Author: Laurie Reed

Published: The Gazette-Times on Medical Accountability

Where is the medical accountability in Healthcare?

When things go wrong in healthcare, accountability from medical providers and institutions is hard to find. While excellence does exist, it often feels like the exception rather than the standard of care.

In a recent Op/Ed for the Gazette-Times (available here as a PDF), I outline the difficulties Phil encountered when obtaining care for a severed quadricep tendon – a lack of transparency, a failure to listen, and poor communication. Phil’s experience resonates because these are common issues in healthcare today.

Many thanks to the Gazette-Times for publishing this Op-Ed highlighting issues with accountability in healthcare. Read more about the additional obstacles Phil faced when seeking accountability:

Published: Failure to Thrive

Published: Failure to Thrive

I am thrilled to announce The Examined Life Journal chose to publish my essay, Failure to Thrive, about my husband’s surgery for a hiatal hernia. I’ve written other pieces on this experience. In an Op/Ed for the San Diego Union-Tribune, I outlined many of the medical missteps that occurred during Tom’s surgery. And in a blog post, I provided specific suggestions for anyone contemplating surgery to help avoid many of the issues we encountered. Before either of these two articles were written though, I wrote the essay, Failure to Thrive. Written just weeks after Tom’s surgery, this essay exposes my fears and frustrations during Tom’s difficult recovery post-surgery.

Here’s an excerpt:

“I kept thinking Tom might be turning the corner – the catheter is out, oh wait, it needs to go back in. The fluid in the drain is supposed to decrease as the week progresses and yet, the amount increased each time we measured it before emptying. Any minor victory was short-lived and often led to only more setbacks.

Tom showed little interest in the different liquids I proffered to tempt his appetite—tasteless or too sugary. In constant pain, he preferred sleep to escape his discomfort. I began to move through the days alone and Tom didn’t seem to notice. Our anniversary slipped by without a word. A Failure to Thrive. As a caretaker, advocate, wife, lover, and friend, roles blur and boundaries bend. It’s difficult to know how much to say, how hard to push, and how long to wait.

I’ve read obituaries describing the death as due to “complications post-surgery”. I now knew what that might mean. Family members helpless to intercede as their loved ones are overwhelmed by pain with no path forward. In my role as a patient advocate, I’ve listened to patients’ stories about their healthcare experiences. Recovery is often a bumpy road. It requires significant effort from both patients as well as those that care for them. If a patient is not engaged, it is difficult to find a way, despite the best intentions.”

I’m happy to report Tom recovered from this surgery.

The Examined Life Journal is a literary publication from the University of Iowa Carver College of Medicine. The journal is published once a year. A call is sent out to over 8600 people and there are between 400 – 600 submissions. This year, 46 writers were selected. It is an honor to be in this space with so many great writers sharing experiences with health, care and medicine.

Published: The San Diego Union-Tribune Op-Ed on Medical Mishaps

Opinion: Medical mishaps are shockingly common in U.S. hospitals. It happened to my husband.

Mistakes in medical care occur far more frequently than any one of us would like to think. But when it happens to you, or to someone you love, it can be devastating. My recent Op/Ed in the San Diego Union-Tribune highlights opportunities to improve on the delivery of healthcare here in the United States based on my husband’s surgery last year for a hiatal hernia.

Many thanks to the San Diego Union-Tribune for publishing this Op/Ed to help others navigating their own healthcare journey. And for steps you can take to try to protect yourself and loved ones before elective surgery, check out my blog:

Advocacy Insights Gained from My Husband’s Surgery

Advocacy Insights Gained from My Husband's Surgery

I nearly lost my husband last summer after his surgery for a hiatal hernia (when the stomach breaches into the esophagus). His recovery was not going well and I feared he would just slip away. Now, one year later I’m happy to report my husband is doing well; I am no longer worried he will die from post-surgery complications. Looking back on this experience, however, it is difficult to not feel angry and frustrated by all that went wrong.

Jump to my key discoveries

Here’s a snapshot of mistakes that were made:

During surgery, when CO2 was injected to open his body cavity for better visibility to the internal organs, some of the CO2 was injected just under the skin causing my husband to blow up like the Michelin Man. In recovery, his face was so swollen his eyes were sealed shut. Nurses and techs scrambled to press cold towels on his face to reduce the swelling. He spent a much longer time in recovery than anticipated as they waited for the swelling to decrease.

