100,000

This blog and sleepdoctor reached 100,000 hits a few minutes ago.

Thanks for reading.

http://cosmos.bcst.yahoo.com/up/player/popup/index.php?cl=5553011

Anticonvulsants for Alcoholism

Several studies studies support the use of the anticonvulsant Topiramate (Topamax) for alcohol dependence.
A new study supports the use of Gabapentin (Neurontin) in the early post-withdrawal period:
NEW YORK (Reuters Health) Dec 17 - The anticonvulsant gabapentin reduces alcohol consumption and craving during treatment for alcohol dependence, Brazilian researchers report in the Journal of Clinical Psychiatry for November.
Dr. Fernando A. Furieri, at the Vitoria Municipal Addiction Treatment Center, and Dr. Ester M. Nakamura-Palacios, at the Federal University of Espirito Santo in Vitoria, conducted a randomized, double-blind trial involving 60 subjects, whose average consumption exceeded 35 drinks per week.
After a 7-day treatment for acute withdrawal, subjects were randomly assigned to gabapentin up to 600 mg/day, or placebo for 28 days. Thirty-nine patients had used diazepam during the acute phase; 15 in the placebo group and 13 in the gabapentin continued to do so during the trial phase.
The number of drinks per day, per week, and over the 4-week course of treatment had declined significantly more in the gabapentin group than in the placebo group. Gabapentin was also associated with fewer heavy drinking days and more days of abstinence. The authors note that 20 subjects in the gabapentin group and 13 in the placebo group maintained complete abstinence.
According to scores on the Obsessive Compulsive Drinking Scale, craving for alcohol was also reduced significantly more by gabapentin.
"Gabapentin has shown great potential in the treatment of alcohol dependence and withdrawal syndromes," either as monotherapy or as an add-on pharmacotherapy, the authors conclude.
J Clin Psychiatry 2007;68:1691-1700.

Non-anticonvulsants useful for the treatment of alcohol dependence include antabuse, naltrexone, and acamprosate.

The World's most dangerous country

http://digg.com/health/Angry_Thai_Women_Lead_the_World_in_Penis_Slashings?OTC-widget

Different duty of care for psychiatrists and internists

A member of iMedExchange posted about this article:
A general practitioner who slept with a patient's wife -- who was also a patient -- can't be sued for malpractice in Pennsylvania, a three-judge panel concluded, affirming a decision issued by the Philadelphia Court of Common Pleas last year in Long v. Ostroff. Sexual misconduct "may be unethical," the court noted, but state law doesn't recognize such a claim for professional negligence because a general practitioner's duty of care doesn't prohibit that behavior. Unlike psychiatrists, who have a "special duty" to refrain from engaging in sexual relations with a patient's spouse, general practitioners don't have such a duty, Senior Judge Justin M. Johnson explained.
I wonder which standard would apply to me. I am boarded in Internal Medicine and Psychiatry. I primarily practice sleep medicine, which is a subspecialty of both internal medicine and psychiatry. Most insurance plans don't recognize sleep medicine as a specialty, and some list me as internal medicine and some as psychiatry. I took the old sleep boards as well as the new sleep boards (results pending) as an internist. As much as the legal process fascinates me, I guess I better not try to become the subject of a Supreme Court case.

R.I.P.

LAS VEGAS (AP) -- David "Chip" Reese, a card star who won one of the biggest cash games in the world and three World Series of Poker championships, has died. He was 56.
Reese died in his sleep and was found by his son early Tuesday morning at his Las Vegas home after suffering from symptoms of pneumonia, said poker great Doyle Brunson, his longtime friend.
Despite winning three World Series champion's bracelets over the last four decades, including a $1.8 million HORSE event in 2005 that combines five poker disciplines, Reese focused his attention on high-stakes cash games away from the limelight.
"I've seen him with a million dollars in front of him," said Dalla, describing how Reese would put out racks of $5,000 chips "like he was betting a few bucks."
Reese was part of a generation of players in the 1970s that challenged established greats like Brunson, Thomas "Amarillo Slim" Preston Jr. and Walter Clyde "Puggy" Pearson, Dalla said.

Chantix Linked to Suicide

The U.S. Food and Drug Administration is looking into reports that the anti-smoking drug Chantix may trigger mood swings and thoughts of suicide in patients taking it.
Information provided to the agency by Chantix manufacturer, Pfizer Inc. cited "erratic behavior" in an individual who had used Chantix. The agency is also investigating the death of the person who used the drug, but was also under the influence of alcohol.
The FDA has asked Pfizer for any additional information it has on reports of adverse reactions in people taking the drug. Its Center for Drug Evaluation and Research is analyzing the data and plans to release its findings to the public once the analysis is completed.
In the meantime, the agency recommends that health care providers monitor patients taking Chantix. Patients taking Chantix should contact their doctors if they experience behavior or mood changes, the FDA said.
The FDA also advises that patients taking Chantix use caution when driving or operating machinery due to reports of drowsiness.
From Foxnews
Ultimately, I don't think this is going to pan out. I don't think that Chantix causes suicide. However, in the short term I forsee further declines in Pfizer's stock price. Currently, it's just above its 52 week low. I think Pfizer will be a good buy at around 20, and recommend waiting until then to buy Pfizer.

Doctors in Debt

Cnn.com Business Section presents a case study of 2 residents deeply in debt:

It's all supposed to pay off, of course. Once they become full-fledged doctors (attending physicians, in the trade), they'll have six-figure incomes, more reasonable hours, a respected occupation and work that they love.
But for this generation of doctors, and for Meg and Chris in particular, financial security won't come guaranteed with their medical licenses. As health-care economics squeeze physician salaries, rising college and med school tuitions are putting young doctors ever deeper in the hole.
Chris and Meg live frugally, work hard and are making the kind of investments in their future that would make any parent proud. But they're also on track to finish their medical training in the next few years with a staggering $700,000 in debt.

Drug Company Lunches

I once sneezed all over a fresh pan of Olive Garden lasagna multiple times. The big, fat office hogs never noticed. They sucked it down like there was no tomorrow.
Read this site before you eat any more drug company lunches.
( via Kevin MD)

Getting Spanked

More banks brace for subprime spanking
I saw this headline in the green section of USAToday this morning.

Rather unprofessional language for a major newspaper. Within a few years we'll probably be reading about the Dow being "bitch-slapped" in the pages of USAToday ("bitch-slapped" is probably a good term to describe today's 55 point drop).

The death of sleep medicine

Please see my post on sleepdoctor about portable testing for obstructive sleep apnea.

I wish to thank Kevin, M.D. for linking to it.

Mississippi's Governor

Mississippi's Governor, Haley Barbour, has been ranked as one of the country's most influential conservatives:
About to be comfortably re-elected as Mississippi governor, Barbour is one of the most accomplished Republican executives in the United States. As a successful Southern governor with immense experience, he is a potential future presidential candidate who would be a clever pick for vice-presidential running mate in 2008. Received national plaudits for his handling of the aftermath of Hurricane Katrina, which devastated Mississippi's Gulf coast, while neighbouring Louisiana's Democratic governor floundered.Barbour, 60, has cut his state's budget deficit in half without raising taxes and used the skills he honed as a Washington lobbyist to good effect in winning over a Democratic-led state legislature. A highly successful chair of the Republican National Committee, Barbour helped lay the foundations for the Republican Revolution and the takeover of Congress in 1994.
(via Drudge)

Atheism

They say that there are no atheists in foxholes. Being unable to sell one's house can also turn a person away from atheism:

The Catholic saint has long been believed to help with home-related matters. And according to lore now spreading on the Internet and among desperate home-sellers, burying St. Joseph in the yard of a home for sale promises a prompt bid.
With the worst housing market in recent years, St. Joseph is enjoying a flurry of attention. Some vendors of religious supplies say St. Joseph statues are flying off the shelves as an increasing number of skeptics and non-Catholics look for some saintly intervention to help them sell their houses.
Some Realtors, too, swear by the practice. Ardell DellaLoggia, a Seattle-area Realtor, buried a statue beneath the "For Sale" sign on a property that she thought was overpriced. She didn't tell the owner until after it had sold. "He was an atheist," she explains. "But he thanked me."
Catholic leaders also say that faith and devotion are necessary, in addition to burying a statue, otherwise the practice amounts to little more than superstition or magic. But they are also enjoying the saint's newfound popularity. "If they have a good result and they think it was St. Joseph, it might inspire them to practice more," says Msgr. Connell.

Mediocre Care for the Poor Elderly

Vulnerable elderly receive mediocre health care, study finds
The quality of care for vulnerable elderly people on Medicaid and Medicare is “mediocre,” the authors of a new study concluded.
Researchers did a cohort study of 100,528 dual Medicaid/Medicare enrollees from 19 California counties who were age 75 and older in 1999 and 2000. They measured the care provided for 44 quality indicators (QIs) by condition, like heart failure, and intervention, such as medication, using QIs developed by the Assessing Care of Vulnerable Elders project. The article was published in the October Medical Care.
This study, as summarized by the American College of Physicians, found "medicore" care for elderly dual Medicare/Medicaid enrollees. This is the sickest, toughest population to treat. Reimbursement is less than mediocre, though that's no excuse.

Keeping Kids Calm with Video Games

If ritalin isn't enough, child psychiatrists have found a new way to keep children calm- video games. Psychiatric Times presents a case in which playing video games 6-7 hours a day helped a child's self esteem:
Case Vignette: Games and Attention/ Learning Disorders
Alex, a 13-year-old boy, spends 6 to 7 hours a day playing video games. He locks himself in his room, misses meals, and often stays up most of the night, which results in school tardiness. He learns "cheats" (tricks to find quick solutions to game-based problems) online, converses with players in chat rooms, and has accumulated a great deal of knowledge about the intricacies of the many, often violent, games he plays.
Although very bright, Alex has a nonverbal learning disability, social difficulties, poor athletic skills, and attention problems, and he was often made fun of at school. The primary source of his self-esteem, beyond academic achievement, is his video game prowess.
His parents have no understanding of the games, nor of the video games' central importance in his life. Other children in school often come to him for advice about games and strategies and ask to play with him. This has become his claim to fame in and out of school.
While his parents need to educate themselves about the games he is playing and to set limits on his game play, their initial response to curtail them has been modified over time, allowing for an important avenue in the socialization of their son.
Therapy for Alex and his parents involved their appreciation of the role and meaning of games in his life. His parents needed to understand that competence is a crucial component of positive self-esteem—something Alex needed tremendously in order to take on academic and social challenges. Video games provided a means for Alex to feel more confident in moving ahead in these areas. With a greater understanding of the role the games played in his life, his parents were much more tolerant of his game playing.
If your child doesn't play video games, it could be a problem:
Ironically, Seung-Hui Cho's college roommates found it odd that he never joined them in playing video games.
(Seung-Hui Cho was the Virginia Tech shooter)

The full article, Children and Video Games: How Much Do We Know? by Cheryl K. Olson, ScD, Lawrence Kutner, PhD, and Eugene V. Beresin, MD is on the Psychiatric Times website.

I encourage readers of this blog to read the full text of this distubing article. Ritalin and video games... what will child psychiatrists recommend next to control our children???

Gray Friday

The Dow Jones industrial average dropped more than 360 points Friday - the 20th anniversary of the Black Monday crash - as lackluster corporate earnings, renewed credit concerns and rising oil prices spooked investors.
The major stock market indexes turned in their worst week since July after Caterpillar Inc. (CAT), one of the world's largest construction equipment makers, soured investors mood Friday with a discouraging assessment of the U.S. economy. In a week dominated by mostly negative results from banks facing difficult credit markets and rising mortgage delinquencies, investors appeared surprised that an industrial name was feeling an economic pinch, too.

The Dow fell 366.94, or 2.64 percent, to 13,522.02. The Dow was down for the fifth straight session and for the week was off 4.05 percent. For the year, the blue chip index is now up 8.5 percent.
Broader stock indicators also fell sharply Friday. The Standard & Poor's 500 index fell 39.45, or 2.56 percent, to 1,500.63, and the Nasdaq composite index dropped 74.15, or 2.65 percent, to 2,725.16.

Friday's pullback pales in comparison to what investors had to contend with 20 years ago. On Oct. 19, 1987 - Black Monday - the Dow plunged 23 percent amid concerns about interest rates and slowing economic growth. A decline of similar proportion given the market's current levels would mean a drop of some 3,100 points.
Friday's decline - the third biggest point and percentage drop this year - was the 9th biggest point drop in the Dow since Black Monday.

via Drudge

Winning a Nobel Prize Doesn't make you Right

Al Gore is wrong about the role of humans in global warming. James Watson, one of the discoverers of the mysteries of DNA, is wrong about genes and racial intelligence:
One of the world's most eminent scientists was embroiled in an extraordinary row last night after he claimed that black people were less intelligent than white people and the idea that "equal powers of reason" were shared across racial groups was a delusion.
James Watson, a Nobel Prize winner for his part in the unravelling of DNA who now runs one of America's leading scientific research institutions, drew widespread condemnation for comments he made ahead of his arrival in Britain today for a speaking tour at venues including the Science Museum in London.
The 79-year-old geneticist reopened the explosive debate about race and science in a newspaper interview in which he said Western policies towards African countries were wrongly based on an assumption that black people were as clever as their white counterparts when "testing" suggested the contrary. He claimed genes responsible for creating differences in human intelligence could be found within a decade.
from The Independent

Stark III

Stark version three is apparently out:

In issuing the third phase of the final regulations implementing the physician self-referral rule, also known as the Stark law, the Center for Medicare and Medicaid Services has returned to a stance it held in the first phase.
The Stark law governs whether, how, and when it is acceptable for physicians to refer patients to hospitals, laboratories, imaging facilities, or other entities in which they may have an ownership interest.
Under the new rule, known as Stark III, published in the Federal Register on Sept. 5, physicians will be considered to be “standing in the shoes” of the group practice when their investment arrangements are evaluated for compliance, according to several attorneys.
This reversion back to the initial Stark policy is among the most important changes in the 516-page document, said Daniel H. Melvin, J.D., a partner in the health law department of McDermott, Will & Emery's Chicago office.
As a result, “the application of exceptions will be different going forward,” Mr. Melvin said in an interview.
That means most physicians who have referral arrangements will have “a lot of contracts that will have to be looked at and possibly revised,” said Amy E. Nordeng, J.D., a counsel in the government affairs office of the Medical Group Management Association. Ms. Nordeng agreed that the return to the “stand in the shoes” view was the most significant component of Stark III.
Under Stark II—an interim policy that began in 2004—physicians were considered to be individuals, outside of their practices.
Exceptions to the law were evaluated using an indirect compensation analysis, which ended up being onerous and was the subject of many complaints to CMS. In comments on Stark II, physician groups, hospitals, and other facilities (called designated health services, or DHS entities under the Stark law) urged CMS to revert to the old policy.
CMS itself came to see the indirect compensation analysis as a loophole that allowed potentially questionable investment arrangements to slip through, said Mr. Melvin.
In the Stark III rule, CMS wrote that the change in policy means that, “many compensation arrangements that were analyzed under Phase II as indirect compensation arrangements are now analyzed as direct compensation arrangements that must comply with an applicable exception for direct compensation arrangements.”
There were several other notable changes in Stark III.
The regulations clarify that physicians who administer pharmaceuticals under Medicare Part B (such as chemotherapy or infusions) or who prescribe physical therapy, occupational therapy, and speech-language pathology, are entitled to get direct productivity credit for those orders, said Mr. Melvin.
The clarification applies to those two ancillary services only, not to radiology or laboratories, or other services typically offered in-house, he said.
CMS also lifted the prohibition on noncompete agreements. Under Stark II, practices could not impose noncompete agreements on physician recruits. Now, practices can bar competition for up to 2 years, but it's not clear how far, geographically, that noncompete can extend, he said.
With the new rule, practices have to “go back and look at everything,” including how their physicians are being compensated and the arrangements the practice may have for equipment and leasing or services with hospitals or other DHS entities, Mr. Melvin said.
“At the very least, they're going to want to do a review of the arrangements in place,” to see if any of the exceptions being relied on will change with Stark III, added Ms. Nordeng.
The final Stark rule goes into effect on Dec. 5, 2007.

It's all pretty confusing to me. However, it is my understanding that sleep labs are not considered DHS entities so hopefully Stark III won't affect me too much.

Mississippi is Number One

Adult obesity is on the rise in 31 states, and no states have experienced a drop in obesity, according to a study from Trust for America's Health.
Mississippi topped the list of the fattest states, with the highest adult obesity rates for the third year in a row. More than 30% of the adult population in the state is obese. Colorado was ranked the “leanest” state with an obesity rate of 17.6%. No state has reached the Health and Human Services department goal of reducing the prevalence of adult obesity to 15% in every state by 2010.
From Clinical Psychiatry News

Go Ahead and Light up a Cigarette

Clinical Psychiatry News reports that cigarette smoking delays the onset of Parkinson's disease:
A pooled analysis of 11 clinical studies has confirmed that cigarette smoking protects against Parkinson's disease in a dose-dependent manner.
Many studies have suggested that smoking may play a protective role in PD, but most have been too small to provide definitive answers. Dr. Beate Ritz of the University of California, Los Angeles, and associates conducted a pooled analysis of eight case-control studies and three cohort studies involving 2,816 subjects who had PD and 8,993 controls. This large data set “enabled us to investigate aspects of cigarette smoking and subgroup-specific associations that could not be addressed adequately in previous studies,” they noted.
The risk of developing PD decreased as pack-years of cigarette smoking increased, so that the average relative risk for the disease dropped 5%–8% for every 10 pack-years of smoking. This dose-response pattern was seen in both men and women, and it was not affected by subjects' educational status.
There was also a strong dose-response trend for the number of years that had elapsed since smoking cessation. Current smokers and smokers who had recently quit showed the lowest risk for PD. People who had quit smoking in the past had a higher risk for PD, but their risk was still lower than that of people who had never smoked (Arch. Neurol. 2007;64:990–7).
Two possible mechanisms for this protective effect have been proposed. Substances such as nicotine in tobacco smoke may promote the survival of dopaminergic neurons, or smoking may alter the activity of metabolic enzymes and thus the production of toxic metabolites.
It is also possible that the same genetic or constitutional traits that raise susceptibility to PD may also deter subjects from smoking. Such traits could be a common cause for both smoking behavior and PD, Dr. Ritz and associates noted.
Tobacco's protective effect appeared to wane in subjects aged 75 and older, another finding that has been reported in previous studies. This is consistent with the hypothesis that smoking delays rather than prevents the onset of PD, the researchers added.
So if you are more scared of PD than lung cancer, COPD, and heart disease, go ahead and smoke!

Psychiatry Residency Training Becomes Even More Wimpy

Psychiatry, the easiest of the residency programs, is becoming even easier:

The Accreditation Council for Graduate Medical Education has reduced the amount of inpatient training necessary for psychiatry residents from a minimum of 9 months to a minimum of 6 months.
At least two psychiatrists who supervise residents say this reduction, which took place in July, “threatens to seriously undermine the quality of training for psychiatry residents.” In a commentary, Dr. Sabina Lim and Dr. Robert Rohrbaugh argue that inpatient training helps foster the development of psychiatry's fundamental skills in indispensable ways, and they note that other specialties appear to place great value on inpatient training (Academic Psychiatry 2007;31:266–9).

Poker and Investing

Sand105 posted an interesting essay on the similarities between poker and investing on the Motley Fool message boards. Here is part of it:
So how are poker and investing similar and dissimilar?
Similarities:1. Most importantly, both games involve incomplete information and randomness. The skill sets developed in one apply directly over to the other. Developing a logic train, calculating odds, and accurately inferring conclusions from incomplete information are exactly what is needed to be successful in both.
2. Both are beatable over the long term. Poker is equivalent to playing one game of chess along with a couple die rolls. Over the short term the die rolls rule – over the long term the chess matches determine the expectation. Equity investing is essentially the same.
3. Both have inherent costs. Poker has rake (5% of each pot, give or take), investing has transaction and frictional costs.
4. Both see black swans occur. No matter the skill set, sometimes the incredibly unusual occurs. Knowing how to recover from these setbacks is a very valuable skill set.
Dissimilarities:
1. By its nature, poker is a negative expectation game if no players are better than one another (due to the rake). Investing naturally has a long term ~10% positive tilt due to the nature of the markets.
2. The inherent costs in investing are lower. As long as the investor doesn’t have huge turnover, transaction costs and frictional costs are well under the cost of rake in poker.
3. More often than not, choosing to do nothing in investing is the right choice. Poker typically requires more risk taking events.
4. The variance in investing is lower than poker. For every $1 I have made in poker over the long haul there has been a ~$10 standard deviation in those results (i.e. for every $1 there is a 67% chance my result will actually be from -$4 to $6 and a 95% chance it will actually be from -$9 to $11.) This type of variance isn’t typical of the equity markets.
5. In poker, to win in the long term a player simply tries to ride out the variance. An investor, however, can use variance to their benefit. BMW has talked about this extensively. Figuring out to what price an equity is likely to jog down to in the short term can greatly juice overall returns.
Lessons Learned:
As a person who has played over 1,000,000 hands of poker in the last few years and been involved in the markets for 15+ years, there are some things that I have learned that I hope folks will find useful.Pretty much in the order I think they are important, these are lessons I think provide for success in both poker and equity investing:
1. Emotional control. Yep, after all the talk about logic trains and odds, I firmly believe emotional control has the most effect on long term results. This is multifaceted. The primary emotion one needs to regulate is tilt (“fear”). Selling in panic is very, very often the exact wrong thing to do. Yet even very experienced investors have it happen. It can’t be stomped out completely – however minimizing it will do wonders for an investor’s return. On the flip side of the coin boredom can be almost as damaging. Playing a hand one shouldn’t or making a trade just because you haven’t had anything enticing float by in a while is usually a mistake. Coincidentally, Whatismyoption has just posted an excellent thread on this subject: http://boards.fool.com/Message.asp?mid=25872875&sort=whole#25876516
2. Recognize that once you buy and equity or put your money into the pot, that money should be treated as if it is no longer yours (in poker it actually is no longer yours). Most people base decisions on selling an equity based on whether or not it has been performing for them. This is wrong! It doesn’t matter if the equity has lost a bunch or gained a bunch since ownership – it is the prospects for the future, the odds that one will see a rise from that price point, that count. In a game sense, when you buy an equity you give your money to Mr. Market. He then takes it and walks around with it – you have no direct control over that walk at all. You are simply betting on the overall direction of his travels. All decisions should be based on that premise. Since most investors feel the loss of money as near physical pain (lots of studies out there on investor psychology), they watch their returns like a hawk and decide to sell based on past performance. Sell decisions should be based on changes in how speculative a stock is, changes in fundamentals, tax loss harvesting, finding a better opportunity, etc. Price by itself, and your buy point relative to that price, is irrelevant.
3. Recognition of high probability situations. Dhandho, in other words. Figure out how to get your money into play with a 60-40 advantage over and over and riches will follow. In investing there are choices every day to hold, buy or sell. Most of the time this will be to hold, but when the high probability situations roll by, grab on and get a piece.
4. The corollary to #3. Don’t bet unless you have lopsided odds. Taking those 51-49 bets, though positive, leads to very high variance. Leave that to the institutional investor who has the bankroll to spread those bets around in enough places to get to the long term. Most individual investors will never get there.
5. Playing games, chess, poker, etc keep the mind agile and greatly assist in both business and investing. Mental cross training. Learning emotional control. Recognizing that both poker, investing, business, and other difficult-but-satisfying-activities are lifelong pursuits and ones in which there is always something new to learn and improvements to be made.

I have found that poker (online Texas no-limit hold'em), stock trading, and sleep medicine are very similar- all three involve long hours staring at a computer screen.
Stock trading and interpreting a sleep study both involve looking at sometimes ambiguous sinusoidal data and trying to interpret the pattern. Online poker and sleep medicine both involve looking at flickering lights/constantly changing patterns on a screen.

Bipolar Disorder Overdiagnosed in Children

The New York Times reports on the alarming increase in the diagosis of bipolar disorder in children:
The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers are to report on Tuesday, in the most comprehensive study to look at the controversial diagnosis. And experts say the numbers have almost certainly risen further in the years since.
But others argue that bipolar disorder is overdiagnosed. The term, they say, has become a diagnosis du jour, a catch-all now applied to almost any explosive, aggressive child. Once children are labeled, these experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side-effects, like rapid weight gain.
“From a developmental point of view, we simply don’t know how accurately we can diagnose bipolar disorder, or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness,” he said. “The label may or may not reflect reality.”
Most children who qualify for the diagnosis do not go on to develop the classic features of adult bipolar disorder, like mania, researchers have found. They are far more likely to become depressed.
Others say their children have suffered from side effects of drugs given for bipolar disorder, without getting much benefit.
Ashley Ocampo, 40, of Tallahassee, Fla., the mother of an 8-year-old boy, Nicholas Ryan, who is being treated for bipolar disorder, said that he had tried several antipsychotic drugs and mood stabilizers, and that he had been better lately.
But, she said in an interview, “He has gained weight, to the point where we were struggling find clothes for him; he’s had tremors, and still has some fine motor problems that he’s getting therapy for.”

What do you call a nurse practitioner?

Codeblog recently posted on the dilemma of whether a nurse should call a physician by his first name. I frequently encounter a similar problem in my sleep practice: how to address a nurse practitioner in a letter.
For example, suppose a Certified Family Nurse Practitioner named Jane Doe has referred me a patient and I am sending her a consult note. Is it more proper to say "Dear Mrs. Doe", "Dear Ms. Doe", "Dear Nurse Doe", "Dear Nurse Practitioner Doe", or "Dear Jane Doe, CFNP"??

This is how I usually address the letter:

Jane Doe, CFNP
123 Maple Street
Jackson MS 39323

Dear Jane Doe, CFNP

Thank you for referring Mr. Smith for...

If I know the Nurse Practitioner's supervising physician's name, I will usually cc him at the bottom of the letter, esp on Medicare patients. This helps to justify billing the patient as a consult rather than a new patient.

Preparing for a career in sleep medicine

Dear Sir,
I am currently enrolling for classes at Brigham Young University - Idaho. I have an interest in sleep therapy and sleep studies. I was wondering if you could offer me some advice as to what kind of Bachelors degree would best suit this line of work. I was thinking that Biology might prepare me the best for medical school. I was wondering if a degree in psychology would be better? I was also thinking about minoring in Health Science. Would this help my occupational and academic choices later on in the field of sleep studies? Thank you for your time.

My response to this letter from a reader:

Sorry about the time to get back to you.

The best type of Bachelors degree would be the one to prepare you for medical school. Any major would be fine, but you will need to take a yr of bio, chem, physics, and organic chem during college, preferably in the first 2 years. Some med schools require calculus. A class in basic statistics would be also be helpful. It would be easiest to fit these pre-med requirements into a bio or biochem major, but you can take any major. Don’t worry about planning for a sleep career until near the end of med school.

Good luck

Michael Rack, MD

The AMA is Threatening me

I recently received the following letter from the Mississippi State Medical Association, Central Medical Society (the branch of the American Medical Association covering central Mississippi):

July 18, 2007





Michael J. Rack, M.D.


1006 Treetops Boulevard


Suite 2


Flowood, MS 39232





Dear Doctor Rack:





2007 is well underway and we have not yet received your membership dues. Our records show that you have not paid your local, state, or AMA dues for 2007. I'm sure this is just an oversight, so please use the enclosed envelope to send your check right away. Pease make your check payable to Mississippi State Medical Association.





According to the MSMA Bylaws, physicians who have not paid annual dues by April 1 forfeit membership privileges and must be removed from the membership roster. Membership in the Mississippi Physician (its actually, plural -Physicians, but I have tried to reproduce the letter as closely as possible) Care Network (MPCN) is also in jeopardy.





MSMA continues working to protect the doctor-patient relationship and to enhance the climate in which physicians practice. I encourage you to continue your membership by remitting your dues right away, beause together we are stronger.





Sincerely,





William M. Grantham, M.D.


President


________________________________________________________________


Return this portion with your dues





2007 REQUIRED DUES





Central Medical Society $90.00


MSMA Dues $450.00


AMA Dues $ 300.00


_______





Total Required Dues $840.00





2007 OPTIONAL DUES





MMPAC/AMPAC $150.00


Alliance Dues $90.00


________





Total Optional Dues $240.00








Total Required and Optional Dues $1080.00








The AMA is threatening me with loss of provider status in a key local insurance network, the Mississippi Physicians Care Network (MPCN), if I do not send $840 to the AMA. I will not give in to this corrupt organization. I will probably drop out of the MPCN, though I believe I have the option of sending an amount roughly equivalent to the $840 AMA fee to the MPCN to stay in their network. I would rather that the MPCN get my money than the AMA. I don't give in to extortion. This is one less physician that the tools in the AMA will be representing.

Crackdown on Juvenile Sex Offenders

Sexual offender registeries, once primarily for adult sexual offenders, are increasingly aimed at teenagers:

Since 1994, federal legislation has required many sex offenders to register with the police, which can aid sex-crime investigations. But Megan’s Law, which went into effect in 1996, mandates that law enforcement also notify the public about certain convicted offenders in their communities. One of the ways states do this is through publicly accessible Web sites. At least 25 states now apply Megan’s Law, also known as a community-notification law, to juveniles, according to a recent survey by Brenda V. Smith, a law professor and the director of the National Institute of Corrections Project on Addressing Prison Rape at American University’s Washington College of Law. That means on many state sex-offender Web sites, you can find juveniles’ photos, names and addresses, and in some cases their birth dates and maps to their homes, alongside those of pedophiles and adult rapists.

However, juvenile sex offenders are different from adult sex offenders:

Adult models, he notes, don’t account for adolescent development and how family and environment affect children’s behavior. Also, research over the past decade has shown that juveniles who commit sex offenses are in several ways very different from adult sex offenders. As one expert put it, “Kids are not short adults.”

while most juveniles who have committed sex offenses are boys around 13 or 14, in other ways they are not a homogeneous population. Though a small percentage — no one knows how many — will become adult rapists or pedophiles, the vast majority, 90 percent or more, will not, Chaffin says. Most have not committed violent assaults or abused multiple children repeatedly. Usually they have had sexual contact — from fondling to oral sex to intercourse — with a child who is at least two years younger than they are. Also, many of the juveniles have been sexually abused themselves, and as a consequence, they act out sexually, typically for a transitory period.

Some, whether they have been abused or not, are what therapists call “naïve experimenters” — overly impulsive or immature adolescents who are unable to approach girls or boys their own age; instead, they engage in inappropriate sexual acts with younger children. Others are generally delinquent juveniles for whom sexual abuse is just one of the ways they break laws, and according to studies, they are much more likely to commit a property crime than they are to commit a second sex offense. They are from working-class, middle-class and upper-middle-class homes, from intact families as well as very broken ones. There are also a number of children — how many is unclear — who are adjudicated for what some therapists would say is “playing doctor” or normative “sexual experimentation.” These are broadly considered to include sexual acts that are spontaneous, intermittent and “consensual” (legally, children under 16 usually cannot consent to sex) between youths within a couple of years age. Similarly, there are the so-called Romeo and Juliet cases, like the highly publicized one in Georgia involving Genarlow Wilson, who is serving an 11-year prison sentence for having consensual oral sex with a 15-year-old girl at a party when he was 17. There have also been court cases of 12- and 13-year-old boys who grabbed girls’ breasts or buttocks in school hallways and were adjudicated as “sex offenders.”

According to the Diagnostic and Statistical Manual of Mental Disorders, a diagnosis of pedophilia requires a person to be at least 16 years old and with “recurrent, intense, sexually arousing fantasies” over a period of six months or longer, that he acts upon with a child who is at least five years younger. Many sex-abuse therapists, however, say they’d be wary of diagnosing pedophilia in even a 16- or a 17-year-old. At 16, a teenager’s history of sexual interest is relatively short, notes David Prescott, a therapist and the president-elect of the Association for the Treatment of Sexual Abusers, and it is still subject to change, compared with the history of a 40-year-old who is sexually attracted to young children.

Some of the juvenile sex offenders are being discovered by neigbors and classmates:

Kids Google one another’s names; curious neighbors type in their ZIP codes on sex-offender Web sites. And the problems begin.

Last year, an eighth grader at a Delaware middle school arrived one morning to find kids in the hallway pointing at him and snickering. At first, the boy, Johnnie, who asked me protect his privacy by identifying him by a friend’s nickname for him, was confused. He thought it might be because of his new haircut. Then one kid called him a rapist. Another jeered, “Hey, aren’t you a sex offender?” One teenage boy threatened to beat him up.

Drug Interactions can cause Pregnancy

The Cortlandt Forum describes an interesting malpractice case in which a drug-drug interaction between Tegretol and a birth control pill led to pregnancy:

The 32-year-old woman suffered from bipolar disorder and depression, which she claimed were exacerbated by a divorce and the difficulties of her young son, who had developmental problems. Dr. T referred her to a psychiatric clinic under the care of Dr. P. The psychiatrist started her on bupropion (Wellbutrin) for depression and the anticonvulsant carbamazepine (Tegretol) for her bipolar disorder.

After her discharge from the clinic, the patient continued to see Dr. T. She told him she was “in a relationship” and was taking norethindrone and ethinyl estradiol (Norinyl 1/35) for contraception. Several months later, she announced that she was pregnant despite the oral contraceptive (OC) and had been advised there was a chance of birth defects because she was taking carbamazepine during the first trimester.

The woman decided to have an abortion. During counseling at an abortion clinic, she was told that carbamazepine could interfere with the contraceptive effectiveness of norethindrone and ethinyl estradiol. A plaintiff’s expert later explained that carbamazepine could induce liver enzymes that metabolize estrogen, further reducing the efficacy of the hormone, which is already at a low dose in Norinyl 1/35.

The case proceeded through the depositions and other discovery, then settled for $135,000 a month before trial.

Tegretol (carbamazepine) is a notorious hepatic enzyme inducer. It induces cytochrome P450 3A4, leading to reduced serum levels of birth control pills. Another medication that can do this, although to a lesser extent, is Provigil (modafinil). I warn all my female patients taking Provigil that it can reduce the effectiveness of birth control pills.

The Quantum State of Cheney

Normally I try to avoid non-medical political commentary on this blog, but I found this Tom Tomorrow cartoon too clever to skip (try clicking on the cartoon or click here if it is too small to read). Although Tomorrow's politics are the opposite of mine, this is one of the best political cartoons I have seen and therefore I'm going to feature it today.

I find the field of quantum mechanics to be fascinating, though my my limited mathematical background only permits a superficial understanding.

If one subscribes to the Many Worlds interpretation of quantum mechanics, one could imagine billions of parallel universes, a few in which Cheney is all executive or all legislative, but most containing a Cheney who is a mixture of executive/legislative. There would also be some in which Cheney is neither, and Gore or Kerry is President- a scary thought.

Practicing Pelvic exams

A commenter asks:

I've been in practice for 30 years,and teach medical students.I went to med school in Vt and FP residency in Mn. I never heard of practicing pelvic exams in woman under anesthesia. Was this the standard practice in any medical school or an urban myth?

Practicing pelvic exams in women under general anesthesia was not done when I was a medical student (93-97) or resident. Can any older docs confirm if this was ever done??

Learning Pelvic Exams

A commenter on Kevin MD asked:

Is it still true today that anesthesized female patients in the OR provide the opportunity for med students to practice pelvic/rectal exams in secret? Secret from the patient who has no idea this is happening to her? Supposedly the vague consent form the patient signs before the operation is the legal cover teaching hospitals and doctors hide behind to justify this clandestine procedure.I wonder if the surgeon would resent the patient should he or she be asked that the practice not be done. Or might the request not even be honored. The idea of medical students lining up to probe and examine the vagina of an unsuspecting unconscious patient for their own benefit, in my opinion, is nothing short of medical rape.

Medical students are no longer allowed to practice pelvic exams on anesthesized female patients.

Most medical students learn the basics of a pelvic exam from "standardized patients."
Below is a link about standardized patients:
http://uwnews.org/uweek/uweekarticle.asp?articleID=27384

However medical students still need to practice to get good, and many leave medical school without the ability to do an adequate pelvic exam. Some learn how to do it during OB/GYN rotations, but in many cases the patients on OB/GYN services don't want students to examine them. Therefore many doctors don't become proficient at pelvic exams until residency, if it all.

The Problems with HIPAA

The 1996 Health Insurance Portability and Accountability Act (HIPAA) has led to family members and caretakers being unable to access needed information about a patient:

Government studies released in the last few months show the frustration is widespread, an unintended consequence of the 1996 law.
Hipaa was designed to allow Americans to take their health insurance coverage with them when they changed jobs, with provisions to keep medical information confidential. But new studies have found that some health care providers apply Hipaa regulations overzealously, leaving family members, caretakers, public health and law enforcement authorities stymied in their efforts to get information.

The law is unclear, and in most cases the safest thing to do is not share information:

Some reports blame the language of the law itself, which says health care providers may share information with others unless the patient objects, but does not require them to do so. Thus, disclosures are voluntary and health care providers are left with broad discretion.

Teaching staff to protect records is easier than teaching them to share them, said Robert N. Swidler, general counsel for Northeast Health, a nonprofit network in Troy, N.Y., that includes several hospitals.
“Over time, the staff has become a little more flexible and humane,” Mr. Swidler said. “But nurses aren’t lawyers. This is a hyper-technical law and it tells them they may disclose but doesn’t say they have to.”

Of the 27,778 privacy complaints filed since 2003, the only cases investigated, she said, were complaints filed by patients who were denied access to their own information, the one unambiguous violation of the law.

So as long as you give patients access to their own information, there is no penalty for being secretive with most others, leading to situations like this:

Birthday parties in nursing homes in New York and Arizona have been canceled for fear that revealing a resident’s date of birth could be a violation.

Patients were assigned code names in doctor’s waiting rooms — say, “Zebra” for a child in Newton, Mass., or “Elvis” for an adult in Kansas City, Mo. — so they could be summoned without identification.

Nurses in an emergency room at St. Elizabeth Health Center in Youngstown, Ohio, refused to telephone parents of ailing students themselves, insisting a friend do it, for fear of passing out confidential information, the hospital’s patient advocate said.

State health departments throughout the country have been slowed in their efforts to create immunization registries for children, according to Dr. James J. Gibson, the director of disease control in South Carolina, because information from doctors no longer flows freely.

8 Random Facts Meme

I have been tagged by Sleep Expert, Steve Poceta MD (he actually tagged my other blog, sleepdoctor, but I try to keep the tone of that blog very professional so I am responding to the meme here).

Here are 8 random facts about myself:

1. I am married and have 2 children.
2. The Republican party is too liberal for me.
3. I own 100 shares of Respironics.
4. I like to gamble, and especially like to play No Limit Texas Hold'em.
5. I am an active member of the American Academy of Sleep Medicine, currently serving as a site visitor (I inspect sleep labs for accreditation). I am also a member of the Behavioral Sleep Medicine Committee.
6. I am medical director of Somnus Sleep Clinic.
7. I do locum tenens work in the Alabama prison system.
8. I'm not originally from the South.


Below are the 8 bloggers (all fellow southerners) I have tagged to share something about themselves:

A chance to cut is a chance to cure
RangelMD
Doctor Hebert
DB's Medical Rants
Scalpel or Sword?
MyHeartOnMySleeve
Just Practicing
GruntDoc

Darth Vader's Psychopathology

Shrink Rap speculates on whether Darth Vader has a personality disorder:
Huh? BPD is not the first diagnosis I would come up with. I would've thought Narcissistic PD before BPD. Needs at least 5 of these :
has a grandiose sense of self-importance
is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
believes that he or she is "special" and unique and can only be understood by other special people
requires excessive admiration
strong sense of entitlement
takes advantage of others to achieve his or her own ends
lacks empathy
is often envious or believes others are envious of him or her
arrogant affect.I think he had them all.
Narcissistic PD is the diagnosis I came up with 2 years ago in this classic post.

A Reader Request

This was posted in the comments section of a recent post:
Hello. I'm Cary Byrd and I write the eDrugSearch Blog. I know that you're a reader of Kevin, M.D. as I am, so I thought you might be interested in an interview I just posted with Kevin. You can find it here: http://edrugsearch.com/edsblog/five-questions-with-kevin-md/

Which Physicians should make the most money?

A frequent topic on other medical blogs is the relative compensation of various physician specialties/practice types: proceduralists vs. cognitivists, primary care vs. specialists, surgeons vs internists, hospitalists vs. officists. Should the healthcare pie be recut, enlarged, both, or neither?
Here are some of my preliminary thoughts on the matter:
1. Emergency/urgent services: When I develop heart problems, the cardiologist treating my heart attack is going to have a lot more leverage than the primary care doc who later manages cardiac risk factors.
As a society, we need to ensure that certain emergency services- such as neurosurgical treatment of brain bleeds, is available on a timely basis. If there is a shortage of dermatologists, neurologists, psychiatrists etc in an area, a majority of Americans can afford to travel elsewhere to seek these services. If you have just been in a car accident, the lack of nearby neurosurgical care can mean you're dead or permanently disabled.
I feel that those who provide emergency services deserve higher compensation than doctors who don't.
2. After Hour Services: Over-useage of ER's would decline if more docs had evening/weekend hours. Doctors should be able to charge patients extra for seeing them outside of the normal work week. I would personally be willing to pay my doctor more out-of-pocket for the convenience of evening hours. If doctors were allowed to charge surcharges for after-hour services, busy professionals would benefit. Retired persons and the unemployed could continue to go to physicians during normal daytime hours. The only group that wouldn't benefit is the working poor.
More to come on this topic later- maybe.

10 Years

I've been a doctor exactly 10 years, over half of that time in residency/fellowship training. Burnt out and cynical already.

If anyone who graduated with me at the University of Iowa College of Medicine is reading this, please post a comment.

I'm still trying to decide on whether I should go the September Class of '97 reunion. If I do go, I'll be sure and drop by the Alpha Kappa Kappa house.

New York spends $$$ on Addiction

Kevin MD linked to a New York Times article describing the huge amounts the New York Medicaid program pays for addiction services:

Through its Medicaid program, New York spends far more than other states on drug and alcohol treatment, including more than $300 million a year paid to hospitals for more than 30,000 detox patients.

Addiction services cost so much in New York for several reasons:

1. lack of outpatient follow up care- when patients are discharged — typically after about five days — the needed transition to an outpatient treatment program often never occurs. That is one reason many patients do not fully recover from their addictions and return to detox wards, experts say.

2. addicts going on drug holidays to reduce their tolerance - Some drug users, especially those on opiates, also set out to clean their systems so they can reduce the dose needed to get high, according to addicts and those who treat them. For a homeless addict, the cost of each dose is a major concern

3. homelessness But at its core, experts say, the overuse of costly inpatient programs is connected to the lack of housing for homeless people. People are less likely to admit themselves to hospitals, and more likely to adhere to treatment programs, when they are not living on the streets.

4. New York medicaid rules encouraging expensive inpatient treatment- In other states, most addicts who go through detox programs do so on an outpatient basis, while in New York the vast majority are inpatients. Medicaid rules in New York also encourage hospitals to provide the most expensive kind of inpatient detoxification, though it is often not medically necessary, while many other states favor a less expensive form of inpatient treatment. ...it pays more than $1,300 a day for medically managed detox — and state officials estimate that more than 40 percent of that is profit for the hospitals. Hospital executives say the margin is not that high, but they concede that the most expensive form of detoxification is a significant money-maker. As a result, many hospitals offer that program, but not the cheaper ones. By law, hospitals cannot turn away emergency patients, and drug or alcohol withdrawal is considered an emergency. So about 80 percent of the detox patients handled by hospitals in New York are treated at the most expensive level — often because it is the only one available.

I think I need new glasses

Last weekend I was at the Imperial Palace Hotel in Biloxi MS for the Mississippi Psychiatric Association meeting. In between sessions, I played no-limit Texas Hold'em. I had trouble seeing the playing cards clearly from the far end of the table and eventually moved to the middle of the table. I plan on seeing my optometrist when I am back in California for Internal Medicine 2007. Despite my minor vision problems, I still won $150 that weekend playing poker (and an additional $25 when I got lucky on a slot machine).

Problem Gambler

Dear Abby has been writing about health issues a lot recently, on March 1st she wrote about obstructive sleep apnea.

Today there is a question about gambling:

How do you tell the difference between someone with a gambling problem and someone who is trying to become a poker champion?
The person is my husband, and I'd like to support his dream of being a champion. I have never been around gamblers, and I am not sure where the line is drawn. -

Dear Abbby responds:

Many men and women enjoy gambling as a form of entertainment, and some can (and do) make a living at it. However, for some people gambling can become an addiction. These compulsive gamblers are unable to overcome the impulse to keep on trying, lose more money than they can afford to spend, and sacrifice their lifestyle and their family's future as their futile attempts drive them deeper and deeper into debt. These people need professional help and/or a 12-step program to overcome their addiction.

Since I am winning small amounts of money playing online poker, I guess I am on my way to becoming a poker champion rather than becoming a problem gambler.

I think I am overdressing at work

How should a psychiatrist dress?

our dress should be best for our patients but also serve our own needs, ideally be pleasing to colleagues, and not break any organizational dress codes. Our own narcissistic or exhibitionistic—or perhaps even to some degree comfort—needs should not take precedence.

There seems to be many psychiatrists dressing inappropriately:

Many years later, and not too long ago, I was supervising a woman psychiatrist and noticed a tongue ring as she was describing a patient. When I asked her whether patients noticed the ring (which she had had for months), she said they hardly ever commented. When I brought this subject up to the residency committee, there was no consensus on appropriate dress for residents.

There is limited literature about this subject:

there was only one recent study of psychiatrists conducted at a university hospital outpatient clinic serving mainly poorer patients; the study was entitled “How Should Psychiatrists Dress?—A Survey” (Community Ment. Health J. 2006;42:291–302).
The study found that both patients and psychiatrists generally felt that professional dress was an important part of the doctor-patient relationship. For male psychiatrists, the majority recommended “casual pants and casual shirt,” with tie and dress shirt preferred by only 10%. Because I work half of my time in such a clinical setting, should I not wear the tie I put on each day?

Maybe I should take off my tie when I go to the state psychiatric hospital and put it back on when I arrive at my sleep clinic.

Old Drug Offers New Hope to Persons with Down Syndrome

The LA Times reports on research looking at the use of pentylenetetrazole for Down Syndrome:
Lab mice with the mental retardation of Down syndrome got smarter after being fed a drug that strengthened brain circuits involved in learning and memory, researchers reported Sunday. After receiving once-daily doses of pentylenetetrazole, or PTZ, for 17 days, the mice could recognize objects and navigate mazes as well as normal mice did, researchers said. The improvements lasted up to two months after the drug was discontinued, according to the report in the journal Nature Neuroscience.
Senior study author Craig C. Garner, a Stanford School of Medicine professor, said his lab was preparing to conduct human trials of the drug, although he said it would take time to complete more preliminary studies and procure a supply of purified PTZ. People with Down syndrome should not be given the drug until it has been studied further, he cautioned, because PTZ can induce seizures at high doses and might have other serious side effects.
Down syndrome is a genetic disorder caused by an extra copy of chromosome 21. The syndrome occurs in one of 660 births and usually causes cognitive deficits, cardiac problems and physical abnormalities, such as low muscle tone, short stature and an upward slant to the eyes. More than 300,000 Americans have Down syndrome, making it the leading cause of mental retardation. There is no approved drug to improve cognition in people with Down syndrome.
PTZ blocks a neurotransmitter called gamma-aminobutyric acid, researchers said. GABA, as it is called, passes messages between neurons along specific brain pathways. Normal brains have a balance of neurotransmitters that excite neurons and make learning possible, and of GABA, which slows neurons down so they do not become overly stimulated. It is believed that people with Down syndrome have too much GABA, inhibiting brain circuits involved in learning and memory.
The drug was used until 1982 to enhance cognition in the elderly and mentally impaired people, but was removed from the market by the Food and Drug Administration because studies showed no clear benefits. Garner said he believed the drug failed in part because the dosing schedule then was different from the one his team used in mice.The mice were genetically altered to possess cognitive impairments similar to those of Down syndrome patients
Mice brains are a lot different from human brains, and I am skeptical of this drug's ability to make much of a difference in the intellectual functioning of persons with Down Syndrome. I tried to look up some of the old literature from the 70's on pentylenetetrazole, unfortunately, Pub Med does not have abstracts online from this time period. The next time I'm at the medical library, I'll look up some of the articles.

Adult Autism

Autism has been in the news a lot recently. Risperidone is now approved for the treatment of pediatric autism. This creates the unusual situation in which a drug is approved for a childhood disease, but not the same disease in adults. Usually it's the other way around.

-------------------

It seems that every day there's a new study showing increasing rates of autism. In my opinion, there are 2 reasons for this:

1) Many studies are now looking at "Autistic spectrum disorders," which include less severe variants of Autism such as Asperger's Disorder.

2) Some parents are pushing for the diagnosis of Autism for their child, because children with autism are generally elgible for higher levels of services than children with (isolated) mental retardation. There is a great degree of comorbidity between autism and mental retardation, and some children who would have just received the diagnosis of mental retardation in the past now also receive the diagnosis of autism.

-------------------------------------------

I don't treat children, but I treat many adults with mental retardation, some who also have autism. I don't understand why autism is on axis I and mental retardation is on axis II of DSM-4, TR.

New Treatment for Bulimia

Drudge links to an article describing a new treatment for bulimia:
An Australian psychologist charged with indecently assaulting a patient told a court on Tuesday that forcing his female patient to wear a dog collar and call him master was within a psychologist's ethical guidelines.
Psychologist Bruce Beaton, 64, pleaded not guilty in the Western Australia District Court to four charges of indecently assaulting a 22-year-old woman in 2005, local media reported.
Beaton told the court he resorted to master-servant treatment with his bulimic patient because other methods had failed. He said he thought forcing the woman to wear a dog collar and call him master would build a more trusting relationship.
"I am not saying it would be all right if I hit her. I did not hit her," he said. The trial continues.
Interesting treatment. I guess it's good the psychologist didn't hit his patient. However, this is not a legitimate treatment and hopefully the psychologist will be convicted.

Baby Heroin

I was working at a prison in Alabama last week. Its hard for the inmates to obtain traditional drugs of abuse (marijuana, cocaine, heroin), so the inmates try to get high on prescribed medications. Controlled substances such as Ativan and Xanax are usually not prescribed in the prison; but the inmates can be quite creative and try to get high off of medications that are not traditionally considered addictive/abuseable. The antipsychotic Seroquel seems to be quite popular these days, and prisoners are calling it "baby heroin." In this prison, it is given to prisoners crushed so they can not trade it or sell it to other inmates. One prisoner, until she was caught and taken off of Seroquel, was in the habit of spitting the Seroquel tablets into her coffee and then selling the coffee.

I will be gone for the next several days

I am doing some locum tenens work at a women's prison in Alabama, so blogging will probably be non-existent from January 15-19.

Mississippi Medical Bloggers

I'm compiling a list of Mississippi medical bloggers. So far it's a short list. Please let me know if I've left anyone out.

Physicians:

Dr. Hebert
Just Practicing


Other:

MyHeartOnMySleeve

Why be a Geriatrician?

Kevin MD links to this article discussing the shortage of geriatricians:
Today, there is about one geriatrician for every 5,000 adults ages 65 and older. By 2030, the American Geriatrics Society estimates that while the population of older adults will have doubled to 70 million, the proportion of geriatricians will have dropped to one doctor per 7,665 people.
Geriatric care is a lot of fun, but it's never been glamorous and no one perceives it as fun. It's very challenging. There are a lot of issues to be dealt with. I think the real key is to find young physicians who share that interest and are willing to make that the focus of their careers. : makes going into geriatric care less appealing for medical students? : think it would be fair to say (that salary for a starting geriatrics specialist is) roughly a third of what a starting cardiologist would make. The typical medical school graduate is finishing med school with $100,000 to $200,000 in debt.
Other than those wanting to enhance an academic career, I can't understand why anyone would want to do a geriatrics fellowship (which is an additional 1 year beyond the standard 3 year internal medicine residency). Internal medicine residency training is sufficient for developing the necessary knowledge and skills to take care of geriatric patients.
For non-academic physicians, a geriatrics fellowship is an additional year of training (and receiving a low resident/fellow's salary) with no payoff at the end. In fact, because of low Medicare reimbursement, a geriatrician in private practice will make less money than a general internist who sees both young adults and geriatric patients.
Being a medical director of a nursing home can be profitable, but this can also be done by a general internist.
I'm all in favor of education and enjoy learning about about the wide field of medicine, but at some point a person needs to begin earning a living, and a geriatrics fellowship is an unnecessary delay in this process.

Overeating is like Drug Addiction

A recent study, published in the journal Proceedings of the National Academy of Sciences stated that overeating is like drug addiction. What do you think?
"The biggest challenge for me has been dropping my eating buddies and acquiring a new group of friends who don't eat."