Saturday, November 29, 2008

Her Body, My Baby - My Adventures with a Surrogate Mom -

At 31 weeks, my baby was kicking and stretching. On the sonogram screen, I could see that he was doing his customary sit-ups. The monitor broadcast the slushy sound of his heartbeat.

The technician varied from visit to visit. The previous time, we were lucky: it was the gregarious young woman named Gisele who wrote things like “Hi Mom and Dad!” over the cloudy portraits of the baby or, on one image of the baby’s genitals, “I’m still a boy!” On this day, we got the terse woman who grudgingly wrote “foot” and “face,” if she wrote anything at all.

Then she tore off the sonogram images and handed them to me with one hand; with the other, she reached down to wipe the gel off the stomach of the woman who was bearing my child.

I did not give birth to my son. He is the product of my egg and my husband’s sperm. After half a decade of trying to become pregnant, sometimes succeeding but always failing to carry a baby successfully to term, I came to the conclusion that if we wanted to have a child who was genetically related to us, we would have to find a woman with a more reliable uterus to gestate and deliver our baby. That was in April 2007. I was 39 years old. Exhausted by years of infertility, wrung emotionally dry by miscarriage, my husband and I decided we would give gestational surrogacy — hiring a woman to bear our child — one try. It was a desperate measure, to be sure, and one complicated by questions from all the big sectors: financial, religious, social, moral, legal, political.

On May 11, 2007, my husband and I sent an e-mail message to a New Jersey lawyer who specializes in gestational-surrogacy cases. In July, a doctor coaxed eight egg cells — oocytes — from my ovaries and fertilized them with my husband’s sperm.

By the beginning of August, a substitute schoolteacher from Harleysville, Pa., named Cathy Hilling was pregnant with our child. On May 11, 2008, I was holding my 3-week-old son in my arms. It was Mother’s Day.

THE DESIRE TO BE a mother — to give birth to a child, to care for that child — has always been rooted in me. I never doubted my ability to be a good mother. I had a charmed, happy childhood; I have a warm, loving, funny mother. Even so, I did not think of raising a child as a goal in itself. I saw motherhood as the natural outgrowth of a loving relationship. If I never met the man, I would skip the child.

I did meet the man, Charles Stevenson, when I was 32. Happily married at 34, I hoped that becoming pregnant wouldn’t be too difficult. My husband — 54 — was older, but his sperm had a track record: he already had children from previous marriages. By the time I turned 35, nothing had happened, and after consulting a handful of doctors, Charles and I decided to start in vitro fertilization. Judging from several friends’ experiences, we figured that I.V.F. would guarantee swift results. In the battle for my fertility, I wanted the big guns.

In a typical I.V.F. cycle, the ovaries are stimulated to produce several, perhaps even dozens of, eggs; after a surgical procedure in which the doctor vacuums the eggs out of your ovaries, the embryologist pairs each mature egg with a healthy sperm. The embryos grow for several days, and one or two — or three or four, depending on the patient’s age and reproductive history — are then implanted through a catheter directly into the uterus. (Doctors will put more embryos in older patients, who generally have less success with implantation.)

We started I.V.F. at Cornell University’s Center for Reproductive Medicine and Infertility in New York City, the towering Emerald City of infertility. Every morning, patients waited for an hour or more in what came to me to feel like a hangar-size waiting room. A nurse would rattle off your name when it was time for one of the available doctors to peer at your ovaries. Occasionally, a name would ring out that you might recognize: someone’s ex-girlfriend, an acquaintance. I was a reporter for The New York Times, so in my case the summons might lead others to remember a byline. Once, a fellow patient stopped me in the hall. “Don’t worry,” she said. “This is like A.A. We’re not supposed to talk about who’s here. Your secret is safe with me.” Her silver sobriety bracelet twitched on her wrist.

I was taken aback. Her gesture underscored the helpless, self-enforced secrecy of the infertile. Couples often erect a barricade of privacy around the process to avoid the questions from friends and family members, and their ceaseless, useless volley of suggestions: You just need to relax. Did you try acupuncture? Soy milk makes you infertile. You’re in front of your computer too much. What’s the problem with all you career girls? Did this cycle work? Are you pregnant this time? How many shots? Where? A low whistle: Boy, you must really want a child.

You must really want a child. As if that were a bad thing.

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The Evidence Gap - A Big Hypertension Study, and Its Minimal Impact

The surprising news made headlines in December 2002. Generic pills for high blood pressure, which had been in use since the 1950s and cost only pennies a day, worked better than newer drugs that were up to 20 times as expensive.

The findings, from one of the biggest clinical trials ever organized by the federal government, promised to save the nation billions of dollars in treating the tens of millions of Americans with hypertension — even if the conclusions did seem to threaten pharmaceutical giants like Pfizer that were making big money on blockbuster hypertension drugs.

Six years later, though, the use of the inexpensive pills, called diuretics, is far smaller than some of the trial's organizers had hoped.

"It should have more than doubled," said Dr. Curt D. Furberg, a public health sciences professor at Wake Forest University who was the first chairman of the steering committee for the study, which was known by the acronym Allhat. "The impact was disappointing."

The percentage of hypertension patients receiving a diuretic rose to around 40 percent in the year after the Allhat results were announced, up from 30 to 35 percent beforehand, according to some studies. But use of diuretics has since stayed at that plateau. And over all, use of newer hypertension drugs has grown faster than the use of diuretics since 2002, according to Medco Health Solutions, a pharmacy benefits manager.

