NYTimes
June 12, 2007
Incentives Limit Any Savings in Treating Cancer
By ALEX BERENSON
When Medicare cracked down two years ago on profits that doctors made on drugs they administered to patients in their offices, it ended a windfall worth hundreds of thousands of dollars a year for each physician.
The change, which mainly affected drugs to treat cancer and its side effects, had an immediate effect. In all, cancer doctors billed about $4.4 billion for chemotherapy and anemia medications in 2005, down from $5.6 billion in 2004, with Medicare covering 80 percent of the bills in each year. The difference mostly represented profit that doctors had made on the drugs.
But the change did not reduce overall federal spending on cancer care, which increased slightly. And cancer doctors say the change did nothing to reduce a larger problem in cancer treatment.
Some physicians say that cancer doctors responded to Medicare’s change by performing additional treatments that got them the best reimbursements, whether or not the treatments benefited patients. Those doctors also say that Medicare’s reimbursement policies are responsible.
“The system doesn’t value the time we spend with patients,” said Dr. Peter Eisenberg, a cancer doctor in Greenbrae, Calif., and director of the American Society of Clinical Oncology. “The system values procedures.”
The ballooning cost of cancer treatment, one of Medicare’s most expensive categories, offers a vivid example of how difficult it may be to rein in the nation’s runaway health care spending without fundamentally changing the way doctors are paid.
Cancer patients and their families play a role in rising costs, too, because they understandably want doctors to exhaust every possible treatment, even if the doctors might serve their patients better simply by talking and listening to them.
In general, oncologists make money by providing chemotherapy, even when it has little chance of success. Oncologists naturally dislike telling cancer patients that they have exhausted all available treatments. Ending chemotherapy, after all, means acknowledging that a patient’s disease has become terminal.
“There’s pretty good evidence at this point,” said Dr. Richard Deyo, professor of medicine at the University of Washington and an expert on health care spending, “that there are plenty of patients for whom there’s little hope, who are terminally ill, whom chemotherapy is not going to help, who get chemotherapy.”
With the new limits on cancer drug profits, some cancer doctors are searching for new income — like performing chemotherapy more often or installing multimillion-dollar imaging machines where they profit when their patients receive diagnostic scans.
They are also putting new pressure on cancer patients to make out-of-pocket drug co-payments, which can amount to hundreds of dollars a month. In some cases, they are requiring patients to get injections of certain drugs at the hospital instead of in their offices.
Some oncologists say that such changes are necessary because Medicare has not raised its fees for chemotherapy enough to make up the difference. They say they are losing money on Medicare patients and are pressing Medicare to reverse the changes.
Unless it does, a number of doctors say they will be forced to close their practices, and cancer patients, especially in rural areas, may not be able to get treatment.
But that does not yet appear to be a problem. An independent federal commission said last year that the Medicare changes had not reduced patients’ access to care.
The system under which cancer doctors profit on chemotherapy drugs — and so-called supportive care medications, like anemia medicine that is given to counter the side effects of chemotherapy — came into being more than two decades ago. That was when advances in treatment made it possible for patients to receive chemotherapy in doctors’ offices instead of hospitals.
Instead of writing prescriptions that patients filled at pharmacies, cancer doctors bought drugs themselves, then administered them to patients and billed Medicare or private insurers for reimbursement.
Today, the drugs range from relatively inexpensive treatments like Taxol, a breast cancer drug that costs about $150 a dose, to a new wave of biotechnology therapies like Avastin, a drug for colon and lung cancer that can cost as much as $8,800 a dose.
Before 2005, Medicare paid a markup of 20 percent to 100 percent on many drugs, and private insurers paid even more. Doctors pocketed the difference, after certain expenses, as profit.
Because the profits on different drugs varied enormously, doctors had an incentive to prescribe medications with the highest margins. Medicare requires a 20 percent co-payment by patients on chemotherapy medicines, but before 2005 doctors sometimes forgave those co-payments because their profits were so great.
The profits helped drive a vast increase in the amounts doctors billed Medicare for injectable drugs, which soared to $10.9 billion by 2004 from $2.9 billion in 1997. Besides drugs for cancer, the figures include injectable drugs for arthritis and other diseases, though chemotherapy and anemia medications were the largest categories.
The increase in spending, and concerns about the perverse incentives created by the system, caused Congress to change the reimbursement system to more closely tie Medicare payments to what doctors actually pay for the drugs.
Now, drug reimbursement is supposed to amount to only 6 percent more than the average price of the drug paid by all doctors. Because of the change, the overall amount that doctors billed Medicare for injectable drugs fell 6 percent from 2004 to 2005, to $10.3 billion.
Doctors who buy large quantities of medicine can still get big rebates from drug companies, so they can continue to make money on prescriptions — even if it is not at the levels of the past. But those who buy only small quantities get no rebates. And once expenses are calculated, they may actually lose money on certain drugs for Medicare patients.
Private insurers are slowly reducing their reimbursement levels as well, though for most cancer patients they are still paying more than Medicare does.
As a result of the Medicare cutbacks, some doctors say they have been forced to refer patients to hospitals for chemotherapy treatment. Because of the complexities of Medicare rules, hospitals can make money providing chemotherapy for patients even in cases when doctors cannot. But it can be a serious inconvenience for people who are very ill and may have a few months to live.
Dr. Arthur Hooberman, a Chicago oncologist, said his group had sent seven patients to hospitals for treatments in the last few months.
“Our feeling is if we break even on chemotherapy, we’ll give it,” Dr. Hooberman said. But, he added, “we’re not going to pay for people’s chemotherapy.” Dr. Hooberman said Medicare needed to start paying doctors more for other care to make up for their lost drug profits.
Geraldine Lotrich, a lung cancer patient of Dr. Hooberman who has had to receive chemotherapy treatment at a local hospital, said she would rather have remained in his office, where the nurses know her and the doctor can stop in during her five-hour infusion.
“It’s kind of upsetting,” Ms. Lotrich said.
Ari Straus, the chief operating officer of Aurora Healthcare Consulting, which works with doctors to increase their profits, said Medicare’s changes had squeezed oncologists. “Five years ago, many physicians were earning over $1 million per year on drug sales alone,” Mr. Straus said. “It created a perception problem for oncologists that they earn an enormous amount on drugs, but that’s not true anymore. Today, the majority of oncologists break even, and some lose money on drugs.”
A few oncologists and their colleagues see the professional situation as worse. “We’re seeing the dismantling of the community oncology system,” said Steve Coplon, chief executive of the West Clinic, a group of cancer centers in Tennessee that has 28 doctors and sees about 5,000 new patients a year.
Mr. Coplon said his practice had lost $3 million in 2006 on Medicare patients. But invoking confidentiality, he declined to explain how the group had calculated that figure, how much money it made on privately insured patients, how much money it made over all, or how much its doctors earned.
For now, even the oncologists most critical of the 2005 rule changes do not say that patients are being denied treatment, rather that they are being inconvenienced by being forced to receive it in hospitals. And no hard statistics exist to show how many patients have been affected in this way.
In testimony to Congress in July 2006, Mark E. Miller, executive director of the Medicare Payment Advisory Commission, said his group had found that “access to chemotherapy drugs remained good” and had “no evidence that quality of care declined” as a result of the reimbursement changes. The commission is an independent federal group that advises Congress on issues affecting Medicare.
Now, oncologists are lobbying Medicare officials and members of Congress to reverse some of the changes and again raise the prices the government pays for drugs.
But Dr. Robert Geller, who worked as an oncologist in private practice from 1996 to 2005 before leaving to become senior medical director at Alexion, a biotechnology company, said that increasing drug reimbursement might raise oncologists’ profits but would not relieve the system’s deeper flaws.
As long as oncologists continue to be paid by the procedure instead of for spending time with patients, they will find ways to game the system, however much money they make or lose on prescribing drugs, he said.
“People go where the money is, and you’d like to believe it’s different in medicine, but it’s really no different in medicine,” Dr. Geller said. “When you start thinking of oncology as a business, then all these decisions make sense.”
Monday, June 11, 2007
Tuesday, June 05, 2007
Age of kids starting kindergarten
NYTimes
June 3, 2007
When Should a Kid Start Kindergarten?
By ELIZABETH WEIL
According to the apple-or-coin test, used in the Middle Ages, children should start school when they are mature enough for the delayed gratification and abstract reasoning involved in choosing money over fruit. In 15th- and 16th-century Germany, parents were told to send their children to school when the children started to act “rational.” And in contemporary America, children are deemed eligible to enter kindergarten according to an arbitrary date on the calendar known as the birthday cutoff — that is, when the state, or in some instances the school district, determines they are old enough. The birthday cutoffs span six months, from Indiana, where a child must turn 5 by July 1 of the year he enters kindergarten, to Connecticut, where he must turn 5 by Jan. 1 of his kindergarten year. Children can start school a year late, but in general they cannot start a year early. As a result, when the 22 kindergartners entered Jane Andersen’s class at the Glen Arden Elementary School near Asheville, N.C., one warm April morning, each brought with her or him a snack and a unique set of gifts and challenges, which included for some what’s referred to in education circles as “the gift of time.”
After the morning announcements and the Pledge of Allegiance, Andersen’s kindergartners sat down on a blue rug. Two, one boy and one girl, had been redshirted — the term, borrowed from sports, describes students held out for a year by their parents so that they will be older, or larger, or more mature, and thus better prepared to handle the increased pressures of kindergarten today. Six of Andersen’s pupils, on the other hand, were quite young, so young that they would not be enrolled in kindergarten at all if North Carolina succeeds in pushing back its birthday cutoff from Oct. 16 to Aug. 31.
Andersen is a willowy 11-year teaching veteran who offered up a lot of education in the first hour of class. First she read Leo Lionni’s classic children’s book “An Extraordinary Egg,” and directed a conversation about it. Next she guided the students through: writing a letter; singing a song; solving an addition problem; two more songs; and a math game involving counting by ones, fives and tens using coins. Finally, Andersen read them another Lionni book. Labor economists who study what’s called the accumulation of human capital — how we acquire the knowledge and skills that make us valuable members of society — have found that children learn vastly different amounts from the same classroom experiences and that those with certain advantages at the outset are able to learn more, more quickly, causing the gap between students to increase over time. Gaps in achievement have many causes, but a major one in any kindergarten room is age. Almost all kindergarten classrooms have children with birthdays that span 12 months. But because of redshirting, the oldest student in Andersen’s class is not just 12 but 15 months older than the youngest, a difference in age of 25 percent.
After rug time, Andersen’s kindergartners walked single-file to P.E. class, where the children sat on the curb alongside the parking circle, taking turns running laps for the Presidential Fitness Test. By far the fastest runner was the girl in class who had been redshirted. She strode confidently, with great form, while many of the smaller kids could barely run straight. One of the younger girls pointed out the best artist in the class, a freckly redhead. I’d already noted his beautiful penmanship. He had been redshirted as well.
States, too, are trying to embrace the advantages of redshirting. Since 1975, nearly half of all states have pushed back their birthday cutoffs and four — California, Michigan, North Carolina and Tennessee — have active legislation in state assemblies to do so right now. (Arkansas passed legislation earlier this spring; New Jersey, which historically has let local districts establish their birthday cutoffs, has legislation pending to make Sept. 1 the cutoff throughout the state.) This is due, in part, to the accountability movement — the high-stakes testing now pervasive in the American educational system. In response to this testing, kindergartens across the country have become more demanding: if kids must be performing on standardized tests in third grade, then they must be prepping for those tests in second and first grades, and even at the end of kindergarten, or so the thinking goes. The testing also means that states, like students, now get report cards, and they want their children to do well, both because they want them to be educated and because they want them to stack up favorably against their peers.
Indeed, increasing the average age of the children in a kindergarten class is a cheap and easy way to get a small bump in test scores, because older children perform better, and states’ desires for relative advantage is written into their policy briefs. The California Performance Review, commissioned by Gov. Arnold Schwarzenegger in 2004, suggested moving California’s birthday cutoff three months earlier, to Sept. 1 from Dec. 2, noting that “38 states, including Florida and Texas, have kindergarten entry dates prior to California’s.” Maryland’s proposal to move its date mentioned that “the change . . . will align the ‘cutoff’ date with most of the other states in the country.”
All involved in increasing the age of kindergartners — parents, legislatures and some teachers — say they have the best interests of children in mind. “If I had just one goal with this piece of legislation it would be to not humiliate a child,” Dale Folwell, the Republican North Carolina state representative who sponsored the birthday-cutoff bill, told me. “Our kids are younger when they’re taking the SAT, and they’re applying to the same colleges as the kids from Florida and Georgia.” Fair enough — governors and state legislators have competitive impulses, too. Still, the question remains: Is it better for children to start kindergarten later? And even if it’s better for a given child, is it good for children in general? Time out of school may not be a gift to all kids. For some it may be a burden, a financial stress on their parents and a chance, before they ever reach a classroom, to fall even further behind.
Redshirting is not a new phenomenon — in fact, the percentage of redshirted children has held relatively steady since education scholars started tracking the practice in the 1980s. Studies by the National Center for Education Statistics in the 1990s show that delayed-entry children made up somewhere between 6 and 9 percent of all kindergartners; a new study is due out in six months. As states roll back birthday cutoffs, there are more older kindergartners in general — and more redshirted kindergartners who are even older than the oldest kindergartners in previous years. Recently, redshirting has become a particular concern, because in certain affluent communities the numbers of kindergartners coming to school a year later are three or four times the national average. “Do you know what the number is in my district?” Representative Folwell, from a middle-class part of Winston-Salem, N.C., asked me. “Twenty-six percent.” In one kindergarten I visited in Los Altos, Calif. — average home price, $1 million — about one-quarter of the kids had been electively held back as well. Fred Morrison, a developmental psychologist at the University of Michigan who has studied the impact of falling on one side or the other of the birthday cutoff, sees the endless “graying of kindergarten,” as it’s sometimes called, as coming from a parental obsession not with their children’s academic accomplishment but with their social maturity. “You couldn’t find a kid who skips a grade these days,” Morrison told me. “We used to revere individual accomplishment. Now we revere self-esteem, and the reverence has snowballed in unconscious ways — into parents always wanting their children to feel good, wanting everything to be pleasant.” So parents wait an extra year in the hope that when their children enter school their age or maturity will shield them from social and emotional hurt. Elizabeth Levett Fortier, a kindergarten teacher in the George Peabody Elementary School in San Francisco, notices the impact on her incoming students. “I’ve had children come into my classroom, and they’ve never even lost at Candy Land.”
For years, education scholars have pointed out that most studies have found that the benefits of being relatively older than one’s classmates disappear after the first few years of school. In a literature review published in 2002, Deborah Stipek, dean of the Stanford school of education, found studies in which children who are older than their classmates not only do not learn more per grade but also tend to have more behavior problems. However, more recent research by labor economists takes advantage of new, very large data sets and has produced different results. A few labor economists do concur with the education scholarship, but most have found that while absolute age (how many days a child has been alive) is not so important, relative age (how old that child is in comparison to his classmates) shapes performance long after those few months of maturity should have ceased to matter. The relative-age effect has been found in schools around the world and also in sports. In one study published in the June 2005 Journal of Sport Sciences, researchers from Leuven, Belgium, and Liverpool, England, found that a disproportionate number of World Cup soccer players are born in January, February and March, meaning they were old relative to peers on youth soccer teams.
Before the school year started, Andersen, who is 54, taped up on the wall behind her desk a poster of a dog holding a bouquet of 12 balloons. In each balloon Andersen wrote the name of a month; under each month, the birthdays of the children in her class. Like most teachers, she understands that the small fluctuations among birth dates aren’t nearly as important as the vast range in children’s experiences at preschool and at home. But one day as we sat in her classroom, Andersen told me, “Every year I have two or three young ones in that August-to-October range, and they just struggle a little.” She used to encourage parents to send their children to kindergarten as soon as they were eligible, but she is now a strong proponent of older kindergartners, after teaching one child with a birthday just a few days before the cutoff. “She was always a step behind. It wasn’t effort and it wasn’t ability. She worked hard, her mom worked with her and she still was behind.” Andersen followed the girl’s progress through second grade (after that, she moved to a different school) and noticed that she didn’t catch up. Other teachers at Glen Arden Elementary and elsewhere have noticed a similar phenomenon: not always, but too often, the little ones stay behind.
The parents of the redshirted girl in Andersen’s class told a similar story. Five years ago, their older daughter had just made the kindergarten birthday cutoff by a few days, and they enrolled her. “She’s now a struggling fourth grader: only by the skin of her teeth has she been able to pass each year,” the girl’s mother, Stephanie Gandert, told me. “I kick myself every year now that we sent her ahead.” By contrast, their current kindergartner is doing just fine. “I always tell parents, ‘If you can wait, wait.’ If my kindergartner were in first grade right now, she’d be in trouble, too.” (The parents of the redshirted boy in Andersen’s class declined to be interviewed for this article but may very well have held him back because he’s small — even though he’s now one of the oldest, he’s still one of the shortest.)
