Who Will Care for Older Adults? We’ve Plenty of Know-How but Too Few Specialists

Yves here. When I was involved in my mother’s care in the last few years of her life, it was depressing but also revealing to see how often the default among doctors was “She’s over 90, what do you expect?” when even at her age, there were therapies, particularly exercise, that would improve her quality of life.

But another factor, and I wonder if it plays into the shrinking population of gerontologists: Medicare rules that restrict care, like hard limits on how long after hospitalization a patient can stay in a skilled care facility. Another deterrent is that most of these facilities are warehouses, as opposed to places where patients get therapeutic care (go look at Medicare ratings and see how shockingly low the average minutes per day of various therapies are).

And even worse, there’s often no ready way to get around the constraints. I wanted my mother to get a blood draw at home during a Covid wave so as to keep her regular 2x a year general practitioner review (the GP insisted their massive outpatient facility was safe; they had tiny treatment and exam rooms, not well ventilated, even before getting to the fact that she’d have to take separate elevators, so clearly not). The outpatient facility did agree to run the labs on a blood draw if we could get the vials to them (which in fairness was more flexible than I expected them to be).

I wasted a staggering amount of time to find out it was impossible. No one in Birmingham, a city of 200,000 with the best med school in the South, was not taking Medicare. If you accept payment from Medicare, you cannot bill a Medicare enrollee for services outside Medicare (theoretically they can if it is not a Medicare-covered service, but no one wanted to take that chance). And a at home blood draw was not a Medicare allowed service. Home visits by nurses were allowed only if a lot more services were also being provided.

By Judith Graham, a contributing KFF Health News columnist, and previously an investigative reporter, national correspondent and senior health reporter at the Chicago Tribune, a regular contributor to The New York Times’ New Old Age blog, the first topic leader on aging for the Association of Health Care Journalists and a contributor Stat News, The Washington Post, and the Journal of the American Medical Association. Originally published at KFF Health News

Thirty-five years ago, Jerry Gurwitz was among the first physicians in the United States to be credentialed as a geriatrician — a doctor who specializes in the care of older adults.

“I understood the demographic imperative and the issues facing older patients,” Gurwitz, 67 and chief of geriatric medicine at the University of Massachusetts Chan Medical School, told me. “I felt this field presented tremendous opportunities.”

But today, Gurwitz fears geriatric medicine is on the decline. Despite the surging older population, there are fewer geriatricians now (just over 7,400) than in 2000 (10,270), he noted in a recent piece in JAMA. (In those two decades, the population 65 and older expanded by more than 60%.) Research suggests each geriatrician should care for no more than 700 patients; the current ratio of providers to older patients is 1 to 10,000.

What’s more, medical schools aren’t required to teach students about geriatrics, and fewer than half mandate any geriatrics-specific skills training or clinical experience. And the pipeline of doctors who complete a one-year fellowship required for specialization in geriatrics is narrow. Of 411 geriatric fellowship positions available in 2022-23, 30% went unfilled.

The implications are stark: Geriatricians will be unable to meet soaring demand for their services as the aged U.S. population swells for decades to come. There are just too few of them. “Sadly, our health system and its workforce are wholly unprepared to deal with an imminent surge of multimorbidity, functional impairment, dementia and frailty,” Gurwitz warned in his JAMA piece.

This is far from a new concern. Fifteen years ago, a report from the National Academies of Sciences, Engineering, and Medicine concluded: “Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future.” According to the American Geriatrics Society, 30,000 geriatricians will be needed by 2030 to care for frail, medically complex seniors.

There’s no possibility this goal will be met.

What’s hobbled progress? Gurwitz and fellow physicians cite a number of factors: low Medicare reimbursement for services, low earnings compared with other medical specialties, a lack of prestige, and the belief that older patients are unappealing, too difficult, or not worth the effort.

“There’s still tremendous ageism in the health care system and society,” said geriatrician Gregg Warshaw, a professor at the University of North Carolina School of Medicine.

But this negative perspective isn’t the full story. In some respects, geriatrics has been remarkably successful in disseminating principles and practices meant to improve the care of older adults.

“What we’re really trying to do is broaden the tent and train a health care workforce where everybody has some degree of geriatrics expertise,” said Michael Harper, board chair of the American Geriatrics Society and a professor of medicine at the University of California-San Francisco.

