U.S. Judges Offer Addicts a Way to Avoid Prison

Todd Heisler/The New York Times

Emily Leitch of Brooklyn, with her son, Nazir, 4, was arrested for importing cocaine but went to “drug court” to avoid prison.

Federal judges around the country are teaming up with prosecutors to create special treatment programs for drug-addicted defendants who would otherwise face significant prison time, an effort intended to sidestep drug laws widely seen as inflexible and overly punitive.

The Justice Department has tentatively embraced the new approach, allowing United States attorneys to reduce or even dismiss charges in some drug cases.

The effort follows decades of success for “drug courts” at the state level, which legal experts have long cited as a less expensive and more effective alternative to prison for dealing with many low-level repeat offenders.

But it is striking that the model is spreading at the federal level, where judges have increasingly pushed back against rules that restrict their ability to make their own determination of appropriate sentences.

So far, federal judges have instituted programs in California, Connecticut, Illinois, New Hampshire, New York, South Carolina, Virginia and Washington. About 400 defendants have been involved nationwide.

In Federal District Court in Brooklyn on Thursday, Judge John Gleeson issued an opinion praising the new approach as a way to address swelling prison costs and disproportionate sentences for drug trafficking.

“Presentence programs like ours and those in other districts mean that a growing number of courts are no longer reflexively sentencing federal defendants who do not belong in prison to the costly prison terms recommended by the sentencing guidelines,” Judge Gleeson wrote.

The opinion came a year after Judge Gleeson, with the federal agency known as Pretrial Services, started a program that made achieving sobriety an incentive for drug-addicted defendants to avoid prison. The program had its first graduate this year: Emily Leitch, a Brooklyn woman with a long history of substance abuse who was arrested entering the country at Kennedy International Airport with over 13 kilograms of cocaine, about 30 pounds, in her luggage.

“I want to thank the federal government for giving me a chance,” Ms. Leitch said. “I always wanted to stand up as a sober person.”

The new approach is being prompted in part by the Obama administration, which previously supported legislation that scaled back sentences for crimes involving crack cocaine. The Justice Department has supported additional changes to the federal sentencing guidelines to permit the use of drug or mental health treatment as an alternative to incarceration for certain low-level offenders and changed its own policies to make those options more available.

“We recognize that imprisonment alone is not a complete strategy for reducing crime,” James M. Cole, the deputy attorney general, said in a statement. “Drug courts, re-entry courts and other related programs along with enforcement are all part of the solution.”

For nearly 30 years, the United States Sentencing Commission has established guidelines for sentencing, a role it was given in 1984 after studies found that federal judges were giving defendants widely varying sentences for similar crimes. The commission’s recommendations are approved by Congress, causing judges to bristle at what they consider interference with their judicial independence.

“When you impose a sentence that you believe is unjust, it is a very difficult thing to do,” Stefan R. Underhill, a federal judge in Connecticut, said in an interview. “It feels wrong.”

The development of drug courts may meet resistance from some Republicans in Congress.

“It is important that courts give deference to Congressional authority over sentencing,” Representative F. James Sensenbrenner Jr., Republican of Wisconsin, a member and former chairman of the Judiciary Committee, said in a statement. He said sentencing should not depend “on what judge happens to decide the case or what judicial circuit the defendant happens to be in.”

At the state level, pretrial drug courts have benefited from bipartisan support, with liberals supporting the programs as more focused on rehabilitation, and conservatives supporting them as a way to cut spending.

Under the model being used in state and federal courts, defendants must accept responsibility for their crimes and agree to receive drug treatment and other social services and attend regular meetings with judges who monitor their progress. In return for successful participation, they receive a reduced sentence or no jail time at all. If they fail, they are sent to prison.

The drug court option is not available to those facing more serious charges, like people accused of being high-level dealers or traffickers, or accused of a violent crime. (These programs differ from re-entry drug courts, which federal judges have long used to help offenders integrate into society after prison.)

In interviews, the federal judges who run the other programs pointed to a mix of reasons for their involvement.

