Software Programs Help Doctors Diagnose, but Can’t Replace Them

SAN FRANCISCO — The man on stage had his audience of 600 mesmerized. Over the course of 45 minutes, the tension grew. Finally, the moment of truth arrived, and the room was silent with anticipation.

At last he spoke. “Lymphoma with secondary hemophagocytic syndrome,” he said. The crowd erupted in applause.

Professionals in every field revere their superstars, and in medicine the best diagnosticians are held in particularly high esteem. Dr. Gurpreet Dhaliwal, 39, a self-effacing associate professor clinical medicine at the University of California, San Francisco, is considered one of the most skillful clinical diagnosticians in practice.

The case Dr. Dhaliwal was presented, at a medical  conference last year, began with information that could have described hundreds of diseases: the patient had intermittent fevers, joint pain, and weight and appetite loss.

To observe him at work is like watching Steven Spielberg tackle a script or Rory McIlroy a golf course. He was given new information bit by bit — lab, imaging and biopsy results. Over the course of the session, he drew on an encyclopedic familiarity with thousands of syndromes. He deftly dismissed red herrings while picking up on clues that others might ignore, gradually homing in on the accurate diagnosis.

Just how special is Dr. Dhaliwal’s talent? More to the point, what can he do that a computer cannot? Will a computer ever successfully stand in for a skill that is based not simply on a vast fund of knowledge but also on more intangible factors like intuition?

The history of computer-assisted diagnostics is long and rich. In the 1970s, researchers at the University of Pittsburgh developed software to diagnose complex problems in general internal medicine; the project eventually resulted in a commercial program called Quick Medical Reference. Since the 1980s, Massachusetts General Hospital has been developing and refining DXplain, a program that provides a ranked list of clinical diagnoses from a set of symptoms and laboratory data.

And I.B.M., on the heels of its triumph last year with Watson, the Jeopardy-playing computer, is working on Watson for Healthcare.

In some ways, Dr. Dhaliwal’s diagnostic method is similar to that of another I.B.M. project: the Deep Blue chess program, which in 1996 trounced Garry Kasparov, the world’s best player at the time, to claim an unambiguous victory in the computer’s relentless march into the human domain.

Although lacking consciousness and a human’s intuition, Deep Blue had millions of moves memorized and could analyze as many each second. Dr. Dhaliwal does the diagnostic equivalent, though at human speed.

Since medical school, he has been an insatiable reader of case reports in medical journals, and case conferences from other hospitals. At work he occasionally uses a diagnostic checklist program called Isabel, just to make certain he hasn’t forgotten something. But the program has yet to offer a diagnosis that Dr. Dhaliwal missed.

Dr. Dhaliwal regularly receives cases from physicians who are stumped by a set of symptoms. At medical conferences, he is presented with one vexingly difficult case and is given 45 minutes to solve it. It is a medical high-wire act; doctors in the audience squirm as the set of facts gets more obscure and all the diagnoses they were considering are ruled out. After absorbing and processing scores of details, Dr. Dhaliwal must commit to a diagnosis. More often than not, he is right.

When working on a difficult case in front of an audience, Dr. Dhaliwal puts his entire thought process on display, with the goal of “elevating the stature of thinking,” he said. He believes this is becoming more important because physicians are being assessed on whether they gave the right medicine to a patient, or remembered to order a certain test.

Without such emphasis, physicians and training programs might forget the importance of having smart, thoughtful doctors. “Because in medicine,” Dr. Dhaliwal said, “thinking is our most important procedure.”

He added: “Getting better at diagnosis isn’t about figuring out if someone has one rare disease versus another. Getting better at diagnosis is as important to patient quality and safety as reducing medication errors, or eliminating wrong site surgery.”

Clinical Precision

Dr. Dhaliwal does half his clinical work on the wards of the San Francisco V. A. Medical Center, and the other half in its emergency department, where he often puzzles through multiple mysteries at a time.

One recent afternoon in the E.R., he was treating a 66-year-old man who was mentally unstable and uncooperative. He complained of hip pain, but routine lab work revealed that his kidneys weren’t working and his potassium was rising to a dangerous level, putting him in danger of an arrhythmia that could kill him — perhaps within hours. An ultrasound showed that his bladder was blocked.

There was work to be done: drain the bladder, correct the potassium level. It would have been easy to dismiss the hip pain as a distraction; it didn’t easily fit the picture. But Dr. Dhaliwal’s instinct is to hew to the ancient rule that physicians should try to come to a unifying diagnosis. In the end, everything — including the hip pain — was traced to metastatic prostate cancer.

“Things can shift very quickly in the emergency room,” Dr. Dhaliwal said. “One challenge of this, whether you use a computer or your brain, is deciding what’s signal and what’s noise.” Much of the time, it is his intuition that helps figure out which is which.

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Software Programs Help Doctors Diagnose, but Can’t Replace Them

SAN FRANCISCO — The man on stage had his audience of 600 mesmerized. Over the course of 45 minutes, the tension grew. Finally, the moment of truth arrived, and the room was silent with anticipation.

At last he spoke. “Lymphoma with secondary hemophagocytic syndrome,” he said. The crowd erupted in applause.

