My Three Shrinks Podcast 20: Mother Talkshoe

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We had to do something a little different this week. We three shrinks were all busy ... Mother's Day weekend, yard work, Longwood Gardens, and luaus kept us too busy to get together to do a podcast. I insisted that we find a way to do it online, so I FINALLY convinced Dinah that even she could do it ;-)

Ten o'clock last night, it all came together, and we were able to do a podcast, thanks to Talkshoe. (If you haven't checked out Talkshoe, do it. It lets you podcast by phone!) As luck would have it, a storm came through and turned the transformer down the street into a Fourth of July celebration. Despite being without power, we still managed to get it done. Is that dedication, or what?

So, here ya go. It is a little rough, as we weren't sure what we were doing (what else is new?), and recording it via cell phone caused occasional lags and silent periods... hmm, just like psychotherapy.

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May 13, 2007: #20 Mother Talkshoe

Topics include:

• Happy Mother's Day!
• Turkewicz law blog a hit with Clinkshrink. Her recommendations? Malpractice Primer and Economics.
  
• Q&A: Zoe Brain asks "Is there a Standard of Care for GIDNOS in the case where the patient is intersexed? And does the degree of intersex affect the therapeutic regime, and if so, how? I'm familiar with the WPATH (Formerly HBIGDA) v6 SOC for GID. But once a diagnosis of GIDNOS is established, the SOC does not appear to apply."
  Answer: Huh? (We did the best we could.) Also, see Farmer v. Brennan.
  
• APA says people with Medicare Part D having trouble getting their psychiatric medications. Also, discussion of the "donut hole."
  
• Medical Truth in Advertising bill: Is your "doctor" really a doctor?
• Ethical conundrums: trains and Tarasoffs and guns (oh my!). Also, Maryland's problematic law requiring reporting of childhood abuse, even if you are now 90 or you don't know who the perpetrator is. And, what do you do with a dead astronaut on the way to Mars?
• If Dinah had Lost It in Space, she Wishes she would have a Crystal Ball.
  
• A shrink like me?
  

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Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Does Anybody Out There Know a Good Literary Agent?

This post is not about psychiatry. At all, in any way, shape, or form. If you want interesting, intellectually stimulating conversation about psychiatric topics today, find another blog. Maybe one of my co-bloggers will be back later with our regularly scheduled program.

I've lost count, not just of the rejections (oh my gosh, I lost count of those years ago), but maybe even of how many novels I've written. Maybe it's time to throw in the metaphoric towel, to devote myself to other pursuits, become a relentless blogger, see more patients, spend more time cooking for my kids, do their laundry even. Gee, when did those kids last have their sheets changed? Travel the world, exercise more, go to all those meetings I tell people I don't have time for ( Roy, you can skip that sentence). Longer walks for Max, perhaps.

It started with Monday at The Charm (see the sidebar). Maybe I queried a million agents? I finally found one, the agent submitted the novel to some publishers, no luck, and I later learned this agent is on every list of evil, avoid-like-the-plague agents. It's okay, no one else was jumping. So then I surrendered on the commercial route and started sending direct queries to small independent publishers--- one called Erica House, fairly local, was interested and offered a contract. I was thrilled-- at least my book could be shared with my friends and family, and this has been a good thing. I went to the bookstore and found some diet book by the same publisher, it looked legit. Somehow, in the course of the year (or was it two?) it took to get published, Erica House vanished and was replaced by an imprint called AmErica House, then PublishAmerica, which has since published a zillion books in something called Print On Demand which somehow likens it to vanity or self-publishing, even though I didn't pay them to publish the book. In literary terms, the book isn't taken seriously. PublishAmerica does no direct marketing, I hired a publicist, there was a little press on the book which came out in August of 2001, not the best timing for a novel, and on the day America invaded Afghanistan, the Baltimore Sun ran a pretty nice review and I was thrilled to be called "a gifted writer" in print. It doesn't get any better than that, though mostly I was beside myself about the state of the world, even I didn't care about some novel.

Next there was Home Inspection. A handful of the many queried agents looked at it, all rejected it. It's about two patients who see the same psychiatrist and their love story plays out in their sessions, perhaps the one who changes the most is the shrink. Okay, so this time I found an agent right away, she had at least one author I'd heard of, a long list of successes, and 50 years in the business (literally) and didn't know how to use a computer ("the machine is broken"). No online mentions at all, and 13 publishers rejected Home Inspection. It's a tough market for fiction I'm told. I tried the small publisher route, found someone local, but whose books had won some awards, and he said, "I'll meet you for coffee and tell you what's wrong with your book." I met him and his assistant for lunch and they gave me a blow-by-blow of what needed to be done. Make it first person, not third person, increase the emphasis on the psychiatrist. I did this, his company went on a publishing freeze. I found all sorts of garbage about him on the internet, lost count of how many lawsuits he'd been involved with, and stayed away. I renamed the characters, changed the title to Patient Pursuits, tried again to find an agent, no one seemed to notice they'd seen the book before, and they all sent the same "sorry this isn't right for us" rejection slip. Even the few I had some more personal contact with didn't notice they'd read the book before. I gave up, figured if something else made me famous, then Patient Pursuits or Home Inspection would gain a life.