The Allhat experience is worth remembering now, as some policy experts and government officials call for more such studies to directly compare drugs or other treatments, as a way to stem runaway medical costs and improve care.

The aftereffects of the study show how hard it is to change medical practice, even after a government-sanctioned trial costing $130 million produced what appeared to be solid evidence.

A confluence of factors blunted Allhat's impact. One was the simple difficulty of persuading doctors to change their habits. Another was scientific disagreement, as many academic medical experts criticized the trial's design and the government's interpretation of the results.

Moreover, pharmaceutical companies responded by heavily marketing their own expensive hypertension drugs and, in some cases, paying speakers to publicly interpret the Allhat results in ways that made their products look better.

"The pharmaceutical industry ganged up and attacked, discredited the findings," Dr. Furberg said. He eventually resigned in frustration as chairman of the study's steering committee, the expert group that continues to oversee analysis of data from the trial. One member of that committee received more than $200,000 from Pfizer, largely in speaking fees, the year after the Allhat results were released.

There was another factor: medicine moves on. Even before Allhat was finished, and certainly since then, new drugs appeared. Others, meanwhile, became available as generics, reducing the cost advantage of the diuretics. And many doctors have shifted to using two or more drugs together, helped by pharmaceutical companies that offer combination pills containing two medicines.

So Allhat's main query — which drug to use first — became "an outdated question that doesn't have huge relevance to the majority of people's clinical practices," said Dr. John M. Flack, the chairman of medicine at Wayne State University, who was not involved in the study and has consulted for some drug makers.

Dr. Sean Tunis, a former chief medical officer for Medicare, remains an advocate for comparative-effectiveness studies. But, as Allhat showed, "they are hard to do, expensive to do and provoke a lot of political pushback," said Dr. Tunis, who now runs the nonprofit Center for Medical Technology Policy, which tries to arrange such trials.

"There's a lot of magical thinking," he said, "that it will all be science and won't be politics."

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Thursday, November 27, 2008

The Lab Says Heart Attack, but the Patient Is Fine -

THE man was 40 years old and seemed perfectly healthy — he had just run a 10-kilometer race. But he fainted after the race and was rushed to a hospital. There, in the emergency room, his blood was tested. His levels of a heart protein, troponin, were sky-high. It looked as if he was having a heart attack.

The runner ended up in the coronary intensive care unit at Hadassah-Hebrew University Medical Center in Jerusalem. He was in the hospital for four days, undergoing test after test. Yet nothing appeared to be wrong, his doctors — Lior Tolkin, Beth Goldstein and David Rott — report in a recent issue of Cardiology. He had no other symptoms of a heart attack; every test of his heart’s function was normal. And his soaring troponin levels, which can be an indicator of heart muscle damage, went down to normal.

A false alarm or a heart attack averted or maybe a lab error? Researchers say the most likely explanation is that the man had been caught up in a poorly understood but surprisingly common phenomenon: blood tested shortly after a long or strenuous bout of exercise is likely to show abnormalities, maybe even indicators of a heart attack or liver failure. But usually the patient is not in danger. Instead, those results are normal and are not a reason for concern.

While it is unusual to find such effects after a race as short as 10 kilometers, researchers say they are well aware of the general problem.

“I can tell you several stories like that,” said Dr. Fred Apple, a professor of laboratory medicine and pathology at the University of Minnesota School of Medicine.

In one, in fact, he is the center of the story.

Dr. Apple likes to experiment on himself, so one day, when he was a medical resident at Washington University in St. Louis, he drew his own blood and sent it to the hospital lab for routine tests.

The next thing he knew, he was being paged and escorted to the coronary intensive care unit. His blood test results were terrifying, with levels of an enzyme, creatine kinase MB, 10 times higher than normal. Like the runner in Israel, it looked as if Dr. Apple was having a heart attack.

His heart was fine. But Dr. Apple had just gone for a long run (he was running 50 to 60 miles a week in those days).

That experience, in the 1980s, made Dr. Apple curious about lab tests after strenuous exercise, and led him to systematically study the problem, documenting the exercise effect.

“I’d say that 5 percent of people who stress their bodies with exercise could bump up some of these levels above the level that signals a heart attack,” Dr. Apple said.

To avoid false alarms, he suggests that patients avoid lab tests within 24 hours of exercise. If not, he said, “you are asking for abnormalities to be detected.”

Dr. Malissa Wood, a cardiologist at the Massachusetts General Hospital who is a marathon runner, goes further. “I think it’s a really bad idea to have blood work unless something is wrong,” she said.

Dr. Wood and her colleagues have studied runners in the Boston Marathon, testing their blood before and after the race for proteins that can indicate a stroke risk or a heart attack.

“Almost everything we looked at went up,” she said.

And it may not take hours of exercise to do it.

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MELD and the Waiting List for Liver Transplant

Livers are donated in the spirit of altruism and are a limited national resource; thus, it is only right that donor livers be allocated in a fair manner. California Pacific Medical Center's Liver Transplant Program adheres to national policies developed by the United Network for Organ Sharing (UNOS). UNOS has a federal contract to operate the National Organ and Procurement and Transplantation Network.

The local federally designated Organ Procurement Organization, California Transplant Donor Network (CTDN), facilitates equitable distribution of donor livers between the local liver transplant centers (Stanford, CPMC and University of California, San Francisco). CTDN acts as a bridge between a donor hospital (a hospital with a patient who is an organ donor) and the local transplant centers. It is the policy of UNOS that all potential recipients of organ transplants must be listed on the national UNOS computer waiting list, with the priority for a donor organ determined by factors discussed below.


