Conscientious Objections?

H/T to Geoffrey for keeping me up on the news. The Bush Administration today issued an expansion of what are called "right of conscience" laws, which allows individuals to refuse treatment on the basis of religious or moral grounds.

From the article in The Washington Post:

"Doctors and other health-care providers should not be forced to choose between good professional standing and violating their conscience," said Mike Leavitt, secretary of the Department Health and Human Services, which issued the regulation.

Some Thoughts:

This is a sticky wicket. It is the opinion of most, that this action is to protect those pharmacies that wish to not have the "morning after" pill on their shelves; that they may do so without fear of retribution. Individual right of conscience legislation regarding abortion has been around and sufficient for many years. The current wording is simply god-awful for a few reasons:

1. Way too broad- it's a sledgehammer, when a scalpel is needed. It encompasses too large a group of providers.

2. It does not differentiate between the individual vs. the corporation. A mom and pop pharmacy does not have to stock the shelves with everything. But denial of treatment is not denial of access there, as it would be if a clinic group was the only one available within a certain radius. If there are sufficient available alternatives, then this could be viable in small numbers.

3. There are insufficient parameters regarding the specifics of the religious beliefs and types of procedures. I see nothing that prevents me from becoming a Christian Scientist or (gasp) Scientologist, and refusing to give care that I am being paid to give. A company that fires me for that would potentially face loss of federal funding. I hope that all hospitals will be prepared to have husbands or unmarriageable male relatives on staff in case their female Muslim physicians are required to treat a male.

4. It is unethical to knowingly deny information to a patient. Refusal to directly treat on the basis of ethical grounds has been fairly well protected, but refusal to provide known information and referral is a violation of allowing access, and against medical ethics and duty to treat. From Laura Katz, in a Physicians News Digest article on ethics of termination and refusal of care:

"If a physician decides not to provide services to a patient on religious, ethical or moral grounds, the physician should discuss the reasons for the refusal with the patient, inform the patient of other resources or providers that can competently respond to the patient’s needs, and document the discussion with the patient in the patient’s medical record."

5. It conflicts with other legislation, such as the Americans with Disabilities Act (ADA). In several cases, the courts have addressed the application of the ADA to a physician’s decision to refuse to treat a patient. For example, in the case of Bragdon v. Abbott, decided by the Supreme Court in 1998, the court found that asymptotic HIV infection is a disability under the ADA. Bragdon involved a dentist’s refusal to fill a cavity of an asymptotic HIV patient in his office, although the dentist was willing to treat the patient in a hospital at a higher cost to the patient. The patient sued Bragdon for violation of the ADA. The court ruled that asymptotic HIV constitutes a disability. The court’s decision speaks to health care providers’ legal obligation to treat HIV infected patients along with patients with other disabilities. Similar diseases or conditions could easily constitute a disability.

It is likely that this regulation will be short-lived. Although the issue will continue. We are seeing a greater number of physicians from different religious backgrounds. We continue to answer questions old (physician assisted suicide) and new (cloning, gene therapy). Defining the balance of a physicians individual beliefs vs. duty to provide treatment will spark debate for generations to come.

Rudy's Little Secret?

Source: Multiple websites- orig. unknown- (feel free to provide citation)


Got a better caption? Do share.

The Skinny on Zoloft

Dr. Ajit, in his quest to educate the general public about medications, one drug at a time, has given an excellent review of Zoloft.

Philkynopy?

A recent conversation regarding altruism has been playing in the back of my head this past week, as the actions of various canines have made their way to prominent (and perhaps not so prominent) news stories. The coincidence of similarly themed news articles could be an interesting topic in and of itself (anyone remember the shark bite stories of early 2001?), but whether coincidental or not, the following have got me wondering about the altruism of man's best friend (the dates given are when I saw the reports on TV or the internet):

Dec. 5th: The most popular story involved a stray dog crossing a busy highway in an attempt to rescue an injured dog. The homeless dog is seen on camera dragging the injured dog across the highway to the safety of a median.

Dec. 8th: A local story here in Virginia about a three year old toddler that wandered off into the woods from the babysitters house. The child would have likely died from exposure overnight, if not for the two 12 week old puppies following him and cuddling up with him to keep him warm overnight.

Dec. 9th: Oklahoma. A dog takes three bullets to the head in chasing off a home intruder.

Dec. 10th: A research team in Austria have determined that dogs have a sense of fairness. The test involved getting dogs to shake hands for a reward. When one dog got a reward and the other didn't, the unrewarded animal stopped playing.

In the discussion I recently had, my friend and I were contemplating if there is a "true" altruism, or if altruism is only a very high defense mechanism borne out of selfishness, insecurity, or both. The actions of our four legged friends may have provided me with a bit of an answer.

Perhaps we humans can learn a bit from them:

Dec. 11th: Chicago: Jogger, dog owner jump in lake to rescue dog.

A Thanksgiving Tribute

Curled up with a good book, by the fire, chatting with family, watching football, eating Aunt C's famous cheese soup, getting sore in the annual football game with the cousins. It's all Thanksgiving, and it's all good! Just for fun, here's a few clips related to my favorite holiday.

Let's remember the story of the first Thanksgiving; the story of tolerance and good will, and uh, politics? I'm thankful that we don't have the turkey as our national bird, as proposed by Ben Franklin:



I'm Thankful that we were able to get our turkey at the local grocery store this year:



I'm thankful for the wonderful spread on this year's table. And on the table we have a few wonderful traditions. Turkey with Stuffing, and of course, we have to do the Mashed Potato:



And, of course, Cranberries:



Gotta scoop up all that gravy! We could have Portishead with "Biscuit," The White Stripes' "Ball and Biscuit," or even Fred Durst and Limp Bizkit. But the best biscuits bounce, and The Blues Brothers bring the bounce with "Rubber Biscuit" (although "corn bread" seems more appropriate for this music):



Finally for dessert! Mincemeat? Pumpkin? Apple? Nah....:


Watch more Pop music videos at EZ-Tracks


Happy Thanksgiving to you and yours!

Thirsty?

Dr. Ajit has posted a nice article on good old H20. For those of us who are not imbibing enough agua-- we should be ashamed.

Drinking Water

Veterans Day

Take time out and thank a Veteran today.

As we remember our Veterans today, those who served, those who fought, and those who died in the service of their country, let us also remember that many of our Veterans are carrying physical and emotional scars. To that end, this bit of historical and educational information is dedicated to the walking wounded....

Today we call it Post-traumatic Stress Disorder (PTSD). It has gone by many names. In the U.S. Civil War, it was "nostalgia," "soldier's heart," and "Swiss disease." Its symptoms are not new. The ancient Egyptians, Greeks and Romans all write of severe anxiety attacks, and physical symptoms associated with battle. Herodotus, writing in the 5th century BCE, tells of somatic symptoms of blindness of a soldier who witnesses the death of a comrade. Herodotus also tells of a Spartan who was so anxious as to be nicknamed "The Trembler;" a soldier who later hanged himself, presumably in shame.

As the 19th century approached, psychology was beginning to gain acceptance in the medical community, and terms like "traumatic neurasthenia" became known in the doctor's offices. World War I gave us "shell shock," a term specifically for those with neurological/physical symptoms, but without overt physical injury. Contrary to the image created by the term, most cases were not due to any actual explosions, but just exposure to the trauma of the battlefield. This was not always diagnosis of understanding: Frederick Parsons, a commanding officer at U.S. military hospital Number 117, said "a war neurosis which persists is not a creditable disease to have ... as it indicates in practically every case a lack of the soldierly qualities which have distinguished the Allied Armies." And that "no one should be permitted to glorify himself as a case of 'shell shock.'"

By World War II, the diagnosis of "combat fatigue" was given to those with a set of symptoms most similar to our current diagnosis. The numbers from WWII are quite impressive. Of the 800,000 or so direct combat troops, greater than 35% required discharge due to psychiatric reasons. Over 1 million American Soldiers suffered some psychiatric debilitation for some period of time, and over 500,000 were discharged or hospitalized due to psychiatric reasons.

