Easy and Legal Ways to Get Free Microsoft Points

Easy and Legal Ways to Get Free Microsoft Points

Xbox Live is the ultimate gaming service provided by Microsoft. It enables Xbox users to access multiplayer games, send and receive voice messages and get exclusive and early content for their Xbox. The two versions of this service: Xbox Live Silver and Xbox Live Gold, offer a 3-month or 12-month service. These packages also include other gaming equipment and one free Xbox Live arcade game. Prices vary from country to country and it's not cheap.

Acquiring the actual free gold Xbox Live codes used to mean that gamers would have to win a competition to acquire a code for free. The particular issue regarding this kind of account is actually that an individual will need to search for some time to find this kind of place. Even when a gamer has found a website that offers this the legitimacy will then be questioned. There A lot of times these type of sites will suddenly no longer exist on the internet. They will close the site without warning and this has not only given a bad reputation, but also affected the legitimate sites. Gamers have experienced this have expressed their frustrations with each other. Through word of mouth, this spreads to a number of individuals very fast.

In order to use the Xbox live codes you need to have an internet connection and access to broadband; ADSL and cable usually work better, because you will need to have a fast speed connection to play your games easily. The codes give access to games like Heroes, Battlefield 2, Star wars, or others, depending on the card you have got and the availability of games at any given moment. You can create your personal account connecting to the gaming console. Once you set up your first account and give the codes, you will be notified that these codes are valid for two months. Once this free period is over, you cannot use any additional trial cards; you will have to pay for your subscription or use some other valid codes.

The easiest way to get free microsoft points is to buy games that offer them. Buy games such as Star Wars Battlefront, Battlefield 2: Modern Combat and Kingdom Under Fire: Heroes. These games will give you up to 48 hours of free trial period but requires paying when your time is up.

For those yearning a longer trial period can buy games that offer a Two-Month Trial Card. You also have to ensure you have a high-speed Internet connection. To access the service and create your account, you should first take note of the Xbox Live code at the base of the card. This code then needs to be entered before you can fully enjoy the service for the next two months. When the trial period is up, you must pay to renew your membership and no, you can't extend the trial period.

If nothing works for you, you can always go online and check if there are free codes. Before actually using them, you have to check if they are legitimate and suitable for your games and your Xbox device.

Sturat enjoys writing articles on topics like How to get free Microsoft points.

Cellulean Cellulite Reviews - Does Cellulean Cream Work?

Are you sick and tired of those stubborn dimples on your legs and butt - the cellulite that refuses to shift, even though you are constantly on a diet and exercising regularly? I came across this 'rather impressive' product that is said to address this issue - and after considerable research I have decided to provide a series on Cellulean reviews to shed some light on this fat-busting product.

With a 14 day free trial on offer, I certainly had nothing to lose and everything to gain especially if it produced the results that they claimed.

My experience is documented below so that you can know what to expect from this product. My aim is to provide you with enough information to help you can make up your mind one way or the other, as to whether Cellulean is the right anti-cellulite cream for you or no

Cellulite, as you know, is the fat stored right beneath your skin's surface. Cellulean has many active ingredients to dissolve this fat, without harming your skin. This anti-cellulite treatment is really based on an original patented formula to dissolve fat. The key element of this formula is an asthma drug called Aminophylline, which triggers the natural process of removing lipid particles in our bodies.

In conclusion, I'd like to add that if you're still doubtful about the effectiveness of Cellulean, then try the free trial offer from Cellulean. It's free, and Cellulean makers promise to double your money if you don't see desired results.

For more information about the free Cellulean trial, visit my Cellulean Cellulite website. You can also read other reviews on Cellulean in this website.

Injury claim

If you have been involved in an accident, and through no fault of your own have suffered an injury as a result, then chances are you will be able to claim compensation. No matter how minor your injury appears to be at this stage or who the person or company at fault was, making an injury claim is your right and should be exercised to bring justice to a difficult situation.

What types of injuries can be claimed for?

One of the most frequent types of injury claim submitted relate to accidents on the road. Whether you were a driver or passenger of a car, or were travelling on public transport or a bike at the time of the accident, if you were hurt and another driver was at fault, you can claim. Common injuries include back and neck injuries, including whiplash, and injuries to the head or hands as a result of the collision.

Less common, but still a source of regular claims, relate to slips and trips when out and about. Building owners, local councils and workmen have a responsibility to ensure public rights of way and the public areas within buildings are kept safe, clean and free from hazards that could cause a trip. Slipping on wet floors, broken paving slabs or tripping over trailing cables can all result in a range of injuries, from twisted ankles to broken wrists, all of which are regularly seen by professionals handling injury claim cases.

Sometimes even the workplace is not as safe as it should be, and workers sometimes become injured as a result of faulty machinery, poor training or bad health and safety practice. In cases like this an injury claim will often result in remedial action by the employer, meaning other employees will be safer at work in the future, so it is especially important to make a claim if this has happened to you.

When should you claim?

As a general rule of thumb, the sooner the better applies to any type of injury claim. The sooner you can start the claims process, the easier it will be for your solicitor to contact any witnesses and get hold of any other evidence required. Also your injury will be fresh, so if you need to see an independent doctor they will be able to see first hand the extent of your injuries.

Personal injury law understands that making an injury claim is not necessarily the first thing on someone’s mind after they have been involved in an accident. That is why claims can still be started up to three years after the accident happened. In the case of industrial disease and other issues that take years to reveal themselves, there is still a chance to claim beyond the three year cap.

How much does it cost?

These days, the majority of solicitors who deal with injury claim cases will work on a no win no fee basis. This means you will not have to pay them anything if your claim is not successful, and there will be nothing to pay up front. 

Goldman Sachs, Corporate Culture, and Medical Ethics

When Greg Smith, an executive director at Goldman Sachs, and head of the firm's US equity derivatives business in Europe, the Middle East, and Africa, explained why he resigned from the company in a remarkable New York Times op ed piece two days ago, the story went viral. Here's the essence of what he had to say:

After almost 12 years at the firm...I believe I have worked here long enough to understand the trajectory of its culture, its people, and its identity. And I can honestly say the environment now is as toxic and destructive as I have ever seen it....I have always taken a lot of pride in advising my clients to do what I believe is right for them, even if it means less money for the firm. This view is becoming increasingly unpopular at Goldman Sachs...I attend derivatives sales meeting where not one single minute is spent asking questions about how we can help clients. It's purely about how we can make the most possible money off of them. If you were an alien from Mars and sat in on one of these meetings, you would believe that a client's success or progress was not part of the thought process at all.

Years ago, my friend Marc Bard, a brilliant consultant, taught me the aphorism - "culture beats strategy every time." This is perhaps especially true in health care, which is so strongly mission-driven. If the shared culture of a health organization is truly patient centered every action will express the organization's values.

I experienced how culture works especially clearly 19 years ago, when my father, near the end of his life, was a patient at the Lahey Clinic. In my distracted and distressed state, I locked my keys in my car. I went to the building services office to get help. A staff member (a) picked the car's lock with expertise, but also (b) conducted excellent common sense psychotherapy with me around how we get forgetful when we're upset, and (c) said he would pray for my father. Remembering the incident and writing about it here brought tears back to my eyes. I'm happy that I wrote to the CEO to report on the excellent care I received from his non-clinical staff and to congratulate him on the culture of the organization.

