Saturday, March 23, 2013

Suddenly, They're All Gone -

Lauri Rotko/Getty Images

Caring for the old is just like parenting an infant, only on really bad acid. It's all there: the head-spinning exhaustion, the fractured brain, the demands and smells. Only this time with the knowledge that it won't get better.

That was my life for five years. First came my mother-in-law, then my father-in-law, then my childless aunt, then my mother — all needing different kinds of help as they weakened and started going downhill, all the care overlapping, and almost all of the work to be done despite distance.

You're so good, friends would murmur, but I wasn't — there were plenty of days I muttered, "Can't do this anymore," and nights when I threw back too many drinks, feeling how badly I needed for it to be over.

Now, though, it is done for real, everyone is dead, and the surprise is that instead of being relieved, I feel worse.

More than a year after the last funeral, I still have all the numbers on speed dial: my in-laws' neighbors in Texas and my aunt's in upstate New York; the security guard at my mother's gated San Diego community; doctors, hospitals and emergency rooms in three states; two home health agencies; the 24-hour hospice nurse. I still sleep with the phone on and stashed on my night table, where I can grab it fast. It's over, but I can't let go. No, it's worse than that: I don't want to.

Maybe there is nothing new to say about the nightmare of shepherding the old through the time that is the prelude to death but not active dying. I knew it would be bad, but you don't really understand until you're there, any more than the childless can grasp why a new mother goes three months without shaving her legs.

"Drowning" was the word that came to my mind as the endless crises unspooled. My terminal mother-in-law, abandoning the 50-year pretense that she could stand her husband to demand: "Put him in a nursing home! Get him out of here!" My father-in-law, newly widowed and alone in an early Alzheimer's haze, barricading himself in the house against caregivers. My aunt, her lungs destroyed by a three-pack-a-day cigarette habit and reeling from one hospitalization after another, begging me to send morphine so she could end it all.

Alerts peppered every hour. Do something! Your father-in-law's behind the wheel again. Your aunt's in the hospital with pneumonia; she's recovering; no, she's failing, come quickly; no, she's been yanked back from death into a life of oxygen concentrators and cognitive crash; find a nursing home — wait, are you in New York? Because your mother's in the hospital in San Diego and it could be serious, can you get on a plane?

Frantic was my new normal and normal the new never, because when someone is old, especially if dementia is involved, nothing is routine. Even the answer to a straightforward question, like "What day is it?," vanishes on the wind; every patched-together arrangement works only until it doesn't.

"Drowning" — also buried, shredded, torn apart. Helping my daughter prep for the SAT, cooking family dinners and maintaining a professional life, while also paying three sets of bills, running three houses in three cities, either planning a trip to see how things were going or recovering from that trip, and never living in just one place.

I started keeping my cellphone on my desk, then leaving it on all night, and finally didn't even risk putting it down because the one time I did, to watch my child in a high school soccer game, there were five frantic caregiver messages by halftime: Where are you, what should I do, she can't breathe!

And yet: Parenting on bad acid is still parenting. I wasn't one of those women who went all dewy-eyed the second she gave birth. "I don't feel anything," I remember thinking in dull panic as I looked at my squash-faced, just-born daughter. "How can I love her? She's a stranger." Within two weeks, though, I was transformed, flattened by a passion I had never even dreamed existed, and it was the grunt work of motherhood that did it to me, the holding, touching, watching, feeding, smelling — the getting to know the specifics of this little creature in a way that went down to my bones.

I had always imagined that you put up with the job of caring for a baby because you loved her, but for me it was the unfathomable, slightly terrifying intimacy of caregiving that brought the love.

And with my old people, it was the same. The fried-brain resentment that gets you drinking at night fades when you are with someone in the living room or kitchen. Just as it is with a baby, your job is tending, and the comfort you bring is simple and physical. You sit for hours, the heat always cranked up high, doling out pills and pouring water, changing the nitro patch, combing hair. You fix lunch, rub in skin cream.

You come to know the precise texture of thin, dry skin, the kind of touch that pleases, the small things that bring a smile. My father-in-law had to have vanilla ice cream every day, but only Blue Bell brand and in a waffle cone. Even with her thinking garbled, my aunt needed the New York Times crossword puzzle and endless games of gin rummy. My techno-challenged mother wanted written computer instructions to consult the next time the infernal machine swallowed her text.

More than anything else, when you're with the old, you listen. My Greatest Generation/Army veteran father-in-law, whose interest in the world essentially ended in the late 1950s, talked in endless circles about his small-town childhood and the World War II campaigns of Italy and North Africa. My aunt, obese and isolated for years in a small upstate town, had spent her 30s and 40s single, teaching history in New York City public schools for nine months a year, then buying elegant clothes and setting out for Europe and Africa.

The giraffes came down to the water hole every night, right in front of where I stayed…. One night, in Turkey, in a cafe next to the sea, we danced in the moonlight….

When the present is unbearable and there is no future, the past comes rushing back: family history, secrets and buried memories rising out of the ether. My relentlessly forward-thinking mother never dwelled on sorrow or regret, but my Aunt Belle committed suicide by jumping in front of a subway train, she told me one night as we sat among the empty cups and crumbs at the dinner table.

I was home alone when someone called. I had to tell my father that his sister was dead. I'd never seen him cry before.

I could see it all: my father-in-law's bungalow in Crandall, Tex., whose open front door proved irresistible to a contrary billy goat one day in the 1920s. The 10-cents-an-hour wage my aunt earned tending a booth on the Coney Island boardwalk during the Depression — I was saving to buy myself a new pair of shoes, but my mother took the money and I still can't forgive her for it. My mother's quiet, wild joy during her first winter in Ithaca, N.Y., when a Cornell scholarship let her escape the dirt and smudge of Queens to a snowfall that stayed white.

All the years I was young, the center of life's drama, I barely saw these people. Now they were simultaneously disappearing and becoming unbearably real to me, heartbreakingly diminished and yet still powerful, deeply rooted trees that against all reason would not let go.

There was my 98-pound mother, befriending the immigrant podiatrist who tried to relieve her painful, bunion-crippled feet; limping to her desk and squinting her one good eye at that maddening computer, so she could finish an article for her community newspaper. There was my wheezing, demented aunt, frowning at the sign "Don't Toutch" that her caregiver had placed above a complicated new hallway thermostat, and pushing her walker to it so she could correct the spelling.

Their singularity dazzled me. Their selves, revealed in all their layered complexity, could never be replaced. I came to know them — and I fell in love.

