Suicide Prevention Day

A couple of thoughts:

1. There are many who are killing themselves slowly, this is also a form of suicide in my opinion.
2. Many who complete suicide often tell others of their intention to do so beforehand. Please always take such statements seriously, and encourage immediate help.
3. If you are a treating physician, counselor, friend, family member or otherwise close to someone who has completed suicide, find someone to talk to about it.
4. They say there are two types of psychiatrists, those that have had a patient commit suicide and those that will have a patient commit suicide. For many of us, this is the ultimate sense of failure in our profession. That is sad, but understandable.
5. 1-800-273-TALK is the number for the National Suicide Prevention Hotline

Why I lose sleep

For the umpteenth time this year, I have received a request to change a medication from a prescription drug plan (this is a government-run one, but others are guilty of the same stupidity) that reads something along these lines:

Dear Doc,

We have reviewed the medications of your patient and would recommend that you switch him/her from the medication you prescribed (clonazepam-a benzodiazepine) for insomnia to zolpidem (a benzodiazepine-like medication). Studies have shown that chronic usage of benzodiazepines can lead to tolerance and addiction... etc, etc. A form (which looks almost identical to a standard refill request) is sent along for my convenience.

So, no big deal. Right? The insurance company wants to use the "safer" medication and ensure quality care for it's client. Except, over the past few years (until last summer), I was receiving letters from the same prescription drug plans that looked something like this:

Dear Doc,

We have reviewed the medications of your patient and would recommend that you switch him/her from the medication you prescribed Ambien (zolpidem) for insomnia to clonazepam(or other similar benzodiazepine). Zolpidem is not approved by the FDA for the treatment of chronic insomnia, and will not be covered... etc, etc. A form again is sent along for my convenience.

To review, the insurance company is requesting that I change their recommended medication to their previously rejected medication. What gives? Did the FDA approve zolpidem for chronic insomnia? Nope. Did benzodiazepines suddenly become more dangerous than previously thought? No. What DID happen is simple: zolpidem became available as a generic. And the benzos got sent back to the "bad drug" bin.

I'm all for cost cutting in health care, and the reality is that benzodiazepine and nonbenzodiazepine sedatives have both risks and benefits, and both are acceptable classes in the treatment of insomnia. Zolpidem is even noted to have some abuse potential (especially for those who choose to use other chemical means to stay awake after taking it). However, phony-baloney excuses by the insurance companies only to save a buck are criminal. If the makers of these medications tried marketing using these practices, they'd be in court faster than you could say class action.

Don't believe me? Ask a doctor how easy it is to get approval for a switch to Ambien CR, Lunesta, or Sonata--some of the other nonbenzodiazepine sedatives--which happen to not be available in a generic. Oh, and by the way, Ambien CR is approved for the treatment of chronic insomnia.

I need a nap.

Music Update

Back to the chill-out Divas I go. Emilana Torrini is from Iceland, where apparently the geothermal energy leads to honey-like voices. She had a break into the western world with the album Love in the Time of Science, and her single "To Be Free." She can also be heard singing Gollum's song in The Lord of The Rings.
"Sunny Road" comes off her 2005 album, which was written after (and presumed influenced by) the death of her boyfriend in a car accident. Her work with Thievery Corporation and Paul Oakenfold is certainly more in the electronica-chill genre, but sometimes less is more, as her simple vocals and guitar play out on this track.

"Maa Tujhe Salaam," off the album Vande Mataram, is an interpretation of a very famous patriotic song. August 15th is Independence Day in India, to commemorate their seperation from British rule in 1947. Those who recall Slumdog Millionaire's soundtrack were treated to the fine work of A.R. Rahman, a true national treasure. Rahman has done for Bollywood "filmi" music what Eli Whitney did for cotton. Rahman brings together elements of Western and Eastern music, and incorporates themes of global cultural acceptance. There is no better medium in which to do that, than in music, in my book.

