Dartmouth Atlas: Readmission Rates Show ’Not Much Progress’

Dartmouth Atlas researchers are again pointing fingers at hospital quality of care, this time showing wide variation in 30-day readmission rates, which have not gone down and in some cases rose between 2005 and 2009.

Hospitals see "their responsibility as ending when the patient leaves their door and have made minimal efforts in terms of coordinating care or communicating to community physicians," said David Goodman, MD, lead author and co-principal investigator for the Dartmouth AtlasProject's latest report. 

"The result is that readmission to a hospital is a fairly common phenomenon," occurring in between one in six and one in five patients discharged, he said. "Probably the most important finding is that for a long-standing and well-recognized problem, not much progress has been made," Goodman said.

Some hospitals argue that they can't be blamed for high readmission rates because they have sicker patients with more co-morbidities, people who are less well educated and hampered by transportation and poverty.  That "may be an explanation, but it shouldn't be an excuse," Goodman said.

While "every hospital and market has its own legitimate story in terms of why they are and where they are today – sometimes it truly is because patients are sicker or poorer – often it's because of an accidental evolution" of the way care is delivered, without coordination or community provider partnerships. Transition processes are "deeply flawed," he said.

The report, entitled "After Hospitalization: A Dartmouth Atlas Report on Post-acute Care for Medicare Beneficiaries," compares readmission rates between 2004 and 2009 for six categories of patients: those admitted for medical care, surgery, congestive heart failure, heart attack, pneumonia, and hip fracture.

It further dissects the data to show rates for each of 1,924 hospitals in the country for those two years. One can see 30-day readmission trends for medium-sized and large cities, hospital referral regions, and states. 

The report also reveals that fewer than half of discharged patients followed up with visits to clinicians – an aspect of care said to help prevent readmissions – within 14 days of leaving the hospital. That rate "fell short of any reasonable expectation," said Goodman, Goodman, who also directs the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice.

The maps and statistical tables within the document show the percentage of patients for both 2004 and 2009 who were seen by a primary care clinician or went to an ambulatory care center within 14 days of discharge or went to the emergency room within 30 days of discharge.

More ...

http://www.healthleadersmedia.com/content/QUA-271444/Dartmouth-Atlas-Readmission-Rates-Show-Not-Much-Progress

Dartmouth Atlas of Health Care

Understanding of the Efficiency and Effectiveness of the Health Care System

For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide information and analysis about national, regional, and local markets, as well as hospitals and their affiliated physicians. This research has helped policymakers, the media, health care analysts and others improve their understanding of our health care system and forms the foundation for many of the ongoing efforts to improve health and health systems across America. 

http://www.dartmouthatlas.org/

Abraham Verghese: A doctor's touch | Video on TED.com

Modern medicine is in danger of losing a powerful, old-fashioned tool: human touch. Physician and writer Abraham Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam.

http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch.html

Therapists Are ‘Seeing’ Patients Online - NYTimes.com

The event reminder on Melissa Weinblatt's iPhone buzzed: 15 minutes till her shrink appointment.

She mixed herself a mojito, added a sprig of mint, put on her sunglasses and headed outside to her friend's pool. Settling into a lounge chair, she tapped the Skype app on her phone. Hundreds of miles away, her face popped up on her therapist's computer monitor; he smiled back on her phone's screen.

She took a sip of her cocktail. The session began.

Ms. Weinblatt, a 30-year-old high school teacher in Oregon, used to be in treatment the conventional way — with face-to-face office appointments. Now, with her new doctor, she said: "I can have a Skype therapy session with my morning coffee or before a night on the town with the girls. I can take a break from shopping for a session. I took my doctor with me through three states this summer!"

And, she added, "I even e-mailed him that I was panicked about a first date, and he wrote back and said we could do a 20-minute mini-session."

Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans' health care facilities and rural clinics — all supervised sites.

But today Skype, and encrypted digital software through third-party sites like CaliforniaLiveVisit.com, have made online private practice accessible for a broader swath of patients, including those who shun office treatment or who simply like the convenience of therapy on the fly.

One third-party online therapy site, Breakthrough.com, said it has signed up 900 psychiatrists, psychologists, counselors and coaches in just two years. Another indication that online treatment is migrating into mainstream sensibility: "Web Therapy," the Lisa Kudrow comedy that started online and pokes fun at three-minute webcam therapy sessions, moved to cable (Showtime) this summer.

"In three years, this will take off like a rocket," said Eric A. Harris, a lawyer and psychologist who consults with the American Psychological Association Insurance Trust. "Everyone will have real-time audiovisual availability. There will be a group of true believers who will think that being in a room with a client is special and you can't replicate that by remote involvement. But a lot of people, especially younger clinicians, will feel there is no basis for thinking this. Still, appropriate professional standards will have to be followed."

The pragmatic benefits are obvious. "No parking necessary!" touts one online therapist. Some therapists charge less for sessions since they, too, can do it from home, saving on gas and office rent. Blizzards, broken legs and business trips no longer cancel appointments. The anxiety of shrink-less August could be, dare one say ... curable?

Ms. Weinblatt came to the approach through geographical necessity. When her therapist moved, she was apprehensive about transferring to the other psychologist in her small town, who would certainly know her prominent ex-boyfriend. So her therapist referred her to another doctor, whose practice was a day's drive away. But he was willing to use Skype with long-distance patients. She was game.

Now she prefers these sessions to the old-fashioned kind.

But does knowing that your therapist is just a phone tap or mouse click away create a 21st-century version of shrink-neediness?

"There's that comfort of carrying your doctor around with you like a security blanket," Ms. Weinblatt acknowledged. "But," she added, "because he's more accessible, I feel like I need him less."

The technology does have its speed bumps. Online treatment upends a basic element of therapeutic connection: eye contact.

Patient and therapist typically look at each other's faces on a computer screen. But in many setups, the camera is perched atop a monitor. Their gazes are then off-kilter.

"So patients can think you're not looking them in the eye," said Lynn Bufka, a staff psychologist with the American Psychological Association. "You need to acknowledge that upfront to the patient, or the provider has to be trained to look at the camera instead of the screen."

The quirkiness of Internet connections can also be an impediment. "You have to prepare vulnerable people for the possibility that just when they are saying something that's difficult, the screen can go blank," said DeeAnna Merz Nagel, a psychotherapist licensed in New Jersey and New York. "So I always say, 'I will never disconnect from you online on purpose.' You make arrangements ahead of time to call each other if that happens."

Still, opportunities for exploitation, especially by those with sketchy credentials, are rife. Solo providers who hang out virtual shingles are a growing phenomenon. In the Wild Web West, one site sponsored a contest asking readers to post why they would seek therapy; the person with the most popular answer would receive six months of free treatment. When the blogosphere erupted with outrage from patients and professionals alike, the site quickly made the applications private.

