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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2018  |  Volume : 60  |  Issue : 4  |  Page : 445-460
Evaluation of psychiatry training in India: A survey of young psychiatrists under the aegis of research, education, and training foundation of Indian Psychiatric Society


1 King Georges Medical University, Lucknow, Uttar Pradesh, India
2 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication28-Nov-2018
 

   Abstract 


Aim: The aim of this study is to assess the perception of the young psychiatrists (aged ≤45 years) about their training received during the postgraduate training period.
Methodology: An online E-mail survey using Survey Monkey electronic platform evaluated the perception of 451 psychiatrists about their own perception of training received during the postgraduation period.
Results: About two-third (n = 308; 68.3%) of the respondents reported that their overall training was 'good' or 'very good'. However, training was rated as poor/very poor in subspecialties of child and adolescent psychiatry and geriatric psychiatry by 26.2% and 26.9% of the participants, respectively. Exposure/training was rated as “poor/very poor” by more than one-fifth of the participants in areas of repetitive transcranial magnetic stimulation and deep brain stimulation (69.9%), rehabilitation psychiatry (47%), forensic psychiatry (45.5%), psychodynamics (40.5%), neuroimaging (38.1%), psychotherapy (34.8%), orientation to private practice (26.9%), statistics (34.1%), writing skills (24.4%), ethical principles of research (23.5%), women mental health (23.3%), psychosexual medicine (22.7%), and research methodology (21.5%). Regarding academic activities involving writing skills, although majority (72.5%) of the participants reported being involved in writing case reports and half (50.3%) reported involvement in writing original articles, but exposure to writing other types of article was quite low. Training in different types psychotherapies in the form of adequate exposure, carrying out and supervision to different types of psychotherapy was inadequate/low for psychodynamic psychotherapies, rational emotive therapy, dialectical behavior therapy, eclectic psychotherapy, and other kind of therapies. A high proportion of respondents reported having good competence in the administration of modified electroconvulsive therapy and making presentation in academic fora just after passing degree from their institutes and at the time of survey (current competence). When comparisons were done between the different groups of institutes, significant difference was noted across all aspects of training.
Conclusions: The present survey reflects that there is a variation in the psychiatry training in India. Accordingly, it can be said that there is a need to develop a model for competency-based training program at the level of the Indian Psychiatric Society in consonance with training regulatory bodies like the Medical Council of India, which can be implemented across the country to harmonize the training.

Keywords: India, postgraduate, psychiatry, training

How to cite this article:
Grover S, Sahoo S, Srinivas B, Tripathi A, Avasthi A. Evaluation of psychiatry training in India: A survey of young psychiatrists under the aegis of research, education, and training foundation of Indian Psychiatric Society. Indian J Psychiatry 2018;60:445-60

How to cite this URL:
Grover S, Sahoo S, Srinivas B, Tripathi A, Avasthi A. Evaluation of psychiatry training in India: A survey of young psychiatrists under the aegis of research, education, and training foundation of Indian Psychiatric Society. Indian J Psychiatry [serial online] 2018 [cited 2018 Dec 17];60:445-60. Available from: http://www.indianjpsychiatry.org/text.asp?2018/60/4/445/246194





   Introduction Top


In India, postgraduate psychiatry training is being carried out since last half a century. The good aspect of postgraduate psychiatry training is that over the last 50 years the numbers of institutes providing postgraduate psychiatry training have increased tremendously. At present, 186 institutes are providing training for MD Psychiatry,[1] 58 institutes are providing training in Diploma in Psychiatry[2] and 37 institutes are providing Diplomate of National Board Psychiatry.[3] The increase in number of seats for postgraduate training in psychiatry can be attributed to the general hospital psychiatry unit movement in the country. Besides increase in the number of postgraduate training seats and centers in the country, in recent times, there is also an increase in interest in different subspecialties of the psychiatry and many centers have started DM courses and postdoctoral fellowships in subspecialties, child psychiatry, addiction psychiatry, geriatric psychiatry, consultation-liaison psychiatry, and brain stimulation.[4],[5],[6]

