May 13th, 2018

Why Experienced HIV/ID Doctors Leave Clinical Practice

Three of my good friends — they’re way more than just colleagues after all this time — in the HIV/ID world have left clinical practice recently.

Abigail (Abbie) Zuger, Joel Gallant, and Chuck Hicks, each of them brilliant in different ways, won’t be caring for people with HIV anymore, something they’ve all been doing since the early days of this epidemic.

And I’m sad.

Sure, I’ll be interacting with them professionally in various capacities — but I’m sad for their patients, for their students, for their readers, and also for what this says about our field of HIV/ID in particular, and outpatient care in general.

Abigail (Abbie) Zuger published a piece in the New England Journal of Medicine last week that should be required reading for all experienced clinicians, not just those in the HIV/ID world. Entitled “Moving On”, it describes beautifully the bittersweet realization that her hospital-based HIV clinical practice isn’t what it used to be.

My health is fine, but my stamina is pretty much gone. Our health care system is not kind to the chronically ill and marginally insured, and it is not particularly kind to their doctors, either … the memories of my patients’ decades of life with a dire disease will become theirs alone. Their old paper medical records are off in storage now, and their digital charts are full of inane computer-speak, cut and pasted into gibberish.

Abbie’s obviously a pro when it comes to putting words together, and you can sense the pain it gives her to see complex medical histories destroyed by our cumbersome electronic medical records.

Because if you want to review that history, that story of their “decades of life with a dire disease”? Good luck.

But now the past is accessible only with a call to a warehouse and a long wait. Though many patients, given the time and encouragement, will eagerly talk about their long journey from sick to well, a 20-minute appointment slot allows for neither.

Joel’s no slouch when it comes to writing himself, and sent a brilliant, on-target, and poignant explanation for his decision to leave practice to all his friends and colleagues.

Many of the same themes (our evolving health care system and awful EMR) figured prominently in his decision too:

For us ancient relics of the pen and paper era, outpatient medicine is not what it used to be. We click boxes on computer screens while doing our best to converse and maintain eye contact with our patients. We provide clinically meaningless documentation so we can satisfy billing requirements and meet required “quality measures.” We fight with insurance companies to get patients what they need. We take mandatory on-line training courses to satisfy administrative requirements. We worry about UDS, MIPS, MACRA, CQM, CQI, PQRS, RSR, FQHC, and PCMH. There’s still medicine in there, but it sometimes feels buried beneath the growing bureaucracy and regulatory burden of modern-day healthcare.

He told me recently that in the last month of his practice, he met with an administrator to review his office notes for compliance reasons. He was criticized for not counseling his patient about smoking cessation.

When Joel pointed out the paragraph in his narrative note that discussed this very topic, he was told — “Yes, but you didn’t click the three required boxes, so it doesn’t count.”

That anecdote alone could be Citation #1 in any review of clinician burnout!

Joel also cited the change to the HIV practice in particular. Not too long ago he was using his encyclopedic knowledge of HIV treatment on a regular basis to help his patients.

Today? Not so much.

With so many patients now on stable HIV therapy, and getting older, he found himself “functioning as a primary care doctor and untrained geriatrician,” focusing on “back pain, knee pain, hypertension, and high cholesterol — all important issues, but neither my passion nor my expertise.”

When Chuck left practice, he picked up another theme that helped push him, one mentioned by both Abbie and Joel — the pain and frustration of seeing medicine as a business drive patient care:

An increasing emphasis on medicine-as-a-business makes wRVU’s and provider productivity measures much more important than quality of care and patient satisfaction. Funds generated by our clinic from welcoming and caring for challenging socio-economically deprived patient groups (for example, 340b money) go not to improve the care of these patients, but instead are used to try to balance ever-growing health system budgets.

Probably everyone who reads this blog already knows this, but let me repeat it since it deserves emphasis — HIV care will never be profitable in a system that values high patient volume and procedures, both of which are impossible for a patient population with its disproportionate share of poverty, addiction, and psychiatric disease.

It’s important to mention that the departures of Abbie, Joel, and Chuck from HIV care are highlighted here because I know them so well, and because they were so public with their decisions.

(Each gave me permission to write this, for the record.)

