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.
Thursday, August 18, 2005
Wednesday, August 17, 2005
Doing Away With Tips
From Cnn.com:
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.
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Instead of a service charge, why not just increase prices by 20% (and put up a sign eliminating tipping)
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.
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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.
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.
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
Smoking
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.
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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)
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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.
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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.
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.
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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 czeanah@tulane.edu. 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.
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 czeanah@tulane.edu. 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.
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From The Hill
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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.
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.
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From the Clarion-Ledger
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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 http://adultaddstrengths.com/2005/06/07/vintage-pharmacetutical-ads/ This is a gallery of actual ads for pharmaceutical products from the 40’s to the 70s. http://www.livejournal.com/community/vintage_ads/88173.html 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
Blog http://www.adultaddstrengths.com
Web: http://www.addcoach4u.com
thought you and your blog readers might be interested in this bit of medical humor (unintentionally so) from the past. Pete Vintage pharmaceutical ads http://adultaddstrengths.com/2005/06/07/vintage-pharmacetutical-ads/ This is a gallery of actual ads for pharmaceutical products from the 40’s to the 70s. http://www.livejournal.com/community/vintage_ads/88173.html 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
Blog http://www.adultaddstrengths.com
Web: http://www.addcoach4u.com
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
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.
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.."
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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.
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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.
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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.
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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.
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.
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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.
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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.
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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.
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.
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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.
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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
Autopsies
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.
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 MSN.com 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.
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.
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.
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.
"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.
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.
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.
////// 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.
thanks
Check out SleepDoctor.
thanks
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.
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
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
DOCTOR UNABLE TO HIDE HIS EXCITEMENT FROM PATIENT WITH ULTRA-RARE DISEASE
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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.
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from The Onion
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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.
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
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.
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.
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.
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.
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.
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.
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.
Nurses
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.
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.
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.
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??
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 - www.hsig.org) 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":http://www.hspig.org/ipw-web/bulletin/bb/index.phpAlso 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 Sitewww.hspig.org*****From: Ron Wright <nar9350@mac.com>TO: Informed Source <editor@informedsource.info>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 Wrightwww.hspig.org*****From: Ron Wright <nar9350@mac.com> TO: Power Line <feedback@powerlineblog.com> 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 http://www.hspig.org/ipw-web/bulletin/bb/viewtopic.php?t=2056 [...]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)
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 - www.hsig.org) 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":http://www.hspig.org/ipw-web/bulletin/bb/index.phpAlso 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 Sitewww.hspig.org*****From: Ron Wright <nar9350@mac.com>TO: Informed Source <editor@informedsource.info>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 Wrightwww.hspig.org*****From: Ron Wright <nar9350@mac.com> TO: Power Line <feedback@powerlineblog.com> 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 http://www.hspig.org/ipw-web/bulletin/bb/viewtopic.php?t=2056 [...]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)"
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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??
"I'm going for it
dqp (double quarter pounder with cheese)"
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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.
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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.
"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.”
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.
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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.
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.
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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.
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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.
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The pass rate for the orals is only 55%. The pass rate is even lower for repeat candidates.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
Lobotomy
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 el-hai@lobotomist.com or check the book's website at http://lobotomist.com. Thanks, and I look forward to telling you more. Jack El-Hai ______________________ Jack El-Hai el-hai@lobotomist.com 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 http://lobotomist.com
Looks interesting
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 el-hai@lobotomist.com or check the book's website at http://lobotomist.com. Thanks, and I look forward to telling you more. Jack El-Hai ______________________ Jack El-Hai el-hai@lobotomist.com 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 http://lobotomist.com
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.
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)
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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).
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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.
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.
Klonopin
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.
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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.
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.
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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 RangelMD.com
Grand Rounds 15 has been posted at RangelMD.com
Dr. Rangel did a great job of organizing and presenting the posts.
Check it out.
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!
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)
"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.
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??
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: glundberg@webmd.net.
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.
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: glundberg@webmd.net.
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.
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