Kelly Bedard, a labor economist at the University of California, Santa Barbara, published a paper called “The Persistence of Early Childhood Maturity: International Evidence of Long-Run Age Effects” in The Quarterly Journal of Economics in November 2006 that looked at this phenomenon. “Obviously, when you’re 5, being a year older is a lot, and so we should expect kids who are the oldest in kindergarten to do better than the kids who are the youngest in kindergarten,” Bedard says. But what if relatively older kids keep doing better after the maturity gains of a few months should have ceased to matter? What if kids who are older relative to their classmates still have higher test scores in fourth grade, or eighth grade?
After crunching the math and science test scores for nearly a quarter-million students across 19 countries, Bedard found that relatively younger students perform 4 to 12 percentiles less well in third and fourth grade and 2 to 9 percentiles worse in seventh and eighth; and, as she notes, “by eighth grade it’s fairly safe to say we’re looking at long-term effects.” In British Columbia, she found that the relatively oldest students are about 10 percent more likely to be “university bound” than the relatively youngest ones. In the United States, she found that the relatively oldest students are 7.7 percent more likely to take the SAT or ACT, and are 11.6 percent more likely to enroll in four-year colleges or universities. (No one has yet published a study on age effects and SAT scores.) “One reason you could imagine age effects persist is that almost all of our education systems have ability-groupings built into them,” Bedard says. “Many claim they don’t, but they do. Everybody gets put into reading groups and math groups from very early ages.” Younger children are more likely to be assigned behind grade level, older children more likely to be assigned ahead. Younger children are more likely to receive diagnoses of attention-deficit disorder, too. “When I was in school the reading books all had colors,” Bedard told me. “They never said which was the high, the middle and the low, but everybody knew. Kids in the highest reading group one year are much more likely to be in the highest reading group the next. So you can imagine how that could propagate itself.”
Bedard found that different education systems produce varying age effects. For instance, Finland, whose students recently came out on top in an Organization for Economic Cooperation and Development study of math, reading and science skills, experiences smaller age effects; Finnish children also start school later, at age 7, and even then the first few years are largely devoted to social development and play. Denmark, too, produces little difference between relatively older and younger kids; the Danish education system prohibits differentiating by ability until students are 16. Those two exceptions notwithstanding, Bedard notes that she found age effects everywhere, from “the Japanese system of automatic promotion, to the accomplishment-oriented French system, to the supposedly more flexible skill-based program models used in Canada and the United States.”
The relative value of being older for one’s grade is a particularly open secret in those sectors of the American schooling system that treat education like a competitive sport. Many private-school birthday cutoffs are set earlier than public-school dates; and children, particularly boys, who make the cutoff but have summer and sometimes spring birthdays are often placed in junior kindergarten — also called “transitional kindergarten,” a sort of holding tank for kids too old for more preschool — or are encouraged to wait a year to apply. Erika O’Brien, a SoHo mother who has two redshirted children at Grace Church, a pre-K-through-8 private school in Manhattan, told me about a conversation she had with a friend whose daughter was placed in junior kindergarten because she had a summer birthday. “I told her that it’s really a great thing. Her daughter is going to have a better chance of being at the top of her class, she’ll more likely be a leader, she’ll have a better chance of succeeding at sports. She’s got nothing to worry about for the next nine years. Plus, if you’re making a financial investment in school, it’s a less risky investment.”
Robert Fulghum listed life lessons in his 1986 best seller “All I Really Need to Know I Learned in Kindergarten.” Among them were:
Clean up your own mess.
Don’t take things that aren’t yours.
Wash your hands before you eat.
Take a nap every afternoon.
Flush.
Were he to update the book to reflect the experience of today’s children, he’d need to call it “All I Really Need to Know I Learned in Preschool,” as kindergarten has changed. The half day devoted to fair play and nice manners officially began its demise in 1983, when the National Commission on Excellence in Education published “A Nation at Risk,” warning that the country faced a “rising tide of mediocrity” unless we increased school achievement and expectations. No Child Left Behind, in 2002, exacerbated the trend, pushing phonics and pattern-recognition worksheets even further down the learning chain. As a result, many parents, legislatures and teachers find the current curriculum too challenging for many older 4- and young 5-year-olds, which makes sense, because it’s largely the same curriculum taught to first graders less than a generation ago. Andersen’s kindergartners are supposed to be able to not just read but also write two sentences by the time they graduate from her classroom. It’s no wonder that nationwide, teachers now report that 48 percent of incoming kindergartners have difficulty handling the demands of school.
Friedrich Froebel, the romantic motherless son who started the first kindergarten in Germany in 1840, would be horrified by what’s called kindergarten today. He conceived the early learning experience as a homage to Jean-Jacques Rousseau, who believed that “reading is the plague of childhood. . . . Books are good only for learning to babble about what one does not know.” Letters and numbers were officially banned from Froebel’s kindergartens; the teaching materials consisted of handmade blocks and games that he referred to as “gifts.” By the late 1800s, kindergarten had jumped to the United States, with Boston transcendentalists like Elizabeth Peabody popularizing the concept. Fairly quickly, letters and numbers appeared on the wooden blocks, yet Peabody cautioned that a “genuine” kindergarten is “a company of children under 7 years old, who do not learn to read, write and cipher” and a “false” kindergarten is one that accommodates parents who want their children studying academics instead of just playing.
That the social skills and exploration of one’s immediate world have been squeezed out of kindergarten is less the result of a pedagogical shift than of the accountability movement and the literal-minded reverse-engineering process it has brought to the schools. Curriculum planners no longer ask, What does a 5-year-old need? Instead they ask, If a student is to pass reading and math tests in third grade, what does that student need to be doing in the prior grades? Whether kindergarten students actually need to be older is a question of readiness, a concept that itself raises the question: Ready for what? The skill set required to succeed in Fulgham’s kindergarten — openness, creativity — is well matched to the capabilities of most 5-year-olds but also substantially different from what Andersen’s students need. In early 2000, the National Center for Education Statistics assessed 22,000 kindergartners individually and found, in general, that yes, the older children are better prepared to start an academic kindergarten than the younger ones. The older kids are four times as likely to be reading, and two to three times as likely to be able to decipher two-digit numerals. Twice as many older kids have the advanced fine motor skills necessary for writing. The older kids also have important noncognitive advantages, like being more persistent and more socially adept. Nonetheless, child advocacy groups say it’s the schools’ responsibility to be ready for the children, no matter their age, not the children’s to be prepared for the advanced curriculum. In a report on kindergarten, the National Association of Early Childhood Specialists in State Departments of Education wrote, “Most of the questionable entry and placement practices that have emerged in recent years have their genesis in concerns over children’s capacities to cope with the increasingly inappropriate curriculum in kindergarten.”
Furthermore, as Elizabeth Graue, a former kindergarten teacher who now studies school-readiness and redshirting at the University of Wisconsin, Madison, points out, “Readiness is a relative issue.” Studies of early-childhood teachers show they always complain about the youngest students, no matter their absolute age. ‘In Illinois it will be the March-April-May kids; in California, it will be October-November-December,” Graue says. “It’s really natural as a teacher to gravitate toward the kids who are easy to teach, especially when there’s academic pressure and the younger kids are rolling around the floor and sticking pencils in their ears.”
But perhaps those kids with the pencils in their ears — at least the less-affluent ones — don’t need “the gift of time” but rather to be brought into the schools. Forty-two years after Lyndon Johnson inaugurated Head Start, access to quality early education still highly correlates with class; and one serious side effect of pushing back the cutoffs is that while well-off kids with delayed enrollment will spend another year in preschool, probably doing what kindergartners did a generation ago, less-well-off children may, as the literacy specialist Katie Eller put it, spend “another year watching TV in the basement with Grandma.” What’s more, given the socioeconomics of redshirting — and the luxury involved in delaying for a year the free day care that is public school — the oldest child in any given class is more likely to be well off and the youngest child is more likely to be poor. “You almost have a double advantage coming to the well-off kids,” says Samuel J. Meisels, president of Erikson Institute, a graduate school in child development in Chicago. “From a public-policy point of view I find this very distressing.”
Nobody has exact numbers on what percentage of the children eligible for publicly financed preschool are actually enrolled — the individual programs are legion, and the eligibility requirements are complicated and varied — but the best guess from the National Institute for Early Education Research puts the proportion at only 25 percent. In California, for instance, 76 percent of publicly financed preschool programs have waiting lists, which include over 30,000 children. In Pennsylvania, 35 percent of children eligible for Head Start are not served. A few states do have universal preschool, and among Hillary Clinton’s first broad domestic policy proposals as a Democratic presidential candidate was to call for universal pre-kindergarten classes. But at the moment, free high-quality preschool for less-well-to-do children is spotty, and what exists often is aimed at extremely low-income parents, leaving out the children of the merely strapped working or lower-middle class. Nor, as a rule, do publicly financed programs take kids who are old enough to be eligible for kindergarten, meaning redshirting is not a realistic option for many.
One morning, when I was sitting in Elizabeth Levett Fortier’s kindergarten classroom in the Peabody School in San Francisco — among a group of students that included some children who had never been to preschool, some who were just learning English and some who were already reading — a father dropped by to discuss whether or not to enroll his fall-birthday daughter or give her one more year at her private preschool. Demographically speaking, any child with a father willing to call on a teacher to discuss if it’s best for that child to spend a third year at a $10,000-a-year preschool is going to be fine. Andersen told me, “I’ve had parents tell me that the preschool did not recommend sending their children on to kindergarten yet, but they had no choice,” as they couldn’t afford not to. In 49 out of 50 states, the average annual cost of day care for a 4-year-old in an urban area is more than the average annual public college tuition. A RAND Corporation position paper suggests policy makers may need to view “entrance-age policies and child-care polices as a package.”
Labor economists, too, make a strong case that resources should be directed at disadvantaged children as early as possible, both for the sake of improving each child’s life and because of economic return. Among the leaders in this field is James Heckman, a University of Chicago economist who won the Nobel in economic science in 2000. In many papers and lectures on poor kids, he now includes a simple graph that plots the return on investment in human capital across age. You can think of the accumulation of human capital much like the accumulation of financial capital in an account bearing compound interest: if you add your resources as soon as possible, they’ll be worth more down the line. Heckman’s graph looks like a skateboard quarter-pipe, sloping precipitously from a high point during the preschool years, when the return on investment in human capital is very high, down the ramp and into the flat line after a person is no longer in school, when the return on investment is minimal. According to Heckman’s analysis, if you have limited funds to spend it makes the most economic sense to spend them early. The implication is that if poor children aren’t in adequate preschool programs, rolling back the age of kindergarten is a bad idea economically, as it pushes farther down the ramp the point at which we start investing funds and thus how productive those funds will be.
Bedard and other economists cite Heckman’s theories of how people acquire skills to help explain the persistence of relative age on school performance. Heckman writes: “Skill begets skill; motivation begets motivation. Early failure begets later failure.” Reading experts know that it’s easier for a child to learn the meaning of a new word if he knows the meaning of a related word and that a good vocabulary at age 3 predicts a child’s reading well in third grade. Skills like persistence snowball, too. One can easily see how the skill-begets-skill, motivation-begets-motivation dynamic plays out in a kindergarten setting: a child who comes in with a good vocabulary listens to a story, learns more words, feels great about himself and has an even better vocabulary at the end of the day. Another child arrives with a poor vocabulary, listens to the story, has a hard time following, picks up fewer words, retreats into insecurity and leaves the classroom even further behind.
How to address the influence of age effects is unclear. After all, being on the older or younger side of one’s classmates is mostly the luck of the birthday draw, and no single birthday cutoff can prevent a 12-month gap in age. States could try to prevent parents from gaming the age effects by outlawing redshirting — specifically by closing the yearlong window that now exists in most states between the birthday cutoffs and compulsory schooling. But forcing families to enroll children in kindergarten as soon as they are eligible seems too authoritarian for America’s tastes. States could also decide to learn from Finland — start children in school at age 7 and devote the first year to play — but that would require a major reversal, making second grade the old kindergarten, instead of kindergarten the new first grade. States could also emulate Denmark, forbidding ability groupings until late in high school, but unless very serious efforts are made to close the achievement gap before children arrive at kindergarten, that seems unlikely, too.
Of course there’s also the reality that individual children will always mature at different rates, and back in Andersen’s classroom, on a Thursday when this year’s kindergartners stayed home and next year’s kindergartners came in for pre-enrollment assessments, the developmental differences between one future student and the next were readily apparent. To gauge kindergarten readiness, Andersen and another kindergarten teacher each sat the children down one by one for a 20-minute test. The teachers asked the children, among other things, to: skip; jump; walk backward; cut out a diamond on a dotted line; copy the word cat; draw a person; listen to a story; and answer simple vocabulary questions like what melts, what explodes and what flies. Some of the kids were dynamos. When asked to explain the person he had drawn, one boy said: “That’s Miss Maple. She’s my preschool teacher, and she’s crying because she’s going to miss me so much next year.” Another girl said at one point, “Oh, you want me to write the word cat?” Midmorning, however, a little boy who will not turn 5 until this summer arrived. His little feet dangled off the kindergarten chair, as his legs were not long enough to reach the floor. The teacher asked him to draw a person. To pass that portion of the test, his figure needed seven different body parts.
“Is that all he needs?” she asked a few minutes later.
The boy said, “Oh, I forgot the head.”
A minute later the boy submitted his drawing again. “Are you sure he doesn’t need anything else?” the teacher asked.
The boy stared at his work. “I forgot the legs. Those are important, aren’t they?”
The most difficult portion of the test for many of the children was a paper-folding exercise. “Watch how I fold my paper,” the teacher told the little boy. She first folded her 8 1/2-by-11-inch paper in half the long way, to create a narrow rectangle, and then she folded the rectangle in thirds, to make something close to a square.
“Can you do it?” she asked the boy.
He took the paper eagerly, but folded it in half the wrong way. Depending on the boy’s family’s finances, circumstances and mind-set, his parents may decide to hold him out a year so he’ll be one of the oldest and, presumably, most confident. Or they may decide to enroll him in school as planned. He may go to college or he may not. He may be a leader or a follower. Those things will ultimately depend more on the education level achieved by his mother, whether he lives in a two-parent household and the other assets and obstacles he brings with him to school each day. Still, the last thing any child needs is to be outmaneuvered by other kids’ parents as they cut to the back of the birthday line to manipulate age effects. Eventually, the boy put his head down on the table. His first fold had set a course, and even after trying gamely to fold the paper again in thirds, he couldn’t create the right shape.
June 3, 2007
When Should a Kid Start Kindergarten?
By ELIZABETH WEIL
According to the apple-or-coin test, used in the Middle Ages, children should start school when they are mature enough for the delayed gratification and abstract reasoning involved in choosing money over fruit. In 15th- and 16th-century Germany, parents were told to send their children to school when the children started to act “rational.” And in contemporary America, children are deemed eligible to enter kindergarten according to an arbitrary date on the calendar known as the birthday cutoff — that is, when the state, or in some instances the school district, determines they are old enough. The birthday cutoffs span six months, from Indiana, where a child must turn 5 by July 1 of the year he enters kindergarten, to Connecticut, where he must turn 5 by Jan. 1 of his kindergarten year. Children can start school a year late, but in general they cannot start a year early. As a result, when the 22 kindergartners entered Jane Andersen’s class at the Glen Arden Elementary School near Asheville, N.C., one warm April morning, each brought with her or him a snack and a unique set of gifts and challenges, which included for some what’s referred to in education circles as “the gift of time.”
After the morning announcements and the Pledge of Allegiance, Andersen’s kindergartners sat down on a blue rug. Two, one boy and one girl, had been redshirted — the term, borrowed from sports, describes students held out for a year by their parents so that they will be older, or larger, or more mature, and thus better prepared to handle the increased pressures of kindergarten today. Six of Andersen’s pupils, on the other hand, were quite young, so young that they would not be enrolled in kindergarten at all if North Carolina succeeds in pushing back its birthday cutoff from Oct. 16 to Aug. 31.
Andersen is a willowy 11-year teaching veteran who offered up a lot of education in the first hour of class. First she read Leo Lionni’s classic children’s book “An Extraordinary Egg,” and directed a conversation about it. Next she guided the students through: writing a letter; singing a song; solving an addition problem; two more songs; and a math game involving counting by ones, fives and tens using coins. Finally, Andersen read them another Lionni book. Labor economists who study what’s called the accumulation of human capital — how we acquire the knowledge and skills that make us valuable members of society — have found that children learn vastly different amounts from the same classroom experiences and that those with certain advantages at the outset are able to learn more, more quickly, causing the gap between students to increase over time. Gaps in achievement have many causes, but a major one in any kindergarten room is age. Almost all kindergarten classrooms have children with birthdays that span 12 months. But because of redshirting, the oldest student in Andersen’s class is not just 12 but 15 months older than the youngest, a difference in age of 25 percent.
After rug time, Andersen’s kindergartners walked single-file to P.E. class, where the children sat on the curb alongside the parking circle, taking turns running laps for the Presidential Fitness Test. By far the fastest runner was the girl in class who had been redshirted. She strode confidently, with great form, while many of the smaller kids could barely run straight. One of the younger girls pointed out the best artist in the class, a freckly redhead. I’d already noted his beautiful penmanship. He had been redshirted as well.