But they are hardly alone — I could have also mentioned Kate, Cal, Ben, Raphael, Corky, Kim, Harold, Andrew, Richard, and many other smart and experienced HIV doctors and researchers, all of whom decided it was time to move on.

It’s an irony, and a painful one, that in the supplement to Journal of Infectious Diseases on Careers in ID, the one on HIV was written by Joel Gallant.

Ouch.

49 Responses to “Why Experienced HIV/ID Doctors Leave Clinical Practice”

  1. Gerald says:

    This is so depressing to read how the system crushes the passion out of our fellow physicians. Thank you for the years of hard work.

    • HIVDocNY says:

      This is sad. Evolve or retire. Standards and best practices exist for many more reasons that the author acknowledges other than “Its no longer profitable”. For shame. Your patients have outlived the care your capable or providing. Read the room.

  2. Max Voysey says:

    It was missionary work – but the Mission is over now. . . .

  3. Josep M Llibre says:

    It is so crazy to see that it happens to be virtually the same in Spain, Italy, UK, Denmark, an accross Europe. Hospital managers and EMR developers work globally with the same objectives. Whe are controlled by fictitiously created “Quality control commissions” unable to evaluate real quality practrice.
    While we are not going to change the system, I am still convinced that in everyone’s microenvironment at work, we create favourable conditions to tech young physicians, do good clinical research, and outstantding patient-centered clinical practice. Our HIV-infected subjects have access to high-level medicine, well over the median of quality delivered at our institutions. Much of that success is due to private efforts of many many physicians and other health-care professionals that replaced deficiencies of our health care system.
    Having all this said, it is good to see that brilliant MDs go to the Med Dpts of big pharma companies. Their work now will contribute to a better understanding of our clinical work and anxieties in those huge depts.

  4. Barrett says:

    If you still have a passion for HIV care and ID but are burnt of from the American system please come to Malawi, Africa. You will see more disease in a week than you likely do in a year in the US. No coding, no EMR. You may find though that you appreciated the burden standards and quality control more than you realize 😉 There are many many teaching opportunities.

  5. Louie says:

    Medical care has devolved into a platform of checkboxes. Surviving a slowly progressive disease will ultimately rely on someone reviewing all checkboxes. That can be mesmerizing and it’s easy to skip thru the checks and unchecks. But alas, some IT analyst will develop another algorithm to put important boxes into “text” —-alas a return to pen and paper, although assembled by a robot. What will the robot do? It will probably upcode the diagnoses and send a bill.

  6. Santiago says:

    Hello,
    I have a proposal: you should all come to Mexico! Our HIV naïve patients sill come in with cd4 <200 and many OIs.
    Those with ARVs come with lots pf resistance

    And… there’s no EMR!

  7. John B says:

    Medical care is increasingly a business that answers to share holders. An enterprise where both doctors and patients are treated as commodities, which if not properly managed threatens growth.

  8. Daniel Walker says:

    I too have left private practice. I was an intern in July 1981 when this disease made it’s debut. I feel so fortunate to have been practicing I an era where a new disease evolved from a death sentence to treatable. I believe as others do that the EMR will kill the patient physician relationship as those of us remember having. I have worked in Africa with HIV and have never had such a great reward. Tiny things change generations to come.

  9. Earl Eye says:

    I too moved on from ID-my true medical love-when rules, regulations, computers, and employee attitudes were changing medicine from a professional occupation to that of a indentured employee. That was 15 years ago, and while I have some regrets, the great news is that there are practices which do not accept insurance, and you can still practice medicine as it was designed to be. I tried to fight the battle in the 80’s when PPO’s, HMO’s etc were sticking thier camels nose under the tent. It is an unfortunate fact that MD’s would rather hang separately, than hang together to prevent business taking over medicine. Now too late we clearly see what our fracturing and mistrust have produced.

  10. Loretta S says:

    I read this post and Dr. Zuger’s NEJM piece. Both were depressing and frightening at the same time. Will the problems highlighted by these 3 doctors eventually cause a mass exodus of most of the wonderful HIV/ID experts out there? Or even more frightening, will they cause an exodus of ID docs more generally? How about other specialists who spend most of their time listening to extensive histories and fitting diagnostic puzzles together (endocrinologists, for example)? In primary care, we lean heavily on specialists like ID and endocrinology.

