Doctor and Patient: When the Doctor Returns to Doctoring

Several years ago, a highly respected medical expert I had just met shared a little-known detail of his illustrious career: as a young doctor, he had stopped practicing medicine for a few years to homeschool his son.

His revelation took me completely by surprise. Doctors rarely talked about taking time off for fear that colleagues would assume them incompetent or in possession of some serious personal flaw.

I understood my colleagues’ hesitation because I always avoided bringing up my own decision to take a professional hiatus.

I had had a harrowing pregnancy, marked by bleeding that worsened anytime I operated. I stopped seeing patients soon after my first trimester and made the decision to extend that break after the birth of healthy twin daughters. But I did so without realizing just how difficult it would be to return.

In all the articles, essays and books on the growing trend among professionals to “opt out” of their careers, doctors, I would discover, remained strangely absent. While the lawyers, accountants, business executives and teachers seemed to ease back into their careers after a few years raising children, attending to their own or loved ones’ health issues or even pursuing entirely new careers, I couldn’t find answers to even my most basic questions. Did I need to be tested, proctored or re-trained? Would I work as an assistant, a doctor-in-training equivalent or a fully trained physician? Were there rules and “industry standards” I needed to pass in order to assure patients I was safe? And in the world of practicing doctors, would the time I spent away from medicine always remain “That-Period-Which-Shall-Not-Be-Named?”

Now, nearly a decade later, studies have shown that more doctors than ever are choosing to take time off, at least twice as many as in previous generations. But while these physicians have more company and support than their predecessors, returning to practice remains daunting in large part because of the persistent stigma. (Interestingly, most of the re-entry doctors I spoke to hesitated or declined to be quoted for this article.)

Although concerns about the competency of returning doctors are justified, the profession’s aversion to discussing the issue and reluctance even to recognize it has had perverse results. There are no national standards for doctors who want to return to clinical practice, only a helter-skelter set of hurdles, hoops and headaches.

“The safety net has big holes in it,” said Dr. Claudette Dalton, the former chair of the American Medical Association’s task force on re-entry who has interrupted her own medical career and re-entered clinical practice twice. For example, roughly half of all the state medical boards, including New York’s, have no policy for doctors attempting to return to clinical practice after an extended period of time away. But even in those states with requirements that range from mandatory completion of an official re-entry training program to passing a written exam, it’s unclear that such policies really do ensure competence. Research on physician re-entry is scarce; and no one really knows when time away begins to affect a doctor’s clinical skills and what might best remediate any deficiencies. Indeed, aside from a few surveys, little is even known about who the re-entering doctors are.

“Our profession needs to be able to reassure patients that the doctor they are seeing knows what he or she is doing and isn’t rusty and creaky like some unoiled door hinge,” Dr. Dalton said.

One particularly promising initiative is a mentored clinical program that slowly re-introduces doctors to practice. At the physician re-entry program at Cedars-Sinai Medical Center in Los Angeles, one of fewer than a dozen such programs throughout the country, re-entering doctors work with three different experienced senior physicians in their field, attend lectures, participate in teaching and work rounds, take call and progressively shoulder more responsibility. At the end of two or three months, the doctors submit to a rigorous exit interview, where they can be drilled on any of the cases they have seen.

Of the 14 doctors who have gone through the Cedars-Sinai program, 13 have successfully returned to practice. But with the costs for such programs ranging from $5,000 to $10,000 a month or more, many doctors cannot even consider enrolling in one even if their state licensing boards mandates them.

“We’ve had a blind spot when it comes to physician re-entry,” said Dr. Leo A. Gordon, who heads the Cedars-Sinai program, “even though it really should be part of the profession’s obligation, especially with the upcoming physician shortage.”

That doctor deficit is expected to surpass 100,000 physicians within the next 15 years. But according to the American Medical Association, at least 10,000 doctors each year are currently looking to return to clinical practice. Re-entry experts believe that these doctors, if successfully returned to practice, could not only help to alleviate the doctor shortage but would do so quickly.

“This is not a seven-year pipeline,” said Dr. Dalton, referring to the usual time required to educate and train a new doctor. “This is a 6-month to a year pipeline at most because a lot of those doctors when assessed could be perfectly fine.”

