February 2010

The Victorians had many names for depression, and Charles Darwin used them all. There were his “fits” brought on by “excitements,” “flurries” leading to an “uncomfortable palpitation of the heart” and “air fatigues” that triggered his “head symptoms.” In one particularly pitiful letter, written to a specialist in “psychological medicine,” he confessed to “extreme spasmodic daily and nightly flatulence” and “hysterical crying” whenever Emma, his devoted wife, left him alone.

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While there has been endless speculation about Darwin’s mysterious ailment — his symptoms have been attributed to everything from lactose intolerance to Chagas disease — Darwin himself was most troubled by his recurring mental problems. His depression left him “not able to do anything one day out of three,” choking on his “bitter mortification.” He despaired of the weakness of mind that ran in his family. “The ‘race is for the strong,’ ” Darwin wrote. “I shall probably do little more but be content to admire the strides others made in Science.”

Darwin, of course, was wrong; his recurring fits didn’t prevent him from succeeding in science. Instead, the pain may actually have accelerated the pace of his research, allowing him to withdraw from the world and concentrate entirely on his work. His letters are filled with references to the salvation of study, which allowed him to temporarily escape his gloomy moods. “Work is the only thing which makes life endurable to me,” Darwin wrote and later remarked that it was his “sole enjoyment in life.”

For Darwin, depression was a clarifying force, focusing the mind on its most essential problems. In his autobiography, he speculated on the purpose of such misery; his evolutionary theory was shadowed by his own life story. “Pain or suffering of any kind,” he wrote, “if long continued, causes depression and lessens the power of action, yet it is well adapted to make a creature guard itself against any great or sudden evil.” And so sorrow was explained away, because pleasure was not enough. Sometimes, Darwin wrote, it is the sadness that informs as it “leads an animal to pursue that course of action which is most beneficial.” The darkness was a kind of light.

The mystery of depression is not that it exists — the mind, like the flesh, is prone to malfunction. Instead, the paradox of depression has long been its prevalence. While most mental illnesses are extremely rare — schizophrenia, for example, is seen in less than 1 percent of the population — depression is everywhere, as inescapable as the common cold. Every year, approximately 7 percent of us will be afflicted to some degree by the awful mental state that William Styron described as a “gray drizzle of horror . . . a storm of murk.” Obsessed with our pain, we will retreat from everything. We will stop eating, unless we start eating too much. Sex will lose its appeal; sleep will become a frustrating pursuit. We will always be tired, even though we will do less and less. We will think a lot about death.

The persistence of this affliction — and the fact that it seemed to be heritable — posed a serious challenge to Darwin’s new evolutionary theory. If depression was a disorder, then evolution had made a tragic mistake, allowing an illness that impedes reproduction — it leads people to stop having sex and consider suicide — to spread throughout the population. For some unknown reason, the modern human mind is tilted toward sadness and, as we’ve now come to think, needs drugs to rescue itself.

The alternative, of course, is that depression has a secret purpose and our medical interventions are making a bad situation even worse. Like a fever that helps the immune system fight off infection — increased body temperature sends white blood cells into overdrive — depression might be an unpleasant yet adaptive response to affliction. Maybe Darwin was right. We suffer — we suffer terribly — but we don’t suffer in vain.

ANDY THOMSON IS a psychiatrist at the University of Virginia. He has a scruffy gray beard and steep cheekbones. When Thomson talks, he tends to close his eyes, as if he needs to concentrate on what he’s saying. But mostly what he does is listen: For the last 32 years, Thomson has been tending to his private practice in Charlottesville. “I tend to get the real hard cases,” Thomson told me recently. “A lot of the people I see have already tried multiple treatments. They arrive without much hope.” On one of the days I spent with Thomson earlier this winter, he checked his phone constantly for e-mail updates. A patient of his on “welfare watch” who was required to check in with him regularly had not done so, and Thomson was worried. “I’ve never gotten used to treating patients in mental pain,” he said. “Maybe it’s because every story is unique. You see one case of iron-deficiency anemia, you’ve seen them all. But the people who walk into my office are all hurting for a different reason.”

Jonah Lehrer is the author of ?How We Decide? and of the blog The Frontal Cortex. This is his first article for the magazine.

Becky McGee and her 19-year-old son, Kyle, fought for years to get help from public schools for his dyslexia.

When it comes to special education, Becky McGee and her 19-year-old son, Kyle, feel as if they’ve seen it all.

And Ms. McGee hopes her hard-won lessons might benefit other parents.

Kyle was born with orthopedic and neurological problems. In elementary school he was found to have several learning disabilities that included severe dyslexia and attention deficit disorder. Ms. McGee sought for years for her son to get the kinds of therapy and intervention that would help him succeed in his public school system in Yorktown, Va.

