Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.

---

Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”

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Well: The 'Monday Morning' Medical Screaming Match

I did not think I would ever see another “morbidity and mortality” conference in which senior doctors publicly attacked their younger colleagues for making medical errors. These types of heated meetings were commonplace when I was a medical student but have largely been abandoned.

Yet here they were again on “Monday Mornings,” a new medical drama on the TNT network, based on a novel by Dr. Sanjay Gupta, CNN’s chief medical correspondent and one of the executive producers of the show. Such screaming matches may make for good television, but it is useful to review why new strategies have emerged for dealing with medical mistakes.

So-called M&M conferences emerged in the early 20th century as a way for physicians to review cases that had either surprising outcomes or had somehow gone wrong. Although the format varied among institutions and departments, surgery M&Ms were especially known for their confrontations, as more experienced surgeons often browbeat younger doctors into admitting their errors and promising to never make them again.

Such conferences were generally closed door — that is, attended only by physicians. Errors were a private matter not to be shared with other hospital staff, let alone patients and families.

But in the late 1970s, a sociology graduate student named Charles L. Bosk gained access to the surgery department at the University of Chicago. His resultant 1979 book, “Forgive and Remember,” was one of the earliest public discussions of how the medical profession addressed its mistakes.

Dr. Bosk developed a helpful terminology. Technical and judgment errors by surgeons could be forgiven, but only if they were remembered and subsequently prevented by those who committed them. Normative errors, which called into question the moral character of the culprit, were unacceptable and potentially jeopardized careers.

Although Dr. Bosk’s book was more observational than proscriptive, his depiction of M&M conferences was disturbing. I remember attending a urology M&M as a medical student in which several senior physicians berated a very well-meaning and competent intern for a perceived mistake. The intern seemed to take it very well, but my fellow students and I were shaken by the event, asking how such hostility could be conducive to learning.

There were lots of angry accusations in the surgical M&Ms in the pilot episode of “Monday Mornings.” In one case, a senior doctor excoriated a colleague who had given Tylenol to a woman with hip pain who turned out to have cancer. “You allowed metastatic cancer to run amok for four months!” he screamed.

If this was what Dr. Bosk would have called a judgment error, the next case raised moral issues. A neurosurgeon had operated on a boy’s brain tumor without doing a complete family history, which would have revealed a disorder of blood clotting. The boy bled to death on the operating table. “The boy died,” announced the head surgeon, “because of a doctor’s arrogance.”

In one respect, it is good to see that the doctors in charge were so concerned. But as the study of medical errors expanded in the 1990s, researchers found that the likelihood of being blamed led physicians to conceal their errors. Meanwhile, although doctors who attended such conferences might indeed not make the exact same mistakes that had been discussed, it was far from clear that M&Ms were the best way to address the larger problem of medical errors, which, according to a 1999 study, killed close to 100,000 Americans annually.

Eventually, experts recommended a “systems approach” to medical errors, similar to what had been developed by the airline industry. The idea was to look at the root causes of errors and to devise systems to prevent them. Was there a way, for example, to ensure that the woman with the hip problem would return to medical care when the Tylenol did not help? Or could operations not be allowed to occur until a complete family history was in the chart? Increasingly, hospitals have put in systems, such as preoperative checklists and computer warnings, that successfully prevent medical errors.

Another key component of the systems approach is to reduce the emphasis on blame. Even the best doctors make mistakes. Impugning them publicly — or even privately — can make them clam up. But if errors are seen as resulting from inadequate systems, physicians and other health professionals should be more willing to speak up.

Of course, the systems approach is not perfect. Studies continue to show that physicians conceal their mistakes. And elaborate systems for preventing errors can at times interfere with getting things done in the hospital.

Finally, it is important not to entirely remove the issue of responsibility. Sad to say, there still are physicians who are careless and others who are arrogant. Even if today’s M&M conferences rarely involve screaming, supervising physicians need to let such colleagues know that these types of behaviors are unacceptable.

---

Barron H. Lerner, M.D., professor of medicine at New York University Langone Medical Center, is the author, most recently, of “One for the Road: Drunk Driving Since 1900.”

Read More..

Television Review: ‘Silicon Valley,’ on ‘American Experience’ on PBS

“Silicon Valley” is a deceptively grand title for the new “American Experience” documentary Tuesday night on PBS. “Fairchild Semiconductor” would be more accurate. It could even be called “Robert Noyce” or, with a musical score and some dance numbers, “Noyce!”

