Tuesday, July 31, 2007

Reasons for sex


July 31, 2007
The Whys of Mating: 237 Reasons and Counting

Scholars in antiquity began counting the ways that humans have sex, but they weren’t so diligent in cataloging the reasons humans wanted to get into all those positions. Darwin and his successors offered a few explanations of mating strategies — to find better genes, to gain status and resources — but they neglected to produce a Kama Sutra of sexual motivations.

Perhaps you didn’t lament this omission. Perhaps you thought that the motivations for sex were pretty obvious. Or maybe you never really wanted to know what was going on inside other people’s minds, in which case you should stop reading immediately.

For now, thanks to psychologists at the University of Texas at Austin, we can at last count the whys. After asking nearly 2,000 people why they’d had sex, the researchers have assembled and categorized a total of 237 reasons — everything from “I wanted to feel closer to God” to “I was drunk.” They even found a few people who claimed to have been motivated by the desire to have a child.

The researchers, Cindy M. Meston and David M. Buss, believe their list, published in the August issue of Archives of Sexual Behavior, is the most thorough taxonomy of sexual motivation ever compiled. This seems entirely plausible.

Who knew, for instance, that a headache had any erotic significance except as an excuse for saying no? But some respondents of both sexes explained that they’d had sex “to get rid of a headache.” It’s No. 173 on the list.

Others said they did it to “help me fall asleep,” “make my partner feel powerful,” “burn calories,” “return a favor,” “keep warm,” “hurt an enemy” or “change the topic of conversation.” The lamest may have been, “It seemed like good exercise,” although there is also this: “Someone dared me.”

Dr. Buss has studied mating strategies around the world — he’s the oft-cited author of “The Evolution of Desire” and other books — but even he did not expect to find such varied and Machiavellian reasons for sex. “I was truly astonished,” he said, “by this richness of sexual psychology.”

The researchers collected the data by first asking more than 400 people to list their reasons for having sex, and then asking more than 1,500 others to rate how important each reason was to them. Although it was a fairly homogenous sample of students at the University of Texas, nearly every one of the 237 reasons was rated by at least some people as their most important motive for having sex.

The best news is that both men and women ranked the same reason most often: “I was attracted to the person.”

The rest of the top 10 for each gender were also almost all the same, including “I wanted to express my love for the person,” “I was sexually aroused and wanted the release” and “It’s fun.”

No matter what the reason, men were more likely to cite it than women, with a couple of notable exceptions. Women were more likely to say they had sex because, “I wanted to express my love for the person” and “I realized I was in love.” This jibes with conventional wisdom about women emphasizing the emotional aspects of sex, although it might also reflect the female respondents’ reluctance to admit to less lofty motives.

The results contradicted another stereotype about women: their supposed tendency to use sex to gain status or resources.

“Our findings suggest that men do these things more than women,” Dr. Buss said, alluding to the respondents who said they’d had sex to get things, like a promotion, a raise or a favor. Men were much more likely than women to say they’d had sex to “boost my social status” or because the partner was famous or “usually ‘out of my league.’ ”

Dr. Buss said, “Although I knew that having sex has consequences for reputation, it surprised me that people, notably men, would be motivated to have sex solely for social status and reputation enhancement.”

But then, men were also more likely than women to say they’d had sex because “I was slumming.” Or simply because “the opportunity presented itself,” or “the person demanded that I have sex.”

If nothing else, the results seem to be a robust confirmation of the hypothesis in the old joke: How can a woman get a man to take off his clothes? Ask him.

To make sense of the 237 reasons, Dr. Buss and Dr. Meston created a taxonomy with four general categories:

Physical: “The person had beautiful eyes” or “a desirable body,” or “was good kisser” or “too physically attractive to resist.” Or “I wanted to achieve an orgasm.”

Goal Attainment: “I wanted to even the score with a cheating partner” or “break up a rival’s relationship” or “make money” or “be popular.” Or “because of a bet.”

Emotional: “I wanted to communicate at a deeper level” or “lift my partner’s spirits” or “say ‘Thank you.’ ” Or just because “the person was intelligent.”

Insecurity: “I felt like it was my duty” or “I wanted to boost my self-esteem” or “It was the only way my partner would spend time with me.”

Having sex out of a sense of duty, Dr. Buss said, showed up in a separate study as being especially frequent among older women. But both sexes seem to practice a strategy that he calls mate-guarding, as illustrated in one of the reasons given by survey respondents: “I was afraid my partner would have an affair if I didn’t.”

That fear seems especially reasonable after you finish reading Dr. Buss’s paper and realize just how many reasons there are for infidelity. Some critics might complain that the list has some repetitions — it includes “I was curious about sex” as well as “I wanted to see what all the fuss was about” — but I’m more concerned about the reasons yet to be enumerated.

For instance, nowhere among the 237 reasons will you find the one attributed to the actress Joan Crawford: “I need sex for a clear complexion.” (The closest is “I thought it would make me feel healthy.”)Nor will you find anything about gathering rosebuds while ye may (the 17th-century exhortation to young virgins from Robert Herrick). Nor the similar hurry-before-we-die rationale (“The grave’s a fine and private place/ But none I think do there embrace”) from Andrew Marvell in “To His Coy Mistress.”

From even a cursory survey of literature or the modern mass market in sex fantasies, it seems clear that this new taxonomy may not be any more complete than the original periodic table of the elements.