    I recently had a pleasant talk with a doctor I would like to work with, for many reasons. But one of the most exciting things he said (exciting to me, that is) was that his practice doesn’t use an EMR. How sad that that is what I found so exciting. No more tyranny of the pull-down menu and checkbox, I thought.

  11. Stephen M. Donahue says:

    I would argue that this is what happens when physicians contract with government. Long before I started practicing medicine, physicians in the United States made a deal to get reimbursement for those who had no insurance, and the government has spent the past 50+ years piling on requirements while minimizing reimbursement. This is a good time to get out of medicine for those who can….

  12. Erin Barnes says:

    I am a new ID physician. What is hard and frustrating in reading such articles is that the old guard is leaving because of how terrible the current system is. My generation has known nothing except this awfulness. I think we are burning out faster and having less job satisfaction because of it. However, there are many who simultaneously sneer at our ‘coddled’ existence with work hour restrictions and want of work-life balance. Older doctors who have their loans paid off and have the ability to are leaving practice. What will become of us who are left behind?

    • Jo says:

      I agree with your comment and with the article. I hear from the “old guard” all the time about how terrible the EMR and current system is. But we are here now, and have to learn how to cope. I agree that EMRs are misused. One of the reasons for this I think is that the people who make decisions about how they are used did not grow up with computers. So systems are designed to translate paper into electronics rather than a completely overhauled approach to information sharing. My technological life is a dichotomy between products designed by innovative and flexible companies like Google and these nutty EMRs.
      I also think there is something to be said for choosing to make less money. We can work part time, have smaller houses and keep more energy for the future.

  13. Burcu Ozdemir says:

    EMR is a great reason for physician burn out. It is sad that we lose many talented primary care physicians for this reason. The burden of EMR especially hits primary care physicians hard since their click and documentation requirements are the heaviest. Every day I need to take care of at least 100 different messages routed to my inbasket in addition to my clinical duties and documentation duties. I am so tired, I am contemplating an early retirement I do not feel like I can do this anymore.
    My complaints fell into deaf ears. I see the only solution to be physicians to organize and fight these requirements. We can go to a click boycott. I will take care of my patients and do the essential documentation but I am boycotting the clicks, I am not going to do it.
    Can we all organize and refuse the clicks? Are they going to fire us all?

  14. Justin Moore says:

    I left clinical endocrinology practice in 2014 for some of the same reasons: the EMR stood between me and patient care; I covered three hospitals that all used different EMRs, all different from the one in my clinic; and I was besieged on one hand by administration disappointed I wasn’t making more money, and by patients on the other hand upset at how much they were being charged. In addition, my patient population had evolved to include so much chronic fatigue/chronic pain and so little actual diagnosable and treatable endocrinopathy that I no longer found joy in a huge slice of my daily patient interactions.

    Fortunately, I was granted an opportunity to do consulting work at the clinical-public health interface, looking at the implementation of and effects of interventions largely outside the clinic space, like the built environment and food policies. It has been very rewarding, and I am confident that I’m making a difference in at least as many lives now as I did in practice.

    I think there is hope for the HIV/ID docs in providing similar services, either here or abroad. I regret we work in a system that pushes people out, but I applaud people who make the leap out of a system that does not make them happy.

  15. Yehuda says:

    This exact scenario is what is driving doctors away from primary care. For example, I entered medical school AND internal medicine residency for the purpose of becoming a primary care internist. While exploring the primary care offers I received, I realized the ultimate burden of useless charting, administrative work, bureaucracy involved. I realized I would get quickly burnt out – so instead, I will be working for a highly-reputable urgent care center, where my mind will receive diagnostic challenges, and my job will be streamlined to medicine only.
    As far as the future of primary care…Who is John Galt?

  16. Sarah Rowan says:

    Glad to see Ben Young acknowledged as well. He’s done so much to change the landscape of HIV treatment in Denver and will be missed as a provider and colleague. (Wish I could tag him here like in Facebook. :-))

  17. K Leaning says:

    What shocks me the most is how truly astonished families seem to be when I actually talk and listen to them in the hospital. I am old enough to have a lot of experience and opinions, but not old enough to have paid off my student loans or to retire. I wonder what kind of care are they getting that they are so surprised when I take time to try to help them. I’m lucky to be doing well baby and NICU care with a group that does not, yet at least, seem to want my soul (which sets it apart from my other employers) and that seems to value my experience and training. I feel lucky, because before I landed here I was ready to leave medicine and I’m not even 50 years old yet. My heart hurts for the amazing and dedicated physicians who can’t find a place in this pathetic system to really care for patients in a way that feels right to them and I mourn their loss. We need these people.