States, too, are trying to embrace the advantages of redshirting. Since 1975, nearly half of all states have pushed back their birthday cutoffs and four — California, Michigan, North Carolina and Tennessee — have active legislation in state assemblies to do so right now. (Arkansas passed legislation earlier this spring; New Jersey, which historically has let local districts establish their birthday cutoffs, has legislation pending to make Sept. 1 the cutoff throughout the state.) This is due, in part, to the accountability movement — the high-stakes testing now pervasive in the American educational system. In response to this testing, kindergartens across the country have become more demanding: if kids must be performing on standardized tests in third grade, then they must be prepping for those tests in second and first grades, and even at the end of kindergarten, or so the thinking goes. The testing also means that states, like students, now get report cards, and they want their children to do well, both because they want them to be educated and because they want them to stack up favorably against their peers.
Indeed, increasing the average age of the children in a kindergarten class is a cheap and easy way to get a small bump in test scores, because older children perform better, and states’ desires for relative advantage is written into their policy briefs. The California Performance Review, commissioned by Gov. Arnold Schwarzenegger in 2004, suggested moving California’s birthday cutoff three months earlier, to Sept. 1 from Dec. 2, noting that “38 states, including Florida and Texas, have kindergarten entry dates prior to California’s.” Maryland’s proposal to move its date mentioned that “the change . . . will align the ‘cutoff’ date with most of the other states in the country.”
All involved in increasing the age of kindergartners — parents, legislatures and some teachers — say they have the best interests of children in mind. “If I had just one goal with this piece of legislation it would be to not humiliate a child,” Dale Folwell, the Republican North Carolina state representative who sponsored the birthday-cutoff bill, told me. “Our kids are younger when they’re taking the SAT, and they’re applying to the same colleges as the kids from Florida and Georgia.” Fair enough — governors and state legislators have competitive impulses, too. Still, the question remains: Is it better for children to start kindergarten later? And even if it’s better for a given child, is it good for children in general? Time out of school may not be a gift to all kids. For some it may be a burden, a financial stress on their parents and a chance, before they ever reach a classroom, to fall even further behind.
Redshirting is not a new phenomenon — in fact, the percentage of redshirted children has held relatively steady since education scholars started tracking the practice in the 1980s. Studies by the National Center for Education Statistics in the 1990s show that delayed-entry children made up somewhere between 6 and 9 percent of all kindergartners; a new study is due out in six months. As states roll back birthday cutoffs, there are more older kindergartners in general — and more redshirted kindergartners who are even older than the oldest kindergartners in previous years. Recently, redshirting has become a particular concern, because in certain affluent communities the numbers of kindergartners coming to school a year later are three or four times the national average. “Do you know what the number is in my district?” Representative Folwell, from a middle-class part of Winston-Salem, N.C., asked me. “Twenty-six percent.” In one kindergarten I visited in Los Altos, Calif. — average home price, $1 million — about one-quarter of the kids had been electively held back as well. Fred Morrison, a developmental psychologist at the University of Michigan who has studied the impact of falling on one side or the other of the birthday cutoff, sees the endless “graying of kindergarten,” as it’s sometimes called, as coming from a parental obsession not with their children’s academic accomplishment but with their social maturity. “You couldn’t find a kid who skips a grade these days,” Morrison told me. “We used to revere individual accomplishment. Now we revere self-esteem, and the reverence has snowballed in unconscious ways — into parents always wanting their children to feel good, wanting everything to be pleasant.” So parents wait an extra year in the hope that when their children enter school their age or maturity will shield them from social and emotional hurt. Elizabeth Levett Fortier, a kindergarten teacher in the George Peabody Elementary School in San Francisco, notices the impact on her incoming students. “I’ve had children come into my classroom, and they’ve never even lost at Candy Land.”
For years, education scholars have pointed out that most studies have found that the benefits of being relatively older than one’s classmates disappear after the first few years of school. In a literature review published in 2002, Deborah Stipek, dean of the Stanford school of education, found studies in which children who are older than their classmates not only do not learn more per grade but also tend to have more behavior problems. However, more recent research by labor economists takes advantage of new, very large data sets and has produced different results. A few labor economists do concur with the education scholarship, but most have found that while absolute age (how many days a child has been alive) is not so important, relative age (how old that child is in comparison to his classmates) shapes performance long after those few months of maturity should have ceased to matter. The relative-age effect has been found in schools around the world and also in sports. In one study published in the June 2005 Journal of Sport Sciences, researchers from Leuven, Belgium, and Liverpool, England, found that a disproportionate number of World Cup soccer players are born in January, February and March, meaning they were old relative to peers on youth soccer teams.
Before the school year started, Andersen, who is 54, taped up on the wall behind her desk a poster of a dog holding a bouquet of 12 balloons. In each balloon Andersen wrote the name of a month; under each month, the birthdays of the children in her class. Like most teachers, she understands that the small fluctuations among birth dates aren’t nearly as important as the vast range in children’s experiences at preschool and at home. But one day as we sat in her classroom, Andersen told me, “Every year I have two or three young ones in that August-to-October range, and they just struggle a little.” She used to encourage parents to send their children to kindergarten as soon as they were eligible, but she is now a strong proponent of older kindergartners, after teaching one child with a birthday just a few days before the cutoff. “She was always a step behind. It wasn’t effort and it wasn’t ability. She worked hard, her mom worked with her and she still was behind.” Andersen followed the girl’s progress through second grade (after that, she moved to a different school) and noticed that she didn’t catch up. Other teachers at Glen Arden Elementary and elsewhere have noticed a similar phenomenon: not always, but too often, the little ones stay behind.
The parents of the redshirted girl in Andersen’s class told a similar story. Five years ago, their older daughter had just made the kindergarten birthday cutoff by a few days, and they enrolled her. “She’s now a struggling fourth grader: only by the skin of her teeth has she been able to pass each year,” the girl’s mother, Stephanie Gandert, told me. “I kick myself every year now that we sent her ahead.” By contrast, their current kindergartner is doing just fine. “I always tell parents, ‘If you can wait, wait.’ If my kindergartner were in first grade right now, she’d be in trouble, too.” (The parents of the redshirted boy in Andersen’s class declined to be interviewed for this article but may very well have held him back because he’s small — even though he’s now one of the oldest, he’s still one of the shortest.)
Kelly Bedard, a labor economist at the University of California, Santa Barbara, published a paper called “The Persistence of Early Childhood Maturity: International Evidence of Long-Run Age Effects” in The Quarterly Journal of Economics in November 2006 that looked at this phenomenon. “Obviously, when you’re 5, being a year older is a lot, and so we should expect kids who are the oldest in kindergarten to do better than the kids who are the youngest in kindergarten,” Bedard says. But what if relatively older kids keep doing better after the maturity gains of a few months should have ceased to matter? What if kids who are older relative to their classmates still have higher test scores in fourth grade, or eighth grade?
After crunching the math and science test scores for nearly a quarter-million students across 19 countries, Bedard found that relatively younger students perform 4 to 12 percentiles less well in third and fourth grade and 2 to 9 percentiles worse in seventh and eighth; and, as she notes, “by eighth grade it’s fairly safe to say we’re looking at long-term effects.” In British Columbia, she found that the relatively oldest students are about 10 percent more likely to be “university bound” than the relatively youngest ones. In the United States, she found that the relatively oldest students are 7.7 percent more likely to take the SAT or ACT, and are 11.6 percent more likely to enroll in four-year colleges or universities. (No one has yet published a study on age effects and SAT scores.) “One reason you could imagine age effects persist is that almost all of our education systems have ability-groupings built into them,” Bedard says. “Many claim they don’t, but they do. Everybody gets put into reading groups and math groups from very early ages.” Younger children are more likely to be assigned behind grade level, older children more likely to be assigned ahead. Younger children are more likely to receive diagnoses of attention-deficit disorder, too. “When I was in school the reading books all had colors,” Bedard told me. “They never said which was the high, the middle and the low, but everybody knew. Kids in the highest reading group one year are much more likely to be in the highest reading group the next. So you can imagine how that could propagate itself.”
Bedard found that different education systems produce varying age effects. For instance, Finland, whose students recently came out on top in an Organization for Economic Cooperation and Development study of math, reading and science skills, experiences smaller age effects; Finnish children also start school later, at age 7, and even then the first few years are largely devoted to social development and play. Denmark, too, produces little difference between relatively older and younger kids; the Danish education system prohibits differentiating by ability until students are 16. Those two exceptions notwithstanding, Bedard notes that she found age effects everywhere, from “the Japanese system of automatic promotion, to the accomplishment-oriented French system, to the supposedly more flexible skill-based program models used in Canada and the United States.”
The relative value of being older for one’s grade is a particularly open secret in those sectors of the American schooling system that treat education like a competitive sport. Many private-school birthday cutoffs are set earlier than public-school dates; and children, particularly boys, who make the cutoff but have summer and sometimes spring birthdays are often placed in junior kindergarten — also called “transitional kindergarten,” a sort of holding tank for kids too old for more preschool — or are encouraged to wait a year to apply. Erika O’Brien, a SoHo mother who has two redshirted children at Grace Church, a pre-K-through-8 private school in Manhattan, told me about a conversation she had with a friend whose daughter was placed in junior kindergarten because she had a summer birthday. “I told her that it’s really a great thing. Her daughter is going to have a better chance of being at the top of her class, she’ll more likely be a leader, she’ll have a better chance of succeeding at sports. She’s got nothing to worry about for the next nine years. Plus, if you’re making a financial investment in school, it’s a less risky investment.”
Robert Fulghum listed life lessons in his 1986 best seller “All I Really Need to Know I Learned in Kindergarten.” Among them were:
Clean up your own mess.
Don’t take things that aren’t yours.
Wash your hands before you eat.
Take a nap every afternoon.
Flush.
Were he to update the book to reflect the experience of today’s children, he’d need to call it “All I Really Need to Know I Learned in Preschool,” as kindergarten has changed. The half day devoted to fair play and nice manners officially began its demise in 1983, when the National Commission on Excellence in Education published “A Nation at Risk,” warning that the country faced a “rising tide of mediocrity” unless we increased school achievement and expectations. No Child Left Behind, in 2002, exacerbated the trend, pushing phonics and pattern-recognition worksheets even further down the learning chain. As a result, many parents, legislatures and teachers find the current curriculum too challenging for many older 4- and young 5-year-olds, which makes sense, because it’s largely the same curriculum taught to first graders less than a generation ago. Andersen’s kindergartners are supposed to be able to not just read but also write two sentences by the time they graduate from her classroom. It’s no wonder that nationwide, teachers now report that 48 percent of incoming kindergartners have difficulty handling the demands of school.
Friedrich Froebel, the romantic motherless son who started the first kindergarten in Germany in 1840, would be horrified by what’s called kindergarten today. He conceived the early learning experience as a homage to Jean-Jacques Rousseau, who believed that “reading is the plague of childhood. . . . Books are good only for learning to babble about what one does not know.” Letters and numbers were officially banned from Froebel’s kindergartens; the teaching materials consisted of handmade blocks and games that he referred to as “gifts.” By the late 1800s, kindergarten had jumped to the United States, with Boston transcendentalists like Elizabeth Peabody popularizing the concept. Fairly quickly, letters and numbers appeared on the wooden blocks, yet Peabody cautioned that a “genuine” kindergarten is “a company of children under 7 years old, who do not learn to read, write and cipher” and a “false” kindergarten is one that accommodates parents who want their children studying academics instead of just playing.
That the social skills and exploration of one’s immediate world have been squeezed out of kindergarten is less the result of a pedagogical shift than of the accountability movement and the literal-minded reverse-engineering process it has brought to the schools. Curriculum planners no longer ask, What does a 5-year-old need? Instead they ask, If a student is to pass reading and math tests in third grade, what does that student need to be doing in the prior grades? Whether kindergarten students actually need to be older is a question of readiness, a concept that itself raises the question: Ready for what? The skill set required to succeed in Fulgham’s kindergarten — openness, creativity — is well matched to the capabilities of most 5-year-olds but also substantially different from what Andersen’s students need. In early 2000, the National Center for Education Statistics assessed 22,000 kindergartners individually and found, in general, that yes, the older children are better prepared to start an academic kindergarten than the younger ones. The older kids are four times as likely to be reading, and two to three times as likely to be able to decipher two-digit numerals. Twice as many older kids have the advanced fine motor skills necessary for writing. The older kids also have important noncognitive advantages, like being more persistent and more socially adept. Nonetheless, child advocacy groups say it’s the schools’ responsibility to be ready for the children, no matter their age, not the children’s to be prepared for the advanced curriculum. In a report on kindergarten, the National Association of Early Childhood Specialists in State Departments of Education wrote, “Most of the questionable entry and placement practices that have emerged in recent years have their genesis in concerns over children’s capacities to cope with the increasingly inappropriate curriculum in kindergarten.”
Furthermore, as Elizabeth Graue, a former kindergarten teacher who now studies school-readiness and redshirting at the University of Wisconsin, Madison, points out, “Readiness is a relative issue.” Studies of early-childhood teachers show they always complain about the youngest students, no matter their absolute age. ‘In Illinois it will be the March-April-May kids; in California, it will be October-November-December,” Graue says. “It’s really natural as a teacher to gravitate toward the kids who are easy to teach, especially when there’s academic pressure and the younger kids are rolling around the floor and sticking pencils in their ears.”
But perhaps those kids with the pencils in their ears — at least the less-affluent ones — don’t need “the gift of time” but rather to be brought into the schools. Forty-two years after Lyndon Johnson inaugurated Head Start, access to quality early education still highly correlates with class; and one serious side effect of pushing back the cutoffs is that while well-off kids with delayed enrollment will spend another year in preschool, probably doing what kindergartners did a generation ago, less-well-off children may, as the literacy specialist Katie Eller put it, spend “another year watching TV in the basement with Grandma.” What’s more, given the socioeconomics of redshirting — and the luxury involved in delaying for a year the free day care that is public school — the oldest child in any given class is more likely to be well off and the youngest child is more likely to be poor. “You almost have a double advantage coming to the well-off kids,” says Samuel J. Meisels, president of Erikson Institute, a graduate school in child development in Chicago. “From a public-policy point of view I find this very distressing.”
Nobody has exact numbers on what percentage of the children eligible for publicly financed preschool are actually enrolled — the individual programs are legion, and the eligibility requirements are complicated and varied — but the best guess from the National Institute for Early Education Research puts the proportion at only 25 percent. In California, for instance, 76 percent of publicly financed preschool programs have waiting lists, which include over 30,000 children. In Pennsylvania, 35 percent of children eligible for Head Start are not served. A few states do have universal preschool, and among Hillary Clinton’s first broad domestic policy proposals as a Democratic presidential candidate was to call for universal pre-kindergarten classes. But at the moment, free high-quality preschool for less-well-to-do children is spotty, and what exists often is aimed at extremely low-income parents, leaving out the children of the merely strapped working or lower-middle class. Nor, as a rule, do publicly financed programs take kids who are old enough to be eligible for kindergarten, meaning redshirting is not a realistic option for many.
One morning, when I was sitting in Elizabeth Levett Fortier’s kindergarten classroom in the Peabody School in San Francisco — among a group of students that included some children who had never been to preschool, some who were just learning English and some who were already reading — a father dropped by to discuss whether or not to enroll his fall-birthday daughter or give her one more year at her private preschool. Demographically speaking, any child with a father willing to call on a teacher to discuss if it’s best for that child to spend a third year at a $10,000-a-year preschool is going to be fine. Andersen told me, “I’ve had parents tell me that the preschool did not recommend sending their children on to kindergarten yet, but they had no choice,” as they couldn’t afford not to. In 49 out of 50 states, the average annual cost of day care for a 4-year-old in an urban area is more than the average annual public college tuition. A RAND Corporation position paper suggests policy makers may need to view “entrance-age policies and child-care polices as a package.”
Labor economists, too, make a strong case that resources should be directed at disadvantaged children as early as possible, both for the sake of improving each child’s life and because of economic return. Among the leaders in this field is James Heckman, a University of Chicago economist who won the Nobel in economic science in 2000. In many papers and lectures on poor kids, he now includes a simple graph that plots the return on investment in human capital across age. You can think of the accumulation of human capital much like the accumulation of financial capital in an account bearing compound interest: if you add your resources as soon as possible, they’ll be worth more down the line. Heckman’s graph looks like a skateboard quarter-pipe, sloping precipitously from a high point during the preschool years, when the return on investment in human capital is very high, down the ramp and into the flat line after a person is no longer in school, when the return on investment is minimal. According to Heckman’s analysis, if you have limited funds to spend it makes the most economic sense to spend them early. The implication is that if poor children aren’t in adequate preschool programs, rolling back the age of kindergarten is a bad idea economically, as it pushes farther down the ramp the point at which we start investing funds and thus how productive those funds will be.
Bedard and other economists cite Heckman’s theories of how people acquire skills to help explain the persistence of relative age on school performance. Heckman writes: “Skill begets skill; motivation begets motivation. Early failure begets later failure.” Reading experts know that it’s easier for a child to learn the meaning of a new word if he knows the meaning of a related word and that a good vocabulary at age 3 predicts a child’s reading well in third grade. Skills like persistence snowball, too. One can easily see how the skill-begets-skill, motivation-begets-motivation dynamic plays out in a kindergarten setting: a child who comes in with a good vocabulary listens to a story, learns more words, feels great about himself and has an even better vocabulary at the end of the day. Another child arrives with a poor vocabulary, listens to the story, has a hard time following, picks up fewer words, retreats into insecurity and leaves the classroom even further behind.
