Paternalism vs Mutual Respect in Local Planning

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paternalismby Tia Will

As my retirement rapidly approaches, I have had time to reflect on the changes that have occurred in medicine over the course of my career. Since I was first licensed in 1984 there has been a major change in the doctor-patient relationship. Medicine has moved from a model in which the doctor was assumed to know best, was expected to simply tell the patient what to do, and the patient either complied or did not, and improved or did not. Over the years, and with much study and self-reflection a new and more effective model has evolved. It is now nearly universally accepted that the doctor-patient relationship works best and achieves the best outcomes when it is considered as a partnership in which the doctor is the acknowledged expert in the anatomic, biochemical, and pharmaceutical aspects of medical treatment and the patient is considered the expert in the more personal aspects of treatment such as their past experience with various approaches, what is and is not acceptable treatment for them, and how much faith they have that a recommended course of action will be beneficial.

Many studies, and much personal experience confirm that the best outcomes are achieved more rapidly when the goals and values of the doctor, the patient and those critical to the wellbeing of the patient, usually family members, are all in alignment from the very first appointment. The doctors who practiced the paternalistic, doctor-knows-best model were not evil, nor greedy, nor uncaring. They had simply been trained to consider that their model was the best way to provide medical care. As it has evolved, they were wrong. The current model of partnership and mutual respect between doctor and patient is a much more effective.

Earlier this week, while attending a City commission meeting, a broader application of this principle occurred to me. As I was listening to comments from both proponents and opponents to a project being considered, the similarity in attitude and process occurred to me. There were a number of highly effective speakers on both sides. There was no doubt to me that both sides were very sincere in their beliefs and that all believed very strongly in their own position. It also was clear to me that different models of process were being invoked. The developers and investors were doubtless sincere in the belief that their project was good for the entire city and that the potential downsides are miniscule by comparison. Those who object to the project (almost all from the most directly affected neighborhood)  do not see their concerns as trivial and believe that there is another, better approach that would be within the current guidelines, would still be profitable for the developers/investors, and would meet the goals of the community in terms of minimizing adverse effects, or to use the medical analogy “side effects”.

From in-person and Vanguard conversations over many months, it appears to me that the issue of development is currently considered as an inevitable struggle between those who propose a project and “push back” from the neighborhood, or the “NIMBYS” as they are derisively called in a shaming process not so different from those who portray all developers as “greedy exploiters” only out for a buck.

I believe that there is a third way that could prove more effective and less costly in terms of time, money, and animosity. I have discussed with some of our  local developers the possibility of considering a new model of engagement using mutual respect and acknowledged different areas of “expertise” between those whose project would change a neighborhood in terms of architecture, land use, and the technical aspects of site development  (analogous to the doctor) and those who live in close proximity and thus will actually have to live with and be most directly affected by the effects of the project, both positive and negative (analogous to the patient). I feel that a collaboration from the beginning, before the land is purchased, before the design is decided upon and long before it is presented to the community with only the possibility for minor “mitigations” would provide a much less expensive, faster and more civil process that does not pit neighbor against neighbor would result in much better outcomes.

I know that for those who do not want peripheral development, the thought of change to a larger footprint is difficult. And yet there are some who believe that we should definitely move in this direction by ending Measure R. I know that for those who do not want large developments in their small, homey neighborhoods the thought of a large building outside design guidelines is a change that they do not want to see. And yet there are many who argue that since the property is owned by someone else, they should just shut up, and take what they get. This is the way the conversation is sometimes framed.

What I am suggesting is that perhaps the developers/investors might also be willing to consider a change from the way things are classically done in their business. They frequently see change as a good for the community. What I have not yet heard on a wide scale is the embrace of change in their processes to be more inclusive from the onset of the initial project concept to consideration of the preferences of the directly affected community.

I freely admit that the change from a paternalistic model to a partnership model in medicine has been slow and in some cases difficult. Humans tend to be slow to accept change, especially if they are the ones that have to change. However, if it can work for one of the most entrenched, arrogant and condescending groups of people that I have ever met, namely doctors as a whole (not necessarily as individuals) I believe that it is at least worthy of consideration by our experts in the field of city and project planning.  A little up front collaboration just might pay off in the long run in terms of quicker project approval, a project that will be universally considered beneficial and freedom from “repeat visits” in the form of contentious meetings both private and public and ultimately the ever present threat of a law suit.