What is MELD? How will it be used?

The Model for End-Sage Liver Disease (MELD) system was implemented February 27, 2002 to prioritize patients waiting for a liver transplant. MELD is a numerical scale used for adult liver transplant candidates. The range is from 6 (less ill) to 40 (gravely ill). The individual score determines how urgently a patient needs a liver transplant within the next three months. The number is calculated using the most recent laboratory tests.

Lab values used in the MELD calculation:

  • Bilirubin, which measures how effectively the liver excretes bile;
  • INR (formally known as the prothrombin time), measures the liver’s ability to make blood clotting factors;
  • Creatinine, which measures kidney function. Impaired kidney function is often associated with severe liver disease.

Within the MELD continuous disease severity scale, there are four levels. As the MELD score increases, and the patient moves up to a new level, a new waiting time clock starts. Waiting time is carried backwards but not forward. If a patient moves to a lower MELD score, the waiting time accumulated at the higher score remains. When a patient moves to a higher MELD score, the waiting time at the lower level is not carried to the new level. The clock at the new level starts at 0. (Example: Patient has a MELD score of 15 and has been at level 11-18 for 100 days. With new laboratory tests, the patient’s MELD score is 22. The patient moves to a new MELD level of 19-24. The patient’s waiting time at this new level starts at 0 days). Waiting time is only used as a tie-breaker when patients have the same MELD score.

The four MELD levels are:

  • greater than or equal to 25
  • 24-19
  • 18-11
  • less than or equal to 10

Wednesday, November 26, 2008

Patient-led drug trials defy medical establishment - FOXNews

Until last year, Alan Felzer was an energetic engineering professor who took the stairs to his classes two steps at a time. Now the 64-year-old grandfather sits strapped to a wheelchair, able to move little but his left hand, his voice a near-whisper.

Felzer suffers from ALS, also known as Lou Gehrig's disease. The fatal neurological disorder steals the body's ability to move, speak and ultimately to breathe. But rather than succumb to despair along with his illness, Felzer turned to the Web to become his own medical researcher _ and his own guinea pig.

Dozens of ALS patients are testing treatments on their own without waiting on the slow pace of medical research. They are part of an emerging group of patients willing to share intimate health details on the Web in hopes of making their own medical discoveries.

Some doctors caution that such patient-led research lacks rigor and may lead to unreliable results, false hopes and harm to patients.

"The Internet is a wonderful tool, but you know, it's buyer beware," said Dr. Edward Langston, immediate past chairman of the American Medical Association's board.

In Felzer's case, the experiment's results illustrate the obstacles that stand between patients and self-discovered breakthroughs. The drug he tried did no good. But he and his family felt they had little time and little to lose in trying.

"ALS is such a short illness," said Felzer's wife, Laura. She helps her husband communicate using sign language with his one good hand when his slow, halting words become difficult to understand. "You want to do what you can as fast as you can."

The U.S. Food and Drug Administration has approved only one drug to treat ALS symptoms. It only works for some patients, and its effects are limited. As a result, Internet forums for ALS patients brim with links to the latest research offering any hint of promise. After Alan Felzer was diagnosed last year, his 33-year-old daughter, Karen, dived into the forums and found new hope.

In a recent small study, Italian scientists reported that every ALS patient given the drug lithium, commonly used to treat bipolar disorder, saw the disease's progress slow substantially.

Many ALS patients began trying lithium on their own. They persuaded their doctors to prescribe it "off-label" _ a use not approved by federal drug regulators. Off-label prescribing is a common practice, researchers say, when patients are facing a terminal illness.

Despite the risks, Langston of the AMA pointed out that doctors often stumble upon treatments, and patients could possibly do the same. "If patients are willing to share their experiences, that may in fact occur," he said.

Felzer began taking lithium in January, and his scientifically minded family reached out to other ALS patients. "All those people are taking it anyway," said Alan Felzer, whose smile remains bright and his gaze sharp even as the rest of his body fails him. "So it only made sense to keep track of what was happening."

The task of leading the ALS-lithium project fell to Felzer's daughter, Karen, a U.S. Geological Survey earthquake researcher. Her partner in the effort was Humberto Macedo, a 42-year-old computer systems analyst, father of six and ALS patient in Brasilia, Brazil.

The study grew naturally out of the strong reliance of ALS patients on one another for information, Macedo said.

Working online, Karen Felzer and Macedo recruited nearly 200 patients worldwide to take a specific lithium dosage and answer standard surveys to gauge their symptoms. They began running their study through a Web site called, using it to attract volunteers and track their progress.

On the site, patients share detailed information about their symptoms and the drugs they are taking. The site focuses on conditions that have stubbornly resisted medical science, such as ALS, Parkinson's and multiple sclerosis.

The site's founders hope professional and amateur researchers alike will dip into the resulting pool of data and emerge with insights that lead to better treatments.

"My ultimate frustration that drove this site into existence was an overall feeling that there was a lack of transparency and speed or urgency" by the medical system, said Jamie Heywood, who co-founded PatientsLikeMe months before his own brother died of ALS.

Heywood too hoped that lithium was the breakthrough he and others had been seeking.
But after six months, none of the 87 people who stuck with the study showed any letup in the disease's progress, said Karen Felzer. She now doubts the Italian study's results.

"It's obvious to everyone it's not the miracle drug we thought at first," she said. She also thinks other tests of lithium for ALS should be halted to spare patients the drug's possible side effects, such as tremors, weakness and difficulty breathing. Her father stopped taking the drug, though Macedo is continuing.

