Fat Dad: Baking for Love

Fat Dad

Dawn Lerman writes about growing up with a fat dad.

My grandmother Beauty always told me that the way to a man’s heart was through his stomach, and by the look of pure delight on my dad’s face when he ate a piece of warm, homemade chocolate cake, or bit into a just-baked crispy cookie, I grew to believe this was true. I had no doubt that when the time came, and I liked a boy, that a batch of my gooey, rich, chocolatey brownies would cast him under a magic spell, and we would live happily ever.

But when Hank Thomas walked into Miss Seawall’s ninth grade algebra class on a rainy, September day and smiled at me with his amazing grin, long brown hair, big green eyes and Jimi Hendrix T-shirt, I was completely unprepared for the avalanche of emotions that invaded every fiber of my being. Shivers, a pounding heart, and heat overcame me when he asked if I knew the value of 1,000 to the 25th power. The only answer I could think of, as I fumbled over my words, was “love me, love me,” but I managed to blurt out “1E+75.” I wanted to come across as smart and aloof, but every time he looked at me, I started stuttering and sweating as my face turned bright red. No one had ever looked at me like that: as if he knew me, as if he knew how lost I was and how badly I needed to be loved.

Hank, who was a year older than me, was very popular and accomplished. Unlike other boys who were popular for their looks or athletic skills, Hank was smart and talented. He played piano and guitar, and composed the most beautiful classical and rock concertos that left both teachers and students in awe.

Unlike Hank, I had not quite come into my own yet. I was shy, had raggedy messy hair that I tied back into braids, and my clothes were far from stylish. My mother and sister had been on the road touring for the past year with the Broadway show “Annie.” My sister had been cast as a principal orphan, and I stayed home with my dad to attend high school. My dad was always busy with work and martini dinners that lasted late into the night. I spent most of my evenings at home alone baking and making care packages for my sister instead of coercing my parents to buy me the latest selection of Gloria Vanderbilt jeans — the rich colored bluejeans with the swan stitched on the back pocket that you had to lie on your bed to zip up. It was the icon of cool for the popular and pretty girls. I was neither, but Hank picked me to be his math partner anyway.

With every equation we solved, my love for Hank became more desperate. After several months of exchanging smiles, I decided to make Hank a batch of my chocolate brownies for Valentine’s Day — the brownies that my dad said were like his own personal nirvana. My dad named them “closet” brownies, because when I was a little girl and used to make them for the family, he said that as soon as he smelled them coming out of the oven, he could imagine dashing away with them into the closet and devouring the whole batch.

After debating for hours if I should make the brownies with walnuts or chips, or fill the centers with peanut butter or caramel, I got to work. I had made brownies hundreds of times before, but this time felt different. With each ingredient I carefully stirred into the bowl, my heart began beating harder. I felt like I was going to burst from excitement. Surely, after Hank tasted these, he would love me as much as I loved him. I was not just making him brownies. I was showing him who I was, and what mattered to me. After the brownies cooled, I sprinkled them with a touch of powdered sugar and wrapped them with foil and red tissue paper. The next day I placed them in Hank’s locker, with a note saying, “Call me.”

After seven excruciating days with no call, some smiles and the usual small talk in math class, I conjured up the nerve to ask Hank if he liked my brownies.

“The brownies were from you?” he asked. “They were delicious.”

Then Hank invited me to a party at his house the following weekend. Without hesitation, I responded that I would love to come. I pleaded with my friend Sarah to accompany me.

As the day grew closer, I made my grandmother Beauty’s homemade fudge — the chocolate fudge she made for Papa the night before he proposed to her. Stirring the milk, butter and sugar together eased my nerves. I had never been to a high school party before, and I didn’t know what to expect. Sarah advised me to ditch the braids as she styled my hair, used a violet eyeliner and lent me her favorite V-neck sweater and a pair of her best Gloria Vanderbilt jeans.

When we walked in the door, fudge in hand, Hank was nowhere to be found. Thinking I had made a mistake for coming and getting ready to leave, I felt a hand on my back. It was Hank’s. He hugged me and told me he was glad I finally arrived. When Hank put his arm around me, nothing else existed. With a little help from Cupid or the magic of Beauty’s recipes, I found love.

---

Fat Dad’s ‘Closet’ Brownies

These brownies are more like fudge than cake and contain a fraction of the flour found in traditional brownie recipes. My father called them “closet” brownies, because when he smelled them coming out of the oven he could imagine hiding in the closet to eat the whole batch. I baked them in the ninth grade for a boy that I had a crush on, and they were more effective than Cupid’s arrow at winning his heart.

