Well: Ask Well: Does Yoga Build Strength?

Photo Credit Damon Winter/The New York Times

A

In general, the few available experiments involving yoga suggest that it leads to measurable but limited and patchy strength gains.

Consider the results of a 2012 study of premenopausal women who were randomly assigned to yoga or to a control group. The yoga group completed twice-weekly, 60-minute sessions of Ashtanga yoga (which consists of sequential, standardized postures), while the control group continued their normal activities. After eight months, the yoga practitioners had developed more powerful legs compared with at the study's start and with those of  the control group, but had not increased strength in other muscles or improved their cardiovascular fitness.

Similarly, in a 2013 study, 12 weeks of Bikram yoga (a variety that consists of other, specific poses done rapidly in a heated, saunalike space), enabled a group of young adults to dead-lift more weight on a barbell than they could at the start, but did not improve their hand-grip strength or any other measures of health and fitness.

Over all, yoga appears to be too gentle physically to be anyone's lone exercise. In one of the most interesting studies of the activity to date, experienced yoga enthusiasts performed their favorite type of yoga for an hour in a metabolic chamber that tracked their caloric usage and heart rate. The volunteers then sat quietly in the chamber and also walked on a treadmill there at a leisurely 2 miles per hour and a brisker 3 m.p.h. pace. In the end, the measurements showed that yoga was equivalent in energy cost to strolling at 2 m.p.h., an intensity of exercise that, the authors write, would "not meet recommendations for levels of physical activity for improving or maintaining health or cardiovascular fitness."

So if you downward dog, jog occasionally as well, and visit the gym to build full-body strength and wellness.

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Doctor and Patient: Throwing Money at the Past

Photo Credit Dario Lo Presti/Getty Images

Doctor and Patient

Dr. Pauline Chen on medical care.

The current physician training system, heavily subsidized by the federal government, has not produced doctors prepared to serve in a changing health care system and cannot account for billions of dollars in public funding each year, an exhaustive new report has concluded.

Compiled by a nonpartisan committee of 21 leading physicians, economists, health care administrators, nurses, physician assistants and a consumer representative, and published under the auspices of the Institute of Medicine, the report describes a remarkable lack of accountability and oversight that may be affecting patient care.

"Little is known," the committee writes, "about the management and effectiveness of the public's more than $15 billion annual investment in Graduate Medical Education" — the period of intensive clinical training physicians must undergo after medical school and before independent practice.

Among other remedies, the committee recommended freezing funding at current levels while siphoning off a portion to medical education research. That recommendation, among others, has roused fierce debate and high-minded harangues from medical and hospital organizations.

Although G.M.E. funding represents less than 2 percent of the Medicare budget, almost $10 billion was handed over to teaching hospitals in 2012, primarily in the Northeast. Some of them stand to lose significant amounts if the recommendations are adopted.

The American Medical Association, the American Hospital Association and the Association of American Medical Colleges have issued sharply critical statements, asserting that the recommendations will exacerbate what they predict will be a physician shortage. Other organizations, like the American Academy of Pediatrics and the American Academy of Family Physicians, contend that the report's recommendations may finally help bring medical education funding more in line with national health care needs.

The steady stream of official statements from these groups, with their varied and even contradictory takes, has created a Rashomon effect, obscuring the real issue at hand for all patients: a nearly complete absence of accountability and oversight in medical training programs that receive vast public funding.

Public financing of physician training began in 1965 with the creation of Medicare and Medicaid. Over the years, Medicare assumed responsibility for the bulk of funding, and lawmakers set the formulae determining who and how much should be paid.

Current G.M.E. funding is based on statutes enacted 20 or 30 years ago, when hospitals were the primary sites of physician training and patient care was centered on doctors. In the last decade, however, health care has shifted increasingly to ambulatory centers, outpatient clinics and team-based care that relies at least as heavily on nurses and physician assistants as it does on doctors.

The Institute of Medicine panel spent two years analyzing the extent to which the current financing system helps prepare physicians to provide "high-quality, patient-centered and affordable care." Ideally, the subsidies would be linked to how well trainees cared for patients and the extent to which they addressed not just a particular hospital's needs, but regional and national health care priorities.

Training programs that produced doctors who had better outcomes, eventually practiced in underserved areas or worked in specialties facing severe shortages would, for example, be eligible for more funding. But committee members were stymied in their efforts to answer even the most basic questions regarding the amount Medicare has contributed to individual G.M.E. programs and the effect of those contributions.

Teaching hospitals, the primary beneficiaries of Medicare G.M.E. funding over the years, have never had to account for anything more than the simple details necessary to calculate future funding. They routinely kept track of the total number of trainees in their programs, the trainees' salaries and benefits, and the percentage of Medicare patients cared for at their hospitals.

But the hospitals were under no obligation to Medicare to account for the quality of care provided by trainees, the places where their trainees eventually opened practices and the percentage of Medicare and Medicaid patients their graduates accepted into those practices.

