With Two You Get Eggroll

From the odd crimes department, this incident occurred on February 13th, in Pennsylvania:

Directly Lifted from the AP story:

"LEECHBURG, Pa. — Police say a western Pennsylvania man who claims to have split personalities confessed to robbing a Chinese restaurant after reading about it in the newspaper and realizing he was the person who did it.
Online court records don't list an attorney for 23-year-old Timothy Beer, of Leechburg, who's been jailed since surrendering in Sunday's robbery of the China King Restaurant about 35 miles northeast of Pittsburgh.
Beer came to the police station Tuesday, saying he wasn't feeling well and "did something stupid."
Beer told police he ordered food and became angry when he perceived the person waiting on him was continuing to speak Chinese. The next thing Beer remembers, he was playing video games at his cousin's home — but says he later realized he committed the robbery when he read about it in Tuesday's Valley News Dispatch."

__________________________________________________________________________Some Thoughts:

1. People still read the newspaper?

2. Weekend, 23 years old, Chinese food, and playing video games? I'm gonna guess there may have been some THC involved in this dissociative state.

3. There is no longer "Multiple Personality Disorder." The correct term is "Dissociative Identity Disorder." There was a time (especially in the West Coast) where further diffraction of the personality was considered de rigeur for the therapy--a person would go in with two seperate personalityies and walk out with five or six. This often would occur during hypnotherapy. That is not what is recommended. Re-integration of the dissociative personality should be the goal of therapy in these situations.

4. There are many different types of dissociative states. Ever missed the exit while driving, becuse of "zoning out?" That is a dissociative state. Some psychiatric illnesses, such as Post Traumatic Stress Disorder, also can have episodes of dissociation (e.g during "flashbacks"). There are amnestic fugue states (where a person may "wake up" wandereing around in a strange city, confused) And, of course, there can be substance induced dissociation. None of these are of the "multiple personality" type-- dissociative identiy disorder.

5. I lifted a Doris Day movie title for this post, but "The Three Faces of Eve." might have been a better choice, and is certainly worth seeing. Does Hollywood present Dissociative Identity Disorder (DID) well? "Primal Fear," and "Sybil" (like "Three Faces," also stars Joanne Woodward) do give DID a fair, by Hollywood standards, treatment. "Secret Window," "Fight Club," and "Identity" take the concept and run with it.

Some new tunes

Time to dust of the blogspot and make a genuine attempt at scribbling some notes. Having recently returned from California, in the Bay Area, I was reminded of a couple of tunes, coincidentally with my format of one old and one new.

Of course, San Fran is not new to music. Every aspect of American music has had some time in the city by the bay (Journey, "Lights"). One does not have to more than just sit on the dock (Otis Redding) overlooking the golden gate bridge, to see some of the wonderment that led many a lyricist to wax rhapsodic on this town. And although it has been claimed to be built on rock and roll (Starship, "We Built this City"), it was the flower power days of past for which places like The Haight became synonymous with the entire music scene of the 60's.

So, with that in mind, I will promptly ignore pretty much all of the above genres for the two selections and proceed in a common non sequitur manner!

The story of Johnny Mathis' "Yellow Roses on Her Gown" is true. It was written by a man who grew up initially in the Bay area, and his father had to move out of town, because of his work. If the internet research is to be believed, the Father was a lawyer who had been defending individuals accused of communist activities during the McCarthy days. Again, if the internet is to be believed, this move caused his mother to be unable to go on. Even without the backstory, this is one of the most beautiful storytelling pieces of music ever written, and my favorite of Mathis' songs.

The next tune is new, and appears on an album released in 2011, called Map of the Forbidden City. The musician, however, is far from new, although he has had a near two decade absence from the music scene. The American audience, for the most part, never really got into Thomas Dolby's storytelling style, instead seeing the facade of the mad genius of synthpop, which became part of the roots of techno. In this album, which is a diverse as can be, Thomas crafts an alternative world full of fantastical songs, and shows that he has surely matured as a songwriter. He works with a British colleague of his on this tune, some guy named Knopfler. It is a wonderful bit of songwriting, and one of my favorites of 2011. The tune is not available online very easily, so for those of you with Spotify, may I send you here.

Life, The Universe, and Everything

As noted in a previous posting, Life's been pretty hectic in the Doc-osphere. Health care is certainly an enjoyable subject, but ironically, it has been health care issues that have generally kept me away from the blogging. All is well, rest assured, and it is high time to return to a bit of writing.

I have learned a few important lessons over the past year, in part due to having an ill loved one, and due to what would best be described as "soul searching." In the area of psychiatry (and just in general!), this is certainly not a bad thing to do periodically-- taking stock of one's self and one's roles. My spirituality, even as it relates to my work, has grown stronger, and I am learning to not to restlessly fight with time; as it unecessary, and, invariably, a battle that one will lose.

Too many.

Troop deaths due to combat in Iraq and Afghanistan in 2010: 462

Troop deaths due to suicide in 2010: 434. Including reservists: 468

Posterized

POSTERIZE: From Wikipedia: North American slang [1] derived from an action in the game of basketball, in which the offensive player "dunks" (see slam dunk) over a defending player in a play that is spectacular and athletic enough to warrant reproduction in a printed poster.


After the Lakers championship win over (my beloved) Celtics this year, Ron Artest did a very curious thing in his post-game interview.

He thanked his psychiatrist. Twice.

Artest thanked "everybody in my hood," "my doctor" and "my psychiatrist."

"Thank you so much," he said to the ABC reporter. "There's so much commotion going in the playoffs. She helped me relax."

Do we have a new Poster Boy for Mental Health?

Now, Artest is no shrinking violet. He's no New Age Bill Walton type, nor some sensitive European Dirk Nowitzki. (Although I could picture the latter going on about his psychoanalysis on a very long couch: "Ich habe eine neue Weltanschauung") No, Artest is about as Mean Streets as it comes. He was once called, by ESPN, "The Scariest Man in Basketball." He was suspended, and darn near kicked out of the NBA, for taking a fight right into the stands during a game in Detroit.

Sure, he was forced to undergo anger management, and (according to the same ESPN report) he has been in therapy since childhood. But to mention it on a post-game interview on one of the biggest nights of his professional career was fascinating.

The blogosphere in the shrink world has tried  to make hay of this interview. The gamut runs from giving kudos to his therapist and psychiatrist, to hoping that the stigma of mental illness may be lessened by his "coming out." Some in the sports world are not a as kind, and harassed him and his "craziness," yet most were at least pleased with the bit of honest fresh air.

Poster Boy? I'm still not sure. (He did also plug his new music single in the interview.)  But it seems that Ron is at least benefiting from some of what we call in the shrink biz as "insight:"  To quote Ron: "When I'm upset, it's not good. I'm not really thinking about the game. I feel like I've failed." 

Music Update

I've been listening to quite a bit of Muse and was fortunate enough to see them live as they opened for U2, and as headliners at the Patriot Center in Fairfax, VA. Muse has been one of those bands that has just been doing their own thing for the past decade, regardless of popularity. They've found a significant audience in their home in the UK, and have a rapidly growing audience here in the states, perhaps due, in part, to the popularity from their work on the Twilight soundtrack.
Muse pulls from all sorts of genres: alternative, prog, classical, jazz, electronica, and metal. The eclectic mix is often compared to Queen, Radiohead, and Pink Floyd, although I think that is selling the absolute diversity of this band quite short. Lead Matthew Bellamy is a complete virtuoso, and appears completely comfortable behind seemingly any instrument.
Their albums span all of the above genres, often covering several in the same song. The song "Knights of Cydonia," is off the album Black Holes and Revelations. The video solidifies what one hears on the song: that Matthew and Company were Ennio Morricone fans.
As enjoyable as all of their albums are, Muse is one of the few not-to-be-missed live bands in the past 20 years. These guys own the stage from start to finish, and are able to create the "Big Rock Show" sound at will.

You've never heard of Eliane. Unless you happen to have been attending coffeehouse shows in NYC or Switzerland. Trained at The New School in Jazz, she adds Brazilian and rock sounds, for a wonderful eclectic mix. She's has turned a few heads in the music world recently, and has toured internationally over the past few years.  This song "As If" is off a self produced CD, and is just one facet of this exceptionally talented young woman. I do hope to hear much more from her in the future.

Worthwhile Research

A study done at UCSD and UC-Davis has looked at the link between chocolate consumption and depression.  Shari Roan at the LA Times has a nice report on it here. 