Throughout Kyle’s elementary, middle and high school years, Ms. McGee had to fight for the special services, particularly for a reading program for dyslexia that worked well for her son. She even enlisted the help of a lawyer who specializes in learning disability cases.

At one point, Ms. McGee and her husband, Chuck, decided to put Kyle in private school for two years before he went to public high school. They often paid out-of-pocket for reading therapies that schools could not or would not provide.

The roller-coaster ride ended well. Kyle is now enrolled in at ECPI College of Technology, studying computer networking.

“Kyle is an amazing kid, and he’s doing great,” Ms. McGee said. “All I can say now is I’m glad public school is behind us.”

The McGees’ travails are hardly unique. More than 6 percent of school-age children ? almost three million students ? are receiving special education services because of learning disabilities, according to the Learning Disabilities Association of America.

The cost of such special services can easily total thousands of dollars a year per child. But the Learning Disabilities Association suggests that when learning disabilities are left untreated, the overall cost to society may be far higher.

That’s where federal special education law comes in. The Individuals With Disabilities Education Act, passed in 1990 as a successor to a similar law from 1975, is meant to give all children with learning disabilities an appropriate education in the least restrictive environment possible. Under the law, known by its acronym IDEA, parents are supposed to be active partners in coming up with the education plan that best fits their child.

Last week my colleague Lesley Alderman gave advice on how to get a proper diagnosis if you suspect your child has a learning disability. This week I’ll delve into ways to make sure your child is getting the educational help he or she needs.

KNOW YOUR RIGHTS “It’s really important for every parent with a learning-disabled child to understand the law thoroughly, so you know what your rights are and what services your child may be eligible for,” said Peter Wright, the education lawyer and advocate who assisted Ms. McGee.

Parents have extensive rights under IDEA, including the right to ask for an evaluation or a re-evaluation of their child at any time. Most important, however, is the parents’ right to be part of the team that decides what special education services and therapies the child will receive.

“The law was written with the idea that parents are equal participants in developing the child’s education plan,” says Ron Hager, senior staff lawyer at the National Disability Rights Network.

IDEA requires each child with a learning disability to have an individualized education plan tailored specifically to his or her needs. This could include services like speech and occupational therapy, reading intervention and a full-time aid in the classroom.

Exactly what services your child receives is supposed to be decided each year at your child’s individualized education plan meeting, which usually includes your child’s classroom teachers, a special education instructor, a school administrator and someone representing the school district.

Before attending such a meeting, you want to be as well informed as possible about your child’s specific disability and what services are provided in your state, says Pat Lillie, president of the Learning Disabilities Association of America.

“I can’t tell you how many times I’ve been the one to tell the school what’s exactly in the law,” Ms. McGee said. “After all, these are teachers and administrators, not lawyers. I always take a copy of the law with me.”

Ms. McGee suggests that when you meet with the school’s staff members about the individualized education plan, you take along a spouse or a good friend who knows your child well. Even in the best cases, these meetings can be extremely emotional, Ms. McGee said.

“The specialists and administrators are on the other side of the table telling me my son is behind on this, he can’t do that, he’s not up to speed on such and such,” she said. “It’s all helpful information, but it’s still difficult.”

GETTING MORE What if you’ve successfully secured an individualized education plan but are convinced your child needs more intervention?

WASHINGTON ? President Obama opened his much anticipated health care forum on Thursday by calling on Democrats and Republicans to “focus not just on where we differ but focus on where we agree,” as Republicans called for the president to scrap his bill and start over.

Mr. Obama, speaking to lawmakers from his seat at the table they shared, not from a podium or with a teleprompter, used his opening remarks to make the case that reforming the health care system is critical to the nation’s economy. He made no opening bids, but instead called on the two parties to abandon their talking points and engage in a real unscripted discussion, even as he conceded that it might not result in a bridging of the deep philosophical divide between them.

“I don’t know that those gaps can be bridged and it may be that at the end of the day we come out of here saying, ‘Well, we’ve had some honest disagreements,’” the president said, adding, “but I’d like to make sure that this discussion is actually a discussion and not just us trading talking points.”

But as the morning ran on, it was clear that Republican anger ran deep. One of the liveliest exchanges came when Mr. Obama clashed with his former Republican rival for the White House, Senator John McCain of Arizona, who unleashed a pointed attack on the president for the process that Democrats used to produce the bill ? even as Mr. Obama tried to redirect him to talking about its substance.

Mr. McCain pointedly reminded Mr. Obama that both of them had campaigned “promising change in Washington” and that the president had promised to televise his negotiating sessions on C-Span. “I’m glad that more than a year later you are,” the senator said, going on to deride the 2,400 page bill as the being produced “behind closed doors” with “unsavory deals.”