My husband has two titanium plates in his neck from a previous surgery that limits how far he can tilt his head back. This information was communicated and discussed with the surgeon prior to the procedure since my husband would need to be intubated during surgery. And yet, when he was anesthetized, his head was tilted beyond a limit he would normally tolerate causing excruciating neck pain once he awoke from the anesthesia.

Upon discharge from the hospital, my husband had a drain attached to his abdomen. The drain works on suction and its purpose is to draw fluid from the chest cavity, which is normal after surgery. Once home, my husband began experiencing agonizing pain in his groin area. He described it as a sharp, stabbing pain. The surgeon dismissed the concern as normal post-op pain. In any position – sitting, standing, walking – the pain persisted becoming quite debilitating. Nearly two weeks post-surgery, after yet another phone call to the doctor’s office, an x-ray image revealed the end of the drain was in the groin area, not the chest cavity as intended. The surgeon claimed the drain migrated. A nurse removed the drain, and the relief from the stabbing pain was immediate.

My husband has a history of back issues (two back surgeries, titanium plates in his neck) due to a degenerative spine. He has found regular exercise for his back essential as preventative therapy for back pain. The surgeon cautioned against exercises such as sit-ups post-surgery that would cause strain on the abdominal area. His concern was certain physical movements could undo the surgery. When my husband asked what exercises might be acceptable, he was told planks and walking. The surgeon refused to prescribe physical therapy claiming a physical therapist would just give him a kettle ball to swing around.

Clearly, mistakes were made. Incidents such as the CO2 and the head tilting were preventable medical errors. It’s difficult to know whether or not the drain migrated or was misplaced but it certainly was not where it was supposed to be, causing havoc with his internal organs. And the refusal to work with physical therapy professionals to develop an appropriate post-surgical exercise plan is simply beyond comprehension.

And sadly, research shows my husband’s experience is not the rare exception. According to a recent study in the New England Journal of Medicine, nearly one-fourth of hospital admissions (23.6%) result in an adverse event (defined as an unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that results in death). The authors note, this percentage is most likely much lower than the actual number given that many U.S. hospitals “…rely on voluntary reporting of adverse events.”

As difficult as this experience has been, it has given me much to consider during this past year when my husband was struggling post-surgery.

Here are some key discoveries I took away from this ordeal:

Choose elective surgery with caution.

  • Surgery is an invasive procedure
  • As we age, recovery can take longer, and be more problematic with unintended complications causing collateral damage
  • U.S. hospitals are under-staffed and are populated with more acute patients which can impact the quality of care
  • Consider surgery vs. no surgery in the context of impact on quality of life

Get a second opinion when a surgeon recommends surgery

  • Many surgeons are biased towards performing surgery
  • A second consult can provide more information to help with decision-making by offering another perspective, other options, or even confirming the initial recommendation
  • Sometimes finding an opening with a specialist can take months. In that case, schedule an appointment for a phone or video consultation. Insurance will often cover an additional consult, and for some surgeries, may be mandatory.

Find a surgeon with years of surgical experience on the specific procedure

  • Experience matters
  • A surgeon who excels at conducting the specific procedure will also know what to do when a situation doesn’t go according to plan

Be fully informed on the surgical procedure

  • Ensure the surgeon explains in detail how the surgery will be performed
  • Conduct your own research on the procedure. Why?
  • Provides context on what is supposed to happen versus what may actually occur
  • Provides perspective on potential side effects, secondary impacts
  • Provides insight on questions to ask the surgeon

Avoid holidays when scheduling surgery

  • If there are post-surgery complications, it’s important the surgeon is available for any questions and concerns. Holidays guarantee limited access and availability
  • Avoid scheduling surgery before a surgeon’s out of office or vacation days

Communication is essential

  • Ensure the surgeon is informed of any previous surgeries, and any current medications – discuss any potential impact on surgery or recovery.
  • Ask questions, share your concerns.
  • If you feel dismissed or not heard, find another surgeon.

My hope for everyone – if you must have surgery, all goes well. It may not be possible to prevent all adverse events but taking the recommendations listed above can pave the way for better outcomes.

