Well: Living With Cancer: Life of the Party

Living With Cancer

Susan Gubar writes about life with ovarian cancer.

The prospect of a party frightened me — probably because the enforced isolation of cancer treatments has rendered me hypersensitive. It was raining outside and festivities would not begin until after 8 p.m. But my husband and I had promised to attend the celebration of a book publication. So we dragged ourselves to Judith and Aidan's house where I hoped to find a comfortable chair in which I would not look like the battle-ax at Mrs. Dalloway's party whom everyone had thought long dead.

The house, crowded with people clutching drinks, pulsed with their robust vitality. Before the cancer diagnosis, I would have moved around the room schmoozing with a series of acquaintances while getting a tad tipsy. Now I was determined to have a drink, but I would need to sit down, and I could not control who might sit with me or indeed whether anyone would. Still, sit I had to do while dealing with a hideous mix of nostalgia, jealousy and self-pity. Exhausted by five years of surgeries and drugs, I have spent too much time alone and have nothing to exchange in return for tidbits of gossip.

My colleagues, kind people, took turns as sitters. Unfortunately, the atmosphere of jollity only underscored my worries: fears that thinning hair would not hide my scalp, qualms about not recalling the names of graduate students I recognized but could not place. The cumulative effect of treatment also left me bereft of the prevarications and censors that ease everyday interactions. The membrane between internal feelings and external expressions (on which I used to rely) has worn thin.

I have neither the time nor the energy to maintain buffers between me and the limited world I inhabit. Cancer has made me porous and susceptible to others — those I know personally, and those I do not. A friend in mourning, or runners and spectators maimed in Boston, reduce me to tears. Have other patients experienced this permeable sense of self when the barrier between the person we present in public and our private sentiments erodes? With few filters, I really do not belong in polite society.

Just when I decided to give my husband a signal for us to up and leave, two guests started to sing in a corner of the room. I settled down, pleased at not having to make chitchat with my current sitter, a very young woman with a crew cut. A succession of musicians followed, producing that vivid vibrancy only live music in an intimate space can create. By the time Jason Fickel stood up to sing, accompanying himself on his acoustic guitar, my exhilaration knew no bounds.

Live music should not be reserved for memorials. Musicians ought to be allowed to play in infusion centers, hospital rooms and hospices. Or so I think as my body feels sprayed and bathed, plumped and pumped by the rhythms of a melody that comes from Jason's mouth and hands but courses through me like currents of energy.

The wine helps, undoubtedly, but it is the thrumming strings and the wry yet sonorous voice that delight me, galvanizing my attention and quickening my spirits. I sense the vibrations on my skin, in my bones, massaging the synapses of my brain: "music, sweet music, music everywhere." Let there be trombones and guitars, flutes and pianos, singing and, especially, cellos for the sick and the dying. During my mother's last months in assisted care, she would have loved to have heard a string quartet: harmonies returning her to pleasures displaced by old age and disease.

Awash and exultant as the music ends, I recall a line of poetry — "we feel that we are greater than we know"— and turn to the girl on my right. I did not remember her because, apparently, I had never met her before. But, she explained carefully, she works out with a member of my cancer support group … in a special class. A beat, a pause, and I understand.

The crew cut has to do with cancer. I shake her hand to wish her well. Her fingers are icy. A surge urges me on: the need, the palpable urgency, to pay tribute to her resolute stamina. I clasp both her frozen hands and kiss them, overwhelmed that someone so young has had to go through what she has gone through, though I scold myself too, for these eruptions of extravagant emotion are sure to make me look like a fool.

By the time Don and I got home, I realized that there are liabilities but also benefits of being thin-skinned. At the party I had felt the beauty, felt the fun. Lucky, lucky, lucky, I thought as I drifted off to sleep.

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Well: Ask Well: Stairs and Knee Pain

A

If it's any comfort, you have company. Most people with knee arthritis — meaning some degeneration of the cushioning cartilage in the joint — experience pain when they go down stairs, even if their arthritis is otherwise mild, said Dr. Kevin J. Bozic, an orthopedic surgeon at the University of California, San Francisco. More so than climbing stairs, descending them places great force on the knee and, in particular, the patello-femoral joint, the portion of the knee beneath the kneecap, he said.

This discomfort is magnified if you have weak quadriceps or thigh muscles, he added, since the force that might otherwise be absorbed by those large muscles moves through the knee instead. So to strengthen your quadriceps, try straight leg raises, Dr. Bozic said. Simply lie on your back with one leg bent. Lift the other leg, straightened, at least six inches off the ground; tighten the thigh muscles and hold for a few seconds. Lower and repeat several times. Then do the same exercise with the other leg. Your physician or an athletic trainer can suggest other safe exercises that target those muscles.

Avoid prolonged sitting, too, said Dr. Freddie H. Fu, a professor and chair of orthopedic surgery at the University of Pittsburgh Schools of the Health Sciences, since uninterrupted sitting leads to stiffness that aggravates the pain of going down stairs.

And if all else fails, turn around, Dr. Bozic said. "Descending stairs backwards reduces loads across the knee joint," he said. According to a 2010 motion-capture study, the forces generated when descending backward migrated toward the hip rather than the knee when people go backward. "Just don't fall down," Dr. Bozic warned.

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18 and Under: A Taste of My Own Manners

18 and Under

Dr. Perri Klass on family health.

When I started my internship, in 1986, I was given a beeper, which was handed over with a certain sense of ceremony and a certain yoke of obligation. Before cellphones were omnipresent, the beeper was a badge of professional importance: I'm a doctor — life and death depend on my instant availability.

If you were talking to a patient and your beeper went off, it was understood to be a medical summons; you were entitled — and expected — to step out of the room and answer. As I went through residency and began practicing, I would never have thought of silencing my beeper when I was seeing a patient, even though I was often paged about things that were not of immediate life-or-death importance. ("Mom, I couldn't find my social studies project this morning. Did you put it somewhere?")

