When the Simple Solution Is the Right One

William Duke

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I had run way too far for my level of training, and I knew it. But I had gotten lost, and the fastest way back to my car was to run. The next day, my left forefoot hurt so much I could hardly walk, so I did just what you might expect — I checked the Internet to see what sort of injury I might have and what to do about it.

My search was frustrating and unhelpful. But I ended up getting just the advice I needed from an unexpected source. And I came away with this lesson: These days, when it is oh so easy to order sophisticated medical tests, sometimes the best test, and the best treatment, can be low-tech.

After I was hurt, I did just what doctors worry that their patients will do. I searched medical Web sites for a diagnosis I could accept. When I did not like the one I found, I tried to convince myself that it had to be wrong.

The Web diagnosis was a stress fracture, a hairline crack in a bone. It sounded bad. It could take months to heal. I might need to immobilize the entire foot and walk around on crutches and then go through weeks of rehabilitation.

I told myself that I didn’t have a stress fracture, that there were aspects of my injury that did not seem to fit. I kept running, four to six miles every other day. Still, I was not getting better.

Finally, in December, six weeks after the injury, I gave in and called one of the few orthopedists in my area who accepts my health insurance. The first available appointment was for Jan. 16. I took it.

Then I wrote about my injury, as part of a longer article for The New York Times about running while hurt. As soon as it appeared, on Jan. 11, I began getting e-mail from readers. A podiatrist told me that I definitely had a stress fracture and had better stop running. A trainer said I had injured a tendon attached to my big toe (he had no way of knowing that the injury was at the base of my third toe). And Paul A. April, a rheumatologist in Tulsa, Okla., said he thought it was either a stress fracture or something called extensor tendinitis. “I’d love to hear what the doctor finds,” he added.

I looked up extensor tendinitis online: an inflammation of a tendon that straightens the toe. I hadn’t found that injury when I first searched the Web, but it sounded right.

On Jan. 16, I finally saw the orthopedist and, of course, mentioned extensor tendinitis. All I got was a cursory exam and an X-ray. When the X-ray showed normal bone, the orthopedist said I needed an M.R.I. His office said someone would call me when my insurer approved it. Then I could schedule it. Then I could return to see the doctor and learn what the scan showed.

I e-mailed Dr. April in Oklahoma telling him what had happened. “Gratuitous advice may be worth nothing, but here goes,” he replied. “Hands-on examination should have revealed tenderness in the distal forefoot and even an increase in pain with forced downward pressure on the toes. If that was the case, then a local injection of a corticosteroid in a small amount with lidocaine or something similar into the extensor tendon sheath would produce relief of pain within minutes and hopefully this would last.”

That sounded great. I could rule out a stress fracture and cure the inflammation all at once. If that did not work, I did not have extensor tendinitis.

I called the orthopedist to see whether he would give an injection. All I could get was an assistant’s voicemail saying not to expect a reply for 48 hours because she was busy and, by the way, she does not work on Fridays. It was a Wednesday. (Thirteen days later, I still have not heard from her.) I also called my internist to see whether she would give an injection. The answer, her nurse said, was no.

Finally, I called an orthopedist who does not accept my insurance and asked whether he would inject cortisone into the tendon sheath of my foot. His assistant knew just what I was talking about.

“You want to rule out a stress fracture?” she asked.

The doctor would do it, for $277. I said that I would be there the next day and that I would pay.

The injection cured me. It also saved my insurer more than $1,000 for an M.R.I. and subsequent doctors’ appointments. But how much simpler to do what the Tulsa doctor recommended and the second orthopedist did: carefully examine my foot, ask about the injury, see that my symptoms seemed more like tendinitis than a stress fracture and simply give the injection.

As for Dr. April, my correspondent in Tulsa, he has learned something, too.

“The idea of telephone medicine seems to be an easy way to make a living if I were inclined to that,” he wrote. “In your case, I was intrigued by a simple problem, the solution of which seemed to be stalled. It really was no big deal, but I loved doing it.”

¶ Tuesday, January 30, 2007 0 comments

The Claim: Drinking Tea Reduces Stress.

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THE FACTS Some call it nature’s tranquilizer, able to smooth away stress and lift the spirits. But are the stress-reducing powers of tea fact or fiction?

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Although the association between tea and relaxation dates back centuries, few independent scientific studies have put that idea to the test. Much of the research has been focused only on animals. But a new study on humans suggests that it may hold only a sliver of truth.

The study was published this month in the journal Psychopharmacology and financed by the British Heart Foundation. It found that adult men who drank black tea four times a day for six weeks reacted no differently in the face of stress from men given a caffeinated placebo. But there was some indication that they were able to calm down more quickly.

The two groups in the study, consisting of about 75 men who were forced to give up their normal caffeinated beverages, were subjected to stressful social situations while their blood pressure, hormone levels and other indicators of stress were measured. All of the subjects showed the same substantial increases in those measures, with no positive effect on heart rate or blood pressure in the tea group. But those who drank tea had slightly lower levels of the stress hormone cortisol an hour later, suggesting that their levels of the hormone were returning to baseline sooner.