But the film’s modest goals work in its favor. “Silicon Valley” takes one piece of the sprawling story of the electronics industry in Northern California and tells it with admirable clarity and detail. Stopping well short of the valley’s modern era — the action ends in the early 1970s, with the invention of the microprocessor — it’s rewarding as both history and nostalgia.

The documentary actually touches on several cycles of wistfulness. Nostalgia for the preindustrial Santa Clara Valley of orchards and farm stands, which has been heavy for more than three decades now, is indulged with grainy shots of apricots being picked and young men in letter sweaters and khaki pants walking past the History Corner of the Stanford quad. (Like many films about Silicon Valley, this one also cheats by including San Francisco vistas and cable cars.)

After that stage setting, the film gets to its central story: how in 1957 eight young men, led by a visionary physicist and engineer, Mr. Noyce, took the revolutionary step of leaving their company to form a start-up called Fairchild Semiconductor and in the process created Silicon Valley. Interviews with an array of industry veterans, including two of the three surviving defectors, outline how Fairchild and the companies it spawned both developed the technologies and established the business and financial cultures that would eventually produce behemoths like Apple and Google.

This is dramatic social and scientific history, revealing, among other things, how the semiconductor industry grew to serve the military and the space program long before the rise of the personal computer. But, again, the film’s visceral appeal has much to do with period detail: neatly groomed engineers wearing suits and ties, even on the production floor or at the bar of Walker’s Wagon Wheel in Mountain View; rows of women in smocks and hairnets assembling transistors. (The gender lines are inviolate in these early-’60s photos, and the men are almost invariably white.)

One startling image shows a handwritten list of the many corporations that declined to bankroll the eight pioneers before Fairchild Camera and Instrument said yes. If any of them had possessed more foresight, the silicon chip might have belonged to National Cash Register, Motorola, Philco, BorgWarner, Chrysler, General Mills or United Shoe.

Even with its relatively narrow focus, “Silicon Valley” is highly compressed, and people familiar with the industry may have complaints: that the infighting that made Fairchild Semiconductor’s reign short-lived isn’t fully explored, or that Intel, the chip giant later founded by Mr. Noyce and Gordon Moore, should receive more attention.

Any quibbling aside, though, the film is a captivating look at recent history that already feels ancient, when high technology involved inventing and building things rather than writing code and selling clicks.

American Experience

Silicon Valley

On PBS stations on Tuesday night (check local listings).

Produced by Film Posse for “American Experience.” Directed and edited by Randall MacLowry; written by Mr. MacLowry and Michelle Ferrari, based on a story by Mr. MacLowry; Mr. MacLowry and Tracy Heather Strain, producers; Mark Samels, executive producer for “American Experience”; Michael Murphy, narrator.

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World Briefing | Europe: Lasagna Products Test Positive for Horsemeat in Britain

British authorities say beef lasagna products recalled from British supermarkets by the frozen-food company Findus have tested positive for more than 60 percent horsemeat. The revelation comes after millions of burgers were taken off shop shelves this month as it emerged that beef products from three companies in Ireland and Britain contained horse DNA. The Food Standards Agency said Thursday that its tests on Findus’s beef lasagna were part of an investigation into mislabeled meat and that there was no evidence the results posed a food safety risk.

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DealBook: Helping Start-Ups With Local Support and National Networks

When Will Fuentes planned an extended business trip to Seattle last year, he tapped into the local chapter of a national networking group there. Within hours, Mr. Fuentes, who founded the Arlington, Va., software company Lemur Retail, had secured a work space, introductions and even restaurant recommendations via the group, the Startup America Partnership.“Before I flew out there, I already had five or six meetings set up with potential clients and other key contacts, as well as one potential acquirer,” Mr. Fuentes said.

A couple of years ago, entrepreneurs would have needed several trips to make similar connections outside their own cities. Even in this era of social networks and venture conferences, start-ups are still surprisingly disconnected on a national level.

“Each region has its ties, but in many cases, entrepreneurs are operating in silos,” said Carolynn Duncan, the chief executive of Portland Ten, a mentoring program for early-stage companies, mainly in Oregon. “An entrepreneur in Oregon doesn’t have an easy way to network with entrepreneurs in Washington D.C.”

