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The rationale and guiding principles to design a psychiatry curriculum for primary care doctors of India
To cite: Dinakaran D, Manjunatha N, Kumar CN, Math SB, Thirthalli J. The rationale and guiding principles to design a psychiatry curriculum for primary care doctors of India. Natl Med J India 2022;35:32–7.
Abstract
Background
Integrating psychiatric care into the general practice of primary care doctors (PCDs) is necessary to overcome the shortage of human resources to cater to the burgeoning public mental health needs of India. The traditional psychiatry curriculum is often top–down and specialist-based that contributes little in terms of skill quotient. We designed an innovative, digitally driven, distance education-based, part-time, modular-based Primary Care Psychiatry Programme (PCPP, skill-based). It is being implemented across many states of India to equip PCDs with skills to provide first-line psychiatry treatment. We discuss the rationale and guiding principles behind designing the curriculum of PCPP.
Discussion
There are nine guiding principles behind designing and implementing PCPP to provide pragmatic, acceptable, feasible modules of higher translational quotient (TQ) that are essential to upskill PCDs. There is a shift in training the location of PCDs in their live brief general consultations utilizing innovative telemedicine-based ‘on-consultation training’ (OCT) augmented with collaborative video consultations. A monolithic treatment protocol-driven, trans-diagnostic approach is used to design a concise, all-inone, point-of-care manual containing a culturally sensitive, rapid, validated screener and taxonomy, called ‘Clinical Schedules for Primary Care Psychiatry’. This incorporates the PCDs’ style of clinical practice that helps in picking up the most commonly prevalent adult psychiatric disorders presenting to primary care.
Conclusion
This PCPP curriculum contains pragmatic modules with higher TQ. This curriculum is dynamic as the learning is bi-directional. This can be used by policy-makers, innovators and academia for integration with national health programmes such as those for non-communicable diseases and reproductive and child health.
INTRODUCTION
Psychiatric disorders are increasingly recognized as a major contributor to the global burden of disease.1,2 Up to 90% of persons with psychiatric disorders in low- and middle-income countries do not receive primary mental healthcare.3,4 India’s National Mental Health Survey (NMHS)5 from a nationally representative adult population reports the current and lifetime prevalence of any psychiatric disorder to be 10.6% and 13.7%, respectively. The estimated prevalence of tobacco and alcohol use disorders is 18.9% and 4.6%, respectively. The estimated prevalences of anxiety disorders, unipolar depressive disorders, schizophrenia spectrum disorders and bipolar disorder are 3.5%, 2.7%, 0.4% and 0.3%, respectively. The NMHS did not report about somatization disorder. There is an alarming treatment gap of >70% for all psychiatric disorders.6
At the primary care level in India and globally, epidemiological data suggest that common mental diseases (CMDs) are among the most frequent causes of morbidity and disability for 17%– 46% of patients.7,8 There is a considerable qualitative difference between treatment gaps in communities vis-à-vis the same at the primary care level. An ‘apparent treatment gap’ is the treatment gap at the community level among the general population who may not seek treatment at all.9 The ‘functional treatment gap’ (FTG) is a peculiar treatment gap that exists at the primary care level where patients seek treatment with physical symptoms. Still, primary care doctors (PCDs) often under-recognize, undertreat and provide symptomatic treatments (hence, the term ‘functional’ denotes the deficiency in the ‘functioning of PCD’ to provide psychiatric care).10 In a pragmatic sense, the FTG is more amenable for corrections to aspire to a ‘zero treatment gap’. There are several reasons for this FTG. First, PCDs are not fully trained to diagnose and/or treat these CMDs.11 Second, specific to India, there is a lack/ absence of psychiatric training during undergraduate medical education and internship.12–14 Third, there is inadequate knowledge about the diagnostic criteria of CMDs, lack of awareness about the appropriate questions to ask about CMDs and limitations of time inherent in a busy clinic setting.15 Fourth and the last, the most important reason, is the absence of a standard adopted psychiatry curriculum for PCDs for their clinical use.16
To fill this gap, a dedicated and specialized ‘Primary Care Psychiatry Programme’ (PCPP) was designed at the Tele Medicine Centre, Department of Psychiatry at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India. It is an innovative, part-time, digitally driven, distance education-based, modular-based curriculum for adult outpatients of primary care and is being implemented across various states of India. A 1-year ‘Diploma in Primary care Psychiatry’ (DPCP) is a prototype course under the broader rubric of PCPP approved by NIMHANS. It is designed exclusively for practising PCDs with an MBBS degree, which is considered throughout this article as a reference. Details of different modules of the curriculum of the PCPP are beyond the scope of this article and are described in detail elsewhere.9,17,18 To date, 21 PCDs of Uttarakhand have graduated with this DPCP,17 and another 20 PCDs serving with the Government of Bihar are undergoing the DPCP course. The primary aim of PCPP is to integrate psychiatry care into the general practice of PCDs with higher translational quotient (TQ). A discussion of the rationale and guiding principles in designing this curriculum is important for policy-makers, academicians and practising psychiatrists as well as for PCDs. A comparison of PCPP with the traditional psychiatric curriculum is also provided.
