Archive for August, 2007

Top doctors

from the Washington Post:

Doctors Rated but Can’t Get a Second Opinion
Inaccurate Data About Physicians’ Performance Can Harm Reputations

By Ellen Nakashima
Washington Post Staff Writer
Wednesday, July 25, 2007

After 26 years of a successful medical practice, Alan Berkenwald took for granted that he had a good reputation. But last month he was told he didn’t measure up — by a new computerized rating system.

A patient said an insurance company had added $10 to the cost of seeing Berkenwald instead of other physicians in his western Massachusetts town because the system had demoted him to its Tier 2 for quality.

“Who did you kill?” the man asked sardonically, Berkenwald recalled.

In the quest to control spiraling costs, insurance companies and employers are looking more closely than ever at how physicians perform, using computers, mountains of health claims and billing data and sophisticated software. Such data-driven surveillance offers the prospect of using incentives to steer patients to care that is both effective and sensibly priced.

It also raises questions about the line between responsible oversight and outright meddling in the relationship between caregivers and their patients. And it shows how people such as Berkenwald are at risk of losing control of their reputations as corporations and other organizations mine electronic data to draw conclusions about them and post them online.

The trend is in its infancy, but such programs are already in more than 100 insurance industry markets or regions across the country, from entire states such as Massachusetts to metropolitan areas such as Los Angeles. Supporters say the programs have slowed the rate of growth of insurance premiums by 3 to 6 percent in their first year.

Arnold Milstein, chief physician for Mercer Health and Benefits, a health-care consulting firm based in New York, said that employers and insurers fully expect resistance but that the benefits are undeniable.

“In every industry, consumers have a thirst for performance information,” said Milstein, whose firm is analyzing data for the Massachusetts program that ranks physicians. “People don’t want to go to a movie or buy a book or buy a car or go to a restaurant without some ability to assess value for dollar. What’s taking place here is inevitable.”

Physicians who have been profiled, including those with top ratings, say that the data often contain errors and that doctors often lack the ability to correct them. The effort is more about cutting costs than raising quality, some say, adding that doctors could begin to “cherry pick” healthier patients whose problems are less costly to treat. Such systems fail to capture the intangibles of quality, such as a doctor who visits a dying patient at home, critics say.

The trend, which parallels a push by President Bush to promote consumer access to information about health-care quality and cost, has spurred a lawsuit in Seattle, a physician revolt in St. Louis and a demand by a state attorney general that one insurer halt its planned program.

Physician profiling relies on the growing practice of creating electronic medical records. Once kept only on paper, records about patients, doctors, hospitals, pharmacies and other caregivers are increasingly aggregated in giant digital storehouses. In Massachusetts, six health plans pooled their data after stripping away names, and the resulting 120 million claims are crunched by analysts to assess a doctor’s performance.

Doctors are rated on standards of quality of care and cost efficiency. An internist, for example, gets higher ratings on quality if he puts his heart attack patients on beta blockers, a medicine that reduces the workload on the heart, or if diabetic patients are tested for blood-sugar control.

Analysts assess cost efficiency by looking at factors such as how many and what types of exams were conducted. Was a breast mass biopsy done in a hospital with an overnight stay or in an out-patient clinic? Was a generic or brand-name pain medication prescribed?

Doctors are then rated against peers in the same community, by type of patient and illness, and against clinical performance guidelines created by specialists such as the American Heart Association.

The systems differ. A doctor who performs well might be awarded stars, a smiley face or a Tier 1 rating. An inferior doctor’s patients might receive higher co-payments, or the physician might be shut out of an insurer’s preferred network.

In the Washington metropolitan area, UnitedHealthcare has been gathering and evaluating data on physicians and in January rolled out a Web site that ranks physicians with zero, one or two stars. Officials at the District of Columbia Medical Society said they were told that the goal of the Premium Designation program was to encourage physicians to refer patients to two-star doctors and for patients to seek out two-star physicians.

“We were shocked that they would be profiling physicians for the past 18 months and not tell anyone,” said Peter Lavine, chairman of the board of the medical society, which met with UnitedHealthcare officials last fall.

Officials with UnitedHealthcare, the nation’s second-largest health insurer and a unit of UnitedHealth Group of Minnetonka, Minn., said the goal is merely to provide information to consumers and to help doctors improve their performance.

“Our focus is really on transparency,” said Lewis Sandy, UnitedHealth Group senior vice president for clinical advancement.

UnitedHealthcare announced it would delay launching its program in New York, New Jersey and Connecticut after doctors complained and after New York Attorney General Andrew Cuomo threatened legal action.

One doctor fighting ratings systems is Seattle internist Michael Schiesser, who said his rating plummeted from excellent to the 12th percentile within a few months. He said initially Regence BlueShield, an insurer in the Northwest, ranked him in its top 90th percentile of doctors and awarded him a $5,000 check.

