Friday, December 30, 2005

Patch Adams

The meeting brought together some 9,000 psychologists, social workers and students, along with many of the world's most celebrated living therapists...
In the opening convocation, Dr. Hunter "Patch" Adams - the charismatic therapist played on screen by Robin Williams - displayed on a giant projection screen photos from around the world of burned children, starving children, diseased children, some lying in their own filth.
He called for a "last stand of loving care" to prevail over the misery in the world, its wars and "our fascistic government." Overcome by his own message, Dr. Adams eventually fell to the floor of the stage in tears.
Many in the audience of thousands were deeply moved; many others were bewildered. Some left the arena.

This guy is bizarre.

Tuesday, December 27, 2005

PTSD in Combat Veterans

There has been a dramatic increase in PTSD claims for Vietnam Veterans:
In the past five years, the number of veterans receiving compensation for the disorder commonly called PTSD has grown nearly seven times as fast as the number receiving benefits for disabilities in general, according to a report this year by the inspector general of the Department of Veterans Affairs. A total of 215,871 veterans received PTSD benefit payments last year at a cost of $4.3 billion, up from $1.7 billion in 1999 -- a jump of more than 150 percent.
Experts say the sharp increase does not begin to factor in the potential impact of the wars in Iraq and Afghanistan, because the increase is largely the result of Vietnam War vets seeking treatment decades after their combat experiences.

I recommend reading the whole article; there is a good discussion about the large number of Veterans who are not being treated for their PTSD, as well as a discussion about the financial implications of a diagnosis of PTSD for an individual Veteran sometimes leading to exaggeration of symptoms or an unwillingness to get well (which is often unconscious)

Sunday, December 18, 2005

Disclosure for Medical Bloggers

Dr. Hsien-Hsien Lei writes (via Shrinkette):
I encourage all science and health bloggers to write a post answering the following 10 questions posed by The National Center for Complementary and Alternative Medicine, part of the U.S. National Institutes of Health:
1. Who runs this site?

Michael Rack, MD
2. Who pays for the site?
The site is provided free by Blogger. I get about 15 cents a day from google adsense for this site and sleepdoctor combined. I often work on this site on "company time" (East Mississippi Medical Center)
3. What is the purpose of the site?
To provide medical information and commentary to doctors, medical students, and patients. I also publish this site to gratify my ego.
4. Where does the information come from?
Some of the info comes from what I learned in medical school, residency, and in my medical practice. Other information comes from various newspapers and industry publications.
5. What is the basis of the information?
See #4
6. How is the information selected?
I link to interesting articles I see on-line, often in the New York Times. I sometimes comment on what I read in other medical blogs.
7. How current is the information?
It is fairly up to date
8. How does the site choose links to other sites?
I try to link to reliable information- medical blogs with good reputations, notable newspapers.
9. What information about you does the site collect, and why?
I check google adsense several times a week to see how many visitors there are and how much money I have made.
10. How does the site manage interactions with visitors?
Visitors can leave comments to each post. I try to answer each serious comment. In the near future I will try to learn how to delete spam comments.

Theater owners want cell phones blocked

The UPI reports:
SANTA MONICA, Calif., Dec. 17 (UPI) -- The National Association of Theater Owners wants the Federal Communications Commission to allow the blocking of cell phone signals in theaters.
John Fithian, the president of the trade organization, told the Los Angeles Times theater owners "have to block rude behavior" as the industry tries to come up with ways to bring people back to the cinemas.
Fithian said his group would petition the FCC for permission to block cell phone signals within movie theaters.
Some theaters already have no cell phone policies and ask moviegoers to check their phones at the door, Fithian said.
The Cellular Telecommunications and Internet Association -- a Washington-based cell phone lobby that is also known as CTIA-the Wireless Association -- said it would fight any move to block cell phone signals.
"We're opposed to the use of any blocking technology, because it interferes with people's ability to use a wireless device in an emergency situation," CTIA spokesman Joseph Farren told the Times.

As a physician who does a combination of private practice, clinical research, and state hospital hospital work, I am on 24 hour/7 day a week call. This is very light call, and on most days I am not called at all. However, I need to be available pretty much all of the time. A policy such as the one the National Association of Theatre Owners proposes would make it more difficult for a physician in my position to lead a normal life.

Saturday, December 10, 2005

Get a Life

A man obsessed with Paris Hilton has created a holiday shrine to her:
See Paris Hilton in all her seductive splendor, striking a provocative pose for passing motorists and spreading hot Christmas cheer in a chilly Rhode Island winter.
Blown-up images of Hilton and strings of pink Christmas lights adorn the front lawn of a home in a middle-class neighborhood of this city, part of a head-turning holiday display that pays homage to the famed hotel heiress.
The over-the-top pictorial is the work of Joe Moretti, a 38-year-old designer who was arrested last year for trespassing on Martha Stewart's property in Maine.

From Dell News, via Snopes

Richard Pryor dies

Richard Pryor, the caustic yet perceptive actor-comedian who lived dangerously close to the edge both on stage and off, died Saturday. He was 65.
Pryor died shortly before 8 a.m. of a heart attack after being taken to a hospital from his home in the San Fernando Valley, said his business manager, Karen Finch. He had been ill for years with multiple sclerosis, a degenerative disease of the nervous system.

From the New York Times

Sunday, November 27, 2005

A Simple Solution to the Transplant Organ Shortage

thousands of people die each year awaiting organs for transplant. This organ shortage would be better addressed if ....organs of the deceased were routinely used, excluding only those from people who explicitly refuse to be donors, in contrast to the current system that requires donors to actively enlist.
From The Ethicist, New York Times

Sunday, November 20, 2005

A Disturbing Report about Abilify (Aripiprazole)

A recent study found that Abilify reduced symptoms such as aggression, hyperactivity, and impulsivity in 56% of 32 children with developmental disabilities.
Unfortunately weight gain occurred in all the children during the course of the study, and three discontinued the medication because of weight gain. The mean body mass index increased from 22.5 to 24.1 kg/m2 during the follow-up period.
This is the first report I have seen about Abilify causing weight gain. Abilify, along with Geodon, was supposed to be a weight-neutral antipsychotic. I find this study especially concerning because a large part of my practice is treating the devolpmentally disabled, the population treated in this study.

Tuesday, October 25, 2005

An Update on What I've Been Doing

Sorry about the lack of posts recently. I have been pretty busy. I left the U of MS on October 3rd. I started working at East Mississippi State Hospital ( 3 days a week) on October 4th. It's over 90 miles between my house in Jackson, MS and East Mississippi State Hospital in Meridian, MS. My new sleep clinic opens up November 1st. I still go to Boswell Regional Center several times per month.

Thursday, September 15, 2005

Malpractice Insurers Faulted

From the September 2005 issue of Cortlandt Forum
The nation’s 15 largest malpractice insurance carriers took in three times as much in premiums last year as they paid out in claims. And over the past five years, their premiums have doubled while their payouts have remained flat, according to a newly released study.
“Doctors have been overcharged for several years,” said Jay Angoff, a former Missouri insurance commissioner who conducted the study, which was based on the insurance companies’ own data. “The numbers underscore the need for tougher oversight to prevent profiteering,” adds Richard Blumenthal, Connecticut attorney general, who joined Angoff at the New York City press conference where the study was presented.
Angoff contrasted his data with those used by insurance companies to justify rate increases or lobby for caps on malpractice awards. “Their figures are largely estimated or are unverifiable or both. They’ve been off by up to 40%,” he said. Angoff’s data come from either the companies’ annual reports or filings with state authorities — “figures that haven’t been comprehensively analyzed before,” Angoff says. The companies include AIG, HCI, The Doctors Company, American Physicians Capital, GE Medical Protective, and Continental Casualty.
Angoff found that several insurers increased their premiums even though their claims payments actually fell, in some cases substantially. ProNational and Medical Assurance, both affiliates of the ProAssurance Corporation, as well as the AIG affiliate Lexington Insurance, were among the worst offenders. Medical Assurance, for example, increased its premiums 89% in 2004 even though its payments decreased by a third. The company paid out only 10 cents in claims for each premium dollar collected. ProNational paid out 13 cents and Lexington 14 cents.
“Perhaps most striking,” said Angoff, “in 2004, these 15 insurers increased their earned premium by 9.3%, even though the amount they estimated they would pay out in the future declined by 21.1%.”
The 25-page study, Falling Claims and Rising Premiums in the Medical Malpractice Insurance Industry, is available from the Center for Justice & Democracy in New York City (
www.centerjd/ANGOFFReport.pdf. Accessed August 15, 2005).

Friday, September 02, 2005

Mississippi Psychiatric Association Katrina site

Mississippi psychiatrists needed. See this new blog:

Quest for Gas (part 2)

For those 2-3 people out there who are curious, I was able to get a rental car today at the Jackson MS airport with a full tank of gas (call ahead if you are thinking of doing this, most of the agencies are out of cars and gas, and many cars have been reserved by FEMA).
Still no electricity.

