Preventive care as a cost saving measure is a fallacy

I like reading Maggie Mahar’s Health Beat.

She usually gets it, from the function of insurance to the complexities of assorted payment systems, I get the sense that she is generally rational when it comes to paying for health care. This doesn’t mean there aren’t times when she gets it wrong. Her embrace of primary care provided by nurse practitioners shows a truly spectacular lack of understanding of what primary care really entails. Still and all, most of the time I find her remarks pretty much on target.

That was the case for the bulk of this post, in which she discusses the “individual mandate” part of the health care reform bill, and explains succinctly and clearly the concept of “insurance”:

The very idea of health insurance is predicated on the notion that none of us knows who will be laid low by accident or disease and when. The great advantage of insurance is that it spreads the risk over a large group of people exposed to the contingencies of fate. It is worth remembering that most disease and injuries can be traced to the accidents of one’s gene pool (accounting for 30% of premature deaths), social circumstances (15%),  “environmental factors”  (such as air quality where you happened to grow up) (5%) , or being in the wrong place at the wrong time, whether on the highway, playing a sport, riding a horse, or crossing a street.

Unfortunately, she goes astray in the very next paragraph:

By paying premiums, we also “pre-pay” for the routine care that we all need. This, too, serves a larger social good. If we ensure that everyone has access to preventive care, with no co-pays (something the new law guarantees), it is less likely that someone will need long-term acute care at some point in the future—treatment that the rest of us would wind up funding through taxes, higher insurance premiums or higher hospital fees.

No, no, no! The idea that preventive care finds medical problems early, treats them more cheaply and effectively than if they weren’t addressed until symptoms appear, and saves money in the long run is attractive, intuitive, and wrong.

Not only that, but which medical services should fall under the label of “preventive care” (the recommendations of the USPSTF seem to be routinely ignored) remains the subject of bitter debate. The need for annual physicals, mammograms, and PSA testing have all been debunked.

The American mentality of “more is better” drives much of the demand for the so-called “Executive Physical”. Annual EKGs, cardiac stress tests, and extensive panels of “screening” blood work is wasteful and expensive. We’re going to go bankrupt in a hurry if this is what people are led to expect from health care reform’s “routine care” (without co-pays or deductibles to boot!)

Don’t get me wrong: I think preventive care is important and valuable in terms of adding productive years of life. But unless you widen your perspective to include the wages earned and taxes paid by those who have benefited from those extra years, you won’t see actual monetary savings. It’s similar to why insurance companies can get away with paying for all the maternity care you want, but not birth control. The reason is that the overall cost of a baby is far more than just the maternity care, as well as dwarfing the cost of the birth control. The financial benefits of preventive care don’t show up on the medical ledger.

I agree with Maggie that the individual mandate is a necessary step towards the provision of reasonable health care for everyone. But I wish she and all the other health care wonks would recognize the fallacy of preventive care as a cost saving measure. Preventive care increases health, happiness, and productivity. But it doesn’t save money.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • Todd Ianuzzi

    It’s similar to why insurance companies can get away with paying for all the maternity care you want, but not birth control. The reason is that the overall cost of a baby is far more than just the maternity care, as well as dwarfing the cost of the birth control.

    Dr. Hornstein,

    Your premise is interesting, but one would like to see some economic analysis to support your arguments. Can you direct us to some research and analysis? It would be interesting to examine and consider.

    • http://www.healthscareonline.com Richard Young, MD

      Todd,

      Check out my website at http://www.healthscareonline.com under the POEM assumptions for a basic explanation. If you want more economic analysis I can send it to you.

      Richard Young, MD

  • Paul Watson

    So Lucy, if my primary care doc gets me to stop smoking this isn’t saving money, not even what I spend on cigarettes?

  • http://www.healthbeatblog.org maggiemahar

    Lucy-
    Everything turns on what you mean by “preventive care”

    As I have indicated many times on HealthBeat, I am talking about the care that the U.S. Preventive Services Task Force gives a high rating– based on effectiveness.

    As I have written, we have no medical evidence that PSA tests,, mammorgrams for younger women, much diagnostic imaging and even the annual physical for asymptomatic patients (which is a fishing expedition unless the patient complains of symptoms) prevents disease.

    (Though I think here is an argument to be made for a yearly “consultation” with a primary care physician which would involve much less testing and much more talking and listening–this might give a patient a chance to open up about his depression, his concern that he is drinking too much, this one little but nagging symptom . . .)

    When I speak of preventive care without co-pays, I’m talking about the eye-checks and other recommended preventive care for a diabetic. He doesn’t have to wind up having multiple amputations(which are expensive.) I am talking about the preventive care that would keep many people suffering from chronic diseases out of the hospital
    (blood pressure checks and change of diet for those suffeering from hypertension; regular eye check-ups to detect glaucoma while eye-drops can still keep it under control; Pap smears (which have actually made cervical cancer a “rare disease,”) childhood immunizations; smoking cessation clniics; routine gynecological exams where sexually active girls and women can get prescriptions for contraceptives and counseling on “Safe Sex.” . All should be available without co-pays or deductibles.

    The problem is that our media, and our health care industry hype many types of prevention (most recentlly CT scans to prevent lulng cancer) when, in fact the medical evidence isn’t there that the benefits outweigh the risks.

    Finally, as to whether preventive care saves money, it all depends on what you die of. If preventive care means that you don’t develop cervical cancer–but live to be 85, and spend your last 8 years suffering from Alzheimer’s, requiring extensive full-time care, then yes, you probably would have cost society less if you died of cervical cancer when you were much younger. On the other hand, if the diabetic is spared the amptuations in this sixties, and instead , and has a fatal stroke at home when he is 68, society probably saves money.
    In general, insofar as preventive care keeps people out of hospitals, it is likely to save money. Hospitals are very expensive and potentially dangerous places . . .

    • Jo

      Isn’t it true that Primary Care physicians who do this type of care annually for patients (including the listening part) find that it does tend towared early diagnosis of disease, therefore saving the patient and the healthcare system money by preventing more expensive specialty, surgical or hospital care.

      For instance a mammogram showing CA in-situ that patient nor doctor can feel with mannual exam can be treated by lumpectomy and radiation, which prevents, masectomy and chemotherapy.

      Annual PSA along with digital prostate exam, annually will see the trend of elevation early and agressiveness early. Also the Primary Care physician who is keeping up with all medications at every visit will pick up along with the elevation of “numbers” the fact the patient went to another physician and was injected with a testosterone pellet, or has increased Androgel applications on his own and just by lowering the testosterone and monitoring labs may prevent the prostate biopsy, etc.

      A polyp removed on colonoscopy is less expensive than treating colon cancer.

      Preventive Primary Care Physicians are not just triage agents for the specialists or tests, they are “primary”, “first in line” diagnostic agents to evaluate, diagnose and treat, in a step wise fashion to rule out serious illness as symptoms occur and annually evaluate what screening tests/labs are needed to detect those that are not so easily detected otherwise.

      • Diora

        Joe – Have you ever heard a little term called “Number needed to treat/screen”? What about false positives and overdiagnosis? Yes removing a polyp is cheaper than treating colon cancer, you need to do colonoscopy on many people to prevent one case of cancer. As to PSA, this test hasn’t even been shown to save lives, but even if you assume that you may save on the treatment of one cancer, again you need to not only add up the cost of screening thousands, but you also need to add cost for false positive evaluation and overdiagnosis i.e. treatment of cancers that would never have become a problem if remained undetected. So – for every one case where you do less treatment, there are thousands, sometimes tens of thousands of tests; false positive evaluation (including biopsies), and in cases like PSA and mammograms – more people treated for cancer.

    • http://www.healthscareonline.com Richard Young, MD

      Maggie,

      All of the preventive interventions you mentioned, except the older childhood vaccines, cost more up front than they save in the long run. Like anything else in life, if you want something good — to not die at a young age of cervical cancer, e.g — there is a cost. One of the fundamental reasons for runaway healthcare costs in the U.S. is the fact we can’t face this reality but other developed countries can. NICE in Britain is the best example of transparency in making these difficult decisions.

  • http://www.drsharma.ca/ Arya M. Sharma

    This is a most interesting post as it addresses the widely held fallacy of the cost-effectiveness of preventive health care.

    This, surprisingly, also appears true for efforts to prevent obesity!

    A recent WHO/OECD report on obesity prevention concluded that although it would be nice to get people to be more physically active, eat healthier, etc., such measures at a population level would not become cost-effective in terms of health care savings at least for the next 3-4 decades! Quite the opposite of the remarkable cost-effectiveness of actually providing obesity treatments to people who have excess weight (especially those who need bariatric surgery). http://www.drsharma.ca/oecd-dont-place-all-your-bets-on-obesity-prevention.html

    Similarly, the recent UK FORESIGHT report concluded that measures targeting prevention of childhood obesity in 6-10 year olds would be about as cost-effective as doing nothing (at least till 2044). In contrast, helping people older than 20 years reduce their BMI levels by 4 units, would result in immediate and substantial cost savings to the health care system.

    These two independent analyses from seemingly credible sources are of course largely ignored as governments the world over cry for greater emphasis on obesity prevention whilst focusing much of their efforts on childhood obesity.

    While such policies are wildly popular and garner enthusiastic public support, there is certainly no data to support the notion that such measures are likely to translate into cost-savings any time soon (which does not mean that they are not worth doing anyway – perhaps this is a luxury we should afford).