Although the A.M.A. and a few professional organizations like the American Academy of Pediatrics have increased their efforts to support returning physicians and create national standards, those initiatives will only falter without a major shift in the attitude of the profession itself.

“We have to realize that it’s not about abdicating your profession,” Dr. Dalton said. “It’s about having some sensibility about the priority in your life at a certain moment, then returning to your clinical roots and coming back to serve your profession.”

I have been back in clinical practice for several years now. My path of return was neither obvious nor straightforward, but I have always remained grateful to the doctor who oversaw my re-entry process. He and his colleagues willingly took me on, persisted in putting me through the paces and displayed an unfailing and contagious devotion to the highest standards of care.

Through it all, they understood that stopping working as a doctor temporarily to be a mother never meant I had stopped loving patient care.

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Correction: The head of the Cedars-Sinair re-entry program is Leo A. Gordon, not Leo G. Gordon.

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France Near Deal to Simplify Labor Regulations

PARIS — French labor unions and business leaders appeared close to striking a deal Friday to make it easier to hire and fire employees in France’s notoriously rigid labor market. An accord would tame some of the most confounding rules in the 3,200-page labor code, as the country tries to increase its competitiveness and curb unemployment.

After weeks of sparring among the five major labor unions and the main employers’ lobby, both sides were edging toward a breakthrough that could pave the way for a series of changes that President François Hollande has said are needed to burnish France’s international allure as a place to do business.

Those ambitions were clouded recently by a series of high-profile episodes, including a recent government threat to nationalize an ArcelorMittal plant in northeastern France to preserve jobs. There was also the audacious decision during the past week by the French actor Gérard Depardieu to take Russian citizenship to escape a proposed 75 percent marginal tax rate on incomes of more than €1 million, or €1.3 million.

The labor measures expected to be cemented in the accord still being worked out late Friday would help address what Louis Gallois, Mr. Hollande’s investment commissioner, has dubbed a “two-speed” labor market in France. Under that system, employees on long-term contracts enjoy extensive, costly job protections and benefits, while temporary workers, whose ranks have surged to one-third of the French labor force, have minimal job security and relatively few benefits.

The changes under discussion would include giving employers more flexibility to reduce working hours in times of economic distress without incurring union strikes. High levels of compensation that courts can award to laid-off workers would be trimmed, and the five-year period that ex-employees now have to contest layoffs would be reduced.

In November, the government introduced a tax credit for companies, potentially worth a total of €20 billion, aimed at easing high employment costs.

In exchange, business negotiators on Friday agreed, as a concession to unions, to pay higher taxes for short-term work contracts. Two unions objected that the offer was not enough, a hitch that could still scuttle the talks. But if approved, that move would expand government coffers meant to support the unemployed, while also nudging employers toward favoring long-term contracts. Employers would also pay somewhat higher contributions for private health insurance.

But whether any of the changes, even if nailed down in a binding agreement, will come fast enough to fix France’s problems is an open question. Some economists now say that France could become the next sick man of Europe if it does not improve the environment for investment and hiring.

“Given the gap we still have between the level of labor market regulation in France and in countries like the United States, Britain and Ireland, it is very clear that when observers look at the outcome, they will say it’s a step in the right direction, but not enough,” said Dominique Barbet, the European economist for BNP Paribas in Paris.

“But we also need to keep in mind that in France, if you want to make reforms, you have to go through small steps first,” he said. “You can’t try to change the system overnight. That usually results in mass protests in the streets.”

Mr. Hollande’s government is expected to sign off on the deal. He has said it will help him keep a promise of reducing unemployment, now at a 13-year high of 10.7 percent, by the end of 2013. Youth unemployment is now around 25 percent.

Mr. Hollande sought the accord after Mr. Gallois issued a stark assessment of the French economy in November, saying the country needed a “competitiveness shock” that would require politicians to curb the “cult of regulation” that the Mr. Gallois said was choking business.

