Maryalicia Post shares some hard-earned tips for visitors to the French capital
What do Gene Kelly and I have in common? Singing? Dancing? No, and not a cheeky grin either. He and I were each An American in Paris. In his case it was for two hours in the famous film; in mine it was for six years in real life. In that time I made a few observations that might be helpful to anyone planning a visit. I realise they are only my conclusions seen through the lens of my personal experience, but if they’re of any use to you – you’re welcome.
1) The French are ‘serious’… by which I don’t mean they are reluctant to laugh. I mean shop attendants, waiters, bus conductors et al seem to have a more professional approach to their job than you might find elsewhere and expect to be treated with due courtesy. On going into any shop greet the staff with ‘bonjour’. (If there are other customers include them with a smile). In a bakery, for example, do not rush in and snap ‘one croissant’. Start with Bonjour and end with Merci.
2) You can’t go wrong if you wait to be shown where to sit, even in an informal cafe. If in any doubt, just stand and look bewildered; someone will point you to a seat, and you’re off to a good start.
3) Don’t feel rebuffed if sales attendants ignore you. In most cases the custom is for them to be available when/if you want help and to stay away until addressed. And, nothing personal, but a French waiter is not automatically your new friend. A smile may not be on the menu.
4) Expect your appearance to be checked out by both men and women in public places like the Metro. Parisians go to some trouble to look their best and assume you do too; being invisible is not the goal.
5) In general, don’t go looking for examples of ‘how rude the French are’. Don’t construe a runny omelette, bloody lamb or smelly cheese as indifference. Au contraire. It’s the way ‘they’ like it and they assume any reasonable person would as well. Make a polite request for a change if necessary.
6) Use whatever French you have. I got used to asking a question in French which would be answered patiently in English, leading to my next question in French, also answered in English… a kind of bilingual duet. When the answer comes in French, buy yourself a drink.
7) If you can’t walk to your destination even in your most comfortable shoes (which you should bring for this very purpose), take the Metro. The best reason for taking the Metro is to avoid taking a taxi. Here’s a useful Metro guide.
8) Are there really rude people in Paris? Oh yes, and they all drive. If you take a taxi you may well find yourself up close and personal with a very rude person indeed. He or she may pretend not to know where you want to go – I always write out the destination and show it in advance – or will bury you under an avalanche of explanations in French as to why he or she is approaching the city via Versailles. Meanwhile, the meter runs on. I pre-book a car to meet me at the airport as this scam seems endemic at CDG. However, if you must, well, c’est la vie. Here’s a good guide to taking a taxi in Paris.
Bon voyage and merci.
How one hospital built awareness and leads by drawing from the digital marketing toolkit
I think it’s common knowledge now that if you want a healthy body, there’s no magic bullet. The celery diet is neither sustainable nor effective alone. You need to combine a balanced diet with an active lifestyle, plenty of rest and recuperation, and a positive mindset. It’s this combination that achieves the best results.
We can apply this concept to your practice. If you want a healthy marketing function, you can’t rely on a panacea to solve all of your marketing challenges. Equally, you can’t expect a shotgun approach to work either – firing as many pellets as possible and hoping something hits. The best results come from a synergy of approaches aimed at very focused objectives.
In 2018, the ESCRS Practice Management Conference set its attendees a challenge; create a marketing campaign that:
Helps create awareness about the practice clinic;
Results in an increase in inquiries and new patients that translate into additional revenue.
Ready to take on the challenge using a multidisciplinary approach was The Beirut Eye & ENT Specialist Hospital (BESH).
BESH is one of the top specialist eye hospitals in the North Africa and the Middle East region. It offers a complete range of services covering all subspecialties in the ever-growing field of ophthalmology.
BESH took the criteria set out by ESCRS and designed a digital marketing mix to generate awareness about glaucoma and promote the company. And it won!
In fact, it exceeded all expectations; reaching thousands of individuals, screening hundreds of patients, collecting data for more than one-thousand patients and scheduling hundreds of follow-up consultations.
Sharing the company’s success story at this year’s ESCRS will be BESH General manager and Director, Michael Cherfan.
He will be revealing the company’s winning approach and sharing helpful advice and tips so that you too can leverage digital media to improve awareness of your clinic, increase inquiries, attract new patients and ultimately drive revenue.
