Doctor and Patient: Afraid to Speak Up to Medical Power

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Stocks inch higher as finance ministers meet for G20









Stocks edged higher in early trading on Wall Street, putting the S&P 500 in line for a seventh straight week of gains.

The Standard & Poor's 500 rose one point to 1,522 as of 10:23 a.m. EST. For the week, the index is four points higher. It has risen every week so far this year.

The Dow Jones industrial average rose 26 to 13,978. The Nasdaq composite advanced 6 to 3,204.

Burger King gained 46 cents to $16.98. The company's fourth-quarter earnings nearly doubled after it revamped its menu.

A stock market rally that started in January has slowed in February. Investors piled into stocks at the beginning of the year after lawmakers reached a last-minute deal to avoid the “fiscal cliff” of sweeping tax hikes and spending cuts. The gains continued as investors were encouraged by signs that the housing and jobs markets are recovering.

Herbalife surged $3.51, or 9 percent, to $41.78 after the billionaire investor Carl Icahn disclosed that he had accumulated a 13 percent stake in the company. The stock of the supplement company slumped last year after Pershing Square Capital Management's William Ackman described it as a massive pyramid scheme and placed bets that it would fall.

The yield on the 10-year Treasury note, which moves inversely to its price, has risen since the beginning of the year as investors put more cash into stocks. The yield rose 1 basis point Friday to 2.01 percent. It started the year at 1.70 percent.

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Oscar Pistorius arrested in slaying of model Reeva Steenkamp




















Paralympian Oscar Pistorius charged with murder
































































South African police Thursday arrested double amputee Olympic runner Oscar Pistorius and said he would be charged with murder after his girlfriend, Reeva Steenkamp, was shot and killed at his home earlier in the morning.


Police spokesperson Brigadier Denise Beukes said that Pistorius was at his home after the death of the victim and that "there is no other suspect involved."


"There are witnesses and they have been interviewed this morning. We are talking about neighbors and people that heard things earlier in the evening and when the shooting took place," Beukes said.








Pistorius' court hearing was originally scheduled for Thursday afternoon but has been postponed until Friday to give forensic investigators time to carry out their work.


The athlete's father, Henke Pistorius, told South Africa's SABC radio news that he didn't know the facts. "If anyone makes a statement, it will have to be Oscar. He's sad at the moment."


Media in South Africa are reporting that Steenkamp was surprising Pistorius for Valentine's Day when he mistook her for a burglar and shot her. Steenkamp was shot in the arm and head and a 9-mm pistol was recovered at the scene.


"We have also taken cognizance of the media reports during the morning of an alleged break-in or that the young lady was mistaken to be a burglar," Beukes said. "Obviously our forensic investigation is still ongoing and we're not sure where this report came from.... Our detectives have been on the scene, our forensic investigators have been on the scene and the investigation is ongoing."

South African police said that there had been "previous incidents" of a domestic nature reported at Pistorius' home.

Pistorius, 26, was born without the fibula bone in both legs. He was known as the "Blade Runner" for his use of carbon fiber prosthetic blades. He was the first double amputee to run in the Olympics and reached the 400 meter semifinals in London 2012.


ALSO:


LeBron James' blistering streak an NBA best


O.J. Simpson holds Super Bowl party in his prison cell


Advisor says Vince Young took out loan for a $300,00 birthday party






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'Sesame Street' nears 1 billion views on YouTube


NEW YORK (AP) — Nearing 1 billion views on YouTube, "Sesame Street" is headed for Justin Bieber territory.


The children's program is closing in on the kind of rarified digital milestone usually reserved for the likes of pop stars and cat videos. "Sesame Street" will soon pass 1 billion views on YouTube and it's celebrating the mark with a campaign to put itself over the hump.


"Sesame Street" on Thursday will post a video featuring the character Telly Monster, urging viewers to click the show past the final 20 million views and unlock a "top secret video." Naturally, for the nonprofit children's series, it's a teaching moment, too. Don't be surprised if Count von Count shows up to ponder such a big number.


For "Sesame Street," the milestone — a first on YouTube for a nonprofit or U.S. children's media outlet — reflects the increasingly multimedia nature of kid entertainment. Big Bird and Oscar the Grouch are now about as likely to be watched on an iPad, phone or laptop as they are on PBS.


