Bits Blog: Report Questions Whether Health Apps Benefit Healthy People

Photo Dr. Iltifat Husain is the editor-in-chief of iMedicalApps.com, a review site for medical professionals.Credit Wake Forest Baptist Health

Consumers looking to use their mobile devices to improve their health — or at least maintain their well-being — have tens of thousands of choices.

But if those consumers are already healthy, the apps won't necessarily do them any good, according to a new report in The BMJ, a British medical journal.

On Tuesday afternoon, for instance, the top 10 free health and fitness apps for iPhones included MyFitnessPal, a calorie counter and diet tracker; the FitBit activity tracker; Pacer, a pedometer and blood pressure tracker; and Period Tracker Lite, a menstrual-cycle tracker, according to data compiled by App Annie, an analytics firm.

For consumers with concerns of a more medical nature, apps in the Google Play store, among others, offer all kinds of advice, self-diagnosis and treatment. One is marketed as an HIV risk calculator, another is a self-described self-test for erectile dysfunction, and a third purports to offer home remedies for cold sores, colitis, conjunctivitis and constipation.

An article published in The BMJ on Tuesday evening, however, questions whether such consumer health apps provide any real health value to already-healthy consumers – and whether the apps could even cause harm by stoking unneeded anxiety among the worried well.

Doctors don't yet have definitive answers to these questions, partly because smartphone apps are so new and partly because government health authorities regulate consumer health apps at their own discretion, depending on the possible risks to users. As a result, many health and fitness apps lack rigorous clinical evidence to demonstrate they can actually improve health outcomes.

The medical journal article, titled "Can Healthy People Benefit From Health Apps?," lays out arguments for and against the apps by juxtaposing the opposing views of two doctors.

Arguing in favor, Dr. Iltifat Husain, the editor in chief of iMedicalApps.com, a review site for medical professionals, contended that some apps, by encouraging healthy behavior, could hold great potential to reduce the rate of illness and death.

"They can help people to correlate personal decisions with health outcomes," Dr. Husain wrote, "and they can help doctors to hold patients accountable for their behavior."

He recommended that doctors become more involved in educating the public on which health details to track and which apps to use. If doctors waited for scientific studies to prove the benefits of health apps, he added, they could lose their power to influence patients to "the industry dictating which tools people should use."

To provide a dissenting perspective, The BMJ enlisted Dr. Des Spence, a general practitioner in Glasgow. He argued that many health tracking apps encouraged healthy people to unnecessarily record their normal activities and vital signs — turning users into continuously self-monitoring "neurotics." He recommended people view these new technologies with skepticism.

"The truth is that these apps and devices are untested and unscientific, and they will open the door of uncertainty," Dr. Spence wrote. "Make no mistake: Diagnostic uncertainty ignites extreme anxiety in people."

Although both doctors agreed there was no evidence that health apps had caused harm, federal regulators in the United States have been cracking down on health apps that make deceptive claims — an issue with the potential to cause mistreatment or misdiagnosis of medical problems.

In 2011, the Federal Trade Commission accused the developers of two acne apps of falsely claiming they could treat acne by shining colored light onto users' skin.

This year, the agency accused two melanoma app marketers of deceptively claiming that their products could accurately analyze skin moles for the risk of melanoma, even in its early stages. Regulators said the marketers did not have sufficient evidence to support those medical claims.

"If an app claims to treat, diagnose or prevent a disease or a health condition, it needs to have serious evidence to back up those claims," Mary K. Engle, associate director of the F.T.C.'s division of advertising practices, said in a phone interview this year. "We hope marketers will take heed of that and do their homework before they get into the marketplace."

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Well: Christopher McDougall Wants You to Go Outside

Photo Credit Stuart Bradford

The author Christopher McDougall helped make barefoot running mainstream with his best-selling book "Born to Run," a tale about a tribe of endurance runners and an annual 50-mile footrace in the mountains of Mexico.

Now Mr. McDougall returns with another tale that he hopes will again upend the fitness world, this time by getting people out of the sterile gym environment to run, jump, throw and climb outdoors. In his new book, "Natural Born Heroes: How a Band of Misfits Mastered the Lost Secrets of Strength and Endurance," Mr. McDougall writes about the benefits of exercising outdoors on trails, creek beds and rocks, where footholds are uncertain and paths contain obstacles like rocks and fallen trees that need to be climbed or hurdled.

For this month's Well Book Club, I spoke with Mr. McDougall about the problem with indoor fitness routines, what kind of workout he has been doing lately and what it really takes to climb a rope. Here's an edited version of our conversation.

Where did the idea for this book come from?

It came out of "Born to Run," but by accident. I was researching indigenous and ancient runners, and I came across a reference to the Cretan runner. He was a foot messenger during World War II. I put it aside but I was intrigued. What was this guy's story? I circled back and found this whole other fascinating story about people doing these superhuman feats on foot, behind enemy lines, running 40 to 100 miles at a time on a starvation diet.