Specifically, he will explain how you can design an interdisciplinary digital platform that focuses on four main channels:
SEO / Google
By the end of this presentation, you will have the knowledge and awareness of how one clinic completely revamped their digital presence to benefit from improved publicity and more leads.
The ESCRS Practice Management and Development Programme will take place on Monday 16 September from 08.00 – 18.00
Divers come to manta ray's aid as ophthalmology goes underwater
Giant manta rays can reach up to seven feet in length. That’s a whole lot of body to come up against whatever ends up in our seas and oceans. One such ray recently found herself with metal hooks in her eye. Thankfully, some conscientious divers were on hand to help out the poor creature.
“I went for a few dives down just to see how she’d react to us being close to her,” said Jake Wilton, photographer and diving instructor.
“This wasn’t my imagination, again and again it came back, turned over, and paused in the water, and – plainly – was looking to us to be helped,” added Monty Halls, photographer, naturalist and marine biologist.
Just like in ophthalmology, the doctor had to gain the trust of the patient.
“Jake went down again and again and again and the animal didn’t move away, because I think the manta knew that Jake was trying to get the hooks out,” Halls said.
He managed to remove the hooks with pliers, to everyone’s relief.
“I went down again one last time to say goodbye – she actually stopped and just waited there,” said Wilton.
Freckles and Jake's story has just featured on @thismorning! Amazing to see that it has reached so many – really demonstrates the power of video and an incredible story! #MondayMotivation #AnimalRescue #FilmProduction #MarineLife pic.twitter.com/hNhgHvKUJN
— Seadog TV & Film Productions (@SeadogProds) July 15, 2019
“Many divers dive ‘to get away from it all’, to disappear into a place completely separate from the rest of the world,” says vitreoretinal and cataract surgeon and diving enthusiast Leigh Spielberg. “It is a form of escapism into the beauty and silence of the sea.
“One’s day job is usually as far from one’s mind as possible while exploring under water. However, in this video, the divers were confronted with what might be considered an ophthalmic emergency; a hook was lodged in or around the manta ray’s eye,” he said.
“As someone who has operated my fair share of ocular trauma, I am aware of the difficulty and potential danger associated with ocular foreign objects, but these divers, presumably non-ophthalmologists, seem to have done a great job combining their hobby with impromptu ophthalmic care for this gentle giant,” Dr Spielberg concluded.
The prompt I needed to declutter my email inbox
I got an email from my potted palm the other day. I was reminded of the letters I sent home from summer camp when I was a kid. No preamble, no ‘hope you’re well’.. Just straight into the complaint. The plant was reporting that it was thirsty and needed more sunlight. As it happened, I felt exactly the same, so I could hardly blame the plant. Still, receiving an email from a palm tree reminded me I’d been meaning to cut the clutter in my email box… and prodded me to start looking at all the good advice out there on the net.
If you are finding a marked increase in the volume of your email, it may be helpful to know it’s not you – it’s us. It’s a worldwide phenomenon. As a travel writer, for instance, I’m getting email from the tourist bureau of every place I’ve ever visited including some I hope never to visit again. Although the inbox of an ophthalmologist or other medical specialist is not as overloaded as that of general practitioners, there’s no escaping the trend and the overall trend is up across the board (regardless of your field of endeavour). An article in MD focuses on the physician’s problem and offers suggestions for dealing with it. Another handy list of tips is here.
Perhaps you’ve chosen to offer your patients the option of email communication with you – and there are arguments for and against offering this service. If you have opened email communication with patients, you’ve probably set up a secure email address for the purpose and may well have messages screened by an assistant, which makes life easier. Detailed advice for managing patient emails can be found here.
All this negative talk about emails doesn’t paint the whole picture. One article describes emails as “an exciting landscape of freedom amidst the walled gardens of social networking and messaging services”. It talks about the feeling we all sometimes experience when a welcome message comes bounding in; it concludes that “email is exciting”.
And so it can be. To be honest, I didn’t really mind receiving that message from a thirsty plant and was glad to be reminded to water it (as for the sun shortage, I’ve ordered a grow light). Obviously, I could unplug the Bluetooth-enabled gizmo I stuck in the soil, thus cutting off communication at the root. But I’m not sure I am ready to ghost the palm tree so early in our relationship. A message from a potted palm seems ‘special’, like hearing from a distant star. Come to think of it, I’ll probably find a transmission from a distant star in my inbox one day. And when I do, it will be exciting.