Click here to read my Op/Ed from the San Diego Union-Tribune on this topic.

Gaslighting – Steps to Counter

I am pleased to share The Baltimore Sun published my Op-Ed on the important issue of Medical Gaslighting.

Most of us have all been there at one time or another. We show up at a doctor’s office with a medical concern that we’ve watched change, grow, or fester. Sometimes it’s a pain that may shift in terms of intensity or a nagging symptom that just won’t go away. And then, even if we’re lucky enough to see a physician, our concerns are ignored or dismissed. We leave the doctor’s office feeling confused, bewildered, and wondering what just happened.

Medical gaslighting is a practice that needs to stop. It causes harm to patients (here’s my Op-Ed in the Baltimore Sun on this important issue, also available here as a PDF). Education and training programs for healthcare professionals must be adjusted to address this issue. And patients must also be proactive with their medical care. Here are steps for patients to take:

  • Listen to your body – Trust your instincts when your body is telling you something is physically wrong
  • Take action – Do not hesitate, or second-guess as to whether or not to seek medical care
  • Be prepared – Brainstorm a list of questions related to your concern, write these down, and be sure to bring the list to your appointment
  • Be specific – If you have arm pain, is the pain in one spot or does it travel down your arm, when does it hurt – all the time or just at certain times (and what are those times), is it a sharp pain or a dull pain. The more specific you can be, the more this will help a physician with a diagnosis.
  • Bring Support – Bring someone with you to the appointment to take notes, to listen, and to debrief with you after the appointment
  • Get a 2nd, 3rd, or 4th opinion – If a physician isn’t listening to you, dismisses your concerns, or you are unsure about a diagnosis do not hesitate to seek a 2nd or a 3rd opinion from another medical professional.

Taking these simple steps may not stop medical gaslighting from occurring but will help the patient to be better prepared and to counter medical gaslighting when it happens.

Published: The Baltimore Sun Op-Ed on Medical Gaslighting

I am pleased to share The Baltimore Sun published my Op-Ed on the important issue of Medical Gaslighting.

I am pleased to share The Baltimore Sun published my Op-Ed on the important issue of Medical Gaslighting (available here as a PDF). Unfortunately, this issue is a common theme in my interviews with people about their healthcare experiences. It’s time to call this practice out, label it for what it is, in the hopes that by creating awareness of the problem, change may occur.

Medical Gaslighting happens when doctors fail to listen or dismiss a patient’s concerns. This practice can happen to anyone but skews more toward women. In her report for the Washington Post, Lindsey Bever cites numerous articles, research studies, and books supporting this phenomenon, noting:

  • a failure of physicians to understand pain differentials between men and women
  • the dismissal of reproductive health complaints
  • racial disparities amplified by gender
  • and the unfortunate choice to attach psychological causes to women’s health concerns or to not take women’s pain complaints seriously.

My Op-Ed outlines why medical gaslighting is problematic.

When the validity of a patient’s reality is questioned, this can lead to self-doubt, confusion and a loss in self-esteem. Medical gaslighting has serious consequences: As people struggle to get a diagnosis, physicians aren’t addressing the real problems leading to misdiagnoses, treatment failures and poor medical outcomes.

Bottom line, medical gaslighting is costly. It drains the financial resources of healthcare institutions, adds to insurance fees, and takes a significant toll on patients’ health, sometimes even claiming their lives. It’s time for medical gaslighting to stop. To read more, here’s the link to my Op-Ed on Medical Gaslighting in the Baltimore Sun. To discover ways for you to counter the practice of Medical Gaslighting, read my post titled Gaslighting – Steps to Counter.

Just What the Doctor Ordered

Book Review: Braving Chemo by Dr. Beverly Zavaleta

Book Review: Braving Chemo

In her book, Braving Chemo, Dr. Beverly Zavaleta provides a comprehensive guide for anyone facing chemotherapy treatment for cancer. Dr. Zavaleta, a Harvard-educated physician, based the book on her own experiences after chemotherapy for breast cancer. But this book defies the confessional, physician turned patient revelations.

Braving Chemo offers an honest, detailed, and practical template on how to prepare for and navigate one of the more arduous steps in the patient journey. In the Introduction, Dr. Zavaleta outlines her reason for writing this book, “I discovered that for all the challenges I faced as a patient, my training as a family physician and a hospitalist gave me insight that very few cancer patients have.” This book aims to fill the gap for others with credible, reliable information.