Startup America, a nonprofit organization with an all-star cast of deep-pocketed backers, is trying to bridge the gap. The organization, which was started in January 2011 as the brainchild of AOL’s co-founder, Steve Case, and the Ewing Marion Kauffman Foundation, wanted to bring a private-sector support to start-ups — without financial strings attached.

“Supporting start-ups throughout the country is the only way to make sure the American economy is firing on all cylinders,” said Mr. Case, who is the chairman of the partnership.

Start-ups are a crucial driver for job creation in the United States. From March 1994 to March 2010, businesses less than one year old created 3.9 million jobs a year on average, according to the Bureau of Labor Statistics, though that number has declined during the recent economic weakness.

The Small Business Administration and United States Chamber of Commerce have long been a resource for start-ups, but these government agencies have a broad mandate. There is a “growing recognition,” said Mr. Case, that high-growth start-ups — those with the potential to be national or international companies — have different needs and requirements than traditional small businesses.

Startup America’s initial focus was to provide support to start-ups through deals on goods and services, like 40 percent off FedEx shipping and free flights on American Airlines. But the group quickly realized that start-ups needed more practical help, like sharing best practices and networking.

Soon after the partnership’s start, entrepreneurs around the country starting contacting Startup America, asking how they could create their own networks and reach out to counterparts in other states. “Most of these regions were already coming up with their own initiatives or thinking about them,” said the organization’s chief executive, Scott Case, a founder and former chief technology officer of Priceline.com (and no relation to Steve Case). “We’re helping to stitch together all these parts.”

Taking cues from the entrepreneurs, Startup America has turned its attention to building such a network. Nearly 12,000 members are now affiliated with local Startup America initiatives in 30 states. The partnership expects to add another 10 states this year.

Each Startup America region is spearheaded by local “champions” who come together several times a year at national conferences, communicate via Google groups and have access to an online “idea center” where they can brainstorm about, say, bringing in outside capital or hosting a start-up conference. These envoys are all “founder types” at different stages of their careers, Scott Case said. “Some have exited companies and are looking to continue to feed that creative drive. Others understand that if they can strengthen their community, they can strengthen their own company.”

Brooks Bell, founder of an eponymous 22-employee digital consulting business based in Raleigh, N.C., became involved with the partnership in 2011 after realizing that many potential clients considered her area a backwater. “I realized that was impacting my company’s brand, too,” she said.

Mrs. Bell pointed out that other national groups, like Entrepreneurs’ Organizations, offer resources for high-growth companies. Yet, their emphasis is typically on supporting individuals rather than elevating the region and networking nationally. “They also tend to focus on early-stage companies,” she said. Until Startup America, she added, “there weren’t a lot of opportunities for early-stage companies to interact with funded companies.”

Though Startup America regions work off the same blueprint, each takes a slightly different approach. In Maryland, the staff and champions volunteer virtually. Startup Tennessee partnered with the Entrepreneur Center in Nashville, which runs a nonprofit incubator program. Startup Colorado works out of Silicon Flatirons, a center for law, technology and entrepreneurship at the University of Colorado Law School, and finds partners to finance specific projects.

Although the regional chapters operate independently, they benefit from the credibility of a national organization. “It’s helping elevate our start-ups nationally and get them in front of audiences we never would have,” said Andy Stoll, an entrepreneur in the Iowa City, Iowa, area, where rebuilding from the floods in 2008 has helped generate a boom in start-up activity.

“To have the opportunity to sit in a room with their board and have Steve Case ask me, ‘What are the three things that those of us at this table can do to really help support the Indiana community?’ is amazing and a humbling experience,” said Michael Coffey, a partner at DeveloperTown, an Indianapolis design and development firm that works with companies of all sizes.

In the end, it’s all about business.

Aaron Schwartz, a co-founder of the San Francisco-based Modify Watches, initially joined Startup America for the discounts. Now, he’s also tapping into the partnership to network, including finding corporate clients who order custom watches and vendors. “I now have a contact in Tennessee who has offered to look into manufacturing our watches there,” he said

Mr. Fuentes of Lemur Retail found two potential clients, both national chains, through his connections in Seattle last year; he’s currently in talks with those companies. He’s also helping his Northwest counterparts make inroads in the Washington area. He likens the experience to a fraternity or alumni organization of entrepreneurs.