When I mentioned Ms. Crawford’s complexion and the poets’ rationales to Dr. Buss, he promised to consider them and all other candidates for Reason 238.

You can nominate your own reasons at TierneyLab. You can also submit nominations for a brand new taxonomy: reasons for just saying “No way!” Somehow, though, I don’t think this list will be as long.

Thursday, July 26, 2007

Cat visits indicate impending death - NEJM

July 26, 2007
Oscar the Cat Predicts Patients' Deaths

Filed at 3:15 a.m. ET

PROVIDENCE, R.I. (AP) -- Oscar the cat seems to have an uncanny knack for predicting when nursing home patients are going to die, by curling up next to them during their final hours. His accuracy, observed in 25 cases, has led the staff to call family members once he has chosen someone. It usually means they have less than four hours to live.

''He doesn't make too many mistakes. He seems to understand when patients are about to die,'' said Dr. David Dosa in an interview. He describes the phenomenon in a poignant essay in Thursday's issue of the New England Journal of Medicine.

''Many family members take some solace from it. They appreciate the companionship that the cat provides for their dying loved one,'' said Dosa, a geriatrician and assistant professor of medicine at Brown University.

The 2-year-old feline was adopted as a kitten and grew up in a third-floor dementia unit at the Steere House Nursing and Rehabilitation Center. The facility treats people with Alzheimer's, Parkinson's disease and other illnesses.

After about six months, the staff noticed Oscar would make his own rounds, just like the doctors and nurses. He'd sniff and observe patients, then sit beside people who would wind up dying in a few hours.

Dosa said Oscar seems to take his work seriously and is generally aloof. ''This is not a cat that's friendly to people,'' he said.

Oscar is better at predicting death than the people who work there, said Dr. Joan Teno of Brown University, who treats patients at the nursing home and is an expert on care for the terminally ill

She was convinced of Oscar's talent when he made his 13th correct call. While observing one patient, Teno said she noticed the woman wasn't eating, was breathing with difficulty and that her legs had a bluish tinge, signs that often mean death is near.

Oscar wouldn't stay inside the room though, so Teno thought his streak was broken. Instead, it turned out the doctor's prediction was roughly 10 hours too early. Sure enough, during the patient's final two hours, nurses told Teno that Oscar joined the woman at her bedside.

Doctors say most of the people who get a visit from the sweet-faced, gray-and-white cat are so ill they probably don't know he's there, so patients aren't aware he's a harbinger of death. Most families are grateful for the advanced warning, although one wanted Oscar out of the room while a family member died. When Oscar is put outside, he paces and meows his displeasure.

No one's certain if Oscar's behavior is scientifically significant or points to a cause. Teno wonders if the cat notices telltale scents or reads something into the behavior of the nurses who raised him.

Nicholas Dodman, who directs an animal behavioral clinic at the Tufts University Cummings School of Veterinary Medicine and has read Dosa's article, said the only way to know is to carefully document how Oscar divides his time between the living and dying.

If Oscar really is a furry grim reaper, it's also possible his behavior could be driven by self-centered pleasures like a heated blanket placed on a dying person, Dodman said.

Nursing home staffers aren't concerned with explaining Oscar, so long as he gives families a better chance at saying goodbye to the dying.

Oscar recently received a wall plaque publicly commending his ''compassionate hospice care.''


Science writer Alicia Chang in Los Angeles contributed to this report.

Volume 357:328-329 July 26, 2007 Number 4

A Day in the Life of Oscar the Cat
David M. Dosa, M.D., M.P.H.

Oscar the Cat awakens from his nap, opening a single eye to survey his kingdom. From atop the desk in the doctor's charting area, the cat peers down the two wings of the nursing home's advanced dementia unit. All quiet on the western and eastern fronts. Slowly, he rises and extravagantly stretches his 2-year-old frame, first backward and then forward. He sits up and considers his next move.

In the distance, a resident approaches. It is Mrs. P., who has been living on the dementia unit's third floor for 3 years now. She has long forgotten her family, even though they visit her almost daily. Moderately disheveled after eating her lunch, half of which she now wears on her shirt, Mrs. P. is taking one of her many aimless strolls to nowhere. She glides toward Oscar, pushing her walker and muttering to herself with complete disregard for her surroundings. Perturbed, Oscar watches her carefully and, as she walks by, lets out a gentle hiss, a rattlesnake-like warning that says "leave me alone." She passes him without a glance and continues down the hallway. Oscar is relieved. It is not yet Mrs. P.'s time, and he wants nothing to do with her.

Oscar jumps down off the desk, relieved to be once more alone and in control of his domain. He takes a few moments to drink from his water bowl and grab a quick bite. Satisfied, he enjoys another stretch and sets out on his rounds. Oscar decides to head down the west wing first, along the way sidestepping Mr. S., who is slumped over on a couch in the hallway. With lips slightly pursed, he snores peacefully — perhaps blissfully unaware of where he is now living. Oscar continues down the hallway until he reaches its end and Room 310. The door is closed, so Oscar sits and waits. He has important business here.