Maximising patient flow in a busy refractive clinic starts before patients arrive
I’m excited to welcome Arthur Cummings to the Practice Development Workshop that I’ll be moderating at the 37th Congress of the ESCRS this September. In Paris, he will present a session called “Optimising Patient Flow in a Busy Practice”. Having consulted in busy refractive settings for the past 20 years (including Mr Cummings’ practice), I have accumulated a wealth of experience in planning effective patient pathways – especially before patients have surgery. In this article, I share my top tips for maximising your patient flow before and during first appointments.
Send an effective confirmation email
Maximising patient flow in a busy refractive clinic starts before patients arrive for their first appointments. Begin with an effective appointment confirmation letter. Here’s the outline I recommend:
Begin enthusiastically and continue that tone throughout the letter
Write personally, from a real person to another real person – avoid stuffy corporate-speak
Take personal responsibility for your patient’s experience and let them know who is responsible to answer their questions before they visit
Mention the date and time (in bold print) within 15 seconds of reading
Tell your patient exactly what you’ll do at the appointment in bullet points – this is your opportunity to show value
Tell your patient how long they can expect to be there (this is crucial to avoid patients needing to leave before you’re done)
Tell your patient how much they can expect to pay (using guide price ranges) should they wish to commit to a procedure so that you can qualify and prepare patients financially
Tell your patient how to prepare for their appointment using a numbered list (what to bring, what to do)
Provide specific instructions related to any attachments you send (maps, questionnaires, registration forms)
Finish with an open invitation to ask questions or change their appointment
Send a follow-up message to the patient’s mobile phone
We get so much email today, many people fail to check it. Nearly everyone, however, looks at text messages on their phones shortly after they arrive. I recommend sending an SMS or WhatsApp message to patients a couple of days before their appointment. In the message, write something like:
“We’ve sent you important information relating to your upcoming appointment at [our clinic]. Check your email.”
That should prompt the patient to check their email so they have the information they need, saving you time down the road.
Plan your clinic day to convert the patient at the first appointment
To perform a reasonable volume of refractive surgery, you need to dedicate a floor’s worth of your clinical space and a team that devotes its day to efficiently processing first appointments. I appreciate that not every clinic chooses this route. However, if you want to do this, this is my best plan for it.
I recommend your clinical team starts every day with a daily huddle that everyone seeing patients that day should attend. That includes receptionists, patient liaisons, healthcare technicians, optometrists and surgeons. During the huddle, share wins, share MTD (month-to-date) numbers, follow-up on errors and go through every patient’s top line notes made by the booking team. Anticipate, discuss and then plan accordingly for circumstances that might affect today’s diary.
For every patient, I recommend the following timeline assuming a patient arrives at 8:45am:
8:45am: The patient arrives 15 minutes before their appointment begins in your diary (if you book a patient in for 9am – have the booking team tell them their appointment starts at 8:45am). That accounts for lateness and enables on-time patients to complete necessary registration forms before someone needs to see them. This is the receptionist’s opportunity to make the patient feel at home and help them transition from their journey into the appointment. Relaxed patients make for cooperative patients.
9:00am: The patient liaison should see the patient for 10 minutes (I allow 15 minutes) in a private room. This gives the patient liaison time to lead the patient through a discovery questionnaire (in private). This step helps to clarify expectations for the patient and prepares the clinical team to address the patient’s emotional needs. You may imagine this might be an unnecessary luxury of time and space, but it can save a lot of time down the road and definitively improves conversion rates.
9:15am: In a flexible refractive surgery pathway (allowing for assessments for both laser vision correction and lens surgery), a healthcare technician will need 30 minutes to perform the necessary assessments. I recommend two diagnostic rooms so you can swap post-ops in-between first appointments for maximum efficiency.
9:30am: In the UK, optometrists can assess a patient for vision correction suitability and recommend a treatment plan. In this scenario, I favour having the optometrist doing most of the initial work-up because they are a less expensive resource compared to a surgeon. I recommend 45 minutes for this part of the appointment. If your setting doesn’t allow for this scenario, an optometrist can see the patient for 30 minutes and then a surgeon must see them for 15.
