Practicing Patients - PatientsLikeMe

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From Sunday's New York Times:

March 23, 2008

Practicing Patients

By THOMAS GOETZ

Todd Small was stuck in quicksand again. It happened, as always, on

the floor of the Seattle machine shop where he worked. His shift

complete, Small was making the 150-yard walk from his workstation to

his car, when he realized that his left leg was sinking deep in the

stuff. Though this had happened before — it happened nearly every day

now — he stopped and glanced down at his feet. His Nikes looked

normal, still firmly planted on the shop's concrete floor. But he was

stuck, just the same. His brain was sending an electrical pulse

saying " walk, " but as the signal streaked from his cerebellum and

down his spinal cord, it snagged on scar tissue where the myelin

layer insulating his nerve fibers had broken down. The message wasn't

getting to his hip flexors or his hamstrings or his left foot. That

connection had been severed by his multiple sclerosis. And once

again, Small was left with the feeling that, as he described it, " I'm

up to my waist in quicksand. "

For the 400,000 Americans with multiple sclerosis, Todd Small's

description will most likely ring true. Muscle stiffness is a

hallmark of the disease, and " foot drop " — the term for Small's

quicksand feeling — is a frequent complaint. The condition is usually

treated, as it was in Small's case, with baclofen, a muscle relaxant

that works directly on the spinal cord. Every day for 14 years, he

took a single 10-milligram pill. " My neurologist always told me if

you take too much it will weaken your muscles. So I never wanted to

go over 10 milligrams. " It didn't seem to have much effect, but he

carried on as best he could.

Small would have continued just as he was had he not logged on last

June to a Web site called PatientsLikeMe. He expected the sort of

online community he'd tried and abandoned several times before — one

abundant in sympathy and stories but thin on practical information.

But he found something altogether different: data.

After choosing a user name and filling out a profile, Small was asked

to list his symptoms and treatments. He entered the 200 milligrams of

Provigil he takes daily to fight fatigue along with the Tysabri

injection he takes to slow the progress of his disease. And then he

clicked on baclofen, and the Web site informed him that nearly 200

patients registered at PatientsLikeMe were taking the drug. He

clicked again, and up popped a bold bar graph, sectoring those 200

across a spectrum of dosages. And there it was. Contrary to what his

neurologist told him years ago, 10 milligrams wasn't the maximum

dose. In fact, it was at the low end of the scale. " They're taking

30, 60, sometimes 80 milligrams — and they're just fine, " Small

recalls. " So it hits me: I'm not taking nearly enough of this drug. "

A few days later, Small asked his neurologist to up his dosage. Now

Small takes 40 milligrams of baclofen a day. His foot drop isn't

cured — there are no miracles in M.S. — but he has found that after

14 years, he can walk to his car without sinking into quicksand. " Oh,

man, I really dreaded that walk, " Small recalled when I spoke with

him recently. " All shift, it'd be in the back of my mind. Am I going

to have trouble? Is it going to get me? Now I almost got it figured

it out. I don't struggle like I used to. "

There are a little more than 7,000 Todd Smalls at PatientsLikeMe,

congregating around diseases like Parkinson's, multiple sclerosis

(M.S.) and AIDS, all of them contributing their experiences and

tweaking their treatments. At first glance, the Web site looks like

just any other online community, a kind of MySpace for the afflicted.

Members have user names, post pictures of themselves and post updates

and encouragements. As such, it's related to the chat rooms and

online communities that have inhabited the Internet for more than a

decade.

But PatientsLikeMe seeks to go a mile deeper than health-information

sites like WebMD or online support groups like Daily Strength. The

members of PatientsLikeMe don't just share their experiences

anecdotally; they quantify them, breaking down their symptoms and

treatments into hard data. They note what hurts, where and for how

long. They list their drugs and dosages and score how well they

alleviate their symptoms. All this gets compiled over time,

aggregated and crunched into tidy bar graphs and progress curves by

the software behind the site. And it's all open for comparison and

analysis. By telling so much, the members of PatientsLikeMe are

creating a rich database of disease treatment and patient experience.

And that's no small thing. As modern medicine has reduced infectious

disease in the U.S., the country's population — like those in other

developed nations — has shifted to longer-term, chronic ailments like

heart disease and diabetes, diseases that patients must cope with for

years and even decades. What's more, conditions like high cholesterol

and obesity demand years of vigilance to minimize their chances of

leading to more serious health problems.

