He's Gone

At 8:30 last night I got the news. It came from somebody who knew me quite well and knew my hardcore loyalty to Apple, enough to call me a "Steve Jobs Apple toady bootlicker." A good friend, yes. He told me: Steve Jobs was dead.

Wow. I remember when John Lennon was killed and I'll remember getting this news.

Steve Jobs has been part of my professional and personal lives for 25 years. I got my first Mac in 1986, during my second year of medical school. It was a huge decision, and even with a student discount a tremendously expensive thing to do. It was a decision I've never regretted. I still have that machine.

The day I went to pick up my new machine they held a special event at the university hockey stadium. The whole place was filled with aisles of Macs stacked six feet high. People were lined up around the block to pick up their new machines. The only time I've seen anything like that was at the opening of the first Apple store in 2001. I was standing in line at Tyson's Corner, fortunately not at the end which curled around the second floor and down the stairs. The waiting time to get in was rumored to be three hours, and there was security in place to make sure the store stayed below the fire marshal's limit of people in the store.

The Apple years without Steve Jobs were grim. A series of five CEO's successively drove the company into the ground. The quality of the machines dropped, there were recalls for broken parts, bad monitors, stuff that never would have happened under Steve. (OK, the Apple Newton eventually became the prototype for the Palm Pilot---using an operating system designed by former Apple engineers---but it never quite got it right.)

Then he came back. Just in time, like Superman coming back just as the bomb is about to explode, to save the world. We got that weird-looking first-ever all-in-one pyramidal iMac. We got OS X, one of the most stable operating systems I've ever used. We got iPods and iPhones and iTunes (without which our My Three Shrinks podcast would never have happened). We got the iPad. We got the software. It just happened.

So here we are. We three Shrink Rappers all use Apple products. We edit podcasts with Garage Band, have iPhones, use MacBooks. Our iPhone edition of Grand Rounds was one of most popular posts (complete with clickable iPhone buttons). Technology for non-geeks.

There's not much else to say. If there is, the Twittersphere has it covered---it's been nothing but mourning for hours after the news broke.

He's gone.

Goodbye.

And thanks.

Guest Blogger Dr. Jesse Hellman: More Thoughts On Rachel Aviv's Article on Involuntary Treatment

Jesse has wanted to do a guest blog post for a while now, and The New Yorker article finally got him blogging. I wrote a brief post yesterday, but he does a more thoughtful analysis of this complicated and provocative issue. Clink is off somewhere.. I am looking forward to hearing her thoughts after the holiday.
__________________________

In “God Knows Where I Am” Rachel Aviv sees the protagonist Linda’s
refusal of treatment as an expression of her illness. The moral
impasse she describes for our profession, though, is real: denial of
the need for treatment, or of one’s illness, can be an expression of
that illness; the refusal of treatment can also be a valid position
which we understand and support.

Mental functioning can be variable, at times better and at times
worse. At times the craziest thoughts are held in check, or do not
manifest themselves, while at others they hold total sway. The
underlying assumptions of our society are shared by us, and these
shape our reaction to the illness that Linda has. Other societies,
with different traditions and philosophical underpinnings, are
comfortable with very different stances.

Before Linda was discharged from the hospital the staff did everything
they could to dissuade her, and to provide for her safety. She
rejected every effort to provide housing and support. The hospital
argued that she was too sick to make decisions which even included not
allowing the staff to notify her sister and daughter. After her death
the family sued, stating that insufficient effort had been made to
protect her. The hospital then argued she was not sick enough to
justify stronger measures. What was true?

When we look at a complex issue, or event, we naturally can only see a
part, and our response is shaped both by what we see as well as the
assumptions we carry. What weight to we place on independence versus
the rights of others? What extrapolation can we make to an unusual
thought, in that do we see it as the harbinger of insanity or of
artistic creativity? Do we value religious musings or find them
suspect?

Aviv lets us see that while a part of Linda’s functioning might have
been creative, artistic, perceptive and so on, it was increasingly
shaped by an imagination which was not tempered by reality. It was as
if she was in a dream but could not awake, a dream which increasingly
dominated the most important parts of her ability to survive.

So what is the proper role of society when confronted by such illness?
What if her fantasies had shifted from thinking spies were all around
her to imagining the world could only be saved if she were to shoot
her congresswoman?

Go to iTunes U and Become a Psychiatrist

An interesting convergence of themes occurred today, from three separate threads. From this remarkable thematic convergence, I have come to the conclusion that one can become a psychiatrist just by sleeping.  Please, follow along.

I couldn't fall asleep last night and could no longer focus on writing a chapter for our book, and so was cruising iTunes U, looking to see what sort of interesting lectures they had there.  (Yes, it is ironic that, despite my above-stated conclusion, I was already a psychiatrist yet could not sleep.)

If you aren't familiar with iTunes U, they make audio and video podcasts of

 college lectures from MIT, Yale, Stanford, and other participating universities, available for free. No enrollment fee. No 8am lectures. No uncomfortable chairs. Alas, no credit, but you get to learn for free.

Believe it or not, I spent 45 minutes watching a Stanford engineering course on Fourier transforms -- and didn't fall asleep!  At 3:00 AM!!  Thank you, Brad Osgood (iTunes link HERE).  I did not take any notes, btw.

So, that was the first thread.  

After a fitful four hours of sleep, dreaming of wavelengths and lambda, I begin my Sunday morning with blueberry and ginger pancakes.  Since this is 2009 and all, I am reading -- not the Sunday paper -- but the Sunday blogs and news on the computer.  I come across a post by a fellow psychiatrist blogger in the Netherlands, DrShock, about a just-published article from Computers & Education, entitled "iTunes University and the Classroom: Can Podcasts Replace Professors?", and written by SUNY psychologist, Dani McKinney et al.  This was a very interesting second thread, which related to the first.  What Dr McKinney did was have two different groups of psychology students receive a lecture on "perception."  One group attended a traditional class lecture and the other received the lecture as a podcast.  They were later tested on their recall of information from the lecture.  Alas, there was no random group assignment, which is a relative weakness of the study design.  

But the findings suggest that a podcast lecture provided more opportunity to re-listen and take notes than the live lecture, as the podcast group scored significantly higher than the live lecture group.  Of those students who took an average amount of notes, the podcast students scored an average letter grade (10 points) higher than the classroom students.  (If you'd like a copy of the entire article, you may write Dr McKinney at mckinneyATfredoniaDOTedu.)

Most of the podcast students listened to the lecture more than once, so they had more opportunity to learn the material.  This is one of the benefits of having a recording of the lecture.

Here's what made me go "Hey, wait a minute, this is quite a coincidence!" -- I have had dinner with Dani McKinney before.  She is, in fact, a close friend of one of my close friends.

So, the third thread of this convergence of ideas hits me when I go to Shrink Rap and see that the Google ad on the right sidebar says,

"Be a Psychiatrist.  Advance your career - earn a degree in Psychiatry completely online."

Well, I can see the handwriting on the wall.  THIS is the 7th future trend in Psychiatry.  Online medical degrees.  You don't even need to go to class.  Just listen to the podcast (at least twice for better retention) and take notes while you listen, and you can advance your career in no time.  I suppose if you are really lazy, you could play the podcasts while you sleep.  I'm not sure if there would be adequate retention to pass the tests under this condition, but Dani assures me that she will be testing out this hypothesis with the next group of psychology students.  Wake me up when we get there.  In the meantime, I'm heading over to iTunes U to take some neurosurgery classes.  Reimbursement for procedures is much better than for cognitive services.

Escape To New York

OK, I'm out of prison. After a few months of listening to guys talk about stabbing people, firebombing houses and other general nasty things, I've escaped to New York. I walked through Central Park, saw a couple art galleries and went to a Broadway play (Speed The Plow, it was great). Oh yeah, and had some delicious food.

So now I'm blogging from the Mac-users mecca, the Fifth Avenue Apple store. The one that looks like a big glass cube. I've just bought my new 16 gigabyte iPod touch and am happy as a clam. Yes, I'm out of prison...and mildly out of control in this store. I've got pictures to send my co-bloggers.

And now a request---soon there is a play opening here called Zombie. It's about a serial killer. They're giving discount tickets to folks interested in forensic psychiatry. I'm going to be gone before it opens. I need somebody to see this thing and post a review. Thanks

iPhone 3G Activation Blues

I thought I'd share my iPhone experience, not that it has anything to do with psychiatry, but I know a lot of our readers and listeners are Apple fanfolks, including yours truly. (Full disclosure: I own a whopping 9 shares of Apple stock, so assume some bias.)

As you may already know, Apple released it's 2nd version of its cell phone, the iPhone 3G (not a third generation phone, but the "3G" refers to its use of a third generation cellphone network) on Friday, July 11, 2008, at 8am local time 'round the world. Our Grand Rounds post on June 24 foreshadowed this release. Unfortunately, Friday's release was a disaster, and the dust has not even settled yet.

Apple ran out of its old iPhone in stores over a month ago, so demand has been building, as well as interest in the 3G's upgrades, which include a faster cell network, a regular-size headphone jack that does not require carrying around an adapter, and a price that is about half that of the first phone.

The usual Apple build-up and mystique contributed to people starting to get in line for the iPhone a full week ahead of release date (this is insane). Even my going to stand in line at 7am was a bit much, as I'm sure I could have gone the next day, walked in and got one.

Anyway, on the left is a picture I took with my Treo (I've had Palm devices since the original Palm Pilot way back in 1996) after getting in line, with about 100 people in front of me. Two hours later, by the time I reached the front of the line to get into the store, there were another 150 or so people behind me. Note that there were two other line opportunities at the mall... the AT&T store and the AT&T kiosk.

The ratios of people standing in line went like this: Apple:AT&T:Kiosk::25:5:1. The buzz in the line related to guesses about how many 16GB iPhones the Apple store had in stock versus the other two stores. It would be interesting to find out if the line proportions mirrored the stock proportions... you know what they say about the wisdom of crowds. Unfortunately, none of the stores' workers would tell us how many they had in stock, which is not very smart, as there were many reports of pissed off AT&T line standers getting upset when the manager later emerged, predictably telling them that they had no more of the precious phones in stock.

As we got closer to the front, I measured the pace of people leaving the store at about 1 person every 2 minutes. Nine people away from entering the store, and then people stopped coming out of the store (and we stopped going in). We found out that the same thing happened at the AT&T store (which we could see from where we were). Soon after, an Appler came out to tell us that the servers handling the phone activations were down, apparently crashing under the heavy load.

After a bit more waiting, a gush of people came out, iPhone bags in hand. But they didn't have that gleeful look on their face. One of them told us that the servers were still down, and that they'd have to activate their phones at home via iTunes. (This is how it was done with the first iPhone, but AT&T insisted on in-store activations this time to reduce the number of phones that get sent internationally to get unlocked later, so they can be used with any cell network.)

We started moving again and the rest of the experience was uneventful (fortunately, given that my bladder was extremely full by then). I walked out with an unactivated iPhone and was able to get it activated later that evening.


So, what went wrong?

It looks like that someone woefully miscalculated the combined effect of the following things happening all on the same day:

-a zillion in-store iPhone activations
-the release of an update to the iTunes software, version 7.7 (a 50MB download)
-the release of a firmware update (iPhone 2.0) to the 6 million first-gen iPhone and iTouch devices
-the release of a new iTunes App store (as in Application Store)
-the conversion of Apple's .Mac service to the new Mobile Me service

On top of all that, existing iPhone users who tried to update their firmware found that their iPhone was now as useful as an iBrick.

The postmortem analysis points to iTunes, not AT&T, as the Achilles heel in the fiasco. Apple has traditionally provided excellent service, so this experience has been particularly painful for many Apple watchers. Hopefully, they will do better next time.

Shrink Rap Grand Rounds: The iPhone 3G Edition

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

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Also known as Podcast #48 ...CLICK to listen while you read

Tuesday, June 24, 2008

[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]

NOW MOVING TO THE iPHONE ON THE RIGHT...

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.

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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.

Regards,

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

And finally, some eye candy at the end. The image below is our word cloud for this post, compliments of wordle.net.

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Find show notes with links at: http://mythreeshrinks.com. The address to send us your Q&A's is there, as well (mythreeshrinksATgmailDOTcom). This podcast is available on iTunes (feel free to post a review) or as an RSS feed or Feedburner feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.