 items, 54% (50-58%)), and information gathering (1 item, 92%). Seventeen RAs completed the survey, 100% felt the workshop provided valuable feedback and taught relevant material, 88% would participate again and 52%reported that the workshop improved their recruitment skills. All RAs reported encountering situations similar to hearing impairment and family member cases, and the majority rated the cases as high in educational value. Just 45% reported experiencing a case similar to the Black male case, and 100% rate it as high in educational value. Key points identified by RAs included the value of building a trusting relationship with potential subjects, recognizing possible barriers to communication early on and addressing these directly in a supportive and respectful style. DISCUSSION / REFLECTION / LESSONS LEARNED: Remote GOSCEs are a feasible mechanism for training RAs in subject recruitment focused on the unique needs of older adults. Responses to the RA survey suggest that GOSCEs are feasible for training RAs in simulated clinical scenarios with which participants are familiar and unfamiliar. SP assessment of RAs identified areas for further reinforcement to improve recruitment skills. This innovation is a feasible, high yield strategy for training research staff. It is highly adaptable to the specific recruitment needs and skills of a clinical trials and will add to the literature on educating RAs
EMBASE:635797045
ISSN: 1525-1497
CID: 4984862

Supporting a learning healthcare system-using an ongoing unannounced standardized patient program to continuously improve primary care resident education, team training, and healthcare quality [Meeting Abstract]

Gillespie, C; Wilhite, J; Hardowar, K; Fisher, H; Hanley, K; Altshuler, L; Wallach, A; Porter, B; Zabar, S
STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): In order to describe quality improvement (QI) methods for health systems, we report on 10-years of using Unannounced Standardized Patient (USP) visits as the core of a program of education, training, and improvement in a system serving vulnerable patients in partnership with an academic medical center. LEARNING OBJECTIVES 1: Consider methods for supporting learning healthcare systems LEARNING OBJECTIVES 2: Identify performance data to improve care DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): The IOM defines a Learning Healthcare System (LHCS) as one in which science, informatics, incentives and culture are aligned for continuous improvement and innovation and where best practices are seamlessly embedded in the delivery process and new knowledge is captured as an integral by-product of the delivery experience. As essential as electronic health records are to LHCS, such data fail to capture all actionable information needed to sustain learning within complex systems. USPs are trained actors who present to clinics, incognito, to portray standardized chief complaints, histories, and characteristics. We designed and delivered USP visits to two urban, safety net clinics, focusing on assessing physician, team, and clinical micro system functioning. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICHWILL BE USEDTOEVALUATE PROGRAM/INTERVENTION): Behaviorally anchored assessments are used to assess core clinical skills (e.g., communication, information gathering, patient education, adherence to guidelines, patient centeredness, and patient activation). Team functioning assessments include professionalism and coordination. Micro system assessment focuses on safety issues like identity confirmation, hand washing, and navigation. Data from these visits has been provided to the residency, primary care teams, and to leadership and have been used to drive education, team training, and QI. FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE FINDINGS WILL BE DISCUSSED): 1111 visits have been sent to internal medicine and primary care residents and their teams/clinics. At the resident level, needs for additional education and training in depression management, opioid prescribing, smoking cessation, and patient activation were identified and informed education. Chart reviews found substantial variation in ordering of labs and tests. At the team level, USPs uncovered needs for staff training, enhanced communication, and better processes for eliciting and documenting Social Determinants of Health (SDoH). Audit/feedback reports on provider responses to embedded SDoH combined with targeted education/resources, were associated with increased rates of eliciting and effectively responding to SDoH. In the early COVID wave, USPs tested clinic response to a potentially infectious patient. Currently, USPs are being deployed to understand variability in patients' experience of telemedicine given the rapid transformation to this modality. Finally, generalizable questions about underlying principles of medical education and quality improvement are being asked & answered using USP data to foster deeper understanding of levers for change. KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY): A comprehensive USP program can provide unique insights for driving QI and innovation and help sustain a LHCS
EMBASE:635796917
ISSN: 1525-1497
CID: 4984892

