Well: The 'Monday Morning' Medical Screaming Match

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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U.S. Official Faults F.A.A. for Missing 787 Battery Risk

The nation’s top transportation safety official said Thursday that the Federal Aviation Administration accepted test results from Boeing in 2007 that failed to properly assess the risks of smoke or fire leaking from the batteries on Boeing’s new 787 jets.  

Deborah Hersman, the chairwoman of the National Transportation Safety Board, told reporters that the problems seemed to have originated in the battery, when one of the eight cells had a short circuit and the fire spread to the rest of the cells. But she said that Boeing’s tests showed no indication that the new lithium-ion batteries on its 787 planes could erupt in flame and concluded they were likely to emit smoke less than once in every 10 million flight hours.

Once the planes were placed in service, though, the batteries overheated and emitted smoke twice last month, and caused one fire, after about 50,000 hours of commercial flights.

“The assumptions used to certify the batteries must be reconsidered,” Ms. Hersman said.

Late Thursday, the F.A.A. said it would allow Boeing to conduct test flights with its 787 to collect data on the batteries and the plane’s electrical system. The agency said the flights “will be an important part of our efforts to ensure the safety of passengers and return these aircraft to service.” It did not immediately specify the number of test flights or when they would begin.

Ms. Hersman, at her news conference, said that before the F.A.A. certified the batteries, Boeing’s tests found no evidence that a short circuit in one of the eight cells could spread to other cells.

But Ms. Hersman said the fire on a 787 parked at an airport in Boston on Jan. 7 started with a short-circuit in one cell and then spread to the other cells.

She said investigators have still not been able to tell what caused the short-circuit in that cell and led to a “thermal runaway,” overheating up to 500 degrees, that then cascaded to the rest of the cells.

Still, she said, “This investigation has demonstrated that a short-circuit in a single cell can propagate to adjacent cells and result in a fire.”

Battery experts said that the finding pinpointed one step Boeing could take to make the batteries safer: It could expand the size of the battery to create more physical separation between the cells. Ralph J. Brodd, a battery industry consultant in Henderson, Nev., said Boeing and its Japanese battery subcontractor, GS Yuasa, could make the design and manufacturing changes needed to do that fairly quickly.

But unless investigators can determine what caused the first cell to short-circuit, federal officials said, Boeing will also be required to make other changes to prevent any of the possible causes and to better contain or vent any overheated materials. And given the safety board’s findings about how poorly Boeing gauged the original safety risks, the F.A.A. is likely to take its time in assessing the validity of any new tests.

The 787 is the first commercial airplane to use large lithium-ion batteries for major flight functions. All 50 of Boeing’s 787s that were delivered to airlines have been grounded since mid-January, when a 787 made an emergency landing in Japan after the pilots smelled smoke in the cockpit. That incident occurred nine days after the Boston fire.

In searching for the cause of the fire on the plane in Boston, Ms. Hersman said the safety board was still looking at the battery’s charging mechanism and potential manufacturing defects or contamination, and whether the cells were not as isolated as they should have been.

Investigators have so far ruled out two possible reasons for the short-circuit — a mechanical or electrical shock from outside the battery.

“We have not yet identified what the cause of the short-circuit is,” she said. “We are looking at the design of the battery, at the manufacturing, and we are also looking at the cell charging. There are a lot of things we are still looking at.”

Boeing said in a statement Thursday that it viewed the safety board’s findings as narrowing the likely source of the problem to within the battery itself, as opposed to other components of the plane’s extensive new electric system. But company officials said they also recognized that it would take a combination of changes to restore confidence in the battery system.

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At War Blog: Interview With Gen. John R. Allen on Leaving Afghanistan

The New York Times interviewed Gen. John. R. Allen on Sunday, a week before his scheduled departure from Afghanistan after 19 months as the commander of the American and allied forces.

Following are some of General Allen’s comments. Brief explanations have been provided in brackets.

On his relationship with President Hamid Karzai:

“I wanted him to understand that he was always going to have my loyalty and I was always going to work with him. In fact, I said a number of times, ‘I’m proud to have served you at the same time I served my own leadership, whether it’s a NATO leadership or U.S. leadership.’ Now, I wanted him to believe it because it happened to be true. I think our personalities matched in that regard.”

“Now, we’ve had some tough times. This has been a time of really dramatic change for the campaign. When I got here, I measured success in how well we and how often we were fighting. Today, it’s a very different environment. The Afghans are virtually entirely in the lead across Afghanistan.”

“This is what I’ve learned about the president. If you listen to him, he’s got some pretty good ideas, and often the controversy that has arisen in the relationships hasn’t been because necessarily you disagree with the ideas. It’s because you haven’t listened to them early enough.”

“And sometimes it’s been strained. I don’t think he ever believes that actions that I have taken were ever intended to disadvantage him as the president, or not do everything I possibly could for the Afghan people. I told him, I’m prepared to die in this country on behalf of his people. I take that very seriously.”