  18. Silvia says:

    The same happened to me, here in Brazil – now my practice is just on my private office, 2 times a week – and I care of HIV patients since 1988…

  19. Jan Briggs says:

    Physicians are not alone in this. I am a Nurse Practitioner who cared for her first HIV+ patient in 1985 and who had specialized in HIV for the last 30 years. I regretfully retired last December because I, too, had lost stamina to deal with the commodification of health care.

  20. James Adams says:

    Thank you for sharing this! We are all holding on the best we can, gripping onto a thread of hope that things will someday magically improve. Our time in research is not offset with the necessary hours needed from clinical practice either, so a lot of us are doing two jobs for the price of one, usually subpar and rushed in such a way that is neither ideal for patient care NOR safe for study subjects. Why in the world would any sane person stay on this endless hamster wheel with very little rewards!?

  21. John Cascone says:

    That was depressing.

  22. I spent the past 15 years in a developing country in SE Asia so I missed all this monetization of medical care. I saw a lot and learned a lot. Now I’m retired, back in the US and glad I’m not fighting the bean counters.

    • Paul Sax says:

      That’s a great piece — captures a lot of what’s wrong with clinical practice these days.
      Paul

  23. Dee says:

    While I share your sentiments on the problems of a very bureaucratic and capitalistic medical system that undervalues chronic care and relationships in healthcare, I am always a little surprised by specific blame on EMR. There should be resources to scan and electronically archive paper charts, but being able to type notes has allowed me to write more thoughtfully and share more easily than scrawling on cumbersome piles of paper with carbon copies prone to fading and slipping out during their long journeys through a physical Borgesian medical record transits. If EMR is burdensome it is because of the bureaucratic, poorly coordinated, and billing-focused system, rather than unique feature of using a computer. It is also a feature of constantly changing a system (record-keeping) while trying to undertake complex activities (clinical care), that is very annoying over a several decade practice and probably has a generational component. That is my two cents, EMRs are like anything else – a weapon or a tool, depending on how you hold it.

    • Joel Gallant says:

      The problem isn’t the computer; it’s the EMR. Before I left Hopkins (which subsequently switched to EPIC), we used a home-grown program in which we dictated a note into the phone (AFTER seeing the patient). It was expertly transcribed and on the computer by the next day. Typing was an option for those averse to dictation. We then scanned for errors and electronically signed the note. A different computer program read the note and determined the billing code, which we could change if we wanted to. It was a great system. The notes were accessible and helpful. They also looked like the notes we were accustomed to from the paper days…except that they were legible. Dictating took less time than writing, and there were no boxes to click.

      The problem with that wonderful system was that our notes were “just” notes, not DATA. They couldn’t be used–at least not by other computers–to determine compliance with quality measures or to justify extra billing. The notes DID reflect quality of care, but only if you read them. (They also couldn’t be shared electronically with other EMRs…but then that promised advantage never materialized with any EMR, did it?)

      In short, our system didn’t put enough burden on healthcare providers, who were doing little more than documenting their encounters with their patients. If there was any box clicking being done, it was being done by people with less education and lower salaries. We can’t have that!

      • Jon Blum says:

        In response to Joel and Dee, I agree with both of you. EPIC began its life as billing software, and in many ways, that is what it remains. The bean-counters have figured out the EHR’s potential as a source of harvestable data. Each time they add clicks for these purposes, it becomes less useful as a clinical tool. Indeed, I was once asked to work on converting the current free-text note into a series of discrete fields so that no typing would be needed, you just choose words in boxes. This creates “notes” that are highly searchable, quantifiable, codeable, billable, painful, clinically-useless garbage. You’ve probably all read some of these. I’d rather eat broken glass than contribute to that project.

        I don’t really think the EHR is the central villain in the physician burnout problem, though it is a facilitator of certain problems. The cost of physician dysfunction and departure is now high enough that some large organizations are starting to take note and try to figure out how to relieve some of the pressures that have gotten us to this situation.

