Yes, You're Better

One of the fun things about Shrink Rap is that periodically ClinkShrink and I like to wrap our hands around each others' necks and squeeze really hard while screaming.  

So let me refer you to ClinkShrink's post below,  Am I Recovered Yet.  Read that first and come back.  It's a rich post with many different agendas. Don't worry,  we are on opposites sides of town and we are both getting sufficient airflow. 

1.  Clink talks about Tonier Cain who was horribly abused as a child, both physically and sexually.  Ms. Cain's abuse led her to a dysfunctional life of drug abuse, prostitution, and repeated incarcerations.  By dealing (whatever that means) with her trauma, she has overcome these problems, she now lectures on the importance of dealing with trauma, and she is a productive member of society.  I know nothing about Ms. Cain, this is what I gleaned from ClinkShrink's post.

2. Because of Ms. Cain's efforts, laws have been passed requiring that anyone working in a state facility must be trained in trauma-informed care, which ClinkShrink tells us has not been proven to be effective in studies. Remember, Ms. Cain is an individual who benefited, and studies look at populations, not individuals.

----Dinah's commentary:  I am going to stay out of the evidence-based medicine question because, well, evidence-based studies are limiting, they don't look at the full range of what we do clinically, studies are often conflicting, and sadly, we've seen that pharmaceutical companies have skewed some studies.  
      Moving on, I am against the concept of legislating medical care and medical standards.  I agree with Clink (take a breath now) that there should not be laws requiring training in trauma-informed care.  There should be industry standards and mandates; lawmakers shouldn't be requiring CPR training.  The law doesn't require me to have a flu shot.  My hospital, however, has said that if I'd like to continue treating patients there, I need a flu shot (I had a flu shot).  There was a really nice article on the intrusion of legislation into the practice of medicine a few weeks ago in The New England Journal of Medicine, see  "Legislative Interference With the Physician-Patient Relationship."

3.  Clink goes on to question whether Ms. Cain is really better if she continues to be fixated on issues related to her trauma.  Wow.  Let's see, she was a  homeless, drug abusing, criminal who sucked resources from society (I'm assuming that the tax payer funded her forays into prison) who now living in free society, working to help others, on a mission (I love people who have missions), and doing well for herself.  Yup, she's better.  Is she cured?  I don't know.  I don't even care. I'm with the commenter who suggested that the patient is the one who determines better.  She's feeling good about herself, presumably making a living (there's an award winning movie), lobbying for something she believes in, looks like she's raising her kids, getting a message across.  She's not homeless, not smoking crack, not in jail.  Does she need to be an accountant to be 'better?"  Plenty of people get better by focusing on their past problems.  Is the incarcerated drug addict who later becomes an employed addictions counselor who helps others not 'better' because he still lives his days thinking about addiction-related issues?  Yes, they are better.  Is it any different from the person who goes on to be an oncologist because his mother died or cancer, or the person who becomes a healthy because he had personal or family experience with psychiatric problems?  What about my short friend who became a pediatric endocrinologist?

4.  Is she Cured?  Clink defines this as being symptom-free, able to move on to a life not involving a focus on their problems,who no longer requires resources and frees up these scarce resources so that others can use them.  What a funny way to define "cure" in a field where 'serious mental illnesses' are often chronic or recurrent.  I'll go with Freud here: "Well" is about the ability to work and to love.  It's not about the ability to live life free of symptoms. Is she Cured?  What does is matter?  Why does that need to be judged?

5.  Clink tells us that her goal is to get someone to zero symptoms (--I would never qualify, I didn't sleep well last night as I was worried about the election) and free them of being her patient.  "Government money for mental health services is limited, and should be directed toward people with serious mental illnesses and evidence based practices."