    Of course the experts who wrote the OECD and FORESIGHT reports may be completely wrong, but I would not want to bet on it.

  • Jane

    Prevention will not help diabetics keep their limbs.
    Why should we do all this preventative care without people paying for it? That is really dumb. If you want a PAP smear, then pay for it. Or better yet, have Maggie pay for it.

    • http://Www.twitter.com/alicearobertson Alice

      I thought weight loss, exercise, and not eating sugar were all helpful? If not, I am heading out to Outback for some delicious, non-deadly steak, fries, and a pop…..real food here I come! :)

      You know sometimes I read “research” and find the results fascinating, fallacy-filled, and so fictitious that you start to wonder who would sign their name to some of this crap. Do they really think we are this gullible?

      Logic is lacking….preventative means exactly what it implies…….it prevents something.

      • Diora

        Alice – this post was about cost not about whether prevention is worthwhile, but whether it saves money. Nobody argues that it’s a good thing to eat right and exercise, and you personally may benefit from certain other preventive measures. But a lot of people assume that it will also save money to others. Well – it will not.

        What a lot of people don’t understand is the difference between cost effectiveness and cost savings. A cost-effective measure is such where the cost of quality-adjusted life year gained is under $50,000. Cost saving is just that – if something will save costs.A measure can be cost-effective but not cost-saving.

        • http://www.twitter.com/alicearobertson Alice

          Diora…..if you read the whole thread it’s about much more than that. My problem is Berwick and his romantic notions about the UK. Study that system and see that if some people have their way it will be coming to a hospital near you. It’s about much more than cost effectiveness…..and I tend to think this is one area doctors may be advocating that which wille ventually not only hurt patients, but themselves. If you read some of the posts…..it’s hard not to have a knee-jerk reaction…..just like most of American has had to the healthcare bill (now that they understand it better…..and see beyond the perks…..and now that they voted out some who didn’t even know what was in bill).

  • westeasterly

    Maggie- your response is fair, but it fails to address the underlying premise of the original post- that even though it seems like primary care should save money in the long run, the overwhelming majority of hard evidence says it doesn’t. And that’s what it comes down to. Everything else is just armchair conjecture.

    Paul- no one can get you to stop smoking….it’s on you buddy. If years upon years and billions of dollars spent on research, public education, regulation, advertising restrictions, tax increases, pack warnings, billboard signs, social pressure, and common sense weren’t enough….there is little chance 10 minutes with a physician is going to change your mind. That’s not to say a physician (or PA/LPN) can’t offer you some help in quitting that you can’t get over the counter; however, it doesn’t mean that more primary care = fewer people smoking.

    Thank you for your post though, it illustrates a really important point. The areas in which we can undeniably save healthcare dollars- cutting out smoking, fat, physical inactivity, alcohol and drug abuse…..all of these things have very little to do with physicians. These are all lifestyle decisions, and if there is one thing American’s are very poor at, it’s making good lifestyle choices. But this isn’t nearly as much an issue for primary care as it is for public health policy. I can’t tell you how many patients I’ve seen just in the past week with moderate to severe COPD that still refuse to quit smoking. Or how many obese patients have no interest in weight loss or exercise. Or how many drug users are satisfied with the status-quo. Certainly better access to primary care may help a few highly-motivated individuals, but not the vast majority of Americans; we know what to do and what not to do….and we make poor decisions anyway. It’s the price we pay for personal freedom.

  • Bladedoc

    Paul – it may save YOU money but it’s much cheaper for society for you to die at 50 of early heart disease or lung cancer than at 80 after 10 years in the nursing home. That is especially true if you die right before becoming eligible for social security.

    And it may be true that universal health care requires an individual mandate; it’s a pity that such a mandate is an unprecedented expansion of governmental authority.

    • http://thehappyhospitalist.blogspot.com Happy Hospitalist

      I think the argument is lost on the bigger question. The government can’t afford to pay for what it has promised.

      Societies which promise everything end up delivering on nothing. You only have to look to the PIGS of Europe to understand where America is heading.

      • gzuckier

        “You only have to look to the PIGS of Europe to understand where America is heading.”
        lower healthcare costs, longer lifespans, lower infant mortality, lower murder rate, better public primary schools, cleaner environment, cheap and effective public transportation, prolific supply of affordable museums, concert halls, theatres, etc., roads kept in repair, decent food…. My God, we have to stop this in its tracks!

    • http://Www.twitter.com/alicearobertson Alice

      Not if you have children under 18 years old. Social security kicks in monthly for the children, which *may* mean monthly checks, medical, possibly food stamps, and college tuition.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Why stop at preventive care?
    Health care in general doesn’t save any money to society. It would be immensely cheaper not to treat anything and just let people die “comfortably”.
    It would also be cheaper to not have Social Security, public education and clean water, amongst other things, because these too only increase “health, happiness, and productivity”.
    What exactly is the point of this argument?

    • Intern

      I believe the point is that the use of cost-savings as an argument for pushing increased investment in preventive care is a shaky one. I don’t believe the author is maligning preventive care proper. Instead, the author, without agreeing or disagreeing with Mrs. Mahar, is encouraging us to make evidence based justifications of such arguments. Here she focuses on a commonly held but poorly defined (what is preventive care now and what additional preventive care is being proposed) contention cited in current healthcare debates. While few would argue that society views general healthcare isn’t a worthwhile cost (despite as you note not being cost-effective), re-working the system based on a belief rather than a studied fact is worth the scrutiny seen here and elsewhere.

    • westeasterly

      Margalit- It’s not an argument so much as it’s a question. Healthcare is here to stay. The question is whether we can reduce out-of-control healthcare spending by focusing on primary care. Furthermore, the operative word in your quote is “productivity.” Productivity IS good for society, and better health equals a more productive populace. Happiness plays a role as well, as studies have shown happier workers are more productive workers. The more we improve health, happiness, and productivity, the better off our society is, and expenditures to increase these things are worthwhile investments. Primary care plays a role in this, but it’s not the magic bullet politicians would have us believe. There is no magic bullet- our problems have many sources and will require many solutions.

    • Bladedoc

      Not one person on this thread has proposed eliminating primary care. As mentioned above the point is that the administration is claiming that the massive cost of the healthcare plan would be offset by the massive savings by “investing” in preventative care. As there are a number of studies which shows this to be utter balderdash this claim is knowingly false (i.e. a lie). This is so obvious that the CBO itself came up with a cost model that discounted these claims (among others that they felt unlikely to happen such as the Medicare cuts to physicians).

    • http://Www.twitter.com/alicearobertson Alice

      I could be wrong…. but if I have read history right it was that way before maybe, 1933? Hmmm…..the life expectancy in1933 was still better than during the time of the Vikings when you would not have lived long enough to even graduate from medical school :)

  • Finn

    I think the point is that the money-saving argument for preventive care is the wrong one to use, because it’s not true. There are other reasons, such as improved health and productivity, for promoting preventive care. Basing an argument for preventive care on a false premise (i.e., that it will save money) makes it too easy to shoot down.

    • http://f-words.blogspot.com Sara

      Yes, I think the productivity thing, in the end, is what gets ignored.

  • http://thedocsquawk.com thedocsquawk

    I was under the impression we DO take into account the wages earned and taxes paid in the extra years people live because of preventive care.

  • MomDoc

    If I have a hammer and nail I can hang a picture. If I have a screw the hammer can still pound it into the wall and get the job done, but it’d not the best way to do it. Medicine and health are screws and nails. Medicine, including medical models of care and medical technology are good fit treating medical problems, but not so good for addressing health. Health depends on access to shelter, safe neighborhoods, freedom from violence – it’s an issue of social justice. Preventive medicine efforts may be well-intentioned, but they’re rarely the right tools for promoting health.

    • http://Www.twitter.com/alicearobertson Alice

      By this analogy, you may be shooting yourself in the foot. If patients start to believe this rhetoric….they may figure they do not need you.

      I have to get yearly colonoscopies because of genetic cancerous growths. Hmmm…..to think I was deluded into thinking this type of preventive care was…ta da….preventive. Ack! Trying to use facetiousness to make a point that seems as clear as the nose on our faces.

      This is just to reasonable to be over analyzed to the point it creates laxness.

  • Angela Caffaratti, MD

    It seems to me that primary care and preventive care are being tossed around as the same. As a family physician, I consider primary care as the right treatments for the right people at the right time and preventive care as pretty healthy people wanting false reassurance. Most screening is not aimed at the right patient population. Primary care has many barriers that need to be overcome to be more effective. If people have the right care at the right time, many special interest groups will lose money. I’m not sure we are ready to attack this issue as a society.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    I don’t have statistics that look at large populations. I do know that in my practice our annual comprehensive exam is a detailed history session, a detailed physical exam and only those laboratory tests that are generally indicated by the responses on the history exam or findings on the physical exam. Yes I get an EKG where appropriate and check lipids and fasting glucose and renal function and urine.Yes I do make sure all the minimal but recommended qualtiy guidelines are attended to. Yes I do believe that the session gives me an opportunity to integrate the life style choices of the patient and genetic and family and social history into a comprehensive care plan. The extra time spent on the history and exam and attention to the total patient has resulted in significant fewer hospitalizations in my elderly and chronically ill patients. The cost savings of reducing inpatient days must be significant. What is most significant is the increased quality of life the patients enjoy allowing them to be productive contributors to society. I am not sure how those figures calculate into the cost benefit ratio of preventive care but it should be .

