Wall Street Journal
Tale of Two Docs:
Why Dentists Are Earning More
Dr. Bryson Focuses On Cosmetics, Not Insurance;
A Family Physician Lags
A $15,000 'Smile Makeover'
By MARK MAREMONT
Staff Reporter of THE WALL STREET JOURNAL
January 10, 2005
(See Corrections & Amplifications item below.)
YARDLEY, Pa. -- Randy Bryson and his brother-in-law Larry Fazioli are both medical professionals in their 40s who practice in Pennsylvania. The similarity ends there.
At Dr. Bryson's office here in suburban Philadelphia, a fountain softly burbles in the airy reception area, and patients are offered cappuccino or paraffin-wax hand treatments while they wait. Dr. Bryson works four days a week, drives a Mercedes, and lives in a 4,000-square-foot house with a pool. He and his wife, who works part-time in the same practice, together take home more than $500,000 a year.
At Dr. Fazioli's busy practice near Pittsburgh, patients crowd a utilitarian waiting room, and his cramped office is piled high with records awaiting dictation. Dr. Fazioli says he works between 55 and 80 hours a week, and his annual income of less than $180,000 has been stagnant or down the past few years. He drives a Chevrolet.
The key to their different lives: Dr. Bryson is a dentist, and Dr. Fazioli is a family-practice physician.
Once the poor relations in the medical field, dentists in the past few years have started making more money than many types of physicians, including internal-medicine doctors, pediatricians, psychiatrists, and those in family practice, according to survey data from the American Dental Association and American Medical Association.
On average, general dentists in 2000, the most recent year for which comparative data are available, earned $166,460 -- compared with $164,100 for general internal-medicine doctors, $145,700 for psychiatrists, $144,700 for family-practice physicians, and $137,800 for pediatricians. All indications are that dentists have at least kept pace with physicians since then.
Those figures are a sharp contrast to 1988, when the average general dentist made $78,000, two-thirds the level of the average internal-medicine doctor, and behind every other type of physician. From 1988 to 2000, dentists' incomes more than doubled, while the average physician's income grew 42%. The rate of inflation during that same period was 46%.
Factor in hours worked -- dentists tend to put in 40-hour weeks, the ADA says, while the AMA says physicians generally work 50 to 55 hours -- and the discrepancy is even greater.
"I feel so bad for Larry," says Dr. Bryson of his brother-in-law the doctor. "Especially when he's on call, he puts in some pretty long hours. Physically, it's really taking a toll on him."
Dr. Fazioli says he still gets a lot of satisfaction out of being a doctor and earns a comfortable living. But he admits he'd steer his children away from primary-care medicine as a career. Of his three sons, he adds, two might be interested in dentistry instead. "They see that Randy is doing OK," he says.
Many specialist physicians, such as cardiologists and radiologists, continue to rake in large incomes, generally exceeding those of specialist dentists such as oral surgeons and periodontists. But specialist dentists, too, have seen their paychecks increase at a much faster rate than their physician counterparts.
Healthier Teeth
Dentists have grown richer even as cavities, once the main cause for visiting them, have declined, largely because of fluoridation of drinking water and improved preventive care. According to a study published in the Journal of the American Dental Association in 1999, cavities in 6-to-18-year-olds dropped by three-fifths from the early 1970s to the early 1990s -- even though many children in lower socioeconomic groups still lack adequate dental care.
As people born in the 1960s and later have grown into adulthood, they tend to need fewer fillings than their parents did and are keeping their teeth longer. Painful disease-related procedures such as root canals are declining, too.
So why are dentists so handily outpacing doctors? In part, it's because dentists have avoided being flattened by the managed-care steamroller, and instead many have turned into upscale marketers. Dental care makes up less than 5% of the overall U.S. health bill, and hasn't been a major focus of cost-cutting.
Although some dental insurers have tightened up on reimbursements, most private dental insurance is still paid on a fee-for-service basis. Many optional procedures aren't covered by insurance, leaving dentists free to charge whatever the market will bear. About 44% of all dental care is paid by patients out of their own pockets, according to federal statistics for 2002, compared with just 10% for all physician and clinical costs.
While dentists may be able to focus more on marketing costly optional treatments, many physicians can't make the same kind of switch in their practices.
In competing for patients' own dollars, dentists have become more entrepreneurial, tapping into today's image-conscious zeitgeist. Many dental offices are festooned with pitches for everything from $400 teeth-whitening treatments to $1,200-per-tooth veneer jobs.
There are even $30,000-plus full "smile makeovers" offered by a growing coterie of dentists who specialize in high-end cosmetic procedures. Public awareness of such techniques has been heightened by reality-TV shows such as ABC's "Extreme Makeover" and Fox Broadcasting's "The Swan."
L. Jackson Brown, an economist who is associate executive director at the ADA, says cosmetic procedures account for about 10% of the nation's $80 billion annual dental bill, and are rising fast.
Sally McKenzie, a dental-practice consultant in La Jolla, Calif., who has been in business for 25 years, calls it a "golden era for dentistry." The most common call she gets, Ms. McKenzie says, is to help dentists manage "uncontrolled growth."
The situation is a sharp turnaround from the 1980s, when dentistry seemed to be in decline. Falling rates of tooth decay and a glut of dentists produced much soul-searching in the profession. Several dental schools closed, while others slashed enrollment. Dentists wrung their hands over their inability to get more insurance coverage -- a failure that now looks heaven-sent.
Dentists also have taken advantage of new technology, some of it controversial even within the profession. One major advance was the invention of porcelain veneers, which are wafer-thin shells of material that are bonded to the fronts of teeth to repair chips or misalignment. Unlike older surfacing materials, porcelain resists staining and looks like a natural tooth surface. Some dentists claim the procedure, which involves an irreversible filing down of natural teeth, can create problems. But proponents say that, done right, such veneers can stay in place for years.
"Today, you can create a smile" from materials that people "can't tell are not real teeth," says Joe Barton, a Jacksonville, Fla., dentist who specializes in cosmetic procedures. He says he typically charges from $12,000 to $14,000 to put veneers on 10 front teeth, requiring about 3½ hours of his time. "We are competing with cars and vacations and jet skis and new homes, in terms of what people are spending their disposable income on," he says.
Some dentists use sophisticated software-imaging programs to show patients virtual before-and-after photos of what their teeth could look like with cosmetic help. Others have installed $100,000 computer-assisted design devices to make crowns in their own offices.
Intra-oral video cameras, tiny pen-shaped devices that can be used to display images of the inside of a patient's mouth, have become de rigueur. The cameras, which typically cost $2,000 or more, have little clinical purpose -- but there's nothing like seeing an up-close video of unsightly teeth on an overhead TV to persuade a patient that something needs to be done.
The turnabout in fortunes has made some dentists pity their physician colleagues. Robert H. Gregg, a dentist in Cerritos, Calif., says he had an operation for a snapped Achilles tendon a few years ago, which required him to go under general anesthesia for more than an hour. He was amazed his insurer paid just $2,000 to his orthopedic surgeon for the procedure. "I get about $3,000 for a three-unit bridge," Dr. Gregg says. "He's getting pennies on the dollar to what his skill level was."
Dr. Gregg says he offered to pay more out of his own pocket. The surgeon's office manager, he adds, "told me I was the first person" to ever make such a request.
The dentist and physician who are brothers-in-law, Drs. Bryson and Fazioli, both grew up in western Pennsylvania. They are related through Dr. Fazioli's wife, Robin, who is Dr. Bryson's younger sister. She sardonically refers to her brother and husband as "the prince and the pauper." She says she "definitely" doesn't want her sons to follow her husband into medicine. "I see how hard he works," she says. "I tell them, 'maybe you should go into dentistry. See how well Uncle Randy is doing.' "
Dr. Bryson, 44 years old, wanted to be a dentist from the time he was 5, his sister recalls. "We called him Rockefeller Bryson," she says. "He always liked the finer things in life."
While attending dental school in Philadelphia, Dr. Bryson met his wife, Toni Margio, a fellow student. They soon opened a joint practice in affluent Yardley, about a half-hour north of the city.
By the late 1990s, their practice was booming. But Dr. Margio says they both felt like they were "always on roller skates." They worked 10-to-12-hour days, and had to rely on Dr. Margio's mother to care for their son, now 8 years old. Dental insurers were forcing them to discount fees.
Five years ago, after attending classes at the Las Vegas Institute for Advanced Dental Studies, a school known for an aggressive brand of cosmetic dentistry, they dramatically changed their practice. They stopped accepting insurance -- patients are billed directly and can wrestle with insurers on their own -- and started plugging veneers, whitening and other elective procedures.
"We shifted from needs-based dentistry to wants-based dentistry," says the youthful-looking Dr. Bryson, who has a dazzling smile. "It has totally transformed our practice and our personal lives. We see a much smaller number of patients, at a slower pace. I can't wait to get in in the morning."
At their open, two-story office, large photos of patients with gleaming smiles adorn walls painted light blue. Classical music plays in the background, and the air is filled with a pleasant smell. "Aromatherapy," says Dr. Margio, a petite, dark-haired woman with a perfect-looking set of teeth.
On a recent afternoon, a patient is sitting in one of Dr. Bryson's exam rooms with small electrodes attached to her face. The nerve-stimulating device feeds data about the patient's jaw muscles to a computer system.
"Move your lower jaw forward," Dr. Bryson instructs, peering at the computer screen. "Perfect."
The patient, who complains of jaw pain from grinding her teeth, is being fitted for a night mouth guard, or orthotic. Although many dentists charge from $200 to $500 for guards, Dr. Bryson sells one he says is designed to keep the patient's jaw more relaxed. The price: $2,200, little or none of which is likely to be covered by insurance.
'Smile Makeover'
To help patients afford such treatments -- or the $12,000 to $15,000 they charge for a partial "smile makeover" of eight to 10 teeth -- Drs. Bryson and Margio offer financing plans that allow patients to borrow from a bank and pay their bills over as long as five years.
The couple say their practice's gross revenues are up about 60% to about $1.6 million a year since they shifted their focus five years ago. Costs have also risen, to close to 65% of revenue in some years, mainly because of outlays for computers and continuing dental education.
Since changing their practice, Dr. Bryson says he has cut back from 60-hour weeks to 32 clinical hours a week, plus some paperwork time. Dr. Margio now works 18 clinical hours, giving her more time with their son. Both take every Wednesday off. "I coach my son's soccer team," Dr. Bryson says. "I don't miss a practice."
The work, he says, is also more satisfying. "I get patient letters, I get hugs. People cry when they see their teeth. I never got that before."
Across the state in New Castle, at 2 p.m. on a recent Wednesday, Dr. Fazioli was scheduled to have left his office an hour earlier. "This is supposed to be my half day," says Dr. Fazioli, a compact man with a mustache, graying temples and a self-deprecating manner. "But I'm lucky if I get home at 3 or 4."
An overflow of patients has left him behind schedule, and his desk is piled high with records to dictate. "Patient canceled colonoscopy," Dr. Fazioli says into his tape recorder, recounting his exam of an elderly woman. "Says she didn't feel comfortable with the procedure. She's still smoking cigarettes. Had a discussion with her about the need for total cigarette cessation."
He groans as a nurse brings in another armful of charts. "No more. I gotta get out of here."
Becoming a doctor once seemed like a dream job for Dr. Fazioli, who grew up in a mill town about 10 miles from New Castle. His father had operated machinery for a U.S. Steel mill until it closed in the 1970s. After working as a pharmacist, Dr. Fazioli attended medical school, and in 1990 hung out his own shingle as a family practitioner.
At first, the practice grew quickly. His income early on was more than $130,000 a year, and he added a couple of partners. Being a doctor in a small city, he says, means "you get a lot of respect. It's nice when you help people. They're grateful."
The trouble started with the managed-care reforms of the mid-1990s, Dr. Fazioli says. Signing managed-care contracts provided him with easy access to new patients. But more patients meant more office visits at the cut-rate fees demanded by insurers. The federal government's Medicare program has been another headache. Medicare patients make up at least a third of his practice.
"Our reimbursements have stayed flat, but our overhead is up," says Dr. Fazioli, 47. "My take-home pay has definitely gone down." He says he had hoped to slow down a bit as he neared 50, "But I definitely can't do that right now. I've got to keep seeing patients."
Although his typical work week is about 50 to 55 hours, every third week he's on call, pushing the work load closer to 80 hours and often requiring him to go to the hospital in the wee hours.
Dr. Fazioli and his family live in a colonial-style house in a wooded area outside of New Castle. He won't give his exact income, but says it's between $150,000 and $180,000 a year. If he had to do it all over again, he says, he'd still consider being a primary-care doctor, but "I'd look hard at other areas, other states."
As for his brother-in-law the dentist, Dr. Fazioli says, "Randy certainly did his homework. People who come to him want his service. He can charge as much as he can."
Dr. Fazioli recently went to a local dentist to get a bridge put in. The procedure, he says, took about 1½ hours over two visits. The bill: $1,200, all of which he had to pay from his own pocket. "I was thinking, 'How many people do I have to see to get that?' " Dr. Fazioli says. "If I made $200 in that amount of time, I'd be lucky."
Corrections & Amplifications:
The total number of root canal procedures performed in the U.S. rose 13% from 1990 to 1999, according to the American Association of Endodontists, a trade group of specialist dentists who focus on that treatment. But the rate among people 45 years and younger is declining. This article incorrectly said the total number of root canals is falling.
Monday, April 14, 2008
Sunday, April 06, 2008
Medicare having difficulty saving money
NYTimes
April 7, 2008
Health Plans
Medicare Finds How Hard It Is to Save Money
By REED ABELSON
An ambitious three-year experiment to see whether the Medicare system could prevent expensive hospital visits for people with chronic conditions like congestive heart failure and diabetes has suggested that such an approach may cost more than it saves.
The test borrowed a practice long available through private health plans. Nurses periodically place phone calls to patients to check whether they are taking their drugs and seeing the right doctors. The idea is that keeping people healthier can help patients avoid costly complications.
After paying eight outside companies about $360 million since mid-2005 to try to improve such patients’ health, Medicare is still trying to figure out whether the companies were able to keep people healthier. But the preliminary data indicate that the government is unlikely to save money.
The experiment, meanwhile, is proving something else: how difficult it can be, politically and practically, to make fundamental changes in the sprawling $400 billion federal Medicare program, which now covers some 44 million Americans.
With health costs soaring, few would dispute that the government needs to find better ways to spend its Medicare dollars. But because the system relies heavily on private industry and is subject to Congressional oversight, few changes come easily, and even experimental programs can take on lives of their own.
Several of the companies, including two that specialize in disease management, Healthways and Health Dialog, are pressing Medicare to continue the project in some fashion beyond the end of this year, saying the government mishandled the experiment.
The senators from the home states of those two companies, including John Kerry, Democrat of Massachusetts, and Lamar Alexander, Republican of Tennessee, have taken up their cause, demanding that Medicare rethink ending the experiment.
“Stopping this program,” the senators wrote in a letter to Medicare last month, “creates serious health risks for the Medicare beneficiaries already enrolled and heavily reliant” on the services provided by the experiment.
Medicare, for its part, says the experiment so far has not reduced medical bills enough to offset the fees the companies are charging the government — as much as $2,000 a year for each patient. A final accounting of the experiment is likely to come no sooner than next year.
About 160,000 people have taken part in the test, known as the Medicare Health Support program, and some 70,000 are still receiving calls from nurses employed by the companies.
Experts say that Medicare and the companies alike were too optimistic about how easy it would be to prevent costly complications and hospital visits by patients who are very sick.
“Everybody shares some blame,” said Dr. David B. Nash, a health policy professor at Thomas Jefferson University in Philadelphia, who at the outset was enthusiastic about the program’s prospects for transforming Medicare.
On the experiment’s front lines are nurses like Jill Coker, who works for Healthways and makes 25 to 30 telephone calls a day, trying to ensure that each patient receives a call every few weeks. Through dozens of such nurses, Healthways, based in Nashville, is overseeing the care of 16,000 people in Maryland and Washington.
Ms. Coker said she spent most of her time on rudimentary issues, like explaining to patients what prescription drugs they are on and helping them devise ways to make sure they remember to take their medicine. She may also arrange a conference call with a patient’s doctor if there are some worrisome new symptoms, or she may direct someone to a specialist to get better care.
“There have been numerous diabetics who didn’t even know what an endocrinologist was,” she said.
Medicare has not finished studying how well patients do under the program and whether patients are satisfied with the help. Three of the original companies — Cigna, McKesson and LifeMasters — eventually dropped out.
The program has failed to meet the government’s original financial target: an overall savings to Medicare of 5 percent after factoring in the companies’ fees and the patients’ medical bills.
Initially, the companies were supposed to return their payments if they did not hit that target. Late last year, Medicare relaxed its standard, requiring only that the experiment not end up costing the government money.
The agency says that it will consider keeping any promising pieces of the program. But it says it cannot legally extend the experiment beyond December if it is not budget neutral.
“We want to lift up the seat cushions to find every nickel and dime we can find,” said Herb B. Kuhn, the deputy administrator for Medicare. The agency says no final decision on the fate of the program has been made.
But some health care experts say Medicare should move on to seek other ways of managing the care of the chronically ill, if alternatives seem to hold greater potential to deliver both cost savings and better care.
“Medicare is doing exactly what we should want Medicare to do — to test different life forms of disease management and see what works best,” said Dr. Arnold Milstein, the chief physician for Mercer Health and Benefits, a consulting firm. But, he said, “This particular form of disease management is not looking promising.”
Medicare is already exploring other ideas, like the development of so-called “medical homes,” where a doctor with a team of other professionals oversees a patient’s care. A few doctors’ groups involved in a separate Medicare experiment have reported some success in saving the government money by more actively managing their patients’ care.
Dr. Mark B. McClellan, who was the head of Medicare when the experiment began and is now a policy analyst at the Brookings Institution in Washington, says the point of Medicare’s experiments is to find out which approaches might work. “This is a hard problem that is not going to be solved all at once,” he said.
Many of the companies involved in the program say the experiment was flawed in the way it was designed and that Medicare has failed to work with them to make the program a success.
“We haven’t proven anything,” said Dr. Jeffrey L. Kang, a former Medicare official who is now the chief medical officer for the insurer Cigna.
The companies say Medicare signed up patients who were much sicker than they had expected. Instead of giving companies a chance to intervene before someone went to the hospital, Dr. Kang said, most of the patients were already so ill that it was “no longer a preventive program.”
The companies also say Medicare failed to make good on its promise to give them timely information about the use of prescription drugs, for example, or lab results that would have allowed them to help direct the patients’ care.
“We overestimated the real desire expressed by the organization,” said Ben R. Leedle Jr., the chief executive of Healthways, who has been an outspoken critic of Medicare. His company’s stock fell by 16 percent in a single day after the agency announced the experiment’s preliminary results in January.
Mr. Leedle says that Healthways will probably be able to demonstrate savings from at least some of its Medicare efforts, although the company also says it is projecting a loss on the experiment because it may have to pay back federal fees. Medicare has not made public data on the results for individual companies.
For its part, Medicare said that it had worked extensively with the companies to address their concerns and that its final analysis would take into account how sick the patients initially were.
One thing that already seems clear is that after the fees are paid to the contractors, any cost savings may be elusive. In late January, the agency estimated that to meet their targets the five remaining companies would need to reduce their monthly claims by an average of $300 to $800 per patient for the remainder of the experiment. That would represent a 20 to 40 percent reduction in the patients’ current medical bills.
George B. Bennett, the chief executive of Health Dialog, which is overseeing about 15,000 Medicare patients in western Pennsylvania, favors continuing the experiment, but with adjustments. He wants Medicare to give the companies more flexibility to manage patients in ways they say have already been proven to work among the employees they cover in commercial plans. Such measures, he said, include giving the insurer a bigger role in selecting the patients, with an eye toward identifying the ones most likely to be helped.
“Medicare actually has the possibility of saving $20 billion to $30 billion,” Mr. Bennett said, “if they undergo what is being done in the private sector.”
Whatever happens with this particular program, Medicare says it wants to keep experimenting. “We’re not giving up on this stuff,” said Mr. Kuhn, the Medicare deputy. “We definitely want these programs to work.”
April 7, 2008
Health Plans
Medicare Finds How Hard It Is to Save Money
By REED ABELSON
An ambitious three-year experiment to see whether the Medicare system could prevent expensive hospital visits for people with chronic conditions like congestive heart failure and diabetes has suggested that such an approach may cost more than it saves.
The test borrowed a practice long available through private health plans. Nurses periodically place phone calls to patients to check whether they are taking their drugs and seeing the right doctors. The idea is that keeping people healthier can help patients avoid costly complications.
After paying eight outside companies about $360 million since mid-2005 to try to improve such patients’ health, Medicare is still trying to figure out whether the companies were able to keep people healthier. But the preliminary data indicate that the government is unlikely to save money.
The experiment, meanwhile, is proving something else: how difficult it can be, politically and practically, to make fundamental changes in the sprawling $400 billion federal Medicare program, which now covers some 44 million Americans.
With health costs soaring, few would dispute that the government needs to find better ways to spend its Medicare dollars. But because the system relies heavily on private industry and is subject to Congressional oversight, few changes come easily, and even experimental programs can take on lives of their own.
Several of the companies, including two that specialize in disease management, Healthways and Health Dialog, are pressing Medicare to continue the project in some fashion beyond the end of this year, saying the government mishandled the experiment.
