It’s Getting Hot in Here:  The Latest on Physician Burnout

by Steven Adelman, M.D.

A recent study* published in the Mayo Clinic Proceedings lends further evidence to what some are starting to refer to as the mounting occupational health crisis in health care.  Between 2011 and 2014, an objective measure of burnout now registers 54% of practicing physicians as “burning out” (up from 46%).   Physicians in high burnout specialties like family medicine, internal medicine and emergency medicine are experiencing burnout at a rate of approximately 60% !  As physician burnout increases, the work-life satisfaction of physicians has decreased from 49% to 41%. 

This is a large study with a non-physician, general population control group.  The burnout rate of other US adults is much lower and not increasing.  As physician work-life satisfaction decreases, others in our society are becoming more satisfied.  Physicians work an average of 55 hours per week as compared to 40 hours for non-physicians.  And we are 75% more likely to experience suicidal ideation in the course of a year (7% vs. 4%). 

Accompanying this eye-opening burnout study is a provocative editorial by William Lanier, MD, editor-in-chief of the Mayo Clinic Proceedings and Dan Ariely, Ph.D., a professor of psychology and behavioral economics at Duke.  They hypothesize that the following 3 factors play a significant role in the burnout and dissatisfaction of practicing physicians:

  1. Asymmetrical Rewards
  2. Loss of Autonomy
  3. Cognitive Scarcity

Asymmetrical Rewards: In our industrialized “zero defect” environment, physicians are expected to deliver excellent and cost-effective care in a fashion that delights every single patient.  In many systems, there is a relentless focus on the practicing physician’s imperfections.  A busy internist may see 30-40 patients in the course of a day in the office.   If a single patient complains that the doctor seemed rushed and unsympathetic, that complaint may become the focus of a time-consuming sit-down that may take on a life of its own.  The positive care experiences of the overwhelming majority of the physician’s patients fade in comparison to the hassles and scrutiny brought on by a single patient complaint.

Loss of Autonomy:  Practicing physicians, especially those who are employed and those who work in primary care, now answer to a coterie of masters.  A bevy of metrics, initiatives, guidelines, prior authorization busy-work and required protocols now jockey with click after click on the electronic medical record to take up the majority of one’s time in the office.  Although the doctor-patient clinical encounter remains at the heart of medical practice, non-value-added intrusions get in the way at every turn.  Here in Massachusetts, some patients come to the office armed with an agenda that they expect their physician to follow.  One internist I met last month was rather taken aback when he tried explaining to his patient why it was unwise for him to switch her to a new medication she had seen advertised on TV.  The patient’s comment to her physician was a curt, “How dare you not listen to me? What are you – an idiot?”  Along with a loss of autonomy, many of us also experience a troubling loss of respect and status.  

Cognitive Scarcity

This refers to the challenge of making complex decisions at a breakneck pace.  ORs are tightly scheduled.  Physicians in office practices are over-booked, with same day requests squeezed in to enhance satisfaction scores.  Changes in coverage and societal ills like drug addiction have many emergency departments filled beyond capacity.  To many physicians, the practice of medicine feels like a game of “Whack-a-Mole.”  But patients are not moles; they are fellow human beings, with serious illnesses, complex problems, life and death concerns.  After Captain Sully landed his plane on the Hudson River he was given 6 months off to recover from the trauma.  Practicing physicians do not have the luxury to recharge their batteries – the onslaught of pain, suffering and rapid-fire decision making is incessant.  The enormity of all of this requires us to reflect and recover, yet we lack time buffers to regain our footing and equanimity.  This depletes us; hence, burnout.

Ariely and Lanier do not offer a concrete fix for a system that is dehumanizing the central figures upon whom it relies.  The profession has changed around us, yet our macho culture and industrialized work environment have failed to accommodate to the reality of this occupational health crisis and the burnout it is producing.  It’s time for us to step up, as individuals, groups, organizations and systems, to identify and address the root causes of a phenomenon that threatens the health and well-being of the best and the brightest. 

*Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014.

Shanafelt TD et al. Mayo Clin Proc. 2015 Dec;90(12):1600-13.

Steven Adelman, M.D., is director of Physician Health Services, a non-profit corporation founded by the Massachusetts Medical Society.

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Doctor: Care for Thyself

Helping handBy Charles J. Hatem, M.D.

It is ironic that we commit our professional work to the care of others, yet often fail to care for ourselves as well as for the significant others in our lives. The disturbing reasons that underlie this reality are many, but the “final common pathway” carries the potential for burnout, impacting ourselves, those close to us, and the care we provide.

Burnout, as characterized by Dr. Christina Maslach, is marked by emotional exhaustion, detachment, and a lack of fulfillment. Burnout is pernicious because of the dysfunction and disability it leaves in its wake, making its prevention vital for a personal and professional life that is balanced and fulfilling.

Recalibrating this reality demands that we step back, reflect, and commit ourselves to reengage the commitment that brought us to medicine. Much like our advocacy for prevention in health care, we ought to be focused on initiatives that deal with wellness and forestall burnout before it materializes.

Framework for Well-Being

As Craig Irvine puts it, “We are ethically obligated to care for ourselves.” Linda Clever, M.D., a prominent physician leader in renewal initiatives, issues a similar reminder. “Taking care of yourself is not selfishness, it is self-preservation,” she writes.

Accomplishing this requires attention to advice we liberally dispense to others: getting enough rest, eating sensibly, exercising, cultivating interests outside of medicine, avoiding “chemical coping” as a strategy for dealing with problems, taking regular vacations, and many other beneficial “interventions” well-known, but often ignored, by us. Without the framework for personal wellness in our own lives, we are not in a position to afford aid others.

Caring for Significant Others

How often do we discuss our life priorities with those close to us? How often do we ask for their validation about our plans? We need to remain connected to our family, significant others, colleagues, and friends — connections requiring an appreciation of the centrality of others in our lives.

 Work

Our well-being is intimately connected with our work and comes from remembering and valuing the joy inherent in caring for others. Joy that comes from the daily application of our scientific skills and our talents for listening and caring. As wonderfully stated by Christine Cassel, president and CEO of the American Board of Internal Medicine, “Medicine is, at its center, a moral enterprise grounded in a covenant of trust … dedicated to something other than its own self-interest.

Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it.” Our role as physicians is demanding and asks us for a measure of equilibrium as we confront economic and regulatory pressures. Yet, we are afforded the privilege of caring for others in moments of health and in times of struggle and death.

Values

This most vital and sustaining life lesson, interwoven with a pursuit of kindness, mindfulness, humor, curiosity, a desire to learn, and daily lessons of humility that the practice of medicine brings, all serve to encourage the wellness essential to our lives as practitioners and individuals striving to lead a full life. Without the emphatic attention to all of these issues we cannot sustain our caring for others and ourselves.


Dr. Hatem is chair of the Department of Medical Education at Mount Auburn Hospital in Cambridge, Mass. This article first appeared in the February 2012 edition of the Massachusetts Medical Society publication Vital Signs.

Physician Health Services, Inc., is a non-profit corporation founded by the Massachusetts Medical Society. PHS  provides confidential consultation and support to physicians, residents, and medical students facing concerns related to alcoholism, substance abuse, behavioral or mental health issues, or physical illness. PHS also provides a safe environment where physicians can talk to other physicians about the stress and demands of modern medical practices. For more information, visit the PHS website or call PHS at (781) 434-7404.

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Avoiding the Slippery Slope

slippery slopeBy Debra Grossbaum

 As a general rule, most doctors are rule followers. They are typically aware of the basis for structured parameters and are willing to take the steps necessary to do things properly. However, doctors are also generally pressed for time, resources, and compensation.

These deficits may lead even the best physicians to succumb to shortcuts, some of which may seem quite harmless, but which may lead to unforeseen and quite consequential outcomes.

Technology

One area of potential risk is in the area of technology. While we now revel in this age of immediate communication, we may not be fully focused on the potential pitfalls of computer and cellphone communications.

For example, a physician was trying to wrap up the last few patient calls of the day when he chose to use his cellphone instead of his office line, so he could talk while heading out of the office. He didn’t consider that by calling on his cell, he was disclosing his personal number to several patients. At least one patient took this as a suggestion that the call was more of a personal nature than was intended, and another later used the number to contact the doctor for inappropriate questions at inappropriate times.

While such calls would otherwise be vetted by a receptionist, this physician now found himself in quite an uncomfortable position that was clearly unintended. Similarly, physicians may use personal email addresses to zip out quick responses when pressed for time.

However, by doing so, not only is the patient receiving the doctor’s personal contact information, but there is also a likelihood that the personal email account lacks the type of encryption required for physician/patient communications.

While the communication may seem benign, just the fact that a patient has come to you as a physician may be sufficiently protected information as to constitute a confidentiality violation if disclosed without proper encryption.

Collegial Consults

Another prevalent, but dangerous, dynamic is the proverbial “curbside consult.” Most physicians acknowledge that care should be provided in the context of a formal doctor/patient relationship, with an exam and patient record.

Many doctors also feel justified in seeking a quick prescription from a friend when pressed for time, especially when the medication is common, or the asking physician appears confident that it is an appropriate use.

However, the risks here may be much more extensive than considered. Ultimately, the physician who is providing the prescription will be held responsible for the care, so if the colleague is abusing the medication, or has a negative drug reaction, the well-meaning colleague may be liable.

Also, sometimes the medication or the casual consult can interfere with necessary medical care. One physician casually and regularly provided a colleague with medication to treat what was assumed to be a migraine headache.

Ultimately it was learned that the physician-patient was suffering from symptoms of a brain tumor. The tumor went undetected for the duration of the time that the colleague provided the analgesic without conducting a complete exam.

Prescriptive Practice

Patients can be very persuasive when it comes to seeking medications. They may describe pain, psychological distress, insomnia, or a variety of other symptoms that are hard to quantify, confirm, or refute. With little time, and an anxious patient, it can seem easiest to just write a quick prescription.

While medication is often necessary, it is important to take the time to use all of the resources available to support the necessity of a prescription, especially for substances that are potentially abused. Even when time is short and pressure is on, it is essential to check the state’s online Prescription Monitoring Program. This can provide critical information as to whether the patient has already obtained medications elsewhere.

Also, whenever possible, gather objective data to confirm or rule out a diagnosis before prescribing. This might include MRI, comprehensive physical exam, or even an independent pain consult. While patients might balk at these extra steps, taking them at the front end may preclude a cascade of subsequent consequences.

We are all faced with daily demands competing for our time, and we have to make quick decisions to best allocate our time and resources. When doing so, as a physician, it is helpful to be mindful of the importance of protocol and the purpose of such protocol before agreeing to take steps, even baby steps, away from the rulebook. It is well worth the time.


Debra Grossbaum is General Counsel for Physician Health Services. This article first appeared in the May  2014 edition of the Massachusetts Medical Society publication Vital Signs.

Physician Health Services, Inc., is a non-profit corporation founded by the Massachusetts Medical Society. PHS  provides confidential consultation and support to physicians, residents, and medical students facing concerns related to alcoholism, substance abuse, behavioral or mental health issues, or physical illness. PHS also provides a safe environment where physicians can talk to other physicians about the stress and demands of modern medical practices. For more information, visit the PHS website or call PHS at (781) 434-7404.

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“I Had No Idea I Could Get in Trouble for That!”

Guidelines for Physicians and Recreational Alcohol/Drug Use

By Steve Adelman, M.D.

Attorneys who help physicians with employment and licensure issues are used to hearing doctors utter those words. The recreational use of psychoactive substances such as alcohol and marijuana can definitely be a source of trouble for practicing physicians.

Allow me to explain: Physicians are smart and capable problem-solvers with excellent interpersonal skills and the ability to adroitly navigate a complex, evolving health care system. However, for even the very best physicians, use of a psychoactive substance or the existence of a symptomatic health condition that interferes with a doctor’s proficiency has the potential to impair performance.

Simply, impaired physician performance can jeopardize patient safety. For this reason, on-duty physicians are expected to be free of the effects of mind-altering substances such as alcohol and marijuana. Furthermore, doctors who have been diagnosed with an addictive disorder are expected to remain clean and sober as long as they continue to practice medicine.

But what about recreational use of alcohol, a legal psychoactive substance, and marijuana, a psychoactive substance that has been decriminalized, medicalized, and legalized in Colorado and Washington? What should practicing physicians who do not suffer from an addictive disorder bear in mind as they consider personal use of alcohol and marijuana?

As for alcohol, I refer to this course of action as “clean-margin drinking.” Physicians without a history of an alcohol problem who choose to drink should consider the following guidelines:

  • Never on duty or on call (if you’re reachable, you’re on duty)
  • Aim to stay well below the legal limit (impaired cognitive performance commences at 0.05)
  • Women: one to two standard drinks per sitting; Men: one to three drinks per sitting (even less on nights before you are scheduled to work)
  • Avoid daily drinking
  • Avoid drinking before driving
  • Never combine alcohol with sedating medication

What about marijuana? Recreational marijuana use is currently illegal in the Commonwealth of Massachusetts. It continues to be classified in Schedule 1 by the DEA. Schedule l drugs are defined as having no currently accepted medical use and a high potential for abuse. It is never prudent for licensed physicians to violate the laws of the Commonwealth or the guidelines of the DEA.

What about physicians who suffer from debilitating medical conditions that qualify them to obtain and possess marijuana for medical use? This remains uncharted territory. It is possible that some may view physicians with debilitating medical conditions who use marijuana to control pain as unable to practice medicine with optimal skill and safety — either because of the debilitating condition itself, or because of the effects of the substance being used for medication.

However, even when someone may not be under the active effects of marijuana, the mere existence of it in one’s system could pose risks. Unlike alcohol, marijuana use has a biological footprint that lingers in the body for weeks. THC levels sometimes even rise after cessation of use before they decrease and disappear.

Because of the pharmacology of THC, and because various regulatory bodies have yet to weigh in on the potentially thorny matter of medical marijuana use in practicing physicians, this poses some particular risks for any use of marijuana by an actively practicing physician.

It may be difficult to demonstrate the difference between impairment as a result of the effects of marijuana in the system, and the mere presence of marijuana in the system absent any impairment.

As access and attitude toward alcohol and — in particular — marijuana change in our society, careful consideration must be given to the use of them by those in high-risk professions, including that of medicine.

This article first appeared in the August 2014 edition of the Massachusetts Medical Society publication Vital Signs. Steve Adelman, M.D., is director of Physician Health Services, a non-profit corporation founded by the Massachusetts Medical Society.

Physician Health Services, Inc., is a non-profit corporation founded by the Massachusetts Medical Society. PHS  provides confidential consultation and support to physicians, residents, and medical students facing concerns related to alcoholism, substance abuse, behavioral or mental health issues, or physical illness. PHS also provides a safe environment where physicians can talk to other physicians about the stress and demands of modern medical practices. For more information, visit the PHS website or call PHS at (781) 434-7404.

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Integrating Mindfulness into Your Daily Routine

Photo by Darragh O'Connor via flickr.com

By Douglas Ziedonis, M.D., M.P.H., Carl Fulwiller, M.D., PH.D., and Makenzie Tonelli

Recent studies have reported on the effectiveness and impact of training physicians on integrating mindfulness approaches into their personal lives and clinical practice. Mindfulness can help improve health, reduce physician burnout, and improve patient satisfaction and outcomes.

Surveys of physicians indicate that two-thirds experience burnout associated with making more errors, having less empathy, substance misuse, and leaving practice. Physicians’ daily routines are challenged by competing tasks, rapidly changing environments, and a flood of thoughts and feelings in the context of our decision-making and interpersonal relationships.

Mindfulness — the state of focusing one’s awareness on the present moment and monitoring the unfolding of experience without judgment — can help us cultivate awareness, compassion, and acceptance.

Mindfulness practice can be both informal and formal. Formal practices occur in structured time periods, similar to physical exercise, devoted to engaging in meditation, yoga, or other similar practices. The informal application of mindfulness to daily experience involves awareness of the present moment, whether pleasant, unpleasant, or neutral, with an attitude of curiosity and acceptance, allowing feelings or thoughts to arise and pass away again without judgment.

In the midst of a stressful clinical encounter, practical techniques can be used, such as taking a short (e.g., one-minute pause) between patients, in which one takes a few deep breaths and becomes aware of any tension in one’s body, without judgment or being critical of taking care of oneself for that moment. Mindfulness during the clinical session helps patients feel heard.

Through mindfulness practice, an enhanced appreciation of pleasant experiences and a greater acceptance of unpleasant experiences emerge. Focusing on the breath and other sensations arising in the body helps to anchor oneself in the present moment. As clinicians, when we are more present, we demonstrate patience, empathy, and an increased capacity to listen. We are also more self-compassionate, handle uncertainty better, and embrace all the moments of our life, including the catastrophic and challenging.

This practice allows for more meaningful interactions with our patients and for opportunities to engage in the patient’s sacred space. A mindful physician encountered by a nervous and concerned patient, is more aware of and empathetic toward the emotional state of the patient, and thus more likely to respond in a way that is most comforting for the patient, such as with eye contact, a calm demeanor, and with language that will resonate with the patient.

Physicians are also well-positioned to help staff and patients integrate mindfulness into their lives. As mindful leaders, we can enhance our ability to focus, be less reactive and more responsive, promote teamwork, and model compassion based on insight.

This article first appeared in the February 2014 edition of the Massachusetts Medical Society publication, Vital Signs.

Douglas Ziedonis, M.D., M.P.H., is professor and chair of the Department of Psychiatry at the University of Massachusetts Medical School and UMass Memorial Health Care. Carl Fulwiler, M.D., Ph.D., is associate professor of psychiatry and director of the Center for Mental Health Services Research at UMass Medical School. Makenzie Tonelli is a project coordinator in the Department of Psychiatry, at the University of Massachusetts Medical School.


Physician Health Services, Inc., is a non-profit corporation founded by the Massachusetts Medical Society. PHS  provides confidential consultation and support to physicians, residents, and medical students facing concerns related to alcoholism, substance abuse, behavioral or mental health issues, or physical illness. PHS also provides a safe environment where physicians can talk to other physicians about the stress and demands of modern medical practices. For more information, visit the PHS website or call PHS at (781) 434-7404.

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The Power of Peer Support: A PHS Client Tells Her Story

By Darleen*

“My name is Darleen. I’m an internist and I have no idea why I am here. I’m doing just fine and I have nothing to report to the group.”

That is how I signed in at my first Physician Health Services (PHS) group meeting. Seven years and hundreds of meetings later, I know exactly why I was there and that I was anything but fine. On that Wednesday night, I walked into a room full of doctors sitting around a table, quietly welcoming me as a new member.

I was convinced, or so I thought with a dose of arrogance and conviction, that my being there was a big mistake. Don’t people know who I am? I’m a doctor! I do not need anyone’s help. I give help. Little did I know, the only thing I did have was a total and profound lack of insight into my situation.

So, I told my story and gave all the reasons why I did not belong there. I rounded up all the usual suspects (i.e., my boss, other doctors, nurses, administrators, HR, patients) and fired away at them as best I could. While I was pointing my finger at them I did not see the other three fingers on my hand pointing right back at me.

A few meetings later, I found myself all alone on the battlefield without anybody left to fire at but myself. At that moment I knew it was all me, my problem and the solution all wrapped up in one. That was the moment I fell apart and began to heal while the group stood by to catch me and give me support. I was on my way.

Later on, I was on standby, waiting to catch and offer support to other fallen heroes. That’s what we do here. We are all in it together — the only thing we have in common is the language we speak, and I do not mean English. That is our own doctors’ language understood by us doctors only. That is the healing power of the group. That is our secret weapon.

Problems at work and the personal difficulties that brought us to the group are as diverse and colorful as we are. We are all smart, educated, hardworking, and dedicated people who want to make something of our lives so we can make a difference in others’ lives.

We listen carefully, gather information, analyze it in our well-known problem-solving manner; we give support, we offer suggestions, we even offer resolution. We do not accuse, we do not judge, we do not patronize, minimize, or ignore the problem. We support and give back our tough love; the newcomer feels and understands that love.

The strength of the group becomes apparent when we are able to redirect the focus of the problem from others to ourselves. We learn from each other how to recognize and accept our part in the problem.

