Triple Chocolate Brownies

Triple Chocolate Brownies
Recipe courtesy Nigella Lawson

3 sticks plus 2 tablespoons unsalted butter
12 ounces best-quality bittersweet chocolate
6 eggs
1 3/4 cups superfine sugar
1 tablespoon pure vanilla extract
1 1/2 cups plus 2 tablespoons all-purpose flour
1 teaspoon salt
1/2 cup white chocolate buttons, chips, or morsels
1/2 cup semisweet chocolate buttons, chips or morsels
Approximately 2 teaspoons confectioners' sugar, for garnish

Special equipment: Baking tin (approximately 11 1/4 inches by 9 inches by 2 inches), sides and base lined with baking parchment.

Preheat the oven to 350 degrees F.

Melt the butter and dark chocolate together in a large heavy based pan over a low heat.
In a bowl or large measuring jug, beat the eggs together with the superfine sugar and vanilla extract.

Allow the chocolate mixture to cool a little, then add the egg and sugar mixture and beat well. Fold in the flour and salt. Then stir in the white chocolate buttons or chips, and the semisweet chocolate buttons or chips. Beat to combine then scrape and pour the brownie mixture into the prepared tin.

Bake for about 25 minutes. You can see when the brownies are ready because the top dries to a slightly paler brown speckle, while the middle remains dark, dense and gooey. Even with such a big batch you do need to keep checking on it: the difference between gooey brownies and dry ones is only a few minutes. Remember, too, that they will continue to cook as they cool.

To serve, cut into squares while still warm and pile up on a large plate, sprinkling with confectioners' sugar pushed with a teaspoon through a small sieve.

City rude driver rankings

May 15, 2007
Miami Holds Top Spot on Rude Driver List
By THE ASSOCIATED PRESS

Filed at 9:38 a.m. ET

MIAMI (AP) -- For the second straight year, rude Miami drivers have earned the city the title of worst road rage in a survey released Tuesday.

Miami motorists said they saw other drivers slam on their brakes, run red lights and talk on cell phones, according to AutoVantage, a Connecticut-based automobile membership club offering travel services and roadside assistance.

Other cities near the top of the rude drivers list were New York, Boston, Los Angeles and Washington, D.C.

South Miami resident Erik Pinto told The Associated Press he's probably seen every bad driving habit on Miami's roads.

''You don't want to know what I've seen,'' Pinto said. ''I've seen everything. I'm from L.A., and we don't see the crazy drivers that you see here.''

Portland, Ore., drivers were the least likely of the cities to see other motorists tailgating on the roadways, and St. Louis motorists were the least likely to swear at another driver, the survey found.

Minneapolis-St. Paul was rated the most courteous city in 2006 but slipped to the middle of the list this year.

The most frequent cause of road rage cited in the survey was impatient motorists. Drivers also cited poor driving in fast lanes and driving while stressed, frustrated or angry.

''The best piece of advice is to take a deep breath. Slow down, be aware and be careful,'' AutoVantage spokesman Todd Smith said, adding the aim of the survey is to increase driver safety across the nation.

More than 2,500 drivers who regularly commute in 25 major metropolitan areas were asked to rate road rage and rude driving in telephone surveys between January and March. The survey was conducted by Prince Market Research has a margin of error of plus or minus 2 percentage points.

The list, ranked from those reporting the most incidents of road rage to the fewest:

1. Miami

2. New York

3. Boston

4. Los Angeles

5. Washington, D.C.

6. Phoenix

7. Chicago

8. Sacramento, Calif.

9. Philadelphia

10. San Francisco

11. Houston

12. Atlanta

13. Detroit

14. Minneapolis-St. Paul

15. Baltimore

16. Tampa, Fla.

17. San Diego

18. Cincinnati

19. Cleveland

20. Denver

21. Dallas-Ft. Worth

22. St. Louis

23. Seattle-Tacoma

24. Pittsburgh

25. Portland, Ore.

America's Most Overpriced Real Estate Markets

Forbes

America's Most Overpriced Real Estate Markets
Matt Woolsey, 05.04.07, 12:01 AM ET

No matter the locale, its denizens almost always gripe about the stiff cost of living, housing and doing business. But in some places the financial pain is clearly more acute than others.

Take San Diego. A slumping housing market, where only 5% of residents can afford the median home, and a high price-to-earnings ratio made the oceanfront city our most overpriced real estate market. Had weather been included as a statistical measurement, there's no doubt San Diego would have avoided our list of top 10 most overpriced cities--but we didn't factor in sunshine.

Arriving at the relative value of a given market isn't as simple as calculating median home prices, income rates and cost of living. Instead, our list of most overpriced real estate markets incorporates a more meaningful methodology.

In Pictures: 10 Most Overpriced Real Estate Markets

In Pictures: 10 Least Overpriced Real Estate Markets

Behind The Numbers
Using the 40 largest metro areas, we started by estimating a "price-to-earnings" ratio for each market. (Like the P/E of a stock, this value attempts to measure the price a homeowner would pay for one dollar of return.) Using data from the National Association of Realtors (NAR), the U.S. Census Bureau and the Office of Federal Housing Enterprise Oversight, we took each market's median home price and divided it by annual rents minus taxes and insurance for those properties. (We assumed for this exercise that other costs don't vary drastically from city to city.)

The average P/E for the 40 markets is 28. Note: Unlike, say, the S&P 500 index of stocks, ours is not a weighted-average P/E. If it were, certain cities with greater overall sheer market value would carry more weight.

In the market for a seven-figure home? How much domain your dollar will net depends on where you look. Find out how far your money will go--and where--here.

We incorporated a second metric: an affordability index. Calculated from National Home Builder Association and Wells Fargo data, the affordability score is the percent of the population who can afford to buy the median-priced home, assuming a 6% mortgage rate. In a city like Los Angeles, No. 4 on the list, a wee 2% of homes are affordable for residents pulling down a median income.

Consider Detroit. Almost 88% of its homes are available to those with a median income, and its 17.5 P/E ratio appears relatively low, but that doesn't make real estate in the Motor City a good investment. Already stagnant home prices have decreased at a rate of 1% over the last year and, of the major metros, Detroit is the only one on our list to have lost jobs since 2005 (other than New Orleans, which we left off; in the wake of Hurricane Katrina the city's statistical figures were such anomalies that it wasn't comparable to the rest of the cities).

Related Stories Inside America's Super-Pricey Apartments World's Most Expensive Homes

So which markets are in bubble territory? Look for a high P/E ratio, low affordability, low income growth and a high cost of living.

San Francisco, ranked fourth, fits that bill. Despite home prices growing at a 2% clip over last year, according to the NAR, the city by the bay ranks third to last in expected income growth, reports Moody's. Not good news in a market where only 7.5% of housing is affordable for the median-income earner. Combine that with a housing P/E ratio over 50, and it isn't difficult to imagine some softening on the horizon.

The usual suspects littered our list: Miami came in second, followed in order by: Sacramento, Calif.; San Francisco; Washington, D.C.; Honolulu; New York; Los Angeles; and Boston. San Jose, Calif., rounded out the top 10.

Tourist in LA

NYTimes

May 13, 2007
Family Travel | Los Angeles
Adventures in Dreamland
By A. O. SCOTT

ONE pleasant April afternoon, I found myself, along with my wife and our two children, in the middle of a quintessential American scene. There was a quaint town square, a sturdy shade tree flanked by cozy shops and Victorian houses. As we surveyed this idyllic tableau, it was pointed out to us that many of the buildings were empty shells, and that the leaves on the trees were bits of green plastic wired to the branches.

The news was not altogether shocking. We had, after all, reached this New England hamlet via a five-minute drive from downtown Chicago, which was itself nestled up against a block of New York brownstones not far from an overgrown patch of jungle. The mountains in the distance seemed real enough. They were the Hollywood Hills, and our immediate surroundings, the Warner Brothers back lot in Burbank.

As a tourist destination, Hollywood is a bit of a tease, at once wide-open and hermetic. It's all around you — the magic of the movies, the homes of the stars, the big sign in the hills — but where, exactly, is it?

Before I became a film critic, I never spent much time in Los Angeles, and my subsequent acquaintance with the city has been colored, and perhaps distorted, by my job. It is all too easy, when you write about movies, to wrap yourself in a carapace of cynicism; you don't want to come off as too star-struck, too susceptible to the glamour that still emanates from Hollywood. And so you learn to inflect the word “Hollywood” with a certain disdain, to show that you don't buy all those clichés about Tinseltown and the Dream Factory. If you come from New York and have seen “Annie Hall” as many times as I have, you may also retain certain snobbish prejudices about the place.