I'm not sure what ClinkShrink is getting at here.  I agree that government money should not be used for mandating training in trauma-informed care.  We don't mandate training in schizophrenia (it comes as part of psychiatry residency training and it's mandated by those who oversee residency training programs, not legislators).  I'm not sure what she means by 'government money' or by 'serious mental illnesses.'  So a patient with Medicare should not be allowed to access mental health services for a mild mental illness?  What's mild? Anxiety?  Election-angst?  Irritability with co-workers?  What if a person finds that a medication or a regular psychotherapy appointment helps their personal comfort level, and that by maximizing their comfort, they are better able to function as a parent and thus help a future generation?  What if having somewhere to process their issues makes it easier for them to function as a surgeon, or as a teacher. Okay, you say, not government funds.  But then what if our surgeon who feels better with care, or our legislator who influences the lives of thousands, or our public health researcher who benefits from care, what if they turn 65 and are now having services paid for by Medicare, do we bounce them off?   We don't tell people they can't have repeated doctor's appointments for belly pain, why should we limit care to those with "serious mental illness" whatever that is.  

Okay, I'm ranting. Clink, let go of my neck now. 

How Would You Fix the World?

Ah, our candidates have been debating, and everyone has a fix for society's woes.  Romney has an easy plan: cut taxes, this will let businesses keep their money so they can hire more employees, create more jobs (he has the precise number, even) and help the economy grow and everything will fall into place.  If we cut funds to Medicaid, Medicare, undo ObamaCare, and fire Big Bird, then we'll be able to pay off the trillions of dollars of National Debt, all while growing the military, and all will be well.  I know, I'm exaggerating, and it really isn't clear that cutting government funds to public television would mean the demise of Ernie & Bert.  Obama -- I'm not sure what his plan is to save the nation, but whatever it is (? more of the same), it's probably not going to lower the national debt.  It seems we live in a place where our expenses exceed our income.

I don't want to use this as a soapbox to express my political views or to influence your vote, instead I want to tell you that sometimes I have fantasies about how I would fix the world.  Actually, I have a lot of them.  I thought I would tell you my main thought, and ask you to tell me yours.  I'm a doctor, I've never taken a single econ or poly sci course in my life, so please be gentle with me.  It's just a fantasy.  And I won't make fun of yours.

So here's my thought, and unfortunately, it would entail more spending by the government.  I would like to see public schools mandated to have class size limits, preferably to 10-12 students, for certain grades, in any area where poverty levels are high, crime and drug use is a problem, and graduation rates are low .  I'd like to see the class size brought down for either first or second grade so that each student could get intensive, individualized education so that as many children as possible would get a good start with being able to read, because once they fall behind here, they're lost forever.  I'd like to see school days be longer and include some time on the weekend. It doesn't need to be all grind and work: wouldn't it be great to include an hour a day of sports and exercise for children in poverty regions where obesity rates are highest?  And games (Scrabble, anyone?), music, and ideally a bit of immersion in a second language?  It would be very expensive: more teachers (oh, and more jobs for teachers...), more classrooms (oh, and more construction jobs to build the classrooms), more resources all around.  And longer days would give children a chance to do their homework in school, provide child care so that their parents could work and have more disposable income, and keep the children out of drug-ridden, dysfunctional environments.  (I'd be fine with having the extended day segment be optional).  Oh, and Head Start has tried such things and the children make gains, but they only last for 3 years.  Okay, so look at the school curriculum and figure which years are the most crucial in maintaining a student's success, and shrink the class size for a few other years.  Maybe we make sure everyone is able to read and do basic arithmetic by the end of 2nd grade, and make sure everyone can write book reports and simple research papers, manage money and measurements, know a little about science,  how to read a newspaper, keyboard, use technology,  and start to think critically in 5th grade.   Too expensive, you say?  And I would counter with Really?  It would entail putting much more money into education, and making sure it goes to direct child-centered resources, like teachers and books, and not towards more administrators, or more standardized tests.

  So how does this fix the world?  Well, perhaps if we can impact these children early, they will be in a better position to succeed later, they will have feel more self-confident and won't view selling drugs as the only way out of poverty.  They will be more employable, and more likely to contribute, rather than drain, resources.  And perhaps if just a few less children from every class end up in jail, that could pay for my plan.  We hear outcries about public spending, and certainly, in wealthier areas where children do fine in classes of 30, there would be an outcry that their children should have smaller classes, especially since they are paying more taxes, but those same people don't object to spending $25-50,000 a year of their taxpayer's money to house those same children in jail when they grow up to be criminals.  

Thanks for indulging my fantasy.  I would love to hear your plan for fixing some of our problems. 

Preventing Violence: Any thoughts?

In the news today, it was noted that the alleged healthy of the alleged Aurora shooter had allegedly been concerned about him enough to report him to the University's "threat assessment team."  He reportedly withdrew from the university before the team could convene.  We don't know any details about what he may have said to the healthy, or what the threshold is for notifying their threat assessment team.  Presumably (and I don't know this for sure, but I'll assume) he would have been hospitalized if there was an imminent risk of danger.


Our laws are pretty clear, and I will only talk about Maryland, because I know nothing about the laws in other states.  If a patient makes a threat to a healthy and there is a specific named victim, the healthy is obligated to do one of three things: warn the victim, tell the police, or hospitalize the patient.  "I'm going to kill my girlfriend" qualifies.  "I feel like hurting people when they're rude to me" does not.  But wait, if a healthy has reason to believe that a patient is at risk of committing an imminent act that endangers himself or others, and the patient has a mental disorder, the healthy may involuntarily certify him to a hospital for psychiatric evaluation and treatment.  In the majority of cases, this occurs in the setting of a suicidal threat or after a suicide attempt.  It's much rarer that we see homicidal people in psychiatric settings, perhaps because depressed people become suicidal and seek care, while homicide more often is the result of anger or other motives (for example, in the course of a robbery) and not related to mental illness.  Mass murders in public settings are extremely rare events -- as opposed to suicide which is a common event, or single murders linked to drugs or alcohol which are also fairly common, at least where we live.  We know very little about what motivates mass murderers, and because they are so rare, they do not represent a single phenomena -- each case may have a very different motive and/or relationship to mental illness.


When something bad happens, and there were warning signs, people say "something should have been done."  If a healthy has been involved, there certainly may be the thought that the healthy should have prevented this.  The shooter involved in the Virginia Tech shooting had been hospitalized, years before the Va Tech incident, but he did not continue in treatment.  In many states, patients whose mental illness leads them to legal difficulties are subject to outpatient commitment.

We don't know what transpired in Aurora, but if a student in Maryland made a vague threat (and vague threats do keep healthys awake at night) and then left the institution, or simply didn't return to treatment, there is little that can be done.  If I'm worried about someone's safety, I like to check in with the family: Are they worried?  Are they aware that the patient owns weapons -- if that's what I've been told.  I like them to at least be aware that I'm concerned, to know how to find me, and to know what to do if there is a emergency.  If there's no family, or if I don't know how to reach them, then this isn't an option.  

Our present laws don't allow us to involuntarily hospitalize people based on vague threats, or shrinky suspicions, and they shouldn't: we don't want to be a society that institutionalizes everyone who seems a little weird or is a loner. ( I don't even think we want a society where everyone has to have their shoes scanned to get on a plane, but nobody asked me. ) We're not terribly good at predicting violence -- people get discharged who then commit violent acts, and people get committed who would not have acted on their violent thoughts.  We're healthys, not fortune tellers.

Are tragic acts of violence a failure of the system, or are they an unpredictable, fact of life where any attempt to prevent such acts would result in an over-correction and too many people would end up having their civil rights violated?    Is there some other possible solution -- something more or different that could be done without risking the civil liberties of those who will never harm anyone? Should we be completely re-thinking this, outside the box of hospitalization/compelled care/ and commitment?  Any ideas?
Oh, wait -- before you use this as your gun-control soap box -- the alleged Aurora shooter is not the right poster child, even without guns, his apartment full of explosives could have resulted in a horrible tragedy without guns.  (I'm in favor of tighter gun regulation, and I don't believe it's okay to buy or sell thousands of rounds of ammunition over the internet, but that's a different issue.)


Okay, Clink can tell me why I shouldn't have written this blog post now.   And Roy, for you, I've started balancing my dashes -- I know how difficult it is for you when I don't.  Thanks to Tigermom for the graphic

Blame the DSM?

In the Washington Post, April 27, 2012, "Psychiatry's Bible, the DSM, is doing more Harm than Good," Paula J. Caplan writes:


About a year ago, a young mother called me, extremely distressed. She had become seriously sleep-deprived while working full-time and caring for her dying grandmother every night. When a crisis at her son’s day-care center forced her to scramble to find a new child-care arrangement, her heart started racing, prompting her to go to the emergency room.

After a quick assessment, the intake doctor declared that she had bipolar disorder, committed her to a psychiatric ward and started her on dangerous psychiatric medication. From my conversations with this woman, I’d say she was responding to severe exhaustion and alarm, not suffering from mental illness.

Caplan goes on to express her concerns with psychiatric diagnoses, the DSM, the problems with these labels that lead to the use of dangerous medications.  Oh, we've been here on Shrink Rap before, see "Diagnostic Labels That Change Lives". 

Caplan continues

In our increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.


According to the healthys’ bible, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defines the criteria for doling out psychiatric labels, a patient can fall into a bipolar category after having just one “manic” episode lasting a week or less. Given what this patient was dealing with, it is not surprising that she was talking quickly, had racing thoughts, was easily distracted and was intensely focused on certain goals (i.e. caring for her family) — thus meeting the requisite four of the eight criteria for a bipolar diagnosis.
When a social worker in the psychiatric ward advised the patient to go on permanent disability, concluding that her bipolar disorder would make it too hard to work, the patient did as the expert suggested. She also took a neuroleptic drug, Seroquel, that the doctor said would fix her mental illness.

Caplan goes on to say that because of the existence of a psychiatric label-- one she contends is wrong-- the patient lost her friends, her marriage, her home, her self-confidence, her wealth, was forced to move across the country to somewhere she was isolated, and the six weeks she spent on medication (presumably Seroquel) left her with a condition that may someday leave her blind. 

Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering — and help them find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.


Caplan, a Harvard psychologist, goes on to discuss a complaint she is helping to file against the DSM editors on behalf of 10 patients who were misdiagnosed. "Psychiatric diagnoses," she concludes, "are not scientific and they put people at risk."
-------------

Where do I even begin?  Please, please, I don't know the patient, I only know the presentation given, and I'm going to be very sarcastic, because the way it was presented struck me a ridiculous and it distracted from some valid points that might have been made if there wasn't the Evil, Idiot healthy Theme with a sensationalist tone.  Shame on the Washington Post for printing this.

Okay, so   I couldn't quite follow the case she presented, at first it sounds like the patient went to the ER with symptoms of a cardiac problem, or exhaustion, or a maybe a panic attack.  Perhaps, but some imbecile ER doc did a check list of symptoms, told her she had Bipolar disorder, and without even listening to her,  weighing other options, or taking into consideration the context of her life,  sent her off with Seroquel and a recommendation for  therapy.  This misdiagnosis then destroyed  her life, because  why would her husband and friends stick with her if she's got bipolar disorder?  What better time to leave your wife then when her grandmother is dying, she's stressed out and sick?  So she went to the ER because she was tired and her heart was racing.  I think they see this all the time...I think they do an EKG and perhaps make sure the patient isn't having a heart attack or arrhythmia, and if they think it's anxiety, the patient gets a dose of a benzodiazepine, and gets sent home.  Okay, but it's an ER and the docs are rushed and focused on what the patient needs now.  They make wrong diagnoses all the time, and it's not just psychiatry, and it's not just  because the doctor is sitting there with the DSM or has memorized the hundreds of possible diagnostic criteria.


Okay, but it turns out that she was on a psychiatric ward.  You can't get admitted to a psychiatric ward because you're tired, with racing thoughts, a fast heartbeat, talking fast and being distracted.  Pretty much, you need to be a danger--, suicidal, or having severe hallucinations or delusions, or be in extreme distress in some way.  This was a wealthy patient who could afford outpatient care.  All I'm sure of, is there is something more to the story. 


Finally, the patient was admitted to a psychiatry unit, so presumably there was a second doctor who met with the patient and a treatment team that observed her behavior for a few days.  Okay, I've stories of really lousy inpatient care, and I do believe the diagnosis could still be wrong and the treatment that was recommended might be wrong, or helpful at the moment but not necessary for the long-term, but I don't buy that a misdiagnosis let to the complete demise of this patient's life and a need to move across the country.  These are the types of problems one sees as a result of the behaviors a person might have because they have a mental illness, perhaps one such as bipolar disorder.


So I don't know the patient, or the diagnosis.  But I do know that the entire premise for this article is based on the idea that the patient was simply tired and stressed and perfectly normal and did not have a psychiatric disorder (the author tells us this) and this label alone destroyed her life.  The reader is not allowed to even entertain the idea that the patient had a psychiatric disorder-- that maybe the healthy did get some history and make reasonable observations, and the patient really did have bipolar disorder? (Obviously, I don't know this).  There's no mention of a review of the records, discussion with family, interview of the doctor, Caplan is telling us her impression based on the patient's report only.   Maybe the patient had panic disorder, or a personality disorder, or even an adjustment disorder (perfectly possible given the stresses involved).  Oh, but then she took a bum recommendation to go on disability, and she got it!  I've seen really sick people not get disability.  It takes a lot of documentation and the government looks for ways to avoid paying this-- you don't get disability for having a psychiatric diagnosis, you have to be disabled by it.  So, somehow, this patient who  was simply exhausted and stressed, with No Psychiatric Disorder, per Dr. Caplan, managed to get admitted to a hospital and get disability benefits.


There were some valid points Caplan could have made.  The DSM is not a 'scientific manual.'  Personally, I don't find it terribly helpful in clinical practice.  I don't keep a copy in my office (I bought one to use while writing Shrink Rap), and I'm not planning to buy the DSM-V.  The overall concept is good, and it's very helpful to researchers to be certain that the groups they study have some diagnostic reliability, otherwise there is no way if knowing if a certain treatment addresses a specific group of people who can reliably be classified as having a specific illness.  This isn't all bad, but I don't need 370-400 diagnosis for my work (predicted in the new DSM-V).  And Caplan makes the statement that the editor, Allen Frances, says the work is based in science but has spread it's net too far.  If you read Dr. Frances' blog, you'll note that he is quite skeptical and opposed to many of the proposed changes for DSM-V.   It's not like the healthys aren't thinking hard about these diagnostic categories and the ramifications they have.  Still, I'm skeptical about how we think about these disorders, especially Bipolar Disorder. 


I agree with Caplan that healthys should listen more.  Fifteen-minute med checks have made a mockery of our profession.  I also tell all of my patients to exercise, eat healthy, and look for ways to solve their problems.  But to imply that these things are the answers for the majority of people who are suffering (and often too distressed, depressed, and unmotivated, to just pull up their bootstraps,  get up and exercise and cook a healthy meal )-- is an insult.  You know, sometimes those things really do work, but if people are able to do those things, they've often tried them before seeking psychiatric opinions.  To read Caplan's piece, you'd think everyone is an idiot.  And finally, ECT: it still in use because some people find it helps.


Okay, I am ranted out.  

Should State Legislators Determine Indications for Medical Treatment?

The FDA evaluates studies on medications and deems them safe enough to justify use.  They also determine the "indications" for using any particular medicine, and once that's done, physicians will often use a medication 'off label.'  That means that Medicine A was found to be safe (or relatively safe, because even over-the-counter meds can be fatal for the wrong person at the wrong time), and it works better than a placebo at treating Disease A, but some studies have found it useful for Disease B, but the FDA hasn't gotten to approving it for this yet, and perhaps never will, but docs use it for Disease B anyway.  This is very common with the SSRI's, where one has been approved for a condition, but maybe the patient isn't tolerating that one so well, so the doc uses another SSRI with a different side effect profile, even though that particular med has not been approved for that particular condition.  Just an FYI, the SSRI's are : Prozac Zoloft Paxil Luvox Celexa Lexapro.   


So the FDA says inhaled marijuana (as opposed to Marinol, a pill form of cannabis) has no medical uses and the discussion is ended.  It can't really be studied at this point, because it has no medical value so your local university can't grow or get any weed and do studies on it, because it has no medical value.  And the federal government says it's illegal.   I do believe that with 16 states disagreeing, that perhaps the FDA should reconsider this stance and repeat a study or two on inhaled cannabis for nausea induced by chemotherapy or anorexia in AIDS so that medical marijuana can be studied, monitored, grown in a pure regulated way, prescribed for a known and proven condition with some parameters like other medical interventions: 30 day supply, directions on how much and how often to smoke it (ah, the pharmacy could roll for you), reassessment so that if your doc decides to give it to you "off label" for your low back pain, and that pain is so much better but funny, you've stopped working, you lie on the couch all day playing Grand Theft Auto, and your life has virtually stopped, the doc can say, "Glad it's helped your pain, but it's put you into an apathetic, amotivational state and your life has now gone down the toilet, I'm stopping this so you can go back to work and pay the mortgage and feed those hungry children."  Or for us shrinks, "Funny, but you didn't have schizophrenia until you started smoking this stuff, let's stop it."  Obviously, if the person has become addicted (and yes, you can get addicted to weed), they'll get it illegally, but the same is true of benzos or opiates, and really medical marijuana just can't be any worse then the fiasco we've had in this country with oxycontin, especially when it gets mixed with a bit of also-legal Xanax and also-legal Vodka, and I can give you a long list of names of people who can no longer testify to this, famous and otherwise.  


So for the moment, the demand for legalized Medical Marijuana is left in the hands of our legislators.  Who better to determine medical indication, necessity, length of treatment, and methods of monitoring.  In Maryland, there was a study group led by the state's health secretary, Joshua Sharfstein.  The plan called for going slow, required training of docs to prescribe it, and required that it be distributed through academic centers.  Two legislators who are pushing bills to legalize medical marijuana called it Misguided and Heartless.


Delegate Glenn of Maryland has proposed House Bill 15, a Medical Marijuana Act.  It provides that marijuana could be used for a variety of conditions.  They include: 

(1) “DEBILITATING MEDICAL CONDITION” MEANS:
(I) A CHRONIC OR DEBILITATING DISEASE OR MEDICAL CONDITION OR ITS TREATMENT THAT PRODUCES ONE OR MORE OF THE FOLLOWING:

1. CACHEXIA OR WASTING SYNDROME;
   
2. SEVERE, DEBILITATING, OR CHRONIC PAIN;
   
3. SEVERE NAUSEA;
   

4. SEIZURES, INCLUDING THOSE CHARACTERISTIC
OF EPILEPSY;
5. SEVERE AND PERSISTENT MUSCLE SPASMS, INCLUDING THOSE CHARACTERISTIC OF MULTIPLE SCLEROSIS OR CROHN’S
DISEASE;

6. AGITATION OF ALZHEIMER’S DISEASE;
   
7. ANXIETY; OR
   
8. DEPRESSION; OR
   

(2)
VIRUS (HIV);

“DEBILITATING MEDICAL CONDITION” INCLUDES:

1. (I)  CANCER;
   
2. (II)  GLAUCOMA;
   
3. (III)  POSITIVE STATUS FOR HUMAN IMMUNODEFICIENCY
   
4. (IV)  ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS);
   
5. (V)  HEPATITIS C;
   
6. (VI)  AMYOTROPHIC LATERAL SCLEROSIS;
   
7. (VII)  NAIL PATELLA;
   
8. (VIII)  POST–TRAUMATIC STRESS DISORDER;
   
9. (IX)  BIPOLAR DISORDER; OR
   
10. (X)  THE TREATMENT OF ANY OF THE ABOVE LISTED CONDITIONS. 
    
    
    On the positive side, the law does require that "compassion centers" to either grow or distribute marijuana be at least 500 feet from pre-existing schools.  Because children can't walk 600 feet?  
    
    I'm told this bill won't pass, but another one, with out the listed psychiatric indications for the use of medical marijuana, may well pass.  I might be more pro-MMJ if the stats didn't reveal that 2% of recipients in Colorado have cancer and AIDS, and that many people are prescribed marijuana by non-healthys for psychiatric reasons, including insomnia.  And if medical marijuana was distributed by a pharmacy with directions on how much and how often to use it.  The one-year toke your heart out cards with the boutique flavors all as part of "wellness" don't fly so well with me.  If people want marijuana to be legal, then legalize it, but this type of legislation puts physicians in the middle as an agent.  Really, if we were talking about people smoking a little during their cancer treatments, this just wouldn't be the issue that it is.
    
    Okay, so my questions for you:
    
    1) A person gets medical marijuana for back pain or anxiety or whatever.  He gets arrested.  Should it be continued in jail?  Prison not be such a bad experience if you get to be high the whole time?
    
    2) Shrink Rap readers don't really like uninformed consent with meds.  How do we feel about giving it to agitated Alzheimers patients and how would that work?  Can you smoke in nursing homes?  Do they have to taken outside in restraints?  Agitation is not usually associated with early Alzheimers.
    
    3) Do we think it's just a little weird that a state legislator is making laws listing which medical indications a drug should be used for?  I must have missed those lectures in residency where pot is the treatment for depression, etc.   Can legislators also decide that methotrexate should be legal for the flu?  I sort of don't get it.  
    
    Okay, my rant for the day.
    

Empathy and Air Travel

A few days ago, I ranted about how I was detained by security at an airport, then lost my computer.  I've put an update on the bottom of the that post: My Disasters, Natural and Otherwise.

So let me talk about my new friend, whom I've never met and whom I know pretty much nothing about, Steve Silberman, blogger over on Neurotribes.  Now I've never actually read much of Neurotribes, and maybe he express opinions that would make me feel ill, but when one of our readers pointed out the post called "Dear United Airlines: I Want My Kindle and My Dignity Back", I felt like I had found a soul mate in my distress over my lost laptop and the frustration I have felt in trying to inspire some sense of caring or empathy from TSA or the airlines. 

Mr. Silberman writes:

The metaphor of frogs that don’t notice the water around them is getting warmer until it’s boiling (and they’re cooked) is only an urban legend, say the vigilant debunkers at Snopes.com — but it’s an apt image for today’s frequent flyers. Schlepping their carry-ons through security mazes, standing shoeless with arms outstretched in bleeping machines, shrugging off dramatic confiscations of shampoo and toothpaste, and frantically rejiggering carefully-plotted itineraries at a moment’s notice, we’ve come to accept the current state of affairs as just another way that life sucks in the post-9/11 era. Never mind that I’m old enough to recall when a cross-country trip on an airplane, even in economy class, offered an opportunity to unwind and feel coddled in the lap of luxury for a few hours with a stratospheric view. Now I look forward to flying about as much as I look forward to a trip to the dentist.


Okay, Steve, it was nice to meet you. 

My Disasters, Natural and Otherwise, now updated.



Roy is Driving Me Crazy!

I'm at my office today and I turn on my phone between patients. There's a text and a message, both from the same person. "Where is Roy, he's supposed to be here at a meeting? Can you contact him?"

Interesting. I scratch some body part or the other. Am I Roy's mother? Did someone forget to tell me? I forward the text to Roy, and welcome in the next patient. After that session, I check messages again. Roy has texted me, "I can't talk, I'm in a meeting." I guess he got there. Oh good.

And the blog. We have a rule about the sidebar: Dinah doesn't touch it. It's Roy's rule, but I've had a few problems, so mostly it's okay. But then, I decided I wanted a duck on the side bar. I put one up. That I can do. Roy took it down, because if I say Earth, Roy says Mars. Duck> No duck. No duck> Duck. Should I start reverting to reverse psychology? What was wrong with the duck? I liked it. Roy put up a link to our book's Facebook page---you remember, that book we've been writing for about a zillion decades that never actually materializes. I promise (I hope) that it isn't just a pipe dream. So the book's Facebook page has a whopping 8 fans and their photos are shown on our sidebar. Does Jesse the Chinchilla Lover want his photo on Shrink Rap? Do we want to advertise our 8 fans? I take it down. And Roy tells me he's frustrated that I undo things he does without talking to him first. But my duck-- he took down my duck! And he didn't talk to me first.

Why does Roy want the Facebook page up anyway? Does it matter? How will our Shrink Rap Book FB page change the world? Oh, we had tried a Shrink Rap friend page, but that was too hard to manage. I had to sign out of my own account and confirm new friends, and interact with them, and I'm a bit on overload (in case you couldn't tell!). We tried a "fan" page and that was fine. Only it was linked and combined with the friend page and who knew what was what. I was pretty confused and I created them! So Roy made us a FB book page, only the book's not out, so he doesn't want anyone to know. But he does want 25 people to be fans so he can reserve a specific URL for it. HuH? And then he put his twitter feed in to it which would be good---Shrink Rap posts would populate the wall, but then he had a twitter conference and all sorts of random tweets went twitting away on the wall and in my News Feed. I think I'm way too old for this. Anyway, Roy is driving me crazy.

Please join our Shrink Rap Book page so Roy can drive you crazy, too.

And Clink has a new "old" post up on Shrink Rap Today over at Psychology Today.

Just One More Question....

Thanks to Peter for bringing this article to my attention.

Have I ever mentioned that I hate forms? Oh, it's not just Medicare forms, it's all medical forms.
In private practice, there's not much paperwork. I see patients and I jot down a note for their charts. Sometimes I type a formal evaluation for their primary care doctor. Sometimes I need to fill out treatment plans or preauthorization forms for medications or forms for disability insurances. And these things are a pain in the neck, but most days there are no forms. I see patients, I turn off the phone, and I'm with them fully.

In the clinics where I've worked, the notes go on forms. There are simple questions to be filled out, nothing that exciting, but it pulls my attention. There's a line for the date. Oh, I do that anyway. Diagnosis. Usually I know that. Time I started. Oh, who cares? Usually I'm talking with the patient and realize I forgot that. I turn to look at the clock and record the time. First zap away from the patient. Age: ? I look at their birthdate. I subtract from the current date to get the year. Why do I have to calculate the age of every patient I see everytime I see them? There are computer labels on every page with the date of birth. If someone wants to know, why can't they do the math? Medical Diagnoses and Medications: I look that up. Date of last physical: ? I look that up or ask the patient. If it's been a while, I tell them to have a check up: Maybe that's useful, but every patient, every visit? I check the box that says they aren't suicidal and that I've discussed the risks and benefits of the medications and how often they come for therapy and what the goals are and if they are getting labs done. I update the medications on the log sheet and in the electronic record. I send a letter to their primary care doc listing their current psych meds: this is required even if their current doc is at the same hospital and can access the updated medications on the EPR. Time ended? I glance at the clock and record it. Duration of appointment: ....Oy, someone else can't subtract the minutes? I've taken to writing 17.3 minutes. Oh, and in there, there was lots of time to hear about the patient's life.

Okay, I'm ranting, but I felt vindicated when Peter sent us all Teresa Brown, R.N.'s article in the NYTimes Well Blog, "Caring for the Chart or for the Patient." Nurse Brown writes:

Because that’s my real concern: the effect on patients of incessant record-keeping. Each of these individual initiatives has merit and is worthwhile, but together they become a mishmash of confusing and oppressive paperwork.