UNIVERSITIES’ ROLES IN THE CONTEMPORARY ERA

The modern way of life, computerization and the influence of Internet lead to the change of way of life

from the earliest age. The risk factors of man’s health are imposed upon from an early phase of adolescence. Adolescence is a period of adjustment, a time of physical and emotional changes and changes in behavior. It is a stressful life period where even the normal maturing gait includes a certain amount of emotional disturbance, as to oneself, so unto others. Adolescence is also a phase of developing an identity and building peer relationships so their online activities mainly focus on interacting with peers. For precisely this reason, the Internet, as a leading form of mass media, greatly affects the risk behavior of young people and consequently their health status. Recently, psychosomatic symptoms are becoming more frequent in adolescent populations (Santalahti et al. 2005). A study conducted in Finland showed an increase of symptoms over a 10-year period resulting from stressful life occurrences and changes in the way of life of young people. Playing video games has presented itself as a strong risk factor for the development of headaches and migraines (Xavier et al. 2015). Excessive Internet use leads to neglect of usual life habits; increasing amounts of time spent online have consequences for one’s health. The most common physical symptoms are the pain, stiffness in arms and joints, dry and strained eyes, back-pain, neck-pain leading to a headache, sleeping disorder, extreme hyperactivity, excessive talkativeness decreases in hygiene, and eating disorders (Saisan et al. 2012). As a form of eating disorder in adolescents, obesity demands attention all by itself, but also for its direct and indirect influence on morbidity and the of life expectancy  (Saisan et al. 2012, Guo et al. 2002). Greater static burdening originating from long-term sitting at a computer can be dangerous for posture and young people’s health. The second most common causes of taking sick-leave are degenerative changes in the spine and spinal pain (Chuang 2006). Internet addiction is a type of psychological addiction and is defined as a form of behavior that is linked to persistence in an activity that causes decreases in health, social functioning, and quality of life. Research on Internet addiction and social deviance has occurred on a global scale in the last 20 years, especially in the frameworks of social psychology, medical sociology, and other public health disciplines. It shows that about 11% of all people using the Internet become addicted to it or show some compulsive behavior related to it. Findings from this research are very applicable in contemporary methodologies aiming at the betterment of physical or psychological well-being and improvements in social relations. The effectiveness of adolescent health services are evaluated by measures of health status, so we can clearly determine targets for action by assessing the broad spectrum of health including mobility, general functioning, mental health, and total well-being. The aim of the study was  to identify the health problems and needs of vulnerable adolescent groups, particularly

Internet addicts who experience a certain degree of pleasure when using the Internet, and mostly psychological symptoms like discomfort, anxiety, and depression when they stop using it. The health status rating depends on individual assessment based on the complete psychological structure of an individual in interaction with their social environment. However, there are multiple effects on health; hence, a broad research health model is required. Besides biological factors, health or the outcome of the disease is also influenced by nonbiological factors – the individual’s personality, motivation, socio-economic status, availability of medical protection, network of social support, individual and cultural beliefs, and behavior. These non-biological factors are reflected in newer indicators of so called subjective health (Bowling 1991). In the majority of survey studies or broader clinical trials, one’s health condition is operationalized as self-assessment of own health or as functional capability. The answer to a seemingly simple question about one’s general health provides information about life expectancy of an individual – information that is difficult to acquire with detailed assessments of medical conditions and problems (Rakowski et al. 1994). General self-assessment of health is a subjective measure that cannot be confirmed objectively. Many researchers consider assessments to be “objective” if they can be medically checked if needed (Idler 1992). If the respondent provides information about his or her “objective” health, there is a danger that responses may be influenced by personality characteristics, such as self-respect, patient role, a perception of control over own health, and so on.