"We have this theory that if we get content on multiple platforms and devices, it gives kids and families a chance to reinforce and experience the curriculum multiple times," says Terry Fitzpatrick, executive vice president of content and distribution for Sesame Workshop, who emphasizes videos are best co-viewed with child and parent. "It blows me away to think about how popular and strong a platform (YouTube) has become for us."


"Sesame Street," a mainstay on PBS since 1970, launched its YouTube channel in 2006, but has continually expanded its mindfulness of online and mobile viewers.


Sesame Workshop last year integrated its digital media group into its TV production, so that digital and interactive elements are considered from the start of an idea. Its most popular video is "Elmo's Song," which has been watched nearly 86 million times since being uploaded in 2009. More recently, another PBS hit, "Downton Abbey," was parodied in "Upside Downton Abbey," a video where British muppets have trouble drinking tea and eating crumpets because, well, they're upside down.


Caitlin Hendrickson, strategic partner manager for YouTube's educational realm, YouTube EDU, says that education is one of the fastest growing content categories on the Google Inc.-owned site. "Sesame Street" reaching 1 billion views, she said in a statement, "is proof of their outstanding leadership in this space and their creative use of YouTube."


___


Online:


http://www.youtube.com/user/SesameStreet


___


Follow AP Entertainment Writer Jake Coyle on Twitter at: http://twitter.com/jake_coyle


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Well: The Well Flu Quiz

What surface is the most friendly to the flu virus? Where’s the best place to stand when you’re talking to a sick person? And how are Australians curbing germs in schools? To find out these answers and more, take the Well Flu Quiz.

With contributions from Laura Geggel and Tara Parker-Pope.

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Europe's recession deepened in 4th quarter as economy shrank 0.6%









WASHINGTON -- Europe's recession deepened at the end of last year as its economy shrank at an annual rate of 0.6% in the final three months, its sharpest contraction since the financial crisis.


The data for the Eurozone released Thursday was worse than analysts had expected, reflecting steeper-than-expected contractions for three of the region's largest economies: Germany, France and Italy.


Germany's economy shrank at an annual rate of 0.6% in the period after expanding at a 0.2% rate in the previous quarter.





Quiz: How much do you know about looming federal budget cuts?


"The decline of the gross domestic product at the end of 2012 was mainly due to the comparably weak German foreign trade: in the final quarter of 2012, exports of goods went down much more than imports of goods," said Germany's Federal Statistical Office.


Italy's economy contracted at an annual rate of 0.9%, while the French economy shrank at a rate of 0.3%, according to Eurostat, the European Union's statistical office.


The news from Europe comes after the U.S. recently reported its economy unexpectedly shrank 0.1% in the fourth quarter. Economists believe the U.S. contraction, the first since 2009, was an anomaly, driven in part by fears of the fiscal cliff and a drop in exports because of economic problems in Europe and China.


Other data, including the January unemployment report, indicate the U.S. economy still is expanding and growth is expected to pick up this year.


The 17-nation Eurozone, however, now has shrunk for three straight quarters. The fourth quarter contraction was sharper than the 0.1% drop in the previous quarter.


The October-through-December period was the worst for the European economy since a nearly 3% contraction in the first quarter of 2009.


Howard Archer, chief European economist for IHS Global Insight, said the report depicted a dismal end to a bad year. He had expected the economy to shrink 0.4%. 


"While Eurozone economic activity saw its low point around last October, we suspect that growth will remain a struggle for some time to come," Archer said. "However, it is looking increasingly possible that the Eurozone could at least stop contracting in the first half of 2013, significantly helped by a return to growth in Germany."


"The hope for the Eurozone is that a sustained overall easing of sovereign debt tensions and generally improved financial markets further reduces uncertainties and steadily lifts consumer as well as business confidence," he added.


ALSO:


Obama, European leaders working on trade deal


American Airlines-US Airways merger formally announced


Economy's slight shrinkage late last year surprises experts



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Charred human remains found in burned cabin




Charred human remains have been found in the burned cabin where police believe fugitive ex-cop Christopher Dorner was holed up after trading gunfire with law enforcement, authorities
said.