6 tablespoons unsalted butter, plus extra for greasing the pan
8 ounces bittersweet chocolate, chopped, or semisweet chocolate chips
3/4 cup brown sugar
2 eggs at room temperature, beaten
1 teaspoon vanilla extract
1/4 cup flour
1/2 cup chopped walnuts (optional)
Fresh berries or powdered sugar for garnish (optional)

1. Preheat oven to 350 degrees.

2. Grease an 8-inch square baking dish.

3. In a double boiler, melt chocolate. Then add butter, melt and stir to blend. Remove from heat and pour into a mixing bowl. Stir in sugar, eggs and vanilla and mix well.

4. Add flour. Mix well until very smooth. Add chopped walnuts if desired. Pour batter into greased baking pan.

5. Bake for 35 minutes, or until set and barely firm in the middle. Allow to cool on a rack before removing from pan. Optional: garnish with powdered sugar, or berries, or both.

Yield: 16 brownies

---

Dawn Lerman is a New York-based health and nutrition consultant and founder of Magnificent Mommies, which provides school lectures, cooking classes and workshops. Her series on growing up with a fat father appears occasionally on Well.

Read More..

Fat Dad: Baking for Love

Fat Dad

Dawn Lerman writes about growing up with a fat dad.

My grandmother Beauty always told me that the way to a man’s heart was through his stomach, and by the look of pure delight on my dad’s face when he ate a piece of warm, homemade chocolate cake, or bit into a just-baked crispy cookie, I grew to believe this was true. I had no doubt that when the time came, and I liked a boy, that a batch of my gooey, rich, chocolatey brownies would cast him under a magic spell, and we would live happily ever.

But when Hank Thomas walked into Miss Seawall’s ninth grade algebra class on a rainy, September day and smiled at me with his amazing grin, long brown hair, big green eyes and Jimi Hendrix T-shirt, I was completely unprepared for the avalanche of emotions that invaded every fiber of my being. Shivers, a pounding heart, and heat overcame me when he asked if I knew the value of 1,000 to the 25th power. The only answer I could think of, as I fumbled over my words, was “love me, love me,” but I managed to blurt out “1E+75.” I wanted to come across as smart and aloof, but every time he looked at me, I started stuttering and sweating as my face turned bright red. No one had ever looked at me like that: as if he knew me, as if he knew how lost I was and how badly I needed to be loved.

Hank, who was a year older than me, was very popular and accomplished. Unlike other boys who were popular for their looks or athletic skills, Hank was smart and talented. He played piano and guitar, and composed the most beautiful classical and rock concertos that left both teachers and students in awe.

Unlike Hank, I had not quite come into my own yet. I was shy, had raggedy messy hair that I tied back into braids, and my clothes were far from stylish. My mother and sister had been on the road touring for the past year with the Broadway show “Annie.” My sister had been cast as a principal orphan, and I stayed home with my dad to attend high school. My dad was always busy with work and martini dinners that lasted late into the night. I spent most of my evenings at home alone baking and making care packages for my sister instead of coercing my parents to buy me the latest selection of Gloria Vanderbilt jeans — the rich colored bluejeans with the swan stitched on the back pocket that you had to lie on your bed to zip up. It was the icon of cool for the popular and pretty girls. I was neither, but Hank picked me to be his math partner anyway.

With every equation we solved, my love for Hank became more desperate. After several months of exchanging smiles, I decided to make Hank a batch of my chocolate brownies for Valentine’s Day — the brownies that my dad said were like his own personal nirvana. My dad named them “closet” brownies, because when I was a little girl and used to make them for the family, he said that as soon as he smelled them coming out of the oven, he could imagine dashing away with them into the closet and devouring the whole batch.

After debating for hours if I should make the brownies with walnuts or chips, or fill the centers with peanut butter or caramel, I got to work. I had made brownies hundreds of times before, but this time felt different. With each ingredient I carefully stirred into the bowl, my heart began beating harder. I felt like I was going to burst from excitement. Surely, after Hank tasted these, he would love me as much as I loved him. I was not just making him brownies. I was showing him who I was, and what mattered to me. After the brownies cooled, I sprinkled them with a touch of powdered sugar and wrapped them with foil and red tissue paper. The next day I placed them in Hank’s locker, with a note saying, “Call me.”

