"When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov
''Once you tell people there's a cure for something, the more likely they are to pressure doctors to prescribe it.'' -Robert Ehrlich, drug advertising executive.
"Opinions are like sphincters, everyone has one." - Chris Rangel
Without a Net: A family physician with nothing to lose is practicing without insurance. That's a risky thing to do. If he were sued, he could lose everything:
Other than $45,000 or so equity in his house, he has little savings. He drives a seven-year-old Toyota and has $130,000 in medical school debts.
"There is a certain risk that a patient is taking because I don't have a million-dollar policy," he said.
A trial lawyer finds this appalling, not because the doctor is risking personal ruin by going without insurance, but because he's depriving his patients of the right to jackpot justice:
But Michael Schostok of the Illinois Trial Lawyers Association said Macumber is being irresponsible. "You ought to have insurance to compensate people if you make a mistake that causes harm or death," he said.
I financial, professional, and personal ruin aren't enough compensation. It's the bucks that count.
Credit-Card Eugenics: Couples who undergo in vitro fertilization can, for $3,000, deselect embryos with genetic abnormalities, such as cystic fibrosis, muscular dystrophy, sickle cell anemia, Down's syndrome, etc. Some call that credit card eugenics:
"It is bad that only a few can afford to ask that question,'' he said, ``while the poor will increasingly bear the burden of raising Down's children.''
McGee calls this ``credit-card eugenics'' -- allowing the rich to upgrade their hereditary lineage, while the poor are left with higher rates of disabilities and disease.
PGD testing costs about $3,000, on top of the $10,000 price tag for in-vitro fertilization. Usually neither procedure is covered by insurance.
``In other words,'' McGee said, ``it makes income and money a genetic condition even if there is no gene for being rich or poor.''
UPDATE: A reader observes:
Another ethicist said a memory-enhancing drug should be suppressed because the rich would have better memories than the poor. Both statements are silly and are ignorant of the economics of inventions.
First Phase: When inventions are introduced they are very expensive and only the rich can afford it. These early adopters pay for the R & D costs and also take on the risk of harm from a new technology.
Second Phase: Once the R & D costs have been recovered and the product is improved the price drops to where the middle class can afford it. Volume builds and the price continues to drop.
Once the volume has reached a high enough level the processes are automated and the price becomes low enough so that the poor can afford it.
Two recent inventions come to mind:
DVD players when introduced 6 years ago cost $1200. Now they cost $129.
Lasik eye surgery cost $3000 an eye when first introduced. Now the price is $800 an eye. Lasik surgery is in the Second Phase of the product cycle and the price should continue to drop.
“Punish the Rich Schemes” always punish the poor instead and these ethicists should know better.
Cures from the Sea: A new drug therapy for hard-to-treat cancers such as melanoma and liver cancer is about to undergo clinical trials. It's produced by mulloscs, but only after they've eaten sea slugs. It isn't clear yet how effective the drug will be:
Early trials on 60 patients with cancers of the prostate, breast, liver and colon which had not responded to other cancers showed promising results and demonstrated what the ideal dose was.
This means researchers know what dosage to give patients in the next stage of research, which has just started to recruit patients.
Ana Ruiz-Casado, a cancer specialist from Pharma Mar in Madrid, who is involved in the research, told BBC News Online: "There are some tumours, such as liver, melanomas and mesotheliomas that we do not have many active drugs that we can use.
"So if we have anything, it's better than having nothing."
The protein, Kahalalide F, disrupts the digestive system of cancer cells:
Kahalalide F alters the function of the lysosomal membrane (part of the internal ‘digestive system’ of a cell), a mechanism that distinguishes it from all other known anti-tumour agents. Studies demonstrate that Kahalalide F induces cell necrosis in vivo (oncosis) and shows selectivity for tumour compared to normal cells in vitro.
And it's natural!
The man who discovered the protein died earlier this year, but a description of some of his other work is here. There's a wealth of treasure under the sea.
Cures from the Sea: A new drug therapy for hard-to-treat cancers such as melanoma and liver cancer is about to undergo clinical trials. It's produced by mulloscs, but only after they've eaten sea slugs. It isn't clear yet how effective the drug will be:
Early trials on 60 patients with cancers of the prostate, breast, liver and colon which had not responded to other cancers showed promising results and demonstrated what the ideal dose was.
