DC Medical Malpractice & Patient Safety Blog

Last year we blogged about the popularity of medical smartphone applications and referred to an investigation showing that the quality of much of the health information available via these apps is questionable.

That’s why although health apps might be fun and even informative, no one should rely solely on them for sound scientific diagnosis or treatment. Last month, the FDA reinforced this idea when it flagged an iPhone app as the first target for establishing regulatory boundaries for mobile medical diagnoses.

As reported by Bloomberg.com, uChek, a smartphone app enabling users to check levels of blood, protein and other substances in their urine, was not approved by the FDA; the feds sent a letter of inquiry to Biosense Technologies, the app’s developer, seeking specific data about how the system works. It was the first such medical device letter directed to a smartphone app developer.

App users, such as people with diabetes who want to check their glucose, dip a test strip in their urine then use the phone’s camera to read the result via a small automated device that generates a value. The test strips are made by Siemens and Bayer, and are approved only for visual, not digital, review. The FDA’s letter, reports Bloomberg, says that the automated reading requires separate approval as a medical device.

As we blogged last year, the proposed FDA standards for mobile device apps that diagnose or treat conditions remain under Congressional review. Proponents of regulation want to set app standards similar to those for other medical devices like heart stents and ultrasound equipment. A spokeswoman for the FDA told Bloomberg that “We intend to finalize the guidance this year. The FDA has proposed a regulatory approach that limits its immediate oversight to a specific, small subset of mobile medical applications that are medical devices and present the greatest risk to patient safety if they don’t work as intended.”

The uChek app became available earlier this year. It’s free, but users must purchase the test strips and the $40 automated reader. In its letter to Biosense, the FDA said the company might need to gain approval for the whole system, not just the app.

Depending on how the company responds to the FDA letter, Bloomberg says, the agency might follow up with a stronger warning enumerating specific violations of the law that must be addressed immediately.

If you want to learn more about health and medicine apps for mobile devices, visit iMedicalApps, where health-care professionals assess various products by app type, medical specialty and app name.

Another new resource for assessing the value of medical mobile device apps is Happtique, whose Health App Certification Program (HACP) is meant to advise both providers and consumers on apps that deliver credible content and protect user data.

Who hasn’t Googled some medical or health topic? And who hasn’t wondered if the information they found is true, useful and relates to them?

A recent survey by the Pew Internet & American Life Project asked more than 3,000 Americans about their online searches for information about their health issues to find out what they’re doing with the stuff they find.

As reported on MedCityNews.com, more than 7 in 10 telephone respondents were described as “online health seekers,” meaning they said they had looked for some kind of health information online in the last year. Of those who did, nearly 6 in 10 were described as “online diagnosers.” They weren’t just curious, they were goal-oriented—their reason for searching online was to figure out what medical condition they or someone they knew had.

According to the survey, about 35 in 100 U.S. adults are “online diagnosers,” and women are more likely to join that club than men.

That’s good in the sense that people need to be actively involved in their health care in order to get the most out of the system and to get the best outcome, but when does curiosity overtake good sense? What’s the risk of medical searchers serving as their own doctors?

Not much, the survey seemed to say.

Slightly more than half of the online diagnosers, MedCity News reported, said they consulted with a medical professional about what they found online. More than 4 in 10 said a medical professional confirmed or partially confirmed the information they found online. Nearly 2 in 10 said they consulted a medical professional who did not agree or couldn’t come to a conclusion.

Of course, said MedCityNews, “We can’t assume that everyone who claimed her doctor backed up his suspicions was truly able to ‘diagnose’ herself accurately using just information from the Web. …. We also don’t know that all of those physician diagnoses were accurate.”

Pew’s mission was to measure the scope of how medical information online is being used; its intention wasn’t to measure the quality of the information.

But the real message of the survey is that despite a robust interest in finding health info online and applying it—or not—to one’s own situation, 7 in 10 respondents still consulted a medical profession when they had a health issue.

And it’s interesting to note that since 2000, when Pew began tracking online health searches, half of the searchers aren’t online diagnosers—they’re looking for information on behalf of someone else.

And pay walls are significant barriers to searchers—1 in 4 respondents said they hit a pay wall during their search, but only 2 in 100 paid to get the information. The rest looked elsewhere or gave up.

The most popular topics for information seekers who weren’t online diagnosers were: specific medical treatments and procedures (See our blog, “Where to Go for Information About Medical Screening Tests”); weight loss; and health insurance. One in 5 reviewed specific drug information, doctors or hospitals.

Pew concluded that although the Internet is a popular and increasingly important tool for health-care consumers, most conversations about health and medicine still occur among live participants in a setting that’s real, not virtual.

Americans love technology. We love our iPods, our tablets and our smartphones. At the swipe of a finger, we can map a route, make a reservation, buy a pair of boots and, now, cure what ails us.

Or can we?