On civilian casualties:

“I’ve met with the families of the casualties that we’ve inflicted. I’ve flown to the villages to personally apologize for the casualties, and do what I can to do the right thing for those families. I’ve taken measures with respect to the employment of certain kinds of fires.” ["Fires” is common military shorthand for a variety of munitions, from bullets to missiles to mortar shells.]

“We had a couple of pretty rough incidents where Afghans were killed by the delivery of aviation fires. I eventually said to President Karzai that civilian structures, tents, potential areas where civilians might be either taking refuge or hiding or living, I’m not going to deliver any more fires on those structures unless my troops are pinned down, can’t move, and the only option they have is to deliver fires on these structures, or I decide, the senior leader out here, I decide to deliver fires on these structures.”

“The civilian causalities as a result of air fires plummeted immediately. It was probably the decision I could have made long before that and none of our forces were put at risk, or a greater risk because of this.”

On the aftermath of the burning of Korans at Bagram Air Base:

“I have to tell you, I thought this could be it for the relationship.

“I immediately got on the phone to a number of Afghan media outlets, immediately cut a video apologizing for this as sincerely as I could possibly appear and sound because this was going to be bad, it could be really bad. I called the president, I went to see him, apologized to him for this. It was completely inadvertent but this culture deserved that apology. We were in their home, so to speak. We are guests in their home and even though it was an accident, even though it was not intentional, we had made a bad mistake, a real error and the people deserved my apology, the president deserved my apology.

“He accepted it and I think in many respects, the personal nature of our relationship was what tempered the language coming out of the palace, the relief, his own engagement with the media and so on. Because of both of our actions, both of them supporting each other, we were able to keep this from being the result of a bad mistake from being something that could have really fractured the relationship.”

On the fallout in March after an American soldier killed 16 villagers in the southern Afghan district of Panjwai, which he first heard about when he was in the United States to testify before Congress:

“The first phone call was something of the effect of — we’ve got mixed reporting from Panjwai. We think an American soldier maybe shot some people and my response was, ‘All right. Let’s develop the situation quickly. Tell me what we got in front of us because we’ve got to make the Afghans were included on this.’ ”

“Then the phone calls started coming in and the numbers started going up and pretty quick and this is as bad a circumstance as you might have imagined.”

“I called President Karzai from home and we had a long conversation about it. I promised him once again that we would take all steps, measures, take all actions necessary to get to the bottom of this and we would do a full and complete investigation and those people necessary would be held accountable.”

“This was still unfolding. It was one shooter. It was multiple shooters. There were wild rumors associated with things that he had done in addition to shooting. So the information environment was wide open at this point. And both for the purposes of internal stability in Afghanistan for the purposes of preserving our relationship we were working very, very hard to confirm what we knew to be the facts and try very hard to get after the rumors that were just flying.”

“Once again, when he could have been angry, when it could have been a very negative conversation, I mean, he was tutorial. He explained to me why this is bad for the relationship, why this is bad for the campaign, and why this will shake the confidence of the Afghan people, his personal gesture of measured conversation with me. He wasn’t angry.”

On why the United States should stay engaged in Afghanistan:

“I put it in the context of this has been worth it. This is bigger than anyone of us. It’s bigger than the president. It’s bigger than the president of Afghanistan, because this isn’t about today. This is about tomorrow. This is about doing all we can to facilitate President Karzai with his desire to be successful. But it’ll be about doing all we can do to set up his successor for success.”

On overcoming the skepticism of officials in Washington, who often express frustration with Mr. Karzai:

“For this president, at this moment of its history, the Afghanistan history, to be able to hold together these tribes and these ethnic groups with these kinds of challenges has got to be one of the hardest jobs going. And so I try to paint the context of the challenges that he faces, the history from which he originates and help conceivably, he will interpret our actions. He may not understand what we are trying to do, or may misinterpret what we’re trying to do or say. And frankly, one of the great things about our democracy is also one of the hardest things about our democracy: That is, we don’t always speak with the same voice.

“So he’ll hear a voice from one part of the government, it will be different for another part of the government and he’ll see to square the differences. It’s not a criticism, it just is who we are. The farther you are away from Kabul, the farther you are away from the palace, the farther you are away from the history of this country in the complexities of society, the easier it is to generalize, frankly.”

On the need for the Afghan government to better serve its people and stamp out corruption within its ranks:

“We’ve worked very hard, obviously, to build a capacity in those. But when your ability to survive the night, or put food on the table was — well, for many years are functionally, what tribe you were part of, or what group you were part of. And those patronage networks undertook economic opportunities which made them some respect, criminal patronage networks.

“They can only survive because institutions of governance are weak. And so now, we find ourselves in this — at this very moment when the future of the country relies on the strength of institutions. The criminal patronage networks recognized that their future, their survival can only be sustained by keeping these institutions weak. That’s the moment we find ourselves in, and the presidential directive on any corruption and government reform and the Mutual Accountability Framework came out of Tokyo.