I'm lucky that the four health organizations I've been part of during my career - the Massachusetts Mental Health Center, Harvard Community Health Plan/Harvard Vanguard Medical Associates (HCHP morphed into HVMA), the Harvard Pilgrim Health Care insurance company, and the Harvard Pilgrim Health Care Institute,  have all had cultures and evinced values I've been proud to be associated with. I doubt, however, that the people at those organizations were intrinsically more ethical than the colleagues Greg Smith is writing about.

When one's colleagues and the leaders of an organization share core values they reinforce each other. Newcomers are selected for fit with the culture, and the culture (what educators call the "hidden curriculum") brings out the best in us. It's easier for a health organization than for Goldman Sachs to cultivate a positive culture because the mission of caring for people who are suffering encourages empathy. I'd like to believe that I'd leave as Greg Smith did if I found myself part of an organization with a environment that is "toxic and destructive" and was unable to influence it, but knowing the human capacity for self-delusion, I can't be smug and certain that I wouldn't follow the same playbook Greg Smith discerned at Goldman Sachs.

Aristotle conceptualized "character" as an inner state or way of being that shows itself in the patterns of our actions. "Culture" is the organizational equivalent of "character." Culture is partly formed by the characters of those who constitute it, but the influence goes both ways. In trying to understand our human natures, we need to consider "culture" and "character" along with "nature" and "nurture."

Is This Doctor-Patient Marriage Unethical?

I shouldn't have been surprised that the most read posts on this blog have been about doctor-patient sex. When I recently had occasion to review these posts a comment I received on April 23 last year caught my attention:

Let us face it squarely. There are only 4 women that a newly qualified overworked doctor intern is exposed to: a fellow doctor (usually out of reach), a nurse (may lead accusation of sexual harassment) a bar waitress (usually not of the best social character) and the patient. I chose the latter and am happily married to her for 8 years. Did I breach the ethics? Can a distinction be made between sexual attraction and real love?

In my response I made an initial sortie into the connection between professional ethics and the ethics of personal relationships. But in retrospect I wish I'd been clearer:

Congratulations on 8 happy years of marriage. I don't know what area of medicine you're in, and what its code of ethics states. In my own specialty - psychiatry - the code asserts that sex with current or former patients is unethical. So if you're a psychiatrist, the code answers your question - you did breach the ethics of the specialty....

So - you may have violated the ethics of your area of medicine, but I'm guessing that you and your wife distinguished right from the start between "real love" and "sexual attraction." You have 8 years of evidence that you got it right! For you as individuals the professional ethics precept would have been a bad guide. 

Suppose the ethics committee of the former intern's medical specialty were asked to review the ethics of the relationship he formed with his patient 8 years ago. For my specialty (psychiatry), the answer would be unambiguous. Forming a romantic or sexual relationship with a current or former patient is defined as unethical.

Given that he violated the ethics of his specialty, should he be disciplined?

If there had been no problems in his medical practice in the subsequent 8 years I think the right outcome would be (a) to reaffirm the correctness of the ethical standard but (b) to find a way of not disciplining him intern, while (c) being careful not to set a precedent that undermines the standard.

The rationale for defining romantic/sexual relationships with current and former patients as unethical is twofold: to protect patients from the harms that these relationships can cause, and to prevent the loss of trust in the profession that would accrue if the public concludes that physicians are prepared to exploit patients for personal gain, as by "hitting" on them. The former intern's happy marriage isn't evidence against the standard. The standard doesn't claim that every doctor-patient romantic/sexual relationship will result in harm, just that we know that harm is a significant possibility and is difficult to predict. And the happy marriage says nothing about the overall trustworthiness of the profession.

If this was a current question for a physician with no pattern of exploitation, an ethics committee might require an extended period of supervised practice. Assuming the former intern has practiced in exemplary fashion for 8 years, that would exceed what a probationary period would entail. As a member of the specialty society it's important for him to understand and support the ethical precepts of the society. As a response to the violation that occurred 8 years ago, the ethics committee might ask the former intern to write an essay on how he would respond to a colleague who asked him: "Look how well your doctor-patient relationship worked out - why should I follow the ethical standard on this?"

If the intern's medical specialty and medical society held the same standard as the American Psychiatric Association, the relationship he formed with his patient violated the ethics of the profession. But his report of 8 years of happy marriage suggests that the ethics of his personal relationship is excellent. The professional and personal domains overlap, but not totally. Four years ago I argued that the Karolinska Institute in Stockholm did the right thing in expelling a medical student who had been convicted of murder 8 years earlier, even though he performed competently in his student role.

In the U.K. the medical profession does not have a blanket ethical rule against romantic/sexual relationships with former patients. The General Medical Council (GMC), whose role is to "ensure proper standards in the practice of medicine," has formulated guidance about professional boundaries in terms of personal ethics. Recast to eliminate reference to the doctor-patient relationship, the values in the GMC espouses could form the basis of a high school or college class on relationship ethics:

• You must not pursue a sexual relationship with a former patient, where at the time of the professional relationship the patient was vulnerable, for example, because of mental health problems or because of their lack of maturity.
• Pursuing a sexual relationship with a former patient may be inappropriate, regardless of the length of time elapsed since the therapeutic relationship ended. This is because it may be difficult to be certain that the professional relationship is not being abused.
• If circumstances arise in which social contact with a former patient leads to the possibility of a sexual relationship beginning, you must use your professional judgment and give careful consideration to the nature and circumstances of the relationship, taking account of the following:
     (a) when the professional relationship ended and how long it lasted
     (b) the nature of the previous professional relationship
     (c) whether the patient was particularly vulnerable at the time of the relationship, and whether they are still vulnerable
     (d) whether you will be caring for other members of the patient's family

Wartime Heroism and Personal Ideals

I'm sorry I never met Dr. Tina Strobos, whose obituary I read in this morning's Boston Globe. But I have a new hero.

Dr. Strobos was a 19 year old medical student in Amsterdam when Nazi Germany invaded in May, 1940. When she and her fellow students refused to sign a loyalty oath to Adolf Hitler, the school was closed.

Dr. Strobos joined the Dutch underground, initially ferrying arms and supplies to resistance fighters. Then she turned to helping her Jewish friends and ultimately others to escape. She and her mother had a secret room constructed on the third floor of their Amsterdam home, just a short walk from the home that sheltered Ann Frank and her family. It became part of an underground railroad for escapees. During the war they helped save 100 Jews, for which, in 1989, the Yad Vashem Holocaust Museum in Jerusalem honored her and her late mother as "righteous among the nations."

 After the war Dr. Strobos came to the U.S. and studied child psychiatry. Despite extensive Google searching I haven't been able to learn much about her career. She appears to have run a treatment facility in Rye, N.Y. One listing said it was for people with chronic psychiatric ailments. Another site said she'd helped Katrina victims. I like to think that her work as a psychiatrist carried forward the same values she lived by during her years of wartime heroism.

I've thought a lot about the concept of health care as a "calling." For religious persons the call may come from their God. But what about agnostics and atheists? Dr. Strobos answered this way: "I never believed in God, but I believed in the sacredness of life." This outlook ran in her family. Her mother and maternal grandmother were also athiests, socialists, and activists. During World War I her grandmother had also hidden refugees! And all three of her children work in helping professions.

