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!
Monday, October 15, 2007
Psychiatry Residency Training Becomes Even More Wimpy
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).
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).
Friday, September 14, 2007
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.
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.
Monday, September 03, 2007
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.”
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.”
Saturday, September 01, 2007
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.
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.
Saturday, August 18, 2007
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
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
Saturday, August 04, 2007
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.
Saturday, July 21, 2007
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.
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.
Friday, July 20, 2007
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.
Saturday, July 14, 2007
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.
Thursday, July 05, 2007
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??
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
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.
Tuesday, July 03, 2007
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.
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.”
“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.
Sunday, June 24, 2007
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
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
Sunday, May 27, 2007
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.
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.
Saturday, May 26, 2007
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/
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/
Saturday, May 19, 2007
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.
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.
Wednesday, May 16, 2007
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.
Tuesday, April 17, 2007
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.
Tuesday, April 03, 2007
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).
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