Over the years, the scope of psychiatry has widened, and the psychiatric training is not limited to training in only general adult psychiatry. For a holistic and complete training program in psychiatry, besides adult psychiatry there is a need for adequate exposure to child and adolescent psychiatry, addiction psychiatry, geriatric psychiatry, consultation-liaison psychiatry, forensic psychiatry, different types of psychotherapies, neuroimaging, electroconvulsive therapy (ECT) and brain modulation treatments, psychopharmacology, rehabilitation psychiatry, research methodology and statistics, ethical principles of research, and clinical practice, etc. In addition, there is also a need to train the postgraduate students in writing and presentation skills as well as to be able to orient them toward teaching.[7] In addition, there is also a need to impart skills to practice psychiatry in private sector.

However, little is known about the quality of training across different institutes. Very few studies have tried to focus on the postgraduate psychiatric training.[7],[8],[9],[10],[11] Besides these studies, in the year 2012, An Indian Psychiatric Society (IPS) task force survey was held to assess the status of postgraduate training in India.[12] The data were collected from the Head of the Departments of the various institutes providing psychiatry training in India. The survey was conducted through E-mail which was sent to 87 centers of which 60 responded but data were analyzed for 57 centers (28 government and 29 private sector centers) only. The survey results revealed low faculty to postgraduate student ratio (1.2) and inadequate number of psychiatric social workers. De-addiction and Child Guidance Clinics were established in 39 centers (70%) only. About one-third (38.6%) and more than half (54.4%) centers did not offer community and rehabilitation services, respectively, suggesting poor exposure/training to the postgraduates in these aspects of psychiatry. With regard to psychotherapy supervision program, 44% of the centers did not have any mandatory psychotherapy supervision programs and centers had a high reliance on external posting for training for neurology and child and adolescent psychiatry. Very few centers offered specialized training in consultation-liaison psychiatry. About half of the institutes surveyed acknowledged that they did not provide any specific inputs to postgraduates regarding medical law, ethics and neuroimaging. Half of the institutes had no formal method of assessment (end semester/end posting examinations) of postgraduate students during the entire course curriculum. Despite these shortcomings, 55.6% and 45.8% centers reported that they were satisfied with the current teaching methods and assessment methods, respectively. This survey suggested that the IPS and MCI norms of postgraduate training were not being followed universally across all the centers in India.[12]

However, little is known about the opinion of the postgraduate trainees about the training received. Accordingly, this survey evaluated the perception of young psychiatrists (aged ≤45 years) about their postgraduate training.


   Methodology Top


This survey was carried out under the aegis of Education, Research, and Training Foundation of IPS. This study received ethical approval from the IPS Ethics Review Board formed for the approval of studies carried out under the aegis of IPS and also Institute Ethics Committee of Postgraduate Institute of Medical Education and Research, Chandigarh. The survey evaluated the perception of participants about their postgraduate psychiatry training and IPS academic activities. This paper focuses only on the postgraduate psychiatry training.

An online survey questionnaire containing 27 questions was sent to psychiatrists (both qualified practicing and trainees aged ≤45 years) across the country in March–May 2015 using Survey Monkey® electronic platform. The survey comprised of questions pertaining to demographic and personal characteristics, a self-designed questionnaire containing questions pertaining to their training in psychiatry, individual's opinion about the competence of the faculty training them, their own competency in carrying out psychotherapy, having adequate exposure to psychotherapy or being/been supervised for psychotherapy during their training period, along with perceived stress due to training activities. In addition, the survey inquired about the opinion of the young psychiatrists regarding their perception about the current format of IPS activities and what kind of changes they would like should be made in the IPS activities. The data pertaining to IPS activities is published separately.

The invitation link of the survey was sent to 2303 psychiatrists all over the country. The E-mail link explained the purpose of survey along with an option to “opt out.” The invitation letter stated that the participation in the survey was voluntary and completion of survey implied their consent to participate. The survey was sent twice during the weekends for 8 consecutive weekends. In case someone did not respond at the first instance, weekly reminders were sent for the next 7 weeks or till they opted out, whichever was earlier. Confidentiality of the information was maintained, and no personal information of the participants was disclosed to anyone.