Other questions abound. How should insurance reimburse online therapy? Is the therapist complying with licensing laws that govern practice in different states? Are videoconferencing sessions recorded? Hack-proof?

Another draw and danger of online therapy: anonymity. Many people avoid treatment for reasons of shame or privacy. Some online therapists do not require patients to fully identify themselves. What if those patients have breakdowns? How can the therapist get emergency help to an anonymous patient? "A lot of patients start therapy and feel worse before they feel better," noted Marlene M. Maheu, founder of the TeleMental Health Institute, which trains providers and who has served on task forces to address these questions. "It's more complex than people imagine. A provider's Web site may say, 'I won't deal with patients who are feeling suicidal.' But it's our job to assess patients, not to ask them to self-diagnose." She practices online therapy, but advocates consumer protections and rigorous training of therapists.

Psychologists say certain conditions might be well-suited for treatment online, including agoraphobia, anxiety, depression and obsessive-compulsive disorder. Some doctors suggest that Internet addiction or other addictive behaviors could be treated through videoconferencing.

Others disagree. As one doctor said, "If I'm treating an alcoholic, I can't smell his breath over Skype."

Cognitive behavioral therapy, which can require homework rather than tunneling into the patient's past, seems another candidate. Tech-savvy teenagers resistant to office visits might brighten at seeing a therapist through a computer monitor in their bedroom. Home court advantage.

Therapists who have tried online therapy range from evangelizing standard-bearers, planting their stake in the new future, to those who, after a few sessions, have backed away. Elaine Ducharme, a psychologist in Glastonbury, Conn., uses Skype with patients from her former Florida practice, but finds it disconcerting when a patient's face becomes pixilated. Dr. Ducharme, who is licensed in both states, will not videoconference with a patient she has not met in person. She flies to Florida every three months for office visits with her Skype patients.

"There is definitely something important about bearing witness," she said. "There is so much that happens in a room that I can't see on Skype."

Dr. Heath Canfield, a psychiatrist in Colorado Springs, also uses Skype to continue therapy with some patients from his former West Coast practice. He is licensed in both locations. "If you're doing therapy, pauses are important and telling, and Skype isn't fast enough to keep up in real time," Dr. Canfield said. He wears a headset. "I want patients to know that their sound isn't going through walls but into my ears. I speak into a microphone so they don't feel like I'm shouting at the computer. It's not the same as being there, but it's better than nothing. And I wouldn't treat people this way who are severely mentally ill."

Indeed, the pitfalls of videoconferencing with the severely mentally ill became apparent to Michael Terry, a psychiatric nurse practitioner, when he did psychological evaluations for patients throughout Alaska's Eastern Aleutian Islands. "Once I was wearing a white jacket and the wall behind me was white," recalled Dr. Terry, an associate clinical professor at the University of San Diego. "My face looked very dark because of the contrast, and the patient thought he was talking to the devil."

Another time, lighting caused a halo effect. "An adolescent thought he was talking to the Holy Spirit, that he had God on the line. It fit right into his delusions."

Johanna Herwitz, a Manhattan psychologist, tried Skype to augment face-to-face therapy. "It creates this perverse lower version of intimacy," she said. "Skype doesn't therapeutically disinhibit patients so that they let down their guard and take emotional risks. I've decided not to do it anymore."

Several studies have concluded that patient satisfaction with face-to-face interaction and online therapy (often preceded by in-person contact) was statistically similar. Lynn, a patient who prefers not to reveal her full identity, had been seeing her therapist for years. Their work deepened into psychoanalysis. Then her psychotherapist retired, moving out of state.

Now, four times a week, Lynn carries her laptop to an analyst's unoccupied office (her insurance requires that a local provider have some oversight). She logs on to an encrypted program at Breakthrough.com and clicks through until she reads an alert: "Talk now!"

Hundreds of miles away, so does her analyst. Their faces loom, side by side on each other's monitors. They say hello. Then Lynn puts her laptop on a chair and lies down on the couch. Just the top of her head is visible to her analyst.

Fifty minutes later the session ends. "The screen is asleep so I wake it up and see her face," Lynn said. "I say goodbye and she says goodbye. Then we lean in to press a button and exit."

As attenuated as this all may seem, Lynn said, "I'm just grateful we can continue to do this."

http://www.nytimes.com/2011/09/25/fashion/therapists-are-seeing-patients-online.html?

The fine art of medical diagnosis | Art and design | The Observer

At the Sainsbury Wing of London's National Gallery, in Room 58, a painting by the 15th-century Italian artist Piero di Cosimo of a woman lying on her side has been hung opposite Botticelli's Venus and Mars. The fame of the latter makes it a significant attraction for visitors. Yet those who shuffle past Cosimo's canvas miss an intriguing work, not just for its enigmatic content but for the unexpected way it shows how art can be opened up through scientific scrutiny.

The painting shows a young woman, half-clothed, lying on the ground as a satyr crouches over her corpse. According to the gallery's guidebook, the work – A Satyr Mourning over a Nymph – depicts the death of Procris, daughter of the king of Athens, who was accidentally killed by her husband Cephalus during a deer hunt. Put "death of Procris" into Google and the search throws up countless versions of Cosimo's painting.

But Professor Michael Baum, one of Britain's leading cancer experts, and a keen art critic, will have none of this. "This is not a depiction of the accidental death that Ovid wrote about," he says. "It is a painting about a murder, and a very nasty one at that."

Baum's interpretation is based on artistic and medical sleuthing which he has been carrying out for the past two decades. Every year he organises an artistic "ward round" for his students, one that takes them through the rooms of the National Gallery in order to show them how medical and scientific knowledge gives a new perspective to classical paintings – and to show how art can provide new insights for a young doctor.

"Dozens of papers have been written up, and published in respected journals, by our students on subjects that range from syphilis to Paget's disease of the skull as a result of the observations they have made in the gallery," says Baum. "It's a great way to learn medicine and appreciate art."

Now Baum, visiting professor of medical humanities at University College London, is widening his audience. At the British Science Festival in Bradford, he will give a lecture, Picture of Health: The Art of Medicine, which will highlight the importance of art in medical practice, and vice versa, and which will be based on his science tours of the National Gallery, including his studies of Cosimo's painting.

"The official guide explanation that accompanies A Satyr Mourning over a Nymph indicates that it shows a woman who has been killed after being struck accidentally by a spear," says Baum. "This is consistent with the story of Procris and Cephalus. However, there are all sorts of clues that show this interpretation to be wrong.

