We Don't Say.

Here and there, now and again, people have come on to the blog or written in to our temporarily dormant My Three Shrinks podcast and asked for our opinion on clinical matters. Scenarios are described and questions are asked about the specifics of treatment or side effects. Our unified response as blogger-psychiatrists has been to not respond.

It's not that we're ignoring anyone and it's not that we don't have thoughts or opinions, but there's a lot going on here, and it's really not possible to say much with only part or one side of a story. More cogently, it's not that we don't care about anyone's concerns, questions, or distress. It's simply very clear: We can't respond. It is unethical for us to express medical opinions, tantamount to medical advice, on a patient we have never examined and to render those opinions in a public place.

There's a rule in psychiatry known as the Goldwater Rule-- this could be a ClinkShrink post, she knows all this stuff. The Goldwater Rule is based on a section of the The Principals of Medical Ethics of the American Medical Association that reads:

Section 7.3

On occasion psychiatrists are asked for an opinion about an individual who is in the light of public attention or who has disclosed information about himself/herself through public media. In such circumstances, a psychiatrist may share with the public his or her expertise about psychiatric issues in general. However, it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.

And why is it called The Goldwater Rule? From a 2007 article in Psychiatric News,

Ethics Reminder Offered About 'Goldwater Rule' on Talking to Media

This passage is referred to as the "Goldwater Rule." How did this eponym come about? A presidential column by APA's 126th president, Herbert Sacks (1997–1998), explains its origin:

"We are reminded of the 1964 Goldwater-Johnson election, when 1,189 American psychiatrists responded to an inquiry for their opinions of the candidates by a now defunct magazine [Fact magazine]. The bulk of the political responses, couched in psychiatric terminology, were so unfair and so outrageous to Goldwater that he sued and won a substantial settlement. APA issued public statements decrying such analyses and in 1973, when The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry were drafted, Section 7.3 stated [see above]."

Dr. Sacks also noted in his column, "Psychobabble reported by the media undermines psychiatry as science." His words remain true today.

When commenting on individuals in the public eye, psychiatrists should be governed by concerns for the potentially inflammatory and harmful consequences of their statements. The reputation of the public figures involved, their own credibility, and the dignity of our profession are at stake. Only after performing an examination and receiving an appropriate waiver of confidentiality should psychiatrists comment on persons in the light of public attention.

But it's just a question and you're not a celebrity and you're not the subject of media attention! Oh, but our blog is public and it seems prudent to observe the standards of our profession that dictate what it is or is not appropriate for us to comment on.

Life After Homicide

Is there life after homicide? No, I obviously don't mean for the victims---I mean for the killers.

This is a question that struck me after one of my patients, a convicted murderer who violated his parole, said to me: "I don't feel good about the fact that I'm a killer."

For some reason that statement just struck me and I'm not sure why. Of course someone would feel bad about killing. Sociopaths don't, but most normal non-sociopathic killers do. I think it hit me because my patient's offense had happened over a decade before and he had done well on parole since his release. He was really sad about what he had done and was trying to make things better.

The fact of the matter is that all killers aren't the same. You have the barfight killers, the enraged jealous lover killers, the cold and calculating hit man killers, the child abuse killers, the sadistic serial killers, the drunk driver killers, the school shooting killers, the newborn infant hidden pregnancy killers, the "teenager who kills his entire family" killers and so on and so on. Everybody's different. Ever since the middle ages and the old English common law, killings have been broken down into different categories of murder and manslaughter so that killers would be punished in accordance with the type of killing they're guilty of.

But back to my patient. The question that came to me was, "How do you handle the guilt of being a killer?"

Is it like dealing with grief in the bereaved, where you never really expect someone to just 'get over' something? Is it something you just have to learn to live with? Do you tell the patient that they're now obligated to live the rest of their lives paying their debt to society? Is there a point where the guilt should end? Or is the person really obligated to spend the rest of their life beating himself with a knotted cord? What good does that do?