Professionals in every field revere their superstars, and in medicine the best diagnosticians are held in particularly high esteem. Dr. Gurpreet Dhaliwal, 39, a self-effacing associate professor clinical medicine at the University of California, San Francisco, is considered one of the most skillful clinical diagnosticians in practice.

The case Dr. Dhaliwal was presented, at a medical  conference last year, began with information that could have described hundreds of diseases: the patient had intermittent fevers, joint pain, and weight and appetite loss.

To observe him at work is like watching Steven Spielberg tackle a script or Rory McIlroy a golf course. He was given new information bit by bit — lab, imaging and biopsy results. Over the course of the session, he drew on an encyclopedic familiarity with thousands of syndromes. He deftly dismissed red herrings while picking up on clues that others might ignore, gradually homing in on the accurate diagnosis.

Just how special is Dr. Dhaliwal’s talent? More to the point, what can he do that a computer cannot? Will a computer ever successfully stand in for a skill that is based not simply on a vast fund of knowledge but also on more intangible factors like intuition?

The history of computer-assisted diagnostics is long and rich. In the 1970s, researchers at the University of Pittsburgh developed software to diagnose complex problems in general internal medicine; the project eventually resulted in a commercial program called Quick Medical Reference. Since the 1980s, Massachusetts General Hospital has been developing and refining DXplain, a program that provides a ranked list of clinical diagnoses from a set of symptoms and laboratory data.

And I.B.M., on the heels of its triumph last year with Watson, the Jeopardy-playing computer, is working on Watson for Healthcare.

In some ways, Dr. Dhaliwal’s diagnostic method is similar to that of another I.B.M. project: the Deep Blue chess program, which in 1996 trounced Garry Kasparov, the world’s best player at the time, to claim an unambiguous victory in the computer’s relentless march into the human domain.

Although lacking consciousness and a human’s intuition, Deep Blue had millions of moves memorized and could analyze as many each second. Dr. Dhaliwal does the diagnostic equivalent, though at human speed.

Since medical school, he has been an insatiable reader of case reports in medical journals, and case conferences from other hospitals. At work he occasionally uses a diagnostic checklist program called Isabel, just to make certain he hasn’t forgotten something. But the program has yet to offer a diagnosis that Dr. Dhaliwal missed.

Dr. Dhaliwal regularly receives cases from physicians who are stumped by a set of symptoms. At medical conferences, he is presented with one vexingly difficult case and is given 45 minutes to solve it. It is a medical high-wire act; doctors in the audience squirm as the set of facts gets more obscure and all the diagnoses they were considering are ruled out. After absorbing and processing scores of details, Dr. Dhaliwal must commit to a diagnosis. More often than not, he is right.

When working on a difficult case in front of an audience, Dr. Dhaliwal puts his entire thought process on display, with the goal of “elevating the stature of thinking,” he said. He believes this is becoming more important because physicians are being assessed on whether they gave the right medicine to a patient, or remembered to order a certain test.

Without such emphasis, physicians and training programs might forget the importance of having smart, thoughtful doctors. “Because in medicine,” Dr. Dhaliwal said, “thinking is our most important procedure.”

He added: “Getting better at diagnosis isn’t about figuring out if someone has one rare disease versus another. Getting better at diagnosis is as important to patient quality and safety as reducing medication errors, or eliminating wrong site surgery.”

Clinical Precision

Dr. Dhaliwal does half his clinical work on the wards of the San Francisco V. A. Medical Center, and the other half in its emergency department, where he often puzzles through multiple mysteries at a time.

One recent afternoon in the E.R., he was treating a 66-year-old man who was mentally unstable and uncooperative. He complained of hip pain, but routine lab work revealed that his kidneys weren’t working and his potassium was rising to a dangerous level, putting him in danger of an arrhythmia that could kill him — perhaps within hours. An ultrasound showed that his bladder was blocked.

There was work to be done: drain the bladder, correct the potassium level. It would have been easy to dismiss the hip pain as a distraction; it didn’t easily fit the picture. But Dr. Dhaliwal’s instinct is to hew to the ancient rule that physicians should try to come to a unifying diagnosis. In the end, everything — including the hip pain — was traced to metastatic prostate cancer.

“Things can shift very quickly in the emergency room,” Dr. Dhaliwal said. “One challenge of this, whether you use a computer or your brain, is deciding what’s signal and what’s noise.” Much of the time, it is his intuition that helps figure out which is which.

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DealBook: UBS Described as Near Deal With U.S. and Britain on Rate Rigging

UBS, the Swiss banking giant, is close to reaching settlements with American and British authorities over the manipulation of interest rates, the latest case in a multiyear investigation that has rattled the financial industry and spurred a public outcry for broad reform.

UBS is expected to pay more than $450 million to settle claims that some employees reported false rates to increase the bank’s profit, according to officials briefed on the matter who spoke on the condition of anonymity because the talks were private.

If the bank agrees to the deals with various authorities, the collective penalties would yield the largest total fines to date related to the rate-rigging inquiry and would increase the likelihood that other financial institutions would face stiff penalties. Authorities dealt their first blow in the rate-rigging case in June when the British bank Barclays agreed to a $450 million settlement.

A spokeswoman for UBS declined to comment. The agencies leading the UBS investigation, the Commodity Futures Trading Commission, the Justice Department and Britain’s Financial Services Authority, also declined to comment.

