Friday, February 17, 2012

New Medical College Admission Test® Approved - News Releases - Newsroom - AAMC

Starting in 2015, when aspiring doctors take the MCAT® examination, they will need more than a solid basis in the natural sciences.  Under changes approved today by the AAMC (Association of American Medical Colleges), they also will need an understanding of the psychology, sociology, and biology that provide the foundation for learning about the human and social components of health. 

The changes to the MCAT exam, the first since 1991, are designed to help students prepare for a rapidly changing health care system and an evolving body of medical knowledge while addressing the needs of a growing, aging, and increasingly diverse population. 

"Being a good doctor is about more than scientific knowledge. It also requires an understanding of people.  By balancing the MCAT exam's focus on the natural sciences with a new section on the psychological, social, and biological foundations of behavior, the new exam will better prepare students to build strong knowledge of the socio-cultural and behavioral determinants of health," said Darrell G. Kirch, M.D., AAMC president and CEO. 

A new section, "Psychological, Social, and Biological Foundations of Behavior," will test the ways in which these areas influence a variety of factors including people's perceptions and reactions to the world; behavior and behavior change; what people think about themselves and others; cultural and social differences that influence well-being; and the relationships among socio-economic factors, access to resources, and well-being.   

By testing what is taught in introductory psychology, sociology, and biology at many undergraduate institutions, this new section will examine concepts that provide a solid foundation for learning in medical school about the behavioral and socio-cultural determinants of health. The changes to the exam also recognize a growing body of evidence  showing that integrating social and behavioral sciences into medical education curricula and clinical practice can improve the health of all patients.  

In addition, a new "Critical Analysis and Reasoning Skills" section will test students' reasoning ability by having them analyze, evaluate, and apply information provided in passages from a wide range of social sciences and humanities disciplines, including ethics and philosophy, cross-cultural studies, and population health. 

The revised exam also will include two natural sciences sections to test concepts typically taught in introductory biology, general and organic chemistry, biochemistry, and physics that medical school faculty, residents, and students rate as most important to the success of entering medical students. Building on the framework described by the report "Scientific Foundations for Future Physicians,"  these sections will ask test takers to combine knowledge of natural science concepts with their scientific inquiry and reasoning skills to solve problems that demonstrate their readiness for medical school. 

In another major change, the exam will no longer include a writing section. Feedback from admissions officers and other data revealed that this section offered little additional information about applicants' preparation for medical school, particularly relative to the insights gained from undergraduate grades and the other sections of the exam. With all the revisions to the test, the length of the exam will increase to about six and a half hours.

Sample questions and a detailed list of concepts and topics covered by the new exam are provided in a Preview Guide for MCAT2015 . In addition, a number of resources are posted on the AAMC Web site to help students, undergraduate faculty, and pre-health advisors prepare for the exam, including an informational videofeaturing students describing the new exam and giving tips for preparation. The AAMC will continue to provide new resources on its Web site as they become available. 

The changes to the MCAT exam were developed by a 21-member advisory panel, the MR5 Advisory Committee, appointed by the AAMC in 2008 to review the exam, which is used for admission to medical school as well as by some other health professions including osteopathy, podiatry, and veterinary medicine. The final recommendations are the product of an extensive, three-year period during which the MR5 committee gathered input from stakeholders at more than 90 outreach events, solicited expert input from blue-ribbon committees and advisory groups, and reviewed more than 2,700 informational and opinion surveys from undergraduate and medical school faculty, administrators, residents, and medical students. 

The revisions to the MCAT exam are part of a broader effort by the AAMC and the nation's medical schools to improve the medical school admissions process. Through efforts such as holistic review and the development of tools to help admissions committees assess the personal characteristics of applicants, medical schools are working on new and better ways to assess prospective medical students on criteria beyond traditional academic predictors of success.