How to address the influence of age effects is unclear. After all, being on the older or younger side of one’s classmates is mostly the luck of the birthday draw, and no single birthday cutoff can prevent a 12-month gap in age. States could try to prevent parents from gaming the age effects by outlawing redshirting — specifically by closing the yearlong window that now exists in most states between the birthday cutoffs and compulsory schooling. But forcing families to enroll children in kindergarten as soon as they are eligible seems too authoritarian for America’s tastes. States could also decide to learn from Finland — start children in school at age 7 and devote the first year to play — but that would require a major reversal, making second grade the old kindergarten, instead of kindergarten the new first grade. States could also emulate Denmark, forbidding ability groupings until late in high school, but unless very serious efforts are made to close the achievement gap before children arrive at kindergarten, that seems unlikely, too.
Of course there’s also the reality that individual children will always mature at different rates, and back in Andersen’s classroom, on a Thursday when this year’s kindergartners stayed home and next year’s kindergartners came in for pre-enrollment assessments, the developmental differences between one future student and the next were readily apparent. To gauge kindergarten readiness, Andersen and another kindergarten teacher each sat the children down one by one for a 20-minute test. The teachers asked the children, among other things, to: skip; jump; walk backward; cut out a diamond on a dotted line; copy the word cat; draw a person; listen to a story; and answer simple vocabulary questions like what melts, what explodes and what flies. Some of the kids were dynamos. When asked to explain the person he had drawn, one boy said: “That’s Miss Maple. She’s my preschool teacher, and she’s crying because she’s going to miss me so much next year.” Another girl said at one point, “Oh, you want me to write the word cat?” Midmorning, however, a little boy who will not turn 5 until this summer arrived. His little feet dangled off the kindergarten chair, as his legs were not long enough to reach the floor. The teacher asked him to draw a person. To pass that portion of the test, his figure needed seven different body parts.
“Is that all he needs?” she asked a few minutes later.
The boy said, “Oh, I forgot the head.”
A minute later the boy submitted his drawing again. “Are you sure he doesn’t need anything else?” the teacher asked.
The boy stared at his work. “I forgot the legs. Those are important, aren’t they?”
The most difficult portion of the test for many of the children was a paper-folding exercise. “Watch how I fold my paper,” the teacher told the little boy. She first folded her 8 1/2-by-11-inch paper in half the long way, to create a narrow rectangle, and then she folded the rectangle in thirds, to make something close to a square.
“Can you do it?” she asked the boy.
He took the paper eagerly, but folded it in half the wrong way. Depending on the boy’s family’s finances, circumstances and mind-set, his parents may decide to hold him out a year so he’ll be one of the oldest and, presumably, most confident. Or they may decide to enroll him in school as planned. He may go to college or he may not. He may be a leader or a follower. Those things will ultimately depend more on the education level achieved by his mother, whether he lives in a two-parent household and the other assets and obstacles he brings with him to school each day. Still, the last thing any child needs is to be outmaneuvered by other kids’ parents as they cut to the back of the birthday line to manipulate age effects. Eventually, the boy put his head down on the table. His first fold had set a course, and even after trying gamely to fold the paper again in thirds, he couldn’t create the right shape.
Mets bang for the buck players
NYTimes
June 5, 2007
Bargain-Basement Acquisitions Help Mets Reach the Top
By BEN SHPIGEL
At 12:01 a.m. on Dec. 21, 2005, the office of Commissioner Bud Selig sent an e-mail message to every team in baseball listing 50 players who had become free agents because their teams had not offered them contracts for the next season.
The message included inauspicious players like Joe Dillon, Brian Myrow and Hiram Bocachica. It also included an outfielder named Endy Chávez, who had hit a combined .216 that season with Washington and Philadelphia. In 48 hours, the Mets were congratulating themselves for quickly signing Chávez to a one-year deal worth $500,000.
Eighteen months later, the Mets are still patting themselves on the back, and why shouldn’t they? They are a third of the way through the 2007 season and are just where they hoped to be — with the best record in the National League and a tidy lead over Atlanta in an improved N.L. East. They have been successful by avoiding slumps — they are one of two teams not to lose more than two games in a row this season — by playing standout defense, and in particular, by using Chávez and other bargain acquisitions like infielder Damion Easley and starting pitcher Jorge Sosa to cope with the numerous injuries the team has had.
It is the success of those backup players this year, and for that matter, the standout performances of Chávez and José Valentín last season, that have underlined how savvy General Manger Omar Minaya and his staff have been the past three seasons in making moves that had more to do with scouting and judgment than with the Mets’ considerable financial resources.
To sign Chávez and Valentín, or Easley and Sosa before this season, a blank check was not required. Other teams, even small-market ones, could have tried to grab them. All told, Minaya acquired those four players for about $3.5 million. They are the kind of below-the-radar moves, perhaps more than the expensive signings of Pedro Martínez, Carlos Beltrán and Billy Wagner or the trades for Carlos Delgado and Paul Lo Duca, that have earned Minaya the admiration of his peers.
“Once you have your core guys, you start filling in the other spots,” Minaya said in a recent interview. ”
The Mets’ method for evaluating talent is not much different from that of other teams. But not every team is benefiting from low-cost moves the way the Mets are. A detailed look at two of those signings — Chávez and Easley — is instructive.
In the case of Chávez, the Mets, toward the end of the 2005 season, sought a backup outfielder who would represent a substantial upgrade over Gerald Williams. They liked Jeff DaVanon, who had played with the Los Angeles Angels in 2005, but not as much as Chávez, a natural center fielder who could play all three outfield positions and had the experience of being an everyday player; Chávez played 273 games in 2003 and 2004 in Montreal. The Expos’ general manager at the time was Minaya, who never forgot Chávez’s superb defense and called his agent, Peter Greenberg, a few hours after learning that Philadelphia did not tender Chávez a contract for the 2006 season.
In the Mets’ front office, questions emerged about Chávez’s offensive skills. His reluctance to bunt and take pitches had quickened his departure from Washington during the 2005 season, and he had a loopy swing that did not match his strengths. But the Mets figured that working with the hitting coach Rick Down would eliminate some of his bad habits. “With Endy, not too many stats guys were jumping all over him,” Minaya said. “He’s a scout’s guy, and as a general manager, you’re only as good as your scouts.”
John Ricco, an assistant general manager for the Mets, was hammering out a deal with Chávez when Minaya learned that Baltimore had joined the bidding. The Baltimore third baseman Melvin Mora, who like Chavez is from Venezuela and is one of his close friends, had implored the Orioles to improve their offer. To reinforce his own recruiting pitch, Minaya spoke to Chávez. Their time together in Montreal might have given the Mets an edge. “I’m trying to take care of him because he took care of me,” Chávez said.
Chávez missed nearly three weeks of spring training last season participating in the World Baseball Classic, and Manager Willie Randolph had trouble forming an opinion of him. “We just kept telling him, ‘Trust our scouts, trust our scouts,’ ” Minaya said of Randolph. “And he did.”
Randolph knew much more about Easley, but not as much as the Mets’ vice president for development, Tony Bernazard. After the Mets decided not to re-sign Chris Woodward, their resident backup middle infielder, they pored over the free-agent class for 2007.
As soon as the free-agent signing period began in November, Bernazard, who had known Easley for about 15 years, called him at his home in Arizona. The Mets, he explained, were looking for a right-handed complement to Valentín, who is on the disabled list, and someone who could come off the bench late in a game and hit a fastball. That is something that Easley, with seven homers this season, one short of the team lead, has done with great success. “We wanted someone unselfish,” Bernazard said. “Mr. Easley was very comfortable in that role.”
Easley drew interest from several other teams, including the Yankees, but he said he did not really consider any team but the Mets for two reasons. He had never been to the playoffs, and he felt the Mets had a great chance to get there. The other reason required a little more analysis. He examined how the Mets used Woodward over the past two seasons and figured that he would probably receive similar, if not more, opportunities.
“I knew I wasn’t going to get 500 or 600 plate appearances here, so I started thinking what kind of a difference I would make if I got 200 or 250 at-bats,” Easley said. “And when you sign a guy expecting to get 200 or 250 at-bats from him, you really have to do your homework. I know the Mets did theirs.”
For that matter, the Mets also did their homework with relief pitchers Chad Bradford and Darren Oliver, two acquisitions who greatly benefited the Mets last season for a combined cost of $2 million. Both have moved on, but Chávez, Easley, Sosa and Valentín are all here. Who knows who else Minaya may have his eye on?
Saturday, June 02, 2007
Money advice for graduates
NYTimes
June 2, 2007
Your Money
More Advice Graduates Don’t Want to Hear
By DAMON DARLIN
Last year at this time, as college graduates walked out into the world, I wrote a column giving advice on how they could save money.
In droves, parents sent the column to their children. And some of those children wrote to me to vent. What I suggested was impractical, many said. How would you like to try to live on $40,000 a year in Washington or San Francisco, several asked.
What I was proposing was not radical. It was mostly the simple things my mother had drummed into me. It was advice like diverting 10 percent of your income to savings before anything else and ignoring raises and putting them into savings, too. Learn to cook, I said, and never borrow money to pay for a depreciating asset.
I also suggested cutting out the latte habit, which was my symbol for those little things in life that when turned into a habit, add up to money that could have been spent on something worthwhile and memorable.
Other people, my wife among them, pointed out that I may have been too draconian on that point. Consistent savings is a lot easier if there are small rewards along the way; otherwise, life seems as if it is just one bowl of cold grass porridge after another.
Fine feedback, indeed, and my wife’s counsel reminds me that I should have added one other bit of advice: find a partner and stay together. Study after study show that two can live more cheaply together than each alone and that divorce is the great destroyer of wealth.
But, dear graduates, the crux of the advice is still compelling. While there may be a debate among economists about how much 50- and 60-year-olds should be saving for retirement, there is little dispute about how much the young should save: more.
Saving while young is critical. It isn’t just because of the power of compounding. By that I mean that if you start saving now it will build to a larger nest egg by the time you are 65 than if you wait to start at 45. Or to put it another way, you can save a smaller amount now rather than a larger amount later.
Bank $250 a month for 40 years in a I.R.A. or a 401(k) and you will receive about $500,000, assuming a 6 percent return. Start at age 45 and you would have to put in $1,078 a month to generate the same amount by age 65.
But there is another compelling reason to get into the habit of saving. (Here is where this column also turns into advice for the older folks who are giving you this to read.) People who save a lot get used to a lower rate of consumption while working, so less money is needed in retirement.
Stretching to save a little more yields a double dividend. You accumulate more assets and you lower the amount you will need in retirement because you will not have the habit of spending extravagantly to feel fulfilled.
Inevitably though, we return to the question: How can you possibly afford to put away that much? If you are only making $40,000, a not-untypical starting salary for a college-educated professional in a big city, the weekly gross of $769 works down to $561 in take-home pay after income taxes and payroll taxes for Social Security and Medicaid.
Were you to divert 10 percent of your salary to a 401(k) plan, the bottom line becomes $509.
In other words, a regular habit of savings costs you $52 a week. You easily frittered that away last week on things that you cannot even recall this week. A useful exercise that proves the point: For a week, try to list everywhere you spend cash or use your credit card.
Could you save another 10 percent a week, or $50? If you do, you are nearly set for life.
Can you live on $1,950 a month? Rents being what they are in certain cities like New York, San Francisco or Washington, sure, it will be tight. People do it by finding a roommate and watching their expenses (or asking for an occasional handout from Mom and Dad).
There may be another compelling reason to save and that is that while many aspects of retirement savings are predictable, the big unknowable is health care costs. “If you believe in the logic of the life cycle model, then once you get used to peanut butter, all else follows,” said Jonathan Skinner, a economics professor at Dartmouth College who has studied retirement issues and recently wrote a paper titled “Are You Sure You’re Saving Enough for Retirement?” for the National Bureau of Economic Research. “That’s the assumption that I am questioning: Do people want to be stuck in peanut butter in retirement?”
He said he came to the conclusion that a strategy to reduce retirement expenses “will be dwarfed by rapidly growing out-of-pocket medical expenses.” He noted projections based on the Health and Retirement Study, a survey of 22,000 Americans over the age of 50 sponsored by the National Institute on Aging found that by 2019, nearly a tenth of elderly retirees would be devoting more than half of their total income to out-of-pocket health expenses. He said, “These health care cost projections are perhaps the scariest beast under the bed.”
As Victor Fuchs, the professor emeritus of economics and health research and policy at Stanford University, told me, money is most useful when you are old because it makes all the difference whether you wait for a bus in the rain to get to the doctor’s appointment or you ride in a cab.
“Saving for retirement may ultimately be less about the golf condo at Hilton Head and more about being able to afford wheelchair lifts, private nurses and a high-quality nursing home,” Professor Skinner said.
His best advice for people in their 20s and 30s: maximize workplace matching contributions, seek automatic savings mechanisms like home mortgages and hope “that their generation can still look forward to solvent Social Security and Medicare programs.”
•
Over the last two years I’ve been dispensing advice in this space about how to spend and save more wisely. This will be my last column for a spell as I am taking on editing duties that give me little time for reporting. But before I go, I want to remind the young graduates, their parents who scrimped and saved to get them there, and anyone else who stuck with me this far that are a few other rules of life worth considering.
Among them are the following. Links are available at nytimes.com/business:
Never pay a real estate agent a 6 percent commission.
Buy used things, except maybe used tires.
Get on the do-not-call list and other do-not-solicit lists so you can’t be tempted.
Watch infomercials for their entertainment value only.
Know what your credit reports say, but don’t pay for that knowledge: go to www.annualcreditreport.com to get them.
Consolidate your cable, phone and Internet service to get the best deal.
Resist the lunacy of buying premium products like $2,000-a-pound chocolates.
Lose weight. Carrying extra pounds costs tens of thousands of dollars over a lifetime.
Do not use your home as a piggy bank if home prices are flat or going down or if interest rates are rising.
Enroll in a 401(k) at work immediately.
Postpone buying high-tech products like PCs, digital cameras and high-definition TVs for as long as possible. And then buy after the selling season or buy older technology just as a new technology comes along.
And, I’m sorry, I’m really serious about this last one: make your own coffee.
June 2, 2007
Your Money
More Advice Graduates Don’t Want to Hear
By DAMON DARLIN
Last year at this time, as college graduates walked out into the world, I wrote a column giving advice on how they could save money.
In droves, parents sent the column to their children. And some of those children wrote to me to vent. What I suggested was impractical, many said. How would you like to try to live on $40,000 a year in Washington or San Francisco, several asked.
What I was proposing was not radical. It was mostly the simple things my mother had drummed into me. It was advice like diverting 10 percent of your income to savings before anything else and ignoring raises and putting them into savings, too. Learn to cook, I said, and never borrow money to pay for a depreciating asset.
I also suggested cutting out the latte habit, which was my symbol for those little things in life that when turned into a habit, add up to money that could have been spent on something worthwhile and memorable.
Other people, my wife among them, pointed out that I may have been too draconian on that point. Consistent savings is a lot easier if there are small rewards along the way; otherwise, life seems as if it is just one bowl of cold grass porridge after another.
Fine feedback, indeed, and my wife’s counsel reminds me that I should have added one other bit of advice: find a partner and stay together. Study after study show that two can live more cheaply together than each alone and that divorce is the great destroyer of wealth.
But, dear graduates, the crux of the advice is still compelling. While there may be a debate among economists about how much 50- and 60-year-olds should be saving for retirement, there is little dispute about how much the young should save: more.
Saving while young is critical. It isn’t just because of the power of compounding. By that I mean that if you start saving now it will build to a larger nest egg by the time you are 65 than if you wait to start at 45. Or to put it another way, you can save a smaller amount now rather than a larger amount later.
Bank $250 a month for 40 years in a I.R.A. or a 401(k) and you will receive about $500,000, assuming a 6 percent return. Start at age 45 and you would have to put in $1,078 a month to generate the same amount by age 65.
But there is another compelling reason to get into the habit of saving. (Here is where this column also turns into advice for the older folks who are giving you this to read.) People who save a lot get used to a lower rate of consumption while working, so less money is needed in retirement.
Stretching to save a little more yields a double dividend. You accumulate more assets and you lower the amount you will need in retirement because you will not have the habit of spending extravagantly to feel fulfilled.
Inevitably though, we return to the question: How can you possibly afford to put away that much? If you are only making $40,000, a not-untypical starting salary for a college-educated professional in a big city, the weekly gross of $769 works down to $561 in take-home pay after income taxes and payroll taxes for Social Security and Medicaid.
Were you to divert 10 percent of your salary to a 401(k) plan, the bottom line becomes $509.
In other words, a regular habit of savings costs you $52 a week. You easily frittered that away last week on things that you cannot even recall this week. A useful exercise that proves the point: For a week, try to list everywhere you spend cash or use your credit card.