Disease management has become a national reality, a common experience

that demands uncommon attention. And PatientsLikeMe is a tool that

allows patients to manage their disease with a sophistication and

precision that would have been unimaginable just a decade ago. The

7,000 members of PatientsLikeMe, in other words, are beta testers —

they may be the vanguard of how we all will care and treat our résumé

of chronic diseases. They're not typical patients, in the sense of

waiting for advice from a doctor. They are, rather, co-practitioners

treating their conditions and guiding their care, with possibly

profound implications. " People who use it will live longer; people

who don't won't, " boasts Heywood, the provocative co-founder of

PatientsLikeMe. " That's evolution. "

Of course, turning patients' experiences into usable data raises a

host of questions for medicine. When patients take the reins of their

own treatment, what role do doctors play? What's to keep patients

from misinterpreting the streams of data and finding false hope — and

what's stopping them from embarking on unproven and even risky

treatments or dosages? And what happens if the real-world information

at PatientsLikeMe contradicts the clinically proved protocols of

medical science?

For many in the medical community, these are unexpected and

unsettling questions. And they reflect the broader concern that many

doctors have with the Internet's emergence as a powerful source of

medical information. According to a 2006 study by the Pew Research

Center, 80 percent of Internet users, or about 113 million adults in

the U.S., get health information from the Internet. Some physicians

disdain this trend, bemoaning their hyperinformed patients

as " Googlers. "

Yet even doctors who consider themselves advocates of online medical

information raise concerns about patients self-medicating or self-

treating. Ensrud, a neurologist at Brigham and Women's Hospital

in Boston, specializes in many of the diseases that PatientsLikeMe

focuses on. " The nervous system is the most complicated system in the

body, " he says. " It's so often much more difficult to quantify and

study than we think it will be. "

For the members of PatientsLikeMe, though, the Web site can seem like

a revelation — it's a community forged not only around shared

circumstance but also around a shared purpose. They say they are part

of a project that may change the way their disease is treated and

could change the way medicine is practiced. It's an experiment in the

future of medicine, running in real time.

PatientsLikeMe started with a single case of amyotrophic lateral

sclerosis. In 1998, Heywood, a 29-year-old carpenter, learned

that he had A.L.S., a neurodegenerative disorder commonly known as

Lou Gehrig's disease. , his older brother, quit his job to find

a cure. An M.I.T.-trained mechanical engineer with a knack for

neuroscience, founded the A.L.S. Therapy Development Institute

in Cambridge, Mass., the following year. So began a radical quest to

save 's life. They tried experimental drug therapies, they

tried a stem-cell transplant and they tried a neural implant, each

effort building on the previous one. After six years, was

among the most documented A.L.S. patients in the world.

The sheer volume of 's data gave an idea — a notion

hatched while browsing Match.com, the online dating site. The

aspiring singles there had posted a trove of information about

themselves — their likes and dislikes, their dating histories, their

height and weight — all to find a perfect match. realized that

a similar tool might be useful in the realm of disease, for treatment

rather than romance. If patients shared their information and could

find someone with a similar symptomatology and disease history, then

they might better plot their own course of treatment and care. And it

didn't just have to be A.L.S. — it could work for any disease.

tapped his brother Ben, who also went to M.I.T. before earning

his M.B.A. at U.C.L.A., and Jeff Cole, a college classmate of Ben's

who'd spent several years building dot-coms. They started with

's own case history, breaking it down into drug dosages,

symptom severities and so on. In March 2006, PatientsLikeMe opened

for business. Within a few months, the company added communities for

M.S. and Parkinson's disease. Last fall the company opened a

community for people with H.I.V. Earlier this month, the company

placed its biggest bet on the model of collective experience,

creating a community for the millions of Americans with a mental-

health condition.

The Web site gathers patient information on two levels: first there's

a quantitative breakdown of symptoms and dosages, data that the

software instantly turns into charts and graphs. Second are the

forums, where members share advice and provide more nuanced feedback

on a certain drug or treatment issue. The site is designed so that

relevant data bolster the conversations in the forums and vice versa.

" Our job is to allow a conversation with the computer that will match

a conversation between two patients, " explains. " Then we

capture that dialogue and turn it into useful, clean data. "

died the day after Thanksgiving in 2006, but his profile,

under the user name ALSKing101, still contributes to that dialogue.