    • Jo

      Thank you. I agree

  • http://www.healthbeatblog.org maggiemahar

    I agree, first of all, that saving money is not the strongest argument for primary care.

    My post wasn’t about saving money– it was about the shared responsibility that we all have to try to keep our society healthy. The post was about the individual mandate, and this was an argument for the mandate. .

    Lucy took one pargraph from my post to give herself a topic to write about (or to disagree wtih)–and this is fine. Many writers often take quote from another piece and use it to focus their argument.

    But I just want to make it clear that I don’t support perventive care because it saves morey. i support preventive care because it reduces suffering.

    That said, it is true that in Europe, there is more focus on preventive care and chronic disease management rather than acute care. Often, there is no co-pay for preventive care, and no deductible–it’s first-dollar coverage. For
    instance in Scandanavian countries every one automatically gets an annual ObGyn exam, and a pap smear. Cervical cancer isn’t just rare; it’s non -esistent.

    Is the emphasis on preventive care one reason why healh care spending is so much lower in Western European countries?

    It’s not at all clear.

    What is clear is that healh care spending is Lower Because There is Less Emphasis on Aggresive Acute Care—-far fewer surgeries, far fewer extreme interventions. ;It’s far less likely that a European will be seen by 10 or more specialists during his final 6 months of life. Chemotherapy isn’t as common in Europe. Iin Western Europe it is far more likely that a European will enjoy palliative care at home or hospice care at home or in a hospice (which is significantlly less costly than dying in a hospital with 10 specialistws doing everythign they can think of.) It’s also less stressful–which is why (as recent reserach shows0 people who undergo palliative or hospice care live longer.
    Btw– ;palliative care specialist Diane Meier argues (rightly, I think) that palliative care is in fact preventive care. And the goals is not to Prevent Death– the goal is to Prevent Crisis– extreme pain, panic, all of the things that you fear when you are seriously ill. . Palliative care aims to “manage” the process of being seriously ill. Some patients will die; some won’t. But they are all so extremely ill that they need a palliative care team to help them get through..
    As I said earlier, in terms of whether preventive care saves money, everything depends on what happens to you later in life. If preventive care helps you live to 70, and then you develop Alzheimer’s, you wind up costing society a lot. If preventive care helps you stay healthy, and you’re lucky with your gene pool, and have enough money to be able to
    eat nutrious foods, exercise in safe surroundings, join a gym where you can swim, take time off to vacation and exercise, and be free of the stress that accompanies being poor, then you may well live to 75 or 85 and die at home,– or after one day in the hospital. In that case, you cost society less.
    As for smoking cessation clinics, we are not talking about a couple of hours of counseling., We are talking about giving patieints access to the counseling and drugs that we knowcan help them stop smoking.
    We know that the vast majority of adults in the U.S. who still smoke are poor. The mentally ill are twice as likley to smoke as other people. Veterans are more likely to smoke–particularly homeless Vets. These people all need help.
    This is not a “lifestyle” choice. 70 percent want to quit. (See this August 2010 report.)http://www.nhchc.org/Network/HealingHands/2010/AugustHealingHandsWeb.pdf
    We have a very hard time helping people quit many drugs. Our success in helping alchholics quite–and stay on the wagon– is modest. But we are more successful in helping smoker’s quit. The nicotine patches, drugs, and support of a counselor can be very effective..
    The cost of helping a smoker is very low compared to the cost of dying of a tobacco-related disease.
    Long-term will the former smoker cost us more than he would if he died of lung cancer at 50? Everything depends on what other diseases he does or doesn’t contract. And where he lives. If he lives in Sweden or Iowa and lives to 80 he will probably see fewer specialists, rack up fewer medical bills of all kinds, and take fewer meds than an equally healthy, equally wealthy person who lives in Manhattan or Miami.

  • http://naturalmedicineisthebestmedicine.blogspot.com Erika

    I think the confusion here is “prevention” versus “screening”. Screening (which is primarily what the USPSTF dictates) is not cost-saving even though it is certainly life-saving, as it allows for early detection of many diseases. Preventive medicine is, by definition, cost-saving, since it prevents diseases that need to be treated at all. I have a much longer post about this on my own blog: http://naturalmedicineisthebestmedicine.blogspot.com/2010/10/prevention-versus-screening.html

    (I hope it’s kosher to post my own link…)

    • gzuckier

      I think you’ve hit the nail on the head. It’s cost effective to change the oil in your car routinely to prevent avoidable wear; it’s not cost effective to send the oil to a lab every year for trace metal analysis to ascertain whether your engine is showing excessive wear and overhauling the engine on the basis of the test results.

  • joe

    @maggie
    “It’s also less stressful–which is why (as recent reserach shows0 people who undergo palliative or hospice care live longer”

    The latest study (I assume) you are quoting from the NEJM does not conclude this and was with one subset of patients those with metastatic lung cancer. You can’t extrapolate a broard overall conclusion with palliative/hospice care with longer life based on this one study involving a cancer with infamously poor treatment options and from an institution which has a large inpatient palliative care service. I am saying this a large proponent of palliative/hospice care. Community palliative care is much more variable and haphazard than at a large academic center (where this study took place). Some docs do a great job at it, some don’t. Often it is simply the lack of resources in more rural settings. Honestly maggie one of the main issues I have always had with you is how you tend to read conclusions of studies and make grand conclusions of your own when you honestly haven’t read the methods/results critically. Think about it.

  • http://www.healthbeatblog.org maggiemahar

    Joe–
    First, the NeJM study is not the only study which suggests that both ‘hospice and non-hospice palliatve care” offer a substantial sruvival advantage.”
    See also: 8. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative
    care intervention on clinical outcomes in patients with advanced
    cancer: the Project ENABLE II randomized controlled trial. JAMA 2009;302:741-9.
    AND
    Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing
    hospice and nonhospice patient survival among patients
    who die within a three-year window. J Pain Symptom Manage
    2007;33:238-46.

    In referring to these other studies showing that pallative care offers “substantial survival advantage” I am quoting Dr. Diane Meier, one of hte nation’s leading palliative care specialists and winner of the McArthur Genius award. She wrote about the recent study in the NEJM .
    I also talked to Diane about this reserach not long ago.

    Meier goes on to write that :: “Future studies of palliative care must begin
    to test and identify the actual components of
    palliative care that are provided and received. to establish
    the evidence for best practice
    She also calls for more studies looking at other diseases–”beyond cancer.”
    Nevertheless, she writes that this study represents an “important step in confirming the beneficial outcomes
    of a simultaneous care model that provides both
    palliative care and disease-specific therapies beginning
    at the time of diagnosis. This study is
    an example of research that shifts a long-held
    paradigm . . . The new approach recognizes that lifethreatening illness, whether it can be cured or
    controlled, carries with it significant burdens of
    suffering for patients and their families and that
    this suffering can be effectively addressed by
    modern palliative care teams.
    ***”Perhaps unsurprisingly,
    reducing patients’ misery may help them
    live longer. We now have both the means and
    the knowledge to make palliative care an essential
    and routine component of evidence-based,
    high-quality care for the management of serious
    illness.”.
    Her argument is that this study confirmis that when a patient is seriously ill, palliative care she begin along with other treatment, at the time that treatment begins.

    I have never read a medical journal study that didn’t acknoweldge limitation of the methods and setting of the study and say that more work needs to be done.

    Perhaps you are in a better position than Meier to evaluate just how important this study is, but I doubt it. She understands what palliative care can do to help patients suffering from many diseaes in different settings–becuse has done it, observed many others doing it, and read all of the resereach.

    Typically when someone emphasizes the limits of a study and the caveats at the end rather than t he results–as you do here– they just don’t like the findings. I can’t help but wonder: are you an oncologist? A surgeon? Meier and others tell me that too often they refuse to let their patients consult with a pallaitive care team because they are afraid that if patients know their options, they will decide not to continue extreme treatments that will almost certainly be fuitle.
    Finally, you write:
    “Honestly maggie one of the main issues I have always had with you is how you tend to read conclusions of studies and make grand conclusions of your own when you honestly haven’t read the methods/results critically. Think about it.”
    Joe, this sure sounds like a grand conclusion/ generatlizaiton about my work. .
    In fact, I read med journal studies very, very carefully–including the “methods.” I was at Barron’s for more than a decade, wrote many stories about new treatments, drugs, and whether the company would make money on them. If I was sloppy in my reserach, my readers would have lost large sums–and I wouldnt’ have been employed very long.
    Never received a letter to the editor claiming that I mis-read medical research.
    Finally, I’m struck by the fact that you address me as if you know me (“one of the main issues I have always had with you.”) I have no idea who you are. Perhaps if you had the confidence to use your full name, I would have some idea of your credentials–and what makes you think that you are in a positioin to attack my work.

    • Neil

      Mrs. Mahar,
      I am unclear on whether the push here is for better symptom management during treatment of chronic disease or increased traditional palliative care consultation with end stage disease. These are two very separate issues both medically and financially especially in the context of the overarching discussion on this thread of cost-saving reform measures.