Communication skills over time for eight medical school cohorts: Exploration of selection, curriculum, and measurement effects [Meeting Abstract]

Gillespie, C; Ark, T; Crowe, R; Altshuler, L; Wilhite, J; Hardowar, K; Tewksbury, L; Hanley, K; Zabar, S; Kalet, A
BACKGROUND: NYU uses the same 14-item checklist for assessing medical student communication skills across our curriculum, which includes highquality Objective Structured Clinical Skills Exams throughout the first three years of medical school: a 3-station Introductory Clinical Experience OSCE (ICE), a 3-station end-of-clinical skills OSCE (Practice of Medicine; POM); and an 8-station, high- stakes OSCE (Comprehensive Clinical Skills Exam; CCSE) after core clerkship. We describe how skills change throughout school and explore how patterns vary by cohort (class) in ways that could be explained by admissions criteria, measurement quality, and/or curriculum changes.
METHOD(S): Three domains are assessed: Info gathering (6 items), relationship development (5 items); and patient education & counseling (3 items). Checklist items use a 3-point scale (not done, partly, well done) with behavioral anchors. Internal consistency (Cronbach's alpha) exceeds .75 for all subdomains and across all years. Domains are supported by Confirmatory Factor Analysis. Mean average % well done was calculated across cases and individuals for each subdomain in an OSCE and compared over the OSCEs and between 8 classes of medical school students entering from 2009 to 2016 (graduating 2013 to 2020) (n=1569).
RESULT(S): Cohorts showed similar patterns communication skills trajectories - improvement over time. Despite changes in admissions criteria and processes, cohorts did not differ in terms of demographics, undergraduate GPA, or MCAT scores. Variability in scores decreased in all cohorts over time while communication improved. Patient education & counseling was significantly and substantially lower than other domains. In terms of cohort effects, communication scores for the entering class of 2013 at the start of medical school (ICE OSCE) were significantly higher than the previous 4. At the end of MS2, scores were similar for cohorts for info gathering and relationship development domains (and high, mean range=77-87% well done) but patient education & counseling varied: Improvement from the 1st to 3rd cohort and then decline for the last 5 cohorts. Within the CCSE (8-station pass/fail, MS3), communication scores increased steadily across entering classes, especially from cohort 4 on. These changes over time and between cohorts were mapped onto a priori descriptions of curricular, measurement and admission changes.
CONCLUSION(S): Our cohort data showed interesting and complex patterns. This study reinforces some limitations of linking curriculum to performance (e.g., no direct measures of the curriculum in terms of content, process and intensity over time, limited data on what makes cohorts different, variable measurement over time, and being unable to control for broader trends likely to influence both cohort and time effects) while also demonstrating the promise of longitudinal perspectives on the development of core competencies. LEARNING OBJECTIVE #1: Understand cohort performance in relation to curricular trends. LEARNING OBJECTIVE #2: Describe variation in performance
EMBASE:635796745
ISSN: 1525-1497
CID: 4984942

Exploring the professional identity of exemplars of medical professionalism [Meeting Abstract]

