On anger management

When appalling behavior fills the news, I should probably abandon my frivolous tone, and try to comment. I'm thinking about the mayhem at the recent Pacers-Pistons game. Much has been written (and blogged) about causes of the melee. I could quote studies and statistics, but blogging seems best when it's personal. Okay, then...here is what I think about, when I watch video footage of the brawl.

I think of one time when I was clobbered - really hard - in the line of duty, and how I felt, and how I reacted. I don't think I've ever been angrier, and I've never struggled so much to stay in control.

I was moonlighting at a state psychiatric hospital. A nurse called me to see a patient who "didn't look good." I found the patient gasping, obtunded, turning blue before my eyes. What had happened?

Without urgent help, death was imminent. I begged the slow, meager staff to help me. My adrenaline started to surge. I checked the airway, searched for a pulse. Where's the nurse? Bring oxygen, bring the crash cart, where's the chart? Heimlich time. Over here, nurse, help me, please...

Then, out of nowhere, a large male patient chose this exact moment to haul off and punch me. Hard. With force.

Words can't describe my shock, my fury. I still marvel at how much I wanted to hit back. Somehow, I did not. I restrained myself. I screamed at the aides to get this guy away from me and help me, please! The code continued. I didn't notice how badly I was shaking (and bruised) until the blue patient had pinked up and left, via ambulance, for the "real" hospital in town. Had I ever been so outraged? People talk about "seeing red," and breathing fire; about bulls chasing matadors around the ring. Is this what it's like? The sensation felt so new to me...

Now I watch the athlete enter the stands, all boundaries broken, and attack the fans. Some elements seem familiar: the pressure to perform as the clock is running out. The high stakes. People watching. The distractions which must be ignored. The sense of imminent disaster, of things spinning out of control. The surging adrenaline. And then...at precisely that moment...to be hit by a hostile bystander. A boundary violated. An insult, a distraction, a provocation...

No excuses here, no rationalization. Just...revulsion and concern, and a bit of recognition. There is a world of difference between his response to his provocations, and mine. What could have made his response different?

Dr. Centor may be correct. Anger management programs may be as ineffective as most weight-loss programs, drug treatment programs, or any efforts that try to control the strongest human impulses. Aggressive behavior occurs in a context. There are biological factors, as well as environmental factors. Even when these factors are addressed in treatment, there are no guarantees. There may be no alternative to completely removing oneself from known provocations...finding another line of work, if necessary.

I did find another line of work, when I got a letter from the state, apologizing that budget cuts had forced my lay-off. I have not been hit much since then (I've learned something about staying out of the way, and looking behind me). And I haven't been that angry in a very long time.

Afterthought - while I'm at it - is it time to comment on something that is beyond appalling? By now, everyone has heard of the woman who severed her baby's arms. As a blogging psychiatrist, I feel uncomfortable that I have acted as though it hasn't happened, but honestly, I've been searching for something to say. This unspeakable tragedy sends a chill through every person, every psychiatrist, every psychiatric patient and their families. No matter that most psych patients are non-violent. This sends the worst message to the world, and spreads the worst kind of stigma. We all know that one of our patients might do something horrific. It is frighteningly easy for any patient to "look good for the doctor." Just a few phrases can do it: "I really like my meds. You're really helping me, doctor." Patients might really be genuinely okay when you see them in the office...until they aren't.

I guarantee that somewhere, there is a psychiatrist - most likely more than one - who has not slept a single night since this was reported. The suffering of everyone involved...is simply unimaginable, and my heart aches for all of them.

Reminder: the next Grand Rounds...

...is at DoctorMental. Deadline is Monday, November 29, 9:00 pm ET. Here is the link with the details. Some thoughts on my own hosting experience:

First, there's an astonishing variety of great blogging out there. I could have easily expanded Grand Rounds with more terrific posts. (The submissions were great, but I didn't wait for them. If I saw something interesting, I grabbed it.)

Second, we're getting hits. Grand Rounds #9 coincided with two blockbuster events: Rather's resignation, and the live-blogging of the crisis in Kiev. Sort of a "perfect storm" in the blogging world...yet, we had readers. In fact, according to my sitemeter, we continue to attract readers. While never ascending to heights attained by the Virgin Mary Cheese Sandwich (clearly another blockbuster event), we did enter the top 50 on Blogdex.