After seven excruciating days with no call, some smiles and the usual small talk in math class, I conjured up the nerve to ask Hank if he liked my brownies.

“The brownies were from you?” he asked. “They were delicious.”

Then Hank invited me to a party at his house the following weekend. Without hesitation, I responded that I would love to come. I pleaded with my friend Sarah to accompany me.

As the day grew closer, I made my grandmother Beauty’s homemade fudge — the chocolate fudge she made for Papa the night before he proposed to her. Stirring the milk, butter and sugar together eased my nerves. I had never been to a high school party before, and I didn’t know what to expect. Sarah advised me to ditch the braids as she styled my hair, used a violet eyeliner and lent me her favorite V-neck sweater and a pair of her best Gloria Vanderbilt jeans.

When we walked in the door, fudge in hand, Hank was nowhere to be found. Thinking I had made a mistake for coming and getting ready to leave, I felt a hand on my back. It was Hank’s. He hugged me and told me he was glad I finally arrived. When Hank put his arm around me, nothing else existed. With a little help from Cupid or the magic of Beauty’s recipes, I found love.

---

Fat Dad’s ‘Closet’ Brownies

These brownies are more like fudge than cake and contain a fraction of the flour found in traditional brownie recipes. My father called them “closet” brownies, because when he smelled them coming out of the oven he could imagine hiding in the closet to eat the whole batch. I baked them in the ninth grade for a boy that I had a crush on, and they were more effective than Cupid’s arrow at winning his heart.

6 tablespoons unsalted butter, plus extra for greasing the pan
8 ounces bittersweet chocolate, chopped, or semisweet chocolate chips
3/4 cup brown sugar
2 eggs at room temperature, beaten
1 teaspoon vanilla extract
1/4 cup flour
1/2 cup chopped walnuts (optional)
Fresh berries or powdered sugar for garnish (optional)

1. Preheat oven to 350 degrees.

2. Grease an 8-inch square baking dish.

3. In a double boiler, melt chocolate. Then add butter, melt and stir to blend. Remove from heat and pour into a mixing bowl. Stir in sugar, eggs and vanilla and mix well.

4. Add flour. Mix well until very smooth. Add chopped walnuts if desired. Pour batter into greased baking pan.

5. Bake for 35 minutes, or until set and barely firm in the middle. Allow to cool on a rack before removing from pan. Optional: garnish with powdered sugar, or berries, or both.

Yield: 16 brownies

---

Dawn Lerman is a New York-based health and nutrition consultant and founder of Magnificent Mommies, which provides school lectures, cooking classes and workshops. Her series on growing up with a fat father appears occasionally on Well.

Read More..

Airbus and Boeing on Different Paths on Battery

When it comes to the volatile new lithium-ion battery technology, Boeing and Airbus are heading in different directions.

Faced with the potential of a lengthy investigation into what caused batteries on two Boeing 787 jets to ignite or emit smoke last month, Airbus said Friday that it had dropped plans to use the technology on its forthcoming wide-body jet, the A350-XWB, to avoid possible delays in producing the planes. But Boeing, which has much more at stake, said later in the day that it would stick with the batteries and that it was working with regulators to reduce risks even if the cause of the hazards is not clearly found.

All 50 of the 787s delivered so far were grounded in mid-January. And even though the problems have embarrassed Boeing and could cost it hundreds of millions of dollars, the company said Friday, “There’s nothing we’ve learned in the investigations that would lead us to a different decision regarding lithium-ion batteries.”

To some extent, Boeing’s bravado reflects a sense among battery experts that they have narrowed down the ways that the batteries, made by a Japanese company, GS Yuasa, could fail. That then increases the chances that a handful of changes may eventually provide enough assurance that the batteries would be safe to use.

Airbus was planning on a more limited use of the lithium-ion batteries than Boeing, and by switching to the more traditional nickel-cadmium batteries, the company can make the necessary changes as it is building the planes. Boeing, on the other hand, has a strong motivation to stick with the lithium-ion batteries in hopes that a solution will emerge.

Under flight safety regulations, industry and government officials said, Boeing might not have to go through as extensive — and time-consuming — an approval process if it redesigned the lithium-ion batteries as it would if it switched to the conventional batteries.

