Tagged Live

Pretty Girls Are Supposed to Smile

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Credit Jon Krause

“There is no one who has not smiled at least once,” writes Marianne LaFrance, a Yale University psychology professor, in her 2011 book “Lip Service: Smiles in Life, Death, Trust, Lies, Work, Memory, Sex and Politics.” Her book explores how smiling unifies us. Like breath, the smile is universal. We smile to connect, to forgive, to love. A smile is beauty, human.

But I have never smiled. Not once.

I was born with Moebius syndrome — a rare form of facial paralysis that results from damage in the womb to the sixth and seventh cranial nerves, which control the muscles of the face. I was born in Britain, on the same day in 1982 the country’s first test-tube twins were born. But while science has created medical miracles like test-tube babies, there’s little that doctors can do for someone with Moebius syndrome.

Decades later, I still cannot smile. Or frown. Or do any of the infinite subtle and not-so-subtle things with my face that I see others in the world around me doing every day.

Doctors describe people with Moebius as having a “mask-like expression.” And that is what strangers must see. A frozen face, eyes unblinking. My mouth always open, motionless, the left corner of my lips slightly lower than the right. Walking down the street, I can feel the touch of casual observers’ eyes.

A child’s very first “social smile” usually occurs six to eight weeks after birth, eagerly awaited by new parents. Because, as an infant, my face remained so expressionless, when I began laughing it took my mother a while to realize that the sound I was making was laughter. At what point, I wonder, did I begin to compensate for the absence of my smile.

I am constantly touching my own face, making it move with my hands. I like the sensation of my fingertips shifting my otherwise motionless lips. It’s something I’ve done since I was very young.

I remember, age 5, kneeling at my grandmother’s dressing table, while my grandmother, without my noticing her, watched from around the doorjamb. Very quietly, I leaned toward her mirror, my elbows pressing into the cool granite top and, with two fingers, lifted the corners of my mouth into a tiny smile — a smile I only dared to share with my reflection.

This was the beginning of my understanding that I was different.

Not until I was 16 did Granny tell me that she had been watching me that day, saying, “It broke my heart.”

Through childhood and adolescence, I continued secretly “smiling” at myself in the mirror. Seeing the appearance, however awkward, of a smile on my own face helped me feel better about the day-to-day missed connections with others — schoolmates, girls in my ballet class, or adults on queue in the supermarket — who perhaps wanted to see me smile back at them.

Not smiling is about much more than surface image, though. It takes real stamina. To swallow a mouthful of food, for example, I use a few delicately placed fingers to press my lips closed. After swallowing, I try to lower the helping hand so that it looks as though I am merely brushing a stray crumb from my mouth, hoping no one notices that I do this many, many times more than a normal person would.

Going to sleep is another challenge. Because I can’t voluntarily close my eyelids fully, I have to either hold my eyelids closed with my right forefinger and thumb until they stay shut, or lie on my back with a cotton tank top laid over my eyes in such a way that their lids are sealed. Sometimes this gets exhausting. Sometimes I shed tears, and that speeds up the process.

I try to act around my disability. To pass. The one missing gesture I can never fully compensate for, though, is smiling. My body feels the smiles my face has never shown. When I explain to new friends why I don’t — can’t — smile, they say, Wow, that must be really hard. Not really, I lie, by now I’m used to it.

Still, there are moments when I feel the smile my face cannot physically make. It might be while I’m laughing over a shared joke with a friend, or when a child passing on the street smiles up at me. It translates as instantaneous pleasure throughout my whole body — a kind of minute awakening, both within and without. For a long time I wondered whether it showed. But close friends tell me my smile does come through, that they can see my smile.

Yet, recently, an elderly man passing me at a bus stop looked me up and down, caught my eye, and said, “Pretty girls are supposed to smile.”

I was speechless. I shook my head and laughed uncomfortably, hoping he wouldn’t pursue the subject. As he walked away, I remembered a high school photographer cheerily calling “Smile!” just before the blinding white flash. “Smile,” someone says, and again I’m 5 in the mirror, or 16, cringing, trying to do something I cannot do, and waiting for the uncomfortable moment to pass.

Effy Redman, a graduate of Hunter College’s creative writing M.F.A. program, lives in Saratoga Springs, N.Y.

Dementia Patients Hold On to Love Through Shared Stories

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Credit Paul Rogers

Can you keep the love light shining after your partner’s brain has begun to dim? Just ask Denise Tompkins of Naperville, Ill., married 36 years to John, now 69, who has Alzheimer’s disease.

The Tompkinses participated in an unusual eight-week storytelling workshop at Northwestern University that is helping to keep the spark of love alive in couples coping with the challenges of encroaching dementia.

Every week participants are given a specific assignment to write a brief story about events in their lives that they then share with others in the group. The program culminates with a moving, often funny, 20-minute written story read alternately by the partners in each couple in front of an audience.

Each couple’s story serves as a reminder of both the good and challenging times they have shared, experiences both poignant and humorous that reveal inner strength, resilience and love and appreciation for one another that can be easily forgotten when confronted by a frightening, progressive neurological disease like Alzheimer’s.

“It’s been an amazing experience for us,” Mrs. Tompkins said of the program. “Creating our story revealed such a richness in our life together and is helping us keep that front and center going forward.”

She added that the program provides “an opportunity to process what you’re going through and your relationship to each other. It helped me digest all the wonderful things about John and how well we relate as a couple, things that don’t go away with Alzheimer’s disease. John is so much more than his disease.”

Ditto for Robyn and Ben Ferguson of Chicago, married 42 years in 2012 when they learned that Ben, a psychologist, had Alzheimer’s disease. “The diagnosis was crushing,” said his wife, who is also a psychologist. “Telling people in the program about it helped us recognize the impact on our lives and relationship and really face that. It made things feel not quite so bad.”

The Fergusons have publicly presented their 20-minute story together 19 times so far, helping to enlighten medical students and those training in social work and pastoral care, as well as researchers and members of the general public. “It reinforces our relationship as a couple, rather than caregiver and patient, even though he is 85 percent dependent on me for the activities of daily living.”

Dr. Ben Ferguson, now 69, said, “I feel we’re giving people information that could be very valuable in their future. It’s helpful to them to see us smile, have a good time and give a good report – as well as a bad report – about what goes on with this disease. It’s helpful for people to hear it from someone who has it, and it’s helped us avoid getting so morose.”

As for their presentations, which they now give almost monthly, his wife said, “They help us stay positive and give us a sense of purpose. We both feel a real need to do advocacy work, and this is the best thing we can do right now. We know there’s a sell-by date on this – we won’t be able to do it forever. But we don’t think about that now. Now we’re focused on helping people understand that your life doesn’t stop with the diagnosis. We want people to hear that you go on with your life, even though you may need a lot of help.”

Another workshop participant, Sheila Nicholes, 76, of Chicago, said of her husband, Luther, who has vascular dementia, that the storytelling “brings him back to being funny again. Writing our story together gave us a way to talk about these things, to think about where we were then and where we are now.”

Noting that dementia is “a very hush-hush illness in our black community,” Ms. Nicholes said she hoped that telling their story would help others speak more openly about it and learn to “just roll with the flow.”

The storytelling workshop, which started in January of 2014, was the brainchild of Lauren Dowden, then an intern in social work at Northwestern’s Cognitive, Neurological and Alzheimer’s Disease Center. She quickly learned from family members in a support group that “their concerns were not being addressed about dealing with loss, not just of memory, jobs and independence, but also what they shared as a couple.”

During the group sessions, Ms. Dowden said, “there’s so much laughter in the room, so much joy and love of life as well as poignancy and tears. As they move forward, as the disease progresses, they can be reminded of who they are, their strength and resilience, what has made their relationship strong, what they loved about the person, as opposed to just being patient and caregiver.”

As the program moves week to week, Ms. Dowden said, “there’s more touching, affection, looking at one another and laughing. There are delightful moments of connection when one member of a couple reveals something the other didn’t know.”

The weekly story assignments require that the couple collaborates, “and they learn how to work together in new ways, how to make adjustments, because they’ll have to make thousands and thousands of adjustments throughout the course of the disease.”

In executing the workshop assignments, Dr. Ferguson said she would ask her husband questions, he would answer and she would write down what he said. “The workshop was really transformative,” she said. “It gave us hope for our future together in dealing with this disease.”

Ms. Dowden said the feedback from those in the audience for the 20-minute joint stories has been heartening. She explained, “Students learn about the biology of neurodegenerative conditions. These stories enable them to see the human side of the disease, what it’s like to live with it, and may help them develop programs that help these families live better. In addition to the stigma, there’s a tendency to write off people with dementia.”

Ms. Dowden said she is currently refining the workshop curriculum so that it can be used as a model for other institutions to replicate. She is also expanding it to include mother-daughter and sibling pairs.

She realizes, of course, that a storytelling workshop may not be suitable for every couple. “It’s not good if there’s a lot of behavioral issues, a lot of conflict, and no insight,” she said. “But for those it does fit, it’s an opportunity to tap into the core of relationships, to still grow and learn and be delighted by one another.”

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Think Like a Doctor: The Boy With Nighttime Fevers Solved!

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Credit Andreas Samuelsson

On Thursday we asked Well readers to take on the case of a 7-year-old boy who’d been having fevers and drenching sweats nightly for over a month. More than 300 of you wrote in, and although 20 of you came up with the right diagnosis, only three of you figured out both the diagnosis and the test needed to confirm it.

The correct diagnosis is…

Coccidioidomycosis, or valley fever.

The diagnosis was made based on a lymph node biopsy.

The first reader to suggest this diagnosis and the test was Dr. Malkhaz Jalagonia, an internist from Zugdidi, in the Republic of Georgia. He says he’s never seen a case like this, but he’s fascinated by zebras and so recognized the disease immediately. Well done, Dr. Jalagonia!

One of the reasons I chose this case was that, although this diagnosis is rare in life, it was the most frequently suggested diagnosis in my last column – the one about the middle-aged man with a cough for over a year. I thought it would be fun to show what valley fever really looks like. Hope you did too.

The Diagnosis

Coccidioidomycosis is a lung infection usually caused by inhaling the spores of a tiny fungus called coccidioides. This organism grows as a mold, a few inches below the surface of the soil in deserts in parts of the southwestern United States, Mexico and other countries of Central America.

In dry conditions, the fungus becomes fragile and is easily broken up into tiny single-celled spores that can be sent airborne with even the slightest disturbance. And once these single cells are aloft they can remain suspended there for prolonged periods of time.

Infection is usually acquired by inhaling the spores. Once lodged in the lung, the organism begins to reproduce almost immediately. The time course between exposure and disease depends on the inhaled dose and the patient’s immune system.

