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.

Doin' the District

While on Lenten Hiatus from the laptop, I had the pleasure of getting up to DC to do a bit o' lobbying fro the American Psychiatric Association. Being so close to the Capitol, I try to get up there once a year to make the rounds. A few of this year's talking points, and comments:

1. Parity has started to make it into the legislation: Finally! For years, the a person going to a psychiatrist (an M.D. in an office or hospital) would only get reimbursed at 50% rates compared to a non-psychiatrist (an M.D. in an office or hospital, with often little training in psychiatric illness) treating the same patient for the same condition. Invariably, some of those costs are often sent down river to the patient's bill, and also probably have contributed to a severe shortage in mental health access from trained specialists.

2. Privacy. There is a push to move towards more electronic records. While I'm certainly strongly in favor of improving health care and using electronic tools to do so, in psychiatry, this always presents a challenge due to the sensitive nature and type of notes (i.e. therapy notes) that may be out there. (I used to scoff at some of these concerns, and would often spout about 64-bit encryption and whatnot--- that was until the entire Health Practitioner Database for Virginia got hacked recently!)

3. A continuing issue that I brought up with our Virginia legislators is the need to continue to be vigilant in treating the mental health needs of our Veterans. Never is this more important than during times of active deployments. It's not a hard sell in the Commonwealth, given our very large percentage of servicemen and women, but it's always an important topic.

Overall, the staffers looked very tired; the transition, economy, and budget are a serious stress on the congressional building inhabitants. (I felt like offering a free half hour on a couch somewhere for some of them.), D.C is still hectic, and double talk is still the native tongue. All-in-all, though, not a bad day in the beltway.

If you got them?

Interesting news in the world of smoke:

From Live Science, an interesting article on the effects of nicotine on the brain. I seems that (at least for those who don't usually smoke) nicotine dulls the anger response mechanism. Subjects were given a (fake) opponent to race to click the fastest when a red mark appeared on the screen. The winner got to blast their opponent with a white noise, and could also see what level they were going to get blasted with if they lost. Those who were given a nicotine patch were less easily provoked by manipulated variables, and would also give shorter punishments.
The study postulates that those who are more likely to be easily stressed or angrier are more likely to smoke.

A Canadian study done based on interviews with 63 adolescents who regularly smoked marijuana had some interesting findings. This article appeared in the April 22 issue of Substance Abuse, Treatment, Prevention and Policy. But it's linked here from Forbes (of all places). About one-third of the adolescents reported that they were using marijuana as a medication rather than for getting high. The main substitute treatment was, not surprisingly, for emotional problems, but also teens reported usage for insomnia, chronic pain relief, and difficulty with concentration.


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Some thoughts:

1. Why does the first study remind me of the James Bond movie "Never Say Never Again?" Ready for World Domination, anybody?

2. The first study was mean, man! Tricking people into thinking an opponent had it in for them! Using loud blasts of white noise! Good thing there weren't studying the effects of THC, they might have had a few paranoid subjects afterward.

3. Of course the study has to have the sciento-political (just made that word up, folks) caveat: "But in the long run, smoking boosts the risk of vascular diseases that lead to heart attacks and stroke, which kill more smokers than all cancers combined. And second-hand smoke has proven as deadly for pets as it is for human partners." As if people will read this and suddenly run out to buy a pack of Luckies.

4. A deeper look at the second study shows some significant misreporting. The actual interviews for this data was only in 20 individuals out of the 63 in the study, as noted in the original article. The current article does not provide much in the way of specifics, and uses fuzzy language throughout. It is "mostly" devoid of scientific methodology.

5. That being said, it is interesting that the teens reported experience with health care was "uniformly negative." Many studies have shown that there is likely significant co-morbidity to those who have chronic marijuana use, so this "self-medicating" number is probably conservative.

6. Difficulty with concentration? Tough sell on that one.

Musing for the day

Old Borderlines never die.
They just split.