Should we erase painful memories? - Salon.com

This article was adapted from the upcoming book, "Memory: Fragments of a Modern History," available in January from the University of Chicago Press.

One of the most tenacious themes of 20th-century memory research was the idea that people tormented by the memories of terrible experiences could benefit from remembering them, and from remembering them better. The assumption — broadly indebted to psychoanalysis — was that psychological records of traumatic events often failed to be fully "integrated" into conscious memories. As long as these records remained "dissociated," the sufferer was compelled to "relive" them instead of benignly remembering them. The more fully and appropriately one remembered terrible events, the more attenuated would be their emotional power.

But in the 1990s — a time when psychoanalytic assumptions were being challenged as never before — neuroscience researchers developed a new framework for thinking about remembering, forgetting, and the mind's record of past events. One result was a highly controversial new paradigm for treating traumatic memories. The problem with bad memories, these new researchers claimed, is not their complex and unresolved relation to one's sense of self, but the simple fact that they are unpleasant. These researchers defined emotional memory not in terms of repressed ideas, but by certain patterns of neuron action and the chemical changes they triggered. The next step was to change these patterns.

In the 19th century, character was commonly portrayed as something that was built up by daily experience and personal choices, through the memories and habits created by those everyday events. Character was the result of how one responded, moment by moment, to the challenges of daily life, because those responses built up a kind of internal machinery of habit. Character was defined, in a way, as an accretion of memory. The idea of "building character" meant striving to make appropriate choices because the hardware one created would become difficult or impossible to change later.

One scholar of the present day who has expressed concerns about memory dampening has used a different analogy to describe the relation between memory and personality, but nevertheless one that describes personality as being made out of discrete memories. William B. Hurlbut, a consulting professor in human biology at Stanford University, wrote that "the pattern of our personality is like a Persian rug." It was built "one knot at a time, each woven into the others. There's a continuity to self, a sense that who we are is based upon solid, reliable experience. We build our whole interpretation and understanding of the world based upon that experience or on the accuracy of our memories."

As recently as the 1990s, people who thought of themselves as survivors of terrible trauma often defined themselves in relation to what they remembered (or what they did not): They were survivors because they had survived certain defining events.Their character as mature adults came from "working through" these terrible memories. But there were also "survivors" who felt they had not truly survived their memories. They described a wounded self whose bad experiences stood in the way of personal realization. This latter convention involved the idea of a hidden, unimpaired self encumbered by adverse conditions. The idea is similar in some respects to the characterization used in the marketing of recent psychotropic drugs, especially Prozac. These drugs' enthusiasts sometimes declared that taking them allowed their "true" selves to emerge, often for the first time.

Philosophers, therapists, filmmakers and bloggers have been quick to reflect on the implications of memory erasure. One of the best-known projects to explore the subject is the 2004 film "Eternal Sunshine of the Spotless Mind," in which the main character attempts to have memories of his ex-girlfriend deleted from his mind pharmaceutically. The film embraces the new neuroscience of emotion, focusing on memories of feelings and the complex ways different kinds and parts of memories are stored in different places in the brain. Central to the plot is the idea that memories with different emotional associations are stored differently.

http://www.salon.com/2011/12/31/should_we_erase_painful_memories/singleton/

Study of Medicare Patients Finds Most Hospital Errors Unreported - NYTimes.com

Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized, federal investigators say in a new report.

Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the "adverse events," according to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services.

In the report, being issued on Friday, Mr. Levinson notes that as a condition of being paid under Medicare, hospitals are to "track medical errors and adverse patient events, analyze their causes" and improve care.

Nearly all hospitals have some type of system for employees to inform hospital managers of adverse events, defined as significant harm experienced by patients as a result of medical care.

"Despite the existence of incident reporting systems," Mr. Levinson said, "hospital staff did not report most events that harmed Medicare beneficiaries." Indeed, he said, some of the most serious problems, including some that caused patients to die, were not reported.

Adverse events include medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.

Federal investigators identified many unreported events by having independent doctors review patients' records.

The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month.

Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said.

When the National Academy of Sciences issued a landmark report on patient safety in 1999, many experts said that hospital employees were often afraid to admit mistakes. But that no longer appears to be the main obstacle to reporting, federal investigators said.

More often, Mr. Levinson said, the problem is that hospital employees do not recognize "what constitutes patient harm" or do not realize that particular events harmed patients and should be reported.

In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or "suspected that the events were isolated incidents unlikely to recur."

To clear up confusion, Medicare officials said they would develop a list of "reportable events" that hospitals and their employees could use. In addition, the Medicare agency said, hospitals should give employees "detailed, unambiguous instructions on the types of events that should be reported."

The Obama administration and hospital industry leaders have placed a high priority on reducing medical errors. But, the report said, at many hospitals, this high-level commitment has not been translated into practice.