Symptoms, or No Symptoms

Disease severity varies considerably. Nearly half of those who breathe in these spores have no symptoms, or symptoms are so mild they never visit the doctor’s office.

More severe infection usually takes the form of a slowly progressive pneumonia known as coccidioidomycosis, or valley fever. This illness is characterized by a cough, fevers, chest pain, fatigue and sometimes joint pain. Indeed, because of the prominent joint pain, in some cases — though not this one — the disease is also known as desert rheumatism.

Rashes are also seen in many patients. Those who get a rash seem to have a more benign course of illness. The thinking is that the skin symptoms are the result of an aggressive immune response in the host to the pathogen.

Symptoms can last for months, and in many cases they resolve without treatment. But in some cases they get worse.

Hard to Diagnose

Those who seek medical attention are often not diagnosed — or not diagnosed quickly — because the symptoms of valley fever are not very specific, and few of the tests that doctors usually order have features that are unusual enough to suggest the diagnosis.

Chest X-rays are often normal. Blood tests may be normal as well, though some patients, like this child, have an unusually high number of a type of white blood cell known as eosinophils. These cells are usually seen in allergic responses or with infections due to parasites.

The most important clue to the possibility of this infection is travel to one of the areas where the fungus lives. In the United States, valley fever is endemic primarily in Arizona and southern California, as well as parts of southern New Mexico and West Texas. Indeed, the name valley fever is a shorter and more general term for an earlier name, San Joaquin Valley fever, because it was so common in that part of California.

A Dramatic Rise

There has been a significant increase in the number of cases of coccidioidomycosis in the past 15 years, with nearly 10 times as many in areas where the fungus is found. Development in areas where the fungus is endemic is thought to be the primary cause. Better diagnostic testing may also play a role.

While this infection may cause only a minor illness in many, there are some – like this child – for whom the disease can spread beyond the lungs into the rest of the body. Disseminated coccidioidomycosis is usually seen in those with some problem with the immune system – an underlying disorder such as H.I.V., for example, or because someone is taking immune suppressing medications such as prednisone.

Once out of the lungs, the bugs can go anywhere in the body, though they seem to prefer joints, skin or bones. Those with disseminated disease have to be treated for a long time – often up to a year, or occasionally for life.

How the Diagnosis Was Made

The little boy had been sick for nearly a month, and his parents were getting quite worried. He was pale, thin and really, really tired.

With their pediatrician’s encouragement, they had gone on a long planned, much anticipated vacation to the mountains of Colorado. But the child wasn’t getting better, and so his mother took him to yet another doctor – this one in a walk-in clinic.

The results of some simple blood tests done at that visit worried the doctor, who suggested that the boy be taken to a hematologist, a specialist in diseases and cancers of the blood.

Now the parents were terrified. The mother faxed copies of the lab results to her brother, a researcher in immunology. He wasn’t a physician but showed the results to friends who were. They agreed with the doctor at the walk-in clinic: The boy needed to be seen by a hematologist.

A Series of Specialists

The next morning the family headed home to Minneapolis. They took the boy to his regular pediatrician, who sent them to a hematologist. It wasn’t cancer, that specialist told them. Maybe some kind of severe food allergy, he suggested, and referred them to a gastroenterologist.

Not a GI thing, that specialist told them, and he referred the now nearly frantic family to an infectious disease specialist and a rheumatologist.

Nearly 10 days after getting the alarming blood test results, the couple and their child found themselves in the office of Dr. Bazak Sharon, a specialist in infectious diseases in adults and children at the University of Minnesota Masonic Children’s Hospital. After introducing himself, Dr. Sharon settled down to get a detailed history of the boy and the family.

A Desert Visit, but Other Possibilities

When Dr. Sharon heard that the family had spent a week at a ranch in the desert of Arizona, he immediately thought of coccidioidomycosis. The fungus isn’t found in Minnesota or Colorado – which is probably why other doctors hadn’t considered it. But it is all over the part of Arizona where they’d visited.

Still, there were other possibilities that had to be ruled out, including some types of cancer. After Dr. Sharon examined the boy, he sent the family to the lab for a chest X-ray and some blood tests.

The results of those tests were concerning. The child was getting worse. Dr. Sharon wasn’t going to be back in clinic for a week, and he was certain the child needed to be seen and diagnosed well before then. He called a friend and colleague who was taking care of patients in the hospital, Dr. Abraham Jacob, and asked if he would admit the child and coordinate the needed diagnostic workup for the boy.

First Some Answers, Then More Questions

Once in the hospital, the child had a chest CT scan. The results were frightening. The lymph nodes that surround the trachea, the tube that carries inspired air to the lungs, were hugely enlarged. They were so big that the trachea was almost completely blocked. The opening at one point was just two millimeters wide – basically the dimensions of a cocktail straw. Any worsening of his disease might cause the tube to close completely, making breathing impossible.

A pediatric surgeon was brought in immediately. The enlarged lymph nodes had to be removed. First in order to protect the child’s airways. And second because those nodes would reveal what the little boy had.

But trying to do surgery on a 7-year-old boy’s neck was complicated. Although the surgeon could easily feel the enlarged gland in his neck, it was close to many vital blood vessels, nerves and organs. The child had to lie perfectly still, and with most children that could only be guaranteed if they were under anesthesia.

Risky Surgery

When the anesthesiologist saw the CT scan, the doctors’ concern grew. They could put the child to sleep, but if anything went wrong during surgery and they had to put a tube down his throat into his lungs, they weren’t sure it would be able to fit.

The trachea was so small, there was no guarantee they could get the tube into place. In order to do this safely, they said they needed to use a technique known as ECMO, or extracorporeal membrane oxygenation – basically a machine that allows them to oxygenate blood without sending it to the lungs.

Rather than subject the child to this risky procedure, Dr. Jacob and the surgeon decided to just take a piece of the lymph node out in order to make the diagnosis. Treatment of whatever the boy had would bring the size of the lymph node down.

Don’t Make a Move

When the boy was brought to the procedure room, the surgeon explained that he was going to put numbing medicine all around the bump in the boy’s neck and take out a piece of it. The child listened calmly and agreed.

He wasn’t to move at all, the surgeon explained. The child nodded solemnly. He understood. The boy was remarkably mature and so brave throughout the entire process of anesthetizing the region that the surgeon thought he might be able to continue and get the entire node out.

He paused in his surgery and consulted the parents. Would they allow him to try this? Their son was doing so well he was sure he could get it. They agreed, and the surgeon returned to his task. The lymph node came out without difficulty.

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Credit

It was sent to the lab and the answer came back almost immediately. The swollen tissue was filled with the tiny coccidioides. You can see a picture of these little critters here.

A Year of Medicine

The boy was started on an intravenous medicine for fungal infections. Then after a week it was changed to one he could take by mouth.

Because the infection had spread beyond the lungs, the child will have to take this medication for a year. After starting the medication, the child began to look a little better. Slowly he was less tired. Slowly he started to eat the way he used to.

It was a long road to the diagnosis, and an even longer road to cure, but at least they were on the right one.

A Perfect Storm?

The mother called the ranch in Arizona where they stayed to let them know what had happened.
The owner told them that their son was not the only person visiting then who got sick. At least one other guest, there at the same time, had come down with the disease.

Apparently the conditions for spread were perfect. Their stay had started off with some rain, followed by heat and some brisk wind. The moisture helped the fungus grow; the heat dried it out so that it could become easily airborne and inhaled when lifted by the wind.

Although the family has loved their visits to this ranch – this was their second year – the child’s mother tells me that she’s not sure she’ll be going back, at least for a couple of years. Most people exposed to valley fever become immune forever, but because her little boy was so very sick, she’s planning to wait a while before they return.

Weight Has Greater Impact on Diabetes Than Heart Disease

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Carrying excess weight may have a greater impact on the risk for diabetes than it does on the risk for heart disease or early death, a new study has found.

To look at the effect of obesity independent of genetics, Swedish researchers followed 4,046 pairs of identical twins whose average age was 58. One of the twins was overweight, and the other was not. Since identical twins have the same genes, their weight difference could not be attributed to genetics. The study is in JAMA Internal Medicine.

After accounting for physical activity, smoking and educational level, the researchers found that having a higher body mass index, or B.M.I. — even among those in the obese range of 30 or higher — was not associated with an increased risk for heart attack or death. But a high B.M.I. was associated with an increased risk for diabetes.

“Based on these results, the association between obesity and cardiovascular disease is explained by genetic, not environmental, factors,” said the lead author, Peter Nordstrom, a professor of geriatric medicine at Umea University. “Unfortunately, this also means that environmental factors that reduce obesity do not reduce the risk of cardiovascular disease or death. But they most certainly decrease the risk for diabetes.”

Think Like a Doctor: The Boy With Nighttime Fevers

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Credit

The challenge: A healthy 7-year-old boy suddenly starts having fevers and night sweats. Can you figure out why?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to sift through a difficult medical case and solve a diagnostic riddle. This month we present the case of a boy who has fevers topping 102 degrees every night for over a month. His parents sought help from nearly a dozen doctors in two states before a diagnosis was made.

Below I’ve given you the information that was available to the doctors who figured out the cause of the boy’s fevers. It’s up to you to use this information to put his story together for yourself.

As usual, the first person to crack the case gets a copy of my book, “Every Patient Tells a Story,” and, of course, that fabulous feeling you get when you solve a really tough puzzle.

The Patient’s Story

“I think you need to take him back home.” Her brother’s voice was calm, but she could hear an undertone of anxiety even over the poor cellphone reception that was all she could get from rural Colorado. “He needs to see a hematologist. It could be a virus, but it could also be something else.” He didn’t say it, but she knew what he was thinking: cancer.

Her son, just 7 years old and always a little delicate, had been sick for nearly a month. He was fine during the day, but every night he’d spike a fever of 102 or 103.

Even before they’d come to the mountains for a much needed vacation, she’d taken him to see his pediatrician at home in Minneapolis several times. At each visit, the doctor or one of his partners had looked the boy over closely, and each time he’d seemed fine.

It was probably viral, she was told, time after time. But he seemed to be having one viral infection after another.

A Vacation Cut Short

The day before they left for Colorado, the boy’s father took him to the doctor’s office one more time.

Maybe it wasn’t viral, the pediatrician acknowledged, and prescribed a “Z-pak” — a five-day course of azithromycin. Don’t cancel the trip, the doctor reassured him. He’ll get better.

But he hadn’t. While on vacation, his mother took him to a walk-in clinic, where they’d checked his blood. A worried looking doctor told her that he didn’t know what was wrong with her boy. He should probably see a cancer specialist.

Now she was really worried. There weren’t any specialists anywhere near the bucolic town where they were staying. That’s when she’d sent the test results to her brother, a researcher in immunology. He wasn’t a doctor, but he passed the results to friends who were, and they were worried, too.