Twenty-five minutes later, the door finally opens, and out walks a nurse's aide carrying dirty linens. "Hello, Oscar," she says. "Are you going inside?" Oscar lets her pass, then makes his way into the room, where there are two people. Lying in a corner bed and facing the wall, Mrs. T. is asleep in a fetal position. Her body is thin and wasted from the breast cancer that has been eating away at her organs. She is mildly jaundiced and has not spoken in several days. Sitting next to her is her daughter, who glances up from her novel to warmly greet the visitor. "Hello, Oscar. How are you today?"

Oscar takes no notice of the woman and leaps up onto the bed. He surveys Mrs. T. She is clearly in the terminal phase of illness, and her breathing is labored. Oscar's examination is interrupted by a nurse, who walks in to ask the daughter whether Mrs. T. is uncomfortable and needs more morphine. The daughter shakes her head, and the nurse retreats. Oscar returns to his work. He sniffs the air, gives Mrs. T. one final look, then jumps off the bed and quickly leaves the room. Not today.

Making his way back up the hallway, Oscar arrives at Room 313. The door is open, and he proceeds inside. Mrs. K. is resting peacefully in her bed, her breathing steady but shallow. She is surrounded by photographs of her grandchildren and one from her wedding day. Despite these keepsakes, she is alone. Oscar jumps onto her bed and again sniffs the air. He pauses to consider the situation, and then turns around twice before curling up beside Mrs. K.

One hour passes. Oscar waits. A nurse walks into the room to check on her patient. She pauses to note Oscar's presence. Concerned, she hurriedly leaves the room and returns to her desk. She grabs Mrs. K.'s chart off the medical-records rack and begins to make phone calls.

Within a half hour the family starts to arrive. Chairs are brought into the room, where the relatives begin their vigil. The priest is called to deliver last rites. And still, Oscar has not budged, instead purring and gently nuzzling Mrs. K. A young grandson asks his mother, "What is the cat doing here?" The mother, fighting back tears, tells him, "He is here to help Grandma get to heaven." Thirty minutes later, Mrs. K. takes her last earthly breath. With this, Oscar sits up, looks around, then departs the room so quietly that the grieving family barely notices.

On his way back to the charting area, Oscar passes a plaque mounted on the wall. On it is engraved a commendation from a local hospice agency: "For his compassionate hospice care, this plaque is awarded to Oscar the Cat." Oscar takes a quick drink of water and returns to his desk to curl up for a long rest. His day's work is done. There will be no more deaths today, not in Room 310 or in any other room for that matter. After all, no one dies on the third floor unless Oscar pays a visit and stays awhile.

Note: Since he was adopted by staff members as a kitten, Oscar the Cat has had an uncanny ability to predict when residents are about to die. Thus far, he has presided over the deaths of more than 25 residents on the third floor of Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. His mere presence at the bedside is viewed by physicians and nursing home staff as an almost absolute indicator of impending death, allowing staff members to adequately notify families. Oscar has also provided companionship to those who would otherwise have died alone. For his work, he is highly regarded by the physicians and staff at Steere House and by the families of the residents whom he serves.

Sunday, July 15, 2007

waubers's China Impressions


First off, Shenzhen China is an arm-pit of a city. Don't go there unless you have to.

If you do go there, the only good hotel (i.e. one with anyone who speaks any English and a level of quality at least as good as a holiday inn in the USA) is the Dragon Spring.

Some points on the Dragon Spring Hotel:
1. The lobby smells of fish.
2. The AC in your room only runs in spurts. It will typically stop working around 23:00, so do try to fall asleep by then, unless you enjoy falling asleep in your own sweat.
3. If you drop a duce, be sure you flush before you put any TP into the bowl. All 3 of us in my group managed to plug up the shitter. Sadly, it was a Kohler Toilet, which you'd think could handle my decadent western shits.
4. Don't eat the steamed buns at breakfast. Seriously, this wasn't a joke and we didn't know. We all ate a couple our first day and one guy even said "these taste like paper." We found out about the news story the next day.
5. Orange Juice = Orange Fanta; Apple Juice = Pineapple Fanta; Haw Juice = whothefuckknows.
6. Don't pour your own beer into your glass, you make the servers look sad when you do that.

If, like my companions, you feel the need to go out drinking every night you're traveling for work, and you happen to be staying at the Dragon Spring hotel DO NOT patronize the Dragon Spring Garden Opera House Bar and Lounge. If you do, some tips:

3. Don't nod your head when they say "you like beer but not girl" This is a question, not a funny statement.
5. DON'T LET THEM SIT THE MUSICAL ACT AT YOUR TABLE, they will drink all your beer, which is amazing because they couldn't have weighed more than 160lbs combined.
6. REFUSE THE FRUIT PLATE, it's $290cny
7. When you try to leave, regardless of how drunk you might be, don't get off on the 6th floor, even if it's the first floor the elevator opens on. It's a brothel. With women.
8. When asked, do not follow the hostess to the 5th floor. It's a brothel. With no women.
9. Always know where your buddy is, lest he be abducted.
10. Laugh at the jokes of the comedian, even though you can't understand them.
11. Tsing Tao is pronounced Chee-ing Tao.
12. DO NOT LET YOUR MANAGER SIGN YOUR NAME AND ROOM TO THE BILL. I have know idea how I'm going to explain a 1200CNY bill for "Night Club" to accounting, even though I only had three beers.
13. You might be a Westerner, but FOR THE LOVE OF GOD YOU ARE NOT A VIP, and as such, DO NOT PRESS THE VIP BUTTON IN THE ELEVATOR.