It's a matter of public record that the Emmy Award-winning actor Charles Dutton was an inmate in our correctional system back in the 1970's for killing someone. To my knowledge he's never been in trouble since then, he's turned his life around, and he's contributed a lot to society since he's gotten out. Most killers don't put their pasts behind them quite so successfully. In my experience a killer who successfully has turned his life around is someone who gets out, has a job, has a place to live, has people who love him and who doesn't commit too many more crimes. It's a bit much to expect someone to never get in trouble again---life is weird, circumstances happen beyond your control and bad reputations throw a long shadow---but at least it shouldn't be another violent offense.

As all of my patients know, it's better to make a life than take a life. It's just a lot tougher to make a life.

My Sister Says...

So when I give a medication recommendation I talk about why I think the medication would help, I talk about what it treats, what the side effects are and what the risks of taking the medication are. That's a lot of information to absorb all at once so I ask my patients if they have any questions about what I've said. Most of the time they decide to take medication, sometimes they don't. When they decide not to take it they've got good reasons, most of the time.

The only bad reason I've heard is: "I talked to my mother and she heard bad things about it, so I'm not going to take it."

Every inmate has a sister, a girlfriend, an aunt or a mother somewhere with some health care training. All of these family medical advisors know more about psychotropics and are more reliable sources of information than I am, apparently.

I try to be generous and remember that maybe there are idiosyncratic issues here, like maybe the patient did have a weird reaction to some medication that he doesn't remember but his mother does, or maybe there are multiple family members who all had the same problem with a certain medication so he might too.

But usually it's just a matter of trust. The inmate's LPN sister has taken care of him all of his life, has rescued him and given him shelter and sent him money when he needed it, so what she says about medication goes.

It reminds me of a story I heard when I was an intern. My attending went to visit his mother, who was in the hospital for elective surgery. He offered her some advice about her anesthesia, and she responded: "I'll talk to my doctor about that." Her doctor was an intern. My attending was the chairman of the anesthesia department at a major academic institution.

So I guess it goes both ways when it comes to being the family medical advisor. Are you the family medical advisor? Do you want to be? And if so, do they listen?

CBT4CBT

I heard a talk today on CBT4CBT: Computer Based Training for Cognitive Behavior Therapy where substance abuse treatment is supplemented with On-line real-time psychotherapy groups. I hope I'm saying this right.

The patients go to regular appointments, but in addition, there is an on-line group. The patients and a therapist all 'meet' at a pre-arranged time. There is a camera on the therapist, so his image pops up in the corner of the screen. He can write on the main part of the screen. The participants call in over their computers (each is given a microphone). They're aren't seen, but they have screen names, and they talk one at a time: they press a button to speak and release it when they are done, assuring that people don't talk over one another (I could use one of these buttons in real life). All the patients liked it and they did as well as the controls who had real-life treatment without the supplemental on-line group.

Here's a link if you want to read about this stuff.

And the talk I heard used a platform designed by eGetgoing, an online substance abuse treatment service. I learned something new today.