   Results Top


The survey was sent to 2303 psychiatrists (qualified and trainee residents). Of these, 105 E-mails bounced back, and 111 opted out of the survey. Out of the remaining 2087, 547 mental health professionals responded to the survey (response rate 26.2%). Out of the 547, who initially responded, 73 were not aged 45 or less and were not able to take the survey. This resulted in actual responders as 474 (22.7% of the 2087 recipients). However, data were available for only 451 participants for the analysis due to lack of completion of any response on the training aspect. For some of the questions, data were available for lesser number of participants. However, we retained the data to avoid bias.

The details of the participants are shown in [Table 1]. The participants were spread across 115 institutes/medical colleges.
Table 1: Details of the participants (n=451)

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Evaluation of different aspects of psychiatry training

Different aspect of training was evaluated on a Likert scale with response options of “very poor,” “poor,” “average,” “good,” and “very good.” The evaluation considered rating of “overall” training and training in different aspects of psychiatry and various subspecialties. As is evident from [Table 2], about two-third (n = 308; 68.3%) of the respondents reported that their overall training was “good” or “very good.” Details of training in various specialties are provided in [Table 2].
Table 2: Aspects of training: Individual opinion about their own training in psychiatry in their institute (n=451)

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To understand the impact of training institutes on the training, depending on the institute of training, the study participants were divided into two groups. Group-I (n = 228) included participants who were trained at The National Institute of Mental Health and Neurosciences Bengaluru, Post Graduate Institute of Medical Education and Research Chandigarh, All India Institute of Medical Sciences New Delhi, Central Institute of Psychiatry Ranchi, King George's Medical University Lucknow, Kasturba Medical College, Manipal, Jawaharlal Institute of Postgraduate Medical Education and Research Puducherry, King Edward Memorial Hospital Mumbai and Christian Medical College, Vellore. Participants trained in other institutes were grouped into the Group-II (n = 223). As is evident from [Table 2], when both the groups were compared by considering the responses on the Likert scale as continuous or categorical variables, training for participants in Group-II was inferior, with respect to overall training and training in all other aspects except for forensic psychiatry, psychodynamics, and orientation to private practice [Table 2].

Competence of faculty who trained the participants

As is evident from [Table 3], overall competence of faculty was rated as “good” or “very good” by three-fourths (76.1%) of the participants. When participants of Group-I and Group-II were compared, overall competence of faculty in Group-I was rated as “good” or “very good” by significantly higher proportion of participants for all the aspects except for forensic psychiatry [Table 3].
Table 3: Competency of the faculty who trained/is training them in psychiatry in their institute (n=380)

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Exposure to academics during the training period

Details of the exposure to various academic activities during the training period are given in [Table 4].
Table 4: Exposure in the form of making academics presentations and writing skills (n=451)

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When participants of Group-I and Group-II were compared, significantly lower proportion of participants from Group-II, made presentations in the form of case conferences, seminars, psychotherapy forum, thesis protocol presentation and thesis presentations. Similarly, significantly lower proportion of participants from Group-II, were involved in writing review articles [Table 4].

Exposure to patient care activities

Details regarding number of patients seen every day, seeing patients independently and freedom in writing prescriptions are given in [Table 5].
Table 5: Individualized rating of training in patient care related activities (n=380)

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When both the groups were compared, participants in Group-I reported significantly higher freedom of prescription, time allotted for each patient, training in providing continuity of care, overall level of patient care and learning during the training period with respect to overall patient care [Table 5].