Observations on Hong Kong.
1. Hong Kong is hot!
2. Hong Kong IS FUCKING HOT, wear deodorant on your balls.
3. Hong Kong is awesome, easily the coolest city I've ever seen.
4. Visit Victoria Peak at night, it's awe-inspiring.
5. Take a taxi to Victoria Peak, the tram is fucking scary.
6. The waiters at Bubba Gump Shrimp (on top of Victoria Peak) are pretty cool.
7. Hong Kong has a city-wide lazer and fireworks show every Saturday night, it's sweet, especially when you're a couple thousand feet above the city.
8. DRINK LOTS OF WATER. It's a bad sign when you stop sweating an it's 35C outside.
9. Remember that beer != water, even beer as watery as Tsing Tao.
10. Taxi's are a very reasonable way to get around the city.
11. The SkyLounge at the Hotel Nikko is awesome, but for the love of god be careful what you order. I still don't know how we're going to explain a $400us bar-tab with only 3 people drinking, for less than 2 hours.
12. The SkyLounge has impeccable service.
13. Hong Kong is very very expensive.
14. Everyone should visit Hong Kong, it's truly an amazing city. More impressive than London or Paris. IMO.

Saturday, July 14, 2007

Energy saving in NYC buildings


July 15, 2007
The Cost of Saving Energy

NEW YORKERS have often been told that they use less energy than most Americans, partly because they live in the most densely populated city in the country.

And that’s true, up to a point.

Sure, New Yorkers have the benefit of an extensive mass-transit system, which means lower auto emissions, but the city’s residential buildings are less energy-efficient than those in many other places in the country, particularly in eco-friendly states like California and Vermont.

“The main reason that New Yorkers use much less electricity is that our apartments are so much smaller” than homes in other cities, said Rohit Aggarwala, the director of the Long-Term Planning and Sustainability Office, part of the Mayor’s Office of Operations.

In fact, most big New York buildings, both commercial and residential, are wasting thousands of dollars a year on energy, the city says. Energy use by buildings accounts for almost 80 percent of the city’s greenhouse gas emissions, and residential buildings for about a third of that. These gases are released in creating the energy used to heat, cool and light the buildings, as well as to run myriad household appliances and gadgets.

Mayor Michael R. Bloomberg has created a blueprint, called PlaNYC, to control future development in the city, with a goal of reducing total greenhouse gas emissions in 2030 by 30 percent, compared with 2005 levels.

While some reductions can be accomplished by toughening the requirements for new construction, about 85 percent of the buildings that will exist in the city in 2030 are already standing.

And those buildings need to go on an energy diet.

There are a number of relatively inexpensive things that residential buildings could do that would immediately lower their energy costs and that would reduce their “carbon footprints,” the emissions these buildings are responsible for, Mr. Aggarwala said.

The easiest, and cheapest, is to install energy-efficient light bulbs in all common areas. More expensive plans — the costs of which can often be offset by loans and grants from New York State — include replacing old inefficient boilers with more efficient modern ones and installing solar panels on the roof.

Ashok Gupta, a senior energy economist and the director of the air and energy program at the Natural Resources Defense Council, a nonprofit environmental group in New York, said many buildings start with the least expensive measures with the biggest immediate payoff — buying fluorescent bulbs for about $4 each, for example, or thermostatic radiator valves for about $90 each.

But that is where a lot of buildings stop, and Mr. Gupta said he would like to see them reach a bit further, to measures whose costs could be recouped in two to five years. The next step, for example, might be installing motion sensors that would dim the lights by 50 percent when the hallways and stairwells were not in use.

In a 60,000-square-foot building with 40 apartments, hiring an electrician to install motion sensors might cost $11,000, according to estimates produced by Optimal Energy Inc., a consulting company in Bristol, Vt., that has done regional energy-efficiency studies for New York State and Con Edison. The building could save that much in lower electricity bills over two years, assuming that it was already using fluorescent bulbs, and the sensors alone would reduce its carbon dioxide emissions by about 40 metric tons per year, the company said.

That would be the equivalent of driving a car that gets 25 miles per gallon for 110,250 miles, according to Dr. Stuart Gaffin, an associate research scientist at the Center for Climate Systems Research at Columbia University.

As you would expect, it would take longer to recoup the costs of the more expensive measures.

Optimal Energy estimates, for example, that it would cost about $20,000 to weatherize that 60,000-square-foot apartment building, which could be paid for by five years of lower heating bills. Weatherizing would include sealing gaps around windows, exterior doors, and interior pipes and wiring.

Some residential buildings might also consider installing solar panels on the roof, to provide a nonpolluting source of electricity to light the hallways and run the elevators. Experts recommend doing this only after more glaring energy inefficiencies have been addressed, because in a large apartment house, solar panels are not going to produce enough energy to replace Con Edison.

Solar requires patience. It could take up to 15 years to break even on $19,000 spent on solar panels, and that is after subsidies and tax breaks offered by the state and federal governments. Mayor Bloomberg has proposed an additional subsidy for installing solar panels on buildings in New York City.

Mr. Gupta of the Natural Resources Defense Council contends that environmentalists often sell themselves short by focusing too much on payback periods. “Nobody asks what the payback period is for a marble lobby,” he said. But if a lot of large commercial and residential buildings installed solar panels, he said, that could go a long way toward reducing the city’s overall impact on global warming.