“These created very helpful, very useful, both domestic and international expectations for reform. So we need to see how smoothing past the written word and the spoken word and start moving towards action. I think the president, if he were sitting here would tell you that they have achieved some good action, good results in his presidential decree. The Mutual Accountability Framework is constantly being audited to see that there’s progress on reform. But again, we’re still pretty fresh in the process and we’ve got to let this play out some more.”

On the future of the war and Afghanistan:

“Let me make sure I’m clear on this. Nothing is sure in a post-conflict society. But I think the indicators, as far as I’m concerned, are that we’re on the right trajectory. What you have to understand, what people have to understand is some of these reforms take a very long time. In an environment where human rights were crashed under multiple different invasions or civil wars or the Taliban, creating once again the kind of bias for human rights that we would all expect in the Western society, just doesn’t come easily to this country.

“Nothing will happen in this country without security. And that security is being purchased every single day by the Afghan National Security Forces. And then, on the platform of that security, this president has announced a program or platform that he intends to follow. Now, he’s moving forward in some areas, he’s having resistance in others, but we just have to expect this is going to take time. That’s where huge patience has to come in. That’s where the decade of transformation comes in.”

On the surge of “insider attacks” against Westerners that took place in 2012:

“The losses became to this particular means of attack became very troubling, very significant, and tragic. And while on the tactical level and on the operational level, we were able to deal with the problem. This was becoming a strategic crisis — a strategic crisis in capitals, a strategic crisis for the alliance — and the Taliban saw this. They knew this. They saw that. They saw that the future of the A.N.S.F. relied on our being close, partner or adviser inside the Afghan formations.

“We were very careful in our reaction to insider attacks. Not to wall ourselves off from the Afghans and create distance. I used to tell them, you may not be able to do anything about the linear distance that you have to deal with but there’s a lot you can do about your proximity and the closer you all feel to each other, the more secure you will be. And that’s in an environment where we’re transitioning to being advisers almost entirely across Afghanistan. That has to be one of the operative principles for philosophically how we’re going to live with the Afghans. You treat them like brothers. You live with them like they’re family. That reduces the unknowns, it reduces the potential for cultural affront, and it makes you more secure.”

“That doesn’t mean we’re not going to keep a close eye on the environment. We still have these people called Guardian Angels because there are enemies in the ranks and they’re waiting to take that shot.”

“We took a lot of measures and the numbers are down. But I don’t in any way want anybody to become complacent about the number being down. I don’t want anyone to lift up on the security measures that they’re taking or reduce the attentiveness that they have to the environment around. So, I want everybody to be attentive and we’re going to periodically refresh our training both at the very lowest levels and for the units coming in. So, we’re not going to give up on this.”

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Signing Day: Ole Miss muscles in on power programs

Alabama. Ohio State. Michigan. Florida. Notre Dame. Mississippi?

Ole Miss muscled in on the powerhouses that usually dominate national signing day, landing some of the most sought-after prospects in the country on college football's annual first-Wednesday-in-February frenzy.

The Rebels, coming off a promising 7-6 season in their first season under coach Hugh Freeze, had the experts swooning by signing three of the bluest chips still on the board and building a well-rounded class otherwise.

The day started with defensive end Robert Nkemdiche from Loganville, Ga., rated the No. 1 recruit in the country by just about everyone who ranks them, deciding to join his brother, Denzel, in Oxford, Miss.

"I feel like it's the right place for me," Nkemdiche said after slipping on a red Ole Miss cap. "I feel like they can do special things and they're on the rise. I feel like going to play with my brother, we can do something special."

Nkemdiche originally committed to Clemson last year, then backed off that and narrowed his picks down to LSU, Florida and Mississippi — and the Rebels beat the big boys.

They weren't done. Coaches in the Ole Miss war room were exchanging hugs and high-fives again a couple hours later when Laremy Tunsil, a top-rated offensive tackle from Lake City, Fla., picked the Rebels over Florida State and Georgia.

"Tunsil to Ole Miss I think was the biggest surprise of the whole (recruiting season)," said JC Shurburtt, national recruiting director for 247Sports.com.

And, as if the Ole Miss needed more good news, highly touted defensive back Antonio Conner from nearby Batesville, Miss., chose the Rebels over national champion Alabama.

The end result was a class good enough to even catch the attention of LeBron James.

"Ole Miss ain't messing around today! Big time recruits coming in. SEC is crazy," the NBA's MVP posted on his Twitter account.

Crazy good. While the Rebels racked up, it's important to remember they still have plenty of ground to gain on the rest of their conference competition.

Nick Saban reloaded the Crimson Tide with a class that Rivals.com ranked No. 1 in the country.

SEC powers Florida, LSU and Georgia pulled in typically impressive classes. SEC newcomer Texas A&M cracked the top 10 of several rankings. Even Vanderbilt, coming off a nine-win season, broke into the top 25.

It's the cycle of life in the SEC, which has won seven straight BCS championships. Stock up on signing day and scoop up those crystal footballs at season's end.

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SLIPPING AWAY FROM USC

Signing day didn't do much to soothe the scars left from a difficult season for Southern California.

NCAA sanctions limited the number of scholarships coach Lane Kiffin and the Trojans could hand out this year, and then as signing day approached USC had several players who had given verbal commitments change their minds.