Achieving that level of fitness seems so unattainable. Is there a lesson here for a regular person?

The big reveal to me was that they're not superhuman at all. Where we have really gone off the rails in our modern concept of the hero is this Hollywood assumption that they are all like Hugh Jackman. In reality, the classic Greek ideal of a hero was a common person. It was a virtue, a responsibility, that every person should be able to develop these natural, very attainable skills to be reliable in a crisis, to be capable of helping someone else out.

What are the skills of a natural-born hero?

It's about developing your natural abilities so you have dexterity for throwing, climbing or crawling. Strength is about using that natural elastic recoil in our body to tap into these latent reservoirs of strength. They are there; we just don't use them.

One of the skills you write about is climbing. Can you tell me more about that?

Kids love to climb. They want to get off the ground all the time. After the age of 5 or 6, we stop practicing the ability to get our bodies off the ground. One of the things I never could do was climb a rope. Climbing a rope is not a muscular challenge; it's a dexterity challenge. I got a 30-foot rope, slung it over a branch in my yard and started studying climbing techniques. Within a day, I was climbing. You trap the rope between your feet. You don't pull yourself up by your arms; you step up with your legs.

Why do you think people have lost these natural abilities for throwing and climbing?

At age 5 or 6, we stick kids in a class and say: "Sit there. Don't move until 3 p.m. and then go home and do homework." We take these physical animals and turn them into sedentary animals. And one of the things I've really come to believe passionately while researching this book is that most recreational sports are created by men for men, and they use male attributes like body strength. But the real skills, the human skills, are the ones where the differences between men and women are the slimmest. Humans have great dexterity and adaptability. Some of the greatest rock climbers in the world are women.

So how should people change their exercise habits in the modern world?

Add things to your workout that you don't think you can do. Try to climb a rope. Walk on all fours. Get outside and do things you're not expecting.

Why is an outdoor workout better than a workout in a gym?

In a gym, you are stationary and artificially balanced. You're on a padded seat, strapped in and isolating one muscle. All of the uncertainty in the range of motion has been stripped away. In the real world when you move, you don't isolate one muscle. We have been trying the stationary machine model for 40 years, and it's failed. It's based on body building. Size was never the goal of the hunter gatherer. You never wanted to be big; you wanted to be mobile and agile.

So many people embraced barefoot running after your first book. What is the ultimate advice in this book?

I think it's that we should be fit to be useful. What's the point of your exercise? Why are you getting big or lifting stuff if it's not useful? Can I use this skill to pick up a child who needs help or use this to pull a rope? There is this group called the November Project. In Boston when they got hit by the blizzard, they got snow shovels and dug out subway stations. How cool is that? They probably got the best workout of their lives, and so many people were benefiting from it.

So what kind of training do you do now?

I've become infatuated by Parkour. People think it's daredeviltry on rooftops, but it's about learning how to shift our body weight and using parts of your body you tend to ignore. I also take my runs off of trails and into creek beds. That uncertain footing allows you to work on agility and nimbleness. An immediate benefit is that it focuses you on the present.

---

Are there physical challenges that intimidate you? Author Christopher McDougall is responding to your posts and comments.

Join the conversation

Want a free Parkour lesson and a chance to meet Christopher McDougall? If you are among the first 10 Well readers to participate in our discussion who can attend, you'll receive a free Parkour lesson for you and a friend and two tickets to the "Natural Born Heroes" stage show in Central Park.

Winners will gather at the Society for Ethical Culture on Wednesday, April 15, at 5:30 p.m. for their Parkour lesson with The Movement Creative, New York's premier Parkour academy, and attended by Dan Edwardes, co-founder of London's Parkour Generations, and Julie Angel, movement specialist. The "Natural Born Heroes" show begins immediately after at 7 p.m.

A version of this article appears in print on 04/14/2015, on page D6 of the NewYork edition with the headline: Workout for an Everyday Hero.

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Listeria in Sabra Hummus Prompts New Wave of Recalls

Photo Sabra Dipping Company recalled 30,000 cases of its classic hummus after tubs in Michigan tested positive for listeria. Credit Spencer Platt/Getty Images

Two food manufacturers have issued nationwide recalls of products because of the discovery of the potentially lethal bacterium listeria, which federal authorities have now linked to three deaths and five illnesses in Texas and Kansas.

On Wednesday, the Sabra Dipping Company recalled 30,000 cases of its classic hummus after one tub in Michigan tested positive for the food-borne bacteria. No illnesses related to the hummus have been reported so far, according to Jennifer Holton, a spokeswoman for the Michigan Department of Agriculture and Rural Development.

Separately, the Centers for Disease Control and Prevention has confirmed that three people in Texas fell ill after eating Blue Bell ice cream from 2011 to 2014. The agency had already connected the company with three listeria-related deaths and two additional cases.

