What's in a Name?

Second day in a row that I'm stealing ideas from Dr. Crippen over at NHS blog. I hope he doesn't mind.


Today, in Making Friends with the Doctor, Dr. Crippen writes about his preference for addressing patients by their last names (surnames) and he comments about physicians who address their patients by their first names:

I think it is presumptuous and impertinent. It is done to give the feeling of a deep and meaningful personal relationship with the patient. It is bogus.

It's okay if I say that Dr. Crippen has a way with words?

He goes on to take a survey of his readers, asking their opinions. Actually, Blog polls seem to be the thing to do these days, Dr. A has his readers dressing him and telling him how to deal with his comments.

So back to the question of what should a doctor call a patient. In psychiatry, where relationships are so intimate and boundaries are so essential, this stuff has meaning.

To start with, I'm a fairly formal person. Well, sometimes, but definitely at work. It feels strange enough in blog-o-land to address physicians I've never met as "Foofoo" and especially "Fat Doctor." Even "Shiny Happy Person" is a bit of a stretch for me, but okay, it's a blog, it's what you want to be called and I'm not your psychiatrist. At work, with very few exceptions I introduce myself to patients as Dr. Shrinkrap (no, not really, but you get the picture) and I call folks by their last names. So, it's taken me this long to say that my blog post today is not about what I call my patients.

My blog post, instead, is about what my patients call me. Psychiatry, being a bit more intimate, and being in many ways similar to friendship, inspires patient to want to be my friend (even ClinkShrink wants to be my friend). As such, some people, even people much younger than I, will not infrequently address me by my first name, sometimes over the phone before they've met me, and sometimes after a few sessions. I have to tell you, it doesn't sit right. To quote Dr. Crippen, it feels presumptuous and impertinent. And I feel like I should confront this, but the truth is it remains a bit uncomfortable for me. Mostly, I've opted out. It's usually a thing that comes up on the phone where people are most apt to use names, and what I've done so far is to simply ignore it, and to return phone calls with "Hello, Mr. X, this is Dr. Shrinkrap, I'm returning your call." I'd say that mostly works, except that it ALWAYS works. People get the message, and probably I'm missing some great psychotherapeutic opportunity to discuss boundaries and presumption and all sorts of other things, but it feels just so stiff to ask someone why they think it's okay to call their doctor by their first name, and often I imagine it's about wanting a friendship and maybe that doesn't always need to be dissected. My favorite, by the way, were the series of calls I received from a patient's physician spouse where the messages were left for me as "Dinah, this is Dr. Smith and I want to speak with you about my husband." If Dr. Smith were say 85 maybe it would feel okay, but let's just say she's not that old.

I lied. I am going to talk a little about what I call patients. Because I want to be called Dr. Shrinkrap, and I don't like what Dr. Crippen refers to as an adult-child gradient ....or what I would call an imbalance of power and respect...I'm most comfortable calling patients by their last names. People often ask that I address them by their first names, and this feels very awkward to me, especially if the patient is my age or older. For a while, I dealt with this by simply not using the patient's name. This actually isn't as difficult as it might sound, there's not a whole lot of need for names in a one-on-one psychotherapy session where no one else is in the room. When it comes up though, it does remain awkward: on the one hand it feels disrespectful to address an adult patient by a first name, on the other hand it feels disrespectful to ignore a patient's request to be addressed in a specific way. I have, after many years and probably way too much thought, figured it out only recently. When a patient asks that I use their first name, I now say, "Psychotherapy is very intimate work and because of that it's important to have some boundaries. Using last names is one type of boundary. Having said that, it's your name and I'll call you anything you'd like."

And so, Dr. Crippen, what are we writing about tomorrow?

Death and Suffering

[posted by dinah]

A few days ago, Dr. Crippen (NHS Blog) wrote a moving piece called Removing Death from Life. He takes a look at dying, the hospice system, the what we've come to expect from death:


There is a danger that the hospice movement will steal death from life. Death should take place in the home. With the family. If there is no family, the hospices are wonderful. If the family cannot manage, for whatever reason, the hospices are wonderful. But they are not compulsory, nor are they a “better” option. They are a failsafe.