The inspector general found that "hospitals made few changes to policies or practices" after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any "systemic quality problems."

Organizations that inspect and accredit hospitals generally "do not scrutinize" how hospitals keep track of medical errors and other adverse events, the study said.

The federal investigators did an in-depth review of 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers, and 28 were investigated by the hospitals, but only five led to changes in policies or practices, the study said.

More than 2,900 hospitals have joined the administration in a "partnership for patients" intended to reduce errors and save 60,000 lives in three years.

At least 27 states have laws that require hospitals to report publicly on infections that patients develop in the hospital, according to the National Conference of State Legislatures, up from 6 at the end of 2005.

In view of the state laws, Obama administration officials said they were not proposing new federal requirements for the public reporting of adverse events.

http://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html?src=recg&pagewanted=print

12 entrepreneurs reinventing health care - CNNMoney

These 12 startups are working to make medical care more affordable and efficient -- a change that could save billions of dollars and save lives.

http://money.cnn.com/galleries/2011/smallbusiness/1112/gallery.health-care-entrepreneurs/index.html

FBI crackdown on unproven stem cell therapies - health - 05 January 2012 - New Scientist

They are the modern equivalent of snake oil merchants: clinics that charge desperately ill people thousands for unproven stem cell "cures". Now the US federal government is cracking down on one of the most notorious – and the defendants include a scientist at a leading research university.

Vincent Dammai, of the Medical University of South Carolina in Charleston, is named in a federal indictment as part of a team that allegedly received more than $1.5 million from people with cancer and neurodegenerative diseases.

The charges follow an investigation by CBS News into Lawrence Stowe of Fort Worth, Texas.

Stowe was filmed claiming that infusions of stem cells, given by his associate Francisco Morales at a clinic in Mexico, could reverse symptoms of amyotrophic lateral sclerosis – a fatal and incurable form of motor neuron disease.

Dammai's role, according to the indictment, was to extract stem cells from umbilical cord blood collected by Jesus Alberto Ramon, a midwife in Del Rio, Texas. Dammai and Ramon allegedly worked with Global Laboratories of Scottsdale, Arizona, which supplied the cells to Morales. Fredda Branyon, who ran Global Laboratories, pleaded guilty to supplying an unapproved treatment in August.

The case underlines concerns that some mainstream researchers could be abetting clinics offering unproven stem cell therapies. "I'm personally very happy that the FBI and the Food and Drug Administration has stepped in," says Larry Goldstein, a stem cell biologist at the University of California, San Diego. "I hope that it serves as a warning signal."
Morales, Dammai and Ramon, all named in the indictment, were arrested in December. Stowe, named i

While Dammai is alleged to have been a knowing participant, other scientists may have been duped into supplying cells that are later used by rogue clinics. To avoid this, biologists should ask for credentials when responding to requests for stem cell samples, argued bioethicists Zubin Master of the University of Alberta in Edmonton, Canada, and David Resnik of the National Institute of Environmental Health Sciences in Research Triangle Park, North Carolina, in the journal EMBO Reports last July (vol 12, p 992). They should also make recipients sign contracts detailing how the cells will be used, the pair added.

Internet searches reveal several hundred clinics offering unproven stem cell treatments, says Douglas Sipp of the RIKEN Center for Developmental Biology in Kobe, Japan. How many, if any, have obtained cells from mainstream biologists remains a mystery. "By nature these clinics are opaque and secretive," says Sipp. "We really don't know what's in the vials."

http://www.newscientist.com/article/dn21329-fbi-crackdown-on-unproven-stem-cell-therapies.html

How Yoga Can Wreck Your Body - NYTimes.com

On a cold Saturday in early 2009, Glenn Black, a yoga teacher of nearly four decades, whose devoted clientele includes a number of celebrities and prominent gurus, was giving a master class at Sankalpah Yoga in Manhattan. Black is, in many ways, a classic yogi: he studied in Pune, India, at the institute founded by the legendary B. K. S. Iyengar, and spent years in solitude and meditation. He now lives in Rhinebeck, N.Y., and often teaches at the nearby Omega Institute, a New Age emporium spread over nearly 200 acres of woods and gardens. He is known for his rigor and his down-to-earth style. But this was not why I sought him out: Black, I'd been told, was the person to speak with if you wanted to know not about the virtues of yoga but rather about the damage it could do. Many of his regular clients came to him for bodywork or rehabilitation following yoga injuries. This was the situation I found myself in. In my 30s, I had somehow managed to rupture a disk in my lower back and found I could prevent bouts of pain with a selection of yoga postures and abdominal exercises. Then, in 2007, while doing the extended-side-angle pose, a posture hailed as a cure for many diseases, my back gave way. With it went my belief, naïve in retrospect, that yoga was a source only of healing and never harm.