I believe that we can do better than current process and look forward to your thoughts.

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About The Author

Tia is a graduate of UCDMC and long time resident of Davis who raised her two now adult children here. She is a local obstetrician gynecologist with special interests in preventive medicine and public health and safety. All articles and posts written by Tia are reflective only of her own opinions and are in no way a reflection of the opinions of her partners or her employer.

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19 thoughts on “Paternalism vs Mutual Respect in Local Planning”

  1. SODA

    Morning Tia, thanks for the early morning smile! As a retired clinical pharmacist older than you, I saw more of the paternalistic dynamic than you but agree it is changing for the better.

    To emphasize your point that this new approach would bring the project to the ‘patients’ much sooner than in the traditional way, where the developers have invested large sums and the neighbors are sometimes made to feel there is a timeline and they need to not be an impediment to the deadlines. In addition, projects that have little opposition could still become better, by prospective involvement even if there is no pushback.

    Albeit an idealistic method it would be refreshing to see.

  2. Tia Will Post author

    Morning Soda,

    Albeit an idealistic method it would be refreshing to see.”

    Thanks for the return smile. It made me wonder when “idealistic” came to be used as synonymous with  unrealistic as opposed to something to strive for.

     

  3. Edison

    Tia: Best wishes on your pending retirement, from one who is a relatively recent retiree and has thus far found nothing about it to dislike.  In our case (spouse and me) it meant being able to take multiple backpacking trips last year; Grand Canyon and eastern Sierras are among our favorites, with 9 days scheduled for the John Muir Trail next July.

    The model you espouse has few fatal flaws. It would take a long time to evolve, partly because this isn’t the way urban and regional planning is now taught in universities. State laws guide local general planning and zoning codes, so “permissions” would be needed to gain more flexibility in that regard. Having worked in various aspects of local and regional planning and government affairs since the 1970s, there is one potential obstacle that would perhaps be most difficult to overcome. (My perspective is from both sides, working for large urban chambers of commerce advocating for development interests, and working as an environmental planner for city, county and regional governments.)    That obstacle is the role of money in local decision making; i.e., campaign financing. It takes a great deal of money for a candidate (especially a first time challenger) to obtain public and media attention.  One only need look as far as the neighboring county to the east to see that dynamic at work.  In that case, there is one individual and his family who have vast influence (often unseen) over local political dynamics and land use decisions.  In one instance that entity sought to develop land beyond Sacramento County’s “urban limit line,” and it took a huge effort by the Environmental Council of Sacramento (ECOS) packing the Board of Supervisors meeting room to defeat it.  It was such a large effort that I think it totally exhausted the ECOS leadership and staff; I’ve not heard much from them since then. I’m new enough to Davis politics to be unsure whether a similar mechanism is at work here.

    Another factor is the fear of “bait and switch.”  The residents of Sacramento were promised by the developers along with the city council and staff at the time that development of Natomas would be different, that public amenities like parks, fire stations, and community centers would all be built before the housing was occupied. The public bought into that concept, but it didn’t happen. The public infrastructure lagged and the housing development ended up as totally undistinctive stucco boxes crowded next to each other. That engendered a lot of distrust, resulting in the ouster of a genuinely nice guy who was the council member (Ray Trethaway) and the election of Angela Ashby.

    For me, the concern is not that development will add to our town’s population or necessarily that it will expand the periphery. The concern is that the resulting development will end up following the same generic model one sees traveling around the country. The homes erected by a “merchant builder” like the company overseeing The Cannery look virtually the same as the homes that company builds in Phoenix, Tucson or any other city I’ve been to where they’re active.   There’s no “design with nature” with large roof overhangs to shade the homes, and if one is interested in a Craftsman style home for instance, it will only be visible from the front façade. The sides and back look the same as all the other homes.  The same goes for shopping areas; most new areas of the country have the same wide streets and strip malls; they could be virtually anywhere, and they typically bring economic ruin to traditional downtowns.

    So, here’s my thought. Contrary to others, I think one of the keys to the success of your proposal could actually be Measures R and J. For one thing, it signals to potential developers that they can’t just get what they want by convincing city planners and city council to annex land for a proposed development.  Combined with your model, developers would realize up front that they will need to have extensive conversations with citizens and civic leaders to formulate a mutually acceptable and hopefully profitable project.  The process could in fact start with identifying optimal sites for annexation and development so everyone would know what is envisioned before the first developer dollar is spent.

