http://www.nytimes.com/2008/03/23/magazine/23patients-t.html?em&ex=1206504000&en
=7dc2aabe4f4b8f40&ei=5087%0A

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 Jamie 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.
Erik 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, Stephen Heywood, a 29-year-old carpenter, learned that he had
A.L.S., a neurodegenerative disorder commonly known as Lou Gehrig's disease.
Jamie, his older brother, quit his job to find a cure. An M.I.T.-trained
mechanical engineer with a knack for neuroscience, Jamie founded the A.L.S.
Therapy Development Institute in Cambridge, Mass., the following year. So
began a radical quest to save Stephen'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, Stephen
was among the most documented A.L.S. patients in the world.

The sheer volume of Stephen's data gave Jamie 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. Jamie 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.

Jamie 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 Stephen'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," Jamie explains. "Then we capture that
dialogue and turn it into useful, clean data."

Stephen 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, Stephen 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 Stephen 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; Jamie, 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, Jamie 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, Jamie'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., Leslie 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, "John
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," Susan 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 Jennifer 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 Jamie 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.

Erik 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.

Jamie 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, Jamie
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 Jamie 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."

Thomas Goetz is the deputy editor of Wired magazine.