The second, and more serious problem, is that the hospice movement and the media have conspired together to present death and dying as something that is really rather wonderful. A clap-happy learning experience to be shared and enjoyed with all the family. The gullible like to invest in this.

As a society, we've come to believe that people don't need to suffer. If you're in pain, something's wrong, go to the doctor, it can be fixed. In many ways, this is a good thing, fewer people suffer needlessly with mental illnesses because of the awareness that some suffering is the result of a treatable disease: they come for help and they get it (this is good). Others are diagnosed with illnesses that, had they waited, would have been fatal (say early stage cancers, infections that might spread, and the list marches on). This is also good. Life, however, remains chock full of suffering, and not all of it is about treatable illnesses, and Death is no exception. Family members suffer when their loved ones die miserable deaths, only now they are left to believe they should have done something "more" to help the loved one die differently.

As Dr. Crippen so bluntly puts it:

Dying is unpleasant. With optimum symptom control it need not be painful, or not for long, but it is uncomfortable, it is distressing and it can be undignified. Much can be done, and much should be done, but let us not try to spin dying into something it is not. It is, I repeat, an unpleasant business.

If Microsoft Ran Healthcare

Microsoft recently announced its intention to buy Azyxxi (yes, that's its real name), an acute care information and patient monitoring system developed by some local physicians. This is the start of a new Microsoft initiative to penetrate the healthcare information system market. On the Microsoft HealthBlog Dr. Bill Crounse, HealthCare Industry Director, talks about how wonderful this will be for patients and physicians. I couldn't help but speculate about what would happen if Microsoft ran healthcare:

• Your provider network would force you to install the latest nicotine patch, whether you needed it or not
• There would be four versions of each insurance plan but none of them would pay for an annual physical
• You'd get dire warnings that out-of-plan care might not be compatible with your body
• You'd be allowed to see any specialist except the iPodiatrist
• Bill Gates would donate billions to the third world while ignoring domestic viruses (oh wait, that's already happening)
• Diseases would be destroyed by buying them out then discontinuing support
• Your mother would be referred to as your “Original Equipment Manufacturer”
• Ninety percent of physicians would be in-network, the rest of us would use Apples to keep them away
  

And yes, I thought all these up myself...

Seriously though, you should read one organization's story about Microsoft's response to their information technology needs. FSW Connections is a Connecticut non-profit organization that provides social services and mental health services including domestic violence counseling, homicide victim support groups and psychiatric rehabilitation services. When they needed to become HIPAA compliant they were denied Microsoft's licensure price for non-profits specifically because they were a healthcare provider. This is a revealing story that foreshadows Microsoft's approach to the healthcare market---soon it won't just be the drug companies driving up healthcare costs. (There's a happy ending. FSW ended up saving $100,000 by switching to open-source strategies. Read the full story here.)

Grand Rounds 2.45

This week's Grand Rounds is over at Inside Surgery. I found this post from a health care attorney who states that he's not aware of any lawsuits involving docs who blogged about a patient's situation. Only a matter of time, I suppose.

Psychiatry Board Exam Recertification: Epilogue

So I took my decennial ABPM exam today. The exam process itself was quite smooth. Here's how it works...

You're supposed to start the exam at 9am, but it takes about 6 minutes to check each person in... don't worry, the clock doesn't start until you sit down in front of the computer. Before then, there is a highly secure process including digital signatures, digital photographs, and digital fingerprinting (redundant term), to ensure that you are you and that no ringers can slip in to cheat for you. They provide lockers to place your stuff in... cell phones, papers, change, keys, pens, pencils, even all your paper money. That's right, no #2 pencils. It's just you and your mouse.

There were 200 questions, and you get 5 hours to complete them (more than enough). Note that other folks in the room may be taking other tests (e.g., GMAT, LSAT, etc). You get a corral to sit in so that you are not distracted by movement elsewhere in the room. They even provide you with earplugs if you ask (you cannot bring your own).

Now the test. I cannot give you specific questions, but you can go to the American Board of Psychiatry & Neurology website to see the content areas on the exam. (Had I looked there, I would have realized that I didn't have to spend the time this morning looking up syringomelia.) Read this last linked PDF closely. Each area comprises 13% of the questions. I counted 28 questions on personality disorders. If you get confused between schizoid (emotionally cold, aloof) and schizotypal (eccentric) personality disorders, better get that straight now, Cowboy.

I was surprised to see only 3-4 questions that assessed one's knowledge of drug-drug interactions. This is a glaring deficiency, in my opinion, as drug interactions are highly prevalent, and not a week goes by that I do not consult on a couple patients who have been admitted medically due to problems which can be traced back to drug interactions and unsuspected pharmacodynamics and pharmacokinetics. Many of these are preventable, if one is mindful of the problem (e.g., the SSRI/triptan combo mentioned earlier; however, the significance of this particular combination is overrated... the biggies are lithium/thiazide, tricyclic/SSRI (Prozac or Paxil, mostly), and anticonvulsants).

I will mention my favorite question (I don't think I'm committing a breach here). This question was asking about therapeutic boundaries. It was something like this:

"You are providing psychodynamic psychotherapy to a woman who took an overdose two months ago after being rejected by her boyfriend. She offers you two tickets to a concert for which you have been unable to obtain tickets.
The appropriate response is: ________.

One of the options was: "to tell her that you have to check with your wife and you will get back to her this weekend."

I think I laughed out loud when I read this.

The Lost Chart

[posted by dinah]

I seem to have misplaced a patient's chart. My office is small-- a single room and a very important closet-- and I never took it home, so I know it's somewhere. I've searched every pile, I've gone through the file drawers twice, thumbing each and every file folder along the way. It will show up, I've misplaced charts before and they always show up, usually wedged into another chart or fallen through the hanging files, so I'm not actually worried, it's just the frustration of knowing it has to be there and it isn't.

There's nothing too crucial in this particular chart; if the patient shows up before the chart (and right now, that's a distinct possibility), it will be fine-- I remember her story, remember her meds, there are no irreplaceable consultants' notes, no labwork to be tracked down, it's just the idea: a medical record shouldn't be misplaced, though it happens all the time in clinics, but this is a single office, just me, it has to be there.

First, a little about the patient*. Ms. G first consulted me a couple of years ago. Her previous psychiatrist had moved away, she was down and wanted to resume the medication she'd found helpful, and her life was a mess. By the second appointment, she'd compiled a type-written list of what she wanted to change (oops, that list is in the missing chart). The list was four pages long. She came to a few sessions and then disappeared, calling once to ask for a refill, and then who knows? I wondered, I may have even called and left a message, or maybe I didn't (I probably didn't document "calling to ask how you are" so not in the missing chart). Time went by, well over a year, and she called to request an appointment.

"I want to resume therapy. I'm ready now." I asked what had transpired in the intervening seasons. Things had gotten much better. She'd left the dysfunctional relationship that was causing her so much discomfort. She is seeing a nice guy who treats her well. She stopped (well, almost) smoking pot. "I really didn't like that you thought I had a problem with it," she said. She'd quit (well, almost) to prove me wrong. I'll take it.

I listened.

"So," I said after enough listening (well, almost), "let me get this straight. You're smoking less, you've gotten out of that hellish relationship, you've met someone new and wonderful, you're feeling much better."

"Yes."

"And," I continued "you did this all on your own without psychotherapy, and now that everything is going well, you want psychotherapy?"

She laughed. We set a schedule, and other than a misplaced chart, the sessions are going well.

This afternoon, I scoured the office again. Maybe it's with my dead charts, I thought. I keep charts for patients whom I haven't seen in years, and don't expect to ever see again, in a separate drawer, but I keep them, because I've learned that no chart is really dead, people pop up when I least expect them. I'd been in that drawer recently to dust off the chart of a patient who showed up after a four-year absence.

There' s something hard about going through the dead chart drawer. I'm hit with names of people I don't recall, names that don't even sound familiar. I never pick them up to see, maybe this was someone I saw only once ten years ago, maybe it was someone I saw as coverage for another doctor. Or I see a name and it jogs my memory for a person or a story I'd long ago forgotten. What's the hardest though, is seeing the charts of those patients I'd seen for years, people I knew intimately, and wondering what became of their lives. Some of them disappeared from therapy without an explanation, or even if their was an explanation--maybe never clearly articulated but understandable, like a change in their health insurance or simply being tired of commuting an hour and a half each way to come to appointments-- I'm left wondering where they went, why, how they feel about the therapy they never ended, if they left angry, tired, or simply stale. Some of them, I know (ah, I've learned to call people who just disappear) simply tapered away when they felt better; they hadn't meant the last appointment to be the last, but simply felt the work was done. So there's the chart of the woman with really really bad OCD whose son died during her treatment and the horror of that night, of that phone call, rushes back at me. And there's the chart of the young man who was tormented by his inability to fall permanently in love (he was so young, the story hadn't yet been told), it's been years, he'd be in his early thirties by now: I wonder he'd ever married. Or the gentleman who got lost enroute to the first session at my new office, and after years of therapy had never come back. When I last called him, he sounded awful; he'd be in his late eighties by now, and I feel sad to think that he's possibly been dead a good long time. A book he gave me sits on my shelf. And there is the chart of man who left treatment to pursue something a bit fringy-- I'd heard his new psychiatrist lost his license, read in the paper that his wife had died and had, years after last seeing him, gotten a phone call one morning to hear his intoxicated and distressed voice, just calling to say hello. And finally, there's the chart of a patient who left angry, and of another who also left angry, and I'm left wondering how many others left with bad feelings.

Sometimes it's simply like the projector broke in the middle of the movie and I just want to know how the stories turned out. Other times, it's like looking at photos of my children when they were toddlers-- good things, good memories, but something about it is inexplicably painful.

The dead file drawer is hard. And Ms. G's file was not to be found.

(*Not her real name. Note the patient details are all obscured; I am mostly real.)

Psychiatry Board Exam Recertification

I take my Psychiatry Board recertification exam tomorrow. I was in the second year of people who had to recertify every 10 years, to prove that you keep up to date, rather than coasting on your laurels for the rest of your life.

The initial exam is a nerve-racking affair, consisting of two parts, about a year apart. Part I is a written (now computerized) exam, 6 hours of delightful multiple choice and K-questions, #2 pencils and monitored bathroom breaks (you know how a watched pot never boils? ... well... you know).

Part II is where at least a third of examinees fall down, succumbing to anxiety-stricken paralysis or fumbling mental status exams as you examine a real live patient in front of two real live psychiatrists for precisely 30 minutes, then spend another 30 minutes getting grilled and probed to determine if you know what you should know. A colleague of mine had a patient who peed in the corner of the room, then just stared, not uttering one word for half an hour. (He passed, with a measure of sympathy thrown in, no doubt.)

The recertification exam is a 5 or 6 hour computer-based test. I haven't studied one iota, lazily figuring that it should test me on real-world knowledge. At $2100, it's a bit of a gamble to not study... but as long as I don't pee in the corner of the room, I figure I should be okay.

The Andrea Yates Case

[Dinah hates this
logo. What do you
think?]

I've seen a couple comments on the blog asking for a post about the Andrea Yates case. I know this would be an obvious topic for me, but I haven't touched it for a couple of reasons. First, I've been too...um...upset? annoyed? pissed off? about the recent murder—the second one this year—of a correctional officer in our system that I figured it would be best to avoid the blog for a few days. I'm thinking there should be at least as much outrage over the premeditated killing of a law enforcement officer (see links in Officer Down), committed by two convicted murderers in a maximum security facility on lockdown, as there was over the deaths of the poor little kids in the Andrea Yates case. But enough about that. The legislative inquiry has begun and what must be done will be done.