The most notable defection on signing day was five-star defensive back Jalen Ramsey of Brentwood, Tenn., who flipped to Florida State. Defensive end Jason Hatcher from Louisville, Ky., bailed on USC and signed with Kentucky, and defensive end Torrodney Prevot from Houston not only reneged on his USC commitment, but he landed at Pac-12 rival Oregon.

"People expected (Prevot) to flip from USC, but they thought it would be to Texas A&M," Shurburtt said.

USC's class won't be lacking blue chippers. Quarterback Max Browne from Washington is considered the next in a long line of topflight Trojans quarterbacks, and Kenny Bigelow from Maryland is rated among the best defensive linemen in the nation.

Kiffin will be banking on quality to make up for the lack of quantity, but that's a precarious way to play a game as uncertain as recruiting.

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IF MOMMA'S NOT HAPPY ...

Alex Collins, a top running back prospect out of Plantation, Fla., announced on Monday night that he was going to Arkansas instead of Miami.

It was considered a huge victory for new Razorbacks coach Bret Bielema.

But on Wednesday morning, when it was time to make it official, Collins' letter of intent didn't come spinning through the fax machine in Fayettville, Ark.

There were some odd reports about Collins' mother not being happy with her son's decision to go so far from home.

College coaches aren't allowed to talk about specific players before they sign, but Bielema did acknowledge during his signing day news conference that Arkansas' class of 22 players could "grow by one."

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THE BIG TWO

Ohio State and Michigan received two thumbs up from experts on their signing day classes. They all had the Buckeyes and Wolverines around top five in the country.

After that, there was a drop off. Nebraska received solid grades and Penn State, despite NCAA sanctions that limited its class to 17 signees, held up pretty well.

"That's a tribute to the job (Penn State coach) Bill O'Brien and the staff did," Shurburtt said.

But signing day 2013 signaled that Urban Meyer's Buckeyes and Brady Hokes' Wolverines are primed to pull away from most of the Big Ten, and maybe — just maybe — give the league a team or two that can challenge those SEC teams for a national title.

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BUILT TO LAST

Notre Dame followed up its best season in more than two decades with recruiting class that coach Brian Kelly hopes can keep the Fighting Irish contending for more national titles.

The class includes a famous name in Torii Hunter Jr., the son of the All-Star outfielder. Hunter Jr. is a top-notch receiver prospect, though he broke his leg during an All-Star game and it could be a while before he's back on the football field.

Linebacker Jaylon Smith from Fort Wayne, Ind., is generally regarded as the jewel of a class that experts have ranked among the best in the country.

"I love agreeing with experts," Kelly said.

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BASEBALL OR FOOTBALL?

Oklahoma hopes it has found the next Sam Bradford in Cody Thomas, a pocket passer from Colleyville, Texas.

One small problem. Thomas is also a big-time baseball player who could draw interest in the major league draft this summer.

"We wouldn't have pursued him if we didn't feel there was a great chance he'd be playing football," Oklahoma coach Bob Stoops said.

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QUOTABLE

South Carolina coach Steve Spurrier said recruiting classes "don't always pan out. Of course, they always seem to pan out at Alabama."

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AP Sports Writer David Brandt in Oxford, Miss., and Associated Press Writer Tom Coyne in South Bend, Ind., contributed.

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Follow Ralph D. Russo at www.Twitter.com/ralphdrussoap

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Personal Health: Effective Addiction Treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This is the first of two articles on addiction treatment.

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Media Decoder Blog: Cable TV Revenue Help Spur Time Warner Profit

2:14 p.m. | Updated The cable television business helped propel Time Warner to a 51-percent increase in net income and offset weakness in magazine publishing and movies in the three months that ended Dec. 31.

The media company said Wednesday that an increase in advertising revenue and subscription fees paid by cable and satellite companies to carry channels like TNT and TBS helped lift net income in the fourth quarter to $1.17 billion, or $1.21 a share, up from $773 million, or 76 cents a share, in the same three-month period last year. Revenues remained flat at $8.2 billion.

The results underscore the widening gap between the fast-growing cable television business and the more challenged magazine publishing industry and, to a lesser degree, the movie businesses.

Time Warner also said on Wednesday that its board had approved $4 billion in stock buybacks and that it would raise its quarterly dividend by 11 percent to 28.75 cents per share.

Jeffrey L. Bewkes, Time Warner’s chairman and chief executive, called the cable television business the “core of the company.” He praised the premium cable channel HBO, pointing to the interest fueled by returning series like “Game of Thrones” and “True Blood” and new original series like “Girls.” HBO added domestic subscribers in the quarter, the company reported.

At the same time, Time Inc., the nation’s largest magazine publisher, readied for layoffs of 6 percent of its global work force, cutbacks that it announced last week. Time Warner estimated the reductions would cost an estimated $60 million in restructuring charges, which will be reported in the first quarter of 2013.

