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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Well: Statins May Speed Wound Healing

Statins, the widely used cholesterol-lowering drugs, may have a role in surgical wound healing, a new analysis suggests.

The review, published in The Annals of Thoracic Surgery, covered 20 studies of statins and surgical wound healing. They demonstrated various mechanisms by which statins can lower inflammation, improve the mechanical strength of a healing wound, promote the growth of blood vessels and reduce healing time.

Most were animal or laboratory tissue studies, but two were studies in humans. In one, a retrospective study of 10,782 patients having hernia surgery, statins showed no beneficial effect, but the study failed to account for the use of blood-thinning drugs, which may have affected the results. The other, in six human volunteers, showed that statins can reduce the activity of one of the mediators of inflammation — white blood cell production — without affecting its beneficial function in healing.

The lead author of the review, Dr. Gerard J. Fitzmaurice, a cardiac surgeon at Our Lady's Children's Hospital in Dublin, said that most cardiac patients were already on statins before surgery, and that the drugs were extremely safe.

"The caveat here is that the majority of this is animal research," he said. "But a human randomized trial is now merited to properly answer the question. If statins are beneficial, it could be a big progression in wound management."

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Well: Running 5 Minutes a Day Has Long-Lasting Benefits

Phys Ed

Gretchen Reynolds on the science of fitness.

Running for as little as five minutes a day could significantly lower a person's risk of dying prematurely, according to a large-scale new study of exercise and mortality. The findings suggest that the benefits of even small amounts of vigorous exercise may be much greater than experts had assumed.

In recent years, moderate exercise, such as brisk walking, has been the focus of a great deal of exercise science and most exercise recommendations. The government's formal 2008 exercise guidelines, for instance, suggest that people should engage in about 30 minutes of moderate exercise on most days of the week. Almost as an afterthought, the recommendations point out that half as much, or about 15 minutes a day of vigorous exercise, should be equally beneficial.

But the science to support that number had been relatively paltry, with few substantial studies having carefully tracked how much vigorous exercise is needed to reduce disease risk and increase lifespan. Even fewer studies had looked at how small an amount of vigorous exercise might achieve that same result.

So for the new study, published Monday in The Journal of the American College of Cardiology, researchers from Iowa State University, the University of South Carolina, the Pennington Biomedical Research Center in Baton Rouge, La., and other institutions turned to a huge database maintained at the Cooper Clinic and Cooper Institute in Dallas.

For decades, researchers there have been collecting information about the health of tens of thousands of men and women visiting the clinic for a check-up. These adults, after completing extensive medical and fitness examinations, have filled out questionnaires about their exercise habits, including whether, how often and how speedily they ran.

From this database, the researchers chose the records of 55,137 healthy men and women ages 18 to 100 who had visited the clinic at least 15 years before the start of the study. Of this group, 24 percent identified themselves as runners, although their typical mileage and pace varied widely.

The researchers then checked death records for these adults. In the intervening 15 or so years, almost 3,500 had died, many from heart disease.

But the runners were much less susceptible than the nonrunners. The runners' risk of dying from any cause was 30 percent lower than that for the nonrunners, and their risk of dying from heart disease was 45 percent lower than for nonrunners, even when the researchers adjusted for being overweight or for smoking (although not many of the runners smoked). And even overweight smokers who ran were less likely to die prematurely than people who did not run, whatever their weight or smoking habits.

As a group, runners gained about three extra years of life compared with those adults who never ran.

Remarkably, these benefits were about the same no matter how much or little people ran. Those who hit the paths for 150 minutes or more a week, or who were particularly speedy, clipping off six-minute miles or better, lived longer than those who didn't run. But they didn't live significantly longer those who ran the least, including people running as little as five or 10 minutes a day at a leisurely pace of 10 minutes a mile or slower.

"We think this is really encouraging news," said Timothy Church, a professor at the Pennington Institute who holds the John S. McIlHenny Endowed Chair in Health Wisdom and co-authored the study. "We're not talking about training for a marathon," he said, or even for a 5-kilometer (3.1-mile) race. "Most people can fit in five minutes a day of running," he said, "no matter how busy they are, and the benefits in terms of mortality are remarkable."

The study did not directly examine how and why running affected the risk of premature death, he said, or whether running was the only exercise that provided such benefits. The researchers did find that in general, runners had less risk of dying than people who engaged in more moderate activities such as walking.

But "there's not necessarily something magical about running, per se," Dr. Church said. Instead, it's likely that exercise intensity is the key to improving longevity, he said, adding, "Running just happens to be the most convenient way for most people to exercise intensely."

