Friday, January 13, 2012
Male-Female Attraction: The Thunderbolt and others
This is only a test of the e-mail sending system of my blog.
Thursday, January 12, 2012
Anger Part III----Anger: One Cause of "Acting-Out"
There are probably other causes of acting-out, and certainly there are other self-destructive manifestations of anger, but the following comments are derived from my tutoring of and therefore also life-coaching schoolboys from the 7th, 8th, 9th and 10th grades. In most cases, their acting-out in school was first officially commented on in or near the 4th grade, when they were 10 years old; i.e. still pre-pubertal. They were generally given a diagnosis of ADD/ADHD, and referred to a psychologist for behavior modification and to a psychiatrist for medication, usually a CNS stimulant such as Ritalin or Adderall. They also usually developed insomnia at about the same time.
Their parents referred the boys to me because they knew that I had been a professor of physics, and that I also used to teach in the science honors program given for bright junior high school and high school students Saturday mornings at Columbia University. I was nominally supposed to tutor them in math and science, but of course it evolved into life-coaching since their societal attitudes had to be adjusted by the students themselves, with some input from me. Remember that all of these boys had gone through nursery school in Bergen County, where they had learned to color within the lines, line up, be polite, follow orders, ask for permission, sit in their seats unless given permission to leave, etc. They also were in private school K-8 or 9-12, and the private school would never allow a boy who was obviously acting out in the interview, etc, to be admitted, so we know that they knew how to "behave"; it was just a matter of what they felt like doing in school and why. By the 7th grade it was obvious to everyone that the students were performing way below their abilities, as evidenced by the downward deviation from their previous scholastic levels, and I was asked to tutor/educate/motivate them. They were still being followed by psychiatrists or other therapists.
One common manifestation of their anger/acting-out was their handing in homework late, or incomplete, or not at all. The usual cognitive tricks such as asking the student to place the finished homework by the front door, or giving the parents a copy of the homework assignment never worked, because like the act of doing the homework itself, it required the active cooperation of the student. You know you can't make a two-year-old eat spinach if he is unalterably opposed to it and you also can't push on a rope. Either analogy will do. I had to help the students to understand that this negative behavior, although it made them feel better by "rebelling" only hurt them because they would be labeled as unreliable and undependable.
Another manifestation was that of doing poorly in tests, either by running out of time and not finishing the test, or leaving questions blank and unanswered. Like underperforming their homework assignments, they felt that they had demonstrated something by their actions. Again, I had to point out that all the teacher would note was (a) poor test results and (b) underperforming, and that this "rebellion" served little purpose since no one would understand or applaud their martyrdom.
All of these actions are, of course, examples of passive aggression, taken to the extreme. They all affected "la belle indifference" as a response to all the negative comments about their actions, as though they were above it all, and that it all was of little consequence in the long run and could not possibly affect their lives as grownups. The problem could not be solved by addressing their anger directly, because the anger was disconnected from their self-picture of reality.
Each student had to be convinced that the world at large didn't care if he was angry or unhappy, but was only interested in the results of his actions. They had to understand that actions or lack thereof did have consequences, and if a teacher labeled them as "unreliable", it would make their future lives quite difficult. They finally understood that their first recommendations come from their high school teachers, and that in these days of electronic records, once a comment was entered about their behavior or performance, be it good or bad, it would follow them for the rest of their lives, sort of like a scholastic Facebook.
I have come to the conclusion that parents have to explain to their pre-adolescents that actions and society's opinions of their actions do have long-term consequences. Yelling at the boys to do their homework or make their beds or pick up after themselves usually has little effect. Boys seem to enjoy whatever rebellion against society they can get away with , especially if it also draws attention to themselves. Of course now with cellphones, the boys all talk with each other and give each other advice as to how to "handle" their parents or school. It's not as serious as the website that teaches anorectic girls how to hide their anorexia, but there is always a subculture and a background current of which parents are (blissfully?) unaware.
Their parents referred the boys to me because they knew that I had been a professor of physics, and that I also used to teach in the science honors program given for bright junior high school and high school students Saturday mornings at Columbia University. I was nominally supposed to tutor them in math and science, but of course it evolved into life-coaching since their societal attitudes had to be adjusted by the students themselves, with some input from me. Remember that all of these boys had gone through nursery school in Bergen County, where they had learned to color within the lines, line up, be polite, follow orders, ask for permission, sit in their seats unless given permission to leave, etc. They also were in private school K-8 or 9-12, and the private school would never allow a boy who was obviously acting out in the interview, etc, to be admitted, so we know that they knew how to "behave"; it was just a matter of what they felt like doing in school and why. By the 7th grade it was obvious to everyone that the students were performing way below their abilities, as evidenced by the downward deviation from their previous scholastic levels, and I was asked to tutor/educate/motivate them. They were still being followed by psychiatrists or other therapists.