  24. Thank you Paul for this beautiful but sad description of what has happened to the practice of medicine in our career lifetimes. I finished my ID fellowship in 1972 and thus was able to enjoy my patient care experiences for many years when the patient record was a tool of the doctor to communicate with colleagues about care of the patient, and before it had been transmogrified into the weapon of medical business. I am still practicing happily as a travel medicine specialist and my medical records are entirely a tool of patient care as I have no involvement with third party payers. Though my practice now is a mere shadow of a real infectious disease practice, I am proud of the many years that I was able to provide comprehensive care for persons with complex medical problems and my medical record of those encounters was a document that I proudly and sometimes lovingly produced to document those moments.

  25. Cathy S says:

    Dr. Zuger’s article last week moved me to tears, and reflected my own decision process over the past 2 years ending in my decision to retire from both HIV care and primary care of at risk youth. EMR obstacles to patient engagement and productivity demands factored in, but so too did the realization that it was time to ensure experience and leadership opportunities for younger docs in my field. It has been hard to let go, but inevitable that as the epidemic changes so too does the workforce.

  26. As a family nurse practitioner in primary care for 20 years, I hate the clicks too. I try to do as much clicking as possible back at my desk so I can still get a good look at my patient. However, don’t get too wistful about the old pen and paper days. Don’t you remember hauling in the 6 inch thick chart to the exam room and flipping through reams of paper looking for the MRI of the lumbar spine done 2 years before?
    As others working in low resource settings around the world have mentioned, if you want to be free of the EMR, see stuff you never dreamed you would, and practice bare-bones medicine please come to rural Haiti and volunteer to with us, where there was just a diptheria outbreak.

  27. To digress a bit – does this describe also why physicians are so reluctant to take on board a diagnosis of M.E. / CFS in spite of evidence or to look after patients long-term? No procedures= no money. Long term care but poor outlook.

  28. Don Brown, MD says:

    We have resisted the move to electronic medical records and still use our
    dinosaur-like paper health records (which still works really well). We love the practice of medicine (over 30 years in primary care) and making eye contact with patients ~ 90% of my day is spent with patients. I do love the ePocrates and Up-To-Date so there is some screen time but it’s for my own edification. Don’t forget that there’s always the option to go back to paper health records! BTW we still own our primary care practice. So far we resisted drinking the Kool-Aid and no plans to change. It’s sad to see great physicians leaving practice prematurely because of the “deep state” of modern medicine.

  29. Jeff Kirchner says:

    Thanks Paul for starting this discussion, as someone who started Medical School in 1981 and finished training in 1989 – I have been at this for sometime as well and have had the privilege as a Family Medicine-trained physician to interact, dialogue with at CROI – and learn from Joel, Cal, Harold, Chuck, yourself and quite a few others. I as well was strongly touched and became tearful when reading Abigail’s NEJM essay. I have moved to half-time clinical hoping to “hold on” to my long-term survivors and those who have aged with us. EPIC and EHRs are here to stay and all of the attention to “physician burnout” these days seems to be ironically focused on our students, residents, and younger colleagues. This disease as changed so maybe it is time to “pass the baton” to our younger colleagues – making that transition is the challenging part. And Paul – please keep your blog going when ever you step down, it remains one of the highlights of my week and I think many who commented above share my feelings.

  30. Romina says:

    It is very sad to see the ones that used to teach us, the ones that we used to learn from feeling the unintended or intended consequences of a sinister system looking for metrics instead of feeding our passion for medicine. The needs are still there , the suffering of our underserved and vulnerable patients need us
    I am always being a fighter and I think is a moment in time for a big transformation and we need more than ever that passion based of knowledge, caregiving and constant action that I learned from them
    We transform, we resist bureaucracy, we will always need your knowledge
    Our patients still feel the stigma, the pain , the denial and the loneliness of this plague
    I have the chance to work with many of the mentioned colleagues and with many of you… please keep the fire burning inside… we need you and most importantly … the times are changing but our patients needs and pains are the same but only disguised under the elegant shadow of a “chronic normalised” condition

  31. R. S. Lemos MD says:

    The ID/HIV field is a victim of its own success. Imagine if Oncology had achieved the same success in devising effective and safe treatments for cancer. Hospitals would have their wards emptied of patients that currently have incurable cancer and/or toxicity from chemotherapy. And we would not need the same expertise for managing those patients. The issues related to documentation have to do more with loss of control over decision making related to Corporate take over, mergers and acquisitions. And when one is an employee of a large corporation, it is ‘take-it-or-leave-it’ attitude. CEOs are not elected by employees and it is top down hierarchy. And this is just the beginning. Just wait till machine learning and algorithms start replacing the diagnosis and treatment pathways that are now still carried out by clinicians.