Altshuler, L; Monson, V; Chen, D T; Lusk, P; Bukvar-Keltz, L; Crowe, R; Tewksbury, L; Poag, M; Harnik, V; Belluomini, P; Kalet, A
BACKGROUND: A core responsibility of medical educators is to foster a strong sense of medical professional identity (PI). Few studies specifically examine the qualities that constitute the PI of physicians recognized for exemplary professionalism. We describe those qualities based on an assessment of PI to inform educational efforts and support learners' development of PI.
METHOD(S): We used Colby and Damon's criteria for selection of moral exemplars (1992) to invite nominations of exemplary faculty physicians at NYUGSOM from faculty and trainees. Participants completed the Professional Identity Essay (PIE), a 9-question reflective writing measure based on a wellknown model of adult development that explores meaning making on PI (Bebeau & Lewis, 2004; Kegan, 1982, 1994). Two raters with extensive training and experience in adult developmental theory rated PIE responses for stage or transition phase. PI stages include independent operator, teamoriented idealist, self-defining, and self-transforming. These stages reflect increasing complexity and internalization of PI. We also gathered information on specialty, years in practice, gender, and race/ethnicity.
RESULT(S): Two hundred and twelve faculty were nominated; 35 were invited to participate (based on number of nominations, diversity of ages, backgrounds and career stage), and 21 completed scorable PIEs. They were from 13 specialties; mean career length was 21.5 years (range 6-45), and 35% were female. All but 2 were Caucasian. PIE scores ranged from 3 to 4.5 (Table 1), demonstrating differing and increasingly complex and internalized ways faculty understand their PI, and that not all nominated exemplars share a singular view of professionalism.
CONCLUSION(S): Physicians nominated as exemplars of professionalism embody a range of professional identities and professionalism world-views. Our study provides rich descriptions of multiple pathways to strengthening a physician's professionalidentities, of critical importance to faculty and physician development in a milieu of challenges to recruitment and retention of physicians. This approach can also inform educators' efforts to support PI development in learners and support the development of learning communities that foster a growth mindset. LEARNING OBJECTIVE #1: Recognize importance of strong role models for MPI. LEARNING OBJECTIVE #2: Describe the varying levels of MPI in a cohort of exemplar physicians
EMBASE:635796613
ISSN: 1525-1497
CID: 4984982

Internal medicine tele-takeover: Lessons learned from the emerging pandemic [Meeting Abstract]

Wilhite, J; Altshuler, L; Fisher, H; Gillespie, C; Hanley, K; Goldberg, E; Wallach, A; Zabar, S
BACKGROUND: Healthcare systems rose to the challenges of COVID-19 by creating or expanding telehealth programs to ensure that patients could access care from home. Traditionally, though, physicians receive limited formal telemedicine training, which made preparedness for this transition uneven. We designed a survey for General Internal Medicine (GIM) physicians within our diverse health system to describe experiences with providing virtual patient care; with the ultimate goal of identifying actionable recommendations for health system leaders and medical educators.
METHOD(S): Surveys were sent to all faculty outpatient GIM physicians working at NYU Langone Health, NYC Health + Hospitals/Bellevue and Gouverneur, and the VA NY Harbor Health System (n=378) in May & June of 2020. Survey items consisted of Likert and open-ended questions on experience with televisits (13 items) and attitudes toward care (24 items). Specific questions covered barriers to communication over remote modalities.
RESULT(S): 195/378 (52%) responded to the survey. 96% of providers reported having problems establishing a connection from the patient's end while 84% reported difficultly establishing connection on the provider's end. Using interpreter services over the phone was also problematic for providers, with 38% reporting troubles. Regarding teamness, 35% of physicians found it difficult to share information with healthcare team members during virtual visits and 42% found it difficult to work collaboratively with team members, both when compared to in-person visits. When subdivided, 24% of private and 40% of public providers found info sharing more difficult (p<0.04). 31% of private providers and 45% of public found team collaboration more difficult (ns). Physicians also identified challenges in several domains including physical exams (97%), establishing relationships with new patients (74%), taking a good history (48%), and educating patients (35%). In thematic analysis of open-ended comments, themes emerged related to technological challenges, new systems issues, and new patient/provider communication experiences. Positives noted by physicians included easier communication with patients who often struggle with keeping in-person appointments, easier remote monitoring, and a more thorough understanding of patients' home lives.
CONCLUSION(S): Provider experience differences were rooted in the type of technology employed. Safety-net physicians conducted mostly telephonic visits while private outpatient physicians utilized video visits, despite both using the same brand of electronic medical record system. As we consider a new normal and prolonged community transmission of COVID-19, it is essential to establish telemedicine training, tools, and protocols that meet the needs of both patients and physicians across diverse settings. LEARNING OBJECTIVE #1: Describe challenges and barriers to effective communication and clinical skill utilization during televisits LEARNING OBJECTIVE #2: Conceptualize recommendations for educational curricula and health service improvement areas
EMBASE:635796421
ISSN: 1525-1497
CID: 4985022