If the body is identified
to be Dorner’s, the standoff would end a weeklong manhunt for the ex-LAPD
officer and Navy Reserve lieutenant who is believed to be responsible for a string of revenge-fueled shootings following his firing by the Los Angeles Police Department several
years ago. Four people have died, allegedly at Dorner’s hands.


The latest burst of
gunfire Tuesday came after the suspect, attempting to flee law enforcement
officials, shot to death a San Bernardino County sheriff’s deputy and
seriously injured another, officials said. He then barricaded himself in a wooden cabin outside
Big Bear, not far from ski resorts in the snow-capped San Bernardino Mountains
east of Los Angeles, according to police.


PHOTOS: Manhunt for ex-LAPD officer


Just before 5 p.m., authorities smashed the cabin's windows, pumped in tear
gas and called for the suspect to surrender. They got no response. Then, using
a demolition vehicle, they tore down the cabin's walls one by one. When they
reached the last wall, they heard a gunshot, officials said, and then the cabin burst into flames.


Los Angeles Police Chief Charlie Beck said he would not consider the manhunt
over until a body was identified as Dorner.


"It is a bittersweet night," Beck said as he drove to the hospital
where the injured deputy was located. The deputy is expected to survive, but it is anticipated that he'll need several surgeries. "This could have ended
much better, it could have ended worse. I feel for the family of the deputy who
lost his life."


TIMELINE: Manhunt for ex-LAPD officer

According to a manifesto that authorities say Dorner posted on Facebook, he felt that the LAPD
unjustly fired him several years ago, after a disciplinary panel determined that he lied
in accusing his training officer of kicking a mentally ill man during an
arrest. Beck has promised to review the case.


The manifesto vowed "unconventional and asymmetrical
warfare" against law enforcement officers and their families. "Self-preservation is no longer important to me. I do not
fear death as I died long ago."






Last week, authorities said they had tracked Dorner, 33, to a wooded area near Big Bear
Lake. They said they found his torched gray Nissan Titan with several weapons inside, and that the only trace of the suspect was a short trail of footprints in newly fallen snow.


INTERACTIVE MAP: Searching for suspected shooter


On Tuesday morning, two maids entered a cabin in the 1200 block of Club View
Drive and ran into a man who they said resembled the fugitive, a law
enforcement official said. The cabin was not far from where Dorner's singed
truck had been found and where police had been holding news conferences about
the manhunt.


The man tied up the maids, and he took off in a purple Nissan parked near
the cabin, the official said. About 12:20 p.m., one of the maids broke free and called police.


Nearly half an hour later, officers with the California Department of Fish
and Wildlife spotted the stolen vehicle and called for backup, authorities said. The suspect
turned down a side road in an attempt to elude the officers but crashed the
vehicle, police said.


FULL COVERAGE: Sweeping manhunt for ex-cop


A short time later, authorities said, the suspect carjacked a light-colored
pickup truck. Allan Laframboise said the truck belonged to his friend. Rick
Heltebrake, who works at a nearby Boy Scout camp.


Heltebrake was driving on Glass Road with his Dalmatian, Suni, when a
hulking African American man stepped into the road, Laframboise said.
Heltebrake stopped. The man told him to get out of the truck.


"Can I take my dog?" Heltebrake asked, according to his friend.


"You can leave and you can take your dog," the man reportedly said. He then
sped off in the Dodge extended-cab pickup -- and quickly encountered two
Department of Fish and Wildlife trucks, officials said.


As the suspect zoomed past the officers, he rolled down his window and fired
about 15 to 20 rounds, authorities said. One of the officers jumped out and shot a high-powered
rifle at the fleeing pickup, they said, and the suspect abandoned the vehicle and took off on
foot.


Police said he ended up at the Seven Oaks Mountain Cabins, a cluster of
wood-frame buildings about halfway between Big Bear Lake and Yucaipa. The
suspect exchanged gunfire with San Bernardino County sheriff's deputies as he
fled into a cabin that locals described as a single-story, multi-room
structure.