And here is what Will Femia said, over at Slate/MSNBC News:

Grand Rounds is a relatively new collective effort at a weekly round-up of posts from medical blogs. I prefer to use this space for more specific recommendations, but after clicking three of the links on the list, I decided to just point to the whole thing.

(How did he find us? I have no idea.)

I encourage all medbloggers to send DoctorMental their finest. People are taking notice. Please consider hosting, also. Just drop Nick a line...

Picking up the pieces at Thanksgiving...

"Happy Thanksgiving, how are you today?" I like making rounds on holidays (that's probably why I get so many of them). The staff has a huge banquet laid out for the patients. We're trying to convey a sense of optimism and caring. Two colleagues are helping me (another reason to be thankful!).

Among our challenges: patients' conflicts with their families (either overwhelmed with the stress of increased contact, or devastated by lack of contact). Alcohol and other substances contribute to aggressive or self-destructive behavior. Patients may have been deteriorating in their homes for weeks - or longer - but the crisis only becomes clear on Thanksgiving Day, when relatives arrive and find Mom wandering, confused, her nightgown torn, the house in disarray...

Their holiday has been ruined. Hospitalization increases the stress level enormously, for patients and families. But it's nice to try to sort things out and make them better. The families need as much time with us as the patients...to give history, to ask questions. Okay, back to work.

Perhaps it's time for something lighter. In honor of the holiday, I'm pulling this out of the vault: the psychology of Spongebob. Then after rounds, it's turkey and dressing at our house...

Grand rounds #9

Welcome to Grand Rounds, a rotating compendium of new and noteworthy posts from health-related weblogs. Medical blogs continue to proliferate, and you'll meet some new ones here. DoctorMental hosts next week.

Top story: Safety of medications. An FDA regulator believes that five FDA-approved drugs need closer scrutiny. Medpundit shares her opinions of these meds. Dr. Bob Centor notes:

"On the heels of the recent Vioxx withdrawal this testimony certainly fans the flames of drug safety concern. We would like the FDA to insure safety. However, we also would like the FDA to rapidly approve new helpful drugs. This tension defines the problem. The faster we approve new drugs, the more likely we would miss a safety concern."

Message from the front lines: Geena, a registered nurse, writes codeblog. She implores doctors to tell patients about their plans, before asking nurses to carry them out:

"...I do not relish the look of ... weirdness that comes on my patient's face when he finds out that I'm about to administer treatments that he isn't expecting and hasn't been prepared for..."

Making meds: Dr. Derek Lowe is a pharmaceutical chemist who blogs for Corante. He discusses the perils and promise of RNA interference:

"...I've said for several years now that this field is the most obvious handful of tickets to Stockholm that I've ever seen. (Naturally, there are some worries that the whole field has perhaps been a bit over-promoted. . .)"

Selling meds: Kevin, MD debates direct-to-consumer advertising.

If the majority of DTC marketing were based on sound evidence-based medical principles, I would be in strong favor of it. After all, the more information patients have at their disposal, the better.
However, this is simply not the case...

Reconsidering meds: Is it time to reconsider atenolol, one of the most commonly prescribed antihypertensives? Journalclub reviews a recent Lancet article. The methods aren't his favorites, but he's intrigued by the study. And in another post, he cautions us about the response of drug companies to the demand for evidence-based medicine:

"...armies of drug reps sally forth armed with reprints, while researchers are sent out to spread the gospel of statistical significance. EBM has made us particularly avid of hard data (while relegating clinical significance to a somewhat subordinate role)..."

Using our best judgement: Dr. Bob Centor writes on making medical decisions under conditions of uncertainty.

"As physicians we rarely know answers definitively. We make our best probabilistic guesses, and then hope for the best. But given the uncertainty, we have results that we question in retrospect.
"I doubt that we will ever rid medicine of that uncertainty. The uncertainty attracts me. The quest to make the best decisions (while never really knowing that we did) is a quest worth taking."

A first (and a fifth): Dr. Jacob Reider's medblogging podcast about a day-in-the-life of a family practitioner. (Happy fifth blogging anniversary, doctor, and thanks for medlogs!)

Pathology: Anne, a physician in the Netherlands, submits a post about Lyme disease from her Illness Alphabet. Dr. Charles describes his encounter with a patient with herpes. (No comment on his reaction; I think he's figured it out. Don't miss Dr. Charles here and here.) Codeblueblog speculates on what may have killed ODB...and how he might have been saved. Trent McBride has "fun with microbes." (Warning: not for the queasy!)

Meet the Rebel Doctor: A new medical weblog. Dr. Michael Rack is an academic internist, sleep specialist, and psychiatrist in Mississippi. He sends us a post about treating developmentally-disabled adults.

Mind control: Alarming news, via Book of Joe. Minds out of control: Dr. James Baker, at Mental Notes, brings surprising news about an under-reported culprit at the recent Pacers-Pistons game.

Going the extra mile: At "Morning Retort," a med student delves into complex psychosocial issues of his patient, only to see them ignored by his resident. At "Chronicles of a Medical Madhouse," a resident tries to convince a frightened, unwilling young mother to continue life-saving treatment...and succeeds.

Man with a mission. Codeblueblog is passionately "pro-vaccine", and he'll tell you why:

"...iron lungs -- once ubiquitous in hospital wards...actually became relics of an era gone by because of the polio vaccine which mostly eradicated the major cause of paralytic weakness of the respiratory muscles..."

What is reasonable compensation for a doctor? What is reasonable for patients to pay? At Kevin M.D., the debate goes on. Scroll down, and down:

"...I'm just sick of seeing people like my second cousin (30 years old)-- a guy who makes $140K per year, dines out at the finest restaurants each week for $400, has an extensive wine collection valued at $60K, two plasma TV's valued at $16K, a summer home in the Hamptons worth $1 million etc.-- yet who sees nothing wrong with forking over a paltry $10 to his physician for their services. There is something entirely BROKEN with this picture. How can you not see it?"

Medbloggers at Bloggercon III: Dr. Enoch Choi graciously shares his notes. One participant, a patient, likens physician bloggers to the old Soviet underground press(!).

They're kidding, right? GruntDoc sends word that learning-disabled students want special accommodations for the medical school entrance exam, including more time for the the test:

"The MCAT is many things, but any med school admissions director will tell you those scores do not correlate with success or class rank in med school, but they're really handy to weed out people who have no business being there in the first place."

Choking hazard: Put your coffee down before reading this Public Health Press post about health care policy. The Bush team's plans may end private insurance as we know it.

Hospice Guy makes enemies with his bold advice about hospice and nursing homes:

"Almost every big nursing home company owns their own hospice. Why?...They know the dirty secret. Medicare is paying too much for hospice/nursing home patients..."

Weight loss tips? Dr. Emer, at Parallel Universes, ponders the relationship between obesity and sleep.

Safety of blogging is scandalously under-researched, says Trent McBride. Doctors prescribe blogging at their peril, exposing patients to unknown risks, despite anecdotal reports of efficacy. (Prolonged computer work may harm eyes; as Medpundit says, "uh-oh...")

Such abundance! That's it...my carpal tunnel is asking me to stop.
Prior Grand Rounds here. Contact Nick at Blogborygmi and tell him that you want to host Grand Rounds.

Addendum! Late-breaking news from Matthew Holt:

Shrinkette
Apologies for the late entry (still before Midnight on the west coast!!)
anyway http://www.matthewholt.net/2004_11_14_archive.html
takes you to The Health Care Blog's first ever live (with photos) blogging of the Health Information Technology conference hosted by the California Health Care Foundation. The subject was health IT for chronic care, and it was attended by most of the good and the great of health care IT from across the land.
Thanks and I hope this isn't too late
cheers
Matthew

Calling all medbloggers...

An open invitation for Grand Rounds posts! I've switched on the lights. I've opened the lecture halls, tested the mikes, and placed mints and icewater at your seats. We're almost ready to go....that e-mail is: shrinkette01 followed by @earthlink.net

One worry - Blogger is staggering today. Twice, it has signaled its distress, delivering pages of gibberish and confessing that it can't quite carry on with my posting. (As one commenter said, "Bad Blogger! No biscuit!") If Blogger swoons on the appointed day, I'll forward the Grand Rounds post to another location...

(note: Deadline for submissions is 11/22, 9 PM Eastern Time.)

Cross-covering

Is there a dark cloud over my head? I'm working on the psych unit today, covering for a colleague who's on vacation. I've met only two patients so far, and they are both having medication side effects. The side effects range from "moderate" to "yikes..."

The patients were severely ill when they were first admitted. My colleague has been working very hard with them. The patients' symptoms have obviously improved. But today's labs suggest that some organ systems--the sort that you really can't do without--are being affected. Repeat labs...no better. If it's the meds, it's probably reversible, but I need to do something soon. This is what any branch of medicine can be like. This is what we're reading about every day in the news...monitoring meds, detecting and dealing with side effects.

We have no residents or interns here, so I'm on my own. Call the lab, call the pharmacy, call the internists, call the outpatient psychiatrists who know these patients. Quick calls to the on-call specialists--would they mind looking over these labs, please? (Are they cringing - "Damn, a psychiatrist and her meds...") But they are very nice to me. They all promise to see the patients ASAP. They give instructions for repeat labs, more tests. We debate: What should we do next? Everyone has a different opinion. We go back and forth. My documentation lengthens. I write everything down.

And I talk to the patients. Yes, you have improved, but we're concerned...the labs are telling us that you're having trouble with at least one of these meds, and possibly more than one. We're working on it now. You've just met me today, but I'm working with these other doctors too. We're all working on this...and we need to talk to your families, too. (That's one thing we insist on here...full disclosure.)
But what to do if the patients relapse when their meds are changed? Now I'm not just "filling in" for another doc. I have to roll up my sleeves and dig in. Find old charts, review more history. And write everything down.

And I still have to finish my rounds. What will I run into next? Time for a staff meeting. Got to run...

update: my specialists tell me that one patient's symptoms are unrelated to the psych meds. It's a newly diagnosed, unrelated (and unexpected) medical problem. They've swooped in to manage it, and here I am on the sidelines...I will have quite a report for my colleague when I'm done.

Too funny

Send this to every depressed Democrat you know. (HT: Sullivan.)

A nurse responds to "Safety first"

My post described problems in addressing substance abuse. A registered nurse writes:
"I work in an emergency department in a relatively small community and as a result I'm frequently "in the front lines" in situations that are threatening and potentially violent. More often than not those situations involve alcohol or drugs. My thoughts are directed toward the part of your commments regarding the patient who can recite all the reasons for not abusing substances. They know. They are first in line to know. Education is not the problem.

"Knowing is not going to change their need to use. Why? Because they fear not using, having the comfort it provides, less afraid of the harm they are experiencing from using than the stark void they see facing them when they aren't high. How do you address that?

"On rare occasions, say a teen with a significant adult present or an adult who is currently not high, I have tried this approach. I acknowledge their dependence, their need and validate it by telling them that using is a coping mechanism, a type of self medication, something that, in the short term, makes them feel better, helps them escape or obliterate pain, a thing everyone wants when they are faced with sadness, pain, fear.

"But now they have two problems: the original problem and a new one, dependence or addiction. If, at this point, you can give them some hope of help with the original problem, be it therapy, non-dependence support, then perhaps you can create in them a reaoson to fight their addictions/using. Asking someone to give up the only option for pain control that they have ever used (drugs/alcohol) is akin to asking them to shed sunglasses in the face of blinding glare because they might better be able to see. We walk away shaking our heads and saying well, they're just self-destructive, or some like comment and feel superior to them in that we value ourselves enough to not use by distancing--us vs. them. Our own sort of self protection. I'm not naive, I know that a certain amount of distance is necessary in order to have objectivity.

"I cannot tell you if any of my efforts have produced positive results, the only thing I know for sure is that having taken the opportunity to make these comments I have satisfied my own need for expressing compassion when the opportunity was there, which it often is not. Thank you for giving me a forum, via this e-mail, to make concrete some of my own musing."

Lights on....

There, is that better? Renovations in progress.
I think the black background was more contemplative...well, the heck with that. It was too hard to read. No more sitting in the dark; Grand Rounds will be here soon.

We're seeking topical, engaging, health-related posts for Thanksgiving week. Target audience: "lay" readers. Rules are set forth here. Deadline is Monday, November 22, 9:00 PM Eastern time.
People are sending submissions already. Thank you! That e-mail is shrinkette01 followed by @earthlink.net.

Note also the new disclaimer in the sidebar: all things clinical on this site are so heavily camouflaged that no one, and I mean no one, can recognize them. No medical advice is given on this site, except "talk to your doctor." That goes for Grand Rounds, too...

Grand Rounds at Medrants!

Go immediately to DB's Medical Rants, for this week's Carnival of the Caregivers. Terrific posts about race-based medication, vitamin E, and other commentary.

Reminder: Grand Rounds lands here at Shrinkette's next week. My e-mail is shrinkette01 followed by @earthlink.net. Deadline is Monday, November 22, at 9:00 PM Eastern Time. Any medical topic is welcome.

Here are the rules, as first written by Nick at Blogborygmi. The only real modification is that if we see something else on your site that's marvelous, even if you haven't submitted it, hosts are likely to use it. Thanks to Medrants for a great job!

Patient care, circa 1885

Reading Chekhov stories this afternoon. In "Grief," a man brings his wife to the doctor, and he knows what the doctor will say:

"Soon as we're there, he'll come running out of his room and start cursing. 'What's all this?' he'll shout. 'How did it happen? Why didn't you come earlier? Am I a dog, to be looking after you all day, damn you? Why didn't you come in the morning? Get out! I don't want to see you! Come tomorrow!'

Chekhov was a doctor. When a character is dying, the doctor says, "You've had your life, haven't you? You must be sixty if a day...isn't that enough for you?" When the patient says he'd like to live, the doctor asks, "Whatever for?"
Funny thing...when I read this, I started thinking about insurance companies...no, that's not fair.

(afterthought: yes, okay, you're right. In the last post, a patient was shouting at me. In this post, the doctor is shouting back. What can I say? Freud lives on!)

Safety first

We're supposed to be prepared for this, but it's scary when it happens: threatening behavior from a patient. My office staff heard my patient shouting and was wondering what to do; we'll have to review our emergency procedures.
The theme of the episode was that the patient was enraged about numerous things...including my reluctance to prescribe certain controlled substances that the patient desired. The patient was standing over me, giving commands...loudly.
Was the patient intoxicated, psychotic, or going through some kind of withdrawal? Was this intimidation? Was I in danger? (My hunch: all of the above.) I let the patient shout, and during a pause, I said, "Obviously you are quite angry." More agitation. Requests for clarification were met with more shouting. After about a minute, I explained quietly that things didn't work that way, and that perhaps the patient would prefer to see another doctor. The patient stopped and said yes. I started writing down referrals, knowing that those docs would hate me forever. (Is it time to call the cops?) The patient then became calm and sat down. (Good! That's good!) Meanwhile, I said, "The goal is for you to be healthy and for us to work together." (Work together? Can we work together? I'm just trying to defuse the situation...I guess it is a goal.) "Being healthy means being off drugs. Working together means I am the doctor and you are the patient, and we talk about what to do."
The patient actually calmed down. Confidentiality makes me hesitant to say more - I've already altered this somewhat - but police support and hospitalization definitely play essential roles in these situations. We train for threatening events, but ultimately we are vulnerable. In psychiatry, we have to think about safety: whether patients are safe around docs, and safe around everyone else. Sometimes there is just no substitute for hospitalization. If, despite treatment, patients are still threatening, we have to decide if we can still safely take care of them.

Substance abuse is a huge challenge. I see so many patients who are deeply, deeply addicted to alcohol and/or other substances. They've suffered horrible consequences. They are miserable. But many don't want to quit. Or they don't like the treatment programs that are supposed to help them quit. Or perhaps there is another diagnosis that interferes with drug treatment (but when they are actively using, it's hard to tell.) Sometimes I ask, "What do you think I will say about your use of substances?" Often, they respond with a long and detailed lecture, with state-of-the-art information about consequences of substance use, and treatment options. They've heard all this before. (Sometimes they say it better than I ever could.) By telling me these things, they've avoided a lecture from me...almost. In my least-judgmental voice, I try to say that obviously they are suffering, and that people feel better when they are sober. I re-affirm the good info that they already know, and explain my dissent from the bad info. I try to be encouraging. If they can't or won't quit, I provide resources to significant others...if they have any. Docs can't force anyone to get treatment, unless they are "imminently dangerous to themselves or others."

Auroras

Doc Searls has been posting about northern lights here, here, and here. The displays have been dazzling this week.
These are from the Flickr northernlights tag:


Northern Lights in Minnesota Nov-7-04

Northern Lights in Minnesota Nov-7-04

Aurora

Blog bites blogger...

A cautionary tale from Annie at LiveJournal, who reminds us that blogging has consequences. She posted intemperately about the President, inspiring a surprise visit from the Secret Service.

"A couple of weeks ago, following the last presidential debate, I said some rather inflammatory things about George W. Bush in a public post in my LJ, done in a satirical style. We laughed, we ranted, we all said some things. I thought it was a fairly harmless (and rather obvious) attempt at humor in the face of annoyance, and while a couple of people were offended, as is typical behavior from me, I saw something shiny and forgot about it, thinking that the whole thing was over and done and nothing else would come of what I said.

"I was wrong.

"At 9:45 last night, the Secret Service showed up on my mother's front door to talk to me about what I said about the President, as what I said could apparently be misconstrued as a threat to his life."

No imminent threat, they decided. But the FBI still has her photo.

Notes the Inquirer:

"The tale is a lesson to us all. Number one lesson is that what happens on the internet can and will bite you on the ass in real life. We've seen it time and time again with internet affairs and sordid emails...Number two is that no matter how cool and geeky the community - and LiveJournal is both - there will always be someone that ruins it for everyone else..."

Medical bloggers know these truths, before they even begin to post. We may not meet the Secret Service, but there are laws about what we can say. What starts as a lark can turn into a privacy minefield. Rants circulate endlessly on Google. No matter how much I change clinical details, someone might read my post and say, "Is that me?"
I study other medical blogs, for clues about what I may and may not say. The recent Bloggercon touched on these issues (thanks, medmusings). Lisa Williams has a theory:

"She can't believe that any physicians blog. They live in a police state, with lawsuits & regulations, duty & privacy hanging over their heads. She seed physician's weblogs as the modern version of dissident Russian Slavislak. Of course they're anonymous..."

Well, perhaps it's not that extreme, but medical blogging can feel like that. What have I posted that might re-affirm Number One Lesson? I resolve to not obsess about this...too much.

Excellent Grand Rounds...

at GruntDoc's site this week. Highly recommended! Posts about Arafat's mysterious condition, and other topical and informative fare. (Grand Rounds is coming here in a few weeks, and I'm quite excited.)

Dementia: memory loss is only the beginning...

Good article in NYT about behavioral symptoms of dementia. Most families expect a demented person to be forgetful and disoriented. But personality changes and disinhibited, agitated behavior can be unexpected and unendurable. Medications help modestly. Antipsychotics sometimes reduce agitation, and anticonvulsives can reduce explosive outbursts. Newer treatments may improve behavior, but they can also make a formerly apathetic patient begin to wake up and think, "Wait a minute - what's going on here? I don't get it, I don't know what's happening," and so on. More agitation can ensue. These patients are also exquisitely sensitive to side effects.
Sometimes the best solution is an environment tailored to the demented patient: wandering paths for the wanderer, rummaging rooms for the rummager. Absolutely essential is a skilled, available staff who understand "dementia behavior." Staff must know something about the perspective of a person in these frightening stages of the illness.
This is exceptionally hard to learn. Imagine, if you can, being a demented person with no short-term memory, and no longer able to recognize home or family. No capacity to comprehend where you are, or what is going on. No one allows you to come and go as you please. Nothing is familiar. Nothing makes sense. Strangers give you orders: "Come here, don't do that." But the desire for familiarity and control may persist...indeed, it may grow stronger. A healthy person would soon become enraged in these circumstances. A demented person, with less control over emotions and actions, can respond with violence.
Trained, understanding staff can prevent or mitigate such reactions. They use distraction and suggestion to redirect the patient. They avoid giving direct orders. They give choices. They use "time-outs," defusing situations, and let everyone calm down. They call the doc when things are getting out of hand.
Staff like this are golden. They are lifesavers. They are hard to find. Burnout can be severe.
Some resources:
The Alzheimers Association
Alzheimers Disease Education and Referral Center
WebMD Guide to Alzheimer's Disease
Rush Alzheimer's Disease Center
Johns Hopkins Alzheimers Disease Research Center