The agency is investigating three more potential cases, according to Dr. Rob Tauxe, deputy director of the C.D.C.'s Division of Foodborne, Waterborne and Environmental Diseases, which would bring the total number of cases to 11.

The agency initially linked five patients at a hospital in Kansas who fell ill from January 2014 to January 2015 to Blue Bell Products. The C.D.C. determined that at least four had consumed milkshakes made with Blue Bell ice cream.

Listeria is among the most dangerous food-borne illnesses, particularly to people with compromised immune systems, although it is much more rare than other common diseases like salmonella poisoning. The C.D.C. estimates that about 380 people die of salmonella every year, which translates to less than 1 percent of about one million annual cases. About 260 people, or about 16 percent of about 1,600 cases, die of listeria every year.

Symptoms include headaches, fever and abdominal pain. Consumers who were exposed to Blue Bell or Sabra products and exhibit signs of illness should contact their doctors, Dr. Tauxe said. Consumers who have been exposed but do not exhibit symptoms probably have little reason to worry, he added.

Health officials say that consumers should wrap potentially contaminated products in plastic before throwing them away. Closed containers that have not spilled do not pose a significant risk of spreading listeria to other areas of the home.

Blue Bell has been expanding a recall of its products over listeria concerns since March, when the company recalled 10 frozen snack items manufactured at a plant in Brenham, Tex., where Blue Bell is based. The company said it was its first recall in 108 years.

"This is really surprising, very startling and distressing to the company," said Gene Grabowski, a Blue Bell spokesman.

Days later, the company recalled its chocolate, vanilla and strawberry three-ounce cups manufactured at a second plant in Broken Arrow, Okla. Those cups were available only to institutional buyers like schools and hospitals, Mr. Grabowski said, and not to the public.

Blue Bell expanded the recall a third time this month to include banana pudding, butter crunch, mint chocolate chip, cookies 'n cream, homemade vanilla, Dutch chocolate and "moo-llennium crunch" flavors of ice cream manufactured from Feb. 12 through March 27 at the Broken Arrow plant.

In a statement on its website, Blue Bell said that it suspended operations at the Broken Arrow plant on April 3, and that it was "working with retail outlets to remove all products" made there. The company hopes to resume operations at the plant in the next seven to 10 days, Mr. Grabowski said, once it has identified the source of the contamination and sterilized the facilities.

Blue Bell is offering a full refund for all products made at its Broken Arrow plant. Such products are stamped with a six-digit code and the letter "O," "P," "Q," "R," "S" or "T."

Ice cream, unlike hummus, can stay good in a freezer for years, posing a challenge to health officials.

"We are concerned that there may be contaminated ice cream still in people's freezers," Dr. Tauxe said. "It appears that products from the Oklahoma facility may have been contaminated for some time."

An outbreak of listeria traced to cantaloupe killed 33 people in 2011 and sickened more than 140 others. In March, a district court judge approved settlements for the families of 30 people who died.

The Sabra and Blue Bell recalls follow three other recent food recalls over listeria concerns. Amy's Kitchen, the maker of organic frozen meals, recalled about 74,000 cases of prepackaged products. Wegmans Food Markets issued a recall of more than 12,000 packages of organic spinach, while the Carmel Food Group recalled some of its Rising Moon Organics frozen ravioli.

Correction: April 14, 2015

An earlier version of this article misstated the number of tubs of Sabra hummus that tested positive for listeria in Michigan. It was one, not several.

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Senate Approves a Bill on Changes to Medicare

WASHINGTON — The Senate on Tuesday overwhelmingly approved sweeping changes in the way Medicare pays doctors, clearing the bill for President Obama and resolving an issue that has bedeviled Congress and the Medicare program for more than a decade.

The 92-to-8 vote in the Senate, following passage in the House last month by a vote of 392 to 37, was a major success for Republicans, who devised a solution to a complex policy problem that had frustrated lawmakers of both parties. Mr. Obama has endorsed the bill, saying it "could help slow health care cost growth."

The bill, drafted in the House in negotiations between Speaker John A. Boehner and Representative Nancy Pelosi, the Democratic leader, also extends the Children's Health Insurance Program for two years, through 2017.

Without action by Congress, doctors would have faced a 21 percent cut in Medicare fees on Wednesday or Thursday. Senate leaders cleared the way for final passage by allowing votes on several amendments sought by liberal Democrats and conservative Republicans.

Medicare spent $70 billion last year under the fee schedule used to pay doctors and some other health care professionals. That accounts for about 12 percent of all Medicare spending. Ninety-eight percent of people enrolled in the traditional fee-for-service Medicare program receive at least one physician service during the year.

The legislation moves Medicare in a direction espoused by Mr. Obama and many health policy experts, toward payment based on the quality and value of care, rather than just the volume of services. Organized medicine now accepts that change in principle, and the American Medical Association lobbied strongly for the bill, demanding that Congress "fix Medicare now."