The senators from the home states of those two companies, including John Kerry, Democrat of Massachusetts, and Lamar Alexander, Republican of Tennessee, have taken up their cause, demanding that Medicare rethink ending the experiment.
“Stopping this program,” the senators wrote in a letter to Medicare last month, “creates serious health risks for the Medicare beneficiaries already enrolled and heavily reliant” on the services provided by the experiment.
Medicare, for its part, says the experiment so far has not reduced medical bills enough to offset the fees the companies are charging the government — as much as $2,000 a year for each patient. A final accounting of the experiment is likely to come no sooner than next year.
About 160,000 people have taken part in the test, known as the Medicare Health Support program, and some 70,000 are still receiving calls from nurses employed by the companies.
Experts say that Medicare and the companies alike were too optimistic about how easy it would be to prevent costly complications and hospital visits by patients who are very sick.
“Everybody shares some blame,” said Dr. David B. Nash, a health policy professor at Thomas Jefferson University in Philadelphia, who at the outset was enthusiastic about the program’s prospects for transforming Medicare.
On the experiment’s front lines are nurses like Jill Coker, who works for Healthways and makes 25 to 30 telephone calls a day, trying to ensure that each patient receives a call every few weeks. Through dozens of such nurses, Healthways, based in Nashville, is overseeing the care of 16,000 people in Maryland and Washington.
Ms. Coker said she spent most of her time on rudimentary issues, like explaining to patients what prescription drugs they are on and helping them devise ways to make sure they remember to take their medicine. She may also arrange a conference call with a patient’s doctor if there are some worrisome new symptoms, or she may direct someone to a specialist to get better care.
“There have been numerous diabetics who didn’t even know what an endocrinologist was,” she said.
Medicare has not finished studying how well patients do under the program and whether patients are satisfied with the help. Three of the original companies — Cigna, McKesson and LifeMasters — eventually dropped out.
The program has failed to meet the government’s original financial target: an overall savings to Medicare of 5 percent after factoring in the companies’ fees and the patients’ medical bills.
Initially, the companies were supposed to return their payments if they did not hit that target. Late last year, Medicare relaxed its standard, requiring only that the experiment not end up costing the government money.
The agency says that it will consider keeping any promising pieces of the program. But it says it cannot legally extend the experiment beyond December if it is not budget neutral.
“We want to lift up the seat cushions to find every nickel and dime we can find,” said Herb B. Kuhn, the deputy administrator for Medicare. The agency says no final decision on the fate of the program has been made.
But some health care experts say Medicare should move on to seek other ways of managing the care of the chronically ill, if alternatives seem to hold greater potential to deliver both cost savings and better care.
“Medicare is doing exactly what we should want Medicare to do — to test different life forms of disease management and see what works best,” said Dr. Arnold Milstein, the chief physician for Mercer Health and Benefits, a consulting firm. But, he said, “This particular form of disease management is not looking promising.”
Medicare is already exploring other ideas, like the development of so-called “medical homes,” where a doctor with a team of other professionals oversees a patient’s care. A few doctors’ groups involved in a separate Medicare experiment have reported some success in saving the government money by more actively managing their patients’ care.
Dr. Mark B. McClellan, who was the head of Medicare when the experiment began and is now a policy analyst at the Brookings Institution in Washington, says the point of Medicare’s experiments is to find out which approaches might work. “This is a hard problem that is not going to be solved all at once,” he said.
Many of the companies involved in the program say the experiment was flawed in the way it was designed and that Medicare has failed to work with them to make the program a success.
“We haven’t proven anything,” said Dr. Jeffrey L. Kang, a former Medicare official who is now the chief medical officer for the insurer Cigna.
The companies say Medicare signed up patients who were much sicker than they had expected. Instead of giving companies a chance to intervene before someone went to the hospital, Dr. Kang said, most of the patients were already so ill that it was “no longer a preventive program.”
The companies also say Medicare failed to make good on its promise to give them timely information about the use of prescription drugs, for example, or lab results that would have allowed them to help direct the patients’ care.
“We overestimated the real desire expressed by the organization,” said Ben R. Leedle Jr., the chief executive of Healthways, who has been an outspoken critic of Medicare. His company’s stock fell by 16 percent in a single day after the agency announced the experiment’s preliminary results in January.
Mr. Leedle says that Healthways will probably be able to demonstrate savings from at least some of its Medicare efforts, although the company also says it is projecting a loss on the experiment because it may have to pay back federal fees. Medicare has not made public data on the results for individual companies.
For its part, Medicare said that it had worked extensively with the companies to address their concerns and that its final analysis would take into account how sick the patients initially were.
One thing that already seems clear is that after the fees are paid to the contractors, any cost savings may be elusive. In late January, the agency estimated that to meet their targets the five remaining companies would need to reduce their monthly claims by an average of $300 to $800 per patient for the remainder of the experiment. That would represent a 20 to 40 percent reduction in the patients’ current medical bills.
George B. Bennett, the chief executive of Health Dialog, which is overseeing about 15,000 Medicare patients in western Pennsylvania, favors continuing the experiment, but with adjustments. He wants Medicare to give the companies more flexibility to manage patients in ways they say have already been proven to work among the employees they cover in commercial plans. Such measures, he said, include giving the insurer a bigger role in selecting the patients, with an eye toward identifying the ones most likely to be helped.
“Medicare actually has the possibility of saving $20 billion to $30 billion,” Mr. Bennett said, “if they undergo what is being done in the private sector.”
Whatever happens with this particular program, Medicare says it wants to keep experimenting. “We’re not giving up on this stuff,” said Mr. Kuhn, the Medicare deputy. “We definitely want these programs to work.”
Wednesday, March 12, 2008
Doctors and excess tests & consults
NYTimes
March 11, 2008
Essay
Many Doctors, Many Tests, No Rhyme or Reason
By SANDEEP JAUHAR, M.D.
I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his monthlong stay he was seen by a hematologist, an endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a nutritionist, a general surgeon, a thoracic surgeon and a pain specialist.
He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work-up chronic anemia).
Despite this wearying schedule, he maintained an upbeat manner, walking the corridors daily with assistance to chat with nurses and physician assistants. When he was discharged, follow-up visits were scheduled for him with seven specialists.
This man’s case, in which expert consultations sprouted with little rhyme, reason or coordination, reinforced a lesson I have learned many times since entering practice: In our health care system, where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur.
Though accurate data is lacking, the overuse of services in health care probably cost hundreds of billions of dollars last year, out of the more than $2 trillion that Americans spent on health.
Are we getting our money’s worth? Not according to the usual measures of public health. The United States ranks 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place, according to the Commonwealth Fund, a health-care research group, among major industrialized countries in health-care quality, access and efficiency.
And in the United States, regions that spend the most on health care appear to have higher mortality rates than regions that spend the least, perhaps because of increased hospitalization rates that result in more life-threatening errors and infections. It has been estimated that if the entire country spent the same as the lowest spending regions, the Medicare program alone could save about $40 billion a year.
Overutilization is driven by many factors — “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.
The most important factor, however, may be the perverse financial incentives of our current system.
Doctors are usually reimbursed for whatever they bill. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. If you cut the amount of air you take in per breath, the only way to maintain ventilation is to breathe faster.
Overconsultation and overtesting have now become facts of the medical profession. The culture in practice is to grab patients and generate volume. “Medicine has become like everything else,” a doctor told me recently. “Everything moves because of money.”
Consider medical imaging. According to a federal commission, from 1999 to 2004 the growth in the volume of imaging services per Medicare patient far outstripped the growth of all other physician services. In 2004, the cost of imaging services was close to $100 billion, or an average of roughly $350 per person in the United States.
Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.
“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was.
“I tried to practice ethical medicine, but it didn’t help. It didn’t pay, both from a financial and a reputation standpoint.”
His nuclear imaging camera was in an adjoining “procedure” room. He broke down the monthly costs for me: camera lease, $4,500; treadmill lease, $400; office space, $1,000; technician fee, $1,800; nurse fee, $1,000; and miscellaneous expenses of $200.
“Now say I get on average $850 per nuclear stress test,” he said. “Then I have to do at least 10 stress tests a month just to cover the costs, no profit going into my pocket.”
“So,” I said, “there’s pressure on you to do more than 10 stress tests a month, whether your patients need it or not.”
He shrugged and said, “That is what I have to do to break even.”
Last year, Congress approved steep reductions in Medicare payments for certain imaging services. Deeper cuts will almost certainly be forthcoming. This is good; unnecessary imaging is almost certainly taking place, leading to false-positive results, unnecessary invasive procedures, more complications and so on.
But the problem in medicine today is much larger than imaging. Doctors are doing too much testing and too many procedures, often for the sake of business. And patients, unfortunately, are paying the price.
“The hospital is a great place to be when you are sick,” a hospital executive told me recently. “But I don’t want my mother in here five minutes longer than she needs to be.”
Dr. Sandeep Jauhar is a cardiologist on Long Island and the author of the new memoir “Intern: A Doctor’s Initiation.”
March 11, 2008
Essay
Many Doctors, Many Tests, No Rhyme or Reason
By SANDEEP JAUHAR, M.D.
I recently took care of a 50-year-old man who had been admitted to the hospital short of breath. During his monthlong stay he was seen by a hematologist, an endocrinologist, a kidney specialist, a podiatrist, two cardiologists, a cardiac electrophysiologist, an infectious-diseases specialist, a pulmonologist, an ear-nose-throat specialist, a urologist, a gastroenterologist, a neurologist, a nutritionist, a general surgeon, a thoracic surgeon and a pain specialist.
He underwent 12 procedures, including cardiac catheterization, a pacemaker implant and a bone-marrow biopsy (to work-up chronic anemia).
Despite this wearying schedule, he maintained an upbeat manner, walking the corridors daily with assistance to chat with nurses and physician assistants. When he was discharged, follow-up visits were scheduled for him with seven specialists.
This man’s case, in which expert consultations sprouted with little rhyme, reason or coordination, reinforced a lesson I have learned many times since entering practice: In our health care system, where doctors are paid piecework for their services, if you have a slew of physicians and a willing patient, almost any sort of terrible excess can occur.
Though accurate data is lacking, the overuse of services in health care probably cost hundreds of billions of dollars last year, out of the more than $2 trillion that Americans spent on health.
Are we getting our money’s worth? Not according to the usual measures of public health. The United States ranks 45th in life expectancy, behind Bosnia and Jordan; near last, compared with other developed countries, in infant mortality; and in last place, according to the Commonwealth Fund, a health-care research group, among major industrialized countries in health-care quality, access and efficiency.
And in the United States, regions that spend the most on health care appear to have higher mortality rates than regions that spend the least, perhaps because of increased hospitalization rates that result in more life-threatening errors and infections. It has been estimated that if the entire country spent the same as the lowest spending regions, the Medicare program alone could save about $40 billion a year.
Overutilization is driven by many factors — “defensive” medicine by doctors trying to avoid lawsuits; patients’ demands; a pervading belief among doctors and patients that newer, more expensive technology is better.
The most important factor, however, may be the perverse financial incentives of our current system.
Doctors are usually reimbursed for whatever they bill. As reimbursement rates have declined in recent years, most doctors have adapted by increasing the quantity of services. If you cut the amount of air you take in per breath, the only way to maintain ventilation is to breathe faster.
Overconsultation and overtesting have now become facts of the medical profession. The culture in practice is to grab patients and generate volume. “Medicine has become like everything else,” a doctor told me recently. “Everything moves because of money.”
Consider medical imaging. According to a federal commission, from 1999 to 2004 the growth in the volume of imaging services per Medicare patient far outstripped the growth of all other physician services. In 2004, the cost of imaging services was close to $100 billion, or an average of roughly $350 per person in the United States.
Not long ago, I visited a friend — a cardiologist in his late 30s — at his office on Long Island to ask him about imaging in private practices.
“When I started in practice, I wanted to do the right thing,” he told me matter-of-factly. “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she’d just go down the street to another physician and he’d order all the tests anyway: echocardiogram, stress test, Holter monitor — stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor — a thorough doctor — the other cardiologist was.
“I tried to practice ethical medicine, but it didn’t help. It didn’t pay, both from a financial and a reputation standpoint.”
His nuclear imaging camera was in an adjoining “procedure” room. He broke down the monthly costs for me: camera lease, $4,500; treadmill lease, $400; office space, $1,000; technician fee, $1,800; nurse fee, $1,000; and miscellaneous expenses of $200.
“Now say I get on average $850 per nuclear stress test,” he said. “Then I have to do at least 10 stress tests a month just to cover the costs, no profit going into my pocket.”
“So,” I said, “there’s pressure on you to do more than 10 stress tests a month, whether your patients need it or not.”
He shrugged and said, “That is what I have to do to break even.”
Last year, Congress approved steep reductions in Medicare payments for certain imaging services. Deeper cuts will almost certainly be forthcoming. This is good; unnecessary imaging is almost certainly taking place, leading to false-positive results, unnecessary invasive procedures, more complications and so on.
But the problem in medicine today is much larger than imaging. Doctors are doing too much testing and too many procedures, often for the sake of business. And patients, unfortunately, are paying the price.
“The hospital is a great place to be when you are sick,” a hospital executive told me recently. “But I don’t want my mother in here five minutes longer than she needs to be.”
Dr. Sandeep Jauhar is a cardiologist on Long Island and the author of the new memoir “Intern: A Doctor’s Initiation.”
Friday, February 22, 2008
Go on a savings spree
NYTimes
February 22, 2008
Op-Ed Contributor
Go on a Savings Spree
By DALTON CONLEY
CONGRESS has passed and President Bush has signed legislation to rescue the economy from the jaws of recession. The $168 billion package, which includes an effort to increase consumer spending by distributing $600 rebates to individuals, can be faulted in many ways: with two wars and a budget deficit the nation can’t really afford it; it will probably arrive too late in the business cycle to actually make a difference; and the near-universal aspect of the rebates doesn’t make much sense. But the most fundamentally troubling thing is the premise that while consumer overspending got us into this mess, more will get us out of it. This is akin to the old saw about curing a hangover with the hair of the dog that bit you.
What if instead of giving rebates we helped create an investor society by seeding universal investment accounts? This would not only pump cash into the economy, through the slightly more indirect route of investment, it would also help us correct some of the near-fatal flaws in our long-term economic landscape.
The recent slowdown in gross domestic product growth is only a symptom of recession, not the cause. While there are many things to blame for the current crisis — most notably the subprime mortgage mess — one factor that has received little attention is America’s low savings rate. In 2005, net private savings in the United States were negative. In other words, we were spending money that we didn’t have, chipping away at our national wealth.
The last time the savings rate dipped into the red was during the Great Depression. At that time, of course, it made sense not to save. Joblessness was high and money scarce; we needed to dip into our kitty to survive. But our negative savings during the Bush boom had a different cause. Evidently, we felt so flush with (paper) gains in the stock and housing markets that we spent money as if there were no tomorrow.
Republicans have long argued that the way to stimulate long-term growth is by promoting investment over spending. Hence their perennial efforts to lower taxes on capital gains, dividends and corporate profits. But whether such policies actually stimulate increased investment is open to debate, since the wealthy folks who gain most from these tax reductions are probably already investing their money. And the tax savings don’t trickle down as much as their advocates claim.
Democrats, more concerned with helping working families, consider consumer spending to be the magic bullet, so they favor tax rebates. But this only encourages us to continue our profligate ways.
Why not combine the best of both philosophies and try to stimulate investment by all Americans? The simplest approach would be to seed universal mutual fund accounts for low-income Americans. The best way to do this would be through a so-called refundable tax credit deposited directly into a special investment account for each taxpayer. In future years, the government could contribute an additional 50 cents for every dollar the taxpayer deposited into this account. Think of it as a universal 401(k), but one that could be used not only for retirement but also for things like a down payment on a house, college expenses or unexpected health costs.
Such investment incentives would do more than just help stimulate business growth by providing new capital. They would fundamentally change taxpayers’ lives. Some research suggests that asset-holders behave more responsibly and are more civic-minded than those without wealth. After all, they have a stake in the future of the economy and their community. This is why banks in cities don’t readily offer mortgages for apartments in buildings in which most of the tenants are renters, not owners. My own research suggests that having savings and investment equity is one of the best predictors of whether someone’s children will attend and graduate from college. Investing motivates people of all income levels to defer gratification and become knowledgeable about the economy and society.
Finally, to the extent that investment accounts grow, they decouple economic security from job security. By providing a cushion during employment transitions, they are the best possible form of unemployment insurance.
For some reason, legislation to create universal investment accounts — proposed by senators and representatives from both parties over the past decade — has repeatedly stalled in Congress. But now the economy is in trouble, and there is general agreement that this is a time for action. President Bush has already authorized the plan to stimulate more of the spending that got us into this trouble. But it’s still not too late to make the effort to create a true investor society.
Dalton Conley, the chairman of New York University’s sociology department, is the author, most recently, of “The Pecking Order: A Bold New Look at How Family and Society Determine Who We Become.”
February 22, 2008
Op-Ed Contributor
Go on a Savings Spree
By DALTON CONLEY
CONGRESS has passed and President Bush has signed legislation to rescue the economy from the jaws of recession. The $168 billion package, which includes an effort to increase consumer spending by distributing $600 rebates to individuals, can be faulted in many ways: with two wars and a budget deficit the nation can’t really afford it; it will probably arrive too late in the business cycle to actually make a difference; and the near-universal aspect of the rebates doesn’t make much sense. But the most fundamentally troubling thing is the premise that while consumer overspending got us into this mess, more will get us out of it. This is akin to the old saw about curing a hangover with the hair of the dog that bit you.
What if instead of giving rebates we helped create an investor society by seeding universal investment accounts? This would not only pump cash into the economy, through the slightly more indirect route of investment, it would also help us correct some of the near-fatal flaws in our long-term economic landscape.
The recent slowdown in gross domestic product growth is only a symptom of recession, not the cause. While there are many things to blame for the current crisis — most notably the subprime mortgage mess — one factor that has received little attention is America’s low savings rate. In 2005, net private savings in the United States were negative. In other words, we were spending money that we didn’t have, chipping away at our national wealth.
The last time the savings rate dipped into the red was during the Great Depression. At that time, of course, it made sense not to save. Joblessness was high and money scarce; we needed to dip into our kitty to survive. But our negative savings during the Bush boom had a different cause. Evidently, we felt so flush with (paper) gains in the stock and housing markets that we spent money as if there were no tomorrow.
Republicans have long argued that the way to stimulate long-term growth is by promoting investment over spending. Hence their perennial efforts to lower taxes on capital gains, dividends and corporate profits. But whether such policies actually stimulate increased investment is open to debate, since the wealthy folks who gain most from these tax reductions are probably already investing their money. And the tax savings don’t trickle down as much as their advocates claim.
Democrats, more concerned with helping working families, consider consumer spending to be the magic bullet, so they favor tax rebates. But this only encourages us to continue our profligate ways.
Why not combine the best of both philosophies and try to stimulate investment by all Americans? The simplest approach would be to seed universal mutual fund accounts for low-income Americans. The best way to do this would be through a so-called refundable tax credit deposited directly into a special investment account for each taxpayer. In future years, the government could contribute an additional 50 cents for every dollar the taxpayer deposited into this account. Think of it as a universal 401(k), but one that could be used not only for retirement but also for things like a down payment on a house, college expenses or unexpected health costs.
Such investment incentives would do more than just help stimulate business growth by providing new capital. They would fundamentally change taxpayers’ lives. Some research suggests that asset-holders behave more responsibly and are more civic-minded than those without wealth. After all, they have a stake in the future of the economy and their community. This is why banks in cities don’t readily offer mortgages for apartments in buildings in which most of the tenants are renters, not owners. My own research suggests that having savings and investment equity is one of the best predictors of whether someone’s children will attend and graduate from college. Investing motivates people of all income levels to defer gratification and become knowledgeable about the economy and society.
Finally, to the extent that investment accounts grow, they decouple economic security from job security. By providing a cushion during employment transitions, they are the best possible form of unemployment insurance.
For some reason, legislation to create universal investment accounts — proposed by senators and representatives from both parties over the past decade — has repeatedly stalled in Congress. But now the economy is in trouble, and there is general agreement that this is a time for action. President Bush has already authorized the plan to stimulate more of the spending that got us into this trouble. But it’s still not too late to make the effort to create a true investor society.
Dalton Conley, the chairman of New York University’s sociology department, is the author, most recently, of “The Pecking Order: A Bold New Look at How Family and Society Determine Who We Become.”
Visiting Santa Monica
NYTimes
February 22, 2008
American Journeys | Santa Monica, California
Classic Beach, but Much More in Santa Monica
By LOUISE TUTELIAN
WITH its classic amusement pier, glittering bay and surfers bobbing on swells, Santa Monica was a perfect setting for “Baywatch.” But take a short walk inland, and this city on the edge of Los Angeles reveals itself as more than a stereotypical beach town.
Within its borders, drawings by Picasso and Dubuffet hang in the same art complex as a vast installation by a graffiti crew. A well-preserved Mission-style bungalow sits around the corner from a steel performance space by Frank Gehry. Shops sell goods ranging from vintage Parisian wedding gowns to a whimsical map made entirely out of license plates. There are homegrown coffee bars on nearly every block, with names like Groundwork or the Legal Grind, dispensing caffeine and counsel at the same time.