Some of these training programs even lost track of how much Medicare money they received.

The committee tried to illuminate what it called "the black box of G.M.E. costs and benefits" by focusing on four representative academic medical centers and working closely with their G.M.E. officials. But they came up nearly empty-handed.

The committee's report acknowledges that even without hard data, the financial stability that public funding provides has allowed training programs to improve physician training and therefore the medical work force over the last fifty years. Real progress has been made in increasing the diversity and numbers of practicing physicians, improving trainee working conditions and curtailing their duty hours.

With financial stability in mind, the committee's recommendations emphasize a slow transition to a "performance-based system" of payment and no changes in the overall amount of Medicare spending for the next decade.

But current beneficiaries would probably receive less support, as the Medicare fund would be divided. An "operational" portion would be distributed to training programs according to a single, national per-resident trainee sum, thus eliminating the current funding formula that favors hospitals in regions that had the highest number of trainees nearly two decades ago and relies on an institution's unaudited report of nonstandardized cost data.

The other portion, one the committee calls "the transformational fund," would be reserved for financing research on new approaches to training. The hope is that this research will provide the data necessary to create a reliable performance-based payment system.

Whether or not the committee's recommendations go into effect is now in the hands of lawmakers. But whatever the outcome, the truth regarding how wisely public money has been used to train our doctors may never be known.

Correction: August 7, 2014
An article on Tuesday about a report that was critical of the United States' physician training system, Graduate Medical Education, misstated part of the name of one of the organizations supporting the report's recommendations. It is the American Academy of Family Physicians, not the American Association of Family Physicians.

A version of this article appears in print on 08/05/2014, on page D4 of the NewYork edition with the headline: Throwing Money at the Past.

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Well: Think Like a Doctor: Losing It

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

Photo Credit Anna Kovecses

The Challenge: A 55-year-old man loses the hair on his legs, loses weight and then loses his strength. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a diagnostic riddle. Below you will find the details of a case involving a retired state trooper who starts wasting away. Over a few weeks, he drops 30 pounds and grows so weak he has to use a walker to get around.

As usual, the first person to figure out the diagnosis will receive a signed copy of my book "Every Patient Tells a Story" and the pleasure of figuring out a case that stumped a bunch of doctors.

The Patient's Story

"When did you start shaving your legs?" the woman asked her husband of 20 years.

The couple sat on the porch of their rural Pennsylvania home enjoying the end of a beautiful day. Her husband, a retired state trooper, laughingly replied that he shaved them every Tuesday. But when he took a good look at the limbs emerging from his pants legs, he was surprised to note that they were as smooth as a model's.

"Have you lost some weight?" she added. He always weighed 172, he told her. But he got up and weighed himself on the bathroom scale: he was 160 pounds. The man was not sure what to make of these two wifely observations, but a couple of months later, when his weight continued to drift downward, he made an appointment to see his internist, Dr. William Oleksak.

The Doctor Visit

The patient had not had an appointment with his doctor in nearly two years, so when the doctor saw him that June day, he was shocked by the man's appearance. The retired trooper had always been a slender, fit and vigorous man. Not any more.

The doctor could see that the patient had lost a significant amount of weight. His face looked almost skeletal – the cheek bones and bones around his eyes were prominent as the fat that gave his face a good-natured roundness had melted away. Looking at him, Dr. Oleksak first thought that the man had some kind of cancer.

Although the patient considered himself a pretty healthy guy, he had several medical problems. First, he was a smoker – a pack and a half a day for 40 years. Because of that, he had some early atherosclerotic changes, or hardening of the arteries, in the blood vessels leading to his legs. It got so bad that a few years ago, he had to have one of the big vessels in his leg reopened so he could walk more than a few steps.

And when he had his colonoscopy at 50, his doctor had to cut out a few polyps. He was due for another colonoscopy to make sure they hadn't come back. He had been found to have celiac disease a while back, but he had not had symptoms for years. His thyroid was not quite as cooperative. It stopped working a decade earlier, and he had to take a medication for that every day. Most days, it was the only medicine he took.

Other than the patient's weight and hair loss, Dr. Oleksak could find nothing wrong upon examination. He told the patient he was going to send him for a colonoscopy and a chest X-ray and to get a few blood tests.

"Are you looking for cancer," the man's wife asked. He was, he told the couple, ready to answer any additional questions. There weren't any. The wife just nodded as if that's what she'd been thinking as well.

You can see the results of the blood tests here.

You can see the results of the imaging tests here.

A Summer of Testing

Those tests were the first of many for the patient that summer. The chest X-ray was normal, except for the changes caused by his years of smoking cigarettes. The colonoscopy did not show cancer – just a couple of hemorrhoids. He had a CT scan of his chest, abdomen and pelvis. Normal.

Tube after tube of the blood he gave did not seem to show much. He had a low white blood cell count and mild anemia. When rechecked a couple of weeks later, the count of white blood cells – the warriors of our immune system – was even lower, so Dr. Oleksak sent the patient to a hematologist.

That doctor was worried about cancer, too. She sent off several blood tests, and when they did not tell her what she needed to know, she took a piece of his bone marrow to make sure he did not have cancer there. He didn't.

She did find something that could account for the patient's symptoms. His vitamin B12 level was low. Was that why he felt so bad, he asked the doctor. Could be. The bone marrow needs B12 to make blood. And low B12 can cause weakness as well. It seemed the right answer, yet even taking huge doses of the vitamin did not seem to help.

You can see more of the patient's blood test results here.

And you can see the results of the bone marrow analysis here.

Falling Down

The patient continued to lose weight, drifting from the 160s down to the 140s. It seemed as if his strength was slipping away with the pounds. He was tired all the time; he needed to nap every afternoon.

And then he started falling. He knew he was in deep trouble one morning when he fell as he hurried out of his car to get into the grocery store during a rainstorm. His legs gave out, and he ended up face down on the wet pavement. He had to crawl back to the car to pull himself up.

This time, when he went back to Dr. Oleksak, his exam was not normal. The way doctors test for strength is pretty crude. We pit the strength of our arms against the strength of the patient's arms and legs. For a middle-aged man who keeps pretty active, there has to be significant weakness for the test to show anything at all. But when Dr. Oleksak held the patient's thigh down with one hand, the man could barely lift his leg off the table. And once he had raised it off the table, it was a struggle for him to keep it there.

Weakness can be caused by a problem with the muscles or a problem with the nerves that power them. And distinguishing between these two required a level of expertise that was not found in the rural Pennsylvania town where Dr. Oleksak practiced. He would have to send the patient some 50 miles away to the University of Pittsburgh Medical Center. Dr. Oleksak referred the patient to Dr. David Lacomis, a neurologist he had heard of who specialized in nerve and muscle diseases.

A Specialist Weighs In

The patient was sitting on the exam table in a flimsy cloth gown when Dr. Lacomis entered the room. He immediately made note of the wasted appearance of the patient and his hairless legs. He heard the patient's story and then examined him, focusing on the man's nerves and muscles. He was clearly quite weak. He could not get up from a chair unless he used his arms. He could not walk on his tiptoes or his heels.

Still, the patient's weakness and loss of muscle seemed to be everywhere.

Whatever the patient had, it had to be something that affected the whole body and not just one part or side. Was it a disease of the nervous system? Dr. Lacomis didn't think so, and subsequent testing of the man's nerves confirmed it.

Solving the Mystery

If not the nerves, then what?

That was the question Dr. Lacomis put to himself, and he eventually figured out what was causing this man's weakness and weight loss and why it had occurred. Can you?

Post your answers below in the comments section. The first person to answer both questions — What was the cause of this man's symptoms, and why did he get it? — will receive a copy of my book and that warm, wonderful feeling you get from solving a mystery.

Rules and Regulations: Post your questions and diagnosis in the comments section. The correct answer will appear on Friday on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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Well: Why We Should Know the Price of Medical Tests

Photo Credit Stuart Bradford

One of the common arguments against mandating or providing upfront prices for medical tests and procedures is that American patients are not very skilled consumers of health care and will assume high prices mean high quality.

A study released Monday in the journal Health Affairs suggests we are smarter than that.

The insurer WellPoint provided members who had scheduled an appointment for an elective magnetic resonance imaging test with a list of other scanners in their area that could do the test at a lower price. The alternative providers had been vetted for quality, and patients were asked if they wanted help rescheduling the test somewhere that delivered "better value."

Fifteen percent of patients agreed to change their test to a cheaper center. "We shined a light on costs," said Dr. Sam Nussbaum, WellPoint's chief medical officer. "We acted as a concierge and engaged consumers giving them information about cost and quality."

The program resulted in a $220 cost reduction (18.7 percent) per test over the course of two years, said Andrea DeVries, the director of payer and provider research at HealthCore, a subsidiary of WellPoint, which conducted the study. It compared the costs of scanning people in the WellPoint program with those of people in plans that did not offer such services.

Better still, Dr. Nussbaum said, the exercise in price transparency had a ripple effect: Hospitals in areas with the program lowered their prices too, because "they were beginning to lose patient referrals."

Tests like M.R.I.s show some of the widest price variation in American medicine, studies show, often varying by a factor of 10 even in the same city. Hospital scanners tend to charge the highest prices, a practice that in part reflects higher overhead but also reflects hospitals' power in a market. Physicians affiliated with a hospital often refer to the hospital's radiology department. In some cases, this is because hospitals require them to do so; in others, it is a matter of familiarity and convenience because the results will turn up more rapidly on their office computers.