Nowadays, every patient I see is just as reachable in the exam room as I am, and my reactions to their behavior with their cellphones has made me question my own attitudes toward monitoring messages and tolerating interruptions.

I asked Judith Martin, who writes the Miss Manners books and columns, what the etiquette considerations are here, and she let me know in no uncertain terms that doctors themselves traded on their greater prestige in the doctor-patient relationship to create a culture that allowed rudeness — and that rudeness is now being returned.

"We are reaping the punishment of doctors having used these manners when patients could not," she said.

It's not just doctors, of course; it's a problem outside medical settings as well, she said, with "people keeping one another waiting, ignoring those who are present in favor of taking phone calls." Now everyone has the equivalent of a beeper, and everyone answers because, after all, it might be an emergency.

In the exam room, patients routinely take calls, or at least glance at their phones. And adolescents, needless to say, can go on texting even as they're answering a doctor's questions.

Manners, morals and medicine intersect in the doctor's office, in a quotidian interplay of patient imperatives and medical management, politeness and professionalism, patients and patience.

What are the ethics of keeping one another waiting?

"These issues are hugely important to patient satisfaction, to patient compliance, to patient trust, and to physician peace of mind, or a physician's positive attitude about work and environment," said Arthur L. Caplan, director of the bioethics division at NYU Langone Medical Center. "But ethicists spend almost no time thinking about them."

I am not a particularly patient patient, and recently, when I went with my mother to the eye doctor, I found myself getting pretty cranky in the waiting room. After all, we had made the first morning appointment, gotten ourselves out of bed and out into the cold and across town for a 7:30 time slot.

Was it possible, I wondered irritably, that the doctor hadn't even arrived yet? And I went back to the clinic desk to ask once again, in a polite but clearly provocative way, if they knew how much longer it would be.

But here is my confession: That agonizing sense of the minutes ticking past, that outraged feeling of cosmic unfairness when an early appointment is not matched by a prompt consummation, it all falls away when I'm on the other side of that clinic desk.

Later that very same day, getting ready for my next patient, it made complete sense to me that first I had to read through the child's medical record on screen — and then, yes, check my messages quickly, and then stand in the hallway and speak to a colleague for a little while — all with the patient and her mother (and the next patient and his mother) sitting in the waiting room and, well, waiting.

And keeping children waiting is even more inexcusable than keeping adults waiting; children are not suited for waiting.

The truth is, I was in the doctor's time zone. And I had a feeling of hard-working entitlement that coexisted remarkably easily with the very recent memory of my own sense of outrage at being made to wait.

Later that day, while I was asking a 10-year-old girl some questions about her health, her mother's cellphone rang, with one of those loud, intrusive musical ringtones. I was neither surprised nor outraged when the mother reached into her bag, pulled out the phone and started chatting. But I suspended my conversation with the child and stared questioningly at the mother until she said, "I can't talk now, we're with the doctor," and hung up.

But the calls to my phone, as important as they may be to me, are not actually life-or-death patient issues, and I, too, need to turn it off.

Dr. Caplan pointed out that part of providing good and professional medical care is treating people properly: "How do I cement trust in this relationship? How do we show respect for one another in a health care relationship where respect is partially an intrinsic good but also important for securing cooperation, compliance, continuity of care?"

Sometimes cementing trust and showing respect actually means sitting quietly while a parent takes a phone call and arranges, for example, the pickup that will get her home after that too-long wait in the exam room. Good manners, and good morals, actually depend on getting outside the doctor's time zone and crossing over to where everyone else lives.

A version of this article appears in print on 01/21/2014, on page D4 of the NewYork edition with the headline: A Taste of My Own Manners.

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The New Old Age: When They Don’t Know They Are Ill

Soon after his wife was diagnosed with frontotemporal dementia, Bill Floyd consulted a neurologist who had been a member of his church. People with this illness don't know they have it, the doctor warned. They don't understand that anything is wrong.

This little-known yet common consequence of this kind of dementia, Alzheimer's disease and other brain disorders is called anosognosia, and it leaves people unaware that they are compromised by illness.

Imagine someone who survives a stroke and is paralyzed on the left side of his body, but is convinced he can walk without assistance. A less extreme example: Someone with moderate memory deficiency gets lost on the road or has accidents, but thinks she is driving just as well as ever.

This is not denial, said Sandra Weintraub, a professor of psychiatry and neurology at Northwestern University. "It's a lack of insight and awareness," she said. "Everyone else around them is aware they're not the same, and they are not."

Sometimes anosognosia is selective: An aging parent may realize she has a problem with one kind of activity but is oblivious to other difficulties. But in other cases, the lack of self-awareness is more extensive. According to some estimates, up to 42 percent of people with early Alzheimer's disease have symptoms of anosognosia. And as dementia progresses, the symptoms also advance, evidence suggests.

Trying to make someone with this problem understand that they have changed and need to accept new limits often is an exercise in frustration, Dr. Weintraub said. Reasoning and evidence make little difference to these patients.

Brain studies suggest that the lack of awareness may be linked to the deterioration of the frontal lobes, especially on the right side, which play an important role in problem-solving, planning, and understanding the context and meaning of experiences and social interactions. Some studies also point to atrophy in the temporal lobes.

"Really, as of yet, we have no idea what's going on," Dr. Weintraub said.

Mr. Floyd, 70, a professional photographer in Evanston, Ill., spoke publicly about his experience as a caregiver at a conference on frontotemporal dementia sponsored by Northwestern University that I attended late last year. "My wife never ever acknowledged she had this disease, and to bring it up was painful," he told the audience.