This means researchers know what dosage to give patients in the next stage of research, which has just started to recruit patients.
Ana Ruiz-Casado, a cancer specialist from Pharma Mar in Madrid, who is involved in the research, told BBC News Online: "There are some tumours, such as liver, melanomas and mesotheliomas that we do not have many active drugs that we can use.
"So if we have anything, it's better than having nothing."
The protein,Kahalalide F disrupts the digestive system of cancer cells:
Kahalalide F alters the function of the lysosomal membrane (part of the internal ‘digestive system’ of a cell), a mechanism that distinguishes it from all other known anti-tumour agents. Studies demonstrate that Kahalalide F induces cell necrosis in vivo (oncosis) and shows selectivity for tumour compared to normal cells in vitro.
And it's natural!
The man who discovered the protein died earlier this year, but a description of some of his other work is here. There's a wealth of treasure under the sea.
Unsettling:John Ray uncovers evidence that relocating from a war-torn country to a new country is more stressful than staying. It's an oft repeated fact that change of any kind is the number one cause of depression. Perhaps keeping with the familiar gave the Bosnians who stayed home the strength to deal with their adversities. posted by Sydney on
9/25/2003 11:05:00 AM
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Nothing Left to Lose: Here's a story from my state family physician association that is, unfortunately, not available online. Fed up with wrangling with insurance companies and working harder for less money because of it, two family physicians in Jamestown, Ohio, decided to stop participating in commercial health insurance plans. Instead, their patients pay them for their services. Anyone with commercial insurance has to send in a request for reimbursement themselves to the insurance company. At first, it was tough:
The intense negative feedback from patients lasted two or three months. Hundreds of patients transferred to other physicians....The turbulence in the practice lasted six months. Many patients were angry, while others were sad. It was difficult to go anywhere in twon because of the amount of negative feelings.
But like lancing a boil, the pain soon gave way to relief:
Now they are all glad they have more financial freedom. Their racks of active medical records are now as full as before the change. Their patients are more satisfied, and patients do not complain that they cannot get in.
....The physicians almost always leave at 5pm. Each physician has one morning when he makes nursing home rounds. Each physician has one day off each week. They have no Saturday hours.
....In the first year of the "no commercial insurance" policy, the physicians increased their income. Now they are ecstatic about the decision....the accounting sheets demonstrate a collection rate of 88.6% for 2002!
And they still accept Medicaid and Medicare because they feel they have an obligation to serve the underserved. According to the author, the doctors don't have much competition in their small town. The only other primary care physician in town is one internist. I'm not sure if this strategy would work in a suburb or a city where patients only have to travel a few blocks to go to a new doctor rather than a few miles, but as I wait and wait (going on the fourth week now) for the first of my insurance company payments, their approach sure is tempting.
And, you know, it really is a better arrangement. It makes the patient aware that his healthcare insurance is a business agreement between himself and his insurance company, not his doctor and the insurance company. posted by Sydney on
9/25/2003 10:20:00 AM
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Brave New Brains:We’re living in a brave new world. Or at least our brains are. No longer ensconced behind the fortress of our skulls, they’re giving up their secrets to new functional imaging technology. Scientists seeking the source of our being and intelligence are no longer confined to comparing the heft and convolutions of dead genius brains to ordinary brains, but can now compare living, thinking brains in action. They can see the physiological difference between the ordinary and the extraordinary, the novice and the expert, and our good thoughts and our bad thoughts - taking us closer to our inner selves than we’ve ever been before. One day, this understanding may make the lame walk, the blind see, the slow quick, and the bad good. But at the same time, our poor brains are being assaulted by less noble technological advances. They’re pulled every which way by television, portable music, the internet, cell phones and multitasking jobs - causing a deficit of attention on a national scale. Which will win out? Will neuroscience discover the secret workings of our most inner selves in time to save us from the distraction and dislocation of our information age? Neuropsychiatrist and noted author Richard Restak attempts to answer that question in his latest book, The New Brain. But alas, the answer is far from clear.
On the one hand, Restak is optimistic. He gives us ample proof throughout the book of the amazing plasticity of our minds. Using PET scans and functional MRI’s, science has recorded not only the differences between the ordinary and the extraordinary brain, but the rewiring of the ordinary toward the extraordinary with the right kind of learning. He documents cases of the blind learning to see, the paralyzed learning to move, and the dyslexic learning to read which prove that our brains’ internal circuits are not hard-wired, but amazingly supple and open to infinite remodeling.