10:15am: Now, the patient goes back to the reception room where the patient liaison sees them again for up to 15 minutes to offer dates and times for the surgical and consent appointment with the surgeon. That should give them enough time to answer administrative questions, ask for a payment, overcome objections, and provide the patient with the takeaway information they need.
If you have a surgeon available during the clinical day, then I recommend having the patient go through a 15-minute consent appointment with the surgeon on the same day – immediately following their visit with the patient liaison – whenever possible. If you do not have a surgeon available on the same day, then you’ll need to book this appointment at a mutually convenient time before the surgical appointment.
Ideally, my patient pathway plan relies on having two patient liaisons, two healthcare technicians, two optometrists and one (optional) surgeon (if you want post-op support and same-day consents) on the clinic floor.
Regarding space, my plan relies on two private rooms for patient liaisons, two diagnostic rooms, two optometric lanes and one (optional) surgeon’s office (again, if you want post-op support and same-day consents) on the same floor.
My plan allows everyone to get a 30-minute lunch. Furthermore, I schedule the patient liaisons to cover reception when they go on staggered lunch times.
As a buffer to account for lateness and unforeseen events, I add 15-minute buffers between tests and exams to allow for late patients.
With my plan, you can see eight initial refractive appointments per day. Double up the diary and you can see 16 initial refractive appointments and still see all the necessary post-op appointments in between. To the left I share a sample of a diary I planned for a busy refractive clinic in London, UK.
I hope you’ve found this useful. With the necessary customisations, you can apply this to your own setting. If you need assistance, contact me at firstname.lastname@example.org
Why is it you can often struggle to innovate when it comes to marketing or enhancing customer service?
Innovation is the art of introducing something new, and cataract and refractive surgery have an impressive history of innovation. Think:
Phaco and small incisions
Refractivisation of cataract surgery
As an ophthalmologist, your practice constantly challenges you to think divergently, come up with new solutions for patients and pivot when initial ideas fail in order to achieve the results you want. It’s in your nature. So why is it you can often struggle to innovate when it comes to marketing or enhancing customer service?
Perhaps you just need some inspiration. Here are some useful ways you can foster innovation within your practice:
Be a conscious consumer. Whenever you’re engaging with any business as a customer, ask yourself, what’s the story they’re selling? Who is the ideal customer they are trying to attract? How do I differ from that? How do I fit? What stage of the sales funnel am I in? What phase of the customer value journey am I at?
Hundreds if not thousands of messages impact you every day. Consume consciously and you’ll be on the way to picking up valuable ideas and lessons from your daily interactions with companies.
Maximise everything. When you see robust marketing communications or experience superior customer service, ask yourself – how could I apply this to my practice? How would I make this even better? How could I make this even more customer-oriented?
Copy existing ideas. You don’t need to reinvent the wheel or be the first person in the world to come up with an original plan. The most creative people also tend to be excellent copiers. The famous composer Igor Stravinsky supposedly said: “Immature artists copy, great artists steal.” That doesn’t mean to plagiarise. Instead, find inspiration in the work of others, then use it as a starting point for original creative output. What great ideas already exist that you could apply to your practice?
Generate lots of bad ideas. Self-censorship is the thief of creativity. Don’t reject your ideas too early. Just get them out (write them down, speak them out) and only evaluate them on their merits once you’ve spent all of your creative juices.
Embrace constraints. Some would argue that constraints are a necessary condition for innovation to occur. How can you make the boring, sexy? How can you get attention with no money? How can you stand out in a sea of established competitors? How can you make a commodity feel like an experience?
When faced with limited options, you’ve got to think your way out of a little box – and therein lies the breakthrough.
Remember, ideas are typically free and when executed with enough flair and passion can bring huge rewards even on a tight budget.
If you’re an ophthalmologist with an innovation that enhances patient services, you should enter the ESCRS Practice Management and Development Innovation Award 2019.
Shortlisted entrants will be invited to give a presentation on their projects at the 37th Congress of the ESCRS in Paris. The winning entrant will receive a €1,500 bursary to attend the 38th Congress of the ESCRS in Amsterdam, The Netherlands in October 2020.
Go here to enter.