Describing trends from a decade of resident performance on core clinical skills as measured by unannounced standardized patients [Meeting Abstract]

Wilhite, J; Hardowar, K; Fisher, H; Hanley, K; Roper, H; Wilhite, O; Tenner, R; Altshuler, L; Zabar, S; Gillespie, C
BACKGROUND: Primary care (PC) residency training is a period that provides opportunity to develop skills required for independent practice. Unannounced Standardized Patients (USPs), or secret shoppers, are a controlled measure of clinical skills in actual practice. We sought to describe differences in core clinical communication skills over the last decade for PC residents.
METHOD(S): USPs presented as a new patient for a comprehensive visit while portraying one of six unique, outpatient cases (with either chronic or acute symptomology). Actors received extensive training to ensure accurate case portrayal. Each completed a post-visit, behaviorally anchored checklist (not, partly, or well done) in order to provide extensive, actionable feedback. A standardized checklist was used, consisting of individual items across domains including information gathering, relationship development, patient education, activation and satisfaction. Chronbach's alpha for domains ranged from 0.62- 0.89. Summary scores (mean % well done) were calculated by domain and compared by year for all learners and by PGY within year for the primary care (PC) residency. Differences were assessed using ANOVA. Case portrayal accuracy was ensured using audio tape review.
RESULT(S): 396 visits were conducted with PC residents in our urban, safetynet hospital system between 2013 and 2020. While looking across the 8 years, there was variation in mean scores per domain, though Kruskal-Wallis H test did not show any statistical difference. Relationship development and info gathering were the highest rated skills, at 75% and 76% well done, respectively, on average. Patient satisfaction and activation remained uniformly low across years, with scores averaging 36% and 39% well done, respectively. Multi-variate analysis showed no significant changes across domains by cohort (grad year) and PGY levels. Further, there were no significant differences by PGY year or cohort in terms of scoring using a two-way ANOVA, though there was a slight upward trend in relationship development skills since 2017 for all PGY levels. There were similar trends in most domains, with 2020 scores being higher than previous years. There were no significant differences across domains while looking at PGY1 learners only.
CONCLUSION(S): While there were no significant differences in scores, we can postulate that PC residents enter the residency with consistent foundational communication skills, possibly attributable to training. We elected to use the visit itself as the unit of analysis, which does not allow us to tease out differences in individual learners. We also have small sample sizes for earlier years of the USP visit program, which may hinder results. Regardless, results warrant further research in order to gain a more thorough understanding, possibly in relation to curricular trends. Further study will look at individual resident differences and ideally provide insight into curricular improvement areas. LEARNING OBJECTIVE #1: Describe assessment measures LEARNING OBJECTIVE #2: Explore clinical competency
EMBASE:635796783
ISSN: 1525-1497
CID: 4986582

Complexity of resident-identified challengies during training [Meeting Abstract]