But who am I kidding? Hollywood may connote shameless commercialism, but it also conjures a powerful, undimmed spell of romance. The paradoxical mystique of movie stars — we feel like we know them so well, even as their lives seem so fantastically distant from ours — extends to the place where they are hatched and raised.

Luckily, my children, now 8 and 10 years old, provide an antidote to my put-on professional world-weariness. They are voracious, indiscriminate consumers of popular culture, and while I can't always share their enthusiasm — in the interests of family harmony, we tacitly agree not to bring up my reviews of “Madagascar” or “Chicken Little” — I am always happy to feed it.

And so when work calls me out to Southern California, I try whenever possible to take the family along. Over the last few years, the four of us have developed a collective crush on Los Angeles.

Earlier this spring, I left behind my critical agenda and, inspired by “Little Miss Sunshine,” the National Lampoon “Vacation” movies and a half-dozen relevant episodes of “The Simpsons,” assumed the role of affable tourist doofus dad. In this script my wife, Justine, was perfectly typecast as the voice of skepticism and good sense. Our children adopted pseudonyms, both to protect their anonymity in the newspaper and to pay tribute to the local tradition of self-reinvention that turned Issur Danielovich Demsky into Kirk Douglas and Norma Jeane Baker into Marilyn Monroe. The boy renamed himself Wayne Bruce, in triple tribute to Batman, the Duke and the star of “Die Hard,” which he'd recently seen part of on cable and which is, not coincidentally, a movie about a New Yorker coping with life in Los Angeles. His younger sister chose to inscribe herself in the tradition of single-named divas; we'll call her Melody.

We took an afternoon flight to LAX and found ourselves in the rental car lot just in time for rush hour. Wayne Bruce, true to action-hero form, wanted to roll out in the red Hummer. I'll admit to ogling the Dodge Magnum. Half an hour later, thrift and good sense prevailed and we were crawling north on the 405 in a silver Impala under a disconcertingly cloudy sky. We checked into our cozy suite in West Hollywood, ordered hamburgers and quesadillas and set about storyboarding the days ahead.

The plan was to balance present and past, sensation and education, indoors and out. We wanted not only to explore movie-related tourist sites, but also to score a vicarious taste of what our movie-saturated imaginations pictured as a Hollywood lifestyle. Thus a certain amount of time would be allotted for lounging beside the pool, for being seen in trendy restaurants, for driving aimlessly in the hills, for staring at the Pacific Ocean.

“Will we see any celebrities?” Melody wondered. As it happened, we would not. There was one of those I-know-I've-seen-him-somewhere encounters, in an aisle of the Whole Foods in Santa Monica, with an actor who had the good grace to show up in a rerun on the hotel TV that night. And our guide on the Warner Brothers studio tour did make eye contact with me in his rear view mirror and ask, “Did anyone ever tell you you look like Paul Giamatti?”

But I'm ahead of the story. A studio tour was to be the first order of business. We had done Universal Studios — more of a theme park ride than a tour — on a previous visit; Disney doesn't offer tours of its studio lot, and neither does Fox (D'oh!). Paramount and Sony don't accommodate children under 12. That left Warner Brothers. The voice message said that reservations were accepted for the first tours of the morning (at 8:30 and 9), and that the rest of the day was first come first served.

So after a leisurely breakfast at the Urth Caffé on Melrose in West Hollywood, surrounded by script-readers and -writers and other aspirants to Hollywood glory, we made it to Burbank by 10:30. “Do you have a reservation?” we were asked. Well, no we didn't. Rather than wait three hours, we made reservations for the next afternoon and headed back over the hills, touching down at the intersection of Hollywood and Highland.

This turned out to be a good place to start — the epicenter of Hollywood tourism, an open-air theme park and pilgrimage site. Grauman's Chinese Theater, the Walk of Fame, the Kodak Theater shopping-mall complex where the Oscars are handed out: they're all right here.

We began with the Hollywood History Museum, which occupies a handsome Art Deco building that used to house the Max Factor makeup company. As I bought tickets, Justine pointed her digital camera at a poster in the lobby — an advertisement for the museum itself — and was immediately accosted by a man who seemed more like a junior production executive than the security guard he apparently was. “Ma'am, I'll have to ask you to erase that picture,” he said, explaining that “everything in this museum is a copyrighted piece of intellectual property.”

This was a useful object lesson, a reminder that we were visitors in a company town. We tend to think of movies as public property. Who do they belong to, if not the fans? But of course they are made, distributed, owned and fiercely protected by large commercial interests. And so we checked the camera at the front desk and worked our way through the jumble of memorabilia that is the Hollywood History Museum.

History is not, in that museum or anywhere else in Hollywood, a sequential, chronological affair. The Max Factor Building has been made over into a glorious attic, where posters, costumes, autographs and props line walls and fill vitrines according to no discernable principles of organization. John Garfield, John Wayne, Bruce Willis, Johnny Depp, Elvis Presley, Janet Gaynor, Jodie Foster — they're all thrown together, along with thousands more, just as they would be on the shelves of an especially chaotic video store. That may be the idea: movies exist in an eternal present, which is to say whenever you happen to watch them. And who has ever watched them in chronological — or any other logical — order?

My favorite room was filled with pictures of old-time stars, and also of the city itself, taken at various points in its evolution from a sleepy Western outpost into a sprawling postmodern metropolis. But the feeling was less one of nostalgia than of continuity and equivalence.

The Hollywood tourist experience creates the impression that legends of the past are equal to the glories of the present. This is quite deliberate. If the golden age were located too firmly in the past, then how could the appetite for novelty on which the entertainment industry depends be sustained? Wayne and Melody, big fans of “Some Like It Hot,” were happy to see Marilyn Monroe at the Hollywood Wax Museum (our next stop), but they were more excited by Spiderman and Freddy and Jason and the crew of the Black Pearl.

And the Walk of Fame, which stretches along Hollywood Boulevard in both directions, expands on this happy heterogeneity. Critics and historians can evaluate quality and importance, but the sun shines on the legendary and the forgotten, the great and the awful — Judy Garland's square of pavement and Mary-Kate and Ashley Olsen's — alike. You can follow their names from the Chinese to the Egyptian, home of the American Cinematheque, a shrine to serious cinema art, and stop on the way to have your picture taken with a guy dressed as SpongeBob or Homer Simpson (him again!) and buy a hollow replica of an Oscar statuette with the inscription Best Dad.

As we walked east, the homogenized atmosphere of chain restaurants and licensed merchandise turned seedy, as if the New Times Square were adjacent to the old one, rather than on top of it. We debated joining an organized walking tour of Hollywood sites, or boarding a bus that would take us past movie star homes, but decided to wander instead. We gazed at windows full of wigs and costumes, and were happy, for most of an hour, to trade the magic of Hollywood for Hollywood Magic, a marvelous old-style novelty shop. There, a man behind the counter performed card and coin tricks, much to the delight of Wayne and Melody, who spent some of her allowance on a Whoopee Cushion.

BY dinnertime, we were ready for more refined amusement, or at least a good dinner. Did we have a reservation? No, but when we called Lucques, a highly rated restaurant a short walk from the hotel, we were told that a party of four had just canceled. Justine and Melody shared the seared breast of duck, and Wayne polished off a plate of short ribs.

Justine likes movies, but she loves birds and trees, and so the next day, on our way to Warner Brothers, we drove into Griffith Park, where trails wind through the wooded hillsides toward the Hollywood sign and the Observatory. Scrambling through brush and the rocks, we could imagine ourselves in the Old West, or deep in the jungle, or, once we reached the Observatory terrace, in “Rebel Without a Cause.” All of which were perfectly apt. The varied natural and human topography of greater Los Angeles — desert, forest, suburb, seaside, slum — has made it almost infinitely adaptable. One of the reasons so many movies are made here is that it can so easily pass for just about anywhere.

And what Hollywood cannot find, it builds and recycles. This was the theme of the Warner Brothers tour, which took us through empty back lots and sound stages, further scrambling our sense of location and history. Since it was a holiday, no one was working except the tour guide, who talked as if he was not an employee of Time Warner but one of the original Brothers. As he drove us past the bungalows that once housed writers and actors on contract, he recounted that Bette Davis had once demanded an entire building to herself. “She was one of our biggest stars,” he said, “and since she'd made us so much money we were happy to give her whatever she wanted.” I'm sure he was.