After two years of the price transparency program, price variation between hospital and nonhospital facilities was reduced by 30 percent in areas where it was implemented, the Health Affairs study found.

The study also suggests that patients are more vigilant custodians of cost than their doctors. Several years ago, WellPoint gave physicians similar price information on scanning providers in their practice area but did not see a change in referral patterns, Dr. Nussbaum said.

The newer study did not delve into patient motivations. Some patients probably chose the cheaper scans because their insurance plan required a 20 percent copay, so it made a huge different if the scan was billed at $300 or $3,000. But others had probably already met their annual out-of-pocket maximum, so choosing the cheaper site was merely a matter of principle, Dr. DeVries said.

From experience, I can say that shopping for scans is not always easy. When I learned the price a hospital was charging for an M.R.I. a neurologist had recommended for one of my children, I scheduled the test at an outside center that was two-thirds cheaper. The upside was much better value for my health care dollar. The downside: The hospital and the radiology center would not communicate with each other, though they could have easily done so electronically. I had to go to the center and pick up a disk with the scan and carry it to the hospital neurologist.

Join the Conversation: The New York Times's Paying Till it Hurts Facebook Group is a forum for conversation, analysis and insight into health care pricing and costs in the United States.

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Well: Women Pace Marathons Better Than Men Do

Photo Credit Ryan Pierse/Getty Images

Phys Ed

Gretchen Reynolds on the science of fitness.

During marathons, women pace themselves more evenly than male competitors do, according to a study of thousands of racers. The results provide unexpected insights into some of the physical and emotional differences between male and female runners, and also how both genders might improve their race times by noting how the other one runs.

Anyone who has competed in or seen a marathon knows that maintaining a steady speed throughout the 26.2 miles is advisable. People who start the race at a fast pace generally have to slow and even walk or zombie shuffle as the race goes on.

A few small studies and many anecdotal observations had suggested that men were more apt than women to wind up slowing. But no large-scale examination of marathon racers had confirmed that.

So for the new study, which was published last month in Medicine & Science in Sports & Exercise, researchers at Marquette University in Milwaukee; the Mayo Clinic in Rochester, Minn.; and other institutions began by gathering data about the finishers at 14 marathons. The races included prominent ones, such as the Chicago and Disney marathons, and smaller events. Some were conducted in warm weather, others in chilly conditions, with terrain ranging from hilly to pancake-flat.

The researchers wound up with information about 91,929 marathon participants, almost 42 percent of them women. The data covered all adult age groups and a wide range of finishing times.

They then compared each runner's time at the midpoint of his or her race with his or her time at the finish, a simple method of broadly determining pace. If someone covers the second half of a race in about the same time as the first, then his or her pace is relatively even, with little slowing. (Only rarely does someone speed up in the second half of a race, running what is known as a negative split.)

As it turned out, men slowed significantly more than women racers did. In aggregate, men covered the second half of the marathon almost 16 percent slower than they ran the first half. Women as a group were about 12 percent slower in the second half.

Burrowing deeper into the data, the scientists categorized runners as having slowed markedly if their second-half times were at least 30 percent slower than their first-half splits. In concrete terms, a racer covering the first half of the course in two hours and the second in 2 hours 36 minutes or more would have slowed markedly.

Far more men than women fell into the markedly slower category, with about 14 percent of the male finishers qualifying versus 5 percent of the women.

This disparity in race pacing held true in all age groups and finishing times, the researchers found, even among the fastest runners. The difference, however, was most pronounced at the back of the pack. There, female runners were much more likely than men to steadily maintain the same, less hurried pace throughout.

Wondering to what extent experience might affect the runners' pacing, the researchers next used a public database to gather the racing histories of 2,929 of the runners. Using this data to adjust for marathon experience, the researchers found that men, however many marathons they had completed, were still more likely than equally experienced women to slow during the second half of a race.

The study was not designed to determine why men more frequently fade during marathons. But the reasons are likely to be physiological and psychological, said Sandra Hunter, a professor of exercise science at Marquette University and the senior author of the study.

"We know that at any given exercise intensity, men will burn a greater percentage of carbohydrates for fuel than women," Dr. Hunter said, and women will use more fat. Our bodies, male and female, contain considerably more fat than stored carbohydrates. "So men typically run out of fuel and bonk or hit the wall earlier than women do," Dr. Hunter says.

They are also more prone psychologically to adopt what Dr. Hunter terms a "risky strategy" in their early pacing. "They start out fast and just hope they can hold on," she says.

Interestingly, she continues, that strategy can sometimes pay off in a swifter finishing time. "It's not necessarily a bad thing" to push yourself at the start of a marathon, she says, if you have not catastrophically overestimated your capabilities.

Similarly, she points, out, an evenly paced race is not a well-paced one, "if you run slower than you were capable of running."

The message of the study, then, would seem to be that an approach to marathon pacing that borrows something from men and women might be ideal.