Later, when Regence cut him from its network and patients had to pay out-of-pocket to see him or go elsewhere, he pressed to see his report. He said he discovered that he had been penalized because of errors in data-gathering.

“I couldn’t believe the extent to which they had botched the data,” he said.

He said Regence faulted him for failing to control diabetes in patients who did not have the disease. He said he was docked points for not performing a Pap smear on a woman who had a hysterectomy. He added that his colleague was faulted for not performing a mammogram on a woman who had undergone a double mastectomy.

Last fall, Schiesser joined five other doctors and the Washington State Medical Association in suing Regence BlueShield, claiming defamation and deceptive business practices after the health plan told participating members that they no longer had access to about 500 doctors because the doctors did not meet the insurer’s quality and efficiency standards.

Regence spokesman Charlie Fleet said that because of the lawsuit, the company could not comment on the data issue. He did say, however, that the data were “provided from the physicians themselves.”

In December, Regence abandoned its plan.

Doctors critical of ratings systems say they are held accountable for whether patients exercise, take their medications or follow their prescribed regimens.

Berkenwald, the Massachusetts internist, said he was pushed from Health New England’s top 10 percent of physicians into its second tier because several of his female patients did not get the mammograms or Pap smears he prescribed.

But Berkenwald received a top-tier rating by several other insurers participating in the state’s Clinical Performance Improvement Initiative because the health plans use different cut-points for determining who falls into which tier.

Disparate ratings can confuse patients and cause turbulence in group practices.

When Elizabeth Trobaugh of Amherst, Mass., had a tick bite last fall and her family doctor was not available, she saw her doctor’s partner, who had a lower rating. Trobaugh was upset when she was charged a $10 higher co-pay. “Why should I be penalized for going to this person’s partner?”

Despite its flaws, proponents say the systems encourage much-needed quality and cost control.

Dolores Mitchell, executive director of the Massachusetts Group Insurance Commission, which launched its physician-rating program four years ago, said she’s heard doctors’ complaints about errors. But at $1 billion in annual spending on health care, she said, improving performance and efficiency is crucial.

“The data may not be perfect,” she said. “But they’re better than any data that we’ve had before.”

Staff researcher Richard Drezen contributed to this report.

Are Doctors to Blame for US Health Care Costs?

NY Attorney General Objects to Insurer’s Ranking of Doctors by Cost and Quality

Insurers’ Lists on Doctors Under Fire

Plan Would Tie Copayments to Doctors’ Rankings



from the New York Times
The Nation
Sending Back the Doctor’s Bill

Published: July 29, 2007
Correction Appended

HOW to fix the health care system?
Easy, liberals say. If Washington would just force cuts in prescription drug prices and insurance company profits, plenty of money would be left over to cover the uninsured.

Conservatives prefer to argue that the answer lies in forcing people to pay more of their own medical costs.

But many health care economists say both sides are wrong. These economists, some of whom are also doctors, say the partisan fight over insurers and drug makers is a distraction from a bigger problem: the relatively high salaries paid to American doctors, and even more importantly, the way they are compensated.

“I always find it ironic that when I go to doctor groups and such, they always talk about the cost of prescription drugs,” said Dana Goldman, director of health economics at the RAND Corporation, a nonprofit research institute in Santa Monica, Calif.

Prescription drugs cost, on average, 30 percent to 50 percent more in the United States than in Europe. But the difference in doctors’ salaries is far larger, Dr. Goldman said.

Doctors in the United States earn two to three times as much as they do in other industrialized countries. Surveys by medical-practice management groups show that American doctors make an average of $200,000 to $300,000 a year. Primary care doctors and pediatricians make less, between $125,000 and $200,000, but in specialties like radiology, physicians can take home $400,000 or more.

In Europe, however, doctors made $60,000 to $120,000 in 2002, according to a survey sponsored by the British government in 2004.

Given the years of training that doctors require and the stress and importance of their jobs, few would disagree that they should be well paid. In addition, with a year of medical school now about $30,000, many doctors leave school deeply in debt. And many doctors would argue that cutting salaries would only persuade talented, college graduates to pursue better-paying professions.

Still, the lower salaries are a significant part of the reason that European countries spend less on health care than the United States does — a fact liberals avoid mentioning when they preach the advantages of a European-style single-payer system.

Americans generally do not seem to mind the fact that doctors are well paid. In public opinion surveys, doctors usually rank as the most trusted professionals. Congress has repeatedly blocked Medicare’s efforts to reduce the amount it pays for each procedure doctors perform, even though overall Medicare payments to doctors are soaring and the cuts are legally required to keep the program’s budget balanced.