Like many people with advanced A.L.S., in his last three years,

was living in a wheelchair, completely paralyzed and

breathing through a mechanical vent. One night his breathing tube

snagged and disconnected, and he suffocated while he was sleeping.

Such a death isn't unknown for A.L.S. patients, and many

PatientsLikeMe members — about 75 are on ventilators — have expressed

fears about dying that way. Their main concern is that suffocation is

a painful, unpleasant way to go.

As it turns out, the PatientsLikeMe community tries to allay that

fear. At least two other members of the site have, in fact, had their

breathing tubes accidentally disconnected and suffocated until

passing out — only to be found and resuscitated, just in time. They

have, in other words, almost died in just the way did, in the

way so many have feared, but lived to tell about it: " Long story

short, my vent hose came off in '97, and I was certain I was going to

die. I stared at the clock for exactly 10 minutes until I got tunnel

vision then passed out. Nothing painful, stressful or anxious about

it. It was like I just got sleepy and went to sleep. Suffocation was

nothing like what I expected. Lol. " Laugh out loud, indeed.

The company is located in the brick-walled basement of a former twine

factory, less than a mile from the M.I.T. campus in Cambridge. With

just 15 employees, it is very much in start-up mode. Cole, who is 36,

manages the site's design and software team; Ben Heywood, also 36,

handles overall operations and management; , 41, is the frenzied

visionary, ever eager to sketch out how powerful a database of 7,000

patient profiles can be. The company, which is financed by private

investors, eschews advertising; the business model instead seeks to

exploit the value of the databank itself. By and large, this means

working with pharmaceutical companies. The company has had

discussions with several drug firms to sell anonymized patient data

on various symptoms and treatments. They have also recruited

PatientsLikeMe members to be participants in clinical drug trials.

Ultimately, the company expects that the data will generate insights

with considerable scientific — as well as economic — value.

One afternoon in late November when I visited the office,

turned to a nearby whiteboard and traced out an x-y axis, slashing a

descending line from left to right. " We have the ability to run a

probability engine, " he said. " We can mathematically model each

patient. We can tell them what's going to happen in their life. We

can tell you when you'll need a wheelchair. " He made a mark along the

line. " And we can even tell you the day you'll die, with remarkable

certainty. "

Of course, 's spiel is part bravado. The company hasn't started

to predict specific patients' prognoses — though they have filed for

a patent covering such prediction tools. And not all quests for

scientific precision are likely to succeed or prove worthwhile. But

for the patient coping with the cascade of day-to-day decisions that

come with managing a disease, the site's aggregations offer a

remarkable tool.

Every day, like 453 other members with M.S., Laurie Fournier gives

herself an injection of Copaxone, a drug that impedes the disease's

progress. Together, the group has generated what amounts to a

checklist of best practices. Fournier has learned that by doing the

injection herself, " Wayne-style, " rather than using an auto

injector, she can avoid some of the bruising that's a particularly

aggravating side effect. And she has learned that the optimal needle

stick goes through the skin and into the fat layer — but no

further. " You don't want to get muscle, " she relates. " Last time I

did that, I couldn't use that leg very well for a day and a half. "

Fournier, a self-described information junkie, relates all these

details with a blasé precision. Her willingness to put so much

information about herself online may seem immodest, even imprudent.

But not to her. " I don't worry too much about that, " she

says. " Pretty much everybody I know over 45 has some kind of medical

condition. Some people have had cataracts surgery, or they have high

blood pressure, or high cholesterol or diabetes. Everyone has

something. And if everyone has something, that really levels the

playing field. "

" Any disease that is treated as a mystery and acutely enough feared

will be felt to be morally, if not literally, contagious, "

Sontag wrote in 1978, in " Illness as Metaphor. " " Contact with someone

afflicted with a disease regarded as a mysterious malevolency

inevitably feels like a trespass; worse, like the violation of a

taboo. " The antidote to such stigma, she suggested, is " to rectify

the conception of disease, to demythicize it. "

But the myths surrounding disease are hard to dispel, our impulse to

hide in metaphor difficult to shake. We still talk of wars on cancer

and plagues of lawyers. " Leper " endures as a metaphor for stigma,

long after leprosy itself has been eliminated from most of the world.