Thin and Pale

The family headed home right away, but the 4th of July was coming. They couldn’t get in to see a hematologist until Tuesday.

By now the boy was starting to look sick. He was pale and had dark circles under his eyes. Small for his age — consistently in the fifth percentile for height and weight — he now looked even smaller, thinner. He was a quiet child, always had been. Thoughtful and comfortable in the company of adults, as so many only children are. Even now he never complained.

Nothing hurt. He was simply tired. His fevers started coming a little earlier, peaking a little higher. His mother noticed a cough and wheezing sometimes. Always a picky eater, with these intermittent fevers, very few foods seemed appealing. She tried to hide the terror she felt when he seemed to be fading as she watched.

A Long Line of Specialists

The hematologist examined the boy and sent off more blood. Definitely not cancer, he said. He suggested seeing a gastroenterologist.

The gastroenterologist got an M.R.I. of the child’s digestive system. Nothing there. He noticed the boy’s wheezing and gave him an inhaler, then referred mother and child to a rheumatologist and an infectious disease specialist.

It seemed to the parents that this had to be an infection, but the earliest they could get in to see the infectious disease doctor was the following week. For the boy’s mother, the delay now seemed intolerable.

It had been five weeks since the fevers first started. In that time, the boy had lost nearly 10 pounds. They’d seen eight doctors in two states. They’d all been very nice, thorough, thoughtful, but had no answers.

By the weekend she was desperate. The boy needed to be in the hospital. Couldn’t they see how sick he was? She couldn’t wait for the specialist. She took him to the emergency room of the big university hospital.

The E.R. doctors, like all the doctors they’d seen so far, were kind and thoughtful, and so gentle with her delicate son. But like all the other doctors, they had no answers. They prescribed another inhaler for the boy’s wheezing, since the first hadn’t helped. They also urged her to see the infectious disease specialist. His appointment was just a couple of days away.

TB or not TB?

The boy was sitting quietly between his parents watching a video on his tablet when Dr. Bazak Sharon and the infectious disease fellow he was training entered the exam room. Dr. Sharon’s first thought was that the child looked as if he had tuberculosis.

He’d seen a lot of TB in this clinic, but it was usually among immigrant families who had traveled to Minneapolis from countries where the disease was common. Like this boy, kids with TB were usually thin, sickly looking, pale and quiet. But based on what his fellow told him, the child had no exposures that would put him at risk for this disease. He’d only been out of the country once – to Canada. He’d visited the beaches of South Carolina and the deserts of Arizona, and most recently the mountains of Colorado. But TB was rare in all these locales.

Dr. Sharon introduced himself to the child, who looked up immediately and smiled. How do you feel, he asked the boy? His temperature had been recorded at 103 degrees. I feel good, he’d answered pleasantly. Does anything hurt? No.

His heart was beating rapidly – nearly 140 beats per minute, but that was probably due to the fever. There were several enlarged lymph nodes in the child’s neck and his groin, though none under his arms. Otherwise his exam was unremarkable.

Getting Worse

Dr. Sharon had reviewed the blood tests that had already been done but wanted to see if anything had changed. And given that the only localized complaint was cough and wheezing, he wanted to get another chest X-ray.

Reviewing those studies that night, Dr. Sharon saw that the boy was slowly getting worse. He saw patients at that clinic only once a week and was reluctant to wait that long before having him seen again. He thought they needed an answer much sooner than that.

You can see the note from Dr. Sharon and his fellow here.

Dr. Sharon’s Note

The note from the patient’s visit to the hospital.

To the Hospital

Dr. Sharon called the family the next morning. He’d reached out to one of his friends and colleagues, Dr. Abraham Jacob, who could see them. They should go to the University of Minnesota Medical Center Fairview, where Dr. Jacob would orchestrate a thorough workup. That would be the fastest way to get an answer.

Based on the assessment by Dr. Jacob and his resident and the recommendations from Dr. Sharon, the team reached out to specialists in hematology-oncology and in rheumatology. And since his chest X-ray was abnormal and he had enlarged lymph nodes, they wanted to get a CT scan as well.

You can see the note from Dr. Jacob and his resident here.

Dr. Jacob’s Notes

Here are the notes from the pediatrics department.

Breathing Through a Straw

It was the results of the CT scan that really got things moving. It was the middle of the day when the resident was paged by the radiologist. The pictures showed that the lymph nodes in the boy’s chest were so swollen that they were pressing on the trachea – the breathing tube – so that it was almost completely cut off. Essentially he was breathing through the equivalent of a cocktail straw.

Any additional swelling could cut off the boy’s breath completely. You can see an image from the CT scan here.

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This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.

This CT scan shows the patient’s chest. In a child of this age, the trachea is normally eight to 12 millimeters wide. Much of the gray tissue surrounding the trachea and esophagus is swollen lymph nodes.Credit

A normal trachea in a child this age is four to six times the size seen in the scan. The image added even more pressure to make a diagnosis and treat the child before he got sicker.

Solving the Mystery

A diagnosis was made within the next 24 hours. Can you figure out what the boy had, and how the diagnosis was made?

The first person to offer the correct answers to these two questions will get a copy of my book and that sense of triumph that comes from nailing the right diagnosis when it really matters.

Rules and Regulations: Post your questions and diagnosis in the comments section below. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Read Books, Live Longer?

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Credit Bryan Thomas for The New York Times

Reading books is tied to a longer life, according to a new report.

Researchers used data on 3,635 people over 50 participating in a larger health study who had answered questions about reading.

The scientists divided the sample into three groups: those who read no books, those who read books up to three and a half hours a week, and those who read books more than three and a half hours.

The study, in Social Science & Medicine, found that book readers tended to be female, college-educated and in higher income groups. So researchers controlled for those factors as well as age, race, self-reported health, depression, employment and marital status.

Compared with those who did not read books, those who read for up to three and a half hours a week were 17 percent less likely to die over 12 years of follow-up, and those who read more than that were 23 percent less likely to die. Book readers lived an average of almost two years longer than those who did not read at all.

They found a similar association among those who read newspapers and periodicals, but it was weaker.

“People who report as little as a half-hour a day of book reading had a significant survival advantage over those who did not read,” said the senior author, Becca R. Levy, a professor of epidemiology at Yale. “And the survival advantage remained after adjusting for wealth, education, cognitive ability and many other variables.”

My Vacation With a Brain-Eating Amoeba

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Water rushes along the course at the National Whitewater Center at dusk. The chlorination and filtration systems at the artificial water rapids course were inadequate to kill a rare, brain-attacking organism this summer.

Water rushes along the course at the National Whitewater Center at dusk. The chlorination and filtration systems at the artificial water rapids course were inadequate to kill a rare, brain-attacking organism this summer.Credit Robert Lahser/The Charlotte Observer, via Associated Press

I expected a bumpy ride on a whitewater trip, so when I fell off my raft and coughed up the water I’d inhaled, I wasn’t afraid. But at the time I didn’t know I was swimming with a deadly parasite.

I’d been at a bachelorette party at the U.S. National Whitewater Center in Charlotte, N.C., but after returning home I learned that I had shared the churning rapids with Naegleria fowleri, a single-celled amoeba found mostly in soil and warm freshwater lakes, rivers and hot springs. An Ohio teenager had contracted the amoeba infection after visiting the center around the same time I did, and some of the waters and sediment at and around the center had tested positive for the bug.

News that my friends and I had all been at risk of exposure triggered a few days of worry. The illness is rare and, if infected, symptoms show up between one and 10 days after exposure. Chances were that we were fine (we were), but the experience prompted me to learn more about the parasite.

Naegleria fowleri lives in fresh water, but not in salt water. If forced up the nose, it can enter the brain and feed on its tissue, resulting in an infection known as primary amebic meningoencephalitis. Death occurs in nearly all of those infected with the parasite, usually within five days after infection.

The 18-year-old Ohio woman who died most likely contracted the parasite when she sucked water through her nose after falling from a raft during a church trip.

Samples from a channel at the rafting center, collected by the Centers for Disease Control and Prevention, tested positive for the bug. The center’s channels are man-made, and it gets its water from the Charlotte-Mecklenburg Utilities Department and two wells on its property. The center has announced that it disinfects all water with ultraviolet radiation and chlorine, and it added more after the water tests.

Sediment from the nearby Catawba River, where visitors to the center can paddle board and kayak, also tested positive for the amoeba, although the actual water from the river did not test positive. Dr. Jennifer Cope, an epidemiologist at the C.D.C., said natural bodies of water might have their own ways of controlling the bug. The parasite possibly entered the artificial river through storm water runoff or people tracking it in on their shoes, said Dr. Cope.

Between the time of the young woman’s visit in early June and when the whitewater center voluntarily shut down its rafting activities a few weeks later, thousands of people could have been exposed to the parasite, but there were no additional reports of infections.

“The interesting thing about this infection is it’s almost always one single case that occurs in one location,” said Dr. Cope.

Experts say record-breaking temperatures that week may have enabled the presence of the bug, which thrives at warmer temperatures, and murky water possibly disrupted the effectiveness of the UV and chlorine disinfectant.

The amoeba is more frequently reported in southern states, especially Florida and Texas in the summer. However, after the C.D.C. received a report in Minnesota in 2010, they started tracking the bug to see how climate change might be influencing its habitat. Infections have also been documented in Kansas and Indiana. According to Dr. Cope, cases in Minnesota and other places have followed heat waves or a number of days where the temperature was above 90.

According to the C.D.C., since 1962 only 138 people have been infected, and all but three of them have died. Between 2006 and 2015, there were only 37 documented infections, mainly associated with recreational swimming, but one involved contaminated water on a slip-n-slide, and three cases were from rinsing sinuses with infected tap water, including two involving Neti pots.

Clearly, Naegleria fowleri is not your biggest risk in the water. By comparison, between 2005 and 2014, 3,536 people — which averages to about 10 a day — died of unintentional drownings in the United States.

“Millions of people participate in water activities all the time, and this is a very rare infection,” Dr. Stephen Keener, the medical director for the Mecklenburg County Health Department, said at a press conference. “It’s not the kind of thing where just getting in the water with Naegleria is going to cause you to get sick.”

There are ways to reduce exposure, and even though the risk of infection is low, you should follow them. Avoid putting your head under water in hot springs or other warm, fresh bodies of water. If you do go under water, hold your nose, or use nose clips if you know there is a risk of submersion. Avoid digging scum and sediment up near the water. Avoid fresh water activities during very warm weather, which is not very practical advice for people who enjoy swimming or water skiing in lakes or kayaking in streams and rivers. But you can remind yourself about precautions, especially after several days of 90 degree weather.