One common manifestation of their anger/acting-out was their handing in homework late, or incomplete, or not at all. The usual cognitive tricks such as asking the student to place the finished homework by the front door, or giving the parents a copy of the homework assignment never worked, because like the act of doing the homework itself, it required the active cooperation of the student. You know you can't make a two-year-old eat spinach if he is unalterably opposed to it and you also can't push on a rope. Either analogy will do. I had to help the students to understand that this negative behavior, although it made them feel better by "rebelling" only hurt them because they would be labeled as unreliable and undependable.
Another manifestation was that of doing poorly in tests, either by running out of time and not finishing the test, or leaving questions blank and unanswered. Like underperforming their homework assignments, they felt that they had demonstrated something by their actions. Again, I had to point out that all the teacher would note was (a) poor test results and (b) underperforming, and that this "rebellion" served little purpose since no one would understand or applaud their martyrdom.
All of these actions are, of course, examples of passive aggression, taken to the extreme. They all affected "la belle indifference" as a response to all the negative comments about their actions, as though they were above it all, and that it all was of little consequence in the long run and could not possibly affect their lives as grownups. The problem could not be solved by addressing their anger directly, because the anger was disconnected from their self-picture of reality.
Each student had to be convinced that the world at large didn't care if he was angry or unhappy, but was only interested in the results of his actions. They had to understand that actions or lack thereof did have consequences, and if a teacher labeled them as "unreliable", it would make their future lives quite difficult. They finally understood that their first recommendations come from their high school teachers, and that in these days of electronic records, once a comment was entered about their behavior or performance, be it good or bad, it would follow them for the rest of their lives, sort of like a scholastic Facebook.
I have come to the conclusion that parents have to explain to their pre-adolescents that actions and society's opinions of their actions do have long-term consequences. Yelling at the boys to do their homework or make their beds or pick up after themselves usually has little effect. Boys seem to enjoy whatever rebellion against society they can get away with , especially if it also draws attention to themselves. Of course now with cellphones, the boys all talk with each other and give each other advice as to how to "handle" their parents or school. It's not as serious as the website that teaches anorectic girls how to hide their anorexia, but there is always a subculture and a background current of which parents are (blissfully?) unaware.
Saturday, December 31, 2011
Dangers of taking Prednisone (Anti-inflammatory Steroid)
Prednisone and other anti-inflammatory steroids (not to be confused with testosterone and the other anabolic steroids that athletes use) have an indicated medical use. Prednisone suppresses the immune reaction of the body, and is used when the immune reaction causes the immune system to attack healthy cells and organs. So it is used, for instance, in asthma, multiple sclerosis, poison ivy, polymyalgia rheumatica, swollen nerves, rheumatoid arthritis, systemic lupus, and a host of other diseases.
However, just as aspirin goes throughout the body to suppress the formation of prostaglandins everywhere, anti-inflammatory steroids also go everywhere throughout the body to suppress the immune reaction in every organ, beginning with inhibiting the diapedesis of white blood cells through capillary walls to attack infected tissues and the reduction of immune surveillance of any fungi or other chronic infection that the body's immune system is keeping in check. It is of vital importance to be aware of the multiple possible effects of steroids and to protect the patient against these putative negative effects. Otherwise, like Eleanor Roosevelt, the careless overuse of steroids can cause death from overwhelming tuberculosis and adrenal failure.
I am therefore going to list some ordinary precautions that a physician should take before prescribing anti-inflammatory steroids for his/her patient. This list is neither exhaustive nor all-inclusive, but merely covers the fundamentals of good medical care. I firmly believe that doctors can do untold good or harm by the proper use or improper misuse of prescription drugs, which is why I have always read as much as I could about pharmacology and I subscribe to the FDA drug-warning e-mail emergency list.
Many patients have been infected with tuberculosis (TB) without being aware of it. If you have a robust immune system, you generally can confine live TB germs to your lungs. But if you take enough prednisone for enough days, then the body's immune surveillance of the live TB germs in your body is suppressed, the TB germs multiply, and they can spread throughout your body and kill you. This occurrence has been well documented. Therefore, BEFORE your doctor starts you on an oral steroid, he/she should skin test you for TB, and treat you with isoniazid (INH) if your skin test is positive for as long as you are taking the steroid. (The precise dose and length of treatment with INH should be discussed with a pulmonary or infectious disease specialist).