When you care for the old, life can go on unchanged for years. Then suddenly, without much warning, everything shifts. Six months after her cancer diagnosis, my mother-in-law died; 18 months later, my father-in-law fell, had a small stroke, fell again and lasted only two months in the Alzheimer's unit of a nursing home.

Two years after she survived near-death by respiratory failure, my aunt's breathing got so bad she couldn't even make it to the bathroom; she wanted only to sleep, to talk to her long-dead sister, who she insisted she heard on the stairs. You'd better come quick. Minutes after my plane landed at Kennedy Airport I got the call saying she was gone.

Not long after my mother, radiant in a sun-colored jacket and pearls, celebrated her 90th birthday with a huge party, she said her stomach hurt. A week later, I was in a hospital room sobbing against her cold, still shoulder.

I have my life back now, but that fact is less simple than it was before. When I look at the mementos I've inherited, the crumbling photo albums, cookbooks that smell of cigarette smoke, '50s furniture and cut glass, I also see where they used to sit, in other places and rooms. I miss the quiet afternoons, the houses that eventually came to feel like home, in cities I'll never again have reason to visit. I miss it all. I miss them.

Sometimes, when I'm out, I catch a glimpse of a short, gray-haired man in a baseball cap or a skinny old woman in a tailored bright jacket and my heart stops. I see my old people everywhere, which only reminds me that I'll never see them again.

When you have a baby, it's as if your whole self shifts, reshaping itself around a presence that later you can't even remember living without. You reach down and take a small hand, and joined, you hurtle toward the future. Death just offers stasis, absence, dissolving shadows.

None of that was a surprise, but it's still a shock. While you're caring for the old, you can't believe what you're called on to do and where you find yourself, can't believe that your time with them will ever end. Then one day, it just does.

Carol Mithers is a Los Angeles-based journalist and the co-author, with the 2011 Nobel Peace Prize winner, Leymah Gbowee, of "Mighty Be Our Powers: How Sisterhood, Prayer, and Sex Changed a Nation at War."

Friday, March 22, 2013

Group appointments with doctors: When three isn't a crowd - Vitals

When visiting the doctor, there may be strength in numbers.
In recent years, a growing number of doctors have begun holding group appointments -- seeing up to a dozen patients with similar medical concerns all at once. Advocates of the approach say such visits allow doctors to treat more patients, spend more time with them (even if not one-on-one), increase appointment availability and improve health outcomes.
Some see group appointments as a way to ease looming physician shortages. According to a study published in December, meeting the country's health-care needs will require nearly 52,000 additional primary-care physicians by 2025. More than 8,000 of that total will be needed for the more than 27 million people newly insured under the Affordable Care Act.
"With Obamacare, we're going to get a lot of previously uninsured people coming into the system, and the question will be 'How are we going to service these people well?' " says Edward Noffsinger, who has developed group-visit models and consults with providers on their implementation. With that approach, "doctors can be more efficient and patients can have more time with their doctors."
Some of the most successful shared appointments bring together patients with the same chronic condition, such as diabetes or heart disease. For example, in a diabetes group visit, a doctor might ask everyone to remove their shoes so he can examine their feet for sores or signs of infection, among other things. A typical session lasts up to two hours. In addition to answering questions and examining patients, the doctor often leads a discussion, often assisted by a nurse.
Insurance typically covers a group appointment just as it would an individual appointment; there is no change in the co-pay amount. Insurers generally focus on the level of care provided rather than where it's provided or how many people are in the room, Noffsinger says.
Some patients say there are advantages to the group setting. "Patients like the diversity of issues discussed," Noffsinger says. "And they like getting 2 hours with their doctor."
Patients sign an agreement promising not to disclose what they discuss at the meeting. Although some patients are initially hesitant about the approach, doctors say their shyness generally evaporates quickly.
"We tell people, 'You don't have to say anything,' " says Edward Shahady, medical director of theDiabetes Master Clinician Program at the Florida Academy of Family Physicians Foundation in Jacksonville. Shahady trains medical residents and physicians to conduct group visits with diabetes patients. "But give them 10 minutes, and they're talking about their sex lives."
Though group appointments may allow doctors to increase the number of patients they see and thereby boost their income, many doctors are uncomfortable with the concept, experts say, because they're used to taking a more authoritative approach with patients rather than facilitating a discussion with them.
According to the American Academy of Family Physicians, 12.7 percent of family physicians conducted group visits in 2010, up from 5.7 percent in 2005.
Some studies have found that group visits can improve health. In an Italian trial that randomly assigned more than 800 Type 2 diabetes patients to either group or individual care, the group patients had lower blood glucose, blood pressure, cholesterol and BMI levels after four years than the patients receiving individual care.
Doctors say patients may learn more from each other than they do from physicians. "Patients really want to hear what others patients are experiencing," Shahady says.
Jake Padilla of Westminster, Colo., participated in his first group visit more than a decade ago, shortly after he had heart bypass surgery.
Padilla, now 67, continued to attend group appointments geared to primary-care patients' concerns for years after that at the Kaiser Permanente outpatient clinic near his home. (Kaiser Health News is not affiliated with Kaiser Permanente.) He usually went once a month or so, and the members of the group constantly changed.
One woman who attended the group was 102 years old, he remembers. Fellow patients wanted to know how she managed to live that long. One of her secrets, she said, was deep breathing. Padilla has since used that advice when his blood pressure gets out of control.
But group visits aren't for everyone. Padilla's wife, Tedi, went to one meeting with him and never went back.
"She said she didn't have time to sit there and listen to all those patients," he says.

Thursday, March 21, 2013

American Academy of Pediatrics Backs Gay Marriage -

The American Academy of Pediatrics declared its support for same-sex marriage for the first time on Thursday, saying that allowing gay and lesbian parents to marry if they so choose is in the best interests of their children.

Dr. Travis Kidner, who is in a same-sex marriage, with his children Zoe (being carried) and Nicholas in Los Angeles on Wednesday

The academy's new policy statement says same-sex marriage helps guarantee rights, benefits and long-term security for children, while acknowledging that it does not now ensure access to federal benefits. When marriage is not an option, the academy said, children should not be deprived of foster care or adoption by single parents or couples, whatever their sexual orientation.

The academy's review of scientific literature began more than four years ago, and the result is a 10-page report with 60 citations.

"If the studies are different in their design and sample but the results continue to be similar, that gives scientists and consumers more faith in the result," said Dr. Ellen Perrin, a co-author of the new policy and a professor of pediatrics at Tufts University School of Medicine.