On the other hand, he is also very pessimistic. With very little proof, but much reliance on pop psychological theory, he blames cell phones and our noisy, fast, culture for attention deficit disorder, a condition which he describes as “epidemic.” He takes that theory one step further to suggest that our modern distractions are, in fact, rewiring our brains to make attention deficit not a disorder, but the norm. In a similar vein, he argues that television is rewiring our brains toward violent inclinations. Noting studies that show decreased activity in the orbitofrontal cortex of the brain (the center of our inhibitions) when we think aggressive thoughts and others that show a correlation between the number of hours of television watched a day and an inclination to assault others, Restak makes an astounding leap in logic. Television must be rewiring our inhibition centers, turning them off or turning them down so that we give in to our basest tendencies. But surely, there are other reasons for the correlation between television viewing and violence. Whatever it is that gives a person enough free time to watch more than three hours a day of television - unemployment, willful idleness, depression - might just as likely be the source of the violence. Idle hands are the devil's tools , you know.
And what about that amazing plasticity the author catalogues so well in the rest of his book? If our brains are flexible enough to learn all over again how to walk, to see, to read; aren’t they also flexible enough to adapt to cell phones and multi-tasking jobs? Couldn't it be that the information age isn't making our brains less attentive, but more agile? And if, with the right kind of practice, an ordinary brain can rewire itself to do extraordinary tasks, isn't it also strong enough to overcome the evil influence of television?
Fortunately, these two theories make up but a small portion of the book. The rest of it is an interesting journey through the state of the art of neuroscientific and behavioral research and its implications for the future. Much of it is speculative, of course, for although we’re learning more about the brain every day, its inner workings still remain a mystery wider than the sky, deeper than the sea.
One interesting facet, though, is that most of the groundbreaking recent advancements that Restak notes have been not in pharmacology as it was in the past twenty five years, but in microelectronics and the understanding of the brain’s electrophysiology. In one of Restak’s early books, The Brain: The Final Frontier, written in 1979, he opened with the prediction that in the year 2000, the Nobel Prize in physics (not medicine) would be given for brain research. That didn’t happen. It was given, ironically, for research that made our burgeoning information technology possible. The very technology that Restak now argues is poisoning our minds. The Nobel Prize in Medicine that year, however, was given for brain research, albeit of the pharmacological sort. Perhaps in another twenty years, nanotechnology will make his original prediction come true, and it will be electrophysiology, not biochemistry, that underpins our treatment of the diseased brain. Let’s just hope that when that day comes we use it wisely.
Fashionable at Any Cost: Cosmetic foot surgery is gaining a toe hold in the popular imagination:
Dr. Stephen Smith of Irvine, Calif., says he turns away at least 50 patients a year who seek cosmetic fixes. 'We have some people come in and say, 'My foot is too wide. Can you get rid of my little toe?'' he says.
Fooling the Brain: A European seizure drug (not used in the U.S. because of its visually disturbing side effects) helps some addicts quit cocaine. Twenty addicts in Mexico were given the drug, gamma vinyl-GABA (GVG), or vigabatrin:
Eight addicts who received the medicine daily for six weeks have been clean for more than two months, some for almost 90 days. Twelve addicts dropped out.All were volunteers in a study, published yesterday in the journal Synapse, that was conducted by scientists at Brookhaven National Laboratory, New York University School of Medicine and an addiction treatment clinic in Mexico
...."GVG reduces levels of dopamine, the 'feel-good' chemical that floods the brains of cocaine users, providing the 'high' they crave," said Dr. Frank Vocci, director of the national institute's treatment research. "Using GVG to temper the dopamine system may very effectively block the addiction-related effects of cocaine."
Yet twelve out of twenty is a fairly large drop-out rate. What about side effects?
Dewey said that the eight who remained have not complained of visual problems, but they have gained an average of 18 pounds.
Oh, well, it doesn’t have a chance in the States. Our war on obesity is trumping everything else at the moment. Can’t have those skinny addicts putting on weight. posted by Sydney on
9/24/2003 06:23:00 AM
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Wonderful World: Through the wonders of technology, a soldier in Baghdad attends the birth of his daughter in New York:
Rojas called Saturday afternoon to see how labor was progressing, and his sister told him to call back in four hours, Rodriguez said. When he called again at midnight, his sister took the call in the hospital lobby and was on the phone when their mother motioned to her and told her the baby was on the way.
