Stop blaming video games for America’s gun violence

Recently, America’s attention has been understandably focused on the potential causes of increased violence – especially gun violence – particularly among children and youth, and how to stop it. Alongside gun-control proposals, some of which President Obama is likely to highlight in his State of the Union address tonight, much of that attention has looked at the potential of violent video games to cause or exacerbate the tendencies of youth to engage in real, harmful violence.

While I applaud increased vigilance on the part of parents in supervising their children’s behaviors and pastimes, a child playing a violent video game does not necessarily increase the likelihood that he or she will engage in real violence at that age or later in life.

Various reports and commentaries have documented the fact that Sandy Hook shooter Adam Lanza’s video game playing included violent shooter games like Call of Duty, Counterstrike, and Starcraft. Some have cited that activity as a possible cause for his shooting massacre.

ANOTHER VIEW: Gabrielle Giffords and NRA are both right about one thing: US culture of violence

But if Lanza was playing Call of Duty 4, he was one of millions. On the Xbox 360 console alone, the game’s developer, Infinity Ward, has documented nearly 4.4 million online players, not counting players who use a PlayStation 3 or aren’t online. The statistics for Counterstrike are similar – an estimated 62,142 per day. And Starcraft is so popular in Korea, that it has professional leagues and an estimated online player population of around 50,000 each day.

Of those millions of players, few commit an act of violence, certainly not enough to say that, statistically, video game play is a principle cause – or even a significant cause – of real-world violent behavior.

So why are so many people blaming the video game industry?

It’s a phenomenon known as “cultural lag,” and it’s what causes us to be hesitant in adopting new technologies, trying new fads, and changing our social mores. Cultural lag can be a good thing – some new things are dangerous, come with high levels of risk, and can infinitely do more harm than good. But cultural lag also can inhibit the development of technologies and society because of irrational fears, which is what I’m seeing with recent criticism of the gaming industry.

Before video games, society blamed rock ‘n’ roll for violence and bad behavior among young people. Before rock ‘n’ roll, we blamed television. Before television, movies. Before movies, mystery novels, which were once known as “penny dreadfuls.” Before mystery novels, Shakespeare, who repeatedly was accused of producing violent, lecherous, and otherwise improper behavior in his audience.

In essence, as a society, we always will try to find out “why” bad things happen, but we aren’t actually very good at finding the answers. We look back at our past with rose-colored glasses and look forward into the future with trepidation.

We see our own childhoods as joyful and carefree, and when, as adults, we are exposed to the grim realities of our world, we wonder, “What happened?”. And then we try to explain the difference between the past that we remember and the present as we perceive it. When we do this, we very often look to technologies that did not exist 20, 30, or 40 years ago, and we think: That didn’t exist back then when things were “better,” therefore it must have some impact on why things have “gotten worse” now.

First of all, I am unconvinced that “things have gotten worse,” but even if we assume that they have, in blaming technologies like video games for real-life violence, we assume causation, where numerous studies show there is only correlation – at best. This is tantamount to assuming, as journalist Jeanine Celestin-Greer of Gamastura (a gaming journalism website) points out, that because Lanza drank Mountain Dew, Mountain Dew causes violent behavior.

In a recent article in The Chronicle of Higher Education, Christopher J. Ferguson, a psychologist at Texas A&M International University, claimed that the recent outcry against video games as the cause of “school shootings” in general is patently fallacious. He explains that among hundreds of studies on violence and video games, not a single one has proven conclusively a causal relationship between violent behaviors in the real world and violent video-game play. And yet, scholars and politicians who often have little to no experience playing video games themselves continue to suggest that this is the case.

Americans need to stop trying to blame something other than ourselves for the increase – if there is an increase – in violent behavior.

Video games, music, television, movies, novels, and Shakespeare don’t cause violence. Mental illness, psychological abuse, and physical abuse cause violence. Ideologies that reward and condone aggression, particularly in men, cause violence. Global genocide causes violence. The only conclusive evidence we do have is that it is real-life violence that causes real-life violence.