Other scientists called the evidence lackluster and said the academy's endorsement was premature. Loren Marks, an associate professor of child and family studies at Louisiana State University in Baton Rouge, said there was not enough national data to support the pediatric association's position on same-sex marriage. "National policy should be informed by nationally representative data," he said. "We are moving in the direction of higher-quality national data, but it's slow."

The academy cited research finding that a child's well-being is much more affected by the strength of relationships among family members and a family's social and economic resources than by the sexual orientation of the parents. "There is an emerging consensus, based on extensive review of the scientific literature, that children growing up in households headed by gay men or lesbians are not disadvantaged in any significant respect relative to children of heterosexual parents," the academy said.

A large body of evidence demonstrates that children raised by gay or lesbian parents fare as well in emotional, cognitive and social functioning as peers raised by heterosexuals, the academy said.

One study in England compared 39 families with lesbian mothers to 74 heterosexual parents and 60 families headed by single heterosexual women. No difference was found between the groups in emotional involvement, abnormal behaviors in children as reported by parents or teachers, or psychiatric disorders in them. Both mothers and teachers reported more behavioral problems among children in single-parent families than two-parent ones, whatever their sexual orientation.

A 2010 study of children born to 154 lesbian parents in the United States compared mothers' reports of their 17-year-olds to a national sample of age-matched peers. The mothers' reports indicated that their sons and daughters had high levels of competence and fewer social problems, compared with their peers.

"Marriage strengthens families and benefits child development, and it also increases a parent's sense of competence and security when they are able to raise children without stigma," said Dr. Nanette Gartrell, the lead author of the study and a visiting scholar at the University of California, Los Angeles, School of Law.

The research on same-sex marriage has limitations, experts note, including the relatively small sample sizes of gay or lesbian parents even in long-term studies. Many studies have relied on parental assessments of their children's well-being, and there is relatively little data about the well-being of children raised by gay men compared with lesbians.

"Many studies compare wealthy, well-educated lesbian mothers to single heterosexual mothers instead of married couples," Dr. Marks said. "This matters, because children from married families do better on numerous outcomes including psychological and physical health and avoidance of high-risk behaviors than children of single-parent families."

Timm Ryan-Young, a 48-year-old married Brooklynite and father of Zelia, 6, found the academy's support of same-sex marriage reaffirming.

"Whenever a formal institution validates or confirms that a same-sex family is valid," he said, "and there are no measurable negatives to it, or deterrents to it, it means a great deal, frankly."

Dr. Travis Kidner, 36, a surgeon in Los Angeles, and Hernan Lopez, 42, a media executive, married in 2008 and adopted Nicholas, 2 1/2 years old, and Zoe, 21 months. "It's important for kids to know they are from a stable home and that their parents are married," Dr. Kidner said.

The pediatrics academy's support for same-sex marriage heartened him. "The arc is in our favor now," he said.

Another reason same-sex couples should be allowed to marry, the academy said, is that divorce law provides for a legally structured arrangement for visits and custody.

"If people can't get married, then they can't get divorced," Dr. Perrin said. "That legal system that exists to protect our most vulnerable, namely children, isn't in play." 

Kaiser Permanente Is Seen as Face of Future Health Care -

When people talk about the future of health care, Kaiser Permanente is often the model they have in mind.

The organization, which combines a nonprofit insurance plan with its own hospitals and clinics, is the kind of holistic health system that President Obama's health care law encourages.

Kaiser has sophisticated electronic records and computer systems that — after 10 years and $30 billion in technology spending — have led to better-coordinated patient care, another goal of the president. And because the plan is paid a fixed amount for medical care per member, there is a strong financial incentive to keep people healthy and out of the hospital, the same goal of the hundreds of accountable care organizations now being created.

"Over the course of the last 15 years, they've been just going into high gear and doing everything right," said Dr. Thomas S. Bodenheimer, a health policy expert at the University of California, San Francisco who recently chose Kaiser as his own health plan.

Yet even with all of its effort, its chairman and chief executive, George C. Halvorson, acknowledges Kaiser has yet to achieve the holy grail of delivering that care at a low enough cost. He says he and other health systems must fundamentally rethink what they do or risk having cost controls imposed on them either by the government or by employers, who are absorbing the bulk of health insurance costs. "We think the future of health care is going to be rationing or re-engineering," he said.

Mr. Halvorson is convinced that Kaiser's improvements in the quality of care save money. But he also says that the way to get costs lower is to move care farther and farther from the hospital setting — and even out of doctors' offices. Kaiser is experimenting with ways to provide care at home or over the Internet, without the need for a physical office visit at all. He also argues that lower costs are going to be about finding ways to get people to take more responsibility for their health — for losing weight, for example, or bringing their blood pressure down.

"The obesity work is incredibly difficult," he said. "It's very, very hard to move the needle."

Other health care experts say that while Kaiser has a place in the future, whether it is the best model for the country's health care remains unclear. "They have not translated some of their strengths into better prices," said David Lansky, the president and chief executive of the Pacific Business Group on Health, which represents employers on the West Coast, many of whom purchase coverage from Kaiser for their workers.

And there are other concerns, such as whether an all-encompassing system like Kaiser's can really be replicated and whether the limits it places on where patients can seek care will be accepted by enough people to make a difference. Or whether, as the nation's flirtation with health maintenance organizations, or H.M.O.'s, in the 1990s showed — people will balk at the concept of not being able to go to any doctor or hospital of their choice.

"The more you restrict the patient's ability to do what they want, you risk reigniting the backlash we had in the past," Mr. Lansky said.

In many ways, Kaiser has been ahead of the curve on health care for decades. Started by a surgeon running a tiny hospital near Desert Center, Calif., to serve construction workers, Kaiser became an H.M.O. with its own doctors and hospital in the mid-1940s and expanded beyond California over the next 50 years. But, as H.M.O.'s fell out of favor, it was forced to leave states like New York, Connecticut and Texas.

But Kaiser persevered, and its membership, which peaked in 1998, is now about the same as its previous high of 9.1 million, about three-quarters of whom are in California. It still operates in a half-dozen states from Maryland to Hawaii and is looking to expand in the Mid-Atlantic region, where membership had been dropping.

The organization, with some $50 billion in annual revenue, owns 37 hospitals and employs 17,000 doctors, all on salary. And its integrated model is in favor again. Hospitals across the country are buying physician practices or partnering with doctors and health insurers to form accountable care organizations, or A. C.O.'s, as a way of controlling more aspects of patient care. Doctors are also creating so-called medical homes, where patient care is better coordinated.