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Economix Blog: Bernanke Defends Stimulus as Necessary and Effective

The Federal Reserve’s chairman, Ben S. Bernanke, picked an unusual time to offer his most recent defense of the Fed’s campaign to stimulate the economy: 7 p.m. on a Friday night in San Francisco, 10 p.m. back home on the East Coast.

The basic message was the same as Mr. Bernanke delivered to Congress earlier this week: The Fed regards its current efforts as necessary and effective, and the risks, while real, are under control.

“Commentators have raised two broad concerns surrounding the outlook for long-term rates,” Mr. Bernanke told a conference at the Federal Reserve Bank of San Francisco. “To oversimplify, the first risk is that rates will remain low, and the second is that they will not.”

If rates remain low, it may drive investors to take excessive risks. If rates jump, investors could lose money – not least the Fed.

Regarding the first possibility, Mr. Bernanke said that the Fed was keeping a careful eye on financial markets. But he noted that rates were low in large part because the economy was weak, and that keeping rates low was the best way to encourage stronger growth. “Premature rate increases would carry a high risk of short-circuiting the recovery, possibly leading — ironically enough — to an even longer period of low long- term rates,” he said.

At the other extreme, Mr. Bernanke said the Fed could “mitigate” any jump in rates by prolonging its efforts to hold rates down, for example by keeping some of its investments in Treasury and mortgage-backed securities.

Three more highlights from the question-and-answer session after the speech.

1. Mr. Bernanke, asked about the outlook for the Washington Nationals, responded by accurately quoting the “Las Vegas odds” of a World Series appearance: 8/1.

2. Although the decision may be made under a future chairman, Mr. Bernanke said the Fed should continue to offer “forward guidance” — predicting its policies — even after it concludes its long effort to revive the economy.

“Providing information about the future path of policy could be useful, probably would be useful, under even normal circumstances,” he said in response to a question. “I think we need to keep providing information.”

3. Not surprisingly, Mr. Bernanke often is asked to reflect on the financial crisis. He offered something a little different than his normal response on Friday night.

“In many ways, in retrospect, the crisis was a normal crisis,” he said. “It’s just that the intuitional framework in which it occurred was much more complex.”

In other words, there was a panic, and a run, and a collapse – but rather than a run on bank deposits, the run was in the money markets. Improving the stability of those markets is something regulators have yet to accomplish.

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India Ink: The Truthers of Pakistan

“As the security situation in Pakistan continues to deteriorate, trading conspiracy theories has become the new national pastime,” Huma Yusuf wrote in the Latitude Blog, “nothing is more popular on the airwaves, at dinner parties or around tea stalls than to speculate, especially about American activities on Pakistani soil.”

These rumors include speculations about the role of Indian spy agency R.A.W., which some Pakistani officials claim “funds and arms the Pakistani Taliban.”

Ms. Yusuf attributes this “penchant for conspiracy theories” partly to decades of military rule. “Mostly, however,” she wrote, “conspiracy theories persist because many turn out to be true.”

Read more »

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Media Decoder Blog: Barnes & Noble Rethinks Its Strategy for the Nook

7:15 p.m. | Updated Barnes & Noble, reporting a sharp drop in sales of its Nook tablets, said on Thursday that it would pull back on its ambitions for its device business, shrinking it in size while focusing more on digital content.

Calling Nook sales over the holiday period an “obvious disappointment,” the bookseller’s chief executive, William Lynch, said the company was taking “significant actions to right size investments” in its digital hardware division through steep cuts in advertising and the manufacturing of devices. Mr. Lynch made his remarks in a conference call with analysts shortly after Barnes & Noble reported a 26 percent decline in the fiscal third quarter for the Nook segment, which includes digital tablets and e-readers.

The retrenching of the Nook unit represents a setback to the Barnes & Noble plan to build up its device business as a way of staying competitive in the rapidly changing e-book market. Last year, the company separated the division from the rest of its operations and struck deals with Microsoft and Pearson for hundreds of millions of dollars in financing — signs that it viewed its digital business as the linchpin of future growth.