“When people contact me from my high school or college, I pick up the phone,” he said. “This is no different.”

Read More..

Personal Health: Effective Addiction Treatment

Countless people addicted to drugs, alcohol or both have managed to get clean and stay clean with the help of organizations like Alcoholics Anonymous or the thousands of residential and outpatient clinics devoted to treating addiction.

But if you have failed one or more times to achieve lasting sobriety after rehab, perhaps after spending tens of thousands of dollars, you’re not alone. And chances are, it’s not your fault.

Of the 23.5 million teenagers and adults addicted to alcohol or drugs, only about 1 in 10 gets treatment, which too often fails to keep them drug-free. Many of these programs fail to use proven methods to deal with the factors that underlie addiction and set off relapse.

According to recent examinations of treatment programs, most are rooted in outdated methods rather than newer approaches shown in scientific studies to be more effective in helping people achieve and maintain addiction-free lives. People typically do more research when shopping for a new car than when seeking treatment for addiction.

A groundbreaking report published last year by the National Center on Addiction and Substance Abuse at Columbia University concluded that “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” The report added, “Only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.”

The Columbia report found that most addiction treatment providers are not medical professionals and are not equipped with the knowledge, skills or credentials needed to provide the full range of evidence-based services, including medication and psychosocial therapy. The authors suggested that such insufficient care could be considered “a form of medical malpractice.”

The failings of many treatment programs — and the comprehensive therapies that have been scientifically validated but remain vastly underused — are described in an eye-opening new book, “Inside Rehab,” by Anne M. Fletcher, a science writer whose previous books include the highly acclaimed “Sober for Good.”

“There are exceptions, but of the many thousands of treatment programs out there, most use exactly the same kind of treatment you would have received in 1950, not modern scientific approaches,” A. Thomas McLellan, co-founder of the Treatment Research Institute in Philadelphia, told Ms. Fletcher.

Ms. Fletcher’s book, replete with the experiences of treated addicts, offers myriad suggestions to help patients find addiction treatments with the highest probability of success.

Often, Ms. Fletcher found, low-cost, publicly funded clinics have better-qualified therapists and better outcomes than the high-end residential centers typically used by celebrities like Britney Spears and Lindsay Lohan. Indeed, their revolving-door experiences with treatment helped prompt Ms. Fletcher’s exhaustive exploration in the first place.

In an interview, Ms. Fletcher said she wanted to inform consumers “about science-based practices that should form the basis of addiction treatment” and explode some of the myths surrounding it.

One such myth is the belief that most addicts need to go to a rehab center.

“The truth is that most people recover (1) completely on their own, (2) by attending self-help groups, and/or (3) by seeing a counselor or therapist individually,” she wrote.

Contrary to the 30-day stint typical of inpatient rehab, “people with serious substance abuse disorders commonly require care for months or even years,” she wrote. “The short-term fix mentality partially explains why so many people go back to their old habits.”

Dr. Mark Willenbring, a former director of treatment and recovery research at the National Institute for Alcohol Abuse and Alcoholism, said in an interview, “You don’t treat a chronic illness for four weeks and then send the patient to a support group. People with a chronic form of addiction need multimodal treatment that is individualized and offered continuously or intermittently for as long as they need it.”

Dr. Willenbring now practices in St. Paul, where he is creating a clinic called Alltyr “to serve as a model to demonstrate what comprehensive 21st century treatment should look like.”

“While some people are helped by one intensive round of treatment, the majority of addicts continue to need services,” Dr. Willenbring said. He cited the case of a 43-year-old woman “who has been in and out of rehab 42 times” because she never got the full range of medical and support services she needed.

Dr. Willenbring is especially distressed about patients who are treated for opioid addiction, then relapse in part because they are not given maintenance therapy with the drug Suboxone.

“We have some pretty good drugs to help people with addiction problems, but doctors don’t know how to use them,” he said. “The 12-step community doesn’t want to use relapse-prevention medication because they view it as a crutch.”

Before committing to a treatment program, Ms. Fletcher urges prospective clients or their families to do their homework. The first step, she said, is to get an independent assessment of the need for treatment, as well as the kind of treatment needed, by an expert who is not affiliated with the program you are considering.