The days when doctors, hospitals and other providers are paid separately for each procedure will disappear eventually, health experts say. Instead, providers will have financial incentives to encourage them to keep people healthy, including lump sums to care for patients or provide comprehensive care for a specific condition. "All of care is going to move down this path, and it has to," Mr. Halvorson said. "Medical homes are doing it; the very best A. C.O's are going to figure out how to do it."

The move by hospitals to buy physician practices is being viewed cautiously by health experts, who say there are downsides to the creation of large health care systems that may be motivated by the desire to increase their clout in the market, making it easier to fill beds and charge the insurers more for care. "They become these huge local monopolies," said Dr. Robert Berenson, a health policy expert at the Urban Institute.

But having an integrated system seems essential to the success of Kaiser and a handful of similar, if smaller, organizations, like Intermountain Healthcare in Utah and Geisinger Health System in Pennsylvania, although some work with doctors whom they do not employ. In California, Kaiser controls nearly every aspect of a patient's care, from providing the M.R.I. for a diagnosis to filling a prescription at one of its pharmacies to running a hospital where the patient undergoes surgery.

"We have all the pieces," said Philip Fasano, Kaiser's chief information officer. "Anything a patient needs you get in the four walls of our offices," he said. As a result, while Kaiser can point to an analysis done by Aon Hewitt, a benefits consultant, showing that its plans are typically at least 10 percent less expensive than others, especially where they control all the providers, its costs are more like the average in places in Ohio, where it does not have its own hospitals and offer as broad a range of services.

And some patients outside of California, where Kaiser operations are less concentrated, complain about being forced to travel for treatment by Kaiser providers. Arva Priola, a 62-year-old Kaiser patient in Fredericksburg, Va., said her Kaiser doctors "are wonderful," but that the plan recently started requiring her to get some treatments where they had physical facilities.

To get IV antibiotics after surgery, for example, she recently had to drive an hour and a half to a Kaiser office in Tysons Corner, Va. "Who wants to drive when you're sick?" she asked. Kaiser says it is adding more services closer to Fredericksburg.

A California state agency recently criticized Kaiser for the long wait times its members had for mental health services and for providing inaccurate information about what services it provides. Kaiser says it has corrected the misinformation and is working to reduce and better track member wait times.

Where Kaiser has a head start that others may have difficulty catching up to is its use of electronic records and technology systems for tracking patient care.

When Dr. Jennifer Slovis, a Kaiser internist in Oakland, recently saw a patient, she was able to spot that the patient had an abnormal blood test several years ago. By reading through the patient's medical history, she determined he was now overdue for an M.R.I. to check the status of a growth in his brain. She was able to e-mail his endocrinologist and schedule the necessary tests without the patient having to make an appointment with the specialist or her having to make her own diagnosis. "It saved a lot of starting over," she said.

In the last five or so years, Kaiser has also been using the information to identify those doctors or clinics that excel in certain areas, as well as those in need of improvement. The organization has also used the records to change how it delivers care, identifying patients at risk for developing bed sores in the hospital and then sending electronic alerts every two hours to remind the nurses to turn the patients. The percentage of patients with serious pressure ulcers, or bed sores, dropped to well under 1 percent from 3.5 percent.

"The tool is an enabler to give information to people who give a damn," said Dr. Jack Cochran, the executive who represents Kaiser's physicians through the Permanente Federation.

Mr. Halvorson, the Kaiser chief, who plans to retire at the end of this year, says the organization is providing evidence to other health systems that re-engineering works. "All of that adds up to better care and cheaper care," he said.

Wednesday, March 20, 2013

Sherpaa - blog

Sherpaa was founded by Dr. Jay Parkinson and Cheryl Swirnow when the need of a real change in healthcare became all too evident. Though so many great companies andcenter for your health needs.

We've gathered a group of amazing doctors to provide the exact care you need. These doctors know healthcare needs to be delivered in a better way. They're driven, well-trained, and have great personalities.

Our job is to make sense of all your health options for you, both in your neighborhood and online. We're working together to simplify your health. Wish us luck.

Jay Parkinson, The Doctor Is in (Well, Logged in) -

Surfing the Web in his all-white Dumbo loft, Dr. Jay Parkinson, 37, looks like any other young tech visionary. He has a trim beard and thick-framed glasses. He wears slim-fitting black outfits and jaunty scarves. He speaks with a measured, "This American Life"-like cadence. And he's a firm believer in the utopian promise of the Internet.

But Dr. Parkinson's start-up isn't a new app or social network. He is a founder of Sherpaa, a Web site that operates like a virtual doctor's office, examining patients by e-mail and text message.

"We're using the Internet to reinvent health care," Dr. Parkinson said proudly, seated next to a Ping-Pong table and a shaggy goldendoodle.

Have a mysterious rash? Send a photo of it to Sherpaa, reply to a few e-mails (Are you sure it's not a bruise? Do you have bed bugs?), and proceed to the nearest Duane Reade to pick up your prescription.

This may seem like health care for the "OMG, I'm sick :( " generation, but clients include high-tech players in New York like Tumblr, Skillshare, General Assembly and Hard Candy Shell. "We're tech-savvy doctors," he said, "for tech-savvy patients."

In fact, Dr. Parkinson is perhaps the most prominent of the city's 2.0 doctors, who are rethinking the health care model along 21st-century lines.

In 2007, after graduating from Penn State College of Medicine, and completing a residency in pediatrics at St. Vincent's Manhattan Hospital in Greenwich Village, and another in preventive medicine at Johns Hopkins in Baltimore, he did what every young roustabout did at the time: he moved to Williamsburg, Brooklyn.

Dr. Parkinson rented a ground-floor apartment on North Ninth Street, and spent his nights at Hotel Delmano and the Brooklyn Ale House and his days caffeinating at Atlas Cafe. He was adrift.

"I knew I didn't want to join a private practice," he said. "I'd be the low man on the totem poll, get paid poorly and not be in control of my hours."

Instead, he started a self-titled blog on which he wrote about health issues relevant to the L train crowd, like the dangers of cocaine and the wonder of Thom Yorke's left eye ptosis. He also started a Tumblr page, which included a flattering photo of himself standing underneath the Williamsburg Bridge with a stethoscope.