Published in the Washington Post, an investigation by the New England Center for Investigative Reporting not only calls into question the quality of much of the health information available via phone app, but sounds an alert about the risks of such “flimsy science.”

As the story notes, “When the iTunes store began offering apps that used cellphone light to cure acne, federal investigators knew that hucksters had found a new spot in cyberspace.” The Federal Trade Commission (FTC) shuttered two such apps, and the FDA is now grappling with how to regulate the industry. “[B]oth the iTunes store and the Google Play store are riddled with health apps that experts say do not work and in some cases could even endanger people,” the story says.

Who wouldn’t jump at the chance to lose weight, relieve arthritis pain, cure a stutter with a quick-fix treatment delivered on your phone? But if the prescription isn’t based on established medical practice and tested by professional researchers whose work is reviewed by their peers, like traditional medical interventions, their patients are, at best, delaying appropriate treatment, and, at worst, threatening their health.

The cost of health apps range from minimal (or free) to hundreds of dollars. The Center reviewed 1,500 health apps available since mid-2011; more than 1 in 5 claimed to treat or cure a medical problem. More than 4 in 10 of the 331 therapeutic apps relied on cellphone sound; 12 required the light from the phone; 2 used phone vibrations. “Scientists say none of these methods could possible work for the conditions in question,” the story says.

The Center makes clear that many outstanding health apps are available, especially for health-care providers. For example, the story recommends:

• Lose It for weight loss;


• Azumio to measure heart rates;


• iTriage to check symptoms and locate hospitals with the shortest emergency room wait times.

But in the absence of government oversight and objective testing of product claims, patients have no way to confirm the useful from the bogus. Reliance on product promotion and online reviews are hardly the gold standard of standards. But, really, common sense is all you need to assess most of these tools.

Satish Misra, a physician at Johns Hopkins Hospital and the managing editor of iMedicalApps, which reviews medical and health-care apps, told the Center that he’s concerned most about apps that claim to test or treat people for serious diseases. Not only can they give inaccurate information, they can encourage patients to ignore symptoms they shouldn’t.

Cardiac Stress Test is once such app, according to the Center. It promises to clear you to participate in sports or not after you do 30 squats in less than a minute, then enter your heart rate into the calculator. As Misra notes, assessing cardiac status is more complicated than just computing heart rate.

In the case of the “cure acne with your cellphone light,” the FTC “false or misleading” charge reflected this product claim: “Rest the iPhone against your skin’s acne-prone areas for two minutes daily to improve skin health without prescription drugs.” Still, according to the FTC, the app was downloaded 11,600 times.

Other apps advise the use of cellphone lights to treat seasonal affective disorder (SAD), a type of depression that strikes in the low light of winter. Although SAD is treated with light therapy, people who treat the disorder, according to the story, say cellphone lights are far too weak to treat depression. Even its manufacturers know they’re dishing out a load of bunk: There’s a disclaimer on the iTunes site that reads, “IMPORTANT. The iSAD Lamp is meant for entertainment purposes … We are not responsible for any misuse or failure.”

Talk about entertainment—Breast Augmentation is positively laughable. It’s based on the fact that breast-feeding women have larger breasts. Duh … they’re filled with milk. But the app claims that women can become better endowed by listening to the sounds of a crying baby at least 20 times a day.

Neither Apple nor Google would discuss with Center reporters their apps or app development. Apple’s guidelines for app developers, according to the story, “say it will reject apps that crash, have bugs, do not perform as advertised or are sexually explicit.” Google’s guidelines ban “sexually explicit material, gratuitous violence or anything that may damage users’ devices.”

In bureaucracy-as-usual, proposed FDA regulations requiring health apps to get government approval are mired in debates, hearings and deep-thinking about whether government oversight would stifle innovation

If you want to learn more about a health app, visit iMedicalApps, an online resource for both medical professionals and patients. Its producers are health-care professionals with no commercial app interests. They follow strict conflict-of-interest policies in order to provide an unbiased view of mobile medical technology.

Another resource identified by the Center, Happtique, comes from the Greater New York Hospital Association. Once launched, it will be the first app certification service for evaluating safety and effectiveness.

Who doesn’t like a good deal? The popularity of Groupon, the online deal-of-the-hour/day/week service has spawned a whole family of mimics. Unfortunately, suggests Gary Schwitzer on Health News Review, it’s a dysfunctional family when it comes to dubious medical treatments.

In the space of mere days, irresistible deals were available for:

• laser toenail fungus treatment;


• MRI for “headache prevention screening”;


• -lipolaser treatments;


• botox;


• B12 injections or allergy test.

Never mind that the evidence for lasers eradicating toenail fungus is sketchy, that the claim that an MRI can prevent headaches is positively ludicrous and the lipolaser might be performed by a guy with less training than your dentist.