But the tour, in keeping with the endless scrambling of past and present, was less about Bette Davis than “The Gilmore Girls.” We stopped in Stars Hollow to take permitted photographs, and wandered through the Gilmore mansion, which is housed in a sound stage. But Stars Hollow used to be Walton's Mountain, and before that, part of it was Kings Row, where Ronald Reagan lived before he went into politics. And the “Gilmore Girls” sound stage used to be “Casablanca.” Much of the lot was built in the early years of the sound era, and its city streets and country towns have been used hundreds of times — in bad and good movies and (more frequently now) in television shows — ever since.

It began to occur to us that what we were encountering was raw materials and byproducts, none of which were quite as satisfying as the movies themselves. It isn't so much that Los Angeles saves its best face for the camera, but more that its ubiquity on screen creates a strange sense of familiarity. The Richard Neutra houses and Spanish-style bungalows; the Capitol Records Building and the Santa Monica Pier; Rodeo Drive and Skid Row — I see them every week, juxtaposed in ways forbidden by traffic and geography, and framed and filtered by more evocative lenses than the ones on my glasses.

Happy as we were to be in the real Los Angeles, we found that what we really wanted to do was go to the movies, and our attempt was thwarted in a quintessentially Hollywood fashion. According to the papers, there was an early-evening screening in the Cinerama Dome, a refurbished 1950s showpiece (now part of the Arclight complex) built for the three-projector wide-screen spectaculars that were meant to save the movies from television. But the Dome is a popular place for premieres, and when we arrived the red carpet and velvet ropes were being prepared for that night's “Entourage” gala.

The next day, Melody and Justine, having decided that some movie-star-grade pampering was in order, went for hot stone massages at a day spa. Wayne and I took a power breakfast in Larchmont Village, a neighborhood that seemed eerily familiar. Dads pushing jogging strollers; moms lugging yoga mats: it was Park Slope, but with palm trees.

Then, hungering for a glimpse of the ocean, even through the persistent cloud cover, the four of us drove up the Pacific Coast Highway to Malibu, and pushed the Impala through hairpin turns into the Santa Monica Mountains, where we found the Paramount Ranch. Now part of a national park, the ranch was where the studio shot many of its westerns. The Western Town, most recently home of “Dr. Quinn, Medicine Woman,” is still there, and Wayne shot me down, just as if I was Liberty Valance, on its dusty main street. The town wasn't big enough for the both of us.

We wound along Mulholland and then turned toward the Pacific, to follow our western with a surfing movie. At Point Dume State Beach we dug our toes into the sand, stared dreamily into the distance and spotted dolphins frolicking not far from shore, a sight more thrilling than any movie.

As the sun set, we turned off the highway onto Sunset Boulevard. The sandy children dozed in the back and I could sense the glow of a Hollywood feeling I had sought without quite knowing it. Maybe it was the feeling of finding myself in a perfectly cinematic moment, as the road snaked through Pacific Palisades, Brentwood and Beverly Hills, past the grand, gated homes, the hand-lettered signs advertising Star Maps and the bored dreamers selling them. The drive was mundane and romantic at the same time, and as we descended onto the Sunset Strip in search of dinner (which we found, without reservations, at a Japanese restaurant where Jim Jarmusch's “Dead Man” was silently projected on a courtyard wall), we felt lost and completely at home.

A few weeks later, back in her third-grade classroom, Melody wrote an essay about her trip “to a place I like to call Hollywood.” I'm not sure exactly which place she meant, but I like to call it that too.

VISITOR INFORMATION

The unassuming Le Parc Suite Hotel blends into its quiet residential block in West Hollywood. Its spacious, reasonably priced suites, which make the hotel popular with musicians and film crews in town for extended stays, also make it appealing for families. The studio and one-bedroom suites can sleep four people comfortably, with varying degrees of privacy, and have kitchenettes and small balconies. Meals can be taken at the Knoll restaurant on the third floor; you can also order food on the rooftop terrace, where there is a small heated pool, a hot tub and tennis courts. (733 North West Knoll Drive; 310-855-8888; www.leparcsuites.com. Rates vary seasonally. Current rates begin at $229 for a studio.)

Groceries can be purchased at Trader Joe's, a 10-minute walk from Le Parc at 8611 Santa Monica Boulevard. Urth Caffé, not far away at 8565 Melrose Avenue, has excellent coffee, healthy and generous breakfast and lunch offerings and good opportunities for movie-industry eavesdropping. Le Parc is also within walking distance of the trendy Melrose shopping district, and from Lucques (8474 Melrose; 323-655-6277; www.lucques.com), which serves creative and thoughtfully prepared Cal-French cuisine in a carriage house once owned by the silent-film star Harold Lloyd. Another memorable meal was at Yatai (8535 Sunset Boulevard; 310-289-0030; www.yatai-bar.com), an Asian tapas bar whose sleek, dark ambience seemed much less child-friendly than its selection of small dishes (including satay, vegetable rolls and addictive nuggets of fried chicken) turned out to be. The mojitos are good, too.

Reservations for the Warner Brothers VIP studio tours can be made by calling (818) 972-8687 or at www.warnerbros.com. The tours last a little more than two hours; children must be at least 8 years old. Tickets are $42 a person.

Tickets for the various sites near Hollywood and Highland can be purchased individually. Or, at any of them, you can buy a Walk of Fame City Pass that includes the Hollywood History Museum or the Kodak Theater, the Hollywood Wax Museum, the Hollywood Behind-the-Scenes Walking Tour and the Starline bus tour. It costs $49.95 and is valid for nine days. Star Maps can be purchased for $5 from anyone sitting in a folding chair under a sign that says “Star Maps, $5.”

Griffith Park is open daily from 6 a.m. to 10 p.m. (Park information is at www.lacity.org/rap/dos/parks/griffithPK or 323-913-4688). Admission to the Observatory (www.griffithobs.org) requires a timed ticket ($8 for adults; $4 for children 5-12) and a shuttle bus ride from Hollywood and Highland. Reservations: (888) 695-0888. The Paramount Ranch is part of the Santa Monica Mountains National Recreation Area (805-370-2301; www.nps.gov/samo) in Thousand Oaks. It is open daily from 9 to 5. There is a covered picnic area and a performance stage behind the Western Town.

Hollywood Magic is at 6614 Hollywood Boulevard (323-464-5610). Collectors, souvenir hunters and comic-book geeks should not miss Meltdown (7522 Sunset Boulevard; 323-851-7223; www.meltcomics.com), which has an impressive and eclectic selection of action-figures, memorabilia, comics and graphic novels.

Pharma and antipsychotic prescribing

NYTimes

May 10, 2007
Industry’s Role in Childrens’ Antipsychotics
By GARDINER HARRIS, BENEDICT CAREY and JANET ROBERTS

When Anya Bailey developed an eating disorder after her 12th birthday, her mother took her to a psychiatrist at the University of Minnesota who prescribed a powerful antipsychotic drug called Risperdal.

Created for schizophrenia, Risperdal is not approved to treat eating disorders, but increased appetite is a common side effect and doctors may prescribe drugs as they see fit. Anya gained weight but within two years developed a crippling knot in her back. She now receives regular injections of Botox to unclench her back muscles. She often awakens crying in pain.

Isabella Bailey, Anya’s mother, said she had no idea that children might be especially susceptible to Risperdal’s side effects. Nor did she know that Risperdal and similar medicines were not approved at the time to treat children, or that medical trials often cited to justify the use of such drugs had as few as eight children taking the drug by the end.

Just as surprising, Ms. Bailey said, was learning that the university psychiatrist who supervised Anya’s care received more than $7,000 from 2003 to 2004 from Johnson & Johnson, Risperdal’s maker, in return for lectures about one of the company’s drugs.

Doctors, including Anya Bailey’s, maintain that payments from drug companies do not influence what they prescribe for patients.

But the intersection of money and medicine, and its effect on the well-being of patients, has become one of the most contentious issues in health care. Nowhere is that more true than in psychiatry, where increasing payments to doctors have coincided with the growing use in children of a relatively new class of drugs known as atypical antipsychotics.

These best-selling drugs, including Risperdal, Seroquel, Zyprexa, Abilify and Geodon, are now being prescribed to more than half a million children in the United States to help parents deal with behavior problems despite profound risks and almost no approved uses for minors.

A New York Times analysis of records in Minnesota, the only state that requires public reports of all drug company marketing payments to doctors, provides rare documentation of how financial relationships between doctors and drug makers correspond to the growing use of atypicals in children.

From 2000 to 2005, drug maker payments to Minnesota psychiatrists rose more than sixfold, to $1.6 million. During those same years, prescriptions of antipsychotics for children in Minnesota’s Medicaid program rose more than ninefold.

Those who took the most money from makers of atypicals tended to prescribe the drugs to children the most often, the data suggest. On average, Minnesota psychiatrists who received at least $5,000 from atypical makers from 2000 to 2005 appear to have written three times as many atypical prescriptions for children as psychiatrists who received less or no money.