Mr. Obama tried to cut Mr. McCain off. “John, we’re not campaigning anymore, the election is over,” he said.

Mr. McCain laughed. “I’m reminded of that every day.”

In the afternoon, however, after Mr. McCain had complained that elderly Floridians were being spared cuts in one program while other seniors were not, Mr. Obama nodded and acknowledged that his former rival had made a “good point” in calling for a more even distribution of reductions.

The forum, which the White House intended as a back-and-forth between Republicans and Democrats on health care policy, is an extraordinary last-ditch effort by Mr. Obama to revive his health care bill. The White House is betting that the public will tune in and conclude Democrats have better ideas for reforming health care; Republicans are betting the public will favor their ideas.

At the least, it will provide the viewers a glimpse of relatively unscripted conversation between the two parties on an issue that has divided them for decades.

In his own remarks, Mr. Obama got personal, recounting the story of his mother’s death from ovarian cancer, and the illnesses of his daughters: Malia, 11, who was rushed to the hospital after complaining she couldn’t breathe and, the president said, was diagnosed as having asthma, and Sasha, 8, who had a potentially dangerous case of meningitis as a baby.

And the president tried to turn the tables a bit on Republicans, citing from their own past statements in which they described the need for reform. “John McCain’s talked about how rising health care costs are devastating to middle class families,” he said, referring to his Republican opponent for the presidency, who was sitting in the room. “Chuck,” he said, turning to Senator Charles Grassley, the Iowa Republican, you’ve been working on this a long time.”

But Senator Lamar Alexander, the Tennessee Republican who was selected to give his party’s opening remarks, called on the president to renounce “reconciliation,” the controversial parliamentary maneuver that would enable Democrats to pass the president’s bill with only Democratic votes.

Mr. Alexander called on Mr. Obama and the Democrats “to renounce jamming” the bill “through in a partisan way.”

Mr. Obama made clear he was not going to do so; he told Mr. Alexander that he preferred to “talk about the substance” rather than legislative process ? a sign that he is reserving his options to push the bill through Congress using only Democratic votes if he cannot get any from Republicans.

And House Speaker Nancy Pelosi, who spoke after Mr. Alexander, rejected the idea of scrapping the bill and starting over, saying the American people can’t wait for health reform any longer.

“They don’t have time for us to start over,” she said. “Many of them are at the end of the line.”

Throughout the morning, Democrats echoed the president’s theme that there was more agreement than disagreement, and sought to make the case that their bill had incorporated Republican ideas.

Senator Max Baucus, Democrat of Montana and chairman of the Finance Committee, said Democrats welcomed many of the ideas suggested by Senator Alexander and other Republicans.

Robert Pear contributed reporting.

WASHINGTON ? After more than six hours of extraordinary debate on Thursday over health care policy, President Obama had not won over any of the Republicans, and he seemed to end the day largely where he started, with little choice but to try to rally his Democrats to act on their own.

Congressional leaders joined President Obama on Thursday in six hours of televised debate.
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Their most viable path seemed to be an effort to attach revisions to the health care bill to a budget reconciliation measure, which the Senate could adopt by a simple majority. “If nothing comes of this we’re going to press forward,” said Senator Richard J. Durbin of Illinois, the No. 2 Democrat. “We just can’t quit. This is a once-in-a-political-lifetime opportunity to deal with a health care system that is really unsustainable.”

But doing so would require mustering the support of centrist Democrats in the House and the Senate who have expressed apprehensions about both the health care bill and the reconciliation process, which Republicans are portraying as an unfair parliamentary tactic to skirt the normal rules.

It was unclear if the event had won over any of those votes, especially among House Democrats who opposed the bill in November, and whose support could be critical to reviving it.

“It’s interesting that they are having a discussion and we are continuing to have the debate we have been having for a year now, but how are you going to get it passed?” said Representative Jason Altmire of Pennsylvania, who was among the 39 Democrats to vote no. Mr. Altmire, who did not attend the session but planned to watch it later on video, said, “I don’t see very many at all who voted no who are going to switch their votes unless there are substantial changes in the bill.”

While the forum was novel, Mr. Obama still seemed burdened with the challenges of having pursued a largely middle-of-the-road proposal that has hampered the Democrats all along. It has disappointed some in the party’s liberal base, especially without a public option. It holds little or no appeal for Republicans, and it confuses and scares many people in the middle.

And yet, just five weeks after the Republican victory in a special Senate election in Massachusetts left the Democrats’ health care legislation on the edge of collapse, Mr. Obama’s unusual forum, and his relentless effort to portray Democrats and Republicans as agreeing on many points, restored the health care issue to center stage, and reminded a skeptical public of the gravity of the problems he is trying to fix.