But Schwitzer was amused most by an offer from Living Social for Colon Hydrotherapy:

“The foliage may be in bloom outside, but if you’re feeling less than fresh inside, today’s deal could help you stem the problem: Pay $35 and get one colon hydrotherapy session (a $75 value). Colon hydrotherapy is a safe, effective method of cleansing the large intestine using water instead of drugs. The gentle infusion of warm filtered water moves naturally through your large intestine, leaving you feeling cleansed and refreshed. The treatment is safe, quick and pain-free. The certified staff uses an advanced state-of-the-art technology to provide you with natural wellness therapies. Don’t be a shrinking violet — nab today’s deal before it goes to seed.”

Commented one guy on the Health News Review site, “Personally, I await the Groupon lobotomy offer…”

Absent pernicious anemia, almost no one needs injections of B12. And no one’s colon is crying out for cleansing. But … got a coupon for hype eradication? We’re in!

Because the effects of nicotine are deadly, because cigarettes are so addictive (some research indicates it’s harder to kick nicotine than it is heroin), any and all efforts should be made to quit smoking.

In trying to wean themselves off of “cancer sticks,” many people turn to nicotine replacement in the form of patches that deliver minute amounts of the chemical compound over time, or via chewing gum, inhalers or nasal spray. But a study released last week indicates that these measures aren’t what they’re cracked up to be.

As widely reported, a study of 787 adults who had quit smoking within the previous two years showed that nearly more than 3 in 10 had relapsed. Subjects who had used nicotine patches, gum, inhalers or nasal sprays were just as likely to relapse as those who had quit without them.

Published in the journal Tobacco Control, the findings contradict the results of several randomized clinical trials conducted before the FDA approved the nicotine replacement products. In those trials, subjects using the replacement products were as much as three times more likely than those who didn’t to kick the smoking habit.

“This may indicate that some heavily dependent smokers perceive NRT [nicotine replacement therapy] as a sort of ‘magic’ pill, and upon realizing it is not, they find themselves without support in their quitting efforts, doomed to failure,” the researchers wrote.

As you might expect, the product manufacturers found fault with the study. They claimed that most of the adults in the study who used nicotine replacement products failed to use them for the recommended eight weeks.

If you’re among the Americans who collectively spend more than $1.5 billion on nicotine replacements every year and still can’t stop smoking, the researchers say it might be a function of time—you have a better chance of staying clean if you’re smoke-free for at least six months. And professional counseling is helpful too, although there’s no guarantee of success.

The one guarantee is that those who do quit smoking feel better, and almost every part of their bodies will show its appreciation for taking away the poison.

Today's news has two reminders of why statisticians are our friends and allies when it comes to getting the right health care and avoiding dangerous and over-hyped treatments.

The headlines:

* Hormone replacement therapy after menopause not only increases the risk of getting breast cancer, but also makes the cancer more deadly. Details here.

* Taking a daily fish oil supplement in pregnancy doesn't make babies any smarter. Details here.

The arc of both stories is similar, and that's no coincidence.

Act One: Medical scientists develop a new treatment that, based on then current knowledge, should work.

In hormone therapy, the idea was that estrogen protected women from heart and blood vessel disease. This was based on a statistical notion -- since proven false -- that there was a big jump in heart attacks and similar disease after menopause, which must mean (so it was thought) that the drying up of estrogen in the body with menopause was depriving the body of a natural protectant.

In fish oil, the idea came from observations that DHA, a key fish oil ingredient, is naturally transmitted to a fetus in the last half of pregnancy and is important to brain development. And premature babies, born with low supplies of DHA, did better in some studies if they received DHA supplements in the first few months of life.

Act Two: Hopeful "observational" studies are published. These involve dozens to hundreds of patients and have very favorable results for the treatment in question.

Act Three: Manufacturers make big bucks pumping the treatment in question.

Act Four: Medical scientists do the hard work of large-scale studies where patients are "randomized" to the real treatment versus a dummy (placebo) treatment.

This takes years of carefully following patients and comparing outcomes.

Act Five: Enter the statisticians.

They come in, crunch the numbers and discover: It doesn't work (see today's fish oil study) or worse, it causes a lot of harm too (today's hormone story).

What's the lesson for the rest of us? As I wrote a few days ago on this blog, it pays to be skeptical of medical research findings, particularly when hyped by commercial interests.

Most people hear about research in the Act One, Two or Three stages.

If you wait till the story plays out in Acts Four and Five, you'll be less disillusioned, and safer and wiser too.

It's such a relief to get a family member home from the hospital that many of us don't realize how crucial the next few weeks are in making sure the patient stays home and gets healthy. Hospitals don't always help the situation by giving out confusing and cryptic discharge instructions.

For this especially vulnerable time, patients and their family caregivers need to be very clear -- before leaving the hospital -- on the following key areas:

1. Is professional therapy needed? Physical therapy, occupational therapy, wound care and other types of care can sometimes be managed at home, as long as you have a caregiver willing to come to the house. If not, the patient may need to go to a transitional place first: a nursing home or rehab facility.