Whether that has any long-term benefit is unclear. Previous studies on animals have pointed to sedative effects of certain compounds in tea, but so far the evidence is weak.

THE BOTTOM LINE There is some evidence, but not much, that tea affects stress levels.

scitimes@nytimes.com

¶ Monday, January 29, 2007 0 comments

Agents of Angst

Illustration by Juliette Borda

RENÉE MIZRAHI suspects that the first real estate agent she worked with deliberately didn’t tell her that a building was only 49 percent owner-occupied.

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The Choices Become Highly Personal (January 28, 2007)

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Michelle V. Agins/The New York Times

SOMETIMES, AN UNEASY PROCESS Jill Sloane of Halstead Property is Renée Mizrahi’s third broker.

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John Marshall Mantel for The New York Times

Rob and Lauren Mank, shown with their daughter, Sadie, now wonder why their agent, a buyers’ broker, pushed them to offer the full asking price.

Her bank subsequently refused to give her a mortgage, and she lost the apartment.

Her second broker was worse. He stood her up at an apartment showing, she said, and he lied about the building’s financial requirements and about having put in her bid for the co-op. Then when she told him that she didn’t want to work with him anymore, he kept calling her — she has caller ID — and hanging up without leaving a message. “So he was like stalking me,” Ms. Mizrahi said. “What a nightmare!”

She is now working with a broker, referred by a friend, with whom she feels comfortable, but her bad broker experiences have nonetheless made her wonder if any broker can really be trusted. “I just want to work with someone who shows up when they say they will and who will tell me the information I need,” she said. “Why is this so hard?”

Ms. Mizrahi is not alone in her hard-earned broker wariness.

A Harris poll conducted last year that ranked occupations in terms of prestige placed real estate brokers at the very bottom of a list of 23 professions. (Firefighters and doctors were at the top.)

Brokers themselves seem well aware that their business isn’t always held in very high regard. The National Association of Realtors has an advertising campaign called “Someone You Can Trust,” which stresses that Realtors are subject to mandatory ethics training. “Not many professionals can claim that on their résumé,” the ads read.

Svetlana Choi, a senior sales associate at Bellmarc Realty, estimated that at least a quarter of her clients are skeptical when they first come to her.

“I just try to draw them out and relate to them in a way that lets them know that I’m not the enemy,” she said. “I’m not trying to snow them. I’m really just trying to be helpful.”

So why do people often have trouble trusting a broker?

To start with, brokers are salespeople, so buyers with suspicious minds would naturally suspect brokers of trying to sell them something they don’t necessarily want or need. But brokers also admit that some real estate agents help to perpetuate stereotypes with classic bait-and-switch schemes and by putting their own desires to close a deal over a client’s best interests. The fact that brokers themselves sometimes find it hard to trust one another only compounds the level of suspicion in real estate.

There are two major sources of broker-to-broker mistrust. The first is the fear that one broker may be trying to poach another’s client. The second is that a seller’s broker may be deliberately avoiding phone calls or refusing to submit an offer because he or she wants to avoid having to share the commission. The cynicism may well stem from the fiercely competitive marketplace and the fact that there are more than 28,700 brokers and sales agents in Manhattan alone and 66,700 in all five boroughs.

Erik Serras, a sales agent at Pari Passu Realty in Manhattan, said another agent recently stood outside an open house that Mr. Serras was holding just to hand out his business card. “It was the equivalent of ambulance chasing, and it sheds a negative light on the industry on the whole,” he said. “There are just too many untrained agents out there doing things that are unethical and unprofessional, and once a client is exposed to that, the damage is done because it’s easy for people to generalize.”

Ann Rothman, a Bellmarc agent, said that some people were quick to judge brokers because they “just have a queasy feeling about real estate.” She added that she sometimes finds herself saying, “I do real estate, so yes, I sell used cars, and people are going to think the speedometer has been changed.”

But Ms. Rothman tries to be philosophical about it. “Any person in a service business is going to be up against that,” she said. “Even if you go to a doctor or a dentist, there are going to be people who think they’re only doing a procedure because they have their kid’s college education or a trip to finance.”

When she comes across skeptical clients, Ms. Rothman said, “I’ll bring it up, and I’ll say, ‘What’s the problem here?’ ” That seems to work, she added, citing as proof an entire family of doubting buyers. “They all have a distrust gene,” she said, “but they keep referring other family members to me.”

Another instance when a broker might appear to be evasive is at an open house. When brokers hold open houses, they represent the sellers, but they also routinely use the events as an opportunity to pick up other clients. So if a potential buyer walks in and doesn’t seem right for that particular apartment, the broker can offer to help the buyer find something else. But under the unwritten rules of the game, the broker does not have to disclose whether there are any other open houses in the same building, particularly if the events are being held by competing firms.

These kinds of situations can easily lead to mistrust on the part of sellers and buyers alike.

Managers at real estate agencies say that the only way to minimize misunderstandings is to train new agents to be highly professional and to establish and enforce industry standards. To that end, the Real Estate Board of New York has established a list of 17 resolutions aimed at addressing ethical questions in residential real estate.