Therefore, “objective” health assessments must not be taken as completely objective measures, but still be

considered distinct from subjective health self-assessment. If there really is a mutual, overlooked factor underlying both objective and subjective health assessments, one can assume it will act the same way in

both assessments. A person’s health depends on several factors: heritage, the social context in which one lives, one’s medical behavior, and the medical system of one’s country (Lalonde 1974). Research shows that risky health behavior is mostly acquired during schooling (Harris et al. 2006). In most cases, changes of risky health behavior occur due to awareness of information and environmental pressure (Satia et al. 2001). The purpose of this research is to contribute to the understanding of individual health factors, primarily the behavior of excessive Internet use as a risky health habit, as well as the self-assessment of subjective feelings of adolescent’s health. Social health determinants are not only important for scientific research, they are also taken into the consideration when formulating developmental health strategies in particular countries (Wilkinson & Marmot 2003). Furthermore, behavior and lifestyle are important health factors and depend on the conditions in which one lives. Health analysis cannot be conducted without

examining health behavior and risky habits. Seeing that social environment and surroundings are important health factors, the researchers examined the influence of country of in adolescents in Croatia and Germany and their relationship to subjective feelings of health status. The aim of the paper was also to examine how a risky health habit, Internet addiction, affects adolescent health status. The SF-36 questionnaire proved very practical in measuring the subjective feeling of mental health due to a firm connection with the most common mental disorders (anxiety, depression) (Weinstein et al. 1989, Rumpf et al. 2001). Anxiety and depression are, among other things, disorders that occur as a consequence of Internet addiction.

Health status self-assessments between Croatian and German adolescents suggest differences in the following categories: general self-assessments of health, and health perception compared to peers. Ratings of German adolescents are somewhat better and more optimistic than those of Croatian adolescents only in 2 questions referring to general perception and change of health. Croatian and German adolescents most commonly rated their health as the medium, in the categories of health perception over a year, a perception of physical functioning, and perception of recent feelings of despondency and happiness.

In ontogenesis of motoric development in adolescence period, one reaches a phase of stabilization which

is linked to individual abilities and affinities, as well as a differentiation-related to gender. Adolescents from Croatia and Germany had relatively low rates of health problems, with an average rate of 9%. Differences were apparent between the 7% of Croatian and the 14% of German adolescents who perceived pain. Hence, German adolescents were twice as likely to be in pain compared to Croatian adolescents. In the period of adolescence begins the phase of independence. Adolescents who are directed towards peer groups want to grow up as soon as possible.

Unlike Croatian, German adolescents are leaving their parents extremely early, 10 and over ten years

earlier. The result of leaving this early is the appearance of anxiety, especially when they meet with problems with inadequate mental or physical growth. A situational variable like this can affect on a stronger feeling of pain. This relates to all types of pain, except neck-pain, which was experienced

by 5% of respondents, while 13% have experienced back-pain and 15% have had headaches.

The average daily amount of sitting has increased to 9.3 hours a day, and that is longer than people spend

asleep (7.7 hrs.). Therefore, it is not surprising that a large percentage (73%) of adolescents experience some consequences related to health and emotional problems.

The percentages by country are 76% of adolescents from Croatia and 67% from Germany respectively. In a

study performed by Andrijašević and Associates, the connection was found between the way free time was spent and subjective experiences of health indicated by a relatively large number of expressed difficulties that are more characteristic of old people than of students

(Andrijašević et al. 2005 ). A young person that spends 38 hours weekly at a computer weekly is already considered an Internet addict. Internet addiction demands involve long-term periods of

sitting, looking at the monitor, using the keyboard, using the mouse, repeating identical moves, the irregular position of the body. This may help explain why younger people display problems associated with old age. The inability to perform some work and other activities due to physical health or emotional difficulties were more common in Croatian than in German adolescents. The change of social system, wartime suffering, displacement, privatization, rising unemployment, the consequences of war trauma in children and adults, a growing number of suicides and violent behavior, migration, etc., are just some of the problems that the average Croatian family is faced with today and therefore adolescents, which then becomes an important indicator of their emotional health. For all other consequences of health problems, the reverse relationship was found. German adolescents more frequently reduced the time they spent working and in other activities, performed a smaller amount of work, and had difficulties in performing certain work and activities. Pain is a signaling mechanism that warns an individual about dysfunctions and danger in their bio-psychological and spiritual functioning. However, it may be noted that physical and emotional difficulties did not create problems in everyday life for most adolescents (61%), although they created very significant problems for 5% of participants. Regarding perceptions of mental health adolescents experienced a fullness of life, depression, tranquility, and peace, as well as nervousness equally often. Every feeling serves its function, and the results suggest that the presence of depression, a fullness of life, tranquility, and nervousness is a consequence of the nature of adolescence and is related to the complete and normal development of personality.

