Sunday, June 29, 2008

Links To Assorted Stuff

Hey, so folks have been letting us know about some cool stuff. I'm just now getting a chance to link you in:

Eric from CBS News let us know about a special on Women Vets and their unique issues. Well, I said links to cool stuff, and this was actually really sad stuff. As time goes by, I imagine we'll be hearing more about specific mental health needs in women who've been in combat.

Roberta Isleib wrote to us from Connecticut. She is a psychologist and a mystery writer. I carry a soft spot for shrink/novelists, so here is a link to Roberta's Website.

I went to visit FatDoctor's Blog today. Apparently she's having issues with here curly hair. And apparently there's a blog devoted to naturally curly hair. I can relate, however I found it interesting that there are two types of curly hair: you can be Juliana Margulies or Nicole Kidman. I guess I'm in my own category with wild crazy madwoman hair that frizzles and frizzles some more. Fat doctor has tried a bunch of stuff, I may eventually opt for that Brazilian keratin hair straightening thing. I'm told if you don't leave it on for too long you can keep your curls while bypassing the frizz. If you've tried it, by all means let me know.

Finally, if you're a reader of FooFoo5's blog, he's back after an extended absence.

Saturday, June 28, 2008

True Emotions

In case you haven't already seen it, be sure to check out our clicky iPhone Grand Rounds!

It was years ago.  I was a resident on an inpatient unit and the patient was floridly manic.  I don't remember the details, what I do remember was that she was running on empty, high as a kite, going 99 revolutions per minute, you name the cliche.  There was a reason why she was on an inpatient unit and not being seen by an out patient doc.  She wasn't getting better and, as is often the case with people suffering from mania, she had no insight that she was ill, she was feeling good-- really good-- and oh so energetic, and even louder than that, and so what's the problem here? Let me outta this joint!  We're talking, I'm trying to reason with her, and finally, she screams at me in a way that stays clear long after her name and the details of her life have oozed from my memory,  "You're problem is you're not Italian!  You don't understand TRUE EMOTION!!"  She had a point.

I'm not Italian, by the way.  And who defines what emotional response is true, what is valid, what is right to have?  

So once patients get the label of Bipolar Disorder, they come under an added scrutiny that makes them, and those who know they suffer from this disorder, subject to both added analysis of their reactions.  It often leaves them feeling invalidated, or questioning themselves in a way that adds an entirely new dimension, if not burden, to life.  I can have a feeling--- it's just my feeling.  I may question if it's valid for me to have that feeling-- come on, we all check out our feelings.  How often do you ask Was it Him or Me?  Or comment that everyone thinks he's a jerk, just to be sure you're not the one being overly sensitive.  People with Bipolar Disorder take this a bit farther.  If they're angry, irritable, have a great idea, in a good mood, in a bad mood, have trouble sleeping...and the list goes on....then they're ill.  No bad hair days for the labeled labile.  They, and everyone around them, are constantly questioning their sanity.  

There are other labels, though, and they aren't all about mental illness.  Perhaps you're a worrier, you want people to be considerate of the fact that you care about them, but they don't like to check in (--this particular example is for us moms).  Maybe they check in so you won't worry, or maybe they label you Neurotic, or Over-protective, or something that lets them blame you for your concern, that frees them from responsibility.  Or maybe you're very sensitive-- a trait that can be a very positive thing, especially if you're sensitive to the needs of others.  But once you're labeled as such, then the someone who says something that upsets you isn't held so accountable.  No biggie that I made Georgie cry, he's too sensitive, you know.

Emotions are a funny thing.  Sometimes I wish they could just be what they are and taken for face value.  And even if I'm not Italian, let it be known on the record that I'll eat pasta and gelato with glee and enthusiasm.

Thursday, June 26, 2008

My Last Day

As I was leaving prison today I noticed a man standing on the corner. He was wearing nice pants and a dress shirt. He had a knapsack thrown over one shoulder and was wearing sunglasses while talking on a cell phone. I didn't think anything of it until he looked over and saw me and yelled, "Doc! Hey doc! Remember me? You helped me, you really did. I'd hug you but I know that wouldn't be appropriate."

Frankly, I didn't recognize him at first. I knew who he was after he called my name, but just to see him standing there, well, the context was quite different and he looked very very different from his appearance in prison.

Anyway, he was doing great. He had a place to live, a job, was going to AA regularly, staying clean. He was waiting for his ride to pick him up for AA. His phone rang and he picked it up. "It's my ride," he said. He told his ride: "Hey, guess what? I'm standing here with the doc who saved my life!" His ride pulled up, and the driver immediately started waving and hollering at me too. My patient said, "You remember him? You saved his life too." I had seen the driver maybe twice, just a few days after he had been arrested. I remembered him, remembered that he had never been in trouble before, was facing serious charges and was pretty upset. Then the driver quoted to me, word for word, something I had said to him four years before that had helped him get through incarceration.

As they were driving off they pointed to me and said, "You keep doing what you're doing. You keep helping people."

I don't have any trouble admitting that I choked up a bit and by the time I got back to my car I was in tears.

You see, today was my last day as a fulltime prison doc. After about fifteen years I've decided that for my own sanity I'd need to cut back to part time and go back to doing another job I've always enjoyed doing (more about that later). This was quite the experience to have as I'm going, literally, out the door. It's the experience I'll remember the next time I hear someone knocking docs who do med checks instead of psychotherapy, or saying that prison doesn't help anybody.

It's good to remember that sometimes there are happy endings.

Tuesday, June 24, 2008

Shrink Rap Grand Rounds: The iPhone 3G Edition

[47] . . . [48] . . . [stay tuned for #49 in Dec '09] . . . [All]

Tuesday, June 24, 2008

My Three ShrinksGrand Rounds 2007MediphoneTortureExcellenceAnorexiaRecoveryVideo PainDrink RightThe JointDr NurseTiny ShrinkBreastNot SickPubMedWinnerADD PhonePopcornDroolingWhat's NewWeb PowerEating NemoPillgateExpressRxiPhoneMail1Safari1iPod1My Three ShrinksNSAIDLabelsSexSwaySham PtEnvironmentDevicesMore AppsPainOne HourCuttingPotter HatSpyingReformAntiPhoneDifficultInsuranceDiscrimStragglerDucksiTunesPrivacyPTSDPhone2Mail2Safari2iPod2

[HOVER or CLICK on any of the above icons to go to the post, or to use the functions at the bottom]

Welcome to Grand Rounds, Volume 4, #40 (see future GR schedule). If you missed our first Grand Rounds last year, with our amazing Clicky Brain, then feel free to pause and enjoy.

This year, since the anticipated release of the Apple iPhone 3G is just around the corner (July 11), we asked for submissions to have some connection to the iPhone, no matter how twisted the logic is to make the connection. The medical blogosphere obliged. So we are including, free of charge, our Clicky iPhone, which will let you visually navigate this week's Grand Rounds submissions (yes, the buttons on the phone really work).

Of course, below that is the regular text for you old-schoolers. And if you have low vision or prefer to LISTEN to your Grand Rounds, you can get our PODCAST of it HERE.

We'll start off with the posts which most closely held to our iPhone theme. Why an iPhone theme? Well, besides the fact that Roy is the resident Apple fanboy and Clink the fangirl, the iPhone has a lot of potential as a flexible and easy to use tool for today's health care professional. Sure, Roy wrote a tongue-in-cheek post about using it as a multi-faceted psychiatric tool, the iShrink, complete with breathalyzer and tremor-diagnosing imaging software, but the fact that its standards are open for third-party development means that we will see a tremendous amount of software written for it and available in the App Store. Joshua from Tech Medicine reviews some of the coming medical applications. Oh, and if you're already tired of hearing about the iPhone, you may as well just close your browser window now, because it only gets worse (better?).

EDIT: Yikes! It's already into Wednesday and I found out that I missed two Grand Rounds submissions... just left them off completely. Sorry about that. But here they are right at the top, so please check them out...

1. Social worker Still Dreaming writes about "Why I Don't Care About the New iPhone." I know what you're thinking... I really did just overlook her. (She actually like the iPhone.)

2. Midwife With a Knife has an excellent, scholarly post about restrictions on work hours for residents. Wish there were restrictions on hours for producing Grand Rounds!

Here's the rest...

Jeffrey from Monash Medical Student also points out some other medical applications for the iPhone.

Annie from Home of the Brave writes about a growing body of evidence which demonstrates that nurses, physicians and psychologists have been used by the government as agents of abuse and torture.

JeffreyMD notes that "Apple has long been considered to be a company that strives for excellence in their products." Which brings us to his post on The Pursuit of Excellence on a personal level. [Good reach.]

What if Apple was no longer deemed to be a computer company? Am from the Cockroach Catcher (yum) speculates about what if anorexia nervosa was no longer deemed to be an illness.

David from Mariana's Eye is still recovering from Grand Rounds last week.

In addition to detecting intoxication, doing your laundry, and filling out your clinic paperwork, the iPhone can play videos to reduce your pain, according to How to Cope with Pain.

How do you prevent neck pain from talking on your phone too long? Jolie from Fitness Fixer teaches us how to use your neck correctly.

Does the Joint Commission have standards for iPhone use in hospitals? Kim from Emergiblog has a humorous script for them when they show up unexpectedly. (Scroll down past the part about smoking.)

PCPs, watch out! "The ascendancy and final triumph of the doctor-nurse is as inevitable as that of the iPhone. Except that, unlike the iPhone (which only has Apple and ATT behind it), doctor-nurses have the undying support of the entire federal-industrial-medical complex (not to mention the formidable Mary Mundinger)," so says Dr Rich from Covert Rationing Blog. [Who's Mary Mundinger?]

Tinyshrink from Why Am I Still Here reminds us to heed HIPAA while using our iPhone on the elevator.

Louise from Colorado Health Insurance Insider says that the iPhone 3G will be the most convenient place for doctors to find and display information about the benefits of breastfeeding to women in hospitals or in remote locations.

Hypochondriac? Jenni from Chronic Babe thinks her always-sick relatives would love the internet connectivity of an iPhone.

Second Life on the iPhone? Bertalan from ScienceRoll wonders if it's possible (this is a Medicine 2.0 carnival).

Inspired by the design innovations in Apple's iPhone 3G (see her Open Letter to Steve Jobs), Amy from DiabetesMine ran a design challenge to encourage innovations in diabetes care. The response was amazing: check out the winners. And, you can listen to the winner on out Grand Rounds Podcast.

Should your 7-year old get an iPhone? Will it cause ADD? See what Mother Jones has to say at Nurse Ratched's Place.

Sandy at Junkfood Science notes that a group in Santa Fe fear getting fried by cell phones and wi-fi, so are trying to get these banned from public buildings. Next thing you know they'll be using iPhones to pop popcorn.

Drooling over the iPhone 3G? Tony from Hospital Impact is. It's a doctor's next best thing.

Laurie at A Chronic Dose eschews the new iPhone and other new medical treatments, finding that what's old is new again. (She gets the gold blogging star for sending me her post while waiting to be seen in the ER. Who needs an appendix, anyway?) FYI, Laurie's new book, Life Disrupted, comes out this week.

Using the web (even on an iPhone) to interact with your doctor improves satisfaction of the patient and the provider. Check our Graham's post on Canadian Medicine, where he describes patients who are happy to pay a small fee for the privilege. Listen to Graham on our Grand Rounds Podcast.

Dr Shock reviews the latest Cochrane evidence-based medicine on the use of omega-3 fatty acids for bipolar disorder, noting that the little iPhone clownfish here are one of the highest in omega-3's.

What if, when you got to the front of the line, the Apple guy gave you a Blackberry instead of an I-Phone? After all, they do essentially the same things, right? Henry at InsureBlog has the disturbing story of a pharmacy chain that pulled that trick on its customers.

David from HealthBlawg also writes about the "evil" pharmacy benefit managers, and noted readers of Paul Levy's column chastised Paul for using the term "medication compliance", which has become a bit of an un-PC term to use. David dutifully points out the the iPhone is as "un-PC" as the come.
[un-PC... get it?... lol]


Will that shiny new iPhone help you remember things? Maybe, but don't expect the Motrin to help. Mona from the Tangled Neuron reviews research from our Hopkins colleague, Constantine Lyketsos, showing that NSAIDs don't help with cognition once Alzheimer's dementia begins. Aspirin doesn't help either, but it helps in other areas.

Walter from Highlight Health has seven ways to get in touch with them. I'm sure that all of them can be done from... you guessed it... an iPhone.

Patient chart out of labels? DrCris from AppleQuack snaps a pic with her iPhone. And be sure to check out her excellent post on branding oneself.

Zoe Brain has a long post about cross-gender brain differences. Somehow I doubt she typed all that on her iPhone (yes, I'm getting tired now of the iPhone references). You can also hear Zoe on our Grand Rounds Podcast.

Speaking of brains, why do smart brains make bad decisions (like paying $599 for a phone last summer that is available for $199 now)? Alvaro from Sharp Brains tells us about how our minds get swayed (and is offering 1,000 bonus points!).

Sham patients? The Samurai Radiologist discusses the reasons behind this fake-out trend on Not Totally Rad.

Paul from Medicine for the Outdoors addresses the important issue of why health care providers, and in particular physicians, should understand environmental issues and their impact upon human health.

Finally. Peter from Medical Pastiche has put his thumb on why we doctors like devices like the iPhone so much.

Dr Penna brings us yet another list of medical applications for the iPhone 3G.

Dean from the Back Pain Blog thinks the only excuse for not getting your mitts on a new Apple iPhone 3G would have to be coming down with a severe case of sciatica, which he addresses in Sciatica and Epidural Injections. Steroids anyone?

Give an Hour. DrVal from Dr Val & the Voice of Reason describes on our podcast an effort to get at least 10% of mental health providers to provide one pro bono hour per week helping our returning veterans and their families, because our government won't provide adequate access to treatment for PTSD and traumatic brain injuries.

In case some of you are struggling with violent thoughts against the iPhone lovers in you, Nancy from Teen Health 411 reviews a book about people who intentionally injure themselves.

ZXC, a family doc from Canadian Medical Blogs, thinks that the sorting hat from Harry Potter could be placed on patients with psychiatric complaints and it would tell him their diagnoses. Looks like the DSM-V will have some competition.

This one is a bit different, being a cartoon. Holly sent this one in from Candorville. I think he's not a shrink, but from Homeland Security. (There's a real Canada theme going through these posts; notice that?)

MJ from Interested Participant notes that the many in the US are pointing to the uninsured as reasons to move to a single-payer system, while folks in Canada are using similar rationale to argue for more private pay options. Maybe the grass is always greener.

The Snarky Gerbil is waiting for her anti-iPhone while talking about Biederman's fall from grace and peer review for journal articles.

Barbara from In Sickness and In Health writes about having hard conversations.

Kerri from Six Until Me writes about trying to get coverage for a diabetes device (Dexcom CGM) that insurance companies routinely decline. Also, congrats on the new hubby (how'd you get that one authorized?).

Are you feeling like a second-class citizen without an iPhone G3? Are you wondering if people will treat you the once you're relegated to the land of Nokia? Doc Gurley wades into the treacherous waters of discrimination of all kinds when she looks at a cluster of recent data about whether or not doctors discriminate when treating patients based on their - not phone - but race/ethnicity.

Zagreus from The Physician Executive got this in way late, but we got it into the post (we weren't able to get these last few on to the podcast).

And, that's the end of Grand Rounds for this week folks. Next week's Grand Rounds is hosted by The Covert Rationing Blog. If you'd like a recap of this week's GR, listen to our podcast as Dinah, Clinkshrink, and Roy take a light-hearted dip into this iPhone Edition of GR.

And, a final note of caution by Dr. Pink Freud (which I read on the podcast):
Dear colleagues,

The new Apple iPhone 3G must be stopped! I first recognized the potential dangers of the device whilst perusing Apple's description of the product:

Consider Apples assertions: "(The) iPhone already gives you mobile multitasking. But 3G technology lets you multitask in more places — without connecting via Wi-Fi. Since 3G networks enable simultaneous data and voice, you can talk on the phone while surfing the web, checking email, or using Maps. All from your 3G cellular network."

My appeal is based on the foundation of simple biology. To date, the data from numerous studies supports strong gender difference in the area of multi-tasking, consistently demonstrating that women's brains, though smaller (apparently size doesn't matter here) are inherently better suited for multi-tasking. The Apple iPhone 3G takes multitasking to heretofore unrealized levels! Simply put, the male gender is not cognitively equipped to handle such technology safely. The implications are dire. Overloading of neuronal circuitry could lead, at a minimum to temporary cognitive impairment. Worst case scenario: What if men attempt to drive and use the new iPhone 3G at the same time? Seizure activity might result, leading to increased traffic accidents. The human toll would likely be catastrophic.

Apple should, at the very least conduct research to assess the short-term effects of the iPhone 3G's multi-tasking capacity on the male gender. Until such time as the effects can be determined, in the interim, Apple could market a less dangerous product to men; perhaps, the iPaper-Cups-With-A-String-Between Phone. As mental health professionals, we need to come together on this issue and be heard as one gender-neutral voice. Who know, maybe someday, perhaps with the aid of cognitive enhancing psychotropic medication, men will be able to handle the iPhone 3G. But for now, this may just be a dream.


Christopher Bush, Psy.D.
(A.K.A. Dr. Pink Freud)

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Thursday, June 19, 2008

Roy Has A One Track Mind

Like any man....

Okay, so it's the middle of the day. A patient calls to say she's running late. I have a spare moment. I decide to text Roy--haven't talked to him in a bit, just some real brief e-mails-- why not? So I send a text message: Will there be lines?

What would you think if you got a random text message to your phone in the middle of the work day: Will there be lines?

I expected a reply: "?" Or: "lines?" Lines in the sand, lines on a page, lines on my face, lines of what, for what, by what?

Did Roy ask? Did he so much as flinch? Within moments, the reply came: On July 11th? Yes.

He knew. Or I knew what was on his mind, what's always on Roy's mind. Will there be lines? Yes. July 11th? The date the new iPhone comes out. And yes, I did mean: Will there be lines to purchase the new iPhone? Somehow, Roy knew what I was thinking. Hard to be cryptic these days.

Oh, and of course, do submit your posts for Grand Rounds at Shrink Rap! You know the theme.

P.s. This story was not confabulated.

Tuesday, June 17, 2008

Submit Your Grand Rounds for Next Tuesday (June 24, 2008)

Okay, this is official, folks. Dinah, Clinkshrink and I will be hosting Grand Rounds next week. It's been over a year since we first hosted. If you don't know, of course, GR is the weekly compendium of all blogs medical and noteworthy.

Last year we had the Amazing Clicky Brain.  This year, the eye candy will be even more spectacular.  

AND, we have a theme.  In some way, no matter how twisted the logic, please tell us how your submitted post is (or is not) connected with the upcoming release on July 11 of Apple's new iPhone 3G.  If you can't find a connection (or non-connection), we will still do our best to fit your post in.

To submit your blog post, please send your submission to:

They must be received by Sunday, June 22, 2008, at Noon (Eastern Time) for them to be considered.  Stragglers will be summarily ignored (or not, depending on where we are in the process of putting it all together).

EDIT: Also, like last year, we will be doing a special podcast on the GR submissions.  If you have a brief (~20 sec) audio file you'd like to email us for consideration on our podcast, please feel free.  I can handle any format.

Monday, June 16, 2008

Should You Shrink Your Prostate?

Okay, bear with me here while I have a brief fantasy about being a urologist.

New York Times
reporter, Gina Kolata writes in "New Take on a Prostate Drug, and A New Debate" about the pros and cons of asymptomatic men taking a medication to decrease their chances of getting prostate cancer. She notes that screening tests reveal cancers (and therefore have surgery and other treatments) that might not prove to be lethal--- some prostate cancers are slow growing and might be better left undiscovered.

With finasteride, as many as 100,000 cases of prostate cancer a year could be prevented, said Dr. Eric Klein, director of the Center for Urologic Oncology at the Cleveland Clinic.

Dr. Howard Parnes, chief of the prostate cancer group at the National Cancer Institute’s division of cancer prevention, also is convinced. “There is a tremendous public health benefit for the use of this agent,” he said.

While it might seem convoluted to offer a drug to prevent the consequences of overtreatment, that is the situation in the country today, others say. Preventing the cancer can prevent treatments that can be debilitating, even if the cancers were never lethal to start with.

“That’s the bind we’re in right now,” said Dr. Christopher Logothetis, professor and chairman of genitourinary medical oncology at M.D. Anderson Cancer Center. “Most of the time, treatment wouldn’t help and may not be necessary. But the reality is that people are being operated on.”

Kolata goes on to talk about whether all men should take the medication as prostate cancer prophylaxis. She says an early study showed that while it shrunk prostates and decreased the rate of cancer diagnosis overall, among study participants there was a slight increase in the percentage of aggressive tumors found, and initially there was concern that the drug was causing aggressive tumors, rather than just unmasking them.

So why does this Shrink Rapper want to blog about prostates? As I read Gina
Kolata's article, I thought about ClinkShrink's post, An Ounce of Prevention where we talked about the theoretical option of treating people at risk for a psychiatric disorder who may never develop one. It seems we do this all the time-- how many people take Lipitor or other statins who might never develop coronary artery disease? How many people with osteoporosis are given medications who might never break a bone without it, who might break bones even with them? Oh, and if you're male, and therefore at risk for Prostate Cancer, now there's something else to think about. There is, after all, iodine in our salt and fluoride in our water. Maybe it's not all bad?

Sunday, June 15, 2008

Schizophrenia, Still Figuring it Out

New York Times reporter Benedict Carey likes to write about mental health issues. Today, he talks about the diverse presentation of schizophrenia, as well as variations patients have with regard to treatment response. Carey writes:

The findings confirmed in a rigorous way what psychiatrists who work in the trenches know from experience: Many patients bounce from medication to medication for years. Some find a drug they can live with; others do not and choose not to take drugs at all.

Psychosis can be miserable — and it says something when people prefer its twisted torments to being on a medication.

The shortcomings of the drugs, in turn, cast doubt on one working theory of the biology behind schizophrenia. The drugs act on the brain by numbing cells to a brain chemical called dopamine, which was thought to be overactive for some reason in people with schizophrenia. Most researchers now regard this so-called “dopamine hypothesis” as simplistic at best.

He goes on to say that, according to European studies,with the right support, there are patients with schizophrenia who can be maintained for years without medications. Wouldn't it be nice if we knew exactly which patients they were?