The suspect fired from the cabin, striking one deputy, law enforcement
sources said. Then he ducked out the back of the cabin, deployed a smoke bomb
and opened fire again, hitting a second deputy. Neither deputy was identified
by authorities. The suspect retreated back into the cabin.


The gun battle was captured on TV by KCAL-TV Channel 9 reporter Carter Evans, who said
he was about 200 feet from the cabin. As Evans described on air how deputies
were approaching the structure, he was interrupted by 10 seconds of gunfire.


Deputies drew their weapons and sprinted toward Evans. Someone yelled for
him to move -- then about 20 more seconds of shooting erupted.


"Hey! Get … out of here, pal," someone shouted. Evans was
unharmed.


The gunfire gave way to a tense standoff. Mountain residents locked their
doors and hunkered down.


Holly Haas, 52, who lives about a mile from where the shootout unfolded,
said she heard helicopters buzzing on and off until about 3:30 p.m. One dipped so
close to her home, she said, "I could throw a rock and hit it."


Others watched the standoff unfold on television. At her home, Candy Martin
sat down to watch TV when, to her surprise, she spotted her rental cabin -- where the suspect was believed to be holed up -- on the screen.


She said she contacted police and told them that the furnished, 85-year-old cabin had
no cable, telephone or Internet service. No one had booked it for Monday.


"There should have been nobody," she recalled saying. "Nobody
in any way."


Within hours, authorities moved in on the cabin. The fire broke out, setting
off ammunition that had apparently been inside. On TV, viewers saw only the
orange flames and curls of black smoke.


LAPD Chief Beck said his officers have been providing
around-the-clock protection for more than 50 people thought to be Dorner's
targets since the manifesto was discovered.


Police say Dorner's first victims were the daughter of the retired LAPD
official who represented him at his disciplinary hearing and her fiance. Monica Quan and Keith Lawrence were
found shot to death Feb. 3 in their car in their condo complex's parking structure.


Days later, Dorner allegedly attempted to steal a boat in San Diego in a
failed bid to escape to Mexico. By Feb. 7, authorities said, he had fled to the
Inland Empire. In Corona, police said, he fired at an LAPD officer searching
for him at a gas station. About half an hour later, he allegedly opened fire on two
Riverside officers, killing Michael Crain, 34, and injuring his partner.


Early on in the manhunt, officers mistakenly fired on three people in the
Torrance area -- two Latina women and a white man -- while searching for Dorner,
who is 6 feet tall and 270 pounds.


FULL COVERAGE: Sweeping manhunt for ex-cop


After his truck was found in Big Bear, authorities swarmed the area, where
many cabins sit empty during the winter.


At the height of the search, more than 200 officers scoured the mountain,
while others sifted through more than 1,000 tips that poured in after officials
offered a $1-million reward.


Just as some officials began to speculate that the former cop had failed to
survive in the wilderness, Dorner apparently surfaced.


ALSO:


Dorner manhunt: Wounded deputy will need several surgeries


Dorner manhunt: Fish and Wildlife officers make the big break


Dorner manhunt: Maids stumbled on suspect, were tied up, then called 911


-- Andrew Blankstein, Joel Rubin and Ashley
Powers; with Phil Willon, Louis Sahagun, Adolfo
Flores, and Ruben Vives in San Bernardino County and Julie Cart, Matt Stevens, Kate Mather, Wesley Lowery, Samantha Schaefer, Frank Shyong and Rong-Gong Lin II


Photo: San Bernardino County Sheriff's Department public information officer Cindy Bachman updates reporters after a standoff and a shootout with
a man suspected to be former Los Angeles Police Department officer Christopher Dorner. Credit: Kevork Djansezian / Getty Images


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Eric Church leads ACM Awards nominations with 7


NASHVILLE, Tenn. (AP) — They don't call him Chief for nothing: Eric Church is the top nominee at this year's Academy of Country Music Awards.


The rising country music star has seven nominations for the April 7 awards show in Las Vegas. Hunter Hayes is next with six, followed by Taylor Swift and Miranda Lambert at five apiece.


Swift and Lambert are up for the academy's top honor — entertainer of the year — with Lambert's husband, Blake Shelton, Jason Aldean and Luke Bryan. Swift is going for her third straight win in that category.