"Maybe go a bit harder than you think you can" in training, Dr. Hunter said, aiming to calibrate what your actual fastest sustainable pace is. Then stick with it during the event, even if your training partners tear away like rabbits at the start. You'll reel them in.

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Doctor and Patient: Throwing Money at the Past

Photo Credit Rachel Denny Clow/Corpus Christi Caller-TImes, via Associated Press

The current physician training system, heavily subsidized by the federal government, has not produced doctors prepared to serve in a changing health care system and cannot account for billions of dollars in public funding each year, an exhaustive new report has concluded.

Compiled by a nonpartisan committee of 21 leading physicians, economists, health care administrators, nurses, physician assistants and a consumer representative, and published under the auspices of the Institute of Medicine, the report describes a remarkable lack of accountability and oversight that may be affecting patient care.

"Little is known," the committee writes, "about the management and effectiveness of the public's more than $15 billion annual investment in Graduate Medical Education" — the period of intensive clinical training physicians must undergo after medical school and before independent practice.

Among other remedies, the committee recommended freezing funding at current levels while siphoning off a portion to medical education research. That recommendation, among others, has roused fierce debate and high-minded harangues from medical and hospital organizations.

Although G.M.E. funding represents less than 2 percent of the Medicare budget, almost $10 billion was handed over to teaching hospitals in 2012, primarily in the Northeast. Some of them stand to lose significant amounts if the recommendations are adopted.

The American Medical Association, the American Hospital Association and the Association of American Medical Colleges have issued sharply critical statements, asserting that the recommendations will exacerbate what they predict will be a physician shortage. Other organizations, like the American Academy of Pediatrics and the American Association of Family Physicians, contend that the report's recommendations may finally help bring medical education funding more in line with national health care needs.

The steady stream of official statements from these groups, with their varied and even contradictory takes, has created a Rashomon effect, obscuring the real issue at hand for all patients: a nearly complete absence of accountability and oversight in medical training programs that receive vast public funding.

Public financing of physician training began in 1965 with the creation of Medicare and Medicaid. Over the years, Medicare assumed responsibility for the bulk of funding, and lawmakers set the formulae determining who and how much should be paid.

Current G.M.E. funding is based on statutes enacted 20 or 30 years ago, when hospitals were the primary sites of physician training and patient care was centered on doctors. In the last decade, however, health care has shifted increasingly to ambulatory centers, outpatient clinics and team-based care that relies at least as heavily on nurses and physician assistants as it does on doctors.

The Institute of Medicine panel spent two years analyzing the extent to which the current financing system helps prepare physicians to provide "high-quality, patient-centered and affordable care." Ideally, the subsidies would be linked to how well trainees cared for patients and the extent to which they addressed not just a particular hospital's needs, but regional and national health care priorities.

Training programs that produced doctors who had better outcomes, eventually practiced in underserved areas or worked in specialties facing severe shortages would, for example, be eligible for more funding. But committee members were stymied in their efforts to answer even the most basic questions regarding the amount Medicare has contributed to individual G.M.E. programs and the effect of those contributions.

Teaching hospitals, the primary beneficiaries of Medicare G.M.E. funding over the years, have never had to account for anything more than the simple details necessary to calculate future funding. They routinely kept track of the total number of trainees in their programs, the trainees' salaries and benefits, and the percentage of Medicare patients cared for at their hospitals.

But the hospitals were under no obligation to Medicare to account for the quality of care provided by trainees, the places where their trainees eventually opened practices and the percentage of Medicare and Medicaid patients their graduates accepted into those practices.

Some of these training programs even lost track of how much Medicare money they received.

The committee tried to illuminate what it called "the black box of G.M.E. costs and benefits" by focusing on four representative academic medical centers and working closely with their G.M.E. officials. But they came up nearly empty-handed.

The committee's report acknowledges that even without hard data, the financial stability that public funding provides has allowed training programs to improve physician training and therefore the medical work force over the last fifty years. Real progress has been made in increasing the diversity and numbers of practicing physicians, improving trainee working conditions and curtailing their duty hours.

With financial stability in mind, the committee's recommendations emphasize a slow transition to a "performance-based system" of payment and no changes in the overall amount of Medicare spending for the next decade.

But current beneficiaries would probably receive less support, as the Medicare fund would be divided. An "operational" portion would be distributed to training programs according to a single, national per-resident trainee sum, thus eliminating the current funding formula that favors hospitals in regions that had the highest number of trainees nearly two decades ago and relies on an institution's unaudited report of nonstandardized cost data.

The other portion, one the committee calls "the transformational fund," would be reserved for financing research on new approaches to training. The hope is that this research will provide the data necessary to create a reliable performance-based payment system.

Whether or not the committee's recommendations go into effect is now in the hands of lawmakers. But whatever the outcome, the truth regarding how wisely public money has been used to train our doctors may never be known.