2. When is the next doctor appointment and who with? Don't leave the hospital without a specific appointment with the patient's primary care doctor. The hospital should help set up this appointment. The sooner after discharge this visit happens, the better the patient's odds of avoiding a readmission to the hospital.

3. What medicines need to be taken, and when? Insist on a specific list that takes into account whatever the patient was taking before the hospital stay and also whatever they need now.

4. Who do we call with any problems? The hospital's discharge instructions need to list a contact name and number, and also should say the types of problems that are worth a call.

5. What else do we need to do? If a family member is expected to give care -- like changing a dressing or helping the patient to walk -- make sure those instructions are precise and in writing.

The bottom line on all the above is that family members, especially when it involves an elderly patient, need to be very very clear on everything they need to know and do.

Here is a downloadable model form of a written discharge instruction sheet. This is from the Society of Hospital Medicine, a group of doctors who specialize in hospital care. Patients and families can use this template to make sure there are no gaps in what they need to know for a successful transition home.

Did you know that rupture of an Achilles tendon can be fatal? This common injury has one potentially fatal but preventable complication: a blood clot can develop in the calf while the leg is immobilized for healing of the injury, and if the clot gets big enough, it can travel to the heart and cause what is called a pulmonary embolism.

The Achilles tendon is the ligament that connects the calf muscles to the heel bone. When it ruptures, the patient must have the calf immobilized for several weeks. That can cause blood clots in as many as three in ten patients, because calf muscles when they flex act as a pump to help bring blood back toward the heart. Immobilized calf muscles allow the blood to pool in the deep veins of the leg and potentially clot.

Samuel Burton, a retired Coast Guard captain, died of such a clot, and a distinguished federal judge recently decided the death should not have happened. Judge Royce Lamberth, chief judge of the U.S. District Court for the District of Columbia, ruled that orthopedic surgeons at Walter Reed Army Medical Center had committed malpractice by failing to warn Capt. Burton when they were treating his Achilles tendon rupture about the risks of this blood clot and what he should do if he developed any of the symptoms of a clot.

When Capt. Burton died, his widow was shocked to learn from the medical examiner who performed the autopsy that two episodes of chest pain and shortness of breath, which Captain Burton had experienced in the weeks before his death, were signs of a potential pulmonary embolism. None of the doctors at Walter Reed had ever warned Captain Burton or his wife of this possible deadly complication and what to watch out for. She sued the government for medical malpractice under the Federal Tort Claims Act. After a trial, Judge Lamberth issued a verdict in favor of the widow, and he ordered the government to pay her $2,080,000. Judge Lamberth concluded that if the doctors had properly educated the patient and his wife, they were responsible people who would have appreciated the need to get to a hospital for treatment before it was too late. Both Captain Burton and his wife had assumed that his two episodes of pain and windedness were from deconditioning because he had resumed some physical activities after being off his feet for weeks.

The judge rejected Walter Reed's defense that since statistics showed that only about one in one hundred Achilles rupture patients died of pulmonary embolism, they didn't need to be warned about the risk.

Captain Burton's family was represented in their medical malpractice case by Patrick Malone & Associates.

Read the judge's decision here.

Acetaminophen, the unpronounceable name for the active ingredient in Tylenol, is the most widely used pain reliever in the United States. But it can destroy the liver in ordinary or near-ordinary doses. That fact is news to many consumers but is old hat to liver specialists who every week treat patients at death's door from acute liver failure due to acetaminophen.

It has now been documented that acetaminophen is the most common cause in the U.S. of acute liver failure, which can result in death if a liver transplant cannot be done.

The Food and Drug Administration has recognized that acetaminophen poisoning is a public health issue and has slowly taken steps to educate the public to this popular drug's dangers. In April 2009, the FDA mandated a new warning label, which will say on 500-mg products (Extra Strength Tylenol and its generic equivalents): “Liver warning: This product contains acetaminophen. Severe liver damage may occur if you take more than eight tablets in 24 hours, the maximum daily amount.” It will also warn against using it with other acetaminophen products or with alcohol use of three or more drinks a day. The FDA rejected a request from the Tylenol manufacturer McNeil to water down the warning by removing the word “severe” and adding the word “overdose,” which the agency said could lead consumers to believe they had to greatly exceed the recommended dosage before jeopardizing their livers.

This warning won't take effect until spring 2010. FDA advisors first recommended such a liver warning in 1977.

In the meantime, an FDA advisory panel will meet in late June to consider other steps intended to make it harder to accidentally cause liver failure from taking too much acetaminophen. A "working group" of advisors has recommended among other things:

• limiting the single adult dose to a maximum of 650 mg, and limiting tablet size to 325 mg (down from the current extra-strength size of 500 mg and single dose of 1000 mg);
• lowering the maximum daily dose for adults from 4000 mg to no greater than 3250 mg (and less than that for chronic alcohol users);
• restricting pediatric liquid formulations to a single mid-strength concentration;
• eliminating acetaminophen from combination products.