Shelton and Bryan will co-host the broadcast, to air live on CBS from the MGM Grand.


Along with naming nominees in a series of videos online Wednesday morning, the academy also awarded trophies in the three new artist categories. Jana Kramer is the new female vocalist of the year, Brantley Gilbert is the new male vocalist winner and Florida Georgia Line took new vocal duo or group, as voted by fans. Those three acts will now compete for new artist of the year.


Fans will continue to have a say in that category and entertainer of the year. Fans can vote in those categories beginning March 25 at http://VoteACM.com.


Church's "Chief" is up for album of the year along with Swift's "Red," Bryan's "tailgates & tanlines," Carrie Underwood's "Blown Away" and Little Big Town's "Tornado." Jay Joyce scored a rare double in the category: He produced the Church and Little Big Town albums and will take home a trophy if either wins. He's also up for producer of the year.


Church is also up for male vocalist of the year with 2012 winner Shelton, Bryan, Aldean and Toby Keith. Lambert will be going for her fourth straight female vocalist of the year award with Swift, Underwood, Martina McBride and Kacey Musgraves, a newcomer who earned four nominations.


Others with four nominations include Bryan and Little Big Town. That quartet is up for vocal group of the year with Lady Antebellum, which has won the award three straight times, Zac Brown Band, Eli Young Band and The Band Perry.


Surprise 2012 vocal duo winner Thompson Square is nominated in that category again along with Sugarland, Big & Rich, Florida Georgia Line, and Love and Theft.


Church also is nominated in the song and single of the year categories for "Springsteen." Lambert's "Over You," Hayes' "Wanted," Eli Young Band's "Even If It Breaks Your Heart" and Lee Brice's "A Woman Like You" round out the song of the year category.


Lambert, EYB and Hayes join Church in the single of the year category with LBT's "Pontoon."


A complete list of nominees is available at the academy's Web site.


___


Online:


http://acmcountry.com


___


Follow AP Music Writer Chris Talbott: http://twitter.com/Chris_Talbott .


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Phys Ed: Getting the Right Dose of Exercise

Phys Ed

Gretchen Reynolds on the science of fitness.

A common concern about exercise is that if you don’t do it almost every day, you won’t achieve much health benefit. But a commendable new study suggests otherwise, showing that a fairly leisurely approach to scheduling workouts may actually be more beneficial than working out almost daily.

For the new study, published this month in Exercise & Science in Sports & Medicine, researchers at the University of Alabama at Birmingham gathered 72 older, sedentary women and randomly assigned them to one of three exercise groups.

One group began lifting weights once a week and performing an endurance-style workout, like jogging or bike riding, on another day.

Another group lifted weights twice a week and jogged or rode an exercise bike twice a week.

The final group, as you may have guessed, completed three weight-lifting and three endurance sessions, or six weekly workouts.

The exercise, which was supervised by researchers, was easy at first and meant to elicit changes in both muscles and endurance. Over the course of four months, the intensity and duration gradually increased, until the women were jogging moderately for 40 minutes and lifting weights for about the same amount of time.

The researchers were hoping to find out which number of weekly workouts would be, Goldilocks-like, just right for increasing the women’s fitness and overall weekly energy expenditure.

Some previous studies had suggested that working out only once or twice a week produced few gains in fitness, while exercising vigorously almost every day sometimes led people to become less physically active, over all, than those formally exercising less. Researchers theorized that the more grueling workout schedule caused the central nervous system to respond as if people were overdoing things, sending out physiological signals that, in an unconscious internal reaction, prompted them to feel tired or lethargic and stop moving so much.

To determine if either of these possibilities held true among their volunteers, the researchers in the current study tracked the women’s blood levels of cytokines, a substance related to stress that is thought to be one of the signals the nervous system uses to determine if someone is overdoing things physically. They also measured the women’s changing aerobic capacities, muscle strength, body fat, moods and, using sophisticated calorimetry techniques, energy expenditure over the course of each week.

By the end of the four-month experiment, all of the women had gained endurance and strength and shed body fat, although weight loss was not the point of the study. The scientists had not asked the women to change their eating habits.