Somewhere between the Korean and Vietnam War, the term "Combat Stress Reaction" gradually made its way into the medical parlance. This description was used somewhat interchangeably with Combat Fatigue, and PTSD, although it became further defined as a more acute process, rather than a persistent and recurrent anxiety state. It was Vietnam, though, that ushered in the PTSD diagnosis. Some studies have shown estimates of 400,000+, out of 2.8 million who served, as having PTSD. PTSD was added to the DSM-III in 1980. The wars in Iraq and Afghanistan have brought a new generation of service personnel affected with PTSD.

The DSM-IV criteria for PTSD are quoted as follows:

A. Exposure to a traumatic event

B. Persistent reexperience (e.g. flashbacks, nightmares)

C. Persistent avoidance of stimuli associated with the trauma (e.g. inability to talk about things even related to the experience, avoidance of things and discussions that trigger flashbacks and re-experiencing symptoms fear of losing control)

D. Persistent symptoms of increased arousal (e.g. difficulty falling or staying asleep, anger and hypervigilence )

E. Duration of symptoms more than 1 month

F. Significant impairment in social, occupational, or other important areas of functioning (e.g. problems with work and relationships.)

For many veterans, PTSD is only part of the picture. Depression, other psychiatric conditions, and substance abuse often present as comorbid and contributory conditions, making for a very difficult to treat cluster of symptoms. Many veterans have difficulties with getting help, in part due to their own reluctance to address the painful issue, and sometimes due to the limitations of the health care and military systems. Stigma continues to be a significant problem; many veterans that I have seen professionally often confide that it took a great deal of courage, support, (and severe symptoms), in order to get them to see a psychiatrist.

Medication and therapy are common treatments for PTSD. Our local VA (like many others) has therapy groups specifically designed for veterans with PTSD. These are mostly in the "support group" modality, and often coincide with other treatments, such as individual therapy.

From an analytic point of view, I have always thought of PTSD as being a very dichotomous state. The cognitive component of the anxiety appears to be definable in two opposite areas: "Destroy" or "Be Destroyed." Both components are often present in the veteran with PTSD. They have not only the fear of harm, but a fear of loss of control, and with that, the potential harm they present to others. This often differentiates (from a therapy standpoint) the PTSD of the veteran from other traumatic sources, such as those who have been in severe car accidents.

Families and friends are often dramatically affected by the chaos that PTSD presents. It is important to be consistent, calm, patient, and supportive of loved ones as they go through the symptoms. Encouragement to seek help, and educating veterans that they are not alone in their struggle is what usually has led most veterans on their path of recovery. Many programs for veterans support exist. Now, more than anytime in the past, the Department of Veterans Affairs has taken a proactive approach to PTSD treatment.

For the rest of us, again, if you know a Veteran, call them, see them, thank them.

Music Update

With all of this angst floating about, I have decided to have a moment or two of Zen.

First up is a trip back to childhood, a good place for Zen to take us. Gordon Lightfoot has always been a favorite, and takes me back to sitting on my father's large chair listening to oversized headphones playing Gord's lilting sound on a Roberts reel to reel.

I have stayed a solid fan throughout, having performed a few pieces at a coffeehouse or two in the folk incarnation of a band called "Evergreen." Pussywillows, Cat-tails is a fairly early Lightfoot number, from the 1968 album "Did She Mention My Name." While not his best, nor even my favorite of Lightfoot's work (perhaps Christian Island, Don Quixote, Black Day in July--ironically, the flip side of "Pussywillows" single--, or Softly would be in the running there), this song definitely sets the mood I am reaching for.

There are no single renditions that can be embedded easily, so this video has a couple of bonus songs, including The Kingston Trio's "Raspberries, Strawberries" and the lovely Marianne Faithful version of "Greensleeves." (UPDATED: The video previously posted is no longer available; I was able to find a suitable replacement. )

For those who have been following along, musically two of my passions are downtempo or "chillout" music and, of course, Norah Jones. Norah has been lending her god given talents to so many artists over the past 8 years, (Willie Nelson, Ray Charles, and Outkast sure fill out a diverse discography), some of her earliest work was with a downtempo/triphop eclectic group called Wax Poetic. Norah was a member of this band before "Come Away With Me," and had a small bit of commercial success with this song "Angels."

Thievery Corporation did a very nice remix, in which they chill it out even more (Nip/Tuck fans may remember), but I still dig the ease of the original most.

Pour a cup of Chai and light some lavender candles. Breathe. All is well.

Angst and Medical Truths #4

It was about four weeks ago when I had a realization. Not an epiphany, but a realization nonetheless. Summer has usually been fairly laid back professionally, with plenty of days to catch up on paperwork, cleaning the cobwebs out of the office, do a bit of journal reading, taking the family down to the beach, etc. Certainly there was sufficient time to take a couple of nice camp-outs with the scouts (one in Jamaica!), and get in a little basketball, reading, and movies. But, otherwise, at the office, it was just busy. September usually brings spike in traffic, as kids get back to school and people are often just a bit more stressed, and more likely to schedule appointments.

This September, however, brought a tidal wave of work to the office. New consults, increased follow-ups and many, many more phone calls have made for a fast paced past several weeks.

Don't get me wrong, there's no complaint, as it comes with the territory, and busy business is certainly better than no business. I was just curious as to what was going on.

Which brings me to Medical Truths #4 :

"When you don't know, ask."

So I did.

What I found out was that people were just more anxious out there. They weren't coming in to the office saying "I'm worried about my 401K" or "I am worried about another terrorist attack." Those were conversations I have with my friends and family; patients weren't bringing it up very often. More curiously, even with patients with severe neuropsychiatric conditions, there seems to be just a bit more frequency in the appointments, and severity in their symptoms.
The anxiety appears to be pervasive, contagious, and ill-defined.

Angst is a wonderful word which is rooted in Old English (and thus, German); it's root is similar to "anger" and a close sibling of "anxiety". Popularized mostly due to the translations of Freud's work, it encompasses neurotic fear, guilt, remorse, and anxiety. Unlike Kierkegaard (who viewed angst as a fear of death and non-being), Freud viewed angst as being without any specific identifiable object. In current parlance, we might consider Freud's definition as a cross between a generalized feeling of dread and anxiety. The term angst has also been co-opted in existential thought, and certainly branches off at times from Freud, which would make for several interesting posts in and of itself. It is these variations of definition that have removed "angst" from common psychodynamic thought, reserving it usually only for the very serious, or not-at-all serious, discussants.

It does however, using Freud's definition, explain why my phone is currently ringing.

Disco Pumps?

Appreciation to a colleague contributor (look for him here soon) for sending this one my way:

WASHINGTON (Reuters) – U.S. doctors have found the Bee Gees 1977 disco anthem "Stayin' Alive" provides an ideal beat to follow while performing chest compressions as part of CPR on a heart attack victim.

The American Heart Association calls for chest compressions to be given at a rate of 100 per minute in cardiopulmonary resuscitation (CPR). "Stayin' Alive" almost perfectly matches that, with 103 beats per minute.

CPR is a lifesaving technique involving chest compressions alone or with mouth-to-mouth rescue breathing. It is used in emergencies such as cardiac arrest in which a person's breathing or heartbeat has stopped.

CPR can triple survival rates, but some people are reluctant to do it in part because they are unsure about the proper rhythm for chest compressions. But research has shown many people do chest compressions too slowly during CPR.

In a small study headed by Dr. David Matlock of the University of Illinois College of Medicine at Peoria, listening to "Stayin' Alive" helped 15 doctors and medical students to perform chest compressions on dummies at the proper speed.

Five weeks after practicing with the music playing, they were asked to perform CPR again on dummies by keeping the song in their minds, and again they kept up a good pace.

"The theme 'Stayin' Alive' is very appropriate for the situation," Matlock said in a telephone interview on Thursday. "Everybody's heard it at some point in their life. People know the song and can keep it in their head."