      More broadly, in your response to Joe which is marked by your understandable offense to his attack on your work, I think you have been unfair to other groups.
      Specifically, I am made uneasy by your questioning of his position based on his potential employment as a surgeon or oncologist. Your statement appears to imply these physicians routinely mis-treat their patients based on greed or arrogance. Moreover, you suggest that these physicians often are guilty of academic bias against palliative care literature while ignoring the possibility that the author a study could be biased in favor of her own study and field. You make these statements while dismissing Joe’s more reasonable point that Dr. Meier’s well-funded, academic palliative program is not uniformly reflective of community palliative care due to issues of cost, access, and skill. To ignore this and broadly impugn professionals who care for these patients is to suggest a bias or agenda removed from the discussion at hand. Yes, we can become irritated by the personal nature of the health care debates and the failings of our current system; however, let’s not throw the baby out with the bath water in trying to get your way. I am confident given your long track record as a reasonable and pre-eminent thought-leader in health care debates that this is all a bit of passion brought on by a personal attack rather than true belief. (As a disclaimer, I am a trainee in an onc field who has the pleasure of working alongside fantastic palliative care and oncology physicians within a cancer center).

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        To Neil’s point, I have to admit that I am not clear what is meant by palliative care here, particularly the type that prolongs life.
        Are we discussing sending the patient home or to hospice saying that there is nothing else we can do except keep you comfortable until you die? Or is it an add-on to aggressive treatment regimens to help manage symptoms and side-effects?
        If the latter, how is this type of palliative care reducing costs of health care?

    • joe

      @ maggie:
      Without sounding rude did you read the references you cited or just copy and paste from Dr Meier’s NEJM editorial?

      1: Bakitas et al’s paper which I read with interest when it came out because I run a rural oncology practice in conclusion had higher scores (in nurse led-palliative care focused group) for quality of life and mood but did not have improvements in symptom scores or reduced days in the hospital, ICU, or emergency dept. As far as survival, which was not a primary endpoint, post hoc analysis showed no stastically significant diffrences in survival between the two groups though there was an impressive trend (8.5 months vs 14 months p=0.14) of surivival towards the early palliative care group.

      2: Conner et al: was a retrospective using medicare databases that showed a small though significant survival for hospice vs nonhospice patients (337 vs 329 days P=0.00079) . When broken up by cancer/CHF this survival statistically significant survival advantage was seen with CHF, lung cancer, and pancreatic cancer. There was a tendancy towards ss with colon cancer. No ss was seen with breast and prostate cancer patients. Given this was a retrospective medicare database study no info on quality of life was obtained.
      These studies do not show a clear “substantial survival advantage.” They offer trends in there own words that warrant further evaluation hence the latest study.
      Honestly as an oncologist I am a huge proponent of palliative care/hospice care. But honestly the Temel study is the first randomized study that I know of that shows a survival benefit. Remember, this is one cancer which any oncologist will tell you has poor treatment options and a relatively short survival. The author’s themselves emphasize the need for replication in a varity of setting and cancer populations not because as you say “I have never read a medical journal study that didn’t acknoweldge limitation of the methods and setting of the study and say that more work needs to be done” BUT RATHER BECAUSE THERE ARE ESSENTIALLY NO MATURE STUDIES LIKE THIS.
      Lastly, I am not that interested what Dr Meier and you said one on one in Manhattan. I am interested in what she wrote in a peer reviewed journal such as the NEJM. I reread her editorial and don’t disagree with a single thing she wrote. She also did not write that “people who undergo palliative or hospice care live longer”

      Her words, from the NEJM editorial: The substantial survival advantage observed, though it is supported by other recent studies (the ones above you referenced) requires replication.

      This is the first of many studies and is a single institution study, with one cancer with a poor prognosis, at one academic center with a large inpatient palliative care service. Intuitively it makes sense that there would be a survival benefit. Intuitively transplants with breast cancer patients made sense in the 90′s. That is why we do randomized studies.
      There are a lot of questions to answer and I am saying that as a firm believer in the hospice/palliative care model. Can this study be replicated in the multi-institutional setting, can it be replicated with other cancers and non-malignant settings, can it be replicated outside those institutions with dedicated palliative care services? As a rural oncologist I and the IM/FP docs are the palliative care/hospice docs. There will never be a “palliative care service” for the same reason there is not a board-certified ER doc. Lastly your insinuation that as an oncologist I am “afraid” of having a serious end of life discussion is insulting. This is what I do EVERY DAY. There certainly isn’t a academic palliative care doc anywhere near me to consult. Honestly Ms. Maher, you are only 3-4 hours from rural NY and Penn. I strongly suggest you spend a little time with these docs and outside the rarefied confines of Manhattan.

  • http://www.uspreventivemedicine.com Fred Goldstein

    Dr. Hornstein,

    I appreciate your comments on this issue and yes there are serious reservations about preventive medicine and its ability to save money when one defines it as “screenings”, but preventive medicine is more than just screenings.

    Studies have clearly shown that people accumulate health risks and conditions over time. Dr. Dee Edington has documented this through decades of research and his model is called the Natural Flow model. He and others have also documented that “as go health risks, so go costs”, so if one adds risks, their medical costs go up and if one reduces risks there medical costs decline.

    We know that anywhere from 60 to 75% of the growth in health care cost over the past decade has been due to an “increase in the prevalence of chronic diseases”. Many of these are preventable.

    My grandfather developed type II diabetes in his late 70s, back when it was called “Adult Onset Diabetes”, we now have children with this preventable disease. If we turn these around, and lower the incidence and prevalence, we will reduce costs.

    Screenings have a role to play in this as they are secondary prevention as discussed in Clinical Preventive Medicine, 2nd edition by Lang and Hensrud, but secondary prevention cannot stand on its own. It must be combined with primary and tertiary prevention, to provide the intereference necessary to “hinder or avert the occurence of disease or injury.”

    I will be discussing Preventive Medicine on my blog in the next day or two at:

    http://healthandpreventivemedicine.wordpress.com

    Thanks for creating an interesting and enlightening discussion.

  • http://www.healthbeatblog.org maggiemahar

    joe–
    First, yes, I read the studies I cite.

    Secondly, In her editorial, Dr. Meier Does say that these patients “live longer” –that’s what enjoy “substantial surviavl advantage” means.

    Here a physician blogger quotes her saying much the same thing::
    ““It shows that palliative care is the opposite of all that rhetoric about ‘death panels,’ ” said Dr. Diane E. Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine and co-author of an editorial in the journal accompanying the study. “It’s not about killing Granny; it’s about keeping Granny alive as long as possible — with the best quality of life.”

    The physicain blogger ais primary care doc who read the study and interprets it as meaning that “Palliative Care Extends Life” (his headline.) In his post, he talks about how his father’s oncologist refused to understand why his father discontinued taking a medication that was causing him severe side effects. The father reported that the oncologist appeared angry. The physician-son agreed with his Dad’s decision.

    That said, I probably should have said “palliative care appears to extend life” or “a recent pallaitve care study seems to confirm what many have suspected that palliatve care MAY extend life. ” MOre studies will be needed, blah , blah, blah

    But I wasn’t writing about palliative care. You originally jumped on the final phrase in a long sentence where I was writing about something else, pulled it out of context and said “Aha!” You’re Wrong!!!

    I was actually writing about chemo and how palliative care could be seen as preventive care. .
    IIf had been writing about the study I would have emphasized that it shows “substantial survival advantage” and “better qualiy of life”. These two idea are linked. As I indicated, undergoing chemo is likely to be less stressful if the patientare recieving palliative care. (This is why Meier is arguing for pallatiive care to begin when the serious disease is first diagnosed.) And continuing chemo to the very end is likely to be more stressful than stopping the chemo while continuing the palliative care.

    This is what I meant when I quoted Meier in my response to you : “Perhaps unsurprisingly,
    reducing patients’ misery may help them
    live longer. We now have both the means and
    the knowledge to make palliative care an essential
    and routine component of evidence-based,
    high-quality care for the management of serious
    illness.”.

    Her argument is that this study confirmis that when a patient is seriously ill, palliative care should begin along with other treatment, at the time that treatment begins

    Reducing the patieint’s misery and improving quality life is key to what the NEJM sgtudy shows.palliative care can do (as do the other two studies.)

    The fact that you skip over this point shows the difference between an oncologist’s perspective and a palliative care expert’s perspective.

    As many others have written, oncologists (like other subspecialists) are trained to “treat the disease” Palliative care experts are trained to “treat the whole pereson.”
    For the oncologist “extending life” is the goal. For the palliative care specialist, as Meier has explained, “the goal is neither to extned life nor to hasten death (to get the person out of his misery as some woudl put it.)
    The goal is to help the patient have a better death– a good death, if you will– wiithout crisis–without extreme pain, panic, despair, etc. And to let the patient take control of how he wants to die.

    Meier emphasizes “survival advantage” shown in the study not becuase that is palliative care’s goal (longer life) but becuase palliative care specialists have been accused of shortening lives by “taking away hope” and encouraging patietns to stop treatment. (In fact they simply lay out the options.)

    Last year I published a “Very Open Letter From an Oncologist” written by Dr. Peter Eisenberg, an experienced oncologist and former member of the American Society of Clinical Oncology.

    In his lettter, Eisenberg very candidly described how too many oncologist s
    do too much chemo–without giving the patient options, and without focusing on the patient’s quality of life in his/her final months. He also wrote about how financial incentives encourage oncologists to do more chemo. Below, from his letter:
    “But we are paid more for administering the drugs than we were in the past, so it makes economic sense to administer them more often. Not every doctor is willing to do that. The practices that shows some restraint and don’t treat everyone who walks through the door with chemo are the ones that are suffering.
    “The truth is that there is no clearly effective chemotherapy for a distressing number of malignances. In those cases, if I find that first line therapy isn’t working, I won’t automatically offer a second type of chemo. Instead, assuming the patient wants a frank appraisal of her condition, I’ll explain the realistic goals and options available. In my experience, and in the community in which I live, patients seem to want to know as much as they can about their illness, even if the news is bad. Delivering terrible news is difficult, time-consuming and extraordinarily painful for all involved. But good decisions depend upon an honest and forthright discussion and providing the patient with the information and tools to make decisions.