The way that doctors are paid may be an even more significant factor driving up costs and may lead to unnecessary care, said Dr. Peter B. Bach, a pulmonary physician at Memorial Sloan-Kettering Cancer Center and a former senior adviser to Medicare and Medicaid.

In the United States, nearly all doctors are paid piecemeal, for each test or procedure they perform, rather than a flat salary. As a result, physicians have financial incentives to perform procedures that further drive up overall health care spending.

Doctors are paid little for routine examinations and very little for “cognitive services,” such as researching different treatment options or offering advice to help patients get better without treatment.

“I don’t have a view on whether doctors take home too much money or not enough money,” Dr. Bach said. “The problem is the way they earn their money. They have to do stuff. They have to do procedures.”

Primary care doctors and pediatricians, who rarely perform complex procedures, make less than specialists. They are attracting a declining percentage of medical students, and some states are facing a shortage of primary care doctors.

Doctors are also paid whether the procedures they perform go well or badly, Dr. Bach said, and whether they are crucial to a patient’s health or not..

“Almost all expenditures pass through the pen of a doctor,” he said. So a doctor may decide to perform a test that costs a total of $4,000 in order to make $800 for himself — when a cheaper test might work equally well. “This is a highly inefficient way to pay doctors,” Dr. Bach said.

Medicare, especially, does not like to second-guess doctors’ clinical decisions, said Dr. Stephen Zuckerman, a health economist at the Urban Institute. “There’s not a lot of utilization review or prior authorization in Medicare,” he said. “If you’re doing the work, you can expect to get paid.”

As a result, doctors have steadily increased the number of procedures they perform on Medicare beneficiaries — and thus have increased their income from Medicare, Dr. Zuckerman said. But the extra procedures have not helped patients’ health much, he said. “I don’t think there’s any real strong evidence of improvements in health status.”

Private insurers like H.M.O.’s are more aggressive than Medicare in second-guessing physicians’ clinical decisions, and they will refuse to pay for imaging scans or other expensive new procedures. Now Medicare and private insurers are moving cautiously to change the current system. Recently, they have proposed pay-for-performance measures that would give doctors small bonuses if their care meets the standards set by national medical organizations such as the American Heart Association.

BUT all those measures are a minor fix, said Dr. Alan Garber, a practicing internist and the director of the Center for Health Policy at Stanford University. Instead, he argues, the United States should move toward paying doctors fixed salaries, plus bonuses based on the health of the patients they care for.

Even in the existing system, some health insurers, notably Kaiser Permanente, already have large networks of salaried doctors. But it would require doctors to give up some of their autonomy and move into larger group practices or work directly for insurers, a step they have been reluctant to take. About 40 percent of doctors are in single or two-physician practices, Dr. Garber said.

Nor is the American Medical Association, which represents doctors, eager for wholesale changes in the system, said Dr. Edward L. Langston, chairman of the A.M.A. board.

Insurance company profits and the rising cost of preventable diseases like diabetes are big culprits in soaring health care spending, Dr. Langston said.

But Dr. Goldman of RAND said that doctors are misleading themselves if they think the current system serves patients’ needs.

For example, if a diabetic patient visits a doctor, he said, “the doctor is paid to check his feet, they’re paid to check his eyes; they’re not paid to make sure he goes out and exercises and really, that may be the most important thing.”

“The whole health-care system is set up to pay for services that are rendered,” he said, “when the patient, and society, is interested in health.”

Correction: August 12, 2007

An article on July 29 about how doctors’ compensation affects health-care costs misstated the views of Dr. Alan Garber, an internist and the director of the Center for Health Policy at Stanford University. He said health care organizations like Kaiser Permanente, which have salaried doctors on staff, are a good model for the future, but he did not say that all doctors should eventually be salaried.


NY Attorney General Objects to Insurer’s Ranking of Doctors by Cost and Quality

Insurers’ Lists on Doctors Under Fire

Plan Would Tie Copayments to Doctors’ Rankings

Physician Rankings: Who are They Really Good For?

Positive Psychology: The Science of Happiness

Posted: August 11, 2007 by Doc in Happiness


from Harvard Magazine Aug 2007
The Science of Happiness
Psychology explores humans at their best.

by Craig Lambert

This doesn’t feel like a normal academic conference. True, the three-day Positive Psychology Summit is a sellout, with 425 attendees thronging the meeting rooms in downtown Washington, D.C. But despite the familiar trappings, something seems different. There’s herbal tea available at breaks, and the conference’s organizer, Shane Lopez of the University of Kansas, walks around smiling and ringing a dinner bell to prompt people to take their seats for the next session. This group is slimmer, healthier, younger, and more female than the usual scholarly crowd. Some stretch in yoga-like postures in the aisles, or recline on friends’ bodies as if resting on a chaise longue. The professional jargon includes recurring words like flow, optimism, resilience, courage, virtues, energy, flourishing, strengths, happiness, curiosity, meaning, subjective well-being, forgiveness, and even joy.