TRAINING LOCATION
Conventionally, the place of training of PCDs is at medical colleges/tertiary care hospitals where the trainer psychiatrists work. PCDs were deputed for these training, which involved travel time and efforts, along with absence from clinical work, depriving their patients of clinical services. Often, PCDs express their reluctance to travel to these locations. These locations (both for classroom teaching and the psychiatric outpatient clinic) are beyond the reality of primary care. We have come across responses of PCDs that ‘they do not come across these kinds of patients in their clinic’ when trained at these medical colleges/hospitals.
In contrast, in PCPP, the training location is shifted to their primary health centre itself: live consultations in a general outpatient clinic, ensuring a minimum disruption in their natural clinical work. This location shift provides an opportunity for a natural clinical flow where PCDs are exposed to a reality check of their practice. This approach not only enhances skill transfer but also builds the confidence of PCDs to treat psychiatric disorders. This shift of location has been found to have better acceptance among PCDs as it saves travel time and effort. This location shift also found better acceptance among the trainer psychiatrists.
TRAINING METHODS
The traditional curriculum practised commonly one-time classroom training (CRT) method in a group format, where the trainer psychiatrists deliver their lecture, didactic, PowerPoint presentation, case vignette methods, or recorded video interview. They may also include the demonstration of some psychiatric patients in outpatient/inpatient settings (akin to a case conference). These are typically using the principles of pedagogy and may not suit adults who have been working at primary health centres for long (some PCDs are even older than trainer psychiatrists). Often, these are one-way training programmes from specialists to PCDs (top–down approach) without understanding the functioning of primary healthcare service delivery, and this has not shown any clinical benefits.19,20 The CRT method has been criticized as a knowledge enhancer rather than a skill and confidence enhancer.21 Training of PCDs in the District Mental Health Programme22 has depended heavily on the CRT method and is often criticized as ‘ineffective’ and may be considered a mere token gesture by the department of health as ‘seen to be doing something’.23 In addition, these short-term CRTs are conducted for a few days (1–10 days) as one-time events and have no provision of continuing clinical support for the PCDs.24
In this innovative PCPP curriculum, the team has implemented two kinds of live consultation-based training methods in an one-to-one format: The ‘on-consultation training’ (OCT) and the ‘collaborative video consultation’ (CVC; similar to the second opinion clinic). The telemedicine variant of OCT is named the ‘Tele-psychiatric OCT (Tele-OCT). In OCT, a psychiatrist, sitting beside the PCD, conducts training during his/her live, real-time consultations of general patients at primary care and not at a specialist clinic. Tele-OCT occurs through video streaming of PCDs’ live consultations. OCT incorporates the principles of adult learning, thus ensuring direct skill transfer and confidence building. The concept, its evolution, details of principles incorporated, contents, process, expected outcomes, limitations and criticisms of OCT/tele-OCT have been described elsewhere.9 To augment and consolidate the skills learnt during OCT/tele-OCT, the CVC module is designed in such a way that PCDs randomly choose their patients for tele-psychiatrist consultations, almost similar to requesting for a second opinion. Both PCDs and the tele-psychiatrist simultaneously consult patients and together decide the management plan for patients of PCDs. These modes of teaching provide an opportunity for timely feedback and better understanding the needs and expectations of PCDs. These two live consultation-based training methods allow two-way learning for both PCDs and trainer psychiatrists and provide an opportunity to update the curriculum. This flexible approach also allows us to design any additional modules for PCDs (the opioid module was designed and implemented for PCDs of Uttarakhand),25 as well as the addition of prescription templates for first consultations in Clinical schedules for primary care psychiatry (CSP) version 2.2 (see below).18