Then there was Mitch & Wendy, a children's book written for my kids. One reputable publisher sat on it for months, said maybe, then no. One agent lost it in a pile, when I called over the summer I was told "they're in the Hamptons." I want to be in the Hamptons. Finally, feeling apologetic about the lost manuscript, she sent a 3 page critique (in a cascade of "dear author f* off" slips, this is noteworthy). Mitch & Wendy have now aged and entered a nursing home. Oh, and the book ends with the Red Sox miraculously winning the World Series, long before it actually happened, so if that one gets dusted off, I'll need to rethink this.

Then, there was By Reason of Insanity, 290 pages of odd dribble about a woman who kills her sister's psychiatrist. Even I can't read it. It took a year and a half to write, and I've dismissed it as a project that got me through a hard time. My husband and sweet cousin were subjected to reading it, but I passed on the whole find-an-agent routine, and probably just as well.

In there, I've searched in funny ways-- I organized a symposium for APA called Telling Stories: The Psychiatrist as Novelist and I met some pretty neat guys, and yes, I've contacted their agents. I could only find one other female psychiatrist novelist, with the same iffy publisher that I have, and she couldn't make the symposium. I went to Robert McKee's Story course-- this was the 3 day screen writing course featured in the Nicholas Cage movie Adaptation-- it was an amazing experience. Robert McKee stands in front of an audience of hundreds and lectures, single-handedly for 10 hours a day for 3 days. I learned a lot about plot construction, movies, all sorts of stuff, and met a couple of interesting people, including a high school teacher who had written a screen play once over a weekend that became a mainstream film, and yes, I went home and rented it. Last year, I took became a grad student and now I know more about constructing fiction, I got some great feedback on my novel of the moment, life goes on.

So the novel of the moment is called Double Billing, named by ClinkShrink after she and Roy were given a one sentence synopsis. Psychiatrist walks into NYC diner to bump into her unknown identical twin. Lots of twists and turns. Several agents have agreed to look at the novel, they've all said "not for me." What is for them? I've read all the books, taken all the advice, wished someone would just tell me "You have no talent, give this up." The blog has helped, it's diverted some of my writing energies and I've been happier being an unpublished novelist since. Yesterday's mail brought a rejection from the agent who represents my favorite book, The Kite Runner, who had agreed to look at a synopsis and three chapters.

I guess it's all part of the journey. Thanks for listening. I'll be back as a Shrink Rapper soon.

I Wish I had a Crystal Ball

I wish I could make decisions knowing how things would play out. Don't we all? In my Johnny Get Your Gun Post below, I presented the case of the episodically violent substance abuser who wants to buy a gun and his therapist tells his family, stopping the gun purchase as well as the psychotherapy. In Roy's post on moral and ethical conundrums, he makes us consider the value of one life versus five with a couple of different scenarios. Some of the commenters pointed out things like how we don't know if we sacrifice someone for his organs that the other folks would live, and it got people asking who even deserves an organ.

I love the blog.

So, Roy and others pointed out that it was the wrong thing for the therapist to violate confidentiality and tell the patient's family that he was thinking of buying a gun, given that the patient is an adult, he was purchasing the gun in a sober state, there was no intended victim, it's legal to own guns. It's not okay for a therapist to tell a family member of such things unless there is a clear and identified victim (and then, our Tarasoff-abiding ClinkShrink tells us, in California we should tell the police or the victim, not the patient's family member) or the imminent risk of suicide or homicide. In the short run, I think it's good that the periodically substance abusing episodically violent patient doesn't have a gun. Roy and others have pointed out that the now ex-therapist may have compromised this patient's ability to continue with anyone in a meaningful psychotherapy, that the patient may lie or hide such potentially important issues in the future, that the therapist missed the boat by not exploring exactly why the patient was telling both his psychiatrist and psychotherapist this anyway (Roy, you are sooo good, you can be my shrink anyday). Maybe the psychotherapist was worried about being sued, and that's perhaps sad or bad.

I would contend that for the moment, we just don't know, and it would be so nice if we did. If the mental health professionals all kept quiet, if the patient on his own decided not to buy a gun, or did buy a gun but didn't use it, this would be good (Though perhaps many sleepless Saturday nights for the shrink & therapists for ages to come), and perhaps the patient would have continued on in a healing nurturing wonderful relationship with his treatment team. Not violating confidentiality is the right answer here, now that we know the outcome.

If the patient bought the gun, got drunk, wandered home angry and impulsive, and shot his sister, it would have been the wrong decision. Family member paying for treatment would never understand that the treatment team knew about the gun and chose not to violate confidentiality. They might sue, though perhaps unsuccessfully, and I assure you that regardless of what was "right" the treating professionals would be beside themselves over any bad outcome that resulted in the injury or death of anyone. Even the patient, now sober in his jail cell, might wish that someone had stopped him. And if he killed 32 innocent people in a school, the treatment team would feel really bad, especially given that they'd contemplated other options.