The resolutions cover issues as basic as the definition of an “exclusive” and the need to have backup brokers available when the exclusive broker is not available. They also try to cut down on typical broker squabbles by declaring it improper to foist a business card on someone else’s client and asserting that brokers should give co-brokers and their customers at least 20 minutes’ grace time if they’re late for an appointment.

Diane Ramirez, the president of Halstead Property and a governor of the real estate board, said, “Some of these things may seem silly, but it creates a framework of proper decorum.”

The board and its policies have evolved to make it clearer that “we are an industry that works for our sellers and buyers, and that should be our primary goal,” Ms. Ramirez said. “That’s the only way to dispel the distrust that comes in, not because it’s earned but because of what our reputation may have been.”

The real estate board also has an ethics committee that handles complaints filed by brokers against other brokers. Stephen Kliegerman, Halstead’s executive director for development marketing and a former chairman of the ethics committee, said the committee handles only a handful of cases each year, but he added that most complaints do not get to the board because agency managers tend to resolve complaints among themselves.

One of the biggest current complaints involves brokers who post listings on their Web sites for the exclusive properties of other brokers. “They’ll advertise a property they don’t represent, or sometimes the property doesn’t even exist,” Mr. Kliegerman said. “So when the buyer calls, it’s a bait-and-switch — the broker knows nothing about the property and winds up trying to take them to something completely different.”

He said the ethics committee is developing a new resolution to deal with the problem. “This kind of thing happens daily, and it taints the consumer’s impression of the entire broker community,” he said.

Consumers can file complaints about real estate agents with the Department of State in New York, the Real Estate Commission in New Jersey and the Department of Consumer Protection in Connecticut.

The New York Department of State can punish agents for infractions ranging from practicing without a license to a catchall category labeled “untrustworthiness and incompetency.” The latter can include things like lying about the school district for a particular address or misleading a buyer about future development in the area.

If the number of complaints filed in New York in recent years is any indication, brokers may actually be becoming more trustworthy. From 2001 to 2005, the last year with complete statistics, the annual number of complaints declined from 1,589 to 1,176.

The complaint category that showed the sharpest drop and that accounts for most of the decline was in “agency disclosure,” indicating that real estate agents have gotten better at disclosing whether they are a seller’s broker or buyer’s broker and what that means in terms of where their loyalty lies.

Of the completed cases from 2005, 109 real estate agents were fined, 3 had their licenses suspended, and 14 had their licenses revoked. Fines can run as high as $1,000, and suspension periods are determined on a case-by-case basis.

But most ethical breaches probably never reach either the real estate board or the Department of State. Ms. Rothman of Bellmarc recalled a case in which she represented a buyer who made an all-cash, full-price offer on an apartment, only to have the seller’s agent stall and falsely claim that the sellers wanted time to consider the offer.

“I later found out that he was waiting for a customer of his own to make an offer and he never even told the sellers about my offer,” she said. She filed a complaint with the other agent’s manager, and her buyers eventually got the apartment.

When training new agents, larger real estate companies stress the need for proper broker etiquette, both with clients and with other brokers.

Vasco Da Silva, the director of sales at Halstead’s Riverdale office, says Halstead’s broker boot camp tells agents when they should keep their business cards in their pockets, advises them to turn off cellphones while showing an apartment and instructs them never to talk about an apartment inside an elevator if there are other people around.

“We go through a logical step-by-step process, and it’s all about winning a customer’s loyalty and trust,” he said. “You don’t get it with your first meeting, so what you have to do is win your customers over with service and with confidence in your ability.”

In its training, Bellmarc urges new agents to be as straightforward as possible and to avoid pushing an apartment on a reluctant customer. “If someone doesn’t want an apartment, you don’t want to try to talk them into it,” said Janice Silver, an executive vice president at Bellmarc. “You can’t say, ‘But it’s fabulous — here’s why you should buy it.’ ”

Instead, she trains agents to ask simple questions like: Do you like this apartment? Can you see yourself living here? Do you want to buy this?

“Don’t be pushy, but be very direct,” she said. “Because if they don’t like the apartment, you should move on and not waste everybody’s time.”

Some brokers say their colleagues should not try to hide a property’s blemishes. Jill Sloane, a senior vice president at Halstead who is Ms. Mizrahi’s new broker, said she once represented a seller whose apartment came with a 33 percent flip tax, and she made a point of including that in her advertising materials.

“There was no point in hiding something like that because buyers would eventually find out about it anyway,” she said. “It’s just not worth the damage it would do to your reputation to be deceptive.”

Patricia Warburg Cliff, a senior vice president of the Corcoran Group, agreed. “If I know that there’s a bus that idles under the living room window, I have to get it out first thing,” she said. “Because if a buyer finds out about it midway into a transaction, you have egg all over your face, and the seller isn’t served because they’re not out to swindle someone.”

Sometimes, even when a transaction provides a happy ending for everyone, a buyer can still be left with lingering doubts about the broker and his or her motives.

