Ben Affleck at the Democratic Convention

Ben Affleck will be doing the samething I will be doing over the next several days, playing poker:
Ben Affleck is upping his stake in politics – with poker. The Oscar winner, 36, will be in Denver this week for the Democratic National Convention, where he'll be celebrating at more than one political party. Among his official duties: performing at a roundtable event for SeaChange Ideas Forum, packing food for the needy and playing poker to benefit paralyzed veterans.

Of course, I won't be in Denver- I'll be playing in Vicksburg.

Another Narcissist

Maureen Dowd has a great collumn today on the Breck Girl (aka John Edwards):

The stunning admission Edwards made to ABC’s Bob Woodruff, and in a written statement from Chapel Hill on Friday afternoon, was that he’s a narcissist.
He admitted that wallowing in “self-focus” out on the trail and thinking you’re “special” can result in a solipsism that “leads you to believe you can do whatever you want, you’re invincible and there’ll be no consequences.”
Even in confessing to preening, Edwards was preening. His diagnosis of narcissism was weirdly narcissistic, or was it self-narcissistic? Given his diagnosis, I’m sure his H.M.O. would pay.
The creepiest part of his creepy confession was when he stressed to Woodruff that he cheated on Elizabeth in 2006 when her cancer was in remission. His infidelity was oncologically correct.

I'm glad Edwards lost the Democratic primaries, bad things can happen when a narcissist comes into power. On the other hand, maybe someday he'll bring balance to the country.

Neuropsychiatric explanation for Alien Abduction

Current Psychiatry has an article about Alien Abduction Experiences, which can be caused by several pscyhiatric and neurological conditions. Some cases are hypothesized to be secondary to sleep paralysis combined with hypnagogic or hypnopompic hallucinations:

Full-body paralysis normally accompanies rapid eye movement (REM) sleep, which occurs several times a night. Sleep paralysis is a transient state that occurs when an individual becomes conscious of this immobility, typically while falling asleep or awakening. These experiences can be accompanied by hypnagogic (while falling asleep) or hypnopompic (while awakening) hallucinations. An estimated 30% of the population has had at least one sleep paralysis episode. In one study, 5% of sleep paralysis patients had episodes that were accompanied by hallucinations.

During sleep paralysis episodes, individuals typically sense a threatening presence. Patients have reported beastly and demonic figures of doom: devils, demons, witches, aliens, and even cinematic villains such as Darth Vader and Freddy Kruger. Others have described this presence in terms of alien visitations or abductions.

Sleep paralysis and associated hallucinations can sometimes be treated by treating any underlying sleep disorders. Treatments for cataplexy, such as tricyclic antidepressants, are often effective for sleep paralysis.

Die Endlosung

This comment was posted on the Wall Street Journal Health Blog today:


Die Endlösung must be applied to individuals who chronically do not participate in the production and consumption of commodities.
Comment by DM - August 4, 2008 at 9:42 am

I posted this comment 11 hours later:

I’m surprised that the first comment promoting The Final Solution (Die Endlosung) hasn’t been removed by the moderators of this blog yet. I would think that a statement arguing that the chronically unemployed should be killed would be considered offensive.
Comment by Michael Rack, MD - August 4, 2008 at 8:56 pm

DM's comment, in addition to being offensive to both Jews and the chronically unemployed, doesn't make sense. While not everyone produces commodities, everyone consumes commodities.
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Update (8/5) DM's comment has been removed from the Wall Street Journal Health Blog. Mine has been too- I guess the Wall Street Journal is trying to cover up the lax monitoring of their blog.

Woo in Psychiatry II

In response to my "Woo in Psychiatry" post, an anonymous poster advised:
read work by Steven Sevush MD

A quick google search reveals that Dr. Sevush is a geriatric psychiatrist, that he's done some work on Alzheimer's, and that he is written on consciousness. I am not sure if this essay is by him, but it came up when I googled "Steven Sevush MD and quantum".

Now quantum mechanics has some interesting philosophical implications, though it takes several years of advanced college mathematics (which I lack) to have even a basic understanding of quantum mechanics. Quantum mechanics has some interesting implications for the concept of consciousness. There has been some research looking at the speed of neural transmission, and whether an action can begin before the person makes the decision to carry out the action (I am probably butchering the concept, see Roger Penrose for more details).

I maintain my assertion that quantum mechanics has nothing to do with psychiatric treatment. I have no problem if a psychiatrist is interested in quantum mechanics and its philosophical implications. However, if a psychiatrist starts talking about "energy fields" to his patients, that psychiatrist is a quack.

At the last Psychiatric Congress (an annual CME seminar), I suffered through an hour session on psychotherapy in which a psychiatrist who thought he knew much more than he actually did about quantum mechanics erroneously said that quantum mechanics is about energy fields and that we are all connected by energy fields (quantum field theory has nothing to do with us all being connected). I had to restrain myself from telling him that he was a fool.
The only "energy" or "energy field" relevant to psychiatric treatment is the energy generated by an electroconvulsive therapy machine.

Autism is not a mental illness (according to Dear Abby)

DEAR ABBY: I just finished reading your June 9 column and am shocked at what I read. Your response regarding autism was way off base. You said, "Autism is a mental health disorder ... some people consider ... to be shameful."
Autism is a neurological disorder, NOT a mental health disorder......
DEAR MELISSA: My thanks to you -- and the many other readers -- who wrote to correct me..... autism is often considered a mental health disorder because it affects behavior, cognitive ability and social skills. However, it is genetically predetermined -- biologically based.
Experts clearly agree that autism is a neurologically based condition. The current criteria used to diagnose autism are contained in the Diagnostic and Statistical Manual of Mental Disorders, a publication of the American Psychiatric Association. However, this does not mean that autism is a "mental illness." Autism is most accurately described as a "neurodevelopmental disorder."

Most psychiatric conditions have at least some biological basis. Schizophrenia can also be considered a "neurodevelopmental disorder," though it has a later onset than autism. There is no clear dividing line between what is considered a neurological brain disease and what is considered a mental illness.

Psychiatrists in the News

A famous psychiatrist has been featured prominently in the news headlines this week:
(CNN) -- Radovan Karadzic, whose Interpol charges listed "flamboyant behavior" as a distinguishing characteristic, was a practicing psychiatrist who came to be nicknamed the "Butcher of Bosnia."
Twice indicted in 1995 by the U.N. International Criminal Tribunal for the former Yugoslavia, Karadzic faces charges of genocide, complicity in genocide, extermination, murder, willful killing, persecutions, deportation, inhumane acts, terror against civilians and hostage-taking.
While president of the so-called Serbian Republic of Bosnia-Herzegovina, Karadzic's troops were reported to have massacred over hundreds of thousands of Muslims and Croats during a campaign of "ethnic cleansing." Early estimates of the death toll from the 3-year war ranged up to 300,000, but recent research reduced that to about 100,000.
Karadzic was born on June 19, 1945, in Petnjica, Montenegro. He studied psychiatry and medicine at the University of Sarajevo during the 1960s and took courses in psychiatry and poetry at Columbia University from 1974 to 1975.

Poker in Mississippi

Those living in Jackson MS no longer have to drive to the coastal region to play No Limit Texas Hold'em. Vicksburg (45 minutes from Jackson) now has 2 poker rooms. The room at the Horizon casino, though, is of low quality and sometimes only has Limit games. I recommend the Ameristar casino- not as good as the Imperial Palace in Biloxi, but Ameristar does usually have several No Limit tables going.

Woo in Psychiatry

Alternative medicine quackery is spreading throughout medicine, but is especially common in psychiatry:

Complexity theory, quantum mechanics, and quantum field theory are conceptual frameworks that have been largely overlooked by Western medicine as potentially useful explanatory models of illness and healing. These nonclassical paradigms may eventually lead to models or research methods that will clarify the nature of putative informational or energetic phenomena related to health, illness, and healing. Phenomena regarded as legitimate subjects of inquiry in nonorthodox paradigms that have been largely overlooked by Western biomedical research include the role of intention in healing and the putative beneficial effects of “subtle energy” on health.