“The pier, the bike path — they’re the only things most people know about Santa Monica,” said Colleen Dunn Bates, editor of “Hometown Santa Monica,” an insider’s guide to the city. “And they’re fun. But they don’t reflect everything that the city really offers.”
Although it’s surrounded on all sides by districts that are part of the City of Los Angeles — Pacific Palisades, Venice and West Los Angeles — Santa Monica asserts its own identity as an eight-square-mile separate city, and its population of about 96,000 is spread through several distinct neighborhoods. To make the most of time there, enjoy the games and famed carousel of the Santa Monica Pier and then step back from the beach to sample the city’s variety the way Santa Monicans themselves do.
On one recent Saturday, Ren Farrar was luring passers-by to his stand at the open-air Santa Monica Farmers’ Market, close to the beach on Arizona Avenue. By state law, all goods at the market must be grown in California, and much of the produce is picked within 24 hours of its appearance there.
“Care to try a sample?” Mr. Farrar, 37, of Spring Hill Jersey Cheese of Petaluma, shouted as I walked by. Watching intently as I savored a cube of his Old World Portuguese, he observed, “This is mild enough to go with anything, yet firm enough to stand up to the heat.”
Down the block, Adams’ Stuff’ N Olives featured feta and anchovy-stuffed olives. Fair Hills Farms offered six kinds of organic apples. Across the street, shoppers dropped dried nectarines, plums and pears into bags. A family strolled by, munching on Cajun spiced almonds and sipping ice-cold lemonade, both produced only a few miles away.
Nate Allen, 30, a personal chef and restaurant consultant from nearby Venice, shops at the market routinely, as do many of the top chefs in the area.
“The greatest thing about this market is that you’re going to get what is absolutely perfect and in season for this region,” said Mr. Allen, who flaunts his trade by sporting a seven-inch-long tattoo of a knife on one forearm and a tattooed fork on the other. “For visitors, by the time you get to the last vendor, you’ve got a great picnic for wherever you want to go.”
He often takes his own picnic to the Backbone Trail, a 69-mile system that roughly follows the crest of the Santa Monica Mountains from Will Rogers State Historic Park just north of Santa Monica to Point Mugu State Park in Ventura County. Hikers can take an easy, sage-scented, two-mile loop from the parking lot at Will Rogers up to Inspiration Point, a sensational overlook of Santa Monica Bay from the Palos Verdes Peninsula to Point Dume in Malibu.
On a clear day, a hiker can see Catalina Island and the white dots of sails. Behind are the slopes of the Santa Monica Mountains, and in the distance, the high-rises of downtown Los Angeles. Up there, the muted chattering of birds and the hum of insects are the only sounds.
Back in northern Santa Monica, natural sights give way to architectural ones. Adelaide Drive, at the north end of the city, offers intriguing examples of early-20th-century architecture. Two of the homes designated as city landmarks are the Craftsman-style Isaac Milbank House (No. 236) — designed by the same firm that did Grauman’s Chinese Theater in Hollywood — and the stucco Worrel House (No. 710), which was built in the mid-1920s and has been described as a “Pueblo-Revival Maya fantasy.”
(Another selection of carefully kept old houses, in styles from Victorian and Craftsman to Spanish colonial revival, await in the Third Street Historic District.)
Some of the city’s best shopping is also on its northern rim, where the 10-block Montana Avenue district is known for upscale clothes, home décor, crafts, jewelry and art. At Every Picture Tells A Story (No. 1311-C) a lithograph of the cover of “Charlotte’s Web” signed by the illustrator, Garth Williams, hangs on a wall, and in the gallery (the store is also a children’s bookstore) original works by Maurice Sendak, Dr. Seuss and others are $150 to $150,000.
Next door, Rooms & Gardens (No. 1311-A) sells furniture, antiques and accessories like pillows fashioned from an antique Indian sari. The actress Mary Steenburgen, one of the store’s three owners, praised the walkability of the area — not a common commodity in Southern California — when I asked her about the location of her store.
“The thing I love about Montana is that you feel as if you are in a pedestrian city,” she said. “It’s fun to look out the window and see people walking by with their dogs, instead of just cars streaming by.”
Santa Monica is sunny almost all the time, but visitors who hit a rare rainy day might spend a good portion of it at Bergamot Station, a complex of art galleries that many miss because it’s so hard to find. Built on the site of a former trolley-line stop — hence its name — the complex is on Santa Monica’s east side, next to a freeway on a dead-end street. Inside corrugated tin warehouses, two dozen galleries show contemporary drawings, paintings, photographs, sculpture and mixed-media works.
Sherrie Goldfarb of West Los Angeles and her friend Nancy Recasner of Studio City, Calif., hopped puddles between buildings after one rain this winter. “I wander through here with friends and the variety of work is amazing,” said Ms. Goldfarb, 57, a regular at the galleries.
Many boldface names are represented. At Ikon Ltd./Kay Richards, drawings by Dubuffet, Basquiat and Picasso, among others, are on display through March 1. “Rarely Seen,” a show of Henri Cartier-Bresson photographs, is running through May 10 at the Peter Fetterman Gallery.
Those who want to sense what Santa Monica was like as a sleepy town of tiny bungalows can visit Ocean Park on the city’s south end, which borders Venice. This funky neighborhood, one of the birthplaces of skateboarding in the late 1960s (part of “Lords of Dogtown” was filmed there), got a makeover in the 1990s; the tiny bungalows now sell for millions.
Artsy Main Street, Ocean Park’s central artery of merchants, restaurants and galleries, manages to merge sneaker stores and used-book shops with Armani Exchange and Patagonia stores. At Varga (No. 2806) apparel and accessories seem jointly inspired by ’40s pin-ups, Barbie dolls and young Hollywood celeb-style. The inventory at Relish, off Main Street at 208 Pier Avenue, ranges from bath salts ($20 to $40) to a pinball baseball game ($110). The Frank Gehry-designed steel boxes of Edgemar (No. 2415-2449 Main Street) house retail tenants and a performance space around an open courtyard.
Appraise your purchases over a martini with a mermaid toothpick at the Galley (No. 2442), a steakhouse with signature décor (think tiki bar with Christmas lights), a soulful juke box and old-salt appeal. No wonder — it opened its thick plank doors in 1934, making it Santa Monica’s oldest restaurant.
As the day wanes, consider watching the jet set (the one with its own jets) fly into the sunset. Opt for dinner next to the runway at the Santa Monica Municipal Airport. Those in the know reserve a window table at the Pan-Asian fusion restaurant Typhoon or the more intimate sushi restaurant the Hump (pilot slang for the Himalayas) upstairs.
But at sunset, the most thrilling view in town is back at the beach, from the top of the solar-powered 130-foot-high Pacific Wheel, the Ferris wheel at the Santa Monica Pier. Yes, it’s touristy, and yes, it might be crowded, but it is, after all, the city’s iconic symbol.
As my seat on the wheel glided upward one evening, the entire city of Santa Monica, and far beyond, slid into view. Below, the cast and crew of the film “17 Again,” starring Matthew Perry and Zac Efron, were shooting on the beach, as they would be all night long. The whole scene was bathed in a deep pink and violet glow.
It felt just fine to act like a tourist for a while.
VISITOR INFORMATION
SANTA MONICA, adjacent to Los Angeles, has 3.5 miles of coastline, all publicly accessible; two miles of this waterfront make up Santa Monica State Beach. The city’s north-south numbered streets run from Second Street, a block from the water, eastward to 26th. The major east-west arteries are San Vicente, Wilshire, Santa Monica, Pico and Ocean Park Boulevards.
The Santa Monica Pier, with rides, games, souvenir shops and a 1922 carousel, is at the foot of Colorado Avenue. The Pacific Wheel, a Ferris wheel at the pier, will be closed May 5 to 22 as a new wheel is installed.
Beach lovers can step onto the sand from Loews Santa Monica Beach Hotel at 1700 Ocean Avenue (310-458-6700; www.loewshotels.com; rooms from $349). The 72-room Ambrose (1255 20th Street; 310-315-1555; www.ambrosehotel.com; from $229) feels more like a Mission-style hideaway with stained-glass windows and fireside library.
The Santa Monica Farmers’ Market is held on Arizona Avenue from Second to Fourth Streets, on Wednesdays from 8:30 a.m. to 1:30 p.m. and Saturdays from 8:30 a.m. to 1 p.m.
The Backbone Trail is in Will Rogers State Historic Park (1501 Will Rogers State Park Road, off West Sunset Boulevard, Pacific Palisades; 310-454-8212; www.nps.gov/samo/planyourvisit/backbonetrail.htm), which is open from 8 a.m. to sunset daily. Parking is $7. Picnic tables are available at Inspiration Point.
Most galleries at Bergamot Station (2525 Michigan Avenue; www.bergamotstation.com) are open from 10 a.m. to 6 p.m. Tuesday to Friday, and 11 a.m. to 5:30 p.m. on Saturday. Because Michigan Avenue is bisected by a freeway, the best access to this dead-end section of it is off Cloverfield Avenue.
At the Galley (2442 Main Street; 310-452-1934, www.thegalleyrestaurant.net) a 12-ounce sirloin is $23 and seafood diablo is $24.
Typhoon, at the Santa Monica Airport (3221 Donald Douglas Loop South off Airport Road; 310-390-6565; www.typhoon.biz) offers Pan-Asian fare including Thai river prawns ($21) and stir-fried crickets ($10). Upstairs, the Hump (310-313-0977; www.thehump.biz) serves some of the freshest sushi in town.
February 22, 2008
American Journeys | Santa Monica, California
Classic Beach, but Much More in Santa Monica
By LOUISE TUTELIAN
WITH its classic amusement pier, glittering bay and surfers bobbing on swells, Santa Monica was a perfect setting for “Baywatch.” But take a short walk inland, and this city on the edge of Los Angeles reveals itself as more than a stereotypical beach town.
Within its borders, drawings by Picasso and Dubuffet hang in the same art complex as a vast installation by a graffiti crew. A well-preserved Mission-style bungalow sits around the corner from a steel performance space by Frank Gehry. Shops sell goods ranging from vintage Parisian wedding gowns to a whimsical map made entirely out of license plates. There are homegrown coffee bars on nearly every block, with names like Groundwork or the Legal Grind, dispensing caffeine and counsel at the same time.
“The pier, the bike path — they’re the only things most people know about Santa Monica,” said Colleen Dunn Bates, editor of “Hometown Santa Monica,” an insider’s guide to the city. “And they’re fun. But they don’t reflect everything that the city really offers.”
Although it’s surrounded on all sides by districts that are part of the City of Los Angeles — Pacific Palisades, Venice and West Los Angeles — Santa Monica asserts its own identity as an eight-square-mile separate city, and its population of about 96,000 is spread through several distinct neighborhoods. To make the most of time there, enjoy the games and famed carousel of the Santa Monica Pier and then step back from the beach to sample the city’s variety the way Santa Monicans themselves do.
On one recent Saturday, Ren Farrar was luring passers-by to his stand at the open-air Santa Monica Farmers’ Market, close to the beach on Arizona Avenue. By state law, all goods at the market must be grown in California, and much of the produce is picked within 24 hours of its appearance there.
“Care to try a sample?” Mr. Farrar, 37, of Spring Hill Jersey Cheese of Petaluma, shouted as I walked by. Watching intently as I savored a cube of his Old World Portuguese, he observed, “This is mild enough to go with anything, yet firm enough to stand up to the heat.”
Down the block, Adams’ Stuff’ N Olives featured feta and anchovy-stuffed olives. Fair Hills Farms offered six kinds of organic apples. Across the street, shoppers dropped dried nectarines, plums and pears into bags. A family strolled by, munching on Cajun spiced almonds and sipping ice-cold lemonade, both produced only a few miles away.
Nate Allen, 30, a personal chef and restaurant consultant from nearby Venice, shops at the market routinely, as do many of the top chefs in the area.
“The greatest thing about this market is that you’re going to get what is absolutely perfect and in season for this region,” said Mr. Allen, who flaunts his trade by sporting a seven-inch-long tattoo of a knife on one forearm and a tattooed fork on the other. “For visitors, by the time you get to the last vendor, you’ve got a great picnic for wherever you want to go.”
He often takes his own picnic to the Backbone Trail, a 69-mile system that roughly follows the crest of the Santa Monica Mountains from Will Rogers State Historic Park just north of Santa Monica to Point Mugu State Park in Ventura County. Hikers can take an easy, sage-scented, two-mile loop from the parking lot at Will Rogers up to Inspiration Point, a sensational overlook of Santa Monica Bay from the Palos Verdes Peninsula to Point Dume in Malibu.
On a clear day, a hiker can see Catalina Island and the white dots of sails. Behind are the slopes of the Santa Monica Mountains, and in the distance, the high-rises of downtown Los Angeles. Up there, the muted chattering of birds and the hum of insects are the only sounds.
Back in northern Santa Monica, natural sights give way to architectural ones. Adelaide Drive, at the north end of the city, offers intriguing examples of early-20th-century architecture. Two of the homes designated as city landmarks are the Craftsman-style Isaac Milbank House (No. 236) — designed by the same firm that did Grauman’s Chinese Theater in Hollywood — and the stucco Worrel House (No. 710), which was built in the mid-1920s and has been described as a “Pueblo-Revival Maya fantasy.”
(Another selection of carefully kept old houses, in styles from Victorian and Craftsman to Spanish colonial revival, await in the Third Street Historic District.)
Some of the city’s best shopping is also on its northern rim, where the 10-block Montana Avenue district is known for upscale clothes, home décor, crafts, jewelry and art. At Every Picture Tells A Story (No. 1311-C) a lithograph of the cover of “Charlotte’s Web” signed by the illustrator, Garth Williams, hangs on a wall, and in the gallery (the store is also a children’s bookstore) original works by Maurice Sendak, Dr. Seuss and others are $150 to $150,000.
Next door, Rooms & Gardens (No. 1311-A) sells furniture, antiques and accessories like pillows fashioned from an antique Indian sari. The actress Mary Steenburgen, one of the store’s three owners, praised the walkability of the area — not a common commodity in Southern California — when I asked her about the location of her store.
“The thing I love about Montana is that you feel as if you are in a pedestrian city,” she said. “It’s fun to look out the window and see people walking by with their dogs, instead of just cars streaming by.”
Santa Monica is sunny almost all the time, but visitors who hit a rare rainy day might spend a good portion of it at Bergamot Station, a complex of art galleries that many miss because it’s so hard to find. Built on the site of a former trolley-line stop — hence its name — the complex is on Santa Monica’s east side, next to a freeway on a dead-end street. Inside corrugated tin warehouses, two dozen galleries show contemporary drawings, paintings, photographs, sculpture and mixed-media works.
Sherrie Goldfarb of West Los Angeles and her friend Nancy Recasner of Studio City, Calif., hopped puddles between buildings after one rain this winter. “I wander through here with friends and the variety of work is amazing,” said Ms. Goldfarb, 57, a regular at the galleries.
Many boldface names are represented. At Ikon Ltd./Kay Richards, drawings by Dubuffet, Basquiat and Picasso, among others, are on display through March 1. “Rarely Seen,” a show of Henri Cartier-Bresson photographs, is running through May 10 at the Peter Fetterman Gallery.
Those who want to sense what Santa Monica was like as a sleepy town of tiny bungalows can visit Ocean Park on the city’s south end, which borders Venice. This funky neighborhood, one of the birthplaces of skateboarding in the late 1960s (part of “Lords of Dogtown” was filmed there), got a makeover in the 1990s; the tiny bungalows now sell for millions.
Artsy Main Street, Ocean Park’s central artery of merchants, restaurants and galleries, manages to merge sneaker stores and used-book shops with Armani Exchange and Patagonia stores. At Varga (No. 2806) apparel and accessories seem jointly inspired by ’40s pin-ups, Barbie dolls and young Hollywood celeb-style. The inventory at Relish, off Main Street at 208 Pier Avenue, ranges from bath salts ($20 to $40) to a pinball baseball game ($110). The Frank Gehry-designed steel boxes of Edgemar (No. 2415-2449 Main Street) house retail tenants and a performance space around an open courtyard.
Appraise your purchases over a martini with a mermaid toothpick at the Galley (No. 2442), a steakhouse with signature décor (think tiki bar with Christmas lights), a soulful juke box and old-salt appeal. No wonder — it opened its thick plank doors in 1934, making it Santa Monica’s oldest restaurant.
As the day wanes, consider watching the jet set (the one with its own jets) fly into the sunset. Opt for dinner next to the runway at the Santa Monica Municipal Airport. Those in the know reserve a window table at the Pan-Asian fusion restaurant Typhoon or the more intimate sushi restaurant the Hump (pilot slang for the Himalayas) upstairs.
But at sunset, the most thrilling view in town is back at the beach, from the top of the solar-powered 130-foot-high Pacific Wheel, the Ferris wheel at the Santa Monica Pier. Yes, it’s touristy, and yes, it might be crowded, but it is, after all, the city’s iconic symbol.
As my seat on the wheel glided upward one evening, the entire city of Santa Monica, and far beyond, slid into view. Below, the cast and crew of the film “17 Again,” starring Matthew Perry and Zac Efron, were shooting on the beach, as they would be all night long. The whole scene was bathed in a deep pink and violet glow.
It felt just fine to act like a tourist for a while.
VISITOR INFORMATION
SANTA MONICA, adjacent to Los Angeles, has 3.5 miles of coastline, all publicly accessible; two miles of this waterfront make up Santa Monica State Beach. The city’s north-south numbered streets run from Second Street, a block from the water, eastward to 26th. The major east-west arteries are San Vicente, Wilshire, Santa Monica, Pico and Ocean Park Boulevards.
The Santa Monica Pier, with rides, games, souvenir shops and a 1922 carousel, is at the foot of Colorado Avenue. The Pacific Wheel, a Ferris wheel at the pier, will be closed May 5 to 22 as a new wheel is installed.
Beach lovers can step onto the sand from Loews Santa Monica Beach Hotel at 1700 Ocean Avenue (310-458-6700; www.loewshotels.com; rooms from $349). The 72-room Ambrose (1255 20th Street; 310-315-1555; www.ambrosehotel.com; from $229) feels more like a Mission-style hideaway with stained-glass windows and fireside library.
The Santa Monica Farmers’ Market is held on Arizona Avenue from Second to Fourth Streets, on Wednesdays from 8:30 a.m. to 1:30 p.m. and Saturdays from 8:30 a.m. to 1 p.m.
The Backbone Trail is in Will Rogers State Historic Park (1501 Will Rogers State Park Road, off West Sunset Boulevard, Pacific Palisades; 310-454-8212; www.nps.gov/samo/planyourvisit/backbonetrail.htm), which is open from 8 a.m. to sunset daily. Parking is $7. Picnic tables are available at Inspiration Point.
Most galleries at Bergamot Station (2525 Michigan Avenue; www.bergamotstation.com) are open from 10 a.m. to 6 p.m. Tuesday to Friday, and 11 a.m. to 5:30 p.m. on Saturday. Because Michigan Avenue is bisected by a freeway, the best access to this dead-end section of it is off Cloverfield Avenue.
At the Galley (2442 Main Street; 310-452-1934, www.thegalleyrestaurant.net) a 12-ounce sirloin is $23 and seafood diablo is $24.
Typhoon, at the Santa Monica Airport (3221 Donald Douglas Loop South off Airport Road; 310-390-6565; www.typhoon.biz) offers Pan-Asian fare including Thai river prawns ($21) and stir-fried crickets ($10). Upstairs, the Hump (310-313-0977; www.thehump.biz) serves some of the freshest sushi in town.
Wednesday, February 06, 2008
Americans cutting back on consumer spending
NYTimes
February 5, 2008
Economy Fitful, Americans Start to Pay as They Go
By PETER S. GOODMAN
For more than half a century, Americans have proved staggeringly resourceful at finding new ways to spend money.
In the 1950s and ’60s, as credit cards grew in popularity, many began dining out when the mood struck or buying new television sets on the installment plan rather than waiting for payday. By the 1980s, millions of Americans were entrusting their savings to the booming stock market, using the winnings to spend in excess of their income. Millions more exuberantly borrowed against the value of their homes.
But now the freewheeling days of credit and risk may have run their course — at least for a while and perhaps much longer — as a period of involuntary thrift unfolds in many households. With the number of jobs shrinking, housing prices falling and debt levels swelling, the same nation that pioneered the no-money-down mortgage suddenly confronts an unfamiliar imperative: more Americans must live within their means.
“We don’t use our credit cards anymore,” said Lisa Merhaut, a professional at a telecommunications company who lives in Leesburg, Va., and whose family last year ran up credit card debt it could not handle.
Today, Ms. Merhaut, 44, manages her money the way her father did. Despite a household income reaching six figures, she uses cash for every purchase. “What we have is what we have,” Ms. Merhaut said. “We have to rely on the money that we’re bringing in.”
The shift under way feels to some analysts like a cultural inflection point, one with huge implications for an economy driven overwhelmingly by consumer spending.
While some experts question whether most Americans, particularly baby boomers, will ever give up their buy-now/pay-later way of life, the unraveling of the real estate market appears to have left millions of families with little choice, yanking fresh credit from their grasp.
“The long collapse in the United States savings rate is over,” said Ethan S. Harris, chief United States economist for Lehman Brothers. “People are going to start saving the old-fashioned way, rather than letting the stock market and rising home values do it for them.”