In the tele-OCT delivery method, each PCD will have to undergo three consecutive tele-OCT sessions. There follows an innovative sequential hand-holding teaching technique, called: See-it-yourself (first tele-OCT session), Try-it-yourself (second session) and Do-it-yourself (third session), abbreviated as ‘STD teaching technique.’ In other words, during the first tele-OCT session, a tele-psychiatrist demonstrates to PCDs all the steps required for psychiatric care, i.e. how to conduct rapid screening in a clinical interview with CSP screener, how to arrive at a diagnosis using CSP and how to choose medications from the list of CSP including counselling and discussion of the follow-up plan. The PCDs are asked to ‘see themselves’ in this live clinical examination in the first tele-OCT session, followed by asking them to ‘try-themselves’ in the second session and in the last and third tele-OCT session, they are asked to ‘do-themselves’ under the supervision of a tele-psychiatrist. This STD teaching technique is also used for the ‘training of trainer’s version’ of PCPP in the Karnataka Telemedicine Mentoring and Monitoring Programme.18
INTEGRATE PCPP CURRICULUM WITHIN THE PRACTICE STYLE OF PCDs
Adopting a standardized tertiary care model in treating patients at primary care can be the best practice to apply, but it is often impractical and utopian.21 In this regard, we considered the following crucial parameters of PCDs’ practising style: consultation time and diagnostic and treatment styles while designing the new PCPP curriculum.
Consultation time
The traditional curriculum focused heavily on a specialist-based model and did not explicitly consider the importance of consultation time of PCDs in busy outpatient settings. A study suggested that the average consultation time of PCDs across countries is <5 minutes.26 This study is also conducted in India and reported the average primary care consultation to be between 1.5 and 2.3 minutes.26 For successful integration, the curriculum should take into account the importance of this average consultation time of PCDs without overburdening them. Hence, the PCPP curriculum is designed with a specific focus on a brief 5-minute consultation.
Develop a simple diagnostic and treatment approach
The traditional psychiatry curriculum was a replica of specialist-based diagnosis, taxonomy and treatment approach. It is complex, complicated and also redundant for PCDs to use in their busy clinic.19,20
To design a new curriculum, it is essential to understand the practising style of a PCD. We use the analogy of paracetamol prescription (by PCDs) to understand their style of functioning. PCDs prescribe paracetamol as the first-line drug for all febrile illnesses irrespective of the aetiology. Antibiotics are prescribed empirically based on symptoms/signs without any laboratory investigation. Conceptually speaking, PCDs’ consultation styles follow a symptom-based approach for diagnosis and management with seldom use of laboratory investigations at primary care.
To synchronize with their practice style, a monolithic treatment (single medicine is equally useful in many psychiatric disorders), protocol-guided trans-diagnostic approach based on symptom clusters (in simple terms, same medication for a symptom cluster), is used in this new curriculum. First, many psychiatrists themselves diagnose the majority of psychiatric disorders based on symptom clusters elicited during a clinical interview without any specific investigations. Second, antidepressants such as serotonin reuptake inhibitors (SSRIs) are standard first-line medications prescribed for depression and anxiety disorders and are even helpful for somatization disorder.27 The monolithic treatment protocol advocates prescribing antidepressants as first-line medications for a broad range of psychiatric disorders ranging from depression, dysthymia, generalized anxiety disorder, panic disorder and somatization disorder. This approach suits busy PCDs. Even from the academic point of view, the efficacy of all antidepressants is the same.27 Similarly, antipsychotics are the first-line treatment for all psychotic disorders irrespective of specialist-based/tertiary care-based diagnoses such as schizophrenia, schizo-affective disorder, acute and transient psychotic disorder and delusional disorder. To utilize this opportunity to provide the first-line treatment, this curriculum offers a simpler treatment protocol for CMDs and severe mental disorders (SMDs). We observed that PCDs are familiar with the older classification of psychiatric disorders as neurosis and psychosis. Hence, these terms are incorporated in the taxonomy as synonyms for CMDs and SMDs, respectively.