As long as we, as a society, condone violence in the name of nationalism, continue to minimize domestic violence and rape, and promote aggression as ideal masculinity, violence will continue to be a problem in our homes, on our streets, and in our schools. Critics will argue that the imagery and plots of video games do just that – and in turn, perpetuate those behaviors. Yes, video games reflect some of these highly problematic aspects of our society that contribute to a tolerance of violence. Just like movies and books. But they don’t cause it.

Remove video games from the equation and you will still have a commensurate level of violence.

And yes, video games can influence ideology, but they aren’t the only – or even the predominant – influence on society or an individual. In fact, video games can influence our ideologies in as many if not more positive ways than they do negative ones. Many recent games actually encourage players to play non-violently and reward players for humane treatment and good judgment.

So while video games are influencing us, and sometimes through violent images and play, many of them are pushing us to criticize the very violence that some people seem to believe they are causing.

OPINION: 6 reasons why President Obama will defeat the NRA and win universal background checks

The dialogue we need to have is about real violence, not virtual violence, and I sincerely hope that America’s leaders recognize this as we move forward in addressing the problem.

Kristin M.S. Bezio is an assistant professor at the University of Richmond’s Jepson School of Leadership Studies. Her research explores the intersection of literature and leadership, looking at influences ranging from Shakespeare to video gaming.

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Putin Aims to Limit Officials’ Investments Abroad

MOSCOW — President Vladimir V. Putin introduced a draft law on Tuesday that would ban senior Russian officials from holding bank accounts or stocks outside Russia, the latest in a series of recent measures intended to insulate the country’s governance from foreign influences.

The draft law, which requires legislative approval, applies to a wide range of top officials, including lawmakers, ministers, top officials at the Central Bank and other state funds, and those whose work involves “the sovereignty or national security of the Russian Federation,” as well as their spouses and young children.

The change, though appealing to the broad public, would come as a jolt to many in Russia’s ruling class, who are both wealthy and deeply integrated into the West.

First presented in discussions on “nationalization of the elite,” the ban has been framed primarily as a way to guarantee officials’ loyalty to Russia, and also as a check on corruption, a topic on which the Kremlin knows that it is politically vulnerable. Commenting on a similar proposal by legislators last fall, a Kremlin spokesman, Dmitri S. Peskov, said officials with investments outside Russia “are not safe, in terms of being firm in defending the state’s interests.”

If the measure becomes law, as expected, officials will have three months to close their foreign accounts and sell their stock, or else face possible dismissal based on “lack of trust.” State auditors can initiate investigations into officials based on information provided by journalists, law enforcement bodies, political organizations and other sources.

The introduction of the draft law met with cheers from lawmakers, who have embraced a series of populist —some say reactionary — measures in the months since Mr. Putin returned to the presidency. An ultranationalist lawmaker, Vladimir V. Zhirinovsky, said foreign holdings marked government officials as members of a “fifth column.”

“They’ve bought half of Europe — the real estate, the accounts in all banks, they vacation there, their children study there, their relatives live there, they give birth there, they get medical treatment there,” he told a television reporter. “And it’s easy to influence them. A fifth column is formed here. One has to live at home, vacation at home, work and study. If you don’t like it, do not enter state service.”

A number of legislators said Tuesday that Mr. Putin’s measure could be broadened. Nikolai Levichev, of the party A Just Russia, suggested widening the circle of relatives who would come under scrutiny, noting that there are “multiple cases when a grown son or a niece of some governor or minister is a multimillionaire, in some cases invested in foreign banks.” In their proposal, some legislators had recommended banning Russians from owning real estate overseas as well, but Mr. Putin seems to have set that provision aside.

Foreign bank accounts have traditionally been used by officials as “an instrument for bribetaking,” noted Yevgeny Minchenko, a political analyst, in an interview with the Kommersant FM radio station. But the measure presented Tuesday leaves gaping loopholes, he said, because officials can still keep their money in accounts associated with offshore companies, or under the names of proxies or friends. “It’s clear that any law can be bypassed,” he said.

High-level corruption — and especially lavish spending by Russian officials overseas — has been a perennial theme for Mr. Putin’s critics, and some saw the measure presented on Tuesday as the president’s attempt to claim the issue as his own. Kirill Kabanov, chairman of the National Anticorruption Committee, a watchdog organization, said he believed that Mr. Putin had resolved to wrest control over the financial practices of the elite.