The Times analysis focused on prescriptions written for about one-third of Minnesota’s Medicaid population, almost all of whom are disabled. Some doctors were misidentified by pharmacists, but the information provides a rough guide to prescribing patterns in the state.

Drug makers underwrite decision makers at every level of care. They pay doctors who prescribe and recommend drugs, teach about the underlying diseases, perform studies and write guidelines that other doctors often feel bound to follow.

But studies present strong evidence that financial interests can affect decisions, often without people knowing it.

In Minnesota, psychiatrists collected more money from drug makers from 2000 to 2005 than doctors in any other specialty. Total payments to individual psychiatrists ranged from $51 to more than $689,000, with a median of $1,750. Since the records are incomplete, these figures probably underestimate doctors’ actual incomes.

Such payments could encourage psychiatrists to use drugs in ways that endanger patients’ physical health, said Dr. Steven E. Hyman, the provost of Harvard University and former director of the National Institute of Mental Health. The growing use of atypicals in children is the most troubling example of this, Dr. Hyman said.

“There’s an irony that psychiatrists ask patients to have insights into themselves, but we don’t connect the wires in our own lives about how money is affecting our profession and putting our patients at risk,” he said.

The Prescription

Anya Bailey is a 15-year-old high school freshman from East Grand Forks, Minn., with pictures of the actor Chad Michael Murray on her bedroom wall. She has constant discomfort in her neck that leads her to twist it in a birdlike fashion. Last year, a boy mimicked her in the lunch room.

“The first time, I laughed it off,” Anya said. “I said: ‘That’s so funny. I think I’ll laugh with you.’ Then it got annoying, and I decided to hide it. I don’t want to be made fun of.”

Now she slumps when seated at school to pressure her clenched muscles, she said.

It all began in 2003 when Anya became dangerously thin. “Nothing tasted good to her,” Ms. Bailey said.

Psychiatrists at the University of Minnesota, overseen by Dr. George M. Realmuto, settled on Risperdal, not for its calming effects but for its normally unwelcome side effect of increasing appetite and weight gain, Ms. Bailey said. Anya had other issues that may have recommended Risperdal to doctors, including occasional angry outbursts and having twice heard voices over the previous five years, Ms. Bailey said.

Dr. Realmuto said he did not remember Anya’s case, but speaking generally he defended his unapproved use of Risperdal to counter an eating disorder despite the drug’s risks. “When things are dangerous, you use extraordinary measures,” he said.

Ten years ago, Dr. Realmuto helped conduct a study of Concerta, an attention deficit hyperactivity disorder drug marketed by Johnson & Johnson, which also makes Risperdal. When Concerta was approved, the company hired him to lecture about it.

He said he gives marketing lectures for several reasons.

“To the extent that a drug is useful, I want to be seen as a leader in my specialty and that I was involved in a scientific study,” he said.

The money is nice, too, he said. Dr. Realmuto’s university salary is $196,310.

“Academics don’t get paid very much,” he said. “If I was an entertainer, I think I would certainly do a lot better.”

In 2003, the year Anya came to his clinic, Dr. Realmuto earned $5,000 from Johnson & Johnson for giving three talks about Concerta. Dr. Realmuto said he could understand someone’s worrying that his Concerta lecture fees would influence him to prescribe Concerta but not a different drug from the same company, like Risperdal.

In general, he conceded, his relationship with a drug company might prompt him to try a drug. Whether he continued to use it, though, would depend entirely on the results.

As the interview continued, Dr. Realmuto said that upon reflection his payments from drug companies had probably opened his door to useless visits from a drug salesman, and he said he would stop giving sponsored lectures in the future.

Kara Russell, a Johnson & Johnson spokeswoman, said that the company selects speakers who have used the drug in patients and have either undertaken research or are aware of the studies. “Dr. Realmuto met these criteria,” Ms. Russell said.

When asked whether these payments may influence doctors’ prescribing habits, Ms. Russell said that the talks “provide an educational opportunity for physicians.”

No one has proved that psychiatrists prescribe atypicals to children because of drug company payments. Indeed, some who frequently prescribe the drugs to children earn no drug industry money. And nearly all psychiatrists who accept payments say they remain independent. Some say they prescribed and extolled the benefits of such drugs before ever receiving payments to speak to other doctors about them.

“If someone takes the point of view that your doctor can be bought, why would you go to an E. R. with your injured child and say, ‘Can you help me?’ ” said Dr. Suzanne A. Albrecht, a psychiatrist from Edina, Minn., who earned more than $188,000 from 2002 to 2005 giving drug marketing talks.

The Industry Campaign

It is illegal for drug makers to pay doctors directly to prescribe specific products. Federal rules also bar manufacturers from promoting unapproved, or off-label, uses for drugs.

But doctors are free to prescribe as they see fit, and drug companies can sidestep marketing prohibitions by paying doctors to give lectures in which, if asked, they may discuss unapproved uses.

The drug industry and many doctors say that these promotional lectures provide the field with invaluable education. Critics say the payments and lectures, often at expensive restaurants, are disguised kickbacks that encourage potentially dangerous drug uses. The issue is particularly important in psychiatry, because mental problems are not well understood, treatment often involves trial and error, and off-label prescribing is common.

The analysis of Minnesota records shows that from 1997 through 2005, more than a third of Minnesota’s licensed psychiatrists took money from drug makers, including the last eight presidents of the Minnesota Psychiatric Society.

The psychiatrist receiving the most from drug companies was Dr. Annette M. Smick, who lives outside Rochester, Minn., and was paid more than $689,000 by drug makers from 1998 to 2004. At one point Dr. Smick was doing so many sponsored talks that “it was hard for me to find time to see patients in my clinical practice,” she said.

“I was providing an educational benefit, and I like teaching,” Dr. Smick said.

Dr. Steven S. Sharfstein, immediate past president of the American Psychiatric Association, said psychiatrists have become too cozy with drug makers. One example of this, he said, involves Lexapro, made by Forest Laboratories, which is now the most widely used antidepressant in the country even though there are cheaper alternatives, including generic versions of Prozac.

“Prozac is just as good if not better, and yet we are migrating to the expensive drug instead of the generics,” Dr. Sharfstein said. “I think it’s the marketing.”

Atypicals have become popular because they can settle almost any extreme behavior, often in minutes, and doctors have few other answers for desperate families.

Their growing use in children is closely tied to the increasingly common and controversial diagnosis of pediatric bipolar disorder, a mood problem marked by aggravation, euphoria, depression and, in some cases, violent outbursts. The drugs, sometimes called major tranquilizers, act by numbing brain cells to surges of dopamine, a chemical that has been linked to euphoria and psychotic delusions.

Suzette Scheele of Burnsville, Minn., said her 17-year-old son, Matt, was given a diagnosis of bipolar disorder four years ago because of intense mood swings, and now takes Seroquel and Abilify, which have caused substantial weight gain.

“But I don’t have to worry about his rages; he’s appropriate; he’s pleasant to be around,” Ms. Scheele said.

The sudden popularity of pediatric bipolar diagnosis has coincided with a shift from antidepressants like Prozac to far more expensive atypicals. In 2000, Minnesota spent more than $521,000 buying antipsychotic drugs, most of it on atypicals, for children on Medicaid. In 2005, the cost was more than $7.1 million, a 14-fold increase.

The drugs, which can cost $1,000 to $8,000 for a year’s supply, are huge sellers worldwide. In 2006, Zyprexa, made by Eli Lilly, had $4.36 billion in sales, Risperdal $4.18 billion and Seroquel, made by AstraZeneca, $3.42 billion.

Many Minnesota doctors, including the president of the Minnesota Psychiatric Society, said drug makers and their intermediaries are now paying them almost exclusively to talk about bipolar disorder.

The Diagnoses

Yet childhood bipolar disorder is an increasingly controversial diagnosis. Even doctors who believe it is common disagree about its telltale symptoms. Others suspect it is a fad. And the scientific evidence that atypicals improve these children’s lives is scarce.

One of the first and perhaps most influential studies was financed by AstraZeneca and performed by Dr. Melissa DelBello, a child and adult psychiatrist at the University of Cincinnati.

Dr. DelBello led a research team that tracked for six weeks the moods of 30 adolescents who had received diagnoses of bipolar disorder. Half of the teenagers took Depakote, an antiseizure drug used to treat epilepsy and bipolar disorder in adults. The other half took Seroquel and Depakote.