But the Nook, while drawing favorable reviews, failed to gain traction against more popular tablets like Amazon’s Kindle Fire and Apple’s iPad, and its performance over the 2012 holiday season was tepid. Barnes & Noble warned last month that Nook sales for the quarter would fall below expectations, and executives hinted recently that the strategy of operating in the highly competitive tablet space had run its course.

“The Nook is not a failure, not technically,” said James McQuivey, an analyst at Forrester Research. “If you go back two years and ask the Nook product managers how many Nooks they would want to sell by now, I bet they have blown past that number. The problem is the fact that the overall tablet market has actually blown way past the Nook’s performance.”

While saying that Barnes & Noble remained committed to the tablet and e-reader market, Mr. Lynch said the company would adjust its strategy quickly. “We are not going to continue doing what we’re doing,” he said in the conference call.

The results announced Thursday underscored the challenges. The company said that Nook revenue declined to $316 million for the quarter that ended Jan. 26, from $426 million over the same period a year ago. Losses in the unit increased to $190 million, from $83 million last year, as measured before interest, taxes, depreciation and amortization.

Over all, the company had a net loss in the quarter of just over $6 million, compared with net income of $52 million a year ago. Revenue in all three major units — Nook, retail and college — was down.

The losses were largely because of lower-than-anticipated sales, inventory charges and higher operating expenses because of advertising costs, the company said.

Mr. Lynch said Thursday that a reformulated Nook strategy would focus more on digital content like e-books and magazines, sales of which increased by 6.8 percent in the quarter. He also said the company planned to be a leader in “digital education” and that it expected that to be a growth area.

In the call with analysts, Mr. Lynch was pressed on whether Barnes & Noble’s digital content was really proprietary. Mr. Lynch acknowledged that what the bookseller possessed was the ability to sell publishers’ content, but he insisted that it was “a strategic asset that is hard to replicate.”

Wall Street seemed heartened by the company’s acknowledgment that it needed to recalibrate its device business, perhaps anticipating that it would accelerate a breakup of the device and retail units. Shares of Barnes & Noble rose 3.35 percent, to close at $15.74.

The company said that there was clear evidence that digital trade book sales were “flattening,” meaning that the bookseller’s physical retail position would be strong in the future. Mr. Lynch said Barnes & Noble continued to take market share from other physical book retailers. The company also promoted prototypes for new stores to be opened in malls and the growth of the college bookstore business.

Combined with the announcement on Monday that Leonard Riggio, the company’s chairman and largest shareholder, was considering purchasing the retail segment, the news added a positive gloss to the brick-and-mortar business that it had not had for some time.

That notion got some support with the earnings report. Retail sales fell just more than 10 percent in the quarter, largely because of the closing of some unprofitable stores. But Barnes & Noble had largely anticipated the lower revenue and despite the sales decline, retail profits increased 7.3 percent, to $212 million, in part because of higher sales margins and “expense management,” the company said.

Despite the shift in digital strategy, Mr. Lynch emphasized that the company was not abandoning the Nook division.

“Nook Media has been financing itself since October of 2012 due to the strong investment partners we’ve been able to attract in Microsoft and Pearson,” he said. He added that the Nook segment and the physical stores drove traffic to each other and needed to remain in partnership.

But analysts sounded a skeptical note. “Barnes & Noble stands at a fork in the road and rather than choose one path, it will likely need to split into two companies and let the retail business go down one path while freeing the Nook division to go down another,” said Mr. McQuivey, of Forrester. “There’s no guarantee that either path will lead to the promised land, but the two units are facing such different challenges and such unique prospects that it doesn’t make sense for them to try to work together to solve such different problems.”

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Jane C. Wright, Pioneering Oncologist, Dies at 93

Dr. Jane C. Wright, a pioneering oncologist who helped elevate chemotherapy from a last resort for cancer patients to an often viable treatment option, died on Feb. 19 at her home in Guttenberg, N.J. She was 93.

Her death was confirmed by her daughter Jane Jones, who said her mother had dementia.