But the main difference probably shows up in the question periods. Typically, academics seem obsessed with poking holes in the argument of the presentation just made—finding fault, pointing out counter-examples, insisting on qualifications—with the transparent purpose of one-upping the speaker. Such shenanigans are absent here. “They’re trying to build,” explains one participant. “There’s none of this academic carping,” observes professor of psychiatry George Vaillant, who has spoken at five of these “summit” events. “The teaching exercises I’ve done for positive psychology audiences have been an absolute joy. Here, people really laugh at the jokes.”

This October morning, they are laughing with Tal Ben-Shahar ’96, Ph.D. ’04, an associate of the Harvard psychology department, who argues in his opening keynote address that positive psychologists need to build bridges between “the ivory tower and Main Street,” to unite academic rigor with the accessibility of popular psychology books. “Most people do not read the Journal of Personality and Social Psychology,” he notes. “In fact, one of my colleagues at Harvard did a study, and he estimated that the average journal article is read by seven people. And that includes the author’s mother.”

Ben-Shahar is a psychologist and author who has never pursued a tenure-track position nor published research in professional journals (even so, his third book, Happier: Finding Meaning, Pleasure, and the Ultimate Currency, is due this spring). Ben-Shahar’s passion is teaching, and he goes on to explain how he teaches positive psychology. His Harvard course on the subject has been offered twice, in 2004 and in 2006, when its enrollment of 854 students was the largest of any course in the catalog, surpassing even introductory economics. This startling fact seized the attention of national media, and pieces about “Happiness 101” (actually, Psychology 1504, “Positive Psychology”) appeared in the Boston Globe and on CNN, CBS, National Public Radio, and overseas in the Guardian, the Jerusalem Post, and the Shanghai Evening Post, making Ben-Shahar one of the best-known positive psychologists alive. At 36 years of age, he is a young star in a field that is only eight years old.

For much of its history, psychology has seemed obsessed with human failings and pathology. The very idea of psychotherapy, first formalized by Freud, rests on a view of human beings as troubled creatures in need of repair. Freud himself was profoundly pessimistic about human nature, which he felt was governed by deep, dark drives that we could only tenuously control. The behaviorists who followed developed a model of human life that seemed to many mechanistic if not robotic: humans were passive beings mercilessly shaped by the stimuli and the contingent rewards and punishments that surrounded them.

After World War II, psychologists tried to explain how so many ordinary citizens could have acquiesced in fascism, and did work epitomized in the 1950 classic The Authoritarian Personality by T.W. Adorno, et al. Social psychologists followed on, demonstrating in laboratories how malleable people are. Some of the most famous experiments proved that normal folk could become coldly insensitive to suffering when obeying “legitimate” orders or cruelly sadistic when playing the role of prison guard. Research funders invested in subjects like conformity, neurosis, and depression.

A watershed moment arrived in 1998, when University of Pennsylvania psychologist Martin Seligman, in his presidential address to the American Psychological Association, urged psychology to “turn toward understanding and building the human strengths to complement our emphasis on healing damage.” That speech launched today’s positive psychology movement. “When I met Marty Seligman [in 1977], he was the world’s leading scholar on ‘learned helplessness’ and depression,” says Vaillant. “He became the world’s leading scholar on optimism.”

Though not denying humanity’s flaws, the new tack of positive psychologists recommends focusing on people’s strengths and virtues as a point of departure. Rather than analyze the psychopathology underlying alcoholism, for example, positive psychologists might study the resilience of those who have managed a successful recovery—for example, through Alcoholics Anonymous. Instead of viewing religion as a delusion and a crutch, as did Freud, they might identify the mechanisms through which a spiritual practice like meditation enhances mental and physical health. Their lab experiments might seek to define not the conditions that induce depraved behavior, but those that foster generosity, courage, creativity, and laughter.

Seligman’s idea quickly caught on. The Gallup Organization founded the Gallup Positive Psychology Institute to sponsor scholarly work in the field. In 1999, 60 scholars gathered for the first Gallup Positive Psychology Summit; two years later, the conference went international, and ever since has drawn about 400 attendees (the maximum for the meeting space, Gallup’s world headquarters) annually. The October conference-goers represented 28 countries, 70 businesses or foundations, and 140 educational institutions.

Teaching has mushroomed, too. In 1999, the late Philip J. Stone, professor of psychology at Harvard, taught a positive psychology course to 20 undergraduates. There were hardly any college courses on the subject then; seven years later, there are more than 200 across the United States. The University of Pennsylvania offers a master’s degree in the field. International growth, too, is strong. Recently, Ben-Shahar gave seminars in China on the relationship of positive psychology to leadership, and he says “interest from Chinese educators and media was huge.”