Anyone who has never run in the past or has health issues should, of course, consult a doctor before starting a running program, Dr. Church said. And if, after trying for a solid five minutes, you're just not enjoying running, switch activities, he added. Jump rope. Vigorously pedal a stationary bike. Or choose any other strenuous activity. Five minutes of taxing effort might add years to your life.

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Well: Rustle, Tingle, Relax: The Compelling World of A.S.M.R.

A few months ago, I was on a Manhattan-bound D train heading to work when a man with a chunky, noisy newspaper got on and sat next to me. As I watched him softly turn the pages of his paper, a chill spread like carbonated bubbles through the back of my head, instantly relaxing me and bringing me to the verge of sweet slumber.

It wasn't the first time I'd felt this sensation at the sound of rustling paper — I've experienced it as far back as I can remember. But it suddenly occurred to me that, as a lifelong insomniac, I might be able to put it to use by reproducing the experience digitally whenever sleep refused to come.

Under the sheets of my bed that night, I plugged in some earphones, opened the YouTube app on my phone and searched for "Sound of pages." What I discovered stunned me.

There were nearly 2.6 million videos depicting a phenomenon called autonomous sensory meridian response, or A.S.M.R., designed to evoke a tingling sensation that travels over the scalp or other parts of the body in response to auditory, olfactory or visual forms of stimulation.

The sound of rustling pages, it turns out, is just one of many A.S.M.R. triggers. The most popular stimuli include whispering; tapping or scratching; performing repetitive, mundane tasks like folding towels or sorting baseball cards; and role-playing, where the videographer, usually a breathy woman, softly talks into the camera and pretends to give a haircut, for example, or an eye examination. The videos span 30 minutes on average, but some last more than an hour.

For those not wired for A.S.M.R. — and even for those who, like me, apparently are — the videos and the cast of characters who produce them — sometimes called "ASMRtists" or "tingle-smiths" — can seem weird, creepy or just plain boring. (Try pitching the pleasures of watching a nerdy German guy slowly and silently assemble a computer for 30 minutes.)

Two of the most well-known ASMRtists, Maria of GentleWhispering (more than 250,700 subscribers) and Heather Feather (more than 146,500 subscribers), said that although they sometimes received lewd emails and requests, many of their followers reached out to them with notes of gratitude for the relief from anxiety, insomnia and melancholy that their videos provided.

Some say the mundane or monotonous quality of the videos lulls us into a much-needed state of serenity. Others find comfort in being the sole focus of the A.S.M.R. actor's tender affection and care. Or perhaps the assortment of sounds and scenarios taps into pleasing childhood memories. I grew up falling asleep hearing the sounds from my father's home office: A computer engineer, he was continually sorting through papers, tapping keys  and assembling and disassembling PCs and MACs.

Dr. Carl W. Bazil, a sleep disorders specialist at Columbia University, says A.S.M.R. videos may provide novel ways to switch off our brains.

"People who have insomnia are in a hyper state of arousal," he said. "Behavioral treatments — guided imagery, progressive relaxation, hypnosis and meditation — are meant to try to trick your unconscious into doing what you want it to do. A.S.M.R. videos seem to be a variation on finding ways to shut your brain down."

So far, it seems to work for me. Like many insomniacs, I have over the years tried natural remedies like valerian root or melatonin, vigorous exercise regimens and strong sleeping pills like Ambien and Lunesta. But sleep rarely came. Nothing has worked as well and consistently as watching a man in an A.S.M.R. video sort through papers and his collection of Titanic paraphernalia.

But locating the neurological underpinnings of this trippy sensation won't be easy. Many of the scientists I reached out to shied away from the subject, saying the area is pseudoscience with a lack of published studies.

Bryson Lochte, a post-baccalaureate fellow at the National Institute on Drug Abuse who looked into A.S.M.R. for his senior thesis as a neuroscience major at Dartmouth College last year, has submitted his paper for publication in a scientific journal. Mr. Lochte said, "We focused on those areas in the brain associated with motivation, emotion and arousal to probe the effect A.S.M.R. has on the 'reward system' — the neural structures that trigger a dopamine surge amid pleasing reinforcements, like food or sex.