MCAT is changing how it tests would-be physicians | Inside Higher Ed

New sections on the social sciences and on critical thinking will be added to the Medical College Admission Test in 2015, representing the first major revision in the exam since 1991 and one of the largest ever since it was introduced in 1928.
The changes have been under consideration for three years and were first formally released to the public in draft form a year ago. On Thursday the board of the Association of American Medical Colleges, which runs the MCAT, approved the changes. Leaders of the association also said that they are embarking on efforts to encourage medical schools to embrace a more "holistic" approach to admissions, and to consider new ways to attract students with broader undergraduate training -- not just those with backgrounds in stereotypical areas as biology and chemistry.
"We haven't abandoned the foundational emphasis on the natural sciences," but "emerging social and behavioral sciences are equally relevant to medicine," Darrell G. Kirch, president of the medical school group, said in a phone briefing for reporters. More health issues in the future will require understanding of why people act as they do, of the conditions in which they live, and their behavioral patterns, he said, and the best physicians in the years ahead will be as educated on such issues as they are in genetics or anatomy.
The changes, Kirch said, should motivate many more pre-meds than has been the case to take courses in psychology or sociology or health behaviors or all kinds of interdisciplinary classes. "I think someone who is a psychology major or even a major in cross-cultural studies should have as much chance of medical school [admission] as a physics major," Kirch said. He said he wants undergraduates to know that one of the best ways they can prepare for medical school and for being a physician is "to read broadly" and "to be knowledgeable about the world at large."
The writing test that has been part of the MCAT is being dropped. Kirch said that admissions officers at medical schools reported that it added little. The total time for the test will grow from 5.5 to 6.5 hours, but Kirch said that previous iterations of the MCAT were that long, so he was not concerned about the endurance of test-takers being a problem.
The AAMC has been encouraging medical colleges to admit more underrepresented minority students, and has been making modest progress in this regard. But large gaps remain in the MCAT averages of different groups. In 2010, the median scores were 26.0 for white students, 25.7 for Asian students, 21.3 for Latino students and 19.7 for black students.
Kirch said that it was hard to predict whether the new MCAT would narrow those gaps. But he said that he didn't see the changes "working against this goal of having a more diverse group of students." He said that he thinks the changes will support the effort. Generally, he said, it was time for medical schools to embrace "an admissions process less bound by test scores," and to rethink all parts of their admissions procedures -- including letters of recommendation, interviews and the applications themselves. He said it was important to "move toward greater diversity."
Charles H. Hauck, pre-medical coordinator at the University of Iowa and president of the National Association of Advisors for the Health Professions, said that the AAMC has been working to "get the word out" about the changes so that he and his colleagues can help new students pick college courses that will prepare them for the MCAT. Hauck said he thought many more pre-meds than in the past would be enrolling in sociology, psychology and related fields.
Hauck said his only concern was about whether pre-med students would simply be adding those courses to an already full schedule of pre-med requirements, limiting their ability to explore other fields. "That's going to be the challenge," he said. "What we don't want to happen is create a premedical curriculum that is too difficult to fit in."
Robert Schaeffer, public education director of the National Center for Fair and Open Testing, which has periodically criticized the existing MCAT, said that the changes are "good as far as they go." He also applauded the AAMC's encouragement of medical schools to place less emphasis on test scores in the admissions process. Currently, he said, there is "a heavy overreliance" on MCAT scores.
The question going forward, he said, is whether medical schools will follow the advice they are getting from the AAMC. "It's all in the doing," he said.

Thursday, February 16, 2012

CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic

In 2007, approximately 27,000 unintentional drug overdose deaths occurred in the United States, one death every 19 minutes. Prescription drug abuse is the fastest growing drug problem in the United States. The increase in unintentional drug overdose death rates in recent years (Figure 1) has been driven by increased use of a class of prescription drugs called opioid analgesics (1). Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined (Figure 2) (1). In addition, for every unintentional overdose death related to an opioid analgesic, nine persons are admitted for substance abuse treatment (2), 35 visit emergency departments (3), 161 report drug abuse or dependence, and 461 report nonmedical uses of opioid analgesics (4). Implementing strategies that target those persons at greatest risk will require strong coordination and collaboration at the federal, state, local, and tribal levels, as well as engagement of parents, youth influencers, health-care professionals, and policy-makers.

Overall, rates of opioid analgesic misuse and overdose death are highest among men, persons aged 20–64 years, non-Hispanic whites, and poor and rural populations. Persons who have mental illness are overrepresented among both those who are prescribed opioids and those who overdose on them. Further defining populations at greater risk is critical for development and implementation of effective interventions. The two main populations in the United States at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids (5), and the roughly 5 million persons who report nonmedical use (i.e., use without a prescription or medical need), in the past month (4). In an attempt to treat patient pain better, practitioners have greatly increased their rate of opioid prescribing over the past decade. Drug distribution through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of >600% (6). That 700 mg of morphine per person is enough for everyone in the United States to take a typical 5 mg dose of Vicodin (hydrocodone and acetaminophen) every 4 hours for 3 weeks. Persons who abuse opioids have learned to exploit this new practitioner sensitivity to patient pain, and clinicians struggle to treat patients without overprescribing these drugs.