Among the principles geriatricians have championed: Older adults’ priorities should guide plans for their care. Doctors should consider how treatments will affect seniors’ functioning and independence. Regardless of age, frailty affects how older patients respond to illness and therapies. Interdisciplinary teams are best at meeting older adults’ often complex medical, social, and emotional needs.

Medications need to be reevaluated regularly, and de-prescribing is often warranted. Getting up and around after illness is important to preserve mobility. Nonmedical interventions such as paid help in the home or training for family caregivers are often as important as, or more important than, medical interventions. A holistic understanding of older adults’ physical and social circumstances is essential.

The list of innovations geriatricians have spearheaded is long. A few notable examples:

Hospital-at-home. Seniors often suffer setbacks during hospital stays as they remain in bed, lose sleep, and eat poorly. Under this model, older adults with acute but non-life-threatening illnesses get care at home, managed closely by nurses and doctors. At the end of August, 296 hospitals and 125 health systems — a fraction of the total — in 37 states were authorized to offer hospital-at-home programs.

Age-friendly health systems. Focus on four key priorities (known as the “4Ms”) is key to this wide-ranging effort: safeguarding brain health (mentation), carefully managing medications, preserving or advancing mobility, and attending to what matters most to older adults. More than 3,400 hospitals, nursing homes, and urgent care clinics are part of the age-friendly health system movement.

Geriatrics-focused surgery standards. In July 2019, the American College of Surgeons created a program with 32 standards designed to improve the care of older adults. Hobbled by the covid-19 pandemic, it got a slow start, and only five hospitals have received accreditation. But as many as 20 are expected to apply next year, said Thomas Robinson, co-chair of the American Geriatrics Society’s Geriatrics for Specialists Initiative.

Geriatric emergency departments. The bright lights, noise, and harried atmosphere in hospital emergency rooms can disorient older adults. Geriatric emergency departments address this with staffers trained in caring for seniors and a calmer environment. More than 400 geriatric emergency departments have received accreditation from the American College of Emergency Physicians.

New dementia care models. This summer, the Centers for Medicare & Medicaid Services announced plans to test a new model of care for people with dementia. It builds on programs developed over the past several decades by geriatricians at UCLA, Indiana University, Johns Hopkins University, and UCSF.

A new frontier is artificial intelligence, with geriatricians being consulted by entrepreneurs and engineers developing a range of products to help older adults live independently at home. “For me, that is a great opportunity,” said Lisa Walke, chief of geriatric medicine at Penn Medicine, affiliated with the University of Pennsylvania.

The bottom line: After decades of geriatrics-focused research and innovation, “we now have a very good idea of what works to improve care for older adults,” said Harper, of the American Geriatrics Society. The challenge is to build on that and invest significant resources in expanding programs’ reach. Given competing priorities in medical education and practice, there’s no guarantee this will happen.

But it’s where geriatrics and the rest of the health care system need to go.

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  1. Lexx

    This may be where having a few billionaires in your neck of the woods comes in handy. They’re funding a lot of research on aging trying to come up with solutions to their own problems, like putting off aging and (yeesh!) dying. Our local billionaire is a healthcare heir and 67.

    Did a quick check to see how many geriatric specialists are practicing here; there were quite a few, most of them well rated online and they seem to be in private practice.

  2. LawnDart

    So, last year my step-mother died on the floor of their home due to a combination of effects of malnutrition and Alzheimer’s while my father lay mere feet away on the bed ignoring her pleas for help, oblivious to her plight, and only much later calling for assistance to help get his wife up and back on her feet: when she was found, the body was already cold.

    Two weeks prior to this, in the space of less than a day, Adult Protective Services opened and closed another case on them, another referral for investigation, without making so much as a phone call or visit to their home.

    My father is likely on the autism spectrum and appears to be suffering from dementia as well: he has no insight into his own condition, let alone demonstrated any into his wife’s. He is “safe” now, and in a nursing home.

    The conditions by which they lived were appalling: neither had bathed in at least a year; his wife was constantly removing and spilling her ostomy bag, he was incontinent and had no control of his bowels: the bed in which they slept was saturated with urine, feces, and vomit.