Check on the credentials of the program’s personnel, who should have “at least a master’s degree,” Ms. Fletcher said. If the therapist is a physician, he or she should be certified by the American Board of Addiction Medicine.

Does the facility’s approach to treatment fit with your beliefs and values? If a 12-step program like A.A. is not right for you, don’t choose it just because it’s the best known approach.

Meet with the therapist who will treat you and ask what your treatment plan will be. “It should be more than movies, lectures or three-hour classes three times a week,” Ms. Fletcher said. “You should be treated by a licensed addiction counselor who will see you one-on-one. Treatment should be individualized. One size does not fit all.”

Find out if you will receive therapy for any underlying condition, like depression, or a social problem that could sabotage recovery. The National Institute on Drug Abuse states in its Principles of Drug Addiction Treatment, “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems.”

Look for programs using research-validated techniques, like cognitive behavioral therapy, which helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance.

Other validated treatment methods include Community Reinforcement and Family Training, or Craft, an approach developed by Robert J. Meyers and described in his book, “Get Your Loved One Sober,” with co-author Brenda L. Wolfe. It helps addicts adopt a lifestyle more rewarding than one filled with drugs and alcohol.

This is the first of two articles on addiction treatment.

Read More..

Personal Health: Effective Addiction Treatment

Countless people addicted to drugs, alcohol or both have managed to get clean and stay clean with the help of organizations like Alcoholics Anonymous or the thousands of residential and outpatient clinics devoted to treating addiction.

But if you have failed one or more times to achieve lasting sobriety after rehab, perhaps after spending tens of thousands of dollars, you’re not alone. And chances are, it’s not your fault.

Of the 23.5 million teenagers and adults addicted to alcohol or drugs, only about 1 in 10 gets treatment, which too often fails to keep them drug-free. Many of these programs fail to use proven methods to deal with the factors that underlie addiction and set off relapse.

According to recent examinations of treatment programs, most are rooted in outdated methods rather than newer approaches shown in scientific studies to be more effective in helping people achieve and maintain addiction-free lives. People typically do more research when shopping for a new car than when seeking treatment for addiction.

A groundbreaking report published last year by the National Center on Addiction and Substance Abuse at Columbia University concluded that “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” The report added, “Only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.”

The Columbia report found that most addiction treatment providers are not medical professionals and are not equipped with the knowledge, skills or credentials needed to provide the full range of evidence-based services, including medication and psychosocial therapy. The authors suggested that such insufficient care could be considered “a form of medical malpractice.”

The failings of many treatment programs — and the comprehensive therapies that have been scientifically validated but remain vastly underused — are described in an eye-opening new book, “Inside Rehab,” by Anne M. Fletcher, a science writer whose previous books include the highly acclaimed “Sober for Good.”

“There are exceptions, but of the many thousands of treatment programs out there, most use exactly the same kind of treatment you would have received in 1950, not modern scientific approaches,” A. Thomas McLellan, co-founder of the Treatment Research Institute in Philadelphia, told Ms. Fletcher.

Ms. Fletcher’s book, replete with the experiences of treated addicts, offers myriad suggestions to help patients find addiction treatments with the highest probability of success.

Often, Ms. Fletcher found, low-cost, publicly funded clinics have better-qualified therapists and better outcomes than the high-end residential centers typically used by celebrities like Britney Spears and Lindsay Lohan. Indeed, their revolving-door experiences with treatment helped prompt Ms. Fletcher’s exhaustive exploration in the first place.

In an interview, Ms. Fletcher said she wanted to inform consumers “about science-based practices that should form the basis of addiction treatment” and explode some of the myths surrounding it.

One such myth is the belief that most addicts need to go to a rehab center.

“The truth is that most people recover (1) completely on their own, (2) by attending self-help groups, and/or (3) by seeing a counselor or therapist individually,” she wrote.

Contrary to the 30-day stint typical of inpatient rehab, “people with serious substance abuse disorders commonly require care for months or even years,” she wrote. “The short-term fix mentality partially explains why so many people go back to their old habits.”

Dr. Mark Willenbring, a former director of treatment and recovery research at the National Institute for Alcohol Abuse and Alcoholism, said in an interview, “You don’t treat a chronic illness for four weeks and then send the patient to a support group. People with a chronic form of addiction need multimodal treatment that is individualized and offered continuously or intermittently for as long as they need it.”