She told her brother he had to call back in about an hour because the baby was coming. Certified nurse/midwife Debby Katz, who was working with Rodriguez, overheard the conversation and asked if that was the father on the phone. Once Katz found out it was, she told Rojas' sister that she could bring the phone into the delivery room.
The hospital had reduced its restrictions on cell phone use about a month ago for certain areas of the hospital, Katz said. Besides, she said, everybody involved in the delivery knew that Rojas was in Baghdad.
'When there's no male present, we always ask about the situation,' Katz said. 'We knew Ricky was over in Iraq, so when it was time for her to start to push, they asked if they could bring the phone in so he could be part of this. Normally, we only allow one or two people, but this was different.'
Rodriguez said her mother was coaching her, her mother-in-law was moving the phone 'as if it were a video camera' placing it where the action was, and her sister-in-law was crying in the background. At 12:20 a.m. Sunday, Amaya was born at 6 pounds, 11 ounces, and 19 inches.
I always thought hospitals were overly strict about cell phones. Glad to see one loosening its restrictions - and all for the good of at least one family. posted by Sydney on
9/24/2003 06:17:00 AM
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Trust Me.... Retired chairman of the Joint Chiefs of Staff, Gen. H. Hugh Shelton, you may remember, fell from a ladder over a year ago and was paralyzed. He's doing fine now, and here's why:
The doctor told Shelton he would never walk or use his hands again. Shelton said he checked the doctor's name tag for 'God'; he didn't see it. Eighty-four days later he walked out on his own, and he is now close to 100 percent recovered.
Non-Medical Aside: This comment by General Shelton was also revealing:
"What do you think of General Wesley Clark and would you support him as a presidential candidate," was the question put to him by moderator Dick Henning, assuming that all military men stood in support of each other. General Shelton took a drink of water and Henning said, "I noticed you took a drink on that one!"
"That question makes me wish it were vodka," said Shelton. "I've known Wes for a long time. I will tell you the reason he came out of Europe early had to do with integrity and character issues, things that are very near and dear to my heart. I'm not going to say whether I'm a Republican or a Democrat. I'll just say Wes won't get my vote."
Ouch.
UPDATE: A reader comments:
A very disappointing quote from a man of apparent integrity and obvious personal courage--either just say you are not going to vote for him (Clark) or state the reason--alluding to ill defined character flaws is tacky and incomplete--if professional obligations or confidentiality makes it inappropriate to disclose the reasons then just say "I am not going to vote for him and I will not discuss it further--period. Next question please.
He reportedly circumvented both Secretary of Defense William Cohen and Joint Chiefs of Staff Chairman Gen. Henry Shelton on numerous occasions in speaking directly to the media and the president. In fact, the situation got so bad that Gen. Clark was relieved of his NATO position several months before his term ended, and in a major snub, neither Mr. Cohen nor Gen. Shelton attended his retirement ceremony/ posted by Sydney on
9/24/2003 06:14:00 AM
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Real Disease Survivors: Unlike Ann Richards and her "battle" against osteoporo.. oops, I mean, osteopenia... children with cancer can justifiably brag about surviving their disease. Not only do they go through difficult and often painful treatment at a young age, but they're at risk for later health problems, too, at least in terms of functional impairment, perception of their general health, pain, and anxiety.
Surviving cancer in childhood can lead to health problems later in life, according to a study.
Researchers found nearly half go on to develop at least one fairly significant health problem linked to their cancer, or its treatment.
But what’s really amazing is that the majority come out of their ordeal psychologically intact:
Almost 20% of survivors showed signs of psychological distress.
So the vast majority show no signs of psychological distress.Yet another testament to the resilience of the human spirit.
