Thursday, September 27, 2012

Defensive Medicine - What Makes Psychiatry Even Harder

When most people think of "Defensive Medicine" they envision what physicians do to cover their backsides rather than really help patients.

I think of being a medical student working in the ER when a drunk patient comes in complaining of chest pain.  My attending physician asks - "what does that patient need?" I answer - "He needs a rally bag, some food and a place to sleep for about 12-18 hours."
She then says - "but you know what we're going to do right?  He's going to get a CBC, CMP, UA, BAL, Chest X-ray and an EKG - and that's just for starters."

And that's how it goes.  We know what's wrong - or least we're pretty sure.  But we have to cover ourselves legally - because what if???

Can a drunk guy with chest pain be having a heart attack?  YES

It's like they say: "Every Hypochondriac eventually dies from something."

My residency director often said: "A man with diseases can have as many as he pleases."

Just because someone uses drugs and has a personality disorder doesn't mean they can't have epilepsy.  Yep - just because someone has pseudoseizures doesn't mean they can't have real seizures too.

And that's why we do it.  Yeah - we don't want to get sued - it's true. 

We would probably be correct and save thousands and millions of dollars if we treated people how we REALLY think they need to be treated.  But we don't get to make that call.

Psychiatrists have it even worse.  I wish I could just look at a depressed patient, or an anxious patient, and give them what they need.  I could give them the medications that are most likely to help them and get them the therapy that is most likely to have a lasting effect - but I have to do more than that.

Every patient I see - I have to look at their medication list and ask myself - "If they took every pill in their medicine cabinet - would they survive?" "If they tried to kill themselves - have I given them the tools to do it?"

I always have to worry about suicide.  Always.

I can't just treat symptoms, or even diseases.  I have to practice defensive medicine - meaning I have to defend the patient from themselves.

It's an impossible task.  I don't control their free will.  I am not their parent or their conscience.  I am merely their psychiatrist.

Yet somehow - when I get that call - the one where some ER doctor tells me that my patient just attempted suicide by overdosing on the pills I gave them - I'll feel responsible.

Maybe I can get used to it.  Is that what makes a good shrink?  Being able to handle things like that?

Maybe that sinking pit of guilt, despair, and regret at having facilitated a patient's suicide goes away?

Maybe it should.

Maybe it shouldn't.

Sunday, September 23, 2012

Does Faith = Ignorance?

Sometimes I am treated like I must be an ignorant, uneducated moron because I believe in God, follow my religion, and try to live my life according to the teachings of God as I understand them.

I walk in very well educated circles - and sometimes people think "Once you're smart enough you don't need a belief in God anymore, you know better."  They can reason their way past a need for faith.

So I decided to do a quick check on the leaders of my church; a group of 15 men.

Is it possible they are just blind faith followers?  Are they just well intended sheep who blindly follow and do what they're told? 

Or is it possible they are well educated, intelligent men who despite (or likely because of) their education believe in God and have made him the center of their lives?

Here is what I found on a quick, cursory search:

Among the 15 men there are:

3 lawyers
1 surgeon
7 masters degrees
6 doctorate degrees including Nuclear Engineering, Business, Religion, American Studies, etc...
4 University Presidents
3 Harvard Graduates
1 Stanford Graduate 
1 Yale Graduate

These men are smarter than me - but even if they weren't, I would still follow them.

They don't need all those degrees, but it's nice to know that very VERY educated men can still humble themselves, get on their knees, and admit that they would be nothing without their creator.

Source of Information: LDS Church News

Saturday, September 22, 2012

Les Miserables Predictions:

Yes - I am one of THOSE people.  I love Les Miserables.  I mean REALLY love it.
Due to lack of funds and time I have only been to see the stage musical twice - but here are a few examples of how much I love the story:

I have read the unabridged book 3 times.
I have read 3 abridged versions.

I have abridged my own version because I don't think anyone else "did it right."

I own the 10th Anniversary "In-Concert" DVD
I own the 25th Anniversary "In-Concert" Blu-Ray even though I don't own a blu-ray player. (I refused to buy the DVD because I wanted higher quality)

I watched the 25th Anniversary concert in a movie theater in Reno because I didn't want to wait to buy the blu-ray.  (which I still can't watch)

I can recognize and name everyone from the original cast, the 10th Anniversary cast, and the 25th.

Get the picture?  I'm sure I'm not the biggest fanatic out there - but I might make the short list.

WITH ALL THAT SAID - Here are my predictions:

Prediction #1 - The movie will be a huge success - and not because of people like me.  I see this movie kind of like the JJ Abrams version of Star Trek.  There are fanatical Star Trek fans around the world - but that isn't the reason that Abrams version succeeded.  His version made over $350 million while the last Star Trek movie before his made just $60 million.
He made it for the masses.  He left enough classic trek material and enough fun inside jokes that trekkers could love it - but even if you had never even heard of Kirk or Spock - you could still love the movie.

That is what Tom Hooper is doing with Les Mis.  He didn't cast Lea Salonga and Alfie Boe, or even Michael Ball (amazing singers from the show) - he cast Anne Hathaway, Hugh Jackman, Russell Crowe, Sacha Baron Cohen, and Helena Bonham Carter.

He cast film actors.

He also included enough classic Les Mis to satisfy fans like me.  The original ValJean (Colm Wilkinson) is playing the Bishop.  Samantha Barks is playing Eponine.

Which brings us to...

Prediction #2 - The name that will be on everyone's lips will be Samantha Barks.

Yes - people will say that Anne Hathaway gave a beautiful and heart wrenching performance.  Hugh Jackman held his own as ValJean, no one knew Russell Crowe could sing and he actually did fairly well. 
They will say that Helena Bonham Carter was perfect in her role - the freaky and intimidating but funny Madame Thernardier.  Her husband, Sacha Baron Cohen will also get some good reviews.
Cosette (Amand Seyfried) will be mediocre.

The name that will be talked and talked and talked about - will be Samantha Barks.  Why - because she is amazing, and she is relatively unknown.

She has never been in a movie that wasn't a recording of Les Miserables.  Her T.V. appearances were on a reality show - auditioning for the lead female role in the musical "Oliver!"
She can act, she can sing, she's gorgeous, and she is going to be the best singer in the movie - and people will notice.  This will be her breakthrough to the masses.

Prediction #3 - More musicals will follow suit with the "live recording of songs." Very few musicals use vocal recordings from the set - they're always recorded in a studio and then the actors lip sync on the movie set.  Les Mis is one of the first in a long time to try it - and I think they'll succeed and start a trend.  They'll have to clean up some of the tacks, and some will have studio recordings mixed in (Amanda Seyfried) - but most will be live recordings, and audiences will love the change.

Hugh Jackman explains it here:

Prediction #4 - SPOILER WARNING! The Bishop (Colm Wilkinson) will be in the last scene. 

The musical really screws up one scene - the last one.  In the end, Valjean is dying. 
In the book it goes this way:

"Do you want a priest?"
"I have one," answered Jean Valjean.
And, with his finger, he seemed to designate a point above his head, where, you would have said, he saw some one. It is probable that the Bishop was indeed a witness of this death-agony.

In the musical Fantine and Eponine appear to ValJean  They sing a beautiful duet and take him to heaven.  It's nice, but it doesn't make sense (I've written an entire blog post about why)
In the film this will be fixed for two reasons. 

1. It makes sense.
2. They want Colm Wilkinson to have one last moment at the end of the film - one last goodbye to the role he defined.  He was the original ValJean, and they'll let him end it.

oh - and here is a screen shot from the trailer that shows ValJean and the Bishop - and ValJean is NOT dressed like a convict.  (hint hint)

The film opens Christmas day.  Enjoy.

Monday, September 17, 2012

Book Review: The Confession

The Confession reminded me of two books I have read before. 

The first is Michael Crichton’s State of Fear.
State of Fear was basically Michael Crichton’s well scripted argument against global warming and it’s bogus research.  Crichton studied so much and cared so much about the topic of global warming that he testified to Congress on the matter. (Read his testimony here  

The Confession by John Grisham, is not about Global Warming.  It is about Capital Punishment.  It’s the story of a young black male, who was questioned for hours and hours and hours about the death of a white female classmate, then  coerced into giving a bogus confession which led to his conviction and death sentence.  The young man is innocent, and is sitting on death row.  His appeals have been denied and all hope is lost until days before the execution, the real killer 9who is dying of a brain tumor) confesses his crime to a pastor.  The pastor then works like mad to get the killer to drive to Mississippi, confess, and stop the execution of an innocent man….
This book is Grisham’s referendum on the death penalty.  Which brings me to the second book it reminds me of:

An Innocent Man, also by John Grisham.
An Innocent Man is THE TRUE STORY about a young man coerced into giving a bogus confession, convicted of murder, sentenced to death, and then left waiting on death row for appeals or execution.  It is rather obvious that writing An Innocent Man had a strong impact on Grisham.  He is now on the board of directors of the Innocence Project in New York, and is chairman of the board of the Mississippi Innocence Project. 

In preparation for writing “The Confession” Grisham made frequent visits to death row at the Mississippi State Penitentiary. He got to know the guards, the inmates and the stories of some of the convicted killers' victims, he said.

He even let guards strap him in the death chamber gurney to get a feel for it.

This book does not go how you expect.  It is not predictable, and it is a good read.  But more importantly it makes you think.  While reading the book I had two strong feelings.
1.       “They have to save the innocent man, and the death penalty shouldn’t be allowed.”
2.       “They should convict the real killer and put him to death immediately for the rape and murder of an innocent girl.”
Grisham makes you think of both sides.  The pros and cons of capital punishment.  He shows the ridiculous politicization of the issue, and the people who are hurt or killed because of it.
I had lost faith in Grisham as a writer – this book brought me back, and reminded me why I enjoy his novels.

Tuesday, September 11, 2012

Fish Oil = Snake Oil. (Omega-3 Fatty Acids are No Better than Placebo)

Ever taken a fish oil pill?

They're gross.  They don't taste good, they don't smell good, and you only force them down because you're trying to save yourself from a heart attack.  It's not because the salesman said "No really!  These are the ones that don't make your breath smell fishy."

 - yeah right.

I've heard of the benefits of Omega-3 Fatty acids for years.  I've even posted about them before on this very blog.

The newest research isn't saying whether or not they help with depression, or your eyesight - it's about heart health. 
Face it - that's the reason most people take Omega 3s - to prevent a heart attack.  

The authors didn't do a new study - they analyzed the results of 20 previous studies involving 70,000 patients, and compiled and compared all that data.

So can omega 3 fatty acids help your heart?  Yes - But only as much as a sugar pill.

Here is one chart of results from the study:

PUFAs stands for "polyunsaturated fatty acids"
IDC stands for "implantable cardioverter-defibrillator"

The chart shows three groups:

Mixed Prevention: Patients had no risk factors or few risk factors
Secondary Prevention: Patients already had risk factors but no signs of disease
ICD: They already had a defibrillator placed


Here's the official conclusion:
"Overall, omega-3 Fatty Acid supplementation was not associated with a lower risk of all-cause mortality, cardiac death, sudden death, myocardial infarction, or stroke based on relative and absolute measures of association."

So taking 70,000 patients, dividing them up, and giving half Omega 3, and half placebo - the two groups  had the same number of heart attacks, strokes, sudden deaths, cardiac deaths and total deaths.

Take home message:  If you like fish-oil by all means keep taking it - it won't hurt you.  But it won't make your heart any healthier.  

But if you're suffering through the experience like the rest of us - save your wallet, your taste buds, and your breath - ditch the Omega-3s and go play in the yard with your kids.  That's proven to help your heart!

Friday, September 7, 2012

How to Lose IQ Points: Smoke Pot

Now there is proof.

Marijuana really does make people dumber - and not just while they're smoking it - but long term. 
Many people thought it was just overprotective parents using scare tactics. Turns out it's true. 

How'd they find out?

There is an ongoing study of 1037 people.  They (or their parents) have answered a HUGE list of questions multiple times: at ages 3, 5, 7, 9, 11, 13, 15, 18, 21, 26, 32 and 38.  (ages 44 and 50 are next).
They also have an IQ test performed at each of these assessments.

One set of questions is about marijuana use.  Age of first use, frequency, dependence, etc...

Here are the IQ changes they found over 30 years (comparing age 8 to age 38)
Never used MJ: +1 point
Used, but very rarely: -1 point
Diagnosed once with MJ dependence: -2 points
Regular MJ use at the time of one assessment: -3 points
Regular MJ use during 3 assessments: -6 points

It didn't matter whether or not they finished high school.  People with the exact same education levels showed the same difference.  Those who didn't smoke pot kept their same IQ or went up one point.  Those who smoked pot lost 1-6 IQ points.

If they started smoking pot before age 18: - 6 to 8 points.
If they started after age 18 and used regularly: - 2 points

There is one silver lining for those who really really want to inhale.

If they started after age 18, and never smoked it frequently (less than once per week): + .5 points

The bad news: If they lost IQ points from smoking pot, and then stopped smoking and stayed clean, their IQ didn't recover.  It didn't bounce back, the damage was done.

What's 6-8 points?  That's the difference between college graduates and college drop-outs.
That's the difference between a skilled labor job, and an unskilled "grunt" worker.

It makes a difference. 

Will this change anything - Probably not.
If the fact that marijuana is illegal and can cause psychosis wasn't enough to stop people from smoking it, I doubt the risk of a 6 point IQ drop will do the trick.

Oops - look at the time.  4:20 - gotta go. (j/k)

Wednesday, September 5, 2012

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We Are Not Single Issue Voters!

Why do people think that any of us are single issue voters?  With all the topics, policies, and the utter complexity of our everyday lives - how could it be possible to have your vote come down to one issue?

I'm a doctor in Residency.  I'm a mormon, married with kids.  I usually vote Republican.  I don't own a gun, but I enjoy skeet shooting and I'll probably own a shotgun someday.  I think everyone should pay their fair share of taxes, from the top to the bottom.  I believe we have a duty to help the poor, but no one is entitled to take what I've earned without my consent.  I want to retire someday, I want my kids to go to college.

I've only written 4 lines about myself (without touching foreign policy) - but I challenge anyone to explain to me why one of those issues should define me completely - and have absolute control over my vote.
Tonight I was reading a CNN story about the Democratic National Convention.  One comment said this:

"If you have a mother, daughter, sister, aunt, niece, grandmother, cousin, then make sure you stand up against the party of No who has a mission to take women's wombs away from them. The GOP platform is to make abortion illegal, by going around the way of creating personhood amendments, that a person is made at conception. There will be no exceptions in any situation."

First, it's wrong, that's not Romney's stance - but let's not debate that here.  Even if it were true. Is the right to have an abortion the most important issue when picking a president?

A 60 year old woman who is getting ready to retire - is that her first priority?  It's not health care, or social security, or anything like that - it's her right to have an abortion???

How about Gun Control?  I like shooting a gun once in a while for sport.  I've never shot a living thing, but sure, I'd go hunting if someone invited me.  Does that define me?  Does that mean I must vote Republican so I have the right to a military grade assault rifle?  That's insane.

How about issues closer to home - Taxes, Health Care, Religion.  

 I'm a flat tax guy.  Does that mean I must vote for Ron Paul, or a flat tax supporter?  Is that the end all, beat all issue?

I'm a Mormon living in Nevada.  Does that mean I must vote for Harry Reid because he's a mormon too?  Must I vote for Romney?  

Health care is huge in my life.  First - I care that my family and I are healthy - and it's also how I get paid.  I serve mostly the indigent population - so government programs pay pretty much my entire salary.  If Medicaid and Medicare don't exist - how do those patients get health care?  How do their doctors get paid?  So must I vote democrat to support the full funding of those programs?

I have many homosexual friends.  Some are Republicans, some are Democrats.  Why are homosexuals treated like their sexual orientation defines them?  They can't have an opinion on foreign policy, the environment, employment, or any other issue?

Why are women treated like their uterus is their entire being?
Why are gun owners treated like that is their only joy in life?
Why, why, why?

Is it because it's easy?  We want people to fit into boxes?  We want to make elections about one issue, and then pick sides and duke it out?

Let's just tell people right now who they are voting for:

Women - Obama
Wealthy - Romney
Gays - Obama
Business Owners - Romney
Blacks/Latinos - Obama
Mormons - Romney
Youth - Obama
Unemployed - Romney

Do you disagree with this list? OF COURSE YOU DO!  It's wrong!

This is how we start ignoring people - we treat them like a demographic.

This is how stereotypes start - which leads to labeling, dismissing, hating, and eventually killing.

To the Republicans, the Democrats, The Libertarians, the Pundits, the Candidates, the Super-PACs and everybody else trying to influence us.  Stop treating us like stereotypical morons who have one track minds.

Thank you.

Saturday, September 1, 2012

Thalidomide - The "Other" Half of Every Medication

50 years later - the makers of Thalidomide have finally apologized. (News article here)

Over 10,000 babies were effected, most of whom died in early childhood.  Those that survived had debilitating defects, like the famous "flipper babies" whose arms were nothing more than little nubs.

Is late really better than never, or does there come a time when it's so late it's just patronizing and pointless to apologize?

There are a small number of victims still alive today.  Their mothers took the drug to treat morning sickness.  They didn't know that only half of the drug treated nausea, the other half caused birth defects. 

That's what this post is about - the "other half" or "mirror image."

Has anyone ever taken Prilosec - and then been switched to Nexium?
How about Celexa switched to Lexapro?
Zyrtec to Xyzal?
Ritalin to Focalin?
Provigil to Nuvigil?
Effexor to Pristiq?

They are the same medication as before - but now you're only getting the half that works.

Have you read the generic names?

All they did was add a prefix to the same drug name. 
They just added "levo," "es," "dex," "ar" or something like it to the beginning of the name.

Citalopram (Celexa) was replaced with Escitalopram (Lexapro).
Venlafaxine (Effexor) replaced with Desvenlafaxine (Pristiq).


When any chemical compound is made - it's possible and even likely to really make two different molecules - they're just mirror images of each other.  Like your left and right hand.  They're called enantiomers.  The mixture of the two is called a racemic mixture.

When medications are made - they often don't worry about whether they are making one compound or both.  The mirror image usually does nothing anyway, and it's cheaper if you don't have to separate the two.
They test the drug, and if it works they produce it.

That was the problem with Thalidomide.  One molecule treated nausea - it's mirror image caused birth defects.  The drug company gave people the mixture.

Even if they had done the extra work to only make the one molecule that worked - there still would have been birth defects because with thalidomide - one mirror image can mutate and become the other one in our bodies.  We were doomed either way.

So what's happening now?  Are any drug companies making NEW drugs - or are they all just relabeling the half that works - and selling it pure instead of mixed?

Anyone taking (Synthroid) Levothyroxine? 

Why didn't the drug company make Dexthyroxine instead?  - because that's the half that didn't work.

We rarely get NEW drugs anymore.  It costs too much to test a drug when you have no idea if it will actually get FDA approval.  But if you know the drug already works - just produce it pure without the mirror image - and you've got another 7-12 years of profits for the new medication.

Thalidomide showed us the horror of not understanding our own science.  Have we really learned the lesson, or just learned how to profit by it?