Dr. Strobos seems to have been a practical idealist. During the war, along with her work in the resistance, she also sought opportunities to continue her medical studies. "You have to be a little bit selfish and look after yourself; otherwise you just die inside, you burn out. There's just so much you can do for other people."

I'm proud to be part of the same psychiatric profession as Tina Strobos!

(For a moving video of Dr. Strobos receiving an award from the Holocaust and Human Rights Education Center in 2009, see here. For additional details on her life, see here, here, and here.)

Tatooing Medical Directives on our Bodies

Unfortunately I don't know Dr. Ed Friedlander, a pathologist in Kansas City, so I haven't had a chance to ask him about his decision to have "No CPR" tatooed on the center of his chest. If you want to see what his distinctive form of advance directive looks like, the Associated Press article about using tatoos to convey medical information shows him holding his shirt open.

Many people are afraid that their wishes for how medical care should and should not be administered will not be followed. Since the default option in emergencies is to "do everything," folks like Dr. Friedlander who want to let nature take its course when their heart stops have good reason to fear chest pounding and electrical shocking if an ambulance was called for them.

It's just a matter of time until we see a Saturday Night Live routine in which the emergency medical technician gets preoccupied reading an essay on the chest of the person whose side they are called to. Whatever Dr. Friedlander's motive for the tatoo is, he's dramatizing the degree to which many people fear that health care on automatic pilot will (literally) run roughshod over them.

Should a Student be Disciplined for Being Disrespectrul on Facebook?

In discussing ethics with medical students and physicians, it's common for someone to ask: "What does the law say?" I typically respond: "Let's first figure out what we think the right thing to do is. Then we can ask how to do it within the law. If the law says we can't do it, we should check to see if we got our reasoning right. If we still think we got it right, we can consider whether the law can be changed, or if civil disobedience is the path to follow."

On July 11, 2011, the Minnesota Court of Appeals ruled against Amanda Tatro in the fascinating case of Tatro v University of Minnesota. The decision is a heartening blend of law and ethics.

Amanda Beth Tatro was a student in the University of Minnesota mortuary-science program, which prepares students to become funeral directors or morticians. The laboratory courses use cadavers that have been donated to the university.

In November and early December 2009, Ms. Tatro posted the following on her Facebook page. I've added some notes in italics:

Amanda Beth Tatro: Gets to play, I mean dissect, Bernie[this is the name she gave to the cadaver. The name comes from the film "Weekend at Bernie's."] today. Lets see if I can have a lab void of reprimanding and having my scalpel taken away. Perhaps if I just hide it in my sleeve . . . .


Amanda Beth Tatro: Is looking forward to Monday‟s embalming therapy as well as a rumored opportunity to aspirate. Give me room, lots of aggression to be taken out with a trocar.

Amanda Beth Tatro: Who knew embalming lab was so cathartic! I still want to stab a certain someone in the throat with a trocar though.[Tatro testified at the Campus Committee on Student Behavior that she was referring to a man who had just broken up with her. But at the campus hearing, faculty members testified that they feared she was referring to them.] Hmm..perhaps I will spend the evening updating my “Death List #5” and making friends with the crematory guy. I do know the code . . . .


Amanda Beth Tatro: Realized with great sadness that my best friend, Bernie, will no longer be with me as of Friday next week. I wish to accompany him to the retort. Now where will I go or who will I hang with when I need to gather my sanity? Bye, bye Bernie. Lock of hair in my pocket.

On April 2, 2010, the Campus Committee on Student Behavior ruled that Tatro should receive a failing grade in the anatomy laboratory class, that she should enroll in a clinical ethics course, that she should write a letter to the mortuary-science faculty on the issue of respect in the profession, and that she should undergo a psychiatric evaluation. Tatro appealed to the court.

Here's the section of the court's decision most relevant to professional ethics:

The university found that Tatro violated rules 6 and 7 of the anatomy-laboratory course rulesRule 7 states, “Conversational language of cadaver dissection outside the laboratory should be respectful and discreet. Blogging about the anatomy lab or the cadaver dissection is not allowable.” Tatro argues that the evidence does not support findings that she violated these laboratory rules.

..As the university asserts, public comments about “playing” with or taking “aggression” out on a cadaver are inconsistent with the notions of respect and dignity whether they occur in person, on Facebook, in a blog, or via other media.

I believe the court was entirely correct that the university had not violated Tatro's right to free speech. A core component of the profession she was preparing for is respectfulness and discretion. Whether or not the ostensible threats she made should have been taken so seriously (the court concluded that the university was correct to do so), her comments about "Bernie" violate the ethics of her profession. The academic penalty imposed by the Campus Committee on Student Behavior was appropriate. (I don't favor requiring a psychiatric evaluation unless there was a medical reason for doing so that the court record does not convey.)

In entering a profession we "profess" our commitment to the ethics of the profession. The first amendment gives Ms. Tatro the right to speak disrespectfully of "Bernie." But it doesn't give her the right to enter the funeral director profession at the same time!

Hand Washing,Teamwork, and Professional Ideals

Hand washing protects hospital patients from healthcare-associated infections. But on average, adherence to hand hygeine standards is under 40%.

In June, 2008, Northshore Hospital on Long Island started an experiment. It installed motion detectors in the doorways of ICU rooms to monitor entrance of staff, and installed cameras focused on the sink and hand sanitizer dispenser. Video auditors (in India) scored each event. The intervention tested the impact of (a) installing cameras and (b) feedback of results. No individuals were identified. Results were only reported in aggregate form.

In the 16 week prefeedback period, hand hygiene rates were under 10%! At that point, electronic boards were installed in the ICU hallway. Results were given on each shift. To my eye, the board looks cheerful. It shows the date, the target rate (>95%) and gives an electronic pep talk ("Sanitize Hands Upon Entry/Exit of Rooms!"). On May 17, 2010, the day displayed in the photo, it tells the staff: "GREAT SHIFT!!" and gives results for physicians and other health professionals.

Once electronic reporting of aggregate performance was given, adherence jumped from under 10% to the mid 80s. The results were sustained for two years.

The report in Clinical Infectious Disease doesn't speculate on what drove the change. There were no financial incentives and no monitoring of individual performance.

So what happened?

Here's my guess. Very few hospital workers doubt the importance of hand hygiene. But resolving to do better is like our New Year resolutions to lose weight or improve ourselves in other ways - easy to vocalize but hard to carry out.

The cameras without feedback accomplished nothing. But daily feedback reminded staff of where it stood relative to its ideals. And the aggregate reporting told staff that everyone was on board. In other words - an experience of unity in relation to professional ideals.

That's like the congregation singing a hymn together and praising the God they adhere to! The electronic board wasn't a voice from heaven, but it spoke to the flock every day on every shift. On a bad day it must have been like the chorus from Messiah - "All we like sheep have gone astray."

I hope a journalist or a qualitative researcher delves into the human side of the statistical story the article tells. We might learn important lessons about what helps us put our healthcare ideals into action.

Complementary Medicine in Australia - an ethical analysis

400 scientists and doctors have attacked the 19 Australian universities that teach, or give degrees in, complementary and alternative medicine (CAM):

 Such courses involve so-called ‘complementary or alternative medicine’ masquerading as, and sitting side-by-side with, evidence-based health-related science courses. We take the view that those universities involved in teaching pseudoscience give such ideologies undeserved credibility, damage their academic standing and put the public at risk.