Mr. Obama also seemed to widen the playing field, giving the Democrats some additional options. They could try to win final approval of the legislation using budget reconciliation, which would avert a Republican filibuster in the Senate. The president suggested a decision on that could be made within six weeks.

They could potentially devise further changes to the bill, adding Republican ideas even without Republican cooperation. One area of common ground to emerge at the forum was an idea put forward by Senator Tom Coburn, Republican of Oklahoma, to use undercover regulators posing as patients to root out fraud by doctors and hospitals. “That’s something that I’d be very interested in exploring,” Mr. Obama said. Senator Charles E. Schumer, Democrat of New York, called it “a great idea.”

Representative George Miller, Democrat of California, said he thought the forum would lead to changes that would improve the bill and gain support. “Today’s meeting was very helpful in that regard,” Mr. Miller said. “You have to go hunt for the votes. But you have to have a product.”

The Democrats could also begin to break their proposal into pieces that have a better chance of winning bipartisan support. The House on Wednesday passed a stand-alone bill to repeal the insurance industry’s exemption from federal antitrust laws by a vote of 406 to 19. Thursday’s summit meeting suggested that other ideas, like extending dependent coverage for adult children, could pass by a similarly big margin.

After Republicans said that they shared some of the Democrats’ goals on tighter insurance regulation, including ending annual and lifetime caps on benefits, Vice President Joseph R. Biden Jr. said Republicans could not argue that government should have no role.

“You’re either in or you’re out,” he snapped at Representative Eric Cantor of Virginia, the House Republican whip, who was highly critical at the session of the Democrats’ legislative plans.

The fundamental question facing Republicans was not whether they could persuade Democrats to take a different approach, but whether continuing their opposition in the wake of Mr. Obama’s grand gesture of bipartisanship could turn into a liability in a tense midterm election year.

While opinion polls show deep public unease over the health care legislation, they also show simmering frustration at the partisanship and gridlock in Washington. For now, Republican leaders seem confident that they have the public on their side.

“It is not irrelevant that the American people, if you average out all of the polls, are opposed to this bill by 55 to 37,” the Senate Republican leader, Mitch McConnell of Kentucky, said at the forum, adding that the public also opposes reconciliation. “We know how the American people feel about this,” he said. “This is not a close call.”

The Democrats told insurance company horror stories, including a tale of an old woman forced to wear her dead sister’s dentures. The Republicans countered with scary metaphor, likening the Democratic health care bill to the ailing auto industry.

The White House briefing room carrying images of President Obama at the health care forum.
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And those narrative choices were at the heart of the marathon health care summit meeting on Thursday. President Obama used the forum to make the case that the two parties had more in common than was generally known. And in one sense at least, that was true: both sides appealed to viewer pessimism.

The Democrats argued that the current health care system was headed in such a bad way that reform could only make it better, and Republicans countered that, flawed as it is, any major change would only make things much, much worse.

Health care is a grim and gloomy subject, and that was aptly reflected in the uninviting setting: the participants sat in a square of banquet tables that made an ad hoc working group of the United Nations General Assembly seem festive.

The meeting was more stilted and scripted than the one-man show Mr. Obama performed last month when he fielded questions from the Republican caucus on live television, but there were spontaneous moments, a few flights of eloquence and plenty of testy exchanges that illustrated how divided ? and uncompromising ? the two sides really are.

It lasted more than an hour longer than the scheduled six hours and ended where it began, with Republicans demanding that Mr. Obama scrap existing proposals and start fresh and Democrats insisting that it is too late to go back. Washington didn’t budge, but viewers got a long, hard look at what makes the issue so intractable. (It was so long and hard that only C-Span stayed with it from beginning to end; MSNBC and CNN took breaks throughout and didn’t show all of the afternoon session. Fox News held out the longest, showing the proceedings without a break until the lunch hour, then returning in the afternoon.)

Mr. Obama, who led the session with a mixture of companionability, irritation and presidential hauteur, scored political points by chiding Republicans for trying to score political points. He cut off Senator John McCain, Republican of Arizona, in mid-rant about what Mr. McCain described as “unsavory” special deals behind the Senate bill. “We’re not campaigning anymore,” Mr. Obama said curtly. “The election is over.”

He interrupted the opening niceties of the minority leader, Eric Cantor of Virginia, to point at the huge pile of paper Mr. Cantor had stacked in front of him. “Let me just guess,” the president said sarcastically. “That’s the 2,400-page health care bill. Is that right?”