He said officials were being presented with a choice: either leave state service and retain foreign assets, or “stay in the real vertical — but if it becomes clear that in reality you are thinking about how to maintain your life in Côte d’Azur, you will be thrown out of the caste.”

“It’s not a secret to anybody that for many people, the motive for entering state service is to provide for a quiet life beyond the borders of our motherland at the expense of our budget,” he said.

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Gonzalez maintains he hasn't used PEDs

VIERA, Fla. (AP) — Gio Gonzalez arrived at spring training with the Washington Nationals on Tuesday and maintained he has not used performance-enhancing drugs.

The Miami New Times reported last month that Gonzalez was among a half-dozen major league players listed as receiving PEDs in purported records of Biogenesis of America LLC, a now-closed anti-aging clinic in Coral Gables, Fla. Gonzalez hopes to be exonerated.

"I feel very confident," the 27-year-old left hander said. "I think that at the end of the day I've never taken performance-enhancing drugs, and I never will."

Gonzalez, a 21-game winner last year, denied the allegations on Twitter on the day they were reported.

"You're stunned. You're shocked," he said Tuesday. "Your name has been brought up out of nowhere. You can't do nothing about it. You just have to wait it out and listen to what's going on. You can't jump the gun. You can't jump to conclusions. At the end of the day you just have to listen in and wait patiently."

Gonzalez said he had been contacted by Major League Baseball officials and has cooperated with their investigation. Gonzalez said he has "done everything that they want, and I feel strong with their program and what they're doing, and at the end of the day I'm waiting on them."

Gonzalez's father, Max, also was listed in the purported Biogenesis records.

"There's no connection for the fact that I say my father admitted that he was a patient there. A legitimate patient," the pitcher said. "And then after that, you know how my father is. ... All of south Florida, all of baseball knows that my father is the most proud father in baseball. He tells everyone about his son. And that's the best I can say. Other than that, I have no clue why my name was on that list, or on a notebook or anything."

Gonzalez doesn't want the allegations to be a distraction for his teammates.

"I'm going to do my best to keep it away from the locker room," he said. "I don't want any of this to be about me. Again, it's about the organization and it's about the team together."

Teammate Drew Storen said he isn't worried.

"Gio's a big part of this team, obviously. He's always been a big character guy for us," Storen said. "I think he'll continue to do that. He'll come in and be able to separate that stuff out. I think that's one of the things our clubhouse has been special for, we're able to cut out the outside factors. . I think we're going to be in good shape. Gio's a stand-up, character guy for us in this clubhouse. It's not going to change a thing."

Gonzalez said he plans to pitch for the United States in next month's World Baseball Classic following an invitation from manager Joe Torre. He figures to bolster a rotation missing David Price, Justin Verlander, Jered Weaver, Clayton Kershaw and Matt Cain.

___

Follow Kyle Hightower on Twitter at http://www.twitter.com/khightower

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Well: Straining to Hear and Fend Off Dementia

At a party the other night, a fund-raiser for a literary magazine, I found myself in conversation with a well-known author whose work I greatly admire. I use the term “conversation” loosely. I couldn’t hear a word he said. But worse, the effort I was making to hear was using up so much brain power that I completely forgot the titles of his books.

A senior moment? Maybe. (I’m 65.) But for me, it’s complicated by the fact that I have severe hearing loss, only somewhat eased by a hearing aid and cochlear implant.

Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins School of Medicine, describes this phenomenon as “cognitive load.” Cognitive overload is the way it feels. Essentially, the brain is so preoccupied with translating the sounds into words that it seems to have no processing power left to search through the storerooms of memory for a response.

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Katherine Bouton speaks about her own experience with hearing loss.

A transcript of this interview can be found here.

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Over the past few years, Dr. Lin has delivered unwelcome news to those of us with hearing loss. His work looks “at the interface of hearing loss, gerontology and public health,” as he writes on his Web site. The most significant issue is the relation between hearing loss and dementia.

In a 2011 paper in The Archives of Neurology, Dr. Lin and colleagues found a strong association between the two. The researchers looked at 639 subjects, ranging in age at the beginning of the study from 36 to 90 (with the majority between 60 and 80). The subjects were part of the Baltimore Longitudinal Study of Aging. None had cognitive impairment at the beginning of the study, which followed subjects for 18 years; some had hearing loss.