    ” I have told patients, “I know that I can make you sick, but I am not certain that I can make you better! . . . In the foreshortened time that you have left, you need to think about what you want to do. Do you want to spend that time in this office, with me and my staff, or is there someplace else you would like to be, something else that you would like to do?”

    You’ll find the whole letter here: http://www.healthbeatblog.org/2009/01/a-very-open-letter-from-an-oncologist.html
    Finally, you suggest that a study done in one academic medical center doesn’t show us what palliative care is like in most places. You suggest that It may not be nearly as effective.

    In fact, much reserach has been done on the effects of pallaitve care in many settings, including a very large randomized controlled trial of palliatve care in VA hospials across the country. The patients are dying of a variety of diseaes–not just lung cancer.

    The study showed that when it came to , “the patieint receiving the treatment he wanted” and “never receiving unwanted treatment” patients receiving palliative care fared far better. These patients and their families also reported that the patients who received palliative care got “better emotional and spiritual support,” better “care around the time of death” (here there was a huge difference. Too often once it’s clear that the patient is dying, the oncologist or heart surgeon stopps visiting him.) The palliative care patients also enjoyed signifciantly better “pain management, “less “confusion” “and overall better well-being and dignitiy” while dying..

    This suggests that specially trained palliative specialists do a bettter job of end-of-life care than most other specialists.
    This is not surprising. This is what they are trained to do. And by and large, they are very good. This is a self-selecting group fo people who choose a very tough field (working with the dying) which is very under-paid, and often not well-respected. They choose the work for its own sake and are usually passionately committed to what they do.

    Finally, palliative care is available in rural areas. If you look at a map of where it is available, you’ll find much more access to pc specialists in the Midwest than the rest of the country. More access in many largely rural states than in New York State.
    Often, oncologists say their patients don’t need palliative care because “we already do that.”
    But in fact, few oncologists have the training to “do that”–nor do they have the hours to devote to talking to and listening to a patient and family.
    Do you ever refer yoru patients to a hospice?
    Or do you feel that you personally can replace a palliative care team– a doctor, a nurse and a psychologist trained in the specialty??
    Finally, I have not spent my life in Manhattan. I grew up
    in Upstate NY and have seen what hospital care there is like. I have watched relatives die in agony, getting far too little pain medication either because the doctor didnt’ know how or didn’t approve.

    • joe

      1: If you had read the studies you would have realized they did not say what you thought they did as I critiqued nor did Dr Meier come to your “grand conclusion”.
      2: Dr Meier is not extrapolating the results of one study to a grand conclusion that “palliative care extends life”…you are. She is pointing out the results of one study, what this may mean, and the need for repetition.
      3: I have never argued against the studies that show increased quality of life. In fact I was part of some of the early VA studies. That does not mean palliative care “clearly extends life” (outside of this study) . That is the purpose of the ongoing studies. That is the scientific method.
      4: Dr Eisenberg opinion aside, In 2005 CMS stopped paying more than a 6% markup for chemo without adding significant payments for chemo nursing (very expensive). The simple fact is I would make more money if I DIDN’T give chemotherapy.
      5: I am not minimizing palliative care docs, I am telling you that they don’t exist in my neck of the woods.
      6: Lastly, though you may claim you “grew up” in upstate NY. your below statement shows your lack of understanding on the subject.
      “Do you ever refer yoru patients to a hospice?
      Or do you feel that you personally can replace a palliative care team– a doctor, a nurse and a psychologist trained in the specialty??”

      I not only regularly refer to hospice, AS OFTEN AS NOT I AM THE HOSPICE DOC. I work with hospice RN’s/social workers DAILY. There is no “palliative care doc”, it is the primary docs or me. Could a palliative care doc show me a thing or two….of course, which is why I go to meetings. But I am telling you there is not palliative care doc to consult. Really, how many times to I have to say the same thing?
      I am sorry, but when you leave the city, new york state IS rural and outside of metropolitan areas there are significant MD shortages, including palliative care. I strongly suggest you go back to upstate NY, actually work with the docs to see what the issues are, and stop extrapolating what happens in Manhattan to the rest of the country.

      Last word is yours, I am tired of trying to tell you what is wrong with your thought process when you main thrust appears to be trying to score debating points.

  • jsmith

    The idea that preventive medicine saves money is yet another example of conventional wisdom–something that sounds good enough to let politicians and pundits persuade the public, but which might or might not have much basis in really. It is a cause of much confusion.
    Here is a better way to think about this issue: Some care, preventive or therapeutic, is more effective or more cost-effective than other care. Such care sometimes saves society money, but it usually does not. Even if it does not save money, it might still be worthwhile. Appendectomies for acute appendicitis cost money but are very useful indeed. Same for childhood immunizations.
    If we wish to maximize public health with a limited amount of resources, we should emphasize more cost-effective preventive and therapeutic care and de-emphasize less cost-effective preventive and therapeutic care.
    The dichotomy between preventive care and therapy is really a false one, reflecting confusion and/or the desire to persuade.
    There is another side to this. Some preventive activists almost seem to think prevention is enough to prevent all illness. All doctors ( as well as almost everyone else) realize the absurdity of this attitude. We almost all get sick, we all die. Prevention is no panacea.

  • http://www.healthbeatblog.org maggiemahar

    Neil–

    First, thanks for the kind words.

    Secondly, I am not accusing oncologists of being consciously “greedy” or “arrogant.”–nor am i reacting to Joe’s attacks.

    Health care is an emotional issue. People attack me fairly fequently. And most importantly, I have often written about
    over-treatment–whether unnecessary angioplasties or futile chemo. Some doctors feel attacked. Others say “You’re right.”

    In fact many oncologists will tell you that many of their colleagues administrer too much chemo and that the financial incentives are misaligned.

    Below an an open letter that Dr. Peter Eisenberg, a well-known and respected oncolgoists wrote for my blog (www.healthbeatblog.org) . In his letter, he discusses how too many oncologists
    do too much chemo–without giving the patient options, and without focusing on the patient’s quality of life in his/her final months. He also writes about how financial incentives encourage oncologists to do more chemo. Below, from his letter:
    “But we are paid more for administering the drugs than we were in the past, so it makes economic sense to administer them more often. Not every doctor is willing to do that. The practices that shows some restraint and don’t treat everyone who walks through the door with chemo are the ones that are suffering.
    “The truth is that there is no clearly effective chemotherapy for a distressing number of malignances. In those cases, if I find that first line therapy isn’t working, I won’t automatically offer a second type of chemo. Instead, assuming the patient wants a frank appraisal of her condition, I’ll explain the realistic goals and options available. In my experience, and in the community in which I live, patients seem to want to know as much as they can about their illness, even if the news is bad. Delivering terrible news is difficult, time-consuming and extraordinarily painful for all involved. But good decisions depend upon an honest and forthright discussion and providing the patient with the information and tools to make I have told patients, “I know that I can make you sick, but I am not certain that I can make you better! . . . In the foreshortened time that you have left, you need to think about what you want to do. Do you want to spend that time in this office, with me and my staff, or is there someplace else you would like to be, something else that you would like to do?”

    That last bit “In the foreshortened time you have left”– seems to me one of hte best pieces of end-of-life counseling that I have ever heard. (Though it drives Eisenberg’s partners crazy–in part because he is telling the patient: “yes, you are giong to die.” )

    You’ll find his whole letter here: http://www.healthbeatblog.org/2009/01/a-very-open-letter-from-an-oncologist.html

    Eisenberg also tried to get his state’s society of oncologists (in California) to draw up some guidelines (not rules) for apppropirate use of chemo. They flatly turned him down–as in “Are You Kidding”? ??

    In the letter he talks about how some oncologists quite openly discuss why they are using one form of chemo (which requires more sessons) rather than another because “I make $500 more” if I use the first one.

    I have found that in all specialties, the very best doctors are very willing to talk about how colleagues do overtreat, and how perverse financial incentives encourage over-treatment. Most say that doctors rationalize over-treatment.
    They tell themselves the patient needs it and wants it. Adn then they persuade the patient that she needs it and wants it.

    A great deal of reserach shows that when paid fee-for-service doctors “do more.” We also know that when doctors lease or buy imaging equipment for their offices, they recommend twice as much imaging for their patients. (See MedPAC).
    Th
    The doctors who indignantly insist: that doctors are never motivated by money are often the ones who think most about money.

    As for the quality of pallaitive care around the country, it is usually very high. Success in the NEJM study is not linked to the fact that the study was done at Mass General.

    We have many studies showing the positive effects of palliative and hospiice care in many settings: at home, in hospitals, in hospcies, in nursing homes.

    A large randomized controlled study of palliative care at many VA hospitals aroudn the country shows better pain management, less unwanted treatment, more of the treatment that the patient wants, more emotional support, more “care around the time of death,” etc.