The issues are complicated, so both sides seized simple ? and at times simplistic ? ways to make their case to the television audience. Mr. Obama, who is often criticized for a professorial manner, repeatedly personalized the issue, making references to the letters from needy people he reads every night, his daughters’ childhood illnesses, his mother’s death from ovarian cancer and his own early struggles with fly-by-night insurance companies.

Representative Louise M. Slaughter, Democrat of New York, cited the woman who couldn’t afford dentures, noting, “She wore her dead sister’s teeth ? which, of course, were uncomfortable and did not fit.”

Defending malpractice suits, Senator Richard J. Durbin of Illinois, the Republican whip, told of a woman who underwent mole-removal surgery and whose face was burned and disfigured when the oxygen caught fire.

Republicans, who mostly cited apocalyptic budget figures if the Senate bill becomes law, did not look thrilled or moved by the recitations of woe, or as Mr. Cantor put it, “alleged” woe. Arguing that Democrats had no monopoly on compassion, he said: “All of us share the concerns when people are allegedly wronged in our health care system. I mean, I think that is sort of a given.”

And when Senator John Barrasso, Republican of Wyoming, said American health care is so superior that the premier of a Canadian province had recently come to the United States for heart surgery, Mr. Obama pounced on the elitist implications, urging him to heed the letters he gets from ordinary folks. “Because the truth of the matter, John, is they’re not premiers of anyplace, they’re not sultans from wherever,” he said. “They don’t fly into Mayo and suddenly, you know, decide they’re going to spend a couple million dollars on the absolute best health care.”

For the most part it was, as Mr. Obama said he had feared, political theater, but that made for good television: not a lively romp, for sure, but a long and instructive spectacle, a C-Span version of Tom Stoppard’s “Coast of Utopia.”

WASHINGTON ? A top health insurance company executive told a Congressional committee on Wednesday that higher premiums were justified by soaring medical costs, and warned that pending legislation could make the problem worse, further driving up costs for young, healthy people.

The executive, Angela F. Braly, president of WellPoint, made the comments in testimony prepared for a hearing of the House Energy and Commerce Committee.

The hearing comes amid growing criticism of WellPoint and the health insurance industry by President Obama and Democrats in Congress, who say the proposed rate increases show the need for federal review and regulation of insurance premiums.

Anthem Blue Cross, a unit of WellPoint, recently informed subscribers in California that premiums for individual insurance policies would rise an average of 25 percent, with some rates going up as much as 39 percent.

“Raising our premiums was not something we wanted to do,” Ms. Braly said. “But we believe this was the most prudent choice, given the rising cost of care and the problems caused by many younger and healthier policyholders dropping or reducing their coverage during tough economic times. By law, premiums must be reasonable in relationship to benefits provided, which means they need to reflect the known and anticipated costs they will cover.”

The increases in premiums are driven by prices charged by doctors, hospitals, drug companies and other suppliers, and by increases in the use of health care by an aging population, Ms. Braly said.

“For 2010,” Ms. Braly said, “we expect hospital inpatient and outpatient costs in California to grow by over 10 percent, driven primarily by hospital reimbursement rates. Additionally, we expect pharmacy costs in California to grow by over 13 percent.”

Ms. Braly said health care providers were charging more to the private sector, “including our members,” because payments from Medicare and Medicaid did not fully cover providers’ costs.

Families with commercial insurance pay almost $1,800 a year more for coverage as a result of this cost shift, Ms. Braly said.

She criticized health care bills passed by the House and the Senate, with strong support from Mr. Obama. The bills would require insurers to accept all applicants and would require most Americans to have health insurance or pay a penalty.

But Ms. Braly said the “personal coverage requirement” would not be fully effective, because millions of people would be exempted and others would make a “logical choice” to pay the penalty rather than buy insurance, unless they needed health care.

“The result,” she said, “will be a national health insurance market that is similar to New York, where the average individual market premium is over twice the average individual premium in California.”

Ms. Braly said the legislation pending in Congress “would increase California individual market premiums for the young and healthy by as much as 106 percent, before premium subsidies for certain eligible individuals” are taken into account.

Democrats have said insurers are raking in large profits while raising premiums. But Ms. Braly said profits accounted for “a very small percentage of a member’s premium.”

Another witness invited to the hearing, Lauren Meister of West Hollywood, Calif., said she was told in January that her Anthem Blue Cross premium was being increased 38 percent, to $516 a month, from $373.

Ms. Meister said she was offered the option of switching to a lower-cost Anthem plan that covered only generic versions of prescription drugs. But she said that was not feasible because she took several brand-name drugs for asthma.

In her prepared testimony, Ms. Meister called for more regulation.

“We saw what deregulation did to the cost of utilities in California,” Ms. Meister said. “We saw what the lack of regulation has done on a national level to our financial and banking system. Well, it’s doing the same thing to our health care system.”