“Compared to individuals with normal hearing, those individuals with a mild, moderate, and severe hearing loss, respectively, had a 2-, 3- and 5-fold increased risk of developing dementia over the course of the study,” Dr. Lin wrote in an e-mail summarizing the results. The worse the hearing loss, the greater the risk of developing dementia. The correlation remained true even when age, diabetes and hypertension — other conditions associated with dementia — were ruled out.

In an interview, Dr. Lin discussed some possible explanations for the association. The first is social isolation, which may come with hearing loss, a known risk factor for dementia. Another possibility is cognitive load, and a third is some pathological process that causes both hearing loss and dementia.

In a study last month, Dr. Lin and colleagues looked at 1,984 older adults beginning in 1997-8, again using a well-established database. Their findings reinforced those of the 2011 study, but also found that those with hearing loss had a “30 to 40 percent faster rate of loss of thinking and memory abilities” over a six-year period compared with people with normal hearing. Again, the worse the hearing loss, the worse the rate of cognitive decline.

Both studies also found, somewhat surprisingly, that hearing aids were “not significantly associated with lower risk” for cognitive impairment. But self-reporting of hearing-aid use is unreliable, and Dr. Lin’s next study will focus specifically on the way hearing aids are used: for how long, how frequently, how well they have been fitted, what kind of counseling the user received, what other technologies they used to supplement hearing-aid use.

What about the notion of a common pathological process? In a recent paper in the journal Neurology, John Gallacher and colleagues at Cardiff University suggested the possibility of a genetic or environmental factor that could be causing both hearing loss and dementia — and perhaps not in that order. In a phenomenon called reverse causation, a degenerative pathology that leads to early dementia might prove to be a cause of hearing loss.

The work of John T. Cacioppo, director of the Social Neuroscience Laboratory at the University of Chicago, also offers a clue to a pathological link. His multidisciplinary studies on isolation have shown that perceived isolation, or loneliness, is “a more important predictor of a variety of adverse health outcomes than is objective social isolation.” Those with hearing loss, who may sit through a dinner party and not hear a word, frequently experience perceived isolation.

Other research, including the Framingham Heart Study, has found an association between hearing loss and another unexpected condition: cardiovascular disease. Again, the evidence suggests a common pathological cause. Dr. David R. Friedland, a professor of otolaryngology at the Medical College of Wisconsin in Milwaukee, hypothesized in a 2009 paper delivered at a conference that low-frequency loss could be an early indication that a patient has vascular problems: the inner ear is “so sensitive to blood flow” that any vascular abnormalities “could be noted earlier here than in other parts of the body.”

A common pathological cause might help explain why hearing aids do not seem to reduce the risk of dementia. But those of us with hearing loss hope that is not the case; common sense suggests that if you don’t have to work so hard to hear, you have greater cognitive power to listen and understand — and remember. And the sense of perceived isolation, another risk for dementia, is reduced.

A critical factor may be the way hearing aids are used. A user must practice to maximize their effectiveness and they may need reprogramming by an audiologist. Additional assistive technologies like looping and FM systems may also be required. And people with progressive hearing loss may need new aids every few years.

Increasingly, people buy hearing aids online or from big-box stores like Costco, making it hard for the user to follow up. In the first year I had hearing aids, I saw my audiologist initially every two weeks for reprocessing and then every three months.

In one study, Dr. Lin and his colleague Wade Chien found that only one in seven adults who could benefit from hearing aids used them. One deterrent is cost ($2,000 to $6,000 per ear), seldom covered by insurance. Another is the stigma of old age.

Hearing loss is a natural part of aging. But for most people with hearing loss, according to the National Institute on Deafness and Other Communication Disorders, the condition begins long before they get old. Almost two-thirds of men with hearing loss began to lose their hearing before age 44. My hearing loss began when I was 30.

Forty-eight million Americans suffer from some degree of hearing loss. If it can be proved in a clinical trial that hearing aids help delay or offset dementia, the benefits would be immeasurable.

“Could we do something to reduce cognitive decline and delay the onset of dementia?” he asked. “It’s hugely important, because by 2050, 1 in 30 Americans will have dementia.