“Living in Arkansas, one of my favorite things to do is spend time at the lake,” said Dr. William Matthew Linam, a physician at Arkansas Children’s Hospital, in an email. “Having said that, I make my children hold their noses if they are going underwater.”

If you’ve been playing around in warm fresh water, especially during summer months, and come down with a headache, fever, nausea or vomiting, experts say to tell your doctor where you’ve been. And the sooner the better. Later symptoms include stiff neck, confusion, loss of balance, seizures and hallucinations.

Dr. Linam thinks early detection is critical. In 2013 he saved a 12-year-old girl named Kali Hardig, who was exposed at an Arkansas water park and is one of only three documented victims of the amoeba to ever survive the infection. He called the C.D.C. immediately, and the amoeba was found in a sample of her spinal fluid. He administered a cocktail of drugs that the C.D.C. has proven effective in the lab, including miltefosine, a breast cancer drug that the C.D.C. is working to make available in hospitals in Texas and Florida, where reports are more common.

But “even with early detection and treatment, survival is not guaranteed,” he said.

Would I go whitewater rafting again? Yes. But probably only on a cool day. And I’d wear nose plugs.

Watching TV Tied to Fatal Clot Risk

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Credit iStock

The more television you watch, the greater your risk for a fatal blood clot, according to a new study.

Japanese researchers studied 86,024 generally healthy people who filled out questionnaires with items about health and lifestyle, including time spent watching television.

During a follow-up of more than 19 years, there were 59 deaths from pulmonary embolism, a blood clot that travels from another part of the body to the lungs.

After adjusting for other factors, they found that compared with watching TV less than two and a half hours a day, watching for two and a half to five hours increased the risk for a fatal clot by 70 percent, and watching more than five hours increased the risk by 250 percent. For each extra two hours of watching, the risk of death rose 40 percent. The effect was independent of physical exercise.

“Television watching is likely to be uninterrupted,” said the lead author, Dr. Toru Shirakawa of Osaka University, and prolonged sitting increases the risk for embolism. “Take a break, stand up, walk around. Drinking water is also important.”

The study, in the journal Circulation, is observational, so it can’t determine cause and effect, Dr. Shirakawa said, but “the dose-response relationship between time spent watching and the risk of mortality from pulmonary embolism would be strong evidence for a causal relationship.”

Cancer in the Family: Compliments on Being Thin

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Credit The author with her daughter, Devon.

“I’m so jealous. You’ve lost so much weight, you look amazing,” a friend says to me. “I’d love to catch the stomach bug this year and lose a few pounds myself.”

I smile. I don’t know what to say.

Since January, one of my 12-year-old twin daughters, Devon, has been in isolation in a Boise, Idaho, pediatric oncology unit receiving chemotherapy for acute myeloid leukemia. Her sister, Gracie, remains behind, in a little town south of Sun Valley. To cope, she has assigned herself as captain of Devo’s Fight Club, a band of peer supporters started with a sweatshirt she designed in the first 36 hours of her sister’s diagnosis.

Their dad and I have been driving the two and a half hours between home and hospital, splitting the week between our daughters, our jobs, middle school’s demands, puberty’s capriciousness, sports, music and running a household that includes cats, dogs, horses, cows and fish.

Devon’s cancer was as random as a dice roll. She had swollen gums for a week and then, a simple blood test to rule out mono instead declared that this sleek, athletic, freckle-faced cowgirl had a rare and often fatal leukemia.

My husband says he has gained weight since Devon’s diagnosis. I have lost weight. A lot. Neither one of us notices the other because we relate over phone or email mostly, and offer a country-style, four-finger half wave from the steering wheel as we blow past each other on the highway between towns.

Over the next 120-mile drive I am perplexed and obsessive.

“I’m so jealous. You look amazing.”

I’m nearly 51 years old and was prepared for the idea that menopause would keep me round despite my best efforts. How much weight have I lost? Was I really that fat before? Should I eat before I get to the hospital or after? The smell of food makes Devon sick. Eating in front of her seems torturous and unfair.

After I arrived at the hospital, a friend stopped by to visit. Before acknowledging Devon, she looked at me. With purrs of envy, she commented on how thin I looked. Again, I was at a loss for words. My daughter was not.

“My mom is not skinny because she worked at it,” Devon told our visitor. “It’s because I’m sick.”

The friend waved it off in the way that one deflects praise of a nice outfit with “this old thing,” and we all moved on. But every time someone notices my weight loss with a tinge of envy it makes me cringe.

Please, I want to tell them, do not admire how thin I have become since my daughter’s diagnosis — unless you are suggesting I look undernourished and want to give me a cupcake. My weight loss is not a goal you should aspire to, nor should it be confused with health and well-being. I was perfectly happy and fit in my pre-cancer-kid size, and a little hurt to hear that this shrinkage that could cost me a lot more than new pants makes me more beautiful than ever.

But what is most painful for me is the collateral damage to my daughters. When they hear that Mom is enviably thin, they hear that this is a reward, a take away for the suffering. That thin is best no matter the circumstances.

Gracie, a minute ahead of her twin, but always an inch and a pound behind, is now getting stretch marks from growing so fast. When her peers note how she “swims” in her choir dress, her mind begins the dance with body consciousness. Weight fluctuations are somewhat inevitable in adolescence and during menopause, but certainly magnified under the circumstances.

Devon’s physical changes are pushed to the bottom of most people’s thoughts now, because in this setting of a hospital room, she’s supposed to look wan and pale. Instead, her inner beauty and sense of humor are noted.

I’ve been sick and thin enough times to know I don’t want to be either. But my girls are facing this for the first time, and the ripple effects of this entire traumatic episode will surface the farther we get from the cancer. Hospital social workers are preparing us to watch for anxiety, regression, depression, eating disorders, apathy and sleeping issues. And signs of cancer returning, of course. And survivor’s guilt in Gracie, which could carve out a whole new emotional journey.

Devon, thankfully, is home now. But I’ve just been told that five months in the hospital have cost Devon nearly a third of her body mass. That her overall strength is that of a 90-year-old, and that after the chemo, her heart, which once pounded fearlessly, is in danger of failing. Her brain is wobbly from the lack of nutrition and her skin is translucent and cold where it once was earthy and warm.

When she returns to school next year, navigating the social riddle of middle school — now half a year behind her peers — and still mostly bald, and undoubtedly still thin, she will return with a self-consciousness she has never known.

Do not covet her thinness. Admire her resilience, and tenacity, and sheer will to live.

And, if you look into her eyes and you can see they are dim from the struggle, a happy-to-see-you smile or just saying nothing at all will do more than you know to help her find her way to loving herself as life has created her in this moment.

If you want to know how someone is, look in their eyes, because their size is not where the information is.

Rediscovering the Kitchen, and Other Tips for Heart Health

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Credit Paul Rogers

First the bad news: After decades of major progress in reducing deaths from diseases of the heart and blood vessels, the decline in cardiovascular mortality has slowed significantly, according to the latest report from the Centers for Disease Control and Prevention. The researchers called their findings alarming, suggesting that cardiovascular benefits from medical interventions may have reached a saturation point and that further improvements depend largely on changes in society and personal behavior.

The new data, published in June in JAMA Cardiology, covered the years from 2000 through 2014. From 2000 through 2010, the annual rates of decline for all cardiovascular deaths heart diseases and stroke averaged 3.69 percent for men and 3.98 percent for women. But since 2011, the rates of decline dropped to a mere 0.23 percent for men and 1.17 percent for women.

These findings point to near stagnation in controlling cardiovascular diseases and deaths, Dr. Stephen Sidney and colleagues wrote. And, they noted, the reasons are not difficult to discern. Based on data from the latest National Health and Nutrition Examination Survey in 2011-12, Americans did better in controlling three major risk factors smoking, high blood pressure and elevated cholesterol, often with the help of medication but many more people became obese and developed Type 2 diabetes.

According to data from the survey, the prevalence of adult obesity rose from 22.9 percent in 1988-1994 to 34.9 percent in 2011-12, and the C.D.C. found that the prevalence of diabetes nearly tripled, from 2.5 percent in 1990 to 7.2 percent in 2013.

Furthermore, the national survey showed, the percentage of adults who in 2012 were consuming an ideal diet that could minimize life-threatening damage to blood vessels was near zero.

Its not that these grim data were unexpected. Four years ago, Dr. Richard J. Jackson, a professor and former chairman of environmental health sciences at the University of California, Los Angeles, predicted that the current generation of young Americans (those born since 1980) may be the first to live shorter lives than their parents.

Even earlier, in 2007, Dr. Earl S. Ford of the C.D.C. and Dr. Simon Capewell of the University of Liverpool wrote that unless measures were taken to transform the abhorrent risk factor profile that currently characterizes much of the U.S. population and dangerous trends were reversed, mortality rates among younger adults may represent the leading edge of a brewing storm.

Now for the good news: Neither medical innovations nor genetic interventions are needed to turn the tide on cardiovascular diseases and deaths and restore their once-significant declines. And the very same changes needed to improve cardiovascular health may also help prevent many common cancers, diabetes, arthritis, cognitive decline, depression and osteoporosis.

Dr. Donald M. Lloyd-Jones, a chief architect of a 2010 strategic plan to improve cardiovascular health, said: The whole may be greater than the sum of the parts. We shouldnt assume that chronic diseases automatically occur with aging. Living healthfully until we die is an achievable goal.

Dr. Lloyd-Jones, a cardiologist and preventive medicine specialist at the Northwestern University Feinberg School of Medicine in Chicago, chaired an American Heart Association committee of experts that adopted the recommended changes. Instead of focusing on the negative, the plan aims to achieve ideal cardiovascular health through ideal health behaviors and ideal health factors.

Heres how the committee defined ideal: No smoking; maintaining a body mass index below 25; being physically active; following current dietary guidelines; and maintaining an untreated total cholesterol level of less than 200 milligrams, an untreated blood pressure level of less than 120 over 80, and a fasting blood glucose level of less than 100 milligrams.

The committee had hoped that fostering these seven health behaviors and targets would, by 2020, improve the cardiovascular health of all Americans by 20 percent while reducing deaths from cardiovascular diseases and stroke by 20 percent.

But current trends project at best a 6 percent improvement.

Although most of us are born with the potential for ideal cardiovascular health, fewer than half of all adolescents have retained five or more of the seven behaviors and factors at ideal levels, Dr. Lloyd-Jones wrote in 2014. And things get progressively worse with age until ideal cardiovascular health becomes rare above age 60, he said.

Still, he has not given up hope for a better result.

Now for the details. First and foremost, quit smoking or never start. Heart risks drop significantly within a year of quitting and eventually reach those of a nonsmoker.