Some thoughts:

1. Did they have a comparator group listening to Mel Torme?
2. Will people compress harder during the “ah, ah, ah, ah” part?
3. Will the AHA have to pay a royalty?
4. For those of you who are under 30, or are Disco-phobic, a la Dr. Johnny Fever, I’ve done some research to find alternatives in the 100-105 BPM range:

-“Werewolves of London” by Warren Zevon (keep pumping through the "Aaaarooo"s)

-“Superstition” by Stevie Wonder

-“Sittin’ on the Dock of the Bay” by Otis Redding (Think of the bass line)

-“I Walk the Line” by Johnny Cash

-“The Real Slim Shady” by Eminem (do not use E's hand gestures.)

-“I Think I love You” by the Partridge Family (also a good song for euthanasia, I imagine)

-“Sledgehammer” by Peter Gabriel (may result in broken ribs?)

-“Back to You” by John Meyer

5. CPR guidelines have changed, per the American Heart Association. No rescue breaths or mouth to mouth is recommended now, just compressions. Some other experts still recommend mouth to mouth as part of the overall CPR, although studies do seem to show a more favorable outcome for compression only training.

6. If you are not CPR trained, please become CPR trained. Find a class near you.

Grand Rounds

Grand Rounds is a weekly summary of some of the medical blogs in the blogosphere. It is hosted by a different blogger each week, and usually with a theme running throughout the post. This week, T. at Notes of an Anesthioboist brings her edition out with some nice organization and a few good movie references to boot.

Click here for Grand Rounds

"I'm your biggest fan."

From iTWire Australia: Study finds most celebrity stalkers are mentally ill

From Craegmore News: Celebrity stalkers are mentally Ill.

From The Sun: Royal stalkers are mentally Ill.

From the APA Headlines: Celebrity stalkers may have much greater incidence of serious psychotic illness

A study suggests celebrity stalkers are more mentally ill?
Wow! Thanks for the newsflash.
Let’s dig a bit deeper:

Here’s a snippet from the APA:

New Scientist (10/8, Nowak) reports that the results of a study presented at a forensic science meeting in Australia suggests that, "rather than being hapless eccentrics, the majority of stalkers suffer from serious psychotic illnesses." Study leader Paul Mullen, D.Sc., a forensic psychiatrist at Monash University and the Victorian Institute of Forensic Mental Health," said, "We didn't expect such high rates of psychosis. It was very surprising to us." For the study, researchers "scrutinized over 20,000 incidences of stalking members of the [British] royal family, such as repeated and threatening letter writing, and repeated attempted approaches and attacks, from 1988 to 2003. The data was contained in files on 8000 people kept by the Metropolitan Police." After culling the files, researchers "examined in detail the files of 250 of the remaining 5000 people judged to be true stalkers. About 80 percent had a serious psychotic illness, including schizophrenia, delusions, and hallucinations, they found." Notably, this "finding contrasts sharply with people who stalk non-famous people," of which only "a fifth...have some sort of serious or severe psychotic disorder." _________________________________________________________________________________

Interesting. The newsworthy part here is that there is a greater rate of comorbid serious mental illness in this group of celebrity stalkers, than what has shown in other studies of non-celebrity stalkers. As to the science, I do wonder if there was a bias in the definition of stalking during the screening process (weeding 8000 people down to 5000). Also, this is a retrospective study (obviously, imagine recruiting for a double blind study!) and is not given an in-study comparator. Also, is this a trend only specific to the royal family? Is there a greater level of impairment if one is hung up over Prince Charles than Eva Longoria?

That all being said, there does seem to be a logic to the trend given that it would seem more “delusional” to develop a fixation with a person one has never met. It would be interesting to see what percentage of those delusional symptoms is persecutory or grandiose. Persecutory delusions are often seen in paranoid schizophrenia, and may involve famous people. For example one might believe that George Bush is bugging his telephone and wants to send him to Guantanamo. (Um, ok, make that Martin Sheen is bugging his phone..) Likewise, it would be consistent with grandiose delusions (as often seen in bipolar disorder) to develop a sense that a famous person is one’s soul mate (as I know that Norah Jones is for me).

Uma Thurman, David Letterman, Mel Gibson, Gwyneth Paltrow, Sheryl Crow, Olivia Newton-John, Sandra Day O’Connor (by the same stalker as Olivia Newton John!), Brittney Spears, Monica Seles, and Michael Douglas, are just a sampling of those in the news who have had celebrity stalkers. The effect can be quite devastating on the individual and their family. Many stalkers have tried to reach celebrities by going to the homes of the celebrity’s parents.

The challenge is in figuring out the severity of the stalkers potential for harm. Is a stalker a potential Mark David Chapman (stalker and eventual murderer of John Lennon)? Or is he a laughable (perhaps) William Lepeska, who swam naked across Biscayne Bay to woo Anna Kournakova, who ended up swimming to the wrong house, and getting an express trip to the psych ward?

The mere presence of “serious mental illness” alone though does not give one a sufficient predictor of dangerousness. Most studies have shown consistently that persons with serious mental illness (usually defined as chronic schizophrenia, bipolar disorder, chronic psychotic depression, or schizoaffective disorder) are more likely to be victims of violence than perpetrators of it.

The movies also portray the dualism of the stalker character. In “The King of Comedy” Sandra Bernhard plays a hapless comedic (albeit darkly so) stalker to Jerry Lewis’ talk show character. Ironically, Jerry Lewis had a stalker once jailed after the stalker showed up at his house with a gun. Wesley Snipes in “The Fan” is an all business stalker--angry, delusional, and on a mission. Kind of the middle ground of the stalker continuum. “Cape Fear” (Mitchum-1962 and DeNiro-1991) has a perfect sociopathic stalker. (Notice three DeNiro movies so far?) BTW, Kathy Bates in Misery is still my favorite, and scariest, on-screen stalker.

For a good book on stalking, and how one (especially young ladies) should respond to stalking, I’d suggest Gavin De Becker’s “The Gift of Fear.”

Stalking stories? Do share. Also, anyone have Norah Jones' phone number? :)

North Carolina Prescription Drug Plan?

This picture just tickled me over at GruntDoc. Go over there and leave a caption if ya' like.

Updated: Hey! How 'bout that, my caption won the contest! Apparently, I play well to the midwest and the southern element. Perhaps I should consider a run for national office. My prize, other than bragging rights, is this nice logo--which I will post with pride.

Does anybody really know what time it is?

Wow! The blog’s been silent a couple of weeks, and it only seemed like a few days. Same thing happened this summer, which apparently lasted only 4 weeks for me. “Time flies when you’re having fun,” the adage goes. Apparently it also moves rapidly when quite busy. But, that got me thinking on some random musings about time; so I took some time to get them down:

The Aborigines of Australia do not always have a linear concept of time. Mental health professionals note occasional difficulty with psychological assessments due to this pattern. Aboriginal people do not see events necessarily in past, present, or future sense, but rather in a “time-circle” on the basis of importance to themselves and their community. To put it in our perspective, September 11^th 2001 would be closer to our “time-circle” than, say, Martha Stewart going to jail.

Those that focus on the present to the exclusion of a stressful past have lower scores on depression scales. A study done by Morton Beiser on Southwest Asia Refugees hypothesizes that a “Nostalgic” time orientation incorporates the actual stressful memory into the sense of time, and thus correlates with a greater depression symptoms. Dr. Herbert Rappaport at Temple U. notes that emotional maturity comes when one is able to project well into the past and the future in a balanced way had the strongest self acceptance.

Acute stressors, such as car accidents, tend to slow the perception of time; while longer stressors, such as being held hostage for days, tend to have a more compressed perception of time. I wonder if the brain attempts to keep the perception of time accurate during stressors or anticipated stressors. Perhaps this is why we whistle when we are nervous?

Altered time perceptions are described frequently in altered neurochemical states. Depression, Anxiety and Substance abuse are all identified with a potential for “remembered time” perception changes. Multiple studies have identified cannabinoid, serotonin, dopamine, and opiate receptor systems that are associated with altering time consciousness.

Attention Deficit Disorder and Parkinson’s disease are also linked to time perception changes. These latter two disease states appear to have a direct difficulty with “perceptual time” or “clock time,” the ability to estimate or compare duration of time. The most recent neuroimaging suggests that the basal ganglia and dopamine, acting upon the parietal lobes are the role players for this sense of time.

“When a man sits with a pretty girl for an hour, it seems like a minute. But let him sit on a hot stove for a minute -- and it's longer than any hour. That's relativity.”
-Albert Einstein

Music Update

I'll be attempting to update the posted music on a (more-or-less) monthly basis. The basic theme is to present one known artist or piece juxtaposed with a lesser known artist, although I'm sure I'll stray frequently.

Other than Norah Jones, for whom I have "an infatuation of unnatural proportions" (so it says here on the restraining order), I have to place Paul McCartney at the top of my music list. My admiration for Sir Paul's music is huge, from the earliest Beatles recordings, to Wings, and his solo work. Memory Almost Full is some of his best work in years, and should be familiar to those who frequented any Starbucks last year, as it was co-promoted by the coffeehouse chain. Some view this as Paul's swan song, as it has a self-referencing elegy, but I wouldn't bet on this intentionally being his last work. (I think London Undersound is his next project) "House of Wax" is my personal favorite off the album, and, while not getting really any radio play, seems to tap into his deeper album-rock sound, that often was overshadowed by the likes of "Say, Say, Say."

I have a passion for downtempo world music, often found under the genre of "chillout/lounge" The Buddha Bar series of mixes probably best demonstrates this type of music. I am particularly partial to some of the smooth female vocalists' works in this area. Sheila Chandra is of South Indian descent, and is from the UK. She started with the group Monsoon at age 16, and has been known for her melodic and classic vocal style, often woven over ragas and other world sounds. Although her voice has only become richer with time, and her exploration into greater sounds increased exponentially, it is the young Sheila heard here in her first (and probably best known) hit "Ever So Lonely." While the video is very early 80's (1982, to be exact), the sound was groundbreaking at the time, and has set the stage for the likes of Nitin Sawhney (who is working with Sir Paul!), Nusrat Fateh Ali Khan, Colonial Cousins, and many other Asian-influenced artists.

Mickey OCD's

FOND DU LAC, Wis. - A 54-year-old man says his obsessive-compulsive disorder drove him to eat 23,000 Big Macs in 36 years. Fifty-four-year-old Don Gorske says he hit the milestone last month, continuing a pleasurable obsession that began May 17, 1972 when he got his first car.

Gorske has kept every burger receipt in a box. He says he was always fascinated with numbers, and watching McDonald's track its number of customers motivated him to track his own consumption.

The only day he skipped a Big Mac was the day his mother died, to respect her request.

The correctional-institution employee says he doesn't care when people call his Big Mac obsession crazy. He says he's in love with the burgers, which are the highlights of his days.

_______________________________________________________________

Some thoughts:

1. Do the math. He's averaging almost two per day.
2. Apparently he has written a 205 page book about this. Because of his OCD, he types only using one finger, and double spaces between each word.
3. He's physically fit. (6 foot, 180). Still, I'd love to see an echocardiogram on this guy.
4. Yes, he's in "Super Size Me."

Shrink Think:
Obsessive Compulsive Disorder is an anxiety spectrum disorder characterized by repetitive, and often anxiety provoking thoughts (Obsessions) and repetitive or ritualistic behaviors (Compulsions). The symptoms should be severe enough to cause a disturbance to "normal" functioning, or to cause significant distress to the individual. I have many patients who have described the difficulty with stopping the compulsive behavior as like trying to stifle a sneeze. (Curiously, I have heard the same comment about tics in Tourette's Syndrome). If a compulsive behavior is missed, sometimes the individual will have to perform a secondary behavior to "make up for" the missed compulsion. This is called "undoing." An example is a person who has to count the stairs, and goes back two steps, if he misses one. Classic OCD patterns include counting routines, germ phobias rituals, and checking (locks, doors, etc.)

Some of the more curious OCD patterns I have seen include:

Grooming: washing each body part 33 times. This made for a long morning routine.

Galeophobia: fear of sharks with OCD. This individual would ruminate about sharks, and have specific undoings when hearing the word "shark" or other trigger words, such as "ocean." Taking a bath was out of the question for many years.

Demonic Possession: A young individual would think the name of the devil repetitively, and that the devil would be in inanimate objects of a certain shape or color, if he did not use his undoing. The pattern of requiring specific numbers, lack of extreme severity, (relatively speaking in Psychiatric terms!), overall awareness of this patterns, and positive treatment response to conventional therapy helped differentiate this diagnosis from schizophrenia or schizotypal personality disorder.

Common treatments include medications, such as SSRI's (Prozac type medications), usually at fairly higher dosages, and behavioral therapy. One example of behavioral therapy is systematic desensitization, for example as with germ phobia rituals, desensitizing the individual with dirt on their hands, and increasing the amount of time that he can tolerate it. Many persons with OCD do not seek out treatment, and try, often successfully, to just work around it.

As with many anxiety symptoms, there is a continuum, upon which most of us exist. Simple phobias, preference towards certain patterns, etc. are often all part of the wonderful variety in life: While I am not one who is usually attuned to organization, I have all of my CD's organized alphabetically, with each CD in the case positioned that one can read the title of the CD when it is opened.

Thoughts? Or, care to share your Obsessions and/or Compulsions?

Smelly Science?

A new study from Craig Roberts in the journal Proceedings of the Royal Society B: Biological Sciences notes that birth control pills could cause a woman to choose the wrong mate.

From an article byJeanna Bryner at LifeScience:

Major histocompatibility complex (MHC) genes are involved in immune response and other functions, and the best mates are those that have different MHC smells than you. The new study reveals, however, that when women are on the pill they prefer guys with matching MHC odors.

MHC genes churn out substances that tell the body whether a cell is a native or an invader. When individuals with different MHC genes mate, their offspring's immune systems can recognize a broader range of foreign cells, making them more fit.

Past studies have suggested couples with dissimilar MHC genes are more satisfied and more likely to be faithful to a mate. And the opposite is also true with matchng-MHC couples showing less satisfaction and more wandering eyes.

"Not only could MHC-similarity in couples lead to fertility problems," said lead researcher Stewart Craig Roberts, an evolutionary psychologist at the University of Newcastle in England, "but it could ultimately lead to the breakdown of relationships when women stop using the contraceptive pill, as odor perception plays a significant role in maintaining attraction to partners."

Sexy scents

The study involved about 100 women, aged 18 to 35, who chose which of six male body-odor samples they preferred. They were tested at the start of the study when none of the participants were taking contraceptive pills and three months later after 40 of the women had started taking the pill more than two months prior.

For the non-pill users, results didn't show a significant preference for similar or dissimilar MHC odors. When women started taking birth control, their odor preferences changed. These women were much more likely than non-pill users to prefer MHC-similar odors.

"The results showed that the preferences of women who began using the contraceptive pill shifted towards men with genetically similar odors," Roberts said.

____________________________________________________________________

The abstract and link to the journal article is here.

A few thoughts:

1. This explains my wife’s disinterest after having kids!

2. There was no placebo group used in this study, always a red flag in my books, especially when one could have easily been done.

3. There is no data to suggest that scent plays a primary role in choosing a mate in this testing group. Only MHC compatible or incompatible scents were tested, which is a far cry from the actual dating choices. That is, there are way too many other factors involved.

4. On the other hand, a new genetic/MHC compatibility internet dating service could be just around the corner for some enterprising person who reads this blog. eSmell.com anyone? Or perhaps a new cologne “infertile, for Men. By Calvin Klein”

5. If my understanding of genetics is correct, MHC is more compatible with first degree relatives. Don’t give your sister the pill.

6. Craig Roberts is the same researcher who determined that women prefer more "rugged" men during the fertile phases of their menstrual cycle (Abstract here). Then again, I'm not sure how much we can trust research from someone who can't spell "odor" correctly.

A Bat, a Mouse, and a Lamb, or How I relaxed this summer.

A movie, and album, and a couple of books have been part of my R & R this summer.

First, “The Dark Knight”. Since apparently everyone has seen and commented on this movie, I’ll save any summary and I’ll try to add just a few thoughts:

1. Heath Ledger was very good. His master gesture got a bit redundant. I was waiting for him to start speaking in Parseltongue.
2. Shrink think: The joker is a good example of a sociopath; he just wants chaos. Two-Face, on the other hand, is delusional to psychotic proportions; he shows extremely clouded judgment but still seems to operate in some moral code. One could also argue that he is responding with narcissistic rage to a breakdown of his ideals and image (and his girlfriend).
3. The philosophical message got a wee muddled: Truth is important for the sake of Truth except when the city doesn’t need a Hero that stands for Truth, or if that Hero has a unneeded variation of Truth, then it redefines what a True Hero is, except when a Hero isn’t, etc., etc.

Second, Beck’s “Modern Guilt”, produced by Danger Mouse. Thoughts:

1. There are a lot of mouse droppings on this album. Those of you familiar with Gnarls Barkley’s “Crazy,” will pick up the heavy usage of snare and funk bass. This is not a bad thing, necessarily, but it comes across as a bit forced at times, where other arrangements might be more complimentary to Beck’s style
2. Beck continues to expand his sound. He moves between 60’s bubblegum, to flower power, 70’s Funk, and Prog, all within the first few songs of the album. He comes back around to some alt-rock sounds that can only be described as “Beck-like” (or Beckish, or something).
3. That prog sound is nicely done on “Chemsounds,” probably my favorite song on the album.
4. Beck doesn’t rap. Hooray!

Third, I’ve had a few re-reads over the summer. A couple of them are worth mention.

Christopher Moore’s “Lamb: The Gospel According To Biff.” And “The Quiet Room, A Journey Out Of The Torment Of Madness,” by Lori Schiller and Amanda Bennett.

Moore’s novel is a hilarious recreation of the life of Jesus, as told by his best friend, Biff. It addresses some of the “lost years” of Jesus’ life, as well as a alternative perspective on the biblical gospels. Yes, it is quite sacrilegious in its style, but I was a bit misty-eyed at the end; even in this format, Moore still is telling the Greatest Story Ever.

Schiller’s book is about the life of a woman who begins having hallucinations, and her downward spiral into chronic psychosis. Clinically, she’d probably be called schizoaffective disorder, bipolar type in today’s language, but it’s serious mental illness, and that’s all we need to know. The fear, stigma, challenges and limitations of treatment, are all well represented in a timeline, with first and second hand perspective. The alternative perspectives of friends and families recorded are quite fascinating. It’s a great read, and I have recommended it at times for families affected with a loved one with serious mental illness.

Politically Incorrect Musings #2

A news article was sent my way via email regarding Sen. Obama. As the advertising had been cut out, the remaining type appeared in what looked like poetic quatrains. The material read a bit like Robert Frost, which got me thinking...
With apologies to Frost:

Two roads diverged on the political trail
Wished I to avoid the divide
And blaze between a combined trail
But I walked the middle to no avail
Thus resigned myself to decide

To the right before me a light path rose
Uphill, and narrowing
To a mountain top where white wind blows
If that had been the path I chose
Clearly more harrowing

To the left the footpath flowered
Colored, shaded, and well worn floor
Berries abounded and nymphs beckoned, showered
pleasantries and riches. The path towered
As if gliding to the White House door.

In my heart I cannot deny
That when upon a political fence
Two roads diverged, and I--
I took the one more traveled by,
And that has made all the difference.

I know, try "Old Man's Winter Night" for McCain next. But Frost's ghost (and probably the copyright owners of his works) will likely be visiting me if I do anymore damage.

But he had great hair

RIP, I hope, to John Edwards' political career. Too bad that the majority of damage that this man has done will never be righted. A malpractice lawyer, and a bottom-feeder (by malpractice lawyer standards!) at that, Edwards made his money on birth-related injury trials, a low-risk, high-yield trial, for the lawyers--that is. The likelihood of a positive settlement for the patient is slim. Edwards would often use his personal family stories to get points with the jury, stories that don't seem so warm and fuzzy anymore. In Edwards's first big case he artfully channeled the words of an unborn baby girl to convince the jurors that an obstetrician's decision not to perform a Caesarean section resulted in the girl being born with cerebral palsy, in spite of the fact that every scientific study available suggests evidence to the contrary--that the vast majority of CP cases are prelabor, and that Caesarian sections do not reduce this risk. He opposed any birth-injury legislation in North Carolina, that would provide a fund to all born with such injuries (a fund that all doctors, including myself, pay annually here in Virginia), to ensure an open cap on these lotto-trials.

The man lied for a living, at the expense of doctors and patients. And apparently his family as well. I imagine he couldn't look too far at himself in the mirror; now I know why his hair was so great.

Medical Truths #3

A doctor's greatest education is from patients.

The average doctor has put in 8-plus years of post-grad education (plus whatever college degree they received), attends hundreds of hours of continuing medical education, grand rounds, conferences, specialty societies, reads countless journals, handbooks, textbooks, and practice guidelines. All important, but nothing compared to the lessons learned from that person in the waiting room. Can a journal teach humility? Does a conference give a sense of the smell of... well, any of the myriad smells in medicine? It's the experience of the interaction that makes me the doctor I am, and hope to be.
A couple of examples:

I have learned great truths in life: Treating an 80 year old lady with dementia, she could not tell you her own name, the day of the week, or what type of building she was in. However, she did observe her 82 year old husband walking slowly with his walker, and turned and commented, "Getting old sucks."

I have learned what the doctor-patient relationship should be, but usually isn't: A first time evaluation of a 40 year old man with moderate mental retardation. I'm going through the usual questions to him and to the staff worker from the patient's group home. I'm asking about medications, symptoms, et cetera. I then ask the question "How well are you sleeping at night." To which he replied, "Pretty good. How about you?" See, I was playing the role of doctor, and he was having a conversation.

That's not in any textbook I've read.

Medicins Dentiste Sans Frontieres

Christine Kearney at Reuters reports on this case. I love the last sentence.

NEW YORK (Reuters) - A New Jersey dentist behind a scheme to steal body parts from corpses, including that of British journalist Alistair Cooke, was sentenced on Friday to a minimum of 18 years and a maximum of 54 years in prison.

Michael Mastromarino, 44, in March admitted to leading a $4.6 million operation that stole body parts from funeral homes in New York, New Jersey and Pennsylvania.

The ring dismembered more than 1,000 cadavers in unsanitary conditions, and sold them to doctors who transplanted them into patients.

"I am sorry for the emotional pain I have caused," Mastromarino told the court, repeating an apology he made to victims and relatives of the dead earlier this month.

State Supreme Court Judge John Walsh made no comment as he sentenced Mastromarino, who had pleaded guilty to body stealing, reckless endangerment and enterprise corruption.

"His sick, disgusting and appalling actions all in the name of greed have devastated my family," Dayna Ryan, 44, told the court.

Ryan contracted Hepatitis B when she was a recipient of stolen body parts during a lower spine operation.

As part of the scheme, a team of so-called cutters removed bones, skin and tendons in an unsanitary embalming room, prosecutors said.

"He fully recognized the gravity of what he has done," Mastromarino's lawyer Mario Gallucci said outside court. "He cut some corners and that is why he is here today." (emphasis mine)

Some thoughts:
1. Ewwwww.
2. Some corners? Did he actually use the word "cut?!" He apparently skipped the semester on public relations in law school.
3. What the hell did he want with Alistair Cooke's body? Was he a fan of Omnibus or Masterpiece Theater?
4. Does this make me an Anti-Dentite?

Dr. Feelgood?

The most recent episode of another pop pseudo-psychologist making headlines has got me perturbed. Dr. Drew Pinsky was babbling about how Tom Cruise is mentally ill, due to his involvement in the cult of Scientology. To quote Drew: “To me, that’s a function of a very deep emptiness and suggests serious neglect in childhood — maybe some abuse, but mostly neglect.”