Connie Floyd died in September at age 67. She was an accomplished woman, Mr. Floyd said in an interview: a director of children's programs at her church for over 20 years. Theirs was a deeply satisfying marriage until July 2010, the first time he suggested his wife needed to see a doctor. For several years, close friends had been telling him privately that something didn't seem right. And several months before she sought help, a physician who knew Mrs. Floyd well had confessed that he was worried she might have a brain tumor, an aneurysm or dementia.

There had been signs at home, times when Mrs. Floyd would seem to forget how to make the bed or would start talking when she and her husband were praying in bed at night. She forgot to hold a soup spoon steady while bringing it to her mouth and pushed her chair out several feet from the dining room table. When Mr. Floyd suggested she move in closer, she would push the chair to the side.

But when Mr. Floyd tried to raise his concerns with his wife, she was shocked. The problems weren't significant, and there were explanations for all of them, she insisted. She couldn't see what he was worried about and felt like she was being unfairly criticized.

From that day on, Mr. Floyd said, she saw him as her accuser. In prepared remarks for the Northwestern conference, he wrote:

For 42 years we discussed everything, sorrows, joys and concerns. In all those things, Connie was my partner and I hers. Suddenly, here we were facing the biggest challenge of our marriage and Connie was the one person with whom I couldn't discuss it. One of the saddest and most frustrating parts of this journey was that we never became a team.

"She seemed to feel that if she could hide the symptoms, the disease wouldn't be there," he told me, adding that she didn't want anyone to know about her illness. "I kept telling her this journey would be so much easier with other people at our side, but she just didn't see it that way."

Any time Mr. Floyd tried to point out her difficulties and offer assistance, his wife would take offense. "She couldn't make the connection between her symptoms and herself," he said.

How do you try to help someone in these circumstances? Mr. Floyd decided to confront his wife only when her safety or that of other people might be compromised. Otherwise, he would let things slide or take care of them on his own.

Mrs. Floyd's condition took a sharp turn for the worse last spring, and by the beginning of September it was clear she was dying. Unable to swallow or talk, she was living in a nursing home and entirely dependent on others. Nonetheless, she looked alarmed and startled when her daughter suggested that Mrs. Floyd's own mother would be waiting for her with open arms in heaven, Mr. Floyd recalled.

"Even at the very end, she had an absolute failure to recognize what was going on," he said. Mr. Floyd was never able to say a real goodbye to his partner of 44 years, he said, a woman he loved with all his heart.

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Well: Coming a Long Way on Smoking, With a Way to Go

Personal Health

Jane Brody on health and aging.

Fifty years ago this month, Dr. Luther L. Terry issued the first "Surgeon General's Report on Smoking and Health," which cited smoking as a cause of lung cancer in men. The hefty report landed like a bombshell on a complacent public, bombarded daily by tobacco advertising and surrounded at work, home and play by people who smoked.

On Friday, Dr. Boris D. Lushniak, the acting surgeon general, issued the 32nd edition, applauding a half-century of progress during which smoking rates have fallen by more than half. Still, he lamented that "smoking remains the leading preventable cause of premature disease and death in the United States."

Kathleen Sebelius, the secretary of health and human services, noted in a statement that "this year alone, nearly one-half million adults will still die prematurely because of smoking."

The new report greatly expands the list of disorders now known to be casually linked to smoking to include age-related macular degeneration, diabetes, colorectal cancer, liver cancer, tuberculosis, erectile dysfunction, cleft palate, ectopic pregnancy, rheumatoid arthritis, inflammation and impaired immune function. Exposure to secondhand smoke is now deemed a cause of stroke.

In 1964, smoking seemed like the thing to do, socially and legally accepted nearly everywhere. If you were not around back then, you'd be shocked by what it was like. Every car was a smoking car. On flights, passengers inhaled recirculated smoke-filled air. The aroma of exquisite restaurant meals were tainted by tobacco smoke.

Hospital visitors smoked in patients' rooms, as did many patients themselves. Movies were watched through a smoky haze. Cigarette samples were widely distributed on college campuses, and students smoked freely in their dorms.

Young people associated smoking with glamour and sophistication. I tried it in college myself, but quickly gave it up, deterred by the odor, the eye irritation and the nagging worry that my mother's fatal ovarian cancer might have been related to this terrible habit.

Although the surgeon general's report prompted Congress in 1965 to pass a cigarette labeling and advertising law, it took six years for that famous warning — "The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health" — to appear on packs. Cigarette advertising was banned on radio and television, whereupon the ads moved to magazines.

I was a cub reporter at The Minneapolis Tribune when the historic report landed in the newsroom. I was assigned to interview the smoking "man in the street," to assess his reaction to the news that what many nonsmokers viewed as a noxious habit was actually a killer.

Several told me they'd cut back, and a few thought they would try to quit. But the overwhelming majority defended their right and intent to continue smoking. As more than one put it, "By the time I get lung cancer, they'll know how to cure it."

Well, a half-century later, we still don't know how to cure lung cancer, and we may still not know in another 50 years. Furthermore, in the decades since the 1964 report, damning evidence for the health hazards of smoking has continued to mount. The consequences include damage to nearly every organ in the body; one in three cancer deaths; risk to the health and lives of unborn babies; and disease and death among nonsmokers exposed to secondhand smoke.

Smoking causes one in five deaths in the United States, more than 440,000 each year, according to the Centers for Disease Control and Prevention. "Tobacco is in a league of its own in terms of the sheer numbers and varieties of ways it kills and maims people," Dr. Thomas R. Frieden, the C.D.C. director, wrote in JAMA.

And as millions of women came "a long way, baby" — egged on by this slogan for Virginia Slims and a desire to control their weight and achieve gender equity— smoking-related risks caught up to them. More women now die each year from lung cancer than breast cancer — about 28,000 more, though annual walks, runs or ribbons devoted to conquering this runaway killer are lacking.