Quantum brain dynamics is a nonclassical model that uses quantum field theory to explain subtle dynamic characteristics of brain functioning, including postulated influences of nonclassical forms of energy and information on the brain. It has been suggested that healing intention operates through nonlocal energetic interactions between the consciousness of the medical practitioner and the physical body or consciousness of the patient. Conventionally trained physicians generally regard reports of beneficial outcomes following “energy” treatments as examples of the placebo effect because contemporary Western science is not able to substantiate the role of postulated forms of nonclassical energy when these modalities are employed.

If you hear a psychiatrist using the word "quantum" or if you hear him talking about "energy fields", that psychiatrist is a quack and you should run out of his office as fast as possible. Quantum mechanics has nothing to do with psychiatric treatment.

suicide nation

USA Today reports on the Japanese suicide epidemic, which is being fueled by economic hard-times as well as Japanese cultural traditions promoting suicide:

"Suicide is not considered a sin," says sociologist Masahiro Yamada of Chuo University in Tokyo. "We've made it a bit of a virtue."
A decade of weak economic growth and the unraveling of Japan's system of lifetime employment have left many middle-age and elderly men unemployed and in financial ruin. Among Japanese suicides, nearly 71% are men, more than 73% are 40 or older, and more than 57% are jobless.
For an unemployed, former "salaryman," suicide can be "a rational decision," Yamada says. When a man commits suicide in Japan, his beneficiaries can still collect his life insurance. And insurers pay off Japanese home mortgages when a family's breadwinner dies — even if the death is a suicide. "If he dies, the rest of the family gets money," Yamada says. "If he continues to live without a job, they will lose the house."

Should Pre-meds have to take Organic Chemistry??

The Wall Street Journal Health Blog discusses this issue. Here is the comment I posted:

I am all for weeding out people, but I think that the 2nd semester of O chem is a waste of time. Instead of a 2nd sem of O chem, I would require a semester of med-school level Biochemistry (and use this as a weed out course, in addition to the 1 semester of Ochem). I disagree with the previous comment of getting rid of physics. A basic knowledge of physics is helpful for many areas of medicine - neurophysiology (EEG/sleep studies), radiation oncology, nuclear radiology, and ophthalmology.

Psychiatry and the Pharmaceutical Industry

Congress is accusing the profession of Psychiatry and its leading organization, the American Psychiatric Association, of prostituting themselves to the pharmaceutical industry:

But now the profession itself is under attack in Congress, accused of allowing this relationship to become too cozy. After a series of stinging investigations of individual doctors’ arrangements with drug makers, Senator Charles E. Grassley, Republican of Iowa, is demanding that the American Psychiatric Association, the field’s premier professional organization, give an accounting of its financing.

“I have come to understand that money from the pharmaceutical industry can shape the practices of nonprofit organizations that purport to be independent in their viewpoints and actions,” Mr. Grassley said Thursday in a letter to the association.

In 2006, the latest year for which numbers are available, the drug industry accounted for about 30 percent of the association’s $62.5 million in financing. About half of that money went to drug advertisements in psychiatric journals and exhibits at the annual meeting, and the other half to sponsor fellowships, conferences and industry symposiums at the annual meeting.

Here is the Consumerist's take on the issue:

Psychiatry is nothing more than a well-funded front for big pharma, according to lawmakers investigating the field's premier organization, the American Psychiatric Association. Unlike psychologists, psychiatrists can write prescriptions, giving pharmaceutical companies a powerful incentive to lavishly subsidize both their lifestyle and profession.
A psychiatrist's office is a "safe space," where it's ok to ask any question, including: "have you received any compensation from any drug company?"
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My practice is mainly sleep medicine- largely osa and cpap. Unless you count hypnotics like Ambien and Lunesta (I typically start off with generic Ambien before trying Lunesta or Ambien CR), I prescribe less psychotropics than the typical internist and much less than the typical psychiatrist. I resigned my membership in the APA over a year ago. I am not in the pay of the pharmaceutical companies.

The Disadvantages of having a doctor for a mother

I haven't had much time to blog recently, and I don't really have anything original to say today. I did come across an interesting post, via Kevin MD, on the Mothers in Medicine blog. In the post "Second generation", a mother/resident discusses her current situation and how it was like for her to grow up as a child of a doctor:

"I really adored my nanny (who coincidentally had the same first name as my mother), and that was a good thing since she was the adult I spent the most time with."

Every day when I leave in the morning, she reaches out for me and cries. And I think to myself, "What kind of mother am I to leave her like this?" But when I go to work, I’m earning the money that pays the rent and building a career that hopefully someday she’ll be proud of.

The 7 Deadly Sins

The Medical Board of California lists the seven deadly sins that can cost a doctor his license.
Often its possible to committ more than 1 sin at a time:
Each Medical Board investigator probably can recount three or four outrageous cases of sexual misconduct that they have investigated. For me, one was a renowned psychiatrist who had a seven-year affair with a schizophrenic patient. Their sexual relationship began in the library of a university medical school. Their relationship culminated with the psychiatrist using the patient to procure prostitutes with whom he, and the patient, would have group sex. Instead of paying money for the prostitutes' services, he bartered by providing them with prescriptions for Klonopin or other controlled substances. Not to be limited to a mere one or two violations of law, he would then bill Medi-Cal for group therapy (definitely one of the more creative liberties I've seen taken with a CPT code). This physician's license was revoked and he was also criminally convicted of fraud. Lust and Greed.
Not everyone agrees that Greed is bad:
"The point is, ladies and gentlemen," Gordon Gekko pontificated in the movie "Wall Street," "that greed - for lack of a better word - is good. Greed is right. Greed works. Greed clarifies, cuts through, and captures the essence of the evolutionary spirit. Greed, in all of its forms - greed for life, for money, for love, knowledge - has marked the upward surge of mankind."

In my opinion, Pride is probably the most common deadly sin among physicians:
There are a lot of doctors out there who are brilliant practitioners, but they have no business acumen. Being too proud to admit it, they are lured into contracts and obligations due to their business naiveté and end up being cited for all kinds of violations (failing to have a fictitious name permit, aiding/abetting the unlicensed practice of corporate medicine, advertising violations). I hate to be the bearer of bad news, but ignorance is never a valid defense.

Pride is also known as Vanity:
Vanity, definitely my favorite sin.

For those of you who don't watch movies much, that last quote is from The Devil's Advocate- A great performance by Al Pacino.

Vitamin D

Vitamin D has recently become a hot area of research.

Low vitamin D- 25(OH)D- has been linked to depression.

Low Vitamin D levels have also been linked with a poorer prognosis in women with breast cancer.

Are Psychiatrists Real Doctors?

Dr. Moffic attempts to answer this question in Clinical Psychiatry News:
A flight attendant came down the aisle asking whether there was a doctor on the plane. My wife must have thought I was one, and told the flight attendant so. She then woke me and told me of the concern.
Was I a “real” doctor? After all, hadn't I been writing about how psychiatrists' medical backgrounds should distinguish them from psychologists, even to the extent that I suggested that our next diagnostic manual should only be for us? But being a “real” doctor in real life is far different from just writing about it. Was this some sort of cosmic test for me?
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My wife, who is a psychiatrist, has volunteered my medical services on a flight before.

There are some inaccuracies in Dr. Moffic's article:
These days, a medical internship is the first of the 4 years of psychiatric residency training, and consists exclusively of medical rotations, including neurology.
A psychiatric internship is not the same as a medical internship. A typical psychiatry internship consists of 4 month of medicine, 1-2 months neurology, and 6-7 months of psychiatry. Most psychiatrists are ill-prepared to treat medical illness.

ER call ethics

I was recently asked to comment on this article written for the blog Brain Blogger (shortened version below, I encourage you to read the full article):

In a fit of rage, a thirty year old otherwise healthy man punches a hole through his window.

Unfortunately, there is no hand surgeon in the community that takes on-call service for the ER. Thus, the ER doctor calls various community hand surgeons to see if they will take care of the patient.
Finally, the ER is able to get a hand surgeon who will answer his pager. The hand surgeon agrees to get involved with the care of the patient. He listens to the story over the telephone and feels in his best judgment that the patient will need an exploration of his hand in the operating room. Studies show that there is no difference whether this happens sooner or later as long as it is done within 24 hours. Thus he explains to the ER doctor that he is out to dinner with his family and won’t be able to see the patient until the morning. He tells the ER physician to either discharge the patient and have him come to his office in the morning, or to admit the patient and that he will see the patient in the morning.

Several ethical issues are raised later in the article and by commenters to the article, and I will only address a few of them, but I encourage comments.

1. I do not think that physicians have an ethical obligation to provide hospital/ER call. I think this is a matter of negotiation between hospitals and the doctors who apply for medical staff privileges. Hospitals have the right to refuse medical staff privileges to doctors who don't want to meet the hospitals' call requirements. Doctors have the right not to apply for privileges at hospitals that have onerous call requirements. To attract physicians of certain specialties, some hospitals may need to pay the doctors for taking call, though this is a legally tricky area.

2. Regarding the specific case, once the surgeon "agrees to get involved with the care of the patient", I think he is obligated, at least from a medicolegal perspective, to go in and see the patient that night. If he wasn't prepared to go in that night, he should have told the ER doctor that in general that type of injury requires surgery within 24 hours, but that he couldn't comment on the specific patient. If I was in that surgeon's place, I would have offered to see the patient in the morning, but made clear that the ER doc was responsible for the patient until then and that no doctor patient relationship would exist until and unless the patient arrived at my office. I would tell the ER doctor that if he was uncomfortable with that disposition, he could always send the patient to a university hospital/tertiary care center (if the ER doc thought the patient was stable for transfer).

Iowa floods

Fifteen years ago I arrived in Iowa City, Iowa to begin medical school, just as the great flood of 1993 was ending. It looks like this year's medical students will have a similar experience.

Here's a link to more information about the situation in Iowa City.

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edit (6/15): The University of Iowa makes it's last stand.

More on the Primary Care Shortage

Medical Economics magazine reports that graduating primary care doctors are getting more job offers than previously. This is in a large part due to the decreasing number of physicians going into primary care.
So why the continuing shortage in primary care? In a word, money, despite a boost in financial incentives for new recruits beginning last year. Even today, medical graduates shouldering huge debts survey the practice landscape and see a real disconnect between the hours PCPs put in and their incomes, at least compared with specialists and surgeons. Compounding the problem is graduates' perception that, as PCPs, they'll occupy a lower rank in the medical pecking order. No wonder, then, that primary care practice still isn't a big draw, at least not for US medical residents.

Never-Never-Land

Over the last several months, much has been written on the medical blogosphere and on medical websites about "never events":
In August 2007, Medicare announced that, starting October 2008, it will no longer reimburse the treatment hospitals must provide to redress eight medical errors, a list likely to lengthen in the future. In fact, CMS has already announced its plan to add ventilator-associated pneumonia and deep vein thrombosis to its list in fiscal year 2009.
Some of the events on the list are expected complications of treatment rather than true medical mistakes.
For now, the Medicare decision affects only hospitals. So why should physicians worry?
Although under the never-event rule physicians may still bill for their services when a mistake on Medicare’s list occurs in the hospital, Gosfield says those days are numbered. “I think at some point that will change,” she says. “There’s going to be more and more emphasis on shared clinical responsibility for patients — that you should pay attention to where you are referring to and who you’re taking referrals from.