Could you save another 10 percent a week, or $50? If you do, you are nearly set for life.
Can you live on $1,950 a month? Rents being what they are in certain cities like New York, San Francisco or Washington, sure, it will be tight. People do it by finding a roommate and watching their expenses (or asking for an occasional handout from Mom and Dad).
There may be another compelling reason to save and that is that while many aspects of retirement savings are predictable, the big unknowable is health care costs. “If you believe in the logic of the life cycle model, then once you get used to peanut butter, all else follows,” said Jonathan Skinner, a economics professor at Dartmouth College who has studied retirement issues and recently wrote a paper titled “Are You Sure You’re Saving Enough for Retirement?” for the National Bureau of Economic Research. “That’s the assumption that I am questioning: Do people want to be stuck in peanut butter in retirement?”
He said he came to the conclusion that a strategy to reduce retirement expenses “will be dwarfed by rapidly growing out-of-pocket medical expenses.” He noted projections based on the Health and Retirement Study, a survey of 22,000 Americans over the age of 50 sponsored by the National Institute on Aging found that by 2019, nearly a tenth of elderly retirees would be devoting more than half of their total income to out-of-pocket health expenses. He said, “These health care cost projections are perhaps the scariest beast under the bed.”
As Victor Fuchs, the professor emeritus of economics and health research and policy at Stanford University, told me, money is most useful when you are old because it makes all the difference whether you wait for a bus in the rain to get to the doctor’s appointment or you ride in a cab.
“Saving for retirement may ultimately be less about the golf condo at Hilton Head and more about being able to afford wheelchair lifts, private nurses and a high-quality nursing home,” Professor Skinner said.
His best advice for people in their 20s and 30s: maximize workplace matching contributions, seek automatic savings mechanisms like home mortgages and hope “that their generation can still look forward to solvent Social Security and Medicare programs.”
•
Over the last two years I’ve been dispensing advice in this space about how to spend and save more wisely. This will be my last column for a spell as I am taking on editing duties that give me little time for reporting. But before I go, I want to remind the young graduates, their parents who scrimped and saved to get them there, and anyone else who stuck with me this far that are a few other rules of life worth considering.
Among them are the following. Links are available at nytimes.com/business:
Never pay a real estate agent a 6 percent commission.
Buy used things, except maybe used tires.
Get on the do-not-call list and other do-not-solicit lists so you can’t be tempted.
Watch infomercials for their entertainment value only.
Know what your credit reports say, but don’t pay for that knowledge: go to www.annualcreditreport.com to get them.
Consolidate your cable, phone and Internet service to get the best deal.
Resist the lunacy of buying premium products like $2,000-a-pound chocolates.
Lose weight. Carrying extra pounds costs tens of thousands of dollars over a lifetime.
Do not use your home as a piggy bank if home prices are flat or going down or if interest rates are rising.
Enroll in a 401(k) at work immediately.
Postpone buying high-tech products like PCs, digital cameras and high-definition TVs for as long as possible. And then buy after the selling season or buy older technology just as a new technology comes along.
And, I’m sorry, I’m really serious about this last one: make your own coffee.
Wednesday, May 23, 2007
Hamburger hints
NYTimes
May 23, 2007
The Minimalist
For the Love of a Good Burger
By MARK BITTMAN
I’M sure you know how to make a burger. But do you make a burger you love, one that people notice, one that draws raves?
In a world where “burger” most often means a thin piece of meat whose flavor is overwhelmed by ketchup, mustard, pickle or onion, it doesn’t take much effort to make a better one. In fact, it’s almost as easy to cook a really great burger as it is to cook a mediocre one.
When I was young, my mother and her friends produced good burgers. They used different butchers (some were kosher), had different preferences (chuck, round or sirloin), and cooked either in a pan or the broiler (there was no grilling, except when we visited some relatives on Long Island).
A favorite recipe in the neighborhood called for garlic powder, an exotic ingredient in 1958; chopped onion; and — gasp! — Worcestershire sauce. This avant-garde recipe was treasured and shared sparingly.
What the burgers of my childhood all had in common was high-quality meat, and this is exactly what is missing from most of the backyard barbecues I visit. I see people buying everything from packaged ground meat to frozen patties. With these ingredients, the best they can hope for is to mimic fast food.
The key is to avoid packaged ground meat. When you buy it, you may know the cut of the meat — chuck, for example — and the fat content.
But you have no way of knowing whether the meat came from high- or low-quality animals. It could come from dozens of animals, and they could all be poor-quality animals — old dairy cows, for instance, rather than cattle raised for beef. The meat from these animals is ground together in huge quantities.
If the aesthetics of that don’t give you pause, consider the health concerns. Massive batches of ground meat carry the highest risk of salmonella and E. coli contamination, and have caused many authorities to recommend cooking burgers to the well-done stage. Forgive my snobbishness, but well-done meat is dry and flavorless, which is why burgers should be rare, or at most medium rare.
The only sensible solution: Grind your own. You will know the cut, you can see the fat and you have some notion of its quality.
“Grinding” may sound ominous, conjuring visions of a big old hand-cranked piece of steel clamped to the kitchen counter, but in fact it’s not that difficult. As the grinder was an innovation in its day, the food processor has taken over. It does nearly as good a job — not perfect, I’ll admit — in a couple of minutes or less.
Take a nice-looking chuck roast, or well-marbled sirloin steaks or some pork or lamb shoulder. Cut the meat into one- to two-inch cubes, and pulse it with the regular steel blade until it’s chopped.
If you have a 12-cup food processor, you can do a pound or a little more at a time; with a smaller machine, you’ll need to work in batches. You can do a few pounds at a time and freeze what you won’t use immediately, or you can grind the meat as you need it.
There are a few rules here. One, buy relatively fatty meat. If you start with meat that’s 95 percent lean — that’s hardly any fat at all — you are going to get the filet mignon of burgers: tender, but not especially tasty. If you use chuck or sirloin, with 15 to 20 percent fat — still quite lean by fast-food standards, by the way — you’re going to get meat that is really flavorful, along with the good mouth-feel that a bit of fat brings.
The same holds true with pork and lamb, though the selections are in fact easier, because the shoulder cuts of both animals contain enough internal fat that they’ll remain moist unless you overcook them horribly.
Next, don’t overprocess. You want the equivalent of chopped meat, not a meat purée. The finer you grind the meat, the more likely you are to pack it together too tightly, which will make the burger tough.
The patties should weigh about 6 ounces each: not small, but not huge, either. Handle the meat gently. Make the patties with a light hand, and don’t press on them with a spatula, like a hurried short-order cook.
Finally, season with salt and pepper aggressively. I’d start with a large pinch of salt and a bit of pepper and work up from there. If you grind your own beef, you can make a mixture and taste it raw.
(To reassure the queasy, there’s little difference, safety-wise, between raw beef and rare beef: salmonella is killed at 160 degrees, and rare beef is cooked to 125 degrees.)
If you are cautious, you can cook a little meat and then taste it. Though there are virtually no reported cases of trichinosis from commercial pork in the United States, few people will sample raw pork — or lamb, with which the danger is even less. So the thing to do is season the meat, then cook up a spoonful in a skillet, taste and season as necessary.
A final word about seasoning: Remember that the burger is the cousin not only of the steak — which often takes no seasoning beyond salt and pepper — but also of the meatloaf and the meatball, both of which are highly seasoned. Think about adding minced garlic in small quantities (we’ve moved beyond garlic powder, no?), chopped onion, herbs (especially parsley), grated Parmesan, minced ginger, the old reliable Worcestershire, hot sauce, good chili powder and so on. It’s hard to go wrong here.
Then there’s the grilling: Burgers cook so fast that the heat source doesn’t matter much. You want a hot fire, but not a blazing hot one; that fat, as we all know, is quick to ignite. The rack, which should be very clean, should be three or four inches above it.
Turn the burger only after the first side releases its grip on the grill, after a few minutes; if you don’t press with the spatula, you’ll get less sticking, too. Cooking time depends on the size of the burger, of course, but mine take about 6 to 8 minutes total, for rare to medium-rare. Pork takes a little longer, but not much.
The grilling is the easy part. The more important steps are shopping and grinding. The difference they make, you will find, is astonishing, and will change your burger-cooking forever.
May 23, 2007
The Minimalist
For the Love of a Good Burger
By MARK BITTMAN
I’M sure you know how to make a burger. But do you make a burger you love, one that people notice, one that draws raves?
In a world where “burger” most often means a thin piece of meat whose flavor is overwhelmed by ketchup, mustard, pickle or onion, it doesn’t take much effort to make a better one. In fact, it’s almost as easy to cook a really great burger as it is to cook a mediocre one.
When I was young, my mother and her friends produced good burgers. They used different butchers (some were kosher), had different preferences (chuck, round or sirloin), and cooked either in a pan or the broiler (there was no grilling, except when we visited some relatives on Long Island).
A favorite recipe in the neighborhood called for garlic powder, an exotic ingredient in 1958; chopped onion; and — gasp! — Worcestershire sauce. This avant-garde recipe was treasured and shared sparingly.
What the burgers of my childhood all had in common was high-quality meat, and this is exactly what is missing from most of the backyard barbecues I visit. I see people buying everything from packaged ground meat to frozen patties. With these ingredients, the best they can hope for is to mimic fast food.
The key is to avoid packaged ground meat. When you buy it, you may know the cut of the meat — chuck, for example — and the fat content.
But you have no way of knowing whether the meat came from high- or low-quality animals. It could come from dozens of animals, and they could all be poor-quality animals — old dairy cows, for instance, rather than cattle raised for beef. The meat from these animals is ground together in huge quantities.
If the aesthetics of that don’t give you pause, consider the health concerns. Massive batches of ground meat carry the highest risk of salmonella and E. coli contamination, and have caused many authorities to recommend cooking burgers to the well-done stage. Forgive my snobbishness, but well-done meat is dry and flavorless, which is why burgers should be rare, or at most medium rare.
The only sensible solution: Grind your own. You will know the cut, you can see the fat and you have some notion of its quality.
“Grinding” may sound ominous, conjuring visions of a big old hand-cranked piece of steel clamped to the kitchen counter, but in fact it’s not that difficult. As the grinder was an innovation in its day, the food processor has taken over. It does nearly as good a job — not perfect, I’ll admit — in a couple of minutes or less.
Take a nice-looking chuck roast, or well-marbled sirloin steaks or some pork or lamb shoulder. Cut the meat into one- to two-inch cubes, and pulse it with the regular steel blade until it’s chopped.
If you have a 12-cup food processor, you can do a pound or a little more at a time; with a smaller machine, you’ll need to work in batches. You can do a few pounds at a time and freeze what you won’t use immediately, or you can grind the meat as you need it.
There are a few rules here. One, buy relatively fatty meat. If you start with meat that’s 95 percent lean — that’s hardly any fat at all — you are going to get the filet mignon of burgers: tender, but not especially tasty. If you use chuck or sirloin, with 15 to 20 percent fat — still quite lean by fast-food standards, by the way — you’re going to get meat that is really flavorful, along with the good mouth-feel that a bit of fat brings.
The same holds true with pork and lamb, though the selections are in fact easier, because the shoulder cuts of both animals contain enough internal fat that they’ll remain moist unless you overcook them horribly.
Next, don’t overprocess. You want the equivalent of chopped meat, not a meat purée. The finer you grind the meat, the more likely you are to pack it together too tightly, which will make the burger tough.
The patties should weigh about 6 ounces each: not small, but not huge, either. Handle the meat gently. Make the patties with a light hand, and don’t press on them with a spatula, like a hurried short-order cook.
Finally, season with salt and pepper aggressively. I’d start with a large pinch of salt and a bit of pepper and work up from there. If you grind your own beef, you can make a mixture and taste it raw.
(To reassure the queasy, there’s little difference, safety-wise, between raw beef and rare beef: salmonella is killed at 160 degrees, and rare beef is cooked to 125 degrees.)
If you are cautious, you can cook a little meat and then taste it. Though there are virtually no reported cases of trichinosis from commercial pork in the United States, few people will sample raw pork — or lamb, with which the danger is even less. So the thing to do is season the meat, then cook up a spoonful in a skillet, taste and season as necessary.
A final word about seasoning: Remember that the burger is the cousin not only of the steak — which often takes no seasoning beyond salt and pepper — but also of the meatloaf and the meatball, both of which are highly seasoned. Think about adding minced garlic in small quantities (we’ve moved beyond garlic powder, no?), chopped onion, herbs (especially parsley), grated Parmesan, minced ginger, the old reliable Worcestershire, hot sauce, good chili powder and so on. It’s hard to go wrong here.
Then there’s the grilling: Burgers cook so fast that the heat source doesn’t matter much. You want a hot fire, but not a blazing hot one; that fat, as we all know, is quick to ignite. The rack, which should be very clean, should be three or four inches above it.
Turn the burger only after the first side releases its grip on the grill, after a few minutes; if you don’t press with the spatula, you’ll get less sticking, too. Cooking time depends on the size of the burger, of course, but mine take about 6 to 8 minutes total, for rare to medium-rare. Pork takes a little longer, but not much.
The grilling is the easy part. The more important steps are shopping and grinding. The difference they make, you will find, is astonishing, and will change your burger-cooking forever.
Tuesday, May 22, 2007
Personality and narration about self
NYTimes
May 22, 2007
This Is Your Life (and How You Tell It)
By BENEDICT CAREY
For more than a century, researchers have been trying to work out the raw ingredients that account for personality, the sweetness and neuroses that make Anna Anna, the sluggishness and sensitivity that make Andrew Andrew. They have largely ignored the first-person explanation — the life story that people themselves tell about who they are, and why.
Stories are stories, after all. The attractive stranger at the airport bar hears one version, the parole officer another, and the P.T.A. board gets something entirely different. Moreover, the tone, the lessons, even the facts in a life story can all shift in the changing light of a person’s mood, its major notes turning minor, its depths appearing shallow.
Yet in the past decade or so a handful of psychologists have argued that the quicksilver elements of personal narrative belong in any three-dimensional picture of personality. And a burst of new findings are now helping them make the case. Generous, civic-minded adults from diverse backgrounds tell life stories with very similar and telling features, studies find; so likewise do people who have overcome mental distress through psychotherapy.
Every American may be working on a screenplay, but we are also continually updating a treatment of our own life — and the way in which we visualize each scene not only shapes how we think about ourselves, but how we behave, new studies find. By better understanding how life stories are built, this work suggests, people may be able to alter their own narrative, in small ways and perhaps large ones.
“When we first started studying life stories, people thought it was just idle curiosity — stories, isn’t that cool?” said Dan P. McAdams, a professor of psychology at Northwestern and author of the 2006 book, “The Redemptive Self.” “Well, we find that these narratives guide behavior in every moment, and frame not only how we see the past but how we see ourselves in the future.”
Researchers have found that the human brain has a natural affinity for narrative construction. People tend to remember facts more accurately if they encounter them in a story rather than in a list, studies find; and they rate legal arguments as more convincing when built into narrative tales rather than on legal precedent.
YouTube routines notwithstanding, most people do not begin to see themselves in the midst of a tale with a beginning, middle and eventual end until they are teenagers. “Younger kids see themselves in terms of broad, stable traits: ‘I like baseball but not soccer,’ ” said Kate McLean, a psychologist at the University of Toronto in Mississauga. “This meaning-making capability — to talk about growth, to explain what something says about who I am — develops across adolescence.”
Psychologists know what life stories look like when they are fully hatched, at least for some Americans. Over the years, Dr. McAdams and others have interviewed hundreds of men and women, most in their 30s and older.
During a standard life-story interview, people describe phases of their lives as if they were outlining chapters, from the sandlot years through adolescence and middle age. They also describe several crucial scenes in detail, including high points (the graduation speech, complete with verbal drum roll); low points (the college nervous breakdown, complete with the list of witnesses); and turning points. The entire two-hour session is recorded and transcribed.
In analyzing the texts, the researchers found strong correlations between the content of people’s current lives and the stories they tell. Those with mood problems have many good memories, but these scenes are usually tainted by some dark detail. The pride of college graduation is spoiled when a friend makes a cutting remark. The wedding party was wonderful until the best man collapsed from drink. A note of disappointment seems to close each narrative phrase.
By contrast, so-called generative adults — those who score highly on tests measuring civic-mindedness, and who are likely to be energetic and involved — tend to see many of the events in their life in the reverse order, as linked by themes of redemption. They flunked sixth grade but met a wonderful counselor and made honor roll in seventh. They were laid low by divorce, only to meet a wonderful new partner. Often, too, they say they felt singled out from very early in life — protected, even as others nearby suffered.
In broad outline, the researchers report, such tales express distinctly American cultural narratives, of emancipation or atonement, of Horatio Alger advancement, of epiphany and second chances. Depending on the person, the story itself might be nuanced or simplistic, powerfully dramatic or cloyingly pious. But the point is that the narrative themes are, as much as any other trait, driving factors in people’s behavior, the researchers say.
“We find that when it comes to the big choices people make — should I marry this person? should I take this job? should I move across the country? — they draw on these stories implicitly, whether they know they are working from them or not,” Dr. McAdams said.