You can read the working group's recommendations at the FDA's web site here.

In the 1990s, Patrick Malone was one of the first attorneys in the United States to successfully sue the Tylenol manufacturer for hiding the dangers of acetaminophen from doctors and the public. Read about his case of Benedi v. McNeil here. Watch the ABC Prime Time Live segment on this subject by clicking here.

Nobody wants to go home from the hospital only to be readmitted within a few weeks. But that revolving door is very common in conditions like heart failure, where the patient's heart muscle doesn't pump effectively after it has been weakened by heart attack or other heart disease.

The open secret of the hospital industry is that the financial incentives of Medicare and private insurers are tilted toward keeping that revolving door going. Hospitals that actually invest money in following patients after they leave the hospital to try to keep them healthy find that they lose money on this follow-up care. Reed Abelson of the New York Times wrote a report describing how progressive hospitals that have tried to keep their patients from readmission have lost millions of dollars in the process. Those include the Park Nicollet Health Services in Minnesota and Catholic Healthcare Partners in Cincinnati.

One lesson from this story is that patients don't have to wait for medical payment reform to get better care and avoid the revolving door. If you or someone in your family has heart failure, here are the early warning signs that symptoms may be worsening and a doctor or nurse should be called:

* Weight gain. Patients need to weigh themselves every day. Sudden weight gain often means a buildup of fluids caused by the heart not pumping effectively.

* Shortness of breath. Fluid buildup often is most apparent in the lungs and is signaled by being out of breath.

* Ankle swelling. Another place where fluid buildup can be spotted early.

A phone call to the nurse can result in an adjustment of medication that may ease the problem. If that doesn't work, a visit to the doctor's office might be in order. The goal is to intervene before a crisis develops and you have to be rushed to the hospital in an ambulance.

If your doctor already has a system in place that helps you monitor yourself at home, that means you have a top-quality doctor. If you have a hard time getting such a monitoring system going with your doctor, then it might be time to switch to someone who is more responsive.

Patrick Malone discusses how to find a top primary care doctor in his new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst

Getting a loved one home from the hospital is always a relief for both patient and family, but the weeks immediately after hospital discharge are fraught with peril, as many families don't discover until the patient has to be readmitted for a new problem. This is especially common with Medicare patients: an alarming one in five Medicare patients are back in the hospital within thirty days, and one in three are readmitted within ninety days. Fully half of the non-surgical patients who have to be readmitted in the first month after going home had no followup visit with any doctor during that same month. That means the patients were basically set adrift to fend for themselves. These numbers come from an analysis published in the New England Journal of Medicine, as reported in an editorial in the New York Times.

Leaders in the health care field freely admit that hospital readmissions come about from poor discharge planning and inadequate communication with family members about what they need to do to keep the patient healthy. The president of the American Hospital Association said in a letter to The Times about the editorial: "Most unplanned readmissions can be traced back to our fragmented delivery system, and to the lack of social support programs for many elderly and sick patients."

What is the answer?

Family members who are assigned by hospitals to take care of a loved one at home need to be very clear on what they are supposed to do. Do not let a family member be dumped on your lap without a clear, written list of everything they need, including medications, therapies, and appointments for return visits. Family members need a lifeline they can call on when things don't seem to be going right.

The leaders of our health care system are talking about extending Medicare benefits so that nurse managers can coordinate the transition from hospital to home, or teams of caregivers can conduct house calls on recently discharged patients. These are promising ideas, but what is needed right now is for anyone who has a family member coming home from the hospital to speak up and insist on clear instructions and advice. Being forceful and clear can help the caregivers help you to make sure there is a well thought out plan and that you can realistically carry it out.

Patrick Malone's new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, has a chapter on how family members can become effective patient advocates when they have someone in the hospital. The chapter includes a list of key checkoff points that you need to understand when a loved one is discharged to your care. You need to have at a minimum:

* A written set of discharge instructions.

* A specific appointment with the doctor in charge for a followup visit.

* A list of bad things to watch out for, and the contact person to relay this information to.

* Written lists of all medications that need to be taken, when and how; plus all therapies that need to be done with similar detailed instructions.

In a newly released Thomson Reuters survey, one in five respondents say they have delayed medical care, and one in four of those who did listed financial cost as the primary reason, reports Maggie Fox of Reuters. The survey also predicted that in the next three months, one in every five adults in America will have difficulty paying for health insurance or health care.

The data show a significantly higher number of Americans putting off healthcare than in 2006, when the same question was asked in a survey. Leaders of the study associate this increase with growing number of Americans losing employer-sponsored health insurance.