Croatian and German adolescents experienced similar frequencies of positive feelings. To be precise, about half of adolescents in both countries almost always have these kinds of feelings frequently. Croatian and German adolescents also experienced similar frequencies of negative feelings. Two-thirds of adolescents in these two countries rarely or almost never have negative feelings. Upon closer examination, adolescents from these two countries experience somewhat different individual positive and negative feelings. Among positive feelings, feelings of the fullness of energy and happiness are more frequent in Croatian adolescents, while the feeling of peace and tranquility are more common in Germans.

Negative feelings of nervousness, fatigue, and exhaustion are less represented in Croatia than in Germany.

Fatigue and exhaustion are mostly connected to a stressful way of life. Furthermore, chronic fatigue has negative consequences for health and 73% of people with chronic fatigue have an increased risk for different illnesses. A low level of bodily activities is a predictor of chronic fatigue. Bodily activity in free time reduces deterioration in physical health.

The results showed that feelings of nervousness, fatigue, and exhaustion were less represented in Croatia,

while there were no differences in perceiving feelings of despondency, depression, and sorrow. There was no difference in perception of health status change among Croatian and German adolescents; that is, there were no differences in whether physical health and emotional problems disturbed or did not disturb their social activities. The majority of adolescents (70% of them) rarely and never experienced such disturbances.

Subjective ratings of general perceptions of health did not differ with respect to claims that “I get ill more

easily than other people,” “I am healthy as anyone else I know,” “I think my health will worsen,” and “My health is excellent. Croatian and German adolescents had a similar tendency to become ill (about 15%). Two-thirds of participants denied a tendency to become ill. There were no differences in perceptions of health and social functioning between Croatian and German adolescents regarding any variables.

Interventions based on social planning can be highly effective when they target individuals at the earliest

stages of development. However, social planners must be careful not to intervene in ways that disrupt living conditions or interfere with normal development, to avoid causing psychological or social problems for individuals. Most adolescents (70%) rarely or never experience disruptions in social functioning.

Adolescents were classified into three health status groups based on their composite health scores.

Approximately 25% of adolescents rated their health as bad, 51% of them rated it medium, and 24% rated their health as good. Retrospect on own health mostly superficial and uninterested. There were no statistically significant connections between respondents’ gender, age, and health quality. A research sample of 844 subjects in a high school in Košice, Slovakia showed significant worsening of mental health and vitality in both genders, with boys self-reporting a larger worsening of health, while the differences between the proportions of respondents who reported either betterment or worsening were negligible (Salonna et al. 2008). However, there was a statistically significant connection between the country of the respondent and health quality in this study. Notably, the percentage of respondents who reported bad health was 23% for Croatians and 31% for Germans. Furthermore, the percentage of respondents with medium health was 54% in Croatia is, and 42% in Germany. Therefore, one can conclude that compared to Croatian respondents, Germans evaluate their health as being worse. There was a highly significant statistical connection between adolescents’ health quality and the degree of their addiction. Among all adolescents in bad health, 39% of them were moderately or severely addicted to Internet use; 20% of those in medium health were moderately or severely addicted; while only 13% of adolescents in good health were moderately or severely addicted. Accordingly, better adolescent health is associated with lower rates of Internet addiction, while worse health is associated with higher rates. Kim and Chun showed in their study that severe Internet addicts had the lowest ratings of promotion and perception of health status suggesting that Internet addiction has a negative influence on the health status of adolescents (Kim & Chun 2005). Tendencies towards risky behavior increase a young person’s chance of developing inappropriately, depending on their environment. Socioeconomic status affects how factors such as social networks, family, and individual health behavior influence risky behavior and should be understood within the broader concepts of health guidelines. This key conclusion in the research is further analyzed according to adolescents’ gender, age, and origin. Namely, one wishes to know is this conclusion valid with men as well as with women, with younger as well as with older adolescents, with Croatian adolescents as well as with German ones.