The layout of the book is linear beginning with the Diagnosis, taking deep dives into each of the major issues with chemotherapy – side effects, infections, nutrition, appearance, mind games – and ending on Recovery. Such a detailed narrative makes it easy for the reader to pick out information most relevant as needed. And segments within chapters are packed with great material, in an easy-to-read format, punctuated with definitions, helpful hints, checklists, medical alerts, exercises, and resources with links for further research.

Dr. Zavalata brings the objective perspective of a clinician with the humanity of the lived patient experience. Any patient about to start chemotherapy, or in the midst of treatment, should have this book as a key resource to read and to reference as questions arise. Caretakers could also benefit from information in this book for guidance and perspective. Braving Chemo provides an authoritative guide for the chemotherapy experience.

4 Points to Remember During Recovery After Illness

The Path to Recovery

As I’ve learned through my interviews with patients experiencing serious illness, treatments can be grueling, leaving patients emotionally and physically exhausted. During her treatment for breast cancer, Jackie, a single mom with a teenage son, recalls:

Many, many times, you get home and you just, you feel so alone, and I’ll have that emotional breakdown. I’m like, this is really hard. I had no one there to just hold me, But, you have to allow yourself to do that too, you really, really do. You have to allow yourself to let that out.

The focus for patients in treatment is making it through each day, as it should be. Getting through to the other side of treatment is a goal, wrapped in hope and the expectation of reclaiming the life, the way of being in the world so cruelly interrupted by illness. The reality though is often different.

Jaime, a young mother with two children, was diagnosed with Stage 4 colon cancer after a year and a half of chasing doctors in search of an answer for her pain. Our interview happened just a few months after she was told the cancer was gone so her answer to my question about how the disease had affected other areas of her life surprised me.

[With] survivorship a lot of times, people will say okay, well, you’re cancer-free now, so, everything goes back to normal. Not so much. [She laughs] I would almost rather go through treatment and knowing what I’m dealing with then, you’re disease free and having that fear in the back of my head… There’s always that little seed of doubt that, what if it comes back.

The challenge of recovery is a reoccurring theme in my interviews. It is also a theme that is beginning to be shared by other writers who are former patients. These writings sharply illustrate the surprise to find post-treatment often more painful, difficult, and frightening than treatment. Jamie Aten, founder and executive director of the Humanitarian Disaster Institute, utilized techniques he teaches PTSD patients to manage his own experiences post-treatment¹.

Beth Stebner, a Brooklyn-based writer and editor diagnosed with ovarian cancer six months before her wedding, describes what she felt after leaving treatment²:

I carried more sadness, anger, anxiety, and fear than I’d ever had before – or even during – my health scare. I was terrified that the second I became comfortable in my old routines my disease would return, taking away everything that I worked so hard to rebuild.

In all of these experiences, there is an element of surprise. Recovery remains somewhat shrouded in mystery. Patients don’t talk about it and the focus of healthcare dollars and research is on diagnosis and treatment rather than what happens after treatment ends.

In fact, recovery, similar to a serious illness, hits the trifecta of factors that contribute to a healthy balance for living – psychological, social, and physical. Here are some of the ways issues emerge during recovery:

  • Physical – Pain, Nauseousness, Fatigue, Unsteadiness, Weight gain/loss, Side effects from treatment
  • Psychological – Anxiety, Fear of a recurrence of illness, Depression, Lack of self-esteem/confidence, Shame
  • Social – Isolation, Loneliness, Support systems after treatment wane or vanish, Reluctance to reach out and ask again for support

It is critically important to recognize recovery is just as much a part of the patient journey as diagnosis and treatment. Here is an opportunity to begin a dialogue for change. Key points to consider:

  • Awareness – A recognition that just because treatment ends, doesn’t mean that all is better. In fact, recovery is a new beginning. Recovery is a time to allow the body to rest and heal.
  • Communication – Let people know what is going on, rather than trying to pretend that all is well. Be honest with yourself and others.
  • Advocacy/Support – Trying to go it alone only slows and impedes the body’s ability to recover. Support is needed as much in recovery as in times of serious illness.
  • Compassion – Be kind to yourself. Patience and understanding are needed in abundance.