Even though the behavior of the more traditional batteries is better understood, they have not yet been certified for use in the 787s, and the batteries and related parts of the plane’s electrical system would have to be created and tested from scratch. Under the safety directive grounding the planes, Boeing might have a more straightforward path to get them flying again if it could persuade the Federal Aviation Administration that redesigning the lithium-ion batteries would work.

Federal and industry officials said Boeing would probably have to spread the eight cells in the batteries farther apart — or increase the insulation between them — to keep a failure in one cell from cascading to the others in the “thermal runaway” that led to the smoke and fire. Battery experts are also looking into whether vibrations in flight could have added to the risks of unwanted contact between the cells. And Boeing would undoubtedly have to wall off the battery within a sturdier metal container and make it easier to vent any hazardous materials outside the plane.

Aviation experts said the examination of such changes reflected what could end up being a difficult calculation for safety regulators: Will there be a way to assure the safety of the batteries if they cannot tell for certain what set off the problems on the two planes?

Until now, most of the public statements by regulators have focused on the need to pin down the cause of the battery problems. But investigators, now weeks into their work, have only been able to find limited clues in the charred remains of the two batteries.

As a result, government and outside experts, working closely with Boeing engineers, have been studying the research on lithium-ion batteries carried out since Boeing won approval for its batteries in 2007 and, in essence, trying to come up with a safer design.

Government and industry officials said Friday that it was still too early to know if Boeing could devise enough changes to satisfy regulators and the flying public.

Airbus said it started informing airline customers on Thursday that it would not move ahead with an original plan to use the lithium-ion batteries on its A350s.

“Airbus considers this to be the most appropriate way forward in the interest of program execution and reliability,” said Marcella Muratore, an Airbus spokeswoman.

This article has been revised to reflect the following correction:

Correction: February 15, 2013

An earlier version of this article mischaracterized incidents in January involving lithium-ion batteries in Boeing 787 Dreamliners. In one case a battery caught fire, and in another a battery emitted smoke; both batteries did not catch fire.

Read More..

French Forces Needed Longer in Mali, U.S. Official Says

WASHINGTON — French military forces will probably be needed to carry out operations against militants in Mali even after a United Nations peacekeeping force is organized to secure the country, a senior State Department official told Congress on Thursday.

“There’s going to be an ongoing need for a counterterrorism operation in northern Mali, and that probably will always reside in the hands of the French and not in the hands of the United Nations,” Johnnie Carson, the top State Department official on Africa issues, told the House Foreign Affairs Committee.

Mr. Carson’s comments reflected extensive consultations between France and the United States regarding the military operation in Mali and suggested that there would be a longer-term role for French forces in the country. French officials declined to comment on Thursday night.

France rushed 4,000 troops to Mali in January, but French officials have made it clear they would like to hand over responsibility for the bulk of the mission to West African and Malian forces when the terrorist threat is reduced. Eventually these units are to be supplanted by a United Nations peacekeeping force made up of African troops.

In a brief interview after the hearing, Mr. Carson sketched out his vision of how the military operation might evolve, including a likely role for French counterterrorism forces in tracking down militants in the rugged northern part of Mali.

“It would be very separate and very different,” he said, making the point that while French forces might be in Mali at the same time as peacekeepers they would operate under a separate chain of command. “A bilateral agreement between the Malian government and French government would be able to do that.”

Edward R. Royce, the California Republican who is chairman of the panel, expressed concern that the mission might be handed over to the United Nations prematurely.

“We do not want to do that hastily,” Mr. Carson responded. “We think that over time the U.N. does have peacekeeping norms and standards that would be applicable and useful in Mali.”

The United States is barred by law from providing direct support to the Malian military after the coup there last year. But it has been providing intelligence, refueling French aircraft, flying equipment and troops to the region, and helping to train West African troops.

Read More..

Media Decoder Blog: Indian Music Service, Taking Page From Spotify, Goes Pro

Western music fans have no shortage of digital music services to choose from, and that abundance is spreading around the world. Apple’s iTunes is now in 119 countries, and others are racing to plant their digital flags everywhere. This week, for example, Spotify opened in Italy, Poland and Portugal, bringing its reach to 23 countries.

But just as interesting, and in the long run perhaps as significant to competition, is the rise of services that serve regional markets intensely. One is Saavn, a Spotify-like streaming service that specializes in Indian music, and has garnered 10.5 million monthly users with advertising-supported free listening. This week it will announce that it has taken another page from Spotify’s book, by offering a premium version at $4 a month that eliminates the ads, lets users listen to songs offline and will eventually add other features like higher quality audio.