“If we could delay the onset by even one year, the prevalence of dementia drops by 15 percent down the road. You’re talking about billions of dollars in health care savings.”

Should studies establish definitively that correcting hearing loss decreases the potential for early-onset dementia, we might finally overcome the stigma of hearing loss. Get your hearing tested, get it corrected, and enjoy a longer cognitively active life. Establishing the dangers of uncorrected hearing might even convince private insurers and Medicare that covering the cost of hearing aids is a small price to pay to offset the cost of dementia.

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Katherine Bouton is the author of the new book, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You,” from which this essay is adapted.

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This post has been revised to reflect the following correction:

Correction: February 12, 2013

An earlier version of this article misstated the location of the Medical College of Wisconsin. It is in Milwaukee, not Madison.

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DealBook: Big Investors Strengthen Opposition to Dell's Sale

12:29 p.m. | Updated

One of the country’s biggest mutual fund managers signaled its opposition to Dell‘s proposed $24.4 billion sale on Tuesday, as another investor disclosed a major step in a campaign to fight the deal.

T. Rowe Price said in a statement that it was opposed to the $13.65-a-share takeover bid being offered by the company’s founder, Michael S. Dell, and the investment firm Silver Lake. With a stake of about 4.4 percent, T. Rowe Price is Dell’s third-biggest shareholder.

The second-biggest shareholder, Southeastern Asset Management, meanwhile disclosed in a regulatory filing that it had retained D.F. King, a big proxy solicitation firm, as an adviser. It also confirmed that it held about 8.44 percent of Dell’s shares, trailing only Mr. Dell.

Proxy solicitors like D.F. King play important roles in fights over shareholder votes. They canvass a company’s investor base, providing their clients with estimates of how shareholders are leaning and strategies for winning over allies.

Southeastern has also hired Dennis J. Block of Greenberg Traurig, an experienced mergers and acquisitions lawyer, according to a person briefed on the matter.

The emergence of T. Rowe Price as an opponent of the deal is the latest sign of discontent with the management buyout bid. While Mr. Dell controls about 16 percent of the company’s stock, his offer for the computer maker requires the approval of a majority of independent shareholders.

In a statement, T. Rowe Price’s chairman and chief investment officer, Brian C. Rogers, said, “We believe the proposed buyout does not reflect the value of Dell, and we do not intend to support the offer as put forward.”

A spokesman for Dell repeated a statement made on Friday, saying that a special committee of the board had considered a number of strategic alternatives. “Based on that work, the board concluded that the proposed all-cash transaction is in the best interests of stockholders,” according to the statement.

Silver Lake declined to comment. 

Shares of Dell closed on Monday above the buyout price for the first time since the offer was announced last week, signaling expectations that the bid might be increased.

In a company release on Friday, Southeastern said it planned to consider all of its options to fight the deal, including a proxy fight, a lawsuit and calling on a Delaware court to determine the fair value of Dell shares.

The high price the firm paid for its holding is probably driving its opposition. Analysts have estimated that Southeastern paid more than $20 a share on average, meaning it would lose over $800 million if the current deal were completed.

A person close to the firm disputed that estimate, suggesting that Southeastern’s cost basis was closer to $16.90 a share.

Southeastern and its chief executive, O. Mason Hawkins, have been unafraid to challenge companies when their stock prices fall. The firm was a major force for change at the oil and natural gas driller Chesapeake Energy last year, eventually winning representation on its board.

With Dell, there is a long road ahead. The vote for shareholders to approve the buyout offer is at least several months away.

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NH bills: Bosses can’t seek social media passwords

CONCORD, N.H. (AP) — New Hampshire is considering joining a handful of states that bar employers from asking job applicants and employees for their social media user names and passwords.

The House’s labor committee is holding a hearing on two similar bills Tuesday that would prohibit an employer from requiring the disclosure. Maryland, California, Delaware, Michigan, New Jersey and Illinois have similar laws and two dozen besides New Hampshire are considering legislation, according to the National Conference of State Legislatures.

In their effort to vet job applicants, some companies and government agencies have started asking for passwords to log into a prospective employee’s accounts on social media sites, such as Facebook and Twitter. Critics call it an invasion of privacy akin to handing over the keys to the person’s house.