Please know that although illness and recovery can be very isolating experiences, you are not alone. Others have travelled this path, and there is an opportunity to learn from these experiences.

* Quotes in this post are from interviews conducted for my book, Navigating Illness: The Patient Experience, a work in progress. Names were changed upon an individual’s request.

¹ Aten, J., (April 29, 2019). Coping with Trauma. Cancer Today.
² Stebner, B. (May 9, 2019). After Beating Ovarian Cancer at 30, The Real Battle Began.

The Practice of Medicine is Both Art and Science

The Practice of Medicine is Both Art and Science

Learning medicine is a scientific endeavor, practicing medicine is an art.

During my visit to the Urgent Care Center for an infected eye late last year, I was reminded that medicine is both art and science. The physician brought in the final paperwork with the instructions for discharge. As we exited the exam room and walked down the hall toward the exit, I peppered the physician with questions – Did he think my eye infection was caused by a virus? Did I have a virus? Did I, in fact, have the flu?

To all of my questions, the physician simply shrugged his shoulders, as if to say, he didn’t know. Now there are tests that could determine if my eye infection was bacterial or viral. However, results from such tests would take a few days. The doctor’s approach — treat the symptoms, watch for improvement, and if my eye got worse return for follow-up.

I was curious though and pushing for answers, wanting his perspective. The physician finally said, ‘you know, it’s all just a bunch of voodoo. There’s so much we really don’t know.’ I burst out laughing. How refreshing to hear a physician say, in so many words, that doctors don’t always have the answers.

Medicine as Science

Unfortunately, many physicians will not admit to not knowing, particularly in interactions with patients. There is an expectation, stubbornly held by both physicians and patients, that physicians are always supposed to have the answers. This is simply unrealistic. Patient harm often results when physicians fail to admit they do not know. Patients are diagnosed and treated for ailments they may not have. Communication and coordination of care often falters. And there is a general reluctance to call in specialists and experts for different perspectives or recommendations. Calling in reinforcements, in fact, may be just what is needed to achieve better outcomes. Recent research published in JAMA Network reveals higher diagnostic accuracy with a collective versus an individual approach

Medicine as Art

Acknowledging the mystery in medicine is a step in the right direction. According to Dr. Ricardo Rosenkranz², magic may serve to provide the insight, perspective, and passage to a deeper connection between physician and patient.

In December of 2016, I had the privilege to attend a magic show highlighting this relationship between magic and medicine.³ The magician was Dr. Ricardo Rosenkranz, a practicing physician and Assistant Professor in Clinical Pediatrics at the Northwestern University Feinberg School of Medicine.

The performance, as all good magic does, mystified and dazzled. But this particular magic show also highlighted –

  • the value of listening
  • the need for ritual
  • the importance of storytelling
  • and the power of empathy

— all essential ingredients not just to a great magic show but to best practices in medicine as well. Dr. Rosenkranz is committed to changing medicine . He uses his skills as a magician to first spark the imagination, with the intent to transform behavior, acknowledging both the art and science of medicine.

Creating a New Path

In addition to his performances, Dr. Rosenkranz has created a “curriculum on magic and medicine for the Medical Humanities and Bioethics Program at Northwestern targeting first and second year medical students. The intent of the program is to help medical students develop a deeper understanding of the doctor-patient relationship.” [as stated in the program]

Dr. Rosenkranz is teaching medical students how to be better doctors. In turn, Dr. Rosenkranz asks patients, as he asks his audience members, to come prepared to engage. By improving the dynamic between physician and patient, there is an opportunity to positively influence the experience, not necessarily the outcome, but the experience.

During times of serious illness, moving forward in the face of uncertainty is challenging. It is essential, however, for both physicians and patients to acknowledge medicine as an imperfect science. There might not always be answers, but it is in this acknowledgement that both physicians and patients can move forward in a healthy way. Medicine is both art and science, come prepared and stay engaged.

¹JAMA Network Open. 2019;2(3):e190096. Doi:10.1001/jamanetworkopen.2019.0096

²The Rosenkranz Mysteries, the Show, About Ricardo Rosenkranz. December 2016

³Medicine is a performance art: combining magic and medicine | Ricardo Rosenkranz | TEDxNorthwesternU. 2015

Are These Medical Tests Really Necessary?