Take Rob and Lauren Mank, who are now happily living in an Upper West Side apartment they bought last year. Mr. Mank said they had no qualms about their agent, a buyers’ broker, until final negotiations, when she pushed them to offer the full asking price, which would have meant raising their bid by $45,000. They ultimately went up by $35,000 and got the apartment because two competing buyers did not raise their bids.

“I felt like it was very high pressure and her loyalty to us was compromised by her desire to do the deal,” he said. “It left us with a bad taste.”

But Ms. Mank said she didn’t believe there was any malice involved and noted that without a crystal ball, there is no way of knowing if they could have gotten the apartment for less.

“Maybe you’re always going to want to blame someone for some infraction because you’re always going to feel taken advantage of in some way,” she said. “It’s a delicate and intimate situation because it’s your home and it’s your finances — the whole thing is just so fraught.”

¶ Friday, January 26, 2007 0 comments

A Word From Our Sponsor

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WHEN Clinique made its debut in 1968, the cosmetics brand altered America’s beauty landscape by using scientific language and clinical iconography at a time when highly perfumed, elaborately packaged creams dominated department stores.

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Forum: Fashion and Style

Fred R. Conrad/The New York Times

WHAT’S IN A NAME? Dr. Richard D. Granstein, chairman of the dermatology department at Weill Cornell, which has received financing from Clinique and an anonymous donor to build a skin wellness center.

Clinique hired a prominent dermatologist, Dr. Norman Orentreich of Manhattan, to help develop the line. It outfitted its sales force in pristine white lab coats and installed them at cosmetics counters where they diagnosed the skin types of customers. Even its name carried a clinical aura.

But now Clinique has gone one step further in aligning itself with therapeutic imagery — and in the process has raised the ante for beauty companies seeking affiliations with doctors.

Officials today are scheduled to open the new Clinique Skin Wellness Center at Weill Medical College of Cornell University in Manhattan. The project, financed by a $4.75 million donation from Clinique along with $2.25 million from an anonymous donor, involves medical research and the construction of a clinic within the dermatology department of the medical school.

At the clinic, made up of examination rooms and a workstation, doctors will conduct skin examinations, with a particular focus on educating patients on how to prevent skin cancer and maintain skin health. Patients at the center may also make on-site appointments with Clinique representatives to learn about makeup that can cover skin redness or facial scars.

But critics said the sponsorship is the clearest example yet of what they see as the blurring of lines between medicine and the beauty industry.

At a time when some doctors in private practice can earn six-figure consultancy fees from the makers of facial injections or wrinkle creams, Weill Cornell’s alliance with a cosmetics firm, critics say, has the potential to further diminish the stature of academic medicine as an unbiased authority and give the impression that dermatology is for sale to the highest bidder.

“I think the image of our specialty is particularly tarnished by myriad physicians hawking their own eponymous skin-care products and by academic departments appearing to sell their names to beauty companies,” said Dr. Amy E. Newburger, a dermatologist in Scarsdale, N.Y. In an editorial last month in the Archives of Dermatology, Dr. Newburger and Arthur L. Caplan, chairman of the medical ethics department at the University of Pennsylvania, warned medical schools away from alliances with beauty companies.

“Is dermatology for sale? Well, yes,” Dr. Newburger said.

Dermatology is not the only field struggling with commercial interests. In a climate of reduced federal financing for basic research and fixed fees imposed by managed care for services, medical institutions and individual doctors are increasingly looking to industry sponsorship.

Pharmaceutical companies regularly pay for research on diseases that can be treated by their own products, with the studies frequently published in influential medical journals. Doctors whose research has been sponsored by industry or who are consultants to companies regularly lecture on these studies at national medical meetings. Drug company representatives routinely visit doctors’ offices, handing out free drug samples and providing meals to staff members.

Dr. Jeffrey J. Meffert, a dermatologist in San Antonio who exposes the methods by which companies try to sway doctors, said that some medical schools have prohibited drug representatives from visiting their campuses or providing speakers for hospital grand rounds to try to curb the influence of industry.

BUT potential conflicts of interest seem particularly troubling in dermatology, where doctors can make a seven-figure income by performing expensive — and entirely elective — cosmetic treatments, which are often paid for out of pocket because they are not covered by insurance. Some dermatologists also conduct research for companies or have lucrative contracts as consultants for drug, device or cosmetics companies.

The question of the relationship between medicine and the beauty industry came to the forefront last year when researchers affiliated with Johns Hopkins Medicine signed a contract to vet a new skin-care brand. The researchers were to review studies of a skin-care line called Cosmedicine, produced by Klinger Advanced Aesthetics, and the institution was to receive company stock. Signs posted in Sephora stores touted the relationship with Hopkins.

But after articles about the deal appeared in newspapers, the medical school gave up its equity position in Klinger. (Though doctors associated with Johns Hopkins Medicine have also helped the company design model cosmetic medical offices in malls in Dallas and Chevy Chase, Md., where nurse practitioners treat patients.)