And having received BCG vaccine against TB does not mean that a positive PPD (TB skin test) can be ignored.
Second, there is a rather common intestinal parasite called strongyloides stercoralis. This nematode inhabits and is fastened to your distal colon, and its reproduction and spreading is also kept in check by your immune system. When the first kidney transplant patients were immunosuppressed, a number of them died from overwhelming strongyloides auto-infection. Therefore before your doctor starts you on oral or IV steroids, you should have a stool exam for evidence of intestinal parasites, especially strongyloides. Again, like ignoring a possible TB infection, omission can prove fatal.
Third, and in the same vein, steroids also attack the part of the immune system that keeps live viruses under active suppressive surveillance. So if you have received a live virus vaccine (mumps, rubella, oral polio, yellow fever) or have a herpes infection in your eye, the prednisone should be deferred until one month after the vaccine or until the eye infection has been cleared. On theoretical grounds, you should also probably defer any steroid treatment if you have a bacterial abscess, such as acute diverticulitis.
I should mention here that your body's natural production of prednisone is approximately 7.5 mg/day, with a diurnal variation, so the peak levels are in the morning. The secretion of prednisone is controlled by a feedback loop to your pituitary gland, which secretes ACTH to stimulate the production and secretion of prednisone by cells in your adrenal gland. If you take enough prednisone for a long enough period of time (and this amount and time should be determined by testing by an endocrinoligist), then the pituitary gland gets so suppressed that when you stop taking the exogenous steroid, the pituitary gland has lost its ability to manufacture ACTH, so the first time your body is stressed by an infection, your adrenal gland will be unable to make "stress doses" of prednisone and you will die in adrenal crisis.
Now, for completeness, let me list some of the documented conditions that the chronic use of steroids can create in your body, which, while damaging, are rarely fatal, although they can be permanent:
high blood pressure
congestive heart failure
salt and water retention
bleeding stomach ulcer
insulin-dependent diabetes
seizures
mania
insomnia
ocular cataracts
insatiable appetite
osteoporosis
clotting problems
myopathy
tendon rupture
pseudotumor cerebri
glaucoma
pancreatitis
Needless to say, not all of these side effects happen to all users of steroids, but it is probably prudent to start any patient, male or female, on a drug such as Fosamax that can prevent osteoporosis when steroids arfe started, so long as there is no concomitant esophagitis or gastritis.
But of course, if the steroid treatment is necessary for your continued good health, such as reversal of an asthmatic attack, treatment of kidney failure caused by lupus, certain bullous dermatoses, then the above risks should not stop you from taking the medicine.
However, just as aspirin goes throughout the body to suppress the formation of prostaglandins everywhere, anti-inflammatory steroids also go everywhere throughout the body to suppress the immune reaction in every organ, beginning with inhibiting the diapedesis of white blood cells through capillary walls to attack infected tissues and the reduction of immune surveillance of any fungi or other chronic infection that the body's immune system is keeping in check. It is of vital importance to be aware of the multiple possible effects of steroids and to protect the patient against these putative negative effects. Otherwise, like Eleanor Roosevelt, the careless overuse of steroids can cause death from overwhelming tuberculosis and adrenal failure.
I am therefore going to list some ordinary precautions that a physician should take before prescribing anti-inflammatory steroids for his/her patient. This list is neither exhaustive nor all-inclusive, but merely covers the fundamentals of good medical care. I firmly believe that doctors can do untold good or harm by the proper use or improper misuse of prescription drugs, which is why I have always read as much as I could about pharmacology and I subscribe to the FDA drug-warning e-mail emergency list.
Many patients have been infected with tuberculosis (TB) without being aware of it. If you have a robust immune system, you generally can confine live TB germs to your lungs. But if you take enough prednisone for enough days, then the body's immune surveillance of the live TB germs in your body is suppressed, the TB germs multiply, and they can spread throughout your body and kill you. This occurrence has been well documented. Therefore, BEFORE your doctor starts you on an oral steroid, he/she should skin test you for TB, and treat you with isoniazid (INH) if your skin test is positive for as long as you are taking the steroid. (The precise dose and length of treatment with INH should be discussed with a pulmonary or infectious disease specialist).