While designing a new curriculum, we also considered the following relevant points about the presentations of CMDs/ neurosis at primary care. The clinical presentation of CMDs at primary care is complex and usually mixed. Comorbidity among CMDs at primary care is high.10,28,29 There is also a higher prevalence of subclinical CMDs at primary care that is more disabling and in need of clinical attention.30,31 A substantial proportion of the patients with false-positive screen results for at least one diagnosis met the diagnosis criteria for other psychiatric disorders. They also had a more significant functional impairment and higher rates of utilizing mental health services. This possible over-diagnosis suggests that false-positive results in primary care screening should also receive clinical attention.32 Hence, we provided an option for PCDs to sub-divide if they wish, i.e. CMDs—predominantly depressive disorder and CMDs—predominantly somatization disorder. This kind of sub-division in the taxonomy may guide PCDs to choose appropriate first-line treatment (such as amitriptyline which may be a better choice for CMDs—predominantly somatization disorder, and SSRI combined with short-term clonazepam for anxiety disorders).
To make it easy for PCDs to understand the management of psychotic disorders/SMDs at the primary care level, the diagnosis of psychotic disorders was sub-classified into acute, episodic and chronic psychotic disorders. For example, to decide the duration of antipsychotic medication by a PCD, the diagnosis of acute versus chronic psychotic disorder would be helpful21 (1-year course of medication for acute psychotic disorder versus indefinite duration in chronic psychotic disorder). The primary care diagnosis of episodic psychotic disorder is to cover bipolar disorder. In this case, CSP recommends referral or collaboration with a psychiatrist to decide the treatment protocol of this episodic psychotic disorder.
Focus on the adult patient population in the beginning
The traditional psychiatric curriculum of PCDs covers patients of all age groups. This inclusion of all ages is an ideal approach but not realistic. At one end, the prevalence of childhood psychiatric disorders in primary care in India is poorly researched. On the other hand, even if they seek help at primary care, the presentations are usually complex. They require predominantly multimodal non-pharmacological management, which needs longer consultation time of PCDs.33 A study of primary healthcare in India had reported that the adult populations are the major service users (84%).34 All prevalence studies of psychiatric disorders at primary care are focused on adults.5 Hence, the newly designed PCPP curriculum has focused only on adult patients, including the geriatric population, but excludes children below 18 years. The rationale is to concentrate on adult psychiatric disorders in the initial phase of PCPP. Childhood psychiatric disorders could be introduced in a phased manner once reasonable success is achieved in the adult population.
Synchronize with the prevalent practice of ‘medication first’ approach
In India, patients at primary care are treated mostly with pill-based prescriptions that jell well with the perception that ‘pills’ are to be received if a patient goes to a doctor. However, we concede that this goes against the standard guidelines that suggest psychological interventions as the first-line option for CMDs.35 For primary care patients with psychiatric disorders, revising from the existing pill-based treatment to simple brief interventions/reassurance for sub-syndromal and mixed presentations would be the ideal choice. Classical psychotherapy as first-line treatment for CMDs at the primary care level is difficult.36 We believe it is beyond the scope of Indian PCDs’ practice. Besides, the acceptability of Indian patients ‘for psychotherapy alone’ is also beyond reality. However, such attitudinal change might happen over time. Hence, the rationale for the pharmacotherapy-based treatment approach is to synchronize with the pill-based practice style of busy PCDs in India. Outpatients with psychiatric disorders, especially CMDs at primary care, would already be receiving symptomatic treatment with analgesics, sedatives and multivitamins. The aim of this curriculum is to replace these symptomatic pills prescription with the first-line standard pharmacotherapy-based prescription along with brief counselling for every patient of PCDs. The brief interventions are helpful for these conditions.37
Focus on more prevalent psychiatric disorders in primary care
The traditional curriculums focus more on SMDs without considering the reality of the patient’s profile of primary care. Among the general population, the NMHS reported a higher prevalence of alcohol (4.6%) and tobacco use disorders (13%) along with CMDs (3.5%) than SMDs (<1%). The Global Burden of Disease Study from Indian states (1990–2017) had reported a higher prevalence of CMDs (3.3%) over SMDs (0.4%).9,38 The epidemiology of psychiatric disorders among the general population in India suggests that alcohol and tobacco disorders are highest, followed by CMDs, and SMDs are the last.5 At the primary care level, CMDs are highly prevalent as reported in various studies—between 17% and 46%.7,8 Around 30% of patients attending general medical care also have comorbid CMDs. In contrast, specialist psychiatrists are inherently inclined towards SMDs.39 We did not find any specific studies on the prevalence of alcohol and tobacco users in primary care in India. However, in primary care, patients usually do not voluntarily seek treatment for nicotine and alcohol disorders. Patients with CMDs and alcohol/tobacco use seek help for physical symptoms such as sleep disturbances, lethargy and body aches. Sensitizing PCDs to these conditions may help in the early recognition of depression and prompt delivery of interventions.40 Utilizing these familiar presentations at the primary care level, the newly designed PCPP curriculum focuses mainly on the commonly prevalent illnesses. Hence, the PCPP curriculum included alcohol, tobacco disorders and CMDs on priority. In CMDs, a triad of depressive, anxiety and somatization disorders is included. Among anxiety disorders, only the most prevalent anxiety disorders at primary care, such as generalized anxiety disorder and panic disorder, are added to the curriculum.