Dr. Wright descended from a distinguished medical family that defied racial barriers in a profession long dominated by white men. Her father, Dr. Louis T. Wright, was among the first blacks to graduate from Harvard Medical School and was reported to be the first black doctor appointed to the staff of a New York City hospital. His father was an early graduate of what became the Meharry Medical College, the first medical school in the South for African-Americans, founded in Nashville in 1876.

Dr. Jane Wright began her career as a researcher working alongside her father at a cancer center he established at Harlem Hospital in New York.

Together, they and others studied the effects of a variety of drugs on tumors, experimented with chemotherapeutic agents on leukemia in mice and eventually treated patients, with some success, with new anticancer drugs, including triethylene melamine.

After her father died in 1952, Dr. Wright took over as director of the center, which was known as the Harlem Hospital Cancer Research Foundation. In 1955, she joined the faculty of the New York University Medical Center as director of cancer research, where her work focused on correlating the responses of tissue cultures to anticancer drugs with the responses of patients.

In 1964, working as part of a team at the N.Y.U. School of Medicine, Dr. Wright developed a nonsurgical method, using a catheter system, to deliver heavy doses of anticancer drugs to previously hard-to-reach tumor areas in the kidneys, spleen and elsewhere.

That same year, Dr. Wright was the only woman among seven physicians who, recognizing the unique needs of doctors caring for cancer patients, founded the American Society of Clinical Oncologists, known as ASCO. She was also appointed by President Lyndon B. Johnson to the President’s Commission on Heart Disease, Cancer and Stroke, led by the heart surgeon Dr. Michael E. DeBakey. Its recommendations emphasized better communication among doctors, hospitals and research institutions and resulted in a national network of treatment centers.

In 1967, Dr. Wright became head of the chemotherapy department and associate dean at New York Medical College. News reports at the time said it was the first time a black woman had held so high a post at an American medical school.

“Not only was her work scientific, but it was visionary for the whole science of oncology,” Dr. Sandra Swain, the current president of ASCO, said in a telephone interview. “She was part of the group that first realized we needed a separate organization to deal with the providers who care for cancer patients. But beyond that it’s amazing to me that a black woman, in her day and age, was able to do what she did.”

Jane Cooke Wright was born in Manhattan on Nov. 30, 1919. Her mother, the former Corinne Cooke, was a substitute teacher in the New York City schools.

Ms. Wright attended the Ethical Culture school in Manhattan and the Fieldston School in the Bronx (now collectively known Ethical Culture Fieldston School) and graduated from Smith College, where she studied art before turning to medicine. She received a full scholarship to New York Medical College, earning her medical degree in 1945. Before beginning research with her father, she worked as a doctor in the city schools.

Dr. Wright’s marriage, in 1947, to David D. Jones, a lawyer, ended with his death in 1976. She is survived by their two daughters, Jane and Alison Jones, and a sister, Barbara Wright Pierce, who is also a doctor.

As both a student and a doctor, Dr. Wright said in interviews, she was always aware that as a black woman she was an unusual presence in medical institutions. But she never felt she was a victim of racial prejudice, she said.

“I know I’m a member of two minority groups,” she said in an interview with The New York Post in 1967, “but I don’t think of myself that way. Sure, a woman has to try twice as hard. But — racial prejudice? I’ve met very little of it.”

She added, “It could be I met it — and wasn’t intelligent enough to recognize it.”

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Jane C. Wright, Pioneering Oncologist, Dies at 93

Dr. Jane C. Wright, a pioneering oncologist who helped elevate chemotherapy from a last resort for cancer patients to an often viable treatment option, died on Feb. 19 at her home in Guttenberg, N.J. She was 93.

Her death was confirmed by her daughter Jane Jones, who said her mother had dementia.

Dr. Wright descended from a distinguished medical family that defied racial barriers in a profession long dominated by white men. Her father, Dr. Louis T. Wright, was among the first blacks to graduate from Harvard Medical School and was reported to be the first black doctor appointed to the staff of a New York City hospital. His father was an early graduate of what became the Meharry Medical College, the first medical school in the South for African-Americans, founded in Nashville in 1876.

