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.”

A New Antidepressant

Amarin Corporation plc (NASDAQSC: AMRN) today announced positive data analysis from two exploratory phase IIa clinical studies using Miraxion (formerly referred to as LAX-101c) to treat depression. An analysis of the data from the two studies identifies a significant clinical benefit with Miraxion for a sub-group of patients with specific symptomology.
In a recent exploratory phase IIa study, Miraxion was used as monotherapy in 77 patients with a new episode of depression in a six-week trial. In this study it was prespecified, that the presence of specific depression symptomology (patients with melancholic vegetative symptoms) at the time of entry to the study (baseline), would predict response. In an exploratory analysis the Bech-Depression Scale, a subscale of the Hamilton Depression Rating Scale, which defines the affective core symptoms of depression, was used as the outcome variable. Miraxion achieved statistical significance over placebo in the sub-group of patients meeting these criteria.

Miraxion (formerly LAX-101) is a semi-synthetic, highly purified derivative of the n-3 fatty acid eicosapentaenoate (EPA). The mechanism of action is believed to involve stabilization of mitochondrial integrity of suffering neurons, thereby preventing or slowing progression from neuronal dysfunction to apoptosis.
Two Phase II clinical trials have been conducted with Miraxion in treatment-unresponsive depression that concluded with statistical significance that a 1-gram per day dose of Miraxion was effective in treating depression in patients who remained depressed despite receiving standard therapy. The results of these trials were published in the Archives of General Psychiatry in October 2002 and the American Journal of Psychiatry in March 2002.
It's exciting to hear about a new antidepressant under development. I expect few new developments with antidepressants that target the traditional neurotransmitters (serotonin, norepinephrine, dopamine). It will be interesting to see if Omega-3 fatty acids (like Miraxion) and glucocorticoid receptor antagonists turn out to be effective antidepressants.

Tuesday, January 11, 2005

Sunday, January 09, 2005

Psychiatry Board Exams

I am taking my psychiatry oral board exams on Saturday the 15th. This is my 3rd attempt.
Unlike most specialties, psychiatry has both written and oral board examinations. The written examination is a multiple choice test; most psychiatrists pass it. After passing the written boards, a psychiatrist can sign up for the oral boards. During the oral boards, the psychiatrist interviews a patient, presents him to examiners, and also answers the examiners' questions. Another part of the orals is the video exam, in which the psychiatrist watches a patient being interviewed on a videotape, presents the patient to examiners, and also answers the examiners' questions. To pass the orals, a psychiatrist must pass both the live patient interview and the video exam.
The pass rate for the orals is only 55%. The pass rate is even lower for repeat candidates.
Each exam (written or oral) costs about $1600. So far I have spent about $6400 on exam fees alone. Adding in travel costs brings the figure up to about $9500. Adding in the cost of board review courses brings up the cost to about $14000. Adding in the money I spent passing my sleep and internal medicine boards brings my total board exam expenditures to over $25,000.
This is my last attempt at passing the psychiatry oral boards. After flunking for the 3rd time, the whole process starts all over again. You have to turn in another application and take the written boards ($1600) before taking the orals (another $1600) again. It's just too much money.
I am pessimistic about my chances of passing the orals; the pass rate for repeat candidates is less than 50%. I am taking another board review course this week with mock examinations, but I am not sure how much it will help. Both times I took the orals in the past, I passed the live patient interview but flunked the video exam. Most residency programs prepare you for the live patient interview, but it's hard to prepare for the video exam. Hopefully this board review course will help.
If I flunk this time, I am giving up on psychiatry. I will need to look for a new job, probably one that is mainly sleep medicine. This blog will no longer be "The commentary of an academic internist/sleep specialist/psychiatrist" but just the commentary of an internist and sleep specialist.
tomorrow I am heading back to my home state of California for the board review course and the oral exams. Wish me luck. Posting will be light for the next week.