And having received BCG vaccine against TB does not mean that a positive PPD (TB skin test) can be ignored.
Second, there is a rather common intestinal parasite called strongyloides stercoralis. This nematode inhabits and is fastened to your distal colon, and its reproduction and spreading is also kept in check by your immune system. When the first kidney transplant patients were immunosuppressed, a number of them died from overwhelming strongyloides auto-infection. Therefore before your doctor starts you on oral or IV steroids, you should have a stool exam for evidence of intestinal parasites, especially strongyloides. Again, like ignoring a possible TB infection, omission can prove fatal.
Third, and in the same vein, steroids also attack the part of the immune system that keeps live viruses under active suppressive surveillance. So if you have received a live virus vaccine (mumps, rubella, oral polio, yellow fever) or have a herpes infection in your eye, the prednisone should be deferred until one month after the vaccine or until the eye infection has been cleared. On theoretical grounds, you should also probably defer any steroid treatment if you have a bacterial abscess, such as acute diverticulitis.
I should mention here that your body's natural production of prednisone is approximately 7.5 mg/day, with a diurnal variation, so the peak levels are in the morning. The secretion of prednisone is controlled by a feedback loop to your pituitary gland, which secretes ACTH to stimulate the production and secretion of prednisone by cells in your adrenal gland. If you take enough prednisone for a long enough period of time (and this amount and time should be determined by testing by an endocrinoligist), then the pituitary gland gets so suppressed that when you stop taking the exogenous steroid, the pituitary gland has lost its ability to manufacture ACTH, so the first time your body is stressed by an infection, your adrenal gland will be unable to make "stress doses" of prednisone and you will die in adrenal crisis.
Now, for completeness, let me list some of the documented conditions that the chronic use of steroids can create in your body, which, while damaging, are rarely fatal, although they can be permanent:
high blood pressure
congestive heart failure
salt and water retention
bleeding stomach ulcer
insulin-dependent diabetes
seizures
mania
insomnia
ocular cataracts
insatiable appetite
osteoporosis
clotting problems
myopathy
tendon rupture
pseudotumor cerebri
glaucoma
pancreatitis
Needless to say, not all of these side effects happen to all users of steroids, but it is probably prudent to start any patient, male or female, on a drug such as Fosamax that can prevent osteoporosis when steroids arfe started, so long as there is no concomitant esophagitis or gastritis.
But of course, if the steroid treatment is necessary for your continued good health, such as reversal of an asthmatic attack, treatment of kidney failure caused by lupus, certain bullous dermatoses, then the above risks should not stop you from taking the medicine.
Wednesday, December 28, 2011
Anger Part II--Anger grows out of Frustration
Anger seems to be amplified frustration, so the questions are (a) what makes us frustrated, and (b) what amplifies it? It seems that frustration is created by the loss of an object, either property or a person, either a real loss or a fancied or predicted/feared-for loss. We get frustrated and angry in a traffic jam because we are deprived of freedom of movement. We even honk at the "slowpoke" driving in front of us because we are frustrated at our inability to drive faster. Righteous anger is a special category because then we justify our anger by saying that it is directed at a sinner or a breaker of society's laws or mores who therefore deserves both scorn and anger, which may be amplified by our own frustration and anger at never having participated in "sex, drugs, and rock and roll" as the hippies of the '60s did.
It seems that frustration is caused by loss plus the inability to do anything about the loss. (It is notable that in classical psychodynamic theory depression is also caused by a loss. Could the strictures of society then explain why more women than men get depressed, and more men than women get homicidal with rage?) This immediately harkens back to a baby's instant anger when deprived of his/her rattle. Society may have taught us how to channel and not act on the rage we feel from being frustrated, but we have never learned how not to feel frustrated. Giving trophies to all the members of all the little league teams' players rather than just to the winners does not prevent adult feelings of frustration in later life; it just makes the sensation rarer and therefore more difficult to deal with.
So unlike what all mental health practitioners tell us, it is the reaction and negative feeling of frustration that is inborn, and not anger. We must therefore ask what tools our family and society has given us to help us prevent our frustration from exploding into anger, and why, under certain circumstances, our feelings of frustration are relieved by exploding into anger. Of course society accepts our getting furious at ourselves if we drop and break something---we are instantly angry at our loss, and everyone empathizes with us. In a somewhat similar way society understands our getting angry when our favorite team loses, although what it is about the loss that led to our frustration is less clear since in that case nothing tangible was taken from us.