Dr. Jane Wright began her career as a researcher working alongside her father at a cancer center he established at Harlem Hospital in New York.

Together, they and others studied the effects of a variety of drugs on tumors, experimented with chemotherapeutic agents on leukemia in mice and eventually treated patients, with some success, with new anticancer drugs, including triethylene melamine.

After her father died in 1952, Dr. Wright took over as director of the center, which was known as the Harlem Hospital Cancer Research Foundation. In 1955, she joined the faculty of the New York University Medical Center as director of cancer research, where her work focused on correlating the responses of tissue cultures to anticancer drugs with the responses of patients.

In 1964, working as part of a team at the N.Y.U. School of Medicine, Dr. Wright developed a nonsurgical method, using a catheter system, to deliver heavy doses of anticancer drugs to previously hard-to-reach tumor areas in the kidneys, spleen and elsewhere.

That same year, Dr. Wright was the only woman among seven physicians who, recognizing the unique needs of doctors caring for cancer patients, founded the American Society of Clinical Oncologists, known as ASCO. She was also appointed by President Lyndon B. Johnson to the President’s Commission on Heart Disease, Cancer and Stroke, led by the heart surgeon Dr. Michael E. DeBakey. Its recommendations emphasized better communication among doctors, hospitals and research institutions and resulted in a national network of treatment centers.

In 1967, Dr. Wright became head of the chemotherapy department and associate dean at New York Medical College. News reports at the time said it was the first time a black woman had held so high a post at an American medical school.

“Not only was her work scientific, but it was visionary for the whole science of oncology,” Dr. Sandra Swain, the current president of ASCO, said in a telephone interview. “She was part of the group that first realized we needed a separate organization to deal with the providers who care for cancer patients. But beyond that it’s amazing to me that a black woman, in her day and age, was able to do what she did.”

Jane Cooke Wright was born in Manhattan on Nov. 30, 1919. Her mother, the former Corinne Cooke, was a substitute teacher in the New York City schools.

Ms. Wright attended the Ethical Culture school in Manhattan and the Fieldston School in the Bronx (now collectively known Ethical Culture Fieldston School) and graduated from Smith College, where she studied art before turning to medicine. She received a full scholarship to New York Medical College, earning her medical degree in 1945. Before beginning research with her father, she worked as a doctor in the city schools.

Dr. Wright’s marriage, in 1947, to David D. Jones, a lawyer, ended with his death in 1976. She is survived by their two daughters, Jane and Alison Jones, and a sister, Barbara Wright Pierce, who is also a doctor.

As both a student and a doctor, Dr. Wright said in interviews, she was always aware that as a black woman she was an unusual presence in medical institutions. But she never felt she was a victim of racial prejudice, she said.

“I know I’m a member of two minority groups,” she said in an interview with The New York Post in 1967, “but I don’t think of myself that way. Sure, a woman has to try twice as hard. But — racial prejudice? I’ve met very little of it.”

She added, “It could be I met it — and wasn’t intelligent enough to recognize it.”

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F-35 Jets Returned to Service by Pentagon

The Pentagon lifted its grounding of the new F-35 jet fighter on Thursday after concluding that a turbine blade had cracked on a single plane after it was overused in test operations.

The office that runs the program said no other cracks were found in inspections of the other engines made so far, and no engine redesign was needed.

It said the engine in which the blade cracked was in a plane that “had been operated at extreme parameters in its mission to expand the F-35 flight envelope.”

The program office added that “prolonged exposure to high levels of heat and other operational stressors on this specific engine were determined to be the cause of the crack.”

All flights were suspended last week for the 64 planes built so far once the crack, which stretched for six-tenths of an inch, was found during a routine inspection.

Pratt & Whitney, which makes the engines, investigated the problem with military experts. The company, a unit of United Technologies, said on Wednesday that the crack occurred after that engine was operated more than four times longer in a high-temperature flight environment than the engines would in normal use.

The F-35, a supersonic jet meant to evade enemy radar, is the Pentagon’s most expensive program and has been delayed by various technical problems. The program could cost $396 billion if the Pentagon builds 2,456 jets by the late 2030s.

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Japan to Begin Restarting Idled Nuclear Plants

Junji Kurokawa/Associated Press

Japan's Prime Minister Shinzo Abe delivers his policy speech at the lower house of parliament in Tokyo.

TOKYO -- Japan will begin restarting its idled nuclear plants once new safety guidelines are in place later this year, Prime Minister Shinzo Abe said Thursday, moving to ensure a stable energy supply despite public safety concerns after the Fukushima disaster.

In a speech to Parliament, Mr. Abe pledged to restart nuclear plants that pass the new guidelines, which are expected to be adopted by a newly created independent watchdog agency, the Nuclear Regulation Authority, as early as July.

All but two of Japan’s 50 operable nuclear reactors were shut down following the March 2011 triple meltdown at the Fukushima Daiichi plant, which spewed radiation across northern Japan after a huge earthquake and tsunami knocked out vital cooling systems. Responding to public safety concerns, leaders from the previous Democratic Party government had vowed to slowly phase out nuclear power by the 2030s in favor of cleaner alternatives like solar and wind.

However, Mr. Abe, who took power after his Liberal Democratic Party won national elections in December, has vowed to scrap that planned phase out, saying that Japan needs stable and cheap electricity from nuclear power to compete economically.

On Thursday, Mr. Abe said that Japan had learned the need for tougher safety standards from the Fukushima accident, which forced more than 100,000 people to evacuate. He said the new safety standards will be enforced "without compromise."

However, he did not specify when plants that meet those new standards will be allowed to resume operations. Mr. Abe also said Japan will continue seeking energy alternatives in order to reduce its dependence on nuclear power, even without going so far as to eliminate it.

In the case of the Fukushima Daiichi meltdown, the plant’s operator, Tokyo Electric Power Company, recently admitted that it had failed to take stronger measures to prevent disasters for fear of inviting lawsuits or protests against its nuclear plants.

In the October 2012 report, Tepco said that before the accident it had been afraid to consider the risk of such a large tsunami, fearing admissions of risk could result in public pressure to shut plants down. The report was intended to showcase internal changes as the government considers when to allow other reactors to resume operation.

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I.B.M. Exploring New Feats for Watson

Robert Caplin for The New York Times

I.B.M. plans to serve a breakfast pastry devised by Watson and the chef James Briscione at its meeting on Thursday.

I.B.M.’s Watson beat “Jeopardy” champions two years ago. But can it whip up something tasty in the kitchen?

That is just one of the questions that I.B.M. is asking as it tries to expand its artificial intelligence technology and turn Watson into something that actually makes commercial sense.

The company is betting that it can build a big business by taking the Watson technology into new fields. The uses it will be showing off to Wall Street analysts at a gathering in the company’s Almaden Research Center in San Jose, Calif., on Thursday include helping to develop drugs, predicting when industrial machines need maintenance and even coming up with novel recipes for tasty foods. In health care, Watson is training to become a diagnostic assistant at a few medical centers, including the Cleveland Clinic.

The new Watson projects — some on the cusp of commercialization, others still research initiatives — are at the leading edge of a much larger business for I.B.M. and other technology companies. That market involves helping corporations, government agencies and science laboratories find useful insights in a rising flood of data from many sources — Web pages, social network messages, sensor signals, medical images, patent filings, location data from cellphones and others.

Advances in several computing technologies have opened this opportunity and market, now called Big Data, and a key one is the software techniques of artificial intelligence like machine learning.

I.B.M. has been building this business for years with acquisitions and internal investment. Today, the company says it is doing Big Data and analytics work with more than 10,000 customers worldwide. Its work force includes 9,000 business analytics consultants and 400 mathematicians.