    They had a wealth of assets and the best insurance you can buy… my efforts to get them assistance were stymied or met with failure.

    I understand that there are too few doctors for seniors… there’s too few clinicians, nurses, and too few of everyone else too, even if you can get the senior in need to assistance.

    The aging of the boomers alone threatened to collapse the system, now toss in the health-effects from covid… the system is so not ready. So many live under the illusion that help will be there for them if they need it… well I got news for you, folks…

    1. i just don't like the gravy

      That is appalling, and I fear not uncommon.

      Very sorry your parents lived that way. I hope your father will have a more comfortable remainder of his life as compared to his wife.

      Stay strong.

      1. LawnDart

        I should note that it was at an appointment for a neuro/psych eval for my father that the doctor/staff notified Adult Protective Services after they were unable to complete my father’s exam because his wife (who had accompanied him) was totally out of control: this was the first referral. And it went nowhere.

        The second referral to Adult Protective Services (APS) was made by a caseworker that I was working with through APS’s sister agency. And this too went nowhere.

        My father and step-mother were “frequent-fliers” to area emergency rooms. My step-mother’s dementia was full-blown and very obvious, as well as her weight-loss (think of those Auschwitz photos from the history books). She was under the “care” of the Mayo Clinic Health System, and, to my knowledge, she never saw or was referred to a dementia-care specialist.

        The burden of “caring” for his wife (actually, dealing with her 24/7) nearly killed my father, and certainly helped destroy what was left of his own mental capacity as well as his physical health.

        Because of my father’s lack of insight, inability to seek help, my only hope that he and his wife could get assistance was if it was mandated through the courts– Adult Protective Services should have been the vehicle (and was pretty much the only one available) to get the case there, but they failed us, failed in their stated mission to protect elderly and vulnerable adults.

        This whole episode kinda sidetracked my career for a time and blew a hole in my finances, but whatcha gonna do?

        1. Sue inSoCal

          I am so sorry for you and your family. What a sad, frightening nightmare. This seems to be the way of the country, whether it’s geriatric patients or chronic illness. It doesn’t surprise me that the Mayo Clinic was involved. After I had a consultation with them a number of years back (the advice they gave me I should have ignored and had terrible consequences), but worse, I subsequently received a letter that they would not be accepting Medicare, only private plans (which I had at the time I saw them). We’re talking regular Medicare with gap they weren’t accepting. They are now. But I believe they do not accept Medicare Advantage at all, even though folks are being forced onto it. The Mayo is like any other “healthcare” provider making a not-for-profit fortune in my opinion. I couldn’t believe that letter I received.


  3. EAC

    Considering that over the years I have seen many international students do MBAs or even undergraduate programs in finance and other areas which have joined the never-ending list of STEM programs that add three years of optional practical training – which gives them 3 years to work in the U.S. after they graduate, then seen them to hop into private equity and other financial sector work on H1Bs, and then apply for green cards once they are eligible, I see no reason why our fearless elected leadership could not pry open the USMLE (U.S. Medical School Licensing Exam), make the USMLE more accessible to International Medical Graduates (IMGs), and then tie in a requirement that they work in the field of geriatrics maybe for a certain number of years. As far as any brain drain blah, blah – there are countries (I know mostly for Eastern Europe) where they have a surplus of young doctors who are unemployed.
    Funny how we have managed to find all kinds of work arounds to keep our financial markets well-staffed with talent from all over the world, but addressing our shortage of healthcare workers at many levels…well not so much interest…

  4. i just don't like the gravy

    I don’t foresee the younger generation wanting to care for the old.

    Why spend your time helping those who left you an uninhabitable planet? There will be more pressing issues to attend to than care for the elderly, particularly because I expect many of them to not care that they lived a life of relative material comfort at the cost of future generations.

    Not a happy thought I know, but from young people I talk to, many are not sympathetic to the old.

  5. telling the hard truth

    Nobody will care for the old. Why should they? Kids born today will be lucky to live in a world with even a fraction of the material comforts we currently have.

    1. kareninca

      I’m taking care of the old. My 99 year old father in law lives with us. And I grew up in a small town and I know plenty of young people who feel great affection for their elderly friends and relatives, and who help them out a great deal. Actually I know a lot of young people here in Silicon Valley who are happy to help elderly people. I’m not sure the people you know are representative. Of course, it doesn’t follow that there will be enough resources for the old; that is a different matter.

  6. John9

    I think this is a result of the fact that we have lost the ability to undertake large complex operations in any field effectively. This spans everything from creating ammunition for industrial warfare to adequate care for the elderly. High speed rail? Never gonna happen. We adher to the state religion of profit and private property for most new large social undertakings. Doing so guarantees failure. It also means loss of geopolitical power. We are becoming a “sick man” empire like the Ottomans in early 1900’s. Unable to do much of anything and not very well.

  7. Vicky Cookies

    My father died last week. We (my mother, a brother, and myself) had been taking care of him full-time for around a year and a half; much if that time he was “full assist” (no mobility), especially after the extreme decompensation brought on by hospital stays. It was a lot of work, physically, emotionally, and intellectually demanding (learning the systems with which we had to interact, logistical issues), and we all took our turns burning out.

    I can’t recommend the experience enough. Even though the relationship was often difficult or complicated by this or that personal failing on either side, to have been able to provide support and tenderness to the man who gave me life has given me peace and satisfaction; I can’t think of a better way to have spent my time, though I can of course think of more pleasurable or profitable pursuits.

    Industrial medicine seems to be a racket, though one the operators themselves don’t consider to be. We certainly met some caring, if not particularly comprehending, medical professionals, but there is no substitute for love when it comes to caregiving. The best of them were usually EMTs or CNAs.

    1. Bsn

      Vicky, beautiful story. I hope to get old someday and have a caring person nearby. Being a musician, I volunteer for hospice services in our region. I, hubby and friends bring music to people in their last stages. Really fun and it feels so good to help others. Point being, that as the population ages and the world collapses, I feel that younger people will receive much joy in helping those older people. And the stories they share when we visit. Incredible. And, of course the music. Reading new (to me) music (known to the elderly as their teen year’s jams) is fabulous as well. Reading music that is new to the musician is like reading poetry. “Oh, that’s interesting, that’s odd, that’s funny, that’s unique”. Reading and playing music that is new to you, though it may be quite old, brings the player into a distant time and space as you connect with the elderly listener who often joins in with song and even dance. Unimaginable joy for player and listener. I can’t wait to be taking my last few breaths and have my visitor bang out some Albert Ayler or Art Ensemble of Chicago. Gonna go practice now.

      1. Vicky Cookies

        You’re amazing for sharing your talents like that. I played a lot of guitar for my father, and he seemed to find it soothing.

        Reading yours and other comments on this post, I think we see an answer, however insufficient, to “who will take care of aging populations?”: for-profit institutions which are ostensibly responsible for it will pass off as much of the work as possible to folks who, acting contrary to their own short-term economic interests, perform the functions out of love or charity.

        I understand there are some ways to be reimbursed, given certain circumstances (if the patient is on Medicaid, one can be employed as a Personal Care Worker); hopefully these can be expanded, as it does seem that, with a bit of training and experience, those who see the work as valuable in itself are motivated to do it both effectively and lovingly.

        Our economic setup seems to have a major problem with incentivizing pro-social behavior. The model of human nature it assumes (wealth-maximizing, selfish) is, happily, daily refuted by people like you, something we can all be grateful for.

      2. Alice X

        I’ve just been reading through Scarlatti, he is simple if you play him at half speed. Music has been sitting on my piano for some years but my vision was so far gone that I couldn’t read anything. I recently got my eyes taken care of and can read again. I need to get back to reading on my violin which is so much better than my piano effort. I made my living with music.

        I’m 74, when I go I don’t think I want any Albert Ayler but the Art Ensembles’ People in Sorrow could do nicely.

        Actually I’d rather play something myself, even if feebly.

        My oldest Aunt played piano until the last day, she put the piano cover down, went to bed, and died in her sleep.

        1. Carla

          Alice X — my grandmother did much the same as your oldest Aunt. My grandmother’s father was a music professor, and he discovered when she was two years old that she had perfect pitch. Ah, hah! She would be a violinist. He sent her abroad to the Leipzig Conservatory, from which she graduated in both violin and piano, then returned to the U.S. and a career performing and teaching violin (while a stepmother to two and mother to five more). When she was 65, she could no longer hear the highest notes on the violin in tune, so she laid down that instrument and turned to the piano, which she played and taught joyfully until her death at 93. Directly before she died she played the piano for an hour or two. Then she laid down and died.