Under current labor rules, many entrepreneurs in France hesitate to hire large numbers of workers. Some employers even resort to operating several companies with no more than 49 employees each, instead of running larger ones that employ hundreds.

That is because after the 50th person is hired, a stack of new regulations come into play, including lengthy firing procedures even for underperforming employees, and requirements for numerous union representatives.

Temporary contracts fall on the other end of the scale: they are often lower-paid and offer far fewer protections, something that has alarmed French labor unions. More than 80 percent of new contracts now issued in France are short term, a trend that has grown steadily as employers turn to them to escape the costly rules protecting permanent workers.

Mr. Gallois’s report said that unless France relaxed its labor rules, the country would continue on an industrial decline that had destroyed more than 750,000 jobs in a decade and helped shrink France’s share of exports to the European Union to 9.3 percent from 12.7 percent. The report also called for cuts to a variety of business taxes used to pay for government and France’s expensive social safety net.

The International Monetary Fund in December warned that France needed to lift competitiveness or risk rising unemployment. Because of continued impediments in the functioning of labor and product markets, the fund added, French companies were earning lower profit margins than in other European countries, in turn affecting the ability of enterprises to invest and innovate.

While the impact of such changes will take time, France has already taken a series of steps that could help it skirt the worst in coming years. A fiscal consolidation begun in 2010 is continuing, in which tax increases and spending cuts are being applied to bring the overall budget deficit down to 3 percent of gross domestic product in 2013, from an estimated 4.5 percent in 2012.

The economy is expected to grow about 0.4 percent in 2013, according to the I.M.F.

“What’s most important is that France get an economic recovery,” said Mr. Barbet, of BNP Paribas. “If we don’t have that, people won’t hire no matter what the new labor rules are.”

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Blasts in Pakistan Kill at Least 88 and Raise Fears Over Elections

Waheed Khan/European Pressphoto Agency

The worst violence was concentrated in the southwestern city of Quetta, where two explosions killed at least 57 people and wounded more than 110, the police said.

ISLAMABAD, Pakistan — Bomb blasts in two Pakistani cities killed at least 88 people on Thursday and wounded more than 270, offering harrowing evidence of how the country’s myriad internal conflicts may destabilize it as elections approach.

The worst violence was concentrated in the southwestern city of Quetta, where two explosions a few minutes apart in the evening ripped through a billiards hall in a neighborhood dominated by ethnic Hazara Shiites, killing at least 57 people and wounding more than 110, the police said.

A suicide bomber detonated his explosives inside the hall, and a second attacker then blew up his vehicle outside the club as police officers and journalists arrived, a senior police officer, Mir Zubair Mehmood, told reporters. The television channel Samaa said one of its camera operators was killed by the second explosion after rushing to the scene. Hospitals were overwhelmed as casualties arrived through the evening.

Quetta is no stranger to sectarian, nationalist and Islamist violence. Most violence against Shiites there has been directed by Lashkar-e-Jhangvi, a Sunni militant group with strong ties to the Pakistani Taliban. But there was no immediate claim of responsibility for the billiard hall attack.

An ethnic Baluch separatist group claimed responsibility for another bombing earlier on Thursday, aimed at paramilitary soldiers in a commercial part of Quetta, which killed 12 people.

The Hazara, minority Shiites who migrated from Afghanistan more than a century ago, have been the target of dozens of attacks from sectarian death squads led by Lashkar-e-Jhangvi in Quetta over the past year, but the billiard hall attack was by far the bloodiest.

Human rights activists said the police and the security forces failed to protect the vulnerable community. “The callousness and indifference of authorities offers a damning indictment of the state, its military and security agencies,” said Ali Dayan Hasan, the Pakistan director at Human Rights Watch.

The other focus of violence on Thursday was the Swat Valley, in the Hindu Kush mountains in northwestern Pakistan, where an explosion in the basement of a religious seminary killed at least 22 people and wounded an additional 60. It was not clear why the seminary, run by the Islamic missionary group Tableeghi Jamaat, was a target.

Initial reports said a gas leak had caused the explosion, but police and hospital officials later said that there was clear evidence of a bomb.