Next, get regular physical exercise, at least 150 minutes a week of moderate physical activity or 75 minutes a week of vigorous activity, or a combination of the two. Keep in mind that this is the minimum amount of physical activity needed to glean health benefits. More is better.

Exercise should be part of your daily routine, like brushing your teeth. I do a combination of moderate and vigorous exercise every day. It energizes me and helps me control my weight without having to watch every calorie.

As for diet, the committee recommended focusing on foods, not nutrients. (As Dr. Lloyd-Jones put it, We dont eat nutrients.) It refrained from suggesting how many calories people should eat, since caloric needs vary tremendously based on an individuals basal metabolic rate, body size, lean body mass and physical activity.

Rather, it suggested a version of the DASH diet (for Dietary Approaches to Stop Hypertension) that was successfully tested by the National Heart, Lung and Blood Institute. It calls for four and a half or more cups of fruits and vegetables a day; two or more 3.5-ounce servings of fish each week; three ounces of fiber-rich whole grains a day; at most 36 ounces of sugar-sweetened drinks (less than 450 calories, or the equivalent in other sweets) a week; four or more weekly servings of nuts, legumes and seeds; and no more than two servings a week of processed meats.

At the same time, limit saturated fats to less than 7 percent of total calories and daily sodium to 1,500 milligrams for people with high blood pressure and no more than 2,300 milligrams (or one teaspoon of salt) for everyone else. Currently, Americans consume an average of 3,500 milligrams of sodium a day, most of it from processed and restaurant foods.

Which brings me to a final recommendation of my own: Rediscover your kitchen. No matter how busy you are, finding time to prepare healthy foods for yourself and your family should be a top priority.

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Robotic Surgery for Prostate Cancer May Offer No Benefits Over Regular Surgery

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Robotic prostate surgery may be no more beneficial than a conventional operation, a randomized trial has found.

In robotic surgery, the doctor operates through quarter-inch incisions using tiny instruments and cameras guided by robot, giving the surgeon a clear view of the operating site and precise control of the tools. In conventional surgery, the doctor makes a larger incision and uses standard surgical equipment.

Several earlier observational studies had reached the same conclusion. For the current study, in The Lancet, researchers randomly assigned 163 men with localized prostate cancer to robotic surgery and 163 to conventional operations.

Three months after the operations, there was no difference between the two groups in urinary or sexual function, or in complications of surgery. The operations were equally effective in removing cancerous tissue.

Longer-term follow up is needed, but for now, “we recommend that patients choose a urologist with whom they have rapport and who is experienced with either open or robotic prostatectomy,” said the senior author, Dr. Robert A. Gardiner, a urologist at the Royal Brisbane and Women’s Hospital in Australia. “At this stage, we advise that the choice should be based on the person and not on the operative approach. A surgeon may have good clinical reasons for advocating one or the other approach, and the patient should be open to consider his or her advice.”

Flu Vaccine Has Added Benefits for People With Diabetes

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People with Type 2 diabetes may get an added benefit from the flu vaccine: a reduced risk of cardiovascular disease.

British researchers studied 124,503 people with Type 2 diabetes over a seven-year period. About two-thirds of them had been vaccinated against flu.

After controlling for sex, age, smoking, body mass index, hypertension, medications and other health and behavioral factors, they found that people with Type 2 diabetes who had gotten the flu vaccine had a 30 percent lower risk of stroke, a 22 percent lower risk of heart failure and a 24 percent lower risk of dying from all causes. They also had a slightly lower, but statistically insignificant, risk for heart attack.

The lead author, Dr. Eszter P. Vamos, a clinical fellow at Imperial College London, said that people with diabetes are already at high risk for cardiovascular disease, and flu is particularly dangerous for them.

“The flu vaccine is largely underused among people with chronic illnesses,” she said. “It’s really important that people with diabetes receive their annual flu vaccine.”

The study, published in the Canadian Medical Association Journal, had a large sample and a long follow-up time, which give it considerable strength. Still, the authors acknowledge they were unable to account for all of the factors that could make people who get a flu shot different from people who do not.

Just a Regular Doctor

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Credit iStock

“What’s your specialty?” That’s the question people always ask, as soon as they learn that you are a doctor.

My specialty? This question continually flummoxes me. This is the moment that I experience a brief surge of envy toward my cardiology and dermatology colleagues who have simple one-word answers to this question that any lay person can understand.

But what do internists say? What is our specialty?

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Danielle Ofri, M.D.

Danielle Ofri, M.D.Credit Joon Park

I sometimes say, “general internal medicine.” But that’s a mouthful. Plus many people have no idea what general internal medicine actually means.

I usually end up saying that I’m just a regular doctor, but it always feels deflating to have to add that “just.”

The American College of Physicians, the professional group for internal medicine, started an ad campaign several years ago to address the confusion. They came up with the slogan of internists as “doctors for adults,” wanting us to credibly sound like specialists, people with more training than the old-fashioned G.P.s. But it just didn’t catch on. I don’t fault the A.C.P. or its Madison Avenue colleagues who came up with this lusterless campaign; there’s just not a lot of pithy material to work with.

Internists, along with the others in the primary care field — family physicians, pediatricians, gynecologists — make up the bulwark of the medical system, though nothing we do or say or represent is especially snappy. No one is rushing to make an edgy cable TV series about adjusting blood pressure medications or treating constipation.

But the need is surely there. Anyone who’s tried to get an appointment with his or her doctor already knows about the primary-care crunch. The Affordable Care Act has highlighted the need for more primary care doctors, with the shortage only likely to grow more acute with a growing and aging population.

In most other countries, the vast majority of physicians are primary care doctors, in recognition that they deliver the vast majority of health care. It is only in the United States that the free market for higher-paid fields results in the number of specialists actually surpassing that of primary care doctors.

We all know the stats — primary care doctors get paid less than specialists, have more administrative headaches, more paperwork, and are generally viewed as lower on the totem pole. Reputation always has it that the smartest medical students go into the specialties; the generalist fields get everyone else who couldn’t make up their mind or who didn’t want to compete in the big leagues.

Dr. Wayne Riley, the president of the American College of Physicians, strongly disputes this characterization. He notes the wisdom acquired by physicians who are required to take both the long view and the wider view of medicine. “I proudly tell people that my specialty is internal medicine.” And if people are still confused, he humorously describes an internist as, “Like television’s Dr. House, but without the bad manners or ethical issues.”

The stereotype of specialists handling the more complex and intellectually challenging cases makes many generalists fume. Generalists observe that specialists get the “simplicity” of handling very narrow slivers of medicine. It’s much easier to be an expert when you only have a handful of diseases to worry about. And any issue that a specialist doesn’t want to deal with can be permissibly kicked back to the generalist.

The generalist, however, gets no dispensation. Every issue that the patient raises must be addressed. Every symptom from any organ has to be acknowledged. Plus, every medication prescribed by every specialist must be accounted for. Every competing interest between the many medical cooks in today’s fragmented health care environment must be integrated.

A recent study regarding patients with diabetes illustrates this reality. In a review of more than 4,500 patients with diabetes, 80 percent of visits to specialists involved only one diagnosis. However, only 45 percent of visits to generalists involved a single diagnosis. Of patients with four or more diagnoses, 90 percent fell to the generalists.

Specialists also get the added ease of pre-screening. A patient referred to a gastroenterologist is generally known to have a GI issue. A patient sent to a cardiologist has some type of heart condition. But the patient who walks into a generalist’s office will often just report pain somewhere in the middle of the body. The generalist has to figure out if the source of the pain is cardiac or pulmonary or gastric or muscular or inflammatory or infectious or hematologic or autoimmune or psychosomatic — a tall order that is somehow considered less intellectually rigorous, and less worthy of reimbursement, than specialty care.

To me, primary care and specialty care are equally demanding. They perhaps represent different types of intellectual challenges, but there’s no reason for one to be thought of as more worthy of respect (or pay).

Primary care doctors, the generalists, won’t be likely to achieve parity in pay or respect until the economics of American medicine changes drastically to reflect more realistically the needs of our patients. Right now, the system values procedures far more than talking to the patient, and so generalists — who do far fewer procedures — continue to rank at the bottom.

But generalists can take heart in the fact that they are what people usually have in mind when they say that they need a doctor. So now when people ask what my specialty is, I say that I’m just a regular doctor. Though I try to remember to leave out the “just.”


Danielle Ofri’s newest book is What Doctors Feel: How Emotions Affect the Practice of Medicine. She is a physician at Bellevue Hospital and an associate professor of medicine at the New York University School of Medicine, as well as editor in chief of the Bellevue Literary Review. She spoke on Deconstructing Our Perception of Perfection at TEDMED.

Meet the Super Flasher: Some Menopausal Women Suffer Years of Hot Flashes

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Credit Kim Murton

What kind of hot flasher are you?

The hot flash — that sudden feeling of warmth that can leave a woman flushed and drenched in sweat — has long been considered the defining symptom of menopause. But new research shows that the timing and duration of hot flashes can vary significantly from woman to woman, and that women appear to fall evenly into four hot-flash categories.

Some women, called “early onset” hot flashers, begin to experience hot flashes long before menopause. Symptoms can begin five to 10 years before a woman’s last period, but the symptoms stop with the end of the menstrual cycle.

Then there are women who don’t experience their first hot flash until after menopause, the “late onset” hot flasher. And some women fall into a group the researchers called the “lucky few.” Some of these women never experience a single hot flash, whereas others briefly suffer only a few flashes when they stop menstruating.

And then there are the “super flashers.” This unlucky group includes one in four midlife women. The super flasher begins to experience hot flashes relatively early in life, similar to the early onset group. But her unpleasant symptoms continue well past menopause, like those in the late onset group. Her symptoms can last 20 years or more.

The findings come from the Study of Women’s Health Across the Nation, or SWAN, a 22-year-old study that has been tracking the physical, biological and psychological health of 3,302 women from a variety of racial and ethnic backgrounds. The study is being conducted at seven research centers around the country and is paid for by the National Institutes of Health.

“It explodes our typical myth around hot flashes, that they just last for a few years and everyone follows the same pattern,” said Rebecca Thurston, the senior author and a professor of psychiatry and epidemiologist at the University of Pittsburgh. “We may be able to better help women once we know in what category they are more likely to fall.”

That includes women like Lynn Moran, a 70-year-old retired financial planning assistant who lives near Pittsburgh and falls into the “super flasher” category. She remembers having her first hot flash around the age of 47. While the symptoms were subtle at first, soon the hot flashes became more bothersome. “It was enough to wake me up out of a sound sleep,” she said. “I wasn’t sleeping well because they were coming all night long and during the day. I was just miserable.”

Ms. Moran began hormone therapy, which helped but did not eliminate the symptoms. But when medical studies began to show health risks associated with the treatment, her doctor advised her to stop using hormones. She waited another 18 months until she retired, then stopped taking hormones in 2005.