    Second, it would hopefully encourage a long and hard look at all potential development sites within the city. Discussions could occur about desirable projects, and decisions could be made about changes in the general plan and land use designations that would facilitate subsequent development. The city could then publish a map or similar document showing what the city and residents have determined would be acceptable at each site. Such a process would certainly been a lot easier than the difficulties now being experienced at the Hyatt hotel, Trackside and Sterling sites.  The big question is how many people, especially outside central Davis, would have the time and energy for such efforts. Many people I know commute daily to jobs in Sacramento, the Bay Area and points in between, and have busy family obligations when they return home daily.

    All that being said, I think your approach has potential and should be given serious consideration. The big gorilla in the room, however, is UCD. Despite last month’s attempt by the Interim Chancellor and Vice Chancellor Ratliff to assure the Board of Regents that a wonderful and communicative “town and gown” partnership exists here, UCD has yet to demonstrate any real and responsive commitment to sustainable planning and effective use of its vast land holdings. The sole focus seems to be how many more students can be recruited under the “2020 Initiative” and then dispersed for residency throughout the Sacramento region after freshman year.

    This situation reminds me of the traditional Western movie, in which a cattle baron controls the town.  The baron here is UCD, even if it can’t fund city council election campaigns.  It uses more insidious methods, such as executing master leases on apartment buildings, thereby depriving the city of badly needed property tax revenue, or its recent attempt to buy the University Research Park, which would have had the same local tax impact. Lucky for Davis that Mark Friedman’s company was the successful bidder.  And when it came to the Nishi project, UCD’s behavior was completely different. As one councilmember pointed out at the December 6 council meeting, UCD was virtually absent during those project discussions. Unfortunately, I believe UCD’s mindset of UCD will definitely need to change before your model will find applicability here.

     

     

  4. Alan Miller

    The fatal flaw is:  war is defined by the aggressor.  Expecting an aggressor to behave even remotely similar to a trusted friend is a good way to get oneself killed.

  5. Mark West

    Tia describes the changes to the medical profession that she has witnessed during her career and uses that as an analogy for how she wants the development process to change. The problem that she does not seem to understand is that she could not have implemented the changes to the medical profession by herself (as she seems to expect now) nor could she have expected her suggestions for change to be accepted by her peers and superiors back when she was a newly minted MD. Change of that magnitude occurs over time and generally comes about from those within the system, not those on the outside. The analogy completely falls apart however when one realizes that Tia is not even acting as the equivalent of a newly minted MD here with a solid basis in the basics of medicine, but rather someone who has watched a couple of episodes of ‘Grey’s Anatomy’ and who now acts as if that experience makes her qualified to tell a neurosurgeon how to operate.

    “I feel that a collaboration from the beginning, before the land is purchased, before the design is decided upon and long before it is presented to the community with only the possibility for minor “mitigations” would provide a much less expensive, faster and more civil process that does not pit neighbor against neighbor would result in much better outcomes.”

    Developers risk a great deal of money on their projects, even to just get them to the point of submission to the planning department. You don’t have a project to propose until you have control of the property in question (through purchase or option). In these situations, information is money, and information in the wrong hands at the wrong time could well become very expensive, to the point of making the project infeasible. That is why non-disclosure agreements are often required between parties prior to the discussion of future projects.

    At the most basic level, to implement Tia’s plan, the community would need to agree to mitigate all of the developer’s financial risk during the planning process. Essentially to pay all of the predevelopment costs, including securing the option to purchase the property. Otherwise, all we are doing is increasing the financial risk for the developer (ie. spending other people’s money) and making all projects that much more expensive and that much less likely to occur.

    Tia’s approach may make sense to her, and perhaps to some others who feel they have a ‘stake’ in every project within their ‘sphere of daily life,’ but it is an approach that makes no sense to those risking their financial future on the venture. All advance disclosure will do is make the project more expensive, provide an opportunity for outsiders to gin up controversy, and in the end, likely guarantee that the project will be infeasible. It may work in an idealistic world, but it falls flat in the real one.