The study leader Gary Pickens predicted that America’s “collective well-being” will be hurt if people continue to delay necessary treatments.

If you find yourself unable to afford healthcare or health insurance, check with your state and local agencies to see if you are eligible for Medicaid or other forms of financial assistance. Pharmaceutical companies often have programs for uninsured patients. Additional resources may be available: Walgreens, for example, recently announced that its Take Care program will offer free routine clinic services for the uninsured and unemployed.

One of the true pioneers of modern medicine is Dr. Thomas Sarzl, who performed the first liver transplant and who developed many of the procedures that have made transplantation a safe lifesaving treatment for thousands of people.

Dr. Sarzl is still active at age 83. He was interviewed recently by another transplant surgeon, Dr. Pauline Chen, for her column in the New York Times.

From his many years of experience, Dr. Starzl gave three nuggets of advice to patients, which I am reprinting because I think he is right on target:

"As for the patients," he told Dr. Chen, "I would give this advice — I followed it myself. That is to get a practitioner of general medicine to take care of you, somebody who is not a narrow specialist. And have that person take care of yourself and the people you care for most, your family. The second is to be constantly learning so you can be informed and have some judgment about advice you are given. And then the third item would be to get a second opinion if some really significant thing happens that requires drastic therapy. Those decisions are so important that I think you should get a second opinion if you come to a point where you need the treatment required for cancer or transplantation or catastrophic indications."

My new book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," makes some of these same points. For example, Step Three of my "nine steps" says: "Team up with the best primary care doctor you can find." And Chapter 9 is titled: "The Second Opinion: Always Your First Choice."

Everybody knows that close friendships can be wonderful, and medical researchers are now coming up with tangible evidence that friendship can pay off in longer and healthier lives as well.

"Friendship has a bigger impact on our psychological well-being than family relationships," says sociologist Rebecca Adams of the University of North Carolina, Greensboro. She was quoted in an article by Tara Parker-Pope in the New York Times.

Ms. Parker-Pope's article was inspired by a book, "The Girls from Ames: A Story of Women and a 40-Year Friendship." Author Jeffrey Zaslow documents how eleven childhood friends from Iowa continued to nurture and sustain each other, including two of them who recently learned they had breast cancer.

Researchers have found that friendship has an even greater effect on health than being married or having family members nearby. No one is quite sure what it is about friendship that sustains people, but perhaps what we all take heart from is the idea that "we're all in this together."

As if there is not already a multitude of problems awaiting those who lead an inactive lifestyle, researchers recently found yet another inactivity-related condition that threatens human health, a condition called non-alcoholic fatty liver disease (NAFLD), according to Medical News Today.

In an article published in The Journal of Physiology, Dr. John Thyfault of the University of Missouri reports his research group’s findings that established a link between low aerobic fitness level and fatty liver disease. His group carefully bred two groups of rats of different levels of intrinsic aerobic capacity, so that after 17 generations the rats in the “fit” group can run 1500 meters, whereas the “unfit” rats can undertake only 200 meters.

Rats in the “fit” group normally live healthy lives, even though they are not more active than those in the unfit group. However, those in the “unfit” group often display clear symptoms of NAFLD, including fibrosis, which is a form of liver damage seen in alcohol abuse patients.

Fatty liver disease causes fat deposit in patients’ livers and elevated levels of fat in their blood. The “unfit” rats in Thyfault’s study also were found to have poor fat processing power. These effects together result in high fat retention in patients, making them prone to obesity and its related risks of heart disease, strokes and diabetes.

Widely hailed for saving lives through early detection of breast cancer, mammography may in fact “do more harm than good,” writes Roni Rabin of the New York Times. Rabin reports that British health care advocates and experts complained in a letter to The Times of London that candidates for mammography receive informational fliers that exaggerate the exam’s benefits and neglect to advise patients of potential harms.

Mammography detects cancers indiscriminatingly, picking up aggressive tumors as well as those so slow-growing that they present no health risks for women who have them. As a result, for every woman saved from deadly breast cancer by routine mammography, at least one other woman would have her life unnecessarily disrupted by overtreatment of a slow-growing cancer that’s not life-threatening.

Mammograms also often result in "false positive" reports which scare women who think the test has shown they have a deadly cancer when further testing shows they have no disease. This is particularly a problem when mammograms are used in low-risk groups like women under age 50.

Further, early detection of the deadly form of breast cancer may not necessarily be life-saving, says Dr. Ned Calonge, chairman of the United States Preventive Services Task Force, which writes consensus reports on all sorts of screening tests, because the cancers are too aggressive to treat even when found early.

In addition to unnecessary emotional distress and extraneous treatment and related costs, other potential harms of mammography include exposure to radiation during the exam.

On the other hand, many doctors, including the director of cancer screening for the American Cancer Society, still believe mammography should be recommended to women of normal risks for breast cancer (e.g. over 50 years of age, family history of the cancer), preferring overdiagnosis to delayed diagnosis.

