When patients blog about their doctors

An e-mailer wanted to know: what are the ethics of posting about my own doctor? Dr. Bernstein, of Bioethics Discussion Blog, sends his reply:

I heard the page for me..so I came running. I understand you want an ethics consult? OK. Here are the questions and my answers:

"What are the confidentiality ethics for patients writing about their experiences?" If you desire to disclose your personal experience for the world to read, you do so at your own risk and pleasure. It is ethical because it is your autonomous decision to do so. "Not use the doctor's name?" Using the doctor's name or any information that may cause someone to identify the doctor would be unethical (the doctor deserves the same right as the writer to decide about publication) and it might be illegal if comments are made about the doctor's behavior or practice which could be interpreted in a court of law as libelous.

"Should a patient mention it to the psychiatrist?" Sure, again emphasize to the doctor he/she was not identified in any way. This informing by the patient, if the patient desires, will facilitate the physician to perform the act in the next question. "Should the psychiatrist read the blog?" Absolutely. As every physician should know, patients might not tell the physician everything, particularly regarding emotions or about the doctor-patient relationship, in the office. The doctor is right there looking the patient in the eye. On a blog, the patient may find some freedom to express what the patient really feels.

However, and here is the caution, on a blog there may not be a chance for the doctor to discuss the patient's concerns (remember, the world is reading and also eye-contact and body language is missing). Soo... be prepared to discuss your views openly with your physician at the next visit. He or she may very likely initiate the issue after you enter the office and sit down. I hope this ethics consultation is helpful and it is free. ..Maurice.

(Now I have visions of twenty or thirty patients asking me,"Did you read my blog?" In psychiatry, we usually focus on the interaction between doc and patient, during sessions...the process, not just the content. Through that interaction, we explore the patient's life and symptoms. Have psychiatrists begun to consider the implications of patients' blogs?)

Under the spreading pasta tree

The "#1 April Fool's Hoax of All Time," according to The Museum of Hoaxes website:

On April 1, 1957 the British news show, Panorama, broadcast a segment about a bumper spaghetti harvest in southern Switzerland. The success of the crop was attributed to an unusually mild winter. The audience heard Richard Dimbleby, the show's highly respected anchor, discussing the details of the spaghetti crop as they watched a rural Swiss family pulling pasta off spaghetti trees and placing it into baskets...

Dimbleby anticipated some questions viewers might have. For instance, why, if spaghetti grows on trees, does it always come in uniform lengths? The answer was that 'this is the result of many years of patient endeavor by past breeders who succeeded in producing the perfect spaghetti.'

And apparently the life of a spaghetti farmer was not free of worries: 'The last two weeks of March are an anxious time for the spaghetti farmer. There's always the chance of a late frost which, while not entirely ruining the crop, generally impairs the flavor and makes it difficult for him to obtain top prices in world markets.'

But finally, Dimbleby assured the audience that, 'For those who love this dish, there's nothing like real, home-grown spaghetti.'

Of course, the broadcast was just an April Fool's Day joke. But soon after the broadcast ended, the BBC began to receive hundreds of calls from puzzled viewers. Did spaghetti really grow on trees, they wanted to know. Others were eager to learn how they could grow their own spaghetti tree. To this the BBC reportedly replied that they should 'place a sprig of spaghetti in a tin of tomato sauce and hope for the best.'

--via our local Eugene daily, in honor of April Fools Day. Other noteworthy ruses:

Instant color TV: In 1962, Sweden's only TV channel tells viewers they can begin receiving color TV by simply pulling a nylon stocking over their sets, even showing a demonstration. Color TV didn't actually come to Sweden until 1970.

The Taco Liberty Bell: In 1996, the Taco Bell Corporation announces that it has bought the Liberty Bell from the federal government and is renaming it the Taco Liberty Bell.

Nixon all over again: In 1992, NPR's "Talk of the Nation" announces that Richard Nixon will run for president again. His new campaign slogan? "I didn't do anything wrong, and I won't do it again."

Different pi: The April 1998 issue of "New Mexicans for Science and Reason" newsletter contains an article claiming the Alabama Legislature has voted to change the value of the mathematical constant pi from 3.14159 to the "biblical value" of 3.0.

More on Cyberbullies

Ms. Liz Ditz, author of I Speak of Dreams, responds:

My natural, kick the tires, all-y'all are so full of bs nature is saying...

Cyberbullying is nothing new. Kids 1-5 have been ganging up on kid #6 since the beginning of time...

But then,

I wonder. If my daughter were receiving IM after IM, filled with cutting comments about her face, her figure, her demeanor, her deportment in school -- that is, she has a cell phone, it is with her at all* times, she uses it as a timer and an alarm clock

It is almost like a psychosis, isn't it? A whispering voice you cannot escape. In other words, you have to read the message in order to know if it is abusive.

But to say, "cyberbullying is wrong" is correct, and does not solve the problem. Hell, alcoholism is wrong, but we've been living with that problem for thousands of years.

The victim of an abuser can only change his or her own response.

Grand Rounds #27 is up...

and who will respond to the first post, about a med student's thoughts on psychiatry? Few fields attract - and deserve - as much scrutiny and criticism as my own. Given that, I must add that there are many reasoned arguments against our current theories and practices, and that the Grand Rounds post does not include them. He does link uncritically to an article filled with distortions. He also links to a transcript of a debate between Szasz and the opposing camp: "Is depression a disease?" No, says the student: it's a mental and spiritual process.

This argument always reminds me of the tale of the blind men and the elephant (with some "chicken-or-egg" thrown in). Clinical depression is clearly a mental (and often spiritual) process, but why dismiss the mounting evidence (hormonal, neurochemical, and genetic) that's converging on a physiologic disease mechanism? I suppose it's because that evidence is only converging. We blind folk are still palpating the elephant. Until a lab test or x-ray can establish the diagnosis, some will not be satisfied. The debate most certainly does not end here...

"Oh, by the way..."

Associated Press discovers the Doorknob Phenomenon. (The article is curiously similar to my blog post on the same topic, including the phrase "Oh, by the way," and the word "bombshell." No doubt, it's a coincidence....isn't it?) Anyway, they have tips for improving communication between patients and doctors, so important subjects aren't saved until the departing doc's hand is literally on the doorknob.

Doctors' rushed schedules and patients' natural reluctance to reveal frightening or embarrassing symptoms make those questions at the doorknob almost inevitable, but medical schools increasingly are teaching students how to avoid such situations.

Dr. Rita Charon, who runs the narrative medicine program at Columbia University's medical school, said the phenomenon might even be one reason that doctors' visits often don't start on time — the previous patient may have had a doorknob question requiring another exam.

Part of Charon's program encourages doctors-in-training to listen and better "read" patients and their greatest concerns.

"You really have no idea of what part of life is going to come up and you really need to signal some desire to hear about it," Charon said.

Charon teaches a method she has adopted with her own new patients, whom she tells: "'I'm going to be your doctor and I need to know a lot about your health and your body and your life' — and then I stop talking."

She doesn't write anything down, or check the computer — she just listens.

"When I did this the first time, the patient started crying, saying 'No one ever let me do this before,'" Charon said...

Nancy Conley, a 48-year-old secretary in Springfield, Mo., says embarrassment led to her own doorknob questions about chronic constipation, along with a belief that nothing could be done for the condition, caused by irritable bowel syndrome.

She sometimes talked herself out of mentioning it at all, trying to downplay it in her mind during the visit "even though I'd go home to my own little hell," she said.

Conley's advice to doctors for avoiding such resistance is to "slow down."

A rushed atmosphere can make patients feel uncomfortable about mentioning bothersome issues. Instead, Conley said, doctors should take a moment to imagine what it's like to be the patient.

"They're scared, they're taking off work probably to be there ... they don't want to be humiliated by putting on those stupid little gowns. If a doctor just stops and says 'Whoa, how would I feel if I were in their shoes right now,'" that could help break the ice, Conley said.

See also Dr. Centor's excellent post about Doorknob behavior. The phrase "Oh, by the way..." came to my post, via his post. Both posts were inspired by a New York Times article. (You see how convoluted we have become, tracing lineage of blog items...)

Sleep myths exploded

Are you a night-owl, living among larks? This NYT article is for you:

At least since Benjamin Franklin included the proverb 'Early to bed and early to rise makes a man healthy, wealthy and wise' in his Poor Richard's Almanac, Americans have looked at sleeping habits as a measure of a person's character. Perhaps because in the agrarian past people had to wake at dawn to get in a full day's work outside, late sleepers have been viewed as a drag on the collective good.

Even today, said Edward J. Stepanski, the director of the Sleep Disorders Service and Research Center at Rush University Medical Center in Chicago, "it's a uniformly negative characteristic to be asleep while everyone else is going about their business."

But before slinking back under the covers in shame, slugabeds of the world should consider: Sleep researchers are casting doubt on the presumed virtue and benefits of waking early, with research showing that the time one wakes up has little bearing on income or success, and that people's sleep cycles are not entirely under their control. Buoyed by the reassessment of their bedtime habits, a few outspoken and well-rested night owls are speaking out against the creep of sleepism...
Whatever the negative associations with sleeping late, scientists say there's good reason to doubt the boasts of the early risers. Dr. Daniel F. Kripke, a sleep researcher at the University of California, San Diego, said that in one study he attached motion sensors to subjects' wrists to determine when they were up and about. While 5 percent of the subjects claimed they were awake before 4 a.m., Dr. Kripke said, the motion sensors suggested none of them were. And while 10 percent reported they were up and at 'em by 5 a.m., only 5 percent were out of bed.

Dr. Stepanski said the same is true of people who boast they need little sleep. In a study in which subjects claimed they could get by on just five hours' sleep, he said, researchers found the subjects were sneaking in long naps and sleeping in on weekends to make up for lost z's.

"There's a tendency to generalize and to do it in a self-serving way," Dr. Stepanski said. "If your view is that you can get by on less sleep than the average person, then you're going to play that up."

Scientists call early risers larks, and late sleepers owls, and speak of morningness and eveningness to describe their differing circadian rhythms. Researchers believe that about 10 percent of the population are extreme larks, 10 percent are extreme owls and the remaining 80 percent are somewhere in between. And they say the most important factor in determining to which group a person belongs is not ambition, but DNA.

"Timing of sleep is genetically determined, whether you're an owl or lark," said Dr. Mark Mahowald, the medical director of the Minnesota Regional Sleep Disorders Center. While most people are a little bit owl or a little bit lark, for others, Dr. Mahowald said, altering sleep habits is "like changing your height or eye color."

Addendum: Dr. Michael Rack is back with a new blog, Sleepdoctor...coming soon to my blogroll!

"Driver on cell phone loses control, plunges into river"

Fortunately, she survived:

PORTLAND - A woman talking on her cell phone lost control of her car, which crashed into the guard rail of the Morrison Bridge in downtown Portland, then plummeted into the Willamette River, police said Saturday.

Melisa Borgaard, 31, somehow managed to freed herself from her car, which sank to the bottom of the river, and was rescued by a diver, said Lt. Mike Shults with the Multnomah County Sheriff's Office...

The woman was taken to Oregon Health & Sciences University for treatment of hypothermia and injuries, including cuts on her face and hands.

Shults said the woman told detectives she was talking on her cell phone to family members when she veered out of her lane and crashed into the guard rail.

Mailbag's getting full...

An e-mailer writes:

"Through a series of unforseen events, I wound up delivering my baby by c-section under general anesthesia. After delivery I was prescribed valium and demerol. The combination caused hallucinations, memory loss, and general insanity for 48 hours. My ob/gyn recognized that my problems were due to drug interaction and changed the prescriptions. But during that 48 hours of hell, the hospital psychiatrist diagnosed me as having post-partum depression...I've never had post-partum depression. I'd like that diagnosis out of my medical records as it is erroneous. How do I remove it? Or how do I challenge it?"

The HIPAA website addresses this problem:

You can ask to change any wrong information in your file or add information to your file if it is incomplete. For example, if you and your hospital agree that your file has the wrong result for a test, the hospital must change it. Even if the hospital believes the test result is correct, you still have the right to have your disagreement noted in your file. In most cases the file should be changed within 60 days, but the hospital can take an extra 30 days if you are given a reason.

Patients may also wish to meet with their doctor and ask questions about why a particular diagnosis was made.

Another e-mailer has a different concern about confidentiality, and I don't know the answer:

"What are the confidentiality ethics for patients writing about their experiences? Not use the doctor's name? Should a patient mention it to the psychiatrist? Should the psychiatrist read the blog?"

I've never thought about that! I couldn't promise a patient that I would read their blog, and I would hope that we could discuss things directly in sessions. For the ethics of blogging about your doctor, I'm tempted to page Dr. Maurice Bernstein (although he's been pretty busy with the Schiavo case!).

The author of the excellent Botanical Girl sends an intriguing link:

"July 7 — A recent study by German researchers reportedly found that the Borna virus, an infection that is known to cause behavioral changes in some animals, was present in up to 100 percent of people experiencing severe mood disorders, but in only 30 percent of people who were healthy. The results prompted new speculation as to whether or not the Borna virus causes depression."

A friend sent me this link and I thought it was interesting. I just noticed this was published in 2001 though. There might be new information at this point. Anyway, feel free to blog it if you like.

-BotanicalGirl (http://botanicalgirl.blogspot.com)

If there's new information, I haven't heard it. I'll have to do a Medline search. I must add Botanical Girl to my blogroll, too.

As for the requests to provide medical advice, endorse specific charities (except for the Red Cross), and march in your town's homecoming parade: regretfully, I must decline. I need to have some limits here!

Cyberbullies

From the Oregonian:

The rise of cyberbullying -- the use of new communication technology to hurt others -- is affecting more and more middle and high school students, experts say. It's an insidious new form of bullying because those who do it can harass their victims anonymously, and away from adults' notice...

"It's like an electronic Dodge City," said Tim Drilling, principal of Lake Oswego's Lakeridge High School, referring to the brawling town in the long-running "Gunsmoke" television series. "Nobody seems to respect the behavioral norms -- it's wide open, people seem to be able to say whatever they want. You can be anonymous, and that seems to make people feel very free."

Attacks are vicious because the senders can be anonymous, said Nancy Willard, director of the Center for Safe and Responsible Internet Use in Eugene. "The social norms online seem to encourage disinhibition. Also, students often don't have any tangible feedback about how they're affecting someone..."

Cyberbullies "just rip into other kids, and they are so brutal and ruthless," said J.D. Gates, an 18-year-old senior at Rex Putnam High School in Milwaukie. In the past year, he said he's come across more and more hurtful Web logs about classmates. "You can see that those kids (who've been cyberbullied) are unhappy about it. It's definitely hurtful."

...While parents have struggled to understand how cyberbullying happens, schools are only beginning to look for ways to fight it. Cyberbullying often happens off school premises and after hours, and experts say much of it is protected by free speech. If schools can identify the students who are doing it, they take measures to stop the cyberbullying, but tracking messages and Web log entries requires serious detective work.

You want us to do what?

Some urges are so horrifyingly self-destructive that they defy belief. I hesitate to post on this disturbing NYT article. (Sitemeter says that most of my readers prefer posts about eating crayons.) But Ann Althouse has already noted it. What to make of physically healthy people who demand to have their limbs amputated, and what to make of surgeons who do their bidding?

The patients' disorder already has an unpronounceable name: "apotemnophilia." There's debate about whether to include it in DSM:

...an obsessive desire for a limb amputation - one that drives people to cut off healthy arms and legs - tests the tolerance of even the most open-minded.

Body integrity identity disorder has led people to injure themselves with guns or chain saws in desperate efforts to force surgical amputations. A few have sought out amputations abroad, including one man who died of gangrene after an elective amputation in a clinic in Tijuana, Mexico.

The disorder has been known by several names. In 1977, Dr. John Money, an expert on sexuality at Johns Hopkins University, named it apotemnophilia (literally, love of amputation). He considered it a form of paraphilia - that is, a sexual deviation.

The syndrome apparently may share features of delusional disorders, obsessive-compulsive disorders, gender-identity disorders (which may involve sex-change surgeries) and eating disorders (which may involve starvation and the belief that one is obese). When patients request amputations, I'm hopeful that surgeons won't simply take them at face value, but will arrange to get Psychiatry involved. It looks like some of these patients are hard to stop, though:

In May 1998, the urge drove one man to a California surgeon who had lost his license more than 20 years earlier for several botched attempts at sex reassignment surgery. At a clinic in Tijuana, the surgeon, John Ronald Brown, 77, cut off the left leg of Philip Bondy, 79, of New York, who had paid him $10,000. Then Mr. Brown sent Mr. Bondy to a motel in a run-down section of San Diego to recover on his own.

Two days later, Mr. Bondy was dead of gangrene, and Mr. Brown was charged with second-degree murder. During the trial, newspaper reports said that Mr. Bondy had sought the operation to satisfy a "sexual craving." Mr. Brown was found guilty in October 1999 and sentenced to 15 years to life in prison.

Mr. Bondy was not alone in his desperation. Among the body integrity identity disorder sufferers in the documentary "Whole" by Melody Gilbert, broadcast on the Sundance Channel in May 2003, is a Florida man who shot his own leg so it would be amputated in the emergency room, and a man from Liverpool, England, who packed his leg in dry ice for the same reason. The man who froze his leg referred to the resulting amputation as "body correction surgery."

As Dr. Hamlet once told Horatio: "There are more things in heaven and earth than are dreamt of in your Psychiatry..."

Grand Rounds XXVI is up...

with posts on Terry Schiavo and.......surgery on conjoined marshmallow peeps? Go immediately to The Well-Timed Period, and see our favorite posts of the week.

(I'm trying to stay out of the terribly sad debate about Ms. Schiavo. I've read that bulimia caused her heart attack, which then caused her brain damage. I've seen many eating-disordered patients locked in power struggles with their families, jockeying for control. Usually, the major battles involve food: what will be eaten, and when, and how much, and under what circumstances. Food becomes a metaphor in these struggles. I have never met an eating-disordered patient who welcomed a feeding tube in any circumstances, perhaps because it is so often mentioned as a threat: "Eat, or you'll get the tube." It raises the specter of losing control, and the specter of gaining weight, with all the dreaded emotional baggage therein.

So it's interesting to see the debate about her feeding tube. We don't know what was going on emotionally in this family before or after Ms. Schiavo's brain injury, and it's wrong to speculate. Ms. Schiavo should not be a Rorschach test for the rest of us, an "inkblot" toward whom we project our own wishes and feelings. Based on what I've read, only her husband and family are suffering now...)

Update: Medpundit has written about "Ms.-Schiavo-as-Rorschach" here.

"13 things that do not make sense"

In The New Scientist. Their first item: "The placebo effect."

DON'T try this at home. Several times a day, for several days, you induce pain in someone. You control the pain with morphine until the final day of the experiment, when you replace the morphine with saline solution. Guess what? The saline takes the pain away.

This is the placebo effect: somehow, sometimes, a whole lot of nothing can be very powerful. Except it's not quite nothing. When Fabrizio Benedetti of the University of Turin in Italy carried out the above experiment, he added a final twist by adding naloxone, a drug that blocks the effects of morphine, to the saline. The shocking result? The pain-relieving power of saline solution disappeared.

So what is going on? Doctors have known about the placebo effect for decades, and the naloxone result seems to show that the placebo effect is somehow biochemical. But apart from that, we simply don't know...

Benedetti has since shown that a saline placebo can also reduce tremors and muscle stiffness in people with Parkinson's disease (Nature Neuroscience, vol 7, p 587). He and his team measured the activity of neurons in the patients' brains as they administered the saline. They found that individual neurons in the subthalamic nucleus (a common target for surgical attempts to relieve Parkinson's symptoms) began to fire less often when the saline was given, and with fewer "bursts" of firing - another feature associated with Parkinson's. The neuron activity decreased at the same time as the symptoms improved: the saline was definitely doing something.

We have a lot to learn about what is happening here, Benedetti says, but one thing is clear: the mind can affect the body's biochemistry. "The relationship between expectation and therapeutic outcome is a wonderful model to understand mind-body interaction," he says. Researchers now need to identify when and where placebo works. There may be diseases in which it has no effect. There may be a common mechanism in different illnesses. As yet, we just don't know."

I have more items for their list, but they haven't asked me yet.

(Hat tip: Slate's What I Clicked.)

"Too Soon Old: Too Late Smart"

It's flying off the shelves - a self-help guide that promotes personal responsibility:

"The statute of limitations has expired on most of our childhood traumas... .Any relationship is under the control of the person who cares the least... .Feelings follow behavior... .Only bad things happen quickly... .There is nothing more pointless, or common, than doing the same things and expecting different results."

The author, Dr. Gordon Livingston, MD, is a Maryland psychiatrist. In Psychiatric News, he's praised for "avoiding sound-bite solutions to life's eternal problems." He's been compared to Job:

In 1991 Livingston's 22-year-old son Andrew committed suicide after a long struggle with bipolar disorder. Lucas, his youngest son, was diagnosed with leukemia six months later. That child died at age 6 after an unsuccessful bone-marrow transplant from his father.

How does one deal with such losses? Not with the aim of reaching closure about the experience, said Livingston.

In fact, he wrote, "Like all who mourn, I learned an abiding hatred for the word `closure' with its comforting implications that grief is a time-limited process from which we all recover."

Instead, Livingston wrote of the possibility of honoring the memory of his children by expressing the love he feels for them to those who still need him.

He has some harsh words for psychiatry:

"Managed care and insurance company reimbursement schedules have turned many of us into pill pushers."

He laments the diminishing role of the psychiatrist as a "source of wisdom and guidance for people seeking help with the eternal questions of how to live meaningful lives."

Grand Rounds #25, brought to you live...

by Orac, at Respectful Insolence. Finally, some high-quality medical programming! Don't miss it.

Cannabis soup and biscuits

Cosmo Landesman meets a pot-eating senior, in Sunday Times Online:

Last week she appeared in Newcastle crown court convicted of possession and intent to supply cannabis (she will be sentenced next month). Now she is planning to stand as an MP against Peter Hain on behalf of the Legalise Cannabis Alliance and has signed a book deal for her recipes.

“You should try my cannabis leek and chicken pie, it’s wonderful,” she said. “And my cannabis lime cheesecake is heaven.”

But in February last year she was on the verge of suicide.For the previous three months she had been living a reclusive existence: no bathing, rarely eating, rarely sleeping: “A doctor had given me a prescription drug for my depression and I was suffering from terrible side effects like tinnitus, hair thinning, bruises on my arms, red lumps on my face.”

What medicine was she taking? We aren't told. The story continues:

A worried friend banged on her door and when Tabram asked for a cigarette, proferred a roll-up. “After two puffs my head was like a balloon. I lay in my chair and started singing,” Tabram recalls.

She had just smoked her first joint and it was like discovering a miracle cure. “That night I slept for 12 1⁄2 hours. In the morning I cooked my first proper meal in eight months, the red lumps on my face had gone down, my tinnitus had stopped and my hearing improved.”

Tabram did not like smoking cannabis, so her friend told her that she could cook with it and gave her the name of a Newcastle pub to make her purchases. “The place was full of all these long-haired teenagers. When the dealer came in, I went up to him and said, ‘Hello dear, are you the man with the cannabis?’ "

Mr. Landesman believes that "Tabram sincerely believes in the medicinal value of cannabis but has become an addict — to all the attention that has come her way.

"The granny who eats cannabis is suddenly a celebrity and that is one of the hardest habits to break." More on cannabis here.

How to leave your body

Helpful Mr. Sun links to a do-it-yourself guide to "out-of-body experiences."
It says - surprise! - that there is power in suggestion:

The first method, affirmations or self-suggestion, is to tell yourself, "I want to have an out-of-body experience," "I want to leave my body" or similar suggestions. The best times to do this are right before you fall asleep and especially right after you wake up in the morning. At these times you are in close contact with your subconscious. I wake up very slowly. For about a half hour I'm in contact with my subconscious mind. When I give myself suggestions then, they are very effective. Make these affirmations several times a day.

Mr. Sun informs us that, "if he had your body, he'd also do anything he could to get out of it."

More on spirit departure:

"Mr. Albert Sykes reports the following experience: "I was sitting having biscuits with some friends when I felt my spirit leave my body and go make a telephone call. For some reason, it called the Moscowitz Fiber Glass Company. My spirit then returned to my body and sat for another twenty minutes or so, hoping nobody would sugest charades. When the conversation turned to mutual funds, it left again and began wandering around the city. I am convinced that it visited the Statue of Liberty and then saw the stage show at Radio City Music Hall. Following that, it went to Benny's Steak House and ran up a tab of sixty-eight dollars. My spirit then decided to return to my body, but it was impossible to get a cab. Finally, it walked up Fifth Avenue and rejoined me just in time to catch the late news. I could tell that it was reentering my body, because I felt a sudden chill, and a voice said, 'I'm back. You want to pass me those raisins?'

(from Woody Allen, "Examining Psychic Phenomena," in "Without Feathers." Warner Books, NY: 1976, page 13)

C. O. Undercover

The Cheerful Oncologist visits his own doctor for a check-up. He doesn't tell the office staff that he, too, is a doctor:

As I introduced myself to the receptionist she asked for my insurance card and said, "Mr. Hildreth, please take a seat. We'll call you when we're ready." ...Did I hear correctly? She called me mister - Mr. Hildreth. Why, I'm a layperson again!
After a week of seeing patients and answering millions of questions I relished the thought of going through this visit anonymously. I smiled slyly and wondered how long I could go without anyone knowing my true occupation; after all, we medicos have big egos. Maybe I wouldn't be able to carry out the charade. I decided to give it a try - to fake being a normal person and see if the employees treated me differently than if I had brought a bullhorn and announced "WATCH OUT - I AM A DOCTOR!"

His discoveries are not to be missed. Example: "Patients who read of a new medicine have a better chance of getting helpful advice from the doctor if they bring the information with them, rather than say 'You know, doc, it's that thing they gave to all the baboons in China.' This doesn't narrow it down much."

Health risk for bloggers?

Perhaps for some of us, anyway. Long hours in front of a computer can increase risk of deep-vein thrombosis, aka blood clots. Andrew Lycett, of the Times of London, blames Google for his DVT's:

...When I started writing biographies a decade ago, finding a date or checking a quotation required a trot to the library. Now I sit at my desk, punch words into a search engine and the information appears before me. It makes writing much easier but also dangerously sedentary, as I have learnt to my cost. Last year not just one but three deep-vein thromboses were diagnosed in my right leg.

A report by MPs this week says that thousands of hospital patients are dying unnecessarily of blood clots every year because doctors aren’t alert to the problem. It estimates that clots kill 25,000 people in England a year. But I wasn’t in hospital; nor had I taken a long-distance flight. DVT has become over-identified as the “economy-class syndrome”. The combination of pressurised cabins, dehydration and cramped seating does cause veins to tighten, blood to congeal and, if you are unlucky, send a clot to your lungs (the dreaded pulmonary embolism). But driving for long periods can also do the trick. Or, like me, sitting at a desk at home, writing 1,000 words a day to meet a book deadline...

Looking back, I am certain that they developed from my sedentary lifestyle, though not so much from sitting ( many do that) but from my manner of doing so...

He has tips for avoiding DVT's (hint: get moving!).

"Should we just play along?"

In the New York Times, a hospital patient wants treatment on her own terms: "An Insurrection On the Mighty Ship of Health Care," by Dr. Kent Sepkowitz, MD.

She breaks the patients' dress code. She treats her doctor like a friendly equal. "She was notifying us that she did not intend to go along with the parade, the basic hey-everybody-let's-do-what-they-say ethos that is the organizing principle of hospital care."

She is firmly in charge. But is she also minimizing her illness? As she improves, the doc happily plays along:

Her room was my favorite stop of the day.

But then the situation soured. Her fever returned; she was sick once more. Her illness indeed was not just a minor inconvenience, a slightly bad hair day, but rather life and death, a genuine danger to her.

And suddenly everything changed. She became distrustful of us, of me. Our exchanges became awkward and hurried. I was now one of the bad guys, a willing ambassador for the dehumanizing, demoralizing, disappointing hospital.

For we had crushed her fantasy. What then became unsettling was not her antipathy (which was no fun) but rather the fact that I had agreed to play along and low-ball the gravity of the situation. I had participated in her costume ball, she in her PJ's and I in my starchy white coat. Like many others in the hospital, I was a card-carrying member of her folie à deux.

Doctors are often caught in this uneasy halfway house between medical reality and the wishes of a patient, a patient who probably knows plenty, but insists on putting on a happy face, and it raises a basic question. Is it up to us to rub a patient's face in her own frightening situation, to overwhelm the tricks and sleights of hand used to maintain sanity?

Or should we just play along. I mean there's no harm in hoping, right?

Except this. Much has been made of the problems engendered by the grim Dickensian doctor who spreads bad news with apparent glee. But what of the eternally cheerful physician, one who at times comes to resemble a used car salesman, assuring that the odd whirring noise is nothing really, nothing at all to be worried about.

Doesn't such bounciness, such resolute optimism, such eagerness to cheer up the patient at any cost finally cause avoidable harm by raising hopes on a faulty foundation?

The high-wire act required to balance hope and simple facts will remain a work in progress for years to come. But doctors and patients should remember that hope - although the most precious element in the hospital cosmos - is also the most potent. And all involved are well advised to dispense and consume it wisely.

-via blog.bioethics.net.

It's a girl!

Congratulations and best wishes to Dr. and Mrs. Madhouse Madman, on the birth of their Future Intern! (I would be knitting baby garments for her, if I knew where to send them. Perhaps a tiny cashmere scrub outfit.)

Social psychology of the Yankees

...profiled in the New York Times. Do less tightly-knit groups have a competitive advantage?

...social scientists who have studied group performance under pressure say that often it is decentralized groups (like the Yankees) that prove more resilient than strongly connected ones (like the Red Sox); they are better able to weather outside criticism and internal quarrels...

Evidence from personality profiles and from studies of military, corporate and space flight crews suggests that looser ties between group members can be a strength, if the team includes individuals who can generate collective emotion when needed. And the Yankees have several of them.

"So much of psychology and sociology emphasizes the importance of communicating and creating strong bonds to improve group performance, but in a lot of situations that is just not how it works," said Dr. Calvin Morrill, a professor of sociology at the University of California, Irvine, who has studied group behavior in competitive corporate situations and in high schools. "Baseball is an odd mix of an individual and team sport, and an ideal example of where a diffuse team with weak ties to one another may help the overall functionality of the group...


When a common purpose is shared, loosely tied groups can function better than strongly bonded ones when it comes to containing dissent or bickering, research suggests. In studies of neighborhood organizations and corporate teams, social scientists have observed that members with weak ties can withdraw from disagreements without disrupting the group or their own work.

On a tightly knit team, by contrast, a falling out between key members can divide a squad, forcing people to take sides, psychologists say. "The idea is that any sort of problem is likely to ripple more strongly and quickly through a close group than one with weak ties," said Dr. Mark Granovetter, a professor of sociology at Stanford.

Psychologists who have studied the personality profiles of people who face far greater pressures than winning in October - including special-operations forces and astronauts - agree that those who do well share distinct qualities: they tend to be independent, confident, able to tolerate uncertainty and socialize easily with others.

"But they are not too outgoing, not socially needy, not the sort of people who need others for support," said Dr. Lawrence Palinkas, an anthropologist at the University of California, San Diego, and the chief adviser to the National Space Biomedical Research Institute, which studies spaceflight.

Whether such independent, loosely tied people ultimately succeed as a unit depends not only on strong management, researchers say, but on the presence of individual group members who can circulate through disparate parts of the team, reduce conflict and help generate collective spirit when it is needed.

Grand Rounds #24 is up...

hosted by Hospice Guy. (How often has he given a speech like this one?)

You have two options, and I'll tell you what they are...
One: You can click on the links, read the posts, and learn something.
Two: You can not click on the links and learn very little.
As a hospice worker, I'm a big fan of patient choice. You can do what you want, I am offering you something here that I think you may very well find useful. I hope you take advantage of the opportunity before you, but I can't make you do anything you don't want to do. How you proceed from here is totally up to you.

Nine days without cigarettes

At least she tried to quit:

In the end, I survived nine days without fags; nine derelict lunchtimes in a fag free world. It was a terrible experience, although, as I promised, I did learn to knit. I began a mohair turquoise flak-jacket, with Leon Trotsky's face embroidered on the front. (Minus the ice pick that killed him; it was too fiddly).

The worst part of quitting was the amount of saliva I produced. I almost drowned in it. The whole of my being seemed to sit on my tongue. I was reduced to a mouth; just a mouth and a tongue, with a large mammal attached to it. Usually I have at least a finger as well. When the mouth that was me could sit up, it knitted Trotsky, ate biscuits and watched the Exorcist 3, a film about exploding Catholic priests. When it couldn't it dreamt; of self-help books and patches and nicotine-themed sex.

(From the Guardian.)

"The bottom of the mountain"

At WebMD, a husband writes about his wife's severe depression:

Each time she has fallen down this well, it's been triggered by some small concerns nagging her, and she starts to worry about them. It's like watching a snowball coming down a mountain -- it just gets bigger and bigger. And I can't stop it. Finally, it comes to rest at the bottom of the mountain...

Depression is taxing not only to the one that suffers it, but also to all those around the depressed: relatives and friends. Coping requires lots of love and patience. Unlike physical illness, a depressed person cannot 'think correctly.' Those around the depressed must not take it lightly.

Oh God, depression is so bad!

Have you done what you can, for Darfur?

New addition to sidebar: a link to my post on Sudan. It's easy to contact your senators and representatives via e-mail, and ask them what they're doing about the genocide...

"Your assistance with ending this genocide is much appreciated."

Here is an e-mail I received today:

Subject: Sudan

Hey Everyone,

While I generally attempt to refrain from sending out emails like this as much as possible, sometimes there is no compelling reason not to. Sometimes I can't not.

Most likely, very few of you know about what is currently happening in Sudan. The only real word to describe it is genocide. I'll spare you the details (check out Nicolas Kristof's numerous articles in the New York Times if you're curious), but suffice it to say that the death toll is slowly approaching that of the tsunami with fatalities far more gruesome.

In this case, however, we can change the course of history. While Congress and the U.N. have officially recognized the acts in Sudan as genocide, there seems to be a lack of interest in actually stopping them. A critical push is needed if we are to do anything but write reports about it and take pictures of the damage.

That is where you come in.

As Senator Paul Simon said after the Rwandan genocide, "If every member of the House and Senate had received 100 letters from people back home saying we have to do something about Rwanda, when the crisis was first developing, then I think the response would have been different." Rwanda, if you don't know, was a genocide that occurred in the mid-1990's where millions and millions of people were systematically killed using machete's and sticks and something that the U.S. could have stopped with ease.

Straight from the horse's mouth: If we write enough letters, something will get done. I've drafted a form letter and supplied you with all the necessary websites to contact (our senators and representatives). Please take less time than you spend brushing your teeth everyday to send out a cheesy letter. Generally I'm pretty apathetic about sending letters to senators and representatives, but this situation is so disgusting and so stoppable that, as I said earlier, I can't not.

Thanks,
Josh

Here's my letter:
Senator _______,

I am writing in regards to the terrible situation occurring right now in the Darfur region of Sudan. As I am sure you know, the Sudanese government is supporting militias who are trying to completely remove non-Arabs in a genocidal manner.
The U.S. government must not repeat the mistake of inaction that we made during the genocide in Rwanda in the mid-1990s. In that case, the U.S. had the power to change the course of events, but did nothing while millions were brutally murdered—a sequence of events that makes Saddam Hussein look trivial. Today, we can prove our ability to learn from our mistakes and stop the atrocities occurring at this very second. If we are to be the police of the world and strive to bring democracy and freedom to all as the Bush Administration purports, then we cannot pick and choose our engagements. The people in Darfur are being robbed of much more than their their lives.
Your assistance with ending this genocide is much appreciated—not by me, but rather the men, women, and children who are maimed and killed daily. As an elected member of the most powerful nation in the world, the ability and puissance necessary to stop this lies solely in your hands.

Thank you for your time and assistance.

Sincerely,

(_______________)


To contact your senators, click here. You might paste the letter into their web form.

And to contact your representatives in the House, click here.

Grand Rounds #23 is up

...at intueri: to contemplate.