Congress has passed 17 short-term bills since 2003 to block cuts in Medicare doctors' fees that were called for under the existing law. Such cuts would most likely prompt some doctors to accept fewer Medicare patients.

The Senate majority leader, Mitch McConnell, Republican of Kentucky, said the bill taken up Tuesday was "designed to ensure that seniors on Medicare don't lose access to their doctors."

Continue reading the main story

"It's a solution to a broken Medicare payment system that has vexed congressional leaders of both parties for years," he said. "It would mean an end to the annual exercise of Congress passing a temporary fix to the problem one year and then coming right up to the very same cliff the next year, without actually solving the underlying problem."

Senator Ron Wyden of Oregon, the senior Democrat on the Finance Committee, called the bill "a milestone for Medicare." But he and other Democrats said it would have been better to extend the children's insurance program for four years, rather than two.

Mr. Wyden said the current formula for paying doctors was "horrendously flawed" but had "dominated much of the discussion" in the last 18 years.

Before passing the bill, the Senate rejected a half-dozen proposed amendments on Tuesday night. Democrats, for example, wanted to provide more money for women's health care. Republicans wanted to repeal a provision of the Affordable Care Act that requires most Americans to have health insurance, and they tried to force Congress to pay for the Medicare bill so it would not increase budget deficits.

The current payment formula, set by Congress in 1997, links Medicare spending on doctors' services to growth of the overall economy. Medicare spending has regularly exceeded the targets. Under the law, the excess is supposed to be recouped in subsequent years through cuts in payment rates for doctors.

The bill would repeal that formula. Fiscal conservatives object because only one-third of the cost would be offset. The rest, $141 billion from 2015 to 2025, would add to federal budget deficits.

"This bill is not paid for," said Senator Jeff Sessions, Republican of Alabama.

New spending would total $211 billion over 10 years, the Congressional Budget Office estimated. Higher-income Medicare beneficiaries would pay additional premiums totaling nearly $35 billion, and Medicare would save a similar amount by trimming payments to hospitals, nursing homes and home health agencies.

Senator Mike Lee, Republican of Utah, said the bill "doubles down on Medicare's broken price control model" and "inflates the administration's power as regulator and compliance officer."

"The principal change proposed in this bill is to move from a Medicare payment system based on volume to one based on bureaucratic measures of quality and value," Mr. Lee said.

The votes against the bill came from Republicans: Mr. Sessions and Mr. Lee, along with Senators Ted Cruz of Texas, David Perdue of Georgia, Marco Rubio of Florida, Ben Sasse of Nebraska, Tim Scott of South Carolina and Richard C. Shelby of Alabama.

For a few hours on Tuesday, it seemed senators might also be close to an agreement to vote on Mr. Obama's nomination of Loretta E. Lynch to be attorney general, but the prospect evaporated.

Senator John Cornyn of Texas, the No. 2 Senate Republican, offered a plan to overcome an impasse over abortion restrictions in a sex-trafficking bill, but Democrats quickly rejected it. Republican leaders have held up a vote on Ms. Lynch until the Senate finishes work on the trafficking bill.

Democrats on Tuesday repeated their opposition to the abortion restrictions and denounced the delay of Ms. Lynch's nomination. "They can stall her for 157 days; she is going to be attorney general of the United States," said Senator Harry Reid of Nevada, the Democratic leader.

Commenting on the Medicare bill, federal officials welcomed its emphasis on the quality of care but said it would probably not provide a permanent solution.

Paul Spitalnic, the chief actuary of the Medicare program, said the bill could lead to "a payment reduction for most physicians" after 2025. "If not addressed by subsequent legislation," he said, "we expect that access to and quality of physicians' services would deteriorate over time for beneficiaries."

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Study Finds Broad Rise in Medication Use by Those Newly Joining Medicaid

Photo In Miami, an ad for the Affordable Care Act. Expanded access to Medicaid led to a 25 percent rise in prescriptions in 2014. Credit Joe Raedle/Getty Images

People newly covered by Medicaid drove a significant increase in prescription drug use in 2014, even as those with private commercial coverage filled fewer prescriptions and, over all, patients did not visit the doctor as often, according to a new report by the IMS Institute for Healthcare Informatics, which tracks the health industry.

The report, released on Tuesday, offers a window into how consumers used their insurance in 2014, the first full year after millions of Americans gained coverage through the health care law, which expanded eligibility for Medicaid in many states and set up marketplaces where consumers could shop for insurance.

Patients with Medicaid in states that expanded access to the program filled 25.4 percent more prescriptions than in the previous year, before the expansion. In states that opted not to expand the program, the increase was much smaller at 2.8 percent.

Sabrina Corlette, a senior research fellow at the Center on Health Insurance Reforms at Georgetown University, described the difference as "stark," adding, "it suggests that in the Medicaid expansion states, people are accessing the health care system. They are seeing physicians and other prescribers and getting needed drugs."