Revenue at the company’s television networks, which include TNT, TBS, and CNN, rose 5 percent to $3.67 billion in the quarter. Subscription and advertising revenues at Time Warner’s suite of cable channels grew 7 percent and 3 percent, respectively, in the quarter, compared with last year. An increase in the number of National Basketball Association games on Turner channels, as well as coverage of the presidential election on CNN, led to higher ratings.

Mr. Bewkes said that, even with the boon from election coverage, CNN’s ratings disappointed. He praised the recent choice of Jeff Zucker, a former chief executive of NBC Universal, to lead CNN. “I’m optimistic that with the new leadership we’ve announced, CNN will once again fulfill the promise of its iconic brand,” he said on a conference call with analysts.

Revenue at the Warner Brothers studio fell 4 percent in the quarter to $3.7 billion, due largely to a tough comparison with 2011, which included the home entertainment release of the popular “Harry Potter and the Deathly Hallows: Part 2.” The performance of “Argo” and “The Hobbit: An Unexpected Journey” lifted Warner Brothers’ performance in the quarter and contributed to a 29 percent increase in operating income to $522 million.

Last week, Time Warner announced that Kevin Tsujihara, currently the head of the studio’s home entertainment division, would succeed Barry M. Meyer as chief executive of Warner Brothers. “I chose him because he’s got the greatest breadth of experience across Warner’s businesses,” Mr. Bewkes said on Wednesday.

Time Inc., the publisher of People, Sports Illustrated and InStyle, represents a small part of Time Warner’s overall business, but nevertheless continued to weigh on the company’s overall results. Revenues at Time Inc. declined 7 percent to $967 million, while advertising revenues fell 4 percent, or $24 million. Subscription revenues remained flat.

For the full fiscal year, which also ended Dec. 31, Time Warner reported net income of $3 billion, or $3.09 per share, compared with $2.9 billion, or $2.71 per share in 2011. In the full fiscal year, revenues decreased 1 percent to $28.7 billion.

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North Korean Propaganda Video Imagines Attack on U.S.

SEOUL, South Korea — North Korea is not known for its subtlety, famous instead for its soaring patriotic rhetoric and threats to turn the capital of its rival, South Korea, into a “sea of fire.”

But even by those standards, the latest volley of North Korea propaganda is noteworthy. Posted recently on YouTube, a video by one of the North’s propaganda agencies shows an animated version of Manhattan in flames — part of a dream in which a young Korean man envisions a glorious future of rocket launchings and the reunification of the Korean Peninsula. The background music to the celebration of perceived military might: an instrumental version of “We Are the World.”

“I see black smoke billowing somewhere in America,” the text that scrolls across the screen says in what are, in essence, subtitles of the man’s dream. “It appears that the headquarters of evil, which has had a habit of using force and unilateralism and committing wars of aggression, is going up in flames it itself has ignited.”

By Tuesday afternoon, the video had been removed from YouTube after a copyright complaint from Activision, the maker of the video game “Call of Duty,” from which the fiery New York scene was lifted. Copies, however, were up elsewhere on the Web, including on Live Leak.

The three-and-a-half-minute clip — titled “On Board Unha-9” and posted on YouTube on Saturday by Uriminzokkiri, a North Korean government Web site — is the latest evidence of the propaganda mileage Pyongyang is extracting from its Dec. 12 launching of its Unha-3 rocket, which the West considers North Korea’s first successful test of long-range-missile technology.

North Korea has been trumpeting the success of the rocket, which put a satellite into orbit, to its people, saying it was proof that their country was advancing toward a high-tech future. But the latest video is part of a years-long effort by the North to reach South Koreans and Koreans around the world through the Internet. (North Korea keeps its people, except for a tiny portion of its elite, cut off from the Internet.)

This is not the first time North Korea has portrayed attacks on the United States. Propaganda posters have shown a missile striking what looks like Capitol Hill.

The latest propaganda assault comes after weeks of increasingly strident missives from the North, which is angered by a Washington-led United Nations resolution tightening sanctions as punishment for the rocket test. The country has since promised a nuclear test, its third, as it tries to build what it calls a deterrent against attack by the United States or others.

There is no evidence that the North has the ability to strike the United States mainland with missiles.

The launching of the Unha-3 has become a symbol of pride in impoverished North Korea, where the government has told its people the success came despite American plots to “strangle and stifle” North Koreans. Thousands of scientists and officials there who were involved in the rocket project have been awarded government medals, according to North Korean news media.

Another YouTube video, also uploaded on Saturday, showed the Unha-3 rocket blasting off while a narrator identified as a worker in a Pyongyang cosmetics factory compared the moment to “flame of love igniting at first sight.” She also likened South Korean diplomats who pushed for United Nations sanctions to “ugly things” and “confrontational maniacs.”

Uriminzokkiri has been running Twitter and YouTube accounts since 2010, uploading more than 5,470 songs, news reports and videos. Earlier pieces had called Hillary Rodham Clinton, when she was secretary of state, a “minister in a skirt” and South Korean officials “servile dogs.”

South Koreans are blocked by their government’s firewall from gaining access to North Korean Web sites, but they could watch Uriminzokkiri posts on YouTube.