CONCLUSION

The goal of this research was to determine the existence of differences concerning health status, among

adolescents in Croatia and Germany. Results of the analysis suggest the following conclusions. Results of subjective health assessment between Croatian and German adolescents show statistically significant differences in the category of general health perception, although there was no difference in change perception compared to peers, health perception over a year, a perception of physical functioning of health, and recent feelings of despondency and happiness. The inability to perform some work and other activities due to physical health or emotional disorders were more frequent in Croatian than German adolescents. German adolescents often reduced time spent working and other activities, did smaller amounts of work, and had difficulties performing some work and activity. However, it is noticeable that the physical and emotional health of most adolescents (61% of them) did not create problems in everyday life. On the other hand, 5% of them experienced substantial problems. Feelings of nervousness, fatigue, and exhaustion were less represented in Croatia, while there were no differences in perceiving feelings of despondency, depression, and sorrow. Furthermore, most adolescents (70%) were not impeded by physical health and emotional problems in social activities. It can be seen that 23% of Croatian respondents had bad health, while 31% of Germans did. Additionally, 54% in Croatia had medium health, compared to 42% in Germany. Hence, one can conclude that German respondents evaluated their health worse than Croatians did. There was a highly significant statistical connection between adolescents’ health quality and the degree of their addiction. Among all adolescents in bad health, 39% were moderately or severely addicted to the Internet use; 20% of those in medium health, were moderately or severely addicted, and only 13% of those in good health were moderately or severely addicted. Accordingly, adolescents in better health are proportionately less likely to be Internet addicts, while conversely, those in worse health are proportionately more likely to be Internet addicts.

*The integral version of this article Silvana Karačić, Stjepan Orešković “INTERNET ADDICTION AND MENTAL HEALTH STATUS OF ADOLESCENTS IN CROATIA AND GERMANY Psychiatria Danubina 29(3):306-314 · August 2017 with tables, pictures, and references were concurrently published in Psychiatria Danubina, 2017; Vol. 29, No. 3, pp 401–125

Italian journalist Andrea Tornielli, when interviewing Pope Francis, asked the pope how he might act as a confessor to a gay person in light of his now famous remarks in a press conference in 2013 when he asked: “Who am I to judge?” The pope answered. “I was paraphrasing by heart the Catechism of the Catholic Church where it says that these people should be treated with delicacy and not be marginalized.

In the healthcare system, we define or imagine as patient centered the patients should also be treated with professional respect, delicacy and not marginalized. If not, the cost of disrespect and the lack of proper care is very high and could be measured in high avoidable mortality rates and burden of disease. In the health care systems with less developed quality control and assurance protocols, there is an intrinsic conflict between the professions efforts to maintain the solidarity of its members and its fiduciary relationship with patients, populations at risk and society as a whole.  The concept that professional work has a moral value compels the physician to behave ethically in his or her personal and professional life.  The greatest number of physicians adhere to high ethical and moral standards and principles of beneficence and non-maleficence. Physicians have a duty to do right and to avoid doing wrong. However, our greatest concerns are related to the method of sustaining the solidarity of the profession at the high expense of patients and lay people.

As Freidson argues, even if the physician does shoddy work or malpractice in the most cases there is a reluctance to judge the work of a colleague physician or specialist.  Physicians respond to societal needs, and their behaviors reflect a social contract with the communities served.  The question is how the profession of medicine understands the fulfillment of social contract?

From the very beginning of its professional and social activities the American Medical Association (AMA) in 1847, primary intentions were to improve medical education. At this time, medicine had not yet become a science-based profession.  It was somewhere in between the social organization, movement and layer organization inclining to support a scientific principle. That inclination helped the AMA to drive the medical reform at the beginning of XX century. The Abraham Flexner’s report, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, was published with the intention of transforming medical education. It was that breaking point after which AMA accomplished the goal of establishing the monopoly over medical education. From that moment in history, medicine has been going through the profound changes. Which had to adhere strictly to the protocols of mainstream science in their teaching and research and was expected to be thoroughly grounded in human physiology and biochemistry. The movement toward an emphasis on basic sciences demonstrated that medicine was embracing science as its foundation instead of the earlier dogma of bleeding and purging. The disciplines of “pathology, bacteriology, and clinical microscopy” were considered the basis for the scientific method, and therefore were emphasized in the new medical curricula. The drive for scientific instead of dogmatic methods was a primary theme running through the Flexner report.  Medical research adheres fully to the protocols of scientific research. The most important recommendation for the establishment of monopoly over the professional education was the recommendation that each state branch of the American Medical Association has oversight over the conventional medical schools located within the state. One of the immediate consequences was that medicine in the US and Canada had become a highly paid and well-respected profession. No medical school can be created without the permission of the state government. Variations in policies and organizations of health care around the world are influencing the power and practice of such professions as medicine and law.