Among patients who are prescribed opioids, an estimated 80% are prescribed low doses (<100 mg morphine equivalent dose per day) by a single practitioner (7,8), and these patients account for an estimated 20% of all prescription drug overdoses (Figure 3). Another 10% of patients are prescribed high doses (≥100 mg morphine equivalent dose per day) of opioids by single prescribers and account for an estimated 40% of prescription opioid overdoses (9,10). The remaining 10% of patients are of greatest concern. These are patients who seek care from multiple doctors and are prescribed high daily doses, and account for another 40% of opioid overdoses (11). Persons in this third group not only are at high risk for overdose themselves but are likely diverting or providing drugs to others who are using them without prescriptions. In fact, 76% of nonmedical users report getting drugs that had been prescribed to someone else, and only 20% report that they acquired the drug from their own doctor (4). Furthermore, among persons who died of opioid overdoses, a significant proportion did not have a prescription in their records for the opioid that killed them; in West Virginia, Utah, and Ohio, 25%–66% of those who died of pharmaceutical overdoses used opioids originally prescribed to someone else (11–13). These data suggest that prevention of opioid overdose deaths should focus on strategies that target 1) high-dosage medical users and 2) persons who seek care from multiple doctors, receive high doses, and likely are involved in drug diversion.

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Phys Ed: How Interval Training Can Improve Health -

While many of us wonder just how much exercise we really need in order to gain health and fitness, a group of scientists in Canada are turning that issue on its head and asking, how little exercise do we need?
The emerging and engaging answer appears to be, a lot less than most of us think — provided we're willing to work a bit.
In proof of that idea, researchers at McMaster University in Hamilton, Ontario, recently gathered several groups of volunteers. One consisted of sedentary but generally healthy middle-aged men and women. Another was composed of middle-aged and older patients who'd been diagnosed with cardiovascular disease.
The researchers tested each volunteer's maximum heart rate and peak power output on a stationary bicycle. In both groups, the peaks were not, frankly, very high; all of the volunteers were out of shape and, in the case of the cardiac patients, unwell. But they gamely agreed to undertake a newly devised program of cycling intervals.
Most of us have heard of intervals, or repeated, short, sharp bursts of strenuous activity, interspersed with rest periods. Almost all competitive athletes strategically employ a session or two of interval training every week to improve their speed and endurance.
But the Canadian researchers were not asking their volunteers to sprinkle a few interval sessions into exercise routines. Instead, the researchers wanted the groups to exercise exclusively with intervals.
For years, the American Heart Association and other organizations have recommended that people complete 30 minutes or more of continuous, moderate-intensity exercise, such as a brisk walk, five times a week, for overall good health.
But millions of Americans don't engage in that much moderate exercise, if they complete any at all. Asked why, a majority of respondents, in survey after survey, say, "I don't have time."
Intervals, however, require little time. They are, by definition, short. But whether most people can tolerate intervals, and whether, in turn, intervals provide the same health and fitness benefits as longer, more moderate endurance exercise are issues that haven't been much investigated.
Several years ago, the McMasters scientists did test a punishing workout, known as high-intensity interval training, or HIIT, that involved 30 seconds of all-out effort at 100 percent of a person's maximum heart rate. After six weeks, these lacerating HIIT sessions produced similar physiological changes in the leg muscles of young men as multiple, hour-long sessions per week of steady cycling, even though the HIIT workouts involved about 90 percent less exercise time.
Recognizing, however, that few of us willingly can or will practice such straining all-out effort, the researchers also developed a gentler but still chronologically abbreviated form of HIIT. This modified routine involved one minute of strenuous effort, at about 90 percent of a person's maximum heart rate (which most of us can estimate, very roughly, by subtracting our age from 220), followed by one minute of easy recovery. The effort and recovery are repeated 10 times, for a total of 20 minutes.
Despite the small time commitment of this modified HIIT program, after several weeks of practicing it, both the unfit volunteers and the cardiac patients showed significant improvements in their health and fitness.
The results, published in a recent review of HIIT-related research, were especially remarkable in the cardiac patients. They showed "significant improvements" in the functioning of their blood vessels and heart, said Maureen MacDonald, an associate professor of kinesiology at McMaster who is leading the ongoing experiment.
It might seem counterintuitive that strenuous exercise would be productive or even wise for cardiac patients. But so far none have experienced heart problems related to the workouts, Dr. MacDonald said. "It appears that the heart is insulated from the intensity" of the intervals, she said, "because the effort is so brief."
Almost as surprising, the cardiac patients have embraced the routine. Although their ratings of perceived exertion, or sense of the discomfort of each individual interval, are high and probably accurate, averaging a 7 or higher on a 10-point scale, they report enjoying the entire sessions more than longer, continuous moderate exercise, Dr. MacDonald said.
"The hard work is short," she points out, "so it's tolerable." Members of a separate, exercise control group at the rehab center, assigned to complete standard 30-minute moderate-intensity workout sessions, have been watching wistfully as the interval trainers leave the lab before them. "They want to switch groups," she said.
The scientists have noted other benefits in earlier studies. In unfit but otherwise healthy middle-aged adults, two weeks of modified HIIT training prompted the creation of far more cellular proteins involved in energy production and oxygen. The training also improved the volunteers' insulin sensitivity and blood sugar regulation, lowering their risk of developing Type 2 diabetes, according to a study published last fall in Medicine & Science in Sports & Exercise.
Since then, the scientists completed a small, follow-up experiment involving people with full-blown Type 2 diabetes. They found that even a single bout of the 1-minute hard, 1-minute easy HIIT training, repeated 10 times, improved blood sugar regulation throughout the following day, particularly after meals.
Of course, HIIT training is not ideal or necessary for everyone, said Martin Gibala, a professor of kinesiology at McMaster, who's overseen the high-intensity studies. "If you have time" for regular 30-minute or longer endurance exercise training, "then by all means, keep it up," he said. "There's an impressive body of science showing" that such workouts "are very effective at improving health and fitness."
But if time constraints keep you from lengthier exercise, he continues, consult your doctor for clearance, and then consider rapidly pedaling a stationary bicycle or sprinting uphill for one minute, aiming to raise your heart rate to about 90 percent of your maximum. Pedal or jog easily downhill for a minute and repeat nine times, perhaps twice a week. "It's very potent exercise," Dr. Gibala said. "And then, very quickly, it's done."