The hot flashes “came back with a vengeance” and haven’t stopped since.

“I still have them. I still laugh about them,” she said, noting that she may experience several hot flashes a day. “I’ll be trying to get ready to go somewhere, curling my hair and have to redo everything and dry my hair again because I’ll be drenched. My makeup will literally run down my face. Here I am, 70 years old, complaining of hot flashes.”

Dr. Thurston notes that understanding variations on hot flashes is important to understanding women’s health in midlife. A 2012 study, published in the journal Obstetrics and Gynecology, suggested that the timing and duration of hot flashes may be an indicator of a woman’s cardiovascular health. The study found that frequent hot flashes were associated with higher cholesterol markers, particularly in thin women.

The latest findings from the SWAN study identified some patterns around the four subsets of women who experienced varying degrees of hot flashes. Women were distributed about equally among the groups, meaning 75 percent of women experienced some degree of hot flashes, while only 25 percent escaped the symptom.

Women in the early onset group were more likely to be white and obese. Women in the late onset group tended to be smokers. The lucky few women who had no hot flashes or only a few were more often Asian women and women in better health. The super flashers were more likely to be African-American, to be in poorer health and to consume alcohol. But the researchers cautioned that while they identified some statistical trends in each group, it’s important to note that each subset of hot flashers included a variety of women representing all races, ethnicities, body weights and health categories. No one factor appeared to determine a woman’s risk for any hot flash category.

For instance, while African-American women were three times as likely to be in the super flashers group, they represented only 40 percent of that group. The remaining 60 percent were white women, some Asian women and other groups.

Dr. Thurston said it is important that doctors understand that 75 percent of women have hot flashes in midlife and that they persist in at least one in four..

“It flies in the face of the traditional wisdom that women have these symptoms for three to five years around the final menstrual period,” she said. “We now know that is patently wrong.”

The Hazards of Ankle Sprains

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Credit Paul Rogers

Many fashion-conscious women wear high heels to show off their legs. But in truth, given the extraordinarily high incidence of ankle sprains, we’d probably all be better off if we had thick stumps like an elephant’s to connect our feet to our legs.

Every day in the United States, about 28,000 people sprain an ankle. Too often the injury is dismissed as “just a sprain,” with no specific treatment and a return to full activity before it has completely healed. Fully 45 percent of all athletic injuries are ankle sprains, and players often go back into the game with little or no treatment as soon as the pain subsides.

In fact, according to the International Ankle Consortium, a global group of researchers and clinicians who study ankle injuries, 55 percent of people who sprain an ankle never seek professional treatment in the aftermath of the injury.

Yet the majority of ankle sprains are doomed to recur. That’s because they often result in a chronically unstable joint that tends to “give way,” poor balance, a distorted gait, difficulty exercising, weight gain, diminished quality of life and early arthritis. Not to mention the expense of dealing with health problems that can result from being overweight and sedentary living.

Sound scary? It should, says Phillip A. Gribble, an athletic trainer at the University of Kentucky and co-director of the International Ankle Consortium, who hopes that knowing the potential consequences of ankle injuries will prompt more people to treat them with respect and seek proper treatment. Even better, he said, would be if more people took steps to prevent injury in the first place. And that, ladies, may include leaving those spike heels in the store.

Dr. Gribble was one of several experts who recently presented the latest technical information on ankle sprains to the National Athletic Trainers’ Association meeting in Baltimore. In a study of 3,526 adults who responded to a questionnaire, more than half, or 1,843, had previously sustained an ankle injury. Those who had injured their ankles tended to weigh more, had greater limitations in their daily activities and were more likely to have cardiovascular or respiratory conditions than those who remained injury free.

While ankle sprains are most common among physically active people, especially amateur and professional sports players and dancers, the general public is hardly immune. The injury can result from walking on an uneven surface (especially while wearing high heels or platform shoes), misstepping off a curb or staircase, being pulled erratically by a dog on a leash, even playing around in the yard with children or friends.

It doesn’t take much. I know — years ago, I sustained two bad sprains, one stepping on a stick while trimming a hedge and the other missing the last step while exiting a plane in the dark. I am now extremely careful about where I walk and what I put on my feet, especially when hiking in the woods (boots are de rigueur).

Most ankle sprains result when the foot abruptly turns in under the leg so that the sole of that foot faces the opposite leg, unduly stretching the ligament on the outside of the ankle. The extent of the injury can range from a minor strain to a complete tear, and the rate and extent of healing can vary greatly.

In one report to the athletic trainers’ convention, 12 college students who had sprained an ankle still had an incompletely healed, overstretched ligament a year after the injury, which “may explain the high percentage of patients that develop chronic ankle instability,” said Tricia Hubbard-Turner of the University of North Carolina at Charlotte.

Even though fewer than half of ankle sprains receive medical attention, the injury is so common (an estimated incidence of 2.06 ankle sprains per 1,000 people a year) that it is the leading lower extremity injury that results in an emergency room visit, according to data from the National Electronic Injury Surveillance System.

As with any injury, ankle sprains are best prevented. One of the best approaches is to improve one’s balance with exercises that train the body to stay upright and maintain control in all kinds of positions. Dr. Gribble recommends spending time standing on one foot, at first on a firm surface, then with eyes closed, then on a soft surface like a pillow. As a final challenge, practice balancing on a wobble board, he said.

Muscles surrounding the ankle can be strengthened by wrapping a towel around the foot for resistance, then moving the foot up, down, in and out. Do stretching exercises that increase the flexibility of the legs, hip and torso to guard against any unanticipated awkward movements.

When participating in sports like basketball, soccer and tennis — which involve jumps or quick changes in direction that can put ankles at risk — consider taping or bracing the ankles to increase their stability.

Finally, avoid being a weekend warrior who indulges in a sport full tilt without adequate preparation. Build up gradually, practice the skills involved and make sure to keep needed muscles strong.

Should you sprain an ankle, avoid the all too common layman’s advice to “walk it off.” At a minimum, leave the game or whatever you were doing and avoid putting weight on that foot to give the injured joint adequate rest. If the injury is severe, you may need to use crutches.

If you do sprain an ankle, apply ice wrapped in a cloth for 15 to 20 minutes every two or three hours for two days, then once a day until pain and swelling are gone. Sit or lie down as much as possible with the injured ankle elevated above the hip. To further minimize swelling, wrap the ankle in an elastic bandage, starting at the toes and working up to the leg.

Seriously consider a medical consultation, especially if pain and swelling persist for more than a few days. Although in most cases, an X-ray or M.R.I. is not needed to make an accurate diagnosis, the injury could be more serious than a simple sprain. Ask about physical therapy, which can strengthen the joint and help prevent reinjury.

Most important of all, don’t rush back into activity before healing is complete and normal, pain-free range of motion has been restored. Reinjuring the ankle can result in permanent pain and disability and the health consequences noted above.

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Can Statins Cause Diabetes?

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Credit Stuart Bradford

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Food, a Place to Sleep and Other Basic Patient Needs

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Credit Earl Wilson/The New York Times

“Doc,” my patient said, his voice a mix of amusement and irritation. “I ain’t got food to eat or a place to sleep. Took me two hours and three buses to get here. And you’re tellin’ me about some numbers?”

He had a point. Though, in my defense, these numbers — his cholesterol and blood pressure — were important ones.

As I tried to persuade him of their relevance, I thought of another number, his ZIP code — or lack of one, since he lived on the street — and how that was a far more important factor for how long he might live than his cholesterol.

What’s remarkable about our conversation isn’t that it happened, but that it doesn’t happen enough. Many of my patients are not forthcoming about their challenges, and when I probe, I’m often surprised by how many struggle with basic needs like housing, food and transportation.

I recently discussed starting insulin with a patient to control his diabetes. He hesitated — his concern not the syringes needed to inject it, but rather not having a refrigerator to store it. Another patient recently called to cancel her appointment. She was moving into a new apartment — again. Her son’s asthma had flared up, and she thought the mold and cockroaches in their current home were making it worse.

These situations highlight what we’ve known for decades: that patients’ social and economic circumstances powerfully influence their health and well-being. But until recently there’s been relatively little effort to systematically address these factors.

The Center for Medicare and Medicaid Innovation, a government organization established by the Affordable Care Act to test new ways to deliver and pay for health care, is trying to change that. It recently announced a pilot program to help health systems close gaps between medical care and social services in their communities. The program, known as Accountable Health Communities, will invest $157 million over five years to study whether helping patients with social needs in five key areas — housing, food, utilities, transportation and interpersonal safety — can improve health and reduce medical costs.

“Clearly we’re not the first to understand that social factors are important,” said Dr. Darshak Sanghavi, the innovation center’s director of preventive and population health care models. “But these efforts have been fragmented. They haven’t been studied in a way that can be nationally scaled.” As the world’s largest purchaser of health care services, the Centers for Medicare and Medicaid Services can help address that, he said.

The Accountable Health Communities program will award grants to 44 organizations around the country to build partnerships among state Medicaid agencies, health systems and community service providers to identify which strategies are most effective for linking patients to the services they need.

There’s good evidence that dedicated attention to social support can improve health and cut costs. Research suggests nutrition assistance for low-income women and children reduces the risk of low birth weight, infant mortality and developmental problems — at a cost that’s more than fully offset by lower Medicaid spending. Other work suggests providing elderly patients with home-delivered meals can help them live independently and prevent expensive nursing home stays. Research also shows that providing housing for low-income and homeless people can substantially reduce medical costs. A housing initiative in Oregon, for example, decreased Medicaid spending by 55 percent for the newly housed; a study of a similar program in Los Angeles found that every $1 spent on housing led to $6 saved on medical costs.

And local efforts around the country can serve as models for change.

Hennepin Health in Minnesota, for example, is an organization that serves low-income patients, and emerged as a partnership between local social service, public health and medical leaders. These groups share data and funding to ensure patients have access to services like housing, utilities, job training and behavioral and substance abuse counseling. The program’s efforts have lowered emergency department use, reduced the need for hospitalizations, improved chronic disease care — and saved money. Other innovative organizations, like the Camden Coalition in New Jersey and Health Leads in several metropolitan areas, have likewise recognized the challenges vulnerable patients face outside the hospital, and tackled them in inspiring ways.

But we haven’t yet done enough to collect, examine and scale these insights. There’s been no concerted national effort to ease the social problems that drive poor health, and consequently, little financial incentive for medical practitioners to collaborate with social service providers. Until now.

“I think what’s most important is the signal we’re sending,” Dr. Sanghavi said of the Accountable Health Communities initiative. “We recognize that hundreds, potentially thousands, of communities have these needs. We can’t meet them all right now. But this sends a broader signal to other innovators out there — be they private, public or philanthropic: Social determinants are important. We want to learn from their efforts. We want to spark that flame.”