Saavn, which has offices in New York, India and Mountain View, Calif., has a catalog of 1.1 million songs in nine languages and is available in more than 200 countries, with about 70 percent of its consumption within India, said Rishi Malhotra, one of its founders. Like Spotify, iHeartRadio and other Western services, it is an official partner of Facebook. About 80 percent of its use is on mobile devices, Mr. Malhotra said, and when the premium service, Saavn Pro, is opened in March, it will at first be available only for Apple devices.

The pricing is significantly lower than Western services. “We wanted to make it globally acceptable,” said Mr. Malhotra, who is based in New York. “The $10 price point that you see from a lot of music services we use here is way out of reach from what would fly in India or a lot of other emerging markets.”

Saavn believes it can succeed in India not only through its catalog of Bollywood hits, but through technological touches that may be meaningful only to Indian listeners. One example is the ability to search for a Bollywood song based on the actor who lip-synchs it — often more memorable to fans than the “playback” singer who actually provided the voice.

If successful, Saavn Pro could give the company an advantage in India’s quickly developing digital music market, which already has a handful of streaming services, like Dhingana, as well as a strong presence in downloads from Nokia. Yet that market is still tiny for a country of India’s size and overall media spending. According to the International Federation of the Phonographic Industry, recorded music had only $141 million in trade (or wholesale) value in 2011. A recent report by Ernst & Young said that music and radio combined count for only 2.4 percent of India’s media and entertainment spending, which for 2011 it estimated at $18 billion.

Part of the reason for music’s small proportion of India’s media economy is that popular music in India is dominated by the film industry. But a greater reason is piracy; the federation estimates that 55 percent of Internet users in India go to unlicensed music services on a monthly basis. That is slowly starting to change, music executives say, as courts there crack down on infringement and legitimate digital services proliferate. Apple’s iTunes opened there in December, and Nokia says it sells 1.4 million songs a day at its download store in India.

And Indian record companies are approaching digital business without the baggage that has been complicating deals with Western labels and services for more than a decade, Mr. Malhotra added.

“The labels in India are not reluctant about digital,” he said. “It’s not like they are protecting against some established, older revenue stream. It’s all found revenue for them.”

---

Ben Sisario writes about the music industry. Follow @sisario on Twitter.

Read More..

Doctor and Patient: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

Read More..

Doctor and Patient: Afraid to Speak Up to Medical Power

The slender, weather-beaten, elderly Polish immigrant had been diagnosed with lung cancer nearly a year earlier and was receiving chemotherapy as part of a clinical trial. I was a surgical consultant, called in to help control the fluid that kept accumulating in his lungs.

During one visit, he motioned for me to come closer. His voice was hoarse from a tumor that spread, and the constant hissing from his humidified oxygen mask meant I had to press my face nearly against his to understand his words.

“This is getting harder, doctor,” he rasped. “I’m not sure I’m up to anymore chemo.”

I was not the only doctor that he confided to. But what I quickly learned was that none of us was eager to broach the topic of stopping treatment with his primary cancer doctor.

That doctor was a rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital’s then lackluster cancer center. Within a few months of the doctor’s arrival, the once sleepy department began offering a dazzling array of experimental drugs. Calls came in from outside doctors eager to send their patients in for treatment, and every patient who was seen was promptly enrolled in one of more than a dozen well-documented treatment protocols.

But now, no doctors felt comfortable suggesting anything but the most cutting-edge, aggressive treatments.

Even the No. 2 doctor in the cancer center, Robin to the chief’s cancer-battling Batman, was momentarily taken aback when I suggested we reconsider the patient’s chemotherapy plan. “I don’t want to tell him,” he said, eyes widening. He reeled off his chief’s vast accomplishments. “I mean, who am I to tell him what to do?”

We stood for a moment in silence before he pointed his index finger at me. “You tell him,” he said with a smile. “You tell him to consider stopping treatment.”

Memories of this conversation came flooding back last week when I read an essay on the problems posed by hierarchies within the medical profession.

For several decades, medical educators and sociologists have documented the existence of hierarchies and an intense awareness of rank among doctors. The bulk of studies have focused on medical education, a process often likened to military and religious training, with elder patriarchs imposing the hair shirt of shame on acolytes unable to incorporate a profession’s accepted values and behaviors. Aspiring doctors quickly learn whose opinions, experiences and voices count, and it is rarely their own. Ask a group of interns who’ve been on the wards for but a week, and they will quickly raise their hands up to the level of their heads to indicate their teachers’ status and importance, then lower them toward their feet to demonstrate their own.