The UBS case will provide a window into systemic problems in the rate-setting process, which affects how consumers and companies borrow money around the world. After reviewing thousands of internal bank e-mails and interviewing dozens of employees, the authorities have uncovered patterns of abuse at the major banks that help set benchmark interest rates.

Libor Explained

The sprawling investigation is focused on benchmarks like the London interbank offered rate, or Libor. The rate, a measure of how much banks charge each other for loans, is used to determine the costs of trillions of dollars of mortgages, credit card charges and student loans.

The authorities claim that UBS traders colluded with rival banks to influence rates in an effort to bolster their profits, according to officials briefed on the matter. Some traders at UBS were suspended this year over the matter.

Given the scope of the case, the UBS settlement is expected to heighten calls for a reform of the Libor system. Lawmakers are pushing to change the way banks report rates, providing more transparency to consumers, companies and investors that rely on the benchmark.

The reform movement gained momentum after global authorities secured the settlement with Barclays. Regulators had accused Barclays of reporting false rates, a scandal that prompted the resignation of the chief executive and other top officials at the bank.

Global authorities are now moving forward with civil and criminal cases, setting up the potential for major fines and regulatory sanctions. Some banks are in advanced settlement talks, including UBS and the Royal Bank of Scotland. The Royal Bank said it expected to disclose penalties before the firm’s next earnings release in February. Deutsche Bank said last month that it had set aside money to cover potential fines, although it was too early to predict the size.

American authorities are hoping to complete a deal with UBS by the middle of the month, according to officials briefed on the matter. The officials noted that the discussions could spill into next year. The talks could also break down, in which case the authorities would file a lawsuit against the bank.

It is unclear whether global authorities will act in tandem on the UBS case. The bank and the regulators would prefer to strike a deal together, but the agencies are proceeding at different speeds.

Investigators say the broader Libor case could go on for years.

Canadian, Swiss and Asian authorities as well as the Justice Department, the Commodity Futures Trading Commission and Britain’s Financial Services Authority are investigating the actions of more than a dozen banks. Along with UBS, the futures commission is focused on potential wrongdoing at two American banks, Citigroup and JPMorgan Chase, the officials said. HSBC is also under scrutiny.

In addition to the regulatory cases, the Justice Department has identified potential criminal wrongdoing by traders at Barclays and other banks. The banks also face private lawsuits from large investors like local governments, which claim to have suffered losses as a result of interest rate manipulation. The New York attorney general has subpoenaed 16 banks over their role in the scandal, an action that could foreshadow civil lawsuits. Analysts predict the financial industry could face penalties of up to $20 billion.

“The evidence that comes out of any future settlement is likely to be enormously helpful for our claims,” said David E. Kovel, a partner at the law firm Kirby McInerney who is representing clients in a potential class-action suit related to Libor.

For UBS, the Libor case comes at a difficult time.

It has faced a series of legal problems since the financial crisis. In 2009, the bank agreed to pay $780 million to settle accusations by American authorities that it helped wealthy clients avoid taxes.

In 2011, it announced a $2.3 billion loss prompted by a rogue trader, Kweku M. Adoboli, who received a seven-year jail sentence for fraud last month. The firm agreed to pay a $47.5 million penalty to the British authorities in connection with the trading loss.

In the Libor case, UBS has been eager to cooperate. It has already reached a conditional immunity deal with the antitrust arm of the Justice Department, which could protect the bank from criminal prosecution under certain conditions. It is also cooperating with Canadian antitrust authorities by handing over e-mails and other documents implicating other banks.

But it did acknowledge publicly that such deals would not shield the bank from potential penalties from other regulators. The Justice Department’s criminal unit, for instance, could still take action against the bank.

UBS disclosed last year that it was the subject of investigations related to Libor, saying it had received subpoenas from American and Japanese authorities. Swiss and British regulators have joined the UBS investigation, which involves a number of currencies in the Libor system.

The timing of the Libor cases against UBS depends in large part on cooperation among regulators.

The Financial Services Authority in Britain has worked closely with its American counterparts. In total, the British regulator has about 160 people working on its various cases against banks, which are at different stages of development.

As the top watchdog of London’s financial services industry, the British regulator has positioned itself as a conduit for document requests from international regulators regarding Libor, which is set daily by banks in London. The agency also organizes interviews for its American counterparts with London-based bankers involved in the inquiries, according to an official with direct knowledge of the matter.

British regulators had been ready to move against UBS a month after officials announced a settlement with Barclays, the person added. The settlement has been delayed, however, as global authorities have tried to pursue a joint agreement with the bank.

“We’ve been going at the pace of the slowest regulator,” the official said.

A version of this article appeared in print on 12/03/2012, on page A1 of the NewYork edition with the headline: Ubs Is Reported To Be Near Deal On Rate Rigging.

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In Damascus, Tense Anticipation of Strongest Push Yet by Rebels

Joseph Eid/Agence France-Presse — Getty Images

Distant explosions have awakened a sense of foreboding even in the tranquil Old City.

BEIRUT, Lebanon — As Syrian rebels and government forces clashed on the outskirts of Damascus on Saturday, with explosions rumbling in the distance and warplanes screeching overhead, the rebels appeared to be making their strongest push toward the city since the government repelled an offensive there in July.