Many women were misled by a prevailing belief that they were somehow protected from smoking's health effects. In fact, the risk of death for women who smoke parallels that of male smokers and "is 50 percent higher than the estimates reported in the 1980s," Dr. Steven A. Schroeder wrote last January in The New England Journal of Medicine.

The good news is that we've made dramatic progress in curbing this huge contributor to disease, disability and death and in reducing billions of dollars in health care expenditures and lost productivity from smoking.

Smoking prevalence is down to 18 percent today from 43 percent of adults 50 years ago. Smoking is banned in public buildings; on public airplanes, trains and buses; inside restaurants, hospitals and most workplaces; and even banished from most private homes.

From 1964 to 2012, "eight million premature deaths have been prevented because of tobacco control measures," Theodore R. Holford, a Yale statistician, and his co-authors reported in JAMA. They attributed about one-third of the gains in life expectancy since 1964 to the decline in smoking.

Still, the industry spends billions of dollars each year — nearly $23 million a day — to keep smokers at it and entice new ones to start. Although manufacturers say they do nothing to attract young smokers, they have managed to infiltrate smoking into movies popular among teens, subliminally suggesting that this is socially desirable behavior.

While teen smoking has declined, still nearly one in five teens is a regular smoker. Feeling invulnerable, teens often ignore warnings about health risks, wrinkles and premature death decades in the offing. And though told repeatedly that smoking is addictive, many still believe they can quit whenever they want.

Of the nearly 42 million Americans still hooked on cigarettes, about 70 percent have said they want to quit. Many have tried quitting one or more times without success. Some experts believe that those who still smoke represent a particularly challenging group of committed smokers.

But I've known several hardcore smokers who have quit in spite of themselves. My husband, Richard, was one. He smoked for 50 years, starting at age 11, and repeatedly insisted that he couldn't quit. (Happily, he persuaded our sons never to start.)

Even after a two-week hiatus following a cardiac scare, Richard resumed smoking. He finally quit once and for all at age 61, after one session with a hypnotist and a few sticks of nicotine gum. He then became an ardent proselytizer, chastising every teenager he saw with a cigarette about having a death wish.

Although Richard succumbed to a smoking-induced lung cancer 15 years later, statistics suggest that quitting when he did gave him four extra years to enjoy life and our four darling grandsons.

This is the first of two columns on smoking.

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Well: Orange Is the New Green

Recipes for Health

Martha Rose Shulman on healthful cooking.

Orange is the color of the week in my kitchen, as it has been since the fall and will be throughout the winter at my farmers' market. I'm making oven fries with sweet potatoes, roasting and simmering carrots and winter squash with seasonings I haven't used before with these vegetables and finding new ways to enjoy grated carrot salads, which have always been a weakness of mine. Sometimes markets can look bleak in winter, but there's nothing drab about carrots, sweet potatoes and winter squash; I'm finding that there is a lot I can do with these nutrient-dense vegetables.

Nutrient-dense they are. In a recent study published by the Dutch National Institute for Public Health and the Environment, investigators looked at the relationship between cardiovascular disease and the colors of fruits and vegetables consumed. The question that the designers of the study were asking was whether the color of fruits and vegetables, which reflect the presence of bioactive compounds, can be associated with protection against cardiovascular disease. Their conclusion was that a high intake of all four color groups — green, orange, red and white — and especially red and orange fruits and vegetables may be protective against cardiovascular disease.

There is a lot that researchers are still uncovering about the compounds in orange vegetables. We do know that the pigments reflect the presence of beta-carotene, and not surprisingly, all three of these vegetables are excellent sources of vitamin A. They are very good to excellent sources of vitamins C and K, as well as very good sources of potassium and manganese. We know they are excellent sources of other phytonutrients that show some antioxidant and anti-inflammatory properties, like lutein, zeaxanthin and lycopene. And those are just the ones we are familiar with; there are plenty that are still under study in these delicious vegetables.

Carrot, Squash and Potato Ragout With Thai Flavors: A colorful ragout that works on its own or over rice.

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Roasted Carrots With Turmeric and Cumin: A delicious way to enjoy carrots, as a side or on their own.

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Roasted Sweet Potato Oven Fries: There are a lot of things to like about these delicious sweet wedges.

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Grated Carrot Salad With Dates and Oranges: A fruity carrot salad, rich in vitamin C.

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Turkish Pumpkin Soup: An intriguingly sweet winter squash soup.

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Think Like a Doctor: A School of Red Herrings

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

The Challenge: Can you figure out what is wrong with a 29-year-old former volleyball player who develops some odd aches and pains and a swollen foot?

Every month the Diagnosis column of The New York Times Magazine asks Well readers to take on a difficult case and offer their solutions to a diagnostic riddle. This month's case revolves around an athletic and previously healthy 29-year-old woman who developed a pain in her groin, a swollen foot and ankle and a slew of lab abnormalities. We will provide you with many of the notes and tests from the many doctors who saw this patient.

The first reader to provide the correct test to make the diagnosis gets a signed copy of my book "Every Patient Tells a Story" and the satisfaction of unraveling a tough tough case.

The Patient's Story:

"Is your blood pressure always this high?" Dr. Becky Miller asked the young woman who had come to see her.

Until recently it had been fine, the slender 29-year-old told her. It was kind of crazy because she'd been healthy her whole life, the young woman continued. But these past several months she'd been seeing doctors almost weekly, and it seemed like every time anyone checked, her blood pressure was high.

Dr. Miller was the newest specialist the young woman had been sent to since her ordeal began eight months earlier. It started innocuously enough. She'd enrolled in a new Pilates class and somehow injured her left hip. As a high school athlete and, briefly, a professional volleyball player, she knew the ache of a pulled groin muscle, but this felt worse — a lot worse.