The “On Board Unha-9” video shows a sleeping man dreaming of traveling in a space shuttle named Kwangmyongsong-21. (The suggestion is that the North has a bright technological future, since the country is apparently up to only the third version of the Unha rocket, and the satellite that North Korea put into orbit in December is named Kwangmyongsong-3.)

The shuttle circles the Earth, passing over the Korean Peninsula, where people are jubilant over a reunification of the two Koreas. The camera then zooms in on the cataclysmic Manhattan scene from “Call of Duty,” which features Russians invading New York.

Marc Santora and Robert Mackey contributed reporting from New York.

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Her knee shredded, Lindsey Vonn done for season

SCHLADMING, Austria (AP) — All it took was a moment. Lindsey Vonn landed hard and tumbled face first with a piercing shriek.

Just like that, her season was done. The star American skier was on the ground with two ligaments in her right knee torn, a bone in her lower leg broken.

The cascading fall down the slope during the super-G at the world championships Tuesday knocked out the four-time World Cup champion for the rest of the season, the latest and most serious in a string of injuries for Vonn at skiing's biggest events.

The U.S. team said in a statement it expects her back for the next World Cup season and the 2014 Sochi Olympics, which start a year from this week.

The harrowing accident came after Vonn was lifted into the air off a jump in the opening race at the championships. As she hit the ground, her right leg gave way and she spun down face first, throwing an arm out to protect herself. She ended up on her back as she smashed through a gate.

On the television feed, Vonn was clearly heard screaming an expletive as she landed, then a despairing "Yes, yes," when someone asked, "Are you hurt?"

Race leader and eventual champion Tina Maze watched with her mouth agape. The concern also was obvious on the face of Vonn's sister, Laura Kildow, who has been traveling with her full time this season.

For 12 minutes, Vonn lay on the snow getting medical treatment before being airlifted by helicopter to a hospital in Schladming.

Vonn tore her anterior cruciate ligament and medial collateral ligament in her right knee, U.S. ski team medical director Kyle Wilkens said in a statement. The broken bone was described as a "lateral tibial plateau fracture."

Christian Kaulfersch, the assistant medical director at the worlds, said Vonn left the Schladming hospital on Tuesday afternoon and will have surgery in another hospital. "She first wanted to go back to the team hotel to mentally deal with all what has happened," Kaulfersch said.

Vonn's father, Alan Kildow, spoke with her by phone and said that she's, "mad at the way things turned out." His daughter told him that she landed in a clump of sugar snow, or ice crystals, that caused her fall forward, he said.

"She's a tough character. A very determined and tough character," Kildow told The Associated Press in a phone interview. "She will be back."

Kildow said that surgery could take place as soon as this weekend, likely at the Steadman Clinic, in Vail, Colo. Recovery time varies, according to Dr. Tom Hackett, an orthopedic surgeon at the clinic and the team physician for the U.S. snowboard squad.

But Vonn could be looking at six-to-eight months before she's back on skis.

"It's not like at six months you say, 'OK, you can get back on a super-G course," Hackett said. "There's a progression to getting back on skis, getting back to taking some easy runs, getting back to some gates, and working your way back to some steeper terrain. There's a whole return to snow progression that we've developed over many years."

Time enough to get back for Sochi?

"I think so," Hackett said. "I would be very optimistic she could come back strong. She's a fierce competitor. She's a fighter and chances are that she will — I would think — essentially take all of that athletic energy and put it into her rehabilitation. There's a really good chance she could come back as strong as ever."

Comebacks are nothing new for Vonn, who has also been afflicted by injuries at her last six major championships — from a thumb she sliced on a champagne bottle at the 2009 worlds in Val d'Isere, France, to a bruised shin that she cured with Austrian cheese at the Vancouver Olympics.

This one, however, could prove the biggest test yet for the 28-year-old who won the downhill at the 2010 Vancouver Olympics.

Vonn took a month off this season after being hospitalized for an intestinal illness in November, and had just regained her form with two wins last month.

That was evident at the start of her Tuesday's run. She led Maze by 0.04 seconds at the first checkpoint and was just 0.12 back at the second interval and seemingly on her way to a medal, if not victory.

Exactly what went wrong was debated by competitors and officials at the championships.

The start of the race was delayed by 3½ hours because of fog hanging over the course and it began in waning light at 2:30 p.m local time. Even before Vonn's crash, a course worker fell and also had to be airlifted. He was reported to have broken his nose.

All the delays made for what skiers call flat light — overcast and dreary conditions — when Vonn raced.

"Lindsey did a great job on top and Lindsey has won a lot of races in flat light so the flat light was definitely not a problem," U.S. Alpine director Patrick Riml told the AP.

"We are upset obviously with what happened but if you don't know the facts and why they decided to start and what the weather forecast was it's hard to say without any reasoning," Riml said. "And they probably had a reason, otherwise they wouldn't have started."

Atle Skaardal, women's race director for the International Ski Federation, defended the decision to go ahead with the event.

"I can confirm that the visibility was great, there were no problems, and the course was also in good shape," he said. "I don't see that any outside factors played a role in this accident. ... The other factors were like they were supposed to be for ski racing."

Vonn's list of injuries at major championships is long.

Two years ago, she pulled out midway through the last worlds in Garmisch-Partenkirchen, Germany, because of a mild concussion. At the 2010 Vancouver Olympics, Vonn skied despite a severely bruised shin to win the downhill and take bronze in the super-G.

At the 2009 worlds in Val d'Isere, she sliced her thumb on a champagne bottle after sweeping gold in the downhill and super-G, forcing her out of the giant slalom. At the 2007 worlds in Are, Sweden, Vonn injured her knee in training and missed her final two events.

And at the 2006 Turin Olympics, she had a horrific crash in downhill training and went directly from her hospital room to the mountain to compete in four of her five events.

The conditions Tuesday varied from racer to racer, and as the light began to fade even more, organizers stopped the race after only 36 of the 59 skiers had come down.

Maze skied immediately before Vonn.

"I saw it was a very high jump, so I knew I had to take the right line to make the next gate," she said. "World championship races often have special conditions and the mistakes from the girls were not because of the slope."

The two racers who started immediately after Vonn, former overall winner Maria Hoefl-Riesch of Germany and local favorite Anna Fenninger of Austria, each skied off course. In all, six women who started the course failed to finish. Still, Skaardal said he never thought about stopping the race.

"It's not a very difficult course but in some parts you couldn't see anything," said Fabienne Suter of Switzerland, who finished fifth.

Vonn's teammate Julia Mancuso also thrived in the difficult conditions and won the bronze medal.

"It's the same for everybody," U.S. speed coach Chip White said. "Everyone had to wait for a long time and that's always difficult. And the holds were every 15 minutes so it really doesn't give you a chance to go and do something else. You're always kind of on edge at the ready. It's a difficult situation but everybody had the same difficult situation."

Not long after Vonn was injured, NBC hosted a news conference in New York to discuss its coverage of the Sochi Games. A poster of a smiling Vonn hung in the room next to one of snowboarder Shaun White, evidence of the network's unsurprising expectations that she would be one of the biggest stars in Sochi.

The network's executives chose to put a positive spin on the injury.

"We expect her to be the comeback Olympian of the year," NBC Sports Group Chairman Mark Lazarus said.

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Associated Press writer Eric Willemsen in Schladming and AP Sports Writers Pat Graham and Rachel Cohen contributed to this report.

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Well: Warning Too Late for Some Babies

Six weeks after Jack Mahoney was born prematurely on Feb. 3, 2011, the neonatal staff at WakeMed Hospital in Raleigh, N.C., noticed that his heart rate slowed slightly when he ate. They figured he was having difficulty feeding, and they added a thickener to help.

When Jack was discharged, his parents were given the thickener, SimplyThick, to mix into his formula. Two weeks later, Jack was back in the hospital, with a swollen belly and in inconsolable pain. By then, most of his small intestine had stopped working. He died soon after, at 66 days old.

A month later, the Food and Drug Administration issued a caution that SimplyThick should not be fed to premature infants because it may cause necrotizing enterocolitis, or NEC, a life-threatening condition that damages intestinal tissue.

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Catherine Saint Louis speaks about using SimplyThick in premature infants.

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Experts do not know how the product may be linked to the condition, but Jack is not the only child to die after receiving SimplyThick. An F.D.A. investigation of 84 cases, published in The Journal of Pediatrics in 2012, found a “distinct illness pattern” in 22 instances that suggested a possible link between SimplyThick and NEC. Seven deaths were cited; 14 infants required surgery.

Last September, after more adverse events were reported, the F.D.A. warned that the thickener should not be given to any infants. But the fact that SimplyThick was widely used at all in neonatal intensive care units has spawned a spate of lawsuits and raised questions about regulatory oversight of food additives for infants.

SimplyThick is made from xanthan gum, a widely-used food additive on the F.D.A.’s list of substances “generally recognized as safe.” SimplyThick is classified as a food and the F.D.A. did not assess it for safety.

John Holahan, president of SimplyThick, which is based in St. Louis, acknowledged that the company marketed the product to speech language pathologists who in turn recommended it to infants. The patent touted its effectiveness in breast milk.

However, Mr. Holahan said, “There was no need to conduct studies, as the use of thickeners overall was already well established. In addition, the safety of xanthan gum was already well established.”

Since 2001, SimplyThick has been widely used by adults with swallowing difficulties. A liquid thickened to about the consistency of honey allows the drinker more time to close his airway and prevent aspiration.

Doctors in newborn intensive care units often ask non-physician colleagues like speech pathologists to determine whether an infant has a swallowing problem. And those auxiliary feeding specialists often recommended SimplyThick for neonates with swallowing troubles or acid reflux.

The thickener became popular because it was easy to mix, could be used with breast milk, and maintained its consistency, unlike alternatives like rice cereal.