Any life story is by definition a retrospective reconstruction, at least in part an outgrowth of native temperament. Yet the research so far suggests that people’s life stories are neither rigid nor wildly variable, but rather change gradually over time, in close tandem with meaningful life events.
Jonathan Adler, a researcher at Northwestern, has found that people’s accounts of their experiences in psychotherapy provide clues about the nature of their recovery. In a recent study presented at the annual meeting of the Society for Personality and Social Psychology in January, Mr. Adler reported on 180 adults from the Chicago area who had recently completed a course of talk therapy. They sought treatment for things like depression, anxiety, marital problems and fear of flying, and spent months to years in therapy.
At some level, talk therapy has always been an exercise in replaying and reinterpreting each person’s unique life story. Yet Mr. Adler found that in fact those former patients who scored highest on measures of well-being — who had recovered, by standard measures — told very similar tales about their experiences.
They described their problem, whether depression or an eating disorder, as coming on suddenly, as if out of nowhere. They characterized their difficulty as if it were an outside enemy, often giving it a name (the black dog, the walk of shame). And eventually they conquered it.
“The story is one of victorious battle: ‘I ended therapy because I could overcome this on my own,’ ” Mr. Adler said. Those in the study who scored lower on measures of psychological well-being were more likely to see their moods and behavior problems as a part of their own character, rather than as a villain to be defeated. To them, therapy was part of a continuing adaptation, not a decisive battle.
The findings suggest that psychotherapy, when it is effective, gives people who are feeling helpless a sense of their own power, in effect altering their life story even as they work to disarm their own demons, Mr. Adler said.
Mental resilience relies in part on exactly this kind of autobiographical storytelling, moment to moment, when navigating life’s stings and sorrows. To better understand how stories are built in real time, researchers have recently studied how people recall vivid scenes from recent memory. They find that one important factor is the perspective people take when they revisit the scene — whether in the first person, or in the third person, as if they were watching themselves in a movie.
In a 2005 study reported in the journal Psychological Science, researchers at Columbia University measured how student participants reacted to a bad memory, whether an argument or failed exam, when it was recalled in the third person. They tested levels of conscious and unconscious hostility after the recollections, using both standard questionnaires and students’ essays. The investigators found that the third-person scenes were significantly less upsetting, compared with bad memories recalled in the first person.
“What our experiment showed is that this shift in perspective, having this distance from yourself, allows you to relive the experience and focus on why you’re feeling upset,” instead of being immersed in it, said Ethan Kross, the study’s lead author. The emotional content of the memory is still felt, he said, but its sting is blunted as the brain frames its meaning, as it builds the story.
Taken together, these findings suggest a kind of give and take between life stories and individual memories, between the larger screenplay and the individual scenes. The way people replay and recast memories, day by day, deepens and reshapes their larger life story. And as it evolves, that larger story in turn colors the interpretation of the scenes.
Nic Weststrate, 23, a student living in Toronto, said he was able to reinterpret many of his most painful memories with more compassion after having come out as a gay man. He was very hard on himself, for instance, when at age 20 he misjudged a relationship with a friend who turned out to be straight.
He now sees the end of that relationship as both a painful lesson and part of a larger narrative. “I really had no meaningful story for my life then,” he said, “and I think if I had been open about being gay I might not have put myself in that position, and he probably wouldn’t have either.”
After coming out, he said: “I saw that there were other possibilities. I would be presenting myself openly to a gay audience, and just having a coherent story about who I am made a big difference. It affects how you see the past, but it also really affects your future.”
Psychologists have shown just how interpretations of memories can alter future behavior. In an experiment published in 2005, researchers had college students who described themselves as socially awkward in high school recall one of their most embarrassing moments. Half of the students reimagined the humiliation in the first person, and the other half pictured it in the third person.
Two clear differences emerged. Those who replayed the scene in the third person rated themselves as having changed significantly since high school — much more so than the first-person group did. The third-person perspective allowed people to reflect on the meaning of their social miscues, the authors suggest, and thus to perceive more psychological growth.
And their behavior changed, too. After completing the psychological questionnaires, each study participant spent time in a waiting room with another student, someone the research subject thought was taking part in the study. In fact the person was working for the research team, and secretly recorded the conversation between the pair, if any. This double agent had no idea which study participants had just relived a high school horror, and which had viewed theirs as a movie scene.
The recordings showed that members of the third-person group were much more sociable than the others. “They were more likely to initiate a conversation, after having perceived themselves as more changed,” said Lisa Libby, the lead author and a psychologist at Ohio State University. She added, “We think that feeling you have changed frees you up to behave as if you have; you think, ‘Wow, I’ve really made some progress’ and it gives you some real momentum.”
Dr. Libby and others have found that projecting future actions in the third person may also affect what people later do, as well. In another study, students who pictured themselves voting for president in the 2004 election, from a third-person perspective, were more likely to actually go to the polls than those imagining themselves casting votes in the first person.
The implications of these results for self-improvement, whether sticking to a diet or finishing a degree or a novel, are still unknown. Likewise, experts say, it is unclear whether such scene-making is more functional for some people, and some memories, than for others. And no one yet knows how fundamental personality factors, like neuroticism or extraversion, shape the content of life stories or their component scenes.
But the new research is giving narrative psychologists something they did not have before: a coherent story to tell. Seeing oneself as acting in a movie or a play is not merely fantasy or indulgence; it is fundamental to how people work out who it is they are, and may become.
“The idea that whoever appeared onstage would play not me but a character was central to imagining how to make the narrative: I would need to see myself from outside,” the writer Joan Didion has said of “The Year of Magical Thinking,” her autobiographical play about mourning the death of her husband and her daughter. “I would need to locate the dissonance between the person I thought I was and the person other people saw.”
May 22, 2007
This Is Your Life (and How You Tell It)
By BENEDICT CAREY
For more than a century, researchers have been trying to work out the raw ingredients that account for personality, the sweetness and neuroses that make Anna Anna, the sluggishness and sensitivity that make Andrew Andrew. They have largely ignored the first-person explanation — the life story that people themselves tell about who they are, and why.
Stories are stories, after all. The attractive stranger at the airport bar hears one version, the parole officer another, and the P.T.A. board gets something entirely different. Moreover, the tone, the lessons, even the facts in a life story can all shift in the changing light of a person’s mood, its major notes turning minor, its depths appearing shallow.
Yet in the past decade or so a handful of psychologists have argued that the quicksilver elements of personal narrative belong in any three-dimensional picture of personality. And a burst of new findings are now helping them make the case. Generous, civic-minded adults from diverse backgrounds tell life stories with very similar and telling features, studies find; so likewise do people who have overcome mental distress through psychotherapy.
Every American may be working on a screenplay, but we are also continually updating a treatment of our own life — and the way in which we visualize each scene not only shapes how we think about ourselves, but how we behave, new studies find. By better understanding how life stories are built, this work suggests, people may be able to alter their own narrative, in small ways and perhaps large ones.
“When we first started studying life stories, people thought it was just idle curiosity — stories, isn’t that cool?” said Dan P. McAdams, a professor of psychology at Northwestern and author of the 2006 book, “The Redemptive Self.” “Well, we find that these narratives guide behavior in every moment, and frame not only how we see the past but how we see ourselves in the future.”
Researchers have found that the human brain has a natural affinity for narrative construction. People tend to remember facts more accurately if they encounter them in a story rather than in a list, studies find; and they rate legal arguments as more convincing when built into narrative tales rather than on legal precedent.
YouTube routines notwithstanding, most people do not begin to see themselves in the midst of a tale with a beginning, middle and eventual end until they are teenagers. “Younger kids see themselves in terms of broad, stable traits: ‘I like baseball but not soccer,’ ” said Kate McLean, a psychologist at the University of Toronto in Mississauga. “This meaning-making capability — to talk about growth, to explain what something says about who I am — develops across adolescence.”
Psychologists know what life stories look like when they are fully hatched, at least for some Americans. Over the years, Dr. McAdams and others have interviewed hundreds of men and women, most in their 30s and older.
During a standard life-story interview, people describe phases of their lives as if they were outlining chapters, from the sandlot years through adolescence and middle age. They also describe several crucial scenes in detail, including high points (the graduation speech, complete with verbal drum roll); low points (the college nervous breakdown, complete with the list of witnesses); and turning points. The entire two-hour session is recorded and transcribed.
In analyzing the texts, the researchers found strong correlations between the content of people’s current lives and the stories they tell. Those with mood problems have many good memories, but these scenes are usually tainted by some dark detail. The pride of college graduation is spoiled when a friend makes a cutting remark. The wedding party was wonderful until the best man collapsed from drink. A note of disappointment seems to close each narrative phrase.
By contrast, so-called generative adults — those who score highly on tests measuring civic-mindedness, and who are likely to be energetic and involved — tend to see many of the events in their life in the reverse order, as linked by themes of redemption. They flunked sixth grade but met a wonderful counselor and made honor roll in seventh. They were laid low by divorce, only to meet a wonderful new partner. Often, too, they say they felt singled out from very early in life — protected, even as others nearby suffered.
In broad outline, the researchers report, such tales express distinctly American cultural narratives, of emancipation or atonement, of Horatio Alger advancement, of epiphany and second chances. Depending on the person, the story itself might be nuanced or simplistic, powerfully dramatic or cloyingly pious. But the point is that the narrative themes are, as much as any other trait, driving factors in people’s behavior, the researchers say.
“We find that when it comes to the big choices people make — should I marry this person? should I take this job? should I move across the country? — they draw on these stories implicitly, whether they know they are working from them or not,” Dr. McAdams said.
Any life story is by definition a retrospective reconstruction, at least in part an outgrowth of native temperament. Yet the research so far suggests that people’s life stories are neither rigid nor wildly variable, but rather change gradually over time, in close tandem with meaningful life events.
Jonathan Adler, a researcher at Northwestern, has found that people’s accounts of their experiences in psychotherapy provide clues about the nature of their recovery. In a recent study presented at the annual meeting of the Society for Personality and Social Psychology in January, Mr. Adler reported on 180 adults from the Chicago area who had recently completed a course of talk therapy. They sought treatment for things like depression, anxiety, marital problems and fear of flying, and spent months to years in therapy.
At some level, talk therapy has always been an exercise in replaying and reinterpreting each person’s unique life story. Yet Mr. Adler found that in fact those former patients who scored highest on measures of well-being — who had recovered, by standard measures — told very similar tales about their experiences.
They described their problem, whether depression or an eating disorder, as coming on suddenly, as if out of nowhere. They characterized their difficulty as if it were an outside enemy, often giving it a name (the black dog, the walk of shame). And eventually they conquered it.
“The story is one of victorious battle: ‘I ended therapy because I could overcome this on my own,’ ” Mr. Adler said. Those in the study who scored lower on measures of psychological well-being were more likely to see their moods and behavior problems as a part of their own character, rather than as a villain to be defeated. To them, therapy was part of a continuing adaptation, not a decisive battle.
The findings suggest that psychotherapy, when it is effective, gives people who are feeling helpless a sense of their own power, in effect altering their life story even as they work to disarm their own demons, Mr. Adler said.
Mental resilience relies in part on exactly this kind of autobiographical storytelling, moment to moment, when navigating life’s stings and sorrows. To better understand how stories are built in real time, researchers have recently studied how people recall vivid scenes from recent memory. They find that one important factor is the perspective people take when they revisit the scene — whether in the first person, or in the third person, as if they were watching themselves in a movie.
In a 2005 study reported in the journal Psychological Science, researchers at Columbia University measured how student participants reacted to a bad memory, whether an argument or failed exam, when it was recalled in the third person. They tested levels of conscious and unconscious hostility after the recollections, using both standard questionnaires and students’ essays. The investigators found that the third-person scenes were significantly less upsetting, compared with bad memories recalled in the first person.
“What our experiment showed is that this shift in perspective, having this distance from yourself, allows you to relive the experience and focus on why you’re feeling upset,” instead of being immersed in it, said Ethan Kross, the study’s lead author. The emotional content of the memory is still felt, he said, but its sting is blunted as the brain frames its meaning, as it builds the story.
Taken together, these findings suggest a kind of give and take between life stories and individual memories, between the larger screenplay and the individual scenes. The way people replay and recast memories, day by day, deepens and reshapes their larger life story. And as it evolves, that larger story in turn colors the interpretation of the scenes.
Nic Weststrate, 23, a student living in Toronto, said he was able to reinterpret many of his most painful memories with more compassion after having come out as a gay man. He was very hard on himself, for instance, when at age 20 he misjudged a relationship with a friend who turned out to be straight.
He now sees the end of that relationship as both a painful lesson and part of a larger narrative. “I really had no meaningful story for my life then,” he said, “and I think if I had been open about being gay I might not have put myself in that position, and he probably wouldn’t have either.”
After coming out, he said: “I saw that there were other possibilities. I would be presenting myself openly to a gay audience, and just having a coherent story about who I am made a big difference. It affects how you see the past, but it also really affects your future.”
Psychologists have shown just how interpretations of memories can alter future behavior. In an experiment published in 2005, researchers had college students who described themselves as socially awkward in high school recall one of their most embarrassing moments. Half of the students reimagined the humiliation in the first person, and the other half pictured it in the third person.
Two clear differences emerged. Those who replayed the scene in the third person rated themselves as having changed significantly since high school — much more so than the first-person group did. The third-person perspective allowed people to reflect on the meaning of their social miscues, the authors suggest, and thus to perceive more psychological growth.
And their behavior changed, too. After completing the psychological questionnaires, each study participant spent time in a waiting room with another student, someone the research subject thought was taking part in the study. In fact the person was working for the research team, and secretly recorded the conversation between the pair, if any. This double agent had no idea which study participants had just relived a high school horror, and which had viewed theirs as a movie scene.
The recordings showed that members of the third-person group were much more sociable than the others. “They were more likely to initiate a conversation, after having perceived themselves as more changed,” said Lisa Libby, the lead author and a psychologist at Ohio State University. She added, “We think that feeling you have changed frees you up to behave as if you have; you think, ‘Wow, I’ve really made some progress’ and it gives you some real momentum.”
Dr. Libby and others have found that projecting future actions in the third person may also affect what people later do, as well. In another study, students who pictured themselves voting for president in the 2004 election, from a third-person perspective, were more likely to actually go to the polls than those imagining themselves casting votes in the first person.
The implications of these results for self-improvement, whether sticking to a diet or finishing a degree or a novel, are still unknown. Likewise, experts say, it is unclear whether such scene-making is more functional for some people, and some memories, than for others. And no one yet knows how fundamental personality factors, like neuroticism or extraversion, shape the content of life stories or their component scenes.
But the new research is giving narrative psychologists something they did not have before: a coherent story to tell. Seeing oneself as acting in a movie or a play is not merely fantasy or indulgence; it is fundamental to how people work out who it is they are, and may become.
“The idea that whoever appeared onstage would play not me but a character was central to imagining how to make the narrative: I would need to see myself from outside,” the writer Joan Didion has said of “The Year of Magical Thinking,” her autobiographical play about mourning the death of her husband and her daughter. “I would need to locate the dissonance between the person I thought I was and the person other people saw.”
Complete cancer care
NYTimes
May 22, 2007
Cancer Care Seeks to Take Patients Beyond Survival
By LESLIE BERGER
As a growing number of Americans are learning, surviving cancer can mean slipping into a rabbit hole of long-term medical problems — from premature menopause and sexual dysfunction to more debilitating side effects of chemotherapy and radiation, like heart disease and even new cancers.
The realization that cancer and its aftermath can go on for years has given rise to a medical specialty known as survivorship. At several major hospitals around the country, survivor programs financed by the Lance Armstrong Foundation are focusing on life after cancer.
“It’s no longer sufficient to say, ‘Well, you survived,’ ” said Mary S. McCabe, who directs the program at Memorial Sloan-Kettering Cancer Center in New York. “We need to maximize their recovery and quality of life.”
Cancer treatment and research are expanding to incorporate long-term postcancer care. With the number of survivors up to 10 million in the United States, from 3 million in the 1970s, cancer is increasingly being treated as a chronic disease, like diabetes or multiple sclerosis. As the presidential candidate John Edwards said in March after his wife, Elizabeth, learned that her breast cancer had returned and spread, the disease was “no longer curable” but “completely treatable.”
At U.C.L.A. Medical Center in Los Angeles, Dr. Patricia A. Ganz is helping patients like Tanya Saunders close gaps in their medical care. Staying healthy has become a full-time job for Ms. Saunders, who has endured one complication after another in the 15 years since she received her diagnosis of Hodgkin’s disease as a college student.
Radiation and chemotherapy thrust her into menopause. After a recurrence and a second round of treatments, she developed congestive heart failure. Last year, the bone tissue in one of her hips collapsed, forcing her to undergo a hip transplant.
Now 36, Ms. Saunders takes 11 medicines a day. She exercises three days a week with other cardiac patients, sees a much-loved psychotherapist (who is treating her free of charge) once a week and takes pottery and sailing classes. She lives on disability payments and qualifies for Medicare.
“It’s a kind of a renewal of spirit I would say I’m looking for while I try to get my strength back,” Ms. Saunders said.