State Sen. Donna Soucy, a co-sponsor on both New Hampshire bills, said Monday that employers can gain access to information about an employee or job applicant through social media accounts like Facebook that they otherwise could not legally obtain. She said people post personal information about themselves on Facebook or others post on the person’s page that should be protected.

She said she has not heard of any New Hampshire employers demanding the information.

“I think the issue is something we need to consider a lot more seriously than we used to” with the growth of social media accounts, she said. “At the very least, I would hope we would have a study.”

Soucy, D-Manchester, said employers can use information on social media accounts to discriminate. For example, the applicant might be obese but the person’s weight would not be required on the application. The employer might not know until seeing a picture on Facebook, she said.

“Would they interview them if they saw their picture on Facebook?” she said.

Soucy said other people can post information on the person’s page that the person might not delete before a prospective employer saw it.

“As responsible as somebody might trying to be, it is still a reflection on them,” she said.

Allowing employers access to social media accounts also gives them access to others linked to the account at the infringement on their privacy, she said.

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The Lede: Latest Updates on the Pope’s Resignation

The Lede is providing updates on Pope Benedict XVI’s announcement on Monday that he intends to resign on Feb. 28, less than eight years after he took office, the first pope to do so in six centuries. (Turn off auto-refresh to watch videos.)

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Eagles, QB Vick agree to restructured deal

PHILADELPHIA (AP) — Quarterback Michael Vick, who was slated to earn $16 million next season, has agreed to a restructured deal with the Philadelphia Eagles.

Vick, who was injured and inconsistent last season, eventually giving way to rookie Nick Foles, now has a three-year contract, and will compete with Foles over the next nine months to see who runs new coach Chip Kelly's offense this season.

Vick, who returned to start the season finale vs. the New York Giants in December because Foles was injured, finished the season with 2,362 yards passing, 12 touchdowns and 10 interceptions. The Eagles finished 4-12 and in last place in the NFC East.

Andy Reid was fired as coach the day after the season ended, and Kelly was hired last month. Vick, who will be 33 when next season begins, is still elusive when healthy, and seems equipped to run Kelly's aggressive, up-tempo offense that he is bringing to the Eagles from Oregon.

"He wanted to be here," Kelly said Monday in his first meeting with the media following his opening press conference on Jan. 17. "I had never met him before. The one thing that attracted me to him, is Michael is a competitor. Nick is, too. You want guys who want to compete."

Vick was signed by Philadelphia in 2009, and became the starter in 2010. He led the Eagles that season to an NFC East title, and a memorable 38-31 December win over the Giants in which he rallied the team from a 21-point deficit.

There are questions, of course, about his durability and his age, as he now seems far removed from that resurgent 2010 season. He finished that year with 3,018 yards passing, 676 yards rushing and 30 total touchdowns.

"He's younger than (Dallas quarterback) Tony Romo, and he's right about the same age as (Giants quarterback) Eli Manning," Kelly said. "The only reason I say that is because I told Michael that this morning, and he didn't know."

Vick only played in 10 games last season, and in the finale vs. New York, he had a quarterback rating of just 68.4 en route to a 42-7 loss.

"I looked at the films, and studied the tape. When you look at Michael, it's his toughness. That cannot be overrated at all," Kelly said. "We looked at his skillset. He still has that skillset. He can still throw the football.

"He's got an unbelievable release, and it's our job as coaches to make sure he can get the ball out quickly."

All told, Vick has started 35 games for Philadelphia over the last three seasons. Foles has started six. The Eagles scored just 280 points last season as they endured an eight- and a three-game losing streak. Only Arizona (250) scored fewer in the NFC.

When asked which quarterback would work with the first-team offense in training camp, Kelly smiled and quickly showed he's going to be able to handle the Philadelphia media just fine.

"We'll go alphabetical," he said with a grin. "First name? Last name? We'll flip a coin."

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Well: Price for a New Hip? Good Luck Getting a Reliable Estimate

Jaime Rosenthal, a senior at Washington University in St. Louis, called more than 100 hospitals in every state last summer, seeking prices for a hip replacement for a 62-year-old grandmother who was uninsured but had the means to pay herself.