A quiet tension prevailed downtown. But security checkpoints were proliferating, and there were reports that President Bashar al-Assad was preparing loyal divisions to defend the city, the capital and heart of his power.

Military analysts warned that it was impossible to know whether a decisive battle for Damascus was beginning, especially as Syrians lost access to the Internet for 53 hours, limiting the flow of information, before it was restored on Saturday. But they said that a government fight to defend its core could be the fiercest and most destructive phase yet of the 20-month conflict.

“We’re waiting for the big battle to begin,” said Emile Hokayem, an analyst based in Bahrain for the International Institute for Strategic Studies.

For decades, the Assad family has settled loyal military families, many from its minority Alawite sect, in the western outskirts of Damascus, where the presidential palace sits on a plateau overlooking the city. The current fighting suggested that the government was trying to insulate those areas, along with the city center and airport, from the semicircle of urban sprawl curving from northeast to southwest, where rebels have strengthened their position in recent days, overrunning a string of small bases.

Analysts say that Mr. Assad, knowing that losing Damascus could be a decisive blow, has been conserving his best and most loyal troops and much of his artillery for a battle there.

“We’re not yet at a point where the regime is in total panic mode and can no longer make rational — however nasty — decisions about military strategy,” Mr. Hokayem said. “He has to decide which cities around Damascus to destroy and which cities to keep in hand.”

When Damascus was threatened in July, the government pulled forces from parts of northern and southern Syria — allowing rebels to consolidate gains in the north — and there were reports that something similar was happening now. An activist in Damascus said Saturday that elements of the army’s feared Fourth Division, led by Maher al-Assad, the president’s brother, were at the Aqraba military airport near the Damascus airport. There were unconfirmed reports that other top divisions and special forces were headed for the city, said Joseph Holliday, an analyst at the Institute for the Study of War, in Washington.

“When the rebels score victories in Damascus, it forces the regime to contract more quickly” in the areas that it contests elsewhere, he said.

To some extent that has already happened, said one diplomat, Nasser Judeh, the foreign minister of Jordan. “There are large areas of Syria that are beyond the control of the regime now,” he said Saturday in Washington. “The opposition and the rebel forces are making serious advances. Things are moving in a different direction compared to what they were a few weeks ago.”

Analysts said rebels were unlikely to quickly overrun the government’s positions in the capital. The government has defended chosen strong points, including its most important helicopter base, in the northern province of Idlib, and a base on the road between Damascus and the commercial hub of Aleppo. Rebels have besieged both for months without taking them.

But the encroachment on Damascus has a profound psychological effect that could hasten the crumbling of Mr. Assad’s support — or deepen it among those who fear their fates are tied to his. In July, when rebels briefly held the southern Damascus neighborhood of Midan and bombed a military headquarters downtown, killing four top officials, some government supporters fled to Lebanon and coastal Alawite strongholds, analysts said.

Last month, rebel bombings in Mezze 86, a neighborhood of Alawite military families near the palace, unsettled government supporters amid suspicions of an inside job. In recent weeks, officials have expressed fear of commuting home to the suburbs, worrying that Sunni Muslim conscript soldiers at checkpoints will turn on them, shifting allegiance to the mostly Sunni uprising, said analysts, activists and a foreign reporter recently in Damascus.

Reporting was contributed by Neil MacFarquhar and Hania Mourtada from Beirut; Thomas Erdbrink from Tehran; Hala Droubi from Dubai, United Arab Emirates; and Elisabeth Bumiller from Washington.

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This Life: Maria Popova Has Some Big Ideas

Elizabeth Lippman for The New York Times

Maria Popova is the editor of Brain Pickings, an online grab bag of eclectic information.

SHE is the mastermind of the one of the faster growing literary empires on the Internet, yet she is virtually unknown. She is the champion of old-fashioned ideas, yet she is only 28 years old. She is a fierce defender of books, yet she insists she will never write one herself.

At precisely 9:30 on a chilly Saturday morning, Maria Popova slips out of her apartment in Brooklyn, scurries down a few stairs and enters a small basement gym. A former recreational bodybuilder from Bulgaria, Ms. Popova is the unlikely founder of the exploding online emporium of ideas known as Brain Pickings.

Her exhaustively assembled grab bag of scientific curiosities, forgotten photographs, snippets of old love letters and mash notes to creativity — imagine the high-mindedness of a TED talk mixed with the pop sensibility of P. T. Barnum — spans a blog (500,000 visitors a month), a newsletter (150,000 subscribers) and a Twitter feed (263,000 followers). Her output, which she calls a “human-powered discovery engine for interestingness,” has attracted an eclectic group of devotees including the novelist William Gibson, the singer Josh Groban, the comedian Drew Carey, the neuroscientist David Eagleman, the actress Mia Farrow and the Twitter founders Biz Stone and Evan Williams.

“She’s a celebrator,” said Anne-Marie Slaughter, a Princeton professor and former State Department official. “You feel the tremendous amount of pleasure she takes in finding these things and sharing them. It’s like walking into the Museum of Modern Art and having somebody give you a customized, guided tour.”