In 1984, Americans were still saving more than one-tenth of their income, according to the government. A decade later, the rate was down by half. Now, the savings rate is slightly negative, suggesting that on average Americans spend more than their disposable income.
Though the savings rate does not account for the increased value of stock and property, or the gains on retirement accounts, many economists still view it as the most useful gauge of the degree to which Americans are making provisions for the future.
For the 34 million households who took money out of their homes over the last four years by refinancing or borrowing against their equity — roughly one-third of the nation — the savings rate was running at a negative 13 percent in the middle of 2006, according to Moody’s Economy.com. That means they were borrowing heavily against their assets to finance their day-to-day lives.
By late last year, the savings rate for this group had improved, but just to negative 7 percent and mostly because tightened standards made loans harder to get.
“For them, that game is over,” said Mark Zandi, chief economist at Economy.com. “They have been spending well beyond their incomes, and now they are seeing the limits of credit.”
Many times before, of course, Americans have found innovative ways to finance spending, even when austerity seemed unavoidable. It could happen again.
The Me Decade was declared dead in the recession of the early 1980s, only to yield to the Age of Greed and later the Internet boom of the 1990s. Over the longer term, the economy should keep growing at a pace that reflects improving productivity and population gains.
But for the first time in decades, credit is especially tight as the bursting of the housing bubble has spread misery across the financial system. In homes now saturated with debt, conspicuous consumption and creative financing have come to seem a sign of excess not unlike that of a suntan in an age of skin cancer.
The return to reality is on vivid display at shopping centers, where consumers used to trading up to higher-price stores are now heading to discounters. Wal-Mart and T. J. Maxx are thriving, but business has slowed at Coach, Tiffany and Williams-Sonoma.
Not long ago, Elena Gamble would have looked at the Cadillac parked across the street from her modest home in Elk City, Okla., and felt a twinge of jealousy.
“We live in a small town, and everybody looks at your clothes and what you drive and where you have your hair done,” said Ms. Gamble, who earns about $2,600 a month as a grievance counselor at a local prison.
Now, she and her husband — a prison guard who brings home $2,000 a month — are grappling with $10,000 in high-interest debt. They no longer go to the movies or out to eat, except occasionally to McDonald’s. They quit their Internet service. Their car was repossessed. “What we say now is, ‘If we can’t afford it, we can’t buy it,’ ” Ms. Gamble said.
And when she looks across the street at that Cadillac, her envy has been replaced by pity for the neighbor on the hook.
“I say, ‘Oh my, you’re living here, and driving that? There’s got to be something wrong,’ ” Ms. Gamble said. “ ‘You’re in debt, and you’re in trouble.’ ”
For decades, that envy has been a prime engine of economic growth. Debt-willing consumers hungering for the latest-generation this and the fastest that kept factories busy from Michigan to Malaysia.
From 1980 to 2007, consumer spending swelled from 63 percent of the economy to over 70 percent, according to Economy.com, while the share of after-tax income absorbed by household debt increased from 11 percent to more than 14 percent.
During the technology boom of the 1990s, an extravagant mind-set took hold. In ads for the discount broker Ameritrade, a spiky-haired hipster ridiculed middle-aged professionals for settling for conventional returns.
Even after the “stock market as money machine” line of thinking proved bogus, extra spending continued. The Federal Reserve cut interest rates to near record lows, banks marketed mortgages with exotically lenient terms and another fable of wealth creation took hold: the notion that housing prices could go up forever.
The come-ons for stocks were replaced by a new crop of advertisements. A house was no longer a mere place to live; it was a checkbook that never required a deposit. Between 2004 and 2006, Americans pulled more than $800 billion a year from their homes via sales, cash-out mortgages and home equity loans.
“People have come to view credit as savings,” said Michelle Jones, a vice president at the Consumer Credit Counseling Service of Greater Atlanta.
Some Americans have so much wealth that they can spend enough to fuel much of the economy. The top fifth of American earners generates half of all consumer spending, noted Dean Maki, chief United States economist at Barclays Capital.
For the others, some say credit is an intrinsic part of modern life, and Americans will soon be back for more. “A river of red ink runs through the history of the American pocketbook,” said Lendol Calder, author of “Financing the American Dream: A Cultural History of Consumer Credit.”
“Partly because of desire, partly because of optimism, partly because lenders have been free to invent useful borrowing tools that minimized shame and bother,” he added, “I think it will take a great catastrophe, greater than the Great Depression, to wean Americans from their reliance on consumer credit.”
Credit counselors are now swamped by calls not just from people of modest means, but from professionals earning six-figure incomes, their access to finance warping their distinction between necessity and desire.
“The longer someone has lived on a high income, the harder it is for someone to cut back,” said Manuel Navarro of Money Management International in San Diego. “I ask them, ‘Do you really need to have a 60-inch flat-screen TV hanging on your wall?’ ”
Fran Barbaro has an M.B.A. and a résumé of computer industry jobs with salaries reaching $150,000 a year. She used to have a stock portfolio worth about $1 million. She hung original art on the walls of her three-bedroom house in Boston.
But divorce, illness and motherhood drained her savings. Her home is worth less than she owes, and she owes another $200,000 to credit card companies, banks and tax collectors.
Ms. Barbaro, 50, said she knew she was living beyond her means. But her house demanded work. Her two boys needed after-school programs running $25,000 a year. Medical bills multiplied.
“These were simple day-to-day expenses,” she said. “The money was always there.”
Until it wasn’t. Her take-home pay is $5,200 a month, but her debt payments reach $4,400.
Ms. Barbaro has rented out her house while negotiating to lower her mortgage. She has moved to an apartment, where her sons sleep in the lone bedroom while she sleeps on a pull-out sofa.
“It’s the worst,” Ms. Barbaro said. “How do you salvage what you have and hopefully go back?”
February 5, 2008
Economy Fitful, Americans Start to Pay as They Go
By PETER S. GOODMAN
For more than half a century, Americans have proved staggeringly resourceful at finding new ways to spend money.
In the 1950s and ’60s, as credit cards grew in popularity, many began dining out when the mood struck or buying new television sets on the installment plan rather than waiting for payday. By the 1980s, millions of Americans were entrusting their savings to the booming stock market, using the winnings to spend in excess of their income. Millions more exuberantly borrowed against the value of their homes.
But now the freewheeling days of credit and risk may have run their course — at least for a while and perhaps much longer — as a period of involuntary thrift unfolds in many households. With the number of jobs shrinking, housing prices falling and debt levels swelling, the same nation that pioneered the no-money-down mortgage suddenly confronts an unfamiliar imperative: more Americans must live within their means.
“We don’t use our credit cards anymore,” said Lisa Merhaut, a professional at a telecommunications company who lives in Leesburg, Va., and whose family last year ran up credit card debt it could not handle.
Today, Ms. Merhaut, 44, manages her money the way her father did. Despite a household income reaching six figures, she uses cash for every purchase. “What we have is what we have,” Ms. Merhaut said. “We have to rely on the money that we’re bringing in.”
The shift under way feels to some analysts like a cultural inflection point, one with huge implications for an economy driven overwhelmingly by consumer spending.
While some experts question whether most Americans, particularly baby boomers, will ever give up their buy-now/pay-later way of life, the unraveling of the real estate market appears to have left millions of families with little choice, yanking fresh credit from their grasp.
“The long collapse in the United States savings rate is over,” said Ethan S. Harris, chief United States economist for Lehman Brothers. “People are going to start saving the old-fashioned way, rather than letting the stock market and rising home values do it for them.”
In 1984, Americans were still saving more than one-tenth of their income, according to the government. A decade later, the rate was down by half. Now, the savings rate is slightly negative, suggesting that on average Americans spend more than their disposable income.
Though the savings rate does not account for the increased value of stock and property, or the gains on retirement accounts, many economists still view it as the most useful gauge of the degree to which Americans are making provisions for the future.
For the 34 million households who took money out of their homes over the last four years by refinancing or borrowing against their equity — roughly one-third of the nation — the savings rate was running at a negative 13 percent in the middle of 2006, according to Moody’s Economy.com. That means they were borrowing heavily against their assets to finance their day-to-day lives.
By late last year, the savings rate for this group had improved, but just to negative 7 percent and mostly because tightened standards made loans harder to get.
“For them, that game is over,” said Mark Zandi, chief economist at Economy.com. “They have been spending well beyond their incomes, and now they are seeing the limits of credit.”
Many times before, of course, Americans have found innovative ways to finance spending, even when austerity seemed unavoidable. It could happen again.
The Me Decade was declared dead in the recession of the early 1980s, only to yield to the Age of Greed and later the Internet boom of the 1990s. Over the longer term, the economy should keep growing at a pace that reflects improving productivity and population gains.
But for the first time in decades, credit is especially tight as the bursting of the housing bubble has spread misery across the financial system. In homes now saturated with debt, conspicuous consumption and creative financing have come to seem a sign of excess not unlike that of a suntan in an age of skin cancer.
The return to reality is on vivid display at shopping centers, where consumers used to trading up to higher-price stores are now heading to discounters. Wal-Mart and T. J. Maxx are thriving, but business has slowed at Coach, Tiffany and Williams-Sonoma.
Not long ago, Elena Gamble would have looked at the Cadillac parked across the street from her modest home in Elk City, Okla., and felt a twinge of jealousy.
“We live in a small town, and everybody looks at your clothes and what you drive and where you have your hair done,” said Ms. Gamble, who earns about $2,600 a month as a grievance counselor at a local prison.
Now, she and her husband — a prison guard who brings home $2,000 a month — are grappling with $10,000 in high-interest debt. They no longer go to the movies or out to eat, except occasionally to McDonald’s. They quit their Internet service. Their car was repossessed. “What we say now is, ‘If we can’t afford it, we can’t buy it,’ ” Ms. Gamble said.
And when she looks across the street at that Cadillac, her envy has been replaced by pity for the neighbor on the hook.
“I say, ‘Oh my, you’re living here, and driving that? There’s got to be something wrong,’ ” Ms. Gamble said. “ ‘You’re in debt, and you’re in trouble.’ ”
For decades, that envy has been a prime engine of economic growth. Debt-willing consumers hungering for the latest-generation this and the fastest that kept factories busy from Michigan to Malaysia.
From 1980 to 2007, consumer spending swelled from 63 percent of the economy to over 70 percent, according to Economy.com, while the share of after-tax income absorbed by household debt increased from 11 percent to more than 14 percent.
During the technology boom of the 1990s, an extravagant mind-set took hold. In ads for the discount broker Ameritrade, a spiky-haired hipster ridiculed middle-aged professionals for settling for conventional returns.
Even after the “stock market as money machine” line of thinking proved bogus, extra spending continued. The Federal Reserve cut interest rates to near record lows, banks marketed mortgages with exotically lenient terms and another fable of wealth creation took hold: the notion that housing prices could go up forever.
The come-ons for stocks were replaced by a new crop of advertisements. A house was no longer a mere place to live; it was a checkbook that never required a deposit. Between 2004 and 2006, Americans pulled more than $800 billion a year from their homes via sales, cash-out mortgages and home equity loans.
“People have come to view credit as savings,” said Michelle Jones, a vice president at the Consumer Credit Counseling Service of Greater Atlanta.
Some Americans have so much wealth that they can spend enough to fuel much of the economy. The top fifth of American earners generates half of all consumer spending, noted Dean Maki, chief United States economist at Barclays Capital.
For the others, some say credit is an intrinsic part of modern life, and Americans will soon be back for more. “A river of red ink runs through the history of the American pocketbook,” said Lendol Calder, author of “Financing the American Dream: A Cultural History of Consumer Credit.”
“Partly because of desire, partly because of optimism, partly because lenders have been free to invent useful borrowing tools that minimized shame and bother,” he added, “I think it will take a great catastrophe, greater than the Great Depression, to wean Americans from their reliance on consumer credit.”
Credit counselors are now swamped by calls not just from people of modest means, but from professionals earning six-figure incomes, their access to finance warping their distinction between necessity and desire.
“The longer someone has lived on a high income, the harder it is for someone to cut back,” said Manuel Navarro of Money Management International in San Diego. “I ask them, ‘Do you really need to have a 60-inch flat-screen TV hanging on your wall?’ ”
Fran Barbaro has an M.B.A. and a résumé of computer industry jobs with salaries reaching $150,000 a year. She used to have a stock portfolio worth about $1 million. She hung original art on the walls of her three-bedroom house in Boston.
But divorce, illness and motherhood drained her savings. Her home is worth less than she owes, and she owes another $200,000 to credit card companies, banks and tax collectors.
Ms. Barbaro, 50, said she knew she was living beyond her means. But her house demanded work. Her two boys needed after-school programs running $25,000 a year. Medical bills multiplied.
“These were simple day-to-day expenses,” she said. “The money was always there.”
Until it wasn’t. Her take-home pay is $5,200 a month, but her debt payments reach $4,400.
Ms. Barbaro has rented out her house while negotiating to lower her mortgage. She has moved to an apartment, where her sons sleep in the lone bedroom while she sleeps on a pull-out sofa.
“It’s the worst,” Ms. Barbaro said. “How do you salvage what you have and hopefully go back?”
Thursday, December 20, 2007
101 simple appetizers
NYTimes
December 19, 2007
The Minimalist
101 Simple Appetizers in 20 Minutes or Less
By MARK BITTMAN
YOU want good food at a holiday cocktail party and you want to impress people? You don’t want a caterer, you refuse to heat up frozen food, and you want to show that your expertise extends beyond buying perfectly ripe hunks of cheese and juicy olives? Then think about doing some cooking.
Here is a collection of party foods that are as easy to eat as they are to make. Each can be produced in 20 minutes or less. Many can be served at room temperature. And none require a plate. (Few people can juggle plate, wineglass and fork successfully, let alone gracefully.)
Most of these recipes are beyond minimalist: they never do in two steps what can be done in one, and they need no embellishment. As you scan these recipes for ideas, mostly think this: The ones you find most appealing are the ones your guests will like. Choose a few, spend an hour or two in the kitchen, and you’ll be in great shape.
On Bread or Crackers
1 Red peppers and anchovies: Drizzle piquillos or other roasted red peppers with olive oil, and top with a good anchovy fillet. A caper or two on each is not amiss.
2 Top rye flatbread with thin slices of crisp apple and pickled plain or schmaltz herring (not herring in cream sauce).
3 Sear skirt steak to medium-rare, not more than 8 minutes. Cut into chunks 1/2-inch to 1 inch, first with the grain, then against it. Spread bread with coarse mustard and/or butter. Top with steak and coarse salt.
4 Toss high-quality crab meat with minced shallots, a little tarragon or a lot of parsley and/or basil, and enough mayonnaise to bind. Also good on lettuce leaves.
5 Mash together best-quality tuna, minced anchovies, minced garlic, chopped oil-cured olives and olive oil as necessary.
6 New York comfort food: Spread cream cheese or crème fraîche on small bagels or bagel chips; black bread is also terrific. Top with sturgeon, sable or lox.
7 Slice soft goat cheese and brush with olive oil. Sprinkle with salt, pepper and chopped herbs, then with bread crumbs. Bake at 350 degrees until soft, about 10 minutes, and serve hot.
8 Might not be the new ketchup, but great stuff: purée skinned roasted peppers or piquillos with some of their liquid, salt and olive oil. Serve alone or with other foods — a piece of cheese, even.
9 Top buttered bread with shaved country ham, prosciutto or regular deli ham and bread-and-butter pickles.
10 Chop shrimp fine, then sauté in a minimum of oil, or poach quickly and drain. Mix premade pesto with mayonnaise so that it is gluey. Combine cooled shrimp with sufficient pesto to bind; chill.
11 Tapenade: Combine about 1 pound pitted black olives in food processor with 1/4 cup drained capers, at least 5 anchovies, 2 garlic cloves, black pepper and olive oil as necessary to make a coarse paste. Can also be a dip. Use sparingly; it’s strong.
12 A kind of Moroccan tapenade: As above, but use good green olives with capers; olive-oil-canned tuna (instead of anchovies); garlic, if desired; and cumin.
13 Chop fresh mushrooms. Cook slowly in olive oil with salt and pepper until very soft. Stir in minced garlic and parsley. Cook a few more minutes until garlic mellows. (Especially good if you add reconstituted dried porcini.)
14 Mix together a bit of flour and good paprika. Cut Manchego or similar sheep’s milk cheese into 1/2-inch-thick slices. Dip in flour, then beaten egg, then bread crumbs, and fry quickly to brown on both sides. Drain on paper towels and serve hot.
15 Beef tartare: Carefully pulse good beef in food processor. For each pound, add an egg, a teaspoon dry mustard, a tablespoon Dijon mustard, a tablespoon Worcestershire, Tabasco to taste, 1/2 cup chopped scallions and a touch of minced garlic. Salt and pepper, if necessary. Amazing stuff.
16 Put a thick film of olive oil in a skillet over low heat with lots of thin-sliced garlic. When it sizzles, add shrimp along with pimentón. Raise the heat just enough to get the shrimp going, and cook until it’s pink. Stir in parsley. Spoon a little of the oil onto pieces of bread and top with shrimp.
17 Season cornmeal with lots of chili powder, salt and black pepper. Heat a thick film of neutral oil (or oil mixed with butter) in a skillet. Dredge shucked clams, oysters or chicken breast pieces in the cornmeal and cook about 2 minutes a side, or until crisp. Serve on bread with mayonnaise, or sprinkle with lemon or lime juice and serve on toothpicks. It’s almost convenience food when prepared with shucked mollusks.
Bruschetta
18 Bruschetta is the basis for so many good things. Don’t make it too crisp, and start with good country bread. Brush thick slices with olive oil. Broil until toasted on both sides. While it’s still hot, rub with cut clove of garlic on one side (optional). Drizzle with a bit more olive oil, sprinkle with salt, and serve, or top with prosciutto or tapenade.
19 More than party food, and an amazing snack: Top bruschetta with white beans cooked soft (or use canned) and finished with minced garlic, sage, olive oil and salt.
20 One more level: Make white beans as above. Toss with good quality canned tuna and mash. Spoon over bruschetta.
21 Top bruschetta with chopped, well-cooked broccoli rabe or other greens tossed with minced garlic and olive oil while still warm. Health food, practically. Also good with a layer of Tuscan beans (above).
On Toothpicks
22 Cut pork tenderloin into 1-inch slices; broil or sauté until done. Cut each piece across into 3 or 4 thin slices, then pile onto round bread slices, toasted or not. Top with slice of Manchego and bit of piquillo pepper.
23 Cut chorizo into chunks. Cook in a lightly oiled skillet until nicely browned. Kielbasa is equally good (or better), if not as hip.
24 Portable Caprese: Skewer a small ball of mozzarella, a grape tomato and a bit of basil leaf. Sprinkle with salt and pepper, and drizzle with oil.
25 A no-brainer: Cut slab of bacon into 1/2-inch chunks. Cook in a skillet, a broiler or a high-heat oven until nice and crisp. Skewer with a grape tomato.
26 Even jazzier: Cut just-ripe pears in 1/2-inch cubes; sprinkle with a little salt, sugar and cayenne. Spear with bacon.
27 Pair crispy bacon chunks with one cube of beet and one of goat cheese.
28 Angels on horseback: Wrap oysters or not-too-large sea scallops in bacon; skewer with toothpicks. Broil, turning once, until bacon is done.
29 You can call them devils on horseback: Wrap pitted dates (replacing the pit with an almond if you like) in bacon. Skewer with toothpicks and broil, turning once, until bacon is done.
30 Rumaki, a 1960s cocktail food that deserves reviving: Brush canned water chestnuts (or chicken liver halves, or crimini mushrooms, or pieces of portobello) with a little soy sauce; wrap in pieces of bacon. Skewer closed with toothpicks and broil, turning once, until bacon is done.
31 Wash mussels or littleneck clams well; steam open in covered pot. Let cool, remove from shells, and serve with aioli, flavored mayonnaise or vinaigrette.
32 Cook real bay scallops in hot butter or oil for just a couple of minutes. Sprinkle with lemon juice and parsley and serve hot.
33 Crab cakes: For each pound crab meat, add an egg, 1/4 cup each minced bell pepper and onion, 1/4 cup mayonnaise, 1 tablespoon Dijon mustard, 2 tablespoons bread or cracker crumbs, salt and pepper. Shape into small cakes and refrigerate, if time allows. Dredge in flour, then brown in oil (or oil mixed with butter). Serve with lemon wedges, aioli or tartar sauce.
34 Meatballs: Combine 1 thick slice white bread with 1/2 cup milk; let sit for 5 minutes. Squeeze milk from bread and gently mix bread with 1/2 pound not-too-lean ground sirloin, 1/2 pound ground pork, 1/2 cup chopped onion, 1/2 cup freshly grated Parmesan, 1/4 cup chopped fresh parsley leaves and salt and pepper. Shape into 1-inch balls. (If mixture doesn’t hold well, add more bread crumbs and an egg.) Broil about 5 minutes, turning once or twice.
35 Cod cakes with sauce rouge: I’m hedging on time here, but you’re really getting two recipes in one: Combine 1 pound chopped boneless cod, an egg, 1/4 cup mayonnaise, a tablespoon Dijon mustard and some salt and pepper. Add bread or cracker crumbs until you can shape the mixture into cakes. If possible, refrigerate for an hour. Meanwhile, cook chopped canned tomatoes in olive oil with salt and cayenne until saucy. Shape small cod cakes. Dredge in flour, sauté in butter and oil until nicely browned. Serve hot or at room temperature, with sauce on the side.