APA backs same-sex civil marriages

From Psychiatric News:
The APA Board of Trustees took a historic step at its July meeting when it made APA the first medical specialty society to support legal recognition of same-sex civil marriage.
Such a position statement had been endorsed by the Assembly at its May meeting in Atlanta (Psychiatric News, June 17). It expands APA's existing position in support of same-sex civil unions and emphasizes the mental health consequences of denying same-sex couples the same legal rights as their heterosexual counterparts. The legal rights to which these couples do not have access can include visiting an ill partner in the hospital, making health care decisions for a disabled partner, financial and retirement planning to prepare for emergencies or a financially secure future, and, in the case of parents, being able to raise a child when the biological parent is unable.
The statement, which applies to civil and not religious marriage, notes that same-sex couples "experience several kinds of state-sanctioned discrimination that can adversely affect the stability of their relationships and their mental health." It also points out that "there is ample evidence that long-term spousal and family support enhances physical and mental health at all stages of development."

I'll leave it for others to comment on this as I don't want to jeopardize my current job or my 2 future jobs.

Thursday, September 01, 2005

Legendary jazz musicians missing

Fox News reports that several notable New Orleans musicians, including "Fats" Domino, are missing.

The Quest for Gas (Jackson, Mississippi)

This morning I got into a line for gasoline that was almost a quarter of a mile long. After going about 30 yards in 30 minutes, I left.
Most of the pumps have electricity now, the problem is a fuel shortage. Most of the gas stations in the Jackson area are out of gas. I heard that there is gas in Canton (about 20-30 miles north of Jackson), but I only have enough gas in the tank to drive 10-15 miles.
Earlier today, I thought that the easiest way to get gas might be to get a rental car with a full tank. I reserved a rental car at the local airport on-line, and even arranged a ride from a resident to pick it up tomorow morning. However, it turns out that the car rental companies are out of gas too.
Little work is being done today at the hospital. Everyone (including myself) is obsessed with electricity, gas, and ice. Some areas are starting to get electricity (not me), but the gas situation is not expected to get better until after the Labor Day holiday.

Wednesday, August 31, 2005

Mississippi has become a 3rd World Nation

In the aftermath of Katrina, most of Jackson, the capital of Mississippi, remains without power- see this article. Some of the gas stations have gas; some have the power necessary to run the pumps; only a few have both. As described here, lines at the few open gas stations are long. As bad as things are in the capital, it is even worse in outlying areas. Some rural areas in central Mississippi will not get electric power back for several months. As I have mentioned in previous posts, if a Mississippian is lucky enough to find an open store or gas station, he better have cash. Credit cards are not usually accepted- see here.
I feel bad about whining as plenty of people have it worse than me, especially those living to the south of me. But with the destroyed infrastructure, it is becoming increasingly difficult to function as a physician. With the power out, I have no way of doing laundry at home. Today, for the first time, I wore a t-shirt to work instead of a shirt with a collar. I guess I could ask a resident where they keep the scrubs. I run out of underwear and socks on Friday- at that point I will need to wash them in a bucket. Another option is sneaking my laundry into the hospital and using the washer on the psych ward.
I am on call (psychiatry attending call) Thursday. Since phone service is out, I will have to spend the night in the hospital to answer the pages (I am one of the few physicians in the country without a cell phone)
I have decided that tomorrow (Thursday) I will leave the hospital in the early afternoon to get gas. For anyone that is interested, I will post my adventure tomorrow night.
That's it for now. Sorry about the whining. Thanks to Dr. Parker for the plug. Read about the situation in Alabama here. Donate to the American Sleep Medicine Foundation Hurricane Disaster Relief Fund here.

Mississippi Katrina Update

It's a sunny, warm day here in Jackson, MS. The power is still out in most residential areas. Some gas stations are open, but lines are an hour long and it's cash only. ATM machines are down but most banks are reportedly open. My wife is planning to walk to AmSouth bank later on today to get money. I hope power comes back soon, I am running out of things to wear. Large fallen trees still block most of the streets that lead to my house.
The situation is much worse in southern Mississippi, Louisiana, and Alabama as described in this report. Good luck to those of you living on the Gulfcoast.

Tuesday, August 30, 2005

Katrina Report from Ground Zero

Power began to fail at noon yesterday in central Mississippi, and pretty much went out for good at 6pm. Today (tuesday) power is still out in most parts of central Mississippi, though as of noon today a few gas stations and large grocery stores in Jackson had power.
Trees are down all over my neighborhood.
At least 80 people are dead in Mississippi, most in southern parts of the state.
Interstate 20, running east-West between Jackson and Meridian, is basically clear- but make sure you have gas before starting the trip as none of the surrounding gas stations have power.
Here is a report of the condition in Hattiesburg, which is 90 miles south of Jackson, MS.
The University of Mississippi Medical Center is fully operational for clinical care, but nonessential personnel will not return until tomorrow.

Friday, August 26, 2005

Jet Lag

ATLANTA—Already hard hit by labor strife and escalating fuel costs, the commercial airline industry faces a new crisis: an epidemic of jet lag caused by a powerful strain that is highly resistant to regular remedies like catnaps.
Airlines have set up napping-triage centers in major airports in response to the "Super Lag," but are unable to keep up with the rising tide of severely weary passengers, who number in the thousands nationwide.
"Infected travelers are really tired out, whether they're on long international flights or domestic flights as short as an hour and a half," said Delta Airlines ticket agent Olivia Gage at Atlanta International Airport, which has seen some of the most advanced cases of Super Lag. "Our supplies of thin blankets and miniature pillows are running dangerously low."
FEMA, the Federal Exhaustion Management Association, has shipped army-surplus cots and urns of hot coffee to several major hubs, but airlines continue to report record dozings. Minneapolis resident Belinda Haynes, 26, is just one of tens of thousands of Americans whose travel plans are affected.
"I'm going to go to Tampa Bay and be asleep through most of my flight," Haynes said. "That means I'm at risk for catching Super Lag and being totally tired all through my sister's whole wedding."
At the Atlanta airport Tuesday afternoon, an estimated 900 Super Lag sufferers could be seen stretched across the molded seats of gate waiting areas. The infected travelers, distinguishable by their testy demeanors and heavy eyelids, argued with ticket agents, slumped listlessly in their seats, and stared blankly at Au Bon Pain pastry displays.
Untreated victims can find themselves sleeping for hours on a plane, then sleeping soundly at night, yet still performing poorly in important business meetings or feeling too fatigued to enjoy their vacations.
Dr. Robert Sanders is one of hundreds of volunteer physicians treating Super Lag sufferers at airports nationwide.
"Jet lag was first documented in the late '50s," Sanders said. "Over the years, we've developed band-aid solutions to combat the disorder—neck pillows, laptops, in-flight movies—but it was really only a matter of time before jet lag mutated into a more virulent strain."
Despite volunteer efforts, the burden of treating Super Lag sufferers has fallen largely on flight attendants who, with little training in this area, are reporting great difficulties.
"One passenger who sleeps through the beverage service and wakes up irritated and thirsty is bad," said Midwest Airlines flight attendant Sandy Wolchek. "You multiply that by five on a Milwaukee-to-Minneapolis flight, and you're talking about a serious disruption."
Prolonged rest is the only known remedy for Super Lag, according to Bill Ziegler of the Centers For Fatigue Control. "Victims can also alleviate their symptoms by wadding jackets or sweaters into makeshift pillows," he said. "And we're recommending that airlines loosen their restriction on reclining cabin seats during the ascent and descent phases of flights."
Scientists at the CFC are working around the clock to find a Super Lag cure, but so far, they have made little progress. For now, they recommend that air-travel passengers look out for Super Lag's warning signs: irritability, an unwillingness to engage in small talk with persons in adjoining seats, and a tendency to doze off while reading in-flight magazines.

From The Onion

Monday, August 22, 2005

Weight Loss Secrets

PURCHASE, NY—Joining a field already crowded with such non-caloric beverages as Coke Steam and Hollo Yello, PepsiCo announced the creation Monday of Pepsi Negative-220, a diet cola that burns twice the calories it contains. "You'll love PN-220 for the super-slimming rush of thyrotropin, PC1 enzymes, and that zesty hint of lemony leptin that zaps away fat, muscle tissue, and some nerve sheathing," PepsiCo spokesperson Ned Caen said. "But you'll drink it for that refreshing cola taste." Despite an FDA label warning of potential cardiac arrhythmia, renal shutdown, intestinal necrosis, and spontaneous erosion of the meninges, plans are underway to debut Pepsi Negative-220 in early October. "For radical and uncompromising weight loss, it's the cola," Caen said.
From The Onion

Thursday, August 18, 2005

Nobel Foundation Urged to Strip Lobotomy Prize

From the August 2005 edition of Psychiatric Annals (not, to my knowledge, available on-line):
Relatives of people who underwent lobotomies between the 1930's and 1970's are petitioning the Nobel Foundation to revoke the 1949 prize for medicine given to Egas Moniz, the Portugese neurologist who developed the procedure in 1936. A new book says that of the 50,000 people in the United States who underwent the procedure, only about 10% were helped. Family members have already asked the foundation to remove or revise an article on its Web site about Moniz and the procedure.

