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.

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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."

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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.