The report also provided some new details on the overall growth of spending on prescription drugs, which, it said, rose substantially in 2014 — by 13.1 percent, to $373.9 billion. The increase is the highest since 2001 — mainly because of the arrival of expensive new drugs for conditions like hepatitis C, cancer and multiple sclerosis, at the same time that sales eroded less for brand-name drugs because of new competition with generic drugs. Spending on so-called specialty drugs — high-priced treatments that typically treat serious chronic diseases — accounted for one-third of drug spending in 2014, up from 23 percent five years ago.

Last year "was a remarkable year in terms of growth in spending on medicines," said Murray Aitken, executive director of the IMS Institute. But he added that while growth in specialty drug spending was expected to continue, the eye-popping increase in 2014 was unique and spending would most likely not rise as sharply in future years.

The report sheds some light on who enrolled in coverage through the new marketplaces. The IMS Institute found that 70 percent of people who used a marketplace plan to fill a prescription in 2014 had been covered by commercial insurance in 2013, either through an employer or through purchasing an individual plan. Nearly a quarter — 24 percent — paid cash in 2013, meaning they may have been uninsured. In all, the number of prescriptions paid in 2014 with cash declined by 5.5 percent compared to 2013.

Steven Jacobsohn, a retired financial analyst who lives in Manhattan, said his prescription drug coverage improved in 2014, when he switched from individual coverage through EmblemHealth to a less expensive marketplace plan sold by Health Republic. He said two common generic drugs to treat high cholesterol and blood pressure cost $10 a month under his old policy, but were free under the Health Republic plan. "It's a very good plan," said Mr. Jacobsohn, who is 57.

But even as some have seen their options improve, the report found that many are cutting back on prescription drug use and doctor visits. Many marketplace plans — and, increasingly, plans through employers — come with high deductibles and co-payments, forcing some patients to make tough choices.

Over all, patients made 3 percent fewer office visits and had 1.7 percent fewer hospital admissions. They filled slightly more prescriptions — 2.1 percent — but that was mainly driven by the large increases among Medicaid patients, the report found.

Researchers found that patients who took one type of diabetes drug were less likely to take the drug after their own costs reached $30, and even more so when their costs exceeded $125. Patients who had recently changed to a plan with a deductible took their drug for 25 fewer days, on average, compared to those with more comprehensive plans.

Gary Claxton, a vice president at the Kaiser Family Foundation, said it was difficult to generalize about consumers' coverage under high-deductible plans because they can vary widely in how they are set up. Still, he said, previous studies support the idea that "with more cost-sharing, you get less use."

Mr. Jacobsohn counts himself among patients who have let costs drive his health care decisions. Last year, he said, his doctor suggested that he switch from his generic atorvastatin prescription to Crestor, a more expensive brand-name drug, because his cholesterol was too high. When he learned that the Crestor prescription came with a $60 co-payment, Mr. Jacobsohn said he decided to wait six months to give the cheaper drug another chance to work. His cholesterol improved at the next visit and he never switched to Crestor.

"Not that I couldn't afford it," Mr. Jacobsohn said. "I just didn't know if I wanted to pay for it."

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Texas Medical Panel Votes to Limit Telemedicine Practices in State

Taking a stand against the rapidly expanding use of telemedicine, the Texas Medical Board voted Friday to sharply restrict the practice in the state, siding with organizations representing doctors over the objections of industry representatives who said the new rules would reduce access to medical care at a time of increasing demand.

The vote was the latest salvo in a four-year battle between the state board, which licenses and regulates doctors, and Teladoc, a national company based in Dallas that provides telephone or video consultations with doctors on its staff, typically for routine problems like urinary tract infections, sore throats and rashes.

It also comes as companies like Teladoc, helped by enthusiastic investors and rapid advances in technology, are seeking to expand around the country, promoting their services as a convenient, inexpensive alternative to the emergency room, retail clinics or doctors who do not work nights or weekends. Many states are loosening restrictions on telemedicine, and requiring insurers to pay for it, citing doctor shortages and pressure to increase convenient access to medical care, partly because of the Affordable Care Act.

Texas, however, is moving in the opposite direction. The Texas board already required doctors to establish a relationship with patients before giving a diagnosis or prescribing drugs.

But on Friday, it changed its rules to state that "questions and answers exchanged through email, electronic text, or chat or telephonic evaluation of or consultation with a patient" are inadequate to establish a doctor-patient relationship. The move significantly tightens rules that already preclude video consultations except under a narrow set of circumstances.

The Texas Medical Association and other groups representing doctors in the state strongly supported the new restrictions, citing concerns about patient safety. In a letter to the board, the association said it "supports the use of telemedicine that can provide safe, high-quality, timely care," but that safeguards must be in place "to protect patients and ensure telemedicine complements the efforts of local health care providers."