Wednesday, February 15, 2012

More Doctors 'Fire' Vaccine Refusers -

Pediatricians fed up with parents who refuse to vaccinate their children out of concern it can cause autism or other problems increasingly are "firing" such families from their practices, raising questions about a doctor's responsibility to these patients.

Medical associations don't recommend such patient bans, but the practice appears to be growing, according to vaccine researchers.

In a study of Connecticut pediatricians published last year, some 30% of 133 doctors said they had asked a family to leave their practice for vaccine refusal, and a recent survey of 909 Midwestern pediatricians found that 21% reported discharging families for the same reason.

By comparison, in 2001 and 2006 about 6% of physicians said they "routinely" stopped working with families due to parents' continued vaccine refusal and 16% "sometimes" dismissed them, according to surveys conducted then by the American Academy of Pediatrics.

"There's more noise among pediatricians, more people willing to argue that it's OK to do this versus 10 years ago," said Douglas Diekema, a professor of pediatrics at the University of Washington in Seattle. Dr. Diekema wrote the AAP's policy on working with vaccine refusers, which recommends providers address the issue at repeated visits, but respect parents' wishes unless it puts a child at risk of significant harm.

Most pediatricians consider preventing disease through vaccines a primary goal of their job. The Centers for Disease Control and Prevention and AAP issue an annual recommended vaccination schedule, but some parents ask if their child's immunizations can be pushed back or skipped altogether, pediatricians say.

While rates for several key inoculations in young children rose between 2009 and 2010, according to the CDC, lower immunization rates have been blamed as a factor in U.S. outbreaks of whooping cough and measles in recent years.

Parents often voice concerns about autism or that their child's immune system may be overwhelmed by too many vaccines at once. Worries about a link between vaccines and autism arose because some parents noticed their children regressed, or lost some skills, around the time of their vaccinations at two years of age. Another concern centered on the former use of mercury as a vaccine preservative.

