Thursday, July 29, 2010

Pharmaceuticals in the Information Age--Guest Blogger Dr. Mitchell Newmark

Look, I found Mitch, a classmate of mine from medical school, when he started to follow me on Twitter. Only I don't tweet (or I don't "emit tweets?" Sometimes I squawk, does that count?). I sent an email and while we were catching up, I invited Mitch to be a guest blogger.

Pharmaceuticals in the Information Age

It’s become a standard for me, when prescribing psychiatric medication, to ask patients if they intend to look it up on the internet. I think the internet is often a terrible place to go hunting for information. Either you’ll find a company sponsored site with happy faces, bells and whistles, or you’ll find disgruntled groups of patients denouncing the evils of one pill or another. The “impartial information” sites are frequently as toxic, especially for anxious patients, who can read through a comprehensive list of side effects, with little reference to their frequency or importance. And who knows if the information you’re finding is up to date? If a patient is paying to see me, it would make sense to bring his or her worries (Will my hair fall out?), concerns (Will this make me gain weight?) and fears (My friend took this and had a terrible reaction!) to me, not to the Web. If patients do want to Google their Rx’s, I ask them to send me whatever information they find which disturbs them. At least I can try to address the questions the internet has raised.

Even worse are television commercials for medications, which are unavoidable. I find that I need to watch at least some network TV just to keep up with what patients are seeing. How confusing to see such pained sufferers become spontaneously functional and cheery, while listening to the diabolical audio undercurrent of debilitating side effects. I know the messages are powerful; I frequently meet a new patient who comes in specifically because they saw a commercial for Abilify or Pristiq or something else during their favorite show. At least these drug mini-dramas do patients the courtesy of asking them to “ask their doctors.” Every patient is different; what works for someone, or causes side effects for someone else, is often an unknown. I find commercials send the message that THIS medicine will fix everyone.

Mitchell Newmark, M.D. is a psychiatrist, living and working in Manhattan, who is both a psychotherapist and psychopharmacologist, with a subspecialty in addictions.

Tuesday, July 27, 2010

The Guilty Doctor

Times are tight and we're all looking to save money, be it our own or someone else's. Many will say that when it comes to the skyrocketing costs of health care, doctors are responsible for part of the problem. We order too many tests, either to cover ourselves in the event of a malpractice suit, or because patients pressure us, or because we genuinely believe that the tests are necessary for patient care, but in many circumstances, a cheaper option is available. We order medications that are expensive when cheaper medications are available. And psychiatrists offer care-- like psychotherapy-- that could be done by clinicians who are cheaper to educate and willing to work for less money.

Here are some voices on decreasing cost: From KevinMD's post on when patients (in this case the patient is a doctor), pay cash. More on the same story directly from Jay Parkinson, here is Today I Was a Patient. The most absolutely cool thing I learned from Dr. Parkinson this morning is about a website I had never heard of before called
ZocDoc which lets people schedule on-line appointments with new physicians (including shrinks!)--like OpenTable for Docs...I asked for more info about this, but such a website fits Roy's vision of dying and going straight to heaven. And MovieDoc has strong opinions on allocating resources: we shrinks should not be letting patients ramble on about their romantic lives, why one psychiatrist can treat 1,000 patients if they stop that psychotherapy nonsense! ClinkShrink, too, has had a lot to say about allocation of services, but I'll stop now before the blog explodes.

I buy it, too. Docs should feel an obligation to care about cost-containment. In recent times, this translates very simply into the fact that I feel guilty no matter what I do. I sit with a patient and I consider trying a cheaper option for medications before I try a more expensive
one. But then I think: isn't my obligation to do my very best by this patient? Why shouldn't my patients get the latest-greatest available medication when other patients do? And what's the cut-off for how much it's worth for....relief from voices, a better mood, a good night's sleep? How do we even begin to put dollar signs on such things?

I'll give you a scenario. A patient comes to me already on an
anti-psychotic medication. He says it helps, but it's unclear why it was ever started. At some point, he stops taking it, and it becomes much more clear why he ever needed it: he becomes flagrantly psychotic and completely unable to function. I restart the medication, using the one he was on, which happens to be fairly cheap as the second generation anti-psychotics go. So all good: the med works, I know he tolerates it, and it's the cheapest of the choices, by a lot. Oh, until he gains 20 pounds. Now what? There's Abilify which is, oh, many times more expensive, but is less associated with weight gain...should I try that? I hesitate because of the cost, and then I think perhaps I should try one of the older medicines, of the Haldol generation-- much, much cheaper, but many patients hate it. As a field, we seem to agree that these first-generation anti-psychotics are not the way to start; the atypicals are the usual first-line treatment. Maybe this patient won't have side effects, maybe he'll be fine, I could "try." But isn't that making my patient into a guinea pig? If it were me, would I want to try a medication with many known side effects, when other medications are available? Nope. So I go back and forth between what is best for my patient and what makes sense for society. I share some of my thoughts with the patient, whose private health insurance pays for them, and he clearly wants what's best for him, not what saves society money.

I suppose the question presumes that I know what's best for him. And clearly, I don't. One of my big concerns is that he had this awful recurrence of a terrible illness, and each time, it takes weeks to get better,time lost from his life. There is no guarantee that
Abilify, with a more favorable side effect profile, will be equally efficacious, or that Haldol, cheaper if you will, will also work. There is the risk of relapse with any medication change and this is why some patients tolerate medications that cause weight gain or diabetes.

And then there is the "at what cost?" for that particular symptom. A patient wants a medication for sleep--
trazodone and benedryl don't work, ClinkShrink flips when anyone prescribes Seroquel for sleep ($3/pill for 25 mg per, benzodiezepines are contraindicated, and then there's Rozerem at $5/pill. Is a good night's sleep worth $5 night? Of whose money? And what if the patient is on generic Ambien ($1/pill or less) but wants to take Ambien CR ($4/pill) because it helps him sleep longer? And how do you feel about Provigil, which comes in at $20 a pill for the 200mg dose? Stepwise therapy, you say--- where a patient must try cheaper medications before he is allowed access to the more expensive ones? And who determines efficacy? And how do we deal with the hassles of pre-authorization? Maybe we should decide that certain medicines are so expensive that they shouldn't be offered to anyone?

Friday, July 23, 2010

Drug Reps in the Waiting Room.

Sarebear has been commenting on our posts for years now, since the very beginning of Shrink Rap. She sent us a link to one of her blog posts on Pie-Bolar Served w/ 3 Flavors of Anksia Tea and the post was a detailed discussion about her session that day with her psychiatrist. Lots of details and lots of sadness and angst, but a wonderful glimpse in to what happens in a session with a psychiatrist. I especially loved that Sarebear started her account in the waiting room where she sat with her family...the psychiatrist was running late and two drug reps were sitting there talking! What does a patient think about when such things intrude on their care? With permission, here's Sarebear's thoughts on Drug Reps in the Waiting Room:

My psychiatrist was twenty minutes late today, which means that she got in to the office at 9:20, which was when she was supposed to see ME, but her FIRST appointment, her 9:00, was still waiting to be seen, so I had to wait longer. UGH!! She said, "I'm sorry I'm so late!!", and the other patient said, "Don't worry about it", but I said absolutely nothing . . . . . lol. Can you tell I was a little peeved? In early morning traffic, it takes about 35 minutes to get there, so we had gotten up early, and had gotten there 10 minutes early, even, not wanting to shave it right to the minute. I suppose everyone has an off day, though. It's still annoying for me, as the patient! Guess I wasn't very "patient", heh. While I waited, just after the first patient went in, a pair of drug reps, one in training, came in, and dropped off some samples in her back room, then sat down to wait. I vowed that I'd get seen before them, because patients are more important. They talked alot of business, and about where each of them had worked, and some of the details of the software they were using on the laptop, that they wish they'd had at the previous place, and stuff. It was interesting to listen to them talk. Drug reps are a sadly necessary "evil" of the medical practice, because they provide drug samples for the doctors, without which you wouldn't be able to start some of the initial doses of certain medications, and sometimes the samples are used to help some patients afford the medications, although they do NOT replace the pharmacy, not at ALL. The drug reps also provide coupons and promotions for the patients to redeem for free two week or one month supplies of the medication, with prescription, at the pharmacy, whenever their companies are offering such coupons and promotions, so again, these things are good for the patient's pocketbook, their bottom line, for being able to afford the medications, when the insurance situation isn't ideal. Obviously some of these don't last very long, while other programs will, say, take half off the cost of the medication for a year, but whatever can help the patient, is a GOOD thing. It's just, the whole salesman aspect of the thing, seems a little . . . smarmy. It also feels a bit intrusive, to have salesmen in the medical setting like that, but as I say, it is a necessary "evil", even if one wonders about the influence that they may have over a doctor's prescribing practices. The most ethical doctors will not be influenced, but no one is perfect. Anyway, sitting there for awhile, listening to them, I didn't think they worked for Pfizer, the makers of Geodon, the medication I had been reduced in dose after my recent bad experience on, and was here today to be likely removed off of and put on possibly something else, but if they did, I wanted to tell them I thought it sucked. So, I asked them eventually, "Do you work for Pfizer?" They said, "No", so I continued anyway, since they'd still have an interest, and they did, and I said, "Well, Geodon sucks". They said, "We think so too, we sell a competing product." I said "Oh, okay. I hate it, because I had unexpected side effects." They then expressed their regrets to me that I'd had a hard time, and again said that they didn't like the med. I thought the whole interaction was a little bit funny, hee. Normally I wouldn't, as a patient, have any kind of interaction with drug reps at all, but since my psychiatrist was late, and since they'd been chatting for awhile so freely in front of my husband, daughter and I in the waiting room (after all, this is the type of location that is basically their workspace for the whole day; that, and their car, so one can't expect them to just sit there silently), so their chatting had encouraged me to eventually strike up a conversation, since there was nothing else to do while I waited for the doctor. When she eventually came out, as she walked past them to the front desk, she asked them if she needed to sign something, (I assume as in, to sign for the samples they'd dropped off in her back room) and they stood up and handed her a clipboard and started talking with her, the one in training did. I wondered if he'd bring up with her anything about the competing product for Geodon, since he knew she'd be bringing me off of that one, and potentially on something else, but it seems they had enough discretion NOT to go there, which amazed me slightly, for salesmen. They just brought up the coupons and promotions that are so helpful for patients, and got the signed clipboard back, and in the middle of signing it, she called me in to the office, which helped let the drug reps know that she'd not be spending a lot of time with them, and made me feel like I was her priority. I didn't feel badly that she'd signed for the samples, because otherwise these men would just be sitting around for another 25 minutes doing nothing, when just 2 minutes of her time took care of the whole matter.

Monday, July 19, 2010

Call Back Never

Okay, so I've been complaining about the hassles with Medicare since I changed my address. So this morning, Monday at 9:23 AM I decided to call the Highmark Medicare Enrollment Helpline. I went through the assorted menus --- with several stops at : Please visit the website. So finally I get to the juncture where I can press O to speak with a live person. Oh, but the message I get is: "We are currently experiencing high call volumes and can not take your call." They suggest I call back later, and specifically suggest that the best time to call is 8AM-9AM on Mondays. Next week, perhaps? Oy.

Saturday, July 17, 2010

Be Our Friend!

I'm trying to figure out the details of an organizational Facebook Page. Somehow, I made two from the same account, and so you can be our Friend on Facebook, or you can be our Fan on Facebook. There's a duck. There's some sideline stuff. There's our feet. I'm hoping I can get Roy to feed his tweets to the Facebook page so that our posts will show up there. I haven't got the kinks out, but please do Friend us and Fan us, especially in this heat! If you look for us on Facebook, we're Shrink Rap, the ones with the feets.

Thanks for being our friend!
And here's the link: Shrink Rap on Facebook

Black and White on Romance ...and Other Things in Life

I'm stealing a post from Jay at Two Women Blogging----which is interesting because it's written by three women blogging and you'd think that three bright women could count (maybe even up to five), but okay.... Here is their stolen post and I'll discuss it below. I think they'll be okay with my stealing, and here's a shout out to Tigermom.

Was Harry Right?
~by Jay

Bluemilk got me started thinking about this. I first heard Harry's thesis advanced by the resident I worked with on my med school psych rotation. She assured me that while I might think I had platonic friendships with men, the men didn't see it that way. I was pretty sure they did see it that way. I wasn't naive - I was engaged to be married and had done my share of dating and flirting; I knew what it felt like when a man was interested in me sexually and I knew the difference. I still know the difference, and I still have men friends. For most of my life, my closest friends have been men.

I had a best girlfriend growing up, but we weren't together very much - she lived in a different neighborhood and had a lot of afterschool activities and we weren't usually in the same class at school. We didn't trade sleepovers and call each other to check our outfits and have long closed-door talks like Eve does with her friends. My day-to-day best friend, the person I hung out after school with and rode bikes with and watched TV with and waded in the creek with, was the boy across the street. We were inseparable until he moved away when we were ten.

During that same psych rotation, we had a lecture on child development in which I learned that "all children" had a same-sex best friend during latency. I asked the lecturer afterwards what would happen if a child had an opposite-sex best friend during that period, and she said "gender development would become abnormal". Perhaps that explains it.

I started to seek out and cultivate female friendships when I was in med school, but I find I still gravitate toward friendships with men. I am blessed, now, with wonderful women friends, and I'm deeply grateful for them, but I still think my psych resident - and Harry - were wrong.

I picked this post to blog about because 1) I liked having the When Harry Met Sally clip in it and 2) because these kinds of black-and-white statements about How Life Works come up all the time in therapy. In the case above, the teacher tells the student that during latency one must have a same sex best friend. Must. If not, the person grows up to be "abnormal" in their gender development. Show me the science. Oh, first define for me "normal" in terms of gender development? And who out there has "normal" gender development? What's the goal? Martha Stewart? Barbie? Elana Kagan? J Lo?

What comes up more often in therapy is the question of can you be friends with an ex-girl/boy friend? An ex-husband or wife? I tend to think that it's usually hard, but there are people who do it, so counseling: "you can't be friends with an ex" or "you can't be friends with a member of the opposite sex" or pretty much any absolute, seems, well, not evidence-based. My personal favorite piece of advice-- to give-- along the 'absolute,' non-evidence based line is to tell people to stay away from the person they are so painfully breaking up with for a good long time, at least until all parties are no longer in love and have moved on with their lives. Now all I need is a movie scene.

Sunday, July 11, 2010

Charlie Rose: The Brain Series: Mental Health

In case you missed it, Charlie Rose had quite the guest list this week in Episode 9 of his Brain Series:

Helen Mayberg
, Jeffrey Lieberman, Kay Redfield Jamison, Eric Kandel, Stephen Warren and Elyn Saks in Science & Health on Thursday, July 8, 2010

Here is a link with the transcript of the interviews:

Nobel Prize winner Dr. Eric R. Kandel co-hosts the show with Charlie Rose, and to quote Dr. Kandel from the transcript:

The whole history of psychiatry, which is a culmination of Emile
Kraepelin, is interesting.  We’ve known about these illnesses since
Hippocrates, the great Greek physician in the 5th century, who not
only spoke about depression and manic-depressive psychosis but
specifically indicated that these are medical illnesses.

But this basic idea was lost on European medicine for the
longest period of time.  During the middle ages, even later in
the Renaissance period, these were thought as demonic disorders,
people possessed by the devil or moral degeneracy.

And people with mental disorders were put away in insane
asylums usually far removed from the center of town and often
they were kept in chains so they don’t move around.

Fortunately, this situation was reversed in about 1800.  The
Paris school of medicine began to really express a very modern
view of medical science.  And Philippe Pinel, a great French
psychiatrist, realized psychiatric disorders, as Hippocrates had
said, are medical illnesses, and he began to institute humane
treatment, the beginning of psychotherapy with mental patients.

But from 1800 to about 1900, no progress was made in
understanding psychiatric disorders.  One couldn’t localize
them specifically so one didn’t know is there one mental illness
or are there many?

And that’s when our mutual hero, Emile Kraepelin, came on the
scene. And his textbooks which began to emerge around 1902 and
continued until he died in 1926, he outlines, for example, in this
book in his first three chapters he defines the fact that mental
illnesses are not unitary.  They affect two different processes,
they affect mood, emotion on the one hand, and affect thinking on
the other.

And he defined the disorders that affect mood -- depression and
manic-depressive disorder, and he defined the disorders of thinking
as schizophrenia.  He called it dementia praecox.  He thought it
was a deterioration of cognitive process in the brain early in life,

And as you outlined, we have some insight into the nature of
these diseases.  We know that depression is an illness that involves
mood, which is associated with the feeling of worthlessness, an
inability to enjoy life.  Nothing, it’s all pervasive -- nothing
gives one pleasure.

And there’s a feeling of helplessness, of worthlessness, often
leading to thoughts of suicide and, tragically, to suicide attempts

And 25 percent of people that have depression also have manic-
depressive illness.  They have the opposite end of the spectrum.
They feel fantastic at the beginning of the disease.  They feel
better than they’ve ever felt in their life.  But ultimately this
leads to grandiosity and frank psychotic episodes.

Schizophrenia is a thought disorder that has three types of
symptoms-- positive, negative, and cognitive.  The positive symptoms
are characteristic I can of schizophrenia.  It’s the thought disorder,
hallucinations, delusions, the acting crazy.  The negative symptoms
are the social withdrawal, the lack of motivation.  And the cognitive
disorders are the difficulty with organizing one’s life and a
difficulty with a certain kind of memory, called working memory,
short-term memory.

Fortunately, as you indicated, we can now see people who have had
effective treatment who have very productive lives.  And Kay Jamison
and Elyn Saks, despite the fact they suffered the this disorder much
of their life, have rich personal lives, both of them involved in
meaningful interpersonal relationships, marriage, that is very
satisfying to them and having spectacular academic careers.

So there’s tremendous hope for the treatment of the disease.

Friday, July 09, 2010

Dear Roy....Love, David Pogue

There's an article in
The New York Times by David Pogue and I think it was written just for Roy.

Roy, in case you didn't know, is a really really smart person. He knows a lot about psychiatry, and maybe more about technology. The only thing is, he sometimes assumes that everyone else knows what he knows and speaks his language, and often that language includes a lot of technospeak. Try writing a book with someone like this! Oh, I did. So glad to be done for the moment.

So Mr. Pogue tells us that The New York Times editors asked their writers not to use the word "tweet" anymore for fear that readers wouldn't understand. Mr. Pogue writes:

“We don’t want to seem Paleolithic,” he wrote. “But we favor established usage and ordinary words over the latest jargon or buzzwords.”

That the Internet’s reaction was so swift and harsh only proves the point: the techno-savvy population can’t even conceive of the existence of a less savvy crowd. If you use jargon every day, you can’t imagine that millions of people have no idea what you’re talking about.

I do a lot of public speaking. And even today, when I ask my audience how many know what Twitter is, sometimes only a quarter of the hands go up.

The article goes on to define the basics for the uninitiated: Facebook, Twitter, Yelp (my favorite), Foursquare (Huh?), and Linkedin. Mostly, though, I liked that it made me think of Roy. So Roy, can you imagine a world where three-quarters of the people don't know what Twitter is?

Wednesday, July 07, 2010

Medicare Oh Medicare

I've written before about the difficulties I'm having with Medicare because I simply wanted to change my address. Medicare has 221 downloadable forms, none of which are change-of-address forms. In order to do this, I needed to fill out a 27-page enrollment form. I did, but was rejected because I didn't also fill out a 5-page form giving Medicare access to deposit funds in my bank account. Oh, but I'm a non-participating provider--- Medicare pays the patient, not me. And, I work in a clinic where they bill Medicare for my work under my name, and I certainly don't want money that belongs to the clinic going to my bank account. There's no upside to them having this information, and much potential for hassles. I filed an appeal, and it was denied. This has been going on for months. I've stopped being aggravated, and I was pleased when one of my patients mentioned she'd gotten a reimbursement check, so who knows how long I will exist, and I may surrender and send them my bank information and hope for the best.

You can read about my prior rantings Here and Here.

So the day of my latest rejection by Medicare, Meg was kind enough to send a link to an article about a Medical Society President (a dermatologist) who opted out of Medicare. The Business Review writes:
Dr. Leah McCormack, who has a dermatology practice in Forest Hills, said in an open letter dated June 30 that “I can no longer bear the shackles of government and insurance company rules, the burdens of their regulations and the fear of their retributions for the paltry reward of their monetary compensation for my services.”

The article goes on:
“I have been in the solo private practice of dermatology for 25 years,” she wrote. “I have tried to practice with the total focus on my patients, but this has become impossible. My staff and I spend an exorbitant amount of time dealing with claim denials, insurance managers, pre-authorization managers and pharmacy benefit managers. There is so much health system managing that there is little time for health care.”
Thanks for the heads up, Buggy!

Tuesday, July 06, 2010

What Treatment Works Best?

So usually we figure this stuff out by 'evidence-based' know, the whole double-blind, placebo-controlled study using only those perfect research subjects who don't have other problems like substance abuse, pregnancy, childhood, or co-occurring disorders.

This month, Consumer Reports gives their own breakdown of what works for the treatment of depression and anxiety. Here's the Link to their overview. Buy a car, buy a dishwasher, get a shrink...same idea.

Ali writes to us:
Dinah, Roy, ClinkShrink:

The July issue of Consumer Reports includes a survey of more than 1,500 readers about the therapies and drugs that helped their depression, anxiety or both (all those surveyed had sought professional help).

The report provides insight into mental health treatment as it's practiced in the real world, as opposed to the carefully controlled environment of clinical trials. A few of the findings:

- Of readers who sought help for a mental-health difficulty, 58 percent had experienced anxiety, up from 41 percent in our previous mental-health survey, in 2004.

- Rates of reported side effects among people taking antidepressants were higher than those reported in studies funded by drug companies.

- Psychologists (Ph.D.s), social workers (M.S.W.s), and licensed professional counselors (L.P.C.s) received equal helpfulness ratings from those who had talk therapy.

- Respondents to our survey who stuck with talk therapy for just a little while—at least seven sessions—reported as much improvement as those who only took medication (though people who did both fared even better).

I hope you will take a few minutes to read through the results and share the information with your readers.

Let me know if you have any questions.

(on behalf of Consumer Reports)

Hmmmmm, so how come they didn't ask if therapy with a psychiatrist works better?

Saturday, July 03, 2010

The Good Old Days

Dr. Psychobabble is a new intern in New York and she's reading the manual on how to work her pager. Her pager? They don't just call/text housestaff on their cell phones, they still need hospital pagers? It got me thinking about my old pager back when I was an intern in New York.....

I saw my first cell phone when I was in medical school. It was in a suitcase. I didn't see another one for years, and I didn't get my own until 1996. My entire training occurred in the virtually pre-cell error. As an intern, I was given a pager. It beeped, then shouted out the number I was being paged to call. The owner of the pager had to listen, it was a auditory thing, not something you could read. In the bathroom, the voice of pag
er woman reverberated off the tile walls in an particularly intrusive tone. For months after I no longer carried the thing, I jumped when the microwave went off (post-traumatic pager disorder). Talk about an object to hate!

PCs showed up when I was in college, but few people had them. A research team I worked with did, and so I learned Volkswriter (? a predecessor of Word) fairly early. Mostly I remember the group panic when the computer lost an 80-page original research document. I did think it was fascinating that you could push one button and have the thing blast out 80 of the same letter addressed to different people. For my own papers, I still used a smith corona and I remember being up all night writing a paper my senior year on bulimia. Mostly I remember that the professor pointed out to me that I'd misspelled bulimia (and Roy says....sigh...and wishes I were obsessional and detail-oriented). I can't imagine what college would have been like for me with internet access. I may not have made it: Facebook might have diverted me from any goal-oriented behavior. How would I would have sat in class and texted my heart out. Oy. But all the professors I was too intimidated to speak to-- I would have emailed them my every thought and it might have been a richer experience...or not?

By med school, word processors were more widely available---there was a whole bank of computers in the library and the night before a paper was due, we'd all be there, keyboarding. No real Internet yet, and I never had much use for the computer beyond the word processing capability.

I did get an answering machine in medical school, something that truly freed society from sitting by the phone w
aiting for a boy, a job, a residency interview.

A few years after I finished residency, the Internet really caught on and I had no real idea. Clink of course, knew it all. I asked her to come show me, so she comes with a laptop and plugs it in to my phone line. She loaded a page and waited. And waited. This was not for me. I wanted to try email. One of her contacts was a mutual friend, a man who'd trained with us and then moved to Minnesota. I sent him an email. He wrote back: he and his wife and two small children were coming to visit, could they stay with my family (in my very small house, with our two small children) for a week? I wasn't so sure about this email stuff.

So now we have a blog, a sometimes podcast, I have a desktop, laptop, iTouch, husband has an iPad and blackberry, kids have laptops and iTouches, everyone has a cell with a zillion minutes and unlimited texting. TV with satellite and DVR and four remotes and a sound system. There's a bunch of digital cameras in the mix, two types of speaker docs for music, voicemails and emails. listservs, and things to check out the wazoo....we all have Facebook pages and some days we're friends and most days we're not. Twitter me this, send me the link to that, YouTube, MySpace, ITunes, oy. When's Roy gonna make a Shrink Rap iPhone app?

And now for announcements:

Happy Fourth of July weekend, Everybody!!!
Happy Birthday, David. I love you and you were great on TV this week.
Welcome home, DB, two delayed flights, days of travel and I'll be glad to have you home and out of Africa, can't wait to see your pics and I love you, too.
Roy? Has anyone seen Roy? Did he eat the beauty queen podcast???
And finally:
Congratulations, Clink and Victor!