    A more collaborative society is something we might all choose to strive for, but we need to live and find solutions that work in our current world, and not just in an idealistic one that we hope for someday in the future.

     

    1. Tia Will Post author

      Mark

      The problem that she does not seem to understand is that she could not have implemented the changes to the medical profession by herself (as she seems to expect now) “

      Please just even one quote from me implying that I “expect” that anyone will do anything or that implies that I believe that I had anything at all to do with the changes that were implemented in medicine. Your distaste for me personally is palpable, but without support or explanation.

      All advance disclosure will do is make the project more expensive, provide an opportunity for outsiders to gin up controversy, and in the end, likely guarantee that the project will be infeasible. It may work in an idealistic world, but it falls flat in the real one.”

      And how would you know this. Please site examples where a collaborative approach has been tried and failed.

      A more collaborative society is something we might all choose to strive for, but we need to live and find solutions that work in our current world, and not just in an idealistic one that we hope for someday in the future.”

      I believe that we have the ability to shape our world through our individual daily decisions. I see no harm at all in discussing and considering different processes. I do not expect change to happen overnight as  implied by the fact that the paternalistic model took many years to change to the more collaborative model that predominates today. But one must start somewhere if one wants to see improvement. I have fully stated and you all know that I have no background in development, and yet, some of the best changes I have made in my own personal practice have been inspired by my patients and medical students who see things with fresh eyes and are willing to question a long standing process.

      I see a problem that is interfering with constructive and much needed development in our community and have suggested consideration of an alternative model. I concluded with a request for the thoughts of others. I fail to see how any of this can be seen as a “demand’ for anything.

       

      1. Mark West

        Tia: “And how would you know this. Please site examples where a collaborative approach has been tried and failed.” 

        I have no idea where any examples might be located, but if I wished to identify some, I would start with the totality of human culture and endeavor. There is a reason why in most examples of human society people have chosen to keep their business dealings private from their nosey neighbors. The fact that you are unable to accept this simple reality does not come as a surprise.

        1. Tia Will Post author

          I would start with the totality of human culture and endeavor.”

          And I would counter that there is no “totality of human culture and endeavor”. Not every society has developed around the idea of mastery of nature, ownership of land and natural resources and subjecting others to one’s whims if one happens to be stronger and or richer.

          As a few, I would site the Amish, many of the indigenous American groups as well as other tribal groups that view themselves as belonging to and dependent upon the land as opposed to masters of it. True these are small groups, but their very existence indicates that humans can organize themselves into more collaborative, less “might makes right ” societies if we choose to. It is a matter of will, not human nature.

    2. Tia Will Post author

      Frankly

      I think now is maybe not the best time to use the modern practice of medicine as a model for other decisions processes since the death rate for many diseases and ailments has started to increase for the first time in decades.”

      And I think that it would be patently ridiculous to imply that because of worsening overall statistics, that there are no processes within the entire field of medicine that might be worth considering.

      Would you have been willing to discount all free market based business practices as failures during the recession ?  I seem to remember threads in which you vigorously defended the free market system even during the worst economic recession since the depression.

       

      1. Frankly

        The market was not free and is not free it was government meddling in the free market that caused the Great Recession.  Nice try at history revision.

        And really, you seem pretty callus about all the additional death caused by the industry of health care.

        The free market will cycle and correct if supported correctly and is not corrupted by politicians… especially those on the left of politics that seem to understand very little about the market.

  6. Tia Will Post author

    Frankly

    Oh, for heaven’s sake. Revisionism …..really….when what I was saying was that tying a single aspect of medicine to the current epidemiology downturns would have been as ridiculous as attempting to connect the recession to a failure of the entire concept of a free market.  Have you lost all sense of nuance to the degree that you cannot see that I was deriding both, not supporting either ?

    Callous, because I do not buy into the simple minded idea that all of medicine including recent improvements in doctor/patient relationships should be held directly responsible for the declining outcomes. Really ?  Also clever omitting the much more likely scenario that I did not address this aspect of your comment because it is self evident the doctor patient relationship is not responsible for the declining outcomes given the much more likely increases in obesity, diabetes,and there attendant complications as well as the well documented increases in white male suicide. Before  you decide that I am either responsible for, or callous about that, I would remind you that I am a gynecologist.

