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.