Rather than set up a standard practice — an office with, say, back issues of Vice magazine and a surly tattooed receptionist to schedule appointments — he invited patients to contact him directly through instant message and e-mail. "We can figure out if I need to come to your work, your home or meet somewhere else in the city," he wrote on the site. "We can even meet in the park or a coffee shop."

The concept seemed so trendy that Gawker mocked Dr. Parkinson in a post entitled, "Williamsburg's Hipster Doctor Will Diagnose You Via IM." The article went viral. "When I read that," he recalled, "I thought my career was over. But after it came out, I had seven million visitors on my site that month. I was offered both a book deal and a movie deal. 'The Tyra Banks Show' called. They wanted me as their Dr. Oz."

(Full disclosure: I was an editor at Gawker at the time but did not write the post in question.)

Dr. Parkinson turned down the various offers, but he rode the wave of popularity. He started a design consultancy called the Future Well. He also stopped seeing patients and let his license to practice medicine lapse. "Seeing patients is stressful for me," Dr. Parkinson said. Instead, he networked.

He held parties, cocktail mixers and backyard barbecues that attracted Web luminaries like David Karp, founder of Tumblr; Chris Hughes, a founder of Facebook and current publisher of The New Republic; and Jakob Lodwick, a founder of Vimeo. "The Internet crowd really latched on to my practice," Dr. Parkinson said.

Instead of making house calls to ailing freelancers, Dr. Parkinson was now hobnobbing with their bosses. His new start-up, he decided, would work exclusively with companies.

Started in 2012, Sherpaa now has eight employees, including two primary-care physicians, and counts 500 customers from 30 companies. Sherpaa's network includes 100 specialists to whom it refers clients.

More than offering 24/7 service, Sherpaa's main selling point to employers is cost. By moving away from a reliance on traditional primary-care physicians and emergency room visits, Sherpaa claims that it can save companies up to $4,000 a year for each employee. (It charges $50 a month for each employee.)

Dr. Parkinson still holds mixers for hepcat medical professionals. At a recent barbecue, he served sausages from the Meat Hook and whisky cheese from the Bedford Cheese Shop at the apartment he now shares with his girlfriend, Paige Ferrari, 30, a producer for "Doomsday Preppers." The décor is classic Bedford Avenue contemporary: a pair of suspenders hang from a lamp; a stuffed javelina is mounted above the bed.

Sitting under a vintage World War II Red Cross flag, guests discussed the health issues of the day like the "quarter-life crisis" among 20-somethings and "hipster belly," a result of too much pulled pork and too few pull-ups.

"Part of being a 20-year-old is doing stupid things," said Dr. Parkinson, spearing a bratwurst. "And part of being a 30-year-old is realizing you can't have this sexy body doing the same thing forever."

Doctors Urge F.D.A. to Restrict Caffeine in Energy Drinks -

A group of 18 doctors, researchers and public health experts jointly urged the Food and Drug Administration on Tuesday to take action on energy drinks to protect adolescents and children from the possible risks of consuming high amounts of caffeine.

"There is evidence in the published scientific literature that the caffeine levels in energy drinks pose serious potential health risks," the doctors and researchers wrote.In their letter to Dr. Margaret A. Hamburg, the F.D.A. commissioner, the group argued that energy drink makers had failed to meet the regulatory burden placed on them to show that the ingredients used in their beverages were safe, specifically where children, adolescents and young adults are concerned. As a result, the group urged the F.D.A. to restrict caffeine content in the products and to require manufacturers to include caffeine content on product labels.

A similar letter was sent to the agency by the San Francisco city attorney, Dennis J. Herrera, who is one of several public officials conducting investigations of the energy-drink industry.

Energy drink makers have insisted their products are safe and that their levels of caffeine, a stimulant, are on a par with other widely consumed drinks, like coffee.

The F.D.A. has said that it is safe for adults to consume about 400 milligrams of caffeine daily, though many experts say that most adults can consume 600 milligrams or more of caffeine without ill effect. A 16-ounce cup of Starbucks coffee has about 330 milligrams of caffeine, an amount about twice that of some similarly sized energy drinks.

Less is known about the safe level of caffeine for a young teenager, experts say, apart from the fact that it is considered to be lower than for an adult. In their letter Tuesday to Dr. Hamburg, the group of researchers and scientists also pointed out that makers of energy drinks aggressively marketed their products to young teenagers and urged them to consume the drinks quickly.

In recent years, the number of reported emergency-room visits in which an energy drink was cited as the primary cause of a health problem, or a contributing factor, has grown sharply. In 2011, there were 20,783 such visits, compared with 10,068 in 2007. Problems typically linked to excessive caffeine consumption can include anxiety, headaches, irregular heartbeats and heart attacks.

Tuesday, March 19, 2013

Cynthia Wachenheim's suicide shows us that new mothers can be vulnerable to anxiety and depression - Slate

On Wednesday, a New York lawyer and new mother named Cynthia Wachenheim strapped her baby son, Keston, to her chest and jumped from the eighth floor of her building. Her 10-month-old son, snug in his Ergo carrier, survived, barely injured. Wachenheim died from her injuries. According to the New York Times, the 44-year-old Wachenheim left behind a 13-page suicide note in which she wrote that she was convinced that her son might have autism or cerebral palsy because he had two minor tumbles—the kind most babies have at some point—and she felt responsible. Her pediatrician did not believe anything was wrong with the child, but she was convinced her son was damaged and that it was her fault.

It's pretty clear that Wachenheim was suffering from postpartum psychosis and was not, to use a cliché that doesn't feel like it expresses the gravity of the situation, in her right mind. No mother, especially a woman who by all accounts was an upstanding and decent person, would do this to herself or her child unless she was in the throes of an awful, debilitating mental illness. That didn't stop Above the Law's Elie Mystal from writing a painfully ignorant post about Wachenheim in which he calls her "a monster" and says that because his family just had a newborn, he's "acutely aware of all the time hospitals, pediatricians, and psychiatrists put in telling new parents how to handle the feelings of anxiety and sometimes depression that affect new parents." He also assumes that Wachenheim refused to seek out "readily available help with her mental health issues" based on no evidence. He says that because she had the money and education to deal with her mental health, she is a monster for not fixing it.

I don't purport to know where Mystal's partner gave birth or what her experience was. But just because she was well-informed about the risk of depression before and after pregnancy doesn't mean everyone is. I know from the survey I did of more than 1,000 women on pregnancy and depression that many women don't get any information from hospitals, pediatricians, or psychiatrists on depression or anxiety and get no support from their families. Secondly, even psychiatrists treating patients in the hospital (and immediate inpatient hospitalization is the recommendation for women experiencing postpartum psychosis) have a notoriously bad track record at predicting which ones will commit suicide. We don't know what went on in Wachenheim's final days, but it's quite possible that her family members—despite having advanced degrees—did not realize how bad things were or were in denial about her mental health. 