Walking hurt, even sitting hurt; exercise was impossible. She asked around and found an orthopedic surgeon in her Los Angeles neighborhood. He diagnosed her with a grade 2 sprain in her groin muscles and sent her for physical therapy. That didn't help. Then several weeks in, with her hip still bothering her, her left foot and ankle swelled up.

A Long List of Doctors:

The young woman went to her primary care doctor. He was the first to take note of her elevated blood pressure. Let's keep an eye on that, he told her. He wasn't much concerned with the swelling; she should just take it easy and use compression stockings when she needed them.

That didn't sit right with her. She felt like this was more than just the pulled muscle, so she went to her endocrinologist. He had helped her a couple of years earlier when she'd had irregular periods. Back then he figured out that she had too much of a hormone known as prolactin, which was messing up her menstrual cycle. An M.R.I. of her brain showed a tiny spot on her pituitary gland, the likely cause of the excess hormone. He put her on a medication called bromocriptine to block the prolactin and her periods improved, though they were still irregular.

The endocrinologist wasn't sure what had caused her swollen foot. He ordered an ultrasound to look for a clot in that leg, but no clot was found.

He ordered a CT scan of her abdomen and pelvis to see whether something might be getting in the way of the blood flowing back into her heart. No obstruction was found, but the scan did reveal that her spleen was somewhat enlarged.

The endocrinologist sent her to a G.I. specialist, who scoped her. He saw some gastritis, but nothing that would cause a big spleen. However, a blood test revealed that she had too many red blood cells — an unusual finding, especially in a young woman who was still menstruating. So he sent her up the street to Dr. Becky Miller, a hematologist at Cedars-Sinai Medical Center.

The Patient's History:

When the patient walked into Dr. Miller's cheerful waiting room that morning, the first thing she noticed was that she was the youngest patient in the office by a good 20 to 30 years. That scared her a little.

Still, Dr. Miller's cheerful manner and brightly colored crocs put her at ease. The doctor led her to a couple of armchairs in the middle of a homey office, and she launched into her by now well-rehearsed story about her symptoms, doctors and tests. Dr. Miller paid close attention, nodding and jotting down notes in the pad on her lap.

When the doctor examined her, she seemed quite surprised by the high blood pressure reading. The patient was quite tall, 5-foot-10, and slender, 150 pounds, with an athletic build. No, she told the doctor, she'd never had high blood pressure until her doctor had noticed it earlier that year.

The young woman looked quite healthy. She had a couple of tattoos on her back and arm. And some tenderness in the upper left quarter of the abdomen, where her spleen was located. Her left ankle was still a little swollen. The rest of her exam was normal.

Some Unusual Lab Results:

Dr. Miller had already reviewed the lab test results obtained by the gastroenterologist; they showed that the patient had a hematocrit of 50. Normal, for a woman, is usually up to 40.

The labs sent to Dr. Miller can be seen here.

Dr. Miller first considered causes of the patient's elevated hematocrit and enlarged spleen. She was worried that this was some type of cancer. Could this be polycythemia vera, an abnormal proliferation of red blood cells? Or was this leukemia?

She sent blood off to be tested for these illnesses, and when the results came back negative, she sent the patient for a bone marrow biopsy. She was reassured when that was unrevealing as well, so she turned her focus to the other medical issue: the patient's relatively new high blood pressure.

You can see Dr. Miller's note here.

Looking for a Cause of High Blood Pressure:

High blood pressure is certainly common. One out of three Americans have it, and for well over 90 percent of them, no cause will be found — a condition called essential hypertension. Many of these individuals will need lifelong drug treatment along with a low-salt diet and regular exercise to prevent complications from their disease.

However, in 5 to 10 percent of cases, high blood pressure has an underlying and, more importantly, treatable cause. Address the cause, and the high blood pressure will usually resolve. The trick is to identify those few who have high blood pressure as a symptom of another problem from the many who have essential hypertension.

This patient was at increased risk for hypertension — her father had it. Still, could some medical problem be causing her blood pressure to rise? And if so, was it also linked to her swollen ankle and high red blood cell count?

The doctor started the patient on an antihypertensive medication, lisinopril, and began looking for something that could have made this young woman's blood pressure rise. Was there a diagnosis that could make all these symptoms make sense?

Feeling the Pressure:

Medications are the by far most common cause of an elevated blood pressure. Many everyday over-the-counter drugs, including painkillers like ibuprofen or decongestants like Sudafed, can raise blood pressure. So can alcohol or stimulants like caffeine, nicotine or cocaine. Ordinary prescription drugs like antidepressants, Ritalin or birth control pills can too. But this patient told Dr. Miller that she took none of those drugs, rarely drank alcohol and never smoked.

In children, the most common cause of high blood pressure is a narrowing, or coarctation, of the aorta. If the condition is not found in childhood, it will continue to cause high blood pressure in adults. A difference in blood pressure between the left and right arm can suggest this problem. This patient's blood pressure was the same in both arms.

Another treatable cause of high blood pressure is narrowing of the smaller arteries leading to the kidneys, but a CT scan of the abdomen showed normal vessels.

You can see the report of the CT scan here.

Finally, some diseases cause excess secretion of body chemicals like thyroid hormone, adrenaline or cortisol that can raise blood pressure. The hematologist sent off tests looking for any of these, and when several came back abnormal, Dr. Miller sent the patient back to her endocrinologist.

You can see the results of the testing that Dr. Miller ordered here.

The endocrinologist ordered several tests to try to figure out what was going on. One of them was quite revealing.

Solving the Mystery:

Now I ask you, gentle reader, if you could order only one test to figure out what was wrong with this patient, which test would you order to lead you most rapidly to the right diagnosis? And what is the correct diagnosis?

I'll post the answer tomorrow.