Are These Medical Tests Really Necessary?

Have you ever stopped a doctor from ordering and performing medical tests and procedures that may be a repeat test, nice to know but not critical, or perhaps even unrelated to your issue or concern? If so, how did that go for you?

I’ve discovered I’m not good at saying ‘NO’. I worry about the consequences: Will my care get compromised? Will I get labelled as a ‘difficult’ patient? Perhaps even denied care? However, data indicates unnecessary testing only drives up costs for healthcare which are already high and out of control. Kaiser Health News estimates the costs of unnecessary medical tests and procedures at $200 Billion.¹ Such data suggests there may be value in asking questions and becoming a better advocate for my own care and treatment.

Test Now, Ask Questions Later

Two years ago, I made an appointment with a podiatrist because I was having foot pain, specifically, heel pain. Before ever seeing the doctor, the technician asked me to stand on a platform and two separate x-rays ($88 each) were taken of my foot. By the time the doctor walked into the exam room, based on my description of the pain to the technician, she was ready with a diagnosis. I had Plantar Fasciitis, a condition that occurs when the ligament, that stretches from the heel to the toe, begins to pull away from the heel and becomes inflamed.

X-rays provide images of bones, they don’t provide a view of ligaments and tendons. In some cases, Plantar Fasciitis can produce a heel spur. Heel spurs though rarely cause pain and wouldn’t change the recommended initial course of treatment. Perhaps my physician used the x-rays to ‘rule out’ other diagnoses, but I’m confident the doctor knew my diagnosis even before the first x-ray was taken. As it said in the literature sent home with me after my appointment, “Heel pain is one of the most common conditions podiatrists treat. It accounts for approximately 15 – 20% of our practice.”

Based on her years of experience, this doctor could have arrived at a diagnosis based on a conversation with me about my pain and by manipulating my foot. However, in today’s healthcare system, physicians are financially rewarded for medical tests and procedures conducted in their offices. A fee-for-service healthcare system, benefits the practice while also driving up healthcare costs. This is a horrific waste of time, money, and resources.

Wait a Minute, Why Did You Ask For My Previous Records?

More recently I accompanied my husband to the eye doctor. He was following up with a specialist due to an unusual speck in his eye discovered during a routine eye examination. When setting up the appointment, my husband was asked to have his records forwarded to the specialist’s office, which was in the same building as the original optometrist. The records were all relatively new, certainly within the past month.

However, at the specialist’s office, the technicians proceeded to conduct the same tests as the first doctor (eye charts, dilation of the eyes) rather than building on information already collected and moving directly to the tests to aid with diagnosis and recommendation. By repeating these tests, the office is able to bill insurance, which pads the monetary return to the specialist.

In the ongoing debate on the future of healthcare there’s a lot of binary discussion – ‘medicare for all’ vs. a private/public option. The main focus for these debates is on access, which is important, but access to a broken system is rather problematic. Medical testing is intrusive taking time away from patients as well as exposing patients to additional tests and procedures which in the end might not actually be necessary. It is not a harmless practice.

The Importance of Patients Asking the Questions

In her book, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, Elisabeth Rosenthal outlines reasons for the high cost of healthcare. According to Rosenthal, insurance companies, hospitals, physicians, and pharmaceutical companies – all share in the blame for rising costs. As she states in the introduction: “These days our treatment follows not scientific guidelines, but the logic of commerce in an imperfect and poorly regulated market, whose big players spend more time on lobbying than defense contractors. Financial incentives to order more and do more – to default to the most expensive treatment for whatever ails you – drive much of our healthcare.”²

Much needs to be changed in the delivery of healthcare in the United States today. But, as Rosenthal asserts, the current situation demands that consumers must be active participants in their own healthcare. As patients, this would suggest we need to begin to ask questions about tests and procedures during a physician or hospital visit. Questions might include: What is the reason for this particular test/procedure? What is the cost? How does this fit with the reason for my visit?

As patients, we have an opportunity to change how medicine is currently practiced. I am more willing to ask questions knowing how critical it is for me to be an active member of my own care team. I hope this article will give you some courage as well. Let me know how it goes.


&sup2Elisabeth Rosenthal, An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (New York: Penguin Books, 2018), p. 5