According to New York state health department stats cited by the Times, postpartum psychosis affects one to two out of every 1,000 new moms; of those one to two moms, 5 percent commit suicide and 4 percent commit infanticide. "Symptoms may appear abruptly" according to the health department, so Mystal's assumption that she would have even had time to get help is really dim. (For another rebuttal to Mystal, Wachenheim's childhood friend Elizabeth Nowicki wrote this important corrective on Above the Law.)

The specific anxieties that Wachenheim mentioned in her suicide note are extreme and obviously the thoughts of a disturbed mind. Still, it's alarming how much they reflect the current thinking about how much mothers are responsible for the ultimate sound health of their newborns. What they eat, what they don't eat, what mood they are in, how long they wait to get pregnant, even what music they listen to—mothers are constantly reminded that every move they make can leave lasting damage on a baby and make them more prone to get even serious diseases like autism and other developmental disorders. (For a great roundup of the crazy-making information about what pregnant women are supposed to do to keep their kids healthy, check out this hilarious and depressing Jezebel post). Of course Wachenheim's psychotic mind could have grabbed onto some other anxiety if fears of autism weren't so outsized in the United States. But her case should give us a slap-in-the-face reminder to lay off a little—new mothers can be vulnerable enough without the extra anxiety.

Staggering 1 in 3 seniors dies with dementia, report says | CTV News

A staggering 1 in 3 seniors dies with Alzheimer's disease or other types of dementia, says a new report that highlights the impact the mind-destroying disease is having on the rapidly aging population.
Dying with Alzheimer's is not the same as dying from it. But even when dementia isn't the direct cause of death, it can be the final blow - speeding someone's decline by interfering with their care for heart disease, cancer or other serious illnesses. That's the assessment of the report released Tuesday by the Alzheimer's Association, which advocates for more research and support for families afflicted by it.
"Exacerbated aging," is how Dr. Maria Carrillo, an association vice president, terms the Alzheimer's effect. "It changes any health care situation for a family."
In fact, only 30 percent of 70-year-olds who don't have Alzheimer's are expected to die before their 80th birthday. But if they do have dementia, 61 percent are expected to die, the report found.
Already, 5.2 million Americans have Alzheimer's or some other form of dementia. Those numbers will jump to 13.8 million by 2050, Tuesday's report predicts. That's slightly lower than some previous estimates.
Count just the deaths directly attributed to dementia, and they're growing fast. Nearly 85,000 people died from Alzheimer's in 2011, the Centers for Disease Control and Prevention estimated in a separate report Tuesday. Those are people who had Alzheimer's listed as an underlying cause on a death certificate, perhaps because the dementia led to respiratory failure. Those numbers make Alzheimer's the sixth leading cause of death.
That death rate rose 39 percent in the past decade, even as the CDC found that deaths declined among some of the nation's other top killers - heart disease, cancer, stroke and diabetes. The reason: Alzheimer's is the only one of those leading killers to have no good treatment. Today's medications only temporarily ease some dementia symptoms.
But what's on a death certificate is only part of the story.
Consider: Severe dementia can make it difficult for people to move around or swallow properly. That increases the risk of pneumonia, one of the most commonly identified causes of death among Alzheimer's patients.
Likewise, dementia patients can forget their medications for diabetes, high blood pressure or other illnesses. They may not be able to explain they are feeling symptoms of other ailments such as infections. They're far more likely to be hospitalized than other older adults. That in turn increases their risk of death within the following year.
"You should be getting a sense of the so-called blurred distinction between deaths among people with Alzheimer's and deaths caused by Alzheimer's. It's not so clear where to draw the line," said Jennifer Weuve of Chicago's Rush University, who helped study that very question.
The Chicago Health and Aging Project tracked the health of more than 10,000 older adults over time. Weuve's team used the data to estimate how many people nationally will die with Alzheimer's this year - about 450,000, according to Tuesday's report.
That's compatible with the 1 in 3 figure the Alzheimer's Association calculates for all dementias. That number is based on a separate analysis of Medicare data that includes both Alzheimer's cases and deaths among seniors with other forms of dementia.
Last year, the Obama administration set a goal of finding effective Alzheimer's treatments by 2025, and increased research funding to help. It's not clear how the government's automatic budget cuts, which began earlier this month, will affect those plans.
But Tuesday's report calculated that health and long-term care services will total US$203 billion this year, much of that paid by Medicare and Medicaid and not counting unpaid care from family and friends. That tab is expected to reach $1.2 trillion by 2050, barring a research breakthrough, the report concluded.

Psych Effects Linger After False Positive Mammograms - ABC News

Mammograms can detect breast cancer early, and save lives. But they can also lead to false alarms that take a heavy psychological toll, a new study found.

The Danish study of more than 1,300 women found that those who received "false positive" results on their screening mammograms reported symptoms of anxiety and depression that still lingered three years later, long after a cancer diagnosis had been ruled out. Their psychological well-being was more closely matched to that of breast cancer patients than healthy women.

"It is comparable to a life crisis, like getting divorced or the death of a close family member," study author Dr. John Brodersen of the University of Copenhagen's department of public health said of mammogram false positives. "People don't trust their body anymore; they interpret their body systems differently; they go to the doctor more frequently the search for security to know they are healthy. These women are turned from healthy people to people [at] risk, to people who are close to being sick."

Women who had false positives were also more likely to report disturbances in sleep and sexuality, according to the study, published today in the journal Annals of Family Medicine.

One in eight American women will battle breast cancer in her lifetime, according to the American Cancer Society. In 2013, roughly 232,340 women will be newly diagnosed with invasive breast cancer. Nearly 40,000 women will die from the disease.

The U.S. Preventive Services Task Force recommends biennial mammograms for women between the ages of 50 and 74. The test, an x-ray of the breast, is often the first step in diagnosing breast cancer. But it can also lead to unnecessary tests and procedures, such as biopsies and lumpectomies, not to mention stress.

"Any abnormal finding sends a woman into a tailspin," Lillian Shockney, a breast cancer nurse at Johns Hopkins Hospital in Baltimore, told "It's awful. But she would rather know if she has something ominous in her breast or not."