Point-of-care manual
There are many psychiatric training manuals for PCDs41–43 but are adopted without the essential issues in primary care. PCDs with little prior exposure to psychiatry (in undergraduate medical school) find these bulky details overwhelming and challenging to integrate in their routine clinical practice.23 Often, the curriculum for NMHP lacks a simplified approach for diagnosis and management. The primary care version of ICD-10 mental and behavioural disorders44 is rarely used in primary care in India.21 The limitations of such an approach are being interpreted mostly from specialists’ perspective and outdated management guidelines.45 The shortcomings of the earlier psychiatric training manuals for PCDs are already discussed.9 Furthermore, a specific operational manual to transfer clinical skills and build PCDs’ confidence in management is lacking.21 None of these manuals contain a culturally sensitive brief screener, which, we believe, is essential for training PCDs in their routine clinical use.
The PCPP curriculum designed a brief, concise, point-of-care (i.e. usable at the time and place of patient care) manual called ‘Clinical Schedules for Primary Care Psychiatry’ (CSP) for the exclusive clinical use of PCDs. The CSP has already traversed through various versions 1.0, 2.0, 2.1 and 2.2 containing all-inone clinical requirements for PCDs’ practice such as:
Culturally sensitive screener
Adopted trans-diagnostic taxonomy
Simplified primary care relevant diagnostic guidelines (e.g. duration of somatization disorder reduced to 6 months, PCD-friendly addiction diagnostic criteria)
Stratified medication guidelines (medication list which has minimal side-effects, lesser drug interactions, categorized PCDs’ dose and specialist dose for each drug to enable PCDs to choose minimally effective dose)
Brief counselling guide for all patients (besides, there is specific counselling for alcohol and tobacco addiction)
Follow-up guidelines
Comorbidity guidelines.
In CSP 2.2 version, a prescription template has been included as a ready reckoner for first consultations based on the feedback of PCDs that makes their job easy. The contents and structure of CSP are described elsewhere and are beyond the scope of this article.9 A copy of CSP version 2.2 is available at http://nimhansdigitalacademy.in/wp-content/uploads/2020/02/CSP-2.2-Oct-2018.pdf.18 The ‘screener’ section of CSP has been shown to have high sensitivity and reasonably high specificity for primary care practice.46 CSP, in its original or adapted form, has become an integral part of the national mental health programmes in many states such as Karnataka, Tamil Nadu, Telangana, Maharashtra, Bihar, Chhattisgarh and Uttarakhand.
Empower PCDs to provide first-line treatment for patients with psychiatric disorders along with their general patients
The traditional curriculum (big textbooks/manuals along with short-term CRT focused on pedagogy) may have ultimately, at a minimum, enhanced knowledge without skill/confidence, and, at a maximum, might have encouraged PCDs to follow the ‘diagnose and refer’ approach with less focus on treating themselves.21 This unidirectional approach may not be acceptable for them (to work as subordinates for specialists as referral doctors). Hence, this was changed to ‘treat (yourself) and refer (if need)’ approach. This approach could encourage PCDs to provide the standard first-line pharmacotherapy with brief counselling for all patients. This bi-directional approach is an essential first step to give a major impetus towards the integration of psychiatric care by PCDs.