  7. John D

    Many of us have grown weary of the incessant and seemingly endless finger-pointing.  There is more than enough “blame” to go around – in terms of how we got to be in the situation we are today (irrespective of how you might view that current condition from wonderful to near DOA).

    Tia’s analogy is creative and useful, particularly given its personalized, human-based context.

    Taking the analogy a little further, Tia seems to want to conflate community planning with a responsible, holistic, life-care form of thinking about personal health – based on expert opinions, a willing patient, and concerned family members – and where all of the parties are interested in the same goal of a best/optimal, long term, life plan for the patient and their selves.

    In this context, there would seem to unfold a logical series of follow-on questions and issues when considering the best course of treatment:

    1)  Is the patient, now approaching advanced middle age (100 years plus), sufficiently concerned, interested and motivated in maintaining a high quality of life, with a good long-term prognosis, to willingly exercise the discipline, investment and sacrifice required to achieve those goals?

    Most importantly, are they even willing to visit the doctor, much less listen to their proscriptions and admonitions?

    2) It seems important to keep in mind; this is a truly exceptional patient – a trusted and valued member of the family and the entire community.  This is a patient who has often given back more than received and truly offers something of value to every business and property owner and every resident within the community.

    And, while the patient still talks a good game, in their personal life, they have not always made the best decisions and, as the result, find themselves significantly overextended – having a difficult time keeping up with expenses, not really contributing what they should for their future retirement or long term medical needs, and maybe becoming a little overwhelmed with the multiple, competing social objectives of their workaday world, its complexities and the continuing competition from neighboring communities.

    3) In this context, one is tempted to ask whether this patient is truly interested in persevering – with continued willingness to do whatever it takes – given their personal habits – to keep up both their own personal finances, while continuing to lead and guide the family and community in a direction that leaves everyone better off in the long run.  Truly, it is not a simple or an easy conversation to have.

    On the other hand, maybe the financial issue is not that hard to address – perhaps the rest of family and community would be only too happy to cover any additional costs of treatment.   In real families, this happens quite often – to the extent resources permit.   Has anyone yet asked that question?  Seems like an important to point to get resolved right up front, as it would significantly simplify the remainder of the conversation.

    We must remember, this conversation is all about staying healthy – the whole community that is – and beyond finances, there are the all-too-human aspects of a patient being a little too concerned about recent health events and certain warning signs, and – having some very real concerns about going to visit the doctor – where the patient risks not liking the diagnosis they might receive or the regimen options among which they are forced to select.  But again, if finances are not an issue, that simplifies the equation.

    On the other hand, and not having resolved the question of financial support, from the patient’s perspective (having become more and more dependent upon the financial good graces of their community) there is always the concern that they may not be as fully supported by their family and neighbors – once their family and supporters learn their patient has kind of let things go, hasn’t been completely forthcoming about their true state of affairs, and hasn’t been building a personal nest egg to take care of the advancing challenges of the future.

    Bottom line, there are a lot of complex concerns for the patient and much of the future course of treatment must – of necessity – depend upon their openness, willingness to address their challenges, and willingness to change.

    4) Next, it would seem, comes the selection of a respected and trusted physician advisor (trusted by the whole family) who is both willing to take on the patient, and has the qualifications and experience to perform the required diagnosis and to proscribe the recommend course of treatment – keeping in mind that this patient isn’t just anybody and that the decision will require the entire extended family to support (including both personal and financial sacrifice) the selection and agree to support the plan of treatment.

    Keeping in mind this patient is a very trusted and highly valued member of the family and community – who or what members of the family/community will be selected to help advise the patient in making this important decision and what are their unique qualifications to be granted such authority?

    5) Following comes the reality of the time, effort and costs involved in performing the initial patient evaluation and analysis.  To begin with, there will be lab tests to be performed and metrics to be compared against relevant baselines.  And, since we are talking about both extending patient longevity, while also maintaining a high quality of life, there are numerous other factors to be considered including the patient’s fitness for the procedures involved, psychological health, physical conditioning and health, spiritual health, as well as current and long terms financial health and ability to finance both their predicted life style needs as well as extended healthcare objectives.