Dhruv Khullar, M.D., M.P.P., is a resident physician at Massachusetts General Hospital and Harvard Medical School. Follow him on Twitter: @DhruvKhullar.

A Hunger Crisis in the L.G.B.T. Community

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Tanya Asapansa-Johnson Walker, a 53-year-old transgender woman has for years relied on food pantries.

Tanya Asapansa-Johnson Walker, a 53-year-old transgender woman has for years relied on food pantries.Credit Yana Paskova for The New York Times

Gay, lesbian, bisexual and transgender Americans are more visible than ever before. Apple’s chief executive, Tim Cook, and the talk show host Ellen DeGeneres are gay. Kate Brown of Oregon is the first openly bisexual governor. The Olympic gold medalist and transgender woman Caitlyn Jenner has a reality show.

But the affluence of such prominent figures masks a bleak reality: Many people in the L.G.B.T. community go hungry.

A new report on hunger found that more than one in four L.B.G.T. adults could not afford to feed themselves or their families at least once in the past year. By comparison, only one in six heterosexual adults reported a similar crisis.

Certain subgroups in the L.G.B.T. community are particularly vulnerable to food insecurity, including minorities, women, the unmarried, bisexuals, those without college degrees, younger people and those who have children in the home. (It is believed that transgender people also go hungry, but data on this group is lacking.) Experts say L.G.B.T. teenagers, who are not covered in this report, are also at risk of going without food, especially if they are homeless.

Behind the statistics are people like Sofia Torres, a lesbian who at 71 is unemployed and receives only $35 a week in food stamps after recent cuts. Or William Gonzalez, a 50-year-old gay man from Queens who survived a hate crime and lives on a government disability check, and relies on a local food pantry called the River Fund for groceries. Or Tanya Asapansa-Johnson Walker, a 53-year-old transgender woman has for years relied on food pantries because finding a job is so difficult.

“As soon as they realize you’re trans, you see their face changes; everything stops right there,” Ms. Walker said.

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Sofia Torres receives only $35 a week in food stamps.

Sofia Torres receives only $35 a week in food stamps.Credit Yana Paskova for The New York Times

Ms. Torres worked her whole life in construction, carpentry and security jobs, but she never married or had children, so her support system is thin. Though she has friends, she said, “Friends come and go.”

The new report, “Food Insecurity and SNAP Participation in the LGBT Community,” published Monday, uses data from four major national surveys that, when combined, represent the lives and challenges of nearly 20,000 people in the L.G.B.T. community.

“This is eye-opening for many people, and it’s even eye-opening for many in the anti-hunger world, who haven’t typically worked with the L.G.B.T. community,” said Adam P. Romero, a scholar of law with the Williams Institute at U.C.L.A. School of Law who is one of the authors of the new study. “I’ve had a number of people from different anti-hunger organizations say, ‘Wow, I had no idea that hunger was such an issue in the L.B.G.T. community.’”

The findings will also surprise many within the community itself, said Lorri L. Jean, the chief executive of the Los Angeles LGBT Center.

“Our own community is as ignorant of these statistics as the straight world,” she said.

The surveys include the Gallup Daily Tracking Survey of Adults, the National Survey of Family Growth, the American Community Survey of Cohabiting Couples and the National Health Interview Survey of 2014. (The SNAP program referred to in the report’s title refers to the Supplemental Nutrition Assistant Program commonly called food stamps.) ConAgra Foods provided some funding for the report.

According to the new report, L.G.B.T. adults are 1.6 times more likely than other adults to report that they did not have enough money for food for themselves or their families at some point in the last year. Same-sex couples are 1.6 times more likely to have received food stamps in the past year, compared with heterosexual couples.

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Credit

Food insecurity has a disproportionate effect on minorities. When asked the question, “Have there been times in the past 12 months when you did not have enough money to buy food that you or your family needed?” the differences are striking.

Nearly half of L.G.B.T. African-Americans (42 percent) answered yes, compared with 28 percent of straight African-Americans. Among Hispanics, 33 percent of L.G.B.T. adults had been hungry, compared with 24 percent of those who are straight. Among whites, 21 percent of L.G.B.T. whites reported not having enough money for food in the past year, compared with 13 percent of those who are straight. Notably, among Native Americans and Alaskans, L.G.B.T. and straight adults were equally hungry, with about 30 percent each reporting that they had been too poor to buy food in the past year. The data is from the Gallup Daily Tracking of Adults which surveyed 81,134 straight people and 2,964 people who identified as L.G.B.T.

Among L.G.B.T. people, women were more likely to be hungry than men; 31 percent of women and 22 percent of men reported not having enough money for food in the past year.

The perception that the L.G.B.T. community is affluent, educated and high-achieving has been perpetuated by Hollywood characters like the lawyer Will Truman on the sitcom “Will & Grace,” and reinforced by a cascade of high-profile celebrities, businesspeople and athletes.

Because gay and lesbian couples have historically been less likely to have children, there also is a perception that such couples have more disposable income than people with families. Though the data is fairly sparse, most studies actually show gay men earn less on average than other men.

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William Gonzalez survived a hate crime and lives on a government disability check.

William Gonzalez survived a hate crime and lives on a government disability check.Credit Yana Paskova for The New York Times

The belief that most L.G.B.T. people are affluent is “one of the most persistent and, frankly, pernicious myths about the L.G.B.T. community,” said Gary J. Gates, who wrote the first report on food insecurity in the L.G.B.T. community and is an author on the new report as well. “It emerged in part from the community itself, as part of a strategy of marketing the population as an attractive consumer market.”

While the strategy of promoting “pink” money and the purchasing power of the L.G.B.T. community “got a lot of companies on board and increased their understanding of L.G.B.T. issues,” he said, it also hid the economic problems faced by vulnerable members of the community.

“It’s not like on TV, where all the gay people are fabulous and live in nice apartments in Manhattan and are white,” said Cathy Bowman, L.G.B.T. and HIV project director at Brooklyn Legal Services.

Many anti-hunger organizers are now starting to think about how they can make their food services more welcoming to L.G.B.T. people, and how to address the issue from a policy perspective, said Abby Leibman, the president and chief executive of Mazon, a national anti-hunger advocacy group.

Ms. Jean, of the Los Angeles L.G.B.T. center, said she planned to use the new report to raise awareness and “raise a ruckus,” and press the local food bank operation to restore the food pantry that used to be at her center.

“I have had government funders over the years say to me things like, ‘Yeah, but you people don’t need it,’” Ms. Jean said. “There’s this myth in our society that gay people are rich, but it’s not the truth. We have this huge swath of people who make less that their straight

Doctors Should Listen to Patient Instincts

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When a patient complains that he or she doesn’t feel well, doctors should pay attention.

That’s the finding of a new study that suggests that how patients say they feel may be a better predictor of health than objective measures like a blood test. The study, published in Psychoneuroendocrinology, used data from 1,500 people who took part in the Texas City Stress and Health Study, which tracked the stress and health levels of people living near Houston.

The survey included self-assessments from a 36-item questionnaire as well as blood samples, which were analyzed for markers of inflammation and the activity of latent herpes viruses. (The viruses were benign and not the type associated with sexually transmitted disease or cold sores.) Inflammation and viral activity are general markers of immune system health, but they don’t typically cause any obvious symptoms or show up in traditional blood tests.

The study found that when people said they felt poorly, they had high virus and inflammation levels. People who reported feeling well had low virus and inflammation levels.

“I think the take-home message is that self-reported health matters,” said Christopher P. Fagundes, an assistant psychology professor at Rice University and a co-author of the study. “Physicians should pay close to attention to their patients. There are likely biological mechanisms underlying why they feel their health is poor.”

Keeping the Disruption of a Move in Perspective

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Credit Camilla Engman

At midnight, the ice cube dispenser on the refrigerator is not merely dripping. Water pours onto the floor. I drop down towels, empty the accumulated cubes from their plastic container and pop it back inside the freezer.

“Was that the right thing to do?” I ask my husband, who is trying to sleep. “For goodness sakes,” Don says, getting out of bed. We must leave for my monthly cancer blood test at 8 a.m. tomorrow.

Don pulls out the tray, puts it in the sink, and props up a little stick in the freezer, pushing up the ice maker’s metal wand in an attempt to stop the leak. Might work, might not… I’ll stay awake to see whether the deluge stops. When an unexpected disaster arises, I diminish its significance by comparing it to the worst of my cancer treatments a few years ago. I can do this because my current condition remains stable with an experimental drug.

Yet as I contemplate all the chairs and sofas and rugs that have to be donated to Goodwill, the mattresses and box springs to be given to the St. Vincent de Paul society, my late mother’s files and cabinets, Don’s late wife’s luggage and papers, his massive collection of 78 r.p.m. records, the yards of books on the shelves in the studies, our daughters’ stored memorabilia and their children’s baby equipment, the sheer volume of stuff seems daunting.

We are moving from a house of 4,000 square feet to an apartment less than half that size. One reason for our relocation: Don and I want to release our girls from the responsibility of dealing with the detritus accumulated over decades. We also have to leave because he cannot negotiate the stairs and both of us together cannot manage the upkeep.

Throughout the weeks and then the months when our beloved but aging house has to be repaired so we can sell it, workers arrive to shore up the porch, to fix the bowed ceiling supports in the garage, the cracks over the foyer doorway, a foundation that needs to be anchored to keep the structure from shifting, broken screen doors, mold in basement closets, chipped kitchen cabinets, and (oh!) a tree appears to be growing out of the chimney, and (yup!) an inspector found clogged drains — which suggest there might be trouble with the septic tank.

People tell me that moving ranks high up there on the stress index. But the commotion comes nowhere close to the terrifying havoc of cancer and its traditional treatments. Throughout the weeks and then the months of removals and renovations, the rhythms seem downright soothing, if measured against the ghastly tempos of surgeries, radiological interventions and chemotherapies.

The magnitude of cancer provides a scale against which everything else falls happily short. Cancer can be so bad that it imparts a sense of proportion. The poet Jane Kenyon once said that leukemia and a bone marrow transplant dispelled her fear of flying.

In the midst of all this chaos, I will postpone treating my recently diagnosed osteoporosis — I’m not clear yet about the efficacy of various remedies — but what about the cataract surgery? With or without glasses, I cannot see clearly and I have become the designated driver. Given the boxes mounting everywhere as well as the appointments of various people who are coming to take away the piano and the records and some paintings we won’t have room for, should I cancel? No way, I decide: a piece of cake, in contrast to cancer.

Ever shifting, the cancer terrain is treacherous to negotiate, its perilous landscape always unstable. There are roadmaps, but they often seem indecipherable. With surgeons, radiologists, and oncologists, I advance without a clear sense of how I will end up where and when.