But Jason Gorevic, the chief executive of Teladoc, said in a statement that the new restrictions were "a huge step backward for Texas," eliminating "a safe, affordable and convenient health care option that many have depended on for more than a decade."

The new restrictions do not outright ban telemedicine, however. Doctors will still be able to treat patients by phone or video from another location under certain circumstances. For example, patients will have to be at a hospital or clinic, with a second health care provider there to "assist." The new restrictions do not apply to mental health visits, most likely because of a continuing shortage of psychiatrists.

Telemedicine companies either directly charge consumers a flat fee, typically around $40 per consultation, or contract with employers or insurers to provide the consultations as a covered benefit. But they emphasize that they cannot treat serious problems or medical emergencies, and that they are meant to complement, not replace, people's relationships with their doctors.

"This is going to quickly emerge as one way to relieve the demand pressures that are being put on the system," said Ceci Connolly, managing director of the PriceWaterhouseCoopers Health Research Institute. "We're just getting started."

Texas is among a handful of states that still require an in-person exam before a telemedicine consult can take place, according to the American Telemedicine Association, a trade group in Washington. Other states have vaguely worded policies that are not clear on whether an in-person visit is needed first.

In a recent interview, Mr. Gorevic said Teladoc's national network of 700 board-certified physicians receive special training in how to conduct telemedicine consultations and follow clinical guidelines that are "specific to telehealth." The company, which operates in every state except Arkansas and Idaho, has seen rapid growth in demand for its services, he said, with almost 300,000 consultations last year, double the number in 2013. It has more customers in Texas than in any other state.

The company says its doctors are available 24 hours a day, seven days a week. When a customer requests a consultation by calling or going to the company's website, Mr. Gorevic said, a doctor licensed in the person's state responds within 10 minutes on average. Its doctors do not prescribe narcotics, other controlled substances, or what it refers to as "lifestyle drugs," such as Viagra.

Teladoc's conflict with the medical board started in 2011, when the board threatened to discipline the company's doctors for prescribing drugs to patients they had not seen in person. Teladoc sued, accusing the board of changing its rules without going through the proper process. Late last year, a state appeals court sided with Teladoc, which led the medical board to issue an emergency rule in January. Teladoc won a temporary injunction while the board went through its formal rule-making process over the last few months.

The new restrictions are to take effect in June. Before voting on them, Frank Denton, an investment executive from the Houston area who was the only board member to oppose them, said telemedicine was the "least desirable" way to deliver health care but that "the public should have the right to use that option."

But another board member, Dr. George Willeford of Austin, expressed the opinion of the majority when he said he worried that telemedicine, unless properly regulated, could weaken doctor accountability to patients. "I'm terribly, terribly worried about the absence of responsibility and accountability," he said.

That view was echoed at a public hearing on Thursday by Dr. Steven Yount, a family practice doctor in Bastrop, near Austin, who said that hands-on diagnosis and treatment was essential.

"A patient encounter that from the very get-go removes many of the abilities of a physician to comprehensively look at any given patient is of a lower quality," Dr. Yount said.

But most of about a dozen people who spoke at the hearing, including several Teladoc officials, opposed the change. Bill Hammond, chief executive of the Texas Association of Business, said the restrictions would "drive a stake through the heart" of telemedicine in Texas at a time when thousands of small businesses are looking for innovative solutions to combat rising insurance costs and to provide health care to employees.

"This proposal is bad for business, bad for health care, bad for consumers," Mr. Hammond said.

Correction: April 14, 2015

An article on Saturday about a vote by the Texas Medical Board to limit the use of telemedicine referred incorrectly to Jason Gorevic's role with Teladoc, a national company that provides telephone or video consultations with doctors. While Mr. Gorevic is Teladoc's chief executive, he is not a founder of the company.

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World Briefing: Sierra Leone: Ebola Trial Begins

Graphic: Ending the Ebola Outbreak

Researchers began vaccinating volunteers in Sierra Leone with an experimental Ebola vaccine in a study officially begun on Monday. The trial, the third to begin in the West African countries hardest hit by Ebola, is sponsored by the Centers for Disease Control and Prevention, Sierra Leone's Health Ministry and the University of Sierra Leone's College of Medicine and Allied Health Sciences. Scientists aim to enroll 6,000 health workers. The vaccine, rVSV-EBOV, licensed by Merck and NewLink Genetics, has also undergone testing in Liberia, Guinea, the United States and other countries. Earlier research showed that the vaccine is protective in nonhuman primates, but it has not yet been proved to prevent Ebola in humans. The epidemic is declining in Sierra Leone, which on Monday reported two new cases.

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Well: Christopher McDougall Wants You to Go Outside

Photo Credit Stuart Bradford

The author Christopher McDougall helped make barefoot running mainstream with his best-selling book "Born to Run," a tale about a tribe of endurance runners and an annual 50-mile footrace in the mountains of Mexico.