The controversy is half scientific, half ethical.

We health educators should be honest. A lot of medical and nursing care is based on evidence. That evidence, and the sciences that allow the evidence to be developed, should, and do, form the center of the curriculum.

But much of what we physicians and nurses do is based on belief and tradition. That doesn't mean we shouldn't do and teach these things. But we should be honest with ourselves and our students about when our practices aren't evidence based. Non-evidence based practice isn't limited to CAM!

Controversy over CAM isn't new. In the early 20th century organized medicine was horrified by the growth of Christian Science. Wise physicians recognized that the emergence of Christian Science reflected a sense that something was missing in "conventional" medicine. That hunger is still present. More than 1/3 of U.S. adults use "alternative" medicine techniques. I'm sure the same is true in Australia.

Gerald Caplan, my mentor in community psychiatry, taught me a valuable lesson about CAM. He experienced intermittent low back spasm, for which he had treatment with a chiropracter. Dr. Caplan told me:

The chiropracter takes low back pain seriously and lays on hands. The orthopedist is bored by it unless he can operate. I think chiropractic theory is nonsense, but chiropractic treatment gives me relief. Bringing relief is our goal in medicine.

There are three primary reasons why physicians should learn about CAM. (1) Many of our patients use CAM, and we should understand what they're doing in order to be able to advise. (2) We need to understand, from their perspectives, what felt needs CAM is addressing and what they hope to get from it. (3) Even if - like Gerald Caplan - we don't believe CAM practice is based on hard evidence and sound theory, we can sometimes learn from the way CAM practitioners carry out their practice.

Unfortunately, one of the Australian Universities manifested the same kind of arrogance that disturbs me when I see it in medicine. (I've interlaced my comments in bold italics.):

Students are taught the science-practitioner model and our aim is to produce graduates who are critical thinkers. [so far so good!] This enables them to distinguish between fad and genuine innovation in the discipline as practitioners, intelligent consumers of research and promoters of the scientific method. [even better!] A clear distinction is made in all of our courses between areas for which the evidence is clear and those in which the science has not caught up with accepted practice and where sufficient evidence has yet to be accumulated. [This is way off base. The speaker is assuming that "accepted practice" is based on science, and the science just hasn't "caught up" yet. That's religious faith, not critical thinking.]

(For previous posts about CAM, see here, here, and here. For the New York Times article from which I learned about Australia, see here.)

Educative Journalism in Massachusetts

Apropos yesterday's post, this editorial from today's Boston Globe is interesting. I've interlaced comments of my own in bold italics:

EVEN BEFORE this year’s grand debate about containing health care costs begins on Beacon Hill, a pointed disagreement has broken out among key players in the state health care arena.

The health plans fear that legislative meddling is opening holes in the very cost-controlling arrangements that a recent law required, while legislators contend they are simply looking out for individuals who might be hurt by policy changes. The editorial makes clear that this is a classic "good vs good" conflict. Constraining costs is an ethical responsibility, since health care costs deplete wages, small business viability, and the state's capacity to fund other public goods. But protecting vulnerable people from unintended impacts of policy decisions is also an ethical responsibility.

There is nothing wrong with trying to minimize disruptions on patients from changes to their insurance plans, but the recent proposal to give certain patients the right to keep receiving treatment at higher-cost hospitals is too broadly written. Until it is clear just how many people would be exempted from policy changes, and how that might add to insurers’ costs, the Legislature should hold off, lest it undermine its own goal of making health care more affordable. If I'd written the editorial I wouldn't have used the phrase "insurers' costs." Those costs are passed through to the businesses and public agencies that purchase insurance. The public doesn't always understand that health plans - especially the regional not-for-profit health plans Massachusetts has - are essentially purchasing agents for the public and private entitites that provide health insurance to their constituents.  

The year before last, the Legislature passed a law requiring insurers to offer limited networks, which restrict plan members to certain hospitals and doctors, and tiered networks, which charge plan members more for using more expensive providers. The moves provided lower-cost insurance options for families and businesses, albeit by limiting patients’ choices of doctors and hospitals. Over the past two years, average annual premium hikes have shrunk from a projected 16.3 percent to 2.3 percent.

But this year, at the behest of Representative Steven Walsh, House chairman of the Joint Committee on Health Care Financing, and other influential legislators, the Legislature passed a budget rider making exceptions for some members of such plans. Walsh says he’s concerned that patients who were undergoing treatment at Children’s Hospital, the Dana-Farber Cancer Institute, and the Floating Hospital under the terms of their previous plans be able to continue their treatments there without bearing large cost increases. He contends that the budget language is crafted to apply to only a relatively small number of patients; he doesn’t, however, have a reliable estimate of just how many.

Although the legislative intentions may well be good, this episode is a cautionary tale.

The insurers, for their part, worry the language would allow a much larger number of patients with chronic conditions to sidestep plan features designed to rein in costs. They also worry that this action sets a bad precedent for future legislative interventions; already, lobbyists for major hospitals are seeking ways to keep their patients while still receiving higher reimbursements from insurers. It will likely now be left to the Patrick administration to work out a compromise.

Although the legislative intentions may well be good, this episode is a cautionary tale. Health care policy is so complex, and with so many moving parts, that it’s best to work out problems beforehand rather than fix them later. In this case, it’s easy to imagine a relatively small number of people with serious illnesses in the midst of rigorous treatment at Children’s, Dana-Farber, or Floating Hospital having a legitimate need to continue seeing the same doctors. I know from research I've done on the appeals process that continuity of care is a common concern for patients and clinicians. When you look at individual situations in detail it's clear that there's a continuum from long term/high complexity treatments in which deep relationships have been created over time to relatively clear cut treatments that could quite reasonably be transferred to another site. The editorial writer(s) recognize this continuum and make a nuanced argument.

But until Walsh and other sponsors can say just how many beneficiaries there are, and be certain that other patients will not be able to use the law to get treatment at their institution of choice without having paid for that option, the Legislature should avoid meddling with a reform that truly has worked.

This is a thoughtful, well-informed editorial. This kind of educative journalism has been an important contributor to the relatively collaborative way in which the state is dealing with the volatile conflicts that any serious health reform effort must tackle.

The Truth about Massachusetts Health Reform

If your view of Massachusetts health reform came from the Republican presidential debates you'd think the program is a catastrophe. That's baloney.

A recent article in Health Affairs shows it's a measured success, a work in progress.

An ongoing annual survey of 3,000 randomly selected households shows that uninsurance among nonelderly adults - the group most vulnerable to being uninsured - is steady at 94-95%, the highest insurance rate in the nation.  Emergency room visits for nonemergency conditions has declined. From 2006, when the reform went into effect, to 2010, self reported "excellent" health status improved from 59.7% to 64. There's been no drop in the rate at which employers offer insurance to employees. Two thirds of the population continue to support the program, though political bashing of "Obamacare" and "Romneycare" has led to an increase of those who are opposed to it from 17% to 27%.