Unlike most blogger celebrities, however, Ms. Popova revels in remaining anonymous, which means her followers know almost nothing about her. In an age when many tweet what they put in their morning coffee, she rarely uses the word “I.” Her personal history is almost completely absent. Her photograph is not on the site. “I don’t feel the necessity to be in the public eye that way,” she said after reluctantly agreeing to sit for an interview. “There’s a certain safety in making people feel like you’re an organization and not a person. ”

A fierce creature of habit, she begins every day by working out. On this morning, she alternates 20 chin-ups with 50 push-ups, then performs a series of planks and stretches. Once on the elliptical, she frantically highlights an obscure 1976 book, “The Creativity Question” (Amazon sales ranking: one million-plus), and checks her RSS feed on her iPad.

Exactly 70 minutes later, she returns to her modest one-bedroom apartment to write a brief essay about Freud and daydreaming, file her thrice-daily blog entries and schedule her regimen of 50 Twitter messages a day. She does this while balancing on a wobble board.

“I try to sit still when I work, but my mind goes spiraling elsewhere,” she said in a mild Slavic accent reminiscent of Bond girls in the 1970s. “When my body is moving, it’s almost like it takes the wind out of this mental spinning, and I’m able to focus.” Recently, she came upon a 1942 book on inspiration chronicling others with the same habit. “Mark Twain paced while he dictated,” she said. “Beethoven walked along the river. Maybe there’s a psycho-biological element.”

Ms. Popova traces her discipline to her upbringing behind the Iron Curtain. Her parents met as teenage exchange students in Russia and had her almost immediately. Her father was an engineering student who later became an Apple salesman; her mother was studying library science. “We’re not very much in touch,” she said of her parents today, “but recently we were on Skype, and this whole library science thing came up. I realized a lot of what I do is organizational, almost like a Dewey Decimal System for the Web. My mother got so emotional. It was very funny, and kind of moving.”

Her paternal grandmother was a rabid biblio and had a collection of encyclopedias, Ms. Popova said, and she credits the act of randomly opening volumes and happening upon entries for her passion to discover old knowledge. “The Web has such a presentism bias,” she said, with Facebook updates, tweets and blog entries always appearing with the latest first. By contrast, flipping through the encyclopedia was “an interesting model of learning about the world serendipitously and also guidedely.”

After graduating from an American high school in Bulgaria, she enrolled at the University of Pennsylvania, where she quickly grew bored with what she calls the “industrial model” of education, involving large-scale lectures. While still a student, she was working part time at an advertising firm in 2005, when a colleague sent around an e-mail with clippings of rivals’ work to inspire the team.

Bruce Feiler’s latest book,“The Secrets of Happy Families,” will be published in February. “This Life” appears monthly.

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Opinion: A Health Insurance Detective Story

I’VE had a long career as a business journalist, beginning at Forbes and including eight years as the editor of Money, a personal finance magazine. But I’ve never faced a more confounding reporting challenge than the one I’m engaged in now: What will I pay next year for the pill that controls my blood cancer?

After making more than 70 phone calls to 16 organizations over the past few weeks, I’m still not totally sure what I will owe for my Revlimid, a derivative of thalidomide that is keeping my multiple myeloma in check. The drug is extremely expensive — about $11,000 retail for a four-week supply, $132,000 a year, $524 a pill. Time Warner, my former employer, has covered me for years under its Supplementary Medicare Program, a plan for retirees that included a special Writers Guild benefit capping my out-of-pocket prescription costs at $1,000 a year. That out-of-pocket limit is scheduled to expire on Jan. 1. So what will my Revlimid cost me next year?

The answers I got ranged from $20 a month to $17,000 a year. One of the first people I phoned said that no matter what I heard, I wouldn’t know the cost until I filed a claim in January. Seventy phone calls later, that may still be the most reliable thing anyone has told me.

Like around 47 million other Medicare beneficiaries, I have until this Friday, Dec. 7, when open enrollment ends, to choose my 2013 Medicare coverage, either through traditional Medicare or a private insurer, as well as my drug coverage — or I will risk all sorts of complications and potential late penalties.

But if a seasoned personal-finance journalist can’t get a straight answer to a simple question, what chance do most people have of picking the right health insurance option?

A study published in the journal Health Affairs in October estimated that a mere 5.2 percent of Medicare Part D beneficiaries chose the cheapest coverage that met their needs. All in all, consumers appear to be wasting roughly $11 billion a year on their Part D coverage, partly, I think, because they don’t get reliable answers to straightforward questions.

Here’s a snapshot of my surreal experience:

NOV. 7 A packet from Time Warner informs me that the company’s new 2013 Retiree Health Care Plan has “no out-of-pocket limit on your expenses.” But Erin, the person who answers at the company’s Benefits Service Center, tells me that the new plan will have “no practical effect” on me. What about the $1,000-a-year cap on drug costs? Is that really being eliminated? “Yes,” she says, “there’s no limit on out-of-pocket expenses in 2013.” I tell her I think that could have a major effect on me.

Next I talk to David at CVS/Caremark, Time Warner’s new drug insurance provider. He thinks my out-of-pocket cost for Revlimid next year will be $6,900. He says, “I know I’m scaring you.”

I call back Erin at Time Warner. She mentions something about $10,000 and says she’ll get an estimate for me in two business days.