Now Mr. McDougall returns with another tale that he hopes will again upend the fitness world, this time by getting people out of the sterile gym environment to run, jump, throw and climb outdoors. In his new book, "Natural Born Heroes: How a Band of Misfits Mastered the Lost Secrets of Strength and Endurance," Mr. McDougall writes about the benefits of exercising outdoors on trails, creek beds and rocks, where footholds are uncertain and paths contain obstacles like rocks and fallen trees that need to be climbed or hurdled.

For this month's Well Book Club, I spoke with Mr. McDougall about the problem with indoor fitness routines, what kind of workout he has been doing lately and what it really takes to climb a rope. Here's an edited version of our conversation.

Where did the idea for this book come from?

It came out of "Born to Run," but by accident. I was researching indigenous and ancient runners, and I came across a reference to the Cretan runner. He was a foot messenger during World War II. I put it aside but I was intrigued. What was this guy's story? I circled back and found this whole other fascinating story about people doing these superhuman feats on foot, behind enemy lines, running 40 to 100 miles at a time on a starvation diet.

Achieving that level of fitness seems so unattainable. Is there a lesson here for a regular person?

The big reveal to me was that they're not superhuman at all. Where we have really gone off the rails in our modern concept of the hero is this Hollywood assumption that they are all like Hugh Jackman. In reality, the classic Greek ideal of a hero was a common person. It was a virtue, a responsibility, that every person should be able to develop these natural, very attainable skills to be reliable in a crisis, to be capable of helping someone else out.

What are the skills of a natural-born hero?

It's about developing your natural abilities so you have dexterity for throwing, climbing or crawling. Strength is about using that natural elastic recoil in our body to tap into these latent reservoirs of strength. They are there; we just don't use them.

One of the skills you write about is climbing. Can you tell me more about that?

Kids love to climb. They want to get off the ground all the time. After the age of 5 or 6, we stop practicing the ability to get our bodies off the ground. One of the things I never could do was climb a rope. Climbing a rope is not a muscular challenge; it's a dexterity challenge. I got a 30-foot rope, slung it over a branch in my yard and started studying climbing techniques. Within a day, I was climbing. You trap the rope between your feet. You don't pull yourself up by your arms; you step up with your legs.

Why do you think people have lost these natural abilities for throwing and climbing?

At age 5 or 6, we stick kids in a class and say: "Sit there. Don't move until 3 p.m. and then go home and do homework." We take these physical animals and turn them into sedentary animals. And one of the things I've really come to believe passionately while researching this book is that most recreational sports are created by men for men, and they use male attributes like body strength. But the real skills, the human skills, are the ones where the differences between men and women are the slimmest. Humans have great dexterity and adaptability. Some of the greatest rock climbers in the world are women.

So how should people change their exercise habits in the modern world?

Add things to your workout that you don't think you can do. Try to climb a rope. Walk on all fours. Get outside and do things you're not expecting.

Why is an outdoor workout better than a workout in a gym?

In a gym, you are stationary and artificially balanced. You're on a padded seat, strapped in and isolating one muscle. All of the uncertainty in the range of motion has been stripped away. In the real world when you move, you don't isolate one muscle. We have been trying the stationary machine model for 40 years, and it's failed. It's based on body building. Size was never the goal of the hunter gatherer. You never wanted to be big; you wanted to be mobile and agile.

So many people embraced barefoot running after your first book. What is the ultimate advice in this book?

I think it's that we should be fit to be useful. What's the point of your exercise? Why are you getting big or lifting stuff if it's not useful? Can I use this skill to pick up a child who needs help or use this to pull a rope? There is this group called the November Project. In Boston when they got hit by the blizzard, they got snow shovels and dug out subway stations. How cool is that? They probably got the best workout of their lives, and so many people were benefiting from it.

So what kind of training do you do now?

I've become infatuated by Parkour. People think it's daredeviltry on rooftops, but it's about learning how to shift our body weight and using parts of your body you tend to ignore. I also take my runs off of trails and into creek beds. That uncertain footing allows you to work on agility and nimbleness. An immediate benefit is that it focuses you on the present.

Are there physical challenges that intimidate you? Join the conversation with Christopher McDougall

A version of this article appears in print on 04/14/2015, on page D6 of the NewYork edition with the headline: Workout for an Everyday Hero.

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Well: Doctors and Decision Fatigue

The phenomenon of "decision fatigue" has been found in judges, who are more likely to deny parole at the end of the day than at the beginning. Now researchers have found a parallel effect in physicians: As the day wears on, doctors become increasingly more likely to prescribe antibiotics even when they are not indicated.

For the study, published in JAMA Internal Medicine, scientists analyzed diagnoses of acute respiratory infections in 21,867 cases over 18 months in primary care practices in and near Boston.

In two-thirds of the cases, antibiotics were prescribed even though they were not indicated. But whether they were indicated or not, the number of prescriptions increased with time. Over all, compared to the first hour, the probability of a prescription for antibiotics increased by 1 percent in the second hour, 14 percent in the third hour and 26 percent in the fourth.