A version of this article appears in print on 08/05/2014, on page D4 of the NewYork edition with the headline: Throwing Money at the Past .

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Well: Picking Nursing Home Shouldn’t Be Trial and Error

Photo Credit Ellen Weinstein

It took three tries before Leslie Reid-Green found a suitable nursing home for her 88-year-old mother, Bella Solomon, who has advanced dementia.

The first home her mother moved into "was dreary and gray, in an old hospital," Ms. Reid-Green said. "The staff wasn't very nice, my mother hated it, and it was far from where I live." Frequent visits were an exhausting challenge.

The second home was "a newer and much nicer facility, though still more like a hospital than a home." But the staff was unable to deal with her mother's aggressive behavior.

Within weeks, the home sent her to a hospital, where she was given antipsychotic medication. She was returned to the nursing home, but that stay lasted just a week or so, followed by three months in a psychiatric hospital. Ms. Solomon's behavior issues were finally stabilized, and she returned again to the nursing home.

After another hospitalization for an infection, she was placed on hospice care. The staff started ignoring her and failed to treat her conjunctivitis, Ms. Reid-Green said. Finally in January, after Ms. Solomon had been on a waiting list for a year and a half, a bed became available at yet another facility, the Parker Home in Piscataway, N.J., closer to Ms. Reid-Green's home in Flemington.

Despite costing significantly less than the other two homes, "Parker has a homier atmosphere, an attentive and pleasant staff, and a more serene environment," Ms. Reid-Green said.

"They take her outside, the other residents seem content, there's no smell of urine in the hallways, the residents are treated with respect, and even aides from other wings say hello to her by name."

Dogs are brought in for pet therapy, and children visit the residents. Ms. Solomon no longer needs antipsychotics, which are poorly metabolized by older adults and often overused.

"The take-home message: More expensive is not necessarily better," Ms. Reid-Green said.

Her experience, and similar ones reported by other families, emphasize the importance of thorough footwork well in advance of the need to place a loved one in a nursing home.

Nearly half of the residents in nursing homes are there because their dementia, primarily Alzheimer's disease, has reached a point where caring for them at home has become unsustainable. They may wander from home, not knowing how to return or even who they are, or awaken many times a night, causing mayhem and exhausting their caregivers. Falls, fires, poisonings, self-injuries and physical aggression often become ever-present dangers.

The important message to families: It's not a sign of weakness — more likely a sign of strength — to move a loved one with advancing dementia to a nursing home. But it isn't easy to find a place that offers the services and environment that the patient needs.

Simply having a specialized dementia unit is not enough: The quality and extent of services may still vary widely.

"There are different levels of dementia, and people with it have different needs," Joanna R. Leefer, the author of "Almost Like Home," a guide to choosing a nursing home, said in an interview.

"Although most nursing homes now have a dementia wing, they're not all good," she said. "I had to move my mother three times before I found the right place for her where my father, who didn't have dementia, could live, too."

She found one home, for example, that was pleasant enough. Yet "people in the dementia unit primarily sat around," Ms. Leefer said. "My mother needed a lot of physical activity and space to walk around."

Ms. Leefer recommends looking for a place with different levels of dementia care. As the disease progresses, a resident's needs will change. The nursing home must be able to adapt to those changes.

Some people with dementia benefit from stimulation, but overstimulation, including a noisy environment, can make others agitated and aggressive. Some homes rely too heavily on sedatives or antipsychotic medications to calm aggressive behavior, experts say.

"Agitation can be triggered by factors like pain, anxiety, hunger or the need to toilet," Ms. Leefer wrote. "Before assuming that sedatives are the only solution, a doctor should assess any possible underlying factors that might be triggering or aggravating a patient's symptoms."

She lists six crucial questions to ask when assessing a nursing home for someone with dementia.

■ Is the dementia unit large enough so that the resident will not feel confined?

■ Does it offer activities appropriate for the person's intellectual abilities?

■ Does it have a positive environment — colorful, but not overly stimulating or confusing?

■ Are music and singing included in the activities? "Many residents with advanced dementia still sing or play musical instruments, even if they can no longer express themselves in other ways," Ms. Leefer said.

■ Is the staff trained to handle patients with dementia and Alzheimer's? How does the staff deal with patients who act out?

■ Are residents in the dementia wing kept clean and well dressed, and treated with the same respect as those in other parts of the facility?

One of the biggest challenges involves patients who wander. While some facilities lock the doors to residents' rooms (or even tie them to their beds), others use a more humane approach: "Wander guards" worn by patients set off an alarm when they stray too far. Of course, all doors to the outside must be locked at all times.

The Alzheimer's Association offers an extensive checklist for finding an acceptable nursing home. The list describes desirable characteristics of the building and its environment, including the facility's services, room designs, meal arrangements and recreational activities. It discusses the appearance of residents, their access to trained staff, the staff's demeanor with patients, and, of course, location and costs.

