What I Learned: Part 2

Welcome to the second day of the AAPL conference. Dinah knows I have to throw in a bird picture somewhere. The fighting gull picture is in honor of the birds duking it out overhead during my boat ride across the bay last night. More to follow.

I started out the day with a review of new legal cases pertinent to forensic psychiatry. In training forensic psychiatry students are required to learn a set of legal opinions known as the "landmark cases," in other words, decisions that have profoundly influenced the practice of psychiatry. The trick with this is that you don't always know when the opinion is issued whether it will have a large impact over the long term. AAPL does a pretty good job of picking out the cases that will have significant influence.

The panel presentation I attended talked about the history of the Plata case, the Supreme Court opinion which ordered the state of California to decrease its prison population by 42,000 inmates. This is a significant decision since there are several other states in this country (Maryland included, the home of the Shrink Rappers) in which the prison system is running at 140% over capacity. This is the same level of overcrowding as California. The Supreme Court was divided about whether to order this. Justice Scalia called this the "most radical injunction in this nation's history." There was data presented about the number of crimes committed by the released inmates, but there was no context given to know if this rate was higher or lower than expected for California's parolees. Most inmates weren't released, they were just moved to local detention centers---thus shifting the burden but not necessarily solving the problem.

The other cases were US v Comstock, the Supreme Court case about the civil commitment of Federally detained sex offenders; Ryan v Gonzales, about competency in habeas corpus proceedings; Delling v Idaho, about the constitutionality of abolishing the insanity defense (states are allowed to do it), and Snyder v Phelps, the Westboro Baptist protest case from Maryland which said that free speech in a public place was not grounds for intentional infliction of emotional distress. On the child psychiatry side of things, all the cases related to the sentencing of juveniles. Graham v Florida outlawed life without parole for nonhomicide offenses. Miller v Alabama outlawed mandatory life without parole for juvenile homicide offenders.

After the landmark case presentation I continued my current theme du jour: immigration. I listened to a great talk by attorneys and a psychiatrist involved in the class action suit, Franco-Gonzales v Holder. For those of you who aren't familiar with what's going on in the world of immigration, now's the time to pay attention because it will affect all of you eventually. (You can read the preliminary injunction here.) Franco-Gonzales is an intellectually disabled immigrant who was arrested for throwing a rock during a public brawl. He was arrested and served a one year sentence. Immediately after this, he was taken into custody by ICE and held for five years. He had no pending criminal charges, had already served his time, and had no lawyer. Because of his mental disability he was unable to represent himself or take any legal action on his own. His case was combined with six others, all involving seriously mentally ill unrepresented detainees who had been held for at least six months. The court in this case has ordered the Federal government and Immigration and Customs Enforcement (ICE---the branch of the government holding the detainees) to provide "qualified representation" (legal services) to these detainees. They have also been ordered to assess their competence for self-representation. All of this means that mentally ill people are starting to be granted fundamental due process rights that never existed before, even though they are not American citizens. We are now also going to have to figure out how to provide community mental health services for undocumented immigrants with serious mental illnesses, even though they are not eligible for public benefits. (Ironically some of these detainees, if deported, might be deported to countries with better mental health systems than ours!)

I really enjoyed listening to the forensic psychiatrist who treated an undocumented immigrant and hearing how she advocated for this patient, as well as from Franco-Gonzales' own lawyer who was in the position of having to figure out what to do for this client when there were no existing laws AT ALL to cover his situation or to provide a basis for release. It's quite creepy to think that in this country someone can be held for five years, without a lawyer or even a right to one, without having committed any new crime.

Lastly, I always make a point of attending the presentation by the AAPL computer committee. This is my rare opportunity to geek-out with fellow tech nerds. The most important topic this year was the new HIPAA requirements for using secure email to transmit protected health information, and the need to have a business associate agreement (BAA) with any cloud storage service you use to save clinical information. This applies to anybody using things like DropBox or Google to store documents or other clinically relevant data. The trick is that Google won't sign a BAA for clinicians unless you're using their fee-for-service business apps (which are reportedly secure, although probably not from the NSA) and I think DropBox may not sign a BAA at all. So: do some homework, this may apply to you.