So, the patient didn't buy the gun and fired the therapist. Is this bad/? Roy worries he'll sour on all therapists, that down the line he might not let someone in to prevent an even worse event. If that happens, if he kills someone 5 years down the line and that could have been stopped if he was in therapy but he wasn't because those damn therapists can't be trusted, then violating his confidentiality was the absolute wrong thing to do.

But what if the patient gets drunk on Saturday night and gets into a fight, and then thinks, "Good thing I didn't have that gun." (He won't think this until late Sunday afternoon). Or what if he seeks help from another psychotherapist who he clicks with better than the first and he feels much better, now he's had an opportunity he wouldn't have had if he'd remained in therapy with his first therapist. At this juncture, he remains in treatment with the psychiatrist who prescribes his meds, maybe he'll go into therapy with him, since knows he can be trusted, and maybe that won't be such a bad thing.

What if, what if, what if ?

So I don't know the patient, but I do know the psychotherapist, the one who snitched to the family about the patient's plans to buy the gun. On a sobering note, she had a personal and terribly tragic violent event touch her own life-- one which I imagine precludes sitting by and allowing a substance abuser to buy a gun. It's probably best that they not work together.

What Happened With the Gun Guy

A quickie, I don't want to divert attention from Roy's Moral Conundrums below. I'm posting the real life what happened on the Johnny Get Your Gun Post in Red below. Click here.

Moral and Ethical Choices

Dr. Richard Schloss posed the following conundrum recently:

The following 2 vignettes are sometimes used to illustrate that there
are universal moral standards that transcend religion, culture, and
ethnicity, because everyone, regardless of background or belief system,
always gives the same answers. See what you think.

Suppose there is a runaway trolley car that is about to mow down and
kill 5 people. Now suppose that there is one observer standing next to
the track watching this, and he realizes that, by throwing a switch, he
can divert the car onto a different track so that it will kill only one
person, but spare the other 5. Virtually everyone says that the morally
correct thing to do is to throw the switch and sacrifice one person to
save 5; most even go so far as to say that it would be morally
reprehensible for him just to stand there and do nothing, once he
realizes that throwing the switch is an option.

Now, a different scenario: there is a hospital with 5 patients who will
die very soon if they do not receive organ transplants, and there are no
donors immediately available. (They all need different organs.) Now,
suppose someone is brought into the emergency department of that
hospital after having suffered a life-threatening, but easily
repairable, injury -- and he has and organ donor card in his wallet.
Would it be ethical for the ER staff to deliberately withhold treatment
and let him die so that his organs can be used to save the other 5
patients? Everyone says "no" to this question. Why? How is it different
from the trolley car scenario? Aren't they both cases of sacrificing one
to save 5? Why is it right to do so in the first case, but wrong in the
second? And why does everyone, regardless of background, give the same
answers to these two illustrations?

Just for fun, I'd like to throw a few qualifiers into the second
scenario. Would your answer change if the potential organ donor who can
be easily saved, but will die without treatment, had been driving drunk?
Would it change if he were a paroled murderer? What about if he had been
speeding at the time of his accident and had killed a family in another
vehicle?

Discuss.

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.

Johnny Get Your Gun

Podcast #19 is up: Check out Xanax Blues.



Okay, we don't do much in the way of clinical cases here at Shrink Rap, but I've got a borrowed case. Not my patient, this was a "Can I fly this by you?" tale from a colleague.

With permission:




The patient is a substance abuser with a history of episodic violence, only when intoxicated. The substance abuse continues. The patient is an adult, but his care is paid for by a family member who has been involved. Psychiatric care is divided between a psychotherapist and a psychiatrist who prescribes the medications (split treatment). The patient tells both the psychotherapist and the psychiatrist that he is planning to purchase a gun, for protection. Neither the psychiatrist or the psychotherapist feel that the patient is imminently dangerous, and neither has expressed concern (that I, sitting on the curb, know about) that an actively symptomatic mental illness is the reason for concern. In other words, the patient is not now suicidal, is not purchasing the gun to either kill himself or someone who is the focus of a delusional system. The only danger (aside from the usual dangers) is that the patient is known to have a substance abuse disorder and is known to sometimes become violent with intoxication.



What should the shrink do?

• Cross his fingers and hope for the best?
• Attempt to hospitalize the patient?
• Violate confidentiality and involve family?
• Refuse to treat patient if he buys the gun?
• Refuse to treat patient if he continues to use drugs?
• Buy a gun for his own protection in case patient comes after him?

The actual case had an answer, even before I heard about it (ah, this makes it so easy when someone wants my advice!), I'll post it here after people have had a chance to think about this one.

Okay, so probably Do Nothing comes closest of the choices above: Review with the patient that he has an ongoing substance abuse problem, that under the influence he has a history of becoming compulsive and violent, and he shouldn't get a gun. I believe, but don't know, that this is a college student with no formal legal history and no interest in giving up his substances. Refusing to treat if he doesn't get substance abuse treatment would likely be the end of treatment. Refusing to treat if he buys the gun seems a little weird-- I do have patients with guns. Clink has also pointed out to me that it can be a real issue if such a patient is required to carry a gun for his job-- no gun, no job, no insurance, can't pay shrink. The shrink buying a gun was a joke. Sorry if it wasn't funny.

