Teenagers, Friends and Bad Decisions - NYTimes.com

Why do otherwise good kids seem to make bad decisions when they are with their friends? New research on risk taking and the teenage brain offers some answers.

In studies at Temple University, psychologists used functional magnetic resonance imaging scans on 40 teenagers and adults to determine if there are differences in brain activity when adolescents are alone versus with their friends. The findings suggest that teenage peer pressure has a distinct effect on brain signals involving risk and reward, helping to explain why young people are more likely to misbehave and take risks when their friends are watching.

To test how the presence of peers influences risk taking, the researchers asked 14 young teenagers (ages 14 to 18), 14 college students and 12 young adults to play a six-minute video driving game while in a brain scanner. Participants were given cash prizes for completing the game in a certain time, but players had to make decisions about stopping at yellow lights, and being delayed, or racing through yellow lights, which could result in a faster time and a bigger prize, but also meant a higher risk for crashing and an even longer delay. The children and adults played four rounds of the game while undergoing the brain scan. Half the time they played alone, and half the time they were told that two same-sex friends who had accompanied them to the study were watching the play in the next room.

Among adults and college students, there were no meaningful differences in risk taking, regardless of  whether friends were watching. But the young teenagers ran about 40 percent more yellow lights and had 60 percent more crashes when they knew their friends were watching. And notably, the regions of the brain associated with reward showed greater activity when they were playing in view of their friends. It was as if the presence of friends, even in the next room, prompted the brain's reward system to drown out any warning signals about risk, tipping the balance toward the reward.

"The presence of peers activated the reward circuitry in the brain of adolescents that it didn't do in the case of adults," said Laurence Steinberg, an author of the study, who is a psychology professor at Temple and author of "You and Your Adolescent: The Essential Guide for Ages 10 to 25." "We think we've uncovered one very plausible explanation for why adolescents do a lot of stupid things with their friends that they wouldn't do when they are by themselves."

Dr. Steinberg notes that the findings give a new view of peer pressure, since the peers in this experiment were not even in the same room as the teenager in the scanner.

"The subject was in the scanner, so the friends were not able to directly pressure the person to take chances," Dr. Steinberg said. "I think it's helpful to understand because many parents conceive of peer pressure as kids directly coercing each other into doing things. We've shown that just the knowledge that your friends are watching you can increase risky behavior."

Dr. Steinberg notes that the brain system involved in reward processing is also involved in the processing of social information, explaining why peers can have such a pronounced effect on decision making. The effect is believed to be especially strong in teenagers because brain changes shortly after puberty appear to make young people more attentive and aware of what other people are thinking about them, Dr. Steinberg said.

The study results are borne out in real-world data that show teenagers have a much higher risk of car accidents when other teenagers are in the car. More study is needed to determine if the effect shown in the game study is the same when teenagers are in the presence of an opposite-sex friend or romantic interest. In the study, there were no meaningful differences in risk taking among boys and girls. However, some real-world driving data suggests that teenage boys take more risks behind the wheel when one or more boys are in the car, but drive more carefully if they are with a girlfriend.

For parents, the study data reinforce the notion that groups of teenagers need close supervision.

"All of us who have very good kids know they've done really dumb things when they've been with their friends," Dr. Steinberg said. "The lesson is that if you have a kid whom you think of as very mature and able to exercise good judgment, based on your observations when he or she is alone or with you, that doesn't necessarily generalize to how he or she will behave in a group of friends without adults around. Parents should be aware of that."

http://well.blogs.nytimes.com/2011/02/03/teenagers-friends-and-bad-decisions/?src=me&ref=general

For Tucson Survivors, Cost of Medical Care Is a Concern - NYTimes.com

TUCSON — Seconds after gunfire erupted outside a supermarket here last month, Randy Gardner, one of those struck during the barrage, said another potential crisis immediately entered his mind.

"I wondered, 'How much is this going to cost me?' " he said. "It was a thought that went through my head right away."

Tucson's medical system quickly swung into action after the shootings, with ambulances and medical helicopters rushing victims to hospitals where trauma specialists awaited them. The life-saving treatment the victims received over the ensuing days carried a heavy cost, though, and the bills — the costliest of which may be in the hundreds of thousands of dollars for Representative Gabrielle Giffords — are still being tallied.