I.B.M. forecasts that its revenue from Big Data work will reach $16 billion by 2015. Company executives compare the meeting in San Jose to one in 2006, when Samuel J. Palmisano, then chief executive, summoned investment analysts to I.B.M.’s offices in India to showcase the surging business in developing markets, which has proved to be an engine of growth for the company.

I.B.M. faces plenty of competitors in the Big Data market, ranging from start-ups to major companies, including Microsoft, Oracle, SAP and the SAS Institute. These companies, like I.B.M., are employing the data-mining technology to trim costs, design new products and find sales opportunities in banking, retailing, manufacturing, health care and other industries.

Yet the Watson initiatives, analysts say, represent pioneering work. With some of those applications, like suggesting innovative recipes, Watson is starting to move beyond producing “Jeopardy” style answers to investigating the edges of human knowledge to guide discovery.

“That’s not something we thought of when we started with Watson,” said John E. Kelly III, I.B.M.’s senior vice president for research.

I.B.M.’s Watson projects are not yet big money makers. But the projects, according to Frank Gens, chief analyst for IDC, make the case that I.B.M. has the advanced technology and deep industry expertise to do things other technology suppliers cannot, which should be a high-margin business and give I.B.M. an edge as a strategic partner with major customers. And the new Watson offerings, he said, are services that future users might be able to tap into through a smartphone or tablet.

That could significantly broaden the market for Watson, Mr. Gens said, as well as ward off potential competition if question-answering technology from consumer offerings, like Apple’s Siri and Google, improve.

“It will take years for these consumerized technologies to compete with Watson, but that day could certainly come,” Mr. Gens said.

John Baldoni, senior vice president for technology and science at GlaxoSmithKline, got in touch with I.B.M. shortly after watching Watson’s “Jeopardy” triumph. He was struck that Watson frequently had the right answer, he said, “but what really impressed me was that it so quickly sifted out so many wrong answers.”

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Well: Think Like a Doctor: The Man Who Wobbled

The Challenge: Can you solve the medical mystery of a man who suddenly becomes too dizzy to walk?

Every month, the Diagnosis column of The New York Times Magazine asks Well readers to try their hand at solving a medical mystery. Below you will find the story of a 56-year-old factory worker with dizziness and panic attacks. I have provided records from his two hospital visits that will give you all the information available to the doctor who finally made the diagnosis.

The first reader to offer the correct diagnosis gets a signed copy of my book, “Every Patient Tells a Story,” and the satisfaction of solving a case that stumped a roomful of specialists.

The Patient’s Story:

The middle-aged man clicked his way through the multiple reruns of late-late-night television. He should have been in bed hours ago, but lately he hadn’t been able to get to sleep. Suddenly his legs took on a life of their own. Stretched out halfway to the center of the room, they began to shake and twitch and jump around. The man watched helplessly as his legs disobeyed his mental orders to stop moving. He had no control over them. He felt nauseous, sweaty and out of breath, as if he had been running some kind of race. He called out to his wife. She hurried out of bed, took one look at him and called 911.

The Patient’s History:

By the time the man arrived at Huntsville Hospital, in Alabama, the twitching in his legs had subsided and his breathing had returned to normal. Still, he had been discharged from that same hospital for similar symptoms just two weeks earlier. They hadn’t figured out what was going on then, so they weren’t going to send him home now.

The patient considered himself pretty healthy, but the past year or so had been tough. In 2011, at the age of 54, he had had a mild stroke. He had no medical problems that put him at risk for stroke — no high blood pressure, no high cholesterol, no diabetes. A work-up at that time showed that he had a hole in his heart that allowed a tiny clot from somewhere in his body to travel to the brain and cause the stroke. He was discharged on a couple of blood thinners to keep his blood from making more clots. He hadn’t really felt completely well, though, ever since. His balance seemed a little off, and he was subject to these weird panic attacks, in which his heart would pound and he would feel short of breath whenever he got too stressed. Mostly he could manage them by just walking away and focusing on his breathing. Still, he never felt as if he was the kind of guy to panic.