A 2012 study of 100,000 women suggested the risks of mammogram false positives may even outweigh the benefits. It's estimated that for one woman's life to be saved, 2,000 women have to be screened, leading to 200 false positives and 10 unnecessary surgeries.

"The default is to assume that screening must be good; catching something early must be good," study author James Raftery, professor of health technology assessment at the University of Southampton, U.K., told at the time. But "breast cancer screening was introduced because it was assumed to benefit women's health overall. And the side effects are pretty damn serious."

Breast cancer screening guidelines have been a topic of ongoing of debate among researchers, with some studiessupporting more frequent screening for women over 40and others suggesting a minimal role for mammography in the reduction of breast cancer mortality overall.

In June 2012, the American Medical Association came out in support of routine mammography for women starting at age 40, bucking the USPSTF recommendation. And in Janurary 2013, a review of Medicare data found that more then $410 million was spent on screening women 75 and older -- another group for whom mammography is not recommended.

But Americans appear to like their screening, according to a 2011 Gallup poll that found that 58 percent of responders were satisfied with the current level of screening and 31 percent wished there was more. A mere 7 percent thought there was too much.

Brodersen hopes his study will highlight the risks of overscreening.

"We are producing a need for health care that is unnecessary," he said. "Please stop screening every year from age 40 to death. Trust the USPSTF recommendation."

Monday, March 18, 2013

How Creative Is Your Doctor? -

What are you doing creatively these days?
It's not a question you hear commonly, and certainly not in a medical journal. But that was the title of a commentary in a recent issue of Academic Medicine. It caught my eye, because medicine is a field with a strong history of creativity, but its daily practice feels less and less so. Health care is being pushed steadily toward standardization, insisting on an algorithmic approach to diagnosis and treatment. Some ramifications of this trend have been beneficial, but many of these algorithms have been mechanized to the point where there is little need for human beings and their intricately personal neural networks.
Part of this stems from the way in which we are taught to think about clinical medicine. Medical school can seem like an ongoing exercise of committing lists to memory, the only creativity being the mnemonics for memorizing branches of the facial nerve or diseases with anion-gap metabolic acidosis. When students present cases, there is a sense of roteness. A patient with chest pain, for example, becomes, "Rule-out M.I. (myocardial infarction). Get an EKG, serial troponin levels, stress test, cardiology consult…."
Some of this roteness, of course, is thoroughness. You need to cover all your bases to ensure you are not missing anything serious. But rote recitation inhibits the ability to think beyond diagnostic straightjackets.
In one of my recent clinic sessions, I saw four patients with diabetes over the course of a morning. One was a young man whose glucose, weight and early-onset heart disease resist control, despite jogging 10 miles a day and eating like a rabbit. Another was an elderly woman with fragile bones, congestive heart failure and a medication list longer than my arm. A third was a middle-aged man unable to compromise a single French fry in his diet. And the fourth was a middle-aged woman whose depression snowplows all of her other salutary efforts.
Other than insulin dysregulation, these patients have nothing in common. Yet our medical approach is expected to be "standardized."
Dr. Niamh Kelly, the author of the creativity essay, wonders what it would take "to bring the notion of creativity into the everyday delivery of health care." It is a question we, as a profession, should take seriously. Patients and diseases do not come as prepackaged widgets. A slavish approach to standardized treatments without any creativity can do more harm than good. "It is much more important to know what sort of a patient has a disease," the famous Sir William Osler is reputed to have said, "than what sort of a disease a patient has."
When I talk to medical students about how creativity can fit into the medical world, I often cite the case of Witty Ticcy Ray, profiled by Dr. Oliver Sacks in his now-classic book, "The Man Who Mistook His Wife for a Hat." Ray had a severe case of Tourette's syndrome. The unpredictable bouts of facial grimaces and grunts — often laced with expletives — interfered with many aspects of his life. When Dr. Sacks prescribed Haldol, the tics were eliminated, and Ray's job and family life were markedly stabilized as a result.
But in addition to removing the tics, the Haldol had a "side effect" of flattening out Ray's ability to improvise as a jazz drummer. Typically, the medical profession would not have done much at this point beyond nodding sympathetically about having to take the bad with the good.
But Ray and his doctor came up with a plan: Ray would take his medication Monday to Friday, and be the "sober, solid" person that his job required. On weekends, however, he'd ditch the Haldol and be the "witty ticcy Ray," reveling in the frenetic, free-wheeling music that he so loved.
This solution was quite simple, but it was also remarkably creative because it looked beyond the standard definitions of "treatment success" and "medication side-effects." It is unlikely that this arrangement would have come about in the algorithmic approach to medicine that is insisted upon today.
How do we teach creativity in medicine? For one thing, Dr. Kelly suggests, people's creative sides should be brought to the forefront. She imagines water-cooler conversations and medical conferences that start by asking, "What are you doing creatively lately?" There is likely more creative talent lurking in medical professionals, and in patients, than we suspect. Bringing it forward could have a salutary effect on the medical interactions that follow.
Explicitly focusing on the creative process is the important next step. Many medical schools are beginning to incorporate arts, literature and humanities into the curricula. Critics deride this as fluff, but I think it is crucial in medical education.
Poetry is one of my favorite tools because of its unselfconscious focus on metaphor. By definition, metaphor requires the stringing together of parts of the mind that don't normally work together. Master diagnosticians and scientists cogitate in the same way, actively considering ideas that don't normally sit together.
If all patients and their diseases presented in exactly the manner of the textbooks, then the algorithms would be sufficient. Computers could surely do our job much more efficiently. Lord knows, they certainly wouldn't keep misplacing their reading glasses.
But the human condition is far messier — in health and even more so in illness. Complex biology and the many overlays of social, psychological and economic issues make medicine a complicated, and nuanced, affair. The serpentine logic often seems closer to literary metaphor than to the orderly taxonomy of knowledge that we cut our teeth on.
It is our job as clinicians to work with patients to untangle these metaphors. For this, solid medical knowledge is necessary but not nearly sufficient. We need to flex the oddball neurons that connect the disparate corners of our consciousness. They need to be honed in the same manner as muscles at the gym, with ongoing stretches and workouts.
The next time you see your doctor, you might want to ask what he or she is doing creatively these days.
Danielle Ofri is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review. Her most recent book is "Medicine in Translation: Journeys With My Patients."

How Good Is Your Hospital? Depends Who You Ask | PBS NewsHour

How good a hospital is St. Mary Mercy Livonia Hospital? Depends on whom you ask.

The Leapfrog Group, a respected nonprofit that promotes patient safety, gave an "A" to this Michigan hospital. The company Healthgrades named it one of America's best 50 hospitals.