“It was word of mouth, then neonatologists got used to using it. It became adopted,” said Dr. Steven Abrams, a neonatologist at Texas Children’s Hospital in Houston. “At any given time, several babies in our nursery — and in any neonatal unit — would be on it.”

But in early 2011, Dr. Benson Silverman, the director of the F.D.A.’s infant formula section, was alerted to an online forum where doctors had reported 15 cases of NEC among infants given SimplyThick. The agency issued its first warning about its use in babies that May. “We can only do something with the information we are provided with,” he said. “If information is not provided, how would we know?”

Most infants who took SimplyThick did not fall ill, and NEC is not uncommon in premature infants. But most who develop NEC do so while still in the hospital. Some premature infants given SimplyThick developed NEC later than usual, a few after they went home, a pattern the F.D.A. found unusually worrisome.

Even now it is not known how the thickener might have contributed to the infant deaths. One possibility is that xanthan gum itself is not suitable for the fragile digestive systems of newborns. The intestines of premature babies are “much more likely to have bacterial overgrowth” than adults’, said Dr. Jeffrey Pietz, the chief of newborn medicine at Children’s Hospital Central California in Madera.

“You try not to put anything in a baby’s intestine that’s not natural.” If you do, he added, “you’ve got to have a good reason.”

A second possibility is that batches of the thickener were contaminated with harmful bacteria. In late May 2011, the F.D.A. inspected the plants that make SimplyThick and found violations at one in Stone Mountain, Ga., including a failure to “thermally process” the product to destroy bacteria of a “public health significance.”

The company, Thermo Pac, voluntarily withdrew certain batches. But it appears some children may have ingested potentially contaminated batches.

The parents of Jaden Santos, a preemie who died of NEC while on SimplyThick, still have unused packets of recalled lots, according to their lawyer, Joe Taraska.

The authors of the F.D.A. report theorized that the infants’ intestinal membranes could have been damaged by bacteria breaking down the xanthan gum into too many toxic byproducts.

Dr. Qing Yang, a neonatologist at Wake Forest University, is a co-author of a case series in the Journal of Perinatology about three premature infants who took SimplyThick, developed NEC and were treated. The paper speculates that NEC was “most likely caused by the stimulation of the immature gut by xanthan gum.”

Dr. Yang said she only belatedly realized “there’s a lack of data” on xanthan gum’s use in preemies. “The lesson I learned is not to be totally dependent on the speech pathologist.”

Julie Mueller’s daughter Addison was born full-term and given SimplyThick after a swallow test showed she was at risk of choking. It was recommended by a speech pathologist at the hospital.

Less than a month later, Addison was dead with multiple holes in her small intestine. “It was a nightmare,” said Ms. Mueller, who has filed a lawsuit against SimplyThick. “I was astounded how a hospital and manufacturer was gearing this toward newborns when they never had to prove it would be safe for them. Basically we just did a research trial for the manufacturer.”

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Bits Blog: Most Facebook Users Have Taken a Break From the Site, Study Finds

Facebook is the most popular social network in America — roughly two-thirds of adults in the country use it on a regular basis.

But that doesn’t mean they don’t get sick of it.

A new study released on Tuesday by the Pew Research Center‘s Internet and American Life Project found that 61 percent of current Facebook users admitted that they had voluntarily taken breaks from the site, for as many as several weeks at a time.

The main reason for their social media sabbaticals?

Not having enough time to dedicate to pruning their profiles, an overall decrease in their interest in the site as well as the general sentiment that Facebook was a major waste of time. About 4 percent cited privacy and security concerns as contributing to their departure. Although those users eventually resumed their regular activity, another 20 percent of Facebook users admitted to deleting their accounts.

Of course, even as some Facebook users pull back on their daily consumption of the service, the vast majority — 92 percent — of all social network users still maintain a profile on the site. But while more than half said that the site was just as important to them as it was a year ago, only 12 percent said the site’s significance increased over the last year — indicating the makings of a much larger social media burnout across the site.

The study teases out other interesting insights, including the finding that young users are spending less time overall on the site. The report found that 42 percent of Facebook users from the ages of 18 to 29 said that the average time they spent on the site in a typical day had decreased in the last year. A much smaller portion, 23 percent, of older Facebook users, those over 50, reported a drop in Facebook usage over the same period.

Facebook’s biggest challenge revolves around figuring out how to continue to profit from its rich reservoir of one billion users — and a large part of that involves keeping them entertained and returning to the site on a regular basis. Most recently, the company introduced a tool called Graph Search, a research tool that promises to help its users find answers on everything from travel recommendations to potential jobs and even love connections.

Lee Rainie, the director of the Pew Research Center’s Internet & American Life Project, which conducted the survey, described the results as a kind of “social reckoning.”

“These data show that people are trying to make new calibrations in their life to accommodate new social tools,” said Mr. Rainie, in an e-mail. Facebook users are beginning to ask themselves, ” ‘What are my friends doing and thinking and how much does that matter to me?,’ ” he said. “They are adding up the pluses and minuses on a kind of networking balance sheet and they are trying to figure out how much they get out of connectivity vs. how much they put into it.”

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