Numerous studies since have dispelled these concerns among scientists. Rather, scientists say, it is more likely that autism symptoms begin showing up around the same age children are vaccinated.

The rise in patient firings reflects another factor. As patients have become savvier and more willing to challenge doctors, physicians have become increasingly reluctant to deal with uncooperative patients, said Arthur Caplan, a bioethics professor at the University of Pennsylvania. In addition, doctors may feel financial pressure to see more patients and so have less time to contend with recalcitrant ones.

For Allan LaReau of Kalamazoo, Mich., and his 11 colleagues at Bronson Rambling Road Pediatrics, who chose in 2010 to stop working with vaccine-refusing families, a major factor was the concern that unimmunized children could pose a danger in the waiting room to infants or sick children who haven't yet been fully vaccinated.

In one case, an unvaccinated child came in with a high fever and Dr. LaReau feared the patient might have meningitis, a contagious, potentially deadly infection of the brain and spinal cord for which a vaccine commonly is given. "I lost a lot more sleep than I usually do" worrying about the situation, he said.

"You feel badly about losing a nice family from the practice," added Dr. LaReau, but families who refused to vaccinate their kids were told that "this is going to be a difficult relationship without this core part of pediatrics." Some families chose to go elsewhere while others agreed to have their kids inoculated.

Pediatricians disagree about what their duty is to these families. "The bottom line is you should try to do whatever you can to maintain the family in the best care," said Michael Brady, chair of the pediatrics department at Nationwide Children's Hospital in Columbus, Ohio, and a member of the AAP's immunization committee. "If they leave your practice, they're probably going to gravitate toward another practice with unhealthy practices."

Other physicians say they rarely have had luck persuading vaccine opponents to change their minds.

David Fenner and his 20-plus colleagues at Children's Medical Group in Rhinebeck, N.Y., discuss vaccine concerns but ask families to leave if they don't comply by a certain point.

Dr. Fenner said he tells new families, "You've been bombarded with information before you came here, some accurate and some not." Iif a family refuses to vaccinate after a discussion of the issue, he tells them "there are so many things we're not going to see eye-to-eye on."

So far, the practice has fired a couple of families per year since it implemented the policy about five years ago.

Pamela Felice, who lives in an Atlanta suburb, had difficulty finding a pediatrician for her two children though they have waivers from a previous pediatrician exempting them from school requirements for immunizations. Her older child had gastrointestinal trouble and regressed development after receiving vaccines, she said, which she believes were related to the shots.

Ms. Felice received a letter from her pediatrician a few years ago stating that because the family chose not to vaccinate, it needed to find another doctor. She called four or five other practices but none would agree to an appointment after she told them she was opposed to vaccines. The family ended up with an elderly family doctor who said he had "seen it all" and was willing to treat the children if they got sick, Ms. Felice said.

"A doctor should feel obligated to discuss [potential vaccine] risks with any parent who wants to discuss them," said Ms. Felice.

Tuesday, February 14, 2012

Feeling Anxious? Soon There Will Be an App for That -

The very idea of psychotherapy seems to defy the instant-access, video screen chatter of popular digital culture.

Not for long, if some scientists have their way. In the past few years researchers have been testing simple video-game-like programs aimed at relieving common problems like anxiety and depression. These recent results have been encouraging enough that investigators are now delivering the programs on smartphones — therapy apps, in effect, that may soon make psychological help accessible anytime, anywhere, whether in the grocery store line, on the bus or just before a work presentation.

The prospect of a therapy icon next to Angry Birds and Fruit Ninja is stirring as much dread as hope in some quarters. "We are built as human beings to figure out our place in the world, to construct a narrative in the context of a relationship that gives meaning to our lives," said Dr. Andrew J. Gerber, a psychiatrist at Columbia University. "I would be wary of treatments that don't allow for that."

The upside is that well-designed apps could reach millions of people who lack the means or interest to engage in traditional therapy and need more than the pop mysticism, soothing thoughts or confidence boosters now in use.

"That is what makes the idea so promising," said Richard McNally, a psychologist at Harvard whose lab recently completed a study of 338 people using a simple program accessible on their smartphones. "But there are big questions about how it could work, and how robust the effect really is."