36 The banderilla: The first tapa created, or at least that’s what people tell me. Skewer a crisp pickled pepper, an anchovy and a pitted green olive. Incredible with dry (fino) sherry.
37 Toss peeled shrimp with lots of minced garlic, pimentón or paprika, cayenne, olive oil, lemon juice, salt and pepper. Broil until done, turning once, about five minutes.
38 Marinated mushrooms: Cut button mushrooms into chunks and toss with lemon juice, olive oil, salt and pepper. Let rest five minutes. Spear two chunks with a piece of Parmesan about the same size.
39 Cut tuna or tenderloin of beef into bite-size pieces. Sear in hot pan until browned on one side; turn; smear browned side with dark miso slightly thinned with sake. Continue to cook another minute or two.
40 Flash-cooked squid: Marinate whole baby squid for 5 minutes in olive oil, a little sherry vinegar, salt and pepper. Sear on both sides in a very hot pan or broiler for less than 3 minutes total. Cut into pieces and sprinkle with more salt. You can do this with shrimp and scallops, too.
41 Soak a couple of tablespoons of black beans in sherry. Blast bite-size shrimp in a little peanut oil until just about cooked through; add minced garlic (and chili and ginger, if you like), then cook 30 seconds. Add black beans and their liquid, and toss. Turn off heat and add a little soy sauce. Serve on toothpicks.
42 Chicken meunière: Sounds fancier than it is, and works with veal, turkey, pork, oysters, clams, shrimp, etc. Cut boneless meat into bite-size pieces (not too small). Dredge in flour, brown quickly in a combination of butter and oil. Serve with lemon wedges.
43 Cut tenderloin or other tender beef into bite-size chunks. Toss with a lot of roughly chopped basil (say, 1 cup basil per pound of meat) and peanut oil. Stir-fry with garlic and red pepper flakes until rare. Sprinkle with soy sauce or nam pla and lime juice.
On Skewers
44 Chicken kebab, Greek style: Cut boneless, skinless chicken thighs into 1-inch chunks. Toss with minced onion, minced garlic, lemon juice, olive oil, salt, pepper, crumbled bay leaf and oregano. Skewer. Broil, turning occasionally, until browned.
45 Chicken kebab, South Asian style: Cut boneless, skinless chicken thighs into 1-inch chunks. Toss with equal amounts ground cardamom, minced garlic, ground allspice, ground turmeric and thyme leaves; add a dash of nutmeg and peanut oil to moisten. Skewer. Broil, turning occasionally, until nicely browned.
46 Chicken kebab, faux-tandoori style: Cut boneless, skinless chicken thighs into 1-inch chunks. Toss with yogurt, chopped onion, minced garlic, minced lime zest, ground cumin, coriander, paprika, cayenne and lime juice. Skewer and broil, turning occasionally, until nicely browned.
47 Chicken teriyaki: Cut 1 pound of boneless, skinless chicken thighs into 1-inch chunks. Toss with 1/4 cup each soy sauce, sake and mirin, and a tablespoon of sugar. Skewer. Boil remaining sauce for a minute or so. Broil the chicken, turning and basting with the sauce after a couple of minutes.
48 Pork kebabs, West Indian style: Mix 1 tablespoon garlic, 1/2 teaspoon ground allspice, a pinch of nutmeg, a teaspoon of fresh thyme leaves, 1/4 cup chopped onion and the juice of a lime. Toss with 1 pound pork shoulder (you need some fat or these will be tough) cut into 1-inch cubes. Skewer and broil about 5 minutes.
49 Pork kebabs, Iberian style. Mix 1 tablespoon garlic, 1/4 cup chopped onion, 1 tablespoon ground cumin, 2 teaspoons paprika, 1 tablespoon grated or minced lemon zest and 1/4 cup freshly squeezed lemon juice. Toss with 1 pound cubed pork shoulder (with fat). Skewer. Broil about 5 minutes.
Finger Foods
50 The egg’s gift to cocktail parties: Hard-cook eggs, peel, and cut in half; carefully remove the yolks. Mash yolks with salt, mayonnaise, good mustard and cayenne. You can also add minced radish, snow peas, scallions (or any crunchy vegetables) or curry powder. Spoon back into the whites, sprinkle with paprika, pimentón or parsley.
51 Even more fabulous: Cook eggs as above. Mash yolks with cooked and minced shrimp, a little chopped olive, minced onion, parsley, salt, pepper and mayonnaise to bind. Spoon back into whites. Garnish with parsley or a piece of anchovy or shrimp.
52 Aioli with steamed cold vegetables: Make the mayonnaise yourself or flavor bottled mayonnaise with lemon, garlic, anchovy (if you like it) and a little saffron (if you have it) for amazing color. Serve with lightly cooked carrots, snap peas, purple potatoes, seafood, etc.
53 Shrimp cocktail: Combine ketchup with chili powder, pepper, lemon juice, Worcestershire, Tabasco and horseradish. Make lots, because people will be double-dipping. Serve with cooked shrimp.
54 Sprinkle rib lamb chops (rack of lamb, separated) or loin chops with good coarse curry powder, or any spice mix you like. Broil quickly, until crisp but not well-done. Serve hot, with yogurt mixed with same spice rub. These will go very fast.
55 Stuff Medjool dates with a piece of Parmesan or Manchego or an almond. Or fresh goat cheese. Or mozzarella, and bake until the cheese begins to melt.
56 Wrap small pieces of melon, figs and/or dates with thinly sliced prosciutto.
57 Buy the best anchovies you can find. Curl each around a tiny ball of butter. Eat.
58 Teeny tiny hamburgers: The hardest part is finding teeny tiny buns, but you can use toast squares. Make them small from beef mixed with salt and pepper. Cook quickly in a hot skillet and serve with ketchup and bits of onion and tomato.
59 Nachos: Yes, nachos. Top a layer of tortilla chips with grated cheese (something orange is traditional) and bake until cheese melts. Top with warm beans seasoned with chili powder, along with chopped scallions. Other possible toppings: jalapeños, sour cream, cilantro, tomatoes, olives.
60 Hot wings: Cut chicken wings into three sections; discard the tips. Sprinkle with salt and pepper and broil until browned on one side, about 5 minutes. Meanwhile, melt butter with vinegar, garlic and hot sauce to taste. Pour off excess fat, baste the wings with hot sauce, turn them, baste again, and brown. Baste once more and serve, with napkins.
61 Sweet wings: As above, but melt the butter with Dijon mustard and honey or maple syrup.
62 Soy ginger wings: This time baste with equal parts vinegar and soy sauce, mixed with a couple of tablespoons each minced ginger and sesame oil. You can sprinkle toasted sesame seeds on the wings.
63 Put peeled raw shrimp in a food processor with garlic, chili, ginger, shallot or red onion, salt, pepper and cilantro; chop finely. Shape into small patties and shallow-fry or broil, then serve with napkins or on buns, with lime juice or spiced mayonnaise.
64 Gently cook raw nuts in oil or butter (or a mixture) with salt and spices — pimentón, chili powder, curry powder, ginger, sugar — whatever combination you like. When they’re fragrant, bake for 10 minutes at 350 degrees. Let cool or they won’t be crunchy.
65 Beyond simple: Buy decent tortilla chips; sprinkle with lime juice and chili powder. Eat fast, before they get soggy.
66 Coat good olives in olive oil mixed with crushed garlic, rosemary, thyme, and/or lemon or orange peel; spices, like chilies, are O.K. Let sit overnight if time allows.
67 Little pizza bianca: Cut prepared dough into small pieces and press out. Brush with oil, sprinkle with rosemary and good coarse salt. Bake at about 500 degrees until browned. Cut up to serve.
68 Quarter quail, rub with olive oil or peanut oil. Broil, skin side down, about 3 minutes. Broil, skin side up, until brown, crisp and cooked through, about 5 minutes more. Brush lightly with pesto or soy sauce and sesame oil, and serve hot or warm.
69 Popcorn parmigiana: Make real popcorn, pour melted butter over it, and toss with fresh Parmesan.
70 Cut baby back ribs into individual ribs; sprinkle with salt and pepper (lots). Broil, turning as needed, 10 minutes or so. Sprinkle with lemon juice.
71 Fill endive leaves with crème fraîche or sour cream and caviar or salmon roe. Or use drained ricotta mixed with chopped parsley, thyme, a little olive oil and a little minced garlic.
72 Steamed asparagus wrapped in prosciutto. That’s the recipe.
73 Cucumber and caviar: Take 3/4-inch-thick slices of cucumber. (The quality of the cuke is more important than that of the caviar; it has to be good enough to leave the skin on.) Scoop out most of the seeds, leaving the bottom of each slice intact. Fill it with a spoonful of yogurt, sour cream or crème fraîche mixed with dill, and top with caviar or salmon roe.
74 Boil frozen or fresh edamame in pods for 3 to 5 minutes. Sprinkle with coarse salt. For this they charge you eight bucks.
Dips and Spreads
75 Purée white or other beans (if canned, drain them) with garlic and olive oil in food processor, adding olive oil as needed. Stir in lemon juice to taste. Garnish with chopped scallions or red onion. You can add cumin or chopped rosemary with lemon zest.
76 Hummus: Truly one of the great culinary inventions. Mix four parts well-cooked or canned chickpeas with one part tahini, along with some of its oil, in a food processor. Add garlic, cumin or pimentón and purée, adding as much olive oil as needed. Stir in lemon juice, salt and pepper to taste; garnish with olive oil and pimentón.
77 Drain good whole-fat yogurt in cheesecloth for 15 minutes; squeeze to remove remaining liquid. Add salt, pimentón and olive oil. Thin with a little more yogurt to use as a dip, or serve on crackers or bread.
78 Mix four parts drained yogurt (as above), farmer cheese or cream cheese with one part sour cream, until creamy. Add thyme and chopped parsley (or any fresh herbs), minced garlic, salt and pepper.
79 Start by draining yogurt as above but do not squeeze; or use sour cream. Stir in chopped seeded cucumber, bell pepper, scallion, dill, then add salt, pepper and lemon juice to taste. Or use chopped arugula and/or cress, with some herbs. Or use horseradish and/or Dijon mustard, with or without vegetables. Or minced or puréed onion or shallots and chopped fresh parsley. Always taste for salt.
80 Drain yogurt as above but do not squeeze; or use sour cream. Add flaked smoked trout or whitefish, or minced smoked salmon, along with chopped parsley, cayenne and lemon juice. Or add minced onion with salmon roe or caviar.
81 Taramosalata: Take 3 or 4 slices good white bread, preferably stale, and soak in water to cover for a few minutes. Squeeze out water, purée bread with 2 or 3 cloves garlic, 8 ounces fish roe (tarama) and at least 1/4 cup olive oil, adding more as needed. Stir in lemon juice and pepper to taste.
82 Mix four parts cream cheese or fresh goat cheese to one part chopped walnuts. A little spice mix (chili powder, curry powder, whatever) is nice in here. Or, replace the nuts with roasted peppers, olive oil and minced anchovies.
83 Boursin: Maybe you have a few Ritz? Mash cream cheese with minced garlic (if you have roasted garlic, so much the better), pepper and small amounts of minced thyme, tarragon and rosemary.
84 Mix three parts cream cheese, one part minced cooked shrimp, a few mashed capers and pepper.
85 Mash four parts goat cheese with one part fig jam.
Little Sandwich Triangles
86 Layer cooked ham and cheese (Gruyère, Cantal or good Cheddar) on thin bread, then press and grill in a not-too-hot skillet with butter or oil.
87 Finding top-quality roast beef is worth a little legwork. Slice it thin and serve with horseradish on rye.
88 Dice cooked shrimp, toss with chopped onion and/or celery, and bind with aioli or well-seasoned mayonnaise.
89 Extra seasoning takes this egg salad higher: Toss chopped hard-cooked eggs with scallions, chopped anchovies and parsley. Bind with well-seasoned mayo.
90 Toss shredded or cubed chicken with minced shallot or red onion, chopped black olives, olive oil, lemon zest, lemon juice, salt, pepper and chopped herbs. Adjust seasoning to taste. Serve on slices of toast.
91 Cheese quesadillas: Use 4-inch tortillas; on each, put grated cheese, scallions and minced canned green chilies or chopped fresh poblanos. Salsa and beans are optional. Top with another tortilla. Griddle with oil, turning once, about 5 minutes.
You Might Need a Fork
92 This is easier than carpaccio: Cut trimmed filet mignon into 1/2-inch or smaller cubes. Toss with arugula, parsley, olive oil, lemon juice, salt and pepper.
93 Make parsley pesto (parsley, garlic, oil, lemon juice) in a food processor. Sauté whole shrimp or small pieces of fish in oil. Arrange fish on small beds of the pesto. You can put this on bread and forget the plates.
94 Ceviche: Thinly slice — or cut into 1/4-inch dice — sea or true bay scallops (or any really fresh fish). Toss with a bit of peeled and minced bell pepper, some lime zest and about 1/4 cup lime juice per pound. Add salt and cayenne to taste. Garnish with cilantro.
95 Mock ceviche: Briefly poach a mixture of (for example) shrimp, scallops and squid, cut to bite size. Drain, then combine with olive oil, minced fresh chili, red onion, and (optional) garlic. Finish with lime juice and cilantro and serve in lettuce cups.
Soups and Wraps
96 Bisque: Heat shrimp, lobster, fish or chicken broth with minced onion and chopped tomato for 5 minutes. Add chopped shrimp or lobster to the simmering stock, and cook another two minutes. Purée, then add heavy cream or half-and-half, along with salt and pepper. Serve in small cups garnished, if you like, with a piece of cooked shrimp or lobster.
97 Avocado soup: Put 2 cups avocado flesh in a blender with 3 cups whole milk along with some salt and cayenne. Purée, then add fresh lime or orange juice to taste, and adjust seasoning. Refrigerate or serve immediately in small cups garnished with a piece of avocado or cooked shrimp.
98 Gazpacho: Chop 2 pounds of tomatoes and a cucumber; blend with a couple of slices of day-old bread, torn into pieces, olive oil, sherry vinegar, garlic (optional) and anchovies (optional). Add a little water (or more oil) to the blender, if necessary. Taste and adjust seasoning, then serve in small cups. Optional garnishes include minced bell pepper, a drizzle of olive oil, a piece of anchovy, and/or parsley.
99 Buy roast duck and take meat off bones; toss with hoisin sauce and roughly chopped scallions. Roll in small tortillas.
100 Roll prosciutto and Parmesan in small tortillas. Bake gently to soften the cheese.
101 Broil a good hot dog, roll in a good tortilla spread with brown or Dijon mustard. Slice. You know everyone will eat them.
December 19, 2007
The Minimalist
101 Simple Appetizers in 20 Minutes or Less
By MARK BITTMAN
YOU want good food at a holiday cocktail party and you want to impress people? You don’t want a caterer, you refuse to heat up frozen food, and you want to show that your expertise extends beyond buying perfectly ripe hunks of cheese and juicy olives? Then think about doing some cooking.
Here is a collection of party foods that are as easy to eat as they are to make. Each can be produced in 20 minutes or less. Many can be served at room temperature. And none require a plate. (Few people can juggle plate, wineglass and fork successfully, let alone gracefully.)
Most of these recipes are beyond minimalist: they never do in two steps what can be done in one, and they need no embellishment. As you scan these recipes for ideas, mostly think this: The ones you find most appealing are the ones your guests will like. Choose a few, spend an hour or two in the kitchen, and you’ll be in great shape.
On Bread or Crackers
1 Red peppers and anchovies: Drizzle piquillos or other roasted red peppers with olive oil, and top with a good anchovy fillet. A caper or two on each is not amiss.
2 Top rye flatbread with thin slices of crisp apple and pickled plain or schmaltz herring (not herring in cream sauce).
3 Sear skirt steak to medium-rare, not more than 8 minutes. Cut into chunks 1/2-inch to 1 inch, first with the grain, then against it. Spread bread with coarse mustard and/or butter. Top with steak and coarse salt.
4 Toss high-quality crab meat with minced shallots, a little tarragon or a lot of parsley and/or basil, and enough mayonnaise to bind. Also good on lettuce leaves.
5 Mash together best-quality tuna, minced anchovies, minced garlic, chopped oil-cured olives and olive oil as necessary.
6 New York comfort food: Spread cream cheese or crème fraîche on small bagels or bagel chips; black bread is also terrific. Top with sturgeon, sable or lox.
7 Slice soft goat cheese and brush with olive oil. Sprinkle with salt, pepper and chopped herbs, then with bread crumbs. Bake at 350 degrees until soft, about 10 minutes, and serve hot.
8 Might not be the new ketchup, but great stuff: purée skinned roasted peppers or piquillos with some of their liquid, salt and olive oil. Serve alone or with other foods — a piece of cheese, even.
9 Top buttered bread with shaved country ham, prosciutto or regular deli ham and bread-and-butter pickles.
10 Chop shrimp fine, then sauté in a minimum of oil, or poach quickly and drain. Mix premade pesto with mayonnaise so that it is gluey. Combine cooled shrimp with sufficient pesto to bind; chill.
11 Tapenade: Combine about 1 pound pitted black olives in food processor with 1/4 cup drained capers, at least 5 anchovies, 2 garlic cloves, black pepper and olive oil as necessary to make a coarse paste. Can also be a dip. Use sparingly; it’s strong.
12 A kind of Moroccan tapenade: As above, but use good green olives with capers; olive-oil-canned tuna (instead of anchovies); garlic, if desired; and cumin.
13 Chop fresh mushrooms. Cook slowly in olive oil with salt and pepper until very soft. Stir in minced garlic and parsley. Cook a few more minutes until garlic mellows. (Especially good if you add reconstituted dried porcini.)
14 Mix together a bit of flour and good paprika. Cut Manchego or similar sheep’s milk cheese into 1/2-inch-thick slices. Dip in flour, then beaten egg, then bread crumbs, and fry quickly to brown on both sides. Drain on paper towels and serve hot.
15 Beef tartare: Carefully pulse good beef in food processor. For each pound, add an egg, a teaspoon dry mustard, a tablespoon Dijon mustard, a tablespoon Worcestershire, Tabasco to taste, 1/2 cup chopped scallions and a touch of minced garlic. Salt and pepper, if necessary. Amazing stuff.
16 Put a thick film of olive oil in a skillet over low heat with lots of thin-sliced garlic. When it sizzles, add shrimp along with pimentón. Raise the heat just enough to get the shrimp going, and cook until it’s pink. Stir in parsley. Spoon a little of the oil onto pieces of bread and top with shrimp.
17 Season cornmeal with lots of chili powder, salt and black pepper. Heat a thick film of neutral oil (or oil mixed with butter) in a skillet. Dredge shucked clams, oysters or chicken breast pieces in the cornmeal and cook about 2 minutes a side, or until crisp. Serve on bread with mayonnaise, or sprinkle with lemon or lime juice and serve on toothpicks. It’s almost convenience food when prepared with shucked mollusks.
Bruschetta
18 Bruschetta is the basis for so many good things. Don’t make it too crisp, and start with good country bread. Brush thick slices with olive oil. Broil until toasted on both sides. While it’s still hot, rub with cut clove of garlic on one side (optional). Drizzle with a bit more olive oil, sprinkle with salt, and serve, or top with prosciutto or tapenade.
19 More than party food, and an amazing snack: Top bruschetta with white beans cooked soft (or use canned) and finished with minced garlic, sage, olive oil and salt.
20 One more level: Make white beans as above. Toss with good quality canned tuna and mash. Spoon over bruschetta.
21 Top bruschetta with chopped, well-cooked broccoli rabe or other greens tossed with minced garlic and olive oil while still warm. Health food, practically. Also good with a layer of Tuscan beans (above).
On Toothpicks
22 Cut pork tenderloin into 1-inch slices; broil or sauté until done. Cut each piece across into 3 or 4 thin slices, then pile onto round bread slices, toasted or not. Top with slice of Manchego and bit of piquillo pepper.
23 Cut chorizo into chunks. Cook in a lightly oiled skillet until nicely browned. Kielbasa is equally good (or better), if not as hip.
24 Portable Caprese: Skewer a small ball of mozzarella, a grape tomato and a bit of basil leaf. Sprinkle with salt and pepper, and drizzle with oil.
25 A no-brainer: Cut slab of bacon into 1/2-inch chunks. Cook in a skillet, a broiler or a high-heat oven until nice and crisp. Skewer with a grape tomato.
26 Even jazzier: Cut just-ripe pears in 1/2-inch cubes; sprinkle with a little salt, sugar and cayenne. Spear with bacon.
27 Pair crispy bacon chunks with one cube of beet and one of goat cheese.
28 Angels on horseback: Wrap oysters or not-too-large sea scallops in bacon; skewer with toothpicks. Broil, turning once, until bacon is done.
29 You can call them devils on horseback: Wrap pitted dates (replacing the pit with an almond if you like) in bacon. Skewer with toothpicks and broil, turning once, until bacon is done.
30 Rumaki, a 1960s cocktail food that deserves reviving: Brush canned water chestnuts (or chicken liver halves, or crimini mushrooms, or pieces of portobello) with a little soy sauce; wrap in pieces of bacon. Skewer closed with toothpicks and broil, turning once, until bacon is done.
31 Wash mussels or littleneck clams well; steam open in covered pot. Let cool, remove from shells, and serve with aioli, flavored mayonnaise or vinaigrette.
32 Cook real bay scallops in hot butter or oil for just a couple of minutes. Sprinkle with lemon juice and parsley and serve hot.
33 Crab cakes: For each pound crab meat, add an egg, 1/4 cup each minced bell pepper and onion, 1/4 cup mayonnaise, 1 tablespoon Dijon mustard, 2 tablespoons bread or cracker crumbs, salt and pepper. Shape into small cakes and refrigerate, if time allows. Dredge in flour, then brown in oil (or oil mixed with butter). Serve with lemon wedges, aioli or tartar sauce.
34 Meatballs: Combine 1 thick slice white bread with 1/2 cup milk; let sit for 5 minutes. Squeeze milk from bread and gently mix bread with 1/2 pound not-too-lean ground sirloin, 1/2 pound ground pork, 1/2 cup chopped onion, 1/2 cup freshly grated Parmesan, 1/4 cup chopped fresh parsley leaves and salt and pepper. Shape into 1-inch balls. (If mixture doesn’t hold well, add more bread crumbs and an egg.) Broil about 5 minutes, turning once or twice.
35 Cod cakes with sauce rouge: I’m hedging on time here, but you’re really getting two recipes in one: Combine 1 pound chopped boneless cod, an egg, 1/4 cup mayonnaise, a tablespoon Dijon mustard and some salt and pepper. Add bread or cracker crumbs until you can shape the mixture into cakes. If possible, refrigerate for an hour. Meanwhile, cook chopped canned tomatoes in olive oil with salt and cayenne until saucy. Shape small cod cakes. Dredge in flour, sauté in butter and oil until nicely browned. Serve hot or at room temperature, with sauce on the side.
36 The banderilla: The first tapa created, or at least that’s what people tell me. Skewer a crisp pickled pepper, an anchovy and a pitted green olive. Incredible with dry (fino) sherry.
37 Toss peeled shrimp with lots of minced garlic, pimentón or paprika, cayenne, olive oil, lemon juice, salt and pepper. Broil until done, turning once, about five minutes.
38 Marinated mushrooms: Cut button mushrooms into chunks and toss with lemon juice, olive oil, salt and pepper. Let rest five minutes. Spear two chunks with a piece of Parmesan about the same size.
39 Cut tuna or tenderloin of beef into bite-size pieces. Sear in hot pan until browned on one side; turn; smear browned side with dark miso slightly thinned with sake. Continue to cook another minute or two.
40 Flash-cooked squid: Marinate whole baby squid for 5 minutes in olive oil, a little sherry vinegar, salt and pepper. Sear on both sides in a very hot pan or broiler for less than 3 minutes total. Cut into pieces and sprinkle with more salt. You can do this with shrimp and scallops, too.
41 Soak a couple of tablespoons of black beans in sherry. Blast bite-size shrimp in a little peanut oil until just about cooked through; add minced garlic (and chili and ginger, if you like), then cook 30 seconds. Add black beans and their liquid, and toss. Turn off heat and add a little soy sauce. Serve on toothpicks.
42 Chicken meunière: Sounds fancier than it is, and works with veal, turkey, pork, oysters, clams, shrimp, etc. Cut boneless meat into bite-size pieces (not too small). Dredge in flour, brown quickly in a combination of butter and oil. Serve with lemon wedges.
43 Cut tenderloin or other tender beef into bite-size chunks. Toss with a lot of roughly chopped basil (say, 1 cup basil per pound of meat) and peanut oil. Stir-fry with garlic and red pepper flakes until rare. Sprinkle with soy sauce or nam pla and lime juice.
On Skewers
44 Chicken kebab, Greek style: Cut boneless, skinless chicken thighs into 1-inch chunks. Toss with minced onion, minced garlic, lemon juice, olive oil, salt, pepper, crumbled bay leaf and oregano. Skewer. Broil, turning occasionally, until browned.
45 Chicken kebab, South Asian style: Cut boneless, skinless chicken thighs into 1-inch chunks. Toss with equal amounts ground cardamom, minced garlic, ground allspice, ground turmeric and thyme leaves; add a dash of nutmeg and peanut oil to moisten. Skewer. Broil, turning occasionally, until nicely browned.
46 Chicken kebab, faux-tandoori style: Cut boneless, skinless chicken thighs into 1-inch chunks. Toss with yogurt, chopped onion, minced garlic, minced lime zest, ground cumin, coriander, paprika, cayenne and lime juice. Skewer and broil, turning occasionally, until nicely browned.
47 Chicken teriyaki: Cut 1 pound of boneless, skinless chicken thighs into 1-inch chunks. Toss with 1/4 cup each soy sauce, sake and mirin, and a tablespoon of sugar. Skewer. Boil remaining sauce for a minute or so. Broil the chicken, turning and basting with the sauce after a couple of minutes.
48 Pork kebabs, West Indian style: Mix 1 tablespoon garlic, 1/2 teaspoon ground allspice, a pinch of nutmeg, a teaspoon of fresh thyme leaves, 1/4 cup chopped onion and the juice of a lime. Toss with 1 pound pork shoulder (you need some fat or these will be tough) cut into 1-inch cubes. Skewer and broil about 5 minutes.
49 Pork kebabs, Iberian style. Mix 1 tablespoon garlic, 1/4 cup chopped onion, 1 tablespoon ground cumin, 2 teaspoons paprika, 1 tablespoon grated or minced lemon zest and 1/4 cup freshly squeezed lemon juice. Toss with 1 pound cubed pork shoulder (with fat). Skewer. Broil about 5 minutes.
Finger Foods
50 The egg’s gift to cocktail parties: Hard-cook eggs, peel, and cut in half; carefully remove the yolks. Mash yolks with salt, mayonnaise, good mustard and cayenne. You can also add minced radish, snow peas, scallions (or any crunchy vegetables) or curry powder. Spoon back into the whites, sprinkle with paprika, pimentón or parsley.
51 Even more fabulous: Cook eggs as above. Mash yolks with cooked and minced shrimp, a little chopped olive, minced onion, parsley, salt, pepper and mayonnaise to bind. Spoon back into whites. Garnish with parsley or a piece of anchovy or shrimp.
52 Aioli with steamed cold vegetables: Make the mayonnaise yourself or flavor bottled mayonnaise with lemon, garlic, anchovy (if you like it) and a little saffron (if you have it) for amazing color. Serve with lightly cooked carrots, snap peas, purple potatoes, seafood, etc.
53 Shrimp cocktail: Combine ketchup with chili powder, pepper, lemon juice, Worcestershire, Tabasco and horseradish. Make lots, because people will be double-dipping. Serve with cooked shrimp.
54 Sprinkle rib lamb chops (rack of lamb, separated) or loin chops with good coarse curry powder, or any spice mix you like. Broil quickly, until crisp but not well-done. Serve hot, with yogurt mixed with same spice rub. These will go very fast.
55 Stuff Medjool dates with a piece of Parmesan or Manchego or an almond. Or fresh goat cheese. Or mozzarella, and bake until the cheese begins to melt.
56 Wrap small pieces of melon, figs and/or dates with thinly sliced prosciutto.
57 Buy the best anchovies you can find. Curl each around a tiny ball of butter. Eat.
58 Teeny tiny hamburgers: The hardest part is finding teeny tiny buns, but you can use toast squares. Make them small from beef mixed with salt and pepper. Cook quickly in a hot skillet and serve with ketchup and bits of onion and tomato.
59 Nachos: Yes, nachos. Top a layer of tortilla chips with grated cheese (something orange is traditional) and bake until cheese melts. Top with warm beans seasoned with chili powder, along with chopped scallions. Other possible toppings: jalapeños, sour cream, cilantro, tomatoes, olives.
60 Hot wings: Cut chicken wings into three sections; discard the tips. Sprinkle with salt and pepper and broil until browned on one side, about 5 minutes. Meanwhile, melt butter with vinegar, garlic and hot sauce to taste. Pour off excess fat, baste the wings with hot sauce, turn them, baste again, and brown. Baste once more and serve, with napkins.
61 Sweet wings: As above, but melt the butter with Dijon mustard and honey or maple syrup.
62 Soy ginger wings: This time baste with equal parts vinegar and soy sauce, mixed with a couple of tablespoons each minced ginger and sesame oil. You can sprinkle toasted sesame seeds on the wings.
63 Put peeled raw shrimp in a food processor with garlic, chili, ginger, shallot or red onion, salt, pepper and cilantro; chop finely. Shape into small patties and shallow-fry or broil, then serve with napkins or on buns, with lime juice or spiced mayonnaise.
64 Gently cook raw nuts in oil or butter (or a mixture) with salt and spices — pimentón, chili powder, curry powder, ginger, sugar — whatever combination you like. When they’re fragrant, bake for 10 minutes at 350 degrees. Let cool or they won’t be crunchy.
65 Beyond simple: Buy decent tortilla chips; sprinkle with lime juice and chili powder. Eat fast, before they get soggy.
66 Coat good olives in olive oil mixed with crushed garlic, rosemary, thyme, and/or lemon or orange peel; spices, like chilies, are O.K. Let sit overnight if time allows.
67 Little pizza bianca: Cut prepared dough into small pieces and press out. Brush with oil, sprinkle with rosemary and good coarse salt. Bake at about 500 degrees until browned. Cut up to serve.
68 Quarter quail, rub with olive oil or peanut oil. Broil, skin side down, about 3 minutes. Broil, skin side up, until brown, crisp and cooked through, about 5 minutes more. Brush lightly with pesto or soy sauce and sesame oil, and serve hot or warm.
69 Popcorn parmigiana: Make real popcorn, pour melted butter over it, and toss with fresh Parmesan.
70 Cut baby back ribs into individual ribs; sprinkle with salt and pepper (lots). Broil, turning as needed, 10 minutes or so. Sprinkle with lemon juice.
71 Fill endive leaves with crème fraîche or sour cream and caviar or salmon roe. Or use drained ricotta mixed with chopped parsley, thyme, a little olive oil and a little minced garlic.
72 Steamed asparagus wrapped in prosciutto. That’s the recipe.
73 Cucumber and caviar: Take 3/4-inch-thick slices of cucumber. (The quality of the cuke is more important than that of the caviar; it has to be good enough to leave the skin on.) Scoop out most of the seeds, leaving the bottom of each slice intact. Fill it with a spoonful of yogurt, sour cream or crème fraîche mixed with dill, and top with caviar or salmon roe.
74 Boil frozen or fresh edamame in pods for 3 to 5 minutes. Sprinkle with coarse salt. For this they charge you eight bucks.
Dips and Spreads
75 Purée white or other beans (if canned, drain them) with garlic and olive oil in food processor, adding olive oil as needed. Stir in lemon juice to taste. Garnish with chopped scallions or red onion. You can add cumin or chopped rosemary with lemon zest.
76 Hummus: Truly one of the great culinary inventions. Mix four parts well-cooked or canned chickpeas with one part tahini, along with some of its oil, in a food processor. Add garlic, cumin or pimentón and purée, adding as much olive oil as needed. Stir in lemon juice, salt and pepper to taste; garnish with olive oil and pimentón.
77 Drain good whole-fat yogurt in cheesecloth for 15 minutes; squeeze to remove remaining liquid. Add salt, pimentón and olive oil. Thin with a little more yogurt to use as a dip, or serve on crackers or bread.
78 Mix four parts drained yogurt (as above), farmer cheese or cream cheese with one part sour cream, until creamy. Add thyme and chopped parsley (or any fresh herbs), minced garlic, salt and pepper.
79 Start by draining yogurt as above but do not squeeze; or use sour cream. Stir in chopped seeded cucumber, bell pepper, scallion, dill, then add salt, pepper and lemon juice to taste. Or use chopped arugula and/or cress, with some herbs. Or use horseradish and/or Dijon mustard, with or without vegetables. Or minced or puréed onion or shallots and chopped fresh parsley. Always taste for salt.
80 Drain yogurt as above but do not squeeze; or use sour cream. Add flaked smoked trout or whitefish, or minced smoked salmon, along with chopped parsley, cayenne and lemon juice. Or add minced onion with salmon roe or caviar.
81 Taramosalata: Take 3 or 4 slices good white bread, preferably stale, and soak in water to cover for a few minutes. Squeeze out water, purée bread with 2 or 3 cloves garlic, 8 ounces fish roe (tarama) and at least 1/4 cup olive oil, adding more as needed. Stir in lemon juice and pepper to taste.
82 Mix four parts cream cheese or fresh goat cheese to one part chopped walnuts. A little spice mix (chili powder, curry powder, whatever) is nice in here. Or, replace the nuts with roasted peppers, olive oil and minced anchovies.
83 Boursin: Maybe you have a few Ritz? Mash cream cheese with minced garlic (if you have roasted garlic, so much the better), pepper and small amounts of minced thyme, tarragon and rosemary.
84 Mix three parts cream cheese, one part minced cooked shrimp, a few mashed capers and pepper.
85 Mash four parts goat cheese with one part fig jam.
Little Sandwich Triangles
86 Layer cooked ham and cheese (Gruyère, Cantal or good Cheddar) on thin bread, then press and grill in a not-too-hot skillet with butter or oil.
87 Finding top-quality roast beef is worth a little legwork. Slice it thin and serve with horseradish on rye.
88 Dice cooked shrimp, toss with chopped onion and/or celery, and bind with aioli or well-seasoned mayonnaise.
89 Extra seasoning takes this egg salad higher: Toss chopped hard-cooked eggs with scallions, chopped anchovies and parsley. Bind with well-seasoned mayo.
90 Toss shredded or cubed chicken with minced shallot or red onion, chopped black olives, olive oil, lemon zest, lemon juice, salt, pepper and chopped herbs. Adjust seasoning to taste. Serve on slices of toast.
91 Cheese quesadillas: Use 4-inch tortillas; on each, put grated cheese, scallions and minced canned green chilies or chopped fresh poblanos. Salsa and beans are optional. Top with another tortilla. Griddle with oil, turning once, about 5 minutes.
You Might Need a Fork
92 This is easier than carpaccio: Cut trimmed filet mignon into 1/2-inch or smaller cubes. Toss with arugula, parsley, olive oil, lemon juice, salt and pepper.
93 Make parsley pesto (parsley, garlic, oil, lemon juice) in a food processor. Sauté whole shrimp or small pieces of fish in oil. Arrange fish on small beds of the pesto. You can put this on bread and forget the plates.
94 Ceviche: Thinly slice — or cut into 1/4-inch dice — sea or true bay scallops (or any really fresh fish). Toss with a bit of peeled and minced bell pepper, some lime zest and about 1/4 cup lime juice per pound. Add salt and cayenne to taste. Garnish with cilantro.
95 Mock ceviche: Briefly poach a mixture of (for example) shrimp, scallops and squid, cut to bite size. Drain, then combine with olive oil, minced fresh chili, red onion, and (optional) garlic. Finish with lime juice and cilantro and serve in lettuce cups.
Soups and Wraps
96 Bisque: Heat shrimp, lobster, fish or chicken broth with minced onion and chopped tomato for 5 minutes. Add chopped shrimp or lobster to the simmering stock, and cook another two minutes. Purée, then add heavy cream or half-and-half, along with salt and pepper. Serve in small cups garnished, if you like, with a piece of cooked shrimp or lobster.
97 Avocado soup: Put 2 cups avocado flesh in a blender with 3 cups whole milk along with some salt and cayenne. Purée, then add fresh lime or orange juice to taste, and adjust seasoning. Refrigerate or serve immediately in small cups garnished with a piece of avocado or cooked shrimp.
98 Gazpacho: Chop 2 pounds of tomatoes and a cucumber; blend with a couple of slices of day-old bread, torn into pieces, olive oil, sherry vinegar, garlic (optional) and anchovies (optional). Add a little water (or more oil) to the blender, if necessary. Taste and adjust seasoning, then serve in small cups. Optional garnishes include minced bell pepper, a drizzle of olive oil, a piece of anchovy, and/or parsley.
99 Buy roast duck and take meat off bones; toss with hoisin sauce and roughly chopped scallions. Roll in small tortillas.
100 Roll prosciutto and Parmesan in small tortillas. Bake gently to soften the cheese.
101 Broil a good hot dog, roll in a good tortilla spread with brown or Dijon mustard. Slice. You know everyone will eat them.
Sunday, November 25, 2007
Doctor as drug rep experience
NYTimes
November 25, 2007
Dr. Drug Rep
By DANIEL CARLAT
I. Faculty Development
On a blustery fall New England day in 2001, a friendly representative from Wyeth Pharmaceuticals came into my office in Newburyport, Mass., and made me an offer I found hard to refuse. He asked me if I’d like to give talks to other doctors about using Effexor XR for treating depression. He told me that I would go around to doctors’ offices during lunchtime and talk about some of the features of Effexor. It would be pretty easy. Wyeth would provide a set of slides and even pay for me to attend a speaker’s training session, and he quickly floated some numbers. I would be paid $500 for one-hour “Lunch and Learn” talks at local doctors’ offices, or $750 if I had to drive an hour. I would be flown to New York for a “faculty-development program,” where I would be pampered in a Midtown hotel for two nights and would be paid an additional “honorarium.”
I thought about his proposition. I had a busy private practice in psychiatry, specializing in psychopharmacology. I was quite familiar with Effexor, since I had read recent studies showing that it might be slightly more effective than S.S.R.I.’s, the most commonly prescribed antidepressants: the Prozacs, Paxils and Zolofts of the world. S.S.R.I. stands for selective serotonin reuptake inhibitor, referring to the fact that these drugs increase levels of the neurotransmitter serotonin, a chemical in the brain involved in regulating moods. Effexor, on the other hand, was being marketed as a dual reuptake inhibitor, meaning that it increases both serotonin and norepinephrine, another neurotransmitter. The theory promoted by Wyeth was that two neurotransmitters are better than one, and that Effexor was more powerful and effective than S.S.R.I.’s.
I had already prescribed Effexor to several patients, and it seemed to work as well as the S.S.R.I.’s. If I gave talks to primary-care doctors about Effexor, I reasoned, I would be doing nothing unethical. It was a perfectly effective treatment option, with some data to suggest advantages over its competitors. The Wyeth rep was simply suggesting that I discuss some of the data with other doctors. Sure, Wyeth would benefit, but so would other doctors, who would become more educated about a good medication.
A few weeks later, my wife and I walked through the luxurious lobby of the Millennium Hotel in Midtown Manhattan. At the reception desk, when I gave my name, the attendant keyed it into the computer and said, with a dazzling smile: “Hello, Dr. Carlat, I see that you are with the Wyeth conference. Here are your materials.”
She handed me a folder containing the schedule of talks, an invitation to various dinners and receptions and two tickets to a Broadway musical. “Enjoy your stay, doctor.” I had no doubt that I would, though I felt a gnawing at the edge of my conscience. This seemed like a lot of money to lavish on me just so that I could provide some education to primary-care doctors in a small town north of Boston.
The next morning, the conference began. There were a hundred or so other psychiatrists from different parts of the U.S. I recognized a couple of the attendees, including an acquaintance I hadn’t seen in a while. I’d heard that he moved to another state and was making a bundle of money, but nobody seemed to know exactly how.
I joined him at his table and asked him what he had been up to. He said he had a busy private practice and had given a lot of talks for Warner-Lambert, a company that had since been acquired by Pfizer. His talks were on Neurontin, a drug that was approved for epilepsy but that my friend had found helpful for bipolar disorder in his practice. (In 2004, Warner-Lambert pleaded guilty to illegally marketing Neurontin for unapproved uses. It is illegal for companies to pay doctors to promote so-called off-label uses.)
I knew about Neurontin and had prescribed it occasionally for bipolar disorder in my practice, though I had never found it very helpful. A recent study found that it worked no better than a placebo for this condition. I asked him if he really thought Neurontin worked for bipolar, and he said that he felt it was “great for some patients” and that he used it “all the time.” Given my clinical experiences with the drug, I wondered whether his positive opinion had been influenced by the money he was paid to give talks.
But I put those questions aside as we gulped down our coffees and took seats in a large lecture room. On the agenda were talks from some of the most esteemed academics in the field, authors of hundreds of articles in the major psychiatric journals. They included Michael Thase, of the University of Pittsburgh and the researcher who single-handedly put Effexor on the map with a meta-analysis, and Norman Sussman, a professor of psychiatry at New York University, who was master of ceremonies.
Thase strode to the lectern first in order to describe his groundbreaking work synthesizing data from more than 2,000 patients who had been enrolled in studies comparing Effexor with S.S.R.I.’s. At this time, with his Effexor study a topic of conversation in the mental-health world, Thase was one of the most well known and well respected psychiatrists in the United States. He cut a captivating figure onstage: tall and slim, dynamic, incredibly articulate and a master of the research craft.
He began by reviewing the results of the meta-analysis that had the psychiatric world abuzz. After carefully pooling and processing data from eight separate clinical trials, Thase published a truly significant finding: Effexor caused a 45 percent remission rate in patients in contrast to the S.S.R.I. rate of 35 percent and the placebo rate of 25 percent. It was the first time one antidepressant was shown to be more effective than any other. Previously, psychiatrists chose antidepressants based on a combination of guesswork, gut feeling and tailoring a drug’s side effects to a patient’s symptom profile. If Effexor was truly more effective than S.S.R.I.’s, it would amount to a revolution in psychiatric practice and a potential windfall for Wyeth.
One impressive aspect of Thase’s presentation was that he was not content to rest on his laurels; rather he raised a series of potential criticisms of his results and then rebutted them convincingly. For example, skeptics had pointed out that Thase was a paid consultant to Wyeth and that both of his co-authors were employees of the company. Thase responded that he had requested and had received all of the company’s data and had not cherry-picked from those studies most favorable for Effexor. This was a significant point, because companies sometimes withhold negative data from publication in medical journals. For example, in 2004, GlaxoSmithKline was sued by Eliot Spitzer, who was then the New York attorney general, for suppressing data hinting that Paxil causes suicidal thoughts in children. The company settled the case and agreed to make clinical-trial results public.
Another objection was that while the study was billed as comparing Effexor with S.S.R.I.’s in general, in fact most of the data compared Effexor with one specific S.S.R.I.: Prozac. Perhaps Effexor was, indeed, more effective than Prozac; this did not necessarily mean that it was more effective than the other S.S.R.I.’s in common use. But Thase announced that since the original study, he had analyzed data on Paxil and other meds and also found differences in remission rates.
For his study, Thase chose what was at that time an unusual measure of antidepressant improvement: “remission,” rather than the more standard measure, “response.” In clinical antidepressant trials, a “response” is defined as a 50 percent improvement in depressive symptoms, as measured by the Hamilton depression scale. Thus, if a patient enters a study scoring a 24 on the Hamilton (which would be a moderate degree of depression), he or she would have “responded” if the final score, after treatment, was 12 or less.
Remission, on the other hand, is defined as “complete” recovery. While you might think that a patient would have to score a 0 on the Hamilton to be in remission, in fact very few people score that low, no matter how deliriously happy they are. Instead, researchers come up with various cutoff scores for remission. Thase chose a cutoff score of 7 or below.
In his study, he emphasized the remission rates and not the response rates. As I listened to his presentation, I wondered why. Was it because he felt that remission was the only really meaningful outcome by which to compare drugs? Or was it because using remission made Effexor look more impressive than response did? Thase indirectly addressed this issue in his paper by pointing out that even when remission was defined in different ways, with different cutoff points, Effexor beat the S.S.R.I.’s every time. That struck me as a pretty convincing endorsement of Wyeth’s antidepressant.
The next speaker, Norm Sussman, took the baton from Thase and explored the concept of remission in more detail. Sussman’s job was to systematically go through the officially sanctioned “slide deck” — slides provided to us by Wyeth, which we were expected to use during our own presentations.
If Thase was the riveting academic, Sussman was the engaging populist, translating some of the drier research concepts into terms that our primary-care-physician audiences would understand. Sussman exhorted us not to be satisfied with response and encouraged us to set the bar higher. “Is the patient doing everything they were doing before they got depressed?” he asked. “Are they doing it even better? That’s remission.” To further persuade us, he highlighted a slide showing that patients who made it all the way to remission are less likely to relapse to another depressive episode than patients who merely responded. And for all its methodological limitations, it was a slide that I would become well acquainted with, as I would use it over and over again in my own talks.
When it came to side effects, Effexor’s greatest liability was that it could cause hypertension, a side effect not shared by S.S.R.I.’s. Sussman showed us some data from the clinical trials, indicating that at lower doses, about 3 percent of patients taking Effexor had hypertension as compared with about 2 percent of patients assigned to a placebo. There was only a 1 percent difference between Effexor and placebo, he commented, and pointed out that treating high blood pressure might be a small price to pay for relief from depression.
It was an accurate reading of the data, and I remember finding it a convincing defense of Effexor’s safety. As I look back at my notes now, however, I notice that another way of describing the same numbers would have been to say that Effexor leads to a 50 percent greater rate of hypertension than a placebo. Framed this way, Effexor looks more hazardous.
And so it went for the rest of the afternoon.
Was I swallowing the message whole? Certainly not. I knew that this was hardly impartial medical education, and that we were being fed a marketing line. But when you are treated like the anointed, wined and dined in Manhattan and placed among the leaders of the field, you inevitably put some of your critical faculties on hold. I was truly impressed with Effexor’s remission numbers, and like any physician, I was hopeful that something new and different had been introduced to my quiver of therapeutic options.
At the end of the last lecture, we were all handed envelopes as we left the conference room. Inside were checks for $750. It was time to enjoy ourselves in the city.
II. The Art and Science of Detailing
Pharmaceutical “detailing” is the term used to describe those sales visits in which drug reps go to doctors’ offices to describe the benefits of a specific drug. Once I returned to my Newburyport office from New York, a couple of voice-mail messages from local Wyeth reps were already waiting for me, inviting me to give some presentations at local doctors’ offices. I was about to begin my speaking — and detailing — career in earnest.
How many doctors speak for drug companies? We don’t know for sure, but one recent study indicates that at least 25 percent of all doctors in the United States receive drug money for lecturing to physicians or for helping to market drugs in other ways. This meant that I was about to join some 200,000 American physicians who are being paid by companies to promote their drugs. I felt quite flattered to have been recruited, and I assumed that the rep had picked me because of some special personal or professional quality.
The first talk I gave brought me back to earth rather quickly. I distinctly remember the awkwardness of walking into my first waiting room. The receptionist slid the glass partition open and asked if I had an appointment.
“Actually, I’m here to meet with the doctor.”
“Oh, O.K. And is that a scheduled appointment?”
“I’m here to give a talk.”
A light went on. “Oh, are you part of the drug lunch?”
Regardless of how I preferred to think of myself (an educator, a psychiatrist, a consultant), I was now classified as one facet of a lunch helping to pitch a drug, a convincing sidekick to help the sales rep. Eventually, with an internal wince, I began to introduce myself as “Dr. Carlat, here for the Wyeth lunch.”
The drug rep who arranged the lunch was always there, usually an attractive, vivacious woman with platters of gourmet sandwiches in tow. Hungry doctors and their staff of nurses and receptionists would filter into the lunch room, grateful for free food.
Once there was a critical mass (and crucially, once the M.D.’s arrived), I was given the go-ahead by the Wyeth reps to start. I dove into my talk, going through a handout that I created, based on the official slide deck. I discussed the importance of remission, the basics of the Thase study showing the advantage of Effexor, how to dose the drug, the side effects, and I added a quick review of the other common antidepressants.
While I still had some doubts, I continued to be impressed by the 10 percent advantage in remission rates that Effexor held over S.S.R.I.’s; that advantage seemed significant enough to overcome Effexor’s more prominent side effects. Yes, I was highlighting Effexor’s selling points and playing down its disadvantages, and I knew it. But was my salesmanship going to bring harm to anybody? It seemed unlikely. The worst case was that Effexor was no more effective than anything else; it certainly was no less effective.
During my first few talks, I worried a lot about my performance. Was I too boring? Did the doctors see me as sleazy? Did the Wyeth reps find me sufficiently persuasive? But the day after my talks, I would get a call or an e-mail message from the rep saying that I did a great job, that the doctor was impressed and that they wanted to use me more. Indeed, I started receiving more and more invitations from other reps, and I soon had talks scheduled every week. I learned later that Wyeth and other companies have speaker-evaluation systems. After my talks, the reps would fill out a questionnaire rating my performance, which quickly became available to other Wyeth reps throughout the area.
As the reps became comfortable with me, they began to see me more as a sales colleague. I received faxes before talks preparing me for particular doctors. One note informed me that the physician we’d be visiting that day was a “decile 6 doctor and is not prescribing any Effexor XR, so please tailor accordingly. There is also one more doc in the practice that we are not familiar with.” The term “decile 6” is drug-rep jargon for a doctor who prescribes a lot of medications. The higher the “decile” (in a range from 1 to 10), the higher the prescription volume, and the more potentially lucrative that doctor could be for the company.
A note from another rep reminded me of a scene from “Mission: Impossible.” “Dr. Carlat: Our main target, Dr. , is an internist. He spreads his usage among three antidepressants, Celexa, Zoloft and Paxil, at about 25-30 percent each. He is currently using about 6 percent Effexor XR. Our access is very challenging with lunches six months out.” This doctor’s schedule of lunches was filled with reps from other companies; it would be vital to make our sales visit count.+
Naïve as I was, I found myself astonished at the level of detail that drug companies were able to acquire about doctors’ prescribing habits. I asked my reps about it; they told me that they received printouts tracking local doctors’ prescriptions every week. The process is called “prescription data-mining,” in which specialized pharmacy-information companies (like IMS Health and Verispan) buy prescription data from local pharmacies, repackage it, then sell it to pharmaceutical companies. This information is then passed on to the drug reps, who use it to tailor their drug-detailing strategies. This may include deciding which physicians to aim for, as my Wyeth reps did, but it can help sales in other ways. For example, Shahram Ahari, a former drug rep for Eli Lilly (the maker of Prozac) who is now a researcher at the University of California at San Francisco’s School of Pharmacy, said in an article in The Washington Post that as a drug rep he would use this data to find out which doctors were prescribing Prozac’s competitors, like Effexor. Then he would play up specific features of Prozac that contrasted favorably with the other drug, like the ease with which patients can get off Prozac, as compared with the hard time they can have withdrawing from Effexor.
The American Medical Association is also a key player in prescription data-mining. Pharmacies typically will not release doctors’ names to the data-mining companies, but they will release their Drug Enforcement Agency numbers. The A.M.A. licenses its file of U.S. physicians, allowing the data-mining companies to match up D.E.A. numbers to specific physicians. The A.M.A. makes millions in information-leasing money.
Once drug companies have identified the doctors, they must woo them. In the April 2007 issue of the journal PLoS Medicine, Dr. Adriane Fugh-Berman of Georgetown teamed up with Ahari (the former drug rep) to describe the myriad techniques drug reps use to establish relationships with physicians, including inviting them to a speaker’s meeting. These can serve to cement a positive a relationship between the rep and the doctor. This relationship is crucial, they say, since “drug reps increase drug sales by influencing physicians, and they do so with finely titrated doses of friendship.”
III. Uncomfortable Moments
I gave many talks over the ensuing several months, and I gradually became more comfortable with the process. Each setting was somewhat different. Sometimes I spoke to a crowded conference room with several physicians, nurses and other clinical staff. Other times, I sat at a small lunch table with only one other physician (plus the rep), having what amounted to a conversation about treating depression. My basic Effexor spiel was similar in the various settings, with the focus on remission and the Thase data.
Meanwhile, I was keeping up with new developments in the research literature related to Effexor, and not all of the news was positive. For example, as more data came out comparing Effexor with S.S.R.I.’s other than Prozac, the Effexor remission advantage became slimmer — more like 5 percent instead of the originally reported 10 percent. Statistically, this 5 percent advantage meant that only one out of 20 patients would potentially do better on Effexor than S.S.R.I.’s — much less compelling than the earlier proportion of one out of 10.
I also became aware of other critiques of the original Thase meta-analysis. For example, some patients enrolled in the original Effexor studies took S.S.R.I.’s in the past and presumably had not responded well. This meant that the study population may have been enriched with patients who were treatment-resistant to S.S.R.I.’s, giving Effexor an inherent advantage.
I didn’t mention any of this in my talks, partly because none of it had been included in official company slides, and partly because I was concerned that the reps wouldn’t invite me to give talks if I divulged any negative information. But I was beginning to struggle with the ethics of my silence.
One of my most uncomfortable moments came when I gave a presentation to a large group of psychiatrists. I was in the midst of wrapping up my talk with some information about Effexor and blood pressure. Referring to a large study paid for by Wyeth, I reported that patients are liable to develop hypertension only if they are taking Effexor at doses higher than 300 milligrams per day.
“Really?” one psychiatrist in the room said. “I’ve seen hypertension at lower doses in my patients.”
“I suppose it can happen, but it’s rare at doses that are commonly used for depression.”
He looked at me, frowned and shook his head. “That hasn’t been my experience.”
I reached into my folder where I kept some of the key Effexor studies in case such questions arose.
According to this study of 3,744 patients, the rate of high blood pressure was 2.2 percent in the placebo group, and 2.9 percent in the group of patients who had taken daily doses of Effexor no larger than 300 milligrams. Patients taking more than 300 milligrams had a 9 percent risk of hypertension. As I went through the numbers with the doctor, however, I felt unsettled. I started talking faster, a sure sign of nervousness for me.
Driving home, I went back over the talk in my mind. I knew I had not lied — I had reported the data exactly as they were reported in the paper. But still, I had spun the results of the study in the most positive way possible, and I had not talked about the limitations of the data. I had not, for example, mentioned that if you focused specifically on patients taking between 200 and 300 milligrams per day, a commonly prescribed dosage range, you found a 3.7 percent incidence of hypertension. While this was not a statistically significant higher rate than the placebo, it still hinted that such moderate doses could, indeed, cause hypertension. Nor had I mentioned the fact that since the data were derived from placebo-controlled clinical trials, the patients were probably not representative of the patients seen in most real practices. Patients who are very old or who have significant medical problems are excluded from such studies. But real-world patients may well be at higher risk to develop hypertension on Effexor. +
I realized that in my canned talks, I was blithely minimizing the hypertension risks, conveniently overlooking the fact that hypertension is a dangerous condition and not one to be trifled with. Why, I began to wonder, would anyone prescribe an antidepressant that could cause hypertension when there were many other alternatives? And why wasn’t I asking this obvious question out loud during my talks?
I felt rattled. That psychiatrist’s frown stayed with me — a mixture of skepticism and contempt. I wondered if he saw me for what I feared I had become — a drug rep with an M.D. I began to think that the money was affecting my critical judgement. I was willing to dance around the truth in order to make the drug reps happy. Receiving $750 checks for chatting with some doctors during a lunch break was such easy money that it left me giddy. Like an addiction, it was very hard to give up.
There was another problem: one of Effexor’s side effects. Patients who stopped the medication were calling their doctors and reporting symptoms like severe dizziness and lightheadedness, bizarre electric-shock sensations in their heads, insomnia, sadness and tearfulness. Some patients thought they were having strokes or nervous breakdowns and were showing up in emergency rooms. Gradually, however, it became clear that these were “withdrawal” symptoms. These were particularly common problems with Effexor because it has a short half-life, a measure of the time it takes the body to metabolize half of the total amount of a drug in the bloodstream. Paxil, another short half-life antidepressant, caused similar problems.
At the Wyeth meeting in New York, these withdrawal effects were mentioned in passing, though we were assured that Effexor withdrawal symptoms were uncommon and could usually be avoided by tapering down the dose very slowly. But in my practice, that strategy often did not work, and patients were having a very hard time coming off Effexor in order to start a trial of a different antidepressant.
I wrestled with how to handle this issue in my Effexor talks, since I believed it was a significant disadvantage of the drug. Psychiatrists frequently have to switch medications because of side effects or lack of effectiveness, and anticipating this potential need to change medications plays into our initial choice of a drug. Knowing that Effexor was hard to give up made me think twice about prescribing it in the first place.
During my talks, I found myself playing both sides of the issue, making sure to mention that withdrawal symptoms could be severe but assuring doctors that they could “usually” be avoided. Was I lying? Not really, since there were no solid published data, and indeed some patients had little problem coming off Effexor. But was I tweaking and pruning the truth in order to stay positive about the product? Definitely. And how did I rationalize this? I convinced myself that I had told “most” of the truth and that the potential negative consequences of this small truth “gap” were too trivial to worry about.
As the months went on, I developed more and more reservations about recommending that Effexor be used as a “first line” drug before trying the S.S.R.I.’s. Not only were the newer comparative data less impressive, but the studies were short-term, lasting only 6 to 12 weeks. It seemed entirely possible that if the clinical trials had been longer — say, six months — S.S.R.I.’s would have caught up with Effexor. Effexor was turning out to be an antidepressant that might have a very slight effectiveness advantage over S.S.R.I.’s but that caused high blood pressure and had prolonged withdrawal symptoms.
At my next Lunch and Learn, I mentioned toward the end of my presentation that data in support of Effexor were mainly short-term, and that there was a possibility that S.S.R.I.’s were just as effective. I felt reckless, but I left the office with a restored sense of integrity.
Several days later, I was visited by the same district manager who first offered me the speaking job. Pleasant as always, he said: “My reps told me that you weren’t as enthusiastic about our product at your last talk. I told them that even Dr. Carlat can’t hit a home run every time. Have you been sick?”
At that moment, I decided my career as an industry-sponsored speaker was over. The manager’s message couldn’t be clearer: I was being paid to enthusiastically endorse their drug. Once I stopped doing that, I was of little value to them, no matter how much “medical education” I provided.
IV. Life After Drug Money
A year after starting my educational talks for drug companies (I had also given two talks for Forest Pharmaceuticals, pushing the antidepressant Lexapro), I quit. I had made about $30,000 in supplemental income from these talks, a significant addition to the $140,000 or so I made from my private practice. Now I publish a medical-education newsletter for psychiatrists that is not financed by the pharmaceutical industry and that tries to critically assess drug research and marketing claims. I still see patients, and I still prescribe Effexor. I don’t prescribe it as frequently as I used to, but I have seen many patients turn their lives around because they responded to this drug and to nothing else. +
In 2002, the drug industry’s trade group adopted voluntary guidelines limiting some of the more lavish benefits to doctors. While the guidelines still allow all-expenses-paid trips for physicians to attend meetings at fancy hotels, they no longer pay for spouses to attend the dinners or hand out tickets to musicals. In an e-mail message, a Wyeth spokesman wrote that Wyeth employees must follow that code and “our own Wyeth policies, which, in some cases, exceed” the trade group’s code.
Looking back on the year I spent speaking for Wyeth, I’ve asked myself if my work as a company speaker led me to do bad things. Did I contribute to faulty medical decision making? Did my advice lead doctors to make inappropriate drug choices, and did their patients suffer needlessly?
Maybe. I’m sure I persuaded many physicians to prescribe Effexor, potentially contributing to blood-pressure problems and withdrawal symptoms. On the other hand, it’s possible that some of those patients might have gained more relief from their depression and anxiety than they would have if they had been started on an S.S.R.I. Not likely, but possible.
I still allow drug reps to visit my office and give me their pitches. While these visits are short on useful medical information, they do allow me to keep up with trends in drug marketing. Recently, a rep from Bristol-Myers Squibb came into my office and invited me to a dinner program on the antipsychotic Abilify.
“I think it will be a great program, Dr. Carlat,” he said. “Would you like to come?” I glanced at the invitation. I recognized the name of the speaker, a prominent and widely published psychiatrist flown in from another state. The restaurant was one of the finest in town.
I was tempted. The wine, the great food, the proximity to a famous researcher — why not rejoin that inner circle of the select for an evening? But then I flashed to a memory of myself five years earlier, standing at a lectern and clearing my throat at the beginning of a drug-company presentation. I vividly remembered my sensations — the careful monitoring of what I would say, the calculations of how frank I should be.
“No,” I said, as I handed the rep back the invitation. “I don’t think I can make it. But thanks anyway.”
Daniel Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report.
November 25, 2007
Dr. Drug Rep
By DANIEL CARLAT
I. Faculty Development
On a blustery fall New England day in 2001, a friendly representative from Wyeth Pharmaceuticals came into my office in Newburyport, Mass., and made me an offer I found hard to refuse. He asked me if I’d like to give talks to other doctors about using Effexor XR for treating depression. He told me that I would go around to doctors’ offices during lunchtime and talk about some of the features of Effexor. It would be pretty easy. Wyeth would provide a set of slides and even pay for me to attend a speaker’s training session, and he quickly floated some numbers. I would be paid $500 for one-hour “Lunch and Learn” talks at local doctors’ offices, or $750 if I had to drive an hour. I would be flown to New York for a “faculty-development program,” where I would be pampered in a Midtown hotel for two nights and would be paid an additional “honorarium.”
I thought about his proposition. I had a busy private practice in psychiatry, specializing in psychopharmacology. I was quite familiar with Effexor, since I had read recent studies showing that it might be slightly more effective than S.S.R.I.’s, the most commonly prescribed antidepressants: the Prozacs, Paxils and Zolofts of the world. S.S.R.I. stands for selective serotonin reuptake inhibitor, referring to the fact that these drugs increase levels of the neurotransmitter serotonin, a chemical in the brain involved in regulating moods. Effexor, on the other hand, was being marketed as a dual reuptake inhibitor, meaning that it increases both serotonin and norepinephrine, another neurotransmitter. The theory promoted by Wyeth was that two neurotransmitters are better than one, and that Effexor was more powerful and effective than S.S.R.I.’s.
I had already prescribed Effexor to several patients, and it seemed to work as well as the S.S.R.I.’s. If I gave talks to primary-care doctors about Effexor, I reasoned, I would be doing nothing unethical. It was a perfectly effective treatment option, with some data to suggest advantages over its competitors. The Wyeth rep was simply suggesting that I discuss some of the data with other doctors. Sure, Wyeth would benefit, but so would other doctors, who would become more educated about a good medication.
A few weeks later, my wife and I walked through the luxurious lobby of the Millennium Hotel in Midtown Manhattan. At the reception desk, when I gave my name, the attendant keyed it into the computer and said, with a dazzling smile: “Hello, Dr. Carlat, I see that you are with the Wyeth conference. Here are your materials.”
She handed me a folder containing the schedule of talks, an invitation to various dinners and receptions and two tickets to a Broadway musical. “Enjoy your stay, doctor.” I had no doubt that I would, though I felt a gnawing at the edge of my conscience. This seemed like a lot of money to lavish on me just so that I could provide some education to primary-care doctors in a small town north of Boston.