What was the turning point in the historical development of the notion of professionalism in medicine and health care?

Eliot Freidson argues that professionalism is sustained If there are two essential elements and four distinctive conditions of professionalism. The two essential elements are the commitment to practicing the body of knowledge and skills of special value and to maintain a fiduciary relationship with clients/patients.  And what about the four distinctive conditions? How are they related to the essential elements of the medical profession?

According to  Freidson, the first and most distinctive condition is the ownership of the specialized knowledge not easily understood by the citizens with an average education. The medical profession holds the monopoly, argues Freidson, over the use of the medical knowledge and responsibility for its teaching. In the United States, medical profession developed institutions designed to “control the selection, training, and credentials of their members and to gain privileges providing a marked advantage in the marketplace.”  What are the grounds on which the institutions implement the monopoly over the health care services and the strict professional rules? When the idea of professional approach appeared?

Second, argues Freidson, this knowledge should be used in services of individual patient and society in an altruistic manner if we understand altruism as the performance of cooperative unselfish acts beneficial to others.  However, physicians altruism towards their patients and others has not been a broad subject of studies, and there is fragile empirical evidence on what does it mean in everyday behavior of physician although it is often mentioned in statements about medical professional values and attitudes. It has been studied in contexts of the donation of organs and genetic material and patients’ participation in potentially hazardous experiments and trials. 

Freidson’s third distinctive condition of the medical profession is inaccessible nature of the knowledge and commitment to altruism. They are the justification for the profession’s autonomy to establish and maintain standards and practice of self-regulation. It is not only a technical knowledge and skills that assure quality. The core tasks of medical professionals are taught to require discretionary judgment “so that ordinary mechanization or bureaucratic rationalization is not possible” and believed to be “beyond the capacity of untrained lay people to evaluate.” Peer-review is understood more the collegial rather than the hierarchical method of evaluating of the professional knowledge base and research. They accept only professional cognitive superiors.

Freidson considers responsibility for the integrity of their knowledge base and expansion through research as the way to ensuring the highest standards of the medical profession. Physicians  do not “merely exercise complex skills but identify themselves with it.”

Licensing bodies and professional associations like American Medical Association have the responsibility based on the above mentioned four distinctions, to establish common professional goals and encourage commitment to them. AMA also has organizational power and obligation to discipline unprofessional behavior.

To what extent we experience threats to the maintenance of this four condition?

Studies dealing with quality assurance in health care and clinical risk management suggested that rates of adverse events in patients in the hospitals in the developed world were much higher than previously thought.  Multiple sources and studies are showing rates of at least 8% of total amenable mortality rates. Of these adverse events, more than 50% were judged to be preventable. These reports suggest that the deaths of between 0.5% and 2% of patients in the hospital are associated with an adverse event, which was often, but not always, preventable. Reducing the number of deaths and injuries attributable to medical error is also related to favoring of a fiduciary relationship with professional colleagues instead to patients. The consequence is measurable in a report from the Institute of Medicine in Washington which estimated that as many as 98 000 deaths a year were caused by the medical error (BMJ 1999;319:1519).

Picture 1. Major Causes of Death in the USA

These studies would rank harm from health care high on the list of all causes of death for the countries being considered. All published studies to date, however, have been from developed countries, with no reports from developing or transitional economies. In the whole region of South East Europe in last twenty, five years not a single case of hospital deaths was registered and attributed to medical error. The simple calculation, if the lowest US standard of o,5% would be applied, we would be speaking about thousand of death associated with the adverse event. This estimation shows extremely worrisome situation with negligence of medical profession and non-fiduciary relationship with patients.

Preventable harm to patients resulting from their healthcare is unacceptable at any time. Patient safety is first and foremost a clinical problem, but it is also an important cause of wasted resources.