The two groups did about equally well until the last few days of the study, when those in the Seroquel group scored lower on a standard measure of mania. By then, almost half of the teenagers getting Seroquel had dropped out because they missed appointments or the drugs did not work. Just eight of them completed the trial.

In an interview, Dr. DelBello acknowledged that the study was not conclusive. In the 2002 published paper, however, she and her co-authors reported that Seroquel in combination with Depakote “is more effective for the treatment of adolescent bipolar mania” than Depakote alone.

In 2005, a committee of prominent experts from across the country examined all of the studies of treatment for pediatric bipolar disorder and decided that Dr. DelBello’s was the only study involving atypicals in bipolar children that deserved its highest rating for scientific rigor. The panel concluded that doctors should consider atypicals as a first-line treatment for some children. The guidelines were published in The Journal of the American Academy of Child and Adolescent Psychiatry.

Three of the four doctors on the panel served as speakers or consultants to makers of atypicals, according to disclosures in the guidelines. In an interview, Dr. Robert A. Kowatch, a psychiatrist at Cincinnati Children’s Hospital and the lead author of the guidelines, said the drug makers’ support had no influence on the conclusions.

AstraZeneca hired Dr. DelBello and Dr. Kowatch to give sponsored talks. They later undertook another study comparing Seroquel and Depakote in bipolar children and found no difference. Dr. DelBello, who earns $183,500 annually from the University of Cincinnati, would not discuss how much she is paid by AstraZeneca.

“Trust me, I don’t make much,” she said. Drug company payments did not affect her study or her talks, she said. In a recent disclosure, Dr. DelBello said that she received marketing or consulting income from eight drug companies, including all five makers of atypicals.

Dr. Realmuto has heard Dr. DelBello speak several times, and her talks persuaded him to use combinations of Depakote and atypicals in bipolar children, he said. “She’s the leader in terms of doing studies on bipolar,” Dr. Realmuto said.

Some psychiatrists who advocate use of atypicals in children acknowledge that the evidence supporting this use is thin. But they say children should not go untreated simply because scientists have failed to confirm what clinicians already know.

“We don’t have time to wait for them to prove us right,” said Dr. Kent G. Brockmann, a psychiatrist from the Twin Cities who made more than $16,000 from 2003 to 2005 doing drug talks and one-on-one sales meetings, and last year was a leading prescriber of atypicals to Medicaid children.

The Reaction

For Anya Bailey, treatment with an atypical helped her regain her appetite and put on weight, but also heavily sedated her, her mother said. She developed the disabling knot in her back, the result of a nerve condition called dystonia, in 2005.

The reaction was rare but not unknown. Atypicals have side effects that are not easy to predict in any one patient. These include rapid weight gain and blood sugar problems, both risk factors for diabetes; disfiguring tics, dystonia and in rare cases heart attacks and sudden death in the elderly.

In 2006, the Food and Drug Administration received reports of at least 29 children dying and at least 165 more suffering serious side effects in which an antipsychotic was listed as the “primary suspect.” That was a substantial jump from 2000, when there were at least 10 deaths and 85 serious side effects among children linked to the drugs. Since reporting of bad drug effects is mostly voluntary, these numbers likely represent a fraction of the toll.

Jim Minnick, a spokesman for AstraZeneca, said that the company carefully monitors reported problems with Seroquel. “AstraZeneca believes that Seroquel is safe,” Mr. Minnick said.

Other psychiatrists renewed Anya’s prescriptions for Risperdal until Ms. Bailey took Anya last year to the Mayo Clinic, where a doctor insisted that Ms. Bailey stop the drug. Unlike most universities and hospitals, the Mayo Clinic restricts doctors from giving drug marketing lectures.

Ms. Bailey said she wished she had waited to see whether counseling would help Anya before trying drugs. Anya’s weight is now normal without the help of drugs, and her counseling ended in March. An experimental drug, her mother said, has recently helped the pain in her back.

Basic kitchen essentials

NYTimes

May 9, 2007
The Minimalist
A No-Frills Kitchen Still Cooks
By MARK BITTMAN

THE question I’m asked more often than any other is, “What kitchen equipment should I buy?”

Like cookbooks, kitchen equipment is a talisman; people believe that buying the right kind will make them good cooks. Yet some of the best cooks I’ve known worked with a battered batterie de cuisine: dented pots and pans scarred beyond recognition, an old steak knife turned into an all-purpose tool, a pot lid held just so to strain pasta when the colander was missing, a food processor with a busted switch. They didn’t complain and they didn’t apologize; they just cooked.

But famous TV chefs use gorgeous name-brand equipment, you might say. And you’d be right. But a.) they get much of that stuff free, the manufacturers hoping that placing it in the hands of a well-known chef will make you think it’s essential; b.) they want their equipment to be pretty, so you’ll think they’re important; and c.) see above: a costly knife is not a talisman and you are not a TV chef.

Finally (and this is crucial), the best chefs may use the best-looking equipment when they are in public view, but when it is time to buy equipment for the people who actually prepare those $200 restaurant meals, they go to a restaurant supply house to shop for the everyday cookware I recommend to people all the time.

In fact, I contend that with a bit of savvy, patience and a willingness to forgo steel-handle knives, copper pots and other extravagant items, $200 can equip a basic kitchen that will be adequate for just about any task, and $300 can equip one quite well.

To prove my point I put together a list of everything needed for almost any cooking task. I bought most of the equipment at Bowery Restaurant Supply, 183 Bowery Street (Delancey Street), where the bill came to just about $200. Throw in a few items the store didn’t have and a few extras, and the total would be about $300. (New York happens to have scores of restaurant supply shops, but every metropolitan area has at least one.)

I started with an eight-inch, plastic-handle stainless alloy chef’s knife for $10. This is probably the most essential tool in the kitchen. People not only obsess about knives (and write entire articles about them), but you can easily spend over $100 on just one. Yet go into any restaurant kitchen and you will see most of the cooks using this same plastic-handle Dexter-Russell tool. (Go to the wrong store and you’ll spend $20 or even $30 on the same knife.)

I found an instant-read thermometer, a necessity for beginning cooks and obsessive-compulsives, for $5. Three stainless steel bowls — not gorgeous and maybe a little thin — set me back about $5. You are reading that right. Sturdy tongs, an underappreciated tool: $3.50 (don’t buy them too long, make sure the spring is nice and tight, and don’t shop for them at a “culinary” store, where they’ll cost four times as much).

For less than $6 I picked up a sturdy sheet pan. It’s not an ideal cookie sheet but it’s useful for roasting and baking (not a bad tray, either, and one of the more common items in restaurant kitchens). A plastic cutting board was about the same price. For aesthetic purposes I’d rather have wood, but plastic can go into the dishwasher.

At $3, a paring knife was so cheap I could replace it every year or two. I splurged on a Japanese mandoline for $25. (It’s not indispensable, but since my knife skills are pathetic, I use mine whenever I want thin, even slices or a real julienne.)

You, or the college graduate you are thinking of, might own some of the things I bought: a $4 can opener; a vegetable peeler (I like the U-shaped type, which cost me $3); a colander ($7, and I probably could’ve gotten one cheaper).

You are thinking to yourself: “Humph. He’s ignoring pots and pans, the most expensive items of all.” Au contraire, my friend; I bought five, and I could live with four (though I’d rather have six): a small, medium and large cast-aluminum saucepan (total: about $30); a medium nonstick cast aluminum pan (10-inch; $13); and a large steep-sided, heavier duty steel pan (14-inch; $25). I bought a single lid ($5; I often use plates or whatever’s handy for lids because I can never find the right one anyway).

I like cast iron, and I have used it in some kitchens for nearly everything; but it can be more expensive than this quite decent cheap stuff, and it’s very heavy. What you don’t want is the awful wafer thin (and relatively more expensive) sets of stainless or aluminum ones sold in big-box stores.

Other things, like the mandoline, are almost luxury items: a skimmer (I like these for removing dumplings or gnocchi); a slotted spoon; a heat-resistant rubber spatula (which can replace the classic wooden spoon); a bread knife (good for crusty loaves and ripe tomatoes); and a big whisk (which I might use three times a year).

You should also have a food processor (you want 12-cup capacity, and Amazon.com, for example, has an adequate 14-cup Hamilton Beach for $60); a salad spinner (the one at Bowery Restaurant Supply was as big as my kitchen; you will find one for $15 somewhere); a Microplane grater (the old box graters have been largely replaced by the food processor, but you’ll need something for cheese, nutmeg and your oft-used asafetida; it’ll set you back less than $10). A coffee and spice grinder is another $10 item.

A blender is a bit more optional. An immersion one is nice, but standard ones are more useful, and you can find them for as little as $15.