    2. Alice X

      So sorry about your dad.

      Starting 35 years ago my mom and I took care of my dad who had several rather severe problems. That was over seven years, by his last year my mom was worn out and they both were in wheel chairs. He was total care and that was crushing. When he was gone I took care of her for another seven years although it was a piece of cake compared to him. It took me a long time to recover, if I ever did. Now I’m 74 and don’t have anyone to take care of me so I’m going to have to plan carefully.

      1. Vicky Cookies

        I’m humbled and inspired by your story.

        Alice, that’s a life’s work of rare value. If Karma in its popular sense is a force at work in the world, someone of a similar depth of spirit will find their way to you. Here’s hoping!

  8. justsomeguy05

    Slightly off topic. I spent about 15 years doing “companion care” for seniors. One thing I always told the adult children that usually hired me is that whatever you do, bad things are going to happen. It is inevitable. Make the best decisions that you can based on what you know, and know that even if you made different decisions, bad stuff will still happen along the way.

  9. Beth Oram

    I recently retired from a 30 year career in geriatrics. As a Geriatric NP. My status outside of medicine gave me a unique outsider perspective on this specialty. The least important person in a geri practice is the doctor, the most important is the social worker. But the doctor is the gate-keeper for the social services elderly people need to live independently. So there’s that. Comprehensive Geriatric Assessment has been a very important contribution from geriatric medicine, however my experience is that people trained in medicine simply cannot resist over-prescribing one medication after another, even new medications to treat the side effects of old medications. Fatigue caused by unnecessary beta blockers (and treated with antidepressants). Parkinsonian tremor cause by unnecessary Metoclopromide. Atrial fibrillation caused by unnecessary and unmonitored L-thyroxine. Hyponatremia caused by unmonitored SSRIs. Mental status changes caused simply by polypharmacy. Most patients and families are totally unaware of these contributions to the depredations of “normal aging.” “Start low go slow” was supposed to be the rule in geriatrics but is ignored by many geri-trained MDs. Medicine provides a lousy paradigm for caring for the elderly, and even “multi-disciplinary” always means the physician is in charge.

    1. Yves Smith Post author

      Erm, I’d like to see MDs react. My mother’s MD tried cutting her meds down (she was not taking many) and she resisted. I finally got her off statins and two others. And I do not understand your comment on needing social services. My mother had no need for them.

      1. Beth Oram

        Its good that your mother was fully independent and had no need of social services. But for many older people the struggle to remain independent and in their own homes in the face of functional decline is a major crisis. Most eventually have need of in-home support and services, for instance home health aides, home physical therapy, durable medical equipment delivery, home respiratory equipment, home occupational therapy, nutritional support, home laboratory services (all of my patients got their blood drawn at home), transportation services to and from appointments, home medical visits, home nursing, etc. Application for and maintenance of these essential services from a patchwork of agencies and providers is a full time job. But these services are absolutely essential for many elderly people to maintain their independence and quality of life. The physician is the gate keeper because in a medicalized system that validation by signature is required, but it is the social worker who makes it all happen.

        But yeah, by all means get the real experts to weigh in here.

      2. Dan

        You were the social services for your mom, which is why she didn’t need them. If you didn’t exist then she would have needed the assistance of someone else.

      1. Beth Oram

        All medications have secondary effects. So they have to be monitored with an knowledge of these potential side effects, which differs depending on the medication. Thyroid supplementation requires monitoring of thyroid blood tests. Diuretics require monitoring of electrolytes and uric acid (gout) depending on which one is used. Some psychotropics require the EKG to be checked regularly. The list goes on and on.

        Prior to Covid displacing it, the third leading cause of death in this country was prescription drugs – no not illegally obtained – we are talking medications routinely prescribed by physicians. I saw this over and over throughout my 40 years as a nurse. Failure to properly monitor powerful medications is medical malpractice and it is almost never prosecuted as such.