There were, remarkably, almost no differences in fitness gains among the groups. The women working out twice a week had become as powerful and aerobically fit as those who had worked out six times a week. There were no discernible differences in cytokine levels among the groups, either.

However, the women exercising four times per week were now expending far more energy, over all, than the women in either of the other two groups. They were burning about 225 additional calories each day, beyond what they expended while exercising, compared to their calorie burning at the start of the experiment.

The twice-a-week exercisers also were using more energy each day than they had been at first, burning almost 100 calories more daily, in addition to the calories used during workouts.

But the women who had been assigned to exercise six times per week were now expending considerably less daily energy than they had been at the experiment’s start, the equivalent of almost 200 fewer calories each day, even though they were exercising so assiduously.

“We think that the women in the twice-a-week and four-times-a-week groups felt more energized and physically capable” after several months of training than they had at the start of the study, says Gary Hunter, a U.A.B. professor who led the experiment. Based on conversations with the women, he says he thinks they began opting for stairs over escalators and walking for pleasure.

The women working out six times a week, though, reacted very differently. “They complained to us that working out six times a week took too much time,” Dr. Hunter says. They did not report feeling fatigued or physically droopy. Their bodies were not producing excessive levels of cytokines, sending invisible messages to the body to slow down.

Rather, they felt pressed for time and reacted, it seems, by making choices like driving instead of walking and impatiently avoiding the stairs.

Despite the cautionary note, those who insist on working out six times per week need not feel discouraged. As long as you consciously monitor your activity level, the findings suggest, you won’t necessarily and unconsciously wind up moving less over all.

But the more fundamental finding of this study, Dr. Hunter says, is that “less may be more,” a message that most likely resonates with far more of us. The women exercising four times a week “had the greatest overall increase in energy expenditure,” he says. But those working out only twice a week “weren’t far behind.”

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Treasury nominee Jacob J. Lew says he would work to boost recovery









WASHINGTON -- Treasury secretary nominee Jacob J. Lew told senators Wednesday that his top priority was to boost the economic recovery while also grappling with the nation's growing debt.


In his confirmation hearing before the Senate Finance Committee, Lew warned that automatic government spending cuts coming March 1 would damage the recovery. And he called for Democrats and Republicans to work together to improve the economy, citing his history of working across party lines.


"In recent years, some have argued that Washington is irrevocably broken, that our government cannot tackle the nation’s most serious problems, that bipartisanship is a thing of the past. I disagree," Lew said in his prepared remarks.





"The truth is, we all share the same goals. We want an economy that is expanding," he said.  


Quiz: How much do you know about looming federal budget cuts?


President Obama nominated Lew, 57, to replace Timothy F. Geithner, who stepped down as Treasury secretary last month. Lew had been Obama's chief of staff, and also served as head of the Office of Management and Budget in the Obama and Clinton administrations.


As the budget director for two Democratic presidents, Lew negotiated spending deals with Republican majorities in Congress. Between his government stints, Lew worked in the private sector. He was president of New York University and worked from 2006 to 2009 at Citigroup.


Lew was managing director and chief operating officer at Citi Global Wealth Management from 2006 to 2008. He held the same position at Citi Alternative Investments in 2008-09.


Lew descibed his role at Citigroup as being "part of the senior management team trying to drive organizational change at one of our nation’s largest banks."


Sen. Orrin Hatch (R-Utah) said he would press Lew at the hearing on his time at Citigroup and was among several Republicans who planned tough questions.


"Some of the units’ activities included proprietary trading along with sales and marketing of risky investments," Hatch said.


"If you knew about the marketing and sales of those investments, it would be instructive for us to find out what you knew," he continued. "If you did not know much about them, then it would be instructive for us to find out why, and to determine exactly what your responsibilities were during your years at Citi when you were very well compensated, including times when Citigroup was being propped up by American taxpayers."


Senate Finance Committee Chairman Max Baucus (D-Mont.) said that Lew, if confirmed, would need to focus on three areas -- job creation, stabilizing the federal goverment's finances and simplifying the tax code.


"The state of the economy is still fragile," Baucus said. "Unemployment near 8% for the next two years is unacceptable."


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