Stigma endures in more material ways, as well — most pointedly in

concerns over medical privacy. For decades, our personal health

information has been protected largely by disorganization and chaos,

suggests Mark Rothstein, a bioethics and health-policy professor at

the University of Louisville. But now, with major health-maintenance

organizations and hospitals finally adopting electronic records,

fallow storerooms of paper records are being converted into neat and

portable digital form. " Technology is racing ahead of society, " says

Rothstein, who advises the Department of Health and Human Services on

electronic privacy. " If this is sensitive information — sexual

history, mental illness, substance abuse — even if nothing bad

happens, people are subject to stigma and embarrassment. "

The government has tried to protect patient privacy, most notably

with the Health Insurance Portability and Accountability Act, or

Hipaa. Enacted in 1996 to help streamline the adoption of electronic

records, Hipaa was modified in 2002 to address concerns over how

those records might be misused or distributed to unauthorized people.

The law stipulates that if 18 categories of personally identifiable

information are stripped from records then they may be transferred

for research purposes without a patient's consent.

Perhaps not surprisingly, Hipaa satisfies no one — not the privacy

advocates, who argue against most any form of electronic record, and

not the medical researchers, who now face onerous restrictions on

their work. PatientsLikeMe upends this dialectic; in technology

terms, it routes around the problem. Since the company is an opt-in

service and not a health-care provider, Hipaa doesn't apply. Good

thing, really, since the site identifies members' cities and their

ages, two of Hipaa's 18 prohibited categories of personal

information.

But Hipaa is extraneous not just legally but philosophically as well.

Many PatientsLikeMe members volunteer even more information from

those 18 categories. They not only post their photos but also post

photos of their children and spouses. They add brief autobiographies

and describe their conditions in precise detail — including

potentially embarrassing particulars on sexual function, bladder

control or constipation. And though they all have user names, most go

by their first names on the site's forums.

PatientsLikeMe's privacy policy clearly states that this sharing

carries risks. It acknowledges that since anybody can register at the

Web site, anybody can look at member profiles. It makes clear that

there's no guarantee that registered members are, in truth, who they

say they are. And it nods to the fact that, yes, this is a business,

not a public service — some personally identifiable information may

be sold to " approved vendors. " But this is boilerplate. The most

striking notice is the company's Openness Philosophy, a manifesto

posted prominently on the site.

" Currently, most health-care data is inaccessible due to privacy

regulations or proprietary tactics, " it declares. " As a result,

research is slowed, and the development of breakthrough treatments

takes decades. . . . When you and thousands like you share your data,

you open up the health-care system. . . . We believe that the

Internet can democratize patient data and accelerate research like

never before. "

In 1990, Alan Westin, a political scientist at Columbia University

and an expert in privacy issues, offered a useful taxonomy of

Americans' attitudes toward privacy. On one end of the spectrum were

what he called privacy fundamentalists — the 25 percent of Americans

who feel that their privacy is paramount and that no one, not the

government or corporations or their family, should have access to

their personal information without explicit permission. At the other

end of the spectrum were the privacy-unconcerned — about 15 percent

of Americans — who paid no mind to privacy issues and didn't figure

they had anything to hide. In the middle were the vast majority, the

60 percent whom Westin called privacy pragmatists: those who felt

that they could give a company they trusted some information — birth

date, ZIP code, telephone number — for particular benefits.

The members of PatientsLikeMe aren't all radicals culled from the

privacy-unconcerned, though no doubt some are. Most more likely fit

the profile of pragmatists. " I know it sounds like really personal

information, but it's not like I'm putting my phone number up, " says

Jodoin, a hotel manager in Palm Beach, Fla., who has changed

her M.S. medications based on information gleaned at

PatientsLikeMe. " I'm not posting my address and saying, `Come on by.'

It's an exchange of information to get help and to give help. "

That pretty much defines pragmatism, and it exemplifies these

strategic information-for-benefit exchanges people make like taking a

blood test to get life insurance or consenting to a background check

to secure a new job. Only now, at places like PatientsLikeMe,

information has a currency that's far more liquid than ever.

Converted into data and bundled with information from those like us,

private information can be invested for both immediate gains and long-

term returns.

And there's a fortunate side effect to converting your health history

into data — it strips it of metaphor, of secrecy, of stigma. It

becomes concrete, manageable and valuable. It becomes, just as Sontag

suggested 30 years ago, demythicized.