Altshuler, L; Abraham, M; Boardman, D; Tannenbaum, J; Park, A; Lipkin, M
BACKGROUND: On the road to becoming competent, compassionate and ethical physicians, trainees need to reflect on their experiences, understand the clinical and social contexts, and integrate cognitive and affective reactions in ways that build resilience and a coherent professional identity. Using a qualitative approach, this study seeks to identify medical residents' stressors and challenges, and to understand their experience of the internal and external factors of such situations. Such information can guide educators to develop curricula that better meet residents' needs.
METHOD(S): Primary Care residents at NYU School of Med have ongoing Psychosocial Rounds (PSR) throughout their 3 years, facilitated by a faculty member and Chief Resident, where residents present challenging cases or situations, framed by a specific question. Semi-structured notes taken by facilitators, including question, case description, process of discussion and teaching points were compiled into a deidentified database of 119 cases spanning 2010-2019. These notes were coded by three coders using iterative thematic analysis.
RESULT(S): Seventy four of the 119 cases have been coded to date. Four general themes emerged, with each comprised of 2 to 4 main codes. These themes were 1) Self (S): including management of medical uncertainty, emotional reactions, roles and responsibilities, self-care; 2) Teams (T): including relationship with peers, supervisors, other health professionals; 3) Understanding Patient and Families (PF): including social and cultural context, mental health issues, patient/ family and provider disagreements; and 4) Hospital, Healthcare and Societal issues (HHS). There was a high co- occurrence of themes within cases, 60% had 2 themes present, 24% had 3, and only 16% had one theme. Cases with 3 themes most often included S, T and PF.
CONCLUSION(S): This analysis of PSR cases identifies issues for which residents seek help and support in a safe, case-oriented problem-solving discussion group, and allows for in-depth reflection and exploration. The cooccurrences of themes indicate the complexity of issues faced, and the importance of integrating multiple domains when beginning to understand these issues. LEARNING OBJECTIVE #1: Professionalism: Coping with challenges of becoming resilient physician with emotional and cognitive capacity to deal with complex situations LEARNING OBJECTIVE #2: Interpersonal and Communication Skills: Develop awareness and skills to negotiate interpersonal situations
EMBASE:635796758
ISSN: 1525-1497
CID: 4986602

Validation of the comprehensive clinical skills exam (CCSE) measurement model [Meeting Abstract]

Ark, T; Gillespie, C; Hardowar, K; Mari, A; Wilhite, J; Crowe, R; Kalet, A; Altshuler, L; Zabar, S
BACKGROUND: Performance-based assessment & feedback during medical training is essential for a successful transition before moving onto residency and independent clinical practice. Learners at New York University's School of Medicine (NYUSOM) participate in a routine comprehensive clinical skills examination (CCSE) that takes place at the tail end of medical school. During this exam, learners interact with standardized patients (SPs) and are rated on specific skills using a standardized checklist, measuring important clinical skills domains. NYUSOM has utilized the same assessment tool since 2005. To date, there is limited evidence on the tool's validity and ability to differentiate among students. We sought to provide evidence for it's reliability, validity, and generalizability.
METHOD(S): 1157 learners participated in the CCSE from 2011-2019 and were included in the analysis. Communication domain items assessed included patient education (3 items), relationship development (4 items), information gathering (6 items) and organization/ time management (3 items). Items were scored using a 3-point behaviorally-anchored scale (not, partly, or well done). In order to determine the degree to which the data mapped onto our theoretically-informed communication domains, we conducted a four-factor confirmatory factor analysis (CFA) allowing for factors to correlate (oblique rotation) and using means and variance adjusted weighted-least squares estimation (WLSMV) in order to account for the ordered categorical nature of the communication items. Model fit was assessed using root mean square of approximation (RMSEA) < 0.08, comparative fit index (CFI) > 0.95, and standardized root mean square error (SRMR) <0.08.
RESULT(S): The model fit the data using RMSEA (0.04), CFI (0.98), and SRMR (0.05). All factors were significantly correlated with one another (p < 0.05), with the largest correlation between patient education and organization/ time management (0.86), and information gathering (0.77). The smallest correlation was between organization/ time management and information gathering (0.66). All items (factor loadings) significantly loaded on the factors they measured. Only one item had an insignificant threshold loading between partly and well done, suggesting this part of the response scale may be hard for SPs to differentiate between students with varying ability on this item. Each factor had at least one item that had a factor loading less than 0.7.
CONCLUSION(S): The analysis suggests each item on the communication checklist significantly measures domains they were designed to measure, and that items can be summated to compute overall scores. Domains had one item with a lower loading than the rest, suggesting these items may be measuring something different. Follow up measurement modeling and profile analysis is the next logical step in determining if there is an important sub-domain that identifies a student group operating differentially. LEARNING OBJECTIVE #1: Understand clinical communication LEARNING OBJECTIVE #2: Describe communication measures
EMBASE:635796583
ISSN: 1525-1497
CID: 4986652