Rules and Regulations: Post your responses in the comments section. The correct answer will appear Friday on Well. The first person to get the correct test and diagnosis is the winner and will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

Updated, Friday Jan. 17 3:50 p.m. | Thanks for all your responses! You can read about the correct diagnosis at "Think Like a Doctor: Red Herrings Solved!"

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Well: Think Like a Doctor: Red Herrings Solved!

Think Like a Doctor

Solve a medical mystery with Dr. Lisa Sanders.

On Thursday we challenged Well readers to take the case of a 29-year-old woman with an injured groin, a swollen foot and other abnormalities. Many of you found it as challenging as the doctors who saw her. I asked for the right test as well as the right diagnosis. More than 200 answers were posted.

The right test was…

The dexamethasone suppression test, though I counted those of you who suggested measuring the cortisol in the urine.

The right diagnosis was…

Cushing's disease

More than a dozen of you got the right answer or the right test, but Dr. Davin Quinn, a consultant psychiatrist at the University of New Mexico Hospital, was the first to be right on both counts. As soon as he saw that the patient's cortisol level was increased, he thought of Cushing's. And he had treated a young patient like this one some years ago as a second year resident.

The Diagnosis:

Cushing's disease is caused by having too much of the stress hormone cortisol in the body. Cortisol is made in the adrenal glands, little pyramid shaped organs that sit atop the kidneys. It is normally a very tightly regulated hormone that helps the body respond to physical stress.

Sometimes the excess comes from a tumor in the adrenal gland itself that causes the little organ to go into overdrive, making too much cortisol. More often the excess occurs when a tumor in the pituitary gland in the brain results in too much ACTH, the hormone that controls the adrenal gland.

In the body, cortisol's most fundamental job is to make sure we have enough glucose around to get the body's work done. To that end, the hormone drives appetite, so that enough fuel is taken in through the food we eat. When needed, it can break muscle down into glucose. This essential function accounts for the most common symptoms of cortisol excess: hyperglycemia, weight gain and muscle wasting. However, cortisol has many functions in the body, and so an excess of the hormone can manifest itself in many different ways.

Cushing's was first described by Dr. Harvey Cushing, a surgeon often considered the father of modern neurosurgery. In a case report in 1912, he described a 23-year-old woman with sudden weight gain, mostly in the abdomen; stretch marks from skin too thin and delicate to accommodate the excess girth; easy bruising; high blood pressure and diabetes.

Dr. Cushing's case was, it turns out, a classic presentation of the illness. It wasn't until 20 years later that he recognized that the disease had two forms. When it is a primary problem of an adrenal gland gone wild and producing too much cortisol on its own, the disease is known as Cushing's syndrome. When the problem results from an overgrown part of the pituitary making too much ACTH and causing the completely normal adrenal glands to overproduce the hormone, the illness is called Cushing's disease.

It was an important distinction, since the treatment often requires a surgical resection of the body part where the problem originates. Cushing's syndrome can also be caused by steroid-containing medications, which are frequently used to treat certain pulmonary and autoimmune diseases.

How the Diagnosis Was Made:

After the young woman got her lab results from Dr. Becky Miller, the hematologist she had been referred to after seeing several other specialists, the patient started reading up on the abnormalities that had been found. And based on what she found on the Internet, she had an idea of what was going on with her body.

"I think I have Cushing's disease," the patient told her endocrinologist when she saw him again a few weeks later.

The patient laid out her argument. In Cushing's, the body puts out too much cortisol, one of the fight-or-flight stress hormones. That would explain her high blood pressure. Just about everyone with Cushing's disease has high blood pressure.

She had other symptoms of Cushing's, too. She bruised easily. And she'd been waking up crazy early in the morning for the past year or so – around 4:30 – and couldn't get back to sleep. She'd heard that too much cortisol could cause that as well. She was losing muscle mass – she used to have well-defined muscles in her thighs and calves. Not any more. Her belly – it wasn't huge, but it was a lot bigger than it had been. Cushing's seemed the obvious diagnosis.

The doctor was skeptical. He had seen Cushing's before, and this patient didn't match the typical pattern. She was the right age for Cushing's and she had high blood pressure, but nothing else seemed to fit. She wasn't obese. Indeed, she was tall (5- foot-10) and slim (150 pounds) and athletic looking. She didn't have stretch marks; she didn't have diabetes. She said she bruised easily, but the endocrinologist saw no bruises on exam. Her ankle was still swollen, and Cushing's can do that, but so can lots of other diseases.

The blood tests that Dr. Miller ordered measuring the patient's ACTH and cortisol levels were suggestive of the disease, but many common problems — depression, alcohol use, eating disorders — can cause the same result. Still, it was worth taking the next step: a dexamethasone suppression test.

Testing, Then Treatment:

The dexamethasone suppression test depends on a natural negative feedback loop whereby high levels of cortisol suppress further secretion of the hormone. Dexamethasone is an artificial form of cortisol. Given in high doses, it will cause the level of naturally-occurring cortisol to drop dramatically.

The patient was told to take the dexamethasone pills the night before having her blood tested. The doctor called her the next day.

"Are you sure you took the pills I gave you last night?" the endocrinologist asked her over the phone. The doctor's voice sounded a little sharp to the young woman, tinged with a hint of accusation.

"Of course I took them," she responded, trying to keep her voice clear of any irritation.

"Well, the results are crazy," he told her and proposed she take another test: a 24-hour urine test.

Because cortisol is eliminated through the kidneys, collecting a full day's urine would show how much cortisol her body was making. So the patient carefully collected a day's worth of urine.

A few days later, the endocrinologist called again: her cortisol level was shockingly high. She was right, the doctor conceded, she really did have Cushing's.

An M.R.I. scan revealed a tiny tumor on her pituitary. A couple of months later, she had surgery to remove the affected part of the gland.

After recovering from the surgery, the patient's blood pressure returned to normal, as did her red blood cell count and her persistently swollen ankle. And she was able to once again sleep through the night.