So the doc who "flew this by me," then told me that the psychotherapist told the family member who pays for treatment and has sometimes been involved. The family member threatened to stop supporting patient if he got a gun, patient reportedly didn't get gun, but got mad at therapist and fired her. My response: "Therapist did you a favor and solved your difficult problem." Was this "legal?" Nope, the therapist violated confidentiality. Can the patient sue-- I suppose so, but for what damages? We'll never know, but if the patient had done something awful with the gun, it would have been very troubling to his treatment team, even if not snitching was the "right" thing to do. I don't know the extent of the past history of violence, and that would have mattered to me. Remember, this question got asked on the heels of the Virginia Tech shootings and I believe we're all still feeling a bit vulnerable.

My Three Shrinks Podcast 19: Xanax Blues

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Last week's Grand Rounds podcast was very successful. We've had over 300 downloads in the past week and over 3000 hits from iTunes. For the Grand Rounds post itself, we've had over 6000 page views in the past week from over 3000 unique visitors. Thank you.

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May 7, 2007: #19 Xanax Blues

Topics include:

• Q&A: Emailing patients
• Q&A: What is Psychiatry doing about asexuality?
• Q&A: Talk about Munchausen's disease and Dissociative Identity Disorder (DID).
• Is denying care malpractice?
  
• California forensic psychiatry staffing problems
• More troubles with Xanax

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Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.

Dinah: I Have Relatively Moderate Wisdom

It's Sunday morning (2pm is still "morning," right?) here in Shrink Rap land. I've had coffee with the judge, I've done a load of laundry, I've run a 10 minute mile and then walked another one, and, of course, I've read part of the Sunday New York Times.

It's been an exciting morning with the paper. I've discovered that I'm either middle-aged or on the cusp of it. This is okay, not really news and now that I have teenage kids, I think I'm entitled to it.

So, first I read a review of a book by Gina Kolata called Rethinking Thin. The book reportedly downplays the dangers of obesity (let's not go there) and trails four patients as they go through a clinical trial at a University of Pennsylvania obesity treatment group. Back in the day when middle-age wasn't even on my radar, I worked as a research assistant in that group--some of those folks are even still there (I think that makes them Old). I hear the book isn't all flattering to the group, but I may have to buy it anyway.

So now that it may be okay for me to be fat, I moved on to the issue of Wisdom, a rather vaguely defined condition and it was sort of amazing that so long an article could say so little. I thought of Roy when I read, "One of the most interesting areas of neuroscience research involves looking at the way people regulate their emotions and how that regulation can change over the course of a lifetime." Roy, why aren't you here? Yes, yes, yes: there were fMRI studies quoted, not to mention salivary cortisol levels. No oxytocin, I'm so sorry. Okay, so I read and read, all the time wondering if I am Wise. I got to the end of the article and there it was, a link to an on-line test I could take. I was on it-- the test scored as 1-5 and answering quickly, I scored a 3.7. I have relatively moderate wisdom. Probably one different answer and I could have gotten a 4 and had moderately high wisdom. Okay, I'm off to test my husband (who is definately wise), maybe the kids, maybe Max, and I still have to read the article on the guy who stopped his anti-depressants. I may be back.

Community in Uproar After California Psychiatrist Fired

This is an interesting story, not because of the controversy of a psychiatrist being fired and the poor communication about her replacement, but because of the way the community has had so much involvement in the discourse about the whole thing, by way of the Comments section of the local newspaper's online version.

Where? SCHC, Redding, California, in Shasta County. Here's the first few paragraphs from the May 2 story in the Record Searchlight:

A Redding health clinic that serves mostly low-income residents has fired one of its two psychiatrists, leaving hundreds of her patients scrambling to find other care.

The Shasta Community Health Center terminated the contract of clinical psychiatrist Lynne Pappas on Friday, Chief Executive Officer Dean Germano said. A former Shasta County psychiatrist, Pappas had been with the clinic for about four years.

Neither Pappas nor Germano would say what led to her dismissal, but patients said they were told by clinic employees that Pappas had been escorted from the building several weeks ago and suspended after an argument with her supervisor, medical director Dr. Ann Murphy. Murphy did not return a call Tuesday seeking comment.

“It’s an employment matter and the only thing I can say is it was just not working out,” Germano said Monday. “I will say Dr. Pappas in my judgment is a fine physician. It has nothing to do with her competency or care of patients.”

What follows the story is more than 60 comments from the community, mostly skeptical about the reason for the firing, suggesting politics or unwillingness of the departing doctor to cut corners.

You should go read some of the comments; it's really quite an outpouring of support for Dr. Pappas and concern for their family member's follow-up care.