The field’s roots go back at least to 1962, when Brandeis psychologist Abraham Maslow wrote about what a human life could be at its greatest in Toward a Psychology of Being. His “humanistic psychology” became the discipline’s “third force,” following psychoanalysis and behaviorism. “The fundamental difference between humanistic psychology and positive psychology is in their relationship to research, epistemology, and methodology,” says Ben-Shahar. “Many who joined the ‘Third Wave’ were not rigorous. Humanistic psychology gave birth to the self-help movement, and lots of self-help books have come out with concepts grounded in emotion and intuition. Positive psychology combines those things with reason and research.”

Doing so apparently answers needs the first and second forces have left unsatisfied. “I’m in a department of psychiatry, and psychiatry does not have a good model of mental health,” says clinical instructor in psychology Nancy Etcoff, who is based at Massachusetts General Hospital (MGH). “Is there a model of mental health beyond ‘no mental disease’?” Vaillant, a psychiatrist and a trained psychoanalyst, says, “As a psychoanalyst, I’m paid to help you focus on your resentments and help you to find fault with your parents. And secondly, to get you to focus on your ‘poor-me’s’ and to use up Kleenex as fast as possible.” He recalls visiting, as a medical student, the most famous teaching analyst at Harvard and asking him if he knew of any case history in which psychoanalysis had worked. “Yes,” the great man said, after a moment’s thought. “Why, just recently, a former patient of mine referred her 18-year-old daughter to me.”

Vaillant notes that the Comprehensive Textbook of Psychiatry, the clinical “bible” of psychiatry and clinical psychology, “has 500,000 lines of text. There are thousands of lines on anxiety and depression, and hundreds of lines on terror, shame, guilt, anger, and fear. But there are only five lines on hope, one line on joy, and not a single line on compassion, forgiveness, or love. Everything I’ve been taught encouraged me to focus on the painful emotions, ‘because people can’t do that themselves.’ My discipline taught me that positive thinking was simply denial, and that Pangloss and Pollyanna should be taken out and shot. But working with people’s strengths instead of their weaknesses made a difference. Psychoanalysis doesn’t get anybody sober. AA [Alcoholics Anonymous] gets people sober.”

Effective psychological interventions like AA are in acute demand nowadays. “There is an epidemic of depression in every industrialized nation in the world,” declared Seligman at the 2006 positive psychology summit. “It’s a paradox; the wealthier we get, the more depressed young people get.” Richard Kadison, chief of mental health at the Harvard University Health Services, writing in the New England Journal of Medicine in 2005, cited a national survey of 13,500 college students which found that 45 percent reported feeling depression deep enough to prevent them from functioning, and 94 percent felt overwhelmed by everything they had to do. “In our time, depression is on the rise,” Ben-Shahar says. “More and more students experience stress, anxiety, unhappiness. Until a few years ago, we didn’t have e-mail; now, students check their e-mail 20 times a day. Students work longer hours and are having to build up their résumés to levels that, 20 years ago, were not expected of young people. Students today are looking for ideas that will help them to lead better lives.”

Such ideas affect not only psychological states, but economics and culture. “Our world has been run according to neoclassical economics,” said Gallup’s longtime chairman and CEO, Jim Clifton, at the fall summit. “We squeezed every drop out of that rock—data and equations—and that got maxed out. The world has gotten so much more competitive and now, you need so much more. Edward Deming went to Japan and then the world put Total Quality Management on top of classical economics. Now that’s maxed out. The next wave will be behavioral economics and cognitive economics—positive psychology, well-being, strengths science. I’m betting my job and this company on it. We are in it for keeps.”

Despite abundant evidence arguing for building success on one’s personal strengths, about 75 percent of respondents in surveys say that working on one’s weaknesses is more important than fostering strengths. This may be because human beings are “very sensitive to danger or pain,” says Nancy Etcoff. “Our taste buds respond more strongly to bitter tastes than to sweet ones. That might help us to avoid poison.” Etcoff, an evolutionary psychologist, studies how natural selection may have shaped not only our bodies, but our psychological dispositions. Extending the sweet/bitter argument to relationships, she mentions research showing that, unlike couples destined for divorce, spouses in successful marriages have a five-to-one ratio of positive-to-negative gestures when they argue.

“We start with a mild tendency to approach [others],” Etcoff continues. “But when we encounter something negative, we pay extraordinary attention to it. Think about hearing a description of a stranger: ‘Joe is happy, confident, and funny. But he’s cheap.’” Negative information like this can forecast a problem: if Joe is cheap he may hoard, rather than share his resources with us. “Our emotions are like a smoke detector: it’s OK if they sometimes give a false signal,” Etcoff says. “You don’t die from a false positive. It’s better to be too sensitive. We evolved in a world of much more immediate danger—germs, predators, crevasses.”