However, other reseachers say professional lithium studies should go forward. Dr. Merit Cudkowicz, a Harvard Medical School professor, is set to begin one in December with 84 patients. Her study will stick to the so-called gold standard of research, in which each patient will be randomly chosen to take the drug in question or a placebo. Neither patients or researchers will know who got the drug to avoid introducing bias.

Because the patient-led lithium study lacked those tight controls, it is unreliable as a measure of safety and effectiveness, Cudkowicz said. With an incurable disease, she said, "You don't want to be throwing something away that works because of a bad study.",4675,MEDPatientsTakeCharge,00.html

Tuesday, November 25, 2008

Her Body: When to Get a Second Opinion | Newsweek

Your doctor is recommending a surgical procedure you're unsure about. Or maybe you've just received a diagnosis you don't understand. Or perhaps your doctor isn't giving you any diagnosis at all and you still don't feel right. In all these situations, you should seek a second opinion from another physician. That's a message most Americans don't seem to get. According to a 2005 Gallup poll, about half of 5,000 Americans surveyed said they never seek a second opinion when their doctor "diagnoses a condition, or prescribes a treatment, drug, or operation" while just 3 percent say they always seek one.

What's the problem? In most cases, it's ignorance of how the health-care system works. Patients just don't understand that doctors think seeking a second opinion is routine. Many insurers recommend it and some even require it for certain procedures. But women in particular often say they feel awkward about consulting another doctor because they worry that their primary physician will be less than cordial in future visits. In fact, that's rarely the case. "I think the physician benefits almost as much as the patient from having a second opinion," says Dr. Charles Cummings, executive medical director of Johns Hopkins Medicine International. "It is always a good idea to get another set of eyes looking at the slides, looking at the lab data … to structure a diagnostic and treatment plan."

Doctors say that both men and women should seek a second opinion in virtually all types of non-emergency surgery, when your doctor recommends long-term medication that has potential side effects and if you are not feeling better despite repeated visits to your doctor. In the first two cases, studies indicate that the second physician is most likely to confirm the initial recommendation, but may also suggest alternatives for you to consider. In the last case, "another set of eyes," especially if they belong to a specialist, may catch something your first doctor missed.

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Dr. Ronald Melzack – The king of (understanding) pain

Dr. Ronald Melzack is an emeritus professor of psychology at McGill who revolutionized the study and treatment of pain. His historic partnership with Dr. Patrick Wall of MIT led to the 1985 publication of the Gate Control Theory of Pain, which overturned the then-accepted view of pain as a primitive and static danger warning system. Instead, Melzack and Wall argued that psychological factors and environment play a large role, and that pain is subjective and ultimately at the mercy of the brain. Widely lionized for his breakthroughs, Melzack has been honoured with a Killam Prize, is an Officer of the Order of Canada and l’Ordre du Qu├ębec and was recently inducted into the Canadian Medical Hall of Fame.

Born in 1929 in a working-class district of Montreal, Melzack was the only member of his family to attend university. He studied psychology at McGill under the great Dr. Donald Hebb, and obtained his PhD in 1954. After postdoctoral stints at the University of Oregon and MIT, Melzack returned to McGill as a professor in the early 1960s and was instrumental in the establishment of the McGill Pain Clinic, first at the Royal Victoria Hospital and later at the Montreal General. He also developed one of the most powerful pain research tools in use today: the McGill Pain Questionnaire, which allows patients to precisely pinpoint the type and degree of pain they are experiencing. The questionnaire has since been translated into 20 languages and is accepted as a standard worldwide.

The McGill Reporter interviewed Dr. Melzack at his office in the Stewart Biology Building a few days after the Nov. 10 announcement of his induction into the Canadian Medical Hall of Fame.

More ... A specialty relegated to the basement

Psych wards tend to be hidden away in hospitals for a reason: Mentally ill people - and their doctors - are stigmatized by the medical community. Experts say this negativity is contributing to a national shortage of psychiatrists and shoddy care for patients


Jai Shah could have been any sort of doctor he wished. Even before he graduated with honours from the University of Toronto's medical school, the 30-year-old Edmonton native had earned a master's degree in international health policy from the London School of Economics, published papers and worked for the Canadian Institutes of Health Research.

Praise follows him wherever he goes. Except for last fall - when he decided to specialize in psychiatry.

"A psychiatrist?" some of his supervisors said, "But you're smart! ... You're taking the easy way out ... Your patients will make your life hell ... Your patients will make you depressed ... What a waste of talent!"

Dr. Shah knew mentally ill people battle both their disorders and the social stigma their conditions carry. But it surprised him that psychiatrists confront a certain stigma, too

"I'm sure the feedback has discouraged some young doctors from choosing this as their career," said Dr. Shah, now at the Harvard Longwood Psychiatry Residency Training Program in Boston.

In fact, Susan Abbey, who heads the U of T first-year residency program in psychiatry, said the disparaging comments are "ubiquitous."

"I don't think there's one of our incoming residents who hasn't been exposed to negative comments from family or friends or academic supervisors," Dr. Abbey said.

Just as lawyers can face a barrage of bottom-feeder jokes, psychiatrists, both in film and real life, have long been seen as doctors of a lesser science. Even their own physician colleagues can view their patients as difficult and time-consuming. The negativity, experts say, is contributing to a national shortage of psychiatrists and shoddy care for mentally ill people.

Across the country, Canadians are unable to see a psychiatrist when they need one. A survey from the B.C.-based Fraser Institute released last month suggests the national median waiting time for psychiatric care this year is 18.6 weeks, longer than for any physical treatment.

A Canadian Psychiatric Association survey has found that even in emergency cases - where the CPA recommends a patient be admitted for acute care within 24 hours due to a "high degree of risk to self or others" - delays in some regions range from 57 hours to nearly five days.

"It's the patients who doubly suffer from the stigma," Dr. Shah said. "First, from the social perception of their illness and then, on top of it all, from the shortage of treaters, and the gaps in care reflect the stigma within the medical profession and that contributes [to the social perception]... so it's a vicious circle."

Studies suggest these attitudes take a toll on medicine's front lines: Mentally ill people have a tougher time finding a family doctor, are more likely to need urgent medical care and less likely to receive life-saving treatments. They're also more likely to die of conditions such as heart attacks, strokes and cancer.

At the same time, funding for mental-health research and psychiatric services has paled compared with monies doled out for physical ailments. Mental illness, meanwhile, is the No. 1 cause of disabilities in Canada and accounts for 20 per cent of all hospital admissions.

The inequities are so apparent that the Mental Health Commission of Canada has made it a top priority to fight stigma among health-care professionals, and this year the Canadian Medical Association, which represents the country's doctors, has launched a campaign to combat the stigma within its ranks.

"Doctors will be inclined to see mental illness differently than other medical illnesses ... it's not like a broken bone, you don't see it clearly," said CMA president Dr. Robert Ouellet. "We feel mental illness has not received its fair share of attention."

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The Doctor Will See You Now — Online - Bits Blog -

American Well aims to reinvent the house call.

If Roy Schoenberg, the start-up's co-founder and chief executive, has his way, patients will no longer have to wait a month to see a doctor for an urgent sore throat, wait all day for a doctor to return their call or leave work midday and drive a long distance for a routine appointment. Instead, patients will log on to their computers and find themselves face-to-face with physicians over Webcam.

Consumers are bombarded with health information from their insurance companies and from the Web, often full of advice from writers or fellow patients, not physicians. "What we're missing is the very bare-bones health care: talking to a doctor. That's why I started American Well," said Dr. Schoenberg, a doctor who has founded two other software companies. He co-founded American Well with his brother, Ido Schoenberg.

He has big plans for the potential of the service to address health care reform in the United States. So far, policy makers' approach to health care reform has been antiquated, he said. "We need to take a fresh look at what's available in 2008. Online care means that without reworking the budget, without going through Congress, we can bring affordable health care to people who cannot access it," he said.

Consumers whose health plans use American Well will log on to their health plans' Web sites to access the service. The first plan to sign on is Blue Cross Blue Shield of Hawaii, which starting in January will offer patients virtual visits with its doctors. Other states and health plans, yet to be announced, will also activate it in 2009.

Patients who are members of the health plan pay a co-pay, just like at the doctor's office. Doctors hold 10-minute appointments, which can be extended for an optional fee, and can file prescriptions through the system. Uninsured patients can also use it, for a fee that the health plans choose but which will be less than $50, much less than a visit to the emergency room, which is where the uninsured often end up. Health plans pay American Well a license fee per member to use the software, as well as a transaction fee of about $2 a patient each time a patient sees a doctor.

Doctors, meanwhile, pick up a few extra dollars on the side. They get paid less than an office visit but more than a phone consult and do not have to worry about scheduling, overhead and paperwork. They just log on and wait for patients to come to them. American Well files all the claims, and the money is deposited into the doctor's bank account.

Dr. Schoenberg expects it to be popular among retired physicians or those who have practices but want to see a few more patients when they have a free hour on a Saturday afternoon. "Then, if they decide they want to watch 'Lost,' they're finished," he said. "That flexibility is why we're getting such a favorable response from physicians" who have felt shackled by the burdens of scheduling, chasing down payments, filing with insurance companies and paying for office costs and malpractice insurance.

A.I.G. has agreed to provide malpractice insurance to doctors providing online care, and the cost is low enough that most of the health plans are paying for it instead of charging the doctors, Dr. Schoenberg said.

Patients benefit from receiving continuous care from a doctor who knows their medical history. Dr. Schoenberg said that American Well allows for that. If a patient's primary care physician is online, the patient can see him or her. If not, the doctor who sees the patient sends a report back to the patient's usual doctor.

American Well has formed a partnership with HealthVault, Microsoft's electronic medical records service, so patients can get access to and share their medical information with doctors while using American Well. It has also teamed up with ActiveHealth, a subsidiary of Aetna, which has technology that will scan a patient's medical history and alert doctors about gaps in care during an American Well appointment. For example, if a woman is consulting online with a gynecologist, ActiveHealth would alert the doctor if she had not been receiving regular mammograms.

Of course, not all conditions can be diagnosed and treated over a Webcam. "If you have a heart attack, don't use our system — go to the E.R.," Dr. Schoenberg said. "But the vast majority of health care is primary care."

He said that national studies on online care have found that patients would like to have Web chats with primary care doctors about colds or diabetes management, for example, or with specialists about symptoms such as lower back pain or bad headaches.

Microsoft Examines Causes of ‘Cyberchondria’ -

If that headache plaguing you this morning led you first to a Web search and then to the conclusion that you must have a brain tumor, you may instead be suffering from cyberchondria.

On Monday, Microsoft researchers published the results of a study of health-related Web searches on popular search engines as well as a survey of the company's employees.

The study suggests that self-diagnosis by search engine frequently leads Web searchers to conclude the worst about what ails them.

The researchers said they had undertaken the study as part of an effort to add features to Microsoft's search service that could make it more of an adviser and less of a blind information retrieval tool.

Although the term "cyberchondria" emerged in 2000 to refer to the practice of leaping to dire conclusions while researching health matters online, the Microsoft study is the first systematic look at the anxieties of people doing searches related to health care, Eric Horvitz said.

Mr. Horvitz, an artificial intelligence researcher at Microsoft Research, said many people treated search engines as if they could answer questions like a human expert.

"People tend to look at just the first couple results," Mr. Horvitz said. "If they find 'brain tumor' or 'A.L.S.,' that's their launching point."

Mr. Horvitz is a computer scientist and has a medical degree, and his fellow investigator, Ryen W. White, is a specialist in information retrieval technology.

They found that Web searches for things like headache and chest pain were just as likely or more likely to lead people to pages describing serious conditions as benign ones, even though the serious illnesses are much more rare.

For example, there were just as many results that linked headaches with brain tumors as with caffeine withdrawal, although the chance of having a brain tumor is infinitesimally small.

The researchers said they had not intended their work to send the message that people should ignore symptoms. But their examination of search records indicated that researching particular symptoms often led quickly to anxiousness.

They found that roughly 2 percent of all Web queries were health-related, and about 250,000 users, or about a quarter of the sample, engaged in a least one medical search during the study.

About a third of the subjects "escalated" their follow-up searches to explore serious illnesses, the researchers said.

Of the more than 500 Microsoft employees who answered a survey on their medical search habits, more than half said that online medical queries related to a serious illness had interrupted their day-to-day activities at least once.

Mr. Horvitz said that in addition to his interest in creating a Web search tool that would give more reliable answers, the research was driven by clear memories from his medical school education of what was often referred to as "second-year syndrome" or "medical schoolitis."

He said he remembered "sitting on a cold seat with my legs dangling off the examination table," convinced that he was suffering from a rare and incurable skin disease.

While the doctor was out of the room, Mr. Horvitz said, he took a look at his medical chart and saw that the doctor's notes read, "Eric is in medical school, and he has been reading a lot."

The researchers said that Web searchers' propensity to jump to awful conclusions was basic human behavior that has been noted by research scientists for decades.

In 1974, the psychologists Amos Tversky and Daniel Kahneman wrote a seminal paper about decisions that are based on beliefs about the likelihood of uncertain events, like the outcome of an election or the future value of the dollar.

They said that people usually employ common sense rules to aid in decisions. The rules can be quite useful, but they also frequently lead to systematic errors in judgment.

The Microsoft researchers noted that reliance on the rankings of Web search results contributes a similar bias to the judgments people make about illness.

At the same time, Mr. Horvitz said he believed that the Web would evolve to offer more reliable information.

In the 1990s, Microsoft researchers built a health advisory system for pregnancy and child care. Mr. Horvitz said that in the future it would be possible to create search engines that were able to detect medical queries and offer advice that did not automatically make Web searchers fear the worst.

Sunday, November 23, 2008

Staying in Touch - The New Old Age Blog -

My brother and sister-in-law went to Rome recently, and I didn’t pay too much attention to when they were leaving, where they were staying or when they’d be back. So what, you might ask? What does this have to do with us, your New Old Age readers? Well, stick with me. The logic is a bit strained, but I suspect this will ring true.

Travel can be disruptive for families caring for an aging parent. (Alan Zale for The New York Times)

When my mother was in precarious health, I always knew where my brother was and vice versa. We exchanged detailed itineraries before trips, even weekend jaunts, something we’d never done before. We touched base at departure. We touched base every day or two when we were out of town. We touched base again when the plane put down on arrival home.

“The eagle has landed,’’ was our shorthand for “I’m back. You don’t have to worry that all hell is going to break loose on your watch. You’re no longer in this alone.’’

When I was out-of-town on business, it was distracting to have my cell phone on all the time, and I worried that answering it was rude to my interview subjects. I warned them immediately that we might be interrupted. Usually, I got as far in the explanation as “My mother…” and they knew where I was headed.

Within a certain age band, we all had parents who were, literally, a moment away from a potential crisis: A fall. A stroke. Even when nothing bad was happening, it might. Knowing that was exhausting. Everyone had a story. (See Part I of a two parter on family caregiving by my colleague Jane Brody, who discusses many of the same issues we discuss here.)

So, the tether that connected me and my brother also connected me to others I spoke with. With each preemptive “My mother…,” I was drawn into a circle of commiseration. It was comforting, in the way it was comforting to know my brother was never more than a speed-dial away.

When we were both in town, the one unbreakable rule of our collaboration, even in its stormiest moments, was to stay in touch. My brother knew when I was at home, in the office, in the car, out for dinner, at a movie and vice versa. Cell phones remained on at all times. Whoever we might be talking to, the other one’s number on caller ID always took precedence. In simpler times, we had spoken rarely, so this was not a slight adjustment of communication patterns but rather a sea change.

Most of the time it consoled me. Take the days when my mother chose the worst possible time to call about something annoying but not earth shattering, say lukewarm coffee at the assisted living place or a surly aide at the nursing home. She’d never been a complainer or a pest. Now she was both, agitated by helplessness, and she spared neither of us. Between the calls we’d call each other and vent. Who else could we comfortably ask, “Is this ever going to end?’’

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Bad News Can Be Better Than Nothing -

No one likes bad news, but for some people, no news is worse. People who are mildly neurotic are stressed by uncertainty even more than by bad news, a new study finds.

Psychologists have long known that bad news grabs attention, making its recipients take notice, while good news often is given short shrift in the brain. Scientists have explained the phenomenon as a survival mechanism, a part of the brain’s wiring adapted to warn of dangers or threats.