Ms. Meister added: “The City of West Hollywood, where I live, regulates how much landlords can raise the rent each year to keep rents stabilized. Why can’t the federal government regulate how much health insurance companies can raise their rates per year, in order to stabilize premiums?”

The patient was already on the operating room table when the other transplant surgeons and I arrived to begin the surgery that would remove his liver, kidneys, pancreas, lungs and heart. He was tall, with legs that extended to the very end of the table, a chest barely wider than his 16-year-old hips, and a chin covered with pimples and peach fuzz.

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He looked like any one of the boys I knew in high school.

Those of us in the room that night knew his organs would be perfect ? he had been a healthy teenager before death ? but the fact that he had not died in a terrible, mutilating automobile or motorcycle crash made us all that much more certain.

The boy had hung himself and had been discovered early, though not early enough to have survived.

While I had operated on more than a few suicide victims, I had never come across someone so young who had chosen to die in this way. I asked one of the nurses who had spent time with the family about the circumstances of his death. Was he depressed? Had anyone ever suspected? Who found him?

“He was playing the choking game,” she said quietly.

I stopped what I was doing and, not believing I had heard correctly, turned to look straight at her.

“You know that game where kids try to get high,” she explained. “They strangle themselves until just before they lose consciousness.” She put her hand on the boy’s arm then continued: “Problem was that this poor kid couldn’t wiggle out of the noose he had made for himself. His parents found him hanging by his belt on his bedroom doorknob.”

The image of that boy and of the dangling homemade noose comes rushing back whenever I meet another victim or read about the grim mortality statistics associated with this so-called game. But one thing has haunted me even more in the years since that night. As a doctor who counts adolescents among her patients, I knew nothing about the choking game before I cared for a child who had died “playing” it.

Until recently, there has been little attention among health care professionals to this particular form of youthful thrill-seeking. What has been known, however, is that children ages 7 to 21 participate in such activities alone or in groups, holding their breath, strangling one another or dangling in a noose in the hopes of attaining a legal high.

Two years ago the Centers for Disease Control and Prevention reported 82 deaths attributable to the choking game and related activities. This year the C.D.C. released the results of the first statewide survey and found that one in three eighth graders in Oregon had heard of the choking game, while more than one in 20 had participated.

The popularity of the choking game may boil down to one fact: adolescents believe it is safe. In one recent study, almost half of the youths surveyed believed there was no risk associated with the game. And unlike other risk-taking behaviors like alcohol or drug abuse where doctors and parents can counsel teenagers on the dangers involved, no one is countering this gross misperception regarding the safety of near strangulation.

Why? Because like me that night in the operating room, many of my colleagues have no clue that such a game even exists.

This month in the journal Pediatrics, researchers from the Rainbow Babies and Children’s Hospital in Cleveland reported that almost a third of physicians surveyed were unaware of the choking game. These doctors could not describe any of the 11 warning signs, which include bloodshot eyes and frequent and often severe headaches. And they failed to identify any one of the 10 alternative names for the choking game, startlingly benign monikers like Rush, Space Monkey, Purple Dragon and Funky Chicken.

“Doctors have a unique opportunity to see and prevent this,” said Dr. Nancy E. Bass, an associate professor of pediatrics and neurology at Case Western Reserve University and senior author of the study. “But how are they going to educate parents and patients if they don’t know about it?”

In situations where a patient may be contemplating or already participating in choking activities, frank discussions about the warning signs can be particularly powerful. “The sad thing about these cases,” Dr. Bass observed, “is that every parent says, ‘If we had known what to look for, we probably could have prevented this.’ ” One set of parents told Dr. Bass that they had noticed knotted scarves and ties and a bowing closet rod in their son’s room weeks before his death.

“They had the telltale signs,” Dr. Bass said, “but they never knew what to look for.”

Nonetheless, broaching the topic can be difficult for both parents and doctors. Some parents worry that talking about such activities will paradoxically encourage adolescents to participate. “But that’s kind of a naïve thought,” Dr. Bass countered. “Children can go to the Internet and YouTube to learn about the choking game.” In another study published last year, for example, Canadian researchers found 65 videos of the choking game from postings to YouTube over an 11-day period. The videos showed various techniques of strangulation and were viewed almost 175,000 times. But, Dr. Bass added, “these videos don’t say that kids can die from doing this.”

Still, few doctors discuss these types of activities with their adolescent patients. Only two doctors in Dr. Bass’s study reported ever having tackled the topic because of a lack of time. “Talking about difficult topics is really hard to do,” Dr. Bass noted, “when you just have 15 minutes to follow up.”

But it is even harder when neither doctor nor patient has any idea of what the activity is or of its lethal consequences.