At Sankalpah Yoga, the room was packed; roughly half the students were said to be teachers themselves. Black walked around the room, joking and talking. "Is this yoga?" he asked as we sweated through a pose that seemed to demand superhuman endurance. "It is if you're paying attention." His approach was almost free-form: he made us hold poses for a long time but taught no inversions and few classical postures. Throughout the class, he urged us to pay attention to the thresholds of pain. "I make it as hard as possible," he told the group. "It's up to you to make it easy on yourself." He drove his point home with a cautionary tale. In India, he recalled, a yogi came to study at Iyengar's school and threw himself into a spinal twist. Black said he watched in disbelief as three of the man's ribs gave way — pop, pop, pop.

After class, I asked Black about his approach to teaching yoga — the emphasis on holding only a few simple poses, the absence of common inversions like headstands and shoulder stands. He gave me the kind of answer you'd expect from any yoga teacher: that awareness is more important than rushing through a series of postures just to say you'd done them. But then he said something more radical. Black has come to believe that "the vast majority of people" should give up yoga altogether. It's simply too likely to cause harm.

Not just students but celebrated teachers too, Black said, injure themselves in droves because most have underlying physical weaknesses or problems that make serious injury all but inevitable. Instead of doing yoga, "they need to be doing a specific range of motions for articulation, for organ condition," he said, to strengthen weak parts of the body. "Yoga is for people in good physical condition. Or it can be used therapeutically. It's controversial to say, but it really shouldn't be used for a general class."

Black seemingly reconciles the dangers of yoga with his own teaching of it by working hard at knowing when a student "shouldn't do something — the shoulder stand, the headstand or putting any weight on the cervical vertebrae." Though he studied with Shmuel Tatz, a legendary Manhattan-based physical therapist who devised a method of massage and alignment for actors and dancers, he acknowledges that he has no formal training for determining which poses are good for a student and which may be problematic. What he does have, he says, is "a ton of experience."

"To come to New York and do a class with people who have many problems and say, 'O.K., we're going to do this sequence of poses today' — it just doesn't work."

According to Black, a number of factors have converged to heighten the risk of practicing yoga. The biggest is the demographic shift in those who study it. Indian practitioners of yoga typically squatted and sat cross-legged in daily life, and yoga poses, or asanas, were an outgrowth of these postures. Now urbanites who sit in chairs all day walk into a studio a couple of times a week and strain to twist themselves into ever-more-difficult postures despite their lack of flexibility and other physical problems. Many come to yoga as a gentle alternative to vigorous sports or for rehabilitation for injuries. But yoga's exploding popularity — the number of Americans doing yoga has risen from about 4 million in 2001 to what some estimate to be as many as 20 million in 2011 — means that there is now an abundance of studios where many teachers lack the deeper training necessary to recognize when students are headed toward injury. "Today many schools of yoga are just about pushing people," Black said. "You can't believe what's going on — teachers jumping on people, pushing and pulling and saying, 'You should be able to do this by now.' It has to do with their egos."

When yoga teachers come to him for bodywork after suffering major traumas, Black tells them, "Don't do yoga."

"They look at me like I'm crazy," he goes on to say. "And I know if they continue, they won't be able to take it." I asked him about the worst injuries he'd seen. He spoke of well-known yoga teachers doing such basic poses as downward-facing dog, in which the body forms an inverted V, so strenuously that they tore Achilles tendons. "It's ego," he said. "The whole point of yoga is to get rid of ego." He said he had seen some "pretty gruesome hips." "One of the biggest teachers in America had zero movement in her hip joints," Black told me. "The sockets had become so degenerated that she had to have hip replacements." I asked if she still taught. "Oh, yeah," Black replied. "There are other yoga teachers that have such bad backs they have to lie down to teach. I'd be so embarrassed."

More ...

http://www.nytimes.com/2012/01/08/magazine/how-yoga-can-wreck-your-body.html?pagewanted=print

U.S. twin births have doubled in three decades: study | Reuters

The number of twins born in the United States has doubled in the last three decades largely as a result of fertility treatments, with one in 30 infants born in 2009 a twin, the Centers for Disease Control and Prevention said on Wednesday.

"The increases are quite widespread, affecting all age groups and all parts of the country," said Joyce Martin, a CDC epidemiologist and coauthor of the new study.

More than 137,000 twins were born in the United States in 2009, accounting for one in every 30 babies. That compares to 68,339 twins born in 1980 when just one in 53 infants born was a twin, the CDC said.

A third of the increase in the twin birth rate can be attributed to women waiting longer to have children, the CDC said. From 2000 to 2009, more than 35 percent of all births were to mothers ages 30 and over, up from 20 percent in 1980.

The number of twins per 1,000 births rose in all 50 states and doubled in Connecticut, Hawaii, Massachusetts, New Jersey and Rhode Island.