The quotes she received might surprise even hardened health care economists: only about half of the hospitals, including top-ranked orthopedic centers and community hospitals, could provide any sort of price estimate, despite repeated calls. Those that could gave quotes that varied by a factor of more than 10, from $11,100 to $125,798.

Ms. Rosenthal’s grandmother was fictitious, created for a summer research project on health care costs. But the findings, which form the basis of a paper released on Monday by JAMA Internal Medicine, are likely to fan the debate on the unsustainable growth of American health care costs and an opaque medical system in which prices are often hidden from consumers.

“Transparency is all the rage these days in government and business, but there has been little push for pricing transparency in health care, and there’s virtually no information,” said Dr. Peter Cram, an associate professor of internal medicine at the University of Iowa, who wrote the paper with Ms. Rosenthal. He added: “I can get the price for a car, for a can of oil, for a gallon of milk. But health care? That’s not so easy.”

President Obama’s Affordable Care Act focused primarily on providing insurance to Americans who did not have it. But the high price of care remains an elephant in the room. Although many experts have said that Americans must become more discerning consumers to help rein in costs, the study illustrates how hard that can be.

“We’ve been trying to help patients get good value, but it is really hard to get price commitments from hospitals — we see this all the time,” said Jeff Rice, the chief executive of Healthcare Blue Book, a company that collects data on medical procedures, doctors visits and tests. “And even if they say $20,000, it often turns out $40,000 or 60,000.”

There are many caveats to the study. Most patients — or insurers — never pay the full sticker price of surgery, because insurance companies bargain with hospitals and doctors for discounted rates. When Ms. Rosenthal balked at initial high estimates, some hospitals produced lower rates for a person without insurance.

But in other ways the telephone quotations underestimated prices, because they did not include the fees for outpatient rehabilitation, for example.

In an accompanying commentary, Andrew Steinmetz and Ezekiel J. Emanuel of the University of Pennsylvania acknowledged that there was “no justification” for the inability to provide estimates or for the wide range of prices. But they said that more rigorous data on quality — like infection rates and unexpected deaths — were required to know when high prices were worth it.

“Without quality data to accompany price data, physicians, consumers and other health care decision makers have no idea if a lower price represents shoddy quality of if it constitutes good value,” they wrote.

But, broadly, researchers emphasized that studies had found little consistent correlation between higher prices and better quality in American health care. Dr. Cram said there was no data that “Mercedes” hip implants were better than cheaper options, for example.

Jamie Court, the president of the California-based Consumer Watchdog, said: “If one hospital can put in a hip for $12,000, then every hospital should be able to do it. When there’s 100 percent variation in sticker price, then there is no real price. It’s about profit.”

Dr. Cram said the study did contain some good news: some of the country’s top-ranked hospitals came up with “bargain basement prices” in response to repeated calls. “If you’re a good consumer and shop around, you can get a good price — you don’t have to pay $120,000 for a Honda,” he said.

But that shopping can be arduous in a market not set up to respond to consumers. To get a total price, Ms. Rosenthal often had to call the hospital to get its estimate for on-site care, and a separate quote from doctors. And many were simply perplexed when she asked for a price upfront, Ms. Rosenthal said, adding, “The people who answered didn’t know what to do with the question.”

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How to Cope With Time Zone Changes and Jet Lag When Flying

Ilona De March, who lives in Amsterdam and travels frequently to Atlanta, has a strict rule when she flies across time zones: no alcohol.

A business traveler for 20 years, Ms. De March, a president at BCD Travel, knows the intricacies of long-haul flying — what works and what doesn’t.

When she arrives, she has another guideline. “I don’t lie down because then I would fall asleep,” she said. “I get busy working; I contact people in Atlanta. Then I am able to go to sleep at the right time.” What is the right time?

For her, the right time is nighttime in Atlanta. “I am trying to listen to my own body,” said Ms. De March, who oversees BCD Travel’s operations in Europe, the Middle East and Africa.

She still relishes the lifestyle. “I still haven’t lost the interest,” she said, though she added that “the travel isn’t as glamorous as it used to be, with tighter security.”

Yet, according to circadian rhythm experts, the lifestyle can take a toll on the mind and body. Just how much it affects an individual varies.