There are reasons that beauty companies might seek an alliance with a medical institution or with doctors. Americans spent about $7.8 billion last year on skin-care products, according to Euromonitor International, a market research firm. In such a competitive market, cosmetics companies like to ally with doctors and medical schools because such relationships can infuse a brand with an aura of scientific credibility.

In the last decade, nearly two dozen dermatologist skin-care brands have appeared in stores. And established brands like Lancôme, Dior and Prescriptives have hired dermatologists as consultants.

Clinique, which created the quasi-scientific image, is now the best-selling prestige skin-care brand in the country, according to statistics from Euromonitor.

Lynne Greene, global president of Clinique, said the company’s new relationship with Weill Cornell should further enhance the brand’s image.

“At Clinique, we see ourselves as the last stop before the dermatologist and the first stop after the dermatologist,” Ms. Greene said. “The Weill Cornell partnership emphasizes our position as the skin-care authority.”

But Dr. Richard D. Granstein, chairman of the dermatology department at Weill Cornell, distinguished the medical school’s relationship with Clinique from other academic-cosmetic partnerships. Weill Cornell will not research cosmetics, test cosmetics, vet cosmetics, sell cosmetics or allow its name to be used in product promotion, he said. The center, he said, is merely a “naming opportunity” for Clinique.

“We are not in the beauty business,” said Dr. Granstein, who is receiving research financing from Clinique. “You are not going to walk into a Sephora and see a sign that says ‘Weill Cornell,’ or I’d resign.”

Clinique is giving a five-year grant to the medical school that covers research and the construction of the dermatology clinic.

One project involves research to investigate how stress can affect the skin’s immune system, making it vulnerable to everything from skin cancer to allergies. Clinique has also endowed a research fellow to be known as the Clinique Clinical Scholar; the first recipient, Dr. John A. Carucci, studies genetic changes linked to skin cancer. In addition, the company will also sponsor an annual scientific conference and public lectures on topics like skin cancer and skin maintenance.

But the most visible aspect of the arrangement is the Clinique Skin Wellness Center, a unit of the medical school’s dermatology department. There, doctors will conduct skin exams and advise patients about preventive skin care. Clinique representatives will also be available to offer suggestions on how to camouflage skin conditions or post-treatment inflammation.

“If you are 22 and you want to know what you can do to prevent skin cancer, or you want to avoid looking like your mom whose sun damage makes her look 80 even though she is only 50, we now have a center to deal with that,” Dr. Granstein said.

Ms. Greene said that Clinique initially plans to hold monthly office hours at the center. If there is sufficient demand, Clinique representatives could potentially visit the center weekly, with up to 500 patient consultations a year, she said.

She said the company’s consultants will offer general suggestions on products like gentle cleansers or sunscreens, but not recommend specific products by name. The company will also distribute its own educational brochures — with titles like “Can a tan signal DNA damage?” and “Is a wrinkle a wound?” — which discuss skin care in layman’s terms, she said.

“There is a chance here to be really helpful to patients,” said Dr. Granstein, recalling a recent patient who was so embarrassed about burns on her leg that she had stopped wearing skirts until she learned about camouflage makeup. “I don’t care if they go buy the Clinique whatever-it-is or the L’Oréal whatever-it-is.”

But critics said that, even without on-site cosmetics sales or specific product recommendations, the arrangement would appear to patients as an endorsement of the beauty industry. It is believed to be the first time that a cosmetics firm has branded a medical researcher and a skin-care center at a medical school and also the first time that a medical school has set up an on-site program allowing a beauty firm access to patients.

Dr. Caplan said that cosmetics, which are defined by the Food and Drug Administration as products that do not fundamentally alter the skin, have no place in mainstream medicine. He added that patients would interpret the Clinique sign, beauty advisers and brochures as the medical school’s seal of approval for the brand.

“With that kind of Clinique billboarding, you have totally left the realm of neutral medical provision and decided to open a beauty parlor on your premises,” Dr. Caplan said.

Dr. Newburger said that such a setup could also unconsciously bias doctors and affect patient care. In the absence of other competing brands, the presence of Clinique could lead dermatology residents to familiarize themselves with fewer products or to delegate post-treatment recommendations to beauty advisers, she said. She added that patients would be vulnerable to the incidental marketing.

“When a patient sees a doctor in a private setting, the patient expects the individual doctor to have a profit motive,” Dr. Newburger said. “But you don’t expect it when you go to a medical school, a place which is supposed to be above the fray and not involved with one company or another.”

Dr. Granstein called relationships with beauty companies a “slippery slope” for medicine. But he said that beauty was not a new territory for medical schools because dermatology inherently involves a patient’s appearance. Acne and psoriasis, for example, are “essentially cosmetic diseases,” he said.

“I recognize the potential for conflict here, especially in having someone give advice to a patient,” Dr. Granstein said. “If it turns out that we can’t do it right, then we won’t do it.”

¶ Friday, January 26, 2007 0 comments

Plain Cellphones Can Overachieve, With a Little Help

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IF you have an ordinary cellphone — the type that you got free, or cheaply, when you signed up for service — you might envy those with phones that are also personal digital assistants, like BlackBerrys, Treos, Sidekicks and Windows smartphones.