But no matter how good a home might be, experts say that continued family support and involvement are critical to assuring good patient care. Plan to spend several hours with the patient on the day of admission, when anger, hurt and acting out are likely. Visit often on different days and times, and get to know the staff.

Finally, if the facility you choose does not offer personalized music therapy, which can reawaken "lost" memories and emotions in dementia patients, encourage the staff to watch "Alive Inside," an inspiring documentary available on iTunes for $14.99.

This is the second of two columns on choosing a nursing home.

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Well: The Joy of Becoming a Veterinarian

This article is from a special issue of Education Life that looks at professional schools.

Set aside the biology and chemistry for a moment to recall why you want to be a vet.

The Society for Veterinary Medicine and Literature wants to help students and vets "grasp the nonmedical aspects of their chosen profession," says Elizabeth Stone, dean of the Ontario Veterinary College at the University of Guelph. "Literature can help them retain their sense of joy about becoming/being a veterinarian."

Dr. Stone and her society co-founder, Hilde Weisert, first turned the narrative medicine trend into pet-friendly pedagogy at North Carolina State, where they taught an elective that used stories and poems about the animal kingdom to debate ethics and the life-or-death decisions unique to vets, as well as to help students navigate relationships with pet owners and speechless patients. No small task, as Ms. Weisert illustrates in her poem "Diagnosis."

Archie trembles — in pain, or fear?
No words, but the vet's hands hear.

Besides hosting conferences and teaching, Dr. Stone and Ms. Weisert have edited "Animal Companions, Animal Doctors, Animal People," an anthology that leads off with a Mark Doty poem, "Golden Retrievals," that is also read each year at the Ontario college's welcoming ceremony for new students.

Golden Retrievals

Fetch? Balls and sticks capture my attention
seconds at a time. Catch? I don't think so.
Bunny, tumbling leaf, a squirrel who's — oh
joy — actually scared. Sniff the wind, then

I'm off again, muck, pond, ditch, residue
of any thrillingly dead thing. And you?
Either you're sunk in the past, half our walk,
thinking of what you never can bring back,

or else you're off in some fog concerning
— tomorrow, is that what you call it? My work:
to unsnare time's warp (and woof!), retrieving,
my haze-headed friend, you. This shining bark,
a Zen master's bronzy gong, calls you here,
entirely, now: bow-wow, bow-wow, bow-wow.

(From "Fire to Fire: New and Selected Poems," HarperCollins, 2008)

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The New Old Age: Many Problems Lead to Thoughts of Suicide, Study Finds

Photo Credit Henri Silberman/Photodisc

Older adults contemplating suicide do not cite depression as the primary reason, according to research presented recently at the annual meeting of the American Association for Geriatric Psychiatry. More often, they blame their struggles with illness, disability, financial concerns, family difficulties and bereavement for their suicidal thoughts.

All of these factors may contribute to depression. But the finding suggests that treatment of depression alone may not be sufficient to reduce suicide rates among the elderly.

"We need a broader approach that encompasses these psychosocial concerns," said Dr. Gary Kennedy, director of geriatric psychiatry at Montefiore Medical Center in the Bronx and a lead investigator with the New York City Neighborhood and Mental Health Study.

As my colleague Paula Span wrote last year, suicide rates among people 65 years and older are higher than the national average, and elderly white men — especially those over the age of 85 — have the highest rates of all. Previous research suggests that up to 87 percent of seniors who end up taking their lives suffer from major depression.

But those statistics were drawn from research on older people after they had actually committed suicide. The new report focused on seniors who acknowledged thinking of it but chose not to follow through. It asked seniors directly what they were feeling, rather than relying on retrospective efforts to understand their mental state.

In the new study, Dr. Kennedy and his colleagues screened nearly 3,500 New Yorkers between age 65 and 75 for symptoms of depression such as apathy, hopelessness, negativity and reduced appetite. One of the questions asked was, "In the last two weeks, have you felt at times that you would be better off dead or harming yourself in some way?"

Dr. Kennedy called every survey participant who responded positively to that question and asked a series of follow-up questions of those who were willing to talk. (Some weren't.) The answers allowed him to identify a sub-group who had clearly contemplated suicide — 60 people in all.

He then tallied the reasons these people cited for their despair. About three-quarters blamed illness, financial concerns, pain, family difficulties, bereavement or other problems, such as landlords who harassed them. Depression was named by 25 percent of them.

Dr. Kennedy also asked this group what convinced them to put aside suicidal thoughts. Forty older adults said family relationships were a definitive factor; twenty referred to their faith. When the doctor inquired about the adequacy of social support, 33 seniors said they were satisfied, while 27 said they were not.

Dr. Charles Reynolds, a professor of geriatric psychiatry at the University of Pittsburgh Medical Center who wasn't involved in this research, discounted the notion that depression isn't involved in older adults' thoughts of suicide. In the vast majority of cases, he said, thoughts of suicide signal a significant distortion of mood.