  32. Jaan Naktin says:

    Hard to stand on the shoulders of giants when the giants are leaving or gone. I personally think the cup is half full – we have had excellent ID and HIV physicians join and stay in our practice which suffers the same slings and arrows. I think it is fine to lament these departures, but a message of faith in our young and energetic replacements should have closed this piece. On the way out the door, I am not going to blame the system, but champion those who persevere to make changes from within.

    • Paul Sax says:

      Thanks for your note, I completely agree.

      Stay tuned for the more upbeat perspective, which is in the works!

      Paul

  33. joseph pulvirenti says:

    Frankly I like EMR in that it can enhance communication between us in the medical profession. The problem is not the EMR but the piling on of bogus indicators that has been done to create a fiction of compliance to myriad oversight agencies. I have also been criticized for my notes because I write my progress notes to reflect my true thoughts about what is going on with the patient. These notes are about my observations about what is important with the patient, what was actually discussed with the patient and what I feel is important in the care of the patient going forward and are not cut and paste robotic inanities. We need to fight for our right to be physicians

  34. Joseph Ondercin says:

    I am now a relic-in-practice after 30 years of providing HIV care to thousands of patients. In the Autumn of my career (maybe now the Winter), I work in Public Health. I understand all the frustrations that EMR present on a daily basis, but in its defense: I can read anyone’s note who may have provided care to a patient beside me. That was usually not the case when we were all writing, or scribbling our notes in days gone by. While it is sad to hear about providers I consider as icons leaving the HIV medicine practice arena, as well as local colleagues/friends who have also moved on from HIV, I applaud any provider who has stayed in active practice, especially you Dr.Sax. As people, we all must do what we need to do in life to survive and be happy, but it takes a great deal of strength and personal commitment to our patients to continue to provide HIV care in this current environment. I have considered leaving a few times myself, and I certainly know the meaning of burnout. But when I start with the first patient of the day, I am quickly reminded of why I stay: It is them, the patients, who still desperately need not only expert medical care, but the assurance that I will be, and still am, very much there for them each day. Bravo to all of you who are still here in the trenches. It has always been about the patient, not the system.

  35. Wouldn’t it make sense for them to just see very few patients, but not retire completely?

    Like the Professor Emeritus who keeps his/her office hours, contact with students?

    Seeing patients is essential to our identity. Leaving clinical medicine completely often leads to sadness.

    Just my 2 cents.

  36. Also, until physicians band together (i.e. unionize) to change the health system and adopt a single payer ie PNHP, people will be burning out more and more…

  37. Sara V says:

    Exactly what happened to me; after 20+ years of Ryan White work, suddenly most folks got private insurance AND we got NextGen—as I clicked radio buttons all day and prior-auth’ed into the night, my brain shriveled and my heart wizened…. I left feeling humiliated and guilty and angry.

  38. Paul says:

    It’s been disheartening to see and hear of so many elder physicians leaving practice in ID and medicine due to the changes. As a current trainee who has taken on significant debt and time spent in training, there was hope that at the end, I’d find comfort in the sacrifices I’d made to practice medicine. Maybe that still comes to be, but my co-fellows and I often discuss whether this was worth it. When elder physicians leave because they can no longer stomach the current system, I’m left to wonder how I will sustain it for another 30 years in ID, let alone, in medicine. I want to, though the sentiment we sometimes see in our elder physicians does little to reassure those of us still in training. Retiring from the field of medicine should be a celebration in the culmination of one’s craft, not a sigh of relief.

Leave a Reply

Note: This is a moderated forum. By clicking on the "Submit Comment" button below, you agree to abide by the NEJM Journal Watch Terms of Use.

Our physician bloggers cannot respond to requests for personal medical advice, and recommend patients discuss health issues with their individual physicians.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.