Treatment for infertility such as in-vitro fertilization accounts for much of the remainder of the increase in twins, the CDC said.

"We seem to be making improvements, refinements to fertility-enhancing therapies, so that could then result in a lowering of the increase of the pace in twin and other multiple births," Martin told Reuters.

Twin births are riskier than single births, she said.

"Infants born in twin deliveries are at greater risk of poor outcome," she said. "They are born smaller, they are born earlier. They are more likely not to survive the first year. Most twins do fine, but they are at higher risk."

http://www.reuters.com/article/2012/01/04/us-twins-idUSTRE8031YP20120104

It Costs More, but Is It Worth More? - NYTimes.com

If you want to know what is wrong with American health care today, exhibit A might be the two new proton beam treatment facilities the Mayo Clinic has begun building, one in Minnesota, the other in Arizona, at a cost of more than $180 million dollars each. They are part of a medical arms race for proton beam machines, which could cost taxpayers billions of dollars for a treatment that, in many cases, appears to be no better than cheaper alternatives.

Proton beam therapy is a kind of radiation used to treat cancers. The particles are made of atomic nuclei rather than the usual X-rays, and theoretically can be focused more precisely on cancerous tissue, minimizing the danger to healthy tissue surrounding it. But the machines are tremendously expensive, requiring a particle accelerator encased in a football-field-size building with concrete walls. As a result, Medicare will pay around $50,000 for proton beam therapy for a patient with prostate cancer, roughly twice as much as it would if the patient received another type of radiation.

The higher price would be worth it if proton beam therapy cured more people or significantly reduced side effects. But there is no evidence showing that this is true, except for a handful of rare pediatric cancers, like brain and spinal cord cancer. For children, the treatment does a better job of limiting damage to normal brain cells and reducing the risk of cognitive impairment and hearing loss. But — fortunately — fewer than 3,500 American children get these cancers each year. It is impossible to keep all nine existing proton beam centers in full use, much less the approximately 20 others in planning or construction, with so few patients.

To generate sufficient revenue, proton beam facilities need to treat patients with other types of cancer. Consequently, they have been promoted for patients with lung, esophageal, breast, head and neck cancers. But the biggest target by far has been prostate cancer, diagnosed in nearly a quarter of a million men each year.

There is no convincing evidence that proton beam therapy is as good as — much less better than — cheaper types of radiation for any one of these cancers. There has not been a single randomized trial, only small, short-term studies. Such trials cannot evaluate the therapy's long-term outcomes, nor resolve the concerns that some experts have raised regarding a potentially increased risk of hip fractures, bowel problems or other delayed effects associated with the therapy's treatment for prostate cancer.

So why is the venerable Mayo Clinic building two proton beam facilities? Because it's competing against Massachusetts General Hospital, M. D. Anderson in Texas, the University of Pennsylvania, Loma Linda in California — all of which have one. With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.

But it is crazy medicine and unsustainable public policy.

One solution is for Medicare to simply refuse to pay for proton beam treatment except for diseases where there is valid evidence that it is clinically superior, as many private insurers do. This would certainly help keep costs down, and it would also encourage manufacturers and researchers to actually conduct studies comparing proton beam therapy to other treatments.

However, it is often difficult to begin clinical trials without some reimbursement for the treatment that is being studied. So a second option is "coverage with evidence development." In this approach, Medicare would pay for proton beam treatment for patients with prostate and other cancers, but only if the patients were enrolled in a randomized trial that would compare the outcomes of their treatment to those from surgery, other kinds of radiation or active surveillance. Medicare has used this approach sparingly, but it should be applied to more cases like this one.

The most promising option is a new approach called dynamic pricing. Medicare would pay more for proton beam therapy, but only for diseases that are proven to be treated more effectively by the therapy than by other forms of radiation. For cancers like prostate, it would pay only what it pays for the cheaper alternatives. But if studies were done showing that proton beam therapy was better than other treatments, the payment would go up. If no studies were done, or the new evidence demonstrated no advantages, then coverage would continue, but at the lower reimbursement.

Of course hospitals could continue charging patients more for proton beam therapy, and patients who wanted the treatment could pay the difference themselves. But this should not be seen as unfair to those who can't afford it, because there are alternatives that are just as effective.

Everyone wants the best available care, especially for life-threatening diseases like cancer. But that doesn't mean Americans should pay exorbitant costs for treatments that can't be shown to be better than other, cheaper, options. If the United States is ever going to control our health care costs, we have to demand better evidence of effectiveness, and stop handing out taxpayer dollars with no questions asked.