He compared A.S.M.R. to another idiosyncratic but well-studied sensation called musical frisson, which provokes a thrilling ripple of chills or goose bumps (technically termed piloerection) over one's body in emotional response to music. Mathias Benedek, a research assistant at the University of Graz in Austria who co-authored two studies on emotion-provoked piloerection, says A.S.M.R. may be a softer, quieter version of the same phenomenon. "Frisson may simply be a stronger, full-blown response," he said. And like A.S.M.R., the melodies that ignite frisson in one person may not in another.

Robert J. Zatorre, a professor of neuroscience at the Montreal Neurological Institute and Hospital at McGill University who has also studied musical frisson, said that "the upshot of my paper is that pleasurable music elicits dopamine activity in the striatum, which is a key component of the reward system" in the brain. Writing in The New York Times last year, in an article titled "Why Music Makes Our Brain Sing," he notes, "What may be most interesting here is when this neurotransmitter is released: not only when the music rises to a peak emotional moment, but also several seconds before, during what we might call the anticipation phase."

Perhaps the everyday experiences that A.S.M.R. videos capture — whispering, crinkling, opening and closing of boxes — evoke similar anticipatory mechanisms, sparking memories of past pleasures that we anticipate and relive each time we watch and listen.

"The whole topic is still very much unknown," Mr. Lochte said. "I would be very interested to see what other traits correlate with A.S.M.R sensitivity, whether it is an inherited attribute and what sort of physiological effects the sensation has on the body. All of these questions will be easy to answer with quick follow-up studies. Our study, we hope, will help lay the groundwork."

A version of this article appears in print on 07/29/2014, on page D6 of the NewYork edition with the headline: A Tingly Feeling, Then Zzzzzz.

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DealBook: Equinox Fitness Is Buying Rest of Millennium’s Gyms

Photo The Reebok Sports Club/NY gym is one of several properties Equinox Fitness has acquired in a $110 million deal.Credit Richard Perry/The New York Times

The high-end fitness industry may be awash in trendy concepts — CrossFit, boot camps and the like — but one of the biggest players in the luxury gym market is continuing to expand all the same. Equinox Fitness, the purveyor of expensive workout centers and risqué advertising, said it planned to announce as soon as Monday that it had acquired Sports Club/LA gyms in New York and four other cities, as well as the Reebok Sports Club/NY gym on the Upper West Side of Manhattan. All will soon bear the Equinox brand and feature the company's classes and products.

The $110 million deal, Equinox's second-biggest acquisition, is for the remaining gyms owned by Millennium Partners, the real estate company that sold half of its clubs to Equinox three years ago. That transaction was Equinox's biggest deal. More important, the new deal expands Equinox's empire to 73 locations worldwide, primarily in major cities like New York, San Francisco, Los Angeles and London.

Much has changed for Equinox since 2011, when it bought the first of the Sports Club/LA and Reebok Sports Club locations for $130 million. The company also bought SoulCycle, the popular spinning chain, and started the low-cost Blink Fitness brand, in an effort to grow in an economy recovering from recession.

Both are performing well, according to Harvey Spevak, the company's chief executive, with SoulCycle now operating 29 locations and Blink having opened more than two dozen gyms in New York and New Jersey. He declined to elaborate on the privately held company's performance, except to say that its growth remains strong.

Still, the most popular fitness trends today tend to be less luxurious than what Equinox has traditionally offered: CrossFit practitioners call their gyms "boxes" and eschew fancy machines for cold, hard iron. But Mr. Spevak argued that Equinox would continue to focus on its core offerings, while still covering seemingly durable fitness movements like yoga and spinning.

"A lot of the noise that's out there will dissipate over time," he said. "We're not feeling pressure from those."

Instead, Equinox is focused on introducing more advanced technology to help customers track their workouts and diets, including through an app for iPhones. And it still will position itself as a luxury experience for members; after all, it still sells Kiehl's cosmetics in its gyms, and will soon do so in its newest acquisitions.

"We will be much more sophisticated than anyone else in our industry," Mr. Spevak said.

A version of this article appears in print on 07/28/2014, on page B2 of the NewYork edition with the headline: Equinox Fitness Is Buying Rest of Millennium's Gyms.

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Well: Nursing Home Unthinkable? Be Prepared in Case It’s Inevitable

Photo Credit Ellen Weinstein

Personal Health

Jane Brody on health and aging.

Nobody looks forward to spending their final years in a nursing home, yet 1.4 million Americans are living in this often-feared institutional setting.

You may not want to place a loved one in a nursing home for more than a short-term recovery — but never promise an aging relative that it won't happen.