    Keeping in mind this patient is a very trusted and highly valued member of the family and community – who or what members of the family/community will be selected to help advise the patient in their evaluation and understanding of these important considerations, the costs, resources, and investments required – and what should be their unique qualifications, talents and professional experience to be accorded such authority?  How will the decision be made in terms of who should be conducting these proceedings, what will constitute the final selection criteria for these family committee members, and what will be the best venue for such discussions and debate?

    6) And finally, should we not be asking if this next frontier of holistic caring be viewed as the last full measure of the patients success as they confront the necessary life style changes, the learning of essential new habits and strategies, the openness and willingness to embrace the challenges of the future, and the desire to move forward in welcoming and leading the next generation of leaders.

    Well, that’s probably enough to consider for now.

    Sound exhausting?   That would be a serious disappointment.  Are these questions and steps really too complex for a community of our stature and aspiration?

    Perhaps you have some suggestions for simplifying the procedure?

  8. Tia Will Post author

    John D

    Thanks for sharing. Even more to think about.

    based on expert opinions, a willing patient, and concerned family members – and where all of the parties are interested in the same goal of a best/optimal, long term, life plan for the patient and their selves.”

    We so far have focused on the “patient” and the “doctor”. What I would hope that such a model would also address would be the “public health”. It would seem to me that if each “doctor” and “patient” achieved a better outcome more rapidly, and less contentiously, then the community as a whole would benefit significantly from not having to fight the same battles over and over again as we are now seeing play out.

  9. John D

    Tia,
    No argument there.  It seems, however, that we have neither the capacity nor the will to engage in the type of deep self-reflection that would normally accompany this process.

    You began your commentary as an observation about the community planning process.  The community could be either the patient or the public health in this context – and yet, the typical progression of diagnosis and treatment would hopefully be one and the same in either case.

    So, again, what should be the essential steps to an initial diagnosis – assuming the patient has a desire to participate?

    Medically speaking, there would be a recognized starting point – would there not?  Would you care to elaborate?

  10. Tia Will Post author

    John D

    So, again, what should be the essential steps to an initial diagnosis – assuming the patient has a desire to participate?

    Medically speaking, there would be a recognized starting point – would there not?  Would you care to elaborate?”

    Your comment made me smile precisely because I thought this was exactly what I was doing with this article, taking an initial step.

    As Mark West has correctly pointed out, I am far outside my area of expertise so I cannot opine on the starting point for the “experts” ( doctor in my analogy or developer in the real world. But what I will be able to put forward are some initial first steps that I could suggest while hoping that those with actual expertise might join in.

    First I would like to emphasize that I do not believe that it is only the patient or neighborhood that must agree to participate. The “doctor” or developer/ investor would also have to be fully on board with the community also playing a vital role. The collaboration of all three would be necessary for the model to work.

    So I will address your questions from the medical perspective and hope that someone may care enough to play along and tell me what the corresponding step might be in the  area community development. Where I have ideas, I will share them, and where I don’t please feel free to fill in the gaps.

    1. In medicine, the first step when one is confronted with a question is to gather as much information as possible. This can be done by reading up on the issue but this presupposes a fair amount of background knowledge usually obtained over years of medical school and residency.

    2. One can also gather information from those who have more experience in the field than you do. The problem with expert testimony and guidance is that it is frequently limited by the knowledge base and habits of the mentors you seek.

    So my first thought is that I could seek information from the instructors in community planning and related fields. Question number one for readers. “Who would you suggest as good sources of information ?”

    Next, I could seek information from city staff, the city manager and council members. I suspect again that the information would be highly tilted towards an explanation of current practice, but without much insight into what systems and processes might actually work better. I could also talk with developers, investors which I have started in a very small way. However, I see that none of them ( some of whom I am sure read the Vanguard) have as yet reached out to make suggestions or offer comments.

    3. In medicine, once one has gained insight into how a process works, why it has typically been taught and adhered to, what alternatives have previously been considered, then and only then does one usually start to formulate a new idea.

    4. Once a new idea or process has been conceived, one would then usually present it to one’s partners and all other involved individuals whether that is the medical assistants, nurses, housekeeping, or whomever else is likely to be impacted for their input.

    In the case of city planning, I have no idea who constitutes all appropriate individuals who would have to be on board to make such a large change in process work. This is where help would be needed from those whose area of expertise this is in order to compile a complete list of stakeholders.

    That should be enough to demonstrate both my degree of interest and my lack of knowledge in this area for now.

     

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