Picture 2. Health Care System Waste in the USA

Norm Levinsky in his paper “The doctor master”  argues that the physician is required to do everything that may benefit each patient “without regard to costs or other societal considerations” and physician is permitted and even obliged to all that they can for their patients “without regard to any costs to society.”  Physicians cannot discharge “their responsibility to their individual patients if they try to conserve societal resources by discounting treatment on statistical grounds.” His radical position which explains and defends doctor-patient relationship as socially, ethically and economically isolated. His key argument is that doctors cannot serve two masters, society, and the patient. Other considerations related to cost-containment or the greater good of the alleged population of patients being served by a given community or organization must never interfere in the doctor-patient relationship. Doctor’s master must be the patient he concludes his vigorous and straightforward argumentation. He draws a superficial and flat analogy with the role of a lawyer defending a client against criminal charges.

Morreim, on the other hand, claims that contemporary notions of professionalism must expand to include responsibility for both patient and population-based concerns. Morreim’s argumentation and logic are more complex and systemic. She argues that every medical decision has its economic costs as well as its medical wisdom.  Not only clinical or diagnostics decisions are subject to economic rational but “every laboratory test, every roentgenogram”  is an allocation issue. She understands that modern medicine, evidence-based medicine, and evidence based practice,  cannot ground itself into  the logic of “do anything that might help.” An intervention which is based on marginal benefits to the patients belongs to the 19^th century professional logic of bleeding and purging. Morreim understands the basic health care law that “our finite resources cannot possibly meet the limitless health care needs.” Modern medicine has developed instruments, tools, models, concepts, and theories capable of establishing a relationship between efficiency, quality, safety and equality in health care delivery. The World Health Organization has carried out analysis of the world’s health systems using five performance indicators to measure health systems in 191 member states. It finds that France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria, and Japan. The model taken from the OECD database shows how the health system in France, considered best healthcare system in the World, manages to establish a simultaneous relationship between different clinical procedures and clinical, economic and indicators and between structures, processes, and outcomes of health care.

Picture 3 Health Care Indicators and Quality of Care in France

Considering doctor-patient relationship like the one in which physician is permitted and even obliged to do all that they can for their patients “without regard to any costs go society” sounds like more cynical than emphatic one.

We cannot escape from the proper ethical, professional, clinical and economic obligation to make decisions about fair, and efficient resources allocation. We are obliged to understand and implement the best practice of medical care not only to a single patient but as many as possible members of body social. And yes, we are obliged to make hard professional decisions and ethical judgments in the professionally and morally challenging situations.

Reference:

Pellegrino, E,  and Thomasma, D. For the Patient’s Good. Chapter 9. “The good physician.” In: New York: Oxford University Press, 1988.

Freidson, E. Professionalism Reborn: Theory, Prophecy, and Policy. Chapter 12. “Nourishing Professionalism.” Chicago: University of Chicago Press, 1994.

Jones, R. Declining altruism in medicine. Understanding medical altruism is important in workforce planning. BMJ. 2002. Mar 16:324 (7338): 624-624.

R. M. Wilson et all. Patient safety in developing countries: retrospective estimation of scale and nature of the harm to patients in the hospital. BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e832

A Makary, M, Daniel Medical error—the third leading cause of death in the US. BMJ2016;353 doi: http://dx.doi.org/10.1136/bmj.i2139

Coulehan, J. and Williams, P. “Conflicting professional values in medical education.” Cambridge Quarterly of Healthcare Ethics Vol. 12, No. 1 (2003): 7-20.

Brook RH. “The role of physicians in controlling medical care costs and reducing waste.” JAMA Vol. 306, No.6 (August 30, 2011): 650-651

Morreim, EH. “Fiscal scarcity and the inevitability of bedside budget balancing.” Arch Intern Med 149 (1989): 1012-1015.

Levinsky, NG. “The doctor’s master.” NEJM December 13, 1984; 311(24): 1573-1575.

Angell, M. “The doctor as a double agent.” Institute of Ethics Journal 1993; 3(3): 279-286

Space

Dear readers,

first up on this site is an op-ed my colleagues prof Julie Rueben and dr Sebastian Porsdam Mann wrote for the Huffington Post on the responsibility of universities in this time and age where the definition of personhood, rights beyond us humans is being redefined and recrafted and the responsibilities such rights should carry with them, especially for institutions such as universities that herald the most enlightened task of educating the world.

The op-ed can be read on here: http://www.huffingtonpost.com/entry/are-universities-responsible-persons_us_593ef42ee4b0c5a35ca24989

Please kindly provide any comments, thoughts, and reflections.