As I see it, the key lesson from Massachusetts health reform is the process by which it launched and is currently handled. Prior to passage of the 2006 law, there were several years of discussions, reports, conferences, committee meetings, and more. From this combination of education, argument and deliberation, what emerged was a consensus that government, employers, and individuals had to share responsibility for making things better. And, at least as important, all that interaction created some trust among the key parties and a culture of civility that is all-too-lacking in the pathetic national non-dialogue on federal reform.

In terms of shared sacrifice: individuals accepted a mandate that we be insured; employers accepted a requirement that they provide insurance or pay into a state pool; and the state accepted responsibility for subsidizing low income folks and for creating a mechanism - the Connector - to administer the new forms of insurance that were made available.

Those leading the reform process decided to defer the most challenging aspects of reform - (1) cost containment and (2) delivery system reform, until almost everyone in the state was insured. The agenda for Massachusetts has now shifted to those two issues.

In 2012, Governor Patrick, a Democrat, is using the same process that Governor Romney, a Republican, used in 2006 - orchestrating broad stakeholder participation, and using the bully pulpit of the state house. Instead of bashing insurers for the health cost trend the Governor is directing insurers to drive hard bargains. This repositions the insurer from being the enemy of the public to being the agent of the public. The fact that more than 90% of the Massachusetts insurance market consists of locally based not-for-profits makes this a viable strategy for the state.

I'm deeply skeptical about the readiness of the U.S. to come to grips with health costs, but I'm guardedly optimistic about Massachusetts. This year rates in the small group market are going up by only 1.8% (see here and here). Fee-for-service is diminishing - 1.2 million folks (20% of the insurance market) are already in programs with global budgets. And from conversation with friends who practice in different hospitals and medical groups I know that the medical community is working on reengineering clinical systems to produce equal or better results at a lower cost.

If the Supreme Court finds the Accountable Care Act constitutional and it becomes clear that the law will stand, it will be easier for other states to do the kind of long term work with messy and difficult problems that Massachusetts is doing. Hysterical tantrums about "Obamacare" are getting tiresome!

(If you're interested in Mitt Romney's role in launching the Massachusetts reform process, see this excellent New Yorker article.)

The ethics of writing about children with mental illness

I was recently asked about the ethics of writing about children and adolescents with mental illness. I've edited the actual question to preserve privacy:

I've been asked to consider writing a book about a parent and a mentally ill child. I'm convinced that the story needs to be told; but I'm not sure how to do it ethically. We don't want to re-traumatize the child, who is unable to give informed consent to interviews or to decide about making the story public, and probably won't be able to give informed consent even after reaching the age of majority.

We want to be responsible -- to respect the child's privacy and to do no harm. But we want to validate the experiences of other parents who are living through this with their children; to improve public understanding of the condition; and to advocate for the kids and families who are struggling. They're suffering in silence right now.

Because of the nature of the disorder and the behaviors that children with the condition display, the "commercial" literature that's available pushes the boundaries of good journalism. So much is changed to protect the children's privacy that it damages the credibility of the writing. But it's impossible to guarantee privacy if we write honestly. If we describe even one event exactly as it happened, SOMEBODY is going to recognize the child.

What an important question this is! It poses a fundamental "good vs good" conflict: the value that the story might have for other parents and folks who make policy relevant to the child's condition vs the child's right to privacy and protection as a minor.

Apart from how individuals will weigh these values, cultures themselves vary. Many years ago I joined a psychiatrist in India at a session in a clinic serving the poor. I knew him to be a kind and considerate man of great personal and professional integrity. He asked patients who spoke English to "talk with the doctor who is visiting with me from the United States." After an extended discussion with a couple I asked my host if it would be acceptable for me to ask for their permission to take a photograph of them. To my astonishment, my host responded - "just go ahead - you don't need to ask permission." (I wasn't comfortable doing this and put aside the photograph idea.) Subsequently I experienced the same cultural perspective in settings where I was the only Caucasian - people sometimes took photographs of me as an interesting phenomenon.

My reaction to the question is unambiguous. For me, the child's interests come first. I advised writing a well-disguised version of the story that met my rule of thumb - the child's neighbors, teachers, and friends shouldn't recognize who the story is about, and the child, now or at an older age should feel respected by the way she or he is written about. That level of disguise may diminish the value of the story for other parents or policy makers, but in my view that's the correct trade off among values.


On World AIDS Day in 2005 I was in Madurai, India. A man disguised as a giant condom was circulating in the crowd. When I pointed my camera at him he indicated that I should stand next to him and be part of the photo. Perhaps he felt that I should collaborate with him and not objectify him. FYI, here's the photo:
 

Kristin Barker, a sociologist at Oregon State University, has a fascinating, fun to read article in a recent issue of Social Science & Medicine - "Listening to Lyrica: contested illnesses and pharmaceutical determinism."

In my psychiatric practice I was often asked to see patients with mysterious symptoms. Many of the patients resented being asked to see a psychiatrist, feeling they were being sloughed off as whiners, hypochondriacs, or malingerers and told that their symptoms were "all in the head." There was no doubt that they were suffering. But what were they suffering from?

Some of these patients had been diagnosed with fibromyalgia syndrome, a condition of unkown etiology characterized by chronic widespread musculoskeletal pain, multiple tender points, sleep disturbance, fatigue, and other "non-specific" symptoms. In June 2007 the FDA approved an antiseizure medication - appealingly branded as "Lyrica" - for treatment of fibromyalgia. Having a drug officially endorsed as treatment for their condition went a long way towards validating the symptoms as reflecting a "real" illness.

Barker makes three key points:

• Having a treatment strengthens belief in the disease. If there's a pill that helps, the person must be ill. From a sociological perspective, Lyrica wasn't simply treating a condition, it was validating the condition as real!
• Direct to consumer advertising (DTCA) has a powerful impact on social behavior. Insofar as Lyrica ads reduced the blame patients often experienced, the ads were a boon.
• But the ads, which helped make Lyrica a billion dollar blockbuster drug for Pfizer, did so in part by showing glamorous women (actresses) supposedly with the condition, and by portraying the drug as a magical cure. In real life Lyrica rarely acts in the magical way the ads suggest. Some women with the condition felt that the ads led to their being blamed for not getting fully well as the actress portrayed. (For an example of such an advertisement, see here.)

Barker concludes that Lyrica has been a decidedly mixed blessing. It contributed to diminished blaming of the victim. It gave physicians and patients an additional intervention to try. But it fostered false hopes and led to further medicalization - women who might have recovered from a bad spell without diagnosis or medical intervention were persuaded that they had an illness and needed a drug. And when Lyrica didn't perform as the ads suggested it would, some women were blamed for refusing to get better.

(For another post about blaming the victim, see here.)

Bereavement is Sad, but it's not a Depressive Illness

The status of bereavement in the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders ("DSM") is in the news again.

DSM IV, first published in 1994, defines "major depression" by a constellation of symptoms. Depressed mood and/or loss of pleasure capacity must be present, along with symptoms like sleep disturbance, fatigue, restless agitation or a feeling of being slowed down, loss of appetite and diminished ability to concentrate. The symptoms must represent a change from prior status and be present for at least two weeks. All of these symptoms may be present in normal bereavement.