Training in psychotherapies

Training in various types of psychotherapies was evaluated by asking the participants to respond whether they were exposed to, they carried out and they were supervised for various kinds of psychotherapies [Table 6]. Regarding group differences, significantly higher proportion of participants in Group-I (except for rational emotive therapy) reported having exposed to, having carried out and being supervised for various kinds of psychotherapies [Table 6].
Table 6: Training in various types of psychotherapies during his/her training period (n=370)

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Perceived stress during training

Participants were asked to grade the level of stress associated with different kind of clinical and academic activities during their training period on a scale of 0–100, results of which are shown in [Table 7]. When participants with Group-I and Group-II were compared, participants in the Group-I reported significantly higher overall stress as well as stress in the areas of academics, clinical documentation, regular assessment examinations and stress due to thesis [Table 7].
Table 7: Perceived stress due to various activities

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Participant's perception of their competence at the time of completion of their training or current level of training

The respondents were asked to retrospectively rate their own competence on various clinical, legal, and research activities as “poor,” “average,” and “good” at the time of passing the degree from their respective institutions. As shown in [Table 8], administration of modified ECT and making a presentation in academic for a were the only two activities for which more than half (50%) respondents rated their competence as “good". When Group-I and Group-II were compared, higher proportion of participants from Group-I rated their competence to be better in all the aspects except for competence for doing private practice.
Table 8: Participant's perception of their competence at the time of completion of their training or current level of training (n=380)

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Participant's perception of their competence at the time of participation in the survey

As shown in [Table 8], regarding the current level of competence, administration of modified ECT and making a presentation in academic for a were the only two activities for which more than half (50%) respondents rated their competence as “good.” When Group-I and Group-II were compared, higher proportion of participants from Group-I rated their competence to be better in all the aspects except for competence for administration of modified ECT and doing private practice.

Participant's perception of need for improvement in the training practices at their institute

More than half of the participants rated the need for improvement in various aspects of interventions except for the administration of ECT. The need for improvement was reported by higher proportion of participants in the Group-II when compared to Group-I.


   Discussion Top


One of the aims of any professional medical body is to update the knowledge of its members in terms of their clinical and research need. However, these needs can be fulfilled only if the professional bodies are aware about the needs of their members. Till now little information is available from India, with respect to postgraduate psychiatry training in India. However, information regarding the perception of trainees per se is lacking.

This survey aimed to evaluate the perception of young psychiatrists across the country about their postgraduate psychiatry training. This study was carried out under the aegis of IPS, to have an understanding about the areas of deficits of the young psychiatrists, which can be fulfilled by the professional body. Understanding and identifying the areas of deficits in training can help the professional bodies such as IPS in designing scientific programs, which can supplement the knowledge and competence base of its members. Further to understand the disparity across the training centers, we divided the participants into two groups. Few institutes which are considered to be of repute were included in the Group-I and remaining institutes were kept in Group-II. Authors in no way want to imply that institutes not included in the group are of inferior standards.

This study was first of its kind in India which tried to assess the ground reality of postgraduate psychiatry training across the country. Although the study included participants aged ≤45 years, the mean and median of duration of training including the years of postgraduate training were 8 and 7 years, respectively and about two-fifths (39%) of the participants were junior residents and senior residents suggesting that the survey results are the actual opinion of the trainees or of those who completed their training in recent past or were pursuing their training. The survey can be said to be representative of psychiatry training in the country as it covered respondents from 115 institutes/medical colleges, out of possible 230 postgraduate training institutes in the country. About half of the participants belonged to nine institutes, which have been involved in postgraduate psychiatry training for more than 27 years and are considered to be institute of repute in postgraduate training and also regarding research output in the speciality of psychiatry. Keeping this in mind, these institutes were clubbed together as a single group and information of all the other institutes was compared against this group.