Wednesday, August 17, 2005

Doing Away With Tips

Effective September first, Per Se, one of the most highly rated Manhattan restaurants, is instituting a 20 percent service charge to all checks in lieu of a tip. The service charge will then be used by the restaurant to help pay all hourly employees -- kitchen staff, waiters, and busboys -- a flat hourly wage.
Management at Per Se doesn't seem particularly troubled by these concerns.
Chef Keller has said he instituted a service charge at one of his other restaurants, The French Laundry in Napa Valley, and it has gone well.
A spokesman for Per Se said the stable salary -- which also comes with benefits like vacation and health insurance -- would create a more professional environment and increase motivation. He also said the customers might find it convenient not having to contemplate a tip.

Instead of a service charge, why not just increase prices by 20% (and put up a sign eliminating tipping)

Saturday, August 06, 2005

Medicare Benzodiazepine Exclusion

Psychiatric News reports on the Medicare Benzodiazepine exclusion:
Last month APA praised Reps. Benjamin Cardin (D-Md.) and Jim Ramstad (R-Minn.) for co-sponsoring legislation that would reverse the exclusion of benzodiazepine medications from reimbursement under the new Medicare Part D drug benefit. The Medicare Modernization Act of 2003 (MMA) contained language that required that benzodiazepines be excluded from coverage by the new drug benefit, which begins January 1, 2006 (Psychiatric News, February 4). Psychiatrist Stevan Gressitt, M.D., founder of the Maine Benzodiazepine Study Group, told Psychiatric News during an interview for a previous article, "The alternatives really are grim. If these patients don't have access to benzodiazepines after January 2006, then they will most likely be switched to something that is covered—an SSRI or an atypical antipsychotic. Neither one of those would be my first choice for an elderly or disabled patient with multiple medical problems who is probably taking several other medications."
Dr. Gressitt's comments don't make sense. For an elderly patient, an SSRI is often a better choice than a benzo. Most psychiatrists try to avoid benzodiazepines in the elderly due to the cognitive side effects and the risk of falls.

Wednesday, July 13, 2005

Asthma Drug Withdrawal

The New York Times reports: A panel of lung experts is being convened today to advise the government on whether three popular asthma drugs should stay on the market or be withdrawn because of safety concerns.
The drugs are Advair and Serevent, made by GlaxoSmithKline, and Foradil, made by Novartis and sold in the United States by Schering Plough. Advair and Serevent contain the same drug, salmeterol; in Serevent, salmeterol is alone, while in Advair it is combined with another medicine. Foradil does not contain salmeterol; its active ingredient is formoterol.

Concerns have arisen about the three drugs, the Food and Drug Administration said, because in a small number of patients they "have been associated with severe asthma exacerbations."
It will be chaos in the asthma clinics if Advair is withdrawn from the market; most asthmatics at the U of MS asthma clinic are on it. Advair combines serevent with an inhaled steroid and is a convenient and effective treatment for asthma.

Sunday, July 10, 2005


A reader (MaryBeth) asks Why isn't SMOKING treated with the same intensive interventions as other addictive substances, like alcohol, drugs, food, . Why even the 12 step programs , don't include smoking, among them.Any information or thoughts on this is appreciated.
In my opinion, doctors do treat smoking intensively, at least from a medication standpoint. In the resident internal med clinic I work in, we ask patients about smoking status and offer medication treatment for cessation (Wellbutrin, nicotine patch, nicotine gum, etc). I think the reason that there are no 12 step programs for smoking is because it does not ruin the average smoker's life (at least not right away). Drug addicts and alcoholics often destroy their lives while still young- for example stealing to support a crack habit, drunk driving convictions, blackouts, financial devastation, divorce, etc. Most cigarette smokers remain productive members of society throughout the normal working years. Usually they don't develop lung cancer or severe COPD until they're older (this is a generalization, some smokers develop health problems at a younger age, some never do)

Sunday, July 03, 2005

Rising Medicaid Costs in Mississippi

Rising Medicaid Costs in Mississippi (and other states) are forcing a cut in benefits:
Starting Friday, most Medicaid recipients in Mississippi will be limited to five prescription drugs at a time, with no process for appeal. The cap appears to be the most restrictive in the nation, but is just one of many measures being taken by states seeking to rein in soaring Medicaid costs.
Obesity is one of the causes of rising Medicaid costs:
Mississippi's rate of obesity is not simply a matter of vanity or even of health — it's a fiscal crisis and a physical crisis for those carrying around a dangerous amount of weight.Mississippi has been identified as "ground zero" in the prevalence of obesity in the nation.The most recent U.S. Centers for Disease Control study ranked Mississippi No. 1 in obesity prevalence with an obesity rate of 26 percent.
The two major national obesity studies indicate that Mississippi spent $263 per capita or some $757 million annually on medical costs related to obesity — the 23rd highest amount in the nation.But because of Mississippi's poverty and high Medicare and Medicaid recipient populations, the more disturbing number indicated in the studies are the fact that the taxpayers are subsidizing an estimated annual $223 million in Medicare costs and $221 million in Medicaid costs that are attributable to obesity.That estimated $444 million annual taxpayer burden related to obesity in Mississippi includes direct health care costs in the Medicaid and Medicare programs. They manifest themselves in the high costs of treating diseases like Type II diabetes and other obesity-related health problems.
Over 1/4 of Mississippi adults are obese. Other contributors to poor health in Mississippi include high rates of poverty and smoking. The health status of poor Mississippians will worsen with the Medicaid cutbacks, which started several days ago. I will witness this from ground zero in the U of MS resident Internal Medicine clinic as a new academic year starts. I hope the new interns are up to the task.

Friday, July 01, 2005

Scientology Sucks

Other physician bloggers have been blogging about Scientology's/Cruise's attack on psychiatry. These Bloggers have been putting asterixes in the word Scientology to avoid detection by search engines. I have nothing new to say about Scientology, but I could use more readers so I left the asterixes out.

Infant Psychiatry

I saw this ad today in Psychiatric News:
INFANT PSYCHIATRY FELLOWSHIP. The Section of Child and Adolescent Psychiatry at Tulane University Health Sciences Center is seeking a full-time Fellow in Infant Psychiatry. This one or two year fellowship includes clinical and research experiences with the multidisciplinary Infant Mental Health group at Tulane. Completion of a fellowship in Child and Adolescent Psychiatry preferred. Faculty appointment at the Instructor level is possible. Applications will be accepted until a suitable qualified candidate is found. Applicants should send letter of interest, updated CV and list references to Charles Zeanah, MD, Vice Chair and Director of Child and Adolescent Psychiatry, 1440 Canal Street TB52, New Orleans, LA 70112. Interested eligible applicants may obtain further information regarding this position by contacting Dr. Zeanah at 504-988-5402 or Tulane is strongly committed to policies of non-discrimination and affirmative action in student admission and in employment.
I can't imagine trying to practice psychiatry with infants. They're too young for both meds and psychotherapy, though I guess their parents could be taught behavioral interventions. I'd be interested in knowing what an infant psychiatrist actually does.

Thursday, June 30, 2005

Why did Drudge Link This?

The Drudge Report links to the following news report about a 10 year-old girl being raped and impregnated by her step-father. Maybe I've been in psychiatry too long, but this story does not seem surprising or unusual to me. I've heard many stories from young and middle-aged adults of being sexually abused when they were children. I guess 10 is a little young to go through puberty and be biologically capable of being pregnant, but it' not unheard of. This story does not seem unusual enought to be newsworthy to me. Sexual abuse and rape happens to children all the time.

Wednesday, June 29, 2005

Congress attacks Tom Cruise

Tom Cruise’s erratic behavior on his recent worldwide publicity tour has been fodder for gossip columnists and late-night talk-show hosts for weeks, but now the movie star’s comments on mental-health issues last week are attracting serious criticism from members of Congress.Appearing on NBC’s “Today” show to promote his upcoming movie “War of the Worlds,” Cruise called psychiatry “a pseudoscience” and dismissed the effectiveness of antidepressants.The Congressional Mental Health Caucus this week criticized his remarks, saying that the celebrity has reinforced negative perceptions.“It is unfortunate that Tom Cruise has sought to use his celebrity to once again negatively reinforce the unfortunate stigma associated with mental illness,” said Rep. Grace Napolitano (D-Calif.), co-chair of the caucus. “Mr. Cruise is correct in saying that some of the drugs used to treat psychiatric disorders can be abused, but these same drugs have been beneficial to countless numbers of people who can now focus on their work in school or on the job.”Rep. Tim Murphy (R-Pa.), a psychologist and the other co-chair of the caucus, took issue with Cruise’s apparent belief that attitude adjustment alone can overcome mental illness.“If this was the case, mental illnesses would have been cured during the time of the Salem witch trials,” Murphy remarked.“Throughout history, various forms of attitude adjustment including torture, incarceration, relaxation techniques, bloodletting, ice water immersion, and hypnosis have been used to try to cure mental diseases and none have worked,” he continued. “By promoting such a theory, Cruise is providing a false hope that deters people from getting the help they need.”Rep. Patrick Kennedy (D-R.I.), who has long pushed for legislation to enhance mental-health services, labeled Cruise’s comments “irresponsible and counterproductive.” Kennedy said it was wrong to denigrate effective treatments at a time when “10 kids die every day from suicide as a result of untreated mental illnesses” and “when our businesses lose $31 billion per year in productivity as a result of depression alone.”Mental-health groups also have admonished Cruise. The American Psychiatric Association, the National Alliance for the Mentally Ill and the National Mental Health Association (NMHA) issued a joint statement last week: “Mental illnesses are real medical conditions that affect millions of Americans. … It is irresponsible for Mr. Cruise to use his movie publicity tour to promote his own ideological views and deter people with mental illness from getting the care they need.”Mental-health experts said that the statements by Cruise, because of his immense popularity, could lead some people to stop taking their prescribed antidepressants. Michael Faenza, president and CEO of the NMHA, said Cruise’s comments could even prevent some people from seeking help in the first place.The pharmaceutical industry is criticizing Cruise as well. Ken Johnson, senior vice president of Pharmaceutical Research and Manufacturers of America, said, “Actors should act, and highly skilled psychiatrists should treat patients. Cruise’s pronouncements fly in the face of science and effective treatment of a growing number of Americans who depend on medicines to lead normal, productive lives.”Cruise’s agent, Creative Artists Agency, referred a request for a response to the actor’s publicist, who did not comment by press time.Several members of Congress have dealt directly with tragedies related to mental illnesses. Senate Minority Leader Harry Reid (D-Nev.), Sen. Gordon Smith (R-Ore.) and Reps. Bart Stupak (D-Mich.) and Todd Tiahrt (R-Kan.) have lost family members to suicide, the ninth leading cause of death in the United States.Cruise has been active in politics, contributing thousands of dollars over the past decade to Democrats, including Sens. Barbara Boxer (Calif.), Hillary Rodham Clinton (N.Y.) and John Kerry (Mass.).Cruise’s remarks on the “Today” show, which were made in a testy exchange with host Matt Lauer, was the latest in a series of unusual publicity appearances.In contrast to his interview with Lauer, Cruise was jovial while appearing on “The Late Show with David Letterman” last week — even when Letterman indirectly asked Cruise about his earlier interview with Oprah Winfrey, where Cruise jumped up and down to describe his feelings for his fiancée, Katie Holmes.
From The Hill

Saturday, June 18, 2005

Heading for conference

Heading off for a conference (see sleepdoctor for details). Will be back on the 24th. Some parting thoughts...
Psychiatry is a unique specialty. At a major university hospital, every other specialty admits its own patients to the hospital. A psychiatry resident frequently has to make arrangements for a psych pt to be hospitalized somewhere else. No other type of resident does this.
Gotta run, running late for the airplane, will write more about the strangeness of psychiatry later.

Tuesday, June 14, 2005

In the Future, All Americans will be Fat

According to University of Missouri-Columbia biomedical researchers Frank Booth and Simon Lees, every U.S. child and adult will be obese by 2044 and 2058, respectively, if the current progressive rise continues.In a recent lecture, Booth cited statistics that demonstrated a three- to fourfold increase in the percentage of overweight U.S. children and adolescents since the mid-1980s. Booth believes the increase in obesity is because of an incompatibility between human genes and societal pressures. Human genes evolved to support a great deal of physical activity, yet in the last 20 years, physical activity has decreased dramatically in the United States, Booth said.
From the Clarion-Ledger

Monday, June 13, 2005

Vintage Ads

Received this email (you will have to cut and paste the links into your browser window):

thought you and your blog readers might be interested in this bit of medical humor (unintentionally so) from the past. Pete Vintage pharmaceutical ads This is a gallery of actual ads for pharmaceutical products from the 40’s to the 70s. Not a parody site but some of these drug ads are pretty funny. i.e., injectable whole opium from the juice of the poppy. Via Boing Boing
Pete Quily Adult ADD Coach

Friday, June 10, 2005

The Matrix and Teen Killers

Few films have achieved cult status as quickly as “The Matrix.” The lead character—a passive, unassuming young man—discovers that a malevolent system controls him and almost everyone else. He learns martial arts, then attacks and destroys the system and its allies.
Not surprisingly, “The Matrix” has a particular grip on adolescent and young adult males. For most, the film’s themes and special effects are simply entertainment. Others are drawn—and their concerns perhaps affirmed—by questions the film raises about reality and control over destiny. For a few, the film speaks to overpowering psychic pain.

19-year-old Josh Cooke of Oakton, VA, who murdered his parents with a 12-gauge shot gun, wore out his first copy of ‘The Matrix’ and got a second one.
Like “The Matrix” protagonist, destroying the system—and themselves—begins to seem like their only option. Add access to weapons, and you have a recipe for disaster.
The full article is available at Current Psychiatry

Wednesday, June 08, 2005

My Grandfather is my Father

Medpundit writes "Two Mothers/Two Aunts: If a woman conceives a baby thanks to her sister's ovary, is she the baby's mother or aunt? (Not to mention the question of the sister.) If this becomes popular, as the surgeon hopes it will, we'll need a new word for the mother/aunt combo. (Maunt?)"
If you have no difficulties conceptualizing this complicated family relationship, then you have what it takes to be a psychiatrist. Recently when I asked a new patient why she was coming to see me, she told me "My Grandfather is my Father" (The mother of the patient was sexually abused by her (the mother's) father). Psychiatrists are used to hearing complicated stories about incest and about step and half siblings molesting each other, as well as sexual abuse by step-parents and boyfriends. Sadly, it doesn't take me long anymore to understand how everyone is related.

Tuesday, June 07, 2005

Diagnosis of Darth Vader

Realspace writes (6/6/05) "Watching Star Wars 3 (much better than the first two), I couldn’t help the train of thoughts running through my mind: Paranoid delusions. Grandiosity. Impulsivity. Inflexibility in thinking. Black and white thinking. Anger management issues. Issues with authority figures. Tendency to aggression and violence. Ambivalence. Labile. Poor coping style. Difficulty with trust. Psychomotor agitation. Lack of insight. Query psychosis. Query antisocial personality disorder, possibly psychopathic. Query borderline personality disorder. At very high risk of PTSD, depression. Management? Likelihood of medication compliance? Need for involuntary treatment order? We’d need a lot of backup.."
I think Realspace is on the right track when he mentions the cluster B personality disorder diagnoses of antisocial personality disorder and borderline personality disorder, though I would vote for a diagnosis of narcissistic personality disorder (he has a grandiose sense of self-importance, is preoccupied with fantasies of unlimited power, believes that he is special and should only associate with other high-status people, requires excessive admiration, has a sense of entitlement, shows arrogance, and is often envious of others or believes that others are envious of him. He also lacks empathy, at least at the end of the movie). Anakin is very grandiose and believes that the jedi masters are envious of his power; at the same time he envies their postion on the jedi council. He wants the admiration of others and does not feel that he is getting due respect from the other Jedi. Anakin is preoccupied with power; near the end of the movie he talks about taking over the Galactic Empire from Palpatine.
I agree that he would have been at risk for developing depression and PTSD after he killed his wife and got burned, but there was no direct evidence for either of these diagnoses in the movie. I did not detect any true psychosis in Anakin/Vader.
Managment: he might have been a candidate for intensive psychodynamic therapy before he went to the dark side; after that he was essentially untreatable. Don't think any mediction would have helped. I don't think anyone is powerful enough to enforce an involuntary treatment order on Vader, and it can be hard to get an involuntary treatment order for an axis 2 diagnosis in many jurisdictions. He could have been imprisoned for killing the jedi younglings, but soon after he did this most of the police (jedi) were killed by order 66.

Shifting Costs from the states to the Federal Government

Academic medicine is one big shell game. Initially academic physicians are supported by the state, but as their career develops they are expected to get federal grants. We are expected to shift our support from the state taxpayer to the taxpayers of the USA as a whole.
Medicaid is a similar situation. For every $1 the state of Mississippi spends for Medicaid, it gets $3 from the US government. All the local Mississippi politicians treat this $3 as if it is free money, and don't consider the cost to this country and our sky-rocketing national debt.

Friday, June 03, 2005

Demoralization and Psychiatric Diagnosis

This week's issue of Psychiatric News has several articles on treating demoralization in medical patients dealing with significant illness.
One suggestion given in the article is:
Normalize the patient's distress. State to the patient, "I do not believe that you have a psychiatric disorder. You are someone coping normally with a hard situation. Almost anyone would feel as badly as you are feeling in this situation."
It makes it kind of hard for a consultant psychiatrist (or any psychiatrist) to bill for his services if he doesn't give the patient a psychiatric diagnosis. This leads to overdiagnosis and pathologization of normal human conditions.

Friday, May 06, 2005

What it's like to be a physician

Red State Moron (May 5) blogs about a program to help pre-meds determine if they are cut out to be a physician:
So Santa Clara University is helping its students determine whether they're cut out for it early, long before they even enter medical school. Pre-med students who land a much-coveted spot in a special university program shadow doctors, nurses, social workers, chaplains and business administrators at San Jose's O'Connor Hospital for the better part of an academic year.
They see births. And deaths. They learn how to remove a catheter and burp a baby. They watch the calming bedside manner of chaplains during a patient's final hours, and discuss how hospitals can keep financially afloat when caring for many uninsured and under-insured patients.

Being a physician isn't so bad. The money is good, usally at least $2000 annual salary per hours worked in a typical week (40 hours per week= at least 80,000, 60 hours per week = at least $120,000). The job can be stressful at times, but it's probably less stressful than working for minimum wage at McDonalds. There's a lot of flexibility; administrative positions are possibilities for those who don't like seeing patients all day.
Being a physician is easy, it's becoming a physician that sucks. What these pre-meds need to learn is what it's like to accumulate $150,000 of debt during med school, and then watch the interest on the debt build up during residency. What it's like to work eighty hours per week during residency (when I was a Med/psych resident, there were some medicine rotations that I worked 110 hours per week on, but there are now strict caps on hours). They need to learn what it's like to spend thousands on board exams and board review courses.
The pre-meds should shadow surgery interns and see the crap they have to put up with. The program should have these pre-meds hold retractors for 6 hours during surgery and then have an attending yell at them for no apparent reason.
Being a fully trained physician is great. Being a med student or resident sucks. Med school and residency are long hours during the best years of your life.
I like being a doctor. I don't like the price I had to pay to get here. I don't know if I would do it all over again.

Saturday, April 23, 2005


The New York Times Magazine has a good article about autopsies.
The rate of autopsies has declined markedly in the last 40 years, partly due to economic pressures:
Hospitals say the problem is money. An autopsy can cost from $2,000 to $4,000, and insurance won't cover it. Most patient families blanch if asked to pay for it, and many can't afford to after paying medical and funeral bills. So the hospital gets the tab. For most of the postwar period up to 1970, hospitals generally paid it, essentially because they had to: the Joint Commission on Accreditation of Healthcare Organizations required hospitals to maintain autopsy rates of at least 20 percent (25 percent for teaching hospitals), which, then and now, is the rate most advocates say is the minimum for monitoring diagnostic and hospital error. The commission eliminated that requirement in 1970. Lundberg says that this happened because hospitals, which had already allowed the rate to drop to close to 20 percent since its 1950's high of about 50 percent, wanted to let it drop further and pressured the commission. The commission's current president, Dr. Dennis S. O'Leary, says it eliminated the standard because too many hospitals were doing poor autopsies -- and often only the cheapest, simplest ones -- just to make the quota. In any event, few hospitals have paid for autopsies since then. Money is too scarce, they say, the needs of living patients too great.
Improvements in medical technology have not eliminated the need for autopsies:
Perhaps the most troubling reason for the decline of the autopsy is the overconfidence that doctors -- and patients -- have in M.R.I.'s and other high-tech diagnostic technologies. Bill Pellan of the Pinellas County medical examiner's office says: ''We get this all the time. The doctor will get our report and call and say: 'But there can't be a lacerated aorta. We did a whole set of scans.' We have to remind him we held the heart in our hands.'' In fact, advanced diagnostic tools do miss critical problems and actually produce more false-negative diagnoses than older methods, probably because doctors accept results too readily. One study of diagnostic errors made from 1959 to 1989 (the period that brought us CAT scans, M.R.I.'s and many other high-tech diagnostics) found that while false-positive diagnoses remained about 10 percent during that time, false-negative diagnoses -- that is, when a condition is erroneously ruled out -- rose from 24 percent to 34 percent. Another study found that errors occur at the same rate regardless of whether sophisticated diagnostic tools are used. Yet doctors routinely dismiss possible diagnoses because high-tech tools show negative results. One of my own family doctors told me that he rarely asks for an autopsy because ''with M.R.I.'s and CAT scans and everything else, we usually know why they died.''
The bottom-line is that autopsies, though useful for quality control and for the detection of emerging pathogens, will not make a comeback unless 1) Medicare directly pays for each autopsy done or 2) the Joint Commission or Medicare requires a certain autopsy rate for hospitals.

Tuesday, April 19, 2005

Bankruptcy Reform (a comparison of doctors and lawyers)

An article at talks about the bankruptcy reform legislation recently passed by Congress. An interesting part of the article mentions the probable effect of the legislation on bankruptcy lawyers:
Ehrenberg sees another change in the new bankruptcy law that could affect women. Attorneys will now be liable for inaccuracies in a debtor's bankruptcy papers."They're going to have to investigate their own clients," he says. "It's widely believed in the bankruptcy community that many attorneys who provide moderate-cost legal services will pull out because they can't afford to do the case for that amount of liability for the same price. It would not be surprising that women would be adversely affected by not being able to find affordable legal representation."
So for bankruptcy lawyers who provide services to poor/lower middle class clients, the liability may outweigh the payment received for the services. Sounds similar to the situation that doctors who see Medicaid/uninsured patients are in. Of course, most doctors continue to provide these services, at least on a limited basis. It will be interesting to see if the lawyers do.

Friday, April 15, 2005

Teaching Psychotherapy

Ten things to avoid when teaching psychotherapy (from an interview with Dr. Glabbard in Psychiatric News).

Teach psychotherapy as though it is isolated from the rest of psychiatry
Use "straw man" arguments to denigrate psychotherapeutic approaches that are different from your own
Teach psychotherapy as a discipline that demands theoretical purity rather than creative eclecticism
Assign nonpsychiatrist faculty to teach psychotherapy to residents
Avoid illustrating theory with clinical examples
Avoid letting them see you sweat
Teach professional boundary issues and ethics as rigid rules isolated from clinical struggles
Ignore all psychotherapy research
Worship at the altar of evidence-based therapies
Protect residents from the "dirty business" of patient fees

Most psychiatry residency programs are guilty of using psychologists and social workers to teach residents psychotherapy.

Tuesday, April 12, 2005

Tips on Preparing a Living Will

A living will is a legal document that provides directives for your medical care in the event that you are physically unable to express them. Here are some things to keep in mind while creating a living will:
Specify which flavor of feeding-tube nutrient you prefer. Otherwise, you may get stuck with cream of mushroom day in and day out.
Leave at least one reasonably flattering photo for the press. This point cannot be emphasized enough.
Explain in no uncertain terms that, should you die and return as a zombie, loved ones must shoot you in the head without hesitation.
Research medical life-support technology and specify whether you'd prefer to be hooked up to a Danninger Continuous Passive Motion device, an Emerson suction unit, or a Slushee machine.
Comatose people have been shown to exhibit a brainstem-level response to music, so prepare a decade's worth of mix tapes in advance.
A living will is a great way to meet a notary public, if notaries public are your thing.
A health-care agent is the person assigned to make your medical decisions in the event you are unable to. A talented, aggressive health-care agent will score you the absolute best medical care available, but will charge you a 15- to 20-percent commission.
Telling your friends while you're drunk that it would suck to be on life support doesn't constitute a living will. Make sure to write it on the back of a coaster.

From the Onion, with some of the more tasteless tips edited out.

Friday, April 08, 2005

Repeat Residency Training??

A letter to the editor in Medical Economics states:
"I believe most of us are under the impression that organizations that oversee professional behavior are extremely reluctant to take genuine disciplinary actions. While I agree that only substantiated charges should be made public, I'd like to see stronger punishment than a meaningless letter of censure, yet less than revoking a license. Perhaps physicians could be required to repeat residency training to re-establish their skills."
I would rather lose my medical license than to repeat residency.

Thursday, April 07, 2005

Peer Review

Does peer review of submissions to journals work?? Slate discusses the lack of evidence for peer review.

Wednesday, April 06, 2005

Physician of the Year

Kevin, MD writes about the Republican "Physician of the Year" award, which is discussed in this article. Basically, by donating money to the National Republican Congressional Committee, a doctor can become a "Physician of the Year." It is not an award of merit, but a reward for party donors.
Last year I donated some money to the Republicans. This year I got the same fax as in the article, except that they wanted a little more than $1,250 from me (I decided not to pay for the award). It's pretty obvious that this is not a genuine award for merit. The article mentions that "on the Internet, ABC News found physicians across the country doing just that — listing NRCC's Physician of the Year among their honors and credentials." It's fine to donate money to a political party that you believe in. I have nothing against the Republican party for offering this "award" to their physician donors. But any physician who would list this phoney award on his CV is pathetic. The fault in this case lies not with the Republican party, but with dishonest physicians. To reiterate, there is nothing wrong with having a "Physician of the Year" plaque hanging in your home to demonstrate your loyalty to the Republican party, but to list this on your CV among your credentials is unprofessional and in my opinion any physician who does this should be investigated by their state medical board for unprofessional behavior.

Friday, April 01, 2005

Problems with the Mental Status Exam

A letter in Psychiatric News discusses the problems with the mental status examination:

The MSE, often characterized as psychiatry's equivalent of the physical exam, is in fact a mixture of historical information, observations, and conclusions. "Thought process" is known from examination, but what we describe as "thought content" is history—phobias, compulsive behavior, and suicide ideation, for example. Hallucinations occurring at the time of the examination are "current mental state"; yesterday's hallucinations are history. "Judgment" is an evaluation.

The MSE is flawed because of a lack of agreement about the meaning of some of the terms. "Mood" and "affect" are often confounded. "Orientation to person" refers to the patient's awareness of his or her own identity, but some take it to mean recognition of the examiner, while "orientation to situation" is not a standard question. "Judgment" may reflect the patient's answers to test questions, or it may reflect recent conduct, such as fighting with a police officer or giving money to a con man. Some describe a patient as having impaired judgment if he or she has a drug habit or stops taking prescribed medication.

Note to medical students: the mental status examination is an examination of the patient's complete mental state, including mood, organization of thoughts, abnormal perceptions (hallucinations), cognition, etc. This is different from the Folstein Mini-mental status exam, which is a 30 point scale that measures only cognition.

Tuesday, March 22, 2005

Medicine/Psychiatry Combined Residencies

Looking over the match results from the last several years, it appears that the combined 5-year Internal Medicine/Psychiatry combined residency is slowly dying off (with a brief rebound in 2003):

////// Positions offered////// #filled US grads ///// #filled total

2001 /////41 ///////////////////////// 19 ////////////////// 23
2002 /////32 ////////////////////////// 14 /////////////////// 22
2003 /////31 ////////////////////////// 19 ///////////////////// 24
2004 /////26 ////////////////////////// 14 /////////////////////// 18
2005///// 23 ////////////////////////// 12 ////////////////////////// 17

This 5-year program combines the training of the 3-year internal medicine residency and the 4-year psychiatry residency. I think that the main reason that this residency program is shrinking is that the extra 1-2 years of training do not increase a doctor's income. It is hard to keep up in both specialities; most graduates end up practicing only one of the specialities. Previously many Med/Psych doctors did inpatient consultation psychiatry, but with the new Psychiatric subspeciality of Psychosomatic medicine, completing a med/psych residency no longer offers much of an advantage in this field.

Thursday, March 17, 2005

SleepDoctor blog

Medlogs is taking a long time to list my new blog, so I thought that I would announce it this way, through my old blog.
Check out SleepDoctor.


Wednesday, February 02, 2005

A Soldier with Sleep Apnea

An interesting case of obstructive sleep apnea was reported in yesterday's newspapers. Unless this soldier's sleep disorder suddenly worsened for some reason (e.g., weight gain), it's hard to imagine how he functioned in the military:
Sleepy soldier may be problem at trial
By ESTES THOMPSON, Associated PressFebruary 1, 2005
FORT BRAGG, N.C. - If a soldier accused of killing two officers in a grenade attack in Kuwait doesn't get help for his sleep apnea, he may not be able to stay awake enough to participate in the defense at his trial, his attorney said Monday.
Sgt. Hasan Akbar of the 101st Airborne Division stayed awake during a 45-minute hearing Monday, responding to several questions with, "Yes, your honor." But his drowsiness at previous proceedings prompted the judge to order treatment for a breathing condition that impedes sleep.
Defense lawyer Maj. David Coombs said Akbar continues to be plagued by problems and if a visit to his original doctor doesn't help, more extensive studies will be requested to determine "why he may have sleep apnea. ... It has been a consistent problem."
With Akbar's court-martial set for April, Coombs also asked military judge Col. Stephen Henley to make coffee available at the defense table and to order a break after every witness.
Henley said he was willing to consider special measures to keep Akbar awake but denied the request for a break after each witness. He said he also would consider allowing someone to sit next to Akbar during the trial to try to keep him awake, if the defense makes such a request.
Henley also ordered that Akbar be given an additional medical evaluation at Fort Knox, Ky., where he is being held while awaiting trial.
The 101st is based at Fort Campbell, Ky., but Akbar's trial is being held at Fort Bragg, where the 101st's higher command, the 18th Airborne Corps, has its headquarters.
If the medical evaluation does not resolve Akbar's problems, extensive neurological studies may be needed, the defense said.
Defense lawyers have said they intend to present an insanity defense, and the April trial date was a delay, intended to give them time to gather evidence.
Henley already has ruled that Akbar's statement acknowledging that he rolled grenades into tents at Camp Pennsylvania, Kuwait, will be admissible at his court-martial. The judge excluded statements Akbar made to two sergeants who guarded him after the attack, saying Akbar had not yet been informed of his legal rights.
Akbar, 33, is accused of stealing the grenades from a Humvee and initiating the attack on fellow members of the 101st just days into the March 2003 invasion of Iraq. Killed were Army Capt. Christopher Seifert, 27, and Air Force Maj. Gregory Stone, 40. Another 14 soldiers were injured.
If convicted of two counts of premeditated murder and three counts of attempted premeditated murder, the 33-year-old Akbar could get the death penalty.
The case marks the first time since the Vietnam War that an Army soldier has been prosecuted for the murder or attempted murder of another soldier during wartime.

Like Chocolate and Peanut Butter...

Some things just seem to go together: popcorn and the movies, a hot dog at the ball park, loud music while cruising down the interstate at 2am...
It seems that some feel that alcohol and caffeine go together:
BE Addicted?
Caffeine addicts are toasting Anheuser-Busch's latest invention — a beer infused with caffeine, guarana and ginseng. The new beer, BE (pronounced B to the E) has 59mg. of caffeine for each 10 oz. can. To put that in perspective, a can of Red Bull has 80 mg and an 8 oz. coffee has averages about 110 mg. Is adding caffeine to beer or other alcoholic beverages a good thing? We contacted several sleep experts and no one could state any benefit. Some expressed concern that adding caffeine might keep a person awake and drinking more instead of falling asleep or passing out. An added concern is that the caffeine might give a person a false sense of confidence and encourage drunk driving

From the National Sleep Foundation

Friday, January 28, 2005

Hopefully we don't act like this

ROCHESTER, MN—Dr. Erich Stellbrach, a general practitioner at the Mayo Clinic, could barely contain his exhilaration Monday upon discovering that patient Oliver Patterson, 54, has the extremely rare degenerative nerve disease Gertsmann-Straussler-Scheinker syndrome. "Mr. Patterson, I'm so sorry to tell you this, but you have—you're not going to believe it—spinocerebellar ataxia!" Stellbrach said, waving an x-ray of Patterson's spinal cord. "It afflicts only one in 2.9 million people!" Stellbrach recommended Patterson begin aggressive treatment to mitigate his impending brain dysfunction and onset of dementia, and made the patient promise to remain in his care.
from The Onion

Wednesday, January 26, 2005

Sleepy Drivers

From the National Sleep Foundation:
Massachusetts Senator Richard Moore, D-Uxbridge, sponsored a bill that would make it illegal to fall asleep while driving. The charge would carry the same penalties as drunken driving. If the bill is passed, Massachusetts would join the ranks of Maggie's Law in New Jersey, the only state to currently enforce a law against drowsy driving.

Tuesday, January 25, 2005

Grand Rounds Eighteen

Grand Rounds Eighteen is now up at Cut to Cure.

Pediatric sleep apnea

Treatment of pediatric obstructive sleep apnea with adenotonsillectomy improves behavior and quality of life:
NEW YORK (Reuters Health) Jan 17 - Children with obstructive sleep apnea (OSA) are at increased risk for behavioral and emotional difficulties, but tonsillectomy/adenoidectomy can improve both these problems as well as quality of life, new research shows.
The findings are based on a study of 42 children with OSA who underwent tonsillectomy and adenoidectomy and 41 control children with no snoring who underwent unrelated elective surgery. Behavioral and quality of life measures were assessed before and 3 months after surgery.
Dr. Nira A. Goldstein and colleagues, from SUNY Downstate Medical Center in New York, report their findings in the Archives of Otolaryngology-Head and Neck Surgery.
As noted, baseline behavioral scores were worse for children in the OSA group than for controls. However, following surgery, the former group experienced a significant improvement in scores (p = 0.009) compared with the latter group, whose scores tended to deteriorate.
Moreover, quality of life scores, both overall and in individual domains, improved significantly in OSA patients compared with controls.
"This study provides further evidence that behavioral and emotional problems are present in children with OSA and improve after treatment," Dr. Goldstein's team notes. "Additional work is needed to define the precise spectrum of behavioral abnormalities, to elucidate their pathophysiologic mechanism, and to provide diagnostic clues to facilitate their early recognition."
Arch Otolaryngol Head Neck Surg 2005;131:52-57.

Sunday, January 23, 2005

I want this job

From Fox News:
ALBANY, N.Y. — Pat Freund has a job most people would envy. She spends her days at work reading the newspaper and finishing crossword puzzles, and earns about $100,000 a year for her troubles, including benefits.
But Freund isn't content to put up her feet and watch the paychecks roll in. Rather, she is suing her employer, the state of New York, for not giving her any real work to do.
"It could have been a lot easier for Pat had she continued to sit in her office and do nothing, and continue to basically be the most avid reader that the state has employed," says Sue Adler, the attorney representing Freund in her federal civil rights lawsuit. "But she decided that was not how she wanted to live out her years working for the state."
Freund, who has been a New York State Liquor Authority (
search) employee for 25 years, says it all started in 2000. She believes her superiors were angered after she questioned the practice of colleagues attending Gov. George Pataki's (search) annual prayer breakfast. But instead of firing her, Freund says, her responsibilities were taken away.
Now Freund does nothing at work, on the taxpayers' dime.

Mike Causey (search) of Federal News Radio has examined government employment issues for more than 20 years, and says the same protections that make it difficult to fire government workers sometimes backfire.
"People say that they're [employers] either trying to drive them out one way or the other, and one of the ways to do it is to give them nothing to do," Causey says.
When asked about the lawsuit, the Liquor Authority said it was policy not to comment on pending litigation. So until a trial, Freund will most likely continue to do nothing at work.

Johnny Carson Dead

WASHINGTON (Reuters) - Legendary television entertainer Johnny Carson has died of emphysema at age 79, the NBC television network reported on its Web site on Sunday.
Carson hosted NBC's popular "The Tonight Show" for nearly 30 years, long dominating late-night television with an estimated 12 million viewers each night. He did his final show on Friday, May 22, 1992, seen by 55 million, and was replaced the next Monday by the current host, Jay Leno.
Sidekick Ed McMahon introduced him nightly with the rallying cry of "Heeeeeeere's Johnny!" Carson's blend of humor, music and conversation was the last thing millions of Americans heard before drifting off to sleep.
"I am one of the lucky people in the world. I have found something I liked to do, and I have enjoyed every single minute of it," a teary-eyed Carson said as he closed the show for the last time. "I bid you a very heartfelt goodnight."
In later years, Carson became something of a recluse in his Malibu, California, home, rarely venturing into the public eye.
After a 1999 quadruple bypass heart operation, Carson cut back on his tennis and discontinued his annual treks to Africa, the French Riviera and the Wimbledon tennis tournament. He had battled emphysema for years.

Health care workers needed

A rather poorly written article in the New York Times discusses the shortage of medical clerical workers in the New York region:
the New York region is confronting an acute shortage of physician assistants and clerical workers at the entry level in medicine, according to government labor statistics and industry executives.
Although many see the demand as positive, they also see a downside. The situation may provide ample opportunity for jobs, some experts say, but medical assistant and record-keeping work may lead to few, if any, chances for advancement because of rigorous training and licensing requirements.

Maritza Rodriguez of Manhattan, a 42-year-old divorced mother of two, had worked at clerical jobs in offices and in retail customer service before completing a 10-week course in medical billing and record keeping in October. She said she immediately found jobs with two doctors, splitting her workweek between Brooklyn and Manhattan. "There is so much demand," said Ms. Rodriguez, who said she rarely logged more than 40 hours a week total and expected to make more than $50,000 this year, also receiving health care benefits.
This isn't the greatest of articles; it combines discussion of 2 distantly related fields- physician assistants and medical clerical workers. And I fail to see how a career in which someone can earn $50,000 a year after a 10-week course offers "..few, if any, chances for advancement.." I think the New York Times dropped the ball with this article; I don't think the reporter fully understood what she was writing about.

Saturday, January 22, 2005

Reminyl and Safety Concerns

The New York Times reports on new safety concerns regarding Reminyl, a medication for Alzheimer's disease:
In the trials, which lasted two years, 15 patients taking Reminyl died compared with 5 taking the placebo. There were various causes of death but many were from heart attacks and strokes, a company spokeswoman, Carol Goodrich, said.
The announcement comes at a time of heightened concern over the safety of widely used drugs after the withdrawal from the market of
Merck's pain reliever, Vioxx, which studies indicated posed an increased risk of heart attacks and strokes.
Johnson & Johnson said that overall number of deaths in the trials was low for the elderly population in the trial and that the incidence of serious side effects was the same for patients getting the drug and the placebo. Also, it said, the investigators in the trials had not thought the drug caused any of the deaths.

Isn't it ironic?

ROME (Reuters) - An Italian pensioner committed suicide after his wife fell into a coma, but just hours after he killed himself the woman woke up, Italian media has reported.
Recalling the end of "Romeo and Juliet", the 70-year-old man, Ettore, who had sat by his wife's bedside for four months after she slipped into a coma following a heart attack, finally gave up hope and gassed himself in the garage of his family home.
Less than a day later, his wife, Rossana, woke up in her hospital bed in Padua and immediately asked for him.
The northern town of Padua lies just 60 km (40 miles) from Verona, where star-crossed lover Romeo killed himself believing Juliet to have died. But minutes later Juliet woke up and seeing Romeo dead, stabbed herself.


Shrinkette posts today on the world of nurses.
Nurses do a very important job- they are the ones on the front lines, actually caring for the patients. When a psychiatrist writes an order for a haldol injection for an out-of-control patient, its a nurse who actually gives the shot while the psychiatrist is safe behind locked doors. Unfortunately, nurses have increasing amounts of administrative work to do. Nurses today spend too much of their time (like doctors) writing in charts instead of providing direct patient care. If it's not written in the chart it didn't happen. Nurses often have too many patients to care for and patients suffer because of it. I have seen many instances of patients having prolonged waits for prn (as needed) meds such as pain meds because their overworked nurse was busy charting.

Friday, January 21, 2005

New Psychiatric Diagnosis

From Psychiatric News:
Paul Chodoff, M.D.
Washington, D.C.
I would like to suggest a new diagnostic entity for DSM-V. The diagnosis is "the human condition." Diagnostic criteria would be any combination of the following:
For children: (1) distractability, (2) being fidgety, (3) disobedience, (4) disliking school. For adults: (1) unhappiness, (2) nervousness, (3) shyness, (4) dissatisfaction with one's looks, (5) dissatisfaction with one's sexual performance, (6) getting angry, (7) playing the horses, (8) getting upset when things go wrong, (9) preferring one's own company, (10) showing off, and (11) orderliness.
The advantages of this diagnosis are that it would facilitate insurance reimbursement, dispose of the bothersome problem of comorbidity, and encourage the quest for a drug to cure the disorder of being human.

Thursday, January 20, 2005

Psychologist Prescribing

I was looking through some old journals and found this letter in the October 2004 Clinical Psychiatry News:
I continue to be amazed that psychiatrists are so up in arms about having psychologists prescribe medications after added training in psychopharmacology (“Prescribing Law in Louisiana Rankles Psychiatrists,” July 2004, p. 1 ).
We have no one to blame but ourselves. For years we have been content to give away our reflex hammers and stethoscopes for a prescription pad, and now we wonder why we are not heard when we invoke that we are medical doctors. We now even claim that monitoring blood work on atypical antipsychotics puts us in the domain of primary care. I teach residents who all too soon forget the basics of medicine and then feel uncomfortable about treating even simple medical problems.
Before we become more defensive, maybe we need to look at our own houses first. Why not reintroduce the 1-year medicine requirement into our residencies and continue to make our residents and attendings handle medical problems in their patients? If we do this, then we can state that we are qualified to prescribe where psychologists are not. Until then, we will continue to lose one state after another and we will have only one another to blame.
John Norton, M.D.Jackson, Miss.-->

The letter was written by one of my colleagues, a neurologist/psychiatrist at the U of MS Medical Center. I agree with him that psychiatry residents need more internal medicine training. I think that an ideal internship for neurology and psychiatry interns would consist of 8 months of internal medicine, 2 months of neurology, and 2 months of psychiatry. Currently most psychiatry interns only receive 4 months of internal medicine experience during their internship.

Plavix vs. Aspirin

The New York Times reports on a study comparing aspirin plus Nexium to Plavix:
Patients taking Plavix, a popular and expensive antistroke drug, experience more than 12 times as many ulcers as patients who take aspirin plus a heartburn pill, a study to be published today in The New England Journal of Medicine found.
This study was not a fair comparison of Plavix vs aspirin, since the Plavix group did not get a "heartburn pill":
Rob Hutchison, a spokesman for Bristol-Myers, said that the study did not directly compare aspirin and Plavix. Instead, the difference in ulcers could be entirely a result of the heartburn pill, which has long been known to prevent ulcers. He said the study should have included a group of patients who got Plavix plus a heartburn pill.
Both Plavix and aspirin are antiplatelet agents that are use to prevent heart attacks and strokes. Plavix costs several dollars per pill, while aspirin costs pennies. They are approximately equally effective in preventing heart attacks and strokes, though each has advantages in certain situations. When an antiplatelet agent is necessary, I usually start off with aspirin at a dose of 81-325 mg per day. Sometimes I add Plavix to aspirin (for example, in patients with recent cardiac stents). I rarely use Plavix instead of aspirin- the only situation in which I would commonly do this is in patients with a history of a serious allergic reaction to aspirin.
I haven't had too many difficulties with patients developing ulcers or GI bleeding on aspirin (unless they are also taking an NSAID such as ibuprofen/aleve). I question the main premise of this study- that many doctors are prescribing Plavix because they feel it is safer from a GI standpoint. I have never prescribed Plavix soley for this reason. I'm interested in hearing from anyone with experience in this area: have you prescribed Plavix instead of aspirin due to the past perceived GI safety of Plavix??

Wednesday, January 19, 2005

Med Blog Spam

The following was e-mailed to many of the med blogs. Since I have nothing else I wish to post about today, I am posting the e-mail. Feel free to debunk it in the comments section.

DOD'S ANTHRAX VACCINE IS CAUSAL FACTOR OF GULF WAR SYNDROME OR GULF WAR ILLNESS"Vaccine-A" by Gary MatsumotoDear Elite Minds of the Blogosphere:We could greatly use your assistance in a matter of utmost urgency. And no thisis not another Nigerian 419 scam. Trust Me! :--). In my day job (paid) I'm acop (actually detective).The Homeland Security Polity Institute Group (HSPIG - isinterested in all things WMD including bioterrorism its agents and defenses. "Vaccine-A" a new book by Gary Matsumoto, a well-respected investigativejournalist, caught our attention. Matsumoto is reporting that the DOD's anthraxvaccine is the causal agent for Gulf War Syndrome or Illness (Autoimmuneresponse and disorder). This is a complex medical mystery thriller thatunfortunately is not fiction. Matsumoto is reporting direct forensic evidence(smoking gun)exists to conclude the vaccine is the causal agent.The vaccine adjuvant, squalene, was found in lots of this vaccine known to causeGWS. Squalene is a known immulogoically active agent. The key evidence issqualene antibodies has been identified in GWS victims' blood and not in controlgroups. Evidence suggests that squalene was used as emulsion "carrier" agent innew recombinant vaccine. However DOD may have knowingly used squalene secretlyfor its immune "boost" to make their recombinant anthrax more active. Withoutthis "boost" the new recombinant vaccine takes 5 or 6 doses to give anyimmunity. Mucho bucks spent to develop this "pure" vaccine only to ?fizzle.? It appearssmall factions within DOD's USAMRIID "Lil Shoppe of Horrors", the NIH, andFerengi pharma capitalists have run amuck pursuing "utilitarian" ethics in questfor personal fame and wealth.Problem is body's immune system "tolerance" factor - too little squalene noimmune boost - too much generates squalene antibodies that indiscriminatelyattack both "foreign" and the body's own "sequestered" squalene in cellularwalls. When this happens, cells are gutted causing a whole cluster ofautoimmune related disorders as seen in GWS. See groundbreaking work by Dr.Robert Parry and Dr. Pamela Asa. (Attached zipped file with two research papersas PDFs)My wife who is a Dr. of PH, MPH and OTR, teaches medical ethics and has taughtbioterrorism preparedness for healthcare professionals. She has spoken withMatsumoto and Dr. Asa for many hours and finds them to be very credible,ethical, methodical, meticulous researches. Dr. Asa was involved in the siliconbreast implant litigation and mad the cross connection with GWS. Dr. Asa isalso "off the grid." She is not on Uncle Sam's payroll and her research is notfederally funded. HSPIG over the last several weeks has attempted to break this story into theBlogos to fact check and report this story to the American people who then candecide what is the truth and/or fiction.Please exam the info below and consider this a research question to bechallenged. This is your quadrant area of the collective human consciousness ofthe Blogos. Please share this info with your colleagues Please visit ourforums section for updates and further information under "vaccine area": you can visit Matsumoto's discussion board at:www.vaccine-a.comIf you decide what Matsumoto and Dr. Asa and others are saying is the truth thenyou need to hold your governmental, public health researchers, and industrycolleagues accountable for their total disregard of medical ethics.HSPIG is also tracking information that this vaccine technology has been used ina clinical vaccine trial in young children that resulted in injuries and deaths. A similar trial may soon begin in Japan. In short this could compromise confidence in critical vaccines necessary tocontrol the real scourges of mankind e.g., smallpox.Please see the attached email I just sent to John Hinderacer of Powerline (TimeMagazines Blog of the Year) that assisted in breaking Rathergate.Ron Wright, ModeratorHSPIG Forums*****From: Ron Wright <>TO: Informed Source <>Date: Wed Jan 19, 2005 09:26:22 AM PSTSubject: HSPIG LTR TO POWERLINE RE DOD ANTHRAX VAC ANTHRAX VACCINE STORY RE MATSUMOTO'S BOOK -DOD's anthrax vaccine causal factor of Gulf War SyndromeFYI - see the email I sent to John Hinderaker at Powerline yesterday. Pleasefeel free to share or forward in any manner you wish. The MSM is avoiding thisstory like the Plague. The MSM has failed the American people in itsjournalistic responsibility to report objectively the news of the day. The MSMwas given the right of the free press to serve as a watchdog by WE THE PEOPLE tohold accountable those who WE THE PEOPLE chose to govern.This is a story the American people need to hear in an objective manner so theycan decide what is the truth and/or fiction and hold our government accountableif necessary.REPORT THE STORY - and yes I'll will wear my "tin foil hat" if that's necessary.Ron*****From: Ron Wright <> TO: Power Line <> Date: Tue Jan 18, 2005 04:10:25 PM PST Subject: ATTN JOHN - ANTHRAX VACCINE STORY RE MATSUMOTO BOOKMr. Hinderaker, Thx for taking the time to listen to this story on the phone today. Here's athumbnail sketch. Sorry in advance for the amount of info I'm downloading here. My bloodhound nose has definitely detected several "big rats" in the works - asRoss Perot says, follow the money honey. HSPIG believes there is reasonable cause to believe that what Matsumoto's hasreported is true. Since the MSM is avoiding this story like the Plague, we aretrying to stir the Blogos to fact check this story and report it to the Americanpeople. With the MSM abdicating its journalistic responsibility that WE THE PEOPLE gaveit under the First Amendment to be our watchdog, WE THE PEOPLE cannot holdaccountable those who WE THE PEOPLE choose to govern accountable. We are attempting to fire off the Blogos on this story with its unimaginablepower/resources for distributive parallel processing like SETI. Here are some links on our site that will give a quick summary: CHALLENGE TO THE MSM TO REPORT "VACCINE-A" STORY [...]Read more in "power3" file attachedAttached files:Read more in power3 (MS Word .doc file)Letter to AIM (MS Word .doc file)Letter to Hewitt (MS Word .doc file)Research Papers (zipped file containing two PDF files)

Tuesday, January 18, 2005

Monday, January 17, 2005

I'm Going for It

I saw a new poster at the local McDonald's which said:
"I'm going for it
dqp (double quarter pounder with cheese)"
According to the McDonald's website, it has 730 calories and 40 g of fat.

What are we supposed to be going for, an angioplasty??

The Cardiologist Shortage

Kevin, MD recently posted about this article from American Medical News. The article reports on the efforts of the American College of Cardiology to increase the number of cardiologists by creating a 5-year cardiology residency that combines the traditionational 3-year internal medicine residency and 3-year cardiology fellowship. Graduates of this shorter program would not do invasive procedures such as angioplasty:
"The ACC would like to add an alternative five-year program that eliminates the third year of internal medicine and cuts out training in the high-tech cardiology procedures."
The article goes on to say:
"The money saved by cutting out that year could be used to train more cardiology residents or fellows, according to the ACC. More cardiologists would be turned out over time, and such a program would attract medical graduates who might be turned off by either the length of the six-year program or the high-intensity lifestyle of a proceduralist."
I think that a 5-year cardiology residency is a pretty lame suggestion on the part of the ACC. Cutting training by one-year wouldn't save that much money. And the last I heard, there's no shortage of internal medicine residents trying to get into cardiology fellowships. Cardiology is a very popular specialty. There's no reason to try to attract "...graduates who might be turned off by either the length of the six-year program or the high-intensity lifestyle of a proceduralist."
If more cardiologists are needed, then the solution is to simply increase the number of slots in cardiology fellowships. This will require more Medicare funding.
The proposal for a 5-year cardiology program is a power grab by the cardiologists, who want more autonomy from the American Board of Internal Medicine.

Thursday, January 13, 2005

Why Clinton had a Heart Attack

This article from e Clinical Psychiatry News explains why former-President Clinton may have had a heart attack:
In a laboratory test intended to induce extreme stress, healthy subjects who reported engaging in penile-vaginal intercourse during the previous 2 weeks experienced significantly smaller increases in blood pressure than those who reported masturbating or engaging in noncoital sexual activity, Stuart Brody, Ph.D., said at the annual meeting of the Society for Psychophysiological Research.
The peak systolic blood pressure for the intercourse-only group averaged 130 mm Hg, while the other groups' averages ranged from 143 mm Hg to 165 mm Hg, which Dr. Brody described as “an enormous difference.” The effects on diastolic blood pressure were not as dramatic.
The magnitude of this effect was much greater than that reported in other studies. The beneficial effect of penile-vaginal intercourse on systolic blood pressure in the Trier Social Stress Test is apparently more pronounced than any other intervention, including whether the subjects smoke or have a family history of hypertension; whether they're using ACE inhibitors, -blockers, or oral contraceptives; or whether they exercise, are depressed, or are in marital distress, he said.
The beneficial effect of penile-vaginal intercourse on blood pressure seemed to disappear in people who also engaged in masturbation or noncoital intercourse during the 14-day period.

Dr. Brody described his results as politically incorrect: “The politically correct thing is to parrot the ideology first espoused by Kinsey and also by Herbert Marcuse, which is that all forms of sex are equivalent, except that intercourse is worse because it's part of the patriarchal power structure.”