Red Herrings Everywhere:

As many readers noted, there were lots of findings that didn't really add up in this case. Was this woman's groin sprain part of the Cushing's? What about the lower extremity swelling, and the excess red blood cell count?

In the medical literature, there is a single case report of high red blood cell counts as the presenting symptom in a patient with Cushing's. And with this patient, the problem resolved after her surgery – so maybe they were linked.

And what about the weird bone marrow biopsy? The gastritis? The enlarged spleen? It's hard to say for certain if any of these problems was a result of the excess cortisol or if she just happened to have other medical problems.

Why the patient didn't have the typical symptoms of Cushing's is easier to explain. She was very early in the course of the disease when she got her diagnosis. Most patients are diagnosed once symptoms have become more prominent

By the time this patient had her surgery, a couple of months later, the round face and belly characteristic of cortisol excess were present. Now, two years after her surgery, none of the symptoms remain.

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Well: Landscapes Tainted by Asbestos

Poison Pen

Deborah Blum writes about chemicals and the environment.

For the past few years, Brenda Buck has been sampling the dust blowing across southern Nevada. Until recently, she focused on the risks of airborne elements such as arsenic. But then she started noticing an oddity in her samples, a sprinkling of tiny, hairlike mineral fibers.

She found them on herself as well. After a ride on horseback down a dirt road 20 miles south of Las Vegas, her clothes and boots were dappled with the fibrous material. Dr. Buck, a professor of geology at the University of Nevada, Las Vegas, turned to her colleagues to help identify it.

Their verdict: asbestos. And lots of it.

In a paper published late last year, titled "Naturally Occurring Asbestos: Potential for Human Exposure, Southern Nevada, USA," Dr. Buck and her colleagues reported that the fibers were similar to those found at asbestos-contaminated Superfund sites and warned that they "could be transported by wind, water, cars or on clothing after outdoor recreational activities." The research raises the possibility that many communities in the region, including Las Vegas, may face a previously unknown hazard.

Dr. Buck and her co-author Rodney V. Metcalf, a fellow U.N.L.V. geology professor, are now trying to quantify the range and the danger posed by natural asbestos-bearing mineral deposits spread across 53,000 acres, stretching from the southern shore of Lake Mead to the edges of the McCullough Range. "Nobody wants bad news — we're all hoping the health risks will be very low," Dr. Buck said in an interview. "But the fact is, we don't know that yet."

Similar concerns are arising in an unexpectedly wide swath of the United States: Naturally occurring asbestos deposits now have been mapped in locations across the country, from Staten Island to the foothills of the Sierras in California.

Elongated asbestos fibers are created by natural mineral formations. When they turn up in industrial products, it is because people have excavated them and refined them for use — a practice dating back more than 2,000 years. Ancient Greeks used asbestos to strengthen everything from napkins to lamp wicks.

Stories of asbestos-linked illnesses date back almost as long. But it was the post-World War II embrace of these fibers, in products ranging from insulating materials to ceiling tiles to roofing shingles, that provided undeniable evidence of health effects. By the 1960s, scientists had demonstrated that a chain of occupational illnesses, including a lung cancer called mesothelioma, could be directly linked to the presence of such mineral fibers.

The term asbestos technically refers to a group of six silicate-based fibrous minerals. But this definition may underestimate the extent of naturally occurring risks, scientists say. The mineral erionite, for instance, also forms needlelike structures, which have been linked to startlingly high levels of mesothelioma in Turkey and which have recently been discovered in the oil-and-gas boom regions of North Dakota. The discovery of airborne erionite fibers in North Dakota recently led the Centers for Disease Control and Prevention to describe it as "an emerging North American hazard."

"Essentially, these fibers flow aerodynamically into the deep lung tissue and lodge there" said Geoffrey Plumlee, a geochemist with the United States Geological Survey in Denver. They remain embedded for years, like needles in a pincushion, spurring the onset of not only mesothelioma but also other lung cancers and diseases of the respiratory system.

By the 1970s such health effects were so well documented that the Environmental Protection Agency moved to limit asbestos use, and in 1989 the agency banned almost all industrial use of the minerals. But a recent cascade of research has renewed scientific worries.

For one thing, recent soil studies show that residential developments have spread into mineral-rich regions. California's state capital, Sacramento, for example, spilled into neighboring El Dorado County, where, it turned out, whole neighborhoods were built across a swatch of asbestos deposits.

And sophisticated epidemiological studies have shown that this was more than an occupational health issue. The small mining town of Libby, Mont., provided one of the most dramatic case studies. Almost a fifth of the residents have now received diagnoses of asbestos-linked illnesses, from mesothelioma to severe scarring of lung tissue.

When these conditions began cropping up across the entire town in the late 1990s, investigators assumed that those sickened were all workers at a nearby mine. But the illnesses weren't appearing only in mine workers. Family members were stricken, too, as were residents of the town who had nothing to do with the mining business.

Investigations by alarmed government agencies — including the E.P.A, the Geological Survey and the National Institute of Environmental Health Sciences — established that miners brought asbestos fibers back to town with them on clothes, vehicles and other possessions. But residents were also exposed to fibers blowing about the surrounding environment — and, to the dismay of researchers, people were being sickened by far smaller exposures than had been thought to cause harm.

"Libby really started the new focus on the issue," said Bradley Van Gosen, a research geochemist with the Geological Survey in Denver. Dr. Van Gosen has been put in charge of a new U.S.G.S. mapping project, an ambitious effort to trace the minerals not only across Western mining states but also elsewhere, from the Upper Midwest to a rambling path up the Eastern Seaboard, starting in southern Appalachia and stretching into Maine.

Dr. Van Gosen said that most of the Eastern deposits were linked to an ancient crustal boundary, perhaps a billion years old, that underlies mountain ranges like the Appalachians. Wherever they are found, though, minerals in the asbestos family tend to form when magnesium, silica and water are transformed by superheated magma from the earth's mantle.