And he had always been quick on his feet. The first half of his career he had been in the steel business — building huge metal trusses and supports. He and his team put together 60-plus tons of steel structures every day. For the past decade he had been machining car parts. After his stroke, work seemed to get a lot harder.

The Dizziness:

A few weeks ago, he stood up and wham — suddenly the whole world went off-kilter. He felt as if he was constantly about to fall over in a world that no longer lay down flat. His first thought was that he was having another stroke. He went straight to his doctor’s office. The doctor wasn’t sure what was going on and sent him to that same emergency room at Huntsville Hospital. After three days of testing and being evaluated by lots of specialists, his doctors still were not sure what was going on. He hadn’t had a heart attack; he hadn’t had a stroke. There was no sign of infection. All the tests they could think of were normal.

The only abnormal finding was that when he stood up, his blood pressure dropped. Why this happened wasn’t clear, but the doctors in the hospital gave him compression stockings and a pill — both could help keep his blood pressure in the normal range. Then they sent him home. He was also started on an antidepressant to help with the panic attacks he continued to have from time to time.

You can read the report from that hospital admission below.

You can also read the consultation and discharge notes from that hospital visit here.

He had been home for nearly two weeks and still he felt no better. He tried to go back to work after a week or so at home, but after driving for less than five miles, he felt he had to turn around. He wasn’t sure what was wrong; he just knew he didn’t feel right. Then his legs started jumping around, and he ended up back in the hospital.

The Doctor’s Exam:

It was nearly dawn by the time Dr. Jeremy Thompson, the first-year resident on duty that night, saw the patient. Awake but tired, the patient told his story one more time. He had been at home, watching TV, when his legs started jumping on their own and he started feeling short of breath. His wife sat at the bedside. She looked just as worried and exhausted as he did. She told the resident that when he spoke that night at home, his speech was slurred. And when the ambulance came, he could barely walk. He has never missed this much work, she told the young doctor. It’s not like him. Can’t you figure out what’s wrong?

The resident had already reviewed the records from the patient’s previous hospital admissions. He asked a few more questions: the patient had never smoked and rarely drank; his father died at age 80; his mother was still alive and well. The patient exam was normal, as were the studies done in the E.R.

The first E.R. doctor thought that his symptoms were a result of anxiety, culminating in a full-blown panic attack. The resident thought that was probably right. In any case he would discuss the case with the attending in a couple of hours during rounds on the new patients. Till then, he told the worried couple, they should just try to get a little sleep.

An Important Clue:

Dr. Robert Centor was definitely a morning person. His cheerful enthusiasm about teaching and taking care of patients made him a favorite among residents. At 7:30 that morning, he stood outside the patient’s door as Dr. Thompson relayed the somewhat frustrating case of the middle-aged man with worsening dizziness and panic attacks. Then they went into the room to meet the patient. He was a big guy, tall and muscular with the first signs of middle-aged thickening around his middle. His complexion had the look of someone who spent a lot of time outdoors. Dr. Centor introduced himself and pulled up a chair as the rest of the team watched. He asked the patient what brought him to the hospital.

“Every time I get up, I get dizzy,” the man replied. Sure, he had had some balance problems ever since his stroke, he explained, but this felt different – somehow worse. He could hardly walk, he told the doctor. He just felt too unstable.

“Can you get up and show us how you walk?” Dr. Centor asked.

“Don’t let me fall,” the patient responded. He carefully swung his legs over the side of the bed. The resident and intern stood on either side as he slowly rose. He stood with his feet far apart. When asked to close his eyes as he stood there, he wobbled and nearly fell over. When he took a few steps, his heel and toes hit the ground at the same time, making a strange slapping sound.

Seeing that, Dr. Centor knew where the problem lay and ordered a few tests to confirm his diagnosis.

You can see the review report and notes for the patient’s second hospital visit below.

Solving the Mystery:

What tests did Dr. Centor order? Do you know what is making this middle-aged man wobble? Enter your guesses below. I’ll post the answer tomorrow.

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Rules and Regulations: Post your questions and diagnosis in the Comments section below. The correct answer will appear tomorrow on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.

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