Metaphor Abuse: Combat metaphors are common in medicine. Doctors in training refer to newly admitted patients as "hits," researchers describe their work as a "quest" for a cure, and those fortunate enough to be cured are called "survivors." But sometimes, the metaphor can be taken too far. Take, for example, former Texas governor Ann Richards' new book about osteoporosis:
She was in Fort Worth to promote her new book, I'm Not Slowing Down (Dutton, $23.95), an account of winning her battle with osteoporosis, and to urge women to start taking better care of themselves. (emphasis mine)
As opponents go, osteoporosis is an ideal one. In most cases, it's a consequence of aging. It isn't disabling. Although it does make one more prone to breaking bones, having it isn't painful. It's completely asymptomatic. There's some debate about whether or not it should even be considered a disease. It's a finding on an x-ray, and the consequence of those findings are themselves controversial, guidelines not withstanding. And it certainly isn't fatal, although in her rush to claim the mantle of survivor Richards insists otherwise:
Even today, people don't think of osteoporosis as a fatal disease, but it is, Richards insists.
``My mother died of it."
She did?
".... Well, that is not literally true. She died of cancer, but I swear her spirit died from osteoporosis. Mother just accepted it as part of aging, just part of growing older, but it's not. It's a disease, and there's medicine for it,'' she says."
Richards's mother, apparently, had more sense than she does. Or at least didn't crave the limelight as much. What's more, Richards doesn't even have osteoporosis:
I have osteopenia, a less severe form of it, because I started taking medication and doing weight-bearing exercise.
``I'll be damned if I'm going to let a disease like this slow me down,'' says Richards, whose osteopenia was diagnosed after she fell in September 1996.
Lucky for her, you don't have to try too hard to keep osteopenia from slowing you down:
Bone density naturally declines with age. By definition, 45% of white women aged 55 have 'osteopenia' - but this definition was not intended to be a treatment guideline. We can't all be above average!
No, but many of us can pretend to be!
ADDENDUM: Don't suppose this has anything to do with her book, do you?
One of the other high profile people at the Lilly-supported Roundtable of International Women Leaders was the former governor of Texas, Ann Richards. Just days after that Lisbon meeting Ms Richards appeared on CNN's Larry King show, talking about the star-studded roundtable on osteoporosis and strongly endorsing the value of a good diet and plenty of exercise. She also revealed she was taking a medication. According to the transcript, she told Larry it was 'Evista. It works for me.' Her assistant later confirmed that Ann Richards worked for Lilly from time to time.
The Other Side: An interesting article from the Washington Post on the travails of the obese, and he has statistics to back up something I've noticed and written about before:
Research demonstrates that the overweight are under-served. Puhl and Brownell cite a 1993 study in Women's Health that showed that the heavier a woman is, the less likely she is to undergo a pelvic examination. Another, a 1998 study in the Archives of Family Medicine, concluded that higher BMI measurements were associated with fewer preventive procedures like Pap smears and breast examinations. Yet another, published in 1994 in the Archives of Family Medicine, demonstrated that the higher a woman's BMI, the more likely she is to delay or cancel a visit to the doctor.
It is not a matter of the system refusing to treat the obese. It is the obese choosing not to use the system, because they feel put down by it, constantly reminded that they should do what so many of them seem unable to do: lose weight.
And that reluctance to go the doctor is one of the reasons behind the higher rates of cancer and other diseases in the obese. It isn't all due to their fat levels.
posted by Sydney on
9/22/2003 11:01:00 PM
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Cutting Edge for Deep Pockets: A while back I mentioned a patient of mine who was spending $600 a month on an injectable parathyroid hormone to help with osteoporosis. Or at least his insurance company was paying for it. The sticking point was that the drug wasn’t all that effective in clinical trials - at least not $600 a month effective. The brother of that drug is in the news today, having recently been found to be more effective when used alone than when used in combination with an oral osteoporosis drug, Fosamax:
The interim results come from a one-year study, sponsored by the National Institutes of Health, in 238 post-menopausal women.
Some received only Preos, a bioengineered full-length version of human parathyroid hormone, some only Fosamax, an osteoporosis drug sold by Merck & Co., while others were treated with both drugs.
Bone mineral density at the spine increased in all the treatment groups, but was highest, at a rate of 6.3 percent, in the parathyroid hormone group. The volume of spongy bone at the center of the spine also increased, but the 24 percent increase in the parathyroid hormone group was about twice that found in either of the other groups.
Increased bone density at the hip was highest with Fosamax, but the volume of bone was actually higher with Preos. 'The inference is that you're building new bone on the outside,' Black said, noting that other studies suggest that it takes more than a year of hormone therapy for bones to mineralize.