A snippet:


When the researchers controlled for other dietary factors that could be linked to mood — such as caffeine, fat and carbohydrate intake — they found only chocolate consumption correlated with mood.
It's not clear how the two are linked, the authors wrote. It could be that depression stimulates chocolate cravings as a form of self-treatment. Chocolate prompts the release of certain chemicals in the brain, such as dopamine, that produce feelings of pleasure.
There is no evidence, however, that chocolate has a sustained benefit on improving mood. Like alcohol, chocolate may contribute a short-term boost in mood followed by a return to depression or a worsened mood. A study published in 2007 in the journal Appetite found that eating chocolate improved mood but only for about three minutes.
it's also possible that depressed people seek chocolate to improve mood but that the trans fats in some chocolate counteract the effect of omega-3 fatty acid production in the body, the authors said in the paper. Omega-3 fatty acids are thought to improve mental health.
Another theory is that chocolate consumption contributes to depression or that some physiological mechanism, such as stress, drives both depression and chocolate cravings.
"It's unlikely that chocolate makes people depressed," said Marcia Levin Pelchat, a psychologist who studies food cravings at the Monell Chemical Senses Center in Philadelphia. She was not involved in the new study. "Most people believe the beneficial effects of chocolate are on mood and that they are learned. You eat chocolate; it makes you feel good, and sometime when you're feeling badly it occurs to you, ‘Gee, if I eat some chocolate I might feel better.' "

___________________________________________________________

Some Thoughts:


1. I hope this will lead to a double blind study, as I would be very willing to sign up. I'm not sure what the placebo control group would ingest, though! What's a placebo to chocolate?


2. We now have chocolate Cheerios!?!


3.  Previous studies on chocolate and mood show  a few consistencies:  Women reach for the cocoa more than men, there is at least a short term elevation of mood, and those with mixed anxiety/depression or atypical depression seem to use chocolate more.


4. Why does chocolate have any effect? Chocolate has several chemicals that are likely psychoactive: Serotonin is a mood enhancer (increased by medications like Prozac) and Tyramine potentiates Serotonin. Theobromine and Caffeine are both stimulants. (Side note: Dogs lack the enzyme to break down Theobromine, thus it is neurotoxic to dogs). Chocolate also has Phenylethylamine, which releases endorphins (natural opiods) which give  a sense of euphoria. This is similar to the "runner's high." One study done in 1995 (by Andrew Drewnowski at the University of Michigan)  showed that when one blocked this natural endorphin with a medication (Naltrexone), than the subjects ate less chocolate. (Side note: Phenylethylamine is also released when one is falling in love)


5. Over 3 million tons of cocoa beans are consumed around the world annually. The market value of the current annual cocoa crop is $5.1 billion. (Source: World Cocoa Foundation)

This too shall pass.

For those not living in a bunker, (which is where I think some of the far-right leaning shack-in-Montana types may be), Obama and the Democrats passed through a health care bill on Sunday. There has been much misinformation regarding the bill, and plenty of unfounded rhetoric across the political spectrum. I have read through the Senate version, but not all of the "fixes" yet, and I might examine and opine on some of the details in some future postings, until then I am just going to offer a few general thoughts and observations for now:




1. Sadly, I fear that there will be many unintended consequences of the recent healthcare legislation. The shift towards "universal healthcare" will likely result in a two-tiered system in which those who are utilizing insurance will find themselves limited to very overcrowded and lower quality medical centers. This system is fairly common in New York, where some clinics have two doors into the same building-- one for those with insurance, and one for those that pay cash.



2. This bill does not implement a public option. Period.



3. The rhetoric on the left has been horrible. The White House, and many of the Democrats have basically said, "If you do not agree with this bill, you are for the status quo." This is intellectual bankruptcy and complete arrogance. It reminds me of George W. Bush's attitude regarding amnesty (and a few other issues!). Most individuals are in favor of access to quality health care. Disagreement with this bill does not equal a preference for others to have no access to healthcare.



4. The rhetoric on the right has been horrible. "Baby Killer?!?!" Are you kidding me? Fearmongering (see item 2 above) regarding things that are not in this bill is intellectual bankruptcy and counter-productive. Agreement with this bill does not equal a preference for the destruction of America.



5. While the Democrats seemed (to me) to make this a case regarding access, I think they are off target. This should be a discussion about cost. More importantly than "is this a right that everyone should have" is "how can we ensure that we don't bankrupt our country, as we are currently doing with health care costs?" If we cannot afford the system, access is moot.



6. To that end, the elephant in the room is exactly that-- medical economics. This bill does very, very, little to address the actual problem in how we practice medicine and its economic ramification. Simply put, we are going to need to change this. Too much time and money are wasted in the practice of overly defensive medicine, beaurocracy, and in dealing with systems outside of the doctor-patient relationship. Until we have a new weltanschauung on the methods and delivery of health care, it will not matter who is stroking the check, our GDP will not be able to cash it.



7. The current batch of Republicans who are whining need to take a long, hard look in the mirror, and use their pointer finger. The issue of burgeoning health care costs did not appear overnight. Their failure to address that with any viable legislation is a substantial reason that they got to play the role of by-stander this go around.



8. The current batch of Democrats should not be too quick to light their cigars (outside of DC or Maryland public places, please). This bill was rushed, ramrodded, and back-doored to death. Rep. Patrick Kennedy says (in an ABC interview Monday) to those that dislike this bill, "I would say, wait until you hear more about it." That's a problem; Americans should have heard more about it before the vote. The administration hasn't sold us on it. Again, it reminds me of how Bush handled the war, and I think it will result in a similar election outcome.



9. I just can never understand the uproar over the issue of who is paying for abortion. If ever a cause makes for strange bedfellows, this is it. This is one area where my pragmatist logic reaction causes a sharp pain behind and between my eyeballs.



10. As I will now be preparing to pay significantly more taxes, I might as well have fun. My favorite tax in the bill? Tanning Tax: A 10 percent excise tax on indoor tanning services.

Honey, it's for you. It's your medication calling.

3-D Television, LCD screens in microwaves, refrigerators that let you know when you're out of milk, and now this product being rolled out by Express scripts.  An electronic pill container.

The container—actually a high-tech top for a standard pill bottle called a "GlowCap"—is equipped with a wireless transmitter that plugs into the wall. When it is time for a dose of medicine, the GlowCap emits a pulsing orange light; after an hour, the gadget starts beeping every five minutes, in arpeggios that become more complicated and insistent. After that, the device can set off an automated telephone or text message reminder to patients who fail to take their pills. It also can generate email or letters reporting to a family member or doctor how often the medication is taken.

____________________________________________________________________

Some Thoughts:

1. I see that our boomers are entering the age that there's a greater probability of forgetfulness.

2. Likewise, this would be useful for men who don't have the most effective reminder system to date: Their spouses. I know that works for my father. Perhaps we could incorporate voice recordings of a wife yelling "Don't forget to take your Xanax."  On second thought, scratch that. It could lead to an overdose.

3. This could be very embarrassing for some medications: "Dad? What's Cialis?"

4. Psychiatrists need to be aware of this, lest we start hospitalizing patients who report that  their medications are talking to them .

5. Novartis' edible chip in a pill  "that sends a signal to the patient and designated individuals," sounds very cool, but a tad scary. Who would need to know that information other than those who wanted enforced compliance? Given the number of states that have been rewriting their laws on outpatient committment, this certainly can create some ethical issues.

6. Play the clip on the automated telephone message. It seems a bit, I don't know, something.

(Hopefully) The Last of The Red Hot Lovers

The issue of sexual relationships between therapist and patient is serious, this one made the news recently: The following is a quote from the AP report.


TAMPA, Fla. — A psychologist is accused of having sex multiple times with one of his female patients and billing her insurance company $1,400 for "sessions," according to records from the Florida Department of Health.


Dr. Daniel Lerom, 49, and a 37-year-old patient identified only as "H.F." had a sexual relationship between February and May of 2009, department board members wrote in a report filed in January. Lerom also repeatedly asked H.F. for her prescription medications, saying he needed them for back pain.


The relationship ended when Lerom's wife discovered the affair, the report said.


Lerom's license has been suspended and the patient is suing him, claiming malpractice, gross negligence, breach of duty of care and infliction of emotional distress, among other things.


She claims in the lawsuit she suffered a "complete emotional collapse" and was institutionalized after being rejected personally and professionally by Lerom.


Lerom did not return messages left at his home and office. An assistant for patient H.F.'s attorney said the attorney would not be commenting on the case.


Both the lawsuit and the Department of Health documents are filled with extensive, and often salacious, details.


According to the report, Lerom would often text H.F. after their trysts, often at her condo or a hotel. He said that he was "falling in love with her" and gave her jewelry from Tiffany's.


"U r sooo hot!!! i worry that i m holding u back from a younger stud who can really meet your needs!! lol!!" one alleged text from Lerom to H.F. said.


Another: "if i were there i would rub u all over and kiss u all over!!! that's the dr. dan cure!!! XOXOXO."


The doctor also referred to himself as a "RHL," or, "red hot lover."

_________________________________________________________________________

Some Thoughts:

1. That is so 1980's hollywood. At what point are those in the therapy biz gonna figure out that sleeping with your patient is malpractice?

2. As a professional therapist, he should lose his licence to practice, and face whatever legal or civil consequences come his way.

3. As a 49 year old man, for texting "u r sooo hot," and calling himself "RHL," he should receive the death penalty.

4. Did you know that many of the founders of psychotherapy had sexual realtionships with their patients? The list includes: Jung, Balint, Groddeck, Rado, Rank, Reich, and Tausk. One of Freud's inner circle, Sandor Ferenczi, had a particularly interesting number of such relationships including the following, noted in a letter from Elma Palos-Laurvik, his stepdaughter, whom he seduced and then abandoned amply demonstrated these factors. Mrs. Palos began an analysis with Ferenczi after the suicide of her lover, at the recommendation of her mother, Gisella Palos, Ferenczi's mistress. Mrs. Palos later recalled her "therapeutic" experience in a letter to Michael Balint:

"...So, after a few sessions (on the couch) Sandor got up from his chair behind me, sat down near me on the couch and obviously carried along by passion, kissed me and in a state of great excitement told me how much he was in love with me and asked me if I could love him. I don't know if it was true or not, but I answered him 'yes' and I hope that I really believed it...I don't remember for how many days or weeks Sandor came daily to lunch with us as my fiance before I realized that already I loved him less than I had thought during the analysis."

5. 19 States have enacted laws making it a crime to have sexual activity with a patient.

6. Yes, there are many factors involved in why such horrific boundary violations occur. Therapists should have a good education regarding the very emotionally sensitive nature of therapy. Transference reactions certainly are likely to be a large issue in these boundary issues. But, in my opinion, there should no longer be any excuse for such destructive behavior, and therapists who have sex with patients should be tossed out of the professional pool.

Take A Hike!

As New Years' rapidly approaches, I offer some thoughts on those curious resolutions that predominate this time of year. Some of the most common resolutions, per most surveys (including the American Psychological Association), are lose weight, quit smoking, exercise more, reduce drinking, reduce stress, improve finances.

Why do we make resolutions? Maybe it is to justify (or as a response to) our indulgent behaviors between Thanksgiving and New Years? Perhaps it is the decreased structure of that same time frame. Biologically, maybe it's a response to a cyclical down time brought on by shorter daylight periods. Psychologically, there is something appealing about new beginnings; the idea of starting over with a clean slate--perhaps it's just optimism for the future. And that coincides with the looking back that occurs at the end of a cycle, so we have the knowledge of our transgressions, and the opportunity to make amends.

The ability to make these resolutions stick is covered commonly in many magazines and newspapers on the grocery store check-out aisle. I would direct you to Dr. Wallin's nice summary of advice in this area.

I offer only one suggestion: walk. Walking is an excellent form of exercise, that is not very hard on the body, and is second only to swimming in low impact bang-for-your-buck exercises. It makes an excellent distraction from cravings for nicotine, alcohol, or food, and can activate neurochemical pathways to directly assist in those areas. Similarly for stress reduction. Exercise has been shown to improve outcomes in double blind, placebo controlled studies of treatment of depression, as both an adjuvant and stand alone treatment. An interesting article on that can be found here.

So regardless of whatever other resolution you may be making, or if you're just looking to burn off some of that Holiday Fruitcake, I suggest slipping on a pair of sneakers, and hitting the treadmill or sidewalk for 20-30 minutes a day.

Happy New Year!

Thanks!

A note to those who queried: I have learned that in order to blog, I must be in the appropriate "headspace." Suffice it to say that life has sent enough medical issues (amongst persons close to me) over the past few months, that there was insufficient room in the headspace for keeping up with a medical blog. I appreciate all of the encouragement and well wishes. I shall attempt to resume normal programming- which means blogging on an irregular basis; i.e. whenever I darn well feel like it!

Suicide Prevention Day

A couple of thoughts:

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

Why I lose sleep

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

Dear Doc,

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

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

Dear Doc,

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

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

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

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

I need a nap.

Music Update

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

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

Jacko fades to Blacko

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

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

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

To wit:

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

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

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

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

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

Indentured Servitude

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

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

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

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

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

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

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

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

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

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

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

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

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Some Thoughts:

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

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

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

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

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

Music Update

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

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

Musing for the Day

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

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.