The smartphone study is only one of the most recent tests of an approach called cognitive bias modification, or C.B.M., that seeks to break some of the brain's bad habits. The premise, pioneered by Colin MacLeod of the University of Western Australia, is straightforward. Consider people with social anxiety, a kind of extreme shyness that can leave people breathless with dread.. Studies have found that many who struggle with such anxiety fixate subconsciously on hostile faces in a crowd of people with mostly relaxed expressions, as if they see only the bad apples in a bushel of mostly good ones.

Modifying that bias — that is, reducing it — can interrupt the cascade of thoughts and feelings that normally follow, short-circuiting anxiety, lab studies suggest. In one commonly used program, for instance, people see two faces on the screen, one with a neutral expression and one looking hostile. The faces are stacked one atop the other, and a split-second later they disappear, and a single letter flashes on the screen, in either the top half or the bottom.

Users push a button to identify the letter, but this is meaningless; the object is to snap the eyes away from the part of the screen that showed the hostile face, conditioning the brain to ignore those bad apples. That's all there is to it. Repeated practice, the researchers say, may train the eyes to automatically look away, or the frontal areas of the brain to exercise more top-down control.

"It's a little boring, because it's repetitive, but you're only doing it for a few minutes a few times a day," said Stefanie Block, 26, a University of Michigan graduate student who took part in the Harvard study while living in Boston. "I just did it when commuting to work on the subway; it's crowded, there isn't much you can do, it was the perfect time."

In lab experiments, some researchers have gotten very strong results, "with effect sizes like you'd see in regular therapy," said Nader Amir, a psychologist at San Diego State University. In a series of experiments, Dr. Amir has found that about half of people with an anxiety disorder who complete a full course — practicing on a computer for about 30 minutes twice a week, for four to six weeks — improve enough that the diagnosis no longer applies. He has tested programs that target social anxiety and generalized anxiety disorder and is part owner of a company that is marketing the technology.

study among 40 children with chronic anxiety, published in December, found that a similar attention bias program produced "significant reductions in the number of anxiety symptoms and symptom severity," according to the authors, who included Dr. Daniel Pine of the National Institute of Mental Health and Yair Bar-Haim of Tel Aviv University.

Psychologists in Europe have even tried a bias modification program aimed at heavy drinking — a computer task in which people push away images of alcoholic drinks, using a joystick, and zoom in on nonalcoholic ones — and found that it improved the effectiveness of talk therapy aimed at reducing the habit.

Other researchers have not had quite the same success. "I am far from convinced that this is for real," said Willem Van der Does, a psychologist at Leiden University in the Netherlands, who has several papers under review testing bias modification.

"I did not notice any positive effect," one woman with social anxiety who participated in the Harvard study said in an e-mail. "It seemed similar to when I played Scramble or other games on my phone."

In a review of studies of bias modification, researchers at the University of Pennsylvania concluded last year that the technique had a small effect that "significantly modified anxiety but not depression." The authors noted that there was evidence of what scientists call a "file drawer" problem — in which studies finding no effect are filed away or ignored, while encouraging ones are published. "I think in this field the standards for publishing positive studies are lower than for negative ones," Dr. Van der Does said in an e-mail.

It is perhaps fitting that the largest study to date — by Phil Enock, a graduate student at Harvard; Stefan Hofmann, of Boston University; and Dr. McNally — produced results that were both encouraging and confusing. The team began recruiting participants in the summer of 2010, using Craigslist and online bulletin boards for social anxiety.

In March 2011, they were flooded, after an article in the Economist magazine about cognitive bias modification mentioned the project. Months later, after 338 participants with anxiety symptoms that ranged from mild to severe completed a total of more than 4,000 sessions of the two-face therapy application, the researchers had some results.

Participants who got the treatment improved their scores on a questionnaire measuring anxiety, dropping by an average of 22 points, compared with an 8-point drop among people in a "waiting list" group, who got no computer games to play. However, a placebo group in the study practiced with a two-face video program not intended to shift the eyes from one face or the other, and their anxiety levels as measured on questionnaires also fell by about 22 points, just as they had for those who got the treatment.

Karin Langer, 34, an architectural historian in Chicago who scored high on some measures of social anxiety, was among those who seemed to improve using the app. Ms. Langer works at home, interacts almost entirely by e-mail, and found herself increasingly anxious about phone conversations with colleagues. "I did notice a difference after using the therapy," she said. "But it may have been due to a placebo effect. I felt good about myself, that I was doing something for my issues, and a lot happened in those two months outside the study that could have helped."