And, finally, something with which to keep those knives sharp. A whetstone costs about $6, and if you use it, it will work fine; a decent steel is expensive enough that you may as well graduate to an electric sharpener. Though sharpeners take up counter space and cost at least $30, they work well.

The point is not so much that you can equip a real kitchen without much money, but that the fear of buying the wrong kind of equipment is unfounded. It needs only to be functional, not prestigious, lavish or expensive.

Keep that in mind, stay out of the fancy places and find a good restaurant supply house. If you make a mistake — something is the wrong size or of such lousy quality you can’t bear it — you can spend 20 bucks more another time. Meanwhile, you’ll be cooking.

The Inessentials

YOU can live without these 10 kitchen items:

BREAD MACHINE You can buy mediocre bread easily enough, or make the real thing without much practice.

MICROWAVE If you do a lot of reheating or fast (and damaging) defrosting, you may want one. But essential? No. And think about that counter space!

STAND MIXER Unless you’re a baking fanatic, it takes up too much room to justify it. A good whisk or a crummy handheld mixer will do fine.

BONING/FILLETING KNIVES Really? You’re a butcher now? Or a fishmonger? If so, go ahead, by all means. But I haven’t used my boning knife in years. (It’s pretty, though.)

WOK Counterproductive without a good wok station equipped with a high-B.T.U. burner. (There’s a nice setup at Bowery Restaurant Supply for $1,400 if you have the cash and the space.)

STOCKPOT The pot you use for boiling pasta will suffice, until you start making gallons of stock at a time.

PRESSURE COOKER It’s useful, but do you need one? No.

ANYTHING MADE OF COPPER More trouble than it’s worth, unless you have a pine-paneled wall you want to decorate.

RICE COOKER Yes, if you eat rice twice daily. Otherwise, no.

COUNTERTOP CONVECTION OVEN, ROTISSERIE, OR “ROASTER” Only if you’re a sucker for late-night cooking infomercials.

Future oncologist shortage

Tuesday, April 10, 2007
Breast enhancement, yes; cancer treatment, no
A shortage of cancer doctors is anticipated, in part because other specialties are easier and pay better.
REUTERS

The United States will suffer a significant shortage of cancer doctors over the next two decades, coinciding with an increased need for these specialists by aging Americans, a new report warns.

Experts predict a shortfall of up to 4,080 oncologists by 2020.

The shortage is being fueled, on the demand side, by an aging population and more cancer survivors and, on the supply side, by slowed growth in the number of oncologists available as more reach retirement age.

It's unclear if the shortage will hit relatively affluent communities like much of Orange County. But key trends that drive the expected shortage – the difficulties of working as a cancer doctor and the comparative wealth to be found in other specialties – are at play locally and nationally.

"The graying of America will result in substantial increase in demand for cancer care," said Dr. Dean Bajorin, an oncologist with Memorial Sloan-Kettering Cancer Center in New York City and co-chairman of the American Society for Clinical Oncology's (ASCO) Workforce Implementation Working Group. "This is a looming crisis that already needs to be addressed prospectively."

The study published last month in the Journal of Oncology Practice was commissioned by ASCO.

Experts estimate that nearly 1.4 million Americans will be diagnosed with cancer this year and more than 560,000 will die of the disease, making cancer the second-leading cause of death in the United States after heart disease.

Cancer is primarily a disease of older people and the number of Americans aged 65 and older is expected to double between 2000 and 2030.

Right now, supply and demand for oncologists is relatively balanced but that equilibrium is already showing signs of strain, the report's authors said.

"In 2003, it was apparent that oncologists' workload was increasing and we were having problems locating medical oncologists to hire for academic or community practices," noted Dr. Michael Goldstein, a cancer specialist with Beth Israel Deaconess Medical Center in Boston and chairman of the ASCO Workforce in Oncology Task Force.

This study, actually part one of a two-part project, predicts a 48 percent increase in cancer incidence and an 81 percent increase in people living with or surviving cancer, but only a 14 percent increase in the number of patient visits provided by the projected supply of oncologists between 2000 and 2030.

That leaves a shortfall of 9.4 million to 15 million visits -- or 2,550 to 4,080 oncologists -- about one-quarter to one-third of the total 2005 supply. By 2020 there will be a total of about 12,500 oncologists practicing in the United States.

"The bottom line is no matter which scenario we looked at, it is likely that we'll be facing a shortage," said Dr. Edward Salsberg, director of the Association of American Medical Colleges' Center for Workforce Studies.

One outside expert agreed that U.S. cancer care faces real challenges.

"The article points out obvious issues that are going to be facing the country as we get toward 2020," said Martin Brown, chief of the health services and economics branch at the U.S. National Cancer Institute. "I wouldn't say it's a crisis but it puts on the table a set of problems that need to be solved. They do suggest some pretty major changes in the way medical care is delivered."

"There's certainly room for uncertainty," added Brown, whose department contributed information to the ASCO report. "The demand side might not increase quite as fast as the data suggested. It's the aging that's the overwhelming driver. Other things to offset aging would have to be pretty dramatic."

No one thing is going to remedy the problem, but there are a number of initiatives that may ease the burden, the report's authors said.

On the supply side, the study mentioned increasing fellowship training positions, improving efficiency (for example, by increasing the use of electronic medical records), increasing the use of nurse practitioners and physician assistants in cancer care, and delaying the retirement of oncologists currently practicing.

The demand for oncologists could also be decreased by making more use of primary-care physicians and of hospices, the experts said.

"There are some potential strategies that can be very helpful but we don't see any single strategy being sufficient to fill the gap," Salsberg said. "Some of the scenarios we looked at could lead to an even greater gap. For example, we've noted that younger physicians, including oncologists, are providing fewer visits per year than older physicians."

And it will take years for any changes to actually take effect.

"When you put it all together, we think this is a very serious situation that requires some response sooner rather than later," Salsberg said. "It's important to point out that changing physician supply takes several years. If the decision was made today to increase the number of oncologists, it would take several years to increase training positions and several more years for those oncologists to complete training."

Kids not getting into Harvard

NYTimes

April 29, 2007
Parenting
Young, Gifted, and Not Getting Into Harvard
By MICHAEL WINERIP

ON a Sunday morning a few months back, I interviewed my final Harvard applicant of the year. After saying goodbye to the girl and watching her and her mother drive off, I headed to the beach at the end of our street for a run.

It was a spectacular winter day, bright, sunny and cold; the tide was out, the waves were high, and I had the beach to myself. As I ran, I thought the same thing I do after all these interviews: Another amazing kid who won’t get into Harvard.

That used to upset me. But I’ve changed.

Over the last decade, I’ve done perhaps 40 of these interviews, which are conducted by alumni across the country. They’re my only remaining link to my alma mater; I’ve never been back to a reunion or a football game, and my total donations since graduating in the 1970s do not add up to four figures.

No matter how glowing my recommendations, in all this time only one kid, a girl, got in, many years back. I do not tell this to the eager, well-groomed seniors who settle onto the couch in our den. They’re under too much pressure already. Better than anyone, they know the odds, particularly for a kid from a New York suburb.

By the time I meet them, they’re pros at working the system. Some have Googled me because they think knowing about me will improve their odds. After the interview, many send handwritten thank-you notes saying how much they enjoyed meeting me.

Maybe it’s true.

I used to be upset by these attempts to ingratiate. Since I’ve watched my own children go through similar torture, I find these gestures touching. Everyone’s trying so hard.

My reason for doing these interviews has shifted over time. When I started, my kids were young, and I thought it might give them a little advantage when they applied to Harvard. That has turned out not to be an issue. My oldest, now a college freshman, did not apply, nor will my twins, who are both high school juniors.

We are not snubbing Harvard. Even my oldest, who is my most academic son, did not quite have the class rank or the SATs. His SAT score was probably 100 points too low — though it was identical to the SAT score that got me in 35 years ago.

Why do I continue to interview? It’s very moving meeting all these bright young people who won’t get into Harvard. Recent news articles make it sound unbearably tragic. Several Ivies, including Harvard, rejected a record number of applicants this year.

Actually, meeting the soon-to-be rejected makes me hopeful about young people. They are far more accomplished than I was at their age and without a doubt will do superbly wherever they go.

Knowing me and seeing them is like witnessing some major evolutionary change take place in just 35 years, from the Neanderthal Harvard applicant of 1970 to today’s fully evolved Homo sapiens applicant.

There was the girl who, during summer vacation, left her house before 7 each morning to make a two-hour train ride to a major university, where she worked all day doing cutting-edge research for NASA on weightlessness in mice.

When I was in high school, my 10th-grade science project was on plant tropism — a shoebox with soil and bean sprouts bending toward the light.

These kids who don’t get into Harvard spend summers on schooners in Chesapeake Bay studying marine biology, building homes for the poor in Central America, touring Europe with all-star orchestras.

Summers, I dug trenches for my local sewer department during the day, and sold hot dogs at Fenway Park at night.

As I listen to them, I can visualize their parents, striving to teach excellence. One girl I interviewed described how her father made her watch the 2004 convention speeches by both President Bush and Senator John Kerry and then tell him which she liked better and why.

What kind of kid doesn’t get into Harvard? Well, there was the charming boy I interviewed with 1560 SATs. He did cancer research in the summer; played two instruments in three orchestras; and composed his own music. He redid the computer system for his student paper, loved to cook and was writing his own cookbook. One of his specialties was snapper poached in tea and served with noodle cake.

At his age, when I got hungry, I made myself peanut butter and jam on white bread and got into Harvard.

Some take 10 AP courses and get top scores of 5 on all of them.

I took one AP course and scored 3.

Of course, evolution is not the same as progress. These kids have an AP history textbook that has been specially created to match the content of the AP test, as well as review books and tutors for those tests. We had no AP textbook; many of our readings came from primary documents, and there was no Princeton Review then. I was never tutored in anything and walked into the SATs without having seen a sample SAT question.

As for my bean sprouts project, as bad it was, I did it alone. I interview kids who describe how their schools provide a statistician to analyze their science project data.

I see these kids — and watch my own applying to college — and as evolved as they are, I wouldn’t change places with them for anything. They’re under such pressure.

I used to say goodbye at my door, but since my own kids reached this age, I walk them out to their cars, where a parent waits. I always say the same thing to the mom or dad: “You’ve done a wonderful job — you should be very proud.” And I mean it.

But I’ve stopped feeling bad about the looming rejection. When my four were little, I used to hope a couple might go to Harvard. I pushed them, but by the end of middle school it was clear my twins, at least, were not made that way. They rebelled, and I had to learn to see who they were.

I came to understand that my own focus on Harvard was a matter of not sophistication but narrowness. I grew up in an unworldly blue-collar environment. Getting perfect grades and attending an elite college was one of the few ways up I could see.

My four have been raised in an upper-middle-class world. They look around and see lots of avenues to success. My wife’s two brothers struggled as students at mainstream colleges and both have made wonderful full lives, one as a salesman, the other as a builder. Each found his own best path. Each knows excellence.

That day, running on the beach, I was lost in my thoughts when a voice startled me. “Pops, hey, Pops!” It was Sammy, one of my twins, who’s probably heading for a good state school. He was in his wetsuit, surfing alone in the 30-degree weather, the only other person on the beach. “What a day!” he yelled, and his joy filled my heart.

Questioning carbon neutrality

NYTimes

April 29, 2007
Global Coolness
Carbon-Neutral Is Hip, but Is It Green?
By ANDREW C. REVKIN

THE rush to go on a carbon diet, even if by proxy, is in overdrive.

In addition to the celebrities — Leo, Brad, George — politicians like John Edwards and Hillary Clinton are now running, at least part of the time, carbon-neutral campaigns. A lengthening list of big businesses — international banks, London’s taxi fleet, luxury airlines — also claim “carbon neutrality.” Silverjet, a plush new trans-Atlantic carrier, bills itself as the first fully carbon-neutral airline. It puts about $28 of each round-trip ticket into a fund for global projects that, in theory, squelch as much carbon dioxide as the airline generates — about 1.2 tons per passenger, the airline says.

Also, a largely unregulated carbon-cutting business has sprung up. In this market, consultants or companies estimate a person’s or company’s output of greenhouse gases. Then, these businesses sell “offsets,” which pay for projects elsewhere that void or sop up an equal amount of emissions — say, by planting trees or, as one new company proposes, fertilizing the ocean so algae can pull the gas out of the air. Recent counts by Business Week magazine and several environmental watchdog groups tally the trade in offsets at more than $100 million a year and growing blazingly fast.

But is the carbon-neutral movement just a gimmick?

On this, environmentalists aren’t neutral, and they don’t agree. Some believe it helps build support, but others argue that these purchases don’t accomplish anything meaningful — other than giving someone a slightly better feeling (or greener reputation) after buying a 6,000-square-foot house or passing the million-mile mark in a frequent-flier program. In fact, to many environmentalists, the carbon-neutral campaign is a sign of the times — easy on the sacrifice and big on the consumerism.

As long as the use of fossil fuels keeps climbing — which is happening relentlessly around the world — the emission of greenhouse gases will keep rising. The average American, by several estimates, generates more than 20 tons of carbon dioxide or related gases a year; the average resident of the planet about 4.5 tons.

At this rate, environmentalists say, buying someone else’s squelched emissions is all but insignificant.

“The worst of the carbon-offset programs resemble the Catholic Church’s sale of indulgences back before the Reformation,” said Denis Hayes, the president of the Bullitt Foundation, an environmental grant-making group. “Instead of reducing their carbon footprints, people take private jets and stretch limos, and then think they can buy an indulgence to forgive their sins.”

“This whole game is badly in need of a modern Martin Luther,” Mr. Hayes added.

Some environmental campaigners defend this marketplace as a legitimate, if imperfect, way to support an environmental ethic and political movement, even if the numbers don’t all add up.

“We can’t stop global warming with voluntary offsets, but they offer an option for individuals looking for a way to contribute to the solution in addition to reducing their own emissions and urging their elected representatives to support good policy,” said Daniel A. Lashof, the science director of the climate center at the Natural Resources Defense Council.

But he and others agree that more oversight is needed. Voluntary standards and codes of conduct are evolving in Europe and the United States to ensure that a ton of carbon dioxide purchased is actually a ton of carbon dioxide avoided.

The first attempt at an industry report card, commissioned by the environmental group Clean Air/Cool Planet (which has some involvement in the business), gave decidedly mixed reviews to the field, selecting eight sellers of carbon offsets that it concluded were reasonably reliable.

But the report, “A Consumer’s Guide to Retail Carbon-Offset Providers,” concluded that this market was no different than any other, saying, “if something sounds too good to be true, it probably is.”

Prices vary widely for offsetting the carbon dioxide tonnage released by a long plane flight, S.U.V. commute or energy-hungry house. The report suggested that the cheapest offsets may not be legitimate.

For example, depending on where you shop for carbon credits, avoiding the ton of carbon dioxide released by driving a midsize car about 2,000 miles could cost $5 or $25, according to data in the report.

Mr. Hayes said there were legitimate companies and organizations that help people and companies measure their emissions and find ways to cut them, both directly and indirectly by purchasing certain kinds of credits. But overall, he said, an investment in such credits — given the questions about their reliability — should be looked at more as conventional charity (presuming you check to be sure the projects are real) and less as something like a license to binge on private jet travel.

In many ways, the carbon-neutral campaign mimics other efforts that use markets to save the environment. For nearly two decades, for example, forest protection groups have disputed the merits of “certified” tropical hardwood and other products that manufacturers claim are harvested in ways that don’t imperil virgin forests.

Some environmentalists say it’s better to offer some income to those who use forests in a renewable way. But others insist that instead of trying to police the trade by rooting our fraudulent planks, it’s better to avoid the timber altogether. Only one of many forest certification programs, run by the Forest Stewardship Council, has been widely endorsed by environmental groups.

Michael R. Solomon, the author of “Consumer Behavior: Buying, Having and Being” and a professor at Auburn University, said he was not surprised by the allure of the carbon-offsetting market.

“Consumers are always going to gravitate toward a more parsimonious solution that requires less behavioral change,” he said. “We know that new products or ideas are more likely to be adopted if they don’t require us to alter our routines very much.”

But he said there was danger ahead, “if we become trained to substitute dollars for deeds — kind of an ‘I gave at the office’ prescription for the environment.”

Charles Komanoff, an energy economist in New York, said the commercial market in climate neutrality could have even more harmful effects.

It could, by suggesting there’s an easy way out, blunt public support for what will really be needed in the long run, he said: a binding limit on emissions or a tax on the fuels that generate greenhouse gases.

“There isn’t a single American household above the poverty line that couldn’t cut their CO2 at least 25 percent in six months through a straightforward series of fairly simple and terrifically cost-effective measures,” he said.

Jonathan Shopley, the chief executive of Britain’s CarbonNeutral Company, which does only 5 percent of its offsetting directly for individuals and the rest for businesses, insisted that the voluntary markets fill a vital gap.

This is particularly true, he said, because laws or treaties, like the Kyoto Protocol, that have mandatory limits on greenhouse gases have so far failed to blunt the relentless global rise in such emissions.

“That isn’t going to get us where we need to go,” Mr. Shopley said.

Chemotherapy-associated memory problems

NYTimes

April 29, 2007
Chemotherapy Fog Is No Longer Ignored as Illusion
By JANE GROSS

On an Internet chat room popular with breast cancer survivors, one thread — called “Where’s My Remote?” — turns the mental fog known as chemo brain into a stand-up comedy act.

One woman reported finding five unopened gallons of milk in her refrigerator and having no memory of buying the first four. A second had to ask her husband which toothbrush belonged to her.

At a family celebration, one woman filled the water glasses with turkey gravy. Another could not remember how to carry over numbers when balancing the checkbook.

Once, women complaining of a constellation of symptoms after undergoing chemotherapy — including short-term memory loss, an inability to concentrate, difficulty retrieving words, trouble with multitasking and an overarching sense that they had lost their mental edge — were often sent home with a patronizing “There, there.”

But attitudes are changing as a result of a flurry of research and new attention to the after-effects of life-saving treatment. There is now widespread acknowledgment that patients with cognitive symptoms are not imagining things, and a growing number of oncologists are rushing to offer remedies, including stimulants commonly used for attention-deficit disorder and acupuncture.

“Until recently, oncologists would discount it, trivialize it, make patients feel it was all in their heads,” said Dr. Daniel Silverman, a cancer researcher at the University of California, Los Angeles, who studies the cognitive side effects of chemotherapy. “Now there’s enough literature, even if it’s controversial, that not mentioning it as a possibility is either ignorant or an evasion of professional duty.”

That shift matters to patients.

“Chemo brain is part of the language now, and just to have it acknowledged makes a difference,” said Anne Grant, 57, who owns a picture-framing business in New York City. Ms. Grant, who had high-dose chemotherapy and a bone marrow transplant in 1995, said she could not concentrate well enough to read, garbled her sentences and struggled with simple decisions like which socks to wear.

Virtually all cancer survivors who have had toxic treatments like chemotherapy experience short-term memory loss and difficulty concentrating during and shortly afterward, experts say. But a vast majority improve. About 15 percent, or roughly 360,000 of the nation’s 2.4 million female breast cancer survivors, the group that has dominated research on cognitive side effects, remain distracted years later, according to some experts. And nobody knows what distinguishes this 15 percent.

Most oncologists agree that the culprits include very high doses of chemotherapy, like those in anticipation of a bone marrow transplant; the combination of chemotherapy and supplementary hormonal treatments, like tamoxifen or aromatase inhibitors that lower the amount of estrogen in women who have cancers fueled by female hormones; and early-onset cancer that catapults women in their 30s and 40s into menopause.

Other clues come from studies too small to be considered definitive. One such study found a gene linked to Alzheimer’s disease in cancer survivors with cognitive deficits. Another, using PET scans, found unusual activity in the part of the brain that controls short-term recall.

The central puzzle of chemo brain is that many of the symptoms can occur for reasons other than chemotherapy.

Abrupt menopause, which often follows treatment, also leaves many women fuzzy-headed in a more extreme way than natural menopause, which unfolds slowly. Those cognitive issues are also features of depression and anxiety, which often accompany a cancer diagnosis. Similar effects are also caused by medications for nausea and pain.

Dr. Tim Ahles, one of the first American scientists to study cognitive side effects, acknowledges that studies have been too small and lacked adequate baseline data to isolate a cause.

“So many factors affect cognitive function, and the kinds of cognitive problems associated with cancer treatment can be caused by many other things than chemotherapy,” said Dr. Ahles, the director of neurocognitive research at Memorial Sloan-Kettering Cancer Center in New York.

The new interest in chemo brain is, in effect, a testimony to enormous strides in the field. Patients who once would have died now live long enough to have cognitive side effects, just as survivors of childhood leukemia did many years ago, forcing new treatment protocols to avoid learning disabilities.

“A large number of people are living long and normal lives,” said Dr. Patricia Ganz, an oncologist at U.C.L.A. who is one of the nation’s first specialists in the late side effects of treatment. “It’s no longer enough to cure them. We have to acknowledge the potential consequences and address them early on.”

As researchers look for a cause, cancer survivors are trying to figure out how to get through the day by sharing their experiences, and by tapping expertise increasingly being offered online by Web sites like www.breastcancer.org and www.cancercare.org.

There are “ask the experts” teleconferences, both live and archived, and fact sheets to download and show to a skeptical doctor. Message boards suggest sharpening the mind with Japanese sudoku puzzles or compensatory techniques devised to help victims of brain injury. There are even sweatshirts for sale saying “I Have Chemo Brain. What’s Your Excuse?”

Studies of cognitive effects have overwhelmingly been conducted among breast cancer patients because they represent, by far, the largest group of cancer survivors and because they tend to be sophisticated advocates, challenging doctors and volunteering for research.

Most researchers studying cognitive deficits say they believe that those most inclined to notice even subtle changes are high-achieving women juggling careers and families who are used to succeeding at both. They point to one study that found that complaints of cognitive deficits often did not match the results of neuro-psychological tests, suggesting that chemo brain is a subjective experience.

“They say, ‘I’ve lost my edge,’ ” said Dr. Stewart Fleishman, director of cancer supportive services at Beth Israel and St. Luke’s/Roosevelt hospitals in New York. “If they can’t push themselves to the limit, they feel impaired.”

Dr. Fleishman and others were pressed as to why a poor woman, working several jobs to feed her children, navigating the health care system and battling insurance companies, would not also need mental dexterity. “Maybe we’re just not asking them,” Dr. Fleishman said.

Overall, middle-class cancer patients tend to get more aggressive treatment, participate in support groups, enroll in studies and use the Internet for research and community more than poor and minority patients, experts say.

“The disparity plays out in all kinds of ways,” said Ellen Coleman, the associate executive director of CancerCare, which provides free support services. “They don’t approach their health care person because they don’t expect help.”

But approaching a doctor does not guarantee help. Susan Mitchell, 48, who does freelance research on economic trends, complained to her oncologist in Jackson, Miss., that her income had been halved since her breast cancer treatment last year because everything took longer for her to accomplish.

She said his reply was a shrug.

“They see their job as keeping us alive, and we appreciate that,” Ms. Mitchell said. “But it’s like everything else is a luxury. These are survivor issues, and they need to get used to the fact that lots of us are surviving.”

Among women like Ms. Mitchell, lost A.T.M. cards are as common as missing socks. Children arrive at birthday parties a week early. Wet clothes wind up in the freezer instead of the dryer. Prosthetic breasts and wigs are misplaced at the most inopportune times. And simple words disappear from memory: “The thing with numbers” will have to do for the word “calculator.”

Linda Lowen, 46, had a hysterectomy and chemotherapy for ovarian cancer 13 years ago, and says she still cannot recognize neighbors at the grocery store. “I had a mind like a steel trap, and I ended up with a colander for a brain,” said Ms. Lowen, a radio and television talk show host in Syracuse.

The other night, Ms. Lowen set out to find a good place to store her knitting supplies. She began emptying a cabinet of games that her teenage daughters no longer played. Meanwhile, she noticed a blown light bulb and went to find a replacement. That detour led to another, and five hours later she had scrubbed every surface and tidied the contents of eight drawers. But she still had no storage space for her knitting supplies.

“I have an almost childlike inability to follow through on anything,” Ms. Lowen said.

Solutions come in many forms for women whose cancer treatment has left them with cognitive deficits.

Sedra Jayne Varga, 50, an administrative assistant in family court in Manhattan, is part of a research study of the stimulant Focalin, which she said had helped. But Ms. Varga also plans to have laser surgery on her eyes so that losing her glasses will no longer be an issue.

Lu Ann Hudson, 44, a designer of financial databases in Cincinnati, relies on a key fob that sets off a beep in her car when she is looking for it in parking lots. Terry-Lynne Jordan, 43, who analyzes environmental incidents for an oil company in Calgary, Alberta, uses the calendar on her computer and voice mail messages to herself to remind her of meetings.

And Debbie Kamplain, a 32-year-old stay-at-home mother in Peoria, Ill., hired a $30-an-hour personal organizer to help her sell a house, buy another and get ready to move her family to Indiana next month.

But it is Ms. Kamplain’s 2 ½-year-old son, Daniel, who sees to it that she stays on task. Long before Daniel could talk, he would pull her over to the refrigerator if she got distracted while getting him a drink.

“Poor kid,” Ms. Kamplain said. “I say I’m going to do something, forget about it immediately, and he’s the one who has to remind Mommy about stuff.”