The overall rating for the postgraduate psychiatry training was rated as “good/very good” by four-fifth of the participants, suggesting that the trainees were satisfied with the training they had received. However, when the training in different subspecialties/specific areas was evaluated, it was seen that training in some of the subspecialties (such as the child and adolescent psychiatry and geriatric psychiatry) and in many areas of psychiatry (such as repetitive transcranial magnetic stimulation [rTMS] and DBS, rehabilitation psychiatry, forensic psychiatry, psychodynamics, neuroimaging, psychotherapy, orientation to private practice, statistics, writing skills, ethical principles of research, women mental health, psychosexual medicine, research methodology, and neurology) was perceived to be “poor/very poor” by at least one-fifth of the participants. Moreover, participants from institutes other than Group-I category institutes, reported poorer exposure and inferior training in the above-mentioned areas except for forensic psychiatry, psychodynamics and orientation to private practice, training in which was reported to be poor across all the institutes. These results suggest that there is a variation in the psychiatry training in the country and there are many areas which are poorly addressed during the training period. Professional bodies such as IPS can prioritize its scientific programs across these themes to fulfill the unmet needs of the young psychiatrists. Some of the areas which can be considered on priority basis include forensic psychiatry, child psychiatry, geriatric psychiatry, neuroimaging and neuromodulation interventions. Forensic psychiatry training was rated as “poor/very poor” by majority of the participants in either of the groups. Considering the fact that in recent times, many new Laws and Acts have been enacted, which influence and guide the practice, there is an urgent need to improve the knowledge and competence of the young psychiatrists, so that they can align themselves with legal issues. Similarly, considering the fact that children and adolescents form a major proportion of population of the country and the geriatric population is on rise, there is a need to conduct hands-on training and workshops in these areas. In recent times, IPS has started travel fellowships for young psychiatrists, which provides opportunity to go to the institutes of repute for enhancing their skills.[13] Similarly, the residents/trainees from different institutes in which certain areas/specialty training is considered as deficit areas can be given priority for training in institutes of repute. Some of the deficits in the training can also be fulfilled by developing innovative training programs, such as online continuing medical education (CME) programs with credit points, which can act both as knowledge enhancing activities and also standardize the training. The present survey also suggests that the emphasis on psychodynamics is poor across the country. This possibly reflects that there is a need to improve emphasis on the psychodynamic theories in training and link it with emerging neurobiological theories.

Minimum basic knowledge about statistics, research methodology, and ethical principles of research are essential components of postgraduate training in any subject. The previous survey conducted by the IPS task force on postgraduate psychiatry training had also reported poor exposure of postgraduate trainees to rehabilitation services, neuroimaging, psychotherapy supervision, consultation-liaison and child psychiatry.[12] Findings of the present survey provide support to the same and suggest that there is a need to change the postgraduate psychiatry training and the curriculum too.

Regarding competence of the faculty who trained the participants, it was observed that the participants rated the competence of their faculty “good/very good” in all aspects except in the areas of rTMS/DBS, forensic psychiatry, rehabilitation psychiatry, psychodynamics, research methodology, and statistics. These findings suggest that professional bodies such as IPS should also focus on capacity building and enhance the skills of the faculty too so that the trainees can also benefit from their competence. Poor competence on the part of faculty on research methodology and statistics may be the reason for poor representation of Indian research at the international forefront.

An adequate exposure to academics during the training period of the residents helps in forming a strong foundation for the future. In addition, exposure to academics and subsequent self-evaluation of one's own performance in student-run seminars have been found to be quite helpful for overall growth of an individual academically as well as clinically.[14] The present survey revealed that the majority of the participants had adequate exposure to all types of academic activities except for psychotherapy forum. Similarly, training in different types psychotherapies in the form of adequate exposure, carrying out and supervision to different types of psychotherapy was also dismal for psychodynamic psychotherapies, rational emotive therapy, dialectical behaviour therapy, eclectic psychotherapy, and other kind of therapies with significant group differences in almost all types of psychotherapies. Based on the findings of the previous survey, IPS task force on postgraduatepsychiatry training had recommended that each student/trainee must undertake a minimum of 50 h of supervised psychotherapy and should submit one case seen in therapy for the evaluation as part of the internal assessment in the final year.[12] Findings of the present survey also suggest that there is a need to improve emphasis on psychotherapy training. At the organization level, IPS needs to organize CMEs with focus on psychotherapies and hands-on training for young psychiatrists and those interested. This will help in capacity building and improving patient care. In addition, developing close liaison with other professionals such as clinical psychologists and using online teaching programs can be considered to improve the training in psychotherapy.