Of course, he then has to retract and apologize. He is the host of Celebrity Rehab on VH1 after all. (Ironic, here, that Cruise, et al, called the Jewish Dr. Pinsky, a “Nazi,” in their rebuttal.)

And then, having learned his lesson real good, Drew comes out with this brilliant piece of work:

“I'm concerned with what's really going on with Angelina Jolie. I've never seen someone remit heroin completely. You're either still on heroin, Oxycontin, or something else. Unless you're dead. Is she still using something? Is she in recovery? If she's in recovery, I don't see any evidence of it, because people in recovery invest themselves in simple, selfless acts of service, not global self-serving acts."

I am irritated for multiple reasons. For starters, this causes me to side with (at some level) Tom Cruise and the scientologists, with whom I personally (not professionally) have a few beefs…..another time on that. The last thing this group needs is to win PR points because some wannabe shrink has to publicly apologize to them. And regarding Ms. Jolie, well…I just think Angelina Jolie is hot. Um…and of course there’s the obvious trashing of medical and professional ethics.

Paging Dr. Drew! Dude, where in your Hippocratic Oath did it state that you should make public diagnoses on people who are not your patients, do not want to be your patients, and are not soliciting your advice? Pinsky is a board certified internist and addiction specialist- which means he went to medical school, specialized in internal medicine and passed a board exam. He is not a therapist, either psychiatrist or psychologist. This is critical, because the untrained pseudo-therapists seem to have difficulty with certain concepts, like confidentiality (Hello Dr. Phil, RE: Brittany Spears), neutrality (Dr. Laura, preaching personal dogma like “don’t marry someone from a different religion.”), doctor-patient relationships, and other medical ethics. Dr. Phil has a PhD in Psychology, but was sanctioned by the Texas Board of Examiners and is not licensed to practice psychology anywhere. He appears to be more concerned with skirt-chasing or dollar-chasing than in actual practical therapy. Dr. Laura Schlessinger has a PhD in Physiology, not in any therapy modality, and uses her title to wax rhapsodically about the “biological error” of homosexuality, rather than focusing on an individual’s emotional need, thus ruining any sense of neutrality in the therapeutic relationship.

Perhaps I’m off the mark, but using a title like “Doctor” denotes some professional expertise; and professional service if you are going to a “Doctor” for advice, treatment, etc. There appears to be no such professional service being transacted here, and the use of “Dr.” is nothing more than false advertising. So, Laura, Phil, Drew and others, if you’re just giving your opinion, drop the whole “Doctor” schtick. And Drew and Phil, stick to the scripts handed to you on TV, and otherwise shut up.

Medical Truths #2

The most important sentence a doctor can speak is "I don't know."

Our medical schools are chock full of high performers (gunners, in parlance), being taught that the right answer is imperative. Differential diagnoses are screened a-la-House, M.D. and the message is to always be right, and always have an answer. I remember students being berated for "guessing with your mouth open," a favorite phrase, of one particular attending. That mindset is reinforced all through training. Primary care doctors are told to be gatekeepers, and that they should have the ability to treat everything. Certain insurance structures (such as capitation) financially punish those doctors who refer out to specialists or order to many tests. And doctors are given a heavy responsibility (patients' health), for which they do not want to be wrong, and thus be a failure.

It's good to know stuff. We want our students and residents to learn by experience and going to find information that will help in the diagnosis. Certainly we all want to have confidence in our physicians. And there are many benefits in gatekeeper medicine. (Having one doctor keeping track of all of a patient's treatments is one.) Illness, though is not so black and white. However, there is very little positive reinforcement for the student or resident when presented with these grey areas, and even less for those in practice.

Patients respect an "I don't know," even though it may be frustrating to hear it. Most do not expect doctors to be superhuman. I recently had a friend of mine (another physician) be told that he had stage 4 cancer by a national expert, only to find that his nodules in his lungs began to shrink with antibiotics were given by another doctor who said "I don't know." He's glad that the doctor didn't.

No semen for you!

I’ve been following the news out of the Supreme Court of (The Peoples Republic of) California, regarding the Oceanside woman suing a fertility clinic for their refusal to provide artificial insemination on the basis of religious beliefs. The article, courtesy of the San Diego Union Tribune, is here.

The case has been won by the woman locally, overturned by appeal in favor of the docs, and has hit the CA Supreme court. The ruling is pending, but sources believe it will be found in the favor of the woman.

Interesting. I was discussing a similar case regarding a photography business in New Mexico that was found to be discriminatory in its business practices. Marshall Art's blog was discussing this article in the American Thinker.

My comments then as to that case now appear quite relevant and I have rephrased them as such in the next several paragraphs:

Per the Federal Civil Rights Act, legally, unless there is a legitimate business reason for such discrimination, then they're out of luck.

Many states have additional legislation more stringent than the FCRA.

This is up for interpretation:

In California, a funeral home was sued by a family trying to keep out "punk rockers" from a service. The funeral home allowed their admission, thinking that under the Unruh Civil Rights Act of California, they could be sued if they didn't.

It is really discrimination--by the fact of refusing service--and in the definition as noted in the law. I am viewing the term "discrimination" as a legal term, not an ethical/moral one; which is logical, as we are discussing the interpretation of a specific law. One is better off asking if the law is moral or right, to address that component. On that, it is difficult, as I think there are specific rights of individuals to conduct business within a specific code of conduct.

The problem exists, in such code, as to where one draws limits. As a pragmatist, I do believe that society has the right to clarify, by law, the specific definitions as to how businesses have to act in providing service.

The question is thus in degree: Should a private business be allowed to discriminate (by refusing business) against a specific group of people purely on the basis of their sexual orientation? The law currently says no for each and every business.

Had the owners of this practice argued that this decision falls outside of a noted code of conduct, and made efforts to refer this couple to a willing provider of services, they probably could have made a viable argument of this being a business decision -as it could have caused them to lose other customers, etc. (It also probably wouldn't have become a court case). The bottom line is: Refusal of service needs to be defined in terms of a business or medical decision, lest it be open for such claims.

--------------------------------------------------------------------------------------------------------------------------------

A few additional points and questions:

1. Why was there no suit against the insurance company for not facilitating any other willing provider? There are many instances where physicians may have standards which do not allow comfortable treatment by the physician. An example--treatment of multiple family members by one Psychiatrist is often contrary to professional standards. Shouldn't insurance companies be required to work with clients in these cases?

2. Does the fact that this is a voluntary medical procedure make any difference? Few would argue regarding emergency care, but should a physician have the right to refuse to treat under conscientious objection? Michigan is debating that issue currently. See here.

3. Does this standard apply for other religious groups? There is significant debate in the UK regarding docs of Islamic faith refusing to treat drug or alcohol issues, sexually transmitted diseases, or opposite genders. I am waiting for the day that a Jehovah’s Witness becomes an MD and refuses to treat anyone.

4. These are not the brightest docs to scribble on a pad. There are so many ways around this religious refusal of treatment that I cannot help but wonder if this is not merely a couple attempting to push a political agenda. C’mon! If I’m reading correctly, you agreed to treatment of mediations for this patient, but drew the line at artificial insemination. Huh?! That’s like giving band-aids but refusing stitches.

Doc's Public Service Announcement #1

People with candidate bumper stickers should drive in a safe and courteous manner.

Medical Truths #1

I'm going to try to put out some opinions on how I see the medical field as it is and as it should be. These are truths in the sense of my own personal belief, not necessarily scientific axioms. I will try to keep the initial posts less tome-like, and hope to encourage dialog. With that said, # 1:

Medicine is a science.
The Practice of Medicine is an art.

I notice an increase in the cynicism of the public towards the health care field. I believe there are many political, social, and economic reasons for this. One reason, though, I believe is in the failure of our field to practice this simple truth. We are often blurring the lines of science, by not holding data up to an exacting standard. We are also poor artists. I think that many doctors have a presentation that suggests they are just throwing the drugs out there to see what sticks. Doctors do not often have (or take) the time to explain the science (how the stuff works), and even less time to explain the art (how did we come to this conclusion and plan).

Designer Babies?

From the AP. Link here.

By MALCOLM RITTER, AP Science Writer Mon May 12, 6:25 PM ET

NEW YORK - News that scientists have for the first time genetically altered a human embryo is drawing fire from some watchdog groups that say it's a step toward creating "designer babies."

But an author of the study says the work was focused on stem cells. He notes that the researchers used an abnormal embryo that could never have developed into a baby anyway.

"None of us wants to make designer babies," said Dr. Zev Rosenwaks, director of the Center for Reproductive Medicine and Infertility at NewYork-Presbyterian/Weill Cornell Medical Center.

The idea of designer babies is that someday, scientists may insert particular genes into embryos to produce babies with desired traits like intelligence or athletic ability. Some people find that notion repugnant, saying it turns children into designed objects, and would create an unequal society where some people are genetically enriched while others would be considered inferior.

The study appears to be the first report of genetically modifying a human embryo. It was presented last fall at a meeting of the American Society for Reproductive Medicine, but didn't draw widespread public attention then. The result was reported over the weekend by The Sunday Times of London, which said British authorities highlighted the work in a recent report.

Rosenwaks and colleagues did the work with an embryo that had extra chromosomes, making it nonviable. Following a standard procedure used in animals, they inserted a gene that acts as a marker that can be easily followed over time. The embryo cells took up the gene, he said.

The goal was to see if a gene introduced into an abnormal embryo could be traced in stem cells that are harvested from the embryo, he said. Such work could help shed light on why abnormal embryos fail to develop, he said.

No stem cells were recovered from the human embryo, said Rosenwaks, noting that abnormal embryos frequently don't develop well enough to produce them.

Marcy Darnovsky, associate executive director of the Center for Genetics and Society, said the Cornell scientists were developing techniques that others might use to make genetically modified people, "and they're doing it without any kind of public debate."

A London-based group called Human Genetics Alert similarly criticized the work.

But Kathy Hudson, director of the Genetics and Public Policy Center in Washington, D.C., said she's not troubled by the work. She said the idea of successfully modifying babies by inserting genes remains a technically daunting challenge.

"We're not even close to having that technology in hand to be able to do it right," she said, and it would be ethically unacceptable to try it when it's unsafe.

A few questions:

1. Does it matter that they used an "abnormal embryo?"

2. While it would certainly be unethical for this group of scientists to use this technology for human modification, aren't others able to do so?

3. If so, should the progress be halted based on the possible malfeasance/malevolence of others?

4. Although the idea of successfully modifying babies is a technically daunting challenge at this time, doesn't that seem to be a planned goal?

5. Is that bad?

6. Couldn't we have a better name than "Designer Babies." Sounds like an LA girls pop band.

No Such Thing as a Free....

.... Medication Sample?

In the Empowered Patient column on CNN's website, Elizabeth Cohen wrote, "In a University of Chicago study published this month, those receiving [medication] samples spent $166 in the six months before they obtained free medicine, $244 when they received the samples, and $212 in the six months after that." Since "free samples aren't always so free when you look at it long-term," Cohen lists five steps to take when a physician offers a sample. These include asking "your doctor how long you'll be taking the drug," finding out "if there's a cheaper alternative" to the drug offered, requesting that "your pharmacist to call your doctor" to "suggest cheaper alternatives," doing "your own price shopping," and keeping in mind that physicians "are often hesitant to change a prescription."

Dr. Adair then goes on to note that his physician "was being nice to me, or he thought he was." "Doctors think they're helping people by giving free samples, but we don't think through the long-term consequences."

Food for thought for physicians and patients. But, let's look into this one. The primary study is in April's Medical Care--and an article by Dr. G. Caleb Alexander. For those interested, the link is here. (A pleasant surprise was noted, by the way, seeing one of my colleagues as co-author, Dr. J. Zhang, right here in Richmond.) I was pleased to see that the study included an analysis to try to differentiate the possible confounding variable of samples being due to increased health demand. (i.e. a sicker patient needs a more expensive medication). This is a difficult variable, and was dealt with fairly logically; although the authors do note that there can still be confounding data skewing to explain the cost difference. They also do note some possible selection bias. I think this is perhaps likely in explaining the difference in sample usage being lower in those with less income, on Medicaid, etc. Commonly, lower income patients and Medicaid recipients are in facilities, insurance structures, or community-based programs which do not encourage samples. For example, one living in a group home, or in a community health center, which is not designed to process samples, and prefers (or demands) prescriptions only.
All-in-all, a this represents a fairly well designed study, that does not portend to be anything beyond a starting point for consideration and further research (naturally!). Of course, there will be media-savvy (or hungry) types that will immediately use this data for the purpose of bad-mouthing the insurance companies and perhaps demanding that doctors further distance themselves from this evil industry by no longer accepting samples: In an posting in 2005, Dr David Pisetsky at Duke University (jointandbone.org forum editor) presents the perils of seeing drug reps and accepting free samples. He suggests that it may be time to "pull up the welcome mat, close the door to my office, and put up a 'No Solicitors' sign."

"Does free mean free?" the headlines read. Well, of course it does--(unless the doc is charging in the parking lot or selling samples to the local pharmacy, in which case may a warm HMO await them in hell). No study will ever show a positive cost analysis of identical prescriptions being given vs. samples (e.g. a sample given of Lipitor vs. a prescription).

I am curious though to the possible rationale for studies like this. Is to promote the usage of generic medications? Perhaps more restrictive formularies? Or, is this a not-so-indirect attack on the pharmaceutical industry, or health care providers? (I didn't know we were just "often hesitant to change prescriptions!")

So, what can we learn from this study? First, that there is a possibility that when medication samples are given to patients, there is a possibility of being a greater long-term cost to those patients (or their insurance companies). Second, that the current studies do not provide sufficient data to condemn the practice of giving samples by physicians. and Third, it would make logical sense for patients and physicians to dialogue regarding samples, and treatment options, and that certainly should help not only the patient's decision-making, but maybe their wallet as well.

Bursting Boomers

From a recent news article from the APA:

NBC Nightly News (4/14) reported that "there's a new warning that this nation's medical care system for seniors is nowhere near ready to deal with the 78 million Baby Boomers who are about to begin turning 65," according to a study by the federal Institute of Medicine (IOM), which is part of the National Academy of Sciences.

The 242-page publication states that "[h]ealthcare institutions must rapidly increase training in geriatric care to ward off an 'impending crisis,'" the Wall Street Journal adds. In fact, the report characterizes "the U.S. healthcare workforce [as] 'too small and woefully unprepared' for the growing elderly population," and portrays "a stark picture of increased demand for healthcare workers -- unmet by a stagnant, or even dwindling, supply of those trained to treat the elderly." According to John W. Rowe, chairman of the committee which compiled the data, and former chairman and chief executive of Aetna, Inc., "This could be seen as evidence that our society places little value on the expertise needed to care for vulnerable, frail, older Americans."

The study found that currently, there are insufficient "specialists in geriatric medicine," training is inadequate, and the few "specialists that do exist are underpaid," the AP reports. In fact, the investigators charge that "Medicare may even hinder seniors from getting the best care, because of its low reimbursement rates, a focus on treating short-term health problems rather than managing chronic conditions, and lack of coverage for preventive services or for healthcare providers' time spent collaborating with a patient's other providers."

The data also indicate that since "one out of five Americans will be 65 or older" by 2030, "Medicare, Medicaid, and other health plans will need to pay higher rates for the services of geriatric specialists and direct-care workers to attract more health professionals to geriatric careers".

A crisis looms on the horizon. Are we preparing? Sadly, the answer seems, no. Less doctors are accepting Medicare, due to declining reimbursements. Nursing and Continuing Care Facilities are not likely to keep up with the need of the populations, especially for the lower income groups.

Physicians themselves do not appear well prepared for this burgeoning population. Geriatric patients require more time, due to a higher level of complexity from multiple medical concerns, a greater variability in responses and side effects from treatment, and difficulty with communication. Greater time needs to be spent collaborating with families and coordinating with other physicians. If the numbers noted above are correct, it's time to start preparing....

Politcally Incorrect Musings #1

Having a chat with the 11 year old son yesterday; he was trying to recall the name of the amusement park in Pittsburgh. I told him Kennywood Park- and he said, "oh, yeah... I thought it was Kennedywood."
This is not a bad idea. We have Dollywood, a Hard Rock Park, and even a proposed Ben & Jerry's Theme Park. Why not the family of Camelot? I humbly submit a few suggestions:

Kennedywood Park: Attractions:

The Chappaquiddick Water Adventure
Michael's Ski-N-Slide Thrill Coaster
The Joe Kennedy Boat Ride and Refreshment Stand
Rose's Fun House
The Patrick Kennedy Bumper Cars
Sirhan Sirhan's Shooting Gallery
Maria Shriver Presents: "The Gropinator:4D Experience"
The JFK Jr. "L'il Captains' Plane Ride"

And for relaxing afterwards:

The William Kennedy Smith Bar and Beach Walk
and The Grassy Knoll Picnic Area

The heart of the matter

Yesterday, a country-wide attack occurred by the medical establishment against the makers of Zetia and Vytorin. These are two newer (and more expensive) cholesterol lowering medications.
A sample news article appears here, in the New York Times.
A brief analysis of the article in The New England Journal of Medicine, (article here) notes that there is failure to separate statistically between the new medications (specifically ezetimibe- found in both Zetia and Vytorin) and the older cholersterol lowering medications, known as statins (simvastatin, specifically, for this study). The ENHANCE study measured the lowereing of LDL ("bad" cholesterol) and the thickness of the intima-media of the femoral and carotid arteries (a way of noting how much plaque is building up in the actual arteries). The latter is designed to measure the amount of atherosclerosis, and thus if the drugs are likely to prevent heart disease. On LDL lowering performance, ezetimibe has shown consistent significance at lowering LDL's better than statins; this was also seen in the ENHANCE study. However, no statistical difference was noted in the intima-media thickness (IMT).
So we again have a study that fails to separate (See previous posts on statistics and separation). This evidince is a bit more solid insofar that the drug makers themselves are sponsoring this study, and that there is an upward trend in thickness noted in the data of the newer drugs. Clearly there would be difficulty in declaring any improvement regarding heart disease from the newer medications, as none to date can be shown, and from the IMT results. But let's note just a few points:

1. The older medication showed no difference in IMT either, yet these medications have been shown to reduce heart disease.
2. Ezetimibe does show consistently and significantly lower levels of cholesterol
3. Long term outcome studies on heart disease have not been finished with the newer medicinces.

However, such points do not stop the mainstream media from finding all to willing physicians to get on the TV, radio, and news to declare the absolute failure of these newer products.
I woke up yesterday to hearing a cardiologist on a morning TV program saying "You can prescribe these medications; they just don't work." A similar statement is noted in the NYT article, where Dr. Krumholz recommends going back to statins, because "they work." Well, perhaps.... but not any better than the newer medication if we are to believe the results of the ENHANCE study.

What the ENHANCE study shows, is that we do not understand the mechanisms and correlations between cholesterol and heart disease, and that we need to wait to consider outcome data, before any declaration of what does and doesn't work in prevention of heart disease. In the meanwhile, the newer medications should be considered as part of the ongoing armament to lowering cholesterol. The recommendations for treatment of Familial Hypercholesterolemia have never been to use the newer medications first, so continuing to follow these guidelines and start with more traditional treatment is currently prudent.

Yes, newer is not always better- but remember that statins were the new, expensive drugs once too.

Real Science, and RIP Mr. Cope

Just perusing the news today, and I noticed an article out of the Pittsburgh Post Gazette (hardly a right wing rag). This represents a good example of what a scientific study should look like: Blinded, randomized, peer reviewed.
The link is here.
The article shows a study which shows, shockingly(!), that antidepressants can work- and sometimes when one doesn't (I guess the placebo didn't do so hot either), then another one might. It encourages patience, and a well thought out game plan when deciding on type and rationale in treatment.
On a sadder note for my fellow Steelers fans, Myron Cope- voice of the Steelers and inventor of the famed "Terrible Towel," has passed away today. "Yoi!, and double Yoi!"- Hope they have a nice Hot Pastrami (with fries in it, of course) where you are now, pal.
Cope was also an ardent supporter of national and local autism societies, as his own son Danny is autistic. All proceeds from the Terrible Towels went, and will continue to go, to the Allegheny Valley School- a facility that provides community and residential training and programs for children and adults with mental retardation.

Prozac Attack, Take 58

Today's news offers a study from Professor Irving Kirsh, Psychologist in the field of placebo effect. Prof. Kirsh, et al. have done a meta-analysis on 47 clinical trials for depression and have determined that the effect of the most popular medications (always referred to as "drugs" in such studies) for depression provide no benefit, except in severe cases. Of course, much of the media has been reporting with "unbiased" reports, with headlines such as "Antidepressant may not work" "Do we need antidepressants. and "Antidepressants no better than placebos." Even Fox (fair and balanced) fails to disclose some very basic facts regarding this article- the original which can be found here.

Some of those facts are:

1. This article, (published by the way on an open access journal-a sort of wikipedia for scientists) is a meta-analysis. It is a reconstruction of statistics determined after the fact. Given that one can choose the statistical analysis afterwards can allow one to manipulate the data.

2. There is a selection bias regarding studies chosen for the meta-analysis. Per Glaxo Smith Kline's representative, only studies that were submitted prior to approval, rather than a comprehensive (or at least randomly selected comprehensive) set of studies.

3. As we learn in statistics, failure to prove separation (the null hypothesis) does not prove equality. Many things are involved in a study, such as sample size, completion rates, and statistical methods. It is as if I take two animals, a cat and a dog, and try to prove that they are different based on certain criteria (e.g. type of hair, teeth, claws, number of legs, and weight). If I do this with one hundred cats and dogs, I can prove a difference. If I do it with two, I cannot. This failure to separate statistically does not allow me to state that cat=dog!

4. There is a likely bias of the conductor of the study. Prof. Kirsch has been singing this placebo song for years, and is not just limited to antidepressants. He also has written similar opinions regarding Asthma, and Irritable Bowel Syndrome. So what's his angle? Research money? Perhaps. Personal Bias? Attention? I do not know. He is a supporter of cognitive behavioral therapy, in lieu of medication. Furthermore, he espouses the usage of a certain medication for treatment of depression: can you guess which one? How about Placebo! Dr. Kirsch notes in an interview to NPR that regarding the effect of placebos:
"For years and years and years it has been treated as just noise, as trash. Now we're finding out that it's not just trash, it's really treasure. It's something to be mined, something to be understood, something to be made use of."
NPR- CLICK HERE
Fascinating. I'm not sure how he's going to sell that idea to the FDA: Hey! Don't use a drug that might not work, use one that we know won't work.

5. The UK may have a financial agenda. The nationalized system recently has done this with Alzheimer's medications (the NICE study declaring them to be not cost effective). Perhaps we are seeing the UK starting to put up barriers to obtaining treatment for depression.

Well. Any doc worth his salt will tell you that we are quite aware of the "placebo effect." I used to be quite annoyed and amused with a neurologist in my residency days who used to declare that a person was not having a particular neurological condition just because it improved when he gave a shot of saline to the patient. He would smile and state, "must be one of yours." So of course, we should understand that a "placebo effect" can do some interesting things- that is the amazing part of the mind.

I do not fault Prof. Kirsch his opinion or his data. I do not fault the news media for reporting. They both have their rights. I just strongly disagree with the findings as horribly biased, and the reporting as merely sensationalistic. It is, in short, bad science.

The choice for antidepressant treatment should be made after consultation with a qualified health professional. I do not recommend merely "just trying" any medication, psychotropic or otherwise. It would be a shame, though, if doctors or patients allowed such bad science to bias their decision to offer or consider these medications.