"Look at her hands, for example. Both are covered with deep lacerations. There is only one way she could have got those. She has been trying to fend off an attacker who has come at her, slashing in a frenzied manner with a knife or possibly a sword. Certainly there is no way that a spear could have done that."

There are other clues, adds Baum. The woman's left hand is bent backwards, in a position known by surgeons as "the waiter's tip", typical someone who has received a serious injury at points C3 and C4 on the cervical cord. The severing at these points causes nerve damage that makes the wrist flex and the fingers curl up in the manner of a waiter taking a backhanded tip.

"The wound in her throat also corresponds to the idea that her cervical cord was severed at the C3/C4 position. So what we are looking at is a picture of a woman who has had her throat cut after desperately trying to defend herself from a knife-wielding killer. This is not the outcome of a romantic tragedy. This is the result of a brutal murder."

Intriguingly, Cosimo may still have been trying to depict the death of Procris, adds Baum. The painter may simply have been the victim of his own acute observational powers. "I think he may well have gone to a mortuary and asked to be allowed to paint the body of a young woman and got the body of one who had been murdered by knife – and so he faithfully put on to his canvas what he saw. It just happens not to accord with our modern understanding of what would have happened to a woman struck accidentally by a spear."

The key point of teaching medicine in this manner is that it broadens students' views of their subject. "Art and medicine have parallel histories: accurate drawings of dissections were crucial for anatomical education, for example, while art therapy has provided patients with powerful cathartic releases. And now when we look with a trained eye, it is clear these artists had considerable medical knowledge and often used it with considerable subtlety."

More ...

http://www.guardian.co.uk/artanddesign/2011/sep/11/medicine-clues-doctors-art-paintings

An app a day keeps the doctor away? | The Tennessean

Dr. Mathew Ninan could tell a 19-year-old patient wasn't really listening to his spiel about not smoking, so he said the magic word: app.

Ninan, a thoracic surgeon at Centennial Medical Center, prescribed a smartphone app with a whole toolbox of information to help people toss away their cigarettes for good. It even has a link to a Facebook support group.

"He was the ideal candidate," Ninan said. "He's always got his iPhone in his left hand."

The app, developed at the University of Tennessee Health Science Center in Memphis, is just one example of the ways that cellular phones have changed medicine.

Doctors use smartphones for medical reference, for quick information exchanges and for calculations related to diagnostic tests and treatments. Disease experts even tracked the spread of cholera in Haiti by monitoring population movement through cellphone traffic.

Besides the app to quit smoking, there also are apps for weight loss, pregnancy and diabetes.

Ninan, an avid smartphone user, said the device has quickly become "an invaluable part of my medical everyday existence." He and other physicians sometimes send text messages about specific patient cases, using only the patients' initials, to give one another a heads-up to check the official electronic health records.

"To think about calling up another physician and spending 10 minutes on the phone — how many people can you do that with when you are seeing 30 patients a day or operating on five patients a day?" Ninan said. "Now, I can just walk out of the operating room and text three physicians who are involved with the patient."

The increased use of smartphones by doctors has caused the U.S. Food and Drug Administration to consider oversight of some of these applications. However, information sharing regarding patients is not among applications the FDA may regulate, according to draft guidelines released in July.

The requirements would cover when the phones are used as an accessory to an already regulated medical device or when the application would, in essence, transform the smartphone into such a device. For example, an app that allows doctors to view medical images for diagnostic purposes would have to be cleared by the FDA in the same manner as the device that created the images.

Self-help programs, such as the "Quit Forever App" for smokers, would not fall under the FDA's purview. Launched this summer, it costs $1.99 to download, with no recurring fees. At present, it is available only on the iPhone, but the University of Tennessee Health Science Center expects to introduce an Android-compatible version in the next year to year and a half.

In Tennessee, smokers account for almost one-fifth of young adults between ages 18 and 24 and more than one-fourth of those 25 to 44, according to the U.S. Centers for Disease Control and Prevention.

"We need to target young people in a very appropriate format," Ninan said. "It is surprising what providing them with the appropriate resources can do."

Younger people tend to be early adapters of new technologies, but more 60-somethings are getting smartphones. Cristina Romine, a "Freedom From Smoking" facilitator with the American Lung Association, often works with this age group. At present, she has only one patient using the app.

"It's basically the whole 'Freedom From Smoking' program on your iPhone," Romine said. "It has all the workbooks that we use in the actual classes ... your triggers, every situation that you go through during quitting smoking."

She believes the Facebook link is especially beneficial.

"There's other people out there that you might be able to interact with to get the support group that you would normally get in a physical session," she said.

http://www.tennessean.com/article/20110918/NEWS07/309180044/?odyssey=obinsite

Walter Kirn's Permanent Morning: At Iowa Methodist Hospital My Mother Died from A Strep Infection of the Brain

All the kids now tell their friends "I love you." Girls my daughter's age, 12, all say "I love you." And so, sometimes, do boys my son's age, 10. They say it when they part ways after school. They write it in e-mails, in text messages, on Facebook. "I love you." They even say it to their parents. "I love you," they say, and then head off to the movies. "I love you," they say, and then climb on the team bus. It's not something I did at their age, all those years ago, saying and writing "I love you" all the time, and it's not something that the other kids did, either, particularly not outside the home, the family, where love, as we then defined it, didn't exist. Outside the family, people 'liked' each other. Now they love each other. And they say so. Sincerely. With feeling. I've heard it. Authentic feeling. You can think it's a fad, but I've heard it: it's said with feeling.

Three weeks and three days ago my mother died unexpectedly at 71. She was in Iowa, visiting her boyfriend, which she did every year when the state fair was going. One morning he found her on the bathroom floor. She couldn't speak. Her eyes were open, but barely. An ambulance came and drove her to the hospital, to Iowa Methodist in downtown Des Moines (a city that is beige across the board and has terrible traffic at certain peculiar moments but then seems to empty out entirely), where someone ran a CAT scan and discovered a 'sizable mass' in her brain, behind her eyes. A surgeon went in and found an abscess there, 'encapsulated,' sealed off from other tissue, and immediately he drained it of built-up fluid and then bathed the area in antibiotics. The fluid, infected with something, was sent for tests. Hours passed. Night came. My mother remained unconscious, breathing with noisy mechanical assistance. A nurse said she saw her blink when spoken to sometime between four and five a.m. and rated her coma an optimistic '11' on a scale -- an official coma scale -- that runs to 15, for some reason, and starts at 3.