As diseases go, A.L.S. or M.S. or Parkinson's or even H.I.V. are

relatively rare afflictions, at least in the United States. Mental

illness, on the other hand, afflicts a vast swath of the country.

Nearly 60 million Americans have a diagnosable mental disorder,

according to the National Institute of Mental Health, a population

that includes everything from depression to bipolar syndrome to

anxiety. For PatientsLikeMe, that population represents a huge

market, not to mention the potentially lucrative bounty of data

related to antidepressants and other mood-disorder drugs. But it also

presents a challenge.

Creating a PatientsLikeMe mental-health community — or as they call

it, a " mood community " — requires a new strategy for measuring mental

health. The challenge is in part semantic. Where the argot around

A.L.S. or M.S. is largely clinical, the vernacular around mental

health is more subjective. The official diagnostic criteria for major

depression, for example, include " feelings of worthlessness "

and " indecisiveness. " So PatientsLikeMe faces an input problem: how

to convert the ambiguities of mental illness into metrics?

Whatever its ultimate worth, the site's answer is elegantly

straightforward. Members can update their mood status every hour on a

scale of 1 to 4, from very bad to very good. How they feel may be

subjective, but the resulting data can be mapped across time. The

site treats sessions of therapy as if they were a dose of Prozac; the

type of therapy (say, group or individual) stands as the treatment,

and the length of a session (say, 50 minutes a week) as the dosage.

Such efforts at precise measurement and comparison are not the norm

in evaluating mental-health treatment. Americans spend about $12

billion a year on antidepressants, but we still have little

understanding of how or whether they work. In 2006, the National

Institute of Mental Health released the results of the largest and

longest depression study ever undertaken, the Sequenced Treatment

Alternatives to Relieve Depression Study, or Star-D. Star-D rejected

typical clinical study design and aimed to create a real-world

representation of how patients actually experience and treat

depression: through trial and error, taking one drug after another,

searching for one that helps.

The results were mixed. Star-D found that if you're depressed and

spent three months on a potent psychotropic drug, you had a one-third

chance of achieving remission. After almost six months on drugs, your

chances bump up to about fifty-fifty — a coin flip — and you still

risk side effects like sexual dysfunction, insomnia and weight gain.

Those may be good odds for the industry, but it seems a poor bet for

a patient.

At PatientsLikeMe, Ben Heywood sees pure opportunity in such

statistics. " Those odds just aren't good enough, " he says. " So you

try Wellbutrin, and after six weeks it doesn't work. Then Prozac.

Doesn't work. Now what? Where do you go next? " Plugged in to a

community of patients sharing their depression histories and

treatments, Ben argues, patients could readily find someone with

symptomatology close to their own, compare drug regimens and go

straight to the drug that may be more likely to work for them.

This, for patients, is the promise of a mental-health community:

better tailoring of treatments. It is also the promise of the site as

a business. The pharmaceutical industry should be eager to improve

the accuracy and efficacy of its treatments. After all, sometimes

side effects can turn into blockbusters, most famously when Pfizer

scientists learned that their hypertension treatment was causing

erections in men, leading the way to Viagra. Since PatientsLikeMe

forgoes advertising, selling its data to pharmaceutical companies is

its best apparent way to make money. But so far, it seems, the drug

industry has balked at the prospect of knowing so precisely what

happens to their products after they reach the market.

If Heywood talks about his company as an incendiary force in

the health-care industry — " This is the way it worked before ethics

destroyed medicine, " he told me at one point — the American Medical

Association would pretty much agree. From the perspective of many

doctors,

PatientsLikeMe raises many more questions and quandaries than it

answers.

Joe Heyman, a practicing physician in Amesbury, Mass., and the chair-

elect of the A.M.A.'s board of trustees, praises the potential

benefits of a tool like PatientsLikeMe for patients. He's just

uncomfortable with who's minding the toolbox. " The idea of them is a

wonderful thing, " he says. " But you know, as a physician I have a

code of ethics. We have licensing boards and accreditation and all

these people keeping an eye on us. " Heyman suggests that if

physicians themselves aren't sole stewards of the patient data — his

first choice — then there should be some national standards or a law

that covers a company like PatientsLikeMe that traffics in such data.

