When meds stay in their med-boxes

What can be done for patients who don't take meds as prescribed, even when they know that the consequences are life-threatening? Dr. Robert Steiner MD has a CME activity at Medscape that addresses this problem. It's written for organ-transplant teams, but most docs could insert their own specialty here.

Much of the medication noncompliance observed in transplant recipients would not appear to be rational, which is why it can be so difficult to modify by straightforward educational measures.[62] But in an attempt to understand this behavior, noncompliant patients have been categorized in the following way[6]:

• "accidental" noncompliers: disorganized to the extent that taking their medications is not a high priority;

• "decisive" noncompliers: have well-considered rationales for their noncompliance;

• "immortal" noncompliers: do not defend their noncompliance but are guided by unarticulated, unrealistic beliefs and fears.

...Noncompliance that is not irrational or otherwise based on psychopathology might be amenable to patient education and other straightforward strategies to modify behavior. When patients are first transplanted, they are arguably most susceptible to caregivers instilling in them compliant attitudes and practices.[5] However, over time they develop a false sense of security during a relatively benign early postoperative course[5,55] when the frequency of scheduled follow-up visits decreases, when physicians under-react to early overt signs of noncompliance and reduce doses "under pressure" from the patient, and when anxious medical staff give nonconstructive feedback when patients are noncompliant.[64] (emphasis added.)From the patient's perspective, if nothing bad has happened to their graft thus far, and if the medical staff do not appear particularly concerned about graft loss, including maintenance of adequate drug blood levels, why should they be so meticulous? The end result is often noncompliance.[65,66]

Unintentionally, we can send a message that missing a few meds is "no big deal."

What if the patient can't afford meds? Free meds boost compliance, but not as much as you'd think. This is also evident in our clinic, where large numbers of patients get their meds through Patient Assistance Programs.

Much noncompliance may stem from deeply ingrained beliefs and fears that the patient does not completely recognize and that are therefore difficult to address. The preceding considerations should make it clear that many patients do not exactly "choose" to be noncompliant; rather, they cannot entirely help themselves to do what is manifestly the right thing. Therefore, use of scare tactics and other punitive measures by caregivers may only make the interaction unpleasant and unproductive. It may compel the patient to avoid contact with caregivers, to dissemble ("white coat compliance"), and/or not to try to face up to deep-seated compliance problems. During regular visits, caregivers should encourage patients to express their thoughts to get an idea of whether patient compliance is affected by a fundamental denial of clinical reality, irrational fears of side effects or the medical environment, adverse reaction to authority, feeling of powerlessness, anger at caregivers or others, belief in unsubstantiated alternative therapies, overt depression, or mania. Identifying and dealing constructively with these root causes of irrational noncompliance are challenges to clinicians.

Trauma memories: "Recovered" vs. "False"

I've put my affairs in order, written a hasty will, and disposed of my property. Please tell Mom that when I launched this post, I understood the magnitude of the forces that would be arrayed against me, and expected that I might be vanquished by one (or more) of them. (Deep breath.) All right...I'm going to say a few words about...recovered memories of trauma. To what extent can they be trusted? Skeptics can have a field day with both sides of the debate.

The psychiatrist at Follow Me Here... gets it exactly right when he describes the intensity of feelings on this matter. He's commenting on the trial of former priest Paul Shanley, accused of sexual abuse by a man who claims to have recovered repressed memories, albeit not during psychotherapy.

While traumatic memories are stored in a dissociated way, protectively inaccessible to the victim until recovered, it is also demonstrable that 'recovered memories' can be fictitious after-the-fact creations. Human memory is malleable and, in some instances, how convincing it is is matched by how unreliable it is. I wonder if we are going to see a monumental battle of expert witnesses around the recovered memory issue in the current case. The proponents of the view that these recovered memories are false and the adherents to the trauma model are often zealots who clash as cataclysmically — and unproductively — as any do when they argue about matters of faith. Shanley and his accuser will likely become damaged icons for polemical positions in a prodigious battle played out in the Cambridge courtroom. (emphasis added)

Slate has written an even-handed article about issues raised by the trial:

...whether "repressed memories" represent medical fact or junk science. And the trial itself has become something of a referendum on whether human beings are capable of forgetting, then remembering, details of traumatic, life-changing events.

The notion of repressed memory was floated by Sigmund Freud in the late 19th century. He suggested it occurred when a patient (usually a hysterical female victim of sexual abuse) "intentionally seeks to forget an experience, or forcibly repudiates, inhibits and suppresses" memory. The basic theory of repressed memory, as described by Jacqueline Hough in a 1996 article in the Southern California Law Review holds:

It is often beneficial for victims to forget these events because at the time of the abuse a victim experiences a variety of overwhelming emotions including helplessness, fear, shame, guilt, pain and betrayal. To survive, the victim is forced to mentally cope with these emotions because the victim often cannot physically escape the abusive environment. Blurring of the trauma, denial, repression and amnesia of the experience are common ways children cope with the trauma and the accompanying emotions.

Clinicians argue that repressed memories can be recovered through treatments including hypnosis, age regression, or suggestion therapies, but—as is allegedly the case with Shanley's accuser—some victims experience spontaneous recovery. The American Psychiatric Association formally recognized repressed-memory syndrome in 1994, calling it "dissociative amnesia."

Advocates of repressed-memory syndrome have been well met on the battlefield in recent years by proponents of what's known as the "false memory syndrome." They insist that the recovery of repressed traumatic memories is all bunk and that most repressed memories of sexual abuse are the result of negligent therapists who implant and reinforce false memories during treatment. The APA does not recognize "false memory syndrome," which doesn't help much in the courtroom. But the public is still vaguely aware that repressed memories were fashionable in the '80s and went out again by the late '90s.

The chasm between the two camps in this debate—and the stunning contempt they evince for one another's research—is to some degree a function of warring agendas and approaches. One legal writer claims that "in over 1,000 child sexual abuse, rape and other types of cases in which I have been personally involved, I have not met one real victim who has forgotten that they were assaulted and then remembered it at a later date." On the other hand, Wendy J. Murphy summarily dismisses false memory syndrome, stating, "This simply does not exist as a recognized medical condition. The phrase was coined by the False Memory Syndrome Foundation, an organization formed to provide legal and emotional support to those accused of sexual abuse."

Brain scientists, the proponents of false memory syndrome, must believe that memory is fluid and malleable, whereas clinical therapists who are proponents of repressed memory syndrome have to rely on their patient's autobiographical accuracy in order to treat them. The politics of the parties themselves—with sex-abuse victims on one hand and falsely accused abusers on the other—means the scholarly debate is mired in hate mail, death threats, and near-toxic levels of recrimination...

After reviewing legal aspects of the debate, Slate concludes:

"Still, the bottom line remains that there is probably no one crystalline answer about the scientific truth of repressed memories. As with most overheated scientific controversies in the courtroom, the truth probably lies midway between two bitterly polarized camps: Some witnesses do make up stories, and some therapist do implant memories; but some victims surely do recover lost childhood memories that were too terrible to consider at the time. The reason we have trials—indeed, the reason we have juries—is that sometimes sorting between the "junk" and the "science" has less to do with experts and scientific journals than with the truth behind a witness's eyes.

What to make of that last sentence? If experts and journals are divided, then how will the trial, or the jury, be able to sort the "junk" from the "science," and discern the truth behind witness's eyes? Here's Dr. Robert I. Simon, MD:

The memory debate has polarized most therapists into believers and disbelievers. Strongly held personal biases about recovered memories represent a new occupational hazard for clinicians. Such feelings can undermine the therapists' duty of neutrality to their patients, creating deviant treatment boundaries and the provision of substandard care...Further complicating the matter is the empirical evidence about memory mechanisms, which (as is typical for any emerging science) reveals contradictory findings about how and what persons retain in memory and forget in various settings. Empirical studies often fail to distinguish whether allegedly repressed memories are not retrieved or simply not reported to researchers.

He offers succinct advice to clinicians: Maintain therapist neutrality; do not suggest abuse. Stay clinically focussed. Carefully document the memory recovery process. Manage personal bias. Stay within professional competence; do not take cases you cannot handle. (from Concise Guide to Psychiatry and Law for Clinicians, Third Edition, APA Publishing 2001).

Until research gives us a better understanding of these matters, I'll adhere to his rules. And if anyone wants more from me about this post....should I say that I've forgotten all about it?

The next Grand Rounds...

is at Sue Pelletier's Daily Capsules.

Physician/healthcare bloggers, start your engines! Grand Rounds, otherwise known as the best of the best medical blogs of the week, are coming to Capsules on Tuesday, Feb. 1. Please send your entries as soon as possible, with a final deadline of Monday night.

Her e-mail is spelletier followed by @charter.net.

"Neurotic Iraqi Wife" casts her vote

I'm holding my breath, watching the progress of the vote in Iraq. For obvious reasons, I am drawn to the blog of "Neurotic Iraqi Wife," who describes her first experience at the polls:

Wow what a day, a pretty sureal one. The first day of voting was today for all Iraqis living outside, and I believe that in my city alone, more than half the registrants that registered between the 17th-25th came to vote today. A big factor, I think was that today is a Friday(a public holiday),the equivalent of a Sunday in the west.

I stood there at 650 am, waiting to be ushered in at 7. I smoked 2 cigarettes to pass the time. The clock struck 7 and I brisk walked to my station as to be the first voter, but HEYYYYYYY,a colleague of mine cheated and didnt bother to stand in the queue. Instead he entered the area as a staff member and stood at the station pretending to read things off the wall. Grrrrrrrrr. I was fuming. I couldnt believe it. I coulda easily done the same, but I wanted to do it the right way. the excuse he bloody gave me"You were the first registrant, you cant be the first voter as well". I kept pushing him,lol (can u imagine the scene). Two grown ups fighting for who to be first in line, then out of the blue,a young polling staff member said I wanna be first. I looked into his eyes, and saw the excitement in them. I couldnt but let him go before me(and ofcourse couldnt say no to those innocent puppy eyes,could I now.sigh). At that moment, I cracked up laughing, I never thought the day will come for us Iraqis, fighting for who to vote first. It really was an amazing feeling. And not to mention, my horrible colleague was left there for third place,hehe....

Crowds and crowds of people started walking in at 730am on a Friday morning. It was simply beautiful. Families singing and clapping as they made their way through. I cant describe the feelings of jubilation. There were chocolates and sweets being distributed and one family brought in huge pots of rice and mutton and gave it to everyone in the center. Umm, No Thank You, Mrs here didnt have any...

But she's not in Iraq. Here's A Family in Baghdad:

How can vote for someone that I don’t know his programme or his credibility? How can I take a part of such a foolish act?
These people that will be elected are going to put the new constitution of Iraq, this is a historic responsibility.
Who can handle such a huge task and great honour?
Only people tat we can make sure of their reliability and trustworthiness.
The elected candidates are going to discuss very dangerous issue like suppurating mosque from state, whether religion is the only source of law, the rights for different religious and ethnic groups, the relationships with neighbouring countries including Israel, the relationship with the occupying forces and whether they will be asked to withdraw their forces from Iraq or not.
All of these issues are very controversial and important, and the new government should be reliable enough to take such big decisions.
It is not just about lists and candidates, the issue is more complicated.


The entire world is shouting and asking, are Iraqis going to take a part of the elections or no?
Wallahi I have headache because of times I was asked this question
Yes, of course I am for the elections, and for the participation and voting, but not in this way! Not in this shallow and superficial way!
At the same time, I am against violence and preventing people from going to elections.
The funny thing is that we face the same kind of question in post-war Iraq: are you against or for saddam? Are you against or for the elections?
No one asks: what do you think about what is happening?
You always find yourself in a narrow space put by the person asking you!
And this is funny, because the world is not just Yes and No!

I don't detect an enthusiastic voter in this post...

"This is my last diary"

When BBC reporter Ivan Noble was diagnosed with a malignant brain tumor, he started an online diary. Today he posts that he is too ill to continue.

When I began writing about having a brain tumour, I did not really know why.

That personal style of journalism was never something I was particularly attracted to or interested in reading myself.

But when I was diagnosed back in 2002 I had a strong urge to fight back against what felt like the powerlessness of the situation.

I really wanted to try to make something good out of bad.

I was not sure if what I wrote would be any good and I was not sure if anyone would read it but I wanted to try.

And I also very much wanted to use the diary to maintain my link with my job if I was not well enough to work.

Optimism in dark circumstances

I know now that people have found the diary useful, and it meant a lot to me in particular to know that there were people in a similar situation to me or caring for such people who got something out of it.

The regular feedback from dozens and dozens of people every time I have written has been wonderful, especially in real times of crisis.

I know that it has kept me going much longer than I would have without it and I am grateful...

What I wanted to do with this column was try to prove that it was possible to survive and beat cancer and not to be crushed by it.

Even though I have to take my leave now, I feel like I managed it.

I have not been defeated.

Thank you once again to everyone who helped me and came with me...

I will end with a plea. I still have no idea why I ended up with a cancer, but plenty of other cancer patients know what made them ill.

If two or three people stop smoking as a result of anything I have ever written then the one of them who would have got cancer will live and all my scribblings will have been worthwhile. (emphasis added)

Update: Ovarian cancer survivor Michelle Dellino is now posting at the Cancer Blog. She discusses fear of recurrence, and what to ask upon receiving a cancer diagnosis.

Calling all skeptics...

There's a new blog round-up: "The Skeptics' Circle," brought to us by Saint Nate.

And now my personal news: A week after announcing the idea, I have gotten my act together and am ready to start my own round-up.

The Skeptics' Circle will hold its first gathering here on Thursday, February 3, regardless of whether or not Punxsutawney Phil sees his shadow the day before. My vision is to create a carnival for bloggers who'd rather think critically than criticize thinkers. More specifically, some of the things I'm looking for are posts about:

* Urban legends and hoaxes. If you spotted an oft-reported story that doesn't hold up to critical thought, this is the perfect opportunity to let people what you found. I hate plugging myself, but check out this post about Bill Gates' pictures - and if that doesn't work for you, try one of the examples I cite therein.

* Pseudoscience. Those who know their facts can take this opportunity to correct those who don't. Sean at Preposterous Universes shows how a good report can get misinterpreted by the mainstream media.

*Pseudohistory. Don't like the lessons we all should learn being denied or rewritten? Check out how Orac is continuing his long-running battle against Holocaust denial.

*Hysteria. We've all head countless stories about what is the greatest threats in the world today are, so now it's time to hear why we can still count on the sun rising tomorrow. RealClimate does this well by examining a popular argument against global warming.

*Quackery. Any stories either about potentially harmful alternative medicines or misleading reports from medical news stories. Dr. Charles has a good example of how he works a little magic on his prescription pad to save a witch.

So if you have a story you'd like to contribute to the premiere edition of the Skeptics' Circle, send it to me at saint_nate at hotmail dot com by 11:59 p.m. EST on February 2. Also, please let me know if you're interested in hosting a future Circle so I can set up a schedule.

The history of vanishing options

...for our homeless mentally ill. Liz Ditz, of I Speak Of Dreams, sends links and insights about de-institutionalization:

Jeff Jarvis is historically naive.

It is as likely to have originated with Geraldo Rivera's 1972 documentary on the deplorable conditions at an institution, Willowbrook.

http://www.pdassoc.com/unfd.html

I believe the movement had complex roots in the general movement challenging all authority that began swelling in the 1960s, the romantizing of mental illness that began not with Szasz but with British psychiatrists such as R. D. Laing, (who thought that schizophrenia was not a disease, but a response of a sane person to an insane set of social controls, administered by the patient's parents.)

There were other forces at work: a brief canter

http://www.scientificanalysis.org/30yr2.html

In California, the findings of SPRA and others led to the passage of the Lanterman-Petris-Short Act of 1968. The act, thought to be a major victory for the deinstitutionalization movement, provided a legal basis for treatment, strengthened patient's rights protections, regulated involuntary commitment criteria, and set the stage for community-based mental health services. But the victory was narrowed when then Governor Ronald Reagan saw the act as justification for social service spending cuts. By releasing patients and dismantling state facilities, Reagan shifted the burden for mental health services to county and local governments who lacked the resources to provide the "world-building" support systems recommended by researchers.

Ms. Ditz reminds us that de-institutionalization was devastating for many developmentally disabled patients, and that we're still struggling for solutions:

Current issues:

http://www.raggededgemagazine.com/jan98/calif.htm
The Strauss report was published in July 1996. Dr. David Strauss, a statistician for the University of California, Riverside, found that people with developmental disabilities had a 72 percent higher chance of dying in the community than in an institution. The report was funded primarily by the federal government; some money came from what Strauss calls "allied groups" -- the California Association of Psychiatric Technicians is named as the primary union underwriter.

Fear of people with mental retardation living on the streets, coupled with the Strauss report, has stirred up worries of a repeat botched deinstitutionalization process like the one California experienced under Gov. Ronald Reagan when thousands of psychiatric survivors were freed from institutions without adequate funding or community supports and many became homeless.

Repercussions from what's currently happening in California have been felt across the nation from Tennessee to Pennsylvania. The Strauss report is being touted by such pro-institution groups as Voice of the Retarded (VOR), a parent organization, as definitive proof that people with mental retardation are much better locked up than loose in the community.
========

Other blogs you should read about people working with very damaged kids:

http://www.tard-blog.com
Introduction to Tard-Blog.com This is a weblog written by a real life special education teacher. The original writer, Riti Sped, has retired from teaching and is now pursuing other interests. She may return to teaching at some point, and if so, she is always welcome to come back and write again.

--------------------

If we must have "institutionalization," let's hope that the staff are like Ms. Jaye:

http://www.slowchildren-atplay.com/ Introduction to Slow Children At Play

My name is Stokie Jaye, and I work in a group home for emotionally disturbed boys.

As I drive into work every day, I pass a battered old road sign that was probably erected when the place was built. To me, the sign means absolutely nothing about traffic; it encapsulates what I experience and what I have come to know as the god-awful truth about these kids. It says simply, "SLOW: Children at Play."

The organization I work for is a religious-affiliated non-profit which means its run by very well meaning people who have strong ideals and no idea about how to run a business. Consistency is a problem. Balls are dropped. There are communication breakdowns, grudges kept, infighting, secret liaisons, heavy drinking and AWOLS. And this is just the adults I'm talking about.

For the most part, the average group home counselor is a college student or freshly out of college and applied for the job because they have no idea what a group home is and someone told them that it's like summer camp. For those unlucky applicants, war is not hell--their job is.

I have been a counselor in this home for more than a decade and yes, I do wonder if something is wrong with me to have stayed so long and put up with the shit I've been through time and again. But I love my job and love helping my kids. At least to the extent that they can be helped...

------------------------
Ms. Ditz also sends us this:

"Success: fall down seven times, stand up eight."

How can we stand up again, for our most vulnerable and challenging patients?

Much psych-blogging at Instapundit today....

about homeless mentally ill, and the failure of the "de-institutionalization" movement.

Throughout my training, I heard grim stories about the emptying of psych hospitals in the 1970's. Civil rights activists targeted commitment laws, calling them unconstitutional restrictions of liberty. Thomas Szasz spoke for many activists when he said, "...psychiatric diagnoses are stigmatizing labels phrased to resemble medical diagnoses and applied to persons whose behavior offends or annoys others." There was a movement to limit the power of psychiatrists, to close the dehumanizing wards, and to provide outpatient care (which was never adequately funded).

State legislatures re-wrote statutes. Psychiatrists protested and were overruled.
A hodge-podge of commitment laws evolved, with a maze of legal petitions, hearings, rulings, and appeals. Criteria for "dangerousness" were vague and hard to apply. Soaring costs and declining tax revenues further reduced our treatment options. Here's Dr. E. Fuller Torrey, MD, and attorney Mary Zdanowicz:

At the same time as civil liberties lawyers have been making it virtually impossible to treat severely mentally ill individuals involuntarily until they commit some horrific act, state mental health officials have been increasingly abdicating their responsibility for these individuals." More than 90% of state psychiatric hospital beds that existed in 1960 have been eliminated. Many states have turned over the responsibility for treating severely mentally ill individuals to health-maintenance organizations. Some of them, mostly nonprofits, are doing a creditable job. But for-profit HMOs, with few exceptions, have been disastrous for the severely mentally ill, who are expensive to treat. The newest antipsychotic medications, which are essential for some mentally ill patients, can cost $400 a month.

If we hope to stem this tide of unnecessary violence and preventable tragedies, we will have to address squarely the issue of involuntary treatment. Outpatient commitments, conservatorships, and conditional hospital releases should be used much more widely to ensure that discharged patients comply with the requirement that they take their medication. Since most severely mentally ill individuals also receive federal subsidies such as Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), or Veterans' Administration benefits, such subsidies could be linked to treatment compliance...

We prevent individuals with Alzheimer's disease from living on the streets, because we understand that they have a brain disorder. We mandate involuntary treatment for some tuberculosis sufferers who refuse to take medication, because we understand that they are potentially dangerous to other people. We should do the same for individuals with schizophrenia and manic-depressive illness.

Here in Oregon, at commitment hearings, the judge asks, "Is this person imminently dangerous to himself or others, by reason of a mental illness? " I ask, "What do you mean by imminent?" He hands me a copy of the statute, and says, "Gravely dangerous to self or others within the next two weeks." Apparently, two weeks is considered "imminent" in Oregon (who knows why?).

We can't even predict what will happen this afternoon. I try to bring the court's attention back to the severity of the illness, and any history of violent behavior. But if I can't convince the judge that the next two weeks are critical, the patient goes free.

Is "Cuckoo's Nest" to blame for our current predicament, as Jeff Jarvis says? Ken Kesey is a hero in Eugene. (He lived not far from here.) The movie did generate support for the activists. But they had plenty of ammunition, well before the movie (and book, and play). Some hospitals had become terrible places.

I saw the movie when it first came out, and it had a huge effect on me. I was horrified. Were they doing that to people? How could they do that to people? I couldn't sleep for several days. In med school, I discovered that it wasn't really like that (at least, not where I trained). Now I'm a psychiatrist...and I live about one hour south of Oregon State Hospital, where it was filmed. Those initial impressions have stayed with me. I think I try very hard to not be like the doctors and nurses in Cuckoo's Nest...

It should not be an easy thing, to take away people's freedom and coerce them to take medication. Imagine being given a psychiatric diagnosis you don't agree with. Imagine being told by the state that you must not leave the hospital, and that you must accept treatment. Our patients tell us the horror and pain of that experience, every day. Is there a just way to protect society from potentially dangerous, mentally ill people, and to provide basic care to those who need it, even when they refuse? Your comments are welcome here. (My e-mail is shrinkette01 followed by @earthlink.net.)

Diagnosing: Occam vs. the Saint

The plight of the engineer with two "zebra" diagnoses has drawn more e-mail. Another patient tells of a hard-to-diagnose heart problem:

"I just returned from having corrective surgery (RF ablation) done to correct afib episodes. I went 16 years without a diagnosis of my heart problem, and had accepted early on that I knew something was wrong with my heart and that no doctor was going to recognize that fact." He's written about the stress caused by his illness. There's a happy ending. He's improving now. He seems delighted with his current medical care. But why did he have to wait sixteen years?

How do we try to figure out what's wrong with someone? We usually start with "Occam's razor," looking for the simplest explanation for the patient's symptoms. And when Occam fails us? Here's e-mail from Dr. Bernstein, of Bioethics Discussion Blog:

I thought you might find this excerpt from New England Journal of Medicine Feb.5 2004 "Occam's Razor versus Saint's Triad" by Anthony A. Hilliard, M.D, et. al., appropriate to your recent patient challenge for a valid diagnosis. I have described these two approaches to diagnosis to my second year medical students. My view is to begin with Occam's Razor but if the facts of the case don't fit together then discard Occam and think seriously about Saint. ..
Maurice.
++++++++++++++++++++++++++++++++++++++++++++++++++++++

“What on earth is Saint’s Triad?” So asked C.F.M. Saint several decades ago about his own eponym. Saint, a South African surgeon, emphasized the importanceof considering the possibility of multiple separate diseases in a patient whenever his or her history and the results of the physical examinationwere atypical of any single condition.

The triad that bears his name is the association of hiatal hernia, gallbladder disease, and diverticulosis. There is no pathophysiological basis for the coexistence of these three diseases; that, perhaps, was his point. Saint emphasized that more than one disease may be responsible for a patient’s clinical signs and symptoms.
This is, in fact, the same point made by the apocryphal Hickam, credited with Hickam’s dictum: “A patient can have as many diagnoses as he darn well pleases.”

Because physicians are seeing an increasing number of patients with a multitude of
acute and chronic illnesses, the views of Saint and Hickam warrant consideration in the practice of modern medicine. Neither name, however, is as well known as that of William Osler, who is credited with applying the teaching of Occam to clinical medicine. (Note: see Cheerful Oncologist for more about Osler.)

In the 14th century, William of Occam stated, “Plurality must not be posited without necessity.” A subsequent version of this statement was expressed as “Among competing hypotheses, favor the simplest one” — hence the term “Occam’s razor.” ...parsimony of diagnosis is an important standard in modern medicine; however this principle can fail us. As the population continues to age — and as diagnostic studies increase in number and sophistication — the dulling of Occam’s razor is certain to continue.

+++++++++++++++++++++++++++++++++++++++++++++++++

I was going to "live-blog" January 24, supposedly "the most depressing day of the year" (has Saint Nate started his "Carnival of the Skeptical" yet?). But the day turned out so well here! Sunny, brilliant, 54 degrees. We've had no snow, and hardly any rain this year (I'm afraid that our annual drenching has gone east and turned to blizzards.) We've had some fog, but it doesn't last long. We even found new, pink buds on our daphne yesterday. Has that ever happened in January?
Nothing grim to report from Eugene, at least not yet...

Grand Rounds XVIII is up...

at A Chance To Cut Is A Chance to Cure. Be sure to check it out. He's done an excellent job!

Practicing without malpractice insurance

Imagine practicing with no malpractice insurance coverage. Imagine telling patients, "We don't bill insurance companies here." This doctor in Illinois has been doing exactly that, for a year (registration required, sorry):

“The most surprising and rewarding thing is the response I get from the patients,” said Dr. Macumber, a family physician in Berwyn, Ill., and Chicago.

It's been a year full of surprises for Dr. Macumber since he opened his family medicine practice in September 2003 in Berwyn with no medical liability coverage (CLINICAL PSYCHIATRY NEWS, Feb. 2004, p. 112). Today, he is breaking even and has opened a second location in Chicago.

When he started, he knew he couldn't afford the $40,000 liability premium he would have to pay; he also wanted to draw attention to the skyrocketing malpractice rates many physicians must pay. That's still the case, he said, but his experience has also driven the issue of access to health care to the top of his priority list, he said.

“It started out about medical malpractice, but it's really about access,” Dr. Macumber said.

Since most patients' insurance companies require physicians to carry liability insurance, he doesn't bill insurance companies and, instead, offers his services for a reduced fee—$40 for an average office visit. Patients with insurance can still submit claims to be reimbursed by their insurance company, but Dr. Macumber won't deal with the paperwork.

About 25%-33% of his patients have health insurance, but most are uninsured. Some patients come to see him because they support what he's doing; others have said they want continuity and are sick of changing doctors every year. For still others, it's cheaper to see him at $40 a visit than it is to pay the copayments or coinsurance associated with their health plans.

Some patients come to him because they want the confidentiality he provides by not filing information with insurance companies.

And for Dr. Macumber, cutting out insurance companies means more time, more money, and less aggravation. “I'm so relieved I don't have to deal with that at all,” he said.

Because he does not have to spend time dealing with insurance companies, Dr. Macumber said he can afford to spend 20-40 minutes with each patient.

Not accepting insurance also means that he can charge whatever he wants, including giving someone a break on his or her bill, or even bartering for care. He can also choose to charge for telephone calls, though he hasn't done that yet. He already charges patients about $10 to fill out paperwork.

What does Dr. Macumber think about tort reform? Sounds like he's been reading Curious JD:

Dr. Macumber said he got to really see how destructive the medical liability compensation system had gotten when he decided to practice without it. But he sees traditional tort reform strategies, such as damage caps, as a gut response from physicians who feel angry and cornered.

“Tort reform is nice, but the system itself is flawed on so many levels,” he said.

The medical liability system is a barrier to improving quality and to reporting and learning from our mistakes, he said. Dr. Macumber said that he believes that the answer is a set of comprehensive reforms that address the current system's economic, practice, and ethical problems.

Thanks to Elsevier's Clinical Psychiatry News.

The next Grand Rounds...

is at Dr. Bard-Parker's A Chance to Cut is a Chance to Cure.

The eighteenth edition of Grand Rounds, the weekly exposition of the medical blogosphere's best will be held here on Tuesday, January 25, 2005.
Submissions may be sent either by email : cut_to_cure-at-hotmail.com, or left in the comments section below.
Submission deadline is 9:00 PM EST on Monday, January 24, 2005.
Happy posting.

"What's amazing is not the medical error rate..."

More from the patient who responded to "Worried Sick." He was diagnosed with hypochondria, with symptoms so severe and intractable that his engineering job was affected. Later he was found to have intermittent atrial fibrillation and migraines. I had called him "amazingly magnanimous," because even after his ordeal, he seemed so free of rancor. Here's his comment:

I don't know if "amazingly magnanimous" is the right description for me. More like "amazingly tired of worrying." Living in the past so I can keep worrying about random bad luck just doesn't hold much attraction to me.

Also, as an electrical engineer I have spent days at a stretch figuring out what's wrong with a simple circuit. And that's a deterministic system, not the hundred trillion cells and few hundred thousand genes in a human! What is amazing is not the medical error rate that the media loves to flog, but the success rate. Especially the success rate for things that are almost invisible to objective testing, like your specialty.

I agree - it is amazing when we succeed. Patterns of illness are revealed when something goes wrong wih those cells and genes. But those patterns can be elusive. For every patient like this engineer, there are many more who never receive a strictly medical diagnosis. They are often referred to psychiatrists.

These patients are often miserable. Their distress can take on the quality of an independent problem. Further testing may or may not reveal a medical cause. How to cope with that uncertainty? How to get through today? That becomes the focus of treatment.

A patient responds to "Worried Sick"

"I cannot really blame the doctors for not figuring it out sooner, since it was rare presentations of two disorders," he writes. (He is amazingly magnanimous, after his ordeal.) This patient reminds us of Dr. Robert Centor's advice: "We must keep an open mind," when making diagnoses. Plus, this patient has excellent advice of his own:

Several years ago I developed alarming symptoms that fluctuated over time: extreme indigestion, general feeling of sickness, lightheadedness, ringing in the ears, scratchy dry-feeling eyes, inability to think clearly, stopped-up nose, pounding heartbeat, always feeling like the air was too cold, and these weird attacks where I would feel like something was terribly wrong with my body for a few minutes. After months of investigation, the doctors could find nothing wrong. All the tests and exams had textbook ideal results. "You're the healthiest patient I have," which is dismaying to someone who barely slept in the past two days and feels like death warmed over. The diagnosis was "somatization", a gentle way to say "you're a daft hypochondriac".

Rationally, I had to accept that it was a bizarre set of symptoms, and that I didn't exactly seem to be dying. So I accepted the diagnosis, began bringing my engineering career to a close, pretty much gave up hope, and told an ENT doctor to do whatever it took to fix my poor stopped-up nose. (Telling that to a surgeon is like giving car keys to a teenage boy. He did make my nose work better, but it's still true.) It's hard to accept that you've lost your mind, but what else can you do when real disease has been objectively ruled out by scientific means?

After more months of suffering, the truth finally worked its way out, by sheer blind luck. The attacks of "wrongness" were intermittent atrial fibrillation. (Diagnosed when decongestant from the ENT brought it on long enough to catch on an ECG.) The other stuff was due to migraine with minimal pain and major autonomic effects. (Diagnosed by an ophthalmologist when visual aura appeared.) So I had to unlearn that I had lost my mind and/or developed an untreatable disorder, yet accept that various neurons and heart cells had joined a commune and started dropping acid. It was very confusing.

My family doctor tried to help with Zoloft. It made me so happy it was funny, but also made the migraine problem far worse. I took it for a whole month because I couldn't decide whether things were better or worse. Afterwards it was obvious that the migraine aspect had been grinding me down in a major way. I really empathize with psych patients stuck between drug side effects and their disorders.

I cannot really blame the doctors for not figuring it out sooner, since it was rare presentations of two disorders. I'm not sure what the lesson is. Maybe "When you hear hoofbeats, it can be a pair of zebras." Or how about "Migraine is not a type of headache. It is a major neurological disorder." Or "Sinus headache is diagnosable ONLY by CT scan." Or "The patient is telling you what is wrong with them, even if they sound like a Martian who just stepped off the mothership." Or "Only a fool tries to solve all problems in 15 minute chunks." (emphasis added)

The Internet is certainly a mixed blessing. The literature is vast, confusing, and contradictory. The syndrome descriptions list unremarkable symptoms that everybody has along with terrifying ones. Go looking for information about mild diabetes and you get a gallery of horrors--blindness, nerve damage, gangrene, the whole nine yards--complete with gruesome color photos. It's like a '50s school safety movie: "Don't let this happen to you!" Most of the web is not designed for the layman hypochondriac. Me? I found the web frustrating and useless. There are so many possibilities, and no obvious match to my weird symptoms. I did develop a lasting interest in medicine and biology, so I guess it wasn't a total loss.

What it takes to be a nurse...

A nursing instructor at Top of My Head has started a list. It includes compassion, stamina, and some things that might surprise you ("mega-bladder," for one).

Nursing blogs have been quite compelling lately. Here are some of my favorites:

A nurse at Codeblog has a dying patient whose care seems futile, and discovers that she's lost some objectivity.

I certainly agree with giving the patient a chance to recover, and giving the family some measure of "we did all we could," but I like to think that I can then steer them towards accepting that the end is near.
I can't do that with this family. I have become a little too close to them. To bring up that subject after all we've talked about would feel like a betrayal. (Hat tip: Dr. James Baker at Mental Notes.)

A nursing student sends a message from the front lines, at Jen, SN.

I had 11 patients, 9 of whom were complete care. 2 were hospice, and both wound up dying. One was getting blood, but pretty much bleeding out every unit he got via a GI bleed. 4 were completely out of it--bodies in the bed, turn and position. Most were incontinent, at least to some degree. Most were in pretty much constant pain--hot packs, running for meds, trying massage and repositioning. 5 were on precautions: either special contact (gown and glove) or flu (masks). One of my hospice people needed suctioning...well, constantly, but at least every 30 minutes. The other hospice person had about 30 family members milling about. In addition to all of this, I was training in a new tech.
This would have been possible--not easy, but workable--if I had been working with people who pulled their weight.

Diana, the ER nurse at Write Wing, is tactful, but frank: her "Untruth Detector" is functioning well.

You might not be truthful . . .
if you come to the er and tell us:
"Honestly, I have no idea how that got stuck in there."

"So, why the heck did I decide to become a nurse?" asks Tales of An Aspiring Nightingale.

I oftentimes wonder what I was thinking, leaving my cushy desk job and going into a high stress job where I'm on my feet for twelve hours at a time, dealing with sickness, life and death situations, and people who want me to do hundreds of things at once. Then I remember why I became a nurse:
To save the life of someone who's potentially having a heart attack.
To restore blood in an anemic patient so he can go home to his wife and son.
To release the nursing home patient back into her community in better health.
To ease the mind of a woman who is worried about her ill father.
As a nurse you sacrifice a little of yourself: your time, your energy, your dignity, your lunch, your need to pee. But the end result, your impact on your patients and their lives, makes the job worth while.
The end result helps me get up the next morning, report to the unit at seven o' clock, and do it all over again.

I cringed when I read her remark about nurses sacrificing their dignity. That sort of sacrifice is just not acceptable. And look - another reference to the bladder issue! If nurses aren't able to take care of their own basic needs at work, then how on earth can we expect to have any nurses?

One more! Here's the nurse at Azygos:

You know you have been at work too much when you pick up the phone at home and dial “9” before making the call. Thank God it’s Friday and I’m not on call.

Even worse: when you try to open your own front door with the keys to the psych ward!

You mean there's no pill for that?

I love this post by Rebel Doctor:

From Psychiatric News:
Paul Chodoff, M.D.
Washington, D.C.
I would like to suggest a new diagnostic entity for DSM-V. The diagnosis is "the human condition." Diagnostic criteria would be any combination of the following:
For children: (1) distractability, (2) being fidgety, (3) disobedience, (4) disliking school. For adults: (1) unhappiness, (2) nervousness, (3) shyness, (4) dissatisfaction with one's looks, (5) dissatisfaction with one's sexual performance, (6) getting angry, (7) playing the horses, (8) getting upset when things go wrong, (9) preferring one's own company, (10) showing off, and (11) orderliness.
The advantages of this diagnosis are that it would facilitate insurance reimbursement, dispose of the bothersome problem of comorbidity, and encourage the quest for a drug to cure the disorder of being human.

Some patients are not easily persuaded of this, but:

All sadness is not depression. All inattention is not ADHD. All anxiety is not pathological. All mood swings and spending sprees are not bipolar disorder. There is no "magic pill."

I can't tell you how many times I hear a variant of: "I've taken on too much; it all has to be perfect but it isn't; it makes me overwhelmed and upset, can you give me a pill?"

I tell them: "Those feelings are a signal that something has to change. You need to do something different in your life.

"When we talk about that, to try to figure it out and make changes, it's called psychotherapy.

"So let's get started."

New blog parody...

is up at Dr. Madman's blog. Links from Cheerful Oncologist and Saint Nate are woven into a "Madhouse" vignette. (P.S., Dr. Madman seeks volunteers for future episodes...)

"Worried Sick"

"There's no medical explanation for your symptoms. I recommend that you see a psychiatrist." What patient isn't shocked and angered by those words? No matter how well-intentioned or tactfully conveyed, these referrals can be devastating for patients. "I'm sick, and they don't know what's wrong with me...They think I'm crazy!"

When I first meet these patients, I tread carefully. Most are embarassed, tearful, suspicious, discouraged, helpless. They're completely overwhelmed by their unexplained symptoms. I ask, "Can you help me understand what you've been going through?" and "How has this affected your life?" I encourage them to speak openly about their suffering. Often, the history comes out in torrents, unstoppable. I write down everything they say. Many feel that no one has yet listened, or understood them. Most are unable to talk about anything except their unexplained symptoms. Many feel that their doctors have given up on them, and that their families are burning out. (Sometimes they're correct on both counts.)

In "Worried Sick," Susan J. Landers at American Medical News asks, "What can doctors do about hypochondria?"

"Every physician has a thousand examples," said Robert D. Gillette, MD, a family physician, now semiretired, who works outside of Youngstown, Ohio. "The only question is whether you recognize it and know what to do about it or do you just kind of blow it off."

Ignoring such patients is a technique that has been employed by many. But Dr. Gillette and others have come to understand that dismissing such patients can lead to more trouble down the road for themselves, their patients and the other physicians to whom the patients will inevitably turn. In fact, he decided years ago that a sign he saw on a plumbing shop wall applied to their care: If you can't find the time to do it right, how will you find time to do it over?

"If you have a patient like this and you don't deal with it adequately, you are going to keep seeing the patient over and over again until they go somewhere else. Whereas if you can deal with it effectively, it takes a little longer up front, but it saves time in the long run," he said.

Ms. Landers reports that as many as one in 20 patients suffers from hypo- chondriasis. Most never see psychiatrists, as the referral makes no sense to them. She describes a general approach to assessing and managing these patients (hint: frequent appointments help, reassurance doesn't).

Note the impact of Internet-acquired health information:

...the problem is far from going away. Ready access to the Internet and its vast supply of good and bad medical information has provided additional fuel. Hypochondriacal patients often surf the Web with the hope they are going to find something reassuring, Dr. Barsky said.
'But almost all of them will tell you that by the time they finally get off the computer, they are more frightened than they were initially. They learn about all kinds of other diseases they never even knew about and now they can worry about them. I think it's not very helpful for these people at all.'"

"Dress Rehearsal for Abu Ghraib?"

blog.bioethics.net says:

Given the incredible defense of the ringleader at Abu Ghraib, it makes sense to ask how someone might seriously entertain the idea that orders to exploit and torture prisoners in that way might seem plausible or even appealing. Look no further than the Stanford Prison Experiment, a revolutionary, amazing study, a simulation of prison life using college students in both prisoner and guard roles. The story of the experiments is told in several ways by Philip Zimbardo, who writes in his introduction:
How we went about testing these questions and what we found may astound you. Our planned two-week investigation into the psychology of prison life had to be ended prematurely after only six days because of what the situation was doing to the college students who participated. In only a few days, our guards became sadistic and our prisoners became depressed and showed signs of extreme stress.

There's a horrifying slide show of the Stanford Prison Experiment of 1971. The "prisoners" were systematically abused, and the "guards" were allowed to become abusers.

The word "abuse" springs to mind more readily today than in 1971, but it seems incredible that this research could have been permitted, and that there were so few protections for the research subjects. He justifies elements of the experiment by noting similarities between his "prison," and actual prisons.

Dr. Zimbardo doesn't probe too deeply in his slide show. How was it that he gradually took on the role of a prison boss? Was the lead experimenter also a research subject? Why did the experiment only end when parents sought attorneys for their "prisoner" sons, and when a lone researcher spoke out (i.e., when the powerless gained some power) - six days into the abuse?

Aaron Swartz, at Stanford, has posted about a recent speech by Dr. Zimbardo. I wish I'd heard it! He discussed the the psychology of evil, and Abu Ghraib. He described the concept of the “good guard” — "the man who doesn’t hurt anyone but simply does his job and doesn’t interfere with the hurting. The good guards, Zimbardo notes, are key to the whole thing because if they showed signs of resistance the bad guards would likely begin to resist too."

Zimbardo also laid out the ten lessons he’s drawn from his research, on "how to get people to commit evil:"

1. Create an ideology where the ends justify the means
2. Get a contract from the subjects where they agree to comply
3. Give participants meaningful roles with clear social value
4. Have the rules be vague and changing
5. Re-label actors and actions (“order control”, not guards; “monsters”, not people)
6. Diffuse responsibility so subjects don’t feel liable
7. Start small but slowly increase the requirements, step by step
8. Make the leader seem compassionate at first
9. Permit verbal dissent (“I don’t want to do this; I feel bad”) as long as subjects continue complying
10. Make it difficult to exit

"Further experiments find that people’s inhibitions will be lowered if they or the subjects are “deindividualized” (e.g., they wear uniforms and masks; the subjects wear bags over their heads). In numerous experiments, this doubled the harm participants would voluntarily commit. (Anthropological studies confirm this, finding that cultures with costumes and masks are more violent.) (Any comments from the surgeons?)

"Similarly, changing how people think of their actions is key. In one experiment, where the experimenter called the victims “nice guys” the amount of punishment subjects inflicted went down. But when he called them “monsters” it went up.

"Zimbardo put together all that he had learned into one experiment, the Stanford Prison Experiment, to see how far things could go. Volunteer subjects were recruited and half assigned to be prisoners and half assigned to be guards so that there would be no differences between the two groups. The prisoners were arrested at their home and taken to recently-redecorated basement of the Stanford Psychology department, where they were imprisoned.

"There were no windows, so prisoners could not gauge time. Prisoners were strip-searched and forced to wear dress-like clothes. They were given leg shackles, a constant reminder of their status. Guards were given uniforms and mirror sunglasses (so no one could read their emotions) as well as minimal requirements or training.

"On only the second day of the experiment, the prisoners tried to resist. Guards responded by calling in reinforcements, attacking the prisoners with fire extinguishers, placing the leaders in solitary confinement, and harassing the rest. They also created a privileged cell for the prisoners who most resisted the rebellion, with special benefits. The next day, they reversed things, putting some of the leaders in the privileged cell (to imply the leader had sold out).

"Soon enough, prisoners began going crazy. Guards became so evil and violent that the study had to be prematurely ended.

"The relevance to Abu Ghraib should be obvious. And, sure enough, Zimbardo got a chance to testify before the court trying one of the Abu Ghraib guards, arguing that his sentence should be lowered because, as his research had shown, few could have resisted the powerful situational influences, which were surely even more powerful at a real prison with (presumably at least some) real criminals.

Does anyone know...do our soldiers learn about this stuff, in their training? What about prison guards? And...staff at psych hospitals?

Too painful to watch

Are you watching American Idol? I'm with Ann Althouse on this one: it is heartbreaking to watch some of these contestants. Here's Ann:

"I really feel for the young people who seem not to have anyone to help them, to let them know what isn't appropriate. A lot of these kids are just guessing at what is good and making bad judgments, but if they only had someone to direct them, everything would be different. Some of them seem so all alone. It's really very touching sometimes."

It's trite, it's ridiculous, but it's true: my heart simply aches for them.

It doesn't stop there. After a day at work, it's a challenge to watch contestants lose money on TV game shows. I see their expressions, their loss flickering over their faces. Comforting words rise in my throat. Wheel of Fortune swings to "Bankrupt"...a pile of winnings, gone...No!

(We don't watch much TV around here, anymore...)

Legible, but wrong

The cryptic scrawls that are physicians' handwriting wreak less havoc now, due to EMRs. But we don't always put the right info in our computers:

"Data entry is a top cause of medication errors," says American Medical News.

Computerized prescribing systems might cut the quantity and severity of medication mistakes, but they can't eliminate them entirely, said patient safety experts who reviewed the U.S. Pharmacopeia's 5th annual study of medication error reports.
The study of the more than 235,000 error reports submitted in 2003 by 570 health care facilities was the largest ever by USP. And as the number of reported errors goes up, the percentage that causes patient harm has gone down. But the findings that generated the most discussion are those indicating that electronic prescribing is creating new types of errors.
"Computer entry" was the fourth-leading cause of errors, accounting for 13% (27,711) of the medication errors reported in 2003. In contrast, illegible or unclear handwriting was the 15th-leading cause, and accounted for 2.9% (6,134) of reported errors.
Here's Diane Cousins, vice president for USP Center for the Advancement of Patient Safety: "I was shocked to see computer entry moving up to fourth." (Why is this shocking? Did no one expect this?)

"The fact that it's moving up is a disturbing thing."

What this also shows, some experts said, is that implementing electronic systems requires physician input on design and extensive training with frequent refresher courses.

"It doesn't mean it's unsafe to use technology, it means we have human beings making computer errors," said Institute for Safe Medication Practices Executive Director Allen Vaida, PharmD. "When you use IT correctly, it helps reduce errors that reach patients, but there are still errors."

I recall a patient who received Lamisil instead of Lamictal (Lamictal is for bipolar disorder; Lamisil is for toenail fungus). All of his prescriptions are handled electronically. He asked his pharmacist why his pills were different, and says that he was reassured that they were fine. His mood steadily deteriorated. He also observed that his toes were definitely improving...he had the fungus! It was several weeks before it was all straightened out. A good outcome and a bad outcome, all in one. This study would call it a "performance deficit." EMR's improve safety...up to a point.

Focus on medical errors

at this week's Grand Rounds, hosted by Waking Up Costs.

Medbloggers spend most of their waking hours trying to avoid errors. Why is prevention so daunting and complex? You'll find some answers here...

Update: St. Nate reminds us of what it's like to hear a doctor say "oops."

(p.s. - while you're over there, see his exceedingly charming post about Twinkies. That was also the food of my people.)

Iatrogenosis

In honor of the next Grand Rounds and its theme of medical errors, I submit the following:

A 79 year old woman has hip replacement surgery. Post-op, she is given patient-controlled analgesia (PCA) with a 2 mg morphine loading dose, and 1 mg every 10 minutes prn (maximum dose 6 mg every hour). After 48 hours, she is agitated and hallucinating, seeing insects and dogs. A psych consult is called.

Family reports that she had been healthy, cognitively sharp and living independently before the surgery. On exam, she is severely agitated, incoherent, thrashing, screaming continuously, unconsolable. Screaming increases when she is touched or moved. She has myoclonic jerking movements of her extremities. She appears to be in a great deal of pain, so much so that her morphine dose has been increased. Staff have taken over the PCA, delivering morphine boluses to the patient as she is too confused to do it herself.

She's afebrile. Vitals are stable. WBC 11.0. Hemoglobin 9.4, lytes completely normal, urine normal, chest x-ray normal. Wound clean and surgeon says it looks great. MRI brain: mild atrophy. Creatinine was 1.0 on admission, but is 2.0 now.

Any thoughts? Comments are open. I'll try to delete inappropriate and spam comments asap.

(Based on an actual case, which has been fictionalized.)

UPDATE: Thanks for the comments! My comment is there now. I would post more, but I'm on call...and getting called.

More on "Crazy for You" Bear

Bloggers sound off about the restrained bear, whose commitment papers certify its disturbed and uncontrollable behavior. "Ha! Crazies!" says one. "Lighten up," say others. "It's a follow-up to their popular 'Stalker Bear,'" says the Mock-up, suggesting marketing angles yet to be explored.

Who would want such a gift? What torment has been suffered in those dreaded, humiliating harnesses? Is this something we should "lighten up" about?

I've never actually seen a straitjacket. They were gone long before I started training. I googled "straitjacket" and got predictable results: "Find New and Used Straitjackets on Ebay." These turned out to be leather bondage equipment, suggesting a predicament for the bear that its makers perhaps did not consider...

I imagine buying one of the bears, removing the restraint, and setting it free. But I couldn't reward this silly, clueless company. It's already getting too much publicity, unfortunately.

Long hair starves brain, says Pyongyang

North Korea affirms my parents' beliefs.

NYT cites BBC reports of North Korea's "Official Hair Days."

"The government is telling men to keep their hair short and visit a barber twice a month, saying that long hair 'consumes a great deal of nutrition' and could thus rob the brain of energy...The drive is being led primarily by state television with a series called 'Let Us Trim Our Hair in Accordance With Socialist Lifestyle."(Yahoo News-AFP).

(i.e., my parents always thought that my long-haired boyfriends were deficient in brainpower...)

Unbearable

StigmaBusters has a new target: a straitjacketed teddy bear that comes with its own commitment papers.

The Vermont Teddy Bear Co. said Wednesday it would continue selling its strait-jacketed "Crazy for You Bear" through Valentine's Day, despite protests from mental health advocates.

"We recognize that this is a sensitive, human issue and sincerely apologize if we have offended anyone," the company said in a statement. "That was certainly not our intent.

"This bear was created in the spirit of Valentine's Day and as with all of our bears it was designed to be a light-hearted depiction of the sentiment of love," it added.

The bear, being marketed for Valentine's Day, comes with commitment papers and is meant to convey out-of-control love.

Mental health advocates believe the bear is "a tasteless use of marketing that stigmatizes persons with mental illness," Jerry Goessel, the executive director of the Vermont chapter of the National Alliance for the Mentally Ill, wrote to the Shelburne-based company.

Stigmabusters mobilizes mental health advocates to campaign against stigmatizing, demeaning portrayals of the mentally ill. They once launched a campaign against Nestle's "Tasty Taffy Tangy Candy Bar." This candy carried the names "Psycho Sam," "Loony Jerry," and "Weird Wally." Their website asks,

Are you angry about outdated, outrageous, offensive portrayals or language about persons with mental illness? Become a StigmaBuster and tell the people creating or promoting these ads, characters, editorials and other stereotypes how you feel about their hurtful, demeaning and dehumanizing creations and pronouncements.

Here's how it works:
• Local persons/affiliates deal directly with their own local radio-TV, newspapers and any other business using offensive language or portrayals.
• State Organizations deal with situations in their communities and statewide stigma issues in the media.
• NAMI StigmaBusters E-mail Alerts will inform you about all situations in national media, films, TV, magazines, ads, and press like The Washington Post, NY Times. LA Times, etc. The Alerts will provide details about the offensive portrayals and/or language with the name and e-mail or mailing address of the person responsible for the situation. This will unleash a flood of messages to educate the offending parties. We will inform you about any responses received - positive or negative.
• StigmaBusters also sends letters of appreciation and commendation to producers of TV or motion picture films for their accurate portrayal of a character with a mental illness.

Grand Rounds is up at Dr. Madman's blog...

Thanks to the metaphorically-challenged doctor for including a reference to this site. And Curious JD got a link, too!

Update - some posts about tsunami relief are here and here.

And dear Dr. Madman, I admire your blog, very much! The words "Mad Man" and "Madhouse" evoke images, and in psychiatry we spend much time trying to counter those images. (I've posted about this before.) But anyone who aspires to medicine residency, or to understand doctors, should read Dr. Madman's blog. He brings doctors "real-time flashbacks of residency," as DoctorMental says.

Curious JD has a blog!

An attorney who writes about medical malpractice issues has started his own blog. Welcome to Adversarial Process. I think we'll be keeping him busy...

Doctors feel attacked and victimized by the current legal environment. (Eugene just lost another neurosurgeon last week.) Doctors who've never been sued in their lives are paying huge insurance premiums. Doctors who do everything right can still be sued. Doctors who make mistakes can lose everything (even "protected assets" might not be invulnerable). Just the emotional toll of a lawsuit, or an event that might lead to a lawsuit, is a crisis for any physician.

I may be slightly desensitized, compared to other docs. In med school, we had courses about med-mal, and mock trials. During internship, I trained in a town that was home to many attorneys. Patients were lawyers, their parents were lawyers, their kids were lawyers, their sisters and brothers and cousins were lawyers.

Eventually I started to treat all my patients as though they were lawyers, or were just about to call a lawyer. (I was defensive, and went out of my way to explain things and write them down. Even now, my progress notes can run to 2 or 3 pages.) I worked (and still work) with lawyers, testifying in guardianship cases and commitment hearings.

But I don't think I'll ever be comfortable in an adversarial system. It's not the way I think. I know, I don't have to be comfortable with it, I just have to understand it and accept it. But I still have so much to learn. I have questions for Curious JD (aka "Matt"). I'm curious, as well...

Update: Hat tip to St. Nate for the link to Adversarial Process.

Curious JD also blogs about his practice. He has a moving post about the extreme hardships faced by some of his clients.

"She dragged me to the doctor..."

Dr. Copperfield, at Sunday Times Online, writes about the two types of male patients he typically sees in January.

Category One is incredibly fit, and is there for validation from the doctor. But Category Two...

is commoner and hasn’t really resolved to get healthy at all; he’s had the resolution thrust on him by his well-meaning partner. And he wears it forlornly, like an unwanted, tasteless Christmas woolly.

“I’m a bit overweight,” he mumbles. “I probably need more exercise and I should pack up the fags.”

“Tell him about your drinking,” prompts his other half, who has attended partly to hold his hand, but mainly to prompt him in case he fluffs his lines.

“I drink too much,” he admits, like a teenager caught with a porn mag.

“And he can’t . . . ” says a voice from off-stage.

He turns crimson. “And I can’t . . . er . . . get it up.”

“That’s right, doctor,” confirms his partner. “And he has smelly feet.”

It’s tempting to cut to the chase and suggest that she exchanges him for a sleeker, more vibrant, less pungent model. But I go through the motions and establish that he’s overweight, under-fit and leads an unhealthy lifestyle. He knows this already.

“Thanks, doctor,” says his partner, as they leave. He and I simply exchange glances. He has done his duty but we both know that our next significant encounter could be when I sign his cremation forms.

The next Grand Rounds...

is hosted by "Mad House Madman," at "Chronicles of a Medical Mad House." (Hmmm, I wonder what StigmaBusters would say about his blog?) Regardless, he gives the most vivid, honest description of residency in real-time that I've ever seen. Here's what Dr. Madman says:

This Tuesday's Grand Rounds are quickly arriving. Deadline for submission is January 10th, Monday night at 9 p.m. Please submit your entries to madhousemadman *at* gmail.com.

The better "us" we reach for

Blondzila, at Sanity Optional, lists her New Year's resolutions:

I think it's an essential part of human nature to always be dissatisfied with an element of ourselves. If we weren't, we would cease to try, we would drown in atrophy, and stasis, true stasis, is death. We resolve to be better, and choose the beginning of a new year as a symbol of the newness, the better us, we reach for.

All that said, my resolutions always go for crap. Always.

Admit it. So do yours. C'mon.

The infinitesmally small number of you who actually keep your New Year's Resolutions belong to the same golden group who lose weight and keep it off for the rest of your life, who quit smoking cold turkey and never have a craving, who stop drinking without AA and own a bar... And bully for you for succeeding.

If I was going to make resolutions this year, they'd be pretty simple. But nothing in my life is simple anymore. *sigh* My illness has been on my mind a lot lately. But if a resolution is something that I want to improve about myself, here goes:

First: I resolve to remember to take my medication when I'm supposed to (for those who don't get that, read the blurb under the "Sanity Optional"...it should make sense). But the damned things have an effect on my memory so....ummm...

where was I again?

Second: I resolve to be more honest with my doctor about how my moods have been controlled. ummmm....wait....what was that first resolution again?

Third: I resolve to remember that I don't wear my diagnosis on my forehead like a scarlet letter, so that people really aren't staring at me as often as I think (did I ever tell you the paranoia that comes with bipolar disorder? dunno...I forget...see resolution number one).

Four: I resolve to be more kind to myself, and remember that I'm my own worst enemy when it comes to stigmatizing my illness. I am still a good person, I am still a good mother, I am still a good wife....but as my husband said tonight, I just sleep earlier because of the drugs.

Five: I resolve to thank my lucky stars every day that my worst problem in life is this illness. I still have a husband who loves me (and they say I'm crazy), a son who stays out of trouble and does decently in school, a roof over my head, food to eat and a decent paying job.

My last resolution will be easiest to keep. I resolve to tell you, Internet, thanks for listening to me babble, for giving me an ear and a laugh and a shoulder.

So thanks :-)

On resolutions, and resolve

Dr. Maurice Bernstein, of Bioethics Discussion Blog, writes:

...I haven't seen you write about your experience with the psychiatric/psychologic consequences of people confronting the New Year with either some social or personal pressures to make New Years resolutions and not formally responding or those who actually make them but can't keep them. Or even those who make them AND keep them. Obviously, those you might see professionally have other psych problems which led them to your office in the first place but do you find them to be affected by this custom? Would you think that a normal, mentally healthy Joe could be harmed by this custom? In other words, do you think we should get rid of the idea of making New Years resolutions? ..Maurice.

Dr. Maurice reminds me of the anguish I've seen in people who've repeatedly tried to change, and failed. I've seen patients struggle with the expectations for change that come with a new year. (All right, because the new year brings new deductibles to pay, sometimes I don't see them until February or March.)

But I find myself on some people's list of New Year's resolutions...even those for whom a visit to a shrink means the worst kind of failure. Some resolve to finally start therapy, change therapy, or switch therapists; stop meds, or start meds, or change meds. Some bring relatives and ask us to "fix" them.

Could some people be crushed emotionally by the expectation for change, and the relentlessness of their inability to change? I think I've seen it happen. But rather than get rid of New Year's resolutions, we try to offer hope. I like the idea of being "resolved" to make changes. It implies confidence that one has a future with some possibilities. Maybe together, with the psychiatrist, patients can make some positive changes. They're always going to hear something hopeful from me.

Listen to Maria, at Intueri. She's just met an alcoholic patient who's at the threshold of a resolution to stop drinking:

For every single time we fail—whether it concerns the cessation of alcohol consumption… or nail-biting or pot-smoking or heroin-injecting or diet-breaking or expletive-using—there is another chance to succeed. And there are apparently some reports that indicate that success is more likely with an increasing number of failed attempts (although I need to look at the publications myself, because that doesn’t make intuitive sense to me).

It is so hard to hope. Everyone in the room could sense that this just wasn’t the patient’s moment. Although he said that he was going to stop drinking alcohol, he hadn’t taken ownership of this endeavor. He waffled. He made excuses. He simply didn’t seem committed—yet—to his sobriety.

And again, everyone in the room knew it.

So how do we keep hoping when the signs suggest that we should not? How do we keep working towards an improved quality of life—his life—when we are not entirely convinced that he will participate? After all, should he be sober in five years, we cannot take credit for this… this is something that he needs to do by himself, for himself. Only he can save himself—we can only help set him on the path.

When a whole year of resolve seems impossible, we talk about months. Or weeks. Or minutes. Is it a problem with taking risks, of believing you can do it? May we explore your thoughts about that? May we challenge you with an experiment? (i.e. cognitive-behavioral therapy.)

What about people who resolve to make changes, and succeed? Can they be harmed by their resolve, if their choices were healthy ones? If one feels coerced into making changes, the resulting anger and resentment can guarantee that the change is short-lived. Often patients feel let down if their changes don't produce expected results (for example, they may have hoped to induce others to change also). Some burden themselves with unrealistic expectations for change. Most people navigate pretty well, though...

By the way, I'm enjoying the blogger's New Year's resolutions at Technorati. And look at these Health Resolutions from the Washington Post:

I resolve to change channels during any commercial for a drug whose side effects, recited over music that's a little too loud, include heart attack, stroke, convulsions, loose stools, inability to remember family members' names, a rash shaped like Ukraine or an erection that lasts more than four hours.

Now there's a resolution I can keep!

Mysteries of human behavior

Buried in a NYT Technology article yesterday: weddings that are mock funerals.

"...We brought them out in caskets. Then he got out and gave her a rose, she got out and gave him a lily. They had a catered event afterward."

The purveyors of this ceremony are also auctioning a "mobile home Haunted House" on Ebay. It has an Evil Clown Mouth entrance. Starting bid is $35,000...any takers?

A patient writes about confidentiality

"Confidentiality is an issue that is extremely important to me as a patient, and was even more important to me when I was treated by a psychiatrist. I am curious to know if it is common practice to include psychiatric records in the general medical record at a university student health center, or if most keep those records separate from the general file." This patient tells a harrowing story of her attempt to correct mistakes in her medical record, and to keep her private information confidential.

Confidentiality laws have changed recently, and the best resource is probably the HIPAA website. (HIPAA stands for "Health Insurance Portability and Accountability Act of 1996.") Here are some excerpts from their fact sheet.

Providers and health insurers who are required to follow this law must comply with your right to:
Ask to see and get a copy of your health records
Have corrections added to your health information
Receive a notice that tells you how your health information may be used and shared
Decide if you want to give your permission before your health information can be used or shared for certain purposes, such as for marketing
Get a report on when and why your health information was shared for certain purposes

If you believe your rights are being denied or your health information isn't being protected, you can
-File a complaint with your provider or health insurer
-File a complaint with the U.S. Government
You should get to know these important rights, which help you protect your health information. You can ask your provider or health insurer questions about your rights. You also can learn more about your rights, including how to file a complaint, from the website at http://www.hhs.gov/ocr/hipaa/
or by calling 1-866-627-7748; the phone call is free.

My office

...has the following:

Lexapro pens
Wellbutrin pens
Abilify pens
Prozac wall clock
Abilify weight scale
Zyprexa notepads
Risperdal notepads
Paxil pens
Geodon pens
Depakote pens
Depakote notepads

(Sigh)

Is it really still my office?

Update: Caltechgirl says that drug companys' promotional flotsam are taking over at her lab, too:

I had to let you know that your post about all of the drug rep swag made me laugh. Sounds like my office. Coffee mugs, coasters, pens, notepads, post-its, clocks, etc. all bearing the names of various antipsychotics and SSRIs have populated my office too. And we're a research lab! Drug reps don't even care about us. I guess it all migrated from the clinicians' offices down the hall.

Of course, we also have plenty of junk from the research suppliers as well, and my boss' husband is an executive with a different pharma company, so we are literally swimming in this crap! At least we never have to look for pens :)

This reminds me that I also have Zoloft mugs, Geodon mugs, Eskalith pens, and post-its from the same companies...

Do they think that these trinkets influence our prescribing decisions? When I see a Depakote pen, if I think about the logo at all, I think of the good things and the bad things about Depakote. I think about the potential side effects. But mostly, it's just a pen. The drug companies probably have marketing data about how these things boost sales. I think we're more influenced by the availability of free drug samples...

Another disorder for DSM-5?

From Mr. Sun:

My name is Mr. Sun, and I have AOD.

Annual Organizational Disorder.

All year long, a dormant version of OCD gestates in Mr. Sun's molten core. As the new year approaches, it is born violently in a horrorshock of bloody anxiety as the annual Choosing of the Organizational System plays out at home, work, online, and at the Office Depot across from Krispy Kreme...

At least he's not asking for medication for this!

Excellent Grand Rounds...

at RangelMD today. Go and enjoy!

Let's review...

When you see a patient taking Klonopin, it's helpful to recall the approximate dose equivalents:

Klonopin 0.25 mg is approximately equivalent to Xanax 0.5 mg, or Ativan 1 mg, or Valium 5 mg, or Librium 10 mg.

Of course, the kinetics are different, and there is tolerance and so on. But high potency meds can be...highly potent.

Now, if they are also taking other sedating meds (for example, if their med list also includes an opiate, an anticonvulsant, and a sleeping pill), at certain doses, you might well imagine how the patient might be walking, talking, thinking, or breathing (or not).
Reference: Kaplan & Saddock, Pocket handbook of Psychiatric Drug Treatment, 2nd edition.

Getting out the vote

Vote here for the first Medblog Awards. (Oh, dear...I'm competing with some of my favorite blogs!) The contest is sure to raise awareness of medblogging. Thanks to Echojournal for putting this together!

A drug researcher looks toward 2005

Derek Lowe, a pharmaceutical chemist, reflects on his field and its prospects in 2005.

Silly me. I thought that 2003 was a bad year for the drug industry, and said so here a year ago. How was I to know that 2004 would make it look like a bowl full of strawberry ice cream? That trend had better not continue, or by about 2007 I'm going to be wearing a paper hat and standing behind a french-fry machine.

On one level, things can't continue to deteriorate the way they did this year. The world still needs pharmaceuticals, and it still doesn't have any way to get them other than from the drug companies (large and small.) Those drugs are going to continue to have side effects (large and small!), and regulatory agencies, doctors, and patients are going to have decide case by case if those are acceptable risks or not. We can't just pull everything off the market and start over. There's no "over" to start from. So in that sense, at least, things can't go on like this.

But there are some bad events coming toward us as if they were riding on rails...

He has some interesting thoughts on how his colleagues can ride out the storm.

A question for the New York Times...

which published small photos of 150 decomposing corpses, unidentified victims of the tsunami, in today's Week in Review:

Would you have published photos like this, if the victims were American, with friends and families that could call you and write to you?

Just asking.

Another ER snapshot...

courtesy of Diana, the ER nurse who gives us The Write Wing:

Teen Patient, accompanied by mother, complaining of "stomach pain":

Teen: "What do you mean, a baby? How did it get IN there?? Momma, what are they doing to me?"

MD: "The head is crowning, Diana call OB again..."

Teen's mother: Falls faint on the floor.

"You know the worst place I find stigma? In my own mind."

A patient responds to my post on stigma and the mentally ill:

I was diagnosed bipolar during an enforced hospitalization in September 2003 due to an extreme mixed episode. I was trying to determine, because of thoughts sent to me from outside my brain, how much steady pressure it would take from a steak knife to sever my left hand. I never accomplished it: I had a small and ever-diminishing part of myself that screamed stop and well, ended up in hospital.

I realize there is legislation protecting my job.

I realize that we are a modern society and education is available.

I tell very few of my diagnosis. The few I've told now number people who begin almost every sentence with me: "Please don't take this the wrong way but..."

I haven't told my employers. Yes, the legislation protects me, but that's a hell of a lot of good when I'm fighting from a place of unemployment.

I haven't told a lot of my family and none of my husband's. Part of my particular version of BP gives me a strong tendency to be paranoid. The gossip would be debilitating.

But you know the worst place I find stigma? In my own mind.

I'm an intelligent woman, went to university on an academic scholarship for a history degree. I have an IQ that hovered around 140...I shrink from my diagnosis, a label of "mentally ill", the way I would from a bogey man in my closet. I know it's not what I think, but still I fear it. I try to remember that I'm still me, but then I struggle with the definition of what the real me is: the person I pretended to be in struggling to be "normal" for all those years, or the person who now struggles to be stable and can't remember what "normal" felt like.

I'm my own worst enemy. And all the public service announcements in the world won't change that.

The treatment of bipolar disorder is so much more than just giving lithium (or other mood stabilizers). Patients must learn how to live with the illness...a struggle that this patient describes so powerfully.

Frontiers of sleep research

From the Canadian Medical Association Journal:

"Incidence of and risk factors for nodding off at scientific sessions"
Kenneth Rockwood, David B. Hogan and Christopher J. Patterson for The Nodding at Presentations (NAP) Investigators

Abstract:
We conducted a surreptitious, prospective, cohort study to explore how often physicians nod off during scientific meetings and to examine risk factors for nodding off. After counting the number of heads falling forward during 2 days of lectures, we calculated the incidence density curves for nodding-off episodes per lecture (NOELs) and assessed risk factors using logistic regression analysis. In this article we report our eye-opening results and suggest ways speakers can try to avoid losing their audience...

Methods:
Since we were sitting together at the back of the room, we counted the number of heads falling forward as a sign of nodding off. We chose this method because counting is scientific. We carefully recorded data on what we thought seemed like reasonable risk factors; anything we were unsure of we made up. In as much as a single episode of nodding off indicates submaximal attention, we calculated incidence density curves. To be fair to the speakers (after all, we are Canadians), we counted only 1 nodding-off episode per listener-colleague per lecture. For the logistic regression analysis we dichotomized nodding-off events as occurring at a frequency above the median or, at or below, the median or less. Because this was an exploratory study, we also administered a short questionnaire (Appendix 1) to colleagues who had nodded off.

Results:
About 120 people attended the 2-day lecture series. We had to adjust our analysis because many had left by the end of the second day. The quality of the lectures varied from entertaining and informative, to monotonous and repetitive, to rushed, to Felliniesque. The incidence density curve ranged from 3 nod-off episodes per lecture (NOELs) to 24 NOELs per 100 attendees (median 16 NOELs per 100)...

Interviews with colleagues who nodded off revealed that they were comforted to know they were not alone. Most had no enthusiasm to attend boring lectures but were inclined to go if influenced by payment, CME credits, guilt or obsessiveness. Being internists, all but 1 were relieved to discover that their falling asleep was not their fault but that of the speakers.

Interpretation:
We observed that clinically important proportions of physicians nodded off during the lectures, that there appeared to be a dose–response effect and that speaker characteristics were the strongest risk factors.

Our study had important limitations. Because we sat at the back of the room, we could not see everyone's faces. Thus, people who can sleep without head movement would have been missed. However, since we were counting physicians who were "nodding off" and not "sleeping," we were pretty much covered there...

We were interested to observe that some intrinsically boring talks (those with obscure topics, few data, absent analyses) had unexpectedly low NOEL rates. We attributed this to the bizarreness of the presentation. Factors such as wandering off to inspect the screen, dropping the microphone or just raving — although disconcerting to the audience — helped to keep the physicians awake, as did side bets among attendees on when the speaker's prefatory comments would end and the actual topic of the lecture addressed...

Hat tip: blog.bioethics.net!