Etcoff’s 1999 book, Survival of the Prettiest, argued that our attraction to beauty, and beauty itself, were evolutionary outcomes of natural selection. “One big question was, Are beautiful people happier?” Etcoff says. “Surprisingly, the answer is no! This got me thinking about happiness and what makes people happy.” Etcoff, who directs the Center for Aesthetics and Well-Being at MGH, explored “hedonics”—the science of pleasure and happiness—to find out how scholars have measured happiness. (In mood surveys, at any random moment, around 70 percent of people say they are feeling OK, Etcoff says.)

Nobel Prize-winning psychologist and behavioral economist Daniel Kahneman of Princeton (see “The Marketplace of Perceptions,” March-April 2006, page 50) asked thousands of subjects to keep diaries of episodes during a day—including feelings, activities, companions, and places—and then identified some correlates of happiness. “Commuting to work was way down there—people are in a terrible mood when they commute,” Etcoff says. “Sleep has an enormous effect. If you don’t sleep well, you feel bad. TV watching is just OK, and time spent with the kids is actually low on the mood chart.” Having intimate relations topped the list of positives, followed by socializing—testimony to how important the “need to belong” is to human satisfaction. Etcoff applied these methods to 54 women, in a study sponsored by the Society of American Florists, and found that an intervention as simple as a gift of flowers that stayed in one’s home for a few days could affect a wide variety of emotions—for example, less anxiety and depression at home and enhanced relaxation, energy, and compassion at work.

Environs, too, affect mood. Settings that combine “prospect and refuge,” for example, seem to support a sense of well-being. “People like to be on a hill, where they can see a landscape. And they like somewhere to go where they can not be seen themselves,” Etcoff explains. “That’s a place desirable to a predator who wants to avoid becoming prey.” Other attractive features include a source of water (streams for beauty and slaking thirst), low-canopy trees (shade, protection), and animals (proof of habitability). “Humans prefer this to deserts or man-made environments,” Etcoff says. “Building windowless, nature-less, isolated offices full of cubicles ignores what people actually want. A study of patients hospitalized for gall-bladder surgery compared those whose rooms looked out on a park with those facing a brick wall. The park-view patients used less pain medication, had shorter stays, and complained less to their nurses. We ignore our nature at our own peril.”

Etcoff’s next book, on happiness and evolution, will attempt to deconstruct happiness itself, distinguishing between concepts like pleasure and desire, or euphoria and craving. “Our reward system is fed by [the neurotransmitter] dopamine that is thought to activate the brain’s pleasure centers,” Etcoff says. “It is really a brain desire system—it’s really about wanting. You see all these pleasures, but which ones do you really want? People like good-looking faces, but that doesn’t mean they desire them. Pleasure and pain are related in the brain, through the opioid neurotransmitters that produce a feeling of comfort. The opioid system triggers pleasure. Sugar, which recalls the sweetness of mother’s milk, can set it off. Caressing, sex, fatty foods, sunlight on the skin—all these can do it, too.

“We evolved in a much different world, with much less choice and no sedentary people,” Etcoff continues. “We didn’t evolve for happiness, we evolved for survival and reproduction.” For this reason, we are sensitive to danger. “Pleasure and the positive-reward system is for opportunity and gain,” Etcoff explains. “And pleasure involves risk, taking a chance that can override some of your fear at that moment.”

Like reaching for joy. “Mammalian evolution has hard-wired the brain for spiritual experience,” said George Vaillant at the 2006 summit, “and the most dramatic spiritual experience is joy. Developmentally, the child’s smile, the kitten’s purr, and the puppy’s wagging tail emerge at the same time. These social responses are elicited by, and in turn elicit, positive emotion. They all occur when the infant brain’s more primitive limbic system becomes effectively wired to the forebrain.”

Negative emotions, like aggression and fear, are as developed in lower animals as in humans. But “the limbic system differentiates mammals from reptiles, and contains most of what we know of positive emotions and spirituality,” Vaillant argued. “Negative emotions help us to survive individually; positive emotions help the community to survive. Joy, unlike happiness, is not all about me—joy is connection. Beethoven knew little happiness, but he knew joy. The mystics have linked joy to connection with a power greater than themselves.”

Happiness activates the sympathetic nervous system (which stimulates the “flight or fight” response), whereas joy stimulates the parasympathetic nervous system (controlling “rest and digest” functions). “We can laugh from either joy or happiness,” Vaillant said. “We weep only from grief or joy.” Happiness displaces pain, but joy embraces it: “Without the pain of farewell, there is no joy of reunion,” he asserted. “Without the pain of captivity, we don’t experience the joy of freedom.”