I got there a few hours later from Montana, fighting with my girlfriend the whole way. We fought while we packed, about which supplies to bring and what size containers of liquid -- three ounces or five -- can legally be carried on to planes. We fought on the plane over who was more uncomfortable trying to sleep bolt upright without a pillow. We fought all the way down a hall and up an elevator and down another hall to the CCU, accusing each other of failing to use the sanitizer dispensed from little pumps near all the doorways. Sometimes the sanitizer was a foam, other times it came out as a gel. I liked the gel. As it dried, it cooled my hands. It felt effective. The foam felt weak, a pleasantry.

The right side of my mother's scalp was grey and shaved and there was a run of black staples where she'd been cut. My brother and his wife were standing over her rubbing her wrists and stroking her smooth bare ankles. Everyone was saying the right things. Everyone sounded sweet and stressed and brave. Everyone sounded perfect. We amazed ourselves. We amazed ourselves in the way that people do when they find themselves rising to a grave occasion that they've always known would come someday but didn't practice for out of superstition, because to practice for it might attract it. It turned out that we didn't need to practice, though. We were natural born virtuosos of the deathbed.

Oh God, we were good. It kind of made me sick.

We all went home around eleven that night. My girlfriend and I had a room in a vast Marriott built around one of those plunging central atriums that ought to provoke more suicides than they do and are awkward places to eat breakfast, with all that disquieting space above your heads. I took an Ambien when I laid down and a few minutes later I had a vision of my mother walking behind my girlfriend at a distance of a foot or two but then, as the two of them passed by the TV set, closing the distance and merging with my girlfriend. It was a vision, not a dream, because I described it the instant after it happened to my actual girlfriend, who was awake and who responded by reaching behind herself to feel the space where my mother (I insisted) had physically, or at least visually, entered her.

At six in the morning the phone rang right on schedule and my brother right on schedule said get over here -- don't eat, don't shower, don't think, get over here -- and we, right on schedule, raced over in our rental car and there was the surgeon, all scrubbed and right on schedule, asking permission to go into the skull again and suck out more junk again, more goo, more fluid, he frankly didn't know what it was this stuff (necrotic brain tissue? ordinary pus?) but he sure as hell wanted it out of there this minute ("Your mother will be, if not entirely paralyzed on her left side..." That was in there too somewhere) except that we, the loved ones, right on schedule, and in accordance with the Health Directive kept by my mother always in her purse (she'd worked as a nurse all her life, she knew the truth; the tubes, once they go in, they tend to stay in) told him to please go away and let her die.

Right on schedule.

Which she didn't do.

First she punished us for a while with perfect vital signs until I started laughing, proud of her, proud of her savage creaturely momentum, her mad ungovernable pendulum persistence. Who knew that, despite her pose as my dear mother, my dear autodidact Gibbons-reading mother who once went to Hungary, then crossed it off her list, and then went to Egypt and crossed it off her list, and then learned Italian and crossed it off her list, and Latin and French and The Lives of the Impressionists and the Bob Dylan Songbook and Naguib Mahfouz, was actually, underneath it all, Lou Gehrig, a being of pure brute Newtonian pump and suck.

When it's over you go in a room and sign some papers with people who do their best not to let on that they did this only half an hour ago with people just as brave as you feel you are. (And maybe you are, but if so, then bravery's easy, not a virtue, a reflex, like drawing one's first breath.)

The test came back Streptococcus intermedius and I am afraid I have it and you do too and that it is one of those new mysterious bugs that most of the the time does nothing, just sits or circulates, but that some of the time (and perhaps more often of late, since everything bad seems to happen more often of late) can collect in your brain and destroy you in two days.

Which is why all the kids say "I love you" all the time now, even though, if you ask them, they don't know why. They think it's normal. They think it's what kids always said. It isn't, though. I was a kid once and I remember: We said other things.

Lots of things.

But what?

For Mildred Irene Kirn (Stein), 1940-2011

http://walterkirn.blogspot.com/2011/09/at-iowa-methodist-hospital-my-mother.html

Pharmacist Don Colcord Sustains Nucla, Colorado : The New Yorker

In the southwestern corner of Colorado, where the Uncompahgre Plateau descends through spruce forest and scrubland toward the Utah border, there is a region of more than four thousand square miles which has no hospitals, no department stores, and only one pharmacy. The pharmacist is Don Colcord, who lives in the town of Nucla. More than a century ago, Nucla was founded by idealists who hoped their community would become the "center of Socialistic government for the world." But these days it feels like the edge of the earth. Highway 97 dead-ends at the top of Main Street; the population is around seven hundred and falling. The nearest traffic light is an hour and a half away. When old ranching couples drive their pickups into Nucla, the wives leave the passenger's side empty and sit in the middle of the front seat, close enough to touch their husbands. It's as if something about the landscape—those endless hills, that vacant sky—makes a person appreciate the intimacy of a Ford F-150 cab.

Don Colcord has owned Nucla's Apothecary Shoppe for more than thirty years. In the past, such stores played a key role in American rural health care, and this region had three more pharmacies, but all of them have closed. Some people drive eighty miles just to visit the Apothecary Shoppe. It consists of a few rows of grocery shelves, a gift-card rack, a Pepsi fountain, and a diabetes section, which is decorated with the mounted heads of two mule deer and an antelope. Next to the game heads is the pharmacist's counter. Customers don't line up at a discreet distance, the way city folk do; in Nucla they crowd the counter and talk loudly about health problems.

"What have you heard about sticking your head in a beehive?" This on a Tuesday afternoon, from a heavyset man suffering from arthritis and an acute desire to find low-cost treatment.
"It's been used, progressive bee-sting therapy," Don says. "When you get stung, your body produces cortisol. It reduces swelling, but it goes away. And you don't know when you're going to have that one reaction and go into anaphylactic shock and maybe drop dead. It's highly risky. You don't know where that bee has been. You don't know what proteins it's been getting."
"You're a helpful guy. Thank you."

"I would recommend hyaluronic acid. It's kind of expensive, about twenty-five dollars a month. But it works for some people. They make it out of rooster combs."

Somebody else asks about decongestants; a young woman inquires about the risk of birth defects while using a collagen stimulator. A preacher from the Abundant Life Church asks about drugs for a paralyzed vocal cord. ("When I do a sermon, it needs to last for thirty minutes.") Others stop by just to chat. Don, in addition to being the only pharmacist, is probably the most talkative and friendly person within four thousand square miles. The first time I visited his counter, he asked about my family, and I mentioned my newborn twin daughters. He filled a jar with thick brown ointment that he had recently compounded. "It's tincture of benzoin," he said. "Rodeo cowboys use it while riding a bull or a bronc. They put it on their hands; it makes the hands tacky. It's a respiratory stimulant, mostly used in wound care. You won't find anything better for diaper rash."