The present survey also suggests that although three-fourths of the trainees are exposed to writing a draft of a case report and about half are exposed to writing the draft of an original article, exposure to writing other types of articles is dismal, across all institutes. As per the MCI, it is mandatory for a postgraduate trainee to present at least one research paper, one poster and publish or submit one paper for publication before appearing in the final exit examination.[12] Keeping this in mind, there is an urgent need to address this need of trainees and young psychiatrists. Over the last few years, publication subcommittee of IPS had started CMEs focused on young psychiatrists to improve their skills about analysis of data, making different types of presentations, and writing different types of articles and how to publish the same. Findings suggest that there is a need to scale up these efforts. Further, at the level of the journal, if an article is submitted by the young psychiatrist as the first author, the editorial board needs to provide guidance and support in the form of handholding training to improve the writing skills.

One of the heartening findings of the present survey was the level of satisfaction expressed by the participants with respect to the patient care activities. However, when the different groups were compared, it was seen that there was a significant difference between the premier institutes and other institutes.

Regarding perceived stress during the training period, the activities which were associated with higher level of stress perception included thesis and this was followed by stress related to academics, clinical documentation, regular assessment examinations, and administrative responsibilities. Data from other part of the globe also suggest that psychiatry residency is associated with a significant level of stress, emotional problems, poor sleep quality, burden, and burnt out.[15],[16],[17] However, an important fact to note was that higher level of stress was reported by trainees from premier institutes, suggesting that higher level of stress is associated with better training outcome and perception of competence by the trainee at the end of the training and later. This suggests that there is a need to develop training programs with optimal level of stress, without compromising on quality of training. There is also a need to sensitize the faculty about this issue so that they can note early signs of distress among the trainees due to academics and clinical duties and intervene in timely manner.

Regarding perception of one's own competence on carrying out various clinical, legal and research activities, it was noted that high proportion of respondents reported having good competence over the administration of modified ECT and making a presentation in academic for a just after passing degree from their institutes and at the time of survey (current competence). Yet, more than half of the respondents reported the need for improvement in other areas of competencies and the difference between those passing out of the premier institutes and those passing out from other institutes being significant. This finding again emphasizes the need to have training programs at the level of IPS to improve training in psychotherapies, forensic psychiatry, enhance skills to do private practice, writing research proposals, and statistics.

This survey has certain limitations. First, this survey included psychiatrists who were aged <45 years. This meant that many of them would have completed their training few years back. Hence, it is quite possible that their reporting about their training could have been colored by recall bias. Second, the survey evaluated the broad areas of training and may not necessarily reflect the whole training. Third, the reporting of the training does not necessarily reflect the available infrastructure. Fourth, it is also quite possible that the responders own bias toward their Alma Matar could have influenced either positive or negative evaluation of training. Fifth, no structured assessment tool was used to assess competency, perceived stress, and individualized opinion on different aspects of psychiatry training. Finally, the categorization of centers into two groups was arbitrary and does not necessarily reflect that all other institutes not included in Group-I provide poor training.

To conclude, the present survey reflects that there is a variation in the psychiatry training in India. Accordingly, it can be said that there is a need to develop a model for competency-based training program at the level of IPS in consonance with training regulatory bodies like MCI, which can be implemented across the country to harmonize the training. Further, this survey reflects that there is deficiency in training in the areas of geriatric psychiatry, child and adolescent psychiatry, rTMS/DBS, rehabilitation psychiatry, forensic psychiatry, neuroimaging, women mental health issues, psychodynamics, research methodology, psychotherapy teaching, and supervision and statistics. Moreover, the competence of the faculty training the trainees is also suggested to be poor in certain areas such as forensic psychiatry, rehabilitation psychiatry, psychodynamics, research methodology, and statistics. Accordingly, it can be said that IPS should focus on capacity building in these areas so that training in these areas can be improved.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Prof. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_334_18

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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