The next morning, the conference began. There were a hundred or so other psychiatrists from different parts of the U.S. I recognized a couple of the attendees, including an acquaintance I hadn’t seen in a while. I’d heard that he moved to another state and was making a bundle of money, but nobody seemed to know exactly how.
I joined him at his table and asked him what he had been up to. He said he had a busy private practice and had given a lot of talks for Warner-Lambert, a company that had since been acquired by Pfizer. His talks were on Neurontin, a drug that was approved for epilepsy but that my friend had found helpful for bipolar disorder in his practice. (In 2004, Warner-Lambert pleaded guilty to illegally marketing Neurontin for unapproved uses. It is illegal for companies to pay doctors to promote so-called off-label uses.)
I knew about Neurontin and had prescribed it occasionally for bipolar disorder in my practice, though I had never found it very helpful. A recent study found that it worked no better than a placebo for this condition. I asked him if he really thought Neurontin worked for bipolar, and he said that he felt it was “great for some patients” and that he used it “all the time.” Given my clinical experiences with the drug, I wondered whether his positive opinion had been influenced by the money he was paid to give talks.
But I put those questions aside as we gulped down our coffees and took seats in a large lecture room. On the agenda were talks from some of the most esteemed academics in the field, authors of hundreds of articles in the major psychiatric journals. They included Michael Thase, of the University of Pittsburgh and the researcher who single-handedly put Effexor on the map with a meta-analysis, and Norman Sussman, a professor of psychiatry at New York University, who was master of ceremonies.
Thase strode to the lectern first in order to describe his groundbreaking work synthesizing data from more than 2,000 patients who had been enrolled in studies comparing Effexor with S.S.R.I.’s. At this time, with his Effexor study a topic of conversation in the mental-health world, Thase was one of the most well known and well respected psychiatrists in the United States. He cut a captivating figure onstage: tall and slim, dynamic, incredibly articulate and a master of the research craft.
He began by reviewing the results of the meta-analysis that had the psychiatric world abuzz. After carefully pooling and processing data from eight separate clinical trials, Thase published a truly significant finding: Effexor caused a 45 percent remission rate in patients in contrast to the S.S.R.I. rate of 35 percent and the placebo rate of 25 percent. It was the first time one antidepressant was shown to be more effective than any other. Previously, psychiatrists chose antidepressants based on a combination of guesswork, gut feeling and tailoring a drug’s side effects to a patient’s symptom profile. If Effexor was truly more effective than S.S.R.I.’s, it would amount to a revolution in psychiatric practice and a potential windfall for Wyeth.
One impressive aspect of Thase’s presentation was that he was not content to rest on his laurels; rather he raised a series of potential criticisms of his results and then rebutted them convincingly. For example, skeptics had pointed out that Thase was a paid consultant to Wyeth and that both of his co-authors were employees of the company. Thase responded that he had requested and had received all of the company’s data and had not cherry-picked from those studies most favorable for Effexor. This was a significant point, because companies sometimes withhold negative data from publication in medical journals. For example, in 2004, GlaxoSmithKline was sued by Eliot Spitzer, who was then the New York attorney general, for suppressing data hinting that Paxil causes suicidal thoughts in children. The company settled the case and agreed to make clinical-trial results public.
Another objection was that while the study was billed as comparing Effexor with S.S.R.I.’s in general, in fact most of the data compared Effexor with one specific S.S.R.I.: Prozac. Perhaps Effexor was, indeed, more effective than Prozac; this did not necessarily mean that it was more effective than the other S.S.R.I.’s in common use. But Thase announced that since the original study, he had analyzed data on Paxil and other meds and also found differences in remission rates.
For his study, Thase chose what was at that time an unusual measure of antidepressant improvement: “remission,” rather than the more standard measure, “response.” In clinical antidepressant trials, a “response” is defined as a 50 percent improvement in depressive symptoms, as measured by the Hamilton depression scale. Thus, if a patient enters a study scoring a 24 on the Hamilton (which would be a moderate degree of depression), he or she would have “responded” if the final score, after treatment, was 12 or less.
Remission, on the other hand, is defined as “complete” recovery. While you might think that a patient would have to score a 0 on the Hamilton to be in remission, in fact very few people score that low, no matter how deliriously happy they are. Instead, researchers come up with various cutoff scores for remission. Thase chose a cutoff score of 7 or below.
In his study, he emphasized the remission rates and not the response rates. As I listened to his presentation, I wondered why. Was it because he felt that remission was the only really meaningful outcome by which to compare drugs? Or was it because using remission made Effexor look more impressive than response did? Thase indirectly addressed this issue in his paper by pointing out that even when remission was defined in different ways, with different cutoff points, Effexor beat the S.S.R.I.’s every time. That struck me as a pretty convincing endorsement of Wyeth’s antidepressant.
The next speaker, Norm Sussman, took the baton from Thase and explored the concept of remission in more detail. Sussman’s job was to systematically go through the officially sanctioned “slide deck” — slides provided to us by Wyeth, which we were expected to use during our own presentations.
If Thase was the riveting academic, Sussman was the engaging populist, translating some of the drier research concepts into terms that our primary-care-physician audiences would understand. Sussman exhorted us not to be satisfied with response and encouraged us to set the bar higher. “Is the patient doing everything they were doing before they got depressed?” he asked. “Are they doing it even better? That’s remission.” To further persuade us, he highlighted a slide showing that patients who made it all the way to remission are less likely to relapse to another depressive episode than patients who merely responded. And for all its methodological limitations, it was a slide that I would become well acquainted with, as I would use it over and over again in my own talks.
When it came to side effects, Effexor’s greatest liability was that it could cause hypertension, a side effect not shared by S.S.R.I.’s. Sussman showed us some data from the clinical trials, indicating that at lower doses, about 3 percent of patients taking Effexor had hypertension as compared with about 2 percent of patients assigned to a placebo. There was only a 1 percent difference between Effexor and placebo, he commented, and pointed out that treating high blood pressure might be a small price to pay for relief from depression.
It was an accurate reading of the data, and I remember finding it a convincing defense of Effexor’s safety. As I look back at my notes now, however, I notice that another way of describing the same numbers would have been to say that Effexor leads to a 50 percent greater rate of hypertension than a placebo. Framed this way, Effexor looks more hazardous.
And so it went for the rest of the afternoon.
Was I swallowing the message whole? Certainly not. I knew that this was hardly impartial medical education, and that we were being fed a marketing line. But when you are treated like the anointed, wined and dined in Manhattan and placed among the leaders of the field, you inevitably put some of your critical faculties on hold. I was truly impressed with Effexor’s remission numbers, and like any physician, I was hopeful that something new and different had been introduced to my quiver of therapeutic options.
At the end of the last lecture, we were all handed envelopes as we left the conference room. Inside were checks for $750. It was time to enjoy ourselves in the city.
II. The Art and Science of Detailing
Pharmaceutical “detailing” is the term used to describe those sales visits in which drug reps go to doctors’ offices to describe the benefits of a specific drug. Once I returned to my Newburyport office from New York, a couple of voice-mail messages from local Wyeth reps were already waiting for me, inviting me to give some presentations at local doctors’ offices. I was about to begin my speaking — and detailing — career in earnest.
How many doctors speak for drug companies? We don’t know for sure, but one recent study indicates that at least 25 percent of all doctors in the United States receive drug money for lecturing to physicians or for helping to market drugs in other ways. This meant that I was about to join some 200,000 American physicians who are being paid by companies to promote their drugs. I felt quite flattered to have been recruited, and I assumed that the rep had picked me because of some special personal or professional quality.
The first talk I gave brought me back to earth rather quickly. I distinctly remember the awkwardness of walking into my first waiting room. The receptionist slid the glass partition open and asked if I had an appointment.
“Actually, I’m here to meet with the doctor.”
“Oh, O.K. And is that a scheduled appointment?”
“I’m here to give a talk.”
A light went on. “Oh, are you part of the drug lunch?”
Regardless of how I preferred to think of myself (an educator, a psychiatrist, a consultant), I was now classified as one facet of a lunch helping to pitch a drug, a convincing sidekick to help the sales rep. Eventually, with an internal wince, I began to introduce myself as “Dr. Carlat, here for the Wyeth lunch.”
The drug rep who arranged the lunch was always there, usually an attractive, vivacious woman with platters of gourmet sandwiches in tow. Hungry doctors and their staff of nurses and receptionists would filter into the lunch room, grateful for free food.
Once there was a critical mass (and crucially, once the M.D.’s arrived), I was given the go-ahead by the Wyeth reps to start. I dove into my talk, going through a handout that I created, based on the official slide deck. I discussed the importance of remission, the basics of the Thase study showing the advantage of Effexor, how to dose the drug, the side effects, and I added a quick review of the other common antidepressants.
While I still had some doubts, I continued to be impressed by the 10 percent advantage in remission rates that Effexor held over S.S.R.I.’s; that advantage seemed significant enough to overcome Effexor’s more prominent side effects. Yes, I was highlighting Effexor’s selling points and playing down its disadvantages, and I knew it. But was my salesmanship going to bring harm to anybody? It seemed unlikely. The worst case was that Effexor was no more effective than anything else; it certainly was no less effective.
During my first few talks, I worried a lot about my performance. Was I too boring? Did the doctors see me as sleazy? Did the Wyeth reps find me sufficiently persuasive? But the day after my talks, I would get a call or an e-mail message from the rep saying that I did a great job, that the doctor was impressed and that they wanted to use me more. Indeed, I started receiving more and more invitations from other reps, and I soon had talks scheduled every week. I learned later that Wyeth and other companies have speaker-evaluation systems. After my talks, the reps would fill out a questionnaire rating my performance, which quickly became available to other Wyeth reps throughout the area.
As the reps became comfortable with me, they began to see me more as a sales colleague. I received faxes before talks preparing me for particular doctors. One note informed me that the physician we’d be visiting that day was a “decile 6 doctor and is not prescribing any Effexor XR, so please tailor accordingly. There is also one more doc in the practice that we are not familiar with.” The term “decile 6” is drug-rep jargon for a doctor who prescribes a lot of medications. The higher the “decile” (in a range from 1 to 10), the higher the prescription volume, and the more potentially lucrative that doctor could be for the company.
A note from another rep reminded me of a scene from “Mission: Impossible.” “Dr. Carlat: Our main target, Dr. , is an internist. He spreads his usage among three antidepressants, Celexa, Zoloft and Paxil, at about 25-30 percent each. He is currently using about 6 percent Effexor XR. Our access is very challenging with lunches six months out.” This doctor’s schedule of lunches was filled with reps from other companies; it would be vital to make our sales visit count.+
Naïve as I was, I found myself astonished at the level of detail that drug companies were able to acquire about doctors’ prescribing habits. I asked my reps about it; they told me that they received printouts tracking local doctors’ prescriptions every week. The process is called “prescription data-mining,” in which specialized pharmacy-information companies (like IMS Health and Verispan) buy prescription data from local pharmacies, repackage it, then sell it to pharmaceutical companies. This information is then passed on to the drug reps, who use it to tailor their drug-detailing strategies. This may include deciding which physicians to aim for, as my Wyeth reps did, but it can help sales in other ways. For example, Shahram Ahari, a former drug rep for Eli Lilly (the maker of Prozac) who is now a researcher at the University of California at San Francisco’s School of Pharmacy, said in an article in The Washington Post that as a drug rep he would use this data to find out which doctors were prescribing Prozac’s competitors, like Effexor. Then he would play up specific features of Prozac that contrasted favorably with the other drug, like the ease with which patients can get off Prozac, as compared with the hard time they can have withdrawing from Effexor.
The American Medical Association is also a key player in prescription data-mining. Pharmacies typically will not release doctors’ names to the data-mining companies, but they will release their Drug Enforcement Agency numbers. The A.M.A. licenses its file of U.S. physicians, allowing the data-mining companies to match up D.E.A. numbers to specific physicians. The A.M.A. makes millions in information-leasing money.
Once drug companies have identified the doctors, they must woo them. In the April 2007 issue of the journal PLoS Medicine, Dr. Adriane Fugh-Berman of Georgetown teamed up with Ahari (the former drug rep) to describe the myriad techniques drug reps use to establish relationships with physicians, including inviting them to a speaker’s meeting. These can serve to cement a positive a relationship between the rep and the doctor. This relationship is crucial, they say, since “drug reps increase drug sales by influencing physicians, and they do so with finely titrated doses of friendship.”
III. Uncomfortable Moments
I gave many talks over the ensuing several months, and I gradually became more comfortable with the process. Each setting was somewhat different. Sometimes I spoke to a crowded conference room with several physicians, nurses and other clinical staff. Other times, I sat at a small lunch table with only one other physician (plus the rep), having what amounted to a conversation about treating depression. My basic Effexor spiel was similar in the various settings, with the focus on remission and the Thase data.
Meanwhile, I was keeping up with new developments in the research literature related to Effexor, and not all of the news was positive. For example, as more data came out comparing Effexor with S.S.R.I.’s other than Prozac, the Effexor remission advantage became slimmer — more like 5 percent instead of the originally reported 10 percent. Statistically, this 5 percent advantage meant that only one out of 20 patients would potentially do better on Effexor than S.S.R.I.’s — much less compelling than the earlier proportion of one out of 10.
I also became aware of other critiques of the original Thase meta-analysis. For example, some patients enrolled in the original Effexor studies took S.S.R.I.’s in the past and presumably had not responded well. This meant that the study population may have been enriched with patients who were treatment-resistant to S.S.R.I.’s, giving Effexor an inherent advantage.
I didn’t mention any of this in my talks, partly because none of it had been included in official company slides, and partly because I was concerned that the reps wouldn’t invite me to give talks if I divulged any negative information. But I was beginning to struggle with the ethics of my silence.
One of my most uncomfortable moments came when I gave a presentation to a large group of psychiatrists. I was in the midst of wrapping up my talk with some information about Effexor and blood pressure. Referring to a large study paid for by Wyeth, I reported that patients are liable to develop hypertension only if they are taking Effexor at doses higher than 300 milligrams per day.
“Really?” one psychiatrist in the room said. “I’ve seen hypertension at lower doses in my patients.”
“I suppose it can happen, but it’s rare at doses that are commonly used for depression.”
He looked at me, frowned and shook his head. “That hasn’t been my experience.”
I reached into my folder where I kept some of the key Effexor studies in case such questions arose.
According to this study of 3,744 patients, the rate of high blood pressure was 2.2 percent in the placebo group, and 2.9 percent in the group of patients who had taken daily doses of Effexor no larger than 300 milligrams. Patients taking more than 300 milligrams had a 9 percent risk of hypertension. As I went through the numbers with the doctor, however, I felt unsettled. I started talking faster, a sure sign of nervousness for me.
Driving home, I went back over the talk in my mind. I knew I had not lied — I had reported the data exactly as they were reported in the paper. But still, I had spun the results of the study in the most positive way possible, and I had not talked about the limitations of the data. I had not, for example, mentioned that if you focused specifically on patients taking between 200 and 300 milligrams per day, a commonly prescribed dosage range, you found a 3.7 percent incidence of hypertension. While this was not a statistically significant higher rate than the placebo, it still hinted that such moderate doses could, indeed, cause hypertension. Nor had I mentioned the fact that since the data were derived from placebo-controlled clinical trials, the patients were probably not representative of the patients seen in most real practices. Patients who are very old or who have significant medical problems are excluded from such studies. But real-world patients may well be at higher risk to develop hypertension on Effexor. +
I realized that in my canned talks, I was blithely minimizing the hypertension risks, conveniently overlooking the fact that hypertension is a dangerous condition and not one to be trifled with. Why, I began to wonder, would anyone prescribe an antidepressant that could cause hypertension when there were many other alternatives? And why wasn’t I asking this obvious question out loud during my talks?
I felt rattled. That psychiatrist’s frown stayed with me — a mixture of skepticism and contempt. I wondered if he saw me for what I feared I had become — a drug rep with an M.D. I began to think that the money was affecting my critical judgement. I was willing to dance around the truth in order to make the drug reps happy. Receiving $750 checks for chatting with some doctors during a lunch break was such easy money that it left me giddy. Like an addiction, it was very hard to give up.
There was another problem: one of Effexor’s side effects. Patients who stopped the medication were calling their doctors and reporting symptoms like severe dizziness and lightheadedness, bizarre electric-shock sensations in their heads, insomnia, sadness and tearfulness. Some patients thought they were having strokes or nervous breakdowns and were showing up in emergency rooms. Gradually, however, it became clear that these were “withdrawal” symptoms. These were particularly common problems with Effexor because it has a short half-life, a measure of the time it takes the body to metabolize half of the total amount of a drug in the bloodstream. Paxil, another short half-life antidepressant, caused similar problems.
At the Wyeth meeting in New York, these withdrawal effects were mentioned in passing, though we were assured that Effexor withdrawal symptoms were uncommon and could usually be avoided by tapering down the dose very slowly. But in my practice, that strategy often did not work, and patients were having a very hard time coming off Effexor in order to start a trial of a different antidepressant.
I wrestled with how to handle this issue in my Effexor talks, since I believed it was a significant disadvantage of the drug. Psychiatrists frequently have to switch medications because of side effects or lack of effectiveness, and anticipating this potential need to change medications plays into our initial choice of a drug. Knowing that Effexor was hard to give up made me think twice about prescribing it in the first place.
During my talks, I found myself playing both sides of the issue, making sure to mention that withdrawal symptoms could be severe but assuring doctors that they could “usually” be avoided. Was I lying? Not really, since there were no solid published data, and indeed some patients had little problem coming off Effexor. But was I tweaking and pruning the truth in order to stay positive about the product? Definitely. And how did I rationalize this? I convinced myself that I had told “most” of the truth and that the potential negative consequences of this small truth “gap” were too trivial to worry about.
As the months went on, I developed more and more reservations about recommending that Effexor be used as a “first line” drug before trying the S.S.R.I.’s. Not only were the newer comparative data less impressive, but the studies were short-term, lasting only 6 to 12 weeks. It seemed entirely possible that if the clinical trials had been longer — say, six months — S.S.R.I.’s would have caught up with Effexor. Effexor was turning out to be an antidepressant that might have a very slight effectiveness advantage over S.S.R.I.’s but that caused high blood pressure and had prolonged withdrawal symptoms.
At my next Lunch and Learn, I mentioned toward the end of my presentation that data in support of Effexor were mainly short-term, and that there was a possibility that S.S.R.I.’s were just as effective. I felt reckless, but I left the office with a restored sense of integrity.
Several days later, I was visited by the same district manager who first offered me the speaking job. Pleasant as always, he said: “My reps told me that you weren’t as enthusiastic about our product at your last talk. I told them that even Dr. Carlat can’t hit a home run every time. Have you been sick?”
At that moment, I decided my career as an industry-sponsored speaker was over. The manager’s message couldn’t be clearer: I was being paid to enthusiastically endorse their drug. Once I stopped doing that, I was of little value to them, no matter how much “medical education” I provided.
IV. Life After Drug Money
A year after starting my educational talks for drug companies (I had also given two talks for Forest Pharmaceuticals, pushing the antidepressant Lexapro), I quit. I had made about $30,000 in supplemental income from these talks, a significant addition to the $140,000 or so I made from my private practice. Now I publish a medical-education newsletter for psychiatrists that is not financed by the pharmaceutical industry and that tries to critically assess drug research and marketing claims. I still see patients, and I still prescribe Effexor. I don’t prescribe it as frequently as I used to, but I have seen many patients turn their lives around because they responded to this drug and to nothing else. +
In 2002, the drug industry’s trade group adopted voluntary guidelines limiting some of the more lavish benefits to doctors. While the guidelines still allow all-expenses-paid trips for physicians to attend meetings at fancy hotels, they no longer pay for spouses to attend the dinners or hand out tickets to musicals. In an e-mail message, a Wyeth spokesman wrote that Wyeth employees must follow that code and “our own Wyeth policies, which, in some cases, exceed” the trade group’s code.
Looking back on the year I spent speaking for Wyeth, I’ve asked myself if my work as a company speaker led me to do bad things. Did I contribute to faulty medical decision making? Did my advice lead doctors to make inappropriate drug choices, and did their patients suffer needlessly?
Maybe. I’m sure I persuaded many physicians to prescribe Effexor, potentially contributing to blood-pressure problems and withdrawal symptoms. On the other hand, it’s possible that some of those patients might have gained more relief from their depression and anxiety than they would have if they had been started on an S.S.R.I. Not likely, but possible.
I still allow drug reps to visit my office and give me their pitches. While these visits are short on useful medical information, they do allow me to keep up with trends in drug marketing. Recently, a rep from Bristol-Myers Squibb came into my office and invited me to a dinner program on the antipsychotic Abilify.
“I think it will be a great program, Dr. Carlat,” he said. “Would you like to come?” I glanced at the invitation. I recognized the name of the speaker, a prominent and widely published psychiatrist flown in from another state. The restaurant was one of the finest in town.
I was tempted. The wine, the great food, the proximity to a famous researcher — why not rejoin that inner circle of the select for an evening? But then I flashed to a memory of myself five years earlier, standing at a lectern and clearing my throat at the beginning of a drug-company presentation. I vividly remembered my sensations — the careful monitoring of what I would say, the calculations of how frank I should be.
“No,” I said, as I handed the rep back the invitation. “I don’t think I can make it. But thanks anyway.”
Daniel Carlat is an assistant clinical professor of psychiatry at Tufts University School of Medicine and the publisher of The Carlat Psychiatry Report.
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