"When faced with the responsibilities of providing 24-hour care for an aging person with ever-increasing physical needs beyond what one person can physically handle, a nursing home frequently becomes the best alternative," Joanna R. Leefer writes in "Almost Like Home," a user-friendly guide to choosing a nursing home.

Nursing homes generally have had a bad reputation as smelly, indifferent places where people go to die. But "there are some homes that are better than being at home," Ms. Leefer said in an interview. "And there are many more good facilities than bad ones."

Ms. Leefer developed her expertise through personal and professional experience, and her book is replete with checklists and scores of relevant websites. She learned a lot firsthand as primary caregiver for her aging parents, one of whom lived three years with nursing-home-type care. She worked five years for an advocacy organization for older adults, and she founded a consulting firm, ElderCareGiving, to help families make difficult care decisions.

Finding a place that suits the needs of an aging relative or friend, and those who plan to visit, requires considerable preparation.

"The biggest mistake people make is waiting until the last minute, when faced with a crisis, to find a suitable facility," Ms. Leefer said. "You're forced into an impulsive decision that you're not likely to be happy with unless you're really very lucky."

She likened it to shopping for a new car: "Do the research, start looking around, find out what's available, what each facility offers, what's best for your loved one. Become an educated consumer."

Crass as it may seem, you might start with the cost. When paid for privately, the average ranges from $10,000 to $15,000 a month. Medicare does not pay for long-term nursing home care, only temporary skilled care, usually in the rehabilitation section of the home.

If the patient qualifies for Medicaid, and the nursing home accepts it, most of the cost is generally covered. The beneficiary must be age 65 or older, disabled and a United States citizen. He or she can have no more than a certain amount of assets, as determined by the state. Some patients become eligible by transferring savings and assets to a third party at least five years ahead of time.

Next, choose a reasonably convenient location for likely frequent visitors. You can search for possibilities online by township or ZIP code. Ask neighbors and friends in the area for any recommendations or information they might have about homes in the area.

Make a list of homes in the chosen area and check out the government's report card at NursingHomeCare.com. Every home that receives federal funding must be evaluated and rated on a scale of 1 to 5 (5 being best). The assessments are far from perfect; a recent study, for instance, found that star ratings often don't correspond to how patients feel about their nursing homes.

Still, Ms. Leefer suggests considering only homes with a rating of 3 or higher. Then start examining their characteristics.

What specialized services might the patient need — a dementia program, mobility practice, hospice care? Are there medical specialists on call? Is the home affiliated with a good nearby hospital? If the patient has a personal physician, you might prefer a home where that doctor has privileges.

If the patient is not fluent in English, are there staff members (and other residents) who speak the person's language? Are there activities that would interest the patient, including opportunities to go outdoors?

Don't rely on brochures. Take a tour, preferably more than once at different times, including mealtimes. Visit more than one floor. Does the place look and smell clean? An odor of urine is a clue to neglect. Are the rooms light and airy? Are residents permitted to have a few personal decorative items or furnishings?

Observe how patients are treated by staff members. Are they courteous, patient, friendly and respectful of patients' privacy? Are patients greeted by the staff and addressed by name? Are those that need it helped with eating and drinking?

Are there rigid wake-up, bed and meal times, or do patients have some choice? Do the menus offer selections? If possible, talk with a few of the residents and their family members.

Ms. Leefer suggests preparing a checklist for the nursing homes you are considering, listing issues relevant to quality of life, quality of care, safety, nutrition and hydration.

Admission to a nursing home is not automatic but based on such factors as bed availability, care requirements and the patient's condition. It is best to submit applications to chosen homes well in advance of a needed admission. Waiting lists can be longer than a year.

Your job does not end once a family member is admitted; monitoring the care provided is critical. At first, expect resistance from the patient, often accompanied by a loud desire to "get me out of here now." Visit often and stay as long as possible to ease the transition, Ms. Leefer says.

Be sure you or someone trustworthy is authorized to serve as the patient's health care proxy, so critical medical decisions can be made when he cannot speak for himself. Make sure you have access to medical records and be present when the patient is examined and dressed. Check for any hints of physical abuse and signs of incipient or existing bed sores, which can become infected and hasten death.

Find out the names of staff in charge of various services and speak to them about the patient's special needs or problems. Keep notes, dated, with any issues of concern.

Try to solve any problems with the nursing home staff. Be polite, soft-spoken and avoid confrontation. A hostile approach puts people on the defensive and is unlikely to get the patient's needs addressed.

If necessary, speak to the heads of departments; filing a formal complaint with the health department should be a last resort.

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

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