In Western states, such filamented minerals tend to result from volcanic activity. In the Midwest, where fibers have recently turned up associated with mining interests in Minnesota and Wisconsin, geologists suspect they originated in ancient magnesium-rich seafloors. A recent study in Minnesota linked an increased risk of death among miners to time spent working in mines contaminated by such deposits.

"It has the potential to be a huge deal," said Christopher P. Weis, toxicology adviser to the director of the National Institute for Environmental Health Sciences. "And we want to get the word out, because this is something that can be addressed if we tackle it upfront."

Dr. Buck's discovery of similar hazards in southern Nevada was the first time that naturally occurring asbestos had been reported in the region. At this point, she and her colleagues are simply trying to figure out the extent of the problem. A leading mesothelioma researcher, Dr. Michele Carbone of the University of Hawaii, is analyzing the fibers to help establish the magnitude of any health risk. Dr. Buck and Dr. Metcalf are expanding their sampling deeper into the Nevada desert, trying to build a better map of the hazardous regions.

"We live here. Our children are here," Dr. Buck said. "We want very much to get this right."

And they are approaching their discovery with personal caution. They now wear protective gear while sampling, and Dr. Buck has decided against taking her graduate students out for what appears to be risky fieldwork.

On a larger scale, researchers are investigating alternatives to creating large forbidden zones, such as wetting down roads or requiring that people in high-exposure areas wear protective masks and gear. But even small measures, like bathing after exposure and washing contaminated clothing separately, may help, Dr. Weis said.

"We can be smart and efficient about this, both at the government and at the personal level," he said.

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Well: What Ultra-Marathons Do to Our Bodies

Phys Ed

Gretchen Reynolds on the science of fitness.

Ultra-runners are different from you and me in one simple way: They run more. But a new study of these racers, who compete in events longer than marathons, joins other recent science in finding that they also tend to be older and have some different health concerns than most of us might expect, suggesting that some beliefs about how much activity the human body can manage, especially in middle age, may be too narrow.

In recent years, the health effects of increasing inactivity have received plenty of scientific and media scrutiny. But the potential health effects of relatively gargantuan levels of physical activity have received less attention, and much of the science that does exist focuses on the potential dangers of over-exercise for the heart. Few studies have examined the more general health implications — the benefits as well as the risks — of training for and running more miles in a day than many of us complete in a month.

Hoping to better understand what happens to an ultra-endurance athlete's body, researchers at Stanford University and the University of California, Davis recently contacted more than 1,200 experienced ultra-marathon runners and asked them probing and almost impolite questions about the past and current states of their bones, hearts, blood pressures, prostates, breasts, skin, lungs, moods, bowels, eyes, waistlines, livers and many other body parts and systems. They also asked about their race histories, times, training regimens and any recent injuries and illnesses.

Then they compared the ultra-runners' aggregate answers with comparable health statistics for average, more sedentary adults, while also comparing the training and injury-related data with similar information about recreational runners, like myself, who are not running 50- or 100-mile races on the weekend.

The results, which were published last week in PLoS One, were telling. The ultra-runners had a low, although not nonexistent, incidence of high blood pressure and irregular heartbeats, with about 7.5 percent of the runners reporting one of those problems. But less than 1 percent had been diagnosed with heart disease or had a past stroke, and few had experienced cancer, with basal cell skin carcinoma being the most common malignancy, occurring in 1.6 percent of the runners. Those percentages are generally lower than among age-matched American adults, especially considering that a majority of the ultra-runners were aged 40 or older.

On a less salutary note, the runners did report a high incidence of breathing problems, with almost a third of the group telling researchers that they experienced either allergies or asthma, often after running. That finding, while worrying, makes sense, the researchers note, since ultra-long-distance runners spend many hours outside, striding along trails strewn with pollen-slinging trees and flowers, priming their respiratory systems for allergies and asthma.

They also tend to get hurt, as runners at all mileage levels do. More than half said that they had experienced a running-related injury in the past year that had been severe enough to keep them from training for at least a few days, about the same percentage as often is reported by recreational runners. Many of the injuries were knee problems or stress fractures, along with a few, unexpected concussions. (I once slipped during a trail run and thwacked my head into a tree trunk, so it can happen.)

Interestingly, injuries were most common among younger, inexperienced ultra-runners, and in particular among men not yet aged 40 who trained fast and intensely. Ultra-runners past age 40 whose training pace was more plodding were far less likely to be sidelined with injuries.

That finding jibes with other, rather beguiling recent data about ultra-runners, which finds that, on average, their per-mile race and training paces are much slower than for marathon runners, perhaps explaining why the fastest-growing age groups in most ultra-marathon fields are those for racers aged between 45 and 65, who, as many of us would admit, are no longer as fast as we once were, but can, it seems, just keep going.

And there can be substantial, accruing benefits to covering those miles, says Dr. Eswar Krishnan, an assistant professor at Stanford and co-author of the new study. Over all, the ultra-runners in the study were absent from work less often than other American adults because of illness or injury, he said, and rarely felt compelled to see a physician, with almost half visiting a doctor only once in the past year, usually because of a running injury.

Of course, the ultra-competitors may have "developed stoicism" from their many hours of training, Dr. Krishnan said, and ignored niggling ills that would keep the rest of us from work or send us >>hurrying to the doctor. But they also displayed a substantially reduced risk of developing many of the common diseases of modern life.

Which does not mean that the rest of us should abruptly revise our exercise resolutions upward and start training for a 100-miler, said Dr. Krishnan, who himself runs five-kilometer races and has no plans, he said, to go longer. The real lesson is to "stay the course" with exercise, he said, whatever that means for you, and even as you>> age and slow.

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