But researchers at the University of Toronto wanted to learn more about how people respond to uncertainty — a lack of information or information that isn’t well understood. Forty-one young men and women took a test designed to assess how neurotic they were, then were fitted with electrode caps that measured brain activity as they completed certain tasks. As a way of monitoring stress, the investigators tracked neural activity in the anterior cingulate cortex, a part of the brain involved in conflict, uncertainty and monitoring errors.

The participants later were asked to respond when they thought a second had passed since a symbol had appeared on a computer monitor. After responding, they received feedback on the monitor in the form of a plus sign indicating a job well done, a minus sign indicating improvement was needed, or a question mark with no further explanation. The subjects who had scored higher on the neuroticism scale demonstrated more brain activity in response to uncertain feedback than to negative feedback, the researchers found.

In the real world, such a heightened response might occur when an employee is up for a promotion but does not know the outcome, said Jacob B. Hirsh, a graduate student in psychology at the University of Toronto and lead author of the paper. A highly neurotic individual would respond less intensely to losing the promotion, Mr. Hirsh said.

The opposite is true for people who are not neurotic, Mr. Hirsh added. They are not bothered by uncertainty but are very upset by negative feedback.

Richard Sorrentino, a psychologist at the University of Western Ontario who also studies uncertainty, said he had conducted a similar study looking at married women who were ambivalent toward their partners and not sure whether they could be trusted.

“If they were the type who preferred certainty, they were better off if they didn’t trust their husbands at all than if they were uncertain about whether to trust him,” he said. Wives who preferred certainty but who were uncertain about their husbands often suffered severe symptoms, he added, including depression.

“Basically the motto of the highly neurotic person is, ’Better the devil you know than the devil you don’t,’ ” Mr. Hirsch said.

Complete List - The Year in Medicine 2008 - TIME

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America's Health Checkup - The Year in Medicine 2008 - TIME

What is the measure of a country's health? How do you take the temperature of a population that sprawls across nine time zones, 50 states and a global rainbow of cultures and communities? One way is by taking a close look at yourself.

If you're like 67% of Americans, you're currently overweight or obese. If you're like 27%, your blood pressure is too high. If you're like a whopping 96% of the population, you may not be able to recall the last time you had a salad, since you're one of the hundreds of millions of Americans who rarely eat enough vegetables. And what you do eat, you don't burn off — assuming you're like the 40% of us who get no exercise. Most troubling of all, if you're like any parent of any child anywhere in the world, you may be passing your health habits to your children, which explains why experts fear that this generation of American kids may be the first ever to have a shorter life span than their parents do.

(Read the Year in Medicine 2008.)

By too many measures, America is a lot less healthy than a developed nation has any business being. But just how sick — or just how well — are we? Broad national averages are limited things — very good at telling you the what, but notoriously bad at telling you much more. Who are the one-third of Americans who don't have a weight problem, and how can the rest of us become like them? Why do some of us get our cancer screenings and make sure our kids are vaccinated while others don't? It's hard enough to get a thorough profile of any one person's health outlook. Now imagine putting 300 million of us on the examining table together. That's where TIME's inaugural national health checkup can help.

For this first annual feature, we've gone straight to the numbers to measure the vital signs of a 232-year-old nation that, let's be honest, has let itself go a little lately. The results of such a collective physical are something that should concern us all. If Americans get flabby and inactive together, we can also get fit and healthy together, and a look at the national fever chart is one way to learn not only where any one person needs to improve, but where any one family or entire region should too.

Even a cursory glance at the stats gives us reason for both hope and worry. Each decade since 1980, the Department of Health and Human Services (HHS) has compiled what it calls its Healthy People report, a sort of prospective census in which it sets goals in 28 health areas, from weight and diabetes incidence to cholesterol levels and cancer screenings, and keeps track of how well those targets are met over the 10 years that follow. We are approaching the Healthy People 2010 report, and in an interim assessment, hhs revealed that 59% of its objectives had already been met or were on their way to being met. The goal of vaccinating 80% of babies under age 3 with a core series of shots was surpassed in 2005, with 81% of infants receiving the recommended doses. Half of adults ages 50 and older received a colon scan, meeting the target for colon-cancer screening. Yet at the same time, in 20% of the tracked trends, we have actually retreated from the goals. Only 33% of adults in 2003-06 were at a healthy weight, half the number who ideally should be and 10% fewer than in 1988-94. The prevalence of diabetes, which health officials hope to cap at 25 cases per 1,000 people, is more than double that and has actually risen since 1997.

With a new Administration promising much needed reform in the way health care is accessed, delivered and reimbursed, legislators, health officials, doctors and patients see this as a rare opportunity, a sweet spot in which national need could meet national will and we could actually fix a system that seems to be costing us more and more but delivering less and less. The improvements can't come too soon. In spite of our gleaming hospitals and cutting-edge technology that can detect the tiniest tumors and repair the most complex organ, on some basic health measures the U.S. is starting to fall behind — far behind.

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Wellsphere - Health knowledge made personal

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Recognizing that each person has their own unique health questions, we developed a model that combines personalized information and social support to help people address their individual concerns. After extensive research and development, Wellsphere launched WellPages, powered by its innovative Health Knowledge EngineTM, enabling users to quickly and efficiently find comprehensive, personal answers and support for their specific health needs – all on one personalized webpage. Wellsphere's unique ability to quickly and efficiently answer user's specific health needs has made one of the leading consumer health websites in the world.