Crucial for the current controversy, DSM IV included what has been called a "bereavement exclusion." The diagnosis of depressive illness is not made if:

The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

The DSM V committee that is working on criteria for major depression is proposing to drop the bereavement exclusion, largely based on research taken to imply that the exclusion isn't empirically supported. In a rather technical article, Jerome Wakefield and Michael First from NYU and Columbia, pick apart that research and argue that the exclusion should be retained.

This isn't a matter of arcane definitions and paperwork. Dropping the exclusion will lead to an epidemic of overdiagnosis of depressive illness when what's really happening is painful grief. Overdiagnosis will have harmful consequences, including:

• Medication will often be prescribed. While anti-depressants are relatively well tolerated, all medications can cause harm through side effects.
• Grief typically resolves over time. When this happens, at least some of those taking medication will attribute their improvement to the drug. This can alter self image - "I fell apart when X died - thank God the medicine and the doctor got me out of it."
• Many will stay on the drug and attribute their ongoing wellbeing to its continued use, at the cost of recognizing their own capacity to recover from a painful loss and the potential side effects from long term drug use.
• Even if no harm accrues from diagnosis and medication use, unnecessary interventions will add unnecessary costs for individuals and the wider community.
• And, for all those suffering from normal, though painful, grief, medicalization of the condition may distract from normal healing processes - tears, preoccupation with the loss, rituals, and more.

Dr. Kenneth Kendler, a member of the DSM V work group, argues that these fears aren't warranted:

...diagnosis in psychiatry as in the rest of medicine provides the possibility but by no means the requirement that treatment be initiated. Watchful waiting is important tool for all skilled clinicians. As a good internist might adopt a watch and wait attitude toward a diagnosable upper respiratory infection assuming that it is unlikely to progress to a pneumonia, so a good psychiatrist, on seeing an individual with major depression after bereavement, would start with a diagnostic evaluation...As with the psychiatric response to the other major stressors to which we humans are all too frequently exposed, good clinical care involves first doing no harm, and second intervening only when both our clinical experience and good scientific evidence suggests that treatment is needed.  

"Watchful waiting" is indeed an important tool for skilled clinicians. If clinicians, the public, and pharmaceutical companies, all conducted themselves in accord with Dr. Kendler's wise precepts, the bereavement exclusion wouldn't matter.

But, alas, this prudent approach to clinical practice is in too short supply in American medicine. We're an activist society. Watchful waiting in the face of a serious diagnosis is almost un-American. That's why "watchful waiting," the wisest approach for many men with early prostate cancer, has had to be rebranded as "active surveillance."

If the bereavement exclusion is dropped, it's only a matter of time until media will be flooded by pharmaceutical advertisements targeted at individuals who have suffered loss and their well intentioned families.

Since the American Psychiatric Association agrees with Dr. Kendler that "good clinical care involves first doing no harm," DSM V should retain the bereavement exclusion!

Health Care as a Source of Ill Health

Zeke Emanuel, who is becoming the national educator-in-chief about health care in his new role at the University of Pennsylvania, preaches an excellent sermon in today's New York Times - "What We Give Up for Health Care."

Zeke's point is obvious, but, amazingly, it's one our political process has been oblivious to: what we spend on health care we can't spend for other purposes. That creates an ethical imperative to consider opportunity costs for health care expenditures. The proper question is - "does this health care expenditure create more human benefit than other possible expenditures?" - rather than the one we typically ask - "does this health care expenditure produce any benefit, however small, for the patient?" Zeke shows how health care costs have acted as an economic cancer, invading and obliterating investments we would otherwise make in wages (which have been stagnant or declining), education, and other crucial components of our lives.

As important as medical care can be, income and education are also crucial determinants of health. When we reduce wages to pay for health insurance, and reduce educational investments at every level to pay for Medicare and Medicaid, we're reducing overall health and well-being. The real "death panel" is our reflexive investment in medical interventions that produce minimal or no benefit at the cost of investments that would do more for us!

Should 14 Year Olds be Sentenced to Life in Prison?

Rachel Aviv, who wrote a superb New Yorker article about a woman in New Hampshire who - guided by psychotic delusions - starved to death, has written another gem, this one in the January 2 New Yorker: "No Remorse: Should a teen-ager be given a life sentence?"

On March 6, 2010, Dakotah Eliason shot and killed his grandfather Jesse Miles while Jesse was asleep. For several hours he contemplated the choice between suicide and murder. Dakotah was unhappy about the breakup with a girlfriend, but had not otherwise  seemed depressed.  He loved Jesse and had had no conflict with him. He finally settled on murder. Dakotah was fourteen at the time.

Arthur Cotter, country prosecutor in the area of rural Michigan where Dakotah lived, ruled that Dakotah should be tried for first degree murder as an adult. He based the decision on what he interpreted as Dakotah's "utter lack of remorse." In Michigan conviction for first degree murder carries a mandatory life sentence with no possibility of parole. After three hours of deliberation the jury found Dakotah guilty.

The Michigan appellate defender's office, which represents indigent clients who cannot afford private counsel, is appealing Jesse's conviction, arguing that he received ineffective counsel at the original trial.  In particular, the appeal argues that Dakotah's counsel failed to draw on "So Young and So Untender: Remorseless Children and the Expectations of the Law" - an extraordinary study by Emory  Professor Martha Grace Duncan of how courts punish juveniles for not showing a stereotypical form of remorse.

Professor Duncan provides seven case studies of juveniles who committed murder but did not display conventional remorse. She argues that courts erroneously interpret lack of remorse as a sign of depravity, warranting the kind of penalty Dakotah received. This isn't simply an "academic" study. Here's how it opens:

The morning after my father’s suicide, I went to my classes at Columbia University as usual, wearing a hot-pink, summery top and a pink and white floral skirt. In the elevator of the International House where I lived, a friend who had been with me when I received the news looked at me curiously. No doubt he wondered why I was still in New York and on my way to school – why I showed no signs of grief.

Actually, I showed no grief because I felt none, and did not for a long time. It was a year before I cried over my father’s death, four years before I began, in therapy, to talk to someone about it. When I did begin to cry, I could not stop...

Fortunately, no legal ramifications flowed from my earlier failure to exhibit sadness, for I stood accused of no crime. But this experience of being unable to show or even feel “appropriate” sorrow over my father’s death has resonated for me with many legal cases. It inspired my interest in, and doubts about, the uses of remorse in juvenile and criminal law.

Professor Duncan's article helped me and my wife understand an experience that had puzzled us since I was in residency and she was in graduate school. We went to dinner at a good friend's apartment. We drank lots of wine and listened to songs by a hot new group - the Rolling Stones. It was only as we were leaving that our friend mentioned that her father had died that morning. During the evening we'd seen no signs of grief.

In the New Yorker article, Rachel Aviv lays out the alternative approaches the law has taken towards juvenile offenders. In states guided by the ethic of rehabilitation, Dakotah would be released when he turned 21. In Michigan, which is guided by the ethic of protecting society and punishing "depravity," Dakotah faces life in prison with no possibility of parole.

Unfortunately there is some wisdom in each of these perspectives, which creates a problem for our preference for moral certainty. For some "Dakotahs," the crime would, in retrospect, be an aberrant event followed by an exemplary life. For other "Dakotahs," the crime would be followed by other violent events - a life of incorrigability.