“From a societal perspective, the benefits are huge,” Mr. Gupta said.

As it stands, very few apartment buildings in New York have taken the first step and hired energy consultants. The first step most consultants suggest is to switch to fluorescent bulbs (a cheap fix), and then to solve the heating problems (to keep residents from being uncomfortable).

The Towers Cooperative, an eight-building complex with 111 apartments in Jackson Heights, Queens, last year hired Power Concepts, an energy auditor in Manhattan.

Once the audit was done, Bobbi Turner, the building’s manager, sat down with the board. They decided to start with the fixes that their in-house maintenance staff could do — for example, installing fluorescent bulbs as the old incandescents burned out. Ms. Turner said the electricity bills for the common areas were 7 percent lower last year than in 2005.

For now, Ms. Turner and the board have decided to forgo many costlier measures that were recommended, including installing separate boilers for hot water and heat to cut down on the fuel the co-op uses in the warm weather when residents need hot water but not heat.

It would have cost $86,000 to do this in all eight buildings, with a payback period of five and a half years.

But the buildings’ staff did implement other suggested improvements to the heating system, which included installing thermostatic radiator valves in all apartments.

“Our job is to make sure that we are doing things as efficiently as possible,” Ms. Turner said.

The co-op did not have a maintenance increase this year, and Ms. Turner attributes this largely to the cost savings from the efficiency measures that have been implemented so far.

Other buildings have needed to take more extensive measures to solve more complicated problems.

At 395 Riverside Drive, a 15-story co-op at the corner of 112th Street, the apartments on the west side of the building were often cold because of wintertime blasts of wind off the Hudson River. If the heat was turned up to offset the cold, apartments on the east side of the building got too hot.

The board at 395 Riverside Drive ordered an energy audit from the Association for Energy Affordability, based in Manhattan, which recommended installing additional heat sensors and upgrading the computer that regulated the heat.

These changes were made last fall, at a cost of almost $8,000. The building paid $8,500 less on fuel bills, a decrease of nearly 16 percent, from December 2006 to April 2007, despite a spike in heating oil prices, according to the building’s management company.

And the residents were more comfortable, said Dr. Eric Linden, a periodontist who is a former vice president of the co-op board.

The building also replaced the bulbs in the hallways with fluorescents, although, as at the co-op in Queens, the in-house staff replaced them gradually.

Dr. Linden credits these changes with keeping a lid on maintenance. The monthly fees, which range from $500 to $2,200, depending on the size of the apartment, rose 3 percent this spring.

“But we might have had to raise them 4 to 6 percent if the energy costs had gotten completely out of control,” Dr. Linden said.

Remarkably, the age of a building seems to have no correlation with how energy efficient or inefficient it is. Some of New York City’s most efficient are old brick-and-mortar buildings “that just have amazingly good maintenance staff,” said Michael Colgrove, a senior project manager at New York State Energy Research Authority, whose goal is to make multifamily buildings more efficient.

On the flip side, Mr. Colgrove said, owners in condominiums built 5 or 10 years ago should not be complacent. “Almost all new construction in this city can easily improve their energy efficiency by 20 percent,” he said.

Daniel M. Krainin, a lawyer who is the president of a Brooklyn co-op, had an energy audit done for his building, a converted brownstone with eight apartments in Park Slope.

F. L. Andrew Padian, the director of multifamily services at Steven Winter Associates, an architecture and engineering firm in Norwalk, Conn., that performed the audit, recommended five measures. So far, the co-op has acted on only one, installing a mixing valve on the boiler for $550. Mr. Krainin said that this cut the building’s oil bill by more than $400 in the last year.

Sometimes, Mr. Padian said, cutting fuel use is simply a matter of recalibrating some controls. “When I can walk in with a screwdriver and cut energy bills by 40 percent, people are really happy,” he said. “In other buildings, the old boiler is responsible for 85 percent of the energy waste.”

The four other measures that he recommended for the building would cost about $30,000 in all: replacing the old boiler with an efficient unit, replacing the old beat-up windows with new double-paned windows, insulating the roof and installing motion sensors on the lights in the basement.

“Thirty thousand dollars would be a lot of money for a co-op our size,” Mr. Krainin said.

After reading the audit report, residents voiced their reservations until they learned that the co-op could finance the work with a below-market loan subsidized by the state.

“Now everyone is sold on the idea that if we can do it without increasing the maintenance fees, then it makes sense,” Mr. Krainin said. “But I think we might have had more objections if we’d gotten to the point that it would cost people money in the form of higher maintenance fees or a surcharge.”

That may be the sentiment of many co-op and condo boards now, but energy-efficiency experts say that attitudes are changing fast.

Jonathan F. P. Rose, a New York developer who specializes in energy-efficient construction, said the public is much more aware of environmental issues like global warming than it was a few years ago.

Developers are racing to build new condominiums that can be marketed as “green.” And Mr. Rose said that older condos and co-ops could distinguish themselves with “energy smart building” certificates if they successfully completed the new state energy-efficiency program and cut their energy use by 20 percent.

“This isn’t a fad,” Mr. Rose said. “I think this is a cultural transition. In the future, I think there will be such a preference for green buildings that those buildings will have an edge.”