Patients give hospitals low scores on pain control

A survey of patients regarding the care they received during a hospitalization shows most are satisfied with their experience. Many patients, however, gave low scores to hospitals on pain management and discharge instructions.

Hospitals are routinely assessed for their quality of care based on outcome data. But there has been little information on how patients feel about their care. The study, published today in the New England Journal of Medicine, came from the Hospital Consumer Assessment of Healthcare Providers and Systems survey. The survey of 2,400 hospitals targeted six areas: communication with doctors, communication with nurses, communication about medications, quality of nursing services, how well hospitals prepared patients for discharge, and pain management.

On average, about 67% of patients said they would definitely recommend the hospital in which they were treated. The study found that hospitals with higher nurse-to-patient ratios had more satisfied patients. Moreover, the hospitals that tended to score higher on standard quality measures based on outcome data also tended to have more satisfied patients. "There need be no trade off between ensuring that care is technically superb and addressing the needs of the patients," said senior author Arnold Epstein, chairman of the Department of Health Policy and Management at Harvard School of Public Health.

There was some regional variation, with patients in Birmingham, Ala., giving hospitals the highest marks and patients in East Long Island, N.Y., the lowest marks. The most consistent complaint among all patients was in pain management, where nearly one-third did not give high ratings. About one-fifth of patients also said the hospital did not communicate discharge instructions well.

To view data on individual hospitals, go to the U.S. Department of Health & Human Services Hospital Compare website and click on the "Find and Compare Hospitals."

Get a Life, Doc |

There's an e-mail making the rounds with a job description attached. If you apply, be warned: you will be burdened with "challenging" tasks "in an often chaotic environment" with "variable hours, which will include evenings and weekends and frequent 24-hour shifts on call." You must be "willing to be hated, at least temporarily." Oh, and you'd better love kids, because that's who you'll be working with all day. The job, of course, is "parent"—but it might as well be "pediatrician," which requires a lot of the same skills and then some. That's why lately I've been feeling sorry for pediatrics residents. They're often too busy wiping the noses and taking the temperatures of other people's kids to do likewise for their own.

Training to be a pediatrician—or any other kind of doctor—isn't much fun. The hours are awful. The pay, in some programs, works out per hour to little more than minimum wage. Granted, things could be worse: residents are called "residents" because until the 1950s or so, they lived at the hospital. Their lives now are closer to normal, but a big problem remains: the residency begins around age 26, overlapping exactly with the prime years for bearing and raising children. "We're asking people to do this training right at the time they would normally be starting families," says Ted Sectish, codirector of the combined pediatrics residency at Children's Hospital Boston and Boston Medical Center. "There is an intense commitment to them being well trained—but there also has to be a commitment to them having a life."

Sectish's solution is a part-time pediatrics residency. Children's isn't the only hospital in the country that offers the option—about 25 percent of programs nationwide do—but, with much of medicine still ruled by a masochistic, show-no-weakness mentality, it's one of a precious few where residents choose that track. Take Susan Clinton Martin, who realized during her first year at Children's that her new job left her no time to raise two kids under age 4. "I was leaving before they woke up and coming home after they went to bed, and I was on call every fourth night," she says. "I went into pediatrics because I love children, but I wasn't able to give my own children the time they deserved." Instead of quitting, she went part-time. Now in her final year, she tells the directors she is "their happiest resident."

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When Diagnosing Your Child Takes a Team of Doctors |

When my son came down with a mysterious illness, no doctor seemed to care. Finally, a team approach and positive thinking gave us hope.

Melissa T. Shultz

On a beautiful October afternoon last year, my bright-eyed 12-year-old son went for a bike ride and returned 15 minutes later with a lackluster gaze, a face devoid of color, and the feeling he was on a boat in the high seas. That moment began a medical mystery that has rocked our family's world, and taught us how ill-equipped our medical system is to diagnose complicated cases. It has also taught us never to underestimate the mind's power to help heal the body, and a physician's confidence to heal the mind.

Fatigue set in a day after Nick's dizziness started. Swollen glands followed close behind. Our general practitioner ordered blood work, including studies for mononucleosis and Lyme disease. When everything came back negative, we tried steroids for Nick's swollen glands and a round of antibiotics in case he had a bacterial infection. When the dizziness and fatigue persisted we wondered aloud if the culprit might have been the flu shot he received eight days prior. It was presumed he had viral labyrinthitis (an inner-ear disorder) that would pass in a week or two.

When it didn't, and his tonsils grew exponentially, we tried a different antibiotic. All the while, he was perched in a makeshift bed on our first floor—an overstuffed chair and aging ottoman with a twin sheet stretched to its limit. Suffering from extreme vertigo, Nick was unable to walk up the stairs to his bedroom. He could not lift his head without looking as if he were drowningand mostly slept the days away. School became someplace his friends went.

The second antibiotic helped his tonsils, but otherwise he remained the same. Frustrated, I went into investigative mode and searched for an ear, nose, and throat (ENT) specialist. It took weeks to get an appointment. "Is he a patient?" I was asked repeatedly. By my zillionth call I figured out the game. Make appointments with everyone and take the soonest first. The ENT ordered allergy tests, an inner-ear test, and an MRI of Nick's curly little head. When it was over, the radiologist who read the MRI said it was Nick's right mastoid, a portion of the temporal bone that was the issue. The ENT disagreed. He said that Nick's right inner ear (seen on the inner-ear test) was damaged, but he couldn't really say why. All he told me was that he doubted he could fix it. Ever.

That's not what a mother wants to hear.

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