More ...

http://www.newyorker.com/reporting/2011/09/26/110926fa_fact_hessler?currentPage=all

Gym Jones Preaches the Cult of Physicality - NYTimes.com

INSIDE an unmarked warehouse here, not far from a depressing stretch of fast-food joints and the Southern X-Posure strip club, Robert MacDonald — nickname: Maximus — is torturing a group of people.

Or at least that's how it looks. One man, howling in agony a second ago, has collapsed in a pool of sweat. A woman wipes away tears. A few of the rest are limping.

Maximus is not sympathetic. After all, they had been warned. It's right there on the Web site: "You were free to choose and you did. Now lie in it."

This is Gym Jones, a no-frills private club that caters to extreme fitness buffs, professional athletes, the military's special operations and — on the opposite end of the pampered scale but only slightly less secretive — movie stars. (Jude Law didn't get those contoured pectorals in "Repo Men" by accident.)

Yes, the name is an overt nod to Jim Jones, the sect leader who steered more than 900 people to suicide in 1978. No, the couple that owns the gym, Lisa and Mark Twight, don't see anything obnoxious about that. "We knew some people would call us a cult," Ms. Twight said, "so we decided to own the joke."

The zealous devotion clients have toward the gym and its fitness philosophy, which turns as much on psychology as it does on physicality, can indeed be a little frightening. Picture Scientologists, except with really big biceps.

One prominent fan is Zack Snyder, the Warner Brothers director whose testosterone-turbocharged "300" became a global smash in 2007. It was Gym Jones, using a mix of power lifting and military-style calisthenics, that whipped Gerard Butler, the star of that film, into loincloth shape.

Superman himself has recently been training here. Henry Cavill, hired to play the title character in Mr. Snyder's coming "Man of Steel," arrived with eight-pack abs, or close to it, from training for another film. But Warner brought on Mr. Twight to mold the British actor into a true superhero; the two have been working together since April. "It's not just about muscles," Mr. Snyder said. "In fact, that's the least of it. They have a way of making you find things in yourself, and it's fantastic."

That's easy for him to say. Mr. Snyder's days don't include a 5,000-calorie diet and more than three hours of pumping iron, like Mr. Cavill's. "Mark gave me, or perhaps I could say allowed me, to discover my love of pushing myself beyond my notions of limits," Mr. Cavill wrote in an e-mail. "He also gave me not an arrogance but a humble and healthy belief in my physical abilities, which I never before possessed."

Trainers of this elite caliber tend to dismiss celebrities as dabblers who want results without the work. And don't get the serious fitness crowd started on the use of steroids in some corners of moviedom.

Gym Jones is no exception. But the Twights and Mr. MacDonald, the gym's manager, have also learned to open their minds. "Take Jude Law," Mr. MacDonald said. "At first I wasn't interested in Jude Law at all. He smoked, drank and was out of shape. But he surprised me and worked really hard. He proved me wrong." (Mr. Law declined comment.)

A willingness to take on famous clients has actually been problematic for Gym Jones. The studio cash is nice, and the "300" notoriety was rewarding; a version of a 300-rep workout designed for the cast as a graduation test has gone viral and was even plugged by Men's Health. But the Twights prefer privacy. They aren't angling for their own line of protein powders or a reality show, and accept only 30 to 40 clients at a time. If you are hearing about them through their work with stars, a tiny part of the gym, your chances of getting in are pretty much zero.

The Twights generally require an interview or a referral from a current Gym Jones client, the completion of a written application that's more of a fitness SAT than anything and, if you pass that step, a workout with Mr. MacDonald, a world champion mixed-martial-arts fighter. "If I'm surrounded by substandard people, I'm not going to work that hard myself," Mr. MacDonald said. Again, it's right there on that full-of-itself Web site: "We choose clients. Clients don't choose us."

Gym Jones has another reason to guard its privacy: its military customers like it that way. Although the Twights refuse to talk much about this side of their business, which occurs inside the gym and in the nearby mountains, it appears to be considerable and to involve people who are supposed to be invisible. Six of Mr. Twight's former students, for instance, were among the 30 Americans — most of them Navy Seals, including members of the team that killed Osama bin Laden — who died in Afghanistan in August when their helicopter was shot down.

But don't push for more details: " 'No' is a complete sentence," Ms. Twight said. "I don't need to give a reason."

GYM JONES, of course, is not the only fitness business thriving on tough love. From the boot camp programs that have become trendy in big cities to the screeching trainers on "The Biggest Loser" to CrossFit, a chain that has gained attention for promoting risky exercise, Americans seem to want their workouts served with hiss and spit.

Theories abound as to why. Fads tend to oscillate: the karate- and steroid-fueled bodybuilding of the 1970s (which notably accompanied the rise of women in the workplace) gave way to Jane Fonda's aerobics in the '80s and spinning and cardio hell in the '90s. Next came yoga and Pilates. More recently, economic and political upheaval, not to mention two grinding wars, have tipped people toward strength training and militaristic exercise.

Superbods have also returned as a Hollywood staple. Since April, studios have served up a mega-pumped Dwayne Johnson in "Fast Five," a hulking Chris Hemsworth in "Thor," a bare-chested Chris Evans as "Captain America" and a ripped Jason Momoa in "Conan the Barbarian." Taylor Lautner's beefcake werewolf returns soon in "The Twilight Saga: Breaking Dawn - Part 1."

Theater is a big part of Gym Jones, which the Twights founded in 2003 in a garage with no air-conditioning and no heat. (The couple moved to Utah from Colorado in 2001 to operate a climbing-equipment company and later started Gym Jones as a side project. Eventually, the Twights decided to go full time with Gym Jones.)

Everything about the gym's current configuration screams hard core, from the Web site ("Don't complain if the work is too hard, or if you pass out, drop a barbell on your head, a kettle bell on your toes") to cold décor: cinderblock walls, black rubber floor mats, fluorescent lights, no mirrors or windows. Outside magazine described the gym as "part martial-arts dojo, part smash lab, part medieval dungeon."

Gym Jones calls clients "disciples" and prominently displays a quote from "Fight Club," the 1999 film starring Brad Pitt. It reads in part: "Quit your job. Start a fight. Prove you're alive."

But once you're past all that, the mood at the gym is surprisingly warm. Mr. MacDonald, 33, has a daunting physical presence (at 6-foot-3, he can dead-lift 550 pounds) and blunt speaking style, but he also once taught kindergarten. The pixie-ish Ms. Twight, a 50-year-old jujitsu practitioner, has a quick, infectious laugh. A celebrated mountain climber, Mr. Twight, 50, is direct and aggressive but also quite polite and generous with his time.

And despite his stoic manner, Mr. Twight was clearly emotional over the deaths of his former students in Afghanistan. "Different from the many fatalities that occurred throughout my climbing career, but the impact is still quite strong," he wrote in an e-mail.

The Gym Jones Way notably does not involve a bodybuilding-centered program of progressive overload and over-feeding. Pushing people so hard that they risk rhabdomyolysis — a condition brought on when severely damaged muscle tissue releases toxins into the bloodstream —"is a tremendous failure," Ms. Twight said. She added that the gym encourages its trainers to get to know their subjects personally, whether than means going shopping at the grocery store after a workout or lending a sympathetic ear.

"It's like sex," she said. "You can't just get up and leave afterwards. This is a relationship."

It's possible that a reporter's visit has prompted this convivial tone, but Mr. Snyder and other clients — sorry, "disciples" — insist otherwise. "They don't belittle you," said Mr. Snyder, who has trained with Mr. Twight over the years. Carolyn Parker, a climbing guide who lives in Albuquerque, where she goes by the nickname Blitzkrieg Barbie, also emphasized the lack of drill sergeant behavior. "They're more interested in training the mind than in physical fanaticism," she said of the Twights.

Working with Gym Jones involves completing excruciating tasks. They use some basic machines — rowers, Airdyne stationary bikes — but mostly rely on free weights, kettle bells and low-tech equipment like weighted sleds. The Jones Crawl involves three rounds of dead-lifting 115 percent of your body weight 10 times and then jumping on and off a box 25 times as fast as you can. "Recovery" at the end of a workout might involve a 30-minute run and an ice bath. But not at the gym; it has only one shower, which is for "emergencies," Ms. Twight said.

At the end of the day, working out is just picking stuff up and putting it down. The complicated part, at least at Gym Jones, is the mental workout: constant awareness of what helps or hurts progress, including maintaining proper nutrition and executing recovery accurately. "Breaking someone in a workout is pointless without post-training discussion and analysis," Mr. Twight said.

FITNESS companies inspired by Gym Jones are popping up around the country, mostly opened by people who have apprenticed with Mr. MacDonald and the Twights. Ms. Parker owns Athena Fitin Albuquerque; one in St. Louis is called Project Deliverance.

The Twights say they have no plans to expand beyond Utah, but they have increased the number of seminars they hold, which cost $1,500 to $2,000 a person and range from a two-day Fundamentals course to the five-day Advanced Program Design and Theory. Sessions with a trainer cost from $100 to $300 an hour; clients come either for a few days or on a regular basis.

The Twights now offer Web-based memberships starting at $500 a year; participants log into GymJones.com, which has more than 70 videos and 17 training plans, among other materials.

It was the advanced program that Mr. MacDonald, barefoot and in cargo shorts, was teaching in early August, the one that culminated in tears and sweat. But that was only a small part of the course. The eight participants spent much of their time in front of a white board at the back of the gym.

There, they sat in folding chairs and listened to Mr. MacDonald give a lecture. The class members, some of whom had traveled from as far as London and New York, took notes and followed along with a 135-page study guide.

"You can never get rid of endurance work," Mr. MacDonald said, stabbing at the board with a marker. "If you need to get rid of something in your workout, it needs to be the weight room."

He put the cap on the marker. "And always — always — be prepared to go to a dark place," he said. "Now, who's ready to work out?"

http://www.nytimes.com/2011/09/11/fashion/gym-jones-preaches-the-cult-of-physicality.html?

Canadian MDs consider denying fertility treatments to obese women - The Globe and Mail

Canadian doctors are considering a policy that would bar obese women from trying to have babies through fertility treatments - provoking debate over whether the fat have the same reproductive rights as the thin.

Some studies find obese women face higher risks of medical complications while trying to become pregnant through in-vitro fertilization (IVF). The science is not certain and some believe a ban would be tantamount to discrimination, yet a growing number of fertility doctors worldwide already bar treatment based on a woman's Body Mass Index.

"We've had many angry patients say to us, 'This is discriminatory' and I say, 'Yes, it is' But I still won't do it," said Arthur Leader, co-founder of the Ottawa Fertility Centre. The facility where he works will not treat women with a Body Mass Index (a measurement of weight relative to height) of more than 35. A BMI of 30 meets the clinical definition of obese.

"A patient doesn't have the right to make a choice that's going to be harmful to them," he said.

Those on the other side of the debate argue that denying fertility treatments to obese women stigmatizes and discriminates against those most in need. Excess weight is itself a barrier to conceiving naturally, and obesity rates are rising.

"You'd be denying half the reproductive population from gaining access to fertility treatment," said Anthony Cheung, a fertility expert at the University of British Columbia and Grace Fertility Centre. "These people already know they have a problem - are you going to make it worse, add to feelings of social injustice, low self-worth, depression?"

"We don't say, 'Oh sorry you smoke, so we can't treat you - it could result in pre-eclampsia, or small babies.' It doesn't mean we have this blanket policy where we say we can't treat (smokers)"

Dr. Cheung says it makes him wonder about the "biases of our own society around treating women with high BMI...if it reflects a paternalistic view around obesity."

As the country's fertility doctors meet in Toronto this week, Dr. Cheung plans to argue that studies also show IVF does not pose unacceptable risks for heavy women, and that BMI alone is not a good measure of which patients face the highest risks. Age, he said, is "by far the strongest indicator" of success and dangers. But he believes it is already a "David and Goliath argument - and I am David."

Even one of the leading infertility patient support groups agrees that obese women should be denied treatment.

"If you are more than 100 pounds overweight, that issue must be addressed before you start a family," said Beverly Hanck, executive director of the Infertility Awareness Association of Canada. "Get off your 50 pounds or so and exercise and then see where your fertility is at. A woman can lose 20 pounds and conceivably become pregnant...It could take a year, but it could result in getting pregnant naturally and save thousands of dollars."

Losing weight takes time, however, and for the older woman trying to have a child, time is the enemy. "If you lose time," Dr. Cheung said, "then you have much higher risks with age."

The Canadian Fertility and Andrology Society, which recommends practice standards for the country's fertility doctors, is not the first professional body to consider a treatment ban based on weight. The British Fertility Society recommended a ban in 2006, as has New Zealand, and it was the hot topic of debate at the European meeting on assisted reproduction in Sweden this summer.

"It may be for some women that this is wise advice ... but it's ethically troubling," said the University of Manitoba's Arthur Schafer, director of the Centre for Professional and Applied Ethics. "In our society, the decision to procreate is left to the individual - so why would it be appropriate for the doctors to usurp those rights for women who are obese?"

Doctors would only be justified, he says, if they could "honestly, hand-on-heart say," that the safety risks are so great "that no reasonable fat woman would want to conceive a baby in this way."