NOV. 8 I phone Medicare. Jay says that if I switch to Medicare’s Part D prescription coverage, with a new provider, Revlimid’s cost will drive me into Medicare’s “catastrophic coverage.” I’d pay $2,819 the first month, and 5 percent of the cost of the drug thereafter — $563 a month or maybe $561. Anyway, roughly $9,000 for the year. Jay says AARP’s Part D plan may be a good option.

NOV. 9 Erin at Time Warner tells me that the company’s policy bundles United Healthcare medical coverage with CVS/Caremark’s drug coverage. I can’t accept the medical plan and cherry-pick prescription coverage elsewhere. It’s take it or leave it. Then she puts CVS’s Michele on the line to get me a Revlimid quote. Michele says Time Warner hasn’t transferred my insurance information. She can’t give me a quote without it. Erin says she will not call me with an update. I’ll have to call her.

My oncologist’s assistant steers me to Celgene, Revlimid’s manufacturer. Jennifer in “patient support” says premium assistance grants can cut the cost of Revlimid to $20 or $30 a month. She says, “You’re going to be O.K.” If my income is low enough to qualify for assistance.

NOV. 12 I try CVS again. Christine says my insurance records still have not been transferred, but she thinks my Revlimid might cost $17,000 a year.

Adriana at Medicare warns me that AARP and other Part D providers will require “prior authorization” to cover my Revlimid, so it’s probably best to stick with Time Warner no matter what the cost.

But Brooke at AARP insists that I don’t need prior authorization for my Revlimid, and so does her supervisor Brian — until he spots a footnote. Then he assures me that it will be easy to get prior authorization. All I need is a doctor’s note. My out-of-pocket cost for 2013: roughly $7,000.

NOV. 13 Linda at CVS says her company still doesn’t have my file, but from what she can see about Time Warner’s insurance plans my cost will be $60 a month — $720 for the year.

CVS assigns my case to Rebecca. She says she’s “sure all will be fine.” Well, “pretty sure.” She’s excited. She’s been with the company only a few months. This will be her first quote.

NOV. 14 Giddens at Time Warner puts in an “emergency update request” to get my files transferred to CVS.

Frank Lalli is an editorial consultant on retirement issues and a former senior executive editor at Time Warner’s Time Inc.

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Airbus Parent Expected to Alter Base of Its Investors

PARIS — The board of European Aeronautic Defense & Space, the parent company of Airbus, was expected Monday to announce a significant restructuring of its core shareholder base that would give the German government a direct stake in the group equal to that of France.

The restructuring, which was the subject of a board meeting late Sunday, would dissolve a decade-old agreement that gave the two countries an effective veto over company strategy, a factor that contributed to the failure of a proposed merger between EADS and BAE Systems of Britain in October.

One person familiar with the details of the plans said the state-owned German bank KfW was expected to acquire a 7.5 percent stake currently held by a consortium of public- and private-sector German banks, as well as another 4.5 percent from the German automaker Daimler, which owns 15 percent of the company.

The French government, which already owns 15 percent of EADS directly, has agreed to relinquish 3 percent of its voting rights in the company, said the person, who spoke on condition of anonymity because the board had not yet voted on the change. The French would continue to hold the full dividend rights of its 15 percent stake, but ownership of the other 3 percent would be transferred to a foundation, registered in the Netherlands, that would have no voting rights.

Details of the accord were expected to be announced Monday, the person said.

The new arrangement would end a shareholder pact that dates to the creation of EADS in 2000, which was designed to balance the national interests of France and Germany by giving a core group of shareholders special veto rights and the right to appoint the members of the company’s 11-seat board.

The core shareholder group has until now included Daimler, as well as Lagardère the French magazines and missiles conglomerate, which owns a 7.5 percent stake in EADS and whose chairman, Arnaud Lagardère, is currently chairman of the EADS board.

Both Daimler and Lagardère have long made clear their desire to sell their stakes, which neither considers core to its operations. The dissolution of the shareholder agreement now frees the two companies to dispose of their holdings. Some of the shares could be sold on the open market, but European news media reports last week suggested that EADS was also considering a share buyback that could absorb a significant portion of the outstanding shares.

EADS was expected to call for an extraordinary shareholders’ meeting in the first quarter of next year to approve changes to the ownership structure as well as a new slate of board directors.

Mr. Lagardère was not expected to be renominated as chairman, although he was likely to be replaced by another Frenchman. According to EADS’s bylaws, the chairman and chief executive must be split between a French and a German. Thomas Enders, who took over as chief executive in June, is a German.

EADS has long sought a new shareholder arrangement that would preserve the politically sensitive balance of influence between France and Germany without subjecting key management decisions to the approval of politicians in Paris and Berlin.

The impact of such political interference was on prominent display in October, when the German government led by Chancellor Angela Merkel failed to approve the EADS-BAE combination, sinking a deal that would have created the world’s largest aerospace group.

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Israeli Settlement Plan Would Split West Bank

Rina Castelnuovo for The New York Times

A point in East Jerusalem overlooking a region to the left called E1, where Israel plans to build.

JERUSALEM — High up in an empty, mountainous expanse east of this city there is a stone patio with a pair of green metal benches and a plaque marking the cornerstone of a future Jewish community. Dedicated in 2009, the plaque promises the new city will be built “adjacent to the united Jerusalem, which will be quickly re-established.”