Notice that the end-spin is that the parathyroid hormone is more effective than Fosamax, no matter how you slice it. But in reality, it isn’t all that much more effective. For men, taking parathyroid hormone for thirty months increased the bone density at the spine by a mean of 18% compared to 8% for Fosamax. In the hip, parathyroid hormone increased the bone density by 6% compared to 4% for Fosamax.
And the findings in women were even less impressive. Parathyroid hormone increased bone density in the lumbar spine after one year of use by a mean of 6%, while Fosamax increased it by 4%. In the hip, parathyroid hormone increased bone density by less than 1%, while Fosamax increased it by 2%.
Fosamax itself isn’t cheap (anywhere from $80 to $150 per month), but it’s still a lot less expensive than parathyroid hormone. And even more to the point - neither of them bring about dramatic changes in bone density. The risk of fractures is still very real in their users. Which leaves one wondering if either of them are truly worth their price. posted by Sydney on
9/22/2003 10:12:00 PM
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Medical Blog Alert:Blacktriangle is an excellent pharmacuetical blog by an adverse reaction pharmacist (If only we had those in the U.S. Do we have those in the U.S.?) posted by Sydney on
9/22/2003 09:46:00 PM
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Where the Money Goes: Here's an interesting breakdown of where our healthcare dollars go:
The biggest factor behind rising health-care costs is medical ad vances - new drugs, de vices, treatments and testing, accord ing to a study by Pricewaterhouse Coopers LLC.
Such advances added 3 percent, or $15 billion, to health-care costs between 2001 and 2002, according to the accounting and consulting firm's study.
Prescription drug prices 'have pretty much spiraled out of control,' said Keith Carnahan, benefits consultant at CBIZ Benefits and Insurance Service of Ohio Inc. in Independence. More drugs are helping us live better and longer. But they come at a steep cost, Carnahan said.
We do prescribe more costly drugs these days, but not all of them help us live "better and longer."
Service providers, such as doctors or hospitals, are ordering more tests with costly technologies.
"Every provider has an income target," said Werner Gliebe, a vice president in the Cleveland office of employee benefits consultant Segal Co. "We don't control the number of units of service that are ordered by a provider."
Hospitals and other providers are passing on their own increasing costs. After under-investing in their physical plants during the mid- and late 1990s, hospitals are again building and renovating, the study said. Meanwhile, industry consolidation and rising patient admissions mean fewer care providers, so they have the leverage to raise their prices.
That one's a bit dubious. Hospitals and doctors can't increase their prices - Medicare mandates how much they can charge. One could argue that some specialists order tests - which they then interpret for a fee - to boost their income, but most doctors don't get reimbursed for the tests they order.
Growing government mandates and regulation added $10 billion to health-care costs during the study period, PricewaterhouseCoopers said. The U.S. Department of Health and Human Services estimates the cost of complying with just one law - the Health Insurance Portability and Accountability Act, which makes sure workers who switch jobs get health insurance - was $3.8 billion over five years.
That I can believe, although it isn't just the portability part that's added costs, it's also all the effort and paperwork that's needed to protect privacy - or to at least provide the illusion of protecting privacy.
We use more medical care as we get older. And members of the aging baby boom generation, the oldest of whom are approaching 60, want the best care available.
Which is one reason the managed care model has failed. It was just too easy to paint the insurance companies as villains whenever they denied the latest cutting edge care - even if its benefits were dubious.
On top of those factors pushing the cost of health care up, something else is driving rates for health insurance. Health insurers are consolidating, Klonk said. Only five or six major insurers serve midsize companies in Greater Cleveland, half as many as a decade ago, which means that employers have fewer choices and that insurers have the leverage to raise prices or limit coverage.
"The market is very limited," Klonk said, especially for employers that have sicker workers. Although the market is improving because remaining carriers are profitable, the whole of the insurance industry has "minimal capacity for risk," he said.
Another reason that health insurance should be divorced from employment. Bigger risk pools can only help both the insurance companies and the insured.
The Secret to Happiness: From the letters page of the New York Times Sunday Magazine, by one Harvey Kliman:
As in physics, it may be time to suggest a unifying theory for happiness: Happiness = (Reality x Flexibility) - Expectations.
NOTE: The print version subtracts expectations while the internet version divides by them. I'm not sure which version Mr. Kliman sent them, but I like the print version. It implies that flexibility is much more important than downsizing expectations.