California is currently going thru an evolution in forensic mental health care after a recent court order and prisoner class action lawsuits have required the prisons there to increase the wages paid to forensic mental health providers in order to encourage them to take these jobs. As a result, salaries for psychiatrists in West Coast correctional settings have gone through the roof. This has caused some docs working in community clinics and hospitals to play a Go To Jail card, taking up some of these new positions, which had previously gone unfilled. This is resulting in more difficulties in finding psychiatrists and other mental health professionals to fill community positions, resulting in higher salaries being offered, and breaking county and state budgets.

Lawyers for mentally ill prisoners will ask a federal judge today [Apr 23] to force the state to take drastic action to stem a staff exodus from California's mental hospitals that has jeopardized patient safety and left psychotic inmates to languish in jails and prisons without proper treatment. U.S. District Judge Lawrence K. Karlton in February ordered the state Department of Mental Health to formulate a plan to reverse a staff exodus from the state's beleaguered hospitals in recent months. The staff departures occurred after the same court had ordered raises for prison mental health staff that made prison jobs more attractive than those at hospitals. ... "The plan … is akin to placing a Band-Aid over a gaping hole in an almost empty bucket of water, while doing nothing to refill the lost water," lawyers for the prisoners wrote, calling the approach a "wait, see, and hope for a miracle" strategy that "is reckless and must be immediately addressed by this court."

It doesn't sound like this current firing has much to do with these dynamics, but it is important to understand the occupational landscape in CA.

Back in Shasta County, a second newspaper article triggered additional community support and dismay...

Kathryn Ranken, a private therapist in Redding who sees some of Pappas' clients, said it was "unethical" for the clinic to dismiss Pappas without having a plan in place for treating her hundreds of ailing patients.

...followed by yet a third article yesterday...

Pappas wasn't hit by a meteor; she apparently was suspended a few weeks ago after an argument with the clinic's medical director, and she was fired Friday. That left time to make the best of what was bound to be a rocky transition, yet this week the clinic's managers and Shasta County Mental Health were still figuring out how to handle referrals of Pappas' patients.

And we're not talking about just a few people. Pappas and the health center's one other psychiatrist had more than 2,000 patients...

Sounds like Clink's caseload.

It's just really good to see the paper, and reporter Tim Hearden, use Tim's blog as a way of holding a kind of virtual town hall meeting to help resolve this crisis in the community's ability to meet the mental health needs of its members.

(And... this really is Roy... I know the topic sounds real Clinkshrinky.)

Reading the Mind with Oxytocin

This is one of the images in the Reading the Eyes in the Mind test.
Is this woman feeling aghast, irritated, reflective, or impatient?

Is this man feeling ashamed, alarmed, serious, or bewildered?
Click the WOMAN'S EYES to take the whole test.

I continue to be fascinated about the role that oxytocin appears to play in social behavior. Here's a study from Biological Psychiatry where:

...30 healthy male volunteers were tested for their ability to infer the affective mental state of others using the Reading the Mind in the Eyes Test (RMET) after intranasal administration of 24 IU oxytocin. RESULTS: Oxytocin improved performance on the RMET compared with placebo. This effect was pronounced for difficult compared with easy items. CONCLUSIONS: Our data suggest that oxytocin improves the ability to infer the mental state of others from social cues of the eye region. Oxytocin might play a role in the pathogenesis of autism spectrum disorder, which is characterized by severe social impairment.

...In sum, this study shows that a single dose of intranasally
administered oxytocin is sufficient to cause a substantial increase
in the ability [of] affective mind-reading and therefore in interpret-
ing subtle social cues from the eye region of other individuals.

Reductions in oxytocin levels have been found in people with autism, as have impairments in cognitive processing of facial features in relevant brain structures (amygdala, fusiform face area). Blocking oxytocin in mice blocks their social recognition. Oxytocin has been shown to increase metabolic activity in these areas. Thus, oxytocin may help us recognize another's emotional state by improving our empathic ability to "read" what someone else if feeling.

There's got to be a similar area in the brain that processes auditory emotional clues, but I am not aware of any.

It would be interesting to know if therapists tend to have higher levels of oxytocin, if the level in the therapist is related to feelings of connectedness by their patients, and if oxytocin nasal spray can improve a therapists empathic abilities. (Reminds me of Deanna Troi, the Betazoid therapist on Star Trek: TNG, who had a type of mind-reading capability. Wasn't there a show where she lost her capabilities?)

How To Make Crime Pay

When I'm doing my clinic I sometimes overhear conversations that give me an "inside scoop" about life on the streets and other issues. I found out that our last mayor 'cleaned up the streets so you could hear a pin drop' but under the new administration 'things are going back to normal'. I also heard something this week about how to make crime pay.

An inmate was chatting with another inmate out in the hallway. He talked about how he got shot by "two unidentified black males" and ended up in the hospital. The police came to interview him but he refused to give up the names of the guys who shot him. He was later arrested and charged with various handgun-related offenses. He decided to apply for assistance through the state victim's compensation fund:

Inmate One: "It don't matter if you're locked up. You write to them and they send you a form. I got $5750."

Inmate Two: "What, you sue the police? I thought some guys shot you."

Inmate One: "They did. No, all you gotta show is that you were the victim and you got hurt. I got $5750."

Inmate Two: "So it doesn't matter that they got a witness saying that they saw you returning fire?"

Ya gotta love these guys. At least he'll have the money to pay his restitution and supervision fees.

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I know I'm coming late to this party, but I just discovered Jonathan Coulton's song Your Brains. Given our recent Grand Rounds I thought it would be appropriate to share.

A Shrink Like Me!

We're back to our regularly scheduled program now.

It was April 24th, back when Roy was having Grand Rounds mania and Shrink Rap was under lock and key, when the New York Times printed an article by Dr. Richard Friedman,
Understanding Empathy: Can You Feel My Pain. Dr. Friedman begins his piece by quoting a patient who asks if he's ever been depressed; does he know where she's been?

It's a funny question. Why does a doctor need to have suffered from an illness to treat it? We assume our oncologist hasn't had lung cancer or metastatic colon cancer, he hasn't gone through what his patients are going through, and yet we'll assume he's sympathetic and competent. If the doctor has had the disease, or has had a close relative with it (why is that never the question?) then perhaps he is more understanding, but really, how would this help his competence to treat a given disease? In fact, sometimes those who've conquered something are less sympathetic, sometimes those who've conquered say an addiction, or lost weight, or stopped smoking, or have somehow suffered, develop a bit of condescension toward those who aren't doing as well-- a bit of I did it Why can't You? Maybe it's better if the doctor is an outsider, a technician there to make the proper moves without the burden of his own history or agenda.

Friedman goes on to talk about patients who come with requests for specific flavors of therapists: gay, feminist, African-American, Jewish. These patients want a shrink who identifies with their lifestyles, who better knows what it is to be them.

I think there are two different issues here. Clearly, one can treat an illness if one hasn't had it; mental illnesses really are no different and plenty of patients get treated for schizophrenia by docs who've never been psychotic. Having been depressed doesn't change one's ability to write the right prescription, to imagine what it is to suffer, to listen, learn, and appreciate a patient's distress. If anything, it may color the doc's view. Want more? See my post from last September, A Taste of Our Own Medicine.

The second issue is more about therapy-- does it help to have a therapist who is familiar in some ways with the patient's world or culture or core beliefs? Dr. Friedman says No: "What is critical to understanding someone is not necessarily having had his or her experience; it is being able to imagine what it would be like to have it. Thus, I do not have to be black to empathize with the toxic effects of racial prejudice, or be a woman to know how I would feel about being denied promotion on the basis of sex. "

And what do I think? It seems to me that just as some patients respond to one medication and not another, some people have very strong feelings about who they are comfortable speaking with, while many don't care. I've had many calls from patients who want to see a female psychiatrist. I don't question it (what am I going to do about it anyway?) and I've come to take it at face value. I imagine there are women who prefer to talk to a man or who just don't care about their shrink's gender. The reality is this: if a patient lives in a place where there are options for who will be their therapist, and the patient has means to pay for it, they will select who they want to see--- there is no means for telling someone who wants to see and pay for an available female/gay/Jewish/Hindi psychiatrist, "No, don't do it." For those who go to clinics, where there may or may not be choice, the clinics vary in how responsive they are either willing or able to be to such requests.

In an ideal world, I suppose I think that anything reasonable that makes a patient more comfortable should be accomodated so long as it doesn't make someone else uncomfortable. It's not an ideal world, and some orders are hard to fill.

Any thoughts? I, of course, want a therapist with a blog.

Quack: More Than I Wanted To Know

This New York Times article from May 1st on Duck Genitalia (no, I'm not kidding) caught my attention and I thought I'd share it here. Apparently the duck's phallus can be as long as his whole body. Funny, all those rubber ducky guys look so innocent.

[Clink: This post is for Gerbil, who doubted our ability to re-use the label MNP]

Grand Rounds at Shrink Rap!

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[17] . . . [18] . . . [19] . . . [All]

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Grand Rounds at Shrink Rap: BYOB
(Bring Your Own Brain)
...also, My Three Shrinks Podcast 18...

[Well, this was a lot of fun to put together. We'll have to do it again sometime... in a couple of years (Actually, the iPhone 3G Edition in June 2008)! You can thank Clink for the fancy html work on the brain -- click a brain region or title to go to that section -- Roy for the linking and formatting and producing the podcast (or click here to open a new window with the .mp3 running so you can listen to us blather on about all these excellent posts), and Dinah for... umm... oh, yeah, she wrote a lot of the copy. Watching the three of us try to figure out how to organize all 50 posts into 8 categories was like watching the Three Stooges trying to hang wallpaper. So, charge up your laptop, get yourself a drink, and make yourself comfortable. Then start enjoying these great articles. But, remember, enjoy them responsibly.]

--|May 8 Grand Rounds is at TBTAM (The Blog That Ate Manhattan),
--|where it is "dedicated to our favorite surgery registrar, Barbados Butterfly,
--|whose blog was unceremoniously taken down not too long ago. "

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Be sure to check out Interested Participant, whose link we initially butchered. IP blogs about the serious civil liberty consequences of a bill in Congress to expand the registry of mental health adjudicants in National Database of the Mentally Ill. "After all, that's how Hitler was able to get his Aryan purity project launched." This is a nice summary of current meaning of the term "adjudication" and how redefinition could open the records of many patients.