Another patient of Dr. Ganz’s, Karen Huner, credits her with diagnosing and treating the hypothyroidism that was causing exhaustion and headaches months after she was cured of breast cancer. Other doctors had told her that the symptoms were effects of chemotherapy and that she should “just get used to it,” said Ms. Huner, a 44-year-old yoga and pilates instructor. In fact, she added, it was the radiation she received that probably disrupted her thyroid function.
She recently developed lymphodema, the painful swelling and water retention that can happen in the arm where lymph nodes were removed.
“My lymphodema doctor said to me, ‘Be happy you’re alive,’ ” Ms. Huner said. “I almost strangled her.”
The potential side effects of radiation and chemotherapy have been known for years, especially among survivors of childhood cancers. But the big push for awareness and support followed a strongly worded report in 2005 from the Institute of Medicine, part of the National Academy of Sciences.
“The transition from active treatment to post-treatment care is critical to long-term health,” it concluded. “If care is not planned and coordinated, cancer survivors are left without knowledge of their heightened risks and a follow-up plan of action.” Insurers, it added, “should recognize survivorship care as an essential part of cancer care.”
Another problem is that survivors may shy away from doctors, and not just because of the cost. Dr. Anna T. Meadows, a pediatric oncologist who directs the survivors’ program at the Children’s Hospital of Philadelphia, said people who got their diagnoses as children or teenagers were often wary of care that would force them to revisit a painful part of their past. These survivors do not necessarily need a cancer specialist for routine checkups and screening, she said, but rather someone who understands their previous treatment and its risks.
“A lot of cancer survivors have nothing wrong with them,” Dr. Meadows said. “But what is important is for anybody who’s had cancer is to know what treatment they received and what it’s likely to lead to in the future.” The program is adding two primary care doctors to encourage follow-up visits.
In the largest study so far of survivors of childhood or adolescent cancer, published last October in The New England Journal of Medicine, researchers documented a high rate of illness because of chronic conditions caused by life-saving treatments. The study tracked the health of nearly 10,400 adults now in their 20s, 30s and 40s who were treated for cancer between 1970 and 1986.
More than 62 percent of those survivors had at least one chronic condition; nearly 28 percent had a severe or life-threatening one. The survivors were more than three times as likely as their siblings to have a chronic health condition, and women were at greater risk than men. Survivors of bone tumors, central nervous system tumors and Hodgkin’s disease had the highest risk of a serious chronic condition.
The good news is that almost 80 percent of children and teenagers who get diagnoses of cancer today become long-term survivors. Moreover, treatments have changed to minimize the risks; the lowest effective doses of drugs and radiation are used.
“The silver lining of this is that we know what to expect a reasonable amount of the time,” said Dr. Kevin C. Oeffinger of Sloan-Kettering, a lead author of the report. While young cancer patients are more vulnerable to damage because their organs are still growing, Dr. Oeffinger said, the study has obvious implications for adults.
Age and type of treatment play a huge role in the experience of cancer survivors, several experts said. Many experience no side effects at all. Others, especially women of child-bearing age, face infertility and early menopause.
“Our research shows that younger patients have a harder time, both physically and emotionally,” said Dr. Ganz, of U.C.L.A. “It’s not something they’ve expected.”
At Sloan-Kettering, five social workers are assigned to concentrate exclusively on follow-up care for survivors. Part of the plan, at Sloan and other cancer centers, is to develop an online database of patient-care summaries — of the cancer treatment received, the potential risks and recommended follow-up care — that could be used by any physician.
The hospital also plans to open an off-campus outpatient center devoted to cancer survivors’ physical rehabilitation, in part with a donation from the media entrepreneur Robert F. X. Sillerman, who was treated at Sloan-Kettering six years ago for tongue cancer. He received chemotherapy and radiation and later began to suffer pain and muscle spasms in his shoulders and back, as well as increasing weakness in his left arm.
Today, Mr. Sillerman said, he has reversed the damage with a little bit of medication and a lot of physical therapy. He exercises six days a week with weights, bands and manual resistance, partly with a personal physical therapist whom he puts up in a Manhattan townhouse adjoining his family’s. He said he appreciated the fact that few have the same luxury.
“I was two years out from my cure before I was able to find the right protocol and treatment,” said Mr. Sillerman, 59. “Our hope is to eliminate that and provide access to rehabilitation right away, initially in the New York metropolitan area and eventually to make that a template nationally.”
For premature menopause in patients who can safely use estrogen, Dr. Mercedes Castiel likes to give teenagers and young women birth control pills to control hot flashes and bone loss. “It’s nicer to say I’m on the pill like my peers instead of hormones like my grandmother,” said Dr. Castiel, director of the Barbara White Fishman Women’s Health Center at Sloan.
Even sexual dysfunction, which for years was viewed as a small price to pay for survival, is now treated like any other side effect. Vaginal dryness and missed or blunted orgasms are among the most common complaints.
“We look at it in terms of enhancing intimacy,” said Dr. Michael L. Krychman, Sloan’s expert on the subject. “They want things to get back to normal.”
May 22, 2007
Cancer Care Seeks to Take Patients Beyond Survival
By LESLIE BERGER
As a growing number of Americans are learning, surviving cancer can mean slipping into a rabbit hole of long-term medical problems — from premature menopause and sexual dysfunction to more debilitating side effects of chemotherapy and radiation, like heart disease and even new cancers.
The realization that cancer and its aftermath can go on for years has given rise to a medical specialty known as survivorship. At several major hospitals around the country, survivor programs financed by the Lance Armstrong Foundation are focusing on life after cancer.
“It’s no longer sufficient to say, ‘Well, you survived,’ ” said Mary S. McCabe, who directs the program at Memorial Sloan-Kettering Cancer Center in New York. “We need to maximize their recovery and quality of life.”
Cancer treatment and research are expanding to incorporate long-term postcancer care. With the number of survivors up to 10 million in the United States, from 3 million in the 1970s, cancer is increasingly being treated as a chronic disease, like diabetes or multiple sclerosis. As the presidential candidate John Edwards said in March after his wife, Elizabeth, learned that her breast cancer had returned and spread, the disease was “no longer curable” but “completely treatable.”
At U.C.L.A. Medical Center in Los Angeles, Dr. Patricia A. Ganz is helping patients like Tanya Saunders close gaps in their medical care. Staying healthy has become a full-time job for Ms. Saunders, who has endured one complication after another in the 15 years since she received her diagnosis of Hodgkin’s disease as a college student.
Radiation and chemotherapy thrust her into menopause. After a recurrence and a second round of treatments, she developed congestive heart failure. Last year, the bone tissue in one of her hips collapsed, forcing her to undergo a hip transplant.
Now 36, Ms. Saunders takes 11 medicines a day. She exercises three days a week with other cardiac patients, sees a much-loved psychotherapist (who is treating her free of charge) once a week and takes pottery and sailing classes. She lives on disability payments and qualifies for Medicare.
“It’s a kind of a renewal of spirit I would say I’m looking for while I try to get my strength back,” Ms. Saunders said.
Another patient of Dr. Ganz’s, Karen Huner, credits her with diagnosing and treating the hypothyroidism that was causing exhaustion and headaches months after she was cured of breast cancer. Other doctors had told her that the symptoms were effects of chemotherapy and that she should “just get used to it,” said Ms. Huner, a 44-year-old yoga and pilates instructor. In fact, she added, it was the radiation she received that probably disrupted her thyroid function.
She recently developed lymphodema, the painful swelling and water retention that can happen in the arm where lymph nodes were removed.
“My lymphodema doctor said to me, ‘Be happy you’re alive,’ ” Ms. Huner said. “I almost strangled her.”
The potential side effects of radiation and chemotherapy have been known for years, especially among survivors of childhood cancers. But the big push for awareness and support followed a strongly worded report in 2005 from the Institute of Medicine, part of the National Academy of Sciences.
“The transition from active treatment to post-treatment care is critical to long-term health,” it concluded. “If care is not planned and coordinated, cancer survivors are left without knowledge of their heightened risks and a follow-up plan of action.” Insurers, it added, “should recognize survivorship care as an essential part of cancer care.”
Another problem is that survivors may shy away from doctors, and not just because of the cost. Dr. Anna T. Meadows, a pediatric oncologist who directs the survivors’ program at the Children’s Hospital of Philadelphia, said people who got their diagnoses as children or teenagers were often wary of care that would force them to revisit a painful part of their past. These survivors do not necessarily need a cancer specialist for routine checkups and screening, she said, but rather someone who understands their previous treatment and its risks.
“A lot of cancer survivors have nothing wrong with them,” Dr. Meadows said. “But what is important is for anybody who’s had cancer is to know what treatment they received and what it’s likely to lead to in the future.” The program is adding two primary care doctors to encourage follow-up visits.
In the largest study so far of survivors of childhood or adolescent cancer, published last October in The New England Journal of Medicine, researchers documented a high rate of illness because of chronic conditions caused by life-saving treatments. The study tracked the health of nearly 10,400 adults now in their 20s, 30s and 40s who were treated for cancer between 1970 and 1986.
More than 62 percent of those survivors had at least one chronic condition; nearly 28 percent had a severe or life-threatening one. The survivors were more than three times as likely as their siblings to have a chronic health condition, and women were at greater risk than men. Survivors of bone tumors, central nervous system tumors and Hodgkin’s disease had the highest risk of a serious chronic condition.
The good news is that almost 80 percent of children and teenagers who get diagnoses of cancer today become long-term survivors. Moreover, treatments have changed to minimize the risks; the lowest effective doses of drugs and radiation are used.
“The silver lining of this is that we know what to expect a reasonable amount of the time,” said Dr. Kevin C. Oeffinger of Sloan-Kettering, a lead author of the report. While young cancer patients are more vulnerable to damage because their organs are still growing, Dr. Oeffinger said, the study has obvious implications for adults.
Age and type of treatment play a huge role in the experience of cancer survivors, several experts said. Many experience no side effects at all. Others, especially women of child-bearing age, face infertility and early menopause.
“Our research shows that younger patients have a harder time, both physically and emotionally,” said Dr. Ganz, of U.C.L.A. “It’s not something they’ve expected.”
At Sloan-Kettering, five social workers are assigned to concentrate exclusively on follow-up care for survivors. Part of the plan, at Sloan and other cancer centers, is to develop an online database of patient-care summaries — of the cancer treatment received, the potential risks and recommended follow-up care — that could be used by any physician.
The hospital also plans to open an off-campus outpatient center devoted to cancer survivors’ physical rehabilitation, in part with a donation from the media entrepreneur Robert F. X. Sillerman, who was treated at Sloan-Kettering six years ago for tongue cancer. He received chemotherapy and radiation and later began to suffer pain and muscle spasms in his shoulders and back, as well as increasing weakness in his left arm.
Today, Mr. Sillerman said, he has reversed the damage with a little bit of medication and a lot of physical therapy. He exercises six days a week with weights, bands and manual resistance, partly with a personal physical therapist whom he puts up in a Manhattan townhouse adjoining his family’s. He said he appreciated the fact that few have the same luxury.
“I was two years out from my cure before I was able to find the right protocol and treatment,” said Mr. Sillerman, 59. “Our hope is to eliminate that and provide access to rehabilitation right away, initially in the New York metropolitan area and eventually to make that a template nationally.”
For premature menopause in patients who can safely use estrogen, Dr. Mercedes Castiel likes to give teenagers and young women birth control pills to control hot flashes and bone loss. “It’s nicer to say I’m on the pill like my peers instead of hormones like my grandmother,” said Dr. Castiel, director of the Barbara White Fishman Women’s Health Center at Sloan.
Even sexual dysfunction, which for years was viewed as a small price to pay for survival, is now treated like any other side effect. Vaginal dryness and missed or blunted orgasms are among the most common complaints.
“We look at it in terms of enhancing intimacy,” said Dr. Michael L. Krychman, Sloan’s expert on the subject. “They want things to get back to normal.”
Friday, May 18, 2007
Starting wine tasting
NYTimes
“To Study Wine, Buy and Drink”
By Eric Asimov, New York Times
April 11, 2007
New York Times, April 11, 2007
People ask me, more often than any other question by far, where to go to learn about wine.
Usually I tell them to go home.
No kidding. The best place to learn about wine is at home, particularly if you stop off at a good wine shop on the way.
What I’m about to propose is a do-it-yourself method that has a lot to offer to just about anybody who loves wine, or wants to learn about it. In fact, if you’ll join in with me, we will take this home wine class together and be the better for it. Let me explain.
Wine classes are best if you already know a little something and have decided that you are enthusiastic enough to pursue a passion. But for beginners they can be daunting, and they tend to teach more about how to describe wines rather than helping you learn what you like.
Books can be inspiring and entertaining, and at some point they are essential. But they pose similar problems for beginners. Do you think you can learn to play golf by reading a book? Of course not. You have to get out there and struggle, for years most likely.
Learning about wine is far more pleasant. All you have to do — almost — is drink it.
My approach does require a little thought and a modest bit of work, though, because you will learn only if you pursue wine systematically.
First, identify a good wine shop near you. If the answer isn’t obvious, ask a wine-obsessed friend for some recommendations. Second, find somebody at the shop with whom you seem to have a rapport and who is passionate about wine. Certain clues will help you gauge the passion. For example, if a salesperson tries to entice you by quoting scores from a consumer magazine, forget it. But if the salesperson explains why he or she loves a particular wine, it’s a very good sign.
Now you are ready to get down to business. Ask the salesperson for a mixed case — six red, six white — and give the shop a spending limit. You don’t need to be extravagant, but it’s not a time to stint, either. I suggest $250, give or take $50.
If the shop is a good one, you will be taking home a guide to the diverse and wonderful forms wine takes around the world. Some you will love, others you may detest. Either way, tasting a range is essential to learning about wine and about your own tastes.
Now comes the fun. Every night, or however often seems right, open one of the bottles with dinner. This is important. You want to drink a wine with food for the full experience.
Just the other night in a Spanish restaurant, I tasted a Rueda, a white wine made from the verdejo grape. On its own it was unexpectedly tart and pungent. With a bite of my shrimp-and-fig tapa, it was softer and more harmonious.
Over time you will gain a pretty good idea of which wines correspond with which foods. A really good wine shop may even have suggested general food pairings with the wines.
You will have to take some notes. Write down the name of the wine, the vintage, what you ate with it, and what you liked or didn’t like about it. It’s even easier than it sounds, especially if you don’t try to use the florid language of wine writers.
As you inhale the aromas and taste the flavors, think in general terms — was it sweet? Bitter? Did the aromas remind you of fruit, or maybe something else? Perhaps it didn’t taste like fruit at all, but like a beautiful sunset. Don’t know that I’ve had a sunset, but it’s evocative, at least.
The most important thing, though, is not how you describe the wine but whether you liked it or not, and whether you felt it enhanced what you ate or clashed with it. When you finish the case, return to the wine shop. Go over your list with the salesperson and, based on what you liked best, ask the shop to put together a second case of different bottles.
With this method you will gain a sense of what wines you like best. Eventually, if it’s fun, you may be motivated to find out even more.
That’s the time to buy a book or take a class, because now you have a context for organizing, understanding and digesting a blizzard of information. You may not be driving the ball 300 yards, or picking out Pomerols from Pommards, but you know what? Very few people do.
Now, as I said, I think this method is great not just for beginners but for anybody who wants to learn more about wine. So I’ve gone out and placed an order for a mixed case of wine on a $250 budget. In fact, I placed not just one order but two, from different shops, to see how the selection of the mixed case might differ and what that might mean. …
Out of curiosity, I… placed an order with… Sherry-Lehmann, the ultimate establishment wine shop. I spoke on the phone with Joy Land, a salesperson whom I didn’t know, but she knew exactly what I was after, and she quickly described her own palate.
“My background and my love is French wine,” Ms. Land said. “I like wines that are very elegant. I don’t like wines that are very big. I don’t like purple wines, or wines that stain your teeth.”
I’ll go along with that, though I do admit I kind of like purple.
I’ve now received both cases and they are similar conceptually, though they differ completely in the particulars. Both contain a Bordeaux, a red Burgundy and a white Burgundy. Both include a riesling and a zinfandel. Both include a sauvignon blanc, a Côtes du Rhône and a red from Italy. Both Lyle and Joy decided that one of the whites needed to be a Champagne.
I’ve got my work cut out for me, and I hope you’ll join me. I plan to keep you abreast of my progress on my blog, The Pour.
If you are newsprint-bound, check back here over the next couple of months and I’ll let you know what I’ve learned.
Homework
Your assignment: buy the following wines and drink them. Take notes. The [list was] compiled by… Joy Land of Sherry-Lehmann.
JOY’S CASE
* Deutz Brut NV $27.95
* Selbach-Oster Zeltinger, Schlossberg Spätlese 2002 $22.95
* Domaine Guy Roulot, Bourgogne Blanc 2004 $21.95
* Villa Maria Private Bin, Marlborough Sauvignon Blanc 2006 $12.95
* Salomon-Undhof Kremstal, Hochterrassen Grüner Veltliner 2005 $9.95
* Tablas Creek Paso Robles, Esprit de Beaucastel Blanc 2004 $29.95
* Mommessin Gevrey-Chambertin, 2003 $34.95
* Croix de Beaucaillou Saint-Julien 2003 $31.95
* Ridge Sonoma County, Three Valleys 2005 $19.95
* Guigal Côtes du Rhône 2003 $10.95
* Allegrini Palazzo della Torre IGT 2003 $16.95
* Enrique Foster Mendoza Malbec, Ique 2004 $8.95
“To Study Wine, Buy and Drink”
By Eric Asimov, New York Times
April 11, 2007
New York Times, April 11, 2007
People ask me, more often than any other question by far, where to go to learn about wine.
Usually I tell them to go home.
No kidding. The best place to learn about wine is at home, particularly if you stop off at a good wine shop on the way.
What I’m about to propose is a do-it-yourself method that has a lot to offer to just about anybody who loves wine, or wants to learn about it. In fact, if you’ll join in with me, we will take this home wine class together and be the better for it. Let me explain.
Wine classes are best if you already know a little something and have decided that you are enthusiastic enough to pursue a passion. But for beginners they can be daunting, and they tend to teach more about how to describe wines rather than helping you learn what you like.
Books can be inspiring and entertaining, and at some point they are essential. But they pose similar problems for beginners. Do you think you can learn to play golf by reading a book? Of course not. You have to get out there and struggle, for years most likely.
Learning about wine is far more pleasant. All you have to do — almost — is drink it.
My approach does require a little thought and a modest bit of work, though, because you will learn only if you pursue wine systematically.
First, identify a good wine shop near you. If the answer isn’t obvious, ask a wine-obsessed friend for some recommendations. Second, find somebody at the shop with whom you seem to have a rapport and who is passionate about wine. Certain clues will help you gauge the passion. For example, if a salesperson tries to entice you by quoting scores from a consumer magazine, forget it. But if the salesperson explains why he or she loves a particular wine, it’s a very good sign.
Now you are ready to get down to business. Ask the salesperson for a mixed case — six red, six white — and give the shop a spending limit. You don’t need to be extravagant, but it’s not a time to stint, either. I suggest $250, give or take $50.
If the shop is a good one, you will be taking home a guide to the diverse and wonderful forms wine takes around the world. Some you will love, others you may detest. Either way, tasting a range is essential to learning about wine and about your own tastes.
Now comes the fun. Every night, or however often seems right, open one of the bottles with dinner. This is important. You want to drink a wine with food for the full experience.
Just the other night in a Spanish restaurant, I tasted a Rueda, a white wine made from the verdejo grape. On its own it was unexpectedly tart and pungent. With a bite of my shrimp-and-fig tapa, it was softer and more harmonious.
Over time you will gain a pretty good idea of which wines correspond with which foods. A really good wine shop may even have suggested general food pairings with the wines.
You will have to take some notes. Write down the name of the wine, the vintage, what you ate with it, and what you liked or didn’t like about it. It’s even easier than it sounds, especially if you don’t try to use the florid language of wine writers.
As you inhale the aromas and taste the flavors, think in general terms — was it sweet? Bitter? Did the aromas remind you of fruit, or maybe something else? Perhaps it didn’t taste like fruit at all, but like a beautiful sunset. Don’t know that I’ve had a sunset, but it’s evocative, at least.
The most important thing, though, is not how you describe the wine but whether you liked it or not, and whether you felt it enhanced what you ate or clashed with it. When you finish the case, return to the wine shop. Go over your list with the salesperson and, based on what you liked best, ask the shop to put together a second case of different bottles.
With this method you will gain a sense of what wines you like best. Eventually, if it’s fun, you may be motivated to find out even more.
That’s the time to buy a book or take a class, because now you have a context for organizing, understanding and digesting a blizzard of information. You may not be driving the ball 300 yards, or picking out Pomerols from Pommards, but you know what? Very few people do.
Now, as I said, I think this method is great not just for beginners but for anybody who wants to learn more about wine. So I’ve gone out and placed an order for a mixed case of wine on a $250 budget. In fact, I placed not just one order but two, from different shops, to see how the selection of the mixed case might differ and what that might mean. …
Out of curiosity, I… placed an order with… Sherry-Lehmann, the ultimate establishment wine shop. I spoke on the phone with Joy Land, a salesperson whom I didn’t know, but she knew exactly what I was after, and she quickly described her own palate.
“My background and my love is French wine,” Ms. Land said. “I like wines that are very elegant. I don’t like wines that are very big. I don’t like purple wines, or wines that stain your teeth.”
I’ll go along with that, though I do admit I kind of like purple.
I’ve now received both cases and they are similar conceptually, though they differ completely in the particulars. Both contain a Bordeaux, a red Burgundy and a white Burgundy. Both include a riesling and a zinfandel. Both include a sauvignon blanc, a Côtes du Rhône and a red from Italy. Both Lyle and Joy decided that one of the whites needed to be a Champagne.
I’ve got my work cut out for me, and I hope you’ll join me. I plan to keep you abreast of my progress on my blog, The Pour.
If you are newsprint-bound, check back here over the next couple of months and I’ll let you know what I’ve learned.
Homework
Your assignment: buy the following wines and drink them. Take notes. The [list was] compiled by… Joy Land of Sherry-Lehmann.
JOY’S CASE
* Deutz Brut NV $27.95
* Selbach-Oster Zeltinger, Schlossberg Spätlese 2002 $22.95
* Domaine Guy Roulot, Bourgogne Blanc 2004 $21.95
* Villa Maria Private Bin, Marlborough Sauvignon Blanc 2006 $12.95
* Salomon-Undhof Kremstal, Hochterrassen Grüner Veltliner 2005 $9.95
* Tablas Creek Paso Robles, Esprit de Beaucastel Blanc 2004 $29.95
* Mommessin Gevrey-Chambertin, 2003 $34.95
* Croix de Beaucaillou Saint-Julien 2003 $31.95
* Ridge Sonoma County, Three Valleys 2005 $19.95
* Guigal Côtes du Rhône 2003 $10.95
* Allegrini Palazzo della Torre IGT 2003 $16.95
* Enrique Foster Mendoza Malbec, Ique 2004 $8.95
Med use in US kids
Link
Diabetes drug use spikes in young girlsReport: Pills for insomnia, psychotic behavior up among U.S. kids
Updated: 8:04 a.m. ET May 16, 2007
TRENTON, N.J. - The number of adolescent girls taking drugs for Type 2 diabetes nearly tripled in just five years, while use of chronic medicines for psychotic behavior and insomnia roughly doubled among boys and girls aged 10 to 19, a study shows.
Meanwhile, adolescents’ use of drugs for depression and attention deficit hyperactivity disorder, or ADHD, leveled off or dropped in the last two years, after widespread new warnings about safety concerns.
The study, an analysis of prescription drug use from 2001 to 2006 among 370,000 insured children aged 10 to 19, was conducted by Medco Health Inc. of Franklin Lakes, N.J., the country’s biggest prescription benefit manager, and released exclusively to The Associated Press.
Experts say the findings raise questions about physical and mental health problems in youth, the appropriateness of putting them on strong, long-term medicines mostly designed for adults, and whether it might be better to focus on other strategies, such as counseling, exercise and changes in diet, caffeine intake and bedtime routine.
“There’s increasing use of medication in children the last 20 years, but does that mean we’re treating them successfully or that we’re overmedicating?” said Dr. Thomas Insel, director of the National Institute of Mental Health. Probably both, he said, but some children aren’t getting needed help.
Dr. Wayne Snodgrass, chairman of the American Academy of Pediatrics’ committee on drugs, said the levels of medication usage found in the study might be appropriate, but it’s hard to know without details on why each prescription was written.
“It deserves watching,” he said, particularly because adolescents’ brains are still developing. Snodgrass said worried parents should question their child’s doctor about their treatment or seek a second opinion.
Striking diabetes trend
The most striking trend was a 167 percent spike in girls 10 to 19 taking pills for type 2 diabetes, formerly called adult-onset diabetes. Medco found it jumped from 0.1 percent in 2001 to 0.27 percent in 2006; among boys, prevalence up 33 percent, to 0.08 percent.
 |
“It’s really scary to think about people in their teens developing a disease that in the past only developed in the 40s, 50s and 60s,” Buse said.
The big gap between the sexes, he said, likely is partly due to girls taking a generic diabetes drug, metformin, linked to weight loss and also prescribed for a hormonal condition that involves abnormal insulin function, causes male sex traits and increases cancer risk.
Also, hormone changes in puberty can trigger insulin resistance, or prediabetes. Puberty starts a couple years earlier in girls, so many more girls than boys in the study were in puberty.
Medco found prevalence of kids taking antipsychotic drugs, once called major tranquilizers, roughly doubled, with about 1.2 percent of boys and 0.75 percent of girls taking them in 2006.
Widely used antipsychotic drugs — including Risperdal, Zyprexa, Seroquel and Clozaril — are approved for treating schizophrenia and bipolar disorder in adults, but not children.
Insel said the drugs often are prescribed for kids for disruptive behavior and other unapproved uses, particularly to kids previously on antidepressants and ADHD drugs.
A federal survey of doctors’ office practices estimated a sixfold jump from 1993 to 2002 in patients aged 20 or younger prescribed antipsychotic drugs, to 1.224 million. It found 38 percent of those prescriptions were for disruptive behavior such as ADHD, 32 percent were for mood disorders including depression, 17 percent were for developmental disorders such as mental retardation and autism, and 14 percent were for psychotic disorders such as schizophrenia.
Sleeping pills doubled
Meanwhile, Medco found use of prescription sleeping pills nearly doubled, to about 0.3 percent of boys and 0.44 percent of girls.
“The fact that these kids have to get a prescription pill to go to sleep at night is amazing,” said Dr. Robert Epstein, Medco’s chief medical official, adding parents should try slowing kids down at night with curfews on caffeine and computer use, for example.
He said Medco’s numbers reflect drug use among adolescents covered by private or government insurance, but in general kids in the Medicaid program use more prescription medications and those with no insurance take significantly less.
Use of ADHD drugs leveled off in girls in 2006 at 3.5 percent and dropped in boys to almost 8 percent, while antidepressant use dropped in both sexes in 2005 and 2006, to about 4 percent of girls and 3.2 percent of boys.
Insel said those trends make sense, given that after the drugs ago got stringent warnings about problems such as suicidal thoughts a couple years ago, many parents became concerned about side effects and pediatricians worried about their liability for prescribing the drugs.
Sleep and memory
Link
Good Sleep Wakes Up Memory
By Juhie Bhatia, HealthDay Reporter
HealthDay
(HealthDay News) -- Besides helping you feel well-rested, getting your zzz's may also sharpen your memory, a new study shows.
Researchers found that sleep not only protects memories from outside interferences, it also helps strengthen them.
"There was a very large benefit of sleep for memory consolidation, even larger than we were anticipating," said study author Dr. Jeffrey Ellenbogen, an associate neurologist at Brigham and Women's Hospital, Boston, and a postdoctoral fellow in sleep medicine at Harvard Medical School.
In the study, the researchers focused on sleep's impact on "declarative" memories, which are related to specific facts, episodes and events.
"We sought to explore whether sleep has any impact on memory consolidation, specifically the type of memory for facts and events and time," Ellenbogen said. "We know that sleep helps boost memory for procedural tests, such as learning a new piano sequence, but we're not sure, even though it's been debated for 100 years, whether sleep impacts declarative memory."
The study involved 48 people between the ages of 18 and 30. These participants had normal, healthy sleep routines and were not taking any medications. They were all taught 20 pairs of words and asked to recall them 12 hours later. However, the participants were divided evenly into four groups with different circumstances for testing: sleep before testing, wake before testing, sleep before testing with interference, or wake before testing with interference.
Two of the groups (the wake groups) were taught the words at 9 a.m. and then tested on the pairings at 9 p.m., after being awake all day. The other two groups (the sleep groups) learned the words at 9 p.m., went to sleep, and were then tested at 9 a.m.
Also, prior to testing, one of the sleep groups and one of the wake groups were given a second list of 20 word pairs to remember. These groups were then tested on both lists to help determine memory recall with interference (competing information).
The result: Sleep appeared to help particpants recall their learned declarative memories, even when they were given competing information.
According to the researchers, people who slept after learning the information performed best, successfully recalling more words whether or not there was interference. Those in the sleep group without interference were able to recall 12 percent more word pairings from the first list than the wake group without interference (94 percent recall for the sleep group vs. 82 percent for the wake group).
When presented with interference, those who slept before testing did significantly better at remembering the words (76 percent for the sleep group vs. 32 percent for the wake group).
"We were surprised to find the order of magnitude by which the data demonstrated our effects," Ellenbogen said.
Jan Born, a professor of neuroendocrinology at the University of Lübeck in Germany, said the study offers more proof of the importance of sleep for memory consolidation.
"Considering that learning in every educational setting (schools, colleges, etc.), is centrally based on hippocampus-dependent memory function [declarative memories], people should realize that optimal learning conditions require proper sleep," he said.
Proper sleep may have other benefits, too, added Michael Perlis, director of the Sleep Research Laboratory at the University of Rochester in Rochester, NY. Research has shown that in addition to memory, sleep may be related to physical functioning, good immune function, physical and cognitive performance, and mood regulation, he said.
"These are all theories. The only thing we know is that when we're deprived of sleep, we do less well. Is that a lack of sleep or sustained wakefulness? It's very difficult to figure out how to crack that nut," he said. "We spend 30 percent of our time on sleep. What is sleep for? This is a riddle we're still working on."
SOURCES: Jeffrey Ellenbogen, M.D., associate neurologist, Brigham and Women's Hospital, postdoctoral fellow in sleep medicine, Harvard Medical School; Jan Born, Ph.D., professor, neuroendocrinology, University of Lübeck, Germany; Michael Perlis, Ph.D., director of the Sleep Research Laboratory, University of Rochester, N.Y.
Good Sleep Wakes Up Memory
By Juhie Bhatia, HealthDay Reporter
HealthDay
(HealthDay News) -- Besides helping you feel well-rested, getting your zzz's may also sharpen your memory, a new study shows.
Researchers found that sleep not only protects memories from outside interferences, it also helps strengthen them.
"There was a very large benefit of sleep for memory consolidation, even larger than we were anticipating," said study author Dr. Jeffrey Ellenbogen, an associate neurologist at Brigham and Women's Hospital, Boston, and a postdoctoral fellow in sleep medicine at Harvard Medical School.
In the study, the researchers focused on sleep's impact on "declarative" memories, which are related to specific facts, episodes and events.
"We sought to explore whether sleep has any impact on memory consolidation, specifically the type of memory for facts and events and time," Ellenbogen said. "We know that sleep helps boost memory for procedural tests, such as learning a new piano sequence, but we're not sure, even though it's been debated for 100 years, whether sleep impacts declarative memory."
The study involved 48 people between the ages of 18 and 30. These participants had normal, healthy sleep routines and were not taking any medications. They were all taught 20 pairs of words and asked to recall them 12 hours later. However, the participants were divided evenly into four groups with different circumstances for testing: sleep before testing, wake before testing, sleep before testing with interference, or wake before testing with interference.
Two of the groups (the wake groups) were taught the words at 9 a.m. and then tested on the pairings at 9 p.m., after being awake all day. The other two groups (the sleep groups) learned the words at 9 p.m., went to sleep, and were then tested at 9 a.m.
Also, prior to testing, one of the sleep groups and one of the wake groups were given a second list of 20 word pairs to remember. These groups were then tested on both lists to help determine memory recall with interference (competing information).
The result: Sleep appeared to help particpants recall their learned declarative memories, even when they were given competing information.
According to the researchers, people who slept after learning the information performed best, successfully recalling more words whether or not there was interference. Those in the sleep group without interference were able to recall 12 percent more word pairings from the first list than the wake group without interference (94 percent recall for the sleep group vs. 82 percent for the wake group).
When presented with interference, those who slept before testing did significantly better at remembering the words (76 percent for the sleep group vs. 32 percent for the wake group).
"We were surprised to find the order of magnitude by which the data demonstrated our effects," Ellenbogen said.
Jan Born, a professor of neuroendocrinology at the University of Lübeck in Germany, said the study offers more proof of the importance of sleep for memory consolidation.
"Considering that learning in every educational setting (schools, colleges, etc.), is centrally based on hippocampus-dependent memory function [declarative memories], people should realize that optimal learning conditions require proper sleep," he said.
Proper sleep may have other benefits, too, added Michael Perlis, director of the Sleep Research Laboratory at the University of Rochester in Rochester, NY. Research has shown that in addition to memory, sleep may be related to physical functioning, good immune function, physical and cognitive performance, and mood regulation, he said.
"These are all theories. The only thing we know is that when we're deprived of sleep, we do less well. Is that a lack of sleep or sustained wakefulness? It's very difficult to figure out how to crack that nut," he said. "We spend 30 percent of our time on sleep. What is sleep for? This is a riddle we're still working on."
SOURCES: Jeffrey Ellenbogen, M.D., associate neurologist, Brigham and Women's Hospital, postdoctoral fellow in sleep medicine, Harvard Medical School; Jan Born, Ph.D., professor, neuroendocrinology, University of Lübeck, Germany; Michael Perlis, Ph.D., director of the Sleep Research Laboratory, University of Rochester, N.Y.
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