Thursday, July 12, 2007

Doctor errors


July 7, 2007
Op-Ed Contributor
Mental Malpractice


ONE kind of new year comes for all of us in January — the one we celebrate with Champagne. But another, more stressful new year begins for doctors in July, when the new interns arrive in our emergency rooms, clinics and wards. Hospital personnel have always joked, “Don’t get sick in July,” since for decades the trainees were loosely supervised.

Today, most hospitals closely watch over interns. But at the start of this new medical year, a significant deficiency remains in the system: the way in which doctors are trained to think.

One of my first experiences with the problem came in 1983, during the first week in July as it happens, when my wife, Pam, also a doctor, and I were traveling to Boston from California with our son Steven, then 9 months old. Steve had developed a low-grade fever, had dark and loose stools and was irritable, refusing to nurse. Stopping in Connecticut to visit my in-laws, we consulted the town pediatrician. The doctor quickly dismissed Pam’s concerns. “You’re overanxious,” he told her. “Doctor-parents are like this.”

By the time we arrived in Boston, the baby was ashen and he was jerking his knees to his chest and wailing in pain. We rushed to the emergency room at Children’s Hospital, where a new surgical resident examined him, ordered X-rays and blood tests and made the correct diagnosis: an intussusception, an intestinal obstruction. It was a hectic night, and the novice doctor was being pulled in many directions. He told us there was no urgency to operate and left us alone with our flailing child.

I had worked one year in a research lab at this hospital and phoned the senior hematologist who had been my mentor. He contacted an attending surgeon, who came to the emergency room and whisked Steve to the operating room. “It was fortunate that we operated when we did,” the surgeon told us later. The intestine was at the point of bursting, spilling its contents into the abdomen, precipitating peritonitis and possibly shock.

Today at Children’s Hospital, you no longer need to know a powerful member of the staff. Every intern’s plan of treatment is validated by an attending doctor as part of the “patient safety movement.” Systematic checks and double checks also have been instituted to guard against logistical mistakes, like mixing up blood samples in the laboratory or labeling “left” as “right” on a limb X-ray.

Still, doctors get their diagnoses wrong 15 percent to 20 percent of the time, and half of these mistakes result in serious harm or even death — because the majority of misdiagnoses result from errors in thinking, not logistics.

In analyzing patients’ problems, doctors look for typical signs and symptoms. Often after listening to a patient’s complaints for just 18 seconds, studies show, a doctor will interrupt, having already formulated his or her diagnosis. Too often, shortcuts lead in the wrong direction.

As a young doctor, I had an elderly patient who complained of discomfort under her breastbone. I examined her, performed several tests and quickly concluded that she had indigestion. The antacids I prescribed brought little relief, but my mind was so fixed that her persistent complaints sounded to me like a nail scratching a chalkboard.

Several weeks later, I was paged to the emergency room. The woman was in shock. The discomfort under her breastbone, it turned out, had been caused by a tear in her aorta. After she died, my colleagues commiserated, saying that a torn aorta can be hard to diagnose, that the woman was so old that she probably would not have survived surgery to repair the tear. But that provided cold comfort, and I have never forgotten, nor forgiven myself.

In some hospitals, mistakes are categorized as “E.T.” for errors in technique and “E.J.” for errors in judgment. Errors in technique might involve placing a needle too far into the chest and puncturing a lung or inserting a breathing tube into the esophagus instead of the trachea — mistakes that, with practice, doctors can learn to stop making.

Errors in judgment are not so easily avoided, because we have largely failed to learn anything about how we think. Modern clinical practice has incorporated DNA analysis to illuminate the causes of disease, robotics to facilitate operations in the brain and computers to refine M.R.I. images, but we have paid scant attention to the emerging science of cognitive psychology, which could help us explore how we make decisions.

This science has grown from the work of Amos Tversky and Daniel Kahneman, who some three decades ago began a series of experiments to examine how people make choices when they are uncertain. Economists have used their work to understand why people in the marketplace often make irrational decisions. People invest in a company because their relatives did in the past, for example, or they choose a fund manager simply because he outperformed the market two years in a row.

This growing body of research can illuminate many irrational aspects of medical decision-making, too. The snap judgments that doctors make, for example, can be understood as “anchoring errors”; the first symptoms anchor the doctor’s mind on an incorrect diagnosis. Doctors also fall into a cognitive trap known as “availability,” meaning that we too readily recall our most recent or dramatic clinical experiences and assume they correspond to a new patient’s problem.

We make “affective” errors, too, letting our feelings color our thinking. Such feelings may be drawn from stereotypes — the Connecticut pediatrician casting my wife as overanxious or my viewing my elderly patient as a chronic complainer — or they may be excessively positive. Too much empathy may keep a doctor from performing an uncomfortable procedure that is vital to making the correct diagnosis.

I have started teaching these concepts of cognitive psychology in continuing medical education courses, and recently used my misdiagnosis of the torn aorta to illustrate the common thinking trap. My wife, Pam, has introduced fourth-year medical students at our hospital to the cognitive detours doctors commonly take. But such instruction needs to be widespread. In classes and on hospital rounds, medical schools and hospitals should teach doctors why some diagnoses succeed and why some fail. And as part of the assessment of clinical competency for obtaining a license, doctors should be expected to demonstrate their fluency in the application of cognitive science, as they are required to do in other sciences.