Simple steps can help you on the pathway to happiness
There was a time when happiness was for children and newlyweds. Times change. Research confirms that happiness contributes to health and productivity. Consequently, being happy is recognised not as an optional extra but as a necessary component of a healthy lifestyle. Ophthalmologists are already in an advantageous position in the happiness stakes. When the happiness quota of a variety of medical specialties is surveyed, ophthalmology always figures highly; this year it was at number 8 of 29 specialties reporting.
As happiness contributes to creativity, productivity and longevity, why wouldn’t you check once in a while – ‘am I happy?’ You’re probably already pretty sure you know the answer, but should you be in any doubt here is an app to help. And if you discover you are not happy, there is plenty of advice on the web for turning the situation around.
I’ve had a look at 15 Habits of Incredibly Happy People, 10 Scientifically Proven Ways to be Incredibly Happy and the marginally less self-assured 25 Habits to Help You be Happy.
Aside from the impression that being able to count is the pathway to happiness, I’ve also garnered enough advice to formulate a plan. I’ll it call it the Happiness Five a Day.
Here it is:
1, 2, 3: Be kind; grateful; generous
We all know how to be do this – the warm smile, the sincere compliment, the understanding when things go wrong – consciously practising these virtues daily really does makes us happier.
4: Follow your dream
To give happiness a boost, find something to be excited about, a special interest that makes you glad to wake up in the morning. Need inspiration? Read this.
5: Nurture your relationships.
Maintain a healthy balance of life/work. If you aren’t sure you are in optimal balance, check it out here. If you discover you’re teetering, there are tips for improving your balance here and here. And remember, ‘no one ever died wishing they’d spent more time at the office’. Regretting not getting the life/work balance right is as poignant for an ophthalmologist as for anyone else.
Happiness is not finding this out at the last minute.
Rod Solar, Practice Development Consulting Director of LiveseySolar Practice Builders, previews one of the programme highlights from this year’s ESCRS Practice Management and Development Programme
Ten years ago, when a prospective eye surgery patient received a word-of-mouth referral, read a promotion or saw an article about a particular surgeon, they would simply pick up the phone and call the practice directly to discuss their options or book an appointment.
In today’s environment, however, the prospective patient’s first port of call is to scour the internet for options. In just 10 minutes when they have already conducted 10 online searches, not only would they have reviewed the recommended surgeon’s website and online presence, they would have visited five more practice websites, reviewed the social media platforms and perused each and every customer review out there.
You are what appears online
David Evans, CEO of Ceatus Media Group and ophthalmologist, explains that Google does not rank surgeons, it ranks websites and web presence. When people are making buying decisions, they look to the internet and make judgments on the quality of the patient experience and surgical outcomes based on what they see online. “It’s not entirely fair, but this is the reality,” he adds.
So how does an eye surgeon capture the attention of a prospective patient in a world saturated with so much accessible online information? Evans hopes to answer this question during his practical workshop on the Monday of the 37th Congress of the ESCRS in Paris, France.
Just like investing, Evans believes that you should never put all your eggs in one basket, and digital marketing is no different. You need to spread your digital assets to ensure touch points across the full internet spectrum, ie diversification.
Throughout the session, Evans will demonstrate the very best practices for website development, social media, reviews and other digital touch points, to increase a website’s online visibility and make it easier for prospective patients to access both surgeon and procedure information.
Attendees will also be informed of how the wrong strategy could actually have negative impact on the practice, and how a tailored diversified approach is the only way to be truly successful.
By the end of the workshop, attendees will have all of the necessary knowledge to fine-tune their digital strategy and excel in revenue growth. They will have acquired all of Evans’ useful tips and tricks on the implementation of external marketing to boost search engine rankings, apply an effective social media strategy, develop a positive reputation online with a reviews strategy and, most importantly, will know how to convert website visitors into consultations.
Evans will conclude his presentation with a section devoted to evaluating and improving Return on Investment.
All ophthalmologists will have bad days and failures, but that is part of the learning curve
We all have our bad days. Some days are worse than others.
I am not an ophthalmologist, but I can confidently say that my failures on a daily basis outweigh my successes.
Ophthalmologists pride themselves on their attention to detail and on their ability to deliver the best results to their patients.
Do they ever go home and say to their partners or friends: “Today, I failed.”
I don’t think they do, as failure is usually not an option for high-achieving, highly motivated medical professionals.
That brings me to a recent article by the musician and writer Tracey Thorne who wrote on failure in the New Statesman magazine.