The piercing gaze of The Glittering Eye

David Schuler has sent e-mail, taking me to task for the last post:
"Where to start?
"'Is it a burning issue there?'
"I'm curious about what this reveals about what your
colleague thinks about homosexuality. Are Mississippians
immune? If a Mississippian realizes they are homosexual
do they immediately leave the state? Why would it be less
of an issue in Mississippi than in Florida? Or California for
that matter? Or could it be that it's an issue because the
freakin' Massachusetts Supreme Court made it a freakin'
issue by NARROWLY tossing out stare decisis and declaring
homogamy a right?
"'People do what their churches tell them to do'
"I guess that's why the Roman Catholic clergy is so upset that
so many Roman Catholics poll about the same on issues like abortion,
birth control, and general secularism as non-Catholics. Or that
a larger proportion of African Americans voted for Bush this time
around despite John Kerry campaigning from the pulpit in African
American churches for the last freakin' five weeks?

"Let's see how did that go? Denial, anger, bargaining, acceptance?
Or was it anger, denial, bargaining, acceptance? Whatever. Tell
me when acceptance rolls around so the rest of my stupid political
party will come to their senses and stop blaming the voters for bad
candidates, bad political positions, and bad strategies."

Ouch. Well said, Mr. Schuler. And here's the much-cited David Brooks Op-Ed:

"But the same insularity that caused many liberals to lose touch with the rest of the country now causes them to simplify, misunderstand and condescend to the people who voted for Bush. If you want to understand why Democrats keep losing elections, just listen to some coastal and university town liberals talk about how conformist and intolerant people in Red America are. It makes you wonder: why is it that people who are completely closed-minded talk endlessly about how open-minded they are?"

Speaking as someone who is both coastal and inhabiting a university town, I am taking this much to heart. No more mouthing off about redness and blueness here. Instead, I'll be listening to Bush voters explaining themselves and their votes.

The day after

My ears are still red-hot and painful, from listening to an elderly lady's reaction to the election. In the last 24 hours, I've heard every response imaginable - rage, disbelief, heartbreak, satisfaction, gloating, utter apathy and lack of concern...

It's fascinating. (If anyone out there is upset, vent at this screen if you like, but there can be no therapy here.)

This just in - tort reform failed in Oregon. We were trying for a $500,000 cap on awards for pain and suffering. We missed by less than one percentage point. (Now I want to vent at this screen.) Already it's hard to find a neurosurgeon around here. Looks like it will become harder.

Other results: Oregon declined to approve free medical marijuana for the indigent. (I'd rather give them free food, shelter, and conventional medical care.) The gay marriage ban was approved. (How was marriage "under attack?" Has anyone figured that out?) We're puzzling through this. We are from ultra-liberal Eugene. Some of us have never met a Bush voter.


Here's an esteemed colleague: "Republicans are brilliant at giving people a reason to vote. Look, Mississippi voted on gay marriage. Why would anyone put gay marriage on the ballot in Mississippi? Is it a burning issue there? It's only to mobilize the evangelical vote. It worked, it got everyone to the polls. Plus, they had the churches. People do what their churches tell them to do... How often do non-church-goers let anyone tell them what to do? They're just as likely to do the opposite, or do nothing at all..."

Afterthought - Oregon went for Kerry, but still voted down gay marriage, so something different must be going on here. Also, the last time I checked, people were doing lots of things that their church frowned on...again, the analysis doesn't really work...

Campaign post-mortems...

started weeks ago at our house. My husband, a fervent Democrat, predicted that Bush would win. I could not understand his certainty.
"Abu Ghraib...no WMD's...ballooning deficits...Michael Moore...Kerry's debate performance. Checkmate!" said I.
"You don't get it," said Mike. "You don't know this country. We all 'knew' that Humphrey would beat Nixon, that Carter would beat Reagan, that Mondale would beat Reagan. You can't ever count on the youth vote. Kerry always looks like a piece of cardboard. And there he was, shooting geese...what kind of message is that? 'Vote for Kerry, he'll protect you from geese.' People want their values. They want security. They know that Bush will use the sword. The sword is mightier than the blog..."
Is Mike right? Or was there more to it than that? Time for clinic. I expect I'll hear a lot about the election today...