Ezekiel J. Emanuel, an oncologist and former White House adviser, is a vice provost and professor at the University of Pennsylvania. Steven D. Pearson, a general internist, is the president of the Institute for Clinical and Economic Review at the Massachusetts General Hospital's Institute for Technology Assessment.

http://opinionator.blogs.nytimes.com/2012/01/02/it-costs-more-but-is-it-worth-more/?pagemode=print

Nowhere to Go, Patients Linger in Hospitals, at a High Cost - NYTimes.com

Hundreds of patients have been languishing for months or even years in New York City hospitals, despite being well enough to be sent home or to nursing centers for less-expensive care, because they are illegal immigrants or lack sufficient insurance or appropriate housing.

As a result, hospitals are absorbing the bill for millions of dollars in unreimbursed expenses annually while the patients, trapped in bureaucratic limbo, are sometimes deprived of services that could be provided elsewhere at a small fraction of the cost.

"Many of those individuals no longer need that care, but because they have no resources and many have no family here, we, unfortunately, are caring for them in a much more expensive setting than necessary based on their clinical need," said LaRay Brown, a senior vice president for the city's Health and Hospitals Corporation. Under state law, public hospitals are not allowed to discharge patients to shelters or to the street.

Medicaid often pays for emergency care for illegal immigrants, but not for continuing care, and many hospitals in places with large concentrations of illegal immigrants, like Texas, California and Florida, face the quandary of where to send patients well enough to leave. Officials in New York City say they have many such patients who are draining money from the health system as the cost of keeping people in acute-care hospitals continues to escalate.

But even if Medicaid pays for some care, taxpayer dollars are ultimately being consumed by patients who could be cared for in nursing homes or other health facilities, and even at home if supportive services were available. Care for a patient languishing in a hospital can cost more than $100,000 a year, while care in a nursing home can cost $20,000 or less.

Patients fit to be discharged from hospitals but having no place to go typically remain more than five years, Ms. Brown said. She estimated that there were about 300 patients in such a predicament throughout the city, most in public hospitals or higher-priced skilled public nursing homes, though a smattering were in private hospitals.

One patient, a former hospital technician from Queens, has lived at the city's Coler-Goldwater Specialty Hospital and Nursing Facility on Roosevelt Island for 13 years because the hospital has no place to send him, Ms. Brown said. The patient, who is in his mid-60s, has been there since an arterial disease cost him part of one leg below the knee and left him in a wheelchair. The city's public health system declined to provide the names of any long-term patients or make them available for interviews, citing confidentiality laws.

Five years ago, Yu Kang Fu, 58, who lived in Flushing, Queens, and was a cook at a Chinese restaurant in New Jersey, was dropped off by his boss at New York Downtown Hospital, a private institution in Manhattan, complaining of a severe headache. Mr. Yu was admitted to the intensive-care unit with a stroke.

Within days, he was well enough for hospital personnel to begin planning for his release, but as an illegal immigrant (he had overstayed a work visa a decade ago), he was ineligible for health benefits. And no nursing home or rehabilitation center would take him. Neither would his son in China nor the Chinese government, although the hospital volunteered to fly him there at its expense.

Mr. Yu's protracted hospital stay was first chronicled in an article in The New York Times in 2008 about the treatment of uninsured immigrants.

Mr. Yu remained in the hospital for over four years until he was transferred last spring to the Atlantis Rehabilitation and Residential Health Care Facility, a private center in Fort Greene, Brooklyn, after the federal government certified him as a "permanent resident under color of law," essentially acknowledging that he could not be returned to China and qualifying him for medical benefits.

"This gentleman cost us millions of dollars," said Jeffrey Menkes, the president of New York Downtown. "We try to provide physical, occupational therapy, but this is an acute-care hospital. This patient shouldn't be here."

Mr. Yu said that the hospital had treated him well, but that he had made enormous progress in regaining his ability to walk through his rehabilitation regimen at Atlantis. He hopes to return to China when he is well enough to be discharged.

"Here, I am very happy," he said. "This is very nice — No. 1."

New York Downtown serves a largely immigrant population, and many patients have no insurance or proof that they are in the United States legally, which is necessary for discharge purposes and eventual reimbursements, said Chui Man Lai, assistant vice president of patient services at the hospital.

"These patients often arrive in the emergency room acutely ill and unaccompanied, and we have to treat them until they can be discharged safely," Ms. Lai said. "The hospital is required, by law and its mission, to care for these patients."

Health professionals refer to them as "permanent patients," trussed in red tape and essentially living in hospitals already operating on thin margins. In some cases, health care professionals say, grown children leave ailing parents at the hospitals and go on vacation. Officials call that practice a "pop drop."

Though the problem is particularly severe in the municipal hospital system, longtime patients place a financial burden wherever they end up.

New York Downtown spends about $2 million annually for such patients out of an operating budget of about $200 million. An acute-care patient can cost the hospital more than $1,500 a day.