Outcome indicators
To date, there is no pragmatic and valid outcome indicator to assess the effectiveness of various training methods used for training PCDs, especially real-time, skill-based indices. Trainee PCDs of DPCP will have to undergo 10 criteria-based formative evaluations throughout the year, on-camera theory as well as clinical final/exit examination. Among these criteria, two pragmatic outcome indicators are derived in this newer curriculum to assess the effectiveness of training programmes, which are primary care psychiatry quotient (PCPQ) and TQ.47 The PCPQ is defined as the proportion of psychiatric caseness (as identified by PCDs) among all the general cases cared during their consultations. This may be equated with the prevalence of psychiatric disorders at primary care. It is calculated based on self-report from PCDs on monthly or weekly patient audits or from the register which is maintained in real-time data at their hospitals. Considering the prevalence of psychiatric disorders at primary care as around 30%, we believe that a PCPQ of 30% may be regarded as adequate for a PCPP. The TQ assesses the degree of translation of training methods to real pragmatic clinical psychiatric skills in PCDs in their real primary care clinical scenario. TQ of a training programme is defined as the ability of a training programme to translate learnt/taught knowledge into clinical skills required for use during the routine busy clinical practice.9 This quotient is the most crucial requirement for early diagnosis and first-line treatment at primary care level by PCDs. It is assessed by a tele-psychiatrist periodically in 10 consecutive live general consultations of PCDs. These outcome indicators are essential to understand the effectiveness of the curriculum and might provide solutions to optimize the curriculum.
Strengths and limitations
Although the PCPP curriculum is pragmatic in approach, it could be an oversimplification of the existing diagnostic systems, interview schedules and management guidelines. This oversimplification might lead to over-diagnosis and increase drug prescriptions for common sub-syndromal ailments. Even research states that these sub-syndromal conditions at primary care need clinical attention. In the end, benefit from the curriculum overrides the limitations. For the first time, operational criteria contain culturally sensitive and validated screener in the curriculum. Psychotherapeutic interventions are stressed less in the curriculum. This approach is tailored to the need of the widespread ‘pill’ expectation tendency of the target population. Generic/monolithic treatment options for all CMDs (conceptualized singularly) might be inadequate, especially for second-line treatment. Hence, only first-line treatment guideline is provided in the curriculum and early referral for second-line treatment management in case of treatment resistance/non-response. Although rare, there is a possibility of a manic switch with antidepressants prescribed for various indications at the primary level, which is a major limitation. The CVC module is useful in overcoming this limitation. The core rationale for designing this curriculum was to integrate it within the PCDs’ style of clinical practice without placing additional burden on them. Other clinical conditions, such as dissociative disorders, sleep disorders, sexual dysfunction and headache, are not included. We plan to incorporate them in subsequent phases.
FUTURE DIRECTION
The designed newer curriculum is dynamic by default as the two-way learning provides the designer the opportunity for periodic updates in the curriculum. Future directions may focus on delivering a pocket manual and prescriber’s guide as a supplement. The web/mobile application-based algorithm of CSP might add strength for effective deployment.
CONCLUSIONS
Training of PCDs is a practical step to integrate psychiatric care into their general practice. The traditional curriculum poses many challenges towards this aim and is beyond the reality of primary care. A specialized PCPP designed curriculum with higher TQ is already in various stages of implementation across different states of India. This is an attempt to discuss the rationale and guiding principles to design different modules of this innovative PCPP curriculum. This curriculum is dynamic by default as it provides designers a continuous insight about the need with its imbibed bi-directional as well as adult learning principles. These rationale and guiding principles of the PCPP curriculum may help policy-makers, innovators and academia for replication in other national health programmes such as noncommunicable diseases and reproductive and child health. This article may also provide the opportunity to develop digital-driven, skill-based, medical courses in the future.
ACKNOWLEDGEMENTS
We acknowledge the resident doctors and the nursing team posted at Sakalawara Community Mental Health Centre for their contribution and feedback. We would also like to acknowledge the thousands of PCDs who have attended the training programmes and provided feedback about PCPP.
Conflicts of interest
None declared
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