Bravo, Ms. McArdle...

Megan McArdle (at Instapundit) takes the pledge. No matter who wins the election,
"I will not use my one semester of Psych 101 to make speculative diagnoses of mental disease or defect in the president." (I wasn't aware that she has ever done this. But perhaps she has some influence.) Once more, I condemn the practice of attacking political opponents with psychiatric mudslinging.

She has a list of resolutions. Instapundit is getting slammed with hits right now, but if you manage to squeak in, read the whole thing.

Prozac and baby mice: update

E-mail from Caltechgirl!
"Hi Shrinkette,
"I do research on GABA and stress in development and schizophrenia, a lot of which is behavioral. The task they used in the study is called an elevated plus maze, and it measures fearfulness in rodents. If you've ever seen a mouse in your house, you know that rats and mice like to hide, stay out of the light (being nocturnal) and will stay close to the edges of the room. Rodents that are more fearful will enter the unfamiliar arms of the maze less often. This test has been validated in a number of animal models, and in many cases if you give SSRIs etc., the animals act "less fearful".

"You are absolutely correct to question the leap from animal behavior to emotion. Good behavioral scientists will refrain from anthropomorphizing their animals and over-interpreting their results in this way.

"About the results: Well, it's not surprising. We know a lot of other psychoactive drugs have serious effects on fetal and neonatal development. Specifically, pups who have been exposed to benzodiazepines have CNS abnormalities and altered response to stress. In fact several fetal manipulations have been shown to "reset" the stress response in young animals.

"If you're interested in more studies about psychoactive drugs and fetal/neonatal development, I can send you some references." Yes, please, do! And thanks for writing!

I was very sad to disable comments on this blog, but I can't sweep graffiti away fast enough, so I thank those who e-mail me.

When further treatment is futile....

"In many cases, when a patient is irreversibly ill and dying, resuscitation is simply not an option and is futile. For example, for a patient whose glioblastoma has advanced to the point at which the patient is semicomatose and he or she will die with or without treatment, CPR is not a medical option. Application of it is contrary to the standards of medical practice, unethical, and inhumane. The family who asks that CPR and all life-saving treatment be withheld or withdrawn from such a patient should be obeyed by the physician inclined to provide it. Likewise, in such a case, the physician does not have a duty to consult anyone before writing a DNR order. We recommend that the physician take the opportunity to remind the family just how severe the illness is and that appropriate attention is being given to the needs of the patient: "It is important for you to know that your father's condition has reached the point where he will die with treatment or without it. We will direct every effort to maintaining his comfort and dignity. Treatments like resuscitation or countershock would only brutalize him and he has been protected from them by specific written order."..."No physician is required to provide harmful treatments to a patient...No physician is required to provide useless treatments either." (from Mass General Hospital's Handbook of General Psychiatry, chap. 23, by Ned Cassem MD SJ and Rebecca Brendel, MD, JD)

Several weeks ago, NPR interviewed a med student who was disturbed by one of his cases. As I recall, his patient was terminally ill, and had demanded that the doctors "do everything." The patient was "full code." When the patient lapsed into an irreversible coma, the physicians and family quietly changed his care plan to "do not resuscitate." We don't know the source of this patient's desires for "everything" to be done, nor any discussions that may have laid out what "everything" means. But at some point, a doctor might have said, "When further treatment causes you nothing but suffering and is futile, then we will inform you and your family. There will be no breathing machine, no resuscitation, if those measures are futile, and if the only result is that you would suffer. At that point, all of our efforts will be focused on your comfort and dignity alone." I wonder how the patient would have responded...or how he did respond, when offered this information.

Update: I'm unhappy with the title of this post. I've renamed it, so Blogger has re-published it. One obvious unanswered question: at what point is care determined to be futile? Who decides? Can reasonable people disagree? Perhaps that's for another post.