The group lets the new doctor point fingers at others at the initial meetings, but then he or she slowly becomes aware of the other three fingers pointing back at him or her. We let the person stand there for a while and we know how extremely painful that moment is. We feel the anger and anguish simmering inside; we have all been there. We are waiting for that transformation, for that insight to come, for that magical moment when we realize that we are the problem and the solution — nothing more, nothing less.

My name is Darleen, and I just want to say how glad I am to have been here for the past seven years and how much happier I am — what a better person and a doctor I have become.

* The real name of the author has been withheld at her request.


This article first appeared in the February 2013 edition of the Massachusetts Medical Society publication, Vital Signs.

Physician Health Services, Inc., is a non-profit corporation founded by the Massachusetts Medical Society. PHS  provides confidential consultation and support to physicians, residents, and medical students facing concerns related to alcoholism, substance abuse, behavioral or mental health issues, or physical illness. PHS also provides a safe environment where physicians can talk to other physicians about the stress and demands of modern medical practices. For more information, visit the PHS website or call PHS at (781) 434-7404.

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Avoiding the CRASH: When Toughing it Out Stops Working

By Steven Adelman, MD

The caped heroes in the accompanying illustration don’t need to shed their stethoscopes and white coats to reveal their true identities. We all know that doctors possess super-human skills. Armed with encyclopedic medical acumen, we relieve the suffering of thousands. We stay up late to finish our charts. We wake up early to go on rounds. Sometimes we skip meals in the course of our long and demanding days, doing whatever it takes to get the job done. It works until it stops working, and then …CRASH!

We physicians have been acculturated to tough things out — to endure hardship and overcome adversity in our efforts to master the science of medicine so that we can relieve human suffering and save lives. It starts in college, when we studied organic chemistry into the wee hours in order to be deemed worthy of being accepted to medical school. The basic science curriculum in medical school would overwhelm mere mortals, but with our noses to the grindstone we study 24/7 in order to move forward and gain entry to clinical rotations. Then we arrive on the wards, privates in a medical hierarchy populated by skilled house staff and storied attendings, the lieutenants, colonels, and generals in an elite, crackerjack army. In order to move up through the ranks, we emulate them in every way: patients come first; medicine comes first; we’re doctors, after all, virtually invulnerable.

I have yet to meet a physician who has failed to buy into this culture of medical exceptionalism. Lesser human beings need not take the Hippocratic Oath and all that it entails.

But, alas, we physicians are human. Sooner or later, each of us hits personal and professional speed bumps: work-life balance challenges that affect us as spouses and parents, stressful changes in the work environment, medical problems, emotional burdens, and the inevitable slow-down that occurs in the fourth quarter of any lengthy career.

Many successful physicians minimize the adversity in their lives and counter it with maladaptive coping strategies. Drink a little more alcohol at the end of a grueling work day and you’ll fall off to sleep more readily. Use that tramadol the patient left in your office to take the edge off of that annoying foot pain and you don’t need to waste half a day getting checked out by some other doctor. Avoid the dark hole of depression that seems to be eating away at you by telling yourself and others that you’re just fine, you’ll get through it. Although they never taught us these nifty tricks in medical school, many of us have mastered the art of self-serving rationalizations. “I’ll tough it out and then I’ll be okay.” It works until it stops working. CRASH!

Over the years, more than 2,500 Massachusetts physicians have found their way to Physician Health Services. It’s not surprising that most of these referrals occur just before things are about to come crashing down.

Individually and collectively, our inclination is to wait until it’s almost too late. A new and important trend at PHS is the growth of self-referrals. More and more Massachusetts physicians are picking up the phone and asking for help when their problems are milder and more manageable. That’s how it should be. We all know that a few ounces of prevention are worth tons of cure. That’s especially true for ­superheroes.

For more information please contact Jessica Vautour, Education and Outreach Director at Physician Health Services, Inc., at (781) 434-7404 or visit www.physicianhealth.org.


Steven Adelman, MD, is director of Physician Health Services in Waltham, Mass. This article originally appeared in the Summer 2015 edition of the Massachusetts Medical Society publication Vital Signs.

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