It turns out that this keen awareness of ranking is not limited to students and interns. Other research has shown that fully trained physicians are acutely aware of a tacit professional hierarchy based on specialties, like primary care versus neurosurgery, or even on diseases different specialists might treat, like hemorrhoids and constipation versus heart attacks and certain cancers.

But while such professional preoccupation with privilege can make for interesting sociological fodder, the real issue, warns the author of a courageous essay published recently in The New England Journal of Medicine, is that such an overly developed sense of hierarchy comes at an unacceptable price: good patient care.

Dr. Ranjana Srivastava, a medical oncologist at the Monash Medical Centre in Melbourne, Australia, recalls a patient she helped to care for who died after an operation. Before the surgery, Dr. Srivastava had been hesitant to voice her concerns, assuming that the patient’s surgeon must be “unequivocally right, unassailable, or simply not worth antagonizing.” When she confesses her earlier uncertainty to the surgeon after the patient’s death, Dr. Srivastava learns that the surgeon had been just as loath to question her expertise and had assumed that her silence before the surgery meant she agreed with his plan to operate.

“Each of us was trying our best to help a patient, but we were also respecting the boundaries and hierarchy imposed by our professional culture,” Dr. Srivastava said. “The tragedy was that the patient died, when speaking up would have made all the difference.”

Compounding the problem is an increasing sense of self-doubt among many doctors. With rapid advances in treatment, there is often no single correct “answer” for a patient’s problem, and doctors, struggling to stay up-to-date in their own particular specialty niches, are more tentative about making suggestions that cross over to other doctors’ “turf.” Even as some clinicians attempt to compensate by organizing multidisciplinary meetings, inviting doctors from all specialties to discuss a patient’s therapeutic options, “there will inevitably be a hierarchy at those meetings of who is speaking,” Dr. Srivastava noted. “And it won’t always be the ones who know the most about the patient who will be taking the lead.”

It is the potentially disastrous repercussions for patients that make this overly developed awareness of rank and boundaries a critical issue in medicine. Recent efforts to raise safety standards and improve patient care have shown that teams are a critical ingredient for success. But simply organizing multidisciplinary lineups of clinicians isn’t enough. What is required are teams that recognize the importance of all voices and encourage active and open debate.

Since their patient’s death, Dr. Srivastava and the surgeon have worked together to discuss patient cases, articulate questions and describe their own uncertainties to each other and in patients’ notes. “We have tried to remain cognizant of the fact that we are susceptible to thinking about hierarchy,” Dr. Srivastava said. “We have tried to remember that sometimes, despite our best intentions, we do not speak up for our patients because we are fearful of the consequences.”

That was certainly true for my lung cancer patient. Like all the other doctors involved in his care, I hesitated to talk to the chief medical oncologist. I questioned my own credentials, my lack of expertise in this particular area of oncology and even my own clinical judgment. When the patient appeared to fare better, requiring less oxygen and joking and laughing more than I had ever seen in the past, I took his improvement to be yet another sign that my attempt to talk about holding back chemotherapy was surely some surgical folly.

But a couple of days later, the humidified oxygen mask came back on. And not long after that, the patient again asked for me to come close.

This time he said: “I’m tired. I want to stop the chemo.”

Just before he died, a little over a week later, he was off all treatment except for what might make him comfortable. He thanked me and the other doctors for our care, but really, we should have thanked him and apologized. Because he had pushed us out of our comfortable, well-delineated professional zones. He had prodded us to talk to one another. And he showed us how to work as a team in order to do, at last, what we should have done weeks earlier.

Read More..

Media Decoder Blog: CBS Reports Record Operating Income for 4th Quarter

The CBS Corporation set records in the fourth quarter for operating income and adjusted operating income, the company said Thursday, but the results were short of some analysts’ expectations and its share price fell in after-hours trading.

The adjusted net earnings of $414 million produced earnings of 64 cents a share, also a quarterly record for CBS, though some analysts had forecast income as high as 69 cents.

CBS, which reported full-year results for 2012 as well as for the quarter ending Dec. 31, also announced an additional stock buyback of $1 billion. That brings the total amount of stock CBS has committed to repurchasing for the current year to $2.2 billion.