Jerusalem, which both Israel and the Palestinians see as their capital, is anything but united, with fierce fights over its development posing perhaps the greatest threat to the prospects of peace. And beyond the cornerstone, nothing has been erected since in this contentious 4.6-square-mile area, known as E1, where there are many more goats than people.

But Israel’s announcement on Friday that it was moving ahead with zoning and planning preparations for the area could change all that, and many fear that it could close the window on the chance for a two-state solution to the long-running Israeli-Palestinian conflict.

Construction in E1, in fWest Bank territory that Israel captured in the 1967 war, would connect the large Jewish settlement of Maale Adumim to Jerusalem, dividing the West Bank in two. The Palestinian cities of Ramallah and Bethlehem would be cut off from the capital, making the contiguous Palestinian state endorsed by the United Nations last week virtually impossible.

Although Israeli officials did not call the move retaliation for the United Nations vote, most people here assumed the timing was not coincidental.

“It’s like two 3-year-old children playing, and one is hitting and the other is slapping instead of sitting down,” said Alex Lash, 56, an Israeli who was having a breakfast at a bustling restaurant here on Saturday morning in the Palestinian neighborhood of Beit Hanina after a three-hour mountain-bike ride. “It’s a never-ending story: we are doing something, they are doing something, one movement brings the other side’s movement. There is no end for that.”

Zakaria al-Qaq, a professor of national security at Al Quds University here and a resident of the East Jerusalem neighborhood of Silwan, also described the situation as a hopeless “cycle of action and reaction,” and said that Prime Minister Benjamin Netanyahu was under pressure to act because of the Israeli elections on Jan. 22.

“Maybe the Palestinians got something on paper and morally, but he got something on the ground,” Mr. al-Qaq said. “Netanyahu is trying to enforce something on the ground and gain the hearts and minds of the Israeli public. It’s a strong message to the Palestinian leadership that Netanyahu is not without cards in his hand.”

The development of E1, a project that the United States has blocked several times since 1994, has long been seen as a diplomatic third rail, and several experts said Saturday that they expected that Israel may once again back down from building there. But several other controversial housing projects within Jerusalem have sped forward in recent months, raising the ire of the Palestinian leadership, left-leaning Israelis and the international community, most of whom see the settlements as a violation of international law.

Along with zoning and planning for E1, Israel on Thursday approved 3,000 new housing units in unspecified parts of East Jerusalem and the West Bank.

Dani Seidemann, a Jerusalem lawyer and longtime antisettlement activist, said that even before the latest decision, the government had issued tenders for the construction of 2,366 units in 2012, more than twice the number built in the previous three years combined.

These include more than 1,200 units in Ramot and Pisgat Zeev — decades-old upscale Jewish neighborhoods of 40,000-plus residents that straddle Beit Hanina in the northern reaches of the municipality. Late last month, final approval of 2,610 units in an undeveloped southern stretch known as Givat Hamatos was postponed under international pressure because it was scheduled while Secretary of State Hillary Rodham Clinton was in the region trying to negotiate an end to Israel’s bloody conflict with the Gaza Strip.

“Now approaching the point of no return,” Mr. Seidemann said during a tour of the area Saturday. “It’s the largest settlement surge in Jerusalem since the 1970s.”

Israel began building and expanding East Jerusalem in 1968, shortly after it wrested control of the area from Jordan. There were about 69,000 Palestinians living there then. Now, nearly 300,000 Palestinians and more than 190,000 Jews live in dozens of separate communities scattered throughout the areas north, east and south of the Old City that are collectively called East Jerusalem. (Some 2,500 Jews have also settled house by house in close-in neighborhoods like Silwan and Sheikh Jarrah.)

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Bits Blog: Study May Offer Insight Into Coca-Cola Breach

Spend enough time with cybersecurity experts and chances are you will hear some variation of this line: There are two types of companies in the United States, those that have been hacked and those that don’t yet know they’ve been hacked.

Government intelligence officials and cybersecurity specialists say hackers — predominantly from China — are siphoning gigabytes, if not terabytes, of data from companies in the United States every day. We count on much of this information to deliver the innovative products and services that will lead to new jobs and economic growth. The security software company McAfee estimates that in 2008 alone, companies around the world lost more than $1 trillion because of this sort of intellectual property theft.

“I’ve seen behind the curtain,” Shawn Henry, the Federal Bureau of Investigation.’s former top cyber agent, who recently joined the cybersecurity start-up CrowdStrike, told me in an interview in April. “I can’t go into the particulars because it’s classified, but the vast majority of companies have been breached.”

The problem is that such breaches rarely make headlines because companies fear what disclosure will mean for their stock price. Google was the first to try to change that mentality when, in 2010, it disclosed that it and 34 other companies, many based in Silicon Valley, had been attacked by Chinese hackers. Of those 34, only Intel and Adobe Systems came forward, and they provided few details.

Still, news of some breaches leak out. That was the case, most recently, with Coca-Cola. This month, Bloomberg News reported that Coca-Cola was breached by Chinese hackers in 2009 during a failed $2.4 billion takeover attempt of the China Huiyuan Juice Group. That attempted deal would have been the largest foreign acquisition of a Chinese company.

Now, a 2010 case study published by the Mandiant Corporation, a cybersecurity firm, may offer further details. The study, which does not mention Coca-Cola specifically, details a 2009 breach of a “Fortune 500 Manufacturer” that aligns almost perfectly with Bloomberg’s account of Coca-Cola’s breach.

According to the study:

In 2009, a U.S. based Fortune 500 manufacturing company initiated discussions to acquire a Chinese corporation. During the negotiations, APT [advanced persistent threat] attackers compromised computers belonging to the executives of the U.S.-based company, most likely in an effort to learn more details of the negotiations. Sensitive data left the company on a weekly basis during negotiations, potentially providing the Chinese company with visibility to pricing and negotiation strategies.

As Bloomberg reported, Mandiant’s study said the company gained knowledge of the breach only when law enforcement officials notified it of the intrusion. The study also details how hackers penetrated the company via a so-called spearphishing attack, in which the attackers sent e-mails to certain executives from a fake account ostensibly belonging to the chief executive.

According to Bloomberg, an e-mail containing the subject line: “Save power is save money! (from CEO)” was sent to the e-mail account of Bernhard Goepelt, Coca-Cola’s current general counsel. The e-mail contained a malicious link that, once clicked, downloaded malware that gave the attackers full access to Coca-Cola’s network.

Mandiant’s 2010 report said the e-mail “was crafted to look like it originated from a fellow employee and discussed a message from the CEO on conserving resources.”

Tal Be’ery, a senior Web researcher at Imperva, a data security firm, compared details of the Coca-Cola breach with Mandiant’s study and said the two accounts clearly referred to the same company. Executives at Mandiant and media officers at Coca-Cola did not return requests for comment.

If Mandiant’s study is, in fact, based on Coca-Cola, then it offers new insights into the breach. According to the study, once in, hackers used password-stealing software to gain access to other systems on the company’s network. They also used the compromised executive’s account to launch what is known as an SQL server attack, in which hackers exploit a software vulnerability and enter commands that cause databases to produce their contents.

But one of the most interesting aspects of the breach, according to Mandiant, was how well the attackers had concealed their tracks. According to Mandiant, hackers used so-called stub malware. This is an agile agent whose code can be tweaked by hackers to use it for various functions while leaving a small forensic footprint.

The one discrepancy between the Bloomberg and Mandiant accounts was why, ultimately, the company’s acquisition fell apart. According to Bloomberg, Coca-Cola’s takeover attempt of China Huiyuan Juice Group was thwarted because China’s Ministry of Commerce rejected it for antitrust reasons. Mandiant’s report offered a different take:

The intrusion had a significant impact on the victim organization. As a result of the compromise, the U.S. company terminated their acquisition plans. While it was not possible to determine all the data that had been lost, the victim company was not able to compete the acquisition and accomplish their business objectives.

Updated: In an e-mail, Kent J. Landers, a spokesman for Coca-Cola, said that the company does not comment on security matters, but said Coca-Cola did not complete its acquisition of China Huiyuan Juice Group ”as a result of the China Ministry of Commerce declining approval for the proposed transaction.”

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Media Decoder Blog: Robert Thomson to Be Chief of News Corporation's New Publishing Company

2:53 p.m. | Updated

Robert Thomson, the top editor at The Wall Street Journal and Dow Jones and a confidante of News Corporation’s chairman and chief executive, Rupert Murdoch, is expected to be named chief executive of the media conglomerate’s newly spun-off publishing company.

Mr. Thomson will run the separate, publicly traded company, which will include The Journal, The New York Post, HarperCollins and a suite of lucrative television assets in Australia. The announcement is expected as early as Monday, according to a person briefed on the company’s decision-making.

Mr. Thomson took over at The Journal in 2008, soon after News Corporation completed its $5.6 billion acquisition of Dow Jones. He serves as managing editor of The Journal and editor in chief of Dow Jones, which also publishes Barron’s and the Dow Jones Newswires.

Gerard Baker, a deputy managing editor at the Journal, will take over for Mr. Thomson at The Journal, said the person briefed on the decisions, who could not discuss private conversations publicly.

At The Journal, Mr. Baker has overseen Washington and political coverage, among other topics. He previously wrote a neoconservative column for The Times of London, also owned by News Corporation, and served as Washington bureau chief at The Financial Times, where Mr. Thomson was the top editor of the United States edition.

Mr. Thomson began his career at News Corporation in 1979 as a reporter at The Herald in Melbourne, Australia. He and Mr. Murdoch are both Australian, and have taken family vacations together. Mr. Murdoch is often seen in Mr. Thomson’s office in the Journal newsroom.

In his tenure at The Journal, Mr. Thomson increased circulation by broadening the newspaper’s focus beyond business to include more general-interest and lifestyle news. He oversaw an expansion of the newsroom budget, added photographs to go along with the paper’s signature dot drawings and introduced a local New York section.

Mr. Murdoch will serve as chairman of the publishing company and remain chief executive of the entertainment company, which will include News Corporation’s movie studio, Fox Broadcasting and cable channels like FX and Fox News.

News Corporation plans to complete its split, which was announced in June, in mid-2013. Additional announcements about the publishing company’s board and cash structure are expected before the end of the year.

A News Corporation spokeswoman declined to comment on the expected appointments. Reuters was the first to report on the expected appointments.

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