Dr. Willenbring now practices in St. Paul, where he is creating a clinic called Alltyr “to serve as a model to demonstrate what comprehensive 21st century treatment should look like.”

“While some people are helped by one intensive round of treatment, the majority of addicts continue to need services,” Dr. Willenbring said. He cited the case of a 43-year-old woman “who has been in and out of rehab 42 times” because she never got the full range of medical and support services she needed.

Dr. Willenbring is especially distressed about patients who are treated for opioid addiction, then relapse in part because they are not given maintenance therapy with the drug Suboxone.

“We have some pretty good drugs to help people with addiction problems, but doctors don’t know how to use them,” he said. “The 12-step community doesn’t want to use relapse-prevention medication because they view it as a crutch.”

Before committing to a treatment program, Ms. Fletcher urges prospective clients or their families to do their homework. The first step, she said, is to get an independent assessment of the need for treatment, as well as the kind of treatment needed, by an expert who is not affiliated with the program you are considering.

Check on the credentials of the program’s personnel, who should have “at least a master’s degree,” Ms. Fletcher said. If the therapist is a physician, he or she should be certified by the American Board of Addiction Medicine.

Does the facility’s approach to treatment fit with your beliefs and values? If a 12-step program like A.A. is not right for you, don’t choose it just because it’s the best known approach.

Meet with the therapist who will treat you and ask what your treatment plan will be. “It should be more than movies, lectures or three-hour classes three times a week,” Ms. Fletcher said. “You should be treated by a licensed addiction counselor who will see you one-on-one. Treatment should be individualized. One size does not fit all.”

Find out if you will receive therapy for any underlying condition, like depression, or a social problem that could sabotage recovery. The National Institute on Drug Abuse states in its Principles of Drug Addiction Treatment, “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems.”

Look for programs using research-validated techniques, like cognitive behavioral therapy, which helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance.

Other validated treatment methods include Community Reinforcement and Family Training, or Craft, an approach developed by Robert J. Meyers and described in his book, “Get Your Loved One Sober,” with co-author Brenda L. Wolfe. It helps addicts adopt a lifestyle more rewarding than one filled with drugs and alcohol.

This is the first of two articles on addiction treatment.

Read More..

App Smart: A Review of Video-Editing Apps for the Smartphone

App Smart: Video Editing:
Kit Eaton reviews apps that turn smartphone video into fun short films.

I’ll bet that your smartphone is full of lots of little video clips. You know, ones that you make when you see something cute, surprising or beautiful. They may be nice mementos, but I’ll also bet they are not great examples of cinematography. Instead of just leaving these clips in their raw state on your phone, you can use apps to trim off unneeded parts, string clips together or add special effects.

Cute Cut for iOS feels as if it might be for professional users.

Magisto — Magical Video Editor for iOS and Android does most of the tricky technical stuff for you.

Video Edit is a simple and straightforward app for iOS.

One great video editor for Apple’s iOS devices is called Cute Cut. This app feels as if it might be for professional users, with clean graphics and smartly designed menus. Advice windows pop up over its display to help get you started. Click on the plus button to create a new movie, and then select whether your final edited movie will be high-definition or standard, and in landscape display or portrait.

The app’s main editing window then pops up. Here is where you add and edit movie clips. Each clip is organized on the app’s timeline display, and you can stack several clips to be added together to make your final movie.

A double tap on each clip lets you crop its size, trim its length or tweak other features like the original audio volume. You can also add transitions which are movie effects, like a fade between clips. There are also options to add music or commentary, text boxes or still photos.

Cute Cut is very powerful, but occasionally its menu system is confusing. I found it tricky to add transitions between clips because the tools to do so weren’t obvious from the various icons and buttons in the app.

The basic app is free on iTunes, but it prints a “made with Cute Cut” watermark on your movies and limits their length. A $4 upgrade through an in-app purchase removes both these restrictions.

A similarly powerful app for Android, with a friendly icon-based interface, is called Andromedia Video Editor (free on Google Play). It can add transitions, insert still photos and edit the audio accompaniment. The app’s interface is simpler than Cute Cut’s. For example, each clip you are adding is represented by an icon on the main display. Special-effects transitions are shown as a different icon between your clip icons. To edit a clip or adjust a transition, you tap on its icon. When you are finished, you can save your movie or immediately share it on YouTube.

For free software, this app is both powerful and fun to use, but don’t expect precision editing powers or a wide array of video effects. I also managed to crash it a couple of times.

For a simpler and more straightforward video editing on iOS, I like Video Edit (free on iTunes) for its minimal design and easy-to-use interface, but it has limits. All you can do is stack movie clips from your video archive together into one bigger production. It does let you trim each clip (through a double-tap on the little thumbnail image representing the clips), but there are no clever cinemalike transitions available to link the clips.

When you are finished, a click on the tick mark saves your final movie or lets you share it by e-mail, Facebook or YouTube.

An alternative movie editing app that does most of the tricky technical stuff for you is Magisto — Magical Video Editor (free on iOS and Android). Use it to create cute movies and overlay them with special effects. Simply select clips and a special video effect (from options like “Sentimental” or “Let’s Party”). These add colors, blurs, sparkles and so on.

You can also add a song from its short list of music offerings. It takes a few minutes to produce the final video, and while it is often something that would be fun to share with family or friends on Facebook, it is not going to win you an Oscar.

On the downside, this app can be confusing to use, and it requires you sign up for an account before you can save your final movies.

Quick Calls

Epic Games has brought its 3-D graphics demonstrator Epic Citadel to Android. It’s free, and you will be amazed at the console-like imagery as you wander through a medieval castle. It’s also fun, even if there is no game to play, yet. ... The journal-keeping style of Moleskine paper notebooks is now available digitally through an app on Windows Phone, which is great for keeping track of ideas in the form of notes or sketches.

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Obama Orders Release of Drone Memos to Lawmakers

WASHINGTON — The White House on Wednesday directed the Justice Department to release classified documents discussing the legal justification for the use of drones in targeting American citizens abroad who are considered terrorist to the two Congressional intelligence committees, according to an administration official.

The White House announcement appears to refer to a long, detailed 2010 memo from the Justice Department’s Office of Legal Counsel justifying the killing of Anwar al-Awlaki, an American-born cleric who had joined Al Qaeda in Yemen. He was killed in a C.I.A. drone strike in September 2011. Members of Congress have long demanded access to the legal memorandum.

The decision to release the legal memos to the intelligence committees came under pressure, two days after a bipartisan group of 11 senators joined a growing chorus asking for more information about the legal justification for targeted killings, especially of Americans. The announcement also came on the eve of the confirmation hearing scheduled for Thursday for John O. Brennan, President Obama’s choice to be director of the C.I.A. As Mr. Obama’s counterterrorism adviser, Mr. Brennan has been the chief architect of the drone program, and he is expected to be closely questioned about it at the hearing of the Senate Intelligence Committee.

Critics noted that in 2009, Mr. Obama had ordered the public release of the classified memos governing C.I.A. interrogations under President George W. Bush and accused Mr. Obama of hypocrisy. Administration officials replied that the so-called enhanced interrogations had been stopped, while drone strikes continue.

Until Wednesday night, the administration had refused to even officially acknowledge the existence of the documents, which have been reported about in the press. This week, NBC News obtained an unclassified, shorter legal memo, described as a “white paper,” that officials said described the legal framework that officials follow in using the drones.

Administration officials said Mr. Obama had decided to take the action — which they described as extraordinary — out of a desire to involve Congress in the development of the legal framework for the use of drones. Aides noted that Mr. Obama had made a pledge to do that during an appearance on “The Daily Show” last year.

“Today, as part of the president’s ongoing commitment to consult with Congress on national security matters, the president directed the Department of Justice to provide the congressional Intelligence committees access to classified Office of Legal Counsel advice related to the subject of the Department of Justice White Paper,” the administration official said.

The official said that members of the intelligence committees would now get “access” to the documents. It remained unclear what kind of access that would be.

Christopher Anders, senior legislative counsel for the American Civil Liberties Union, called the president’s move “a small step in the right direction.” But he noted that the legal memo or memos were not being shared with either of the armed services committees, which have jurisdiction over Pentagon strikes, or the judiciary committees, which oversee the Justice Department.

The public should be permitted to see at least a redacted version of the relevant memos, Mr. Anders said. “Everyone has a right to know when the government believes it can kill Americans and others,” he said.

The Congressional intelligence committees were created in the late 1970s to exercise oversight after a series of scandals at the spy agencies. The law requires that the committees be kept informed of intelligence activities. But most administrations withhold at least some legal opinions, treating them as confidential legal advice to the president and agency officials.

Senator Dianne Feinstein, the California Democrat who leads the Senate Intelligence Committee, had proposed a clause for the annual intelligence authorization bill requiring that legal opinions on relevant matters be routinely shared with the committees. But the White House objected, and the measure was dropped from the bill.

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DealBook: The Politics of the R.B.S. Settlement

LONDON — The British government is taking aim at an unlikely target in the latest rate-rigging case: the British government.

The $612 million settlement that the Royal Bank of Scotland reached with authorities on Wednesday over rate manipulation will leave British taxpayers liable for part of the fine.

The government still owns a 82 percent stake in the bank, which was bailed out in 2008 during the height of the financial crisis.

The British government finds itself on the other side of its case as well because the Financial Services Authority, the country’s main financial regulator, has been part of the global investigation into the manipulation of benchmark rates like the London interbank offered rate, or Libor.

The case against the Royal Bank of Scotland has been politically charged after British politicians demanded that bankers’ bonuses should be used to pay for the settlement.

“There is a legitimate concern that British taxpayers, who already have bailed out the bank, will be asked to pay for past mistakes at R.B.S.,” said Pat McFadden, a British politician who is a member of the opposition party and part of the Parliament’s Treasury select committee that oversees the country’s finance industry. On Monday, George Osborne, the chancellor of the Exchequer, also called on the bank to use bonuses to pay the Libor fine.

To help pay for the global settlement, the British bank said it would claw back past and present bonuses totaling $471 million from both the traders implicated in the rate-rigging scandal as well as from employees in the bank’s operations, particularly its investment banking unit, which have not been part of the wrongdoing.

Bank officials said the clawbacks were related to the reputational damage caused to the bank, and would also cover potential future legal liabilities. But that money will be used primarily to pay the fines levied against the bank by the United States authorities.

The Financial Services Authority’s share of the fine is expected not to come from the bonuses. The money will, in a sense, be recycled since it will go to the British government’s coffers.

One of the casualties of the Libor scandal was John Hourican, head of the firm’s investment banking division, who resigned on Wednesday. He will forgo past and present compensation worth a combined $14.1 million. Mr. Hourican, who took over the investment banking unit in 2008 and has not been implicated in the wrongdoing, will receive a one-time payout from the bank of around $1 million.

Libor Explained

“This has been a soap opera for the last four years because of the ups and downs of this job,” the bank’s chairman, Philip Hampton, told reporters on Wednesday. “The bank was in a hell of a mess.”

The taxpayer stake in the bank sets the latest deal apart from the other two big Libor settlements. Last summer, the British bank Barclays agreed to pay $450 million to settle accusations that it reported false rates. In December, the Swiss giant UBS struck a sweeping $1.5 billion deal with authorities in which its Japanese subsidiary pleaded guilty to felony wire fraud.

But despite the vested interest of taxpayers, the Financial Services Authority did not take the government’s ownership stake into consideration when reaching the settlement, according to a person with direct knowledge of the matter who spoke on the condition of anonymity.

The renewed scrutiny on the bank, however, could hinder the government’s ability to sell its stake for a profit, as private investors remain wary of the bank’s future liabilities. Since the bailout in 2008, the bank’s shares have plummeted, and are currently trading around 32 percent below the initial purchase price.

As part of plans to sell the government’s stake in the bank, Vince Cable, the British business secretary, said Royal Bank of Scotland should have been fully nationalized when it was bailed out in 2008. In a speech on Wednesday, he added that one option could be to return shares in the bank to British taxpayers.

“The early hope of reprivatization now looks a very long way off, unless at an unacceptable loss,” Mr. Cable said.

Government officials have held preliminary discussions with a number of investors about selling stakes in the Royal Bank of Scotland, according to a person with direct knowledge of the matter who spoke on the condition of anonymity.

The potential losses facing British taxpayers contrast with the $182 billion bailout of the American International Group in 2008. Over the last two years, A.I.G. issued a series of stock offerings to reduce the United States government’s ownership, generating profit of around $22 billion for American taxpayers.

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