Therefore the thrust of anger management courses should be to teach us how to prevent frustration from escalating into anger, rather than assuming we will get angry and then teaching us how to control it. You should't deal with an alcoholic by teaching him/her how to behave when drunk. By the time we get angry we are already near a dangerous flash point. And it is much more common than we think----boredom, for instance is low-level anger. We are frustrated that we are wasting our time doing whatever it is that is boring us, and then angry at ourselves or others for our not getting up and doing something else. We know deep down that the only thing we have to spend that is uniquely ours is our time, and the time we spend doing something we do not want to do (schoolwork, housework, visiting with inlaws) generates resentment, frustration and eventually anger.
The surest recipe for frustration-amplification-anger is the knowledge that the loss cannot be reversed, thereby adding a feeling of impotence to our frustration. It is all well and good for Omar Khayyam to have written "The moving finger writes.......", but the reality of the irreversibility of time can be a very bitter pill to swallow. Thus when a loved one commits suicide, we become angry because (a) the loved one left us without warning us or seeking permission and (b) it is totally irreversible. Similarly, in a divorce, the children tend to be angriest at the spouse who leaves, no matter what the justification, since it is the act of leaving that certifies the divorce-to-be. In the same vein, when one of a divorced couple gets married, the other spouse and children often get angry all over again because a re-marriage demonstrates to one and all that the marriage is really over.
It seems that frustration is caused by loss plus the inability to do anything about the loss. (It is notable that in classical psychodynamic theory depression is also caused by a loss. Could the strictures of society then explain why more women than men get depressed, and more men than women get homicidal with rage?) This immediately harkens back to a baby's instant anger when deprived of his/her rattle. Society may have taught us how to channel and not act on the rage we feel from being frustrated, but we have never learned how not to feel frustrated. Giving trophies to all the members of all the little league teams' players rather than just to the winners does not prevent adult feelings of frustration in later life; it just makes the sensation rarer and therefore more difficult to deal with.
So unlike what all mental health practitioners tell us, it is the reaction and negative feeling of frustration that is inborn, and not anger. We must therefore ask what tools our family and society has given us to help us prevent our frustration from exploding into anger, and why, under certain circumstances, our feelings of frustration are relieved by exploding into anger. Of course society accepts our getting furious at ourselves if we drop and break something---we are instantly angry at our loss, and everyone empathizes with us. In a somewhat similar way society understands our getting angry when our favorite team loses, although what it is about the loss that led to our frustration is less clear since in that case nothing tangible was taken from us.
Therefore the thrust of anger management courses should be to teach us how to prevent frustration from escalating into anger, rather than assuming we will get angry and then teaching us how to control it. You should't deal with an alcoholic by teaching him/her how to behave when drunk. By the time we get angry we are already near a dangerous flash point. And it is much more common than we think----boredom, for instance is low-level anger. We are frustrated that we are wasting our time doing whatever it is that is boring us, and then angry at ourselves or others for our not getting up and doing something else. We know deep down that the only thing we have to spend that is uniquely ours is our time, and the time we spend doing something we do not want to do (schoolwork, housework, visiting with inlaws) generates resentment, frustration and eventually anger.
The surest recipe for frustration-amplification-anger is the knowledge that the loss cannot be reversed, thereby adding a feeling of impotence to our frustration. It is all well and good for Omar Khayyam to have written "The moving finger writes.......", but the reality of the irreversibility of time can be a very bitter pill to swallow. Thus when a loved one commits suicide, we become angry because (a) the loved one left us without warning us or seeking permission and (b) it is totally irreversible. Similarly, in a divorce, the children tend to be angriest at the spouse who leaves, no matter what the justification, since it is the act of leaving that certifies the divorce-to-be. In the same vein, when one of a divorced couple gets married, the other spouse and children often get angry all over again because a re-marriage demonstrates to one and all that the marriage is really over.
Monday, December 26, 2011
Anger Part I
I decided to write a blog about anger, because it is a condition for which there is no reliable drug treatment and which is also not classified as a psychiatric disease. There are anger management courses offered, but a recent article in a German newspaper reported that the leader of an anger management course stabbed one of the attendees three times. Even Freud did not write a monograph on the psychiatric cause(s) of anger, probably because it is such a primary response that its origin is inborn. He did talk about eros and thanatos, which can be thought of (very loosely) as the need for love and the death wish, and treated them as innate,, because he could find no convincing explanation for the existence of war, let alone torture. It clearly must have something to do with thinking, because man is the only animal who tortures, one of the few animals who kills his own kind, and the only animal that commits suicide.