Doctors at a hospital in Saidu Sharif, near the site, said blast victims were being treated for wounds caused by ball bearings, which are sometimes packed into suicide bombs to make them more deadly.

“There was a smell of explosives,” Muhammad Iqbal, a senior doctor, said by telephone.

The violence underscores the fragility of state authority in parts of Pakistan as the country prepares for a general election that analysts say is likely to take place before June. Many Pakistanis worry that increasing instability could cause the elections to be postponed.

Islamist violence in Swat drew international condemnation in October after Taliban gunmen shot a teenage schoolgirl and education activist, Malala Yousafzai. The episode highlighted how Islamist fighters were slowly returning to the valley three years after a Pakistani military operation drove them away.

Ismail Khan contributed reporting from Peshawar, Pakistan.

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2 Years Into Its Turnaround, Nokia Shows Promise

BERLIN — Nearly two years ago, Stephen Elop, fresh from a senior post at Microsoft, spoke of flaming ocean platforms and shark-infested waters to describe the competitive climate he inherited at Nokia, the erstwhile leader in mobile phones that was then teetering on the brink of irrelevance.

Mr. Elop, an affable Canadian engineer, painted the bleak outlook as he prescribed a radical cure on the once-proud Finnish mobile phone pioneer: The rejection of the company’s own Symbian smartphone operating system for a shotgun collaboration with Microsoft, itself stumbling badly in the sector.

On Thursday, the Nokia chief executive delivered the biggest news from the Finnish company since he started the last-ditch transformation: Nokia may be on its way back.

Thanks in part to an all-out marketing push, sales of its new smartphone line, the Lumia, powered by Microsoft’s Windows Phone operating system, soared more than 50 percent in the fourth quarter of last year, leading Nokia to an unexpected profit. Thanks largely to demand for its newest models, Nokia had to correct its financial forecasts — upward.

In what was seen as a make-or-break quarter, Mr. Elop was able to tell investors that Nokia would break even or turn a 2 percent profit rather than report a loss as large as 10 percent.

“While we definitely experienced some tough challenges in the first half of 2012, we are managing through these issues,” Mr. Elop said during a conference call with journalists.

What Nokia has accomplished under Mr. Elop, whose professional future is tied to resuscitating the company, is to produce a line of increasingly competitive smartphones that are starting to draw favorable comparisons with Samsung and Apple, the two companies most responsible for knocking Nokia from its lofty perch, according to analysts.

“The Lumia smartphones are night-and-day different from Nokia’s old Symbian handsets,” said Francisco Jeronimo, an analyst in London at International Data Corp. “I think what we are starting to see now is what will be a steady turnaround in Nokia’s fortunes.”

The company, which dominated the cellphone business until Apple introduced its iPhone in 2007, still has a long way to go to approach its former stature. In the third quarter, Nokia had just a 4 percent share of the global smartphone market, and was a distant No.10 in the sector, trailing the not-so-illustrious likes of LG and ZTE, among others, according to Strategy Analytics, a research firm.

Samsung and Apple, the No.1 and No.2 smartphone makers, together had 50 percent of the global smartphone market, and their shares were growing. While its competitors rose, Nokia has generated nearly €5 billion, or $6.5 billion, in losses under Mr. Elop, and eliminated of a third of its work force.

In October, Microsoft introduced the Windows Phone 8, the operating system that would be used in the top-of-the-line Lumia 920 and 820. Since then, Nokia has spent heavily on advertising in Britain and Europe to promote the models. The company will not disclose how much it had spent on its campaign, but its television ads were ubiquitous over the holidays, said Neil Mawston, an analyst at Strategy Analytics in London.

The heavy promotion, which was aided by Microsoft, whose own mobile strategy is intimately tied up with Nokia’s, has helped the company recapture some of its lost glory, Mr. Mawston said.

But Mr. Mawston warned that “Nokia still lacks the true killer phone that will enable it to compete with the iPhone 5 or Samsung Galaxy S III.”

Mr. Mawston said he expected Nokia’s share of the global smartphone market to rise to 6 percent by the end of the year.

The company’s financial position is likely to revive even more quickly as a result of the strict cost-cutting imposed by Mr. Elop, who used to run Microsoft’s business software division before coming to Nokia in late 2010.

Mr. Elop has eliminated a third of Nokia’s work force and shut factories across Europe. Last month, Nokia even sold its 540,000 square-foot, or 50,000 square-meter, glass-and-wood headquarters in the Helsinki suburb of Espoo to Finnish investors, and leased it back. The maneuver netted Nokia €170 million.

Besides a more competitive array of phones, Nokia has discarded its market-leader mentality. Employees are now routinely traveling in economy class and sharing rides to airports. Workers no longer use costly telephone conference calling but speak in group teleconferences using less expensive Internet calling services.

“The company is a lot smaller now but people are working better together,” said Susan Sheehan, a Nokia spokeswoman. “Everyone has been pitching in.”

Even at Nokia Siemens, the company’s long-suffering network equipment venture, the future is looking brighter than it was two years ago. On Thursday, Nokia said the unit, which contributes about 40 percent of its total sales, would report an operating profit for the third quarter, its third straight quarterly profit.

Nokia, in its information to investors, even revised the operating profit forecast at the venture to 13 percent to 15 percent of sales, up from a range of 4 percent to 12 percent.

Looking ahead, Nokia said it expected to return to an operating loss of 2 percent of sales in the first quarter amid the post-holiday buying lull and harsh competition. But the results for the coming three months could vary widely, Nokia warned, from an even bigger 6 percent operating loss to a 2 percent profit.

Pete Cunningham, an analyst at Canalys, a research firm in Reading, England, said that Nokia’s improving financial position was a positive step but that the company still faced challenges.

“On face value, this is a positive for Nokia,” Mr. Cunningham said. “But 2013 could still turn out to be another very difficult year for Nokia. It is way too premature to say that the company has made a turnaround.”

Mr. Cunningham said he used the Lumia 920, Nokia’s newest smartphone, during the Christmas holidays and liked the experience.

“But the more I used the phone, the more apparent it became to me that there are big gaps between Lumia and its competitors in terms of the functionality and usability of its apps,” Mr. Cunningham said. “I still think there is a lot of work to be done on Lumia.”

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City Room: How Are You Warding Off the Flu?

Sure, you could go out and get a flu shot like everyone keeps telling you to do. It’s relatively cheap, and available just about everywhere.

But the shot is not 100 percent effective. And it takes two weeks to kick in. Although influenza can be deadly, some have been making light of the virus’s symptoms.

On the bright side, having the flu was a great start to my spring break diet.. eating nothing and still managing to puke

— Allison (@Ally_YM) 6 Jan 13

Turns out I don’t have the flu, I just really like NyQuil and hate wearing pants.

— NYC Blonde (@NYC_Blonde) 10 Jan 13

If you’re holding out, or procrastinating, or have decided against getting vaccinated altogether, what alternative means are you using to keep those bad bugs away? Comment in the box below.

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City Room: How Are You Warding Off the Flu?

Sure, you could go out and get a flu shot like everyone keeps telling you to do. It’s relatively cheap, and available just about everywhere.

But the shot is not 100 percent effective. And it takes two weeks to kick in. Although influenza can be deadly, some have been making light of the virus’s symptoms.

On the bright side, having the flu was a great start to my spring break diet.. eating nothing and still managing to puke

— Allison (@Ally_YM) 6 Jan 13

Turns out I don’t have the flu, I just really like NyQuil and hate wearing pants.

— NYC Blonde (@NYC_Blonde) 10 Jan 13

If you’re holding out, or procrastinating, or have decided against getting vaccinated altogether, what alternative means are you using to keep those bad bugs away? Comment in the box below.

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Sharp Words From European Minister for Countries in North

BRUSSELS — Jean-Claude Juncker, the departing leader of the group of ministers who oversee the euro currency, sharply criticized northern Europeans on Thursday for demanding austerity budgets from their southern neighbors.

But in the same speech he seemed to endorse as his successor an official from the Netherlands, one of countries that has made the toughest demands for fiscal rigor in the euro zone.

Mr. Juncker, himself a northern European and prime minister of Luxembourg, told members of the European Parliament’s influential Economic and Monetary Affairs Committee that northerners had falsely painted themselves as more economically virtuous than southerners. “I’m totally against this distinction,” he said.

Mr. Juncker warned that some members of his own country’s Parliament had become fed up with “the German diktat,” and he said countries making painful economic adjustments should be rewarded for their efforts.

“We have been arrogant” toward countries like Greece, he said.

Still, Mr. Juncker said his successor as head of the Eurogroup of ministers would speak one of the languages of the Benelux, a grouping that includes Belgium, the Netherlands and Luxembourg. Mr. Juncker’s comments were characteristically cryptic, but appeared to lend weight to the chances of the front-runner for the job, Jeroen Dijsselbloem, the Dutch finance minister.

The president of the Eurogroup plays a coordinating role among finance ministers when they make critical decisions like giving political approval for bailouts or pressuring governments to shore up their finances to preserve the stability of the euro. Mr. Juncker has held the post since 2005; although his term expired last summer, he indicated he would stay on for a limited time until a successor was named.

At a news conference Thursday, Mr. Juncker said a decision on his successor should be made on, or shortly after, Jan. 21, because that would be the last meeting of the Eurogroup at which he would serve as president.

Although the president of the Eurogroup is supposed to be elected by ministers, as a practical matter is decided by consensus among governments, opening the way for political horse-trading.

Mr. Dijsselbloem’s candidacy gained strength in recent weeks partly because he comes from a country that still holds a triple-A debt rating, making him a natural ally of Germany. But his candidacy is more problematic for the French, the other major power in the euro area.

The government led by President François Hollande has emphasized giving the most vulnerable members of the euro area the leeway to make painful economic adjustments. By contrast, the Netherlands, along with Germany and Finland, has pressed indebted nations like Greece and Portugal to tighten their belts, despite the recessionary effect on their economies.

One factor that could help the French swing in support of Mr. Dijsselbloem, a member of the Dutch Labor Party, is that he, like Mr. Hollande, is a socialist.

Meanwhile, for the soon-to-be created single banking supervisory agency for the euro zone, Mr. Juncker suggested Thursday that a Frenchwoman could be offered a senior role. And although Mr. Juncker again did not offer names, there are reports in the French news media that Danièle Nouy, an official at the Banque de France, could be offered such a role, partly to assuage French concerns.

Mr. Dijsselbloem, 46, won the finance portfolio, his first Netherlands cabinet post, late last year, and he has little experience at the top levels of government or in European affairs. But he did take office in time to participate in a round of marathon meetings by finance ministers to strike agreements on resuming aid to Greece and the creation of the single banking supervisor.

“I suppose he is suitable as he wouldn’t be finance minister,” said Sophie in ‘t Veld, a Dutch member of the European Parliament for the Democrats 66, a liberal and pro-European political party.

“But how is he going to navigate between the deeply euro-skeptic electorate and a deeply euro-skeptic Parliament that will expect him to be a troublemaker in Europe and, on the other hand, show compromise and consensus as the head of the Eurogroup?” she asked.

Mr. Dijsselbloem told the Dutch daily newspaper De Volkskrant at the end of December that he regarded “strengthening European cooperation inevitable and good for the Netherlands.” But he also cautioned that, “when it comes to Greece, for example, everyone looks to the Netherlands and we have to take the floor” and that, “from us, from Germany and Finland, it’s expected that we exhibit some strictness.”

That, though, is an approach that Mr. Juncker on Thursday cautioned his successor against taking. For countries like Greece and Portugal facing brutal austerity, he said, there should be rewards for meeting targets and “not only a big stick.”

Mr. Juncker also called for euro area countries to adopt a legal minimum wage so as not “to lose the support of the working classes.”

And in a marked contrast to the stance of some Dutch politicians, Mr. Juncker suggested that countries like Spain and Ireland should have some scope for using European bailout funds to bail out their banks directly. Otherwise, said Mr. Juncker, the purpose of the bailout fund “would lose a large part of its sense.”

For his part, Mr. Juncker said at the news conference that he would concentrate on winning another term as the prime minister of Luxembourg and use that perch to continue to play a role in European affairs.

“You will hear from me,” he said.

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Global Update: China Moves to Prevent Spread of Yellow Fever From Africa

In a move that underlines how many Chinese citizens now work in Africa, China’s quarantine officials recently urged greater efforts to make sure that a yellow fever epidemic now raging in Sudan does not come back to China.

Local health authorities were asked to scan all travelers arriving from Sudan for fevers. Chinese citizens planning travel to Sudan were advised to get yellow fever shots. Customs officers were told that containers arriving from Sudan might have stray infected mosquitoes inside.

Sudan’s epidemic is considered the world’s worst in 20 years. Sweden, Britain and other donors have paid for vaccinations. The United States Navy’s laboratory in Egypt has helped with diagnoses.

Estimates of the number of Chinese working in Africa, many in the oil and mining industries or on major construction projects, range from 500,000 to 1 million. Experts on AIDS have previously warned that the workers could become a new means of bringing that disease to China, which has a low H.I.V.-infection rate.

ProMED-mail, a Web site that follows emerging diseases, has tracked reports about the Sudan outbreak, with its moderators adding valuable context. China’s mosquito-killing winters make a large yellow fever outbreak there unlikely, moderators said. But Sudan’s containment efforts are troubled. For example, vaccinated people cannot get cards proving they have had shots, but the cards are reported to be for sale at police checkpoints.

Australia’s now-endemic dengue fever, according to ProMED moderators, may have come from mosquitoes arriving in containers from East Timor.

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Baseball Dumping Dugout-to-Bullpen Landlines

The reserve clause is dead. And so are wool uniforms. There are no longer eight teams in each league. And the Houston Astros have departed the National League.

 Major League Baseball is now about to disconnect the landlines that link dugouts to bullpens. Long after the rest of society embraced cellphones, managers and coaches will soon be able to discuss pitching changes on Samsung Galaxy S III phones.

The 21st-century 4G dugout-to-bullpen connection that is being created by T-Mobile USA as part of its wireless sponsorship with Major League Baseball was announced Tuesday at the International Consumer Electronics Show in Las Vegas.

 “This is baseball’s continued push into the digital age,” said Tim Brosnan, Major League Baseball’s executive vice president for business. “It’s also about a very aggressive wireless provider that sought us out to create this unique communications platform.”

Baseball had not thought of a dugout-to-bullpen phone system in its talks with various wireless providers about a national sponsorship over the past decade, Brosnan said.

The wireless system will be tested at the World Baseball Classic in Arizona in March. After assessing how it works and fixing any problems, baseball will roll it out in the major leagues. Whether each stadium will have it in 2013 has not been determined.

T-Mobile’s sponsorship plans also include enhancing network connectivity for fans at all ballparks and helping MLB Advanced Media create content for smartphones and tablets.

To create the dugout-to-bullpen communications system, each ballpark will get the equivalent of a small cellular system with a miniature cell tower.

But while wireless companies like T-Mobile are continuously trying to broaden their national coverage territory, the dugout-to-bullpen system will have limits enforced by a technology called geo-fencing. So, managers and pitching coaches will not be able to chat with the bullpen coach from the pitcher’s mound. And bullpen coaches cannot ask, “Can you hear me now?” once they leave the bullpen’s environs.

“The guidance we’ve been given is that we shouldn’t fundamentally change what makes baseball baseball,” said Mark McDiarmid, T-Mobile’s vice president for engineering. “There is reason to be cautious about how far the coach could move away from the dugout before the umpires might think it’s inappropriate.”

Baseball is not shifting to cellphones because of an incident during the eighth inning of Game 5 of the 2011 World Series when the noise at Rangers Ballpark in Arlington caused Derek Lilliquist, the Cardinals’ bullpen coach, to misunderstand Manager Tony La Russa’s instructions about which relievers should start warming up.

Twice, La Russa asked that Jason Motte get up. Lilliquist apparently did not hear the first request. When La Russa called again to get Motte ready, Lilliquist thought he was asking for Lance Lynn. The miscommunication led to La Russa’s surprise when he summoned a right-hander and Lynn arrived at the mound, not Motte. Lynn stayed in long enough to issue an intentional walk; Motte quickly got ready and replaced him.

Lilliquist might well have heard La Russa’s instructions if they had used the cellphone system, with multiple microphones, noise mitigation and the ability to raise audio levels.

 Given T-Mobile’s investment over the next three years, it is not surprising that each dugout’s branded cellphone docking station — about the size of a personal computer tower — will be about as visible to TV cameras as the Gatorade vessel is.

But, Brosnan said, baseball has not ordained the obvious commercial tie-in: that each call to the bullpen on Fox, ESPN and TBS’s national telecasts be sponsored by T-Mobile.

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Pap Test May Prove Useful at Detecting More Types of Cancer, Study Suggests

The Pap test, which has prevented countless deaths from cervical cancer, may eventually help to detect cancers of the uterus and ovaries as well, a new study suggests.

For the first time, researchers have found genetic material from uterine or ovarian cancers in Pap smears, meaning that it may become possible to detect three diseases with just one routine test.

But the research is early, years away from being used in medical practice, and there are caveats. The women studied were already known to have cancer, and while the Pap test found 100 percent of the uterine cancers, it detected only 41 percent of the ovarian cancers. And the approach has not yet been tried in women who appear healthy, to determine whether it can find early signs of uterine or ovarian cancer.

On the other hand, even a 41 percent detection rate would be better than the status quo in ovarian cancer, particularly if the detection extends to early stages. The disease is usually advanced by the time it is found, and survival is poor. About 22,280 new cases were expected in the United States in 2012, and 15,500 deaths. Improved tests are urgently needed.

Uterine cancer has a better prognosis, but still kills around 8,000 women a year in the United States.

These innovative applications of the Pap test are part of a new era in which advances in genetics are being applied to the detection of a wide variety of cancers or precancerous conditions. Scientists are learning to find minute bits of mutant DNA in tissue samples or bodily fluids that may signal the presence of hidden or incipient cancers. Ideally, the new techniques would find the abnormalities early enough to cure the disease or even prevent it entirely. But it is too soon to tell.

“Is this the harbinger of things to come? I would answer yes,” said Dr. Bert Vogelstein, director of the Ludwig Center for Cancer Genetics and Therapeutics at Johns Hopkins University, and a senior author of a report on the Pap test study published on Wednesday in the journal Science Translational Medicine. He said the genomes of more than 50 types of tumors had been sequenced, and researchers were trying to take advantage of the information.

Similar studies are under way or are being considered to look for mutant DNA in blood, stool, urine and sputum, both to detect cancer and also to monitor the response to treatment in people who already have the disease.

But researchers warn that such tests, used for screening, can be a double-edged sword if they give false positive results that send patients down a rabbit hole of invasive tests and needless treatments. Even a test that finds only real cancers may be unable to tell aggressive, dangerous ones apart from indolent ones that might never do any harm, leaving patients to decide whether to watch and wait or to go through surgery, chemotherapy and radiation with all the associated risks and side effects.

“Will they start recovering mutations that are not cancer-related?” asked Dr. Christopher P. Crum, a professor at Harvard Medical School who was not involved in the research.

But he also called the study a “great proof of principle,” and said, “Any whisper of hope to women who suffer from endometrial or ovarian cancer would be most welcome.”

DNA testing is already performed on samples from Pap tests, to look for the human papillomavirus, or HPV, which causes cervical cancer. Dr. Vogelstein and his team decided to try DNA testing for cancer. They theorized that cells or DNA shed from cancers of the ovaries and the uterine lining, or endometrium, might reach the cervix and turn up in Pap smears.

The team picked common mutations found in these cancers, and looked for them in tumor samples from 24 women with endometrial cancer and 22 with ovarian cancer. All the cancers had one or more of the common mutations.

Then, the researchers performed Pap tests on the same women, and looked for the same DNA mutations in the Pap specimens. They found the mutations in 100 percent of the women with endometrial cancer, but in only 9 of the 22 with ovarian cancer. The test identified two of the four ovarian cancers that had been diagnosed at an early stage.

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