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Illustration by Alex Eben Meyer

Those devices, typically costing $200 to $400, let you do more than just make phone calls and take pictures. They are pocket-size computers equipped for many functions, including e-mail, Web browsing and contact management, note taking, financial recordkeeping and a calendar.

But as it turns out, that humble cellphone in your pocket may be able to do all this and more, depending on its built-in features and the available add-on software.

The screen may be a bit smaller than on a palmtop, and you will lack an alphanumeric keyboard, making typing a lot harder — but as anyone who has sent text messages or entered names into their phone’s address book knows, you can peck out letters using the numeric keypad.

Cellphone manufacturers, carriers and independent application providers are now offering lots of programs and services that can be used on a wide number of phones. Not all services work on all phones. Some are carrier-specific, and some work only on certain phones.

Many require that the phone be able to handle programs written in Java (most new ones are). Some services are free; others charge a monthly fee.

There are a variety of ways to get these applications, and you probably already have some. In addition to Bluetooth and a camera, the Nokia 6102i, effectively free after a rebate from Cingular Wireless, comes with software applications including an audio recorder, an alarm clock, a calendar, a to-do list, a note taker, a calculator, a countdown timer and a stopwatch. It also has AOL, Yahoo, ICQ and MSN instant messengers, a text messaging program, an FM radio, e-mail and, of course, an Internet browser.

And all of this is before you download any applications over the wireless network from the Cingular Mall, where you can buy games, ring tones, graphics and other applications.

Sprint’s Samsung M500, available for as little as $9.99 after rebate, has a comparable list of built-in features, along with a dictionary and the ability to store files and play music. Like more expensive hand-helds, it comes with a U.S.B. cable to sync with a PC and a 64-megabyte microSD card (for about $30 you can buy a one-gigabyte card) to store MP3 files that you can play on the phone.

It can even display an analog clock, but the real power of this and many other phones is the applications you can buy and download.

Some of the productivity programs that can be downloaded from Sprint are RandMcNally StreetFinder, MapQuest Mobile, Vindigo City Guide, Zagat restaurant guide and FlyteSource Mobile, which gives real-time flight status. These or similar services are also available on phones from other carriers.

All cellular carriers offer some type of e-mail service, sometimes for an extra fee. But consumers have choices. In addition to the carrier’s services, there are free third-party services you can use, including Yahoo Mail, Gmail and Flurry.

Before using any of these services or downloading any applications, check to see what, if anything, it will cost. Even if the application is free, there may be data or air-time charges from your carrier, and there may be plans that can reduce those charges.

Flurry, a free service that works with several carriers, is both an e-mail application and an R.S.S. (for Really Simple Syndication) news reader, which you can use to subscribe to frequently updated content. You start by visiting www.flurry.com from your PC and entering your cellphone number, carrier name, e-mail address and password, and any R.S.S. feeds you wish to subscribe to. The service then sends a text message to your phone with a link for downloading the program.

The service works with most publicly available e-mail accounts, the company’s chief executive, Sean Byrnes, said. It can also import up to 430 contacts from Outlook, Gmail and any other program or service that can export standard comma separated values, or CSV, files. You can also dial a phone number from that contact list.

Google recently started offering a free cellphone version of its popular Gmail service. If you have signed up for a Gmail account, you can download the application by pointing your cellphone browser to gmail.com/app. You enter your Gmail user name and password, and a few minutes later you are reading your mail. You can also compose and respond to mail and bring up your Gmail contact list.

Yahoo is conducting a public beta test of its free Go 2.0 service, which has numerous applications, including a phone-centric Internet search tool. You tell it where you are (a satellite-based locator will be available later) and it can find nearby restaurants, movie show times, stores and services and display a map to your destination. Because it is a downloaded application (at mobile.yahoo.com), it is faster than using a Web page, but it can also link you to Web pages through your phone’s browser.

Yahoo Go also gives you access to Yahoo e-mail synchronized with your Web account. Mail is searchable, and you can display JPEG graphic files. You can track your stock portfolio, follow sports teams and get weather reports. You can also connect to a Flickr photo account to see or share photos from the road. Yahoo Go works with a limited number of phones from Cingular, Sprint, T-Mobile, Verizon, Alltel, Telus and Rogers.

You’re not going to find Microsoft Outlook on a run-of-the-mill cellphone. But with SoonR, a free application (at www.soonr.com) that runs in your cellphone’s browser, you can use your phone to gain access to data from Outlook and other programs running on a PC or Mac.

You can view thumbnails of Word and Excel files, and Windows users can read, respond, compose and send Outlook e-mail. You can make calls from your Outlook contact list and consult and update Outlook’s calendar. The files and programs are not on the phone — you are using the phone for remote access to your home or office computer, and any changes you make on the phone show up on the PC.

You can remotely use most popular PC and Mac desktop search programs and forward files through your computer’s broadband connection. You can even run the Internet phone service Skype on your PC from your cellphone.