Research from June 2012 by AirPlus International, a global corporate card provider, in partnership with Business Travel Market, showed that executives who travel frequently could suffer from “decreases in mental capacity, increased stress levels and decreased productivity.”

The study, which used a tiny device called the Bodyguard to monitor heart rate variations, compared travelers with nontravelers during a 72-hour period.

The business travelers showed reduced mental capacity, diminished communication skills, decreased ability to concentrate and engage others, reduced tolerance levels and an increased risk of ill health. It corroborated earlier research by Mark Rosekind, the former director of NASA’s fatigue countermeasures program who is now a member of the National Transportation Safety Board. The average executive’s productivity and performance while traveling drops up to 20 percent, largely because of insufficient sleep, according to Dr. Rosekind’s research.

How well individuals cope with crossing time zones varies, and everyone must learn what works. “There are some people who can do it,” said Simon Shepard, a physical therapist in London for Optima-life, a British health and performance organization. He worked on the AirPlus study. “There are some people who are adaptable and can cope very well,” he said. But some people are less aware of travel’s effects, and believe they are sleeping better than they are. Mr. Shepard says he encourages frequent travelers to fly in first class or business class, avoid alcohol, move around while in flight, arrange for an early hotel check-in, have a car waiting when they arrive and stay hydrated before, during and after the flight.

David F. Dinges, a performance expert who has worked with NASA astronauts and has conducted research in the area of sleep deprivation and time zones, agreed that everyone dealt with travel across time zones differently. “Some tolerate it better than others. All get in deficit. There are large individual differences.”

Generally, he said, there are three types of people when it comes to crossing time zones. One, which he calls Type 3, who are very disrupted, “really affected”; Type 2, who are somewhat affected; and Type 1, who seem to take longer before they show the effects of frequent travel across time zones. “They cope pretty well,” said Dr. Dinges, who is chief of the division of sleep and chronobiology at the Perelman School of Medicine at University of Pennsylvania.

Dr. Dinges, who travels frequently from Philadelphia to Moscow and Philadelphia to Paris, recounted instances when he and other scientists had arrived in Moscow, Paris, Singapore or Tokyo, and, while waiting in the lobby for a limousine to take them to a meeting, boasted of how well they did with the time zone difference and lack of sleep. The next thing he heard, Dr. Dinges said, was one scientist asking: “Where’s my computer?” Then another: “Where’s my passport?” Both headed back to their hotel rooms to get the missing items.

“What people say has nothing to do with reality,” Dr. Dinges said. “You can have loss of short-term memory, which is especially likely to happen in a novel environment.”

One of the benefits of proper sleep is that it ensures that the brain works efficiently.

Sleep deprivation, Dr. Dinges said, is associated with obesity, diabetes, stroke and heart attack, which could be enough to make frequent travelers question their lifestyle, and some do, he said. Those who have the most difficulty are the ones who quit the lifestyle, if they can. “Eat fish, salad, fruit, juices for vitamins and energy,” said Chris Crowley, senior vice president for global client management for Europe, the Middle East and Africa for BCD Travel. “The big lesson is not to drink alcohol. I’ve been traveling like this for 20 years. I used to accept the first glass of Champagne offered. I would be sluggish and struggling when I arrived. You have to approach the long-haul travel like you’re at work, as a kind of mission. Be as fit as you possibly can be, as well as you possibly can be.”

Dr. Dinges, 63, who has been traveling to far-flung places for 35 to 40 years, said he had developed routines particular to his needs. He does not sleep on planes, drinks no alcohol, avoids rich foods and does not put his airplane seat back, choosing to work instead. “Know your strengths and weaknesses, what happens to you, what kind of mistakes you’re likely to make.” In addition, he said, he tries to arrive at his destination the day before his business meetings.

Over-the-counter sleep medication usually remains in the body for less time than prescription drugs, he said. “Know what drug at which dose is right for you. Don’t guess at it, and don’t mix sleep medication with alcohol.”

Those who travel across time zones recommend a nap to keep going. “Grab sleep whenever you can,” said Mr. Crowley, who travels 220 to 230 days a year. “Even if you’re not tired, you’ll sleep an hour.”

One caveat: Set two or three alarms to make sure you are awake in time for the business meeting or other work commitment.

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