Checking Out the Other Shrink Blogs

When we started blogging, we looked for the blogs of other psychiatrists, and even other non-shrink docs, and linked to them. It's been a while (oh, nearly 3 years) and mental health blogs have come and gone. I thought I'd survey the scene again. So just a list:
Dr. X's Free Associations : psychology with a conservative (?) bent.
May Shrink or Fade: a young(?) inpatient psychiatrist in New England ponders the world.
Turn Your Head and Scoff: by our correctional friend in San Diego, FooFoo5
The Last Psychiatrist: Assorted psychiatric and other rantings
Garth Kroeker is a blogging psychiatrist
The Psychiatrist Blog is written by Dr. Michelle Tempest.
Mind Hacks: Neuroscience and Psychology
Psyched Out: Musings of a psychiatric social worker
In Practice: Peter Kramer's psychiatry blog in Psychology Today.
Oh, Psychology Today actually has a whole list of mental health blogs: try here.
PsychCentral is ...oh, psych central.
Carlat's Psychiatry Blog: focuses on medications and medical research
Clinical Psychology and Psychiatry: A Closer Look
CorePsychBlog: psychiatry with a radio show.
Psychiatric Drug Facts with Dr. Peter Breggin features a psychiatrist who doesn't like meds
The Treatment Advocacy Center -- kind of describes itself.
Mental Nurse: a multi-author mental health blog in the UK
Intueri: to contemplate -- by a psychiatrist.
Ars Psychiatrica: by another psychiatrist! mixes with art and literature Couch Trip: by a psychologist (or soon-to-be?)
Everyone Needs Therapy by a PhD in social work (--Really?)
Jung at Heart by a Jungian psychotherapist
Somatosphere: a multi-author, multi-specialty blog, includes psychiatry
And from Irving, Texas: A psychiatrist who learned from veterans.
I've somehow lost Shiny Happy Person and her Trick Cycling for beginners blog.
The Snarky Gerbil is a psychotherapist-in-training.
Our blog friend psychiatrist TigerMom writes with two other docs on Two Women Blogging (these people can't count).
Juliaink is a psychiatrist who posts on Mothers In Medicine.
Modern Psychoanalysis is a blog by Jim about....psychoanalysis.
Shrinkwrapped (!!!) is a psychiatrist/psychoanalyst in New Jersey. Ah, he needs a better blog name. Might I suggest....
Dr. Deb talks about her work as a psychologist.
Katie Malinski is a social worker who is a parenting coach.
CoffeeYogurt is a blog by a psychologist who visits us.
Dr. Doug Bremmer writes: Before You Take That Pill.
Dr. Shock, M.D., PhD, has a 'neurostimulating blog' with a chocolate post!


Oh, there are more. I tried to confine it to blogs by mental health professionals...but there are so many great medical blogs, and blogs by patients, and many of our readers have neat things going on. More another day. If I missed a psychiatry blog, then by all means....

What Doesn't Kill Us Makes Us Stronger....

So I was bitching to Roy (What, me bitch?) and he responded with "What doesn't kill us makes us stronger." Or some version thereof. Roy, Nietzsche, one of those smart guys said something like that. They actually even kind of look alike.

One thing about being a psychiatrist is that most of us believe that what we do, or hope to do, relieves suffering. We believe that the treatments psychiatry has to offer make people better and relieve their psychic torment. Sometimes they work, sometimes they don't, and sometimes "the remedy is worse than the disease" (--Francis Bacon).

In medicine, the patient's history begins with the "chief complaint." As doctors, we often view our job as being to address that complaint: hopefully to make it go away. Often it is an ache or a pain, physical or mental. And yet, our society clearly values Growth through suffering. What doesn't kill us makes us stronger. When we take away the torment, do we stifle the soul?

I'll Show You

Working with violent patients has its challenges. The main one is when they actually do become violent. When they act up, smash things or assault someone there is a quick need to coordinate interventions between security and mental health staff. Of course, safety is the primary goal. Nothing therapeutic can happen until the patient regains control of himself, or someone else gets him under control.

After that, we get him. Violence is actually pretty rare in my facility---a credit to the quality of the correctional staff---but occasionally it does happen.

The only reason I'm writing a blog post about it is because the management of violent patients gets tricky when you're the one they're violent toward. It can be a challenge to continue working with a patient who has threatened you or, god forbid, actually committed violence against you. I've never been decked by a prisoner but I know colleagues who have been. Bless them, they came back to work the next day too.

The question is, what happens next? I don't have the option of firing a patient from my practice and the patient doesn't have the option of switching physicians. For better or worse, we're stuck with each other.

I've put together some general principles about how to manage this situation. Here they are:

1. Safety first

This is obvious, but I'll say it and get it out of the way. Make sure he's cuffed, in leg irons and a waist chain. Custody may forget this in between appointments, so remind them to cuff him the next time he comes down. Have an officer standing outside the office door. If for some wierd reason you don't want him cuffed, have someone sitting in the room with you during the appointment. Bodies count, and it can't hurt to have someone to call for backup if you don't have a security alarm in your office. Confidentiality? Doesn't count here. In cases of imminent dangerousness, there is no confidentiality.