Yet there is far more research on happiness than on joy, the “least-studied emotion,” according to Vaillant, whose next book’s working title is Faith, Hope, and Joy: The Neurobiology of Positive Emotion. “For the last 20 years, emotion has been an unwelcome guest at the table of scholarship,” he says. “We treat joy as secret, dirty, and awful, the way the Victorians treated sex. Happiness is largely cognitive; it’s a state of mind, not an emotion. That’s why social scientists and economists love to study happiness. Happiness is tame.”

Don’t call Daniel Gilbert a positive psychologist. He isn’t one, and doesn’t approve of the label, although he doesn’t quarrel with the research. “I just don’t see what the parade is for,” he says. “I don’t think psychology needs a movement; movements are almost always counter-productive. By including some people and filling them with irrational exuberance, they divide the field. Positive psychology doesn’t cut psychology at the joint. I wouldn’t condemn the work or ideas; probably 85 percent of the ideas are worthless, but that’s true everywhere in science.”

That said, Gilbert, a professor of psychology, shares a lot of subject matter with the positive psychologists. His book Stumbling on Happiness became a national bestseller last summer. Its central focus is “prospection”—the ability to look into the future and discover what will make us happy. The bad news is that humans aren’t very skilled at such predictions; the good news is that we are much better than we realize at adapting to whatever life sends us.

“Is happiness elusive?” Gilbert asks. “Well, of course we don’t get as much of it as we want. But we’re not supposed to be happy all the time. We want that, but nature designed us to have emotions for a reason. Emotions are a primitive signaling system. They’re how your brain tells you if you’re doing things that enhance—or diminish—your survival chances. What good is a compass if it’s always stuck on north? It must be able to fluctuate. You’re supposed to be moving through these emotional states. If someone offers you a pill that makes you happy 100 percent of the time, you should run fast in the other direction. It’s not good to feel happy in a dark alley at night. Happiness is a noun, so we think it’s something we can own. But happiness is a place to visit, not a place to live. It’s like the child’s idea that if you drive far and fast enough you can get to the horizon—no, the horizon’s not a place you get to.”

Gilbert reconsiders his grandmother’s advice on how to live happily ever after: “Find a nice girl, have children, settle down.” Research shows, he says, that the first idea works: married people are happier, healthier, live longer, are richer per capita, and have more sex than single people. But having children “has only a small effect on happiness, and it is a negative one,” he explains. “People report being least happy when their children are toddlers and adolescents, the ages when kids require the most from the parents.” As far as settling down to make a living—well, if money moves you into the middle class, buying food, warmth, and dental treatment—yes, it makes you happier. “The difference between an annual income of $5,000 and one of $50,000 is dramatic,” Gilbert says. “But going from $50,000 to $50 million will not dramatically affect happiness. It’s like eating pancakes: the first one is delicious, the second one is good, the third OK. By the fifth pancake, you’re at a point where an infinite number more pancakes will not satisfy you to any greater degree. But no one stops earning money or striving for more money after they reach $50,000.”

The reason is that humans hold fast to a number of wrong ideas about what will make them happy. Ironically, these misconceptions may be evolutionary necessities. “Imagine a species that figured out that children don’t make you happy,” says Gilbert. “We have a word for that species: extinct. There is a conspiracy between genes and culture to keep us in the dark about the real sources of happiness. If a society realized that money would not make people happy, its economy would grind to a halt.”

When we try to project ourselves into the future, we make a systematic series of errors, and much of Stumbling on Happiness analyzes them. One common miscalculation is “presentism,” the belief that we will feel in the future the way we feel today. “In a grocery store, feeling hungry, I try to shop for what I will want to eat next Wednesday,” Gilbert says. “Then Wednesday comes, and I ask myself, ‘Why did I buy jalapeño pockets?’”

Secondly, humans are marvelous rationalizers. “Find a large number of people who’ve been left standing at the altar and ask them if that was the worst day, or the best day, of their lives,” Gilbert says. “On the day it happens, almost without exception, they will say it is the worst day. But ask these same people the same question a year later and most will say it was the best day of their lives. People are much more resilient than they realize. In the lab, it’s very easy to get people to rationalize, but almost impossible to get them to foresee it. Rationalization is an invisible shield that protects us from psychological pain, but we don’t realize that we are carrying it.

“Much recent data show that people fare reasonably well in a variety of tragic and traumatic circumstances—Christopher Reeve was not unusual,” Gilbert continues. “Paraplegics are generally quite happy people. And blind people often say that the worst problem they have is that everyone assumes that they are sad: ‘You can’t read.’ ‘But I can read.’ ‘You can’t get around.’ ‘But I can get around.’ People do feel devastated if they go blind, but it does not last. The human mind is constituted to make the best of the situations in which it finds itself. But people don’t know they have this ability, and that’s the thing that bedevils their predictions about the future.”

