Saturday, May 7, 2011

Dr. Richard Olney in last stages, study of disease | SFGate

Dr. Richard Olney is racing to finish what is almost certain to be his last research paper.

The 63-year-old UCSF neurologist is considered one of the country's top clinical specialists for amyotrophic lateral sclerosis, or ALS, popularly known as Lou Gehrig's disease. ALS is also the reason Olney is in a hurry to finish his paper: He was diagnosed with ALS in 2004, and after a long period of relative stability, the disease appears to be rapidly winning out over the doctor.

Olney has almost no muscle function left.

"He's at the end stages now, certainly," said Dr. Catherine Lomen-Hoerth, once Olney's medical trainee, now his doctor. "I'm hopeful he may have at least a few months."

Olney hopes the disease he is studying will spare him at least long enough to finish his research on it. His son, Nicholas, 33, is assisting with the final write-up.

Their goal is to show how certain clinical readings of the muscles and nerves, recorded over a three-month span in the early stages of ALS, might help identify which patients will lose all muscle control quickly and which might have years before they succumb. That kind of information would be invaluable for patients and their families. It also could point researchers toward new genetic clues and treatment strategies for at least some of the many ALS subtypes.

Results are based on only 26 cases. The value of the findings will take time to determine. The study author will have to leave the follow-up to others.

Breathing problems sent Olney to the UCSF emergency room in March, followed by a few days in the intensive care unit. He has lost virtually all muscle control. He communicates by moving his pupils. Sweeping his gaze over a computer tablet, he selects letters and key words one by one, blinking to record each choice.

The computer reads out his sentences in his own voice, which he recorded for this purpose, back when he was still able to speak. As one of the country's top ALS specialists, Olney knew, right from the start, what he was in for.

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Thursday, May 5, 2011

Doctor and Patient: In Search of a Better MCAT -

Recently the college-age daughter of a friend talked to me about her dream of becoming a doctor. She was doing well as a psychology major and in her pre-medical courses, was working as a research assistant for a pediatrician at a nearby medical school and volunteered on the cancer ward at a children's hospital.

I was impressed.

But her enthusiasm dipped sharply when she told me she was preparing for the MCATs, the Medical College Admission Test, the required standardized test that measures mastery of the pre-medical curriculum. She was putting all her extracurricular work on hold so she could focus on reviewing biology, physics, chemistry and organic chemistry for the exam. "Does my ability to memorize the Krebs cycle and Bernoulli's equation really have anything to do with what kind of doctor I'll be?" she asked.

The answer, it turns out, is yes — and no.

The first MCAT, then referred to as the Scholastic Aptitude Test for Medical Schools, was administered in 1928 and represented an effort to address the significant medical school dropout rates of the time. Up until that point, medical school applicants had been evaluated, and accepted, on the basis of stray bits of biographical information, random letters of endorsement, a few prior grades or the existence of a high school diploma. As many as half of those accepted eventually quit, resulting in huge losses of time, energy, educational resources and money. But thanks in part to the MCAT, by the mid-1940s the medical school attrition rate had plummeted to less than 10 percent, even as the standardized exam was becoming a much-maligned rite of passage for aspiring young doctors.

Over the years, the MCAT has gone through four major revisions and has only strengthened its ability to predict success in medical school, particularly when evaluated in combination with grades. Each year more than 70,000 students take the exam, vying for a little more than 19,500 medical school slots. These days, fewer than 4 percent of those finally accepted drop out.

But the MCAT has had one major failing in its otherwise brilliant performance: It has been unable to consistently predict personal and professional characteristics. As early as 1946, medical educators were trying to design the MCAT in a way that might tease out such information, but they, and those who followed, were unable to succeed.

Now the MCAT is about to undergo its fifth revision, the first in nearly 25 years. Last month, the Association of American Medical Colleges, the national organization that administers the MCAT, released the preliminary recommendations of a 22-member advisory committee that has been studying the issue for the last three years. They recommend, among other things, lengthening the four-and-a-half hour exam by 90 minutes and adding questions on disciplines like sociology and psychology. The new exam would also test analytical and reasoning skills in areas like ethics, philosophy and cross-cultural studies, which could include questions about how someone living in a particular demographic situation, for example, might perceive and interact with others.

Despite what some view as a long overdue re-examination of this linchpin of medical school admissions, many medical educators, including members of the advisory committee, remain cautious about tampering with a test that has proved successful so far.

"It's like trying to improve a Honda," said Dr. Ronald D. Franks, vice chairman of the committee and vice president of health sciences at the University of South Alabama College of Medicine in Mobile. "When you've got something that's working extremely well, you can make improvements, but you've got to be mindful of the services it has rendered."

Those services can be gargantuan. Jefferson Medical College in Philadelphia, for example, receives almost 10,000 applications each year and must whittle those numbers down to 800 for interviews for the 260 available slots in each class. In combination with grades, the MCAT can help admissions officers eliminate a quarter of the applications.

"But we and other medical schools have so many great applications from the standpoint of just numbers that we usually also need to go through other parts of the application as well," said Dr. Clara A. Callahan, dean of student affairs and admissions at Jefferson and the lead author of one of the largest longitudinal studies on the predictive validity of the MCAT. "You want to make sure someone isn't just saying that he or she wants to help people."

It's likely that Dr. Callahan and other medical school admissions officers will have to continue to look beyond the MCAT to learn more about their applicants' personal qualities. The science of personality testing has advanced tremendously over the last 25 years, but the committee felt it was still unclear how accurately a test could predict traits like integrity, altruism and the ability to collaborate. Some members were uncomfortable, too, with the long-term implications. "Will we end up labeling someone forever with a 9.2 for their personality?" Dr. Franks asked.

Only time will tell whether this newest version succeeds where earlier ones have not. But one thing is certain: Taking the MCAT is likely to remain a rite of passage for doctors-to-be for years to come.

"The reality is that we doctors are taking standardized tests – in-service exams, board exams, recertification exams – all our life," Dr. Callahan said. "It's something people have to master in medical school and beyond, so it's nice to be able to accurately predict at the outset how someone will do with them in medical school and beyond."

The MCAT advisory committee is continuing to solicit opinions through its Web site until February. The new exam will be administered beginning in 2015.

The way to a man's heart is through his stomach - Roger Ebert's Journal

As an aficionado of industrial design, I find the G-tube admirable. A small tunnel is opened above the belly button and leads directly into the stomach. Food passes through the tube. I dine. No fuss, no muss.
In earlier years I would have found this idea horrifying. Not so much now that I need it to stay alive. Invention is the child of necessity. In this invention, common sense was more important than genius. The Egyptians first hit upon the notion of tubes for feeding people centuries ago.

I learn on this site "the ancient Egyptians used reeds and animal bladders to supply patients with a mix of wine, chicken broth and raw eggs." Indeed, "after President James Garfield was shot in 1881, he stayed alive for 79 days on a mix of beef broth and whiskey."

I am one of about 350,000 Americans with a feeding tube. You probably know one of us. Six times a day, a can of liquid food is dripped into me from a plastic bag on a pole. It takes maybe 15 minutes. I continue to write, read, or watch TV. My care-giver Millie Salmon performs the process so easily that sometimes, half an hour later, Chaz will ask me if I've eaten and I'm honesty unable to say.

The sight of me eating in this way is presumed to be offensive. At film festivals Chaz or Millie will squirrel me away in a private place. On airplanes I go into the toilet and use a syringe to feed myself. In a dispassionate analytical sense, a discreet G-tube is more subtle than someone chomping their way down on an ear of corn or sliding a doubled-up pizza wedge in sideways, but believe me, it isn't nearly as much fun.

Chaz and Millie buy raw vegetables and steam them a little and put them into a juicer. They must be liquid enough to run through the tube. Millie loves to recite long lists of the veggies in my supplementary mix, but they're all the same to me. She goes berserk at the produce counter. There's a web site online encouraging the use of "live food," and I'm sure it's good for my health. But the bottom line remains the canned stuff. I've lived on it in one version or another since the summer of 2006, and my doctor has a patient who has prospered for 30 years this way.

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Derek K. Miller passed away May 3, 2011, age 41, of complications from stage 4 metastatic colorectal cancer

I'm Derek K. Miller, and I have worked as a writer and editor since the 1980s, specializing in technical and scientific subjects. I've been online since 1983, and have also been a drummer, guitarist, singer, recording artist, and photographer. I started this website in spring 1997, and it became in 2000. I live in Burnaby, British Columbia with my wife and two daughters.

I have a marine biology degree and a writing diploma from the University of British Columbia. I've worked at B.C.'s two leading universities, as a park naturalist, in magazine advertising, and for software and hardware companies. My writing has appeared in Macworld, Vancouver, and LINK magazines, the TidBITS online newsletter, and the Vancouver Sun newspaper, among other publications. I have also appeared on radio and television across Canada, and at several conferences, as an expert on various technical topics.

Before finding out that I had stage 4 metastatic colorectal cancerin 2007, I ran the Penmachine Media Company and worked forNavarik, a company that makes web-based software for the marine shipping industry. I have also been the co-host of theInside Home Recording podcast since 2006.

Late in 2010, I discovered that my cancer is terminal. I expect it will probably kill me sometime in 2011 or early 2012.


September 4, 2010

Only once in the past three and a half years, since I found out I had metastatic colorectal cancer that had spread to my lungs, have any of my doctors said anything about how long I might live. At the beginning, my oncologist Dr. Kennecke noted that the median survival for patients with my condition is two years after diagnosis.

That was, I repeat, three and a half years ago. You might think that he predicted I had about two years to live, and was simply (and happily) wrong. But that's not even what he was saying. Because he used the word median, he meant that two years after diagnosis, half of patients with metastatic colon cancer are still alive. Therefore, in 2007, my chances of living more than two years were about 50% (assuming I was a typical patient—more on that below).

And he was right about that, since I'm still here. However, if I'd died within two years instead, he'd still have been right, since I would have been in the other 50%. You can see why doctors like using medians for survival prognoses!


May 4, 2011

Here it is. I'm dead, and this is my last post to my blog. In advance, I asked that once my body finally shut down from the punishments of my cancer, then my family and friends publish this prepared message I wrote—the first part of the process of turning this from an active website to an archive.

If you knew me at all in real life, you probably heard the news already from another source, but however you found out, consider this a confirmation: I was born on June 30, 1969 in Vancouver, Canada, and I died in Burnaby on May 3, 2011, age 41, of complications from stage 4 metastatic colorectal cancer. We all knew this was coming.

That includes my family and friends, and my parents Hilkka and Juergen Karl. My daughters Lauren, age 11, and Marina, who's 13, have known as much as we could tell them since I first found I had cancer. It's become part of their lives, alas.

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Derek K. Miller’s Final Post :

Derek K. Miller was an incredible man. He blogged his way through stage 4 metastic colorectal cancer. He coined the term "digital executor" in 2008. He was a father, husband, musician, podcaster, photographer, writer and inquisitive soul.

He blogged for more than 10 years, leaving behind a gift for us all. His children, Lauren (11) and Marina (13), will have an archive of their father's insights and feelings about the world as a treasured part of their family history.

Derek's father, Karl, was quoted today in the Vancouver Province newspaper, "He was proud of his blog, and now it is his legacy. It connects him to the world, and to his family, forever. We were there for him, but Derek was comfortable sharing his thoughts with a worldwide community."

For everyone, but particularly those who are facing death as a result of cancer or other means, his blog shows how he extracted every last drop of joy that he could out of his life before the end. From his final post:

The world, indeed the whole universe, is a beautiful, astonishing, wondrous place. There is always more to find out. I don't look back and regret anything, and I hope my family can find a way to do the same.

More doctors prescribing placebos to unwitting patients

The practice is discouraged by major medical groups, considered unethical by many doctors and with uncertain benefit, but one in five Canadian physicians prescribes or hands out some kind of placebo to their often-unknowing patients, a new study suggests.

The seemingly widespread use of sugar pills and other inactive treatments identified by the survey highlights a mounting debate over the issue, with some experts arguing that placebos should be accepted as a legitimate — and side-effect-free — alternative to drugs.

Others say giving patients harmless but chemically inert treatments — especially when disguised as something else — cannot be justified until there is better-quality research proving they actually help.

Many in the profession already seem convinced. Most of the 600 MDs across Canada surveyed by Amir Raz, a McGill University psychiatry professor, and colleagues indicated that they thought placebos do, in fact, have some therapeutic advantage, a paper just published in the Canadian Journal of Psychiatry indicates.

"Physicians really know and have known for a very long time that placebos can be clinically effective," said Prof. Raz in an interview. "But at the same time most physicians realize that giving placebos is sort of professional bad form.... At medical schools, they teach absolutely nothing about this."

They should get more attention because health care relies too much now on pharmaceutical products that often do harm as well as good, argues Dr. Ted Kaptchuk, a Harvard University medical professor who has studied the topic extensively. Yet suggesting that inactive substances can make people feel better still rankles some in the medical profession, he said.

"Doctors went to medical school to give out pills, to do procedures, to do surgeries," said Dr. Kaptchuk. "Telling them to actually show their colours -- to admit that a lot of what they do is actually what a shaman does -- is very disconcerting."

Placebos emerged as a major issue in modern medicine in the 1940s with drug trials that tested medicines by comparing their effects to those of similar-looking fake pills or injections.

Such testing is still the norm and drugs with no more impact than a placebo are generally considered worthless, fuelling a negative perception of the inactive treatments, notes Franklin Miller of the U.S. National Institutes of Health in a recent report.

In 2006, the influential American Medical Association issued an ethics policy that specifically barred doctors from giving patients placebos while deceiving them about the true nature of the treatment.

McGill's Prof. Raz and his team conducted a survey of specialists throughout Canada, receiving responses from 606 doctors, 257 of them psychiatrists.

About 20% of both psychiatrists and non-psychiatrists said they had used placebos in treating patients. The specific treatments they confirmed using included actual placebo tablets, sugar pills and saline injections. Some -- including 35% of psychiatrists -- said they also used "sub-therapeutic" doses of real drugs, amounts too small to have any chemical effect on the patient.

Of those who said they might give patients a placebo, just 17% said they would reveal the true nature of the therapy, the others indicating they would use some kind of deception, the researchers wrote.

Even some experts who urge caution in the area acknowledge there is evidence placebos work. Administering them without telling patients they are placebos is unethical, however, and there need to be rigorous, randomized trials -- the gold standard in medical research -- proving their worth before the practice becomes routine, Dr. Miller of the NIH Bioethics Clinical Center in the States concluded in a 2009 paper.

Prof. Raz argues, however, that the evidence is all but incontrovertible that placebos do make some patients better, and it is too late to bar the practice or turn blind eye to it.

In an intriguing display of the dummy-pill effect, he issues medical students in one of his classes either blue or red tablets, and tells them they are placebos. Students then examine each other. Those taking the red pills tend to have higher blood pressure and heart rates, those taking the blue, an opposite, calming effect.

Dr. Kaptchuk says there is evidence that placebos actually trigger chemical changes in the brain, and are especially useful in treating conditions, from back pain to depression and anxiety, that involve patients' subjective feelings.

The practice harnesses the intangible "ritual of medicine -- the white coat, the stethoscope, the diploma," he said.

And contrary to widespread belief, it is not necessary to convince patients they are actually taking a real drug for placebos to work, he said. A trial he and colleagues published a few months ago found that irritable-bowel syndrome patients who took a placebo, and were told what it was and the effect placebos can have, improved significantly compared to those getting no treatment.

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Wednesday, May 4, 2011

Drug theft goes big - FORTUNE

A few years ago a security expert visited Eli Lilly's vast warehouse in Enfield, Conn., one of the pharmaceutical giant's three U.S. distribution sites, where hundreds of millions of dollars' worth of prescription drugs are stored. The expert was surprised to see the facility lacked a perimeter fence. There wasn't even a $10-an-hour guard stationed outside. But Lilly officials assured the consultant there was nothing to be concerned about. Recalls the expert: "They were very proud to show me. 'We have four-foot-thick walls.'"

He then looked up at the ceiling. "I was like, 'What's up there?'" he says. "There" turned out to be a standard tar roof with no extra reinforcement or fortification. Sometime later, Lilly's security team suggested changes to protect the Enfield warehouse, including installing a fence. But those proposals went unheeded, according to two security experts in a position to know. Bob Reilley, Lilly's chief security officer, says the company had a response in the works. But to listen to him today, it didn't seem that urgent. "That warehouse had been there about 20 years in a nice industrial area," Reilley says, "and was part of the community as well."

Sure enough, Lilly's (LLY) Enfield warehouse became the site of a headline-making heist -- the largest pharmaceuticals theft in history. The burglars struck in the early-morning hours of Easter Sunday last year, as a heavy rain and windstorm knocked down trees and power lines, occupying local police.

Security was so lax that they pulled their tractor-trailer directly up to the loading dock and parked there for hours. Security cameras recorded the image of the truck, but no one was monitoring the cameras. The burglars drilled a hole in the tar roof and slid down ropes into the warehouse. Once inside, they disabled an alarm panel with a sledgehammer.

Another alarm went off at some point during the burglary, say those familiar with the break-in. Staff at ADT, which monitored the system, called the first name listed on Lilly's contact sheet and left a message. By the time a Lilly employee responded, the burglars were gone, along with $75 million worth of cancer, psychiatric, and blood-thinning drugs.

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WebMD More Popular Than Social Media as Health Care Resource - iHealthBeat

People who seek health advice online trust health news websites such as WebMD more than user-generated content on sites such as Facebook, Twitter and Wikipedia, according to a survey conducted by Makovsky & Company and Kelton Research, Healthcare IT News reports.

For the nationally representative survey, researchers polled 1,111 consumers ages 18 and older in March.

Researchers found that 68% of respondents said they trust information on health news sites, while 54% said they trust information from Wikipedia, social networking sites and blogs.
In addition, 26% of respondents said Facebook sites created by other users are the least trusted health resource, and 6% said Facebook sites created by patient groups or communities are the least trusted.

Gil Bashe -- executive vice president and health practice leader at Makovsky -- said, "Peer-to-peer communication establishes an emotional, 'tell me your story' connection; yet, when it comes to health care information, patients still trust the experts."

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Sunday, May 1, 2011

Doctors Opt for Retainer Practices to Serve Rich -

Five years ago, Steven L. Glazer, an internal medicine doctor in Norwalk, Conn., told his thousand patients that he would no longer be able to care for them because he was going to focus on only a dozen, wealthy patients who could pay his annual fee.

With that he entered the world of concierge medicine, a growing subset of medicine where patients pay doctors anywhere from $1,500 to $25,000 a year to receive personalized attention and care. (Dr. Glazer said he was paid toward the top of this range.) In most cases, patients presume that in an emergency their concierge doctor will push them to the front of the line to see a top specialist.

Even as more people are struggling to pay medical bills and being rushed through office visits with their doctors, an elite group with money has another option: exclusive medical care, around the clock and anywhere in the world, including on a yacht or private plane.

One of Dr. Glazer's clients, for instance, has had his yacht outfitted with a system from Guardian 24/7, a company in Leesburg, Va., founded by former White House doctors that advertises itself as offering "medical protection previously available only to the president of the United States." The company's "ready room" will allow a doctor trained in the system to perform basic medical care remotely if something should go wrong while the patient is on the high seas.

"There is very little that we can't do with the triage room on their yacht," he said.

The cost of Guardian 24/7's services ranges from $6,000 to $12,000 a month, plus an additional $700,000 for one of the company's top-of-the-line "ready rooms" installed in a client's home, yacht or airplane, said Jonathan Frye, chief executive.

While it is difficult to determine how many people are served by this more personalized care, the number of doctors who have moved to this new model has risen fivefold in the last five years. And that raises questions about medical care in America. For those who can afford it, what do they get for their money? Is it worth it? And for the rest of us, who cannot afford this level of care, is it fair and ethical for doctors to be doing this? Or is concierge care contributing to the growing gulf between the wealthy and everyone else?

COSTS AND BENEFITS Concierge medical care is nothing new. In places like Florida, with a high concentration of Medicare patients, some upper-middle-class retirees pay extra fees so they can see a doctor when they need to.

MDVIP, which has 450 concierge doctors in 34 states, charges patients $1,500 to $1,800 a year. Their doctors are each limited to 600 patients, whereas, the company says, most primary care physicians serve at least 2,000 patients. It says appointments with doctors "start on time and last as long as necessary" and can usually be made the same day or the next one. The company's fee is for the extended care and comprehensive annual physical and wellness plan, but its doctors still bill the patient's insurance company for procedures.

The international, around-the-clock programs take concierge medicine to a different level. Their primary goal is to offer an extra level of oversight to make sure that participants are getting the proper level of care whenever they need it.

Dr. Miles J. Varn, chief medical officer at PinnacleCare Private Health Advisory, which charges annual fees of $1,500 to $25,000, said the starting point for all patients was a complete review of all health records with an emphasis on finding gaps in care.

"We have physicians who look for omissions of care or deviations from standard care," Dr. Varn said. "That record travels with them around the world."

In promoting themselves, the plans say their doctors know each patient's health conditions intimately and are able to discuss it with another doctor anywhere in the world.

Dr. Daniel Carlin, founder and chief executive of World Clinic, which charges $20,000 to $75,000 a year on average, said he recently had to intervene and stop a patient from getting the wrong procedure. The client was at a hospital in Florida where the doctors wanted to do bypass surgery for a blocked vessel. Dr. Carlin said the proper care was putting in a stent, and the difference was months of pain and recovery for the patient and tens of thousands of dollars for the hospital.

"You're holding up a shield and saying, 'We'll weigh everything before we move forward,' " Dr. Carlin said. "With the primary care guy gone, the average patient isn't being treated."

IS IT WORTH IT? Despite reports about the decline in the number of family physicians and the increase in the hours the remaining ones work, many wealthy people are reluctant to pay extra for health care.

Dr. Varn said more than half of the company's members were in a program that costs $10,000 a year, or about $800 a month — on top of whatever private insurance members may have. "How much do you pay to have your lawn mowed every year?" he asked. "Why wouldn't you pay to get the same advice on your health? People think having great insurance means having great health care and that's not the case."

Beyond personalized primary care, the main selling point for high-end plans is access to top specialists when needed. Yet it is difficult to determine just how much shorter the wait is for the specialist.

"We regularly would engage with our clients to facilitate and get them to the appropriate specialist," said Dr. Sean O'Mara, founder and president of Guardian 24/7 and a former Army doctor who was on call when the president or top Cabinet members traveled to South Korea. "We have an extensive Rolodex of medical specialists that we're familiar with."

Mark Murrison, president of marketing and innovation at MDVIP, said: "When the doctor makes that personal call to the specialist, that has a meaningful impact on getting that patient into see the physician quicker than they would be able to on their own."

Beyond that, these companies argue that they help members locate the right doctor, something they would have more trouble doing on their own.

FAIRNESS DEBATE Unlike professions where money is a primary goal, doctors are obligated by their ethical code to provide care for people in need. This becomes an issue when their practices are confined to the wealthy, and it elicits complaints that concierge medicine caters to the elite.

"This isn't fair," said Dr. Carlin, who worked as refugee camp doctor and in an emergency room before starting World Clinic. "I'm a small solution to a vast health care problem."

The American Medical Association's policy on concierge care — or what it calls retainer practices — states that it is part of the "pluralism in the delivery and financing of health care." But the A.M.A. also says these retainer practices "raise ethical concerns that warrant careful attention, particularly if retainer practices become so widespread as to threaten access to care."

But some of the doctors involved in these practices argue that some variation will eventually be available to people who are not wealthy. "The solutions we're developing right now are very expensive ones, but they're going to migrate down to even the poorest people in the world," Dr. O'Mara said.

He said one of Guardian 24/7's members had underwritten a project to make a ready room mobile and put it in a free medical clinic in Northern Virginia. The company hopes that top specialists can be available remotely at the clinic.

Others were less sanguine about the shift to concierge medicine. "My response has been helpful to me and my patients, but it hasn't addressed in any meaningful way the larger policy issue," Dr. Glazer said.

And that is the bigger issue: whether these services for the wealthy can be translated to make the medical system better and more efficient.

A Doctor’s Focus Is the Minds of the Elderly -

MIAMI — The Merry Widows, as they call themselves, were blinged out, Florida-style, to celebrate Elayne Weisburd's 79th birthday at a sprawling community for seniors. Mylar balloons levitated above their table, and sparklers twinkled from a cake.

The guest of honor and her two friends were beaming when Dr. Marc E. Agronin, a geriatric psychiatrist and the director of mental health, arrived with a hug for everyone long after what would be normal office hours.

The Merry Widows moved to the community when their husbands developed Alzheimer's disease and looked to Dr. Agronin to prepare them for what lay ahead. But while treating their husbands' disease, he became their psychiatrist, too. He urged the women to attend therapy groups, made suggestions about medication for anxiety and encouraged new bonds of friendship.

Dr. Agronin calls them his graduates — a trio of success stories among 3,700 patients he is responsible for, in what, by all accounts, is the largest geriatric psychiatry practice in the nation, at the Miami Jewish Health Systems.

The doctor is a rare breed even in Florida, which has the highest proportion of people older than 65. There are only 17 board-certified geriatric psychiatrists in the state, and a mere six here in southeast Florida, where snowbirds from New York often come to perch. In March, acknowledging the crisis in care, the federal Institute of Medicine began a study of the shortage of geriatric mental health workers nationwide.

Dr. Agronin, 45, is unusual not just because of his specialty but because he is a salaried staff member immersed in the fabric of life for patients and caregivers. Residents in most senior facilities must await a shifting cast of mental health professionals, who are available — even for a prescription — only one or two days a week or in an emergency.

Now, a growing number of experts are calling for integrating mental health professionals into all levels of communities for the rising population of aging Americans, from nursing homes to assisted-living centers.

Gary Kennedy, the director of geriatric psychiatry at Montefiore Medical Center in the Bronx, says psychological care is "equally if not more important than" medical care for this group. "Health policy continues to lag behind the reality that these are now mental health facilities," Dr. Kennedy said of communities for the elderly.

While Alzheimer's receives the lion's share of public attention, garden-variety depression, anxiety and sleep disorders also accompany old age. Particularly for late-life depression, Dr. Agronin points to data assembled by the psychiatry department at the University of California, San Francisco, supporting behavioral and group therapy, treatment rarely tried with patients from generations typically considered averse to discussing such issues.

But treatment that focuses on talking, rather than on medical procedures, has a lower Medicare reimbursement rate. The economic difficulties may explain why more doctors have not entered the time-intensive field.

"Approximating what I do is hardly economically feasible," said Dr. Agronin, the author of "How We Age." "Caregivers need assessment and services as well, and this is not reimbursable time."

For Dr. Agronin, and for the social worker and the psychologist who work with him, there is no such thing as the 50-minute billing hour. Rather, on a routine day, his work is often done ad hoc as he wanders the corridors, dining rooms and garden here. He loosens the boundaries set by most schools of psychiatry, which discourage clinicians from befriending patients. Here, staff members are physically affectionate and may even give patients a personal cellphone number.

"He is a lifesaver," Mrs. Weisburd said as Dr. Agronin helped blow out the candles on her cake. "He helps you walk down the mountain."

The mountain is old age, with its physical and cognitive decline, its steady loss of loved ones and its inevitable outcome. Dr. Agronin says his mission is to restore dignity and hope to people who were raised at a time when mental issues were often stigmatized.

Some 700 of Dr. Agronin's patients live on the main campus of Miami Jewish Health Systems, in independent or assisted-living apartments, a nursing home or an Alzheimer's unit. The rest of them come to his clinic or are served by the system's community programs throughout South Florida.

Dr. Agronin and other geriatricians find that behavioral therapy (changing the way one thinks and solving current problems) works better than analysis (excavating the past). And Dr. Agronin, who has written about some of his cases for the Science section of The New York Times, said he relied on group therapy because patients often benefit from the insights of their peers.

That was the case with Francoise Dorville, a 78-year-old Haitian immigrant who uses a wheelchair and is on dialysis and oxygen. Mr. Dorville, a widower estranged from his four surviving children, was stabilized with medication for depression and then agreed — reluctantly — to participate in a group.

Though he did not make eye contact with anyone in the group for the first month, Mr. Dorville did show up for the daily two-hour sessions. Eventually, the group persuaded him to contact his children, discussing his old-country idea that being a good father meant providing food and shelter and little else.

Mr. Dorville told his children that he would welcome a chance to be a more loving parent. Now they visit regularly; one son brings dinner weekly, and a daughter-in-law assembled a family photo album. Mr. Dorville describes himself as "a happy man."

Dr. Agronin said that older people were not by definition miserable. "We have to be very careful in the assumptions we make," he said, "and not project our own fears of aging. Their lives can be way better than we imagine."

The Merry Widows — Mrs. Weisburd, Muriel Cohen, 91, and Sandra Sachs, 78 — made their way here by a common route: from homes at the edge of golf courses. Wives and mothers for 50-plus years, they arrived with their husbands but remained here after their deaths.

"It's like being on a cruise," Mrs. Weisburd said. "You don't have to change the sheets, and there's always something to do."

Dr. Agronin sees them daily as they hurry between knitting classes and lectures on current events. Recently, he wandered into the library where they were chatting. Out of the blue, the usually buoyant Mrs. Weisburd lost her composure. Two of their regular dinner companions had recently died, she told him, breaching a dam of tears.

Mrs. Cohen added, "I cried so bitterly — more than I did for my husband."

Why, Mrs. Sachs asked, "do they send buses of psychologists to a high school every time there's a tragedy," but here, where death is constant, "there's only a brief memorial service and cookies?"

Dr. Agronin talked to them about accumulated grief, how one death re-opens others, how they had held themselves together for their families' sake. He said grief is part of the human condition, not a psychiatric problem.

"You are doing exactly what you should be doing: talking to other people," he reassured them. "But maybe we need to do that more deliberately."

So a new therapy group was born.