Today is my last conference day and I'll be heading home early tomorrow. I give heavy props to my nameless but fearless former fellow who arranged our alumni dinner last night here on his home turf and gave us a terrific tour of the bay. He raised the bar substantially for all future alumni events. (And yes, nameless fellow, you WILL return to Maryland some day. I will not give up. And now I know where to find the boat.)

Follow trending AAPL news today at @ClinkShrink.

What I Learned Part 4

This is a belated post about the AAPL conference, since yesterday was devoted to finding my way home around Sandy. It's rainy heavily here and the wind is starting to pick up a bit. Dinah's at home waiting for a tree to fall on her house but there's no word from Roy. I'm hoping all our readers are home safe and prepared.

The last day of the conference was worth waiting for. I regularly attend the presentations given by the Computers in Psychiatry committee, and this year was no exception. Two presenters had to leave early due to the storm, but the remaining members talked about how to do Google power searches (using conjunctive and disjunctive search terms and site-specific searches) and other non-Google search engines (there's something other than Bing?). There was also a presentation about a wide variety of health care related smart phone apps. As yet, the FDA does not regulate these as medical devices and there is no standard method for assessing accuracy, efficacy or reliability. For those docs "prescribing" or recommending apps, there was discussion about whether or not the use of apps is becoming a standard of care for medicine and at what point there may be liability for their use---not following up on an app "flag" for instance. I was pleasantly surprised to see that one of the first psychiatry apps mentioned was "What's My M3?", a project that Roy has been affiliated with. (Maybe Roy might want to right a post about the standard of care and liability issues I mentioned? I'm sure this has been discussed and I'm curious.)

The last session of the day was about assessment of stalkers. I learned that three-fourths of more than 400 Canadian politicians had experienced an overt threat. When assessing risk, the assessment considers both the stalker and the situation. The three main considerations are level of persistence, risk of injury to the target and the potential for recurrence if the stalking has stopped or interrupted. The most persistent stalkers are those with psychotic illnesses, specifically delusions. Grandiose or erotomanic stalkers are less likely to present a risk of danger since they are seeking intimate contact rather than violent contact. People with paranoid delusions who are also angry are more likely to present a risk of violence. There's a lot more to these assessments, but those were the highlights that I took away.

That was the last session of the conference. I confirmed my flight as I left the hotel, but by the time I got to the airport checkin desk it was cancelled. Such is the risk of the AAPL conference. Last year at this time in Boston we were facing an impending snowstorm.

If you're in need of more conference fixes, I'd recommend the Child Sexual Abuse Conference (hashtag #CSAC12 on Twitter) which is live-streaming some talks.

Baby's First Laptop

I just stumbled across this on the Amazon web site and had to post it. People have been writing lately about the effects of technology on kids, but I guess it's not that serious since we're making 'real' technology for babies now. What's next? Baby-safe web sites? Infant chat rooms? Babble blogs? (Oh what, we've got those already...)

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.

My Three Shrinks Podcast 51: Vegan Gingerbread Cookies

For this podcast I brought some homemade vegan gingerbread cookies that I baked using a recipe from the Steph Davis blog. I'm also looking for a good sugar cookie recipe that doesn't use refined sugar or all-purpose flour. If you've got one, send it along.

We discuss my post Is it malpractice to lie? which involves a surgeon sued for malpractice for allegedly lying to a patient regarding his professional background. We wonder how much, if any, information physicians may some day be obliged to disclose to their patients prior to treatment.

There is a new type of research being done, called "in silica" research, in which people write computer programs to model behavior. We talked about computer models of suicide and how this can replicate suicide epidemics in real life. Roy is inspired to talk about a computer program that models how guys choose urinals in public restrooms, and how people stand in elevators.

We never got to the FAA policy discussion or the cell phones in therapy topic. That was saved for our next podcast.

Last but not least, Dinah takes her dog Max to the new office. Who knew that dogs could be terrified of elevators??

****************************

This podcast is available oniTunes or as an RSS feed orFeedburner feed. You can also listen to or download the .mp3or the MPEG-4 file frommythreeshrinks.com.

Thank you for listening

Send your questions and comments to: mythreeshrinksATgmailDOTcom

Suicide and Social Learning

I found an interesting article on the Public Library of Science web site called The Cultural Dynamics of Copycat Suicide. (And thanks to the author for being willing to share his information under a Creative Commons license---this is how medical research should be!)

The author, Alex Mesoudi, used a computer model to study the effects of social learning and mass media influence on suicide clusters. He used a statistical method to see if suicides were clustered in time and space at an unexpectedly high frequency. This method is called an agent-based similiation, and is commonly used to model transmission of infectious disease. I'm not going to pretend to understand the statistics behind this! If you're curious you can read that part of the article.

He started by explaining the difference between point suicide clusters and mass clusters. Point clusters are suicides that are grouped together in time and space, while mass clusters are suicides that are grouped together in time, but are separated geographically. Suicide clusters have been thought to be due to social learning or mimicry, but it's also possible that they occur through homophiliy (the tendency for similar people to pool together in groups). Mass suicides are thought to be due to the influence of prestigious individuals (eg. celebrity suicide deaths) combined with coverage by the media. This leads to a one-to-many transmission model.

The computer model was run using three different assumptions: that suicides were totally random and unclustered, that clusters were due to social learning, and that clusters were due to homophily. He used different formulas to generate "suicides" under each model, and looked at the kind of clusters (spatiotemporal versus just temporal) that resulted.

What he found was that social learning caused spatiotemporal point clusters while homophilic clusters were more likely to be spacial rather than temporal. In order to understand this better, imagine the difference between teenage suicide epidemics versus correctional suicides. Teen suicides clusters happen among individuals who know each other, they happen in the same geographic area and within a short time frame of one another. These are the "social learning" clusters. Correctional suicides happen at a rate higher than in free society (in other words, they're geographically 'clustered' in a jail or prison), but are spread out over time. These are the homophilic suicides, in other words deaths by high risk people who happen to be grouped together. Based on this study, the correctional deaths are less likely to be due to social learning or mimicry.

Finally, the author studied the factors influencing mass suicide clusters: deaths that happen at the same time over a broad geographic area. These the kinds of suicides you see when a celebrity commits suicide. They are generally associated with a lot of media coverage. The computer model found that social learning played almost no role in these deaths.

It's a really complicated paper and I'm sure I didn't do it justice, but I thought it was pretty fascinating that someone could basically recreate the kind of suicide death patterns we see in the real world based on a theoretical mathematical framework. And I liked the term this author used for this kind of experiment: in silica. If in vivo experiments are done on animals or humans and in vitro experiments are done in test tubes or petri dishes, then "in silica" is a great term for computer model experiments.

And if none of this post made sense, hang on and I'll resurrect it in one of our podcasts.

Dinah's Away, Clink Will Play

So Dinah has gone off on vacation and left Roy and I in charge of the blog. Doesn't she know what a really really bad idea that is??

The day started off with her calling me to help with a computer problem. Dinah wanted to download a movie to watch on her iPod on the plane. No problem, except that she needed to upgrade iTunes to do this. She downloaded iTunes but for some reason it didn't install (she later asked me which password she was supposed to enter during the install process, that may have been part of the problem). So I talked her through the upgrade and told her how to open system preferences and get to the software upgrade control panel:

"Go down to the bottom of the screen until the little launch bar pops up. Then click on the little picture that looks like a gear."

"Deer??" Dinah said. "I don't have any deer!"

"No no, click on the gear," I said. "Gear with a 'g'." I'm hollering this into the dashboard of my car as I'm trying to drive on the beltway in the rain. I wonder if my other tech savvy friends (meaning Roy) end up in situations like this, trying to solve computer problems from memory while multitasking other things. I also wonder how I'm going to teach Dinah how to use GarageBand so she can edit our podcasts when she gets lost looking for deer on her laptop. O gods of computer tech support, have mercy!

Well, she got the upgrade done, went to iTunes and bought her movie then found out it was going to take two hours to download. At that point my tech support was done. I don't know if she ever got her movie or not, but I do know I'm going to schedule an entire afternoon for the GarageBand training.

GotGigs? How many gigs are in YOUR pocket?

It occurred to me recently that most of us carry a fair about of memory devices around in our pockets, purses, and belts.  I pointed out to Dinah at dinner recently my new 16GB thumb drive (Buy.com, $25).  After making some sort of dirty crack, I realized that I typically carry around over 40GB of memory on my person (new 16gig thumb drive, old 8gig thumb drive, 1GB thumb drive on keychain, 16GB iPhone 3G, and my Treo has a 500MB flash memory card in it).

So, I want to know... How many gigs are in YOUR pocket?

Let us know below.  Then post a picture of your gigs to Flickr, using the tag "gotgigs".  I'll put the pics here (as soon as I figure out how to do a flickr gadget).

Programmed Prescriptions

Today a computer told me that I couldn't use Prozac. More specifically, it said that the use of Prozac was contraindicated in people diagnosed with bipolar disorder. This experience led me to conclude that the only thing worse than having an insurance company tell you how to treat your patient is having a computer tell you how to treat him.

I'm required to use an electronic medical record. I don't generally mind this. The constant typing and the amount of time required for data entry is a pain in the rear, but I know it's the best way to ensure continuity of care between prisons. The problem is that the system also has preprogrammed treatment algorithms. I have no idea where they came from, who decided them and what data they're based on, but they exist. Episodically the computer tries to tell me how to practice.

The computer algorithm has also told me not to use lithium with people who are also on certain blood pressure medications and serotonergic reuptake inhibitors with people who have hepatitis. The computer doesn't say "be careful about this combination because it can cause X, Y or Z problems" or "be sure to watch drug levels more closely with this combination". It says, "Use of this drug is contraindicated in these conditions". Then, in order to continue entering the prescription, you have to click an "acknowledge" button to document that You Have Been Warned.

Truly, this is annoying on so many levels.

It's a CYA maneuver so the nameless Company can say it warned you if anything goes wrong. It's unnecessarily alarmist. It confuses the medication nurses who occasionally check to make sure the meds are OK to dispense. But more importantly, it's just bad information. These medication combinations are still effective, and they can be used safely, you just have to monitor them more closely. The geek who designed the system doesn't know this, he or she just programmed in the information he was told to put in. It probably seemed like a good idea.

And it will be someday, once computers are granted prescribing privileges.

*****************

And now I want an opinion from our readers. It's got nothing to do with psychiatry.

If you make hot cocoa from cocoa powder and other ingredients, instead of using hot water and a bag of cocoa mix, is that considered 'homemade'? Dinah says it's all one and the same. I say it's making cocoa 'from scratch' just like baking a cake without using a boxed mix.

What is your definition of 'from scratch'? And what's your favorite hot chocolate recipe? I'm looking for suggestions.

It Was Nice Meeting You

So Dinah, Roy and I ventured down to Washington DC to the American Psychiatric Association conference to talk about the use of computers in psychiatry. I was hoping to get a picture of our feet under the panel table, but that didn't happen. What did happen was that various Shrink Rappers met a couple Shrink Rap readers, and we appreciated the feedback you gave us. I hope our fellow psychiatrists enjoyed all the presentations at that session as much as we did. I personally enjoyed hearing patients talk about how online discussion boards helped them get better. That was pretty cool, and not something you hear every day. I thought it was pretty brave of them to put their histories out there in public, and I appreciated their willingness to do this for the education of psychiatrists.

Thanks again.

It's Sunday Morning--coffee, online shopping and the New York Times

This is published as two posts. The photo was enough to drive blogger mad. Scroll down for the rest.

Roy and I have communicated this morning. We're both on our second cup of coffee. I've been shopping on Lands End and I made a Model Me. The hair is a bit wilder than mine, the complexion much darker, no toenail polish, but aside from that, it's me. Roy tried to make himself and he couldn't. I tried to make him, and I couldn't. We won't talk about how long it took to get my Model Me onto the blog. Do you like my new outfit?



From Clink: I can't believe Dinah's got me doing this. OK, so I fixed her picture a bit and then decided to add me. Save this post for the police sketch artist in case I ever disappear.

What a Great Idea

I'm back from New York. We had a great trip, and now we get to return to our home, where apparently Everyone Who's Anyone is my neighbor! Roy will be moving next door shortly (I hope).

So I'm finally getting to today's New York Times magazine and I read an article by Thomas Goetz called "Practicing Patients." It's about an on-line medical community called PatientsLikeMe where people compare their treatments for a variety of neurologic and psychiatric disorders. People enter their treatments and chart their progress and therefore form a data bank of information. It was founded by the brother of a man who was ill for years with ALS.

Okay, so it's not 'controlled trials' and there's the risk that people will demand unproven treatments based on what they've read as anecdotes on-line (Goetz mentions ALS patients asking for Lithium based on information reported on the site), but what a great idea to get data on treatments, what works, what causes side effects, in a more real-life way. Research trials often eliminate Real people-- any one with a co-occuring illness, people with substance abuse problems, women who might get pregnant, children.

I surfed briefly. I didn't join. What a great idea.

I Just Want To Talk

It's snowing here in Baltimore, it's kind of lovely. Victor, friend of our blog, told one of his classmates to sit down, it's only snow, and the boy told him he'd never seen snow before, they don't have it in his country of origin.

It's not 3:30 AM, but even in the daylight, I'm still worrying about my kid-- nothing awful, he had an issue at school and we feel he's gotten a bum rap at a time in his life when having a bum rap is hard, trying to rescue him from the unjust, and Roy is quick to tell me that life is unfair and it's a good lesson to learn early. I suppose. ClinkShrink and Roy both have things going on in their lives, Roy's working hard, I keep hoping he'll do the things I want him to do, but he's a guy who gets pulled in a lot of directions and judging by the long hours he tells me he's working, his hospital could use a few good shrinks. The blog is suffering a little, I hope not a lot. I haven't been visiting my usual blog friends and I hope everyone is well. I do peek at the results on our anti-psychotic poll and Seroquel is winning by a lot. If you haven't voted, please do.

Okay, so Roy did some Leopard thing this weekend. Yeah Leopard. Someday I'll be a Mac person, too. I'd kind of like an iTouch, but will I be able to get the information from my Palm Pilot over to it?? This story is for Roy: the psychiatrist across the hall from me also did tht iMac Leopard thing last week. Before he did, he backed stuff up, but still lost everything in his organizer-- he had to call 50 patients and ask them when their appointments were. Oh, and he did it twice.

With that thought, the judge in hair curlers sent me so cartoons that made me smile. I can share them with you?And finally, we three shrink rappers have been talking about distilling some stuff from the blog into a book. I suppose it would be for a different audience, one less likely to visit a blog, but perhaps a glimpse into How Shrinks Think? What do you think?

"Going Mental" for iPhone

Leander Kahney, the managing editor of Wired magazine, was quoted as saying, "They are going to go mental for it." He also predicted iPhone-inspired muggings and selling of first-borns. Folks have been waiting in lines all week just to get first dibs on Apple's new digital wunderkind. It is only a matter of time before i see an iPhone-inspired psychiatric problem in my E.R. And i know just the type of medication to use: an SSRi (or, iSSR?).

John Paczkowski from Digital Daily has dubbed the iPhone obsession iOCD -- and apparently this diagnosis is now in the DSM! Funny... the AMA stopped short of calling video game addiction a disorder, but there is clearly an overboard quality to the iPhone hype. Google "iPhone" and you get 118 million hits this evening, which is 50% more than yesterday. This is more than Paris Hilton and Britney Spears combined. And, it is certainly a few million more than "My Three Shrinks".

This video documents some of the iPhone hysteria...

And speaking of hype, how often do you think the iPhone is paired with some sort of psychiatric symptom? Let's see...

• iPhone crazy: 2,440,000 hits
  
• iPhone addiction: 1,900,000 hits
• iPhone suicide: 1,810,000 hits
  
• iPhone madness: 1,620,000 hits
• iPhone depression: 1,520,000 hits
  
• iPhone mania: 1,500,000 hits
• iPhone paranoia: 1,030,000 hits
  
• iPhone obsessions: 710,000 hits
  
• iPhone hysteria: 475,000 hits
• iPhone delusions: 272,000 hits
• iPhone compulsions: 141,000 hits
• iPhone hallucinations: 121,000 hits
  
• iPhone anhedonia: 181 hits

Clearly, the iPhone is one of the coolest tech toys on the planet today. Lack of interest is definitely NOT going to inspire many hits.

EDIT: But it may inspire a new religion (Xenu beware).

Other blogs and links worth checking out:

• iPhone dissected
• quick review on Kottke.org
• Dave Winer not gushing
• Top 10 iPhone apps suck

EDIT: Must-see YouTube Chris Pirillo here, with an iPod and a Zune going at it under the covers ... Zune doesn't satisfy like iPhone (Warning: Graphic Gadget Adult Situations).

Someone Knows the Trouble I've Seen

First: Podcast #23 is up. It's getting great reviews.
Second: The rest of Chapter 8 is up at Double Billing.
And now for our regularly scheduled post:

I don't know Michelle Slatalla. I've never met her, never talked to her, haven't poked her. I imagine she wears her pants too high, but I don't know if she drives a cool car, if she sends text messages to her friends, what shows she watches or wines she drinks. What I do know is that she does a good job of talking about MY life (..maybe she reads Shrink Rap?)

In Thursday's New York Times, in "Cyberfamilias: omg my mom joined facebook!" Ms. Slatalla writes :

I HAVE reached a curious point in life. Although I feel like the same
precocious know-it-all cynic I always was, I suddenly am surrounded by younger precocious know-it-all cynics whose main purpose appears to be to remind me that I’ve lost my edge.


Many of these people are teenagers.

Some of them I gave birth to.

Wait, did I write that? I don't remember writing that. Does this person own the same children I that I do?

My newest comrade in parenting teenagers then goes on to recount how she joined Facebook and repeatedly poked (?harassed) her daughter and her daughter's friends, asking them to be her friends. Her daughter's friends allowed her in-- she now knows who is going where and with whom. Her daughter resisted, but Ms. Slatalla, bless her heart, poked the child into at least partial submission, and the daughter finally befriended her, but with only limited access to her profile-- help me if I get the terms wrong here, I'm decades too old for this world.

Okay, so I have a facebook page. And I poked one of my kids. He said no. He came downstairs in real life and told me not to poke his friends. I would never poke my kid's friends, even I'm not that dumb (sorry, Michelle). I've left it, I poked only once. I'd previously been blocked from his Instant Messenger and I've decided to leave it that I'm happy he doesn't Call Screen me out, but that may be because I pay for his phone. It seems I can E-mail too.

So Michelle Slatella set up her Facebook profile last week, according to her article. I set mine up 6 months ago. This is the photo I've put on my profile:
So six months and I have ONE friend. My niece let me in. I barely know her, she's a college student, and her profile requests that you post memories you have of times you've had together with her. I started to write on her wall, describing how beautiful she was as a baby, how I loved dancing with her in my arms when she was 7 months old. She really was a total doll. Then I decided that no college student wants their aunt on their Facebook wall dancing with them in infancy, so I sent it to her privately. I haven't heard from her since and I've had to content myself with looking at her photos and reading the birthday greetings on her wall.

I had another friend for a while. Rich poked me. I accepted (I've always liked Rich) and I checked off that I knew him because we hooked up. I've never hooked up with anyone, I was married before hooking up was invented. But patients talk about hooking up all the time and here was my cyber-opportunity to pretend I was cool. Now I'm also friends with Rich's wife, and maybe this explains why he's no longer listed as my friend? Apparently, I've been unfriended. Wow.

Patients talk about Facebook. And the truth is, they're all under 30. No one my age talks about Facebook. Then again, no one I've seen over 30 talks about their blogs either. It's a whole other world, with all its own lines of significance and innuendos. Who pokes who, who doesn't poke who, who lets you in, and who unfriends you. I grew up in a world where people slighted you by not returning phone calls and and not saying "Hi" in the hallway.

Okay, enough, I'm going now to poke Michelle Slatalla. I think she's my age. I wonder if she has a blog and a podcast. If she wants to be my friend, I'll write on her wall.

[Roy] Apple tablet

[Posted by Roy]

No, I'm not talking about a new pill. The rumor mills are stirring about Apple coming out with an Ulta-Mobile PC (UMPC)... a tablet PC in a small device, with that special Apple panache that I've grown to love since I switched 2 years ago (and haven't looked back).

I've been holding out on getting a laptop, hoping an Apple tablet would come along. Hopefully, if true, it will be an Einstein to its doomed predecessor, the Newton.