Heyman is also uncomfortable with how PatientsLikeMe encourages

patients to take their medical information and then act on

it. " Sometimes patients misunderstand what a doctor says to them, " he

says, " so by the time it gets to the third or fourth party it's like

a game of telephone. It's not as reliable as coming from the horse's

mouth. "

Heyman may be speaking from the perspective of the injured party —

PatientsLikeMe could be seen as a direct challenge to physicians'

omniscience — but there's still something to his concerns.

PatientsLikeMe not only lets members track their disease; it also

tacitly encourages them to take action. While PatientsLikeMe advises

users to consult a doctor before changing their treatments or

dosages — patients can print out an exhaustive status report, replete

with graphs and charts, to take on doctors' visits, and personal

physicians can register as caregivers on the site — there will

inevitably be patients who treat the Web site's apparent rigor and

depth as a substitute for a physician's training and expertise.

Ensrud, the neurologist at Brigham and Women's Hospital, worries

that patients could spot an animal study or early-stage trial

investigating an off-label usage of a drug and then start taking that

drug in the hope that the researchers are onto something. " Even if a

treatment seems promising, it could result in a very serious

reduction in lifespan, " he suggests. " We're talking survival. "

In fact, some PatientsLikeMe members have already started doing

pretty much what Ensrud warns against. Last November, the A.L.S.

community was abuzz with word that researchers in Italy had found

that taking lithium seemed to slow the progression of A.L.S.

significantly. The Italian study hadn't actually been published yet,

but that didn't stop 34 members with A.L.S. from soliciting lithium

prescriptions from their doctors and coalescing into an ad-hoc

clinical trial. There are now 109 members using lithium and tracking

their progress with the data tools on the site. The company has

rolled out new features to monitor the group with the hope that they

will be able to lend a little credence — or cast a little doubt — on

the Italian study in a matter of months.

insists that PatientsLikeMe isn't encouraging A.L.S. members to

start taking lithium. But he is unmistakably excited by the endeavor.

As he sees it, the experiment perfectly illustrates how

PatientsLikeMe might complement large-scale and long-term clinical

research by conducting observational research " on the fly. " Drawing

on the notion of personalized medicine, calls

this " personalized research. " And it has a certain logic: for those

who already have A.L.S., traditional science works at far too

plodding a pace. " The system is broken for terminally ill patients, "

says Hanns Riederer, a music producer in Los Angeles who has joined

the group of A.L.S. members taking lithium. " It makes us wait five to

seven years for results, when we don't even have that time. Even if

it's half-true, it's still groundbreaking. I don't want to wait for

something else. I don't have time to wait. "

While the members of PatientsLikeMe may seem exceptional today, they

will be fairly typical tomorrow. As we learn more about disease and

are able to identify it earlier, more and more Americans will fall

under the rubric of " patient " and will need to navigate an array of

confusing health decisions. Doctors don't like to admit it, but " most

treatment decisions right now are still based on doctors' judgments

that don't have real research behind them, " says Jodi Halpern, a

physician and bioethicist at the U.C. Berkeley School of Public

Health. " But it takes real data to make the right decisions,

especially for patients. There's a powerful improvement in health

outcomes, people's quality of life, when people are better-informed. "

Physicians, of course, have known this for decades; the idea

of " evidence-based medicine " — that all decisions should be based on

real data — was hatched in the 1980s. But the pace of traditional

research is slow, and the number of outstanding questions far exceeds

the body of evidence to answer them. Only now, with technologies like

PatientsLikeMe, is the pace accelerating. What's more, it's becoming

evident that data — the foundation of evidence and research — are

present not just in laboratories or universities or the proverbial

halls of science but in everyday life.

Really, when you start looking, information can be found everywhere.

If we could gather in structured communities and create databanks to

inform our approach to life decisions, not just health decisions but

also gardening or parenting or car-buying decisions, we could do

everything in a more informed manner. Were we all to avow a

philosophy of openness and churn our experiences into hard numbers,

we could presumably improve our odds in all sorts of decisions. Why

not a PregnantLikeMe or a ParentsLikeMe or even, really, an all-

encompassing PeopleLikeMe?

One evening, I suggested this bigger idea to and Ben. They

shared a glance and a mock-conspiratorial smile, and then looked back

at me. " We know, " Ben said. " We already own all those domain names. "

Goetz is the deputy editor of Wired magazine.