In my view, automatic release at 21 and automatic life imprisonment with no opportunity for parole, are both wrong policies. Rehabilitation, "going straight," is possible, but in no way inevitable. Likewise with depraved incorrigibility. Automatic release at 21 fails to protect society. Life imprisonment fails to protect the individual who no longer poses a threat.

If we allow for this kind of uncertainty we will inevitably make mistakes. Some "Dakotahs" will be released, ostensibly rehabilitated, and go on to commit further serious crimes, as happened with Jack Abbot, author of In The Belly of the Beast. Other "Dakotahs" will be kept in prison when they would have otherwise been positive contributors to society.

Rachel Aviv's writing teaches us that we can't avoid uncertainty other than by embracing falsity. The prosecutor argued that Dakotah is a depraved killer. Maybe he is, but there's absolutely no way of knowing it. Psychiatrists argued that Dakotah had bipolar illness, despite what appears to be lack of evidence for the condition.

As I was mulling over how to conclude this post, a couplet by Ogden Nash popped into mind: "Candy is Dandy...But liquor is quicker." Nash was writing about romantic seduction. Without labelling the theme, Aviv is writing about intellectual and moral seduction. Depravity and exoneration are seductive simplicities.

But they're wrong!

Medical Ethics and Blaming the Victim

A article on female genital pain got me thinking about one of my pet peeves in medicine – blaming the victim.

The condition – vulvodynia - was often blamed on the woman, as in saying “it’s a fear of sex,” “it’s in your head,” or “it’s classical hysteria.” Now it turns out that identifiable, but subtle, anatomical factors appear to cause it. Treatment has improved. Blame is diminishing.

I first heard clinical teachers say things like “the patient failed chemotherapy so we decided to try…” when I was in medical school. The people saying this were typically devoted caretakers. The implication that the treatment didn’t work because the patient “failed” was rooted in health jargon, not their hearts.

But the “patient failed” phrase isn’t just a piece of sloppy grammar. It shows something about the culture of health care, at least in the U.S.

The good thing the phrase reflects is just how responsible caretakers feel for patients. If the treatment doesn’t work we tend to feel guilty, even when we’ve done the best that can be done.

The bad thing the phrase reflects is our collective cowardice. Instead of acknowledging the sad fact that medicine, while powerful, is limited, we blame the patient. Medicine didn’t fail. The patient did.

Looking into what has been written about blaming the victim I came upon this moving 2004 exchange in The Oncologist:

TO THE EDITOR:

As a lung cancer patient and advocate, I have been enormously heartened the past few months with the recent discovery of the epidermal growth factor receptor (EGFR) mutation and its immediate and long-term implications for improved treatment and extended survival for people with lung and other cancers.

In reading about the promise and potential of this new finding in Dr. Bruce Chabner’s editorial, "The Miracle of Iressa" [1], I was jolted from my excitement by one particular phrase. Dr. Chabner stated that "...patients will continue to receive Iressa when they fail chemotherapy." When they fail chemotherapy? Have the patients really "failed" when chemotherapy drugs do not work? Of course they haven’t. So why use a phrase that implies blame?

Dr. Chabner, whom I know to be an excellent and sensitive oncologist, is far from alone in expressing the failure of cancer treatment in a less than patient-friendly way. This unfortunate convention is used in the medical literature, at professional conferences, and not surprisingly, in the clinic. It is common for oncologists to tell patients that they "failed drug X." By telling patients they failed to respond to treatment, doctors may increase the guilt that many patients already struggle with as a result of their cancer diagnoses. For others, like me, it becomes an annoying refrain. At minimum, it puts emotional distance between doctor and patient and undermines the doctor-patient relationship. Just imagine under the same circumstances if the patient said to the doctor, "You failed to give me the right drug to treat my cancer." The question isn’t who failed, but what failed.

I ask Dr. Chabner and The Oncologist readers to be mindful of the language used when discussing the failure of therapies in cancer patients. Something as simple as, "Drug X didn’t work for you, maybe this one will," is one example. There are numerous ways to express the failure of cancer treatment without failing the patient, too.Sincerely,

Karen Parles, MLS
Editor, www.LungCancerOnline.org
Executive Director, Lung Cancer Online Foundation

FROM THE EDITOR:

Our reader, Karen Parles, points out an important, and unfortunate, mistaken use of the word "failure" in my recent editorial, describing a patient’s lack of response to Iressa therapy [1]. The failure of treatment is not the patient’s fault in any regard. The fault lies with the current state of science, and our understanding of the disease. The convenient phrase "failure," so often used in our society to describe an unhappy outcome beyond the control of the individual, has no place in the context of unsuccessful treatment of a disease such as cancer. I apologize for myself and my colleagues, who so often confuse outcome with intent, and I thank Karen Parles for raising our consciousness to the all-important use and impact of our words.

I assure her that I have expunged "that phrase" from my vernacular ... and I urge my colleagues to do likewise.

Bruce Chabner, M.D.
Editor-in-Chief, The Oncologist
Clinical Director, Massachusetts General Hospital Cancer Center.

Hats off to Dr. Chabner! I hope our colleagues follow the example he's set.

Raising the Age for Medicare Eligibility - First Prize Dumb Idea

This week the Congressional Budget Office released a report on proposals to raise the age of eligibility for Medicare and Social Security.

The CBO concludes that raising Medicare eligibility to 67 would reduce federal spending by $148 billion between 2012 through 2021. By 2030, Medicare's net spending would be reduced by 5% - 4.7% of GDP rather than 5%. Those numbers sound good.

But reducing federal expenditures doesn't reduce the need for medical care. Some lucky folks (I'm in that category) (a) have employment that provides health insurance and (b) are happy to continue working. Some who would rather retire will continue to work, increasing health care costs for their employer (and fellow employees). Some will scramble to find alternatives which will cost them more than Medicare would. And some will become uninsured, at an age when this is progressively risky. Overall costs - to individuals, employers and other government programs would probably go up more than the $148 billion reduction in Medicare outlays.

The CBO does not comment on the fact that employers are not clamoring for ready-to-retire employees to stay on the job simply to avoid being uninsured.

Raising the Medicare eligibility age isn't meaningful cost reduction - it's simply a form of hot potato, dumping the costs into other accounts. It intensifies the fragmentation of our health system, and worsens overall quality of care.

In my view, the proposal is born out of despair about achieving constructive Medicare reform in which health professionals, patients and families collaborate on behalf of improved care (basically more compassion and less technology) and reduced costs. From 35 years of practice in a not-for-profit HMO setting I know this kind of collaboration is possible. But it requires a spirit of cooperation and trust that is not easy to find in our toxic political environment. 

The Role of Will Power in Medical Care

I've made a belated New Year's resolution - to read "Willpower: Rediscovering the Greatest Human Strength" - a book about how to make effective resolutions. I made my resolution while reading an article about it in a recent New York Times.

