Grand Rounds Vol. 2, #6

Kidneynotes, an excellent medblog, hosts our latest Carnival of the Caregivers. He links to some wonderful posts. Be sure to check it out!

"Read this! It's making me better!"

She's in her sixties. She lives alone. Her son lives on the East Coast. She sees him once a year.

One night she lies awake and thinks, I may live twenty more years. That means I may only see my son twenty more times...or less!

And soon, it's hard for her to think about anything else. She had felt so young before...or at least, not old. When did the future start shrinking?

So she brushes aside my questions about meds, mood ratings, and side effects. Not today, doctor! We're talking about how to live, how to get through this. She's thrusting a newspaper clipping into my hands. "Read this! This is helping me! I'm showing it to everyone!"

We read it together. It's the New York Times, quoting Joan Didion.

"I'm not telling you to make the world better, because I don't think that progress is necessarily part of the package," she said. "I'm just telling you to live in it. Not just to endure it, not just to suffer it, not just to pass through it, but to live in it. To look at it. To try to get the picture. To live recklessly. To take chances. To make your own work and take pride in it. To seize the moment. And if you ask me why you should bother to do that, I could tell you that the grave's a fine and private place, but none I think do there embrace. Nor do they sing there, or write, or argue, or see the tidal bore on the Amazon, or touch their children. And that's what there is to do and get it while you can and good luck at it."

My patient's eyes sparkle. "Do you know that Joan Didion uses her best silver every single day? She says that today is all we have!"

"Ghost Blog"

"I was jacked into the web, my neuro-sync had just been updated, and was exploring some old blog-files, stuff that is usually unreadable, but can occasionally surprise...I was about ready to call it a day when I picked up on a site that caught my attention. This is what I found there:

????so lonely????????neither alive nor dead,
???????????free me from this void???????????
????????????????????help me?????????????????

"I filed it and resumed my search. Finding nothing, I went back to the site:

I am so lonely?????neither alive nor dead,
can?????free me from this void????????????


-a bloggy ghost story from Professor Batty, at Flipppism is Key.

"It started with a new office chair..."

In WAPO, a patient's harrowing story:

"Within a couple of months of getting the new seat in late 2003, a sharp, electrifying pain shot through my upper left arm whenever I raised it, picked something up, rolled over on my left side in bed or even tried to brush my hair..."

Things go from bad to worse. He still struggles with pain and functional impairment.

"Yet it's hard for my colleagues and my friends to understand how debilitating it is, since it is an invisible pain -- without cast or sling or conspicuous impairment.

At my annual physical in August, my internist urged me to go on disability until the shoulder heals. That's not a viable option. I've now turned to the rehabilitation specialist as the lead doctor to deal with the pain. If and when the pain diminishes, then I have to decide what to do to get the shoulder to work again..."

What pain can do

"Perhaps few persons who are not physicians can realize the influence which long-continued and unendurable pain may have on both body and mind," he wrote. "Under such torments the temper changes, the most amiable grow irritable, the bravest soldier becomes a coward, and the strongest man is scarcely less nervous than the most hysterical girl."

-Jerome Groopman quotes Dr. S. Weir Mitchell, the Philadelphia physician who first described Reflex Sympathetic Dystrophy in 1872. In the New Yorker.

"Ghost Networks"

From Dr. Deborah Serani's blog:

If you live in the United States, has this ever happened to you?

You call a psychologist, social worker of psychiatrist who is "on your plan" only to find out that they "are not" on your plan?"

Have you found yourself feeling disgusted and exhausted from this experience, and deciding not to go further with finding a therapist?

Consider yourself haunted... By a Ghost Network.

Excellent post about "Phantom Networks," with lots of links for patients who find themselves caught in this managed-care trap. Is this problem common with other specialties?

"Termination"

A beautiful post, by Maria at Intueri.

...A smile broke across her face when she completed her recollection. She turned to me, her dark eyes glistening with tears.

“Thank you for listening,” she said. “I really appreciate it. I will miss you.”

“I will miss you, too,” I said, almost trying to mask the fondness in my voice—God forbid I actually sound like I actually care for my patients. “I hope that you will do well and get out of the hospital soon.”

“So do I,” she continued.

We looked at each other, sitting in that moment when something warm and meaningful and touching and perfect should be said, but the words are lacking...

The Prophet of Doom stepped out of the shower and said, "You know...when the first person gets bird flu from another person...or if the world even thinks that happened...the stock market will be...very unhappy."

"What, I'm supposed to do therapy with the stock market now?" I replied, scrunching deeper under the covers.

"No," said the Prophet of Doom, drying himself off. "But you should be thinking about it. Smart people have already thought about it...the government could stop airline flights coming into this country. Global businesses would be...very unhappy. There could be panic...hysteria..."Madness of Crowds"...do you want some coffee?"

"Coffee sounds great," said I. "We're not going to panic about bird flu, remember?"

"Oh, we won't panic...we're talking about other people panicking......and you won't want to live in a glass house when it happens, because mobs with torches will be breaking them, and roaming the streets...where's the cream?"

"We ran out. We don't know what's going to happen! How can we know?"

"Yes, I'm reading tea leaves, that's all...it's just little tea leaves..."

"Psychiatric medications have not been approved for treatment of stock markets!"

Addendum to disclaimer: The preceding is excerpted from this morning's conversation with my Prophet of Doom, who is not and never has been a financial advisor. No investment advice is given on this blog!

Grand Rounds Vol 2, #5

"Welcome to today's Grand Rounds. This week, instead of departmental presentations, I would simply like to read a letter from a janitor in our hospital..."

Hospital Impact has done a marvelous job. Don't miss it!

Medicare Part D: the Chatbot Interview

Jabberwacky: Have you been to the Moon?

User: No, I haven't. We had a seminar about Medicare Part D today.

Jabberwacky: That's exactly what I have wanted to say to YOU the past two days!

User: It's the new prescription drug benefit. Enrollment starts on November 15.

Jabberwacky: What ever it is you're smoking or sniffing, I don't think it's good for your wits...!

User: Ah, you're right. Enrollment continues until May 15, 2006. But to get benefits on January 1, you have to sign up this year. If you wait until after May 15 to enroll, you'll have to pay more.

Jabberwacky: Have you got a slipped disk then?

User: Nope. Monthly premiums will vary. The national average will be about $37.00 per month.

Jabberwacky: What about it?

User: Those with the least resources won't have to pay a premium. Some will have a sliding scale.

Jabberwacky: Mind sees truth and often runs from truth into hands of devils.

User: I'll say! There's a 'Standard Benefit Plan,' sort of the minimum benefit that the plans must offer. Insurance companies can offer this standard plan, or "enhanced" plans. When comparing all the different plans, it helps to use the "Standard Plan" as a yardstick.

Jabberwacky: That's true... I have manic phases.. And that's why I have an interesting thought process. So why must I work here with no consideration for my own being?

User: The Standard Benefit Plan has four steps. Step One: the annual deductible, $250. (Those with the least resources pay no deductible, or may have a reduced deductible).

Jabberwacky: Yes, with my two friends, Swan Lake and The Nutcracker. Quite a reputation the latter one has!

User: In the Standard Plan, after the deductible is paid, Medicare pays 75% of the next $2000 of drug costs. (So you would pay the premiums, and the $250 deductible, and then $500 of the next $2000). That's Step 2.

Jabberwacky: No matter what goes wrong, it will probably look right.

User: Perhaps... Anyway, after that limit is reached, patients are on their own for their drug costs, until their total bill has hit $5100 for the year. That's an extra $2850 that comes out of pocket, in Step 3. Medicare doesn't start paying again until that limit is exceeded (unless you are one of the poorest Americans).

Jabberwacky: And after that ... ?

User: After that, Medicare provides 'Catastrophic Coverage.' Patients will pay only 5% of their drug costs. Medicare will pay 95%. That's Step 4.

The gap in coverage (in Step 3) is called the 'donut hole.' (No donut hole for those with the least resources.)

To get Catastrophic Coverage, you need to spend $250 (deductible) plus $500 (25% of next $2000) plus $2850 (to bring total annual drug cost to $5100). That's a total out-of pocket cost of $3600, before Medicare starts to pay 95%. (Plus, you're paying monthly premiums.) That's the Standard ("minimum") benefit.

Again, those with the least resources will have more benefits and lower copays. If they are too impaired to sign up for a plan, I believe there’s some sort of “default” plan…I think.

Jabberwacky: Of course, you're so right !

User: Why, thank you. If I'm not right, I hope someone lets me know!

Jabberwacky: You're a man.

User: Er, no. Sorry. I'm not.

Links:
www.medicare.gov
CMS Medicare Modernization Act Current Publications
CMS Prescription Drug Benefit Partner Center
SSA: Help with Medicare Prescription Drug Costs
Medicare Rx Education Network
www.MedicareRxMatters.org

Dr. Bernstein, on "The Angry Patient"

The angry patient is a like a thorn suddenly
Pricking the finger of the unwary doctor
But, perhaps, sticking there with great pain and consternation
The doctor trying some way to pull it out
And not push it in deeper

Dr. Maurice Bernstein cites a list of suggestions to help defuse angry encounters. I've met countless angry patients, and I heartily agree with these techniques. My personal favorite: listening. The angrier the patient, the more I try to stop, and hear, and understand.

Here's ACP Online, on "working with tough patients:"

When faced with an angry patient, for example, start talking about patients' emotions at the very beginning of the interview.

"Go for the elephant in the room, which is the looming emotion," Dr. Fortin said. Acknowledge patients' feelings, and apologize for any factors—like long waiting times—that might be tied to you. "At the same time, don't make excuses," he added. "Your goal is to calm them and to try to find common ground."

Be aware that anger often masks fear, particularly in male patients. In one role-playing session, panelist Robert C. Smith, FACP, professor of medicine at Michigan State University, pretended to be an irate patient who initially found fault with every aspect of the office visit. That gruffness faded, however, as the interviewing physician focused on getting the patient to talk about his emotions. The patient eventually admitted how frightened he felt that his chest pain might lead to surgeons cracking open his chest.

While physicians can defuse most encounters with angry patients, there are times when you have to set boundaries, Dr. Dwamena pointed out. If patients become disrespectful or threatening, leave the room.

Dr. Maurice invites comments from doctors and patients...

CNN.com: Elderly man drives with body in windshield

ST. PETERSBURG, Florida (AP) -- A 93-year-old driver apparently suffering from dementia fatally struck a pedestrian and drove for three miles with the man's body through his windshield, police said.

Ralph Parker was stopped after he drove through a tollbooth on the Sunshine Skyway, Traffic Homicide Investigator Michael Jockers said. The toll taker called police, he said.

Parker was not likely to face charges because he did not appear to know what happened or where he was, said Bruce Bartlett, chief assistant in the Pinellas-Pasco County State Attorney's Office.

When should driving privileges be revoked? For a demented person, who has lost so much already, this can be "the final straw" - the crisis that can lead to violent and/or suicidal behavior. I've been threatened by patients who did not want to hear my opinion of their driving abilities. Here's an article from the Alzheimer's Association:

The Driving Dilemma
When Should a Person with Alzheimer's Relinquish the Keys?

"Behind the wheel, the person with Alzheimer’s may forget directions and landmarks and become lost, disoriented, and— worse yet—a danger to himself and others. With grandchildren in the car’s backseat and wife beside him, R. Swisher, who has Alzheimer’s, accelerated into the street, narrowly avoiding being hit broadside by two other cars going 40 miles per hour. Another time, he changes lanes into a car’s path.

"Despite his wife’s insistence that her husband not drive, her fervent please were ignored. She writes: 'Our primary care physician wrote a ‘Do Not Drive’ prescription. He refuses to go back to that doctor.'

"Readers who shared their experiences for this 'Dialogue' column said the decision to sell the car or hide the car keys was painful. "This was the first big life change for Mom as a result of Alzheimer’s. It made the disease real to us—the point of no return," writes Jane Gaboury, of Alpharetta, Georgia, whose 71 year old mother Cecile regularly drove through stop signs before ceasing to drive.

"'The questions of whether or not driving restrictions should be enforced for people with Alzheimer’s is simple in theory and difficult in reality,' notes Gaboury. "In theory, people who are impaired must not be allowed to drive, whether that impairment is the temporary result of alcohol or of a more permanent condition such as Alzheimer’s." Yet caregivers question how family members can determine when the impairment is sufficient to warrant driving restrictions..."

Flickr: Photos tagged with "earthquake"

...the Pakistan/Kashmir/Islamabad cluster. For survivors, time is running out (Guardian, Times Online, NYT).

I'm sitting in my nice home, clicking through these photos, and watching from my fancy HDTV. How lucky I am, and how terrible this is...

Once again, I am posting links to charities: CARE, Unicef, World Vision.

We're still reeling from the tsunami, Katrina, and Stan. We're nervously watching Wilma.

But this earthquake has been called "the worst yet..."

Podcasts we've been waiting for...

are posted! More medbloggers chat with Dr. Bottles, at SoundPractice.Net:

GruntDoc,
ZapGerms,
Aggravated DocSurg, and
Blogborygmi.

I know what I'll be listening to this weekend.

NASA urged to consider sexual aspects of space travel

In the New Scientist:

Sex and romantic entanglements among astronauts could derail missions to Mars and should therefore be studied by NASA, warns a top-level panel of US researchers...

"With the prospect of a very long-term mission, it's hard to ignore the question of sexuality," says Lawrence Palinkas, a medical anthropologist at the University of Southern California in Los Angeles, an author of the report. It reviewed NASA's plans for research to keep astronauts safe and healthy in space – but the plans make no mention of sexual issues in spaceflight.

Palinkas says long-term space missions may be similar to extended periods in the isolated and confined environments of Antarctic research stations. He says crews in those stations often pair up in "bachelor marriages" that last the length of their stay – or less. "If there are instances of sexual conflict or infidelity, that may lead to a breakdown in crew functioning," he told New Scientist.

"Breakups can lead to violence and all kinds of things," agrees Carol Rinkleib Ellison, a psychologist specialising in sexuality and intimacy based in Oakland, California, US, who was not part of the NAS panel. "People are very primitive in their emotions around partnering and sex."

Sexual harassment may also endanger a mission. In an 8-month space station simulation on Earth in 2000, a Russian man twice tried to kiss a Canadian woman researcher just after two other Russians had gotten into a bloody brawl. As a result, locks were installed between the Russian and international crews' compartments.

Palinkas says such problems may be minimised by training astronauts ahead of time in how to deal with stressful situations or by having them speak with psychologists on the ground in group therapy sessions. "You'd deal with it basically the same way you would with any potential crew tension and conflict," he says.

But he says sex may also benefit missions by creating "a sense of stability or normalisation". Ellison agrees, saying sex or masturbation could help alleviate boredom and anxiety on the long, lonely journeys through space.

"It could help or hinder, depending on how many people you've got, their relationship, and what it means to them," she told New Scientist.

Tragedy

San Francisco Chronicle: "3 kids feared dead -- thrown into S.F. bay. Mother who said she heard voices is arrested." What was she thinking, or feeling? We have no information about her diagnosis. Did she have a psychosis related to a medical condition or a substance, such as amphetamine? Did she have a psychotic disorder, or a mood disorder? Episodes like this are rare, and contribute to stereotyping of the mentally ill. (Most mentally ill patients are non-violent.)

But every psychiatrist knows that this can happen. We are asked to predict and prevent these tragedies, but we are not infallible. When I hear news like this, I always freeze, and think: is it my patient?

Bird flu review

The Guardian has an interactive guide to avian flu.

They also note that “a number of niche blogs and wikis have been set up as information clearinghouses on the threat in a concerted attempt to inform readers about the potential risks of bird flu.”

Medpundit has taken the lead, blogging about our current knowledge and the view from her own practice.

This PBS transcript gives a harrowing view of the 1918 flu pandemic.

John M. Barry has an alarming piece at Time.com:

"Victims could die in 24 hours. Symptoms included bleeding from the nose, mouth, ears and eyes. Some people turned so dark blue from lack of oxygen that an Army physician noted that 'it is hard to distinguish the coloured men from the white.'

"False reassurances from the government and newspapers added to the death rate. They also destroyed trust in authority, as Americans quickly realized they were being lied to. The result: society began to break apart. Confidential Red Cross reports noted 'panic akin to the terror of the Middle Ages of the plague' and victims starving to death 'not from lack of food but because the well are afraid to help the sick.' Doctors and nurses were kidnapped...

Doctors and nurses kidnapped? Society breaking apart? Have we learned enough from prior disasters, to prevent panic and hysteria?

"The worst-case scenario is truly frightening," says psychiatrist-blogger
Dr. Neubauer.

Are the reports alarmist or realistic? Should we be fearful of a catastrophe? Is it appropriate to be anxious about an impending flu pandemic? The best answer is don't panic, but do prepare. Some anxiety can be a good thing...

Lifestyles of the hip and ailing

In the Telegraph: "When hip gives way to hip replacement."

The debilitating effects of leading a rock and roll lifestyle are well documented, but it seems that performing live can be particularly hazardous. At the tender age of 47, Prince has been told by doctors that he needs a hip replacement - the fallout from years of dancing onstage in high-heeled boots.

"Following in the faltering footsteps of Eddie Van Halen and Motley Crue's Mick Mars, the 5ft 3in singer, who wears heels to enhance his height, has been prescribed anti-inflammatory drugs for the discomfort in his joints until he undergoes surgery."

Performance-related injuries among rock stars are described. The list includes torn ligaments, hearing loss, and falls onstage. Other hazards: projectiles flung at stars by their fans. "David Bowie was temporarily blinded when a lollipop hit him in the eye during a concert in Oslo. The stick became wedged between his left eyelid and eyeball - which he damaged as a child in a fight at school - and had to be removed by a roadie."

"Accident-prone artists should take a leaf out the Rolling Stones' lyric book - they aren't taking any chances on their current tour of America. Every night, the band's road crew sets up a defibrillator backstage, in case Mick, 62, Ronnie, 58, Keith, 61, or Charlie, 64, suffers a heart attack."

Grand Rounds Vol 2, No 4

Diabetes Mine blogs about diabetes from a patient's perspective. Today she presents the best of this week's medical blogging. Medpundit, Dr. Charles, and Codeblog are there (among many others!). Be sure to check it out.

On a personal note, today is my birthday! We're driving to Sisters to celebrate. More later!

British man takes legal action against his witch doctor.

In The Observer:

Kevin Bird from Cannock split up with his girlfriend and was very depressed about it. His worried mother gave him the business card of a Birmingham-based witch doctor called Mansor Barry...

According to the lovelorn Kevin Bird, Mr Barry 'repeatedly said that he would contact the spirits and reunite me with my girlfriend'. I'm not quite sure what the spirits were supposed to do about it. Sometimes, couples get back together because a problem has been resolved or their co-dependency turned out to be unbreakable; they rarely do it just because the furniture rattled in the night.

It is tricky for spirits to communicate clear instructions. If I heard an unearthly howl, or a vase of flowers suddenly threw itself on to the carpet, I'm not sure I would think: 'Ah, that means I should go to the pictures with my ex-boyfriend, Phil.'

So far, Kevin Bird has handed over a total of 1,500 pounds for Mr Barry's services, but his girlfriend still hasn't come back. He is starting to think perhaps the spirits aren't getting anywhere...

What Kevin actually suspects is that Mr Barry may be a charlatan. Kevin has now asked trading standards officers to investigate.

Are e-mails fattening?

In The Guardian:

Health experts believe millions of hours of vital exercise are being lost every week thanks to the explosion in electronic messaging...

As a result, Sport England, as part of its Everyday Sport campaign, is launching Email-Free Friday this week. Employers, it says, should introduce a ban on internal emails and get staff walking around their office - presumably to complain that they can no longer send emails.

'We're losing millions of hours of exercise through the explosion of email,' said Dr Dorian Dugmore, a health adviser to Sport England. 'People email colleagues who sit next to them, never mind those who work on the other side of the office. We have to change people's lazy attitudes.' Increasing activity levels by 10 per cent could save 6,000 lives and �500 million per year, as well as leading to one million fewer obese people in England, it is argued.

Mom-blogging

I'm so excited! My mom will be visiting us this week. Today, she flies here from the Midwest. We'll go to the coast...or perhaps to the mountains.

Mom was quite anxious when she first heard that I was going to be a psychiatrist. In our family, no one really said the word "psychiatrist" out loud. In fact, it was hardly whispered. "That person is...(words mouthed slowly and deliberately) ...seeing a psychiatrist. He is...(words mouthed inaudibly, again)...mentally ill."

Later I learned that mom's aunt died in a mental hospital. Grandma always insisted that it was a mistake, and that she never belonged there. In every family photo, a ghost-like shape has been carefully cut with scissors. Aunt Catherine has been snipped out.

Mom could not understand how I could work with "the problem people." She called her brother, an OB-Gyne in California, and asked, what is my daughter doing? Why is she doing this? Don't worry, said my uncle. Psychiatrists have the best life, the best hours. They travel all over the world. She'll be fine.

And I am fine. Mom doesn't worry so much about it anymore. And we don't talk about it much.

But I'm worried about her. She's in her late seventies. When we moved, our new address confused her. Today, I see that she gave us the wrong flight number. I'll be asking little memory-testing questions while we're visiting. (What day is it again...mom?) I hope she's not getting a dementing illness...the kind that turns a person's mind into a real-life, empty, ghost-like shape...

Update: she's here. She's great. I love my mom!

"After Hurricane Katrina, the answer to any question beginning with 'are we prepared' is an emphatic negative."

Dana Milbank, in WAPO:

"Halloween came early to the Capitol yesterday, as disease experts lined up to scare the dickens out of lawmakers in a 'congressional briefing' on the coming flu pandemic.

"The elected representatives missed their briefing, because they were home for their Columbus Day recess, trick-or-treating for campaign checks. But a roomful of staffers, pharmaceutical lobbyists and reporters toured a medical house of horrors in the Hart Senate Office Building.

"'We and the entire world remain unprepared for what could arguably be the most horrific disaster in modern history,' inveighed Gregory A. Poland of the Mayo Clinic and the Infectious Diseases Society of America. Somebody in the audience sneezed, and Poland added: 'The clock is ticking. We've been warned.'

"It was hard to top that, but Constance Hanna, an occupational health specialist, tried. 'Let me paint you a little picture,' she began. 'Twenty to 30 percent of your employees don't show up to work . . . schools are closed . . . transportation systems are curtailed or shut down . . . Critical infrastructure will or may fail: food, water, power, gas, electricity.'

He calls it "the coming flu pandemic." There will be another flu pandemic, and it may or may not be bird flu. How to prepare for a worst-case scenario, which may or may not occur, and also avoid panic or hysteria? Excuse me, I must wash my hands now...

NAMI vs. "Bridezilla"

Where does humor end and stigma begin? Consider this ad for a show about overwhelmed brides. Does it cross the line?

Yes, says NAMI:

Unfortunately, the Web site shows a progression of three pictures of a bride in a wedding dress: from "Engaged," to "Enraged," to "About to Be Committed." The final picture shows her wrapped in a straitjacket. Brides on the show, the site declares, go from sweet to certifiable.

Please contact the show and the president of WE's parent company, Rainbow Media, Inc. Send them these messages:

* Change the Web site. Remove the straitjacket and any suggestion of mental illness.
* Straitjackets are extremely offensive symbols, representing the pain and deaths of people with severe brain disorders.
* Straitjackets also are unfair symbols of violence that perpetuate stigma condemned by the U.S. Surgeon General.

We've had this debate before (here, here, and here). Recall the baffled responses to the outcry against "Crazy for You Bear." Will this campaign be similar?

NAMI speaks for patients who know far more about restraints than the rest of us. For them, it's no laughing matter. I hope that Bridezilla listens to NAMI.

"Yankees' recent failures pose mental-health risk for unsettled nation"

Bernie Lincicome's lament:

The Yankees are the only baseball team that is more important than baseball. How they fare on the field has a devout effect on the mental health of the nation.

We do not need to feel sorry for the Yankees. We need them to be what they have always been, something to resent, something safely distant.

We need them to be a surrogate villain, replacing neighbors or mothers-in-law, with whom there is no truce. We could think whatever we wanted to about the Yankees, call them any names we pleased, and they would not let their dogs off the leash or move in with us.

We would feel a lot less edgy if the Yankees were back up there, too good for their own good.

A winning Yankees baseball team is necessary for peace in our time. It is a proven fact that the divorce rate and pet abuse diminish when the Yankees win.

Grand Rounds Vol.2 Issue 3

The week's best medical blogging is at Doulicia. Her theme is the "symbiotic relationship between law and medicine." Categories include "Docket Review," "Advisory Memos" and "Amicus Briefs!" New medbloggers are featured, as well as GruntDoc, Cheerful Oncologist, and Kevin, MD. Go there at once!

New podcasts: Dr. Grohol and Dr. PZ Meyers

Now at SoundPractice.net: Dr. John Grohol of PsychCentral, and PZ Meyers of Pharyngula.

Dr. Grohol discusses "medical blogging, effects of blogs on the doctor-patient relationship, the state of the doctor-patient relationship, transparency, views of mental illness in America, the effect of Katrina on mental health and medical practitioners use of the Internet and blogging."

Dr. Meyers comments on "the role of blogging for science and medicine, using blogs to interpret heavy science for the lay public. The discussion then turns much deeper and heavier to topics such as the erosion of public education, Francis Crick, the conscious being, trust in medicine, peer review, split brain experiments and science as religion."

Thanks to Dr. Bottles, for letting us hear some of our favorite bloggers!

Researchers vs. bird flu: the race is on

...and the virus is winning. Times Online:

As the H5N1 virus moved closer to Europe yesterday with suspected cases among poultry in Turkey, The Times has learnt that urgent studies into improved vaccines are being held up because the Government is stalling over financial support. The Department of Health has yet to respond to detailed proposals submitted by British virologists almost eight months ago, even though the work is widely acknowledged to be desperately needed to create vaccines.

Flu experts said that the delay was unacceptable when vaccine development should be every country’s priority for health research...

A vaccine against H5N1 flu, which has infected 115 people and killed 60 in South-East Asia, will be critical to containing a pandemic if the virus starts to move from person to person. A candidate vaccine has been developed by Sanofi Pasteur, a French pharmaceutical company, but trials in the US have shown that it confers immunity only at very high doses, which must be four times stronger than conventional flu shots.

Without substantial improvements to the vaccine, it will be possible to cover only about 75 million of the world’s population of 6 billion people, even if every conventional factory is switched to make the new jab.

My grandmother had frightening memories of the last flu pandemic. She told of her shock when infected friends died rapidly, and that she was afraid to go outdoors. Eighty-seven years later, we're still ill-prepared...

I see that one Medlog blog is devoted entirely to bird flu news and links: Bird Flu Watch, by "independent researcher Dave Roberts." Unfortunately, it has some characteristics of a link farm (no comments - I think I posted the first one - and lots of ads). But one can learn about the disease on this site.

"On Being a Witness to Suffering"

From the nurse at Digital Doorway: today's must-read.

"What does it mean to be a witness to suffering? What impact does it have on one's psyche and soul to bear the very human burden of sharing others' pain? Is there a cumulative effect? Does one become immune or hardened against the pain of others? Is there a point where one just has to quit altogether?


...I sometimes ask myself why I choose such work, electing to continue to serve those in pain, those suffering, those whose lives are unorganized, chaotic, riddled with disease and dysfunction. There's not always an easy answer to such ruminations, and on days when I witness people making incredibly poor life choices and propelling themselves into further illness and dysfunction, I cringe at my dedication and wonder if my limit will soon be found, the emotional levees breached, the city of my mind flooded beyond its capacity to continue to witness such self-destruction and pain. Until that time, I imagine, it is the golden moments---such as the recent death of my sweet patient and the gratitude of his caregiver---which propel me forward and reinvigorate my desire to serve.

Confessions of a hypochondriac

In The Observer:

'So,' asks the doctor. 'What's the problem?'

As efficiently as I can, I explain about the spot. I try to keep the story straight - not to embellish or waffle, which doctors hate, with good reason. While I'm talking he stares at me, stroking his lips with his thumb...

How should doctors deal with hypochondriacs? In the September 2003 issue of Current Psychiatry, Brian Fallon and Suzanne B Feinstein offer some advice. Doctors need, they say, to set limits to their involvement with 'problem patients'. They suggest doctors tell their patients something like this: 'I will reassure you only at office visits (not by phone), the office visits will be limited to once a month, and during each visit I will reassure you no more than once.'

So what I want to know is, where's my reassurance? After all, it's pretty obvious Gimpface thinks I'm a 'problem patient'...

excerpted from I Told You I Was Ill, by John O'Connell

Fred, Ethel, and Medicare Part D: "Choice is Swell"

PacifiCare recruits I Love Lucy characters to sell its new stand-alone prescription drug benefits:

Through the magic of Hollywood, famously tightfisted Fred (William Frawley) and his irascible wife Ethel (Vivian Vance) are brought back to life in a series of entertaining vignettes. Innovative production techniques combine body doubles, voice impersonators, original sets and computer-generated imagery to enable Fred and Ethel to ''speak'' once more...

"We are confident that the 'Choice is Swell' campaign will effectively highlight our Part D prescription drug plans' affordability and quality," said Phanstiel. "Fred and Ethel are American icons that capture the essence of a generation and its desire to get the best value for its money. After exploring numerous advertising options, we chose Fred and Ethel because of their enduring popularity and strong appeal, not only with seniors, but also with baby boomers and people of all ages."

They'll need lots of Freds and Ethels in their plans. As Procare Blog notes,

...the race to get enrollees in the various Plan D programs is off, with PacifiCare unveiling a list of options approved nationally. You can almost hear the thunder of hooves from Big Insurance...The strategy, essentially, is to get as many enrollees as possible, the fastest, which is going to leave a lot of smaller competition out of the race.

"The thinking is that this is the one-time chance to get that chunk of enrollment," says Matthew Borsch, analyst at Goldman Sachs.

He notes that profit margins are expected to be small, perhaps only 2 or 3 percent. And what's this? A proposed merger between United Health Group and Pacificare will be...very expensive. David E. Willliams, of Health Business Blog, cites Modern Healthcare:

"California Treasurer Phil Angelides criticized UnitedHealth Group's proposed acquisition of PacifiCare Health Systems, Cypress, Calif., calling $314 million earmarked for payouts to top executives excessive. Angelides, who plans to run for governor next year, urged Gov. Arnold Schwarzenegger and two of the state's largest public pension funds to use their investment clout to oppose the $8.1 billion deal if the payments are not rescinded."

Here's David:

"The payouts average $8M per executive. Maybe they should have kept a lower profile and settled for $5M."

Rescuers scramble to reach quake survivors

Earthquake in Islamabad, originally uploaded by mbukhari_prm.

In the Observer:

Caked in thick grey dust and using only candlelight and the cries of the injured as their guide, tens of thousands of rescuers continued a desperate effort last night to save thousands of people buried in rubble after a huge earthquake flattened towns and villages across Pakistan and northern India.

The quake, at 8.50am local time (3.50am BST), was of a magnitude of 7.6 on the Richter scale and wiped out entire villages in the forest-clad mountains in Pakistani Kashmir, near the Indian border, about 60 miles north-east of Islamabad.
...As the earthquake struck, screams were heard across Srinagar, the summer capital of Indian Kashmir, as people fled homes, shops and offices fearing they would be buried under rubble. On the streets, men spontaneously started reading out verses from the Koran and women beat their chests in a traditional display of grief. 'Thanks to Allah, today is Saturday. Had it been Friday many would have died of heart attacks,' said Aminbin Khaliq, a shopkeeper. Muslims widely believe that the day of resurrection will come on a Friday.

...For many in the aftermath of the disaster, described by the US Meteorological Department as the worst to hit the region in decades, the efforts of rescuers and the military to pull them out of the wreckage was already too late.

In Abbotabad, north of Islamabad, dozens of injured victims and other patients, some hooked to intravenous drips, lay on the lawn of the city hospital after officials said aftershocks made it unsafe to stay inside.

In Uri and Baramulla, the worst affected towns in Indian Kashmir, survivors told how people formed rescue teams. Many complained it took hours for heavy lifting gear to arrive. Poor building standards were highlighted by many as responsible for the collapses. 'Construction is rubbish in India. The builders use more sand than cement,' said one rescuer.

'It was like hell,' said Nauman Ali, who lived on the top floor of a 10-storey residence in Islamabad which was reduced to rubble.

Cause of death: obsessive video gaming

CNN:

In August, a 28-year-old man died after nearly 50 straight hours of playing online computer games. The man, whom police refused to identify by name, was moved to a hospital after he collapsed while gaming and died three hours later.

Many of South Korea's 17 million gamers -- some 35 percent of the population, principally males in their teens and twenties -- are obsessive. At the 1,000 won-per-hour ($1) Internet cafes popular among young South Koreans, they'll sit eyes glued to monitors for hours on end. Sometimes play will extend for days...

In this country of 48 million people with the world's highest per-capita rate of broadband connectivity at 70 percent, the rise in addiction to multiplayer online gaming is alarming psychologists.

The number of counseling sessions for game addiction quadrupled last year, the government says. There were 8,978 sessions in 2004 compared with 2,243 cases the previous year, and the first seven months of this year saw 7,649 sessions.

This year's gaming death wasn't the first such case of someone dying at a computer terminal in this game-crazed nation: In 2002, a man died in Kwangju after 86 hours of marathon gaming.

The latest casualty collapsed August 5 in the southern city of Daegu after having eaten minimally and not sleeping.

"The man who's trying to do for happiness what Newton did for gravity has found it a scarce commodity in life."

Times Online:

Seligman describes himself as a "walking nimbus cloud" who spent 50 years "enduring mostly wet weather in my soul". Feeling out of place as a chubby 13-year-old Jewish kid at a wealthy college, he hit on the role of therapist as a route to the hearts of unattainable girls. "What a brilliant stroke! I'll bet no other guy ever listened to them ruminate about their insecurities, nightmares and bleakest fantasies."

As a psychology graduate working in animal- behaviour labs, Seligman discovered "learned helplessness" and became a big name. Dogs who experience electric shocks that they cannot avoid by their actions simply give up trying. They will passively endure later shocks that they could easily escape. Seligman went on to apply this to humans, with "learned helplessness" as a model for depression. People who feel battered by unsolvable problems learn to be helpless; they become passive, slower to learn, anxious and sad. This idea revolutionised behavioural psychology and therapy by suggesting the need to challenge depressed people's beliefs and thought patterns, not just their behaviour.

Dr. Seligman, a professor of psychology, is "famous again, this time for creating the field of positive psychology" - the study of happiness. Well worth the read. And what's this?

Showing how easy it is to give people an intellectual boost, Isen divided doctors making a tricky diagnosis into three groups: one received candy, one read humanistic statements about medicine, one was a control group. The doctors who had candy displayed the most creative thinking and worked more efficiently."

Is it that easy to make doctors happy?

Dr. Choi helps survivors of Katrina

At last, after weeks of delays, Dr. Choi is in Louisiana. Somehow, he's still blogging:

"you can't hear yourself much less patients, with the helicopter landing and leaving.

tips for physicians coming: the patients are sicker than you'd expect. patients so far 8a-9a:
- alb/atr nebulized for asthma. bring steroids to nebulize as well.
- post-double vessel stenting, out of her asprin and antiplatlet plavix (i pray she finds a pharmacy to refil before she re-stenosis)
- bring your script pad (my dad forgot his) since people need tons of refills, and our inventory is small and limited to donations
- people look better than they acutally are. dehydration is insiduous, ask people the last time they peed. it was 2 days for the guy i last sutured up, because he'd had no food and water for 2 days.
- bring elavil, more antidepressants
- bring tons of tylenol and ibuprofen AVOID narcotics and benzos, plenty will ask though.
- lots of rashes, conjunctivitis, allergic rhinitis, diabetes, depression, anxiety"

I'm always amazed

...when wounds heal;

when meds work;

when broken bones mend;

and when people tell me that a Supreme Being has appeared to them, proclaiming that their favorite alcoholic beverage is "holy."

The Haversian Canal: Grand Rounds Vol 2 Issue 2

This Tulane med student was displaced by Hurricane Katrina. This week, he hosts our "Carnival of the Caregivers." He's done a wonderful job. Go there at once!

Annals of Parenting

Supplication: the "Drama Queen" ploy.

Some behavior is best left unrewarded...

via
No Whammies, who shudders to think of what awaits her when she starts a family.

Running through my mind...

An 86-year-old lady's remark.

She said, "The most remarkable thing about getting older...is how much you still feel the same inside."

Painting, and recovering

NYT profiles the artist Elizabeth Murray, who continued painting after brain surgery:

The lone piece that hangs in her studio now, "The Sun and the Moon," was put together a little differently. Ms. Murray painted it while recovering from brain surgery necessitated by metastasized lung cancer. Although she had worked out its basic structure last December, before the cancer was discovered, she only began painting after she returned from the hospital after surgery in March.

Initially, she said, "I was really tottering in there - I could barely climb up the ladder." And, though she usually makes very deliberate decisions about color, fretting over her choices and refining them with drawings, this time she was not able to act on them so easily: she had trouble locating the right tube of paint - even the one she had just put down.

So, she focused more purely than ever on the act of painting, using whatever color or brush came to hand, and adjusting the colors and marks later...

Follow the link to see the artist and the finished work, "The Sun and the Moon."

"Doctor Atomic" opened last night.

It's the new Adams opera about the invention of the first atomic bomb. Alas, one critic is disappointed: there's only one stunning aria, one moment of greatness. He wants two or three! He likes this:

"At the end of Act I, after all the discussions of wind and weather, the chance of widespread radiation exposure around the test site at Alamogordo, and the concomitant health risks (tissue disintegration, bone cancer), Oppenheimer is alone. He walks, hobbled, toward the bomb, which is suspended above the stage and bathed in white light, and sings Adams' setting of John Donne's Holy Sonnet XIV: `Batter my heart, three person'd God.'

"'. . . Knock, breathe, shine, and seek to mend; That I may rise and stand,' Finley sings. A mesmerizing baritone and compelling actor, he beat his chest with each declaration of ``knock.'' He fell to his knees, begging God `to break -- blow -- burn and make me new.' And the music! It is passacaglia-like, tinged with Jewish ritual lamentation and despair. The orchestra's stuttering figures, its tremulous chords and rumbling drums, said everything one needed to know about Oppenheimer's inner state.

"It is in the orchestra that the action really happens; mostly, it forms a steady, edgy undertow to everything on stage. Adams drew inspiration from Varese (sirens, machine sounds) and Stravinsky (his wartime news-alert music). But his concoction is different: Metallic shards of sound seem to take us inside an atom smasher. There are fizzings, blasts, punched and squeezed chords; tremulous and creepy-crawly strings; flashes and groans of brass; piston-fired rhythms that grow thick, plastic, frantic; and icy sound environments that seem to float, eerily. Where are we now? Inside the atom? Or a scientist's hallucinating brain?"

We are Adams fans. We can't wait to see, or hear, this work...

Two thousand years of advice for lovers...

and we're still trying to figure it out. Times Online, on a chronology that you may not want to peruse during work hours:

"The tradition of bestselling love guides goes back to the Ancient Chinese. Our earliest known manuals were first written in 300BC and buried in a family tomb at Mawangdui, in Hunan province. Recent translation reveals the timeless nature of the subjects they tackled...

As ever, it was all nonsense: home-made Viagra recipes involved ingredients such as beetle larvae, wasps and dried snails. The books also promised that any man who had sex with a different virgin every night for 100 nights without ejaculating would live for ever (albeit rather uncomfortably)..."

"Around This Table"

A song about divorce. Jerry Hall still sings it:

'You know how when you get divorced, you kind of obsess over an object that each of you has to have? It was like that.' The object is a dining table that has seen the happy days of a marriage: 'We make love on it./ Our children scratch their names beneath.' Then comes the decline: 'We scream across the surface./ Our hate is carved in stone./ At opposite ends, we fall apart and I am left alone./ Well, now you want this table for your pretty mistress's home.'

So who's got the table now? 'Mick's got it.' Why did she let him have it? 'I just let him have what he wanted. I don't really care about things that much. I was a little irritated, but I've totally gotten over it and I love my new table; it's so much better.'"

Ms. Hall left Mick Jagger in 1999. She says they're on excellent terms now.