Jacko fades to Blacko

I have been trying very diligently to avoid the final act of the three ring circus of Michael Jackson's life. I suppose an interesting post would examine the mass hysteria/grief/outrage brought on by such events. Likewise the idea of "flash memory" (where were you when you heard?) could also provide a good excuse to discuss hippocampal neurophysiology. Certainly a psychobiography of the adult who was never a child, and the child who was never an adult, would provide paragraphs of material. But, as I said, I'm trying to avoid the topic.

That being said, The autopsy report (if one can believe anything that the media presents these days-and I have my doubts) suggests that Mr. Jackson was not going to win the Andrew Weil award for good health. With a diet of (per the New York Post) narcotics Demerol, Dilaudid and Vicodin; the muscle relaxant Soma; antidepressants Zoloft and Paxil; the anti-anxiety drug Xanax; and the heartburn medication Prilosec, it's quite easy conceive a serious case of cardiac suppresion in a person who already is likely to have severe electrolyte imbalance (as commonly seen in severe weight loss).

I imagine there will be an ongoing debate as to whether this was, one one hand, a tragic exploitation of Mr. Jackson, versus, on the other hand, a spoiled addict making very stupid decisions. Or something in between. I'll leave that to the rest of the blogosphere, mostly in disinterest. However, of interest is the fact that a doctor (or in Mr. Jackson's case, allegedly many doctors) are willing to pull out the prescription pad at all in these sort of cases.

To wit:

Marilyn Monroe took enough Nembutal and Chloral Hydrate (in her presumed suicide) to kill more than ten people. She had reportedly agreed to let her psychiatrist wean her off the Nembutal, with using Chloral Hydrate.

In 1977 alone, George Nichopoulos wrote Elvis prescriptions for 10,000 doses of uppers, downers and assorted narcotics.

Dr. Sandeep Kapoor was charged recently with eight felonies, for fraud and misrepresentation, in the treatment of Anna Nicole Smith. The "thousands of pills" included methadone, multiple antidepressants, and sleeping pills.

This pattern is not limited to California. Certainly the most recent generation of athletes (especially Major League Baseball players) are having to live under the cloud of the "steroid era." It is not uncommon that these abuses are with health care professionals as accomplices.

Of course, addicts will find their way to fuel their addictions. And the rich and famous certainly have more resources for doing such, including creating a cadre of enablers. So, we know that the rich can fuel their habits, and surround themselves with "yes-men." However, why do physicians seem to be willing to be blinded by celebrity and money, even to the point of prescription Russian Roulette?

Indentured Servitude

"Back in my day..." As I am at year nine post-residency, perhaps the work shifts that we were forced to absorb do not seem quite as brutal. Perhaps not. A few years ago, ACGME-- the accrediting body for medical residency-- (amidst threats of class action lawsuits) put out recommendations regarding residents weekly work hours. After recommendations from the Institute of Medicine's report on resident duty hours, ACGME is considering further recommendations, namely to a limit of a sixteen hour work day. The Rand Corporation has published a report in the New England Journal of Medicine, to warn the public that this will be and expensive change: to the tune of an estimated $1.6 Billion per year. Here's a snippet of the coverage from HealthDay:

For years, legislators and patient advocates have called for less grueling hours for medical residents to reduce the chances of medical errors.

Now, new research shows that allowing doctors-in-training to work fewer hours and take longer naps during their shifts won't come cheap -- it will cost the nation's teaching hospitals an estimated $1.6 billion a year.

And there are no guarantees that shortening the shifts of medical residents will improve patient safety, according to the study in the May 21 issue of the New England Journal of Medicine.

Some studies have shown that less-fatigued residents make fewer errors, while other research suggests that more frequent patient hand-offs, which would come as a result of shorter shifts, could actually mean more errors.

Doctors whose shifts have ended may have to leave patients at a critical time, and new doctors who come on duty may not be familiar with the patient, explained Dr. Kenneth Polonsky, chairman of the department of medicine at Washington University and co-author of an accompanying editorial.

"When you make physicians work shorter shifts, there is a trade-off," Polonsky said. "The care becomes discontinuous. That's what we're worried about."

The hours of medical residents are legendary. Until recently, residents often worked 120 hours a week and shifts of up to 40 hours with little more than catnaps, said study author Dr. Teryl Nuckols, an assistant professor of medicine at University of California, Los Angeles and health services researcher at the RAND Corporation.