The basic ideas aren't rocket science. But they're practical, well articulated, and grounded in research:

1. Set a single clear goal - not an overwhelming program of total self-modification all at once.
2. Apply a strategic plan. The classic example is Odysseus. When he wanted to hear the sirens sing but to resist their charms he didn't just rely on will power - he had himself tied to the mast, and had his sailors put wax in their ears so they (a) could hear the sirens and (b) couldn't hear his demand to have the ropes taken off.
3. Develop a support team. Years ago a patient of mine described, with pleasure, how when he whined about stress in his AA group the group chanted, in unison, but with affection - "Tough Shit! Don't Drink!" Now, with the burgeoning of web supports, we can supplement the support process with social networking tools.
4. Monitor progress. Over the years there's been debate, for example, as to whether checking weight daily discourages would-be reducers, but evidence now suggests that for most people, regular feedback helps.
5. Don't overreact to lapses. The quality improvement mantra - "every defect is a treasure" - applies to managing ourselves. Falling off the wagon from time to time is almost inevitable. The key is to (a) learn what we can from the episode and (b) not interpret a lapse as a global defeat.
6. One day/hour/minute at a time. Years ago I asked a substance abuse counsellor colleague to join me and a patient who was struggling with alcoholism. She pointed out that if focusing on a day was too much, changing the time scale to "one hour at a time" or even "one minute at a time" could sometimes strengthen our capacity for control.
7. Give frequent rewards. Just focusing on control can be grim and joyless. Most of us need pleasurable payoffs for our efforts as well. The NYT article described a scale that will automatically make donations to a charity if we're meeting our weight target!

I applied most of these precepts in my work with patients suffering from chronic psychiatric conditions, but in a less systematic way than I would if I were starting over. The biggest change for patients and clinicians is the availability of all kinds of web-based tools that can supplement these ancient psychological insights. Scales can track and graph our weight. Pedometers count our steps. Social networking applications orchestrate our support group, supplement it when it needs augmentation, or replaces it altogether with responses we can design.

I ended my clinical practice four years ago, but at the turn of the year I received a series of communications from former patients. One asked me to buff up a voice mail message that has been a useful booster shot over time. Another asked for guidance about significant health-relevant New Year's resolutions. A third simply wanted to report on the status of the major areas we'd worked on for many years.

Many years ago, a patient whose well-being required strengthened assertiveness had identified the second serve in tennis as a valuable monitoring tool. This person's skills were excellent, but fear of double faulting led to a bloopy second serve. Some time after we ended treatment I was happy to receive a three word message: "Second serve humming!"

To care for patients with chronic conditions, we clinicians need to orchestrate the balance of patient self-management and the support and guidance we provide. This is a fascinating aspect of the art of medicine. It touches on the eternal philosophical conundrum of free will vs determinism. When we get the balance right it's usually clear and always satisfying.

A New Blog About Medicare

I started a second blog on New Year's day - "Seniors for Medicare Reform." I'd been dithering about doing it for many months, and I couldn't bear the idea of entering 2012 without getting going.

I define the goals this way on the masthead:

"A voice for seniors who believe that health care should be guided by patients' values, that the care system needs more compassion and less technology, and that Medicare costs should be constrained for the sake of future generations."

Here's the thinking behind the goals for the new blog:

A voice for seniors: Politicians assume that all Medicare beneficiaries are "greedy geezers" monolithically fixated on keeping Medicare exactly as it is. I'm convinced there's a substantial number of beneficiaries who (a) cherish the security Medicare provides but (b) support what I would regard as "progressive" reforms. If I'm right, it's important for politicians to know it. Since I'm part of the Medicare generation, I'll generally refer to "we" and "us."

...who believe that health care should be guided by patients' values: I expect to write a lot on the new blog about the multitude of ways in which we physicians all-too-often guide ourselves by our perspectives rather than by those of our patients, in accord with the old saw that "the operation was a success, but unfortunately the patient died." 

...that the care system needs more compassion and less technology: While cynical politicians scared us with "death panel" lies during the health reform debate, our more enduring fear is of overtreatment - of having things done to us that we don't want. The health policy wonks among us have written tomes about how Medicare policies and reimbursement schemes give too much incentive for technological interventions and too little support for compassion and care

...and that Medicare costs should be constrained for the sake of future generations: I've almost never heard anything different than this from Medicare age folks I've spoken with. But with varying degrees of vehemence we add our overall views of economic justice - "I'll be damned if I want to see Medicare cut in order to finance tax breaks for hedge fund managers/waste federal money on XYZ programs/spend trillions on wars we shouldn't have started/etcetcetc.

I'm decidedly a Massachusetts liberal, but I think there's potential for folks with a wide range of political attitudes to support the advocacy voice I'm hoping to promote. The effort may fizzle and go nowhere, but I want to give it a shot!

What Business Schools Can Learn from Medical Education

The January-February issue of the Harvard Business Review has a column - "What Business Schools Can Learn from the Medical Profession" - by Harvard Business School dean Nitin Nohria.

Dean Nohria praises the way medical education addresses the "knowing-doing" gap by fostering hands-on experience in medical school and residency. In that spirit, this month, for the first time, Harvard will send 900 first year students to developing markets, where they will work in teams of six with a multinational or local company to develop a new product or service offering. At the end of each day students will gather with faculty members to discuss their experience.

I agree with the Dean's sense that immersion in field experience can be enormously educative. But the end-of-day sessions with faculty also play a crucial role. For the past ten years I've had the privilege of co-facilitating the "Patient/Doctor" seminar in the residency in Primary Care and Population Health that my department sponsors with the Brigham and Women's Hospital and Harvard Vanguard Medical Associates. This longitudinal seminar meets over the course of the three year program. Relationships with patients, self-understanding, professionalism and medical ethics are central topics for us.

Albert Schweitzer taught that “example is not the main thing in influencing others…it is the only thing.” Not every influence is positive, and our discussions often focus on how to deal with challenging circumstances, such as difficult patients or consultants who treat colleagues, students and patients badly. The faculty role in the HBS program will be crucial for helping students "process" what is sure to be a powerful but often confusing field experience.

Last year I reviewed notes I made (and kept) from clinical supervision I received as a resident more than forty years ago. Here's part of the note I sent to one of my teachers:

I've been reviewing notes that I kept from my residency at MMHC [Massachusetts Mental Health Center] 1965 - 1968. My clinical notes on the treatment of an especially difficult patient are interlaced with my summaries of what "Dr. X" said in supervision, and I wanted to tell you how excellent your teaching was. You consistently focused my attention on the therapeutic alliance and being very clear for myself and with the patient what the work to be done was. What I took from your teaching was practical, empathic and deep. Reading notes from 45 years ago is a fascinating experience, for a view of myself as a 26 - 29 year old and for a view of what psychiatry looked like through the lens of MMHC in the late 1960s.

Excellent teaching stays with us through a lifetime. Thank you for being such an important teacher and friend to me during those formative years of residency!

Here are some excerpts from the note I got back from Dr. X, who was living in a retirement community:

Good morning Jim! You have made my day with that message...I hope that over the years my teaching has at least held its own and not corroded; what I do know is that teaching has been a mainstay of my life and that it will be the last thing I give up if I have any choice in it.  

...Practical, empathic, and deep--now that is a motto for a life.

Old teachers, like the moon, bask in reflected light from the achievements of their students.

Every good thing to you for 2011, and thank you very much for writing me this splendid note.

The field experience is sure to be an important educational opportunity for the 900 first year HBS students. But it will also be an important educational opportunity for the faculty, especially with regard to ethics education. Before he became dean, Professor Nohria proposed a code of ethics for business. But we know from centuries of medical education that codes don't shape behavior. I look forward to hearing from HBS faculty and students about the ways in which the new field experience program does, and does not, influence the values orientation of the planet's future business leaders.