Breast Care Navigator

The Breast Care Navigator provides individualized guidance to women recently diagnosed with breast cancer. The Navigator follows women throughout every aspect of treatment, aiding in dispelling fear, linking to financial and quality of life support resources, and being a comfort and friend to patients and their families. The Navigator supports almost 200 patients annually.

Susan G. Komen for the Cure- Ozark Affiliate provides significant funding for the Breast Care Navigator program.

Specifically, the Navigator:

• Specializes in educational information about benign and malignant breast diseases, treatments and side effects of treatment.
• Provides facts, not opinions and no treatment advice, and supports the decisions of the physician and patient.
• Provides link to language translation when necessary.
• Provides emotional support to breast cancer patients and their families.
• Conducts continual assessment of the educational, physical, psychological and social needs of the patient and family members.
• Makes appropriate referrals for additional assessment when needed.
• Serves as a support group facilitator for a variety of support groups.
• Coordinates Washington Regional's weekly multi-disciplinary Breast Conference. 
• Provides financial and support services resources to patients and their families.
• Serves as an advocate for breast cancer patients.
• Becomes a knowledgeable friend to each patient.

http://www.wregional.com/body.cfm?id=450

UCLA Kaiser Permanente Center for Health Equity

The UCLA Kaiser Permanente Center for Health Equity (formerly named Center to Eliminate Health Disparities) focuses on eliminating disparities in incidence, prevalence, mortality and burden of disease experienced by disadvantaged and underserved populations. The Center concentrates on "keeping the public healthy" by targeting health promotion, disease prevention, and access to quality and timely care for all in need.

The Center is a collaborative "center without walls" whose members include academic, government, foundation and private/non-profit investigators. Targeting the underserved, the Center promotes population-based intervention approaches to health promotion and disease prevention and control. In addition, it explores barriers preventing more effective collaboration with local health departments and other key partners engaged in the practice of public health.

http://healthequity.ucla.edu/about.php

Are Bad Knees In Our Genes? - NYTimes.com

Are fragile knees inherited? That intriguing question motivated a new study published earlier this month in The British Journal of Sports Medicine, during which researchers looked at one family's propensity for shredding anterior cruciate ligaments during sports. The report was part of a much larger, ongoing study of risk factors for A.C.L. injury, led by researchers affiliated with the Cincinnati Children's Hospital and Ohio State University, which involves thousands of young athletes. For this pocket version of the larger experiment, the scientists singled out a set of fraternal twin girls who already had been videotaped in the laboratory while wearing reflective markers. The angles of their knees during landing and cutting maneuvers had been analyzed, and the knees themselves measured. At the time of the taping, both girls' knees were healthy. But within a year, each had suffered a catastrophic A.C.L. tear during separate volleyball and basketball games, as had an older sister, who wasn't part of the original study.

"We thought this repeated incidence of A.C.L. tears within one family was important to look at," said Timothy Hewett, the director of sports-medicine research for Ohio State University and Cincinnati Children's Hospital and lead author of the new study. "In my lab, we have another set of twins, identical young women, who are post-docs. They both had torn their A.C.L.'s" as high school athletes. "Their father, who is one of a set of triplets, also had torn his A.C.L.," as had his two triplet brothers, Dr. Hewett said. "Those incidences," together with the injuries to the fraternal twins, "made us wonder, How much does familial predisposition influence your risk for an A.C.L. tear?"

The answer may be quite a bit. What Dr. Hewett and his colleagues found when they parsed the data about the fraternal twin girls' knees was that each had unusually loose, flexible knee joints, or "Gumby knees," as Dr. Hewett called them. Each also angled at least one knee outward during landings and had narrower-than-average notches in the knee bone, where the A.C.L. attaches to the bone. Each of these conditions previously had been identified as a risk factor for an A.C.L. tear, but they hadn't been shown to cluster within a family. "It appears that the propensity to be at high risk for an A.C.L. tear is definitely heritable," Dr. Hewett said.

Anyone who has an active daughter or who follows the sports pages knows that the incidence of non-contact-related A.C.L. tears among young female athletes is high and increasing. Many strength- and balance-training programs have been developed to try to reduce the number of these A.C.L. injuries. But part of the problem with the
training programs, Dr. Hewett said, "is that they'll only work if they reach the girls who actually are at risk," because of how their knees are built. "Otherwise it's like giving antibiotics to someone who doesn't have an infection. It won't work."

More ...

http://well.blogs.nytimes.com/2010/09/29/phys-ed-are-bad-knees-in-our-genes/?ref=magazine

The Ethicist - The Anesthesiologist’s Game - Question - NYTimes.com

I am an anesthesiologist. A few of my patients are children undergoing their first surgery — understandably nervous, sometimes in tears. Medications can calm them; developing a rapport with them also helps. One way I do that is to propose a contest. If they can pop the "balloon" (the bag an anesthetized patient uses to breathe), they will win a fabulous prize — a pony, a puppy, a motorcycle. This task is effectively impossible (but their deep breathing puts them to sleep faster). Some nurses complain that children in the recovery room are very disappointed when told they did not win a prize. Should I suspend the contest? MARK ISAAC, MANSFIELD, OHIO

Wait a second: I'm not getting a pony?

Fine. I knew we were only playing. Some young patients, unfortunately, do not, as their post-op responses confirm. Your admirable efforts to ease their fears, although effective in the short term, can soon disappoint these kids and, worse still, undermine their trust in doctors, rendering them yet more anxious the next time they're in a hospital. Thus, while you need not suspend your contest, you should revise it.

It is fine to engage children in a calming game, but there is a difference between a game and a lie. In the former, all participants know they are playing; in the latter, some do not. (Many parents face a version of this situation: the Tooth Fairy Problem. When must a parent honestly explain where that pillow money comes from?) Age is a big factor. Older kids can often understand what younger kids cannot. You might try less-competitive games with younger patients or promise more modest prizes that you can actually deliver — inexpensive toys or games, for example. If your hospital has child psychologists or social workers on staff, they might suggest other ways to soothe fearful children.

http://www.nytimes.com/2010/10/17/magazine/17FOB-Ethicist-t.html?ref=magazine

An Online Tool for Staging Alzheimer's Disease - NYTimes.com

Many Web sites offer help for stressed caregivers in general and information on Alzheimer's disease in particular (the Alzheimer's Association site is particularly comprehensive). But they don't fully harness the Web's interactivity to provide specific, tailored advice regarding Alzheimer's — recommendations that necessarily change as patients' behaviors and symptoms shift.

The folks at Caring.com, a site introduced more than two years ago, have just unveiled an online tool to perform exactly that function. Many of the site's visitors apparently found it difficult to know how to respond to changes as their loved ones declined — and to anticipate what's coming next.

"People feel they're always surprised," Andy Cohen, the site's chief executive, told me in an interview. "They don't know what to expect."

When you log into the new "Steps and Stages" tool and enter a few details about your family member, you're directed to a guide that identifies the stage of Alzheimer's disease or other dementia this person appears to have, explains what's happening and provides tips on managing symptoms.

You'll see advice on how to care for yourself and build a support network. You can sign up for weekly newsletters with further counsel via e-mail. All these options change as you update your relative's condition. Online chat groups also are divided by stage, so that caregivers still dealing with mild impairments, for instance, can talk with others in their situation, not those whose relatives can no longer speak.

Testing the site, I invented 73-year-old "Aunt Meredith," who occasionally repeated questions and stories within minutes, forgot appointments and important tasks, and had to leave herself reminder notes — but could care for herself. (I decided to overlook the fact that I myself had forgotten to meet a friend for coffee last week and that I keep reminder notes stuck all over my house.)

The tool suggested that Aunt Meredith had "mid-mild" Alzheimer's and suggested ways to prolong her independence and bolster her memory. It pointed out what new behaviors might emerge: she might begin forgetting to bathe, for instance.

I can see how useful this stage-specific tool might be to a caregiver, and a couple of experts I consulted, who tried out the tool, also applauded the idea. They mentioned some potential shortcomings, however.

Dr. Laurel Coleman, a geriatrician who sees many Alzheimer's patients in her practice at the Maine Medical Center in Portland, Me., pointed out via e-mail the "tremendous amount of individual variation" in this disease. Even supposedly customized advice won't cover every situation. Most people with late-stage Alzheimer's can no longer walk, for instance — but some can, and different tips will apply than for those who are bedridden.

Dr. P. Murali Doraiswamy, a prominent Duke University researcher who literally wrote the book on early-stage Alzheimer's, found much of the content of high quality but expressed some misgivings. Accurately assessing the stages of Alzheimer's requires looking at many facets of behavior, cognition and function, along with memory, he pointed out. A truly comprehensive questionnaire, with a checklist of dozens of symptoms, probably should take half an hour to complete.

So he's afraid that users will get misleading responses. Dr. Doraiswamy entered a fictional middle-aged man who occasionally forgets to refill prescriptions and leaves himself reminders. "This basically could be me, just a healthy, busy 45-year-old with no dementia whatsoever," he said by e-mail. The tool informed him that those symptoms are typical of mild-stage Alzheimer's disease.

He found that worrisome. "Many people with depression or all sorts of conditions unrelated to dementia will be told they have dementia and get the scare of their lives," he said.

Plus, the staging of Alzheimer's disease, as The Times has been reporting, is probably about to change, for the first time in 25 years. Caring.com's tool will have to change, too.

Yet girding caregivers with useful information is clearly crucial. If users understand (and Caring.com points this out in the small print at the bottom of the page) that no online guide can substitute for a thorough medical assessment, they might be happy to have it.

So let's harness our own interactivity. Lots of New Old Age readers have in-the-trenches experience with caring for family members with Alzheimer's disease — something I've been spared, so far. I hope some of you will give theSteps and Stages tool a try, then share your comments here. (Be aware the site will ask for your e-mail address, though it promises not to use it for spam.) Let the rest of us know how valuable — or inadequate — you find it, and why.

http://newoldage.blogs.nytimes.com/2010/10/13/plotting-the-course-of-alzheimers/

Depression, Incognito - NYTimes.com

Picture this experiment: A group of older adults living independently, most in their 70s and most female, are handed a couple of paragraphs to read. "You are 70," the first line says.

From there, the story heads in one of two directions. "You have been feeling unusually sad for the last few weeks," half of the study subjects read. But the others read this: "You don't seem to be able to enjoy things that you used to, like watching TV and reading the newspaper."

Both sets of paragraphs go on to describe additional and identical problems: trouble sleeping, feeling tired, losing appetite and weight, a lack of concentration. Neighbors have noticed a change.

When the participants finish reading, an interviewer asks them, "What would you say is wrong, if anything, with the person in the story?"

Fewer than half the participants correctly identified this unhappy 70-year-old as suffering from depression, reports a new study in The Journal of Applied Gerontology. That's not encouraging — perceiving the problem, of course, is an important factor in seeking or accepting help.

What's particularly interesting is that the study subjects were more apt to see this fictional person as depressed if he or she were said to suffer the most classic symptom: sadness. "If the person was sad, almost half the respondents knew that the person was depressed," said Amber Gum, a University of South Florida psychologist and the study's lead author. When the story instead referred only to a lack of interest in formerly pleasurable activities, only about a third of the participants described the 70-year-old as depressed.

"I've had older clients say, 'I'm not depressed — I'm not sad and crying all the time,' " Dr. Gum told me in an interview. But depression in old people can take an unusual form. Though depression with sadness (in psych-speak, dysphoria) remains the most common type, seniors are more likely than younger adults to suffer depression marked by loss of interest, also called anhedonia.

Because this form of depression is a bit unusual, even professionals may not recognize it in older people, Dr. Gum said. "If someone comes in and says, 'I'm sad,' you start thinking about depression. If someone says, 'I just don't feel like myself,' it's less obvious."

Two factors bolstered an older person's accuracy in spotting depression, the study revealed. Participants who had some earlier experience with mental health problems, affecting themselves or relatives or close friends, were more apt to grasp that weepy sadness is not the only criterion. And people with higher expectations for aging — those less likely, for instance, to see depression as normal in older people — also did better.

Still, fewer than half the total sample of 244 people, when asked what the hypothetical 70-year-old should do, suggested that he or she see a doctor or a mental health professional.

A pity. Aging will bring some conditions for which the medical and mental health pros can offer only limited options (dementia comes to mind). But depression isn't among them. Old people respond to the standard treatments — talk therapy and antidepressants — in roughly the same proportion as younger ones.

When they don't seek help, we tend to blame elders' unfamiliarity with psychotherapy, or the lack of mental health services in some areas, or the lingering stigma associated with "shrinks." We could also note, I suppose, that most people who just don't feel like themselves will turn first to their family doctors, who may not have much mental health training.

But what Dr. Gum and colleagues have pointed out is that depressed older people may not merely be stubborn or afraid. If they don't recognize the variety of symptoms, they may not see themselves as depressed at all. Public health educators, senior service directors and caregivers, take note.

http://newoldage.blogs.nytimes.com/2010/10/11/depression-incognito/

Diagnosis - Rough Patches - NYTimes.com

"Hey, big guy," Dr. Wolffe Nadoolman called out in a friendly voice, "why don't you come help me and your mom figure out where this rash of yours is coming from?" The gangly 4-year-old boy clambered into the chair and sat down expectantly. The skin on his face was fair and unblemished. But according to his mother, it wasn't clear a week ago.

The rash first appeared three months before, in July, the child's mother told Nadoolman, a pediatrician based in Berkeley, Calif. And it had returned every couple of weeks since. It always started around 4 a.m. Her son would wake her up crying and tell her that he was getting the rash. At that point, it didn't look like much — the skin around the boy's mouth, nose and eyes would be pink and a little puffy. But by morning, the skin on the entire lower half of his face would be red and swollen and as angry-looking as a slap. The same irritated red rash appeared on the skin of his penis as well. A day later, the skin would start to crack and peel. Finally, after a couple of days, the swelling and redness would start to recede, and by Day 4 or 5, he'd be back to normal — until the next time.

And, his mother added, everything seemed to have become worse over the past month or so. He started nursery school just after Labor Day, and since then the outbreaks had become more frequent.

Nadoolman turned to the child. Does the rash ever hurt inside your mouth? he asked the boy. No. Inside your nose? No. Does it itch? No. Does it hurt when you pee? No. Does it hurt when you talk or eat? The boy nodded his head sadly.

A few weeks earlier the child had his most severe attack, the mother told the doctor. His entire face was red and puffy. Even his eyelids were swollen. She was worried. Because the family had recently moved to Berkeley and hadn't yet found a pediatrician, she called the emergency room at the local hospital. The nurse there suggested that it could be a food allergy. She recommended Benadryl. She could bring in the child, but it would be a wait. The mother started calling pediatricians. After several attempts, she found one who could see her son that day. That doctor made his diagnosis almost as soon as he saw the boy: poison oak. Impossible, the mother responded. The only plants he had any contact with were in his grandmother's backyard vegetable garden. She weeded it religiously. There was definitely no poison oak there. That doctor called in his partner for a quick second opinion. As soon as he laid eyes on the child, he pronounced his diagnosis: poison oak, he echoed. The mother sighed. She was sure it wasn't poison oak, she told Nadoolman. What else could it be?

Nadoolman was challenged by the idea of diagnosing a rash he had not seen. Although a patient's story usually provides the most important clues to diagnosis, when it comes to lesions of the skin, visual recognition is a doctor's most powerful tool. Dermatologists in training are tested on their ability to identify a skin finding without ever touching or even talking to the patient. Seeing, they are often told, is everything. So could you make a diagnosis using only the story? Maybe. Nadoolman already had the basic history. Now he would have to dig a little deeper.

He turned to the child's mother. Were the boy's lips ever swollen, the doctor asked, or was the swelling limited to the skin around his lips? This was an important distinction, he explained. Two very severe forms of allergic reaction — angioedema and Stevens-Johnson syndrome — cause swelling of the mucus membranes and lips. If his lips were never involved, it might still be an allergic reaction but probably not one of these life-threatening ones.

The mother thought for a moment. It's not something she had paid attention to, but no, she was pretty sure that the lips themselves were never swollen. It was the skin around them that got so red and painful.

A rash limited to the face and the genitals is not uncommon in pediatrics and suggests that, whatever the cause, the most likely vector, at least in a small boy, was his own hand. "It is classic in poison oak and ivy," Nadoolman told me later. "And I suspect that's why the first pediatricians thought that's what this was." Poison oak can cause an irritating rash, known as a contact dermatitis. The hands are often spared in these kids probably because they are washed more frequently than the regions of the body they touch the most. In addition, the skin on the palms is thicker and more resistant to the allergen.

But the boy and his mom said that the rash wasn't itchy and didn't have the blisters seen in classic poison oak. Moreover, the mother seemed certain that her son had no contact with these plants. They did have a pet though, an American Eskimo dog. Could his long, thick fur be the vector bringing the urushiol — the "poison" in poison oak and ivy — home to the little boy?

The child spent a couple of afternoons a week in the backyard, gardening with his grandmother. They grew strawberries, pumpkin, squash, zucchini, cucumber, tomatoes and lettuce. Could it be something in the garden?

Another possible clue: the rash appeared only after the family moved to Berkeley. Was it something in the new house? And why did the rash appear more frequently after the boy started nursery school? Was there more of whatever it was at the school than at the home?

By the end of the visit, Nadoolman still wasn't sure what this was. Come back in two weeks, he told the pair, and he would try to have an answer for them. The doctor was still pondering the mysterious rash as he drove home. He spotted a small gardening store he passed every day. Maybe he should get a consult, he thought, as he turned into the parking lot. Maybe he was missing something. In medicine, what you don't know really can hurt you.

More ...

http://www.nytimes.com/2010/10/17/magazine/17FOB-Diagnosis-t.html?pagewanted=print

Med Students and the Risk of Doctor Suicide - NYTimes.com

Several years ago, I learned that a physician in a town not too far from where I was practicing had committed suicide. Neither I nor my hospital colleagues knew him, but according to the story we heard, he was the father of young children, was respected by doctors and patients alike and had struggled privately with mental illness since medical school.

But it was not the details of his life that haunted us; it was the details of his death. He had locked himself in a room in the hospital, placed a large needle in his vein and injected himself with a drug that so effectively paralyzed his muscles he was unable to breathe.

Or call for help.

For days afterward, the doctor's death came up repeatedly in conversations. We talked about the grief his family must have been experiencing and speculated on the extent of depression and self-loathing he must have experienced, but we dared not speak of, let alone imagine, the agony of his final moments.

Always, we ended up asking one another the same question: How could a doctor — who most likely knew about what he was suffering from and about the treatments available — never seek help?

For several decades now, studies have consistently shown that physicians have higher rates of suicide than the general population — 40 percent higher for male doctors and a staggering 130 percent higher for female doctors. While research has traced the beginning of this tragic difference to the years spent in medical school, the contributing factors remain murky. Students enter medical school with mental health profiles similar to those of their peers but end up experiencing depression, burnout and other mental illnesses at higher rates. Despite better access to health care, they are more likely to cope by resorting to dysfunctional behaviors like excessive drinking and are less likely to receive the right care or even recognize that they need some kind of intervention.

Researchers have offered several theories to explain these seemingly paradoxical findings. Some have faulted the increasing social isolation of medical education, training and practice. Others have pointed to the tendency for doctors to be highly critical of themselves and to blame themselves for their own illnesses. Still others, in light of the particularly high rates of suicide among female doctors, have suggested that workplace harassment may have a role.

Despite the many studies, theories and, more recently, student wellness programs and confidential mental health services offered by more and more medical schools, the grim statistics for medical students have hardly budged over the last generation. Up to a quarter of young doctors-to-be suffer from depression, more than half may be experiencing burnout, and a just more than 10 percent may be harboring thoughts of suicide.

These sobering numbers have remained unchanged in large part because our understanding of this issue has been hampered by inadequate research methodologies and insufficient financial support. We haven't had the sophisticated tools needed to analyze the causes or appropriate interventions; and even if we did, we haven't had the money to do anything with them.

Now two groups of researchers, using innovative methods and financed by medical school programs and departments with a keen interest in physician well-being, have published separate studies in The Journal of the American Medical Association that go beyond incidence statistics and theoretical considerations. Each study offers new findings about medical student distress and how the learning environment both fosters and exacerbates it. Read together, they offer disquieting views of the world in which tomorrow's doctors are formed.

"There's no arguing anymore over whether there's a high prevalence of distress," said Dr. Liselotte N. Dyrbye, lead author of one of the studies and an associate professor of medicine at the Mayo Clinic in Rochester, Minn. "What's important now is that we hold a mirror up to ourselves and ask why this is happening, because it is clearly not what we medical educators have intended."

Previous studies have linked medical student distress to unprofessional behavior. But, as Dr. Dyrbye and her colleagues show in their research, different types of distress — professional versus personal — can have very different effects on a young doctor's sense of what is right and wrong.

Surveying more than 2,500 medical students across the country, the researchers found that students who suffered from professional distress, more commonly referred to as burnout, a constellation of emotional exhaustion, detachment and a low sense of accomplishment, were more likely to admit to cheating on tests, lying about the status of a patient's laboratory tests or physical exam and espousing less altruistic views regarding their role as physicians. Conversely, students who suffered from personal distress, defined as poor mental or physical quality of life or depression, were not more susceptible to these unprofessional behaviors and self-centered beliefs.

"There certainly is some overlap," Dr. Dyrbye said. "But depression and burnout are two separate entities."

One result of erroneously conflating the two types of distress is stigmatization of mental illness. According to the second study, conducted by researchers from the University of Michigan in Ann Arbor, medical students who are depressed or prone to depression often believe they are viewed as inadequate and incompetent by those around them.

"They feel this from every direction — from other medical students, faculty members, counselors, and even in their applications for residency training," said the study's lead author, Dr. Thomas L. Schwenk, a professor of family medicine at the University of Michigan. While depression can cause individuals to have negative and distorted views of their surroundings, "the culture of medical school makes these students also feel like they can't be vulnerable or less than perfect."

Given that students must compete with one another throughout medical school for postgraduate training positions, many have a difficult time admitting to any perceived weakness. For those who do and want help, there are more obstacles: with the sense that peers, faculty members and others are likely to judge distressed students as less competent, it is nearly impossible to find somewhere truly safe to turn.

But this "survival of the fittest" mentality can affect all medical students, not just those who are depressed or burned out. And it can affect patients by wearing away at a young doctor's sense of empathy.

"If this is the way that students view each other," Dr. Schwenk said, "how do they view their patients who are depressed or struggling with mental illness?"

More long-term studies are needed to test interventions and analyze the factors contributing to student distress. "We have to assume that starting in medical school, there's a pipeline of experiences that leads to an increased risk of suicide," Dr. Schwenk said. But without more evidence-based interventions, even the best intentions of medical educators will continue to do little to stem the tide of medical student distress and physician suicides.

That failure has already and will continue to come at a tremendous cost to doctors and patients. "I still believe that the people who are the most vulnerable are often the most empathic," Dr. Dyrbye said. "They are the ones who get most attached and put the needs of the patient first."

Dr. Dyrbye continued, "Until we know what really helps them and what works best, our learning environment will continue to eat away at our students' empathy and altruism."

http://www.nytimes.com/2010/10/07/health/views/07chen.html?_r=1&pagewanted=print

Science Times: Decoding Your Health

A special issue of Science Times looks at the explosion of information about health and medicine and offers some guidelines on how to sort it all out

http://www.nytimes.com/indexes/2008/09/29/health/healthspecial/index.html

Are patients swimming in a sea of health information? Or are they drowning in it?

The rise of the Internet, along with thousands of health-oriented Web sites, medical blogs and even doctor-based television and radio programs, means that today's patients have more opportunities than ever to take charge of their medical care. Technological advances have vastly increased doctors' diagnostic tools and treatments, and have exponentially expanded the amount of information on just about every known disease.

The daily bombardment of news reports and drug advertising offers little guidance on how to make sense of self-proclaimed medical breakthroughs and claims of worrisome risks. And doctors, the people best equipped to guide us through these murky waters, are finding themselves with less time to spend with their patients.

But patients have more than ever to gain by decoding the latest health news and researching their own medical care.

"I don't think people have a choice — it's mandatory," said Dr. Marisa Weiss, a breast oncologist in Pennsylvania who founded the Web site breastcancer.org. "The time you have with your doctor is getting progressively shorter, yet there's so much more to talk about. You have to prepare for this important meeting."

Whether you are trying to make sense of the latest health news or you have a diagnosis of a serious illness, the basic rules of health research are the same. From interviews with doctors and patients, here are the most important steps to take in a search for medical answers.

Determine your information personality.

Information gives some people a sense of control. For others, it's overwhelming. An acquaintance of this reporter, a New York father coping with his infant son's heart problem, knew he would be paralyzed with indecision if his research led to too many choices. So he focused on finding the area's best pediatric cardiologist and left the decisions to the experts.

Others, like Amy Haberland, 50, a breast cancer patient in Arlington, Mass., pore through medical journals, looking not just for answers but also for better questions to ask their doctors.

"Knowledge is power," Ms. Haberland said. "I think knowing the reality of the risks of my cancer makes me more comfortable undergoing my treatment."

Dr. Michael Fisch, interim chairman of general oncology for the University of Texas M. D. Anderson Cancer Center, says that before patients embark on a quest for information, they need to think about their goals and how they might react to information overload.

"Just like with medicine, you have to ask yourself what dose you can take," he said. "For some people, more information makes them wackier, while others get more relaxed and feel more empowered."

The goal is to find an M.D., not become one.

Often patients begin a medical search hoping to discover a breakthrough medical study or a cure buried on the Internet. But even the best medical searches don't always give you the answers. Instead, they lead you to doctors who can provide you with even more information.

"It's probably the most important thing in your cancer care that you believe someone has your best interests at heart," said Dr. Anna Pavlick, director of the melanoma program at the New York University Cancer Institute. "In an area where there are no right answers, you're going to get a different opinion with every doctor you see. You've got to find a doctor you feel most comfortable with, the one you most trust."

Keep statistics in perspective.

Patients researching their health often come across frightening statistics. Statistics can give you a sense of overall risk, but they shouldn't be the deciding factor in your care.

Jolanta Stettler, 39, of Denver, was told she had less than six months to live after getting a diagnosis of ocular melanoma, a rare cancer of the eye that had spread to her liver.

"I was told there is absolutely nothing they could help me with, no treatment," said Ms. Stettler, a mother of three. "I was left on my own."

Ms. Stettler and her husband, a truck driver, began searching the Internet. She found Dr. Charles Nutting, an interventional radiologist at Swedish Medical Center in Englewood, Colo., who was just beginning to study a treatment that involves injecting tiny beads that emit small amounts of radiation. That appeared to help for about 18 months.

When her disease progressed again, Ms. Stettler searched for clinical trials of treatments for advanced ocular melanoma, and found a National Institutes of Health study of "isolated hepatic perfusion," which delivers concentratedchemotherapy to patients with liver metastases. After the first treatment, Ms. Stettler's tumors had shrunk by half.

"I don't like statistics," she said. "If this study stops working for me, I'll go find another study. Each type of treatment I have is stretching out my life. It gives me more time, and it gives more time to the people who are working really hard to come up with a treatment for this cancer."

Don't limit yourself to the Web.

There's more to decoding your health than the Web. Along with your doctor, your family, other patients and support groups can be resources. So can the library. When she found out she had Type 2 diabetes in 2006, Barbara Johnson, 53, of Chanhassen, Minn., spent time on the Internet, but also took nutrition classes and read books to study up on the disease.

"I was blindsided — I didn't know anybody who had it," said Ms. Johnson, who told her story on the American Heart Association's Web site, IKnowDiabetes.org. "But this is a disease you have to manage yourself."

Tell your doctor about your research.

Often patients begin a health search because their own doctors don't seem to have the right answers. All her life, Lynne Kaiser, 44, of Plano, Tex., suffered from leg pain and poor sleep; her gynecologist told her she had "extremePMS." But by searching the medical literature for "adult growing pains," she learned about restless legs syndrome and a doctor who had studied it.

"I had gone to the doctors too many times and gotten no help and no results," said Ms. Kaiser, who is now a volunteer patient advocate for the Web site WhatIsRLS.org. The new doctor she found "really pushed me to educate myself further and pushed me to look for support."

Although some doctors may discourage patients from doing their own research, many say they want to be included in the process.

Dr. Fisch of M. D. Anderson recalls a patient with advanced pancreatic cancer who decided against conventional chemotherapy, opting for clinical trials and alternative treatments. But instead of sending her away, Dr. Fisch said he kept her in the "loop of care." He even had his colleagues use a mass spectroscopy machine to evaluate a blue scorpion venom treatment the patient had stumbled on. It turned out to be just blue water.

"We monitored no therapy like we would anything else, by watching her and staying open to her choices," Dr. Fisch said. "She lived about a year from the time of diagnosis, and she had a high quality of life."

Dr. Shalom Kalnicki, chairman of Radiation Oncology at the Montefiore-Einstein Cancer Center, says he tries to guide his patients, explaining the importance of peer-reviewed information to help them filter out less reliable advice. He also encourages them to call or e-mail him with questions as they "study their own case."

"We need to help them sort through it, not discourage the use of information," he said. "We have to acknowledge that patients do this research. It's important that instead of fighting against it, that we join them and become their coaches in the process."

http://www.nytimes.com/2008/09/30/health/30pati.html?ref=healthspecial&pagewanted=print

Sick Doctors, Sick Patients - NYTimes.com

One winter toward the end of my training, I came down with a cold. At first, the constant coughing and runny nose made me miserable; then they became tiring. To decrease the chances of spreading my germs, I had to tie on a mask every time I came into contact with patients, wash my hands so frequently my skin became raw and wipe down the phone receivers with alcohol when I answered a page. Unable to scratch, wipe or blow in the operating room without contaminating my hands, I learned that for a surgeon with a runny nose, there are no palatable options for the uncontrollable nasal effluvium; I had to wear two masks every time I scrubbed up for a case.

Within days of the onset of my symptoms, other clinicians on my team were felled with the same. For weeks, we passed the cold back and forth in what became a viral game of hot potato. Even if I felt well enough one day to breathe through my nose, taste the nursing station holiday cookies and laugh without spiraling into a coughing fit, I knew that it would be only a matter of days, if not hours, before I would become sick again, invariably with a virus that had mutated just enough in the interim to dodge any immunity built up during the last go-around.

The doctors and nurses on my team started referring to me as "the vector."

Nonetheless, I continued to drag myself in to work each day. I didn't want to desert the other doctors and nurses or my patients. And any time I was overtaken with a yearning to go home and crawl back in bed, one memory from medical school would quickly push that thought from my mind.

I had been a third-year medical student and had asked my senior doctor-in-training if I could go home because of an upset stomach.

"Sure, go on home," he replied, an impassive look on his broad face. "Just remember that I've never missed a day at the hospital in my life. They'll have to put me in the hospital to keep me from taking care of my patients."

Hacking, febrile or racked with the sequelae of chronic illnesses, doctors who are sick have continued for generations to see their patients. Although published reports for over a decade have linked patient illnesses like the flu,whooping cough and resistant bacterial infections to sick health care workers, as many as 80 percent of physicians continue to work through their own ailments, even though they would have excused patients in the same condition.

For many doctors and other health care professionals, such self-sacrifice is proof of their dedication and professionalism. Moreover, in what are often precariously balanced hospitals and practices, one individual's absence can inflict tremendous stress upon others. Overstretched colleagues are forced to shoulder additional clinical responsibilities, supervisors must solve impossible staffing challenges and, worst of all, patients are left with inadequate care.

Being present — it seems, anyway — causes fewer problems than being absent.

But over the last few years, researchers in the business world have begun to question this assumption. Instead of focusing on problems incurred by absenteeism, these researchers have analyzed the impact of what's been called presenteeism, or working despite being ill. And it turns out, at least in early studies, that those employees who choose to go to work sick are expensive. Presenteeism costs companies more than $150 billion a year in lost worker productivity.

Now, a report in the current issue of The Journal of General Internal Medicine examines the impact of sick workers in health care. Anchoring their analysis with a description of a nursing home outbreak of norovirus gastroenteritis, an infection that causes nausea, vomiting and diarrhea, researchers from the University of California, San Francisco, address an issue that goes beyond the business school matter of worker productivity. They argue that in the health care setting what is important is that the decision to continue working while sick contradicts a core ethical principle of medicine: primum non nocere, or "First, do no harm."

"The culture of medicine is so completely focused on self-sacrifice that when doctors come into work so sick they need intravenous fluids, it's considered a badge of courage," said Dr. Eric Widera, the study's lead author and an assistant professor of geriatrics at the University of California, San Francisco. "No one is standing up for the patient and saying, 'This is wrong.' "

Initially the nursing home infection described by Dr. Widera and his co-authors affected only one staff member and three patients. But over the course of less than two weeks it spread to an additional 22 staff members and 30 patients despite restrictive — but voluntary — measures like stricter hand hygiene and disinfecting procedures, limiting visitors, closing down the dining hall and suspending group activities and outings. Only after the local health department required sick employees to be medically cleared before returning to work was the outbreak finally controlled.

"People probably felt they were showing up at work out of empathy for their patients and out of the kindness of their hearts," Dr. Widera observed. "But they weren't thinking about the risks."

Resisting the pressure to go to work when ill can be particularly difficult for some health care professionals. Students, doctors-in-training and nurses may be afraid that their supervisors will frown upon any absence, regardless of the reason. "It's a sign of being soft," Dr. Widera said, "and they may get a tongue-lashing the next day from those in charge."

Fully trained physicians or nurses who work in a small practice or who may be the only clinician available may feel a heightened sense of personal responsibility toward their colleagues and patients, and their decisions necessarily end up more complicated. For these individuals, "going into work sick becomes a risk-benefit analysis that must be weighed carefully," Dr. Widera said. They may have to reschedule routine visits and limit patient contact to absolute emergencies, instead of what many clinicians have felt pressure to do in the past, "coming in then doing everything you would in a normal day because you are at work anyway."

Dr. Widera and his co-authors suggest that policy changes that include unrestricted paid leave and mandatory time off for sick health care workers, as well as increased redundancy in clinician staffing may help decrease presenteeism in health care. "We need to create a culture where patient safety is more important than making the ultimate sacrifice or maximizing efficiency," he said.

"Patients are happy just to have gotten in to see a physician," Dr. Widera added, "but they are basically cornered when that doctor is sick. The onus and responsibility for changing how we deal with presenteeism has to come from us. It has to come from within the health care system."

After I had struggled for a couple of months with that cold, the chief of my division at the hospital ordered me to go home, turn off my beeper and stay away from the hospital for 48 hours. I protested at first, as did a fellow doctor who was quick to grouse about being left with all the work to do.

But I finally got better. And within days, everyone else did, too.

http://www.nytimes.com/2010/10/14/health/views/14chen.html?ref=health&src=me&pagewanted=print

When the Nurse Disagrees With the Doctor - Theresa Brown - NYTimes.com

A recent conversation with a physician at my hospital was laced with tension about the different roles of doctors and nurses.

"When you get down to it," he told me, "Patients come to me for care, Theresa, not you."

Both of us were called away before we could talk more, but his words have been ringing in my head ever since.

Jeff Swensen for The New York Times Theresa Brown, R.N.

I couldn't believe that this doctor, who had always worked well with the nurses on my floor, had just suggested, at least in my mind, that a nurse's opinion on patient care matters less because patients don't directly make appointments with us.

As I puzzled over our brief but heated exchange, I thought back to the events leading up to the conversation.

It all began after the doctor read a story I had written about a leukemia patient in his 70s. The doctor had not been involved in the case, but he was troubled by my role in it. Due to the patient's existing health problems, I was concerned that giving him chemotherapy would cause more harm than good.

During the course of the treatment, the patient complained in agony, telling me "I can't take it," and I relayed his misgivings to the patient's care team. A more aggressive lament from the patient — "What the hell are you doing to me?" — also got communicated to the team. I was the patient's nurse and his advocate, and I worried that it was not ethical to subject him to more chemotherapy when he was clearly having a hard time with the treatment. The chemo we had given him before this latest round had already sent him into permanent renal failure and caused congestive heart failure.

Other members of the team shared these concerns, but the man's doctor did not. He checked in with the patient to see if he wanted to continue treatment. After some gentle prodding by the doctor ("You want to keep going, right? Right?"), the patient agreed.

I recounted that story with great sadness, as it had been agonizing to watch my patient suffer through treatments that I believed he would not have chosen had he known the harm they could cause and the unlikeliness of being cured.

He eventually was admitted to hospice and died, but only after the chemo had left him with unstoppable and painful bleeding in his bladder, robbing him of a more peaceful and more comfortable end to his life.

The doctor colleague who cornered me at the nursing station was particularly unhappy with my aggressive objection to the patient's care plan. This doctor felt strongly that for cancer patients, end-of-life decisions should ultimately be the responsibility of the physician in charge of his or her care. That physician, he argued, is in the best position to offer advice about care decisions because he knows the patient's full history. Floor nurses, he said, usually only see a snapshot of the patient near the end of a long journey.

I understood his point, but I also felt he was too quickly dismissing the observations of oncology nurses, who intimately confront the suffering sometimes caused by well intentioned treatment.

And that's when the conversation became tense.

Obviously, doctors and nurses have different roles in the hospital. Our training is different, and so are our responsibilities. It's also true that patients choose their doctor and only end up with a particular nurse through the luck of the draw. But when a doctor and a nurse disagree over patient care, should the doctor always prevail?

Many of the nurses I know could share their own, dramatic stories of rescuing patients or catching frightening errors by other health care workers, including doctors. In fact, the same day the doctor cornered me at the nursing station, I had caught a potentially risky medication prescribing error by a doctor in training. I took my care question to a clinical pharmacist and the attending physician to insure that my patient was given the right treatment. Nurses don't have the power to make certain types of care decisions, but they do have the power -– and the responsibility — to go up the ladder until they are satisfied that good decisions are being made.

Nursing care is also an important factor in a patient's recovery. Several studies now show a strong association between nurse staffing levels and rates of patient complications like pneumonia or internal bleeding during a hospital stay. Patients in hospitals with high nurse staffing ratios get better sooner and have shorter hospital stays. Many doctors will tell you that it's nursing care, not physician care, that makes the biggest impact on a patient's recovery.

So is the doctor-patient relationship really more sacrosanct than the nurse-patient relationship? I don't think so. Physicians have the ultimate responsibility for treatment decisions, but because nurses spend so much more time with hospital patients than doctors do, we have a unique view of how the patient is really doing. And at times, patients present very different faces to nurses and to doctors — complaining to a nurse in a way they never would to a doctor.

And while my physician colleague said that nurses only see a snapshot, that picture is often one the doctor does not see.

Later, I had another chance to talk to the doctor who raised this issue in the first place. I told him that I was planning to write about our discussion of the role of doctors and nurses. "Yes,'' he said. "We never got to finish our conversation."

So we finished it. He shared difficulties he'd had with nurses criticizing treatment decisions when they had only known the patient for a few hours. I nodded. Then I said that physicians can have blinders on, too, and he nodded as well.

In the end he said, "The point is, it needs to be a conversation." And we both agreed on that.

But when in doubt, I will err on the side of aggressive advocacy for my patients. Nurses have a professional obligation to make sure that patients receive the best care possible and to insure that all care given in hospitals is safe. For better or for worse, patients who come into our hospital are the responsibility of the nurses, even if the patient has been admitted by a doctor of her own choosing. A good nurse will share his or her opinions with the medical staff — sometimes loudly — because that's part of our job, even if we ruffle a few feathers in the process.

http://well.blogs.nytimes.com/2010/10/13/how-far-should-a-nurse-go/?pagemode=print

Restoring the Lost Art of the Physical Exam - Biography - NYTimes.com

For a 55-year-old man with a bad back and a bum knee from too much tennis, Dr. Abraham Verghese was amazingly limber as he showed a roomful of doctors-in-training a twisting, dancelike walk he had spied in the hospital corridor the day before.

He challenged them to diagnose it. Hemiplegia? Sensory ataxia? Chorea? Spastic diplegia?

"It would be a shame to have someone with a gait that's diagnostic, and yet we can't recognize it," he said.

It was their introduction to a rollicking workshop on abnormal gaits that soon had them shuffling, staggering and thrashing about, challenging one another. Parkinson's? Neuropathy? Stroke?

Dr. Verghese (ver-GEESE) is the senior associate chairman for the theory and practice of medicine at Stanford University. He is also the author of two highly acclaimed memoirs, "My Own Country" and "The Tennis Partner," and a novel, "Cutting for Stone," which is now a best seller.

At Stanford, he is on a mission to bring back something he considers a lost art: the physical exam. The old-fashioned touching, looking and listening — the once prized, almost magical skills of the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope.

Art and medicine may seem disparate worlds, but Dr. Verghese insists that for him they are one. Doctors and writers are both collectors of stories, and he says his two careers have the same joy and the same prerequisite: "infinite curiosity about other people." He cannot help secretly diagnosing ailments in strangers, or wondering about the lives his patients lead outside the hospital.

"People are endlessly mysterious," he said in an interview in his office at the medical school, where volumes of poetry share the bookshelves with medical texts, family photos and a collection of reflex hammers.

His sources of inspiration include W. Somerset Maugham and Harrison's Principles of Internal Medicine. In addition to his medical degree, he has one from the writing workshop at the University of Iowa.

He is out to save the physical exam because it seems to be wasting away, he says, in an era of CT, ultrasound, M.R.I., countless lab tests and doctor visits that whip by like speed dates. Who has not felt slighted by a stethoscope applied through the shirt, or a millisecond peek into the throat?

Some doctors would gladly let the exam go, claiming that much of it has been rendered obsolete by technology and that there are better ways to spend their time with patients. Some admit they do the exam almost as a token gesture, only because patients expect it.

Medical schools in the United States have let the exam slide, Dr. Verghese says, noting that over time he has encountered more and more interns and residents who do not know how to test a patient's reflexes or palpate a spleen. He likes to joke that a person could show up at the hospital with a finger missing, and doctors would insist on an M.R.I., a CT scan and an orthopedic consult to confirm it.

Dr. Verghese trained before M.R.I. or CT existed, in Ethiopia and India, where fancy equipment was scarce and good examination skills were a matter of necessity and pride. He still believes a thorough exam can yield vital information and help doctors figure out which tests to order and which to skip — surely a worthwhile goal as the United States struggles to control health care costs, he said.

A proper exam also earns trust, he said, and serves as a ritual that transforms two strangers into doctor and patient.

"Patients know in a heartbeat if they're getting a clumsy exam," he said.

He has lectured and written about the erosion of examination skills, and his ideas have resonated with many doctors.

Stanford recruited him in 2007, in large part because of his enthusiasm for teaching the exam. He seized the bully pulpit.

"Coming from here, it's taken more seriously," he said.

With colleagues, he developed the Stanford 25, a list of techniques that every doctor should know, like how to listen to the heart or look at blood vessels at the back of the eye. The 25 are not the only exams or even the most important ones, he emphasizes — just a place to start.

More ...

http://www.nytimes.com/2010/10/12/health/12profile.html?ref=homepage&src=me&pagewanted=all

Minorities get less treatment for their pain - Health - Pain center - msnbc.com

It seems like pain would be the great equalizer: Whether you're black or white, we all hurt the same way.

Except, it turns out, how we're treated for it varies greatly.

Blacks and Hispanics are more likely than whites to deal with untreated pain and less likely to get adequate care for it, studies show. And minority patients who don't get proper pain treatment early on are likely to suffer depression and post-traumatic stress disorder down the road, says Dr. Carmen Green, a pain specialist and professor of anesthesiology at the University of Michigan.

Researchers don't know whether the pain imbalance is due to caregiver bias, cultural differences, physiological variances, or a combination of factors, but they do know one thing: Pain is not colorblind.

"There is an unequal burden of pain," Green said.

A recent study by Green of 200 chronic pain patients in the University of Michigan health system found that black patients were prescribed fewer pain medications than whites and that women were given weaker pain medications than men were given. The research published in the Journal of Pain showed that, on average, a minority pain patient would be prescribed 1.8 pain medications compared to 2.6 drugs for non-minority sufferers.

And once they do get a prescription, they have a harder time getting it filled, Green found in an earlier study, also in the Journal of Pain. Only 54 percent of pharmacies in minority neighborhoods had the most common painkillers in stock; in majority-white neighborhoods, 87 percent of pharmacies did.

Green's studies add to two decades' worth of research that shows even when pain is indisputable, such as in late-stage cancer and with broken bones, minorities get less help for their suffering.

That means a lot of unnecessary pain for people like Deborah Chenault-Green (no relation to Dr. Green), a black woman who suffered through seven years of intense pain before finally being diagnosed with herniated discs in her back and neck, as well as multiple sclerosis.

Chenault-Green, now 55, saw countless doctors at inner-city hospitals in her hometown of Detroit, but all they offered her were over-the-counter pain pills. She felt like the doctors weren't taking her pain seriously — or worse, thought she was faking just to get narcotics.

"I can kind of understand where they're coming from because they do get a lot of people who are looking for pain pills, but they kind of blanket everybody," Chenault-Green said. "For seven years I went through doctors looking at me sideways and saying 'Here's a prescription for Motrin.'"

The pain got so bad she was unable to leave her house or even concentrate on anything for a long period of time. She began to question her own sanity, as doctor after doctor sent her home with no solution for the relentless pain.

"I went through depression, I went through thoughts of suicide," Chenault-Green said. "I thought, these are the doctors, so maybe I am crazy, maybe something is wrong with me."

Her experience is echoed by another recent study by Green showing a pronounced link between pain and depression among black men.

Things finally changed for Chenault-Green when the inner-city hospital she'd been going to stopped taking her insurance. She went to a doctor in the suburbs whom she'd seen years before. He heard her symptoms and immediately sent her to a neurologist, who ordered a CT scan and MRI, which identified the herniated discs in her back and neck (for which she had surgery in 2002). Now she's living mostly pain-free.

"I say to this day it was by the grace of God they stopped taking my insurance," Chenault-Green said.

Racial disparities exist in all areas of health care. One reason pain is different is that there's no test for it; the experience of pain is subjective, and the process of identifying and treating pain relies totally on the interaction between patient and doctor.

The rushed pace of modern health care may be partly to blame, said Nomita Sonty, assistant professor of anesthesiology and psychiatry at Columbia University and leader of the American Pain

"With the emphasis being on getting patients in and out of clinics quickly, practitioners do not have the time to spend with those who may need just a little longer to be understood due to language, cultural and other barriers," Sonty said.

Many doctors don't get great training on how to identify and treat chronic pain, much less how to address racial disparities in practice, said Green, the pain specialist and University of Michigan professor.

"From a research standpoint we are probably 40 to 50 years behind in pain research" compared to other areas, Green said. "We need to address pain in a very different way."

Some state medical licensing boards require a continuing education course on health disparities, Sonty said, and she said she would like more medical schools to include pain disparities in their core curriculum. Health-care providers are becoming aware of the problem, she said, but progress is slow.

"There has been some momentum in the direction of decreasing disparities in health care, but we still have a long ways to go," Sonty said. "We need to establish a national agenda for addressing pain disparities."

Green said the best thing that any pain patient can do, regardless of race, is to keep searching until they find a doctor who will listen and take their pain seriously.

"People need to realize the importance of pain," Green said. "It saps you of your energy, your mood, your time with family and friends. But there are things that we can do. There are people who get their lives back."

One of those people is Chenault-Green, the singer and actress is active in her community and currently directing a play at the Wayne State Arts Theater — something she could not have dreamed of a few years ago.

"I'm really doing great," Chenault-Green said. "Back then, my focus wasn't on anything except the pain I was in. Now my focus is on fulfilling my dreams."

http://www.msnbc.msn.com/id/39524989/ns/health-pain_center/#

Nicholas A. Christakis | Podcasts 2009 | Sociology 190: Life and Death in the U.S.A. - Harvard

This course examines the social causes and context of illness, death, longevity, and health care in the U.S. today. Who stays healthy and who falls ill? Who has a long life and who has a short one? What are the circumstances of death for most Americans, and how do these vary? What is a good death and why do so few Americans achieve it? What is good medical care, who gets it, and why? What role do physicians play in producing health in our society? To what extent do factors outside individuals' control (factors such as geography, social networks, parental traits, or hospital quality) influence health and health care? Does socioeconomic inequality in society harm individual health? Do certain kinds of social networks or neighborhoods improve health? What are the collective constraints on individuals' life prospects? What is the difference between an individualistic and a public health perspective on illness? And what issues of ethics and justice are raised by such questions? Would a different organization of society, different public expenditures, or different public policies matter? What policy levers are available to improve the health of the public?

While exploring these questions, we will also consider how social scientists, epidemiologists, public health experts, and doctors address them -- how they use theory to understand them and how they make "causal inferences" based on observational or experimental data. However, students are not expected to have in-depth knowledge of social science methods or statistics. The readings span the medical, public health, and social science literatures, and they reflect both qualitative and quantitative approaches. In many ways, this course serves as an introduction to the field of public health.

***

We will briefly review the burden of illness and death in the U.S., touching on the costs, family effects, and implications for people's well-being and suffering. We will also review the leading causes of death and how they vary by certain socio-demographic attributes. We will note geographic variation in illness and mortality and also the relevance of circumstances of birth, (including in utero exposures, birthweight, birth order, parental occupation, etc.) to life-long health. In short, we will introduce the basic bio-social facts to be explored in the course. And we will introduce the tension between individualistic and collective perspectives on medical care. We will in particular consider the case of suicide and the extent to which it reflects individual decision-making or collective constraints.

http://christakis.med.harvard.edu/pages/teaching/subnav/podcasts_current.html