The other reason I haven't blogged about it is because frankly, from a professional standpoint, it's not that interesting. If the jurisdiction had been any place other than Texas this would have been an uncontested insanity case, a legal walk-through. She had a documented psychotic disorder with an established treatment history. There was no question of drug or alcohol involvement, at least from what I've read in the media. This case became a media event because it was a death penalty case and because it presented political issues related to women—the burden of child-rearing and the role of men in childcare (especially for large families). Frankly, if the defendant had been a man I doubt this case would have gotten as much attention. Carrie made an interesting observation in a comment on my post Why I Hate Jason Burke:

One friend said that you'd have to be crazy to kill your own kids...well that should be proof enough right there that she wasn't in her right mind!

Not so. Most infanticide offenders are not psychotic, and most are male. Some infanticide (called neonaticide when the victim is a newborn) offenses are committed by young women who deny their pregnancy and are able to hide the pregnancy for months from friends and family. Women who kill older children also do so for non-psychotic reasons—remember Susan Smith? The killing of older children is sometimes prefaced with earlier incidents of child abuse and neglect. Full demographic and other background information about child offenders can be found here. As with most violent offenses, drug and alcohol abuse usually plays a role.

So there's my comment on Andrea Yates. I'm not going to comment on whether either of the two verdicts were 'right' or 'wrong'. I don't have access to any of the evidence and that's just not my call to make.

Happy Birthday, Vanuatu

My Dad was a ham radio operator. When I was a kid I sat on his lap and listened to him talk to people in exotic far away places like London and Germany and Iowa. He exchanged QSL cards with them, postcards that had radio call letters printed on them and short messages from the people my Dad talked to.

I think that's why I'm so fascinated by the range of people all around the world who stop by to read this blog. When I write something I get curious about how people from other cultures relate to what I'm saying and what they think about it. I want to ask questions and compare experiences. Today, in honor of all those readers from "somewhere else", I am going to dedicate this post to the smallest country ever to visit Shrink Rap: Vanuatu. Today is Vanuatu's Independence Day.

According to the CIA World Fact Book (does anyone else find it disturbing that the CIA keeps records on all this?), the natural resources of Vanuatu include manganese, hardwood forests and fish. It has active volcanoes and beautiful lagoons that inspired James Michener. It has typhoons, earthquakes and tsunamis. You can get some very nice real estate there too. I think we have much in common. We at Shrink Rap live near a beautiful harbor. We have natural resources like crabs and Old Bay Seasoning and the Orioles (American League champions in 1969 with 109 wins and 53 losses). We have natural disasters like tropical storms and floods and movies filmed here starring Meg Ryan and Kevin Spacey. And the Orioles (54 wins, 107 losses in 1988).

Tying all this in to Shrink Rap, I need to mention that Vanuatu also has at least one prison that houses all of 50 people. It looks like you all are working some new reforms over there, and that's exciting. I wish you the best of luck on your new Correctional Services.

And don't forget to stay in touch.

[Google Analytics Map of Shrink Rap hits for July 6-7, emphasizing Vanuatu]

[Roy] Random searches

One of the things that bloggers get a kick out of (I know I do) is to look at the search terms people used that led them to the blog. I use Google Analytics to review our logs, which is one of the best log analyzers I've ever used. Here are interesting search phrases that led to Shrink Rap.

good breast
As if you were praising a pet or something. Stay.

breastfeeding campaign bronco riding
Now there's an interesting visual.

NFL player who still drinks breast milk
If he gets it from the above chick, it would be a milkshake.
51,000 hits on this search and Shrink Rap is #1. Good blog.

gleason xyrem
Poor guy. He's getting screwed. Probably cataplectic by now.

"put down the duck"
Step away from the duck and put your hands in the air.
#1 search here, too; not surprised.

myspace vs reality
Is it really one or the other?

they might be giants
Not really, but now there will be some.

Why I Hate Jason Burke

I'm posting this story as a warning to anyone who might be tempted to order medicine or other drugs through the Internet.

It all started about a year and a half ago. I got home from work and found one of those automated messages on my answering machine from Federal Express. The mechanical woman's voice (why are these telephone automatons always women?) telling me that there was a package for Jason Burke, and that it would be held for five days. I didn't think to much of it, except to hope that Jason Burke would think to call FedEx to find out what happened to his package. About a week later, I came home to find several “hang up” calls on my answering machine. Later that evening I got a phone call from a heavily accented Hispanic man asking for Jason Burke. I explained that he had the wrong number.

A month or so later, the same thing happened again---the automated FedEx message followed by the Hispanic caller, all looking for Jason Burke. By now I'm starting to think I've been the victim of identity theft. I did all the things you're supposed to do for that, checking my credit card statements etc, and nothing seemed to be amiss. Finally I called FedEx, after discovering that this company purposely does not list the local phone numbers of any of their offices---what a pain. The person on the 1-800 FedEx number assured me that they would change the number listed for Jason Burke's account.

A month later, same thing---FedEx call, followed by multiple Hispanic phone calls. This time I went to the local FedEx office myself. “I'm the person who is not Jason Burke,” I announced. The district manager pulled out the package in question: “You don't live at...(announcing the address, which I'm very tempted to post)? You didn't order something from the online pharmacy?”

“No,” I said. “Do I look like a Jason Burke?”

“We'll change the phone number on his account. He's a regular customer.”

That didn't surprise me. To make a long post longer, I got nowhere with FedEx, which never did change the number, or with the multiple Hispanics who called me from the Mexican online pharmacy asking me if I needed a refill on my Vicodin. Finally I called Jason Burke, whose number is publicly listed and FedEx could easily have looked up. Turns out that Jason Burke used my phone number to order his drugs. More than once. The first time I called him he sounded totally stoned. After he sobered up I talked...er...threatened to sue him again if he continued to use my number. He canceled his Mexican online pharmacy account.

The Mexican online pharmacy is still calling me regularly a year and a half later, sometimes as often as eight times a day. That's why I'm posting this story as a cautionary tale for anyone thinking about ordering medications through the Internet. If you do it once, they will haunt you forever. If someone uses your phone number to do it, they will haunt you forever.

In the meantime, Jason Burke's correct phone number is...

No, I can't do it. Besides, it's public information. Anyone can look it up.

Ranting on Dr. A's Blog

I've been visiting Dr. A's blog and ranting there about the case where the courts have taken partial custody of a child when his parents have supported his decision not to continue with chemotherapy for Hodgkin's disease. Anyone want to rant with me?

[posted by dinah]

Officer Down

As of last night, here is the official body count for 2006:

• Three murdered inmates
• Two murdered officers

Enough said. It's time to rethink Project Restart:

Project RESTART as a whole has been criticized by the state prison workers' union, the American Federation of State, County and Municipal Employees (AFSCME), which accuses the administration of Gov. Robert L. Ehrlich Jr., a Republican, of emphasizing rehabilitation at the expense of safety by adding counselors and case managers while the number of correctional officers has declined at some institutions.

**********
Disclaimer: The opinions expressed in this blog are my own, expressed while off-duty, and do not represent those of my employer or the state government. Please don't let an inmate kill me Governor Ehrlich.

[Roy] God as a natural phenomenon

Dan Dennett spoke in February at the TED Talks (Technology, Entertainment, & Design Conference) about he idea that the concept of God and spirituality is a byproduct of human evolution. It's about 20 minutes and is worth listening to.

It made me think more about the previous discussion about how one accepts or rejects responsibility over one's behavior based on knowledge of one's genetic code. This talk had me thinking about how some do "God's will" unquestioningly, as in "It's not my fault I blew up the abortion clinic" ... while others do good will while being atheists. Have a listen.

Also on the TED blog is a speech by Al Gore on global warming and a hilarious talk by Sir Ken Robinson on how children are taught to stop being creative early on. On University Professors: "They look upon the bodies as a means of transport for their heads... It's a way of getting their heads to meetings. "

Off Label; In Jail

[posted by Dinah > Blogspot ate it > spit half back up > whole post found by Roy, enabled by Safari's RSS feature]

And now for the re-posted post:

From last week's New York Times:
Indictment of Doctor Tests Drug Marketing Rules

At first, Dr. Peter Gleason thought his arrest was a joke.

Dr. Peter Gleason, 53, promoted Xyrem for purposes other than those approved by the federal government and now faces charges.

In the early afternoon of Monday, March 6, half a dozen men in suits surrounded Dr. Gleason, a Maryland psychiatrist, at a train station on Long Island and handcuffed him.

Dr. Gleason, 53, was taken aback because he was arrested, and later charged, for doing something that has become common among doctors: promoting a drug for purposes other than those approved by the federal government.

But prosecutors say that Dr. Gleason went too far. At hundreds of speeches and seminars where he was rewarded with generous fees, Dr. Gleason advised other physicians that a powerful drug for narcolepsy could be prescribed for depressionand pain relief. In doing so, he conspired with the drug's manufacturer to recommend it for potentially dangerous uses, the prosecutors claim.
_____________________________

The article goes on to discuss how Dr. Gleason prescribed Xyrem to 100 patients before the pharmaceutical company recruited him to promote the medication. He promoted the medication for off-label use and down-played (even lied?) about the risks, saying table-salt was more dangerous and that the medication was safe to use in children. These talks were given to physicians, the medication has a black-box warning, and the active ingredient is one found in date rape drugs, so it's possible his physician audience might not have believed his claims, or at least approached them with some skepticism (I can hope?). Did he tell his audience's he was being paid by the drug company to talk? No clue, but anywhere I've given a speech, disclosure of financial interests is mandatory.

I've actually heard of Xyrem only once, at APA when I talked to a drug rep about it-- when I heard the amount of paper work required to prescribe it, I figured I wasn't going to be using it anytime soon. I'm not the biggest fan of addictive medications anyway, as I worry that the problem I will create will be bigger than the one I've solved.

In psychiatry, we use medications "off-label" all the time. We see people who are suffering, and if they don't respond to the conventional stuff, we try something else. And we talk to each other, conveying anecdotal tales all the time--please don't put me in jail. And off-label stuff works, people get better. If I know I'm giving something off-label, I tell the patient. Sometimes I don't realize it. For example, a patient brought me an article the other day showing me that Wellbutrin XL is the first medication approved for Seasonal Affective Disorder. I've been treating people with anti-depressants for SAD for years, it never occurred to me that if their depression occured in winter then nothing was specifically approved for those depressions.

From the Press Release from the Department of Justice:

As alleged in the indictment and a previously filed complaint, Xyrem’s manufacturer, Orphan Medical, Inc. (“Orphan”), relied on GLEASON to give lectures around the country promoting Xyrem to physicians for “off-label” indications and paid GLEASON tens of thousands of dollars for such speaking engagements. In 2004 alone, GLEASON spoke at over 100 events and was paid more than $70,000. GLEASON was allegedly in high demand by Orphan sales representatives because of his proven ability to generate “off-label” sales of Xyrem in their respective sales territories. The indictment charges that GLEASON engaged in deceptive and misleading behavior in promoting Xyrem by, among other things, suggesting to physicians that GHB was not a “date rape” drug, and that Xyrem was safe for very young children when, in fact, the drug’s labeling stated that Xyrem had not been proven safe and effective for people under the age of 16. The indictment also charges that GLEASON conspired with Orphan employees to defraud public and private health insurance plans by concealing, and advising prescribing physicians to conceal, evidence that Xyrem prescriptions were being filled for “off-label” indications that generally were not reimbursable.
_________________________

For my own disclaimer: though Dr. Gleason is from Maryland, I don't know him and have never heard of him. And I don't think physicians should make money by promoting off-label medications for drug companies, effectively being their paid mouth-pieces to say what the company can't say. Interestingly, the drug company in this case is not being charged with anything. I don't know if Dr. Gleason is the only physician in the country paid to promote a medication off-label, though I'm assuming, maybe erroneously, that it's not known to be illegal to do so. I'm not sure why the number of speeches he gave or the amount of money he made is relevant.

So what's the purpose of this post? I suppose I read the article and was left thinking, even if he lied, is this a crime? Not, was the doctor right or would this be reason for an ethics query by a professional board, but is this reason for criminal prosecution? I figured I'd put it out to the blog.