One of Gilbert’s colleagues, professor of psychology Ellen Langer, prefers to spend her time in the present, and she aims to analyze and share that experience with others though her many books—like On Becoming an Artist: Reinventing Yourself through Mindful Creativity—all of which explore her central theme of mindfulness. To Langer, mindfulness means noticing new things and drawing new distinctions. “It doesn’t matter whether what you notice is smart or silly,” she says, “because the process of actively drawing new distinctions produces that feeling of engagement we all seek. It’s much more available than you realize: all you need to do is actually notice new things. More than 30 years of research has shown that mindfulness is figuratively and literally enlivening. It’s the way you feel when you’re feeling passionate.”

Everyone says they want to live in the present, but there’s a paradox: “If you’re not in the present, you’re not there to know you’re not there,” says Langer, with a smile. “So how do you get there? This work tells us how: when you’re actively noticing new things, you become more aware of context and perspective. You end up with a healthier respect for uncertainty, something we are taught to fear. Our baseline state should be mindful; it’s how we should feel virtually all the time.”

What stops us, according to Langer, are our fears of evaluation, our acceptance of absolutes, and our mindless ideas about mistakes. All three are actually different facets of the same sensibility. “Anything hierarchical suggests that there is a single metric—a ‘right’ way of understanding the world, and better and worse ways to view things,” she explains. “But the world is a social construct. Mistakes are not mistakes in all contexts. With writing and art, mistakes tend to make the product more interesting. The major difference between a machine-made rug and a handmade one is that the regularity of the machine-made rug makes it uninteresting. Errors give the viewer something to hold onto. When you make a mistake in a painting, if—instead of trying to correct the mistake—you incorporate it into what you are doing and go forward, you are working mindfully. And when we ask viewers to choose between this kind of art and ‘flawless’ works, people say they prefer the mindfully created pieces.

“We also have mistaken notions of talent,” Langer continues. “People learn about activities as if there are absolute standards. Think about a jockey, a boxer, and an archer: three very different sports. Which one has athletic ‘talent?’ Or suppose someone tells you that you have no artistic ‘talent’—you can’t be a Pollock, Mondrian, Klee, or Picasso. But they are so different from each other! Act mindfully, and that state of consciousness leaves its footprint in what we do. Mindfulness is the essence of charisma; when people are there, we notice. When you don’t take the world as given, but as full of possibilities, it becomes endlessly exciting.”

The positive psychology class Ben-Shahar teaches at Harvard aims to keep its students engaged and excited, too. As they filter in, sit down, and boot up their laptops, a Whitney Houston song plays through the sound system in Sanders Theatre. Ben-Shahar, in black slacks and a blue pullover sweater, fiddles with his own laptop and brings up the first image on the screen for today’s lecture on self-esteem: it’s a New Yorker cartoon of a troubled man writing in his diary, “Dear Diary, Sorry to bother you again…” During the lecture, Ben-Shahar will flesh out his discussion with images and film clips, along with concepts and research citations. He also shares a personal experience with the class, telling how, in his 20s, as a College graduate who had been a national squash champion, he nonetheless “realized that I didn’t have the answers. External validation broke down. I had the success and validation, but still experienced low self-esteem.”

This is another way that positive psychology classes are different: they are experiential. “There are two levels to the course,” Ben-Shahar says. “One is, like any other course, an introduction to the research and to the field. But secondly, students explore ways to apply these ideas to their lives and communities. They write response papers and perform exercises, connecting these theories with their own lives and experiences. We try to ask, to use William James’s phrase, ‘What is the cash value of these ideas?’”

It is clear that the “cash value” of positive psychology can be far greater than enhanced well-being, though that is a good start. Vaillant brings up one of positive psychology’s constructs, forgiveness, in contrasting the Treaty of Versailles and the Marshall Plan. After World War I, Germany agreed not only to apologize but to send its countrymen to rebuild France. The French rejected this on the grounds that it would hurt employment in France if the Germans rebuilt it, and insisted instead on monetary reparations. In contrast, Vaillant says, “The Marshall Plan put people in Gary and Pittsburgh out of work by giving the Germans and Japanese more efficient steel mills. But the result of Versailles was World War II and the Holocaust. The Marshall Plan led to 60 years of peace in Western Europe for the first time in recorded history.”

Forgiveness, of course, means trusting someone who has hurt you, and so inevitably runs a risk. But positive psychology says such risks are worth taking. “You hope to free up people in their lives,” says Langer, “so they will take more chances and live more before they die.”

Happiness 101
Stumbling on Happiness
Happiness Takes Effort