Many of today’s phones make use of the satellite-based Global Positioning System, mainly to help responders find you in an emergency, but the technology can also be tapped for location-based services, like turning your phone into a portable navigation device with turn-by-turn maps and audible directions through the phone’s speaker.

I test-drove both the TeleNav service, which works with select phones from most carriers, and Verizon’s VZ Navigator. Both are $10 a month. VZ Navigator can also be bought for $2.99 a day. Both use the phone network to provide directions, maps and points of interest that are updated on an ongoing basis. They have a “points of interest” database with millions of listings. TeleNav also has a “gas by price” feature that taps into an online database of gas station prices to lead you to the cheapest gas in your area.

So instead of lusting over that palmtop or Apple’s highly anticipated iPhone, reach into your pocket and see what that phone of yours has to offer. You might just be carrying around a poor man’s BlackBerry — minus the keyboard.

¶ Thursday, January 25, 2007 0 comments

Faith in Quick Test Leads to Epidemic That Wasn’t

Jon Gilbert Fox for The New York Times

Dr. Brooke Herndon of Dartmouth-Hitchcock Medical Center, shown at left this month, was told last spring that she appeared to have whooping cough.

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Dr. Brooke Herndon, an internist at Dartmouth-Hitchcock Medical Center, could not stop coughing. For two weeks starting in mid-April last year, she coughed, seemingly nonstop, followed by another week when she coughed sporadically, annoying, she said, everyone who worked with her.

Before long, Dr. Kathryn Kirkland, an infectious disease specialist at Dartmouth, had a chilling thought: Could she be seeing the start of a whooping cough epidemic? By late April, other health care workers at the hospital were coughing, and severe, intractable coughing is a whooping cough hallmark. And if it was whooping cough, the epidemic had to be contained immediately because the disease could be deadly to babies in the hospital and could lead to pneumonia in the frail and vulnerable adult patients there.

It was the start of a bizarre episode at the medical center: the story of the epidemic that wasn’t.

For months, nearly everyone involved thought the medical center had had a huge whooping cough outbreak, with extensive ramifications. Nearly 1,000 health care workers at the hospital in Lebanon, N.H., were given a preliminary test and furloughed from work until their results were in; 142 people, including Dr. Herndon, were told they appeared to have the disease; and thousands were given antibiotics and a vaccine for protection. Hospital beds were taken out of commission, including some in intensive care.

Then, about eight months later, health care workers were dumbfounded to receive an e-mail message from the hospital administration informing them that the whole thing was a false alarm.

Not a single case of whooping cough was confirmed with the definitive test, growing the bacterium, Bordetella pertussis, in the laboratory. Instead, it appears the health care workers probably were afflicted with ordinary respiratory diseases like the common cold.

Now, as they look back on the episode, epidemiologists and infectious disease specialists say the problem was that they placed too much faith in a quick and highly sensitive molecular test that led them astray.

Infectious disease experts say such tests are coming into increasing use and may be the only way to get a quick answer in diagnosing diseases like whooping cough, Legionnaire’s, bird flu, tuberculosis and SARS, and deciding whether an epidemic is under way.

There are no national data on pseudo-epidemics caused by an overreliance on such molecular tests, said Dr. Trish M. Perl, an epidemiologist at Johns Hopkins and past president of the Society of Health Care Epidemiologists of America. But, she said, pseudo-epidemics happen all the time. The Dartmouth case may have been one the largest, but it was by no means an exception, she said.

There was a similar whooping cough scare at Children’s Hospital in Boston last fall that involved 36 adults and 2 children. Definitive tests, though, did not find pertussis.

“It’s a problem; we know it’s a problem,” Dr. Perl said. “My guess is that what happened at Dartmouth is going to become more common.”

Many of the new molecular tests are quick but technically demanding, and each laboratory may do them in its own way. These tests, called “home brews,” are not commercially available, and there are no good estimates of their error rates. But their very sensitivity makes false positives likely, and when hundreds or thousands of people are tested, as occurred at Dartmouth, false positives can make it seem like there is an epidemic.

“You’re in a little bit of no man’s land,” with the new molecular tests, said Dr. Mark Perkins, an infectious disease specialist and chief scientific officer at the Foundation for Innovative New Diagnostics, a nonprofit foundation supported by the Bill and Melinda Gates Foundation. “All bets are off on exact performance.”

Of course, that leads to the question of why rely on them at all. “At face value, obviously they shouldn’t be doing it,” Dr. Perl said. But, she said, often when answers are needed and an organism like the pertussis bacterium is finicky and hard to grow in a laboratory, “you don’t have great options.”

Waiting to see if the bacteria grow can take weeks, but the quick molecular test can be wrong. “It’s almost like you’re trying to pick the least of two evils,” Dr. Perl said.

At Dartmouth the decision was to use a test, P.C.R., for polymerase chain reaction. It is a molecular test that, until recently, was confined to molecular biology laboratories.

“That’s kind of what’s happening,” said Dr. Kathryn Edwards, an infectious disease specialist and professor of pediatrics at Vanderbilt University. “That’s the reality out there. We are trying to figure out how to use methods that have been the purview of bench scientists.”