2. Be upfront

Don't pretend that there is a therapeutic rapport when there isn't one. Bring the issue out into the open by saying out loud what the patient is thinking: "You're probably not too happy about seeing me again but we both know you need treatment." It's also OK for you to acknowledge, out loud, that you're going to have a hard time treating someone who threatens you or hurts you.

3. Use timeouts

You and the patient both may need to take timeouts. If the patient starts to get angry, call attention to it and give him a chance to pull himself together. He may not realize how he's coming across. If he continues to escalate, terminate the appointment. In the parlance of the medical progress note, the phrase "appointment terminated for safety reasons" is another way of saying "I let the guy go back to his cell because he was about to swing on me". If you do this, make sure the patient knows you will continue trying to see him and treat him. He may want to run from you, but you can't abandon him. Sometimes that is enough to impress the patient that you're committed to helping and may engage him in treatment.

You need to take a break too if you find yourself getting angry in return. You need to be impartial and calm in order to give the inmate a fair and thorough clinical evaluation.

4. Remember noise is just noise

An angry prisoner will be loud. He might swear. He will complain (a lot). That's all OK. Let it happen, knowing that eventually he will run out of energy. As long as he's not moving toward you or throwing things or physically out of control, it's OK. Don't be intimidated by noise. When he does calm down, quietly ask permission to make a treatment recommendation. There's a chance he might listen once he's had a chance to vent and be listened to.

5. Work on awareness

Like I said before, in all likelihood the inmate is not going to have any awareness of how he's coming across either in volume or in the intimidation factor. When custody starts peeking in the office to make sure everything is alright, you can carefully point this out to the patient and explain that people are concerned because of how he's behaving. That might be enough to trigger insight.

So that's what I do, for what it's worth. Sometimes it helps, sometimes it doesn't. But at least it's worth a try.

Shrink Rap: Grand Rounds is up at Health Business Blog!

Check out this week's Grand Rounds by David Williams at Health Business Blog.

Interesting topics include PTSD of being ill, Twitter discussion about remembering doc's instructions, and EMTALA and ER visits.

Serotonin du Jour

Scicurious writes in the Neurotopia blog everything you wanted to know about serotonin (*but were too anxious to ask).

This is a very well-done post on this topic. Go there. Read it. Tattoo optional.

"Serotonin is a pretty wild molecule for many reasons. First of all, it is formed form the amino acid L-tryptophan, which is one of the 20 standard amino acids required for life as we know it. Interestingly, tryptophan is also one of the few "essential" amino acids for humans, meaning that we don't make it ourselves, and have to get it from the diet. But don't worry, you've usually got plenty. The only way anyone could really suffer "tryptophan depletion" is if you're in a lab and they give you tons of other amino acids, or if you're starving. And if you're starving, you've obviously got bigger problems.

To make serotonin, start out with some L-tryptophan. This gets broken down in cells by an enzyme known as tryptophan hydroxylase to 5-hydroxytryptophan, this then gets broken down using the enzyme amino acid decarboxylase to 5-hydroxytryptamine, or 5-HT. Then the 5-HT is ready to be stored in vesicles in preparation for..."

Go to Neurotopia for more.

You Didn't Even Ask?

Okay, I'm going to ramble (I know it, even before I've started) and I don't quite know where I'm going with this. Please notify me if I get there.

There's an assumption in medicine that the responsibility for pulling out the truth rests with the doctor. Really? I don't know, and I've never seen it stated as such. It feels like it's there, though, in insidious ways that leave us with the sense that if we don't ask the right questions, don't elicit the right information, that the fault (and, yes, I think I mean fault), and the liability, is with the physician.

Let me explain a little better: a patient commits/attempts suicide...people (which people? I don't know: People! Perhaps everyone. Lawyers, supervisors, family members, other physicians) will ask: Did the psychiatrist ask if he was having suicidal thoughts? A plan or intent? In the two clinics where I work, there is a check-off box on the doctor's progress notes regarding Suicidal Ideation. It's a good jog to the memory to remind us always to ask, but it's also intrusive. It must be checked off and the doctor doesn't have the space to decide it's inappropriate to ask that particular question on that particular day. Some might say it's always appropriate to ask about suicidal ideation, but when I'm seeing a patient whom I've known for years, who has never been suicidal, who tells me they are doing well, feeling fine, well, it sometimes feels a little weird for me to ask, "Are you having any thoughts about hurting yourself?" Them's the regs.

