Saturday, February 16, 2008

Co-Blogger Battle of the N=1 Post

OMG, I'm gonna kill her. Clink complained that I posted over her post, the one she put up to break up my monotonous In Treatment posts. So I re-posted her N=1 post with my intellectually stimulating comments at the beginning and the end in an effort to renew interest in this stimulating topic. This was at 1 AM after the 3 Shrink Rappers had been screaming at each other for 4 hours over a project unrelated to the blog. I got up this morning to see that at 6 AM (when do you sleep, girlfriend???) Clink removed my comments, remade them into another post, placed under the original post, given a similar name. Even I don't know what's flying here.

Some people are never happy.

[Note: This is Dinah's response to my N=1 post. They were originally put in my post, at the beginning and end, but I took them out and moved them here so it would be clear who was saying what. ---ClinkShrink]

We're getting mixed reviews on In Treatment. I'm sometimes enjoying the show, I think it brings up some real-life therapy issues, and I've been trying to talk more about those and less plot synopsis. ClinkShrink hates it, Roy is oblivious, and some of our readers say they miss the old Shrink Rap. It's not the old Shrink Rap, we've got a lot of Life Gets in The Way issues going on, one is that Clink's internet is on the fritz, and we're all involved in some other projects. I've given Roy a "To Do" list which includes posting the last podcast we did-- and we're not even married. We spent the whole podcast screaming about when, who, or even IF, benzodiazepines have a place in clinical practice, so if you've like the Xanax controversies on Shrink Rap, stay tuned and maybe put on your armor.

Okay, and ClinkShrink put up this post the other day to stimulate conversation about the role of doctors and patients in keeping down healthcare costs. It's not about the TV show. Ah, but I posted over it, so if you didn't read it, by all means.... and maybe Comcast will let Clink respond some day.....

So I read this and thought, wait, you don't think people should prescribe benzos for anxiety--they get people addicted, and you don't think people should take expensive meds like Seroquel, off-label for anxiety.....what do you want them to do?

Ah, but Clink says that's not the point of the post, the point is that we all have a role in helping keep down costs. I'm not sure what to do with that, when I have a patient in my office who is suffering-- I think best not cheapest. What's it worth dollarwise for a good night's sleep, or to stop those delusions, or to prevent an episode of mania, or to stop feeling suicidal? To make it so a patient only triple checks the locks? And what constitutes suffering??--Seroquel is perhaps okay if you're hearing voices but not if you're in the midst of an awful panic attack? Or people use it for insomnia, and isn't this an expensive treatment for insomnia, but what if it's the only thing that works or that isn't contraindicated. So we have these medicines, or expensive diagnostic procedures, we're left to ask how to ration them. Easy to blame the insurance companies for not forking over the bucks, or the docs for not being more diligent about cost-containment. But when I'm with a patient, I try to figure out what best helps the patient. Cost is in my head only if there are cheaper options that don't compromise care, have higher risks, or lower efficacy. Might be a little easier not to blame the insurance companies if we weren't reading articles like this from

November 19, 2007

RE "BLUE Cross gave chairman $16.4m in retirement pay: Van Faasen still on salary at insurer" (Business, Nov. 16): At a time when the cost of health insurance and the numbers of uninsured are rising, all sectors of the healthcare community must exercise prudent management of every healthcare dollar. This responsibility cannot be borne solely by the provider sector while the insurance industry passes expenses on to subscribers and employers.

Blue Cross and Blue Shield of Massachusetts voted its CEO a total of $19.4 million in salary and benefits while retaining him as chairman. Because Blue Cross-Blue Shield is a not-for-profit entity, Massachusetts considers it a public charity. As such, the insurer, its board of directors, and the state officials charged with the oversight of public charities should be held accountable by the citizens of the state for better guardianship of the public trust.



ClinkShrink said...

Great post! Thank you for continuing this discussion. As far as the Blues go, they're doing better here in Maryland. From the Baltimore Sun:

"Yesterday, the company pledged to help seniors bridge a coverage gap known as the "doughnut hole" in Medicare drug plans with a $7 million-a-year program. Earlier in the week, CareFirst gave $100,000 to Health Care for the Homeless, a nonprofit group."

ClinkShrink said...

OK fine so you want to go first. If you think it makes sense to put the counterpoint before the point, go for it. Let the record reflect you've threatened to kill me. That's two threats I've gotten in the past week. The lifer gets first dibbs on me I'm afraid.

It's a good thing we've been friends for twenty years or we might not have survived. It's also a good thing you feed me. Thanks for the Indian food last night, it was delicious.

Anonymous said...

I keep a bottle of 100mg Seroquel stocked for sleep issues. I didn't realize it was an overly expensive solution. But it's also my last ditch resort for seriously, seriously nasty insomnia. Luckily, it takes me about a year to go through my 1 bottle of 30 tabs.

From a patient perspective, I don't like benzos. It seems like I know just as many people on benzos as I do on antidepressants these days. Some days I wonder if they passed out like candy.

Anonymous said...

P.S. My Lamictal is a gazillion times more expensive than Lithium, but don't ever try to take away my Lamictal without some good clinical reason. I think quality of life is often a forgot part of the equation. The relatively low side effect profile of Lamictal makes its cost extremely worthwhile.

P.S. What do I expect people with anxiety to do if not Xanax or Seroquel? Try CBT or ACT or some other acceptable form of psychotherapy. Therapy is often underutilized in favor of drug therapy, even though it can be incredibly effective and sometimes a better, more cost-effective longterm solution.

P.S. Can't wait to hear the podcast:)

Anonymous said...

(Sorry for all the P.S.'s, I can see I'm going to be in migraine land today...yay for goofy thinking during aura)