The Dartmouth whooping cough story shows what can ensue.

To say the episode was disruptive was an understatement, said Dr. Elizabeth Talbot, deputy state epidemiologist for the New Hampshire Department of Health and Human Services.

“You cannot imagine,” Dr. Talbot said. “I had a feeling at the time that this gave us a shadow of a hint of what it might be like during a pandemic flu epidemic.”

Yet, epidemiologists say, one of the most troubling aspects of the pseudo-epidemic is that all the decisions seemed so sensible at the time.

Dr. Katrina Kretsinger, a medical epidemiologist at the federal Centers for Disease Control and Prevention, who worked on the case along with her colleague Dr. Manisha Patel, does not fault the Dartmouth doctors.

“The issue was not that they overreacted or did anything inappropriate at all,” Dr. Kretsinger said. Instead, it is that there is often is no way to decide early on whether an epidemic is under way.

Before the 1940s when a pertussis vaccine for children was introduced, whooping cough was a leading cause of death in young children. The vaccine led to an 80 percent drop in the disease’s incidence, but did not completely eliminate it. That is because the vaccine’s effectiveness wanes after about a decade, and although there is now a new vaccine for adolescents and adults, it is only starting to come into use. Whooping cough, Dr. Kretsinger said, is still a concern.

The disease got its name from its most salient feature: Patients may cough and cough and cough until they have to gasp for breath, making a sound like a whoop. The coughing can last so long that one of the common names for whooping cough was the 100-day cough, Dr. Talbot said.

But neither coughing long and hard nor even whooping is unique to pertussis infections, and many people with whooping cough have symptoms that like those of common cold: a runny nose or an ordinary cough.

“Almost everything about the clinical presentation of pertussis, especially early pertussis, is not very specific,” Dr. Kirkland said.

That was the first problem in deciding whether there was an epidemic at Dartmouth.

The second was with P.C.R., the quick test to diagnose the disease, Dr. Kretsinger said.

With pertussis, she said, “there are probably 100 different P.C.R. protocols and methods being used throughout the country,” and it is unclear how often any of them are accurate. “We have had a number of outbreaks where we believe that despite the presence of P.C.R.-positive results, the disease was not pertussis,” Dr. Kretsinger added.

At Dartmouth, when the first suspect pertussis cases emerged and the P.C.R. test showed pertussis, doctors believed it. The results seem completely consistent with the patients’ symptoms.

“That’s how the whole thing got started,” Dr. Kirkland said. Then the doctors decided to test people who did not have severe coughing.

“Because we had cases we thought were pertussis and because we had vulnerable patients at the hospital, we lowered our threshold,” she said. Anyone who had a cough got a P.C.R. test, and so did anyone with a runny nose who worked with high-risk patients like infants.

“That’s how we ended up with 134 suspect cases,” Dr. Kirkland said. And that, she added, was why 1,445 health care workers ended up taking antibiotics and 4,524 health care workers at the hospital, or 72 percent of all the health care workers there, were immunized against whooping cough in a matter of days.

“If we had stopped there, I think we all would have agreed that we had had an outbreak of pertussis and that we had controlled it,” Dr. Kirkland said.

But epidemiologists at the hospital and working for the States of New Hampshire and Vermont decided to take extra steps to confirm that what they were seeing really was pertussis.

The Dartmouth doctors sent samples from 27 patients they thought had pertussis to the state health departments and the Centers for Disease Control. There, scientists tried to grow the bacteria, a process that can take weeks. Finally, they had their answer: There was no pertussis in any of the samples.

“We thought, Well, that’s odd,” Dr. Kirkland said. “Maybe it’s the timing of the culturing, maybe it’s a transport problem. Why don’t we try serological testing? Certainly, after a pertussis infection, a person should develop antibodies to the bacteria.”

They could only get suitable blood samples from 39 patients — the others had gotten the vaccine which itself elicits pertussis antibodies. But when the Centers for Disease Control tested those 39 samples, its scientists reported that only one showed increases in antibody levels indicative of pertussis.

The disease center did additional tests too, including molecular tests to look for features of the pertussis bacteria. Its scientists also did additional P.C.R. tests on samples from 116 of the 134 people who were thought to have whooping cough. Only one P.C.R. was positive, but other tests did not show that that person was infected with pertussis bacteria. The disease center also interviewed patients in depth to see what their symptoms were and how they evolved.

“It was going on for months,” Dr. Kirkland said. But in the end, the conclusion was clear: There was no pertussis epidemic.

“We were all somewhat surprised,” Dr. Kirkland said, “and we were left in a very frustrating situation about what to do when the next outbreak comes.”

Dr. Cathy A. Petti, an infectious disease specialist at the University of Utah, said the story had one clear lesson.

“The big message is that every lab is vulnerable to having false positives,” Dr. Petti said. “No single test result is absolute and that is even more important with a test result based on P.C.R.”

As for Dr. Herndon, though, she now knows she is off the hook.

“I thought I might have caused the epidemic,” she said.

¶ Tuesday, January 23, 2007 0 comments