Stranger still, the people who reported that they had learned about the study from the Economist article responded very well to the program — whether getting the treatment app or the placebo one — as if the article itself had some power of suggestion.

"We're not exactly excited about that finding; we have no idea what it means," said Mr. Enock, adding that there is still a lot of work to do to determine who best responds to which specific type of bias modification, and how strong the effect really is.

But, he said, "We certainly have shown that you can deliver treatments on smartphones, you can put attention and bias modification tools literally in people's hands, and there's no reason to hold back" from testing them.

Sunday, February 12, 2012

Daddy Issues - The Atlantic

RECENTLY, A COLLEAGUE at my radio station asked me, in the most cursory way, as we were waiting for the coffee to finish brewing, how I was. To my surprise, in a motion as automatic as the reflex of a mussel being poked, my body bent double and I heard myself screaming:


Startled, and subtly stepping back to put a bit more distance between us, my co-worker asked what I meant.

"What I mean, Rob, is that even if, while howling like a banshee, I tore my 91-year-old father limb from limb with my own hands in the town square, I believe no jury of my peers would convict me. Indeed, if they knew all the facts, I believe any group of sensible, sane individuals would actually roll up their shirtsleeves and pitch in."

As I hyperventilated over the coffeemaker, scattering Splenda packets and trying to unclaw my curled fingers, I realized it had finally happened: at 49, I had become a Kafka character. I am thinking of "The Judgment," in which the protagonist's supposedly old and frail father suddenly kicks off his bedclothes with surprisingly energetic—even girlish—legs and, standing ghoulishly tall in the bed, delivers a speech so horrifying, so unexpected, and so perfectly calculated to destroy his son's spirit that his son—who until this point has been having a rather pleasant day writing a letter to a friend, amidst a not unpleasant year marked by continuing financial prosperity and a propitious engagement to a well-placed young woman—immediately jumps off a bridge.

Clearly, my nonagenarian father and I have what have come to be known as "issues," which I will enumerate shortly. By way of introduction, however, let us begin by considering A Bittersweet Season, by Jane Gross. A journalist for 29 years at The New York Times and the founder of a Timesblog called The New Old Age, Gross is hardly Kafkaesque. An ultra-responsible daughter given to drawing up to-do lists for caregivers and pre-loosening caps on Snapple bottles, Gross undertook the care of her mother in as professional a way as possible. She was on call for emergencies and planned three steps ahead by consulting personally with each medical specialist. Like the typical U.S. family caregiver for an elder (who is, statistics suggest, a woman of about 50), Gross worked full-time, but (atypically) she was unencumbered by spouse or children. She had the help, too, of her child-free brother, a calm, clear-headed sort given to greeting his sister with a quiet, reassuring "The eagle has landed." What could go wrong?

Plenty. As Gross herself flatly describes it, in her introduction:

 In the space of three years … my mother's ferocious independence gave way to utter reliance on her two adult children. Garden-variety aches and pains became major health problems; halfhearted attention no longer sufficed, and managing her needs from afar became impossible … We were flattened by the enormous demands on our time, energy, and bank accounts; the disruption to our professional and personal lives; the fear that our time in this parallel universe would never end and the guilt for wishing that it would … We knew nothing about Medicaid spend-downs, in-hospital versus out-of-hospital "do not resuscitate" orders, Hoyer lifts, motorized wheelchairs, or assistive devices for people who can neither speak nor type. We knew nothing about "pre-need consultants," who handle advance payment for the funerals of people who aren't dead yet, or "feeders," whose job it is to spoon pureed food into the mouths of men and women who can no longer hold a utensil.

However ghoulish, it is a world we will all soon get to know well, argues Gross: owing to medical advancements, cancer deaths now peak at age 65 and kill off just 20 percent of older Americans, while deaths due to organ failure peak at about 75 and kill off just another 25 percent, so the norm for seniors is becoming a long, drawn-out death after 85, requiring ever-increasing assistance for such simple daily activities as eating, bathing, and moving.

This is currently the case for approximately 40 percent of Americans older than 85, the country's fastest-growing demographic, which is projected to more than double by 2035, from about 5 million to 11.5 million. And at that point, here comes the next wave—77 million of the youngest Baby Boomers will be turning 70.