Hospitals are reluctant to complain publicly about such patients for fear of being perceived as callously seeking to dump nonpaying patients. Elected officials are generally loath to be seen as encouraging illegal immigrants by changing reimbursement formulas. The issue was never addressed during the debate over national health care legislation.

Longtime patients, meanwhile, risk getting sicker because they are exposed to diseases that fester in hospitals.

"At times there is a fine line regarding who meets the criteria to be admitted to a hospital, but if there's no way to immediately contact a family member and the patient needs nonmedical help or is homeless, you're obligated to provide shelter," said Dr. Warren B. Licht, who recently retired as New York Downtown's chief medical officer after seven years to return to full-time clinical practice in the wellness and prevention center that he founded there. "You can't kick a patient out of the hospital."

New York Downtown, Dr. Licht said, has offered to pay for nursing home care for patents who are uninsured and are illegal immigrants, but care facilities are reluctant to risk taking patients for fear that they would be saddled with unexpected and unreimbursed expenses.

"If the patient does not have or cannot obtain health insurance to pay for the next level of care, other non-acute-care health facilities won't routinely accept a patient," Dr. Licht said.

New York Downtown has four or five patients out of a total of 180 who have no place to go, he said, adding, "It cost us several million dollars a year in a hospital struggling to keep its head above water."

http://www.nytimes.com/2012/01/03/nyregion/nowhere-to-go-patients-linger-in-hospitals-at-a-high-cost.html?_r=1&nl=todaysheadlines&emc=tha29&pagewanted=print

In Tight Times, Medical Schools Market Themselves : NPR

Hospitals stepped up their advertising in 2011, and some newcomers to the national marketing game are academic medical centers. While the coast-to-coast commercials help attract faculty and students, they're also aimed at getting more paying patients to travel for treatment.

The biggest spenders on advertising are, not surprisingly, the household names in medical care. Mayo Clinic, Mount Sinai and New York Presbyterian led the way for the first half of 2011. Overall, hospitals shelled out 20 percent more during that period than in the previous year, according to the research firm Kantar Media.

One of the newcomers trying its luck on the national stage is Vanderbilt University Medical Center. In one recent ad, the facility promised that "the most amazing part is that the most amazing part is yet to come. That's the promise of discovery."

In the last year, the Nashville-based teaching hospital bought sponsorship time on CNN, Fox News and NPR.

Vanderbilt's chief marketing officer, Jill Austin, says that the marketing campaign has many goals.

"We think of it almost as a service to the public, to get the word out," she says.

The Vanderbilt ads focus primarily on treatments for cancer and heart disease that are based on an individual's DNA. But Austin says that luring patients hasn't been the primary goal.

"Ultimately, it helps us attract students to Vanderbilt [as well as] faculty and staff," she says. "We ourselves are proud of the work that we do, so it's really focused in that direction."

But despite what some institutions might say, the thrust of national marketing isn't recruiting or even fundraising, says Joel English of the Milwaukee-based marketing firm BVK.

"There are ancillary benefits to an effective national or regional campaign," English says. "That said, during a time in health care where dollars are precious, I don't believe those would be the key reasons for a national campaign. I think the key reason is to attract more patients."

Several teaching hospitals have tried raising their national profiles in recent years. The University of Pittsburgh Medical Center launched a multimillion-dollar campaign in 2005. The University of Michigan Health System has been on NPR; it also bought ads in The New York Times Sunday Magazine.

English says a lot of the impetus comes from shrinking Medicare and Medicaid reimbursements, which put a particular squeeze on teaching hospitals.

"To sustain their research and education and patient care, they have to extend beyond their traditional geographic boundaries," he says.

The concept is relatively new. Twenty years ago, you wouldn't catch an academic medical center using its name and the term "marketing" in the same sentence, says Betsy Gelb, a University of Houston marketing professor.

"We have gotten to the point where it isn't a dirty word," she says.

Gelb points to nearby MD Anderson Cancer Center, part of the University of Texas. It launched its first national campaign in 2009.

As one ad puts it, "There's only one you, and only one MD Anderson."

The TV spots and print ads are meant for the eyes of patients who've gotten a tough diagnosis. But Gelb says that as much as anything, the institution wants its name in front of physicians who ultimately make patient referrals.

The goals vary, Gelb says, and most are hard to measure.

"You can't necessarily quantify it," she says, as in, " 'Hey, 56 patients came in last year.' But you can say the difference from before to after is significantly positive, or it isn't."

As for the latest to broaden its horizons, Vanderbilt reports a "statistically significant change."

The University of Michigan Health System, however, wasn't exactly thrilled with the results of its national ads. A spokesman says it recently moved its national marketing away from pricey traditional media and to the Web instead.

http://www.npr.org/2012/01/04/144622719/in-tight-times-medical-schools-market-themselves

Book Excerpt: Confessions of a Surgeon By PAUL A. RUGGIERI - WSJ.com

"Get this thing out of my operating room!" The colon stapling device exploded into pieces when I hurled it against the operating room wall. I was fed up with its failure to work as advertised by the manufacturer. The stapler had probably cost less than $100 to make. The hospital paid $300 for it (and then billed the patient, or insurance company, $1,200). Now the thing didn't even work.

I do not react well to imperfection inside the operating room. I cannot tolerate it in the tools I use, the staff assisting me, or myself. Defective devices—I can have them replaced. Unmotivated staff—I can have them removed from the operating room. I haven't quite figured out yet what to do with myself.

Several months earlier, I had performed the same operation on a 66-year-old patient, using an identical stapling device. Everything seemed to have worked perfectly until the patient developed severe complications four days after his surgery. We soon discovered the cause: the nonperformance of the stapling device.

Surgeons are control freaks. We have to be. And when things don't go our way in the operating room, we can have outbursts. Some of us curse, some throw instruments, others have tantrums. These explosions are a go-to reaction when we're confronted with the ghosts of prior complications.

When the stapler hit the wall, I had been in the operating room for more than four hours, struggling to remove a diseased segment of colon from someone I'll call Mr. Baker, a 330-pound middle-aged man. Trying to keep his fat out of my way during the operation had been a continuous battle. The pain in my upper back reminded me that I was losing the fight.

Obese patients create more physical work for a surgeon during any type of procedure. The operations take longer, tie our upper body in knots and leave us with fatigue and frustration. Obese patients also automatically face an increased risk of complications like infection, pneumonia and blood clots during recovery.

If the difficulties posed by Mr. Baker's obesity weren't enough, he had been steadily losing blood during the procedure. His tissue reacted to the slightest graze with more bleeding.

Why does this guy have to bleed like this? As if it were his fault. Here I was blaming him, even though I was the one causing the bleeding. But in surgery, it always has to be someone else's fault. It's never the surgeon's fault.

Interestingly, after an operation, most surgeons tend to underestimate the amount of blood that was lost. Whether it's ego or denial, they can't help themselves.

The reality is that blood loss can be measured. Hospitals know which surgeons are losing blood, and how much, during every operation. They have data from their operating rooms, but the public cannot get access to this information. And this information matters, too. A large amount of blood lost during an operation can be a harbinger of complications to come.

Like poker players and their cards, surgeons are sometimes only as good as the patients they are dealt. Obesity, excessive scar tissue from a previous surgery in the same area, disease that is more advanced than anticipated—any one of these physiological conditions creates more work and a more difficult environment for the surgeon.

Even before the surgery begins, underlying or chronic conditions such as a history of hypertension, cardiac disease or lung disease put patients at risk for complications. Today, based on your medical history, surgeons can usually analyze, quite accurately, your risk of complications (or death) before setting foot in the operating room. All you have to do is ask.

I had no idea how bad Mr. Baker's colon disease would be until I opened him up and looked inside. It was a mess. If I were playing poker and this man's anatomy were the hand dealt, it would be time to fold.

"That is one of the ugliest pieces of colon I've ever seen." I grabbed the scrub nurse's hand. "See, touch that thing. Look how inflamed it is." When given the chance, scrub nurses love to touch organs in the operating room. "OK, don't poke it too hard, it will start to bleed again." Her hand drew back onto the instrument stand. I was in for a long night.

Tonight, the diseased colon on the menu was angry, cursing and taunting me: "Good luck, Mr. Big-Time Surgeon, trying to remove me." Surgeons frequently have conversations with the body parts or organs they are trying to remove. We also have conversations with ourselves; it's a way to blow off steam while our minds scramble to deal with the unexpected.

"By the time you are done with me, your back muscles are going to be in a heap of pain," the colon went on. "Looking forward to that drive home in your new Porsche? Well, too bad. It's going to have to wait. You better take your time or I'll come back to haunt you in a few days." I could hear the colon laughing at me. I was crying inside.

"Nurse, hand me a curved scissors." Finally, I was granted a little success in freeing up one end of the colon. But that was short-lived. More bleeding. I hate this. And I had cut myself. I stared at my finger. "Nurse, I need a new glove." The outer skin under my glove was breached, but not deeply.

"Almost got you," the colon said. I could not shut the thing up. "How do you know I don't have hepatitis or H.I.V.?"

Just great, I thought. Now I have something else to worry about.

"You're going to earn your fee tonight, Dr. Surgeon." The colon kept talking. "I hope you're not in this business for the money, like the last guy who operated on me. Between what Medicare pays you, the phone calls in the middle of night and the time you spend guiding my recovery, I figure you will make about $200 an hour for this operation. How does that grab you?"

Should have gone for my M.B.A., I mumbled to myself. Big mistake going into medicine, never mind surgery. If I could only go back and do it over again.

The colon's rant continued: "Wait, subtract what it costs you in overhead to bill for this operation (double that if the claim gets rejected), plus malpractice costs for the day, and we are now at $150 an hour. And how could I leave out the biggest expense of all? The price of the mental stress from worrying about me after the surgery (and double that if there's a complication). Now, I figure you're under $100 an hour. Plumbers make more than that just to step inside your house. I bet they sleep well at night. Just remember, Dr. Surgeon, nobody put a gun to your head. You chose this profession."

I could swear that the thing was laughing at me. "Forget about keeping those dinner reservations tonight. You and me, we're going for breakfast once this is over."

—Adapted from "Confessions of a Surgeon" by Paul A. Ruggieri, M.D. (Berkley Books).

http://online.wsj.com/article/SB10001424052970204720204577128481569245646.html?

On Being Ill - Virginia Woolf (1926) - Wikipedia

"Considering how common illness is, how tremendous the spiritual change that it brings, how astonishing, when the lights of health go down, the undiscovered countries that are then disclosed, what wastes and deserts of the soul a slight attack of influenza brings to light...it becomes strange indeed that illness has not taken its place with love, battle, and jealousy among the prime themes of literature. Novels, one would have thought, would have been devoted to influenza; epic poems to typhoid; odes to pneumonia, lyrics to toothache. But no; ... literature does its best to maintain that its concern is with the mind; that the body is a sheet of plain glass through which the soul looks straight and clear."

http://en.wikipedia.org/wiki/On_Being_Ill

The Fat Trap - NYTimes.com

For 15 years, Joseph Proietto has been helping people lose weight. When these obese patients arrive at his weight-loss clinic in Australia, they are determined to slim down. And most of the time, he says, they do just that, sticking to the clinic's program and dropping excess pounds. But then, almost without exception, the weight begins to creep back. In a matter of months or years, the entire effort has come undone, and the patient is fat again. "It has always seemed strange to me," says Proietto, who is a physician at the University of Melbourne. "These are people who are very motivated to lose weight, who achieve weight loss most of the time without too much trouble and yet, inevitably, gradually, they regain the weight."

Anyone who has ever dieted knows that lost pounds often return, and most of us assume the reason is a lack of discipline or a failure of willpower. But Proietto suspected that there was more to it, and he decided to take a closer look at the biological state of the body after weight loss.

Beginning in 2009, he and his team recruited 50 obese men and women. The men weighed an average of 233 pounds; the women weighed about 200 pounds. Although some people dropped out of the study, most of the patients stuck with the extreme low-calorie diet, which consisted of special shakes called Optifast and two cups of low-starch vegetables, totaling just 500 to 550 calories a day for eight weeks. Ten weeks in, the dieters lost an average of 30 pounds.

At that point, the 34 patients who remained stopped dieting and began working to maintain the new lower weight. Nutritionists counseled them in person and by phone, promoting regular exercise and urging them to eat more vegetables and less fat. But despite the effort, they slowly began to put on weight. After a year, the patients already had regained an average of 11 of the pounds they struggled so hard to lose. They also reported feeling far more hungry and preoccupied with food than before they lost the weight.

While researchers have known for decades that the body undergoes various metabolic and hormonal changes while it's losing weight, the Australian team detected something new. A full year after significant weight loss, these men and women remained in what could be described as a biologically altered state. Their still-plump bodies were acting as if they were starving and were working overtime to regain the pounds they lost. For instance, a gastric hormone called ghrelin, often dubbed the "hunger hormone," was about 20 percent higher than at the start of the study. Another hormone associated with suppressing hunger, peptide YY, was also abnormally low. Levels of leptin, a hormone that suppresses hunger and increases metabolism, also remained lower than expected. A cocktail of other hormones associated with hunger and metabolism all remained significantly changed compared to pre-dieting levels. It was almost as if weight loss had put their bodies into a unique metabolic state, a sort of post-dieting syndrome that set them apart from people who hadn't tried to lose weight in the first place.

"What we see here is a coordinated defense mechanism with multiple components all directed toward making us put on weight," Proietto says. "This, I think, explains the high failure rate in obesity treatment."

While the findings from Proietto and colleagues, published this fall in The New England Journal of Medicine, are not conclusive — the study was small and the findings need to be replicated — the research has nonetheless caused a stir in the weight-loss community, adding to a growing body of evidence that challenges conventional thinking about obesity, weight loss and willpower. For years, the advice to the overweight and obese has been that we simply need to eat less and exercise more. While there is truth to this guidance, it fails to take into account that the human body continues to fight against weight loss long after dieting has stopped. This translates into a sobering reality: once we become fat, most of us, despite our best efforts, will probably stay fat.

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http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-fat-trap.html?pagewanted=print