Before a more definite conclusion is reached within the scientific community, patients should educate themselves about the benefits and harms of mammography, because the ultimate decision of whether to be screened is in their own hands.

A study published in February 2009 in the Journal of the National Cancer Institute reports that low levels of alcohol consumption may be responsible for about 5% of cancers in American women (or 30,000 cases a year), Thomas Maugh writes in a Los Angeles Times story. This newfound risk of low or moderate consumption of alcohol may offset its cardiovascular benefits.

For more than seven years, the British-led research followed more than 1 million women between ages of 45 and 75. That is one in every four U.K. women in their age group. The study found that “[h]aving a daily drink was associated with 11 additional breast cancers per year per 1,000 women, one additional cancer of the oral cavity and pharynx, one additional cancer of the rectum, and 0.7 additional cases each for esophageal, laryngeal and liver cancers.” Two drinks a day doubles the cancer rates, and a third drink triples the figure.

Leader of this research, Naomi E. Allen of the University of Oxford, thinks it’s too soon to draw a conclusion on whether women should abandon their daily drinks. Allen is working on a separate study of potential cardiovascular benefits using the same group of study subjects, which she and other scientists hope will bring the overall benefits and risks of alcohol consumption to light.

Do large doses of vitamins really help ward off health problems, including insomnia, fatigue, digestive disorders, and impaired immune system? A number of recent scientific studies challenge the long-held popular belief in the disease-preventing power of vitamin pills, which cost Americans $23 billion a year, Tara Parker-Pope reports in a New York Times article.

A study published last October showed that taking vitamin E or selenium does not prevent prostate cancer. In a separate study in November, scientists found that neither vitamin E nor vitamin C reduces the risk for cardiovascular diseases for men. Most recently, Women’s Health Initiative released a report in February 2009 that found no connection between vitamin usage and prevention of cancer or heart disease in women.

Not only have scientists discovered that, contrary to public belief, vitamins generally do not prevent or treat diseases, they found harmful effects of vitamin pills – beta carotene users are at greater risk for lung cancer, and those who take folic acid are more likely to have precancerous polyps than those who don’t.

If high doses of vitamin pills aren’t proven to prevent diseases and can potentially be harmful to our health, where else do we turn to avoid vitamin deficiency? Dr. Peter Gann, professor and director of research at the University of Illinois at Chicago, suggests a healthful and balanced diet that includes whole fruits or vegetables, since “[there] may not be a single component of broccoli or green leafy vegetables that is responsible for the health benefits.”

The American public should not throw out their vitamins just yet. Researchers are still studying the benefits of high doses of some promising vitamin extracts, for example, Vitamin D’s potential in reducing risks for cancer. But they again warn that “[w]e should wait for large-scale clinical trials before jumping on the vitamin bandwagon and taking high doses.”

In a recent initiative against contaminated weight-loss products, the FDA finds 69 drugs to be contaminated with prescription drugs and chemicals, and expects the list of brands to grow even longer in the next few weeks, reports Natasha Singer of the New York Times. A complete list of the tainted drugs found so far is available on FDA’s website.

One of the best known drugs on FDA’s list is StarCaps, endorsed by many celebrities, which was found to be tainted with bumentanide, a powerful diuretic that can give rise to serious side effects. FDA’s Michael Levy said that many of the products “either contain dangerous undeclared ingredients or…have no effect at all.”

These weight-loss products are not only illegal – FDA considers a supplement unapproved if it contains an undeclared active pharmaceutical ingredient – they also pose dangerous risks for consumers. For one thing, the ingredients on their own can cause problems like elevated blood pressure or seizures. Worse, the hidden ingredients can have toxic interactions with other medications, making it difficult for doctors to diagnose patients or manage their illnesses.

Although many of the distributors of these 69 drugs have voluntarily recalled the products, others continue to sell them on the internet. Consumers taking weight-loss supplements should monitor FDA’s growing list of products they should avoid and consult their doctors for a healthy and safe weight management plan.

One of the less common forms of cancer, oral cancer was diagnosed in about 35,300 Americans last year and caused the death of 7,600 people. Although oral cancer is one of the easiest to detect and diagnose, the five-year survival rate is only 59%, and more than 60% of cases are diagnosed in the late, incurable stages – which may be a result of people not regularly visiting their dentists or not asking to have visual exams, reports Laurie Tarkan of the New York Times.

The most effective way to screen for oral cancer is to carefully look for it. The dentist or dental hygienist should examine the cheeks, the gums, the floor of the mouth, the area behind the teeth, the palate and the tonsil area (pulling the tongue forward), and should feel the lymph nodes of the neck. Such visual exams are found to reduce mortality by 34% in a study done in India. Emerging on the market are alternative tests and devices that may be more sensitive than the traditional visual exams. However, no decisive study has been done to prove that the more expensive tests are necessarily better.