I received this e-mail today:
Dear Dr. Rack, I thought you and the readers of your blog would be interested in my book The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness, a biography of the infamous psychosurgery pioneer Walter Freeman. Freeman was the neurologist who operated on Rosemary Kennedy, who died on January 7. My publisher, John Wiley & Sons, released the book last week. I began my research on Freeman in 1996 after meeting the family of a lobotomy patient. Over the years, I’ve focused my efforts on answering the questions of why Freeman, an undeniably brilliant and respected physician, felt drawn to lobotomy, and why he continued to stake his career on the procedure when better therapies became available in the 1950s. I found the answers in the grim psychiatric climate of his time and the complex mix of the strengths and weaknesses of his character. I’m the author of several previous books, as well as articles in The Atlantic Monthly, American Heritage, The Washington Post Magazine, The History Channel Magazine, and many other publications. In 2002 I received the June Roth Memorial Award for Medical Journalism. If you’d like to learn more about The Lobotomist, please get in touch with me at or check the book's website at Thanks, and I look forward to telling you more. Jack El-Hai ______________________ Jack El-Hai Author of The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness Just published by John Wiley & Sons
Looks interesting

Friday, January 07, 2005

Everybody's in it for the Money

The latest issue of Medical Economics has a rather cynical article about hospice care:
When Medicare began to reimburse for hospice care in the '80s, it caused a sea change in the business structure of hospices. They went from the largely charity funded, volunteer-staffed organizations of the '60s to nonprofits and a few large for-profit companies.
Medicare reimburses the hospice roughly $122 for every day the patient is in hospice care. In return, the hospice provides meds, medical equipment, regular nurses' visits, pastoral care, and visits by home health workers and social workers. A nurse and doctor must be on-call 24/7.
If a hospice averages 30 Medi-care patients a day—and most larger companies average more than 30—it will generate more than $100,000 in Medicare re-imbursement each month. It doesn't take an accountant to see there's a profit to be made here. Three of the largest companies are showing impressive earnings or growth.

The article goes on to give several examples of hospice company reps trying to inappropriately get patients for their hospices. The author concludes:
I've had negative experiences with various hospices, but I'm still a strong proponent of hospice care. They're not all alike, and there are several things a physician should consider when ordering hospice care for a patient.
Most important, does the patient want hospice services? Some patients and families don't want strangers dropping in during this difficult time. It's very easy nowadays for a physician to have hospital beds, pain meds, and other medical goods delivered to a home without a hospice being involved.
If the decision is made to order hospice care, consider several things when choosing a company. What is its structure? How aggressive is the company? If it's spending a lot of money soliciting your business, do they have their priorities straight? Are they focusing on care or profits? Ask your patients who have lost loved ones to terminal illness if they used a hospice. What did they think of it? Were the nurses caring and responsive? Did they fulfill their obligations?
Lastly, keep your focus on the dying patient. Find out what's important to him, and decide whether a hospice can or is willing to provide for his needs.

We all need to make a living. But our highest priority should be to do what is best for the patient.

Wednesday, January 05, 2005

Interns 1

This is the first of a series of posts about interns (not the type of intern of who works in the White House and ends up with white stains on her dress, but the type of intern who works in a hospital after completing medical school and ends up with all kinds of stains on his/her lab coat)
Intueri writes (1/2/05):

Tomorrow is my last call night as an internal medicine intern.

She goes on to say that she will be starting the psychiatry part of her internship:

It’s like starting internship all over again! I don’t remember anything about psychiatry—it feels that way, anyway. I don’t remember how to conduct a psychiatric interview. I can hardly recollect the medications used, the psychodynamic methods employed, or how to successfully manage feelings of transference and countertransference (don’t ask me what those words mean, because I don’t remember).

As far as psych medications, the most important thing for a psychiatry intern to know is how to quickly calm down an agitated patient. Pych interns need to be especially familar with intramuscular haldol, thorazine, ativan, cogentin, geodon, and zyprexa. Psych interns should also be familar with the risperidone M-tab, and how to load a manic patient with oral depakote. Psychiatry interns do not need to know too much about psychodynamics, transference, or countertransference. The main things to know are that you should never have sex with a patient, and a little bit about the defense mechanisms used in borderline personality disorder (e.g., splitting). How to perform a detailed suicide risk assessment is necessary.

I’ve spent the past six months repleting electrolytes. I’m great at dosing potassium for patients, oh yes. And writing for antibiotics. And giving fluids. And blood. And running around as middle(wo)man for the nurses, social workers, and discharge planning.

Psychiatry interns usually won't have to transfuse a patient with blood. Many psych patients do need IV fluids, though not all psych wards allow the administration of IV fluids. Running around as a middle(wo)man for nurses and social workers is a big part of being a psychiatry inter.

I’ve worn a white coat for the past six months. And now—in two days!—I’m supposed to molt and shed that thing to become the beautiful butterfly of psychiatry (or something).
Nearly one and one-half years have passed since I’ve done any formal psychiatry. What if I’ve made the wrong choice? What if internal medicine is my true calling? What if I miss using my stethoscope? What if I miss reading x-rays? What if I miss repleting electrolytes (unlikely)?
I seriously don’t even know what I am going to wear on Wednesday.

I suggest wearing your lab coat and bringing your stethescope. You'll have plenty of x-rays to read (though in psychiatry it's usually not mandatory to read the x-ray yourself- but I recommend trying to read x-rays yourself instead of just passively reading the radiologist's report)- in my experience, psych patients frequently need chest x-rays and occasionally abdominal films. There will be many brain CT's and MRI's to look at.

Managing the medical problems of psych patients is a big part of being a psych intern on the inpatient psych wards.


Shrinkette recently posted about Klonopin being prescribed at excessively high doses:

When you see a patient taking Klonopin, it's helpful to recall the approximate dose equivalents:Klonopin 0.25 mg is approximately equivalent to Xanax 0.5 mg, or Ativan 1 mg, or Valium 5 mg, or Librium 10 mg. Of course, the kinetics are different, and there is tolerance and so on. But high potency meds can be...highly potent.
I agree with her completely. Patients are often started out on a dose of Klonopin of .5 mg twice a day, which is probably too high of a starting dose. I think that the primary reason this is done is because .5 mg is the smallest dose that the Klonopin tab comes in (though the orally disintegrating wafers also come in .125 mg and .25 mg strengths).
When I start a patient on Klonopin, I typically have them take 1/2 of a .5 mg tab, twice a day. The manufacturers of clonazepam (Klonopin) really need to come out with a .25 mg tab.

Tuesday, January 04, 2005

Grand Rounds 15 at

Grand Rounds 15 has been posted at
Dr. Rangel did a great job of organizing and presenting the posts.
Check it out.

Monday, January 03, 2005

Last Chance for Grand Rounds

Dr. Rangel is hosting Grand Rounds this week:

Accepting submissions for the next Grand Rounds - Deadline is 9 pm mountain standard time (GMT-7) on 1-3-2005. Send submissions to drrangel - at - swbell.netEven though the deadline is 9 pm I will still be checking my email into Tuesday morning and will try and add on late entries however you have the best chance of being read if you get in your submission early. Submit early. Submit often!

Sunday, January 02, 2005

Would you like a side of fries with your CABG?

Hospitals are struggling with the problem of whether to allow fast food:
"It becomes a philosophical question that has to be answered in every hospital. Do we serve healthy foods because we're in a health care facility, or do we serve what the customers are interested in having?" said Joyce Hagen-Flint, president of the AAHCSA. "There are hospitals all over the country that have fast food outlets."
It's not uncommon for hospitals to earn money by leasing space to food court companies or restaurants.

I personally have no problem with a hospital serving "fast food" as long as healthy options are available. This can be a problem in the South, where everything is "chicken-fried."
I must admit that I have come to develop a particular hatred for McDonald's. In their advertisements, McDonald's likes to pretend that they have all these healthy alternatives available. Then when you get to the actual McDonald's, it's not available. There is a McDonald's at the rehab hospital directly adjoining the University of Mississippi Medical Center. When I arrive for work (anytime between 6:30 and 8 am) and try to buy a fruit-and-yogurt parfait, I am usually told that they are not ready yet or that they are out of them. I have never seen them run out of, or not have available, sausage patties.
(edited slightly since time of initial posting)

Who Does a Doctor Treat?

This comment was posted on DB's Medical Rants:

As one from the “payer” side, I’d recommend we take the argument on health care costs a step further. Like it or not, employers pay a significant portion of health care costs, both directly (premiums) and indirectly (cost-shifting for uninsured, FICA taxes, income taxes, etc.)
The real issue employers have with health care costs is they have NO sense for their return on the investment. And that is the fault of the medical and managed care communities. Employers carefully assess each investment into plant and equipment, personnel and training, investment options and new products. They calculate RoIs carefully, assess performance constantly, and get as comfortable as possible with an expenditure BEFORE they make the investment.
Think about health care - what do employers get? Happy employees? Rarely - health insurance is a terrible “good” - people only use it when they are ill or injured, it is convoluted and difficult to understand, and they have topay for part of it too!
Actually, what employers SHOULD be thinking about is the demonstrated ability of a health care provider to “deliver” healthy, fully functional employees and families, thereby enhancing productivity and, therefore RoI. Health insurance is an investment in productivity.
If we can evolve to this way of thinking, much of the present bickering about health care costs will end. Sure, there will be arguments about impact rates, who delivers what benefit, and what evaluation methodology makes the most sense, but that will signal we are talking about the right things.
So, the next time someone complains about charges, costs, or premiums, ask them how that “good” will help them function. They won’t know the answer, but perhaps they’ll start thinking about it.

I see patients one person at a time. My duty is to the patient, not their company. The individual patient is the one who signs a form agreeing to accept the responsibilty for my bill. There are occasional exceptions (I recently did a Workers Comp Eval in which I received payment directly from Workers comp; before the eval I informed the patient that I was providing services to Workers Comp and not him and obtained informed consent before proceeding with the evaluation). In most cases, doctors have relationships with individual patients, not companies or businesses. Although businesses do pay for much of healthcare in this country through health insurance premiums, this is at the expense of higher wages. So ultimately, it is the worker who is paying.

Saturday, January 01, 2005

Schizophrenia and obstructive sleep apnea

Schizophrenics have a higher risk of obstructive sleep apnea than the general population. This increased risk has generally been attributed to obesity and the weight gain caused by antipsychotics.
In addition to obesity, nasal obstruction is also a risk factor for obstructive sleep apnea.
This recent study found reduced nasal cavity size in schizophrenic men:
To investigate, Dr. Moberg's group used acoustic rhinometry to measure nasal volume in 40 men with and 40 without schizophrenia.
They discovered that the schizophrenic patients had smaller posterior nasal volumes in both the left and the right nostrils (p <>

Could reduced nasal cavity size be part of the reason that schizophrenics have higher rates of obstructive sleep apnea??

A Simple Cure for Obesity

I found this on Medscape:
How can we stop the obese from becoming more obese? Pretty simple. Stop feeding them. Think about the other common self-destructive human behaviors. On a commercial airplane, in a saloon, or at a professional sports event, if the customer is deemed to be drunk, the keepers of the booze key will lock the cabinet. If a person drives a car at a dangerous speed, the driver is subject to substantial penalties. For young persons known to be at high risk for early chemical addictions, society tries to prevent exposure to the addicting drugs. Overeating with underexercising is now killing more Americans than anything else except tobacco addiction. Yet, an obese person enters an eating joint, or a supermarket, and buys and eats any and everything he or she wants, and nobody seems to care. Does that make any sense to you? Meanwhile, Big Science strives to understand why people get fat; Big Genetics searches for the obesity gene so that stem cells could correct the flaw; Big Surgery lines up the morbidly obese to shunt their stomachs; Big Pharma seeks the next weight-loss pill that will help more people than it kills; Big Nutrition hawks the newest sure-thing, weight-loss diet; Big Fast Food pushes "healthy food" lines right next to their billion dollar unhealthy food lines; Big Soda and Big School Boards share the profit from drowning kids with calories from vending machines; and Big Exercise pushes group rates for aerobics class. Money made by so many special interests. All this while the simple answer is to stop eating; stop feeding the obese until they are no longer obese. Of course, that may be hard to do, and who makes any money that way? Fat chance for this crazy idea to go anywhere. That's my opinion. I'm Dr. George Lundberg, Editor of MedGenMed. Happy Holidays!
Readers are encouraged to respond for the editor's eye only or for consideration for publication via email:

George D. Lundberg, MD, Editor-in-Chief, Medscape General Medicine
Disclosure: George D. Lundberg, MD, is an employee of WebMD.
Medscape General Medicine 6(4), 2004. © 2004 Medscape

This is a pretty simplistic solution- an alcoholic can avoid alcohol but an obese person can not avoid food- some food is necessary for survival.
On the other hand, we have several 600+ pound patients at our sleep lab who are unable to leave their houses except with the assistance of an ambulance. Yet they manage to obtain and consume buckets of fried chicken and bottles of cola. Someone (usually a relative) is bringing the extremely obese person unhealthy food in these cases.
There aren't any easy solutions to the obesity epidemic, though I have seen good results with bariatric ("stomach stapling") surgery. I have also seen bariatric patients develop wound problems requiring prolonged hospital stays (6+ months) and sometimes leading to death.