But the Joint Commission, a nonprofit organization that accredits hospitals, and U.S. News and World Report omitted St. Mary from their best hospital lists. Consumer Reports gave it an average safety score of 47 points out of 100, citing high numbers of readmissions, poor communication with patients and excessive use of scans. Medicare, which has a new program rewarding hospitals for meeting certain quality measures, is reducing St. Mary's payments by a fraction this year.

Evaluations of hospitals are proliferating, giving patients unprecedented insight into institutions where variations in quality can determine whether they live or die. Many have similar names, such as "Best Hospitals Honor Roll," "America's Best Hospitals" and "100 Top Hospitals." Illinois,Florida and other states have created their own report cards. In some places, such as California, there are more than a dozen organizations offering assessments on hospital quality.

But those ratings, each using its own methodology, often come to wildly divergent conclusions, sometimes providing as much confusion as clarity for consumers. Some hospitals rated as outstanding by one group are ignored or panned by another. Ratings results from an individual group can change significantly from year to year.

"We've alternatively been labeled the least safe hospital in Maine and the safest hospital in Maine," said Dr. Douglas Salvador, vice president of quality at Maine Medical Center in Portland.

And the ratings do not always jibe with the views of authorities who oversee hospitals. For instance, UCSF Medical Center has gotten good grades from multiple safety raters even as California public health officials have fined it $425,000 repeatedly for endangering patients. As ratings multiply, more and more hospitals have something they can boast about. A third of U.S. hospitals -- more than 1,600 -- last year won at least one distinction from a major rating group or company, according to a Kaiser Health News analysis. In the greater Fort Lauderdale hospital market, 21 of 24 hospitals were singled out as exemplary by at least one rating source. In the Baltimore region, 19 out of 22 hospitals won an award.

"I worry a lot about these ratings," said Jerod Loeb, executive vice president for health care quality evaluation at the Joint Commission. "They're all justifiable efforts to provide information, but at the end of the day every single one of them is flawed in some respect. Rather than enlightening, we may be confusing."

There are so many report cards on hospitals that the Informed Patient Institute runs a website that grades the raters. Carol Cronin, its executive director, said most report cards are not easy for consumers to use. "A lot of them don't help users quickly understand which hospital is better than another," she said.

But many hospitals are eager to trump these distinctions in their marketing. Healthgrades, U.S. News and Leapfrog not only encourage this but also profit from it by charging licensing fees to hospitals that want to advertise their awards. "A hospital cannot buy an award, they must achieve it," Healthgrades said in a statement.

Healthgrades and Truven Health Analytics, which publishes the 100 Top Hospitals, offer consulting services to hospitals that want to improve their overall performances. Jean Chenoweth, a Truven senior vice president, said the list doesn't earn Truven any money but it "gives the company a lot of visibility."

Dr. Andrew Brotman chief clinical officer at NYU Langone Medical Center in Manhattan, said the fees can be substantial. "Healthgrades, which is one we did well on, charges $145,000 to use this even on the website as a logo, so we don't do that," he said. "U.S. News is in the $50,000 range. Leapfrog is $12,500."

Consumer Reports bars hospitals from using its ratings in marketing, but patients must subscribe to read them online. (Others generally provide free access to ratings on their sites.) The Joint Commission does not charge hospitals that make its top quality list.

A Pew Research Center survey found 14 percent of Internet users consulted online rankings or reviews of hospitals and medical facilities. Florence Harvey, 70, said when she moved to Washington, D.C., last fall, she picked a health plan and doctor affiliated with Washington Hospital Center after reviewing all the local hospitals rankings on U.S. News' website. "That was the one that had the best across-the-board ratings," she said.

But Harvey may be an anomaly. Dr. Peter Lindenauer, a professor with Tufts University School of Medicine based in Springfield, Mass., said the limited research on rankings "suggests they have had very little impact on patient behavior."

That's not surprising since many admissions, such as those due to a heart attack or car crash, have an immediacy that rules out comparison shopping. Also, researchers note, many patients defer to their physicians' recommendations or go to the hospital where their chosen surgeon has privileges. Still, rating groups say the ratings help keep the pressure on hospital executives to keep quality up.

"Patient safety has to be a priority 24-7," said Leah Binder, Leapfrog's president. "The minute it slips off the priority list, that impacts the rating."

The calculations that go into these ratings are complex. Most hospital assessments synthesize dozens of pieces of data Medicare publishes on its Hospital Compare website, including death rates and the results of patient satisfaction surveys. They also examine other sources and use private surveys to create user-friendly lists or grades, which they display on their websites.

The Joint Commission looks at how frequently patients received recommended treatments, such as flu shots for those with pneumonia. Consumer Reports examines the numbers of patients who die or are readmitted, infection rates and Medicare patient surveys of their experiences. Leapfrog looks at data from its surveys of hospitals, the consistency with which hospitals followed safe surgical practices and frequencies of infections and some types of patient harm. Healthgrades analyzes detailed Medicare records to find death and complication rates for 27 procedures and conditions.

"Ratings and ranking programs certainly offer people information they can use to make their hospital selections, but we don't recommend relying on any one of them completely," Jennifer Kennedy, a spokeswoman for St. Mary Mercy, said in an e-mail. "None are able to tell the whole story or paint a complete picture of the care that is delivered."

The ratings groups believe the public benefits from the multitude of ratings. Dr. John Santa, who directs Consumer Reports' health ratings, said consumers benefit from different vantages just as they do for cars or electronic devices, and the competition spurs each rating group to get better. "We think that's consistent with good science," Santa said.

Avery Comarow, health rankings editor for U.S. News, agrees. "People go to hospitals for different reasons and priorities," he said. "I'm not sure there could be a single rating system that can do it all."

Some of the hospitals that do the best in the rankings have limited respect for them. Advocate Christ Medical Center in Oak Lawn, Ill., last year received praise from Leapfrog, U.S. News, the Joint Commission, Truven and Healthgrades. But Dr. William Adair, vice president for clinical transformation, says the hospital doesn't license any of the distinctions. "We're all made a little bit uneasy, to be frank about it," Adair says. "Some of these organizations are looking for revenue. It blurs the effectiveness of the ratings processes."

Still, many hospitals are happy to use the praise. Dr. Brotman from NYU said: "Even though there's not a hospital executive who won't tell you that they have a great deal of skepticism about a lot of the methodology, there's not one who will tell you they don't want to be on the lists."