Based on the results of their study, Dr. Bass and her co-investigators have started programs that educate doctors, particularly those in training, about the warning signs and dangers of strangulation activities. “The choking game may not be as prominent as some of the other topics we cover when we talk with patients,” Dr. Bass said, “but it results in death.”

And, she added, “If we don’t talk to doctors about this issue, they won’t know about the choking game until one of their patients dies.”

WASHINGTON ? In convening Thursday’s bipartisan health session, President Obama is angling to recreate the kind of spontaneous, unscripted debate that gave him a decided advantage when he took questions on live television at a House Republican retreat in Baltimore last month.

Senator Harry Reid spoke Wednesday to a group gathered in Washington to push lawmakers to pass health care legislation.

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Seating arrangements and camera positions at Blair House have been negotiated. On Thursday, talk will turn to health care.

But this time, Mr. Obama will face adversaries who are well prepared to joust with him on the finer points of health policy before a large audience that will be judging both sides and looking for signs of bipartisanship.

From the seating arrangements to the camera positions and buffet lunch ? not to mention the talking points ? the meeting has been carefully orchestrated, the product of days of negotiations that led to a walk-through on Wednesday for Congressional aides at Blair House.

One way Mr. Obama could throw Republicans off stride would be to make a bold opening offer to embrace one of their health care priorities, like limiting medical malpractice lawsuits ? an idea one Democrat close to the White House said had been under consideration.

But, this Democrat said, such an offer appeared unlikely, in part because Republicans seem dug in against the president’s plan and in part because it would arouse the ire of Mr. Obama’s Democratic base. In a conference call Wednesday, Congressional Democrats warned White House officials “not to go too far” on tort reform, one person familiar with the call said.

White House officials said Mr. Obama would use his opening remarks to make the case that Democrats and Republicans are not as far apart as they think on health care, because both parties are concerned about the deficit and rising health premiums ? issues, the president will argue, that can be addressed only by controlling health care costs.

Republicans said they would frame their arguments in opposition to the Democrats’ expansive plan, and would emphasize a handful of ideas that were part of a House Republican alternative to the Democrats’ legislation in November, including allowing small businesses to band together to buy health insurance at lower prices, permitting the sale of insurance policies across state lines, expanding state high-risk pools to offer coverage to people who otherwise could not obtain it, and limiting damages in medical malpractice lawsuits.

On Capitol Hill, both parties spent Wednesday preparing. Republicans met to plot strategy, even as they continued to deride the event as “political theater.”

At a hearing to question the president of WellPoint, one of the nation’s largest insurers, about rate increases in California, Representative Michael C. Burgess of Texas, the senior Republican on the investigations and oversight subcommittee of the Energy and Commerce panel, accused the Obama administration of trying to use the rate increases to build support for an expansive bill ? and to allow the federal government to interfere with a state issue.

“Tomorrow the president is holding a bipartisan photo op on health insurance reform,” Mr. Burgess said. “A six-hour photo op.”

Senator Harry Reid, the majority leader, and Speaker Nancy Pelosi met to prepare in Ms. Pelosi’s office, as party leaders insisted the session would provide voters a fresh perspective ? even though Washington has been debating health care for nearly a year.

“I honestly think it’s going to be quite constructive, because with TV cameras it’s going to force senators and representatives, both sides, to not over-dramatize but to burrow down on what health care reform does and does not make sense,” said Senator Max Baucus, Democrat of Montana. “I just believe in the disinfectant of the sunshine. The more we have got questions on both sides, gradually the American people are going to see more and more and more that we really do need health care reform.”

As the parties readied themselves, House Democrats were busy counting votes on Wednesday. The Democratic whip, Representative James E. Clyburn of South Carolina, said he believed Democrats could muster the votes to adopt a health care bill that resembled the plan Mr. Obama laid out on Monday, even picking up votes from some Democrats who opposed the House bill that was adopted in November.

Amid Wednesday’s political maneuvering, there was also legislative action. By a vote of 406 to 19, the House passed a bill to eliminate the exemption from federal antitrust law that health insurance companies have long enjoyed. The vote was a rare example of bipartisanship: 253 Democrats and 153 Republicans voted in favor, though all the no votes were cast by Republicans.

The repeal was included in the House version of health care legislation, but with the big bill stalled by the prospect of a Republican filibuster in the Senate, House Democratic leaders moved forward with a stand-alone measure as part of a strategy to continue advancing popular components of the larger bill.

“For too long,” said Representative Maxine Waters, Democrat of California, “consumers have been ripped off by collusion and concentration in the health insurance industry.”

The tussle over the staging of Thursday’s meeting suggests the extent to which each side is trying to use it to make overtures not to each other, but to the viewing public. The talks grew especially intense over the seating arrangements, Republican officials said, when the White House at first proposed a U-shaped table with President Obama and Vice President Joseph R. Biden Jr. in the center and Congressional leaders around the sides.

But the table would not have been big enough to accommodate all the lawmakers, pushing some into the chairs reserved for staff members. Republicans balked, and the White House agreed to close the U, so the lawmakers will now be seated around a hollow O-shaped table. Republicans, remembering well how Mr. Obama addressed them from a lectern at the Baltimore event, said it was important for them to have a level playing field.

“Any time you can be on equal footing with the president of the United States in style, set aside substance, you’re ahead of the game,” said Kenneth Duberstein, a former chief of staff to President Ronald Reagan. “The meeting at Blair House is not about the participants in the room, it’s about the TV audience.”

One lawmaker who sparred with Mr. Obama at the Baltimore meeting, Representative Jeb Hensarling of Texas, said he did not have high hopes for Thursday’s session. “I am having a hard time taking the whole thing seriously,” he said.

But Mr. Hensarling, whom Mr. Obama mistakenly called “Jim” in Baltimore, said such forums could help officials get to know one another better and hear others’ ideas.

“I personally think that although the president didn’t know me before the retreat,” Mr. Hensarling said, “he may know me now.”

Robert Pear contributed reporting.

WASHINGTON ? A top health insurance company executive told a Congressional committee on Wednesday that higher premiums were justified by soaring medical costs, and warned that pending legislation could make the problem worse, further driving up costs for young, healthy people.

The executive, Angela F. Braly, president of WellPoint, made the comments in testimony prepared for a hearing of the House Energy and Commerce Committee.

The hearing comes amid growing criticism of WellPoint and the health insurance industry by President Obama and Democrats in Congress, who say the proposed rate increases show the need for federal review and regulation of insurance premiums.

Anthem Blue Cross, a unit of WellPoint, recently informed subscribers in California that premiums for individual insurance policies would rise an average of 25 percent, with some rates going up as much as 39 percent.

“Raising our premiums was not something we wanted to do,” Ms. Braly said. “But we believe this was the most prudent choice, given the rising cost of care and the problems caused by many younger and healthier policyholders dropping or reducing their coverage during tough economic times. By law, premiums must be reasonable in relationship to benefits provided, which means they need to reflect the known and anticipated costs they will cover.”

The increases in premiums are driven by prices charged by doctors, hospitals, drug companies and other suppliers, and by increases in the use of health care by an aging population, Ms. Braly said.

“For 2010,” Ms. Braly said, “we expect hospital inpatient and outpatient costs in California to grow by over 10 percent, driven primarily by hospital reimbursement rates. Additionally, we expect pharmacy costs in California to grow by over 13 percent.”

Ms. Braly said health care providers were charging more to the private sector, “including our members,” because payments from Medicare and Medicaid did not fully cover providers’ costs.

Families with commercial insurance pay almost $1,800 a year more for coverage as a result of this cost shift, Ms. Braly said.

She criticized health care bills passed by the House and the Senate, with strong support from Mr. Obama. The bills would require insurers to accept all applicants and would require most Americans to have health insurance or pay a penalty.

But Ms. Braly said the “personal coverage requirement” would not be fully effective, because millions of people would be exempted and others would make a “logical choice” to pay the penalty rather than buy insurance, unless they needed health care.

“The result,” she said, “will be a national health insurance market that is similar to New York, where the average individual market premium is over twice the average individual premium in California.”

Ms. Braly said the legislation pending in Congress “would increase California individual market premiums for the young and healthy by as much as 106 percent, before premium subsidies for certain eligible individuals” are taken into account.

Democrats have said insurers are raking in large profits while raising premiums. But Ms. Braly said profits accounted for “a very small percentage of a member’s premium.”

Another witness invited to the hearing, Lauren Meister of West Hollywood, Calif., said she was told in January that her Anthem Blue Cross premium was being increased 38 percent, to $516 a month, from $373.

Ms. Meister said she was offered the option of switching to a lower-cost Anthem plan that covered only generic versions of prescription drugs. But she said that was not feasible because she took several brand-name drugs for asthma.

In her prepared testimony, Ms. Meister called for more regulation.

“We saw what deregulation did to the cost of utilities in California,” Ms. Meister said. “We saw what the lack of regulation has done on a national level to our financial and banking system. Well, it’s doing the same thing to our health care system.”

Ms. Meister added: “The City of West Hollywood, where I live, regulates how much landlords can raise the rent each year to keep rents stabilized. Why can’t the federal government regulate how much health insurance companies can raise their rates per year, in order to stabilize premiums?”