Yet Dr. Reynolds agreed that focusing on depression alone is not sufficient for older adults who might be mulling taking their own lives.

"It's only when we take context — the kinds of issues the person is struggling with — into account that we can arrive at a sense of why the person is so distressed and how we can be helpful," he said.

Correction: August 1, 2014
An earlier version of this post referred incorrectly to the number of seniors in a recent study who said they were satisfied with the social support they received. Twenty-seven, not 27 percent, said they were not.

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Well: Bothered by a ‘Gummy Smile’

Photo Images of study subjects before, at left, and after receiving Botox treatments to correct their "gummy smile," which was defined by the study as two or more millimeters of "gingival exposure upon smiling."Credit Aesthetic Surgery Journal

Susanna Miller-Pence's teeth weren't the problem; her gums were. When she smiled, her upper lip stretched up so high that a ribbon of pinkish gum was exposed, giving her a so-called "gummy smile." She hated it.

"The doctor explained that my gums were longer than my teeth, so the dimensions weren't right," said Ms. Miller-Pence, 52, a psychoanalyst living in San Luis Obispo, Calif.

Fifteen years ago, she had a gingivectomy, an operation to remove some of the extra gum tissue. A month later, she was grinning broadly. "Now everyone comments on my smile," she said.

Gummy smiles occur for a variety of reasons, most commonly a short upper lip, excessive gum tissue or small teeth, all of which are genetic. According to Dr. Stan Heifetz, a cosmetic dentist in New York and White Plains whose office treated Ms. Miller-Pence, ideal smiles show up only to about two millimeters of gum. "Anything over three to four millimeters of gum showing starts to look 'gummy,' " he said.

Studies have been done with dentists, plastic surgeons, dermatologists and regular folk to assess smiles. Most everyone agreed that two millimeters or less of gum tissue showing was the level where most participants thought the smile looked normal. Participants started noticing the gum tissue at three to four millimeters, and thinking that too much gum tissue was showing at more than four millimeters, Dr. Heifetz said.

Doctors who specialize in cosmetic procedures estimate that about 14 percent of women and 7 percent of men have excessive gingival exposure when smiling.

"I believe the incidence is probably higher than we think, but we specialists just see and count the ones we treat, which are on the low side since not many people come to the doctor and ask about treatments for this," said Dr. Jessica Suber, an attending physician in plastic and reconstructive surgery at Southern Ohio Medical Center in Portsmouth. "It's something a lot of patients aren't aware of."

It's hard to know how many operations are done annually to correct a gummy smile; many patients combine it with other medical and aesthetic treatments. According to data from the American Dental Association Health Policy Institute, 569,160 gingivectomies were performed in 2005-6, the most recent years available.

In the past, surgery was the main treatment option, but that is often costly and painful. Doctors sever the muscles that elevate the upper lip so it can no longer rise as high, or they do a crown lengthening procedure that cuts away gum tissue so the crown appears longer.

In extreme cases, they might perform orthognathic surgery, which repositions the upper jaw if it sticks out too much. But this can be complicated and can take up to two years to complete, Dr. Heifetz said. Laser therapy is also sometimes used.

Now people are going another route: onabotulinumtoxinA, otherwise known as Botox.

For the last few years, dentists have been injecting Botox into the upper lip "elevator" muscles. It paralyzes the muscles, inhibiting contraction of the upper lip when smiling to prevent the gummy smile.

In contrast to surgery, Botox is quick and easy, doctors who do the procedure say.

A March 2014 study in Aesthetic Surgery Journal found that off-label use of Botox was a safe and effective procedure for gummy smile, albeit one that lasts only three to four months for the average patient, confirming the findings of an earlier report in the American Journal of Orthodontics and Dentofacial Orthopedics. The price is also more appealing than surgery: Botox costs around $350 (depending on the part of the country you are in and the doctor you see). Ms. Miller-Pence said she paid about $15,000 for surgery and crowns, which was not covered by insurance.

Botox goes directly into the lip tissue, so there's almost no risk of digesting it, said Dr. Peter Taub, a plastic and reconstructive surgeon at Mount Sinai Hospital in New York.

Stephanie McCarrell, a nurse anesthetist in Tampa, Fla.,says she has received Botox three times for her gummy smile, which has always bothered her.

"When I was a girl, the other kids made fun of me," said Ms. McCarrell, 36. "It really bothered me. I would smile without my teeth, just a closemouthed smile."

A few days after her injection, her upper lip had dropped and her gums were less visible, she said.

But Botox works only if the problem is in the lips, not the bone. And doctors have to be careful not to overinject the muscles, or they could create an unnatural look.

As Dr. Ariel Ostad, a cosmetic dermatologist in New York, said, "A little bit too much, and you really inactivate those muscles and when you smile, you smile crooked."

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