"The radical notion here is that doctors are people too," said the lead author, Dr. Jeffrey A. Linder, an associate physician at Brigham and Women's Hospital in Boston, "and we may be fatigued and make worse decisions toward the end of our clinic sessions."

But, he added, the patient can help. "If you want the best care, you should say that you are there to be evaluated, and only want an antibiotic if it's really needed."

Correction: October 29, 2014
A report in the In Brief column on Tuesday about a study that has found that the phenomenon of "decision fatigue" exists in doctors, causing them to prescribe more antibiotics at the end of their shifts than at the beginning, referred incorrectly to the phenomenon in judges. Studies have shown that judges are more likely to deny parole — not bail — at the end of the day than at the beginning.

A version of this article appears in print on 10/28/2014, on page D4 of the NewYork edition with the headline: Nostrums: Prescribing More While Tired.

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Well: Sports Gels Can Improve Marathon Times, but Pace Them Right

Photo Credit Jason Decrow/Associated Press

Many runners in Sunday's New York City Marathon may be overlooking a simple way to improve their finishing time, according to a new study of marathon nutrition. The study finds that consuming the right number of sports gels at the right moments during the race could help average runners achieve better-than-average results.

No one should be surprised to learn that what and when a marathoner eats will affect how well he or she runs. Decades ago, physiologists established that runners who consumed plenty of carbohydrates in the week or so before a race were less likely to become severely fatigued during the grueling event. But the subsequent vogue for carbo-loading by downing large bowls of pasta for days before a marathon has cooled, as newer science and practical experience have shown that carbo-loading can result in short-term weight gain and gastrointestinal distress during the race.

Instead, the best recent studies suggest that eating a carbohydrate-rich diet on the day just before the race but not earlier can be beneficial for marathoners.

Few recent studies, however, had systematically examined how best to fuel during the race itself, and those studies typically had concentrated on elite finishers, not slower, recreational runners.

So, for the new study, which was presented at the International Society of Sports Nutrition Conference in Colorado Springs, scientists at Aalborg University in Denmark turned to 28 local runners who were training for the Copenhagen marathon and asked them about their aspirations for the race, as well as their past running history, including how they previously had fueled and hydrated during races.

The runners, male and female, most in their mid-30s, were experienced but not elite runners. In general, they expected to finish the marathon in a time between three-and-a-half and four hours, they told the scientists.

To more objectively determine their speed and likely finishing times, the scientists asked each runner to complete a 10-kilometer (6.2 mile) race seven weeks before the marathon. Afterward, they numerically paired racers whose times were equivalent, linking the two fastest runners, two slowest, and so on.

Then they divided those pairs, randomly assigning a runner from each unit to one of two groups. The runners in one group were told to fuel and hydrate during the marathon however they chose. The scientists offered them no advice.

They had no such reticence with the second group of runners. These racers were provided with clear, specific directives about how and when to eat and drink during the marathon in order to "avoid dehydration — and overhydration — and depletion of glycogen," which is the body's main fuel during exercise, said Ernst Hansen, an associate professor in the department of health science and technology at Aalborg University, who led the study.

The specific instructions required each runner to consume two sports-gel packets and a glass or two of water 15 or 20 minutes before the start of the race. Each gel packet contained 20 grams, or about 4 teaspoons, of carbohydrates in the form of maltodextrin and glucose, as well as a small amount of sodium and caffeine.

The runners were directed to consume another packet 40 minutes into the race and another every 20 minutes from then on until they crossed the finish line. They were also told to drink a cup or two of water at the race's 10 water stops, in order to stay hydrated and speed digestion of the gels.

All 28 of the runners completed the marathon.

Follow-up questioning by the scientists showed that those runners who had been on their own, nutritionally, consumed significantly fewer carbohydrates (or calories of any kind) during the race than the runners on the scientific program.

Those racers generally finished somewhere near their hoped-for time.

But the runners who followed the scientists' plan and consumed far more carbohydrates finished about 10 minutes faster, on average, than their pace-matched pair, notably outperforming their goals in most cases.

Interestingly, the scientists found no correlation between consuming more carbohydrates and experiencing greater digestive upset. Some runners in each group reported such distress. But those runners generally had a history of gastrointestinal problems while running, the scientists found. Consuming more or fewer carbohydrates did not noticeably affect how the Danish runners' digestive tracts responded.

The study's results do not mean, of course, that all athletes signed up for Sunday's marathon should stuff their pockets with gel packets. The Danish runners in the scientifically mandated nutrition group practiced their eating schedule during training.

If you are unsure how your system might respond to so much goo or you have a history of digestive distress while running, by all means stick with your familiar and practiced nutritional routine, Dr. Hansen said. But otherwise, you might consider eating more during the race, he said, and perhaps finishing faster.

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