Over all, CBS demonstrated improved results in most financial categories and divisions. Revenues for the quarter rose to $3.7 billion, up 2 percent from $3.61 billion for the comparable quarter in 2011.

The company reported net income of $393 million, or 60 cents a share, up 6.2 percent from $370 million, or 55 cents a share, in the fourth quarter of 2011.

CBS cited increases in advertising revenue in the quarter, partly driven by political commercials in an election year. The CBS broadcast network continues to be the most watched in television and will most likely beat all its competitors in the significant ratings categories for the current season.

The company also had increases from subscription fees, driven by improvement in its cable networks. Showtime, the pay-cable channel owned by CBS, has experienced growth in subscriptions, thanks in part to its award-winning drama “Homeland.” CBS has pressed for years for increased compensation from cable systems for the rights to carry CBS broadcast stations, and Thursday the company reported that retransmission fees were also up for the quarter, part of 9 percent growth overall in affiliate and subscription fees.

Adjusted operating income before depreciation and amortization increased 6 percent to $866 million, from $814 million the year before. Operating income increased 12 percent to $726 million, up from $647 million.

For the full year CBS also produced some encouraging results. The company reported revenue of $14.09 billion, up 3 percent from $13.64 billion in 2011. Adjusted income increased to $3.49 billion from $3.16 billion. Operating income of $2.98 billion was up from $2.62 billion in 2011. All represented new highs for CBS.

One troubling area was publishing. Revenue decreased at CBS’s Simon & Schuster unit, to $215 million from $229 million in 2011. CBS attributed the drop to decreasing print book sales that could not be offset by increasing e-book sales.

CBS reported its financial results after the stock market closed. In after-hours trading, its stock fell 44 cents, to $42.50.

Read More..

In Japan, the Fax Machine Is Anything but a Relic

Kosuke Okahara for The New York Times

Yuichiro Sugahara, whose company delivers bento lunchboxes, mostly through fax orders.

TOKYO — Japan is renowned for its robots and bullet trains, and has some of the world’s fastest broadband networks. But it also remains firmly wedded to a pre-Internet technology — the fax machine — that in most other developed nations has joined answering machines, eight-tracks and cassette tapes in the dustbin of outmoded technologies.

Last year alone, Japanese households bought 1.7 million of the old-style fax machines, which print documents on slick, glossy paper spooled in the back. In the United States, the device has become such an artifact that the Smithsonian is adding two machines to its collection, technology historians said.

“The fax was such a success here that it has proven hard to replace,” said Kenichi Shibata, a manager at NTT Communications, which led development of the technology in the 1970s. “It has grown unusually deep roots into Japanese society.”

The Japanese government’s Cabinet Office says that almost 100 percent of business offices and 45 percent of private homes had a fax machine as of 2011.

Yuichiro Sugahara learned the hard way about his country’s deep attachment to the fax machine, which the nation popularized in the 1980s. A decade ago, he tried to modernize his family-run company, which delivers traditional bento lunchboxes, by taking orders online. Sales quickly plummeted.

Today, his company, Tamagoya, is thriving with the hiss and beep of thousands of orders pouring in every morning, most by fax, many with minutely detailed handwritten requests like “go light on the batter in the fried chicken” or “add an extra hard-boiled egg.”

“There is still something in Japanese culture that demands the warm, personal feelings that you get with a handwritten fax,” said Mr. Sugahara, 43.

Japan’s reluctance to give up its fax machines offers a revealing glimpse into an aging nation that can often seem quietly determined to stick to its tried-and-true ways, even if the rest of the world seems to be passing it rapidly by. The fax addiction helps explain why Japan, which once revolutionized consumer electronics with its hand-held calculators, Walkmans and, yes, fax machines, has become a latecomer in the digital age, and has allowed itself to fall behind nimbler competitors like South Korea and China.

“Japan has this Galápagos effect of holding on to some things they’re comfortable with,” said Jonathan Coopersmith, a technology historian who is writing a book on the machine’s rise and fall. “Elsewhere, the fax has gone the way of the dodo.”

In Japan, with the exception of the savviest Internet start-ups or internationally minded manufacturers, the fax remains an essential tool for doing business. Experts say government offices prefer faxes because they generate paperwork onto which bureaucrats can affix their stamps of approval, called hanko. Many companies say they still rely on faxes to create a paper trail of orders and shipments not left by ephemeral e-mail. Banks rely on faxes because, they say, customers are worried about the safety of their personal information on the Internet.