But despite the fears of some victims, it does not appear that the shooting will ruin anyone financially. Interviews with victims as well as advocates assisting them suggest that most, if not all, of the 13 people wounded that morning had health insurance, and health care providers say they expect insurance companies to cover the bulk of the medical costs.

On top of that, the fact that federal charges have been filed against Jared L. Loughner in the shootings means that state victim-compensation money will be supplemented by federal help. Private charitable efforts to aid victims have also been created.

Ms. Giffords, who received a bullet wound to the head and was the most gravely injured of those who survived the shooting, also had probably the best insurance, a federal plan known for its comprehensive coverage that was held out as a model during last year's debate over the health care overhaul.

Dr. Peter Rhee, chief trauma surgeon at Tucson's University Medical Center, has repeatedly said that Ms. Giffords received the same care there as any other gunshot victim. "We don't have time or luxury to ask for insurance cards or to know if they are a good guy or how they are going to pay," he said. "We deal with whoever comes in the door. We don't know if they are immigrants, if they are legal, illegal. We just treat them."

Still, some of those who are following Ms. Giffords's treatment, including her speedy transfer from Tucson to a top rehabilitation facility in Houston, can only wish their health plans were as responsive.

Monique Pomerleau, a mother of three from Northern California, suffered a traumatic brain injury in a traffic accident last February but has not yet undergone rehabilitation because her insurer, Health Net of California, said it lacked such services within the network. Her family has hired a lawyer to press the matter and recently received word that a 30-day rehabilitation program had been approved.

"We watched the congresswoman's care and we thought, How marvelous, but there are real people out there like Monique who don't get the same possibilities," said Lisa Kantor, a lawyer who specializes in challenging insurance companies and was hired by Ms. Pomerleau's father, Tom.

A spokesman for the insurer said federal privacy laws prevented it from commenting on individual patients' cases.

After a tragedy like the Tucson shooting, billing is a topic that appears almost unseemly to raise. But with health costs spiraling, it is one that was on the minds of some victims, not to mention their care providers.

"We have to recover our costs so that we can provide the service to others," said Craig Yale, vice president of corporate development for the Colorado-based Air Methods Corporation, which operates LifeNet helicopter service in Tucson, one of three private helicopter operators that were called to the shooting scene.

At University Medical Center, where the most seriously injured victims were treated, Misty Hansen, the hospital's chief financial officer, said she did not anticipate any problems recovering costs. "It is my expectation that the bills will be paid and the hospital will be appropriately compensated," she said.

Declining to discuss the case of individual patients, Ms. Hansen said 5 percent of patients were "self pay," which means they lack insurance and are billed personally.

Even those like Mr. Gardner, who lost a solid health insurance plan when he retired five years ago and now has a deductible in the $10,000 range, will most likely benefit from the plethora of special public and private victim funds to fill gaps in his coverage.

The Federal Bureau of Investigation's victim assistance fund cannot be used directly for medical care. But the money was used after the Tucson shooting to replace the eyeglasses of two injured victims and to fly relatives of victims to Tucson and the remains of one victim to her home state, said Kathryn Turman, director of the F.B.I.'s office for victim assistance.

The Safeway supermarket where Mr. Loughner is accused of spraying the crowd with bullets has begun a fund to aid victims, although company officials have not yet detailed how the money will be spent. A nonprofit victims rights group based in Tucson, Homicide Survivors, is similarly raising money on behalf of victims.

"My fund is too small to cover their medical bills," said Carol Gaxiola, who is director of the survivors' group. "But we'll be able to pitch in to cover other costs."

Besides the ambulance bill ($991.80 and $16.96 a mile for ground transport) and the hospital expenses, victims could face travel costs if they wish to follow the federal court proceedings against Mr. Loughner, especially if the trial is moved out of state.

There are also the costs of funeral expenses for the six people who died, as well as trauma counselors and loss of wages for the injured.

Mary Reed, who was shot three times that morning, said her insurer, through her husband's job at the University of Arizona, had been unusually accommodating since the shooting, approving medicines and services in 24 hours, significantly faster than usual.

One concern she has, though, is whether her 17-year-old daughter, who was at the scene but was not hit — Ms. Reed threw herself on her daughter to protect her — will qualify as a victim. Her husband and son were there as well, and they ran for cover. They are all undergoing counseling, but Ms. Reed is uncertain who will pick up the cost.

Kenneth Dorushka, 63, was struck in the arm by a bullet and is still awaiting word on how much of his costs will be covered by his insurer, United Healthcare. "It's hard to tell because we haven't gotten any bills yet, so you don't know how much they're going to cover or not," said Mr. Dorushka, adding that he had spent about $100 so far on co-payments and other medical costs.

Ron Barber, district director for Ms. Giffords's Congressional office who was hit twice in the shooting, said he expected to emerge from the shooting without any financial cost.

"I was thinking at first about what kind of deductible I'd have to pay, but then I learned that workers' compensation will cover everything," said Mr. Barber, who was working when he was shot.

Even as he recovers at home, Mr. Barber said he was trying to ensure that the shooting does not cause undue financial strain on those affected.

"It's obvious that those of us who were shot are victims, but there are others," he said. "I don't know anyone who didn't have medical coverage, but I'm interested in making sure no one continues to suffer from this."

http://www.nytimes.com/2011/02/04/us/04tucson.html?_r=1&nl=todaysheadlines&emc=tha23&pagewanted=all

Mourning a husband who has not yet passed - Life stories - Salon.com

I had a life, and now it's gone. No, I'm not writing from the grave. I'm alive, and even reasonably well, but I seem to have lost my life -- you know, the one I've been living for the last five or six decades.

Can anyone really prepare us for the future? Does it really make a difference if someone tells a young girl that one day she'll find blood oozing from her body, or a young boy that he'll wake up with his PJs mucky from a wet dream, or a pregnant woman that birthing her child will be an experience of breathtaking agony, or a middle-aged person that one day she'll notice that her pubic hair has thinned to near baldness, or that we'll all get old and, one way or another, lose our life, even while we're still live.

I lost mine six months ago when I could no longer care for my husband's advancing dementia and sent him into care. Well, maybe I really lost it a couple of years before that, but I didn't know it then. He was here, sleeping in the same bed, eating at the same table, sitting at the same desk -- a living, breathing presence, if not a fully present one. His mind wasn't working so well, but the familiar body was fine, and his heart still tried to be what he had been. Until one day, he couldn't and I couldn't, and we both lost our lives -- only he doesn't know it.

We were close, but I wasn't one of those women of my generation who was defined by her marriage, by her husband's life and status. I had an independent life -- friends, work, travel -- and so did he. A couple of decades ago, Christopher Lasch described the family as a "haven in a heartless world." For us, it was such a haven, but our lives in the "heartless world" enriched and enlivened that haven and were a central part of the strength of our marriage and our family.

Now, he's gone -- and so is the haven. And the world does indeed seem more heartless. Yes, I still have my work, which can distract me from whatever pain and anxieties may beset me at the moment. But notice the language: It "can distract me." Not enliven and enrich me, but distract me. Worse yet, I can't always do it, can't summon it up as easily as I used to before Hank's dementia took a core part of my life.

I tell myself that I need to give in to the feelings, but I'm not even sure what they are. A certain emptiness, maybe fear. But fear of what? I can't say truthfully that I didn't feel some relief when Hank was safely settled in his new home, some sense of freedom to reclaim my life when he didn't need my attention so insistently. I was (still am) grateful not to have to rush home, after an hour or two away, wondering anxiously what I'd find when I opened the door.

Nor can I say that living alone is without its compensations. I don't feel that yearning loneliness I hear others speak of; I enjoy the solitude of it much of the time; and when I get tired of it, I have friends and family to lift me out. But I'm aware that there's an empty space -- not outside, not in the bed or at the dining room table, but inside me -- the space that Hank occupied for nearly a half century and whose presence there I'd come to depend upon.

Over decades as a psychotherapist (never mind living life), I've dealt with people suffering loss, read the literature on mourning, thought about Elisabeth Kübler-Ross's famous treatise on the subject, and wrote a response to it that was both admiring and critical. I remind myself of what I know, tell myself I'm in mourning, to let the feelings flow until they work themselves out and I come to terms with the new reality of my life. But mourning a real death is quite different from mourning a living one. Whatever one believes about death -- it's a passage into a kinder world, it's entry into nothingness, or anything in between -- it's still an undeniable fact. Death is finite; life, as we know it, is over. Yes, I know, people awaken with visions of visitations, but eventually we come to accept death as an end to life. But when the brain dies and leaves the body intact, there is no end.

A few days ago, I talked with a seventy-something man who spoke tearfully about his wife's recent death and his awkward attempts at coping with his new life as a widower and single man. I left our conversation feeling sad for him -- and also envious. At least, I thought, he knows what's ahead; he knows the meaning of the word "widower." But I'm a widow with a husband who's alive; I'm a single woman with the responsibilities of a wife; I have a future, but I have no idea what it will be or how to get there; and if my husband lives much longer, we'll go broke.

There, I've said it, the thought we dare not speak: My life would be easier if Hank had died. My impulse is to take it back, to wipe the words off the page, to retreat from the thought, pretend I never had it, and hope you'll forget I said it. But it would be adding another lie to all those words written these days about the selfless caretakers who think nothing of sacrificing their lives to a loved person who exists but doesn't live.

More ...

http://www.salon.com/life/feature/2011/02/02/living_with_husband_with_dementia/index.html

How Aggressive Is Your Hospital? - NYTimes.com

One morning during my training, I noticed that the belly of a patient in the I.C.U. had grown rounder and tighter overnight. The patient had gone through a difficult liver transplant a day earlier and was bleeding, it seemed, into his abdomen. I was the newest member of the transplant team, but even so, I knew what had to be done right away: We had to take this man back to the operating room.

But I hesitated for a moment. Not because I was unsure of whom to call or how to go about scheduling an emergency operation at the hospital. I paused because I wanted to brace myself for what I imagined would be the reaction of the surgeon in charge.

Wiry and impeccable in his person, the head surgeon of the transplant team was considered one of the finest, and most fearless, in his field. Patients whom others would have considered too far gone or who would have normally just lingered and died made Lazarean recoveries under this doctor's meticulous care. But my guess was that he wouldn't be happy to hear about a complication. Particularly one serious enough to require an urgent return to the operating room.

I was wrong. The doctor barely flinched when I told him the news. Instead of the blast of angry expletives I'd feared, I was greeted with a calm and simple request: "Book him for a take-back to the operating room."

When I later relayed the morning's events to a friend, another surgeon-in-training who was ahead of me in the same program by a year, he laughed. "It's not a lack of complications that makes a great surgeon," he said. "It's being aggressive about taking care of those complications."

Over the last few years, no other aspect of the health care system has lost its luster as much as aggressive care. Once considered a point of pride and a source of strength, aggressive care has now been transformed into the whipping boy for health care reformers of all stripes. Armed with data that shows geographic variations in spending and the outcomes of patients who have recently died, politicians from both sides of the aisle, administration officials and even insurers have transformed the nuanced caveats of the research into a broad "more-is-worse" rallying cry. In this heated environment, restricting payments to hospitals whose total expenditures, total I.C.U. days and total hospital days exceed the norm has become a foregone conclusion so appealing that even usually wary consumer watchdog groups have enthusiastically added their own licks.

The notion that aggressive care leads to worse outcomes has been easy to buy into because it seems to offer an easy remedy for spiraling costs while playing into our worst fears about overzealous health care providers.

But in journals and in newspapers there have been a few brave voices issuing cautions. And most recently one group of researchers has gone so far as to say that at least for one group of patients, hospitals that offer aggressive care are better than those that don't.

Analyzing the insurance claims data of more than four million Medicare patients admitted for vascular, orthopedic or general surgery operations, researchers from the University of Pennsylvania in Philadelphia and the University of Illinois in Chicago found no difference in the rate of complications for aggressive and nonaggressive hospitals. But when they looked at all the patients who had complications and examined their outcomes, the researchers found that regardless of the urgency of their operations, those patients who were cared for at more aggressive hospitals were significantly more likely to survive their complications than those who had their operations at less aggressive hospitals.

"There is something that is going right at those more aggressive hospitals," said Dr. Jeffrey H. Silber, lead author and a professor of pediatrics and health care management at the University of Pennsylvania and the Children's Hospital of Philadelphia. "Aggressive hospitals don't increase your chance of complications, but they decrease your chance of dying if you get a complication because you survive those complications better."

Referred to as "failure to rescue," the inability of a hospital to help its patients survive surgical complications may be a more accurate measure of quality than traditional indicators. Mortality rates, for example, are as dependent on the general health of a hospital's patient population as they are on the quality of care delivered. "The best hospitals are going to attract the sickest and most complicated patients, and that will inevitably taint mortality rates," Dr. Silber noted.

While Dr. Silber and his co-investigators found that a hospital's failure or success in treating surgical complications correlated consistently with factors that also characterized intensity of care — general expenditures, intensive care unit use and the total days of hospitalization — they found that benefits of this more aggressive care extended well beyond the time of the operation. "It's not like these patients were filled up with antibiotics only to die later," Dr. Silber said.

Clearly, lowering health care costs and increasing quality and efficiency will require approaches far more complex than broad penalties for hospitals that offer more aggressive care. "Most people have been saying that the health care system is too aggressive, implying that aggressiveness is bad because people are being operated on unnecessarily or too much stuff is being done on them and can harm them," Dr. Silber said. "But we have to do detailed research that compares the effectiveness of different treatment approaches, because aggressiveness is not necessarily bad and may in fact be sometimes associated with better outcomes."

He added, "We need to rein in expenditures, but we need to do it very carefully."

http://www.nytimes.com/2011/02/03/health/views/03chen.html

$1 Million Prize to Inventor of a Tracker for A.L.S., Lou Gehrig’s Disease - NYTimes.com

Tracking the inexorable advance of amyotrophic lateral sclerosis, the deadly neuromuscular ailment better known as Lou Gehrig's disease or A.L.S., has long been an inexact science — a matter of monitoring weakness and fatigue, making crude measurements of the strength of various muscles.

This imprecision has hindered the search for drugs that could slow or block the disease's progress. But now a neurologist at Beth Israel Deaconess Medical Center here has won a $1 million prize — reportedly the largest ever for meeting a specific challenge in medical research — for developing a reliable way to quantify the small muscular changes that signal progressive deterioration.

The winner, Dr. Seward Rutkove, showed that his method could cut in half the cost of clinical trials to screen potential drugs for the disease, said Melanie Leitner, chief scientific officer of Prize4Life, the nonprofit group that created the competition.

The method does not provide a target in the body at which to aim drugs, nor will it help doctors better diagnose the disease. But Dr. Merit Cudkowicz, a professor of neurology at Massachusetts General Hospital and a chairwoman of the Northeast A.L.S. Consortium, compared Dr. Rutkove's discovery to the way magnetic resonance imaging expedited the development of drugs for multiple sclerosis.

"You can use this as a tool to screen drugs to see if they will affect survival," she said, but added, "The ultimate prize is finding a drug that works for A.L.S."

Dr. Rutkove, 46, who has been treating patients with neuromuscular disease for 16 years, took advantage of the way our muscle fibers change electrical currents. With a hand-held device hooked up to electrodes on the patient's skin, a doctor can send a painless electrical current into a given muscle, then measure the voltage that results.

As A.L.S. spreads, motor neurons die off, causing muscles to atrophy. The deteriorating muscles behave differently from healthy ones, resisting the current less. In studies of humans as well as rats, Dr. Rutkove showed that these variations were closely correlated with disease progression and length of survival.

"It's not like it's the fanciest technology," he said. "But I truly believe it will help people."

Dr. Rutkove was inspired to become a doctor when, as a child, he watched his grandfather have an epileptic seizure while fixing a bicycle.

Each year, doctors diagnose about 5,000 new cases of A.L.S. in the United States, according to the National Institutes of Health. Despite decades of clinical trials, the diagnosis remains a death sentence. It paralyzes and suffocates patients while their minds remain intact.

A few patients live for decades — the physicist Stephen Hawking is the best known — but most survive only three to five years after they first notice symptoms. And riluzole, the only A.L.S. drug approved by the Food and Drug Administration, costs about $10,000 a year and typically extends life by just a few more months.

The high cost of clinical trials limits drug companies' ability to test potential treatments. Researchers must recruit hundreds of patients and run trials that last as long as two years just to eliminate a drug from the running.

"One executive told us, 'For the cost of one A.L.S. drug I can develop two multiple sclerosis drugs, so obviously I go with M.S.,' " wrote Avi Kremer, the 35-year-old founder of Prize4Life.

Mr. Kremer, who has the disease himself (he was given the diagnosis in 2004, while a student at Harvard Business School), cannot speak or type. He made the remark during a Skype video chat from his apartment in Haifa, Israel, using a sensor that tracks his forehead as he lifts his eyebrows.

Dr. Doug Kerr, associate director of experimental neurology at Biogen Idec, which is working on an A.L.S. drug, said more sensitive testing methods "will allow us to test more drugs, more patients, and get an answer earlier." He called Dr. Rutkove's method "a powerful new part of the armament to study A.L.S."

Researchers say the $1 million prize, to be presented to Dr. Rutkove in June at a ceremony in New York, is the largest ever awarded for solving a prescribed challenge in medical research. (The Nobel and Lasker awards are given retrospectively, rather than in response to a challenge.)

This kind of prize is hardly new. In the 18th century, such a challenge spurred a solution to Newton's famous problem of how to determine longitude at sea. (A clockmaker, John Harrison, won the competition by inventing the marine chronometer.) And Charles Lindbergh's nonstop flight across the Atlantic was prompted by a competition, the $25,000 Orteig Prize.

Now these sorts of challenges are coming back into fashion. In December, Congress passed a law authorizing federal agencies to use prize competitions as a complement to grants and contracts.

Competitions can draw new eyes to old problems; among the Prize4Life contestants was a dermatologist from Buffalo who was driven to look for a skin-based biomarker for A.L.S. after he noticed that patients with the disease did not get bedsores.

The danger of a prize competition, on the other hand, is that "if you make the wrong choices, you might be leading people in the wrong direction, or to an R. & D. cul-de-sac," said Paul A. Wilson, a professor at the Mailman School of Public Health at Columbia University. Dr. Wilson has studied the potential of using a prize to encourage development of a tuberculosis diagnostic tool cheap and simple enough to use in rural Africa.

Dr. Rutkove said his work had been under way, and supported by public financing, before he heard of the prize. But he added that the challenge turned his focus toward reducing the cost of clinical trials and sped up his analysis.

The lure of a prize competition is that it can set off a race to achieve what is just beyond reach.

"It is not unlike President Kennedy succinctly challenging us to put a man on the Moon," said Dwayne Spradlin, chief executive of InnoCentive, a matchmaking company for problem solvers and seekers of solutions that helped promote the Prize4Life contest.

For A.L.S. patients like Mr. Kremer, of course, the biggest challenge remains: to survive.

http://www.nytimes.com/2011/02/08/health/08als.html?hpw

The Abaton - DMU Publications - Des Moines University

First produced in 2007, Abaton serves as a creative outlet for DMU students, faculty, alumni and other healthcare professionals. Abaton explores aspects of health care that often elude academic disciplines. It is these often unspoken sentiments of the provider and patient that form a bridge to an evidence-based profession. By allowing these stories to be heard, we give voice to the most fundamental aspect of medicine - humanism.

http://www.dmu.edu/abaton/

The lure of MedLit - National Post

Last year, The Abaton, a Des Moines University literary and arts journals devoted to the healthcare professions, inaugurated a prize for medically themed writing. The prize is named for Richard Selzer, a now-retired surgeon who in midlife embarked on a parallel, successful literary career.

The announcement caught my eye because I got hooked on medical literature for lay people in the 1970s through Dr. Selzer's exquisite writing: first his non-fiction about a surgeon's life -- in particular, Mortal Lessons: Notes on the Art of Surgery, and Taking the World in for Repairs -- and then his short fiction.

His stories never stray far from the lives and quandaries of doctors. In one, the protagonist, a surgeon, is making love to a woman he has no interest in beyond transient sex. Exploring the young woman's body for erotic pleasure, his sensitive fingers find a minuscule, but (to his practiced hands) suspicious, lump in her breast. He is conflicted. The surgeon's knight-like urge to protect vulnerable prey from a marauding disease wrestles with his selfish human wish to escape further involvement with a woman in whom he has no emotional investment. The not-so-subtle message: The good doctor is the better man.

The market for eloquent, moving MedLit is already large, and demand for more will doubtless increase in this touchy-feely culture of ours, as an aging population's health wanes and urgency in pushing back medical frontiers waxes. Doctors who write beautifully are everywhere today, it seems to me (Google "doctors, writers," and you'll agree). When you consider that in most cases the writing is accomplished in patches of time stolen from a particularly demanding profession, the literary polish and sophistication on display is astonishing.

At the apex of the genre, Oliver Sacks has achieved worldwide fame for his profoundly empathetic sojourns into the interior worlds of the neurologically impaired. He continues to work as a neurologist, but mainly, one suspects, to provide material for his greater passion, writing. Prize-winning novelist Ethan Canin took a degree in English literature before attending Harvard Medical School, and after publishing his third novel, quit medicine to teach writing at the Iowa Writers Workshop.

Canada has produced gifted doctor-writers, such as Vincent Lam, a Toronto emergency-room doctor who won the 2006 Scotiabank Giller prize for his book, Bloodletting and Miraculous Cures; and psychiatrist Norman Doidge, who hit pay dirt with his 2008 book for lay people on neuroplasticity, The Brain that Changes Itself.

Both artists and doctors are drawn to the existential mysteries of life, so it is no surprise that there are more doctor-writers than, say, dentists or accountants. Doctor-writers are a demographically diverse group, but they have in common constant exposure to human nakedness in all its manifestations: They see people at the beginning and end of life, in their darkest and their most hopeful hours, at their most craven and at their most heroic.

Writers who have studied medicine are not an exclusively modern phenomenon. But in the past, most writers with medical degrees tended to write about life, not medicine. Rabelais, Somerset Maugham, Oliver Wendell Holmes, Arthur Conan Doyle, William Carlos Williams and Anton Chekhov used their superior powers of observation gleaned from medical training to enhance their literary powers, not as primary creative fodder. As Chekhov put it: "Medicine is my lawful wife, and literature is my mistress."

Medical writing per se is popular today because in our secular culture, science and an obsession with physical health have taken the place of God and concern for the soul. It was only fairly recently in human history, after all, that disease and suffering (relatively) submitted to human control. In other words, it wasn't until medicine became more about healing and hope than pain and fear that doctors became heroes rather than placebo-potion mongers and butchers, and medical professionals could exploit their domain aesthetically with pride.

Poet John Keats's is surely the saddest writer-doctor story. Keats spent six years of his cruelly short life -- he died at the age of 25 in 1821 -- studying medicine, but never practising it. He did make a single, tragically correct diagnosis, though. One day, weak and exhausted, driven to

bed, he noticed the stain on his sheets from a fit of coughing, and announced to a friend: "I know the colour of that [arterial] blood ... that drop of blood is my death-warrant. I must die."

No physician can heal himself, ultimately. But for gifted doctor-writers, at least their words are immortal, a forever-healing balm to the world's existential angst.

http://www.nationalpost.com/todays-paper/lure+MedLit/4207360/story.html

A Concierge Medical Practice Without the Concierge Fee - NYTimes.com

When Jennifer Contreras went to see her new physician, she had hardly arrived in the waiting room before she was called in — by the doctor herself.

That was a pleasant surprise, but it was just the beginning. Ms. Contreras, 40, was prepared for a short visit, but the physician seemed to have all the time in the world. Then came another surprise.

After noting Ms. Contreras's high blood pressure, the doctor told her to take her blood pressure daily using a home monitor and send her an e-mail with each result.

"We did all the careful fine-tuning over e-mail until we got just the right dosage of blood pressure medication," said Ms. Contreras, an associate dean at the University of San Francisco. "It wasn't just 'Oh, take this medication and I'll see you later.' It was 'Let's make sure we get this right.' "

Ms. Contreras is a patient at One Medical Group, a new model for primary care that aims to set a nationwide example. With 31 physicians in San Francisco and New York, it offers most of the same services provided by personalized "concierge" medical practices, but at a much lower price: $150 to $200 a year.

One Medical Group doctors see at most 16 patients a day; the nationwide average for primary-care physicians is 25. They welcome e-mail communication with patients, for no extra charge. Same-day appointments are routine. And unlike most concierge practices, One Medical accepts a variety of insurance plans, including Medicare.

The group's founder and guiding spirit is Dr. Tom X. Lee, a physician and entrepreneur best known as a co-founder of Epocrates, the online medical reference program popular among physicians.

Dr. Lee, 42, trained as a general internist at the Harvard-affiliated Brigham and Women's Hospital in Boston and quickly grew disillusioned. "As I went through my training," he said, "I saw a growing chasm between the ideals of medicine and what's actually practiced."

The time and financial pressures of primary-care medicine are alienating many young physicians just out of medical school. By some estimates, there will be a shortage of 45,000 primary-care physicians in the next 10 years as demand grows, and Dr. J. Fred Ralston Jr., president of the American College of Physicians, said that "those primary-care physicians already in practice are under such stress that they are looking for an exit strategy."

In 2005, with Epocrates already a success, Dr. Lee set out to reverse that trend. He began One Medical Group as a solo practice in a small office in San Francisco.

Two years later, Dr. Lee, who has a master's in business administration from Stanford, approached venture capitalists to help him expand; the Silicon Valley firm Benchmark Capital invested several million dollars, its first investment in health care services.

Some experts say it remains to be seen whether Dr. Lee's experiment is sustainable — in particular, whether he can continue to recruit physicians and deliver the same level of care without relying on new venture capital.

Nor are they sure the One Medical model can be replicated on a broad scale.

"I envision a small number of organizations that will be successful using models like this, and in general I think it's great," said Dr. Ashish Jha, an associate professor of health policy at the Harvard School of Public Health. "But whether such models can scale to cover a large swath of the population that is in greater need of health care is unclear."

Still, the wiry and intense Dr. Lee remains bent on reversing what he calls "bizarre habits that have been ingrained" in the world of primary care.

When he started One Medical Group, he said, "it was very clear that health care organizations were lacking both the service hospitality mind-set of hotels and the operational efficiency you'd see in manufacturing industries."

Indeed, a One Medical waiting room could be mistaken for a lobby at a boutique hotel or day spa. Patients are greeted at a large, open reception desk, and phones have been relegated to an office in the back.

"The people who greet you don't seem frazzled," said Bruce Dunlevie, a general partner at Benchmark Capital, "and there aren't four people sneezing on you."

One Medical physicians say their jobs are like what they envisioned when they first went into the field — before they got their first job in a typical family practice, with its long waits and blizzards of paperwork.

Dr. Andrew Diamond, a One Medical physician in San Francisco, says he now sees 16 patients a day, compared with 24 in his previous practice.

"The most important thing you can do with that amount of time is build a rapport and make people feel at ease," he said. "It's when people are at ease that they can give you get the critical information you need to make a diagnosis."

In his old job, he went on, "when I'd finally see the patient, I would get this very frustrated vibe, which completely got in the way of caring for them."

Dr. Lee's practice is not the first to offer more personalized primary care. Dr. Richard Baron, a former chairman of the American Board of Internal Medicine, runs Greenhouse Internists in Philadelphia, a practice with seven physicians that offers much of what One Medical offers, but without the fee.

And in Portland, Ore., GreenField Health charges a sliding fee based on age (from $195 to $695) that is far below the typical concierge rate, which ranges from $1,000 to $5,000 a year. GreenField's physicians split their time evenly between office visits and consultations by e-mail or telephone.

But One Medical is the first to try to carry out such a model on a large scale. It now has several thousand patients and a growth rate of 50 percent a year, fueled largely by word of mouth. Dr. Lee said he planned to open a third office in Manhattan next month and expand to a third large city next year.

Dr. Baron said One Medical had found "a sweet spot for $200 a year, because there has been a failure on the part of the insurance system and the primary-care community to meet this need for patients."

Dr. Jha, at Harvard, wonders just how large the sweet spot is. "One Medical could potentially scale by getting more and more younger people who are relatively healthy," he said. "But it gets much harder when you have 85-year-olds with multiple medical problems."

Dr. Lee remains confident that his approach is broadly applicable. "We've designed the model so that on average we'll do fine, no matter how often people come in," he said. "Independent of the people we see, our cost structure is lower, and because it's lower we can care for any demographic."

To keep overhead low, he has automated wherever he can. Where most primary-care offices have at least four administrative employees per physician, Dr. Lee has cut that ratio in half. Using the One Medical Web site or a newiPhone application, patients can schedule appointments and refill prescriptions, and, in limited cases, originate new ones.

Tests can be unnecessary and expensive, and Dr. Philip Baird, who works at One Medical Group in New York, says he orders fewer than he used to. A woman in her 40s came in recently with a terrible headache, unlike any she had ever had. After examining her, Dr. Baird said, he doubted it was serious, but was prepared to order a CT scan to rule out a tumor.

As the conversation continued, the woman told him her mother-in-law had just been given a diagnosis of brain cancer. "She admitted she was just really scared," he said. "She saw I was taking the time, and taking her seriously."

He did not order the scan, and the patient is fine.

Mark Hurst, 38, who runs a consulting firm in Manhattan, joined One Medical as a patient after months of having trouble reaching his longtime physician. At One Medical, someone answers the phone right away — even at lunchtime. And no one is put on hold.

"I cannot go back to the kind of practice I was at before, that looked, felt, sounded and smelled so different," he said.

Mr. Hurst never told his doctor there that he was leaving, he said: "I wasn't able to get through to him."

http://www.nytimes.com/2011/02/01/health/01medical.html?src=me&ref=general