"I'm not sure the fertility industry or association can really defend a blanket exclusion on obese women having access to assisted reproduction."

Research has shown women who are severely overweight require higher doses of fertility drugs to spur ovulation - increasing the risk of side effects. As well, obese women face a greater risk of developing high blood pressure, which can trigger strokes, and gestational diabetes, which can pose risks to mother and baby.

While these risks during pregnancy apply to obese women even if they conceive naturally, Carl Laskin, president of the CFAS, believes fertility doctors have a responsibility to address them if a woman wants to conceive with medical help.

"If you don't think a woman should become pregnant for medical reasons, you have no business helping her to become pregnant. ... But it's a tough, tough message to deliver ... there's usually lots of tears," said Dr. Laskin, adding that he asks the women to return every three months to evaluate their weight loss.

For Dr. Leader, a major concern is that the "conscious sedation" used on patients while retrieving their eggs could disrupt breathing, but inserting a breathing tube into a patient who is morbidly obese is tricky and risky - "the patient could choke."

"If that person then dies on my table - how good would I feel?" said Dr. Leader, who asks that women bring their BMI below 35 to receive treatment. He knows some clinics won't treat women with a BMI of 30 - "30," he said, "is a bit extreme."

High BMI is a problem, Dr. Cheung agrees, but with no consensus around what the BMI cut off for treatment should be, no one knows where to draw the line - "32, 35, 40?"

(BMI can be influenced by bone structure and ethnicity)

"If you adhere to BMI blindly or uncritically...you may have people with low risk and still be denying them treatment."

Arya Sharma, a leading expert on obesity at the University of Alberta, doesn't agree that technical risks should exclude women from access to fertility treatments since "obese people undergo surgeries and all sorts of procedures all the time." But he does feel obese women should try to lose weight before turning to IVF to conceive, since it is a risky and costly procedure they have to pay for themselves: "Why take the risks or spend the money, if you don't need it?"

http://www.theglobeandmail.com/life/health/new-health/health-news/canadian-mds-consider-denying-fertility-treatments-to-obese-women/article2173941/?cmpid=nl-news1

Eating-disorder patients battle insurers over care - SFGate

When Jeanene Harlick's weight dropped to 65 percent of normal, her doctors recommended the San Mateo woman go into an intensive residential treatment facility that specialized in treating anorexia and other eating disorders.

But her health insurer, Blue Shield of California, refused to cover her care - not because it wasn't considered medically necessary, but because her plan excluded coverage for residential treatment programs. Harlick spent almost 10 months in residential treatment, while her parents went hundreds of thousands of dollars into debt to cover the cost.

Harlick, now 37, later sued the insurer.

Getting treatment covered for eating disorders has long been a struggle for many of the 24 million Americans diagnosed with anorexia, bulimia and binge-eating disorder. Intensive residential treatment for eating disorders typically costs $900 to $1,200 per day.

In a significant ruling for those seeking residential treatment for mental health conditions, the Ninth Circuit Court of Appeals in San Francisco sided with Harlick last month. The three-judge panel ruled Blue Shield's policy excluding residential treatment violates the state's 2000 Mental Health Parity Law, which requires certain serious mental health diagnoses, including eating disorders, to be covered at the same level as physical health.

"It's a landmark victory for those suffering with eating disorders," said Lara Gregorio, legislative policy program director for the National Eating Disorders Association. "So many families go bankrupt fighting this and still don't win. It sets a precedent for other states to follow suit."

But the legal battle is not over. On Friday, Blue Shield, which is based in San Francisco, filed a petition for a rehearing in front of the same appellate court panel. A lower court had ruled in favor of the insurer.

Blue Shield spokesman Stephen Shivinsky said the petition is based on "several significant errors in the opinion." According to court documents filed Friday, the insurer argued that state law does not require coverage for all medically necessary treatments and allows plans to set coverage limits.

Harlick's attorney, Lisa Kantor, described the appeal as "desperate" and is convinced the appellate court decision will prevail.

"The point of this decision is (insurers) have to provide all medically necessary treatments for severe mental illnesses," Kantor said. "When you exclude a critical modality of treatment such a residential treatment, you're not providing parity."

California has one of the strongest mental health parity laws in the country, but some argue that anorexia and other mental health conditions are still not treated as comprehensively as physical health, often because they are misunderstood.

While many patients with eating disorders can be treated on an outpatient basis, some patients need hospitalization or the constant supervision of a residential treatment center.

"Residential treatment is a key component of working on eating disorders," said Victoria Green, clinical director of New Dawn Eating Disorders Recovery Centers, which has a residential treatment center in San Francisco.

"You have hospitalization, which only stabilizes somebody medically, and we're the next level of treatment. We treat highly acute people who cannot function in the world," she said, adding that insurers either don't cover the care or authorize just a few days of treatment at a time.

Dr. Neal Anzai, medical director of the eating disorders program at Alta Bates Summit Medical Center in Berkeley, said his patients have to be "literally on the verge of death" to get hospitalized and then their insurance coverage often dictates how much care or what kind of care comes next.

"It's hard to get people into the hospital, but once they're there, there's a battle whether we can get them down to residential care or partial hospitalization," he said.

In Harlick's case, her insurer would cover hospitalization but not residential care.

Harlick had been battling anorexia and obsessive-compulsive disorder for more than 20 years when her doctors recommended a residential center in 2006. Harlick finally found a suitable inpatient facility in Missouri, where she stayed almost 10 months - from April 2006 to January 2007.

"The treatment I received helped me have a lot more compassion for myself. I do still struggle and am still working on it," said Harlick, who continues to battle with issues of weight and is on disability, but is working to finish her master's in social work at San Francisco State University.

"I'll keep on fighting, but I know if I haven't received the treatment I did, I would most likely be dead," she said.

Harlick said she wants her case to be successful to help other people receive the treatment they need. She also hopes it will legitimize anorexia as a mental illness, and not an obsession with weight and appearance as some people believe.

"It would just be extremely rewarding to think something a little good came out from my struggle because I still feel enormous guilt and shame," said Harlick, referring to her continuing condition as well as the unspecified amount of money her family spent for her treatment.

For Harlick's mother, Robin Watson, the money was the last thing on her mind.

"We were so desperate, we thought we were going to lose our daughter," said Watson, who lives in Burlingame. "We had to move and deal with the consequences later."

While Watson hopes to recoup the treatment costs, she said the three-year court battle has become about more than money. "It's about the discrimination insurance companies put on mental illnesses and the very little understanding they have about eating disorders," she said.

Kantor, Harlick's attorney, filed a petition last week in state Superior Court in Los Angeles for a class-action suit against Blue Shield on similar grounds.

"Jeanene was lucky. Her family knew they needed to take care of her," Kantor said. "I'm scared to find out what will happen to a lot of young women who had this policy and didn't have a family to support them. I don't know how many lives we've lost."

***

-- About 24 million Americans have anorexia, bulimia and compulsive overeating disorders. .

-- Anorexia is characterized by self-starvation and weight loss. Binge eating and bulimia can involve behaviors such as vomiting, use of laxatives and excessive exercise.

-- More than 90 percent of sufferers are female, with most being diagnosed as teenagers.

-- Anorexia nervosa has the highest mortality rate of all mental health diagnoses.

-- Health effects include fatigue, blood pressure problems, osteoporosis, electrolyte and chemical imbalances, and death.

-- Twenty-three states, including California, have enacted mental health parity laws that require insurers to cover eating disorders, but coverage requirements vary greatly.

Source: National Eating Disorders Association.

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2011/09/10/MN8C1KTQD5.DTL

Mayo Clinic Center for Social Media

The Mayo Clinic Center for Social Media exists to improve health globally by accelerating effective application of social media tools throughout Mayo Clinic and spurring broader and deeper engagement in social media by hospitals, medical professionals and patients.

Mayo Clinic's Social Media Philosophy:

Mayo Clinic believes individuals have the right and responsibility to advocate for their own health, and that it is our responsibility to help them use social media tools to get the best information, connect with providers and with each other, and inspire healthy choices. We intend to lead the health care community in applying these revolutionary tools to spread knowledge and encourage collaboration among providers, improving health care quality everywhere.

Mission of the Center:

Lead the social media revolution in health care, contributing to health and well being for people everywhere.

Vision for the Center:

Mayo Clinic will be the authentic voice for patients and health care professionals, building relationships through the revolutionary power of social media.

http://socialmedia.mayoclinic.org/

CasesBlog - Medical and Health Blog: Presentations from Medicine 2.0 Congress

These are some selected presentations from the 2011 Medicine 2.0 Congress that took place on the Stanford University campus last weekend

http://casesblog.blogspot.com/2011/09/presentations-from-medicine-20-congress.html?

A Mother’s War on Germs at Fast-Food Playgrounds - NYTimes.com

GILBERT, Ariz. — One of those who kicked off her shoes and slithered her way through the multihued plastic tubes of a fast-food restaurant playground here one recent morning was not enjoying herself in the least. In fact, she had a frown on her face.

"It's bad," Erin M. Carr-Jordan said, swab in hand, as she collected samples from a surface that she would later deliver to a lab for microbial testing. Nearby, a restaurant worker diligently sanitized tabletops and banisters outside the play area, but he did not appear to use his rag and spray bottle inside the children's maze.

Dr. Carr-Jordan, a child development professor and a mother of four from Chandler, Ariz., has visited dozens of restaurant playgrounds in 11 states in recent months to test them for cleanliness. What the inspections and lab analyses have revealed is the widespread presence of an array of pathogens, from coliform bacteria to staphylococcus, at levels that experts said indicated that restaurants might not be disinfecting their playlands as diligently as they should.

Those same experts pointed out that germs are everywhere and that they are not always dangerous. They add that hand washing is an important safeguard.

"I'm not shocked or blown out of the water, because this is my business," said Philip M. Tierno Jr., director of clinical microbiology and immunology at NYU Langone Medical Center in New York, who surveyed some of Dr. Carr-Jordan's results. At the same time, Dr. Tierno said, "There are very high counts, and that means these places are not cleaned properly or not cleaned at all."

Dr. Carr-Jordan's campaign, which has attracted the attention of the fast-food industry, began in April when she stopped at a McDonald's near her Phoenix-area home because one of her sons needed to go to the bathroom. On the way out, her children asked if they could play in the children's park, which McDonald's calls a PlayPlace. She assented and accompanied her children inside.

What she saw was alarming.

"My kids were going, 'Yuck!' " she recalled of the scene, which she videotaped with her cellphone and posted on YouTube. "It was gross and sticky. There were curse words and gang graffiti. The windows were black. There was matted hair and an abandoned Band-Aid."

Despite complaints to the manager and several follow-up visits, the play area was not cleaned, she said. So Dr. Carr-Jordan, who has a Ph.D. in developmental psychology but is no expert in microbiology, had samples tested. When the results were analyzed by Legend Technical Services Inc., an environmental testing company, they indicated the presence of potentially harmful bacteria, and she began inspecting and testing the playgrounds at other fast-food restaurants in her neighborhood. Lab results — she has since switched to another commercial lab — showed that most were far from clean, she said.

Intent on showing that the problem was not an isolated matter, she has been mixing family vacations with her play area inspections. From New York to California, she has squeezed herself into the playgrounds at Burger King, Chuck E. Cheese's, Peter Piper Pizza and numerous other restaurants.

Playtime, a Colorado company that supplies play equipment to McDonald's and other restaurants, recommends on its Web site that restaurant operators regularly clean and inspect their equipment to keep a check on "smudges, ink, goo." The restaurants say they have policies in place that require the regular cleaning of their play areas. Danya Proud, a McDonald's spokeswoman, said the company had stringent sanitizing procedures but had nonetheless assigned a team to review those procedures in light of Dr. Carr-Jordan's complaints.

"We're human, and we make mistakes," Ms. Proud said, indicating that McDonald's considers cleanliness a priority.

Still, Dr. Carr-Jordan said that of the nearly 50 play areas she had tested, only one had come back essentially free of pathogens, and that was at a Chick-fil-A restaurant not far from her home. That is now the only restaurant play area she permits her children to visit.

To draw attention to the issue and push for legislation mandating stricter standards for play areas, Dr. Carr-Jordan, who teaches at Arizona State University and several other institutions, has formed a nonprofit group called Kids Play Safe. Her calls to health officials, from local health departments to the Centers for Disease Control and Prevention, have failed to prompt any crackdown, she said.

A C.D.C. spokeswoman, Bernadette Burden, said the federal agency would get involved only if called in by state officials concerned about a major disease breakout. In Maricopa County, which includes Phoenix, the Environmental Services Department considers play areas nonfood areas, and thus less of a priority during inspections than other parts of restaurants, said Johnny Diloné, a spokesman.

So Dr. Carr-Jordan, fast-food vigilante, continues to climb into tubes, wriggle through tunnels and slide down slides. After emerging from one play area she inspected in Arizona last week, she shook her head. "No one would want their child playing in there," she said, "and that one wasn't the worst."

http://www.nytimes.com/2011/09/18/us/a-mothers-war-on-germs-at-fast-food-playgrounds.html?nl=todaysheadlines&emc=tha23