All babies have an inborn need for love and for human contact, and have the capacity for immediate anger which is usually shown by yelling and getting red in the face. When very young, they usually can be soothed at once by nursing at the mother's breast. No one yet understands what makes a baby colicky, and a noted female pediatric psychiatrist wrote an article about how when her baby became colicky she was almost driven crazy, even though she knew full well that she had not caused the condition nor was there any successful way to treat it.
I would like to approach the problem of anger from a different viewpoint: Isn't it more difficult for a totally satisfied person to really get angry and lose his/her temper? When we are satisfied, anger is furthest from our mind because we are pre-occupied with the happiness of our state. Whether it is achieved by being in love, or being high on life or drugs or jogging or anything else that gets our mental endorphins flowing, there is no room for anger. No one knows what chemicals in the brain get increased or decreased when anger surges; we only know the chemical result which is an outpouring of adrenalin, etc.
By the same token, we do not understand what really triggers and escalates anger. It is obvious that it is usually displaced from the real object of our anger to a surrogate at whom it is emotionally safe or acceptable to display the anger. The trivial example is that your boss yells at you so when you get home you kick the dog. A more subtle displacement is the phenomenon of road rage, with or without gunshots. What is the real source of your anger that is discharged by "losing it" at the driver who cut you off on the freeway? What is the real source of anger when you yell at your spouse or children? Who or what are you angry at when you punch a hole in the wall? The question is what the other person's actions symbolize to you or threaten that is of vital concern to you, and whether or not the anger is generated by your frustration at being unable to address the cause of your anger directly. As an aside, what damage has been done to your psyche when your parents have suppressed your need for anger so completely that you "never get angry"?
All mental health workers agree that the emotion of anger is a normal and natural one and only becomes a problem when it escalates out of your control, driving you to an action that you would never have done in a "normal" state. That is, in a state of anger, actions that would normally be egodystonic to you become temporarily egosyntonic, as if you are temporarily not the person you recognize as yourself ( "Dr Jekyll, let me introduce you to Mr. Hyde".) And why are there people who walk around in a state of chronic anger?
We often feel ashamed or embarrassed after such actions when we "cool down", and vow never to let such a thing happen to us again, much as an alcoholic vows to stop drinking after his/her first blackout or arrest for drunken driving, or really severe hangover.
It is as though we become temporarily insane, in that we lose conscious rational control of our behavior. We rant and rave and yell and strike at people or things both emotionally and physically. Who doesn't recall, for instance, the TV picture of Paul O'Neill, the all-star right fielder of the New York Yankees, kicking the water cooler or slamming his hat or bat down in the dougout whenever he made out? Was that due to his nature or his nurturing or a combination of the two?
If anger is a state of temporary insanity, to use that word loosely, is it that we slip the bonds of "civilized" behavior, or is it that there is a parallel being inside of us who is irrational and can erupt by escaping our control under certain emotional stimuli? There is no good evidence for either explanation. And we certainly have no idea why certain thoughts or ideas or concepts infuriate certain people and make them "see red". Very often our anger response is greatly out of proportion to the triggering incident. This is a sure sign that what/who we vented our anger at is not the true focus of our anger.
To Be Continued.....
All babies have an inborn need for love and for human contact, and have the capacity for immediate anger which is usually shown by yelling and getting red in the face. When very young, they usually can be soothed at once by nursing at the mother's breast. No one yet understands what makes a baby colicky, and a noted female pediatric psychiatrist wrote an article about how when her baby became colicky she was almost driven crazy, even though she knew full well that she had not caused the condition nor was there any successful way to treat it.
I would like to approach the problem of anger from a different viewpoint: Isn't it more difficult for a totally satisfied person to really get angry and lose his/her temper? When we are satisfied, anger is furthest from our mind because we are pre-occupied with the happiness of our state. Whether it is achieved by being in love, or being high on life or drugs or jogging or anything else that gets our mental endorphins flowing, there is no room for anger. No one knows what chemicals in the brain get increased or decreased when anger surges; we only know the chemical result which is an outpouring of adrenalin, etc.
By the same token, we do not understand what really triggers and escalates anger. It is obvious that it is usually displaced from the real object of our anger to a surrogate at whom it is emotionally safe or acceptable to display the anger. The trivial example is that your boss yells at you so when you get home you kick the dog. A more subtle displacement is the phenomