Saturday, October 1, 2011

Parents of a Certain Age - New York Magazine

The first time they had sex, during that initial exploration of unfamiliar flesh, John Ross uttered words to Ann Maloney that would sound to her like prophecy. "You have the body of a young girl. You need a baby."

This compliment, though gallant, could not have been objectively true. The first time Maloney and Ross had sex, he was 54 and she was 47. Maloney may have looked good for her age, but she most certainly did not have the body of a young girl. And the subject of babies, not in wide use as a come-on in any cohort, might have struck another woman so deeply middle-aged as creepy. But Maloney had no children at the time, and she wanted them—badly. As she recalls that ancient intimacy over martinis at an Upper East Side restaurant, her voice reverberates with remembered pleasure. Her husband gazes on fondly as she describes the moment when, as she approached 50, her fantasy came true. Maloney had deferred motherhood for the typical reasons: an unhappy first marriage and a late career switch—in her case from interior designer to psychiatrist—that required years of school and training and a radical relocation from suburban Texas to New York City. When she met her future husband, Maloney was establishing her practice and building a national reputation. She was, finally, ready.

Ross had his own procreative urges. Also a shrink, also divorced, he felt that he and his first wife hadn't raised their son, now 35, "the way I thought he should be raised. I wanted to rear a family in a better way." As often happens between mature couples who know what they want, things progressed quickly. The two married within eighteen months of their first date. With their medical backgrounds, they were clear-eyed about this biological fact: The odds that a woman over 45 will get pregnant in the usual, no-tech way are dauntingly low. So, skipping agonizing years of "trying," they began the process of securing a donor egg. With Ross's sperm, Maloney's womb, and the gametes of a much younger woman, they would build the family they both craved.

Donor eggs result in live births about 60 percent of the time, no matter how old the mother-to-be is. But clinics set various age cutoffs, and when Maloney and Ross were attempting to conceive, she was 48, which represented the outer limit. Even after NYU raised concerns about her age, Maloney says she never wondered if she was too old to have children.

Eventually, Columbia University took the couple on. A donor was identified, ejaculate dispensed into a sterile cup. Some of the resulting embryos were immediately transferred into Maloney's uterus, the remainder sent to the deep freeze for future use. Ann Maloney gave birth to Isabella in February 2001, a blissful event followed by severe postpartum depression followed by the hormonal rages that accompany the onset of menopause. A townhouse was purchased, two flourishing practices shuffled and reshuffled to accommodate newly complicated priorities. Lily was born when her mother was 52. This time, Maloney had to be brought out of menopause with hormones before she could get pregnant.

Today, Maloney and Ross, 60 and 66, inhabit their home with a rotating crew of housekeepers, a couple of fish tanks, a cockatiel, two bearded dragons, two dogs, two cats, and a dwarf hamster. Lily and Isabella are 7 and 10 and come with a docket of demands befitting their age—soccer games, birthday parties, sibling fights.

"You don't know how high-energy, actually, both of us are," Ross says. "I acted in 32 productions at Harvard, worked with Erik Erikson, graduated near the top of my class. We are both very intense, and also nurturers."

You know such people. They are your colleagues and friends, your boss or your mother's cousin. You see them on the subway—as I did recently at the Bloomingdale's stop. From behind, the woman looked like a Manhattan-mom archetype: a slim-hipped, pony-tailed blonde in jeans struggling with a stroller. As I passed her, I saw that she had the too-tanned and haggard face of a very fit grandma. In parks and playgrounds, you note a grizzled grown-up and his dimpled charge, and you do the math and you wonder.

The age of first motherhood is rising all over the West. In Italy, Germany, and Great Britain, it's 30. In the U.S., it's gone up to 25 from 21 since 1970, and in New York State, it's even higher, at 27. But among the extremely middle-aged, births aren't just inching up. They are booming. In 2008, the most recent year for which detailed data are available, about 8,000 babies were born to women 45 or older, more than double the number in 1997, according to the Centers for Disease Control. Five hundred and forty-one of these were born to women age 50 or older—a 375 percent increase. In adoption, the story is the same. Nearly a quarter of adopted children in the U.S. have parents more than 45 years older than they are.

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A Scramble for Solutions as a Hip Device Fails -

BOSTON — As surgeons here sliced through tissue surrounding a failed artificial hip in a 53-year-old man, they discovered what looked like a biological dead zone. There were matted strands of tissue stained gray and black; a large strip of muscle near the hip no longer contracted.

Dr. Young-Min Kwon, the lead orthopedic surgeon on the operation, said the damage was more extensive than tests had indicated and might be permanent. "The prognosis is guarded," Dr. Kwon said.

Similar scenes are playing out at hospitals nationwide as a growing number of patients seek to have faulty metal-on-metal artificial hips removed and replaced. More than a decade ago, some researchers had warned that the hips shed tiny pieces of metallic debris that posed potential health threats to patients. But those warnings were not heeded, and now doctors and patients face a growing public health problem as one of the country's biggest medical device failures unfolds.

Some patients with all-metal hips — ones in which the cup and ball of a joint is made of metal — said they had been bounced from doctor to doctor who did not have the knowledge or the tools to properly diagnose the problem. And by the time they reach specialists like Dr. Kwon at Massachusetts General Hospital, potentially lasting damage may have already taken place.

Dr. Kwon's recent patient, Robert Cartier, said he saw seven doctors over the course of a year who told him not to worry or who gave him shots for his pain. Diagnostic tests also did not point to a problem. Only recently have researchers determined that such scans need to be run in a specific way to detect the extent of metal-related damage.

"It really didn't get picked up early. I picked it up," Mr. Cartier said, adding that he learned of Dr. Kwon while researching metal hip problems on the Internet. "It is like buyer-beware kind of stuff, you are trusting the doctors."

All orthopedic implants, regardless of their composition, shed debris as they wear. But researchers say they believe that the particles released by some all-metal hips pose a special threat because scavenger cells dispatched by the body to neutralize the debris convert it into biologically active metallic ions. In some patients, a chain reaction begins that can destroy tissue and muscle.

For researchers like Dr. Kwon, the challenge is to identify both those patients most at risk and the best ways to monitor them.

So far, only a small fraction of the estimated 500,000 people in this country who received an all-metal hip over the last decade have suffered injuries. But studies suggest that those numbers will grow and that tissue destruction is occurring silently in some patients who have no obvious symptoms like pain.

"What we are seeing is a complex phenomenon," Dr. Kwon said.

A recent study in England found that all-metal hips were failing early at three times the rate of hips made from metal-and-plastic components, which can last 15 years or more. Most people recover well from a device replacement procedure, but specialists like Dr. Kwon are also seeing growing numbers of patients with complications.

Over the last year, his caseload has tripled and other specialized hospitals like Rush University Medical Center in Chicago have also seen cases. In the first six months of this year, the Food and Drug Administration received more than 5,000 reports about problems with the all-metal hips, according to a recent analysis by The New York Times.

In May 2010, Mr. Cartier, an electrical contractor who lives in Manchester, N.H., got an all-metal hip on his right side when he underwent a procedure known as "resurfacing," an alternative to traditional hip replacement intended to provide more mobility. A similar procedure performed in 2009 on his left hip appeared to have gone well, but the more recent operation left him in pain.

Frustrated with advice from doctors, he took the trip to Boston to see Dr. Kwon. In 2007, the surgeon had arrived as a fellow at Oxford University in England just as problems with all-metal hips were emerging in England and Australia, two countries where the implants were used earlier than the United States. Since then, he has become a co-author of several studies linking metallic debris and aberrant tissue growth.

For Dr. Kwon, Mr. Cartier's predicament posed a puzzle because he lacked some obvious signs of trouble; his implant, which was made by Stryker, had not been recalled, and the device had been implanted properly. But when the specialist ran his own diagnostic tests, there was evident tissue damage.

"He was the trouble guy," Mr. Cartier said. "He deals with the cases that other people couldn't figure out."

Other patients have encountered frustrations. For example, Cyndi Lafuente, a senior adviser at the Internal Revenue Service, learned last year that the model of artificial hip she got in 2007 was being recalled by its manufacturer, the DePuy division of Johnson & Johnson, because of its high early failure rate. Ms. Lafuente said she contacted her surgeon, who ordered a blood test and diagnostic scans, which came back with normal results. Still concerned, she contacted a British researcher, Dr. David Langton, who had helped sound the alarm about the recalled model.

In January, she met again with her orthopedist, armed with information from that talk and other research. The physician suggested that they run an added test. It showed very high metal levels, she said.

Now, four months after replacement surgery, her recovery has been slow and her leg is still weak, said Ms. Lafuente, who has sued DePuy.

"If I had not played an aggressive role, I think I would have had permanent damage" to muscle or bone, she said.

In May, the Food and Drug Administration ordered makers of all-metal hips to develop studies to determine how frequently the devices were failing and the implications for patients. But those studies are not likely to be completed for years, leaving specialists like Dr. Kwon to face a medical problem playing out in baffling ways.

For example, while some patients like Mr. Cartier with high blood levels of metallic debris show evidence of tissue damage, other patients with high levels appear fine. Tissue damage is also occurring in some patients with low or normal metal blood levels and in some patients who are free of symptoms.

As for Mr. Cartier, Dr. Kwon is not done with him. Even before the recent operation to replace his right hip, the surgeon told him the metal hip joint on his left side would also have to be replaced.

"He told me, 'I can't guarantee that you are going to be one of those guys who come out as well as you went in,' " he said.


In 1989, Research!America's founders came together with the realization that there was a vast deficiency in medical research funding - and that such a gap would be detrimental to Americans for years to come. Through their mutual belief in the fundamental importance of medical research, these visionaries formed the Research!America alliance.


Wednesday, September 28, 2011

Dartmouth Atlas: Readmission Rates Show ’Not Much Progress’

Dartmouth Atlas researchers are again pointing fingers at hospital quality of care, this time showing wide variation in 30-day readmission rates, which have not gone down and in some cases rose between 2005 and 2009.

Hospitals see "their responsibility as ending when the patient leaves their door and have made minimal efforts in terms of coordinating care or communicating to community physicians," said David Goodman, MD, lead author and co-principal investigator for the Dartmouth AtlasProject's latest report. 

"The result is that readmission to a hospital is a fairly common phenomenon," occurring in between one in six and one in five patients discharged, he said. "Probably the most important finding is that for a long-standing and well-recognized problem, not much progress has been made," Goodman said.

Some hospitals argue that they can't be blamed for high readmission rates because they have sicker patients with more co-morbidities, people who are less well educated and hampered by transportation and poverty.  That "may be an explanation, but it shouldn't be an excuse," Goodman said.

While "every hospital and market has its own legitimate story in terms of why they are and where they are today – sometimes it truly is because patients are sicker or poorer – often it's because of an accidental evolution" of the way care is delivered, without coordination or community provider partnerships. Transition processes are "deeply flawed," he said.

The report, entitled "After Hospitalization: A Dartmouth Atlas Report on Post-acute Care for Medicare Beneficiaries," compares readmission rates between 2004 and 2009 for six categories of patients: those admitted for medical care, surgery, congestive heart failure, heart attack, pneumonia, and hip fracture.

It further dissects the data to show rates for each of 1,924 hospitals in the country for those two years. One can see 30-day readmission trends for medium-sized and large cities, hospital referral regions, and states. 

The report also reveals that fewer than half of discharged patients followed up with visits to clinicians – an aspect of care said to help prevent readmissions – within 14 days of leaving the hospital. That rate "fell short of any reasonable expectation," said Goodman, Goodman, who also directs the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice.

The maps and statistical tables within the document show the percentage of patients for both 2004 and 2009 who were seen by a primary care clinician or went to an ambulatory care center within 14 days of discharge or went to the emergency room within 30 days of discharge.

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Dartmouth Atlas of Health Care

Understanding of the Efficiency and Effectiveness of the Health Care System

For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians. This research has helped policymakers, the media, health care analysts and others improve their understanding of our health care system and forms the foundation for many of the ongoing efforts to improve health and health systems across America.

Monday, September 26, 2011

Abraham Verghese: A doctor's touch | Video on

Modern medicine is in danger of losing a powerful, old-fashioned tool: human touch. Physician and writer Abraham Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam.

Sunday, September 25, 2011

Therapists Are ‘Seeing’ Patients Online -

The event reminder on Melissa Weinblatt's iPhone buzzed: 15 minutes till her shrink appointment.

She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend's pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist's computer monitor; he smiled back on her phone's screen.

She took a sip of her cocktail. The session began.

Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: "I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer!"

And, she added, "I even e-mailed him that I was panicked about a first date, and he wrote back and said we could do a 20-minute mini-session."

Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans' health care facilities and rural clinics — all supervised sites.

But today Skype, and encrypted digital software through third-party sites like, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly.

One third-party online therapy site,, said it has signed up 900 psychiatristspsychologists, counselors and coaches in just two years. Another indication that online treatment is migrating into mainstream sensibility: "Web Therapy," the Lisa Kudrow comedy that started online and pokes fun at three-minute webcam therapy sessions, moved to cable (Showtime) this summer.

"In three years, this will take off like a rocket," said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. "Everyone will have real-time audiovisual availability. There will be a group of true believers who will think that being in a room with a client is special and you can't replicate that by remote involvement. But a lot of people, especially younger clinicians, will feel there is no basis for thinking this. Still, appropriate professional standards will have to be followed."

The pragmatic benefits are obvious. "No parking necessary!" touts one online therapist. Some therapists charge less for sessions since they, too, can do it from home, saving on gas and office rent. Blizzards, broken legs and business trips no longer cancel appointments. The anxiety of shrink-less August could be, dare one say ... curable?

Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day's drive away. But he was willing to use Skype with long-distance patients. She was game.

Now she prefers these sessions to the old-fashioned kind.

But does knowing that your therapist is just a phone tap or mouse click away create a 21st-century version of shrink-neediness?

"There's that comfort of carrying your doctor around with you like a security blanket," Ms. Weinblatt acknowledged. "But," she added, "because he's more accessible, I feel like I need him less."

The technology does have its speed bumps. Online treatment upends a basic element of therapeutic connection: eye contact.

Patient and therapist typically look at each other's faces on a computer screen. But in many setups, the camera is perched atop a monitor. Their gazes are then off-kilter.

"So patients can think you're not looking them in the eye," said Lynn Bufka, a staff psychologist with the American Psychological Association. "You need to acknowledge that upfront to the patient, or the provider has to be trained to look at the camera instead of the screen."

The quirkiness of Internet connections can also be an impediment. "You have to prepare vulnerable people for the possibility that just when they are saying something that's difficult, the screen can go blank," said DeeAnna Merz Nagel, a psychotherapist licensed in New Jersey and New York. "So I always say, 'I will never disconnect from you online on purpose.' You make arrangements ahead of time to call each other if that happens."

Still, opportunities for exploitation, especially by those with sketchy credentials, are rife. Solo providers who hang out virtual shingles are a growing phenomenon. In the Wild Web West, one site sponsored a contest asking readers to post why they would seek therapy; the person with the most popular answer would receive six months of free treatment. When the blogosphere erupted with outrage from patients and professionals alike, the site quickly made the applications private.

Other questions abound. How should insurance reimburse online therapy? Is the therapist complying with licensing laws that govern practice in different states? Are videoconferencing sessions recorded? Hack-proof?

Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? "A lot of patients start therapy and feel worse before they feel better," noted Marlene M. Maheu, founder of the TeleMental Health Institute, which trains providers and who has served on task forces to address these questions. "It's more complex than people imagine. A provider's Web site may say, 'I won't deal with patients who are feeling suicidal.' But it's our job to assess patients, not to ask them to self-diagnose." She practices online therapy, but advocates consumer protections and rigorous training of therapists.

Psychologists say certain conditions might be well-suited for treatment online, including agoraphobia, anxiety, depression and obsessive-compulsive disorder. Some doctors suggest that Internet addiction or other addictive behaviors could be treated through videoconferencing.

Others disagree. As one doctor said, "If I'm treating an alcoholic, I can't smell his breath over Skype."

Cognitive behavioral therapy, which can require homework rather than tunneling into the patient's past, seems another candidate. Tech-savvy teenagers resistant to office visits might brighten at seeing a therapist through a computer monitor in their bedroom. Home court advantage.

Therapists who have tried online therapy range from evangelizing standard-bearers, planting their stake in the new future, to those who, after a few sessions, have backed away. Elaine Ducharme, a psychologist in Glastonbury, Conn., uses Skype with patients from her former Florida practice, but finds it disconcerting when a patient's face becomes pixilated. Dr. Ducharme, who is licensed in both states, will not videoconference with a patient she has not met in person. She flies to Florida every three months for office visits with her Skype patients.

"There is definitely something important about bearing witness," she said. "There is so much that happens in a room that I can't see on Skype."

Dr. Heath Canfield, a psychiatrist in Colorado Springs, also uses Skype to continue therapy with some patients from his former West Coast practice. He is licensed in both locations. "If you're doing therapy, pauses are important and telling, and Skype isn't fast enough to keep up in real time," Dr. Canfield said. He wears a headset. "I want patients to know that their sound isn't going through walls but into my ears. I speak into a microphone so they don't feel like I'm shouting at the computer. It's not the same as being there, but it's better than nothing. And I wouldn't treat people this way who are severely mentally ill."

Indeed, the pitfalls of videoconferencing with the severely mentally ill became apparent to Michael Terry, a psychiatric nurse practitioner, when he did psychological evaluations for patients throughout Alaska's Eastern Aleutian Islands. "Once I was wearing a white jacket and the wall behind me was white," recalled Dr. Terry, an associate clinical professor at the University of San Diego. "My face looked very dark because of the contrast, and the patient thought he was talking to the devil."

Another time, lighting caused a halo effect. "An adolescent thought he was talking to the Holy Spirit, that he had God on the line. It fit right into his delusions."

Johanna Herwitz, a Manhattan psychologist, tried Skype to augment face-to-face therapy. "It creates this perverse lower version of intimacy," she said. "Skype doesn't therapeutically disinhibit patients so that they let down their guard and take emotional risks. I've decided not to do it anymore."

Several studies have concluded that patient satisfaction with face-to-face interaction and online therapy (often preceded by in-person contact) was statistically similar. Lynn, a patient who prefers not to reveal her full identity, had been seeing her therapist for years. Their work deepened into psychoanalysis. Then her psychotherapist retired, moving out of state.

Now, four times a week, Lynn carries her laptop to an analyst's unoccupied office (her insurance requires that a local provider have some oversight). She logs on to an encrypted program at and clicks through until she reads an alert: "Talk now!"

Hundreds of miles away, so does her analyst. Their faces loom, side by side on each other's monitors. They say hello. Then Lynn puts her laptop on a chair and lies down on the couch. Just the top of her head is visible to her analyst.

Fifty minutes later the session ends. "The screen is asleep so I wake it up and see her face," Lynn said. "I say goodbye and she says goodbye. Then we lean in to press a button and exit."

As attenuated as this all may seem, Lynn said, "I'm just grateful we can continue to do this."

The fine art of medical diagnosis | Art and design | The Observer

At the Sainsbury Wing of London's National Gallery, in Room 58, a painting by the 15th-century Italian artist Piero di Cosimo of a woman lying on her side has been hung opposite Botticelli's Venus and Mars. The fame of the latter makes it a significant attraction for visitors. Yet those who shuffle past Cosimo's canvas miss an intriguing work, not just for its enigmatic content but for the unexpected way it shows how art can be opened up through scientific scrutiny.

The painting shows a young woman, half-clothed, lying on the ground as a satyr crouches over her corpse. According to the gallery's guidebook, the work – A Satyr Mourning over a Nymph – depicts the death of Procris, daughter of the king of Athens, who was accidentally killed by her husband Cephalus during a deer hunt. Put "death of Procris" into Google and the search throws up countless versions of Cosimo's painting.

But Professor Michael Baum, one of Britain's leading cancer experts, and a keen art critic, will have none of this. "This is not a depiction of the accidental death that Ovid wrote about," he says. "It is a painting about a murder, and a very nasty one at that."

Baum's interpretation is based on artistic and medical sleuthing which he has been carrying out for the past two decades. Every year he organises an artistic "ward round" for his students, one that takes them through the rooms of the National Gallery in order to show them how medical and scientific knowledge gives a new perspective to classical paintings – and to show how art can provide new insights for a young doctor.

"Dozens of papers have been written up, and published in respected journals, by our students on subjects that range from syphilis to Paget's disease of the skull as a result of the observations they have made in the gallery," says Baum. "It's a great way to learn medicine and appreciate art."

Now Baum, visiting professor of medical humanities at University College London, is widening his audience. At the British Science Festival in Bradford, he will give a lecture, Picture of Health: The Art of Medicine, which will highlight the importance of art in medical practice, and vice versa, and which will be based on his science tours of the National Gallery, including his studies of Cosimo's painting.

"The official guide explanation that accompanies A Satyr Mourning over a Nymph indicates that it shows a woman who has been killed after being struck accidentally by a spear," says Baum. "This is consistent with the story of Procris and Cephalus. However, there are all sorts of clues that show this interpretation to be wrong.

"Look at her hands, for example. Both are covered with deep lacerations. There is only one way she could have got those. She has been trying to fend off an attacker who has come at her, slashing in a frenzied manner with a knife or possibly a sword. Certainly there is no way that a spear could have done that."

There are other clues, adds Baum. The woman's left hand is bent backwards, in a position known by surgeons as "the waiter's tip", typical someone who has received a serious injury at points C3 and C4 on the cervical cord. The severing at these points causes nerve damage that makes the wrist flex and the fingers curl up in the manner of a waiter taking a backhanded tip.

"The wound in her throat also corresponds to the idea that her cervical cord was severed at the C3/C4 position. So what we are looking at is a picture of a woman who has had her throat cut after desperately trying to defend herself from a knife-wielding killer. This is not the outcome of a romantic tragedy. This is the result of a brutal murder."

Intriguingly, Cosimo may still have been trying to depict the death of Procris, adds Baum. The painter may simply have been the victim of his own acute observational powers. "I think he may well have gone to a mortuary and asked to be allowed to paint the body of a young woman and got the body of one who had been murdered by knife – and so he faithfully put on to his canvas what he saw. It just happens not to accord with our modern understanding of what would have happened to a woman struck accidentally by a spear."

The key point of teaching medicine in this manner is that it broadens students' views of their subject. "Art and medicine have parallel histories: accurate drawings of dissections were crucial for anatomical education, for example, while art therapy has provided patients with powerful cathartic releases. And now when we look with a trained eye, it is clear these artists had considerable medical knowledge and often used it with considerable subtlety."

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