That began to change in 2003, when the Accreditation Council for Graduate Medical Education (ACGME) established rules for the nation's 1,200-plus teaching hospitals that limited residents to an 80-hour workweek, 30-hour shifts and lightened workloads.

But those rules are widely flouted, according to surveys of medical residents cited in this latest study.

In December, the influential Institute of Medicine (IOM) issued a report calling for greater adherence to the guidelines, increased supervision of residents, more attention to patient hand-offs and even shorter shifts. Among the most significant recommendations: shifts no longer than 16 hours or as long as 30 hours if residents were given five hours of protected nap time.

The IOM, however, can only make recommendations. It's up to the ACGME to enact the rules, which it has so far not done.

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Some Thoughts:

1. The numbers are a bit curious. The suggestion is to limit the consecutive work hours only. An 80 hour work week would not change.

2. Dr. Polonsky appears to have concerns that there would be less continuity with handing off patients after 16 hour shifts instead of 24 hour ones. Hand offs usually occur to the night shift, with on call teams working up to 24 hour shifts and then leaving after early rounds. I cannot see where there would be more than three or four more hand offs per week, maximum. A shift from 10-12 to 12-14 hand offs would be most likely. But, if Dr. Polonsky is truly that concerned, I would also question if he is recommending the same continuity for all hospital employees, especially attending physicians.

3. Of course, the attending physicians would quit if told they had to work the same hours as a resident (in spite of getting paid three times as much, on average). But residents cannot quit (at least not easily, or unless they completely quit medicine), they have to accept the work hours handed to them.

4. While there are no "guarantees" that shorter shifts, or naps will help patient safety, many studies, including those reviewed in the IOM report do show that increased fatigue leads to increased medical errors. Good luck fighting that in court when your resident makes an error after hour 23. Basically the logic being used is, you can't prove it will work, because you haven't done it, so you better not do it because you can't prove it will work. Nice.

4. There are approximately 110,000 residents, of whom, approximately 50,000 are actively involved in direct hospital care. Given the average salary of $50,000 per year (Jeez! this is about double what I got ten years ago!), $1.6 Billion could hire approximately 32,000 more residents. Or almost 20,000 Nurse Practitioners. Are we really seeing a 30 to 60 percent increase in uncovered work load with these proposed changes? No chance.

Music Update

1 Giant Leap is a project from a couple of blokes in the UK. It's sort of a United Colors of Benetton for music (without the shock value). They traveled around the world, blending artists of different genres and nationalities, and then doing some nice mixing back home. Asha Bhosle is the youner sister of Lata Mangeshkar, who is THE female voice of Indian film music for many decades. Asha has a smoother (read, less shrill, in my book) voice than Lata, and also has expanded her horizons to include the occasional foray into fusion or world music. Well into her seventies, Asha still is able to bring her mellow and talented voice to the studio. Her duet here is with Michael Stipe, who I think is best known for singing "Furry Happy Monsters" on Sesame Street. This video is a composite/promo for the project, but has the song throughout, and I think it presents a great view of what 1 Giant Leap is trying to accomplish.

As I have mentioned in the past, some artists have so impressed me with their later work, that I was able to become a fan of their earlier work. Beck comes easily to mind; and so it has been with Green Day. I used to wonder, in their early years, how they defied statistical probability by creating more songs out of three chord permuations than mathematically possible. The album American Idiot changed that. Billie Joe Armstrong and company really stretched their horizons with a modern rock opera (mostly punk, nonetheless!) and while still putting out good sounds. Their new album, 21st Centure Breakdown is a more than adequate sequel. Divided into three parts, it follows a similar rock opera (or perhaps broadway musical?) type feel. Green Day continues to rail against the corporate and government establishment, but hey, it's what they do! The music culls from even more influences, one can almost here Floyd, Queen, Metallica, Harrison, The Offspring, and ELO at times. A couple (at least) of those influences can be heard on my current favorite track on the album, Restless Heart Syndrome.

Musing for the Day

Whomever discovered that light has mass, must have suffered from migraine headaches.