But it's not just suicide, or homicide, or any form of violence. It's other things as well. Roy mentions in his Xanax post that the doctor needs to ASK the patient about a history of substance abuse to find out. Oh, but patients can lie, or forget, and doesn't everyone know Xanax is addictive? Shouldn't a patient with a history of addiction volunteer this information to any doctor who may prescribe an addictive drug that will re-activate a past problem?

It's not mental health issues, it's all of medicine, though certainly, each specialist feels an obligation to attend to his organ system. Do internists second-guess themselves if someone walks out and has a heart attack: "Oops, I forgot to ask if he was having chest pain." Do they check their notes and hope they've documented an appropriate assessment for cardiovascular disease?

So what's my point? It's certainly not that we shouldn't ask questions. We should. And there are issues that might not be obvious to the patient, things they might have forgotten or may not know are relevant-- like asking about a past history of mania/hypomania before prescribing an anti-depressant. But, I think, at some level, we've taken on the burden of blaming ourselves (or our colleagues) if something goes wrong and the doc didn't ask. Maybe it's a fallout from the malpractice era: in terms of a lawsuit, it's probably not good form to have a bad outcome about something one didn't ask about. There is also that sense that if you asked, and the patient said No, then how could we know otherwise? It's not that we don't feel sad about a bad outcome, but if there's the sense that all that could have been done was done, at least there's not that feeling of responsibility.

Sometimes, though, it doesn't just feel like a moment of omission, it feels (to me, at least) as though we blame ourselves and each other for a bad outcome if we didn't ask the right question, as though it's our fault, like we've caused something bad to happen, or at the very least, failed to prevent it. We blame ourselves, we finger-point at our colleagues.

I told you I was going to ramble. Well, what do you think?

Up, Up and Away?

This is another one of my hypothetical questions.

So you're a health care professional (if you're not, pretend) and you're on vacation far, far away. But before you left, you arranged for someone to cover your practice and you gave the covering doc an emergency number. Why? Why not.

You're getting some much needed rest and relaxation-- you've left work behind and it feels so good not to worry about other people. But back home, something bad has happened to one of your patients-- if you're a primary care doc, perhaps someone had an unexpected and fatal heart attack. If you're a shrink, may be a patient committed suicide. Whatever it is, it's awful, and it's done: there's nothing you can do now that would change the outcome.

Do you want to know before you return home? And if you're the covering doc, Do you call? After all, you were given that Emergency Number.

I've never fully come to peace with this one: many years ago, I got a call on vacation that one of my patients had died in a car accident. It haunted me and there was nothing I could do-- I called the mom from my trip, but I had no relationship with the parent, my call seemed to offer no comfort. After that, I went for a time leaving my cell phone home and being inaccessible while away; this is what coverage is for. At some point, I started to realize that I'd return and get anxious as I turned the phone back on: what bad news would I hear? Might it be better to have the phone with me, to keep it mostly off, but to know that no news is good news?

Paxil, anyone?

I ran a poll, not long ago, after reading Peter Kramer's blog post on the relative efficacy of the different SSRI's. Here's what we found:

Which SSRI is the most Effective?

Prozac 15% (22 votes)
Zoloft 14% (21 votes)
Luvox 0% (0 votes)

Paxil 5% (8 votes)
Celexa 7% (10 votes)

Lexapro 19% (28 votes)

Cymbalta (SNRI) 13% (20 votes)

Effexor (SNRI) 18% (27 votes)
Wellbutrin (neither, but it's here anyway) 9% (14 votes)

Total Votes: 150

Which Medicine Causes the Most Side Effects

Prozac 13% (17 votes)
Zoloft 7% (10 votes)
Luvox 5% (7 votes)
Paxil 31% (41 votes)
Celexa 1% (1 votes)

Lexapro 4% (6 votes)
Cymbalta 7% (10 votes)
Effexor 25% (33 votes)