“…….failed job interviews, infertility, divorce, illness. Human frailty, vulnerability, and, ultimately, that one great failure none of us can avoid, mortality – they glue us together, or should do,” said Thorne.
I immediately recalled Thorne’s article when I listened to a EuroTimes Eye Contact interview with Dr Sorcha Ní Dhubhghaill, who discussed what trainees should look for in a mentor and what mentors can offer in that role.
Dr Ní Dhubhghaill is ideally placed to discuss this role having made the transition from trainee to her current position as Corneal Surgeon at Netherlands Institute for Innovative Ocular Surgery (NIIOS) and Antwerp University Hospital.
“There is a saying ‘The master has failed more than the trainee has tried’,” said Dr Ní Dhubhghaill. “When you see this amazing surgeon doing amazing surgery, so quickly and so elegeantly, you may wonder ‘how will I ever get there’.
“You have to remember that the surgeon you are observing did not come out of medical school doing that. They have had bad days, they’ve had failures.”
Dr Ní Dhubhghaill said that part of her job as a mentor is to try and convince young surgeons not to quit out of the surgical programme.
“Every young surgeon, when they have their first complication, sits at home, loses sleep and wonders ‘should I have let somebody else do this procedure?’ You need, as a mentor, to help them over these roadblocks because you have to remember that someone helped you over your roadblocks,” she said.
Dr Ní Dhubhghaill says she was very lucky to have great mentors including Peter Barry and Marie-José Tassignon. “They both helped me over these hurdles when I didn’t want to continue, and now I love it.”
In one of his last works, Worstward Ho (1983), the great Irish writer and Nobel laureate Samuel Beckett wrote:
“All of old. Nothing else ever. Ever tried. Ever failed. No matter. Try again. Fail again. Fail better.”
Beckett’s work is often misinterpreted, but it is possible to argue that what he is suggesting here is that there is no such thing as absolute success or failure.
And that is why ophthalmologists should always remember that to err is human.
Enhance your trip to Athens with some timely background reading
The past is present in Athens. Perhaps it’s because the Parthenon looks down like a benevolent schoolmaster, prompting questions – who, where, when?? If your Greek history is now only a faint memory, why not brush up before you get there for the 23rd Winter Meeting of the ESCRS? A good place to start is with Edith Hall’s book Introducing the Ancient Greeks.
It’s Professor Hall’s theory that the Greeks exhibited 10 specific character traits that supported the miracle that was Greece. The character traits were: an appreciation of the sea, being wary of authority, highly individualistic, of an inquiring mind, receptive to new ideas, witty, competitive, prepared to pursue excellence, elaborately articulate and addicted to pleasure of all kinds. The book is organised into 10 chapters, each pairing one of these traits with the country’s unfolding history from 1600 BC to 400 AD. Interesting and informative, the paperback earns its place in your carry-on luggage or can be downloaded to your Kindle app.
If a visit to Asklepios is on your Greek agenda, or even if it’s not, consider Asklepios, Medicine, and the Politics of Healing in Fifth-Century Greece: Between Craft and Cult. It’s a hardback, so both weighty and expensive, but it’s an engrossing examination and comparison of the practices at Asklepios and those of Hippocratic medicine of the same period. The author, Professor Bronwen Wickkiser, is a specialist in ancient Greek history and culture, especially the intersection between religion and medicine. In a subsequent book, The Thymele at Epidauros, she looks at performance, architecture and acoustics in a Greek healing sanctuary as they relate to music therapy .
If you’re a bit shaky on Greek mythology, now’s the time to remind yourself who was Pandora’s brother-in-law and how long Odysseus was away travelling. There’s a bit of a vogue for retelling the stories in breezy modern dialogue; one example of this approach is Stephen Fry’s book Mythos; another is Robin Waterford’s The Greek Myths: Stories of the Greek Gods and Heroes Vividly Retold. Traditionalists might prefer the classic version by Robert Graves: The Greek Myths: The Complete and Definitive Edition (Penguin, 2017). Available both in paperback and on Kindle.
And if you’d rather catch up ‘on screen’, try The Greeks: Crucible of Civilization.
Narrated by Liam Neeson and with beautiful photography of ancient sites, the 180-minute long documentary was produced by PBS.
The 23rd Winter Meeting of the ESCRS will take place in Athens on February 15-17.