Also, check out ER Nursey's post about a Bad Week for the Thirty Year-Olds.

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And be sure to check out the Medscape interview between us and Dr. Nicholas Genes, the doc who started Grand Rounds!

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DUCKS

• The Shrink Rap Silly Award For Most Duck References goes to Universal Health for posting Duck Soup. Nice job! Such thorough research, but not for quacks!

• Speaking of quacks, Liverpool Leftovers gives us a fun post about Quacktitioners and the Quackometers.

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CASES: ABOVE THE NECK

• Val Jones from Dr Val and the Voice of Reason wonders about aging and what makes one particular demented patient rotten in The Great Unveiling.
  
  
• Adam of NY Emergency Medicine blogs about the challenges of recognizing and managing psychological illness in the emergency department when it presents as physical symptoms. In A Broken Soul, the story had a happy ending.
  
  
• In Tales of an Emergency Room Nurse, a case of psuedoseizures is discussed in Emotion as a Cause of Illness.
  
  
• In a Bad Week for the Thirty Year-Olds, ER Nursey describes three sad cases she saw in the ER.
  
  
• In One Post Can Be All It Takes, Anxiety, Addiction and Depression Treatments looks at new research that points out the effects that one dose of opiate can have on the brain. Using morphine, researchers showed that even a single dose can have a powerful effect in mice, which indicates opiates might have similar repercussions in human brains. [not really a case, but close enough. -R]
  

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CASES: BELOW THE NECK

• Dr. Marc Greenstein shows us pictures of bladders and pelvi. We never knew they did prostatectomies on robots.
  
  
• Healthline's Ken Trofatter writes a poignant post about the delivery of a healthy baby to a couple who'd previously given birth to a stillborn child in Second Verse Different from the First!
  
  
• In Clinical Cases, the question is asked, "Can I Stand on My Head While on Coumadin?."
  
  
• In The Will to Survive, Dr. George from Odysseys of George tells an uplifting story of a young woman who made a miraculous recovery from a horrific accident.
  
  
• In Pride Goeth Before The Fall, Movin' Meat tells us about an obvious case of appendicitis that wasn't.
  
  
• Wandering Visitor shows us pictures of people with extra body parts in Extra...Special.
  
  
• TBTAM in The Blog That Ate Manhattan describes a patient who is concerned about her risks of developing breast cancer now that her sister has been diagnosed, in When Cancer Strikes Close to Home.
  

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DEALING WITH ILLNESS

• Islamic poet Tiel Aisha Ansari of Knocking From Inside writes about the challenge of recovery in Physical Therapy. Whether recovering from mental or physical disability: "I can't cheat just work, and pray, and be it as God wills."
  
  
• AMiB shares this video, "In My Mind". "I came across an interesting video on YouTube that I felt I would like to share on my blog. It is called 'In My Mind', and is a video made by a teenager with Asperger’s Syndrome, explaining to others what it is like to be him." AMiB's blog, An American Medic In Britain, documents his experience with the ancient and respected trade of medicine.
  
  
• Laurie Edwards, whose blog, A Chronic Dose, explores living with multiple chronic conditions from the patient perspective, writes about themes of control, denial, and worrying when loved ones are sick in Who, Me Worry?
  
  
• Amy Tenderich from Diabetes Mine, reviews Jill Sklar's new book The Five Gifts of Illness, which is about Survivorship.
  
  
• Rachel's Wide World of Lunacy gets Flooded Back. "...the feelings of helplessness and despair came back - flooding me like a salad drenched in too much balsamic vinegar - an almost sickening, choked feeling."
  
  
• Emergiblog provides tips on how not to feign illness in You Might Be a Faker If...
  
  
• Adrian of One Version of Things tells us what got him interested in medicine as a child -- seeing his little sister almost die -- in One Sick Little Girl.
  
  
• In Thanking You, type 1 diabetic Kerri Morrone from Six Until Me realizes the profound impact that a support system, specifically the blogosphere, has on her diabetes management.
  
  
• Tangent 90 Degrees illustrates what life is like for family members who donate their loved ones' organs in Celebration and Remembrance.
  
  
• At The Tangled Neuron, we learn about research showing that a systematic program of cognitive rehabilitation can help people with mild Alzheimer’s improve their ability to function, in Cognitive Rehabilitation For People With Alzheimer's and Dementia.
  

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WELLNESS

• Enoch Choi advises us on how to keep from chopping off those digits in How Can I Keep From Cutting Myself While Preparing Food. [At first I thought it was about self-mutilators. -R]
  
  
• Bertalan Meskó from ScienceRoll shows us a really cool idea in Second Life: the Virtual Medical Center: the Future of Medical Education. Go to medical school online.
  
  
• Nancy Brown from Teen Health 411 gives us tips for dealing with tragedies like the Virginia Tech shooting.
  
  
• Jolie Bookspan from The Fitness Fixer encourages us to Exercise Your Sense of Humor.
  
  
• SharpBrains gives us tips on improving brain function in Easy Steps to Improve Your Brain Health Now and Mind and Life Institute.
  

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ETHICS

• Interested Participant blogs about the serious civil liberty consequences of a bill in Congress to expand the registry of mental health adjudicants in National Database of the Mentally Ill. "After all, that's how Hitler was able to get his Aryan purity project launched." This is a nice summary of current meaning of the term "adjudication" and how redefinition could open the records of many patients.
  
  
• In Midwest Med Student Meets East Coast Politics, Paige Hatcher writes about the Virginia Tech tragedy, and how insurance discriminates against people with mental illness, making it harder for folks to get help. She calls for U.S. residents to let their Representatives and Senators know that we want the Mental Health Parity bills passed.
  
  
• Healthline's JC Jones writes about the post-Cho privacy vs. safety debate, in The Human Brain as a Deadly Weapon: Privacy Laws vs. Protecting the Public. "Maybe we need a VT law with a public database with all known persons with potentially violent tendencies..."
  
  
• Our friend, Dr Anonymous, posts The Baby Emilio Debate, about a 17-month old child who "has a rare genetic disorder which will eventually end his life. An ethical debate is taking place in Texas and around the country having to do with end of life issues and who has the final say in these issues."
  
  
• Eric Turkewicz, a New York Personal Injury Lawyer, posts about a different sort of illicit drug trade, in Counterfeit Drugs Update - Trying to Track The Goods.
• 
  Monash Medical Student mixes it up with medicine and religion in HIV, AIDS, Safe Sex & Fornication (the picture of the hot babe doing it with a spider gives new meaning to the term formication).
  
  
• Rima Bishara in The Doctor Blogger provides the low-down on how the relationship between Doctors and Pharmaceutical Reps.
  
  
• Vitum Medicinus goes even one further in You Thought The Pharmaceutical Industry Was Slimy Before Reading This Post? about how drug reps use techniques to get into our heads.
  
  
• HG Stern at InsureBlog talks about the challenges of medical privacy and risks taken by health care providers who blog in The Flipside Of Empowerment.
  
  
• Nick Jacobs from Hospital Impact describes hospitals which have the 7 Traits of a Highly Passive-Aggressive Organization.

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INTERPERSONAL

• In Hooray for Hello Kitty and The Further Adventures of Hello Kitty TSCD writes about the challenge of efficient patient interviews. Also revealed: techniques for maintaining a straight face when people tell you bizarre or disgusting things.
• 
  Mother Jones from Nurse Ratched's Place writes about a moonlighting psychiatrist who winds up in Iraq in The Green Zone. "Dr. J. left a year ago and we haven’t heard from him since."
  
  
• The Snarky Gerbil wonders what she will do if clients come to her garage sale in Privacy Please.
  
  
• In Shaming The Patient, Susan Palwick from Rickety Contrivances of Doing Good wonders if telling patients to lose weight sometimes does more harm than good. "It's a lot harder to go to the doctor when you're ashamed of yourself, especially when you expect the doctor to try to make you feel more ashamed."
  
  
• Are Fat Doctors Just Human? Kendra Campbell, from The Differential: Medscape Med Students Blogs, sees fat people in the Baltimore airport and wonders if doctors should put more emphasis on their own healthy living as an example for their patients. [P.S.: We know Fat Doctor is human, and we love her for it. -DCR]
  
  
• PixelRN discusses a poll of Baltimore firefighters/EMS as to which hospital has the hottest nurses. Dinah wants to know which one has the hottest shrinks.
  

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INTERNET

• Kevin, M.D. provides tips on improving your search engine reputation (SEO) in Google Yourself. He should know.
  
  
• Health Psych gives us Suicide by Internet, about two Australian teens who died together of suicide; a reminder to all parents to read what your children write on FaceBook. "Most experts agree that during adolescence, it is critical is to beavailable to listen, be alert to warning signs and to keep the lines ofcommunication open, even though it may not always be easy to do so."
  
  
• David E. Williams from the Health Business Blog writes about the Google Health initiative in Mr. Google comes to Washington. "I asked Bosworth whether he felt consumers had a role in determining their diagnosis –in partnership with their physicians– as well as their treatment."
  
  
• Walter from Highlight Health provides us a list of Healthcare Self-Mangement Suggestions for e-Patients.
  
  
• Joshua Schwimmer from Tech Medicine provides a 4-part tutorial on medical podcasts, including Intro, Part 2, Part 3, and Part 4 (of course, since Dr Schwimmer left out the best psychiatric podcast, My Three Shrinks, his post rates only a B minus, at best ;-) .

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--|May 8 Grand Rounds is at TBTAM (The Blog That Ate Manhattan),
--|where it is "dedicated to our favorite surgery registrar, Barbados Butterfly,
--|whose blog was unceremoniously taken down not too long ago. "

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My Three Shrinks Podcast 18: Grand Rounds BYOB


If you are looking for the show notes, they're up above. To look at past episodes, with links. go to http://mythreeshrinks.com/.

This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com. Thank you for listening.