Even Japan’s largest yakuza crime syndicate, the Kobe-based Yamaguchi-gumi, has used faxes to send notifications of expulsion to members, the police say.

After the deadly earthquake and tsunami in northeastern Japan in 2011, there was a small boom in fax sales to replace machines that had been washed away. One of the hottest sellers is a model that is powered by batteries so it will keep working during power failures caused by natural disasters.

At Tamagoya, Mr. Sugahara has turned his company’s reliance on the fax and standard telephones into an art form. Every morning, orders for about 62,000 lunches pour in, about half by fax. Most of those lunches are cooked and put onto trucks even before the last order is taken. A small army of 100 fax and telephone operators carefully coordinate deliveries, and fewer than 60 lunches — or 0.1 percent — are wasted.

Hisako Ueno contributed reporting.

Read More..

In Japan, the Fax Machine Is Anything but a Relic

Kosuke Okahara for The New York Times

Yuichiro Sugahara, whose company delivers bento lunchboxes, mostly through fax orders.

TOKYO — Japan is renowned for its robots and bullet trains, and has some of the world’s fastest broadband networks. But it also remains firmly wedded to a pre-Internet technology — the fax machine — that in most other developed nations has joined answering machines, eight-tracks and cassette tapes in the dustbin of outmoded technologies.

Last year alone, Japanese households bought 1.7 million of the old-style fax machines, which print documents on slick, glossy paper spooled in the back. In the United States, the device has become such an artifact that the Smithsonian is adding two machines to its collection, technology historians said.

“The fax was such a success here that it has proven hard to replace,” said Kenichi Shibata, a manager at NTT Communications, which led development of the technology in the 1970s. “It has grown unusually deep roots into Japanese society.”

The Japanese government’s Cabinet Office says that almost 100 percent of business offices and 45 percent of private homes had a fax machine as of 2011.

Yuichiro Sugahara learned the hard way about his country’s deep attachment to the fax machine, which the nation popularized in the 1980s. A decade ago, he tried to modernize his family-run company, which delivers traditional bento lunchboxes, by taking orders online. Sales quickly plummeted.

Today, his company, Tamagoya, is thriving with the hiss and beep of thousands of orders pouring in every morning, most by fax, many with minutely detailed handwritten requests like “go light on the batter in the fried chicken” or “add an extra hard-boiled egg.”

“There is still something in Japanese culture that demands the warm, personal feelings that you get with a handwritten fax,” said Mr. Sugahara, 43.

Japan’s reluctance to give up its fax machines offers a revealing glimpse into an aging nation that can often seem quietly determined to stick to its tried-and-true ways, even if the rest of the world seems to be passing it rapidly by. The fax addiction helps explain why Japan, which once revolutionized consumer electronics with its hand-held calculators, Walkmans and, yes, fax machines, has become a latecomer in the digital age, and has allowed itself to fall behind nimbler competitors like South Korea and China.

“Japan has this Galápagos effect of holding on to some things they’re comfortable with,” said Jonathan Coopersmith, a technology historian who is writing a book on the machine’s rise and fall. “Elsewhere, the fax has gone the way of the dodo.”

In Japan, with the exception of the savviest Internet start-ups or internationally minded manufacturers, the fax remains an essential tool for doing business. Experts say government offices prefer faxes because they generate paperwork onto which bureaucrats can affix their stamps of approval, called hanko. Many companies say they still rely on faxes to create a paper trail of orders and shipments not left by ephemeral e-mail. Banks rely on faxes because, they say, customers are worried about the safety of their personal information on the Internet.

Even Japan’s largest yakuza crime syndicate, the Kobe-based Yamaguchi-gumi, has used faxes to send notifications of expulsion to members, the police say.

After the deadly earthquake and tsunami in northeastern Japan in 2011, there was a small boom in fax sales to replace machines that had been washed away. One of the hottest sellers is a model that is powered by batteries so it will keep working during power failures caused by natural disasters.

At Tamagoya, Mr. Sugahara has turned his company’s reliance on the fax and standard telephones into an art form. Every morning, orders for about 62,000 lunches pour in, about half by fax. Most of those lunches are cooked and put onto trucks even before the last order is taken. A small army of 100 fax and telephone operators carefully coordinate deliveries, and fewer than 60 lunches — or 0.1 percent — are wasted.

Hisako Ueno contributed reporting.

Read More..