Wellbutrin 7% (9 votes)

Total Votes: 134

Okay, so let's start by talking about how this 'poll' is meaningless. We don't know who took it-- patients, docs, random plumbers surfing through. We don't know what experience these people have had with antidepressants-- so the question has different meaning if it's asked to a doc who has only ever prescribed Prozac and Zoloft, then if it's asked to a patient who has been on a long trial of every medication. There's no real head-to-head here, no measures of efficacy, no controls. And I didn't even specify what the efficacy was for: Depression? Anxiety? OCD? Panic? Halitosis? Slipping behind your ear to hold your glasses in place?

Still, we had a clear loser, and I was surprised: Paxil. Few people voted for it's efficacy, many for it's side effects.

I don't start people on Paxil so much anymore: the lore is that it causes more weight gain then the others, and when I do prescribe it, I tell people to get weighed. It may cause weight gain, as an overall risk to populations, but all I care about is if it causes weight gain to my particular patient, and clearly, some people do not gain weight on it. The more concerning thing about Paxil has been the withdrawal syndrome that some people experience and so far I've found that it's manageable, especially if people come off very slowly. Still, all things being equal, these days I may start with something else.

So why was I surprised: I guess I haven't heard a lot of patients complain about side effects, and I have patients who've been on this medicine for some time. It seems to work particularly well, at least that's my impression, for Anxiety, and it seems to be well tolerated, the 'polls' would say otherwise. And for the uninsured, the generic is on Walmart's $4 list (as is Celexa).
Just my thoughts.

And to those who've read yesterday's post about does Facebook wreck your brain: If you read either the original article or the comments to our post, you'll note that the original piece is simply theories that all this computer time may re-wire people; there were no studies, no proof. And as some of our readers pointed out, On-line interactions may well be a segway into the world of Real Life encounters for people who might otherwise hesitate. I often wonder if my college experience would have been broadened by the world of the internet---

Does Facebook Destroy Your Brain?

I have a Facebook page, I even have "friends" (even Fat Doctor!!), but I haven't really figured out what to do with it, so it doesn't eat my time. Something to check here and there. Roy has a Facebook page, but alas, few friends, and he's too busy twittering for it to really matter. ClinkShrink stays out of the fray, but I do write on her sister's wall here and there.

With the kids, it's another story. It consumes their worlds. Even my patients talk in terms of Facebook. Who's befriended you, who's UNfriended you, who's in a relationship with who, it's all there. I stuck my head in a video my own kid was making, only to run into some teens in the grocery store the next day and have them say, "I saw you on Facebook!"

So is this a good thing? (How could it be?).

From today's Mail Online, David Derbyshire writes "Social Websites Harm Children's Brains." I've clipped some parts of the article below:

Baroness Greenfield, an Oxford University neuroscientist and director of the Royal Institution, believes repeated exposure could effectively 'rewire' the brain.

Experts are concerned children's online social interactions can 'rewire' the brain....

'My fear is that these technologies are infantilising the brain into the state of small children who are attracted by buzzing noises and bright lights, who have a small attention span and who live for the moment.'....

Psychologists have also argued that digital technology is changing the way we think. They point out that students no longer need to plan essays before starting to write - thanks to word processors they can edit as they go along. Satellite navigation systems have negated the need to decipher maps....

Educational psychologist Jane Healy believes children should be kept away from computer games until they are seven. Most games only trigger the 'flight or fight' region of the brain, rather than the vital areas responsible for reasoning.

Usually we think of computer games as being harmful in terms of exposure to violence, or in that they suck time away from important parts of life: contact with other people, exposure to new and interesting things. We don't usually think of these things in terms of the brain Hardwiring.

Shrink Rap: Grand Rounds is up at TBTAM

Shrinky links include: couples therapy for anorexia; working memory training; and how to apologize. 

Check out this week's Medical Grand Rounds on The Blog That Ate Manhattan.

Go to iTunes U and Become a Psychiatrist

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

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

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

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

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

So, that was the first thread.  

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

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

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

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

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

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

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