        1. Merf56

          Thank you for your information as an expert here Beth.
          It was enlightening and will help with my 90 yr old inlaw’s care tremendously – especially with regard to dealing with Drs for needed social services sign offs

        2. lcm

          Beth, thanks for your comments. My father refused help with my mother who had dementia, until he was so exhausted that he had to be hospitalized with heart issues. The social workers at the hospital were instrumental in finding a facility that could care for my mother while he recovered. After my mother died and he was living in independent, then assisted living, the social workers at the facility were a lifeline for him and for us. Of course we were all fortunate that he had the means for this. So many don’t and have to live their last years in misery.

          Thanks for mentioning the hyponatremia caused by SSRIs. Although I’ve been on Zoloft for 25 years, no doctor has ever suggested any monitoring because of it.

          1. Beth

            SSRI-related hyponatremIa is mainly a geriatric issue, also more prevalent in females. So unless you are elderly it’s not a big concern!

  10. Laura in So Cal

    So I’m in the trenches on this. My Mom just passed away from Alzheimers which was her primary diagnosis. She was only 81. She had mildly elevated blood pressure and cholesterol and was on minimum level meds for those. Thru Kaiser, we had her long time PCP, a geriatric neurologists and later a geriatric pharmacist as her “team”. They were kind and generally very responsive, but it was my Dad and I who did all the heavy lifting. We researched stuff ourselves and asked lots of questions. Our pushing on the system got Mom some physical therapy which extended her mobilityfor maybe 9 months which was helpful. For Alzheimers at least, there isn’t much they do except manage behaviors. The meds used for Alzheimers are pretty useless (which they acknowledge), and the off label prescriptions they use for psychotic behaviors cause many other problems like loss of mobility and constipation. You end up picking meds (or not) based on what you can and can’t deal with. I will say the dr.pharmacist we had the last year was a gem. Whenever we tried new meds or changed dosages, we would have very frank discussions of what to expect and every other week phone appointments giving status and dealing with issues.

    The worst people on dealing with an Alzheimers patient were ER personnel and imaging techs. They had no clue about how to deal with an uncooperative dementia patient who had fallen or needed care.

  11. CanCyn

    My father lived for almost 5 years after a pretty big stroke left him paralyzed on his left side and with some mild cognitive problems. Unfortunately neither of my siblings nor I were in a place where we could care for him full-time. I believe that with more rehab, he may have walked again. He reached his limit and was assessed for long term care even though he was still progressing and even though it meant LTC would not offer anywhere near the amount of Physio he was getting in the stroke rehab centre (he spent almost a year there). I don’t know that he would have been able to live on his own even walking because of the cognitive problems but with some help, it may have been possible. He had no money beyond his gov pension. He ended up in long term care (Ontario) where we could at least get together enough money to get him a private room, cable and Internet. Ontario health care barely covers the cost of LTC with a shared room. I am still traumatized by his time there, partially that is guilt that he had to spend the end of his life in such a place. We did our best to support him, rarely a day went by without one us visiting, good long visits, not just pop-ins. We brought in dinner every Saturday night. One day I will recount all of the problems we had over that time, in the LTC, in ER, in hospitals, seeing specialists but I still find it difficult to talk about – he died in 2016! The only thing I know for sure is that we do not have any where near the capacity in western society to care for our elders as they deserve to be cared for – and that is wilful and could be changed. I will never, never ever spend even a day in a long term care facility if I get to be that old. The shi*tshow that was COVID in LTC was no surprise to me and I will always be grateful that my Dad didn’t have to go through that.

    1. Beth Oram

      “I believe that with more rehab, he may have walked again”

      PT and OT are absolutely essential to keeping patients in their homes. I know you are in Canada, but here in the US, families are often told that their loved ones have “reached their limit” for home PT reimbursable under Medicare. But this is illegal now under relatively new regulations that state clearly that it is no longer required for PT to document continued progression, if the patient requires home PT for maintenance of function, then it must continue to be reimbursed. We have to fight for everything under this broken system – just another example that the most critical services older people need for a life with dignity and meaning are not medical.

  12. C.M.

    Occupational therapist chiming in, yeah the need is dire. I see day in and day out how a hospital setting and the lack of consideration given to older adults places unnecessary obstacles in their road to healing. I recommend that while we continue to educate ourselves and spread awareness that we all do the best we can to maintain optimal health. Also, please don’t downplay the role of allied health providers if or when you or a family member find yourselves in dire health straits.


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