    Palliative care is, as I’m sure you know, a specialty, and training is both rigorous and difficult. A self-selecting group of physicians nurses and psychologists choose the field. (This has also always been true of hospice workers.) It’s a difficult field that requires great courage and compassion.
    Pain management is an art–and not easy to learn. And palliative care docs are not well paid. The only reason to go into the field is because you have a passionate commitment to helping people die as they want to die, without pain or panic.

    Finally, of course management of chronic diseases and palliative care for people suffering from very serious diseases are both necessary. There is much research showing that palliative care saves money . (The atlernative– ICU care, more surgery, more chemo etc. involves very expensive care.)

    As I indicated above, it’s harder to prove that chronic disease management saves money. Assuming the patient lives longer, everything depends on what he dies of–is it an expensive disease.

    But I tend to think that in many cases (most?) it saves money. And certainly whether or not it saves money, we, as a society, should be pushing for better chronic disease management.

    • Neil

      Ms. Mahar,
      Thanks for the reply; I have enjoyed this opportunity to discuss palliative care as a sort of tertiary prevention paradigm with you. Going on, I think you would find that many in oncology and I will agree with you to a degree about the existence of perverse incentives in healthcare and their consequences. However, the key areas I will focus on center on my disagreement with you over the implications of this issue as applied to oncology and engagement of palliative care.

      Let me begin by saying I agree with some of the anecdotal points and associative data you have used in cautioning oncologists to look beyond their own training when needed in providing palliative care and end of life care transitions. However, I would again disagree with your assumption that what applies in a tertiary centers applies in the community and with your tendency in this discussion to portray oncologists as a group as unable to reliably look beyond financial incentives or treatment focus with the implicit suggestion that referral decisions be taken out of their hands. In short, you are using a shorftall of the overarching system to condemn a solid patient-physician relationship model that works far better than you have characterized.

      In my training program at what is considered one of the major cancer centers in the US, I have the opportunity to learn from compassionate, selfless palliative specialists on a daily basis and consider a couple of the fellows to be good friends. I fully support their work and call them for consults routinely. In my discussions with them, a few things become clear: a) palliative care is neither cheap nor easy to coordinate without a central organization (ie: tertiary center, inpatient status, or large integrated referral networks), a committed primary treating physician (oncologist), and a sophisticated patient (must be able to manage the added appointments and information), b) patients themselves not infrequently can be the biggest barriers to initiating palliative care due to unrealistic expectations or fear of losing their primary relationship with the oncologist (ie: in this situation, the oncologist would be accused of ‘dumping’ a patient no longer a candidate for treatment), and c) palliative care (ie, interventional pain) itself is prone to misalignment of financial incentives. The basic issue Joe, other oncologists, and oncologists-in-diapers such as myself will have with your approach is that you seem to be arguing that oncologists as a matter of routine either do not know when to ask for help or have an insurmountable cognitive blockade in asking for help due to their “focus on the disease.” This latter insinuation is one I have heard from any number of groups arguing that their field/service/new model, that supposedly “focuses on the whole patient” and can do no evil, should supplant a current one. It is also a horribly insulting one in this case considering oncologists occupy a unique, traditional role in treating patients who routinely will require end of life discussions and palliative care–a role that pre-dated formal palliative care training in the US.

      Yes, there are too many instances where treatment persists beyond benefit to the clear detriment and anguish of patient. Moreover, comparisons of equi-potent initial regimens in sarcoma (as recommended by NICE and cancer institution guidelines here) by cost seem to suggest increased use of costlier regimens. Given this background, I nonetheless would argue that you are making the issue more black and white than it is with several false dichotomies/implications: oncologists greed/sub-conscious self-indoctrination vs. palliative care populated by only people who have a passionate commitment; ‘best’ oncologists are those who agree with you and blow whistle on colleagues vs. those who disagree with you are those who are most after financial gain; all patients who can go to palliative care want to go palliative care; patients decide to go to palliative care easily once it is offered and the oncologist need only step aside. In reality, I can tell you as easily as Dr. Eisenberg that an oncologist’s touch is most often the key factor in helping a family and patient transition to accepting palliative care. That said, it is true some oncologists are more willing than others to not engage proactively in this deed as long as they are giving chemo they can charge for or when it may cause them more grief and time in argument with a family than it is worth to them at the current time. The question then becomes is this a necessary evil or what is your alternative?

      Palliative care specialists are consultants; consultants need a primary treating physician to help them integrate and to help the patient adjust to the new care. Given how little faith apparently is put in physicians, central mandates for chemo guidelines or standard reimbursement regardless of work put in logically may deter some physicians from prolonging excessive treatment but may also rob other patients of beneficial care that would cost the physician more time and liability without renumeration. Clearly the answer to the shortcomings mentioned is going to lie somewhere in the middle with flexibility retained for therapeutic choice, provider-patient relationship integrity, patient autonomy, and increased standardization of care regarding both treatment and palliative therapy. What I object to in the meantime is the clear penchant for central solutions and extrapolations which too often are overly generalized and impractical. These hold the potential to damage currently constructive relationships between patients and physicians without offering a justifiable benefit in return other than wiping the grin off a some greedy or over-aggressive docs.

      • Neil

        I should add my disclaimer that this crass discussion of financial gains guiding physicians was one brought out to an extreme rather than reflective of reality in discussing a point. When you actually look at the ledger, overtreating patients with an ‘extra’ cycle of chemo often is just not financially rewarding in the way being depicted. In addition to the costs (hospitalization often lengthy and outside global reimbursement for failure to thrive admit, etc.), it takes away time from the most reimbursed patients in an oncology practice: new pts going on chemo. If you really wanted to be unethical about this, the push would be to transition patients out of practice as soon as main chemo (as opposed to 3rd or later line) was completed to make room for new patients, which would rightfully be called dumping and failing your patient. I think there are lower lying fruit in enhancing utilization of palliative care and supportive care for cancer and chronic condition patients than taking shots at physician’s integrity.

  • Jane

    @Maggie–do you feel there is a need for oncologists and chemotherapy? Should we just forgo all cancer treatments?

  • http://Www.twitter.com/alicearobertson Alice

    Consider this a post from an ignoramus who is thinking aloud….I really don’t know the answers….do not trust a lot of research (a post on this topic didn’t make it…and it is highly frustrating to think that posts without personal attacks are not making it through).

    I will share that the dogmatic stance and reliance on one piece of research is not pragmatic. Everytime I see doctors say something about early detection or preventive medicine research not backing up common sense the patients wonder when the doctor will get their head out of the sand. Personally, I would move on…and did from a doctor with this mindset….I do not care if only one person out of a thousand is helped….when it is your child with cancer you won’t either. I argued with two specialists over this. I begged for a test. I wanted to be wrong….but I was right…it was cancer. I have seen more professionalism and understanding of tests from techs (I believe a tech saved my child’s life).

    Two of the nations top experts were on Larry King discussing cigarettes. They said they are so toxic if Americans all quit smoking half the hospitals could close. That’s astounding! Let’s go one step further and think of incentives for health…..how many doctors will be out of work if this is successful? How many techs when the tests aren’t ordered…..the domino effect on jobs…and then we deal with stress.

    But, ultimately, I sit here and read and wonder how much a life is worth? How many lives are lost in plan A, how many in plan B? Because one thing is certain….if cost is the big factor….whether it be the insurance companies or government deciding people are going to die (wasn’t Paul Krugman just too honest yesterday when he blurted out his economic answer to this question….yeah death panels and VAT were his direct quote….then he got blasted….not for the death panels…but the VAT….he tried to get out of Charlie Brown mode ). He back pedaled.

    Medicine seems impersonal…..yet, patients are more empowered than ever……and it does seem that doctors are placed in the middle. Personally, I do not like this ideology that has been presented over cost saving. Management likes tests….patients like tests…..so who will take responsibility for the people like my child who I believe would have died under a national health type of system in the UK (where the vast majority of our relatives still reside)?

    Maybe we could get the crystal balls out of the wax shop and go to psychics? If doctors can’t/won’t run the tests that I consider vital why should I go to you? For a lecture and some drugs? Oh yeah, usually prescriptions are based on test results…..a lecture….. i’ll pass! Just a little bit cyber dramatics from a patient’s mom who has firsthand experience that clouds all I see and do.

    • Diora

      “Everytime I see doctors say something about early detection or preventive medicine research not backing up common sense the patients wonder when the doctor will get their head out of the sand.”

      Alice, what we perceive as “common sense” is in fact heavily influenced by what we hear in the media as well as anecdotal experiences. Say you know someone whose cancer was found early and who is OK now. You’ll immediately think “the test saved this person life”. You don’t consider the case that 1) this cancer could have been so slow growing that it wouldn’t have spread during person’s lifetime or maybe even would’ve regressed if remained undetected. 2) the cancer could’ve been sufficiently slow growing that it would still be localized if detected later. The thought that not every case of early cancer detected represents a life saved isn’t something you’d consider “common sense”, yet it’s true. And some cancers are so aggressive, they’d kill you anyway.

      What the studies show, and why the research is needed is to determine if there is a subset of cancers for which early detection matter: i.e. those that spread slow enough that a particular test can catch them before they spread yet sufficiently fast to kill you if caught later. In some cases, this subset is non-existent in others – it’s considerable. Studies also determine the risks – how many healthy people get false positives and go through potentially invasive tests, and how many people would get the cancer diagnosis unnecessarily i.e. the cancers would’ve never caused harm if remained undetected.

      Some years ago, it was thought that testing infants for a rare cancer, neuroblastoma, would catch this cancer early and save lives. In japan, they started universal screening program. Some years later they looked at the data. It turned out that while many more kids were diagnosed with early cancer than ever, the number of aggressive cancers detected later hasn’t changed and the same (or even greater – I don’t remember the exact numbers) number of kids died. All of the extra early cases discovered and treated (often with life-long side effects) represented overdiagnosis – cases that would’ve never spread and maybe disappeared.The program was quickly abandoned, but think about the parents whose kids got the diagnosis of cancer unnecessarily, and whose kids health was forever damaged by treatment.

      This is why one needs to look at studies rather than what you think as “common sense”.

      BTW – to really understand the issues, consider reading book by H Gilbert Welch “Should I be tested for cancer. Maybe not and here is why”. The author is a reputable doctor and researcher from Dartmouth, and he isn’t arguing for- or against- screening but explains benefits and risks and terminology you often read here in a very easy lay person language. You could probably get it in the library. it’s an easy read.

      • http://Www.twitter.com/alicearobertson Alice

        Diora do you realize my child would have died without testing. It is great to be dogmatic, save money, support research that is imperfect, but wait until it your child has a lump that only you could see because it located behind an organ and they turned their head a certain way that caused my heart to stop………and see if delaying treatment is something you recommend. Try telling doctors you just want an ultrasound…..even when they say there is nothing there. Iit is common sense that the vast majority of testing is useless, but it’s also common sense that until doctors learn how to perform xrays without radiation from their own set of eyes, or learn some psychic skills the tests are what tell the doctor what is going on, and it gives patients relief when the tests are done. The vast majority of tests are safe, but costly monetariy wise. In my case our surgeon is a researcher who has won some pretty prestigious awards and gets published in the press. He knows the delay in treatment and lack of testing harmed my child.

        As far as research….have you studied how research is done? I believe in early spring TIME or Newsweek covered it and I think it was in The Atlantic a month or so ago. Research is so tainted it’s pretty flustering…yeah, that’s my word for the day! :) Just ask a researcher. I know two, and a coroner. They don’t even trust the flu shots based on their own research, not the widely available stuff. There are several books like Bad Medicine, and topics about how research really works. At the medical examiners office last week the ME”s refused the flu shot while watching people line up for them. That’s fine, but research shows……um……

  • http://www.healthbeatblog.org maggiemahar

    Neil and everyone-

    Neil writes: “That said, it is true some oncologists are more willing than others to not engage proactively in this deed as long as they are giving chemo they can charge for or when it may cause them more grief and time in argument with a family than it is worth to them at the current time. The question then becomes is this a necessary evil or what is your alternative?

    I fully recognize that oncologists often don’t have the hours it would take to descirbe a patieint’s options in great deatil, odds, risks– folowing the “shared decison-making” protocol.
    Nor do they have the hours needed to counsel families who are in denial or disagreeing among themselves. Again we are talkng about meetings that last 2 or 3 hours.

    I am certainly not trying to portray all–or even most– oncologists as greedy. But their training teaches them that their goal is to extend lives, and fight death. In addition, as has been widely recognized fee-for-service leads most phsyicians to do more. This is why the vast majority of heatlh care reformers believe that we must move away from fee-for-service and toward other forms of payment.

    Palliative care specialists are taught that death is not the enemy. Death is a normal part of life.

    As we know, may cancers are incurable. Yet many cancer patients are hospitalized and undergoing chemotherapy during their final months of life. Yet most patietns would prefer to die at home.

    In most cases, the reason patients die in a hospital is not because palliative care is unavailable in their region. The new DArtmouth Atlas report .finds huge variablity in the % of cancer patients who die and hospitals, and her is what is suprising: “Cancer patients were most likely to die in a
    hospital in the Manhattan hospital referral region, where 46.7% experienced death
    in a hospital. The rates were also high in surrounding regions, including Ridgewood,
    New Jersey (42.8%), East Long Island, New York (42.5%) and Newark, New Jersey
    (41.1%). These rates were about six times higher than the rate in the Mason City, Iowa region, where only 7.0% of cancer patients died in the hospital. Cancer
    patients were also much less likely to experience a hospitalized death in Cincinnati (17.8%) and Fort Lauderdale, Florida (19.6%).

    Also in some parts of the country, cancer patients are more likely to die in an ICU: “About 24% of cancer patients were admitted to intensive care at least once during
    their last month of life. However, the percent admitted to intensive care varied
    more than sevenfold across hospital referral regions. More than 40% of cancer
    patients who died from 2003 to 2007 were admitted to intensive care during the last
    month of life in Huntsville, Alabama (42.4%), McAllen, Texas (41.0%), Los Angeles
    (40.3%) and Miami (40.3%). Only 6% of cancer patients were admitted to intensive
    care during the last month of life in Mason City, Iowa. Admission rates to intensive
    care were also low in Madison, Wisconsin (13.0%), Portland, Maine (14.3%) and
    Minneapolis (14.6%).

    In some places, the medical culture accepts palliative care. In other places–llike Manhattan– physicains are less likely to recommend it–even though there are plenty of palliative care teams available who would care for a patient in his home.

    Finally, question Eisenberg asks his patients “In the foreshortened time you have life, how would you like to spend it” is a good one.

    But to ask that question, the oncologist has to tell his patient “You are dying. There is nothing I can do to cure you. At most, I might give you another 2 or 3 weeks of life.”

    Some oncologists are very reluctant to ever directly tell a patient that he or she is dying and that nothing can be done.

    Palliative care specialists are trained to do this. And of course, this is another time-consuming project.

    It sounds as if you have a great relationship with palliative care specialists at your center and probably great training in collaborating with them.

    Unfortuately, this is often not the case, particularly at large academic centers. More than one palliative care specialist has told me about oncologists, surgeons and others refusing to let a palliative care specialist consult with their patient. This happens in the best hospitals in N.Y.
    Even if the patient asks about palliative care, the doctor who is treating him says “Oh we’re no where near that point” as if a palliative care consult is approporiate only if a patient is about to die.

    As Meier argues when discussing the NEJM study, it suggests that pallative care specialists should be called in for any patient who is seriously ill (cancer, etc.) whether or not he his dying. Even if he doesn’t die, palliative care can relieve both physical and mental suffering, and allow him to explore his options — Do I want treatment A or more aggressive treatment B? What are the risks and odds in each case?
    .
    Those interested in palliative care might want to look at Dartmouth’s new (came out today) study of end-of-life care.
    (see http://www.dartmouthatlas.org)
    It concludes that : “The lesson from today’s Dartmouth Atlas Project report on cancer care at end-of-life (www.dartmouthatlas.org) is that too many patients die in hospitals and too few are offered hospice and palliative care.

    “Today’s report from the Dartmouth Atlas Project unfortunately demonstrates that healthcare professionals in our region, and across the nation, may be failing to honor the preferences of patients and their families at end-of-life. These findings suggest that we are underutilizing hospice and palliative care, which receive high marks from families and patients at end-of-life,” said Karen Wolk Feinstein, president and CEO of the Pittsburgh Regional Health Initiative (PRHI), a supporting organization of the Jewish Healthcare Foundation (JHF).

    “These alternative programs emphasize pain-free and personal care when medical interventions aren’t indicated. Unfortunately, too often health professionals can’t move from cure to care when no proven medical treatment exists. This happens in spite of patient and family preference to end life out of hospitals”

  • http://Www.twitter.com/alicearobertson Alice

    I just reread this thread, and indeed, as Fred shared it is really interesting. A bit like Medical Crossfire. I wrote Maggie privately to encourage her (I, too, agree with the author that at times I disagree with her), but it seems a majority of doctors post anonymously. I admire doctors who post with their name and link (the ones who are anonymous are not the Deepthroats of Medicine they pretend to be….overall….they are ranters. Doctors like Groopman and Gawande who do not write with pseudonyms are changing medicine, not the cloaked doctors).

    Anyhoo, this thread shows a doctor doing what he should do…what he is paid to do….find flaws, be specific, get dogmatic, split hairs. Then the patient uses their vision of filtering the choices….the broader picture….the emotional aspects….the result of all of this internalizing of details. ….the revolving questions of how this infornation affects them personally. When done well….it creates satisfaction on both sides.

    Sometimes it seems doctors have tunnel vision…it is their strength and weakness. But where we are being treated at The Cleveland Clinic this year they have emphasized treating the whole patient. It is working wonders. Doctors thinking outside the textbook box that got them through medical school. To look into a patient’s eye,,,the window to the soul…..and understand that as vital as all this data is a hopeful, hurting heart wants healed too. It costs nothing to go beyond your ticker tape of data and listen to concerns. It enlarges your world. It is why I love our award winning, brilliant surgeon.

    It is why what Maggie shared from a conversation with a doctor is important. Published research is limited. My doctor prefers research, and wins big awards for best research paper, but the red tape associated with research drove our other doctor out of the field. He felt he could not publish the real truth. And, no, we all know he isn”t going to put that in writing. But if you want to be dogmatic over research you need to understand all the researcher found. I like Sherlock Holmes and his inductive use of logic, and Watson’s use of deductive logic. Surely, doctors should use both forms of logic?

  • Neil

    Ms. Mahar-
    I think you oversimplify the issues, and your conclusions suffer for it. Specifically, I disagree with your depiction of too many issues in a black and white manner and on selective interpretation of associative, non-causal studies that you present in an almost shotgun manner. Moreover, I think you continue to run rather close to making judgments of training and professions of which you seem to lack full understanding based on your mischaracterizations. What amazes me about having to say this is that I actually agree with you about the need to increase embrace of palliative care amongst patients with cancer. However, I think you make all the wrong conclusions about why the problem exists and how to rectify it, especially regarding a clear penchant for central mandates that are impractical and vague.

    1) You comment on the training of oncologists and palliative care as all or none in reference to ability to dissect treatment of disease and person. This ignores the reality that oncology fellowships are mandated to include education about palliative/hospice care and referral. Though obviously some programs do so better than others, the conclusion cannot be that oncologists are ill suited in principle to deciding when a patient should be encouraged to see palliative care.

    Indeed, supportive care and treatment side effect management are uniquely central aspects of training and practice in oncology. Yes, the pitfall of treating disease over patient at times catches some practitioners; but on the whole you pay no due to a field that has long prided itself on being there to provide hope, compassion, and support to patients who deal with death more frequently than almost any other medical field. Acceptance of death when appropriate is a reality known well to each and every oncologist, and to suggest otherwise is to simply not know oncology. To throw more fragmented, hyper-specialization onto every chronically ill patient encounter as a remedy regardless of need would be costly, arguably redundant, confusing and low yield.

    Well-trained oncologists are qualified and best situated to handle this care up front until an end of life transition or specialty help requires referral. The more productive aim would be to continue education efforts to nurture the role of the oncologist as a primary cancer provider able to direct care in the best interests and wishes of the patient as opposed to in the interest of cancer reduction. Culture change is what the Dartmouth atlas studies and reformers are asking for, not drastic, costly and disruptive experiments with the system.

    In this context, eliminating fee for service becomes a lesser priority as neither global payments, salaried nationalized staff, or other popular financing proposals are free from disincentives in this scenario. In the end, this is hard work that requires compassion and commitment—a role one is more likely to embrace when in a close, rewarding and personal relationship with a patient rather than a rigidly structured one that is controlled by outside mandates. Ironically, the salaried relationship is one seen in academic centers you cite as being underperformers in engaging hospice—something that must be relatively independent of financial incentivizes for treatment.

    2) You comment on what you perceive as inferior performance in palliative care in New York and other Northeast urban academic centers by citing anecdotes and data showing higher rates of death in hospital with the tangential implication that fee for service hungry doctors and administrations are partially to blame. In doing so, you ignore the multitude of other possible and reasonable factors that go into this data.

    Most prominently, academic and urban centers draw a higher proportion of highly motivated, often more treatment focused patients who are more prone to dying in the hospital. I see this everyday in my training center in NYC. Indeed, a wise attending’s observation to me has rung true: “almost all the patients on this floor (inpatient cancer) are here because of unrealistic expectations of the family or of the oncologist.” No oncologist desires for a patient to die inpatient.

    Clearly, I agree with you that we should aim to temper those who unnecessarily risk inpatient deaths due to highly aggressive treatment, but you seem to totally ignore the choice and role of the patient. No matter your incentive system, poor performers that over or under treat will persist–hence why seeking out the right oncologist is an important task of the patient. No palliative care consult or otherwise will save a physician-patient relationship from fundamental value mismatch.

    Further factors that go into the associations seen in the Dartmouth data include cultural differences across geography, especially urban vs. rural, accessibility of inpatient beds, and accessibility of tertiary services. I think you and I both agree fewer cancer patients should die in the hospital, but you will have to convince a lot of the patients themselves of that. Overall, the regional variation aspect of the data is being poorly used in a manner that is at best naïve and at worst intentionally sensationalistic for unrelated arguments ie: beef with the fee system.

    In ending my diversion from my evening duties, I reiterate my agreement with you and others that hospice/palliative care is being poorly matched to those who would benefit greatly from it, as evidenced by the high % of cancer deaths in hospitals. I disagree with your conclusions about why this is and how to rectify it, especially regarding the role of oncologists. At the base of these arguments I suspect is your passion for rooting out financial and cognitive perversions of the duty providers have to their patients. Though I share some of your views on these broader issues, I think you too stretch to far in trying to centralize them in this particular debate.

    PS Alice, the art of medicine sometimes means softening the cold science of it. However, I trust you will believe it is usually not arrogance or blindness but duty that leads physicians sometimes to seem rigidly bound to data when it is sufficient. As for my declaring my name, it brings risks for me being a trainee and shouldn’t further inform judgment of my thoughts here.

  • http://Www.twitter.com/alicearobertson Alice

    Your point is well taken.  You say one thing…the patient hears another.  Stats show the average patient forgets 70% of what they heard in the exam room.

    I wish the first question could sum up our visits.  When it is cancer, and horrific treatments are being discussed I can share your mind goes into such a high gear you really can’t absorb it all.  In a word you are terrified.  

    My doctors encourage email, snd questions…stating I must stay in contact with them.  They are not the norm.  One doctor thought he was there to entertain me…and he did…he is the author of a book on our disease…top of the line with the jokes….but when you were through laughing you and you asked if we could discuss what to do about the spread of cancer he responded that my daughter did not have cancer.   I almost fell off my seat.  He finally opened the EMR and I guided him to the right dates of tests and other doctor’s input.  Two of our specialists wing it and do not have your file open.  That is doctor error because even if the patient listens it is just basic stuff, not your personal, unique status.  They are no longer our doctors….politeness from a patient only goes so far when a life is on the line.  I have to pay for our records, they take weeks to arrive because it is truly the only way to understand it all.  Then research, then scaling the questions down to your particular circumstance, and finding doctors who understand that this may have been covered a thousand times by them….but it is your first…you are acclimating to devastating news….your life is changed forever by what they just shared.  I asked our doctor if he hates his job on days like this (I had just received bad news, and my mind was clicking and desiring denial).  His voice was soft and kind….he said he would not want to be sitting where I am….then responded with some of the kindest words I have ever heard….yes. I listened and heard…because the presenter cared.

    Sure sometimes patients are too angry or distrsught to hear exactly what you said….surely, doctors are trained to help us listen?  I know the two I have now will offer to stay late ot whatever it takes to keep the communication going.  They understand it is more vital that I understand and make this a top priority.  They offer hard headed patients a replacement doctor because they feel personalities can conflict, but few patients move on from the skilled, empathetic good communicator.  

    Quite frankly, I consider our doctors our friends….but when we see two of the others I try to disappear.  So far….we are far from batting 100 and I am at one of the top five hospitals in the country.  Dr. Jerome Groopman shared that in his informal survey 100% of doctors said if they can’t communicate with a doctor they are outta there, and fast!  That’s the motto I think will guide my future visits.   Two doctors who refused to listen to my pleas would have inadvertently killed my child.   Arrogance is not only unbecoming, it’s a killer.    [end quote]

    This is flustering….are you stating the state of medicine means you cannot share honestly under your real name for fear of repercussions? And you want me to trust data given from within the same system you are fearful of? Hmmm…..no wonder this same system shuns patient advocacy,,,it shines a light in dark corners and demands accountability. Hang onto your seat….it’s going to a bumpy ride!

    • Neil

      Alice:
      “This is flustering….are you stating the state of medicine means you cannot share honestly under your real name for fear of repercussions?”

      You misinterpret wildly. Debating anonymously but with declaration of my background to inform on potential bias is sufficient here and an important function of blogging which encourages openness in healthcare and elsewhere. No benefit exists for going further while potential risks always abound. Specifically, my role at my institution is to train well and do right by my patients; any distraction from this is hard to justify when I am not in an official capacity to reflect upon the organization (ie: as a trainee, I have the privilege of visiting with patients of my attendings whose reputations and relationships with patients I may impact with my words and actions). Not everything is a malevolent conspiracy. Regardless, I wish you well in your child’s treatment. I hope you have found those you can trust and thus who can best help.

  • http://www.healthbeatblog.org maggiemahar

    Neill,, Alice, Others.

    See the Dartmouth Atlas report on end-of -life care for cancer patients released ealier this week.

    You will find thatm after adjusting for age, sex, race, socie-eocnomic factors, other chtronic dsesase, etc, . some hospitals offer less palliative and hopsice care, while others offer more -for reasons that are not easily explained.
    . The variatons seem to have little to do with patient wishes, or what doctors surveying the differences say would be in the best medical interests of patients. .
    The vast majority of patients would prefer to die at home–or in a hopsice -not in a hospial,, Intensivec care unit or nrusing home.
    In addition much research shows that those who die with palliative or hoepice care tend to be less dpressed, less anxious (as are their faimilies.) The quality of their final months is better if they die at home or in a hospice center rather than in a hospial.

  • http://Www.twitter.com/alicearobertson Alice

    I know people hate the unofficially use of the words, “death panels” but Krugman used it this weekend on ABC. Anyone want to elaborate on just what he meant? Will this conversation be valid if these appointed panels cut costs? He is an economist, not a bioethicist, so we are commodities, just like the VAT he mentioned in the same breath.

    My question is about input cost and, also, the mindset? I view it as Orwellian…but then again literature is my thing…not economics. Economically, I think Krugman has a point….old people are costly, and useless…a real burden and drain on our resources (hyperbole???). Morally his attitude stinks!

    Francis Schaeffer the great theologian of the last century summed it up well long ago when today’s mindset was predicted:
    ‘If the fetus gets in the way, ditch it. If the old person gets in the way, ditch it. If you get in the way. . .’”

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