Once we are schooled in the way we think, we will also be better able to answer questions from patients and their families about how we arrive at our diagnoses. And that may make everyone more confident about visiting a clinic or a hospital in July.

Jerome Groopman, a professor of medicine at Harvard, is the author, most recently, of “How Doctors Think.”

Tuesday, July 03, 2007

iPhone parts and profit margin

Apple sees fat margins with iPhone, report says
'Teardown' analysis finds device is more profitable than iPod, Apple TV

By Rex Crum, MarketWatch
Last Update: 1:59 PM ET Jul 3, 2007
SAN FRANCISCO (MarketWatch) -- Hot on the heels of the iPhone launch, shares of Apple Inc. jumped to a new all-time high Tuesday following a report on the high profit margins the company is likely to earn from the device. Shares of Apple were up nearly 5% to close at $127.17 during a shortened trading session Tuesday, on a volume of 41.3 million shares. Normal daily average is 28.9 million shares.

That set a new closing high for a stock that has gained nearly 50% since the company introduced the iPhone in early January. The device went on sale Friday to long lines of customers, some of whom camped out on the street to save their place. The action followed a report earlier in the day by technology-research firm iSuppli, which found after taking apart an 8-gigabyte iPhone that producing the device costs Apple about $266 for the hardware. Based on the $599 price tag of the 8-gigabyte iPhone, the company stands to record gross margins of more than 55% for every unit sold, the report said. According to iSuppli, those profits would be even greater that the 40% to 50% margins Apple earns from the various versions of its iPod device. The company's new Apple TV set-top box has margins of about 21%, iSuppli added, after performing "teardown" analysis on those devices as well. Apple stands to record gross margins of more than 55% for every unit sold, according to iSuppli. Apple hopes to sell about 10 million iPhones within a year and claim 1% of the mobile-phone market. ISuppli estimates that Apple will sell 4.5 million iPhones this year and 13.5 million in 2008.

According to iSuppli, the iPhone's component suppliers run the gamut of semiconductor and other technology names. The research firm said that Samsung Electronics is "perhaps the biggest winner" among the iPhone parts suppliers, with its components making up $76.25, or about 30.5% of the parts in the 8GB iPhone. Samsung's contributions include the device's applications processor, NAND flash and DRAM memory chips. Infineon Technologies AG found its way into the iPhone with its digital baseband, radio-frequency transceiver and power-management technologies, and National Semiconductor Corp. supplies the chip that connects the iPhone's display to its graphics controller. ISuppli said the touch-screen, considered to be one of the iPhone's top selling points, is supplied by Epson, Sharp and Toshiba Matsushita, while the display module is provided by German company Balda and its Chinese partner, TPK Holdings.
Other companies in the iPhone include Marvell Technology Group with its Wi-Fi baseband chip; CSR PLC, which provides the iPhone's Bluetooth technology; and Wolfson Microelectronics, which makes the audio-processing chip. Also on Tuesday, media outlets reported that Apple's carrier partner AT&T Inc. has fixed the issues that caused some iPhone buyers long delays in getting their wireless service activated.

HIPAA misunderstandings


July 3, 2007
Keeping Patients’ Details Private, Even From Kin

An emergency room nurse in Palos Heights, Ill., told Gerard Nussbaum he could not stay with his father-in-law while the elderly man was being treated after a stroke. Another nurse threatened Mr. Nussbaum with arrest for scanning his relative’s medical chart to prove to her that she was about to administer a dangerous second round of sedatives.

The nurses who threatened him with eviction and arrest both made the same claim, Mr. Nussbaum said: that access to his father-in-law and his medical information were prohibited under the Health Insurance Portability and Accountability Act, or Hipaa, as the federal law is known.

Mr. Nussbaum, a health care and Hipaa consultant, knew better and stood his ground. Nothing in the law prevented his involvement. But the confrontation drove home the way Hipaa is misunderstood by medical professionals, as well as the frustration — and even peril — that comes in its wake.

Government studies released in the last few months show the frustration is widespread, an unintended consequence of the 1996 law.

Hipaa was designed to allow Americans to take their health insurance coverage with them when they changed jobs, with provisions to keep medical information confidential. But new studies have found that some health care providers apply Hipaa regulations overzealously, leaving family members, caretakers, public health and law enforcement authorities stymied in their efforts to get information.

Experts say many providers do not understand the law, have not trained their staff members to apply it judiciously, or are fearful of the threat of fines and jail terms — although no penalty has been levied in four years.

Some reports blame the language of the law itself, which says health care providers may share information with others unless the patient objects, but does not require them to do so. Thus, disclosures are voluntary and health care providers are left with broad discretion.

The unnecessary secrecy is a “significant problem,” said Mark Rothstein, chairman of a privacy subcommittee that advises the Department of Health and Human Services, which administers Hipaa. “It’s drummed into them that there are rules they have to follow without any perspective,” he said about health care providers. “So, surprise, surprise, they approach it in a defensive, somewhat arbitrary and unreasonable way.”

Susan McAndrew, deputy director of health information privacy at the Department of Health and Human Services, said that problems were less frequent than they once had been but that health care providers continued to hide behind the law. “Either innocently or purposefully, entities often use this as an excuse,” she said. “They say ‘Hipaa made me do it’ when, in fact, they chose for other reasons not to make the permitted disclosures.”