Dentists encourage patients to get a thorough visual exam every year, and they recommend it not only to the high-risk groups (smokers and heavy drinkers) but to every adult, because oral cancer has recently been linked to oral HPV, which is transmitted through oral sex.

In 2008 alone, more than a million Americans underwent various coronary procedures, including balloon angioplasty and coronary artery bypass surgery. However, while these expensive measures can be lifesaving for some, they do not necessarily do a better job at protecting most people’s hearts than a heart-healthy lifestyle would, Jane Brody writes in the New York Times. Essentially, the surgeries are like “‘doing cosmetic surgery on coronary arteries, making them look pretty, but it’s not treating the underlying biology of these arteries,’” Brody quotes the Miami cardiologist and author, Dr. Michael Ozner.

Dr. Ozner is an advocate of preventive coronary care, which he believes is safer, less costly, and more effective than intervention. Interventional cardiology that involves invasive coronary procedures has become lucrative for hospitals and doctors, costing $60 billion a year in the U.S. But such procedures have not been proven to “prevent heart attacks or coronary mortality in most patients.” Worse, they may even be harmful; Brody quotes a 2006 report revealing that the stents inserted in angioplasty can elevate the chance that “a dangerous clot will form in a coronary artery.”

So how do patients find out whether they are candidates for invasive coronary procedures? Dr. Ozner, who authored “The Great American Heart Hoax,” urges patients to seek an independent second opinion if their doctors recommend surgery to them. He said that “unstable patients” who have symptoms that really warrant surgical interventions are those who are in the middle of a heart attack or those with severe chest pain from minimal exertion. If you do not experience any chest pains or cardiac symptoms, you likely do not need surgery on your heart.

Brody writes in the second of her two columns on coronary care about the alternative treatments of the heart. Many of these preventive measures have been well-established and are widely known: selecting foods that are found in the Mediterranean diet (rich in fish oil, nuts, seeds, vegetables and fruits), maintaining good dental hygiene (gum diseases are linked to chronic inflammation), reducing chronic stress (with adequate sleep and regular relaxation activities), and exercising regularly (only 15 minutes of exercise a day for five days a week can make a lot of difference).

People who follow these tips can reduce their risks for heart problems by up to 50%, while avoiding the costly and risky surgeries that have yet to be proven to prevent coronary deaths.

An online service called inSPOT allows patients who test positive for STDs to use a website to notify sexual partners, anonymously if they so choose, of the possibility that the partners were infected. A report done by the San Francisco Department of Public Health finds that since 2004, 30,000 people have used the service to send 50,000 notifications of all sorts of diseases contracted through sexual activity.

This project has enormous potential health benefits because embarrassment and a desire to remain anonymous are factors that can prevent people from notifying past sexual partners of their risk of contracting the disease. Of course, as Dr. Richard Rothenberg of Georgia State University notes in the article, it is difficult to track the effects of the project because of confidentiality issues. Nevertheless, the project is valuable:

However, it may be difficult, if not impossible, to study the impact on health because the service is confidential, Rothenberg said. "I think we, and the authors, must be content with the idea that this appears to be an acceptable method to fulfill the moral imperative of notification, and it has a chance to be a better approach than what we currently do," he said.

Tara Parker-Pope at the NY Times Well Blog has an article about how patients can cope with the vast flood of information (and misinformation) that is now available to them through the Internet.

Nowadays, people can look up their symptoms, self-diagnose certain conditions, find studies about the efficacy of various treatments, and find out what the medical community's consensus opinion is on a wide range of issues--all things that they once relied on doctors for.

Dr. Marisa Weiss, a breast oncologist quoted in the article, points out that doing independent research before a doctor's appointment has become mandatory because doctors have less and less time for patients. So it's in the patients' best interests to come in some idea of what's going on, so they can communicate what they've learned to their doctors and the appointment will proceed with more efficiency.

However, coping with so much information can be a puzzling experience. The article lists several helpful suggestions, such as considering what mental impact doing the research will have on you, exploring non-Internet sources, using your research as a supplement to your doctor rather than as a complete replacement, and other such useful tips. The whole thing is worth a read.

The Washington Post has a thorough and informative article on HealthCentral Network, an online start-up based in Arlington that gives curious readers information on health issues and forums where they can discuss ailments with others.

The site also has a system where visitors can find doctors or patients blogging about their illnesses. The owners of HealthCentral hope that providing a platform for this kind of independent research, communication and socialization will prove to be a good business proposition. They believe it will set them apart from other online health sites. Their hope is that, as more and more readers with health questions use their sites, drug companies will flock to advertise on HealthCentral's pages.

The Washington Post article is worth reading for its descriptions of and quotations from HealthCentral's visitors, which give insight into why people find this type of website useful.