As a cancer patient, I feel like an immigrant in a strange land. The customs of the country bewilder me. Dazed by unfamiliar sounds, sights, tastes, and touches, I had to learn a whole new language quite distinct from the idioms of every day discourse. I will never master it.

I speak of genetic mutations, chemicals and my anatomy in a grammar so simple that it resembles a 2-year-old’s. Terms must be adopted — debulking, PICC, port, PARP inhibitor — for processes I cannot really conceptualize. Frequently, physicians and nurses have to write down or spell out their prescriptions or directions. I mispronounce or stumble over words — anastomosis, extravasation, Gastrografin — that seem foreign.

So even this unsettling removal from a country house to an apartment strikes me as a change I can take in stride. After all, I know the address of my destination, the date of my prospective arrival, the route the truck will take and the neighbors speak my native tongue.

I’m staying up very late and can attest to the fact that the kitchen floor has remained dry. Don and I will travel to the hospital tomorrow and return. I will have cataract surgery and we will reside in a town whose byways may be easier to navigate with improved vision.

When you have cancer, you don’t just have cancer: You might have a broken refrigerator and cataracts and osteoporosis and loads of other issues. But you also have a unique perspective which, in a curious way, helps me keep on moving on.

Susan Gubar is the author of the new book “Reading and Writing Cancer: How Words Heal.”

The Doctor-Patient Relationship Is Alive and Well

It’s 2:20 p.m. and Ms. M. is precisely on time for her appointment. She’s brought her hand-printed list of questions, her sack of medications that need renewal, her mordant observations about her newest home attendant, and a box of chocolates that she will press upon me no matter how hard I protest. At 89, her medical conditions don’t have easy cures and the setbacks from aging are often implacable. Yet we always manage to find something optimistic to work on, even if modest in scope.

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Danielle Ofri, M.D.

Danielle Ofri, M.D.Credit Joon Park

Ms. M. requires the assistance of her daughter to make the hour-plus trip by public transportation. Over the 10 years we’ve worked together, I’ve periodically suggested she might consider a clinic closer to home to avoid the arduous travel. She sniffs sharply at the affront and then barrels into the meat of our visit.

It’s been a rocky decade for medicine — the Affordable Care Act, the migration to electronic medical records, record-breaking medication prices, and the shift from traditional doctor-run practices to mammoth corporate-run organizations have left us all reeling. Physician anger at overwhelming administrative demands and patient frustration at the impossibility of navigating the system have frayed the fortitude of everyone.

Medicine is unquestionably harder than it was 10 years ago. Many more doctors I know talk about quitting (an option that is not equally available to patients). However, there’s been no mass exodus of doctors. We doctors grumble loudly — often with good cause — but we aren’t quitting in droves, mainly because of patients like Ms. M.

A new study by the Physicians Foundation of more than 1,500 patients found that more than 90 percent of patients were satisfied with their relationship with their primary care doctor. They felt that their doctors were respectful of them, listened well, explained well, and had a good understanding of their medical history.

On the surface, this seems to contradict the dyspeptic view of medicine we hear about in the media. But it actually reflects the larger truth that most patient rancor is directed not toward the doctor but to the bureaucratic aspects of medicine — the cost, the hassle, the opaqueness. On the whole, patients are happy with the medical care they receive from their primary care doctors — once they’ve slogged through the seven circles of pre-authorization purgatory to get there.

The same is true for doctors. What doctors hate most is everything that surrounds medicine, but not medicine itself. Peel away the administrative migraines and most doctors relish the practice of medicine.

It’s heartening to see that the doctor-patient relationship is surviving this latest round of upheaval. For primary care doctors in particular, whose daily work life has been pummeled with exceptional relentlessness, this latest survey is immensely validating.

So maybe it’s not surprising that it can feel as if morale is both exceptionally high and exceptionally low at the same time. Just this month, a new set of requirements was piled on to our clinic’s electronic medical record system, and a dreary sigh of resignation echoed from one doctor to the next. With all the computerized busywork that a medical visit requires these days, there’s hardly time to call in our patients from the waiting room.

On the other hand, when we welcome our new students and interns — July is the starting month of the medical calendar — the enthusiasm for primary care is fervent. We all have patients, like Ms. M., who bring joy and fulfillment no matter how much inanity we have to lumber though in the electronic medical records system.

Nothing comes close to the experience of making another human being feel better, even a tiny bit. After months of trial and error, Ms. M. and I finally worked out a schedule of her diuretic pill such that she could go for a midday stroll without having to scramble for a nonexistent public bathroom. This isn’t the sort of high-tech medical wizardry that grabs headlines or stock prices, but it allows a formerly housebound patient to now keep tabs on her Brooklyn neighborhood.

The awe of discovering the human body, the honor of being trusted to give advice, the gratification of helping someone through a difficult illness, the intellectual stimulation of continually learning — these things never grow old.

And word seems to be getting out — applications to medical school are at an all-time high, and new medical schools are opening to meet the demand. (By comparison, law school applications continue to decline and business school applications remain flat.)

When I close the door to the exam room and it’s just the patient and me, with all the bureaucracy safely barricaded outside, the power of human connection becomes palpable. I can’t always solve my patients’ issues, but the opportunity to try cannot be underestimated.

We doctors shouldn’t be afraid to speak up about what’s wrong with medicine — and there is plenty that is wrong. But we also shouldn’t be afraid to speak up about what’s right. While the logistics of practicing medicine may feel like an ever-tightening thumbscrew, the doctor-patient relationship is alive and well, and the prognosis is excellent.

Danielle Ofri’s newest book is “What Doctors Feel: How Emotions Affect the Practice of Medicine.” She is a physician at Bellevue Hospital and an associate professor of medicine at N.Y.U. School of Medicine, as well as editor in chief of the Bellevue Literary Review. She spoke on Deconstructing Perfection at TEDMED.

More Nonsmoking Teens Inhaling Flavored Nicotine Through Vaping

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A study shows that many teenagers who would have never smoked are now vaping.

A study shows that many teenagers who would have never smoked are now vaping.Credit Katie Orlinsky for The New York Times

Many teenagers who never would have smoked cigarettes are now “vaping” with flavored e-cigarettes, leading to a new generation using nicotine at rates not seen since the 1990s, a new study suggests.

The study, released Monday in the journal Pediatrics, tracked the use of cigarettes and e-cigarettes among 5,490 California high school seniors who graduated between 1995 and 2014. E-cigarettes do not burn tobacco, but are battery-operated inhalers that heat up and vaporize liquid containing flavors and nicotine, a practice known as vaping. The liquids used in vaping range in taste from traditional tobacco and menthol flavors to fruity and sweet combinations like gummi bear, banana bread and cotton candy.

When e-cigarettes came on the market in 2007, some public health experts hoped that they would serve as a substitute for traditional tobacco products and lead to declines in tobacco use.

But the data from the latest study, conducted by researchers at the University of Southern California, tell a different story. E-cigarettes do not appear to have made a dent in regular cigarette use — the number of high school seniors who reported smoking tobacco in the past 30 days has largely plateaued. In 2004, the number of 12th graders who reported smoking tobacco in the past 30 days was 9 percent; in 2014 that number was just under 8 percent.

But the rate of teenagers using nicotine — either through tobacco cigarettes or e-cigarettes — is on the rise. About 14 percent of Southern California high school seniors in 2014 said they had smoked or vaped in the last 30 days. Researchers say they have not seen similar levels of nicotine use among teenagers since 1995, when 12th grade smoking rates were 19 percent.

The numbers suggest that rather than prompting teenagers to replace cigarette smoking with vaping, e-cigarettes instead have enticed an entirely new group of teenagers to use nicotine. While the study focused on California teenagers, researchers say the numbers are consistent with national trends.

“Kids are not just using e-cigarettes instead of cigarettes. That is what we were frankly hoping to find,” said Jessica Barrington-Trimis, the lead author of the study and a postdoctoral scholar research associate in the department of preventive medicine at the U.S.C. Keck School of Medicine. All of the teenagers that were expected to be using cigarettes in 2014 are using them, she said, “and then there is a whole group of kids using e-cigarettes on top of that.”

The amount of nicotine in the liquids used with e-cigarettes — often called “vape juice — varies, and users can purchase liquid with no nicotine or nicotine content ranging from 3 milligrams per milliliter to 18 milligrams per milliliter or even higher. While earlier studies have suggested that some teens are using nicotine-free vaping liquids, researchers say the majority of teens appear to be using nicotine-infused liquid in their e-cigarettes.

Dr. Jonathan Winickoff, professor of pediatrics at MassGeneral Hospital for Children and Harvard Medical School, who wrote an accompanying paper in Pediatrics, said this is the first study of e-cigarette use in adolescents to show such a strong longitudinal sample with such a drastic effect.

“We had a trend of decreasing nicotine use,” said Dr. Winickoff. “What the e-cigarette has done is halted that decrease in its tracks…. We don’t want a fifth of our high school students graduating with nicotine addiction.”

While e-cigarettes do appear to be safer than smoking tobacco, they are not risk free. Nicotine disrupts neurotransmitter activity and is highly addictive, particularly in a developing brain. And the liquids contain solvents, formaldehyde and other ingredients that pose health risks when inhaled.

While it’s true that there are nicotine-free vaping liquids, the e-cigarette industry is not regulated, which makes it hard to know what ingredients are actually in any given product. Though the Food and Drug Administration recently took jurisdiction over e-cigarettes, it will be years before any regulations are put into effect. Currently, many products continue to be made in China with little — if any — oversight by the United States.

“The F.D.A. has done tests on these vaping products that supposedly do and do not contain nicotine, and what is advertised is really not what’s in the product,” Dr. Winickoff said. “When the product is labeled as no nicotine, they’ve found nicotine. So kids don’t know what they’re getting, and as a pediatrician it really scares me.”

Not everyone agrees that e-cigarettes pose a significant risk to teenagers. Dr. Michael Siegel, professor of community health sciences at the Boston University School of Public Health, countered that many teenagers say they are using e-cigarettes that contain only flavorings and no nicotine, and therefore are not getting addicted.

“E-cigarette use among teenagers is a largely social phenomenon,” he said. “The fact that you tend to see teenagers doing this in groups, not out in the cold vaping alone, suggests that e-cigarettes are not addictive.”

But there is a growing body of research showing that e-cigarettes do serve as a gateway to traditional tobacco products. Last month, the U.S.C. researchers also reported in Pediatrics that adolescents who vape are six times more likely to smoke cigarettes in early adulthood as nonusers.

“Once kids get hooked on e-cigarettes, they are more likely to go on to become cigarette smokers,” said Stanton A. Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco.