Forensic Psychiatry Steps into the Social Media Age

Regular followers of this blog know that every year about this time I put up a series of posts entitled "What I Learned." The purpose of the posts is to give people a peek inside the annual conference of the American Academy of Psychiatry and the Law as well as some exposure to the kind of topics forensic psychiatrists are interested in. General psychiatry residents may find it helpful, particularly if they are considering a career in forensic psychiatry and if they can't afford to travel to the conference. Our organization, AAPL, is an international group with members from Canada, the UK, Australia, and South America. Our international members deserve to see what's going on, as well.

This year, we will boost our international presence by livestreaming a select number of presentations through the Meerkat mobile app. Here is a schedule of the presentations we will stream. Directions on how to use Meerkat are below. In addition, select AAPL members have volunteered to moderate questions on each presention through Twitter. Hashtags will be announced through Meerkat, Twitter, and slides at the actual presentation. We've never tried this before, and we are all volunteers rather than professional videographers, so there may be a few snags or hitches but overall we're hopeful people will find it educational and fun. The conference begins on Thursday, Oct 22nd and continues through Sunday.

Here's the schedule:

Thursday 8:00-10:00	Graham Glancy  Witness Protection Program: A Matter of Training
Thursday 10:15-12:00	Ken Appelbaum The New APA Guidelines on Correctional Psychiatry
Thursday 2:15-4:00	Ryan Wagoner The Psychiatrist in Peril: Current Topics in Malpractice
Friday 8:00-10:00	Tobias Wasser  Novel Approach to Teaching Residents About Violence & Safety
Friday 8:00-10:00	Drew Kingston PhD  The Relationship Between Mental Illness and Violence
Friday 10:15-12:00	Caitlin Costello  Adolescents and Social Medica: Privacy, Brain Development and Law
Friday 10:15-12:00	Robert Forrest  Treatment of Transgender Inmates
Friday 4:15-6:15	Rosa Negron Munoz  Educational Factors Contributing to Juvenile Delinquency
Saturday 10:00-12:00	Madelon Baranoski  Role of Forensic Psychiatry in Veteran Evaluations
Saturday 2:15-4:00	Anna Glezer  Myths and Realities of Women in Prison
Saturday 2:15-4:00	Jennifer Piel  What Gets Judges in Trouble?
Saturday 4:15-6:15	Keith Stowell  Forensic Issues in Emergency Psychiatry
Sunday 8:00-10:00	Hal Wortzel  TBI Update: International Collaboration on mTBI and DSM-5
Sunday 8:00-10:00	Stephen Simring  Forensic Psychiatry and the Death Penalty
Sunday 10:15-12:15	Lynn Maskel  Rock and a Hard Place: Debating Sexual Sadism Diagnosis

Here’s how you use Meerkat:

1. First, go to the app store, search for “Meerkat app,” and download it.
2. Meerkat will ask you to type in your phone number for verification. Then, they’ll send you a four-digit confirmation code.
3. Next, connect the app with your Twitter account. (If you prefer, you can skip this step and check the app out in stealth mode.)
4. If you don’t want to add friends, don’t connect your accounts. Simply scroll down and you’ll see anyone who’s live streaming right away. Keep scrolling for more.
5. Search for and follow @AAPL2015. We will have a schedule of streams posted each day. For simultaneous sessions, AAPL members may use their own Twitter accounts which we will announce. You can search for them on Meerkat as well.

This is all a tremendous experiment so I want to thank my colleagues, AAPL, and our viewers in advance for participating. I'm looking forward to your questions, comments, and discussion.

--ClinkShrink AKA @ClinkShrink AKA Annette Hanson, MD Program Co-Chair

Can I Hit Back?

Sideways Shrink posed a great question recently in a comment on my post "When A Thick Skin Helps." The question was whether or not physicians are allowed to hit a patient who tries to assault them.

Certainly, physical assaults on patients are not the standard of practice in psychiatry or any other medical specialty. Psychiatrists do undergo some training about physical management of violent patients: I remember in residency we had to get trained in "take down" and restraint procedures. As a group we practiced applying pressure point joint locks on each other in order to make a patient break a grip on us, and to do two person restraints to hold someone immobile until security could arrive. None of this involved any "Crouching Tiger, Hidden Dragon"-type kung fu moves, there was no kicking or hitting or loud kiai karate yells. There was a lot of talk about the importance of being as least forceful as possible. Frankly, I'm not sure how much of that I would have remembered if I had ever been in a position to have to use it. The few times when I was actually assaulted by patients the incidents happened so fast there really wasn't anything I could have done. (OK, so the little manic lady who hit me with a stuffed dog really couldn't count as an assault, and she was already restrained in a geri-chair to begin with.)

But the real question is: will a doctor get into trouble for defending him or herself?

In situations like this it's always best, as one of my friends and mentors regularly states, to think clinically before thinking legally. Safety first, then legalisms. Do what you must do to protect yourself. Learn the security procedures for your hospital or clinic or school or correctional facility, and know them so well you don't have to even think to act on them. If no one orients you to security procedures on your new job, make a point of asking. (Free society employers are particularly bad about this, particularly in an outpatient setting.) Even when you follow the "right" procedures though, it takes some time to get help. By "time", I mean several seconds to minutes, and in that short time a lot of damage can happen. Yes, doctors can and should defend themselves from attack.

What are the potential legal consequences? (Disclaimer: I'm not a lawyer, anything I say can and might be wrong from a legal standpoint, when in doubt call your hospital counsel or malpractice risk management office.)

The consequences could be civil or criminal. An assault or battery charge could be filed by a patient, or a general tort (injury) civil suit could be filed against a physician. A malpractice claim could be made (I doubt anyone could claim that a physician assault against a patient would be a standard part of psychiatric treatment!) however in states that allow contributory negligence (a limitation on damages when an injury is caused in part by patient behavior) the physician's liability would be limited. Finally, the patient could file a board complaint against the physician. So even in the absence of a criminal or civil case the physician could end up on the wrong end of a long, drawn out and painful licensure investigation.

There are factors that could lead to a greater risk of legal consequences if they suggest that more force was used than necessary: if the patient dies or has a serious permanent injury, or if the physician has a chance to escape but chooses to stay and fight instead. And yes, gender discrimination may play a role. If the physician is a young twenty-something, male, six foot four inch tall physician weighing 200 pounds and the patient-attacker is a five foot, 125 pound grey-haired old lady, you could be in trouble.

Off the top of my head I'm not aware of any cases where this has been an issue, and in the heat (or rather terror) of the moment I doubt any doctor is going to stop and weigh out all the potential consequences. And even when the doctor has a legitimate need to defend himself there could still be legal consequences, which are not fun even if the doctor ends up cleared of all allegations.

If I come across any relevant cases or references I'll put them up, but that's what I think off the top of my head.

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??

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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

Is It Malpractice To Lie?

I came across this interesting malpractice case via the HealthLaw Twitter feed which I've been following for a while now. The case is Willis v Bender, a 10th Circuit Court of Appeals case out of Wisconsin.

In this case a surgeon was sued by his patient following complications from a laparoscopic cholecystectomy (gall bladder removal). Before the procedure he explained the risks of the surgery to her, and she also asked him questions about his experience and success rate with the procedure. She asked additional questions about whether he had ever been sued for malpractice or had any action taken against his medical license. He answered no to both questions and added that he had an almost perfect success rate with the surgery. Well, bad things happened. The patient suffered a perforated intestine and an infection. She later found out that the doctor had lost a patient during this same procedure, and that he was disciplined for the board as a result of that case.

At trial the jury found in favor of the doctor because even the plaintiff's expert couldn't say that the complications were the direct result of improperly performed surgery. Even properly done surgery of this type carried the risk of perforation, bleeding and infection. The plaintiff also alleged that the doctor failed to give her informed consent because he gave false information about his personal background. The trial court wouldn't allow the informed consent issue to be raised because in Wisconsin the law only required that physicians tell patients the material risks of proposed treatment. There was no affirmative duty to disclose professional background information even when asked.

So the plaintiff appealed.

The 10th US Court of Appeals reviewed various similar informed consent cases and found that courts took different views on whether or not lying to a patient about a physician's background could be considered a breach of informed consent. Some courts held that doctors could be found liable only if they lied regarding the risks of the proposed treatment. In this case, the appellate court decided that the patient should have had a chance to make the argument, and sent the case back for retrial on that issue.

We'll see what ends up happening on retrial, but I thought this was an interesting emerging area of law. What if the issue wasn't technical incompetence? How much "personal background" should a doctor have to tell a patient before treatment can begin? Medical school grades? Failure to pay income tax? Should doctors be required to disclose to patients the fact that they've been treated for mental illness themselves?

What I Learned Part 3

The final installment in my conference series. Tomorrow I come home to my fellow bloggers! I miss them.

• In France they are doing an interesting project to look at the effects of incarceration. They are asking prisoners to spontaneously describe their incarceration experience and how they think it has affected them, then they are using computerized lexicographical analysis to define common domains of concern.

• There was a poster looking at the neuroanatomical basis of empathy, sympathy and moral reasoning. Highly theoretical and completely lacking in data, unfortunately.

• In 1895 Bridget Cleary was burned to death by her husband, who believed that she had been kidnapped by fairies and a changeling left in her place. It is possible that Michael Cleary suffered from a form of Capgras delusion.

• Someone tried to do a study looking at treatment compliance and motivation for change in sex offenders, but there weren't enough sex offenders motivated to participate in the research.

• Very few states have laws requiring mandatory reporting of impaired drivers to the MVA.

• One Russian psychiatrist proposed that the term "dependent behavior disorder" be used as a diagnosis for a broad range of compulsive behaviors.

• The first documented use of telepsychiatry was in 1959. In the U.K. a criminal justice statute required the installation of teleconferencing equipment throughout the courts and correctional facilities in the country. This is now being used to perform clinical and court-ordered psychiatric assessments. Free society studies have shown patient satisfaction to be similar between telepsychiatry evaluations and face-to-face interviews. In the U.S. there are a number of undefined legal issues with regard to telepsychiatry and computer-assisted treatment. These including licensing issues for practice across state lines, informed consent for remote clients/patients and malpractice coverage across state lines.

• Directors of forensic fellowship training are working to create measurement tools and procedures to meet the core competency requirements of the American Council for Graduate Medical Education (ACGME). There was a very nice workshop that presented a "toolbox" of techniques for documenting residents' competency as well as a discussion regarding how to prepare for an accreditation visit. The workshop also discussed the challenges of funding a forensic fellowship program.

THE END

Thank you for reading

What I Learned Part 2

Here's the second installment in my conference ramblings:

• The Supreme Court decided in Sutton vs. United Airlines that for the purposes of the Americans with Disabilites Act the disability must be assessed only after attempts have been made to correct the impairment.
  

• Liability in medication-related tort claims is best reduced by well-documented informed consent (Duh. But that came up a lot this year so I mention it.)

• In states that allow for outpatient commitment, only 20% of pretrial detainees who are referred for commitment actually end up getting commitment orders. This is because most of them are either sent to prison prior to a commitment hearing or because they are committed to a hospital for restoration to competence prior to an outpatient commitment hearing.

• Death Penalty

In 2006 there were 53 people executed, 32 were white and 21 were black. In 2005 there were 1805 whites and 1372 blacks on death row. One out of 12 death row inmates had committed previous homicides. Death penalty aggravating and mitigating factors are set by state statute. Aggravating factors include victim characteristics (law enforcement or firefighting personnel, children, pregnant women), defendant characteristics (previous violent offenses), and offense characteristics (murder committed during the course of a felony, contract killings). By law all possible mitigating evidence is allowed to be heard during the sentencing phase of a death penalty proceeding. Although mental health issues are statutory mitigating factors, sentencing juries actually consider them as aggravators and they are more likely to result in a death sentence. The main purpose of expert mental health testimony in a death penalty hearing is to humanize the defendant and to change the focus of the hearing from the crime to the defendant. It also serves to give the defendant an opportunity to communicate to the jury through the expert. Surveyed death penalty defense attorneys usually prefer psychiatrist rather than psychologist expert testimony. They prefer forensically trained experts with an area of expertise that is relevant to the case, with good testifying skills.

• Risk Assessment in the U.K.

The U.K. has a relatively new law that allows for the indefinite detention and/or community supervision of violent offenders. This led to the creation of the Risk Management Authority, an administrative body that trains, supervises and regulates official risk management assessors. The assessments are quite exhaustive and includes a minimum 6 hour interview over three days. It is primarily a clinical assessment although it does require the use of at least one "official" approved actuarial tool. There were only 7 orders for assessments filed in 2006. Some offenders refuse to cooperate since they know it could result in a lifetime of supervision and mandatory treatment.

Another development was the creation of a Dangerous and Severe Personality Disorder Service, which essentially is a tool for civil commitment of psychopaths. This has led to 150 referrals a month and an increased number of non-mentally ill sociopaths in forensic hospitals. (One presenter's quote: "The system is swamped.") They are treated with cognitive-behavioral therapy at a cost of $500,000 per inmate per year. Remarkably, there have only been three minor inpatient assaults involving these patients over five years.

• Liability and risk management in forensic practice

Case law is still defining areas of liability for forensic clinicians. Most liability seems to arise as a result of independent medical evaluations (IME's). The 2006 case Harris v. Kreutzer determined that there was a limited physician-patient relationship created during the IME. The three duties created as a result of this are: 1) to cause no injury during the evaluation (read the Harris case), 2) disclose significant findings to the evaluee (eg. an orthopedic surgeon doing an IME who incidentally discovers a tumor), 3) maintain confidentiality (eg HIPAA compliance)

Most states have limited civil immunity for expert testimony but this is not absolute & varies with jurisdiction. Experts appointed by medical boards for peer review have been sued with varying degrees of success by their evaluees. A forensic expert could face discipline from the AMA, the state medical board, or a specialty organization. In general psychiatric practice most liability comes from suicide or from medication-related injuries.

• Ethics of Forensic Psychiatry

In 1982 Harvard professor Dr. Alan Stone gave an address in which he suggested that it was unethical for psychiatrists to be involved in expert testimony. The last panel today was an update by Dr. Stone on his position and a response from a number of illustrious colleagues. I can only give this topic pitiful recapitulation here. Stone argued that psychiatry has no absolute truths to offer and that professional consensus is dangerously misleading. Panelists Ezra Griffith, Stephen Morse and Paul Appelbaum responded that it is ethical for professionals to aid the court's search for truth and to promote justice. While acknowledging potential ethical pitfalls, there was a consensus that evolving standards of science provide something to offer.

(Incidentally, in Podcast #14 (No April Fool) I talked about the New York Times article, Brain On The Stand, which quotes Dr. Morse's views on the use of neuroimaging in forensics. Now that I've had a chance to listen to this guy speak it is clear that he is someone to keep an eye on. Interesting things are going to be coming out of U. Penn, particularly with his involvement in the recent $10 million MacArthur grant for neuroscience and the law. This is probably worth a blog post all on its own, when I get the chance. Right now I'm off to dinner.)

What I Learned Part 1

This is my second annual blog post that summarizes my experiences at the forensic conference I attend every year. Last year I put up a three part "What I Learned" series, which I occasionally go back to when questions come up and I know I heard something about it once but can't remember the details.

So here goes:

• The Atlantic ocean is surprisingly warm for October.
• There are approximately 5000 women murdered every year in honor killings. Syria and Jordan still have laws on the books for men to kill their wives without consequences if they are caught in the act of adultery.
• There is evidence that the Slater method may be effective for restoring developmentally disabled defendants to competence to stand trial.
• Only two states in the country (Connecticut and Indiana) have laws that allow police to seize legally owned weapons from dangerous individuals.
• Violence predictions instruments, even the PCL-R, has not been validated for use with women and it is not recommended to use them as a predictive tool for female defendants or prisoners.
• Vaginal plethysmography exists but has not been validated for use in evaluating female sex offenders.
• In recent years the number of women found Not Guilty By Reason of Insanity (NGBRI) has increased. This may be due to increased awareness of post-partum psychiatric illness.
• Culture-bound syndromes can be seen in immigrant populations and it is necessary to understand these phenomena in order to distinguish them from delusions. Ashanti witchcraft, "root workers" and others may lead to commonly held cultural beliefs.
• A woman named Marti Ripoli was an infamous serial killer in the nineteenth century. She was thought to be responsible for the deaths of 25 children, whose blood she used to make magical remedies that she sold on the streets. Belle Gunness had nothing on this lady.
• Alan Felthous gave an amazing Presidential Address in which he reviewed the religious and philosophical underpinnings of free will from Aristotle up to the neuroanatomy of decision-making as shown by functional MRI's. All in less than an hour. Wow.
• There was a great panel presentation about cults. They discussed the difference between a religion, a sect and a cult. They described characteristics of cult leaders and followers and cult dynamics including recruitment, retention and deprogramming. They presented case law regarding deprogramming practices and risk management issues for psychiatrists. Finally, they presented the satanic cult abuse issues of the 1980's and the lessons learned from this. (I enjoyed the tutorial about the Church of Satan and what to ask your Goth patients. Also the Church of Satan tattoos. Personally, if I saw a 'Satan Rules' tattoo I don't think I'd need to ask too many more questions.)
• In Germany forensic experts are always the agents of the court rather than agents of an adversarial attorney. The goal is a neutral and impartial evaluation. (We could learn something from that here in the States. I bet their malpractice costs are significantly lower.)
• The concealed information test is the most commonly used experimental deception paradigm. It has been used in functional MRI lie detection studies, the first one of which was published in 2001. The number of fMRI lie detection studies has increased quickly since then, but a number of the authors are partners in two companies that do commercial fMRI lie detection, Cephos and No Lie MRI. (We discussed this topic in Podcast 5: Sex, Lies and Neuroeconomics.) Functional MRI's cost about $1800.
  
• SPECT scans are very sensitive but completely nonspecific. They are abnormal in a broad variety of conditions but there is a lot of overlap between conditions. When using SPECT to evaluate mild traumatic brain injury, it is important to first rule out the confounding variable of clinical depression.
• Problematic Internet use covers a broad range of behaviors: cyberstalking, cyberbullying, excessive surfing, excessive online gaming and inappropriate work behavior.
• When evaluating a building for Sick Building Syndrome it is important to do a visual inspection first, then take samples if necessary. Sampling includes measurements of wall and room humidity, temperature, carbon monoxide and carbon dioxide levels and surface swabs. A normal carbon dioxide level is 1000 parts per million. Normal building temperature is from 68-72 degrees in the wintertime with less than 60% humidity. Some plaintiffs alleging sick building syndrome are actually suffering from somatization disorder so it may be necessary to involve forensic psychiatrists in these evaluations.

PHEW. And that's only the first day. Here's the other thing that I learned:

I love eating lobster while watching the ocean. Beats the heck out of working in prison.

Tarasoff Overview & Inservice

Dinah's post Johnny Get Your Gun generated a lot of interest in and comments about public safety and the mental health professional's duty to warn or protect. Some readers commented and cited the Tarasoff case, which made me think a quick inservice was in order. Many of our readers aren't mental health professionals or aren't American, so it's not really fair to leave them without any context for the discussion. Also, many American mental health professionals have heard of Tarasoff but may not really be aware of the limitations or extent of this decision.

First some background:

In 1969 a Berkeley college student, Prosenjit Poddar, became enamored of co-ed Tatiana Tarasoff. He pursued her to the extent that police got involved. They detained Poddar and referred him to the college counselling center where he was seen by a psychologist. The psychologist consulted with his superior at the center, and both decided that Poddar did not need to be hospitalized. Poddar later shot and killed Tarasoff.

Tarasoff's family sued the university, the police, and the mental health professionals for failing to hospitalize Poddar. The suit was originally dismissed by the California Supreme Court (in a case now known as Tarasoff I) because all of the defendants were government employees who were acting within their discretion regarding the hospitalization decision. Thus, they were covered by government immunity. Also, at the time no mental health professional had any duty to a third party---the clinician's only duty was to the patient. The suit was dismissed without prejudice, meaning that the plaintiffs were free to refile the suit on other grounds. The California Supreme Court hinted in their opinion that if the suit had been filed on the grounds of failure to warn or protect the defendants would not be immune from suit. The plaintiffs took the hint and refiled on these grounds.

This led to the case known as Tarasoff II, in which the California Supreme Court found for the first time that mental health professionals had a duty to protect (not just warn) third parties of danger from their patients.

Now the thing to remember about case law is that opinions are only binding on the regions that the appellate court has jurisdiction over. The Tarasoff cases were decided by the California Supreme Court and were binding only in California. Only the U.S. Supreme Court can issue opinions that apply to the entire country. So how did this idea spread across the country?

If I were a complete cynic I'd answer: Blame it on the lawyers. Being only a partial cynic, my answer is that the creation of this new duty created a new fertile ground for recovery in case of injury. A flurry of cases in other states followed the reasoning in Tarasoff and laid the groundwork for mandatory warnings in other jurisdictions. A nice overview of the current state of national Tarasoff laws can be found here.

Fortunately, the Shrink Rappers live in Maryland. Our professional organization took a proactive approach to this impending issue and crafted a Tarasoff duty by statute rather than waiting for it to be created through a lawsuit. It was designed thoughtfully and narrowly so the duty for our clinicians is not as broad as that which is implied in the California cases. It can be found in Courts and Judicial Proceedings (granting immunity for certain actions) and it states:

§ 5-609. Mental health care providers or administrators.

(a) Definitions.-

(1) In this section the following words have the meanings indicated.

(2) "Mental health care provider" means:

(i) A mental health care provider licensed under the Health Occupations Article; and

(ii) Any facility, corporation, partnership, association, or other entity that provides treatment or services to individuals who have mental disorders.

(3) "Administrator" means an administrator of a facility as defined in § 10-101 of the Health - General Article.

(b) In general.- A cause of action or disciplinary action may not arise against any mental health care provider or administrator for failing to predict, warn of, or take precautions to provide protection from a patient's violent behavior unless the mental health care provider or administrator knew of the patient's propensity for violence and the patient indicated to the mental health care provider or administrator, by speech, conduct, or writing, of the patient's intention to inflict imminent physical injury upon a specified victim or group of victims.

(c) Duties.-

(1) The duty to take the actions under paragraph (2) of this subsection arises only under the limited circumstances described under subsection (b) of this section.

(2) The duty described under this section is deemed to have been discharged if the mental health care provider or administrator makes reasonable and timely efforts to:

(i) Seek civil commitment of the patient;

(ii) Formulate a diagnostic impression and establish and undertake a documented treatment plan calculated to eliminate the possibility that the patient will carry out the threat; or

(iii) Inform the appropriate law enforcement agency and, if feasible, the specified victim or victims of:

1. The nature of the threat;
2. The identity of the patient making the threat; and
3. The identity of the specified victim or victims.

(d) Patient confidentiality.- No cause of action or disciplinary action may arise under any patient confidentiality act against a mental health care provider or administrator for confidences disclosed or not disclosed in good faith to third parties in an effort to discharge a duty arising under this section according to the provisions of subsection (c) of this section.

[1989, ch. 634; 1997, ch. 14, § 9; 1999, ch. 44.]

The key points compared to the Tarasoff cases are that the statute requires imminent danger to an identifiable victim. Clinicians are not required to foresee danger to the general public, nor are they required to predict dangerousness into the indefinite future. Clinicians are given the discretion either to warn the victim or to carry out a protective plan; hospitalization is not mandatory. Regardless, a decision to break confidentiality is shielded from liability if the clinician is acting in good faith.

[Roy] Doctor Google

[posted by Roy]

Now that's an interesting job... to be the doctor at Google Headquarters in Mountain View. Dr. Razavi is a physician working part-time for Google, answering questions in her blog about ticks, whooping cough, coccygodynia, among other things. She appears to also have a private practice on the side (or is the Google job on the side?).

At one point in my life, when I had a handful of "side jobs"; one of them was to run a chat room in AOL's Depression Forum on Sunday nights, answering general questions about depression and its treatment. I started doing it for a friend gratis, and it eventually turned into a paid job for a couple years. Until the internet bubble burst, and all these start-ups went belly-up. What I provided was education and information. No therapy. No treatment. No advice (other than to say to "ask your doctor").

My malpractice insurer asked all the insureds about their internet activities. I dutifully explained what I did. They asked for a transcript of a chat, which I provided. They then told me that, not only would I not be covered for this activity (which I wouldn't expect) but that if I did not stop doing it, they would drop me, as they could not quantify the risk exposure. I recall being incensed that providing needed education about what the symptoms of depression were, or what common side effects of Prozac were, was not being embraced but strongly discouraged. (No wonder our health care system is imploding.)

My building righteous rage to fight "the man" on this one was quickly snuffed when AOL ended the contract with my friend's company, thus ending the service. My drive to share information has not been quenched, however. I later ran an e-newsletter about psychiatric medications for a couple years, stopping because the squeeze wasn't worth the juice (it took up too much time).

So I understand Dinah's blogging apprehension. Writers and educators (even physicians, for the most part) have a desire to share their thoughts, ideas, and knowledge with those who are interested. So, the rabbit hole gets deeper. Yet, the number of blogging and sharing netizens in the World Wide Wonderland continues to grow.

I can't help but wonder where it will all lead. Hopefully, we'll all get there before... someone yells, "Off with their heads!"