Mr. Rothstein, one of Hipaa’s harshest critics, has led years of hearings across the country. Transcripts of those hearings, and accounts from hospital administrators, patient advocates, lawyers, family members, and law enforcement officials offer an anthology of Hipaa misinterpretations, some alarming, some annoying:

¶Birthday parties in nursing homes in New York and Arizona have been canceled for fear that revealing a resident’s date of birth could be a violation.

¶Patients were assigned code names in doctor’s waiting rooms — say, “Zebra” for a child in Newton, Mass., or “Elvis” for an adult in Kansas City, Mo. — so they could be summoned without identification.

¶Nurses in an emergency room at St. Elizabeth Health Center in Youngstown, Ohio, refused to telephone parents of ailing students themselves, insisting a friend do it, for fear of passing out confidential information, the hospital’s patient advocate said.

¶State health departments throughout the country have been slowed in their efforts to create immunization registries for children, according to Dr. James J. Gibson, the director of disease control in South Carolina, because information from doctors no longer flows freely.

Teaching staff to protect records is easier than teaching them to share them, said Robert N. Swidler, general counsel for Northeast Health, a nonprofit network in Troy, N.Y., that includes several hospitals.

“Over time, the staff has become a little more flexible and humane,” Mr. Swidler said. “But nurses aren’t lawyers. This is a hyper-technical law and it tells them they may disclose but doesn’t say they have to.”

Many experts, including critics like Mr. Rothstein and proponents like Ms. McAndrew, distinguish different categories of secrecy.

There are “good faith nondisclosures,” as when a floor nurse takes a phone call from someone claiming to be a family member but cannot verify that person’s identity. Then there are “bad faith nondisclosures,” like using Hipaa as an excuse for not taking the time to gather records that public health officials need to help child abuse investigators trying to build a case.

Most common are seat-of-the-pants decisions made by employees who feel safer saying “no” than “yes” in the face of ambiguity.

That seemed to be what happened to his own mother, Mr. Rothstein said, when she called her doctor’s office to discuss a problem. She was told by the receptionist that the doctor was not available, Mr. Rothstein said, and then inquired if the doctor was with a patient or out of the office. “I can’t tell you because of Hipaa,” came the reply. In fact the doctor was home sick, which would have been helpful information in deciding whether to wait for a call back or head for the emergency room.

The law, medical professionals and privacy experts said, has had the positive effect of making confidentiality a priority as the nation moves toward fully computerized, cradle-to-grave medical records.

But safeguarding electronic privacy required a tangle of regulations issued in 2003, followed last year by 101 pages of “administrative simplification.”

Senator Edward M. Kennedy, Democrat of Massachusetts, a sponsor of the original insurance portability law, was dismayed by the “bizarre hodgepodge” of regulations layered onto it, several staff members said, and by the department’s failure to provide “adequate guidance on what is and is not barred by the law.” To that end, Mr. Kennedy, along with Senator Patrick M. Leahy, Democrat of Vermont, plans to introduce legislation creating an office within the Department of Health and Human Services dedicated to interpreting and enforcing medical privacy.

“In this electronic era it is essential to safeguard the privacy of medical records while insuring our privacy laws do not stifle the flow of information fundamental to effective health care,” Mr. Kennedy said.

This spring, the department revised its Web site, www.hhs.gov/ocr/hipaa, in the interest of clarity. But Hipaa continues to baffle even the experts.

Ms. McAndrew explained some of the do’s and don’ts of sharing information in a telephone interview:

Medical professionals can talk freely to family and friends, unless the patient objects. No signed authorization is necessary and the person receiving the information need not have the legal standing of, say, a health care proxy or power of attorney. As for public health authorities or those investigating crimes like child abuse, Hipaa defers to state laws, which often, though not always, require such disclosure. Medical workers may not reveal confidential information about a patient or case to reporters, but they can discuss general health issues.

Ms. McAndrew said there was no way to know how often information was withheld. Of the 27,778 privacy complaints filed since 2003, the only cases investigated, she said, were complaints filed by patients who were denied access to their own information, the one unambiguous violation of the law.

Complaints not investigated include the plights of adult children looking after their parents from afar. Experts say family members frequently hear, “I can’t tell you that because of Hipaa,” when they call to check on the patient’s condition.

That is what happened to Nancy Banks, who drove from Bartlesville, Okla., to her mother’s bedside at Town and Country Hospital in Tampa, Fla., last week because Ms. Banks could not find out what she needed to know over the telephone.

Her 82-year-old mother had had a stroke. When Ms. Banks called her room she heard her mother “screaming and yelling and crying,” but conversation was impossible. So Ms. Banks tried the nursing station.

Whoever answered the phone was not helpful, so Ms. Banks hit the road. Twenty-two hours later, she arrived at the hospital.

But more of the same awaited her. She said her mother’s nurse told her that “because of the Hipaa laws I can get in trouble if I tell you anything.”

In the morning, she could speak to the doctor, she was told.

The next day, Ms. Banks was finally informed that her mother had had heart failure and that her kidneys were shutting down.

“I understand privacy laws, but this has gone too far,” Ms. Banks said. “I’m her daughter. This isn’t right.”

A hospital spokeswoman, Elena Mesa, was asked if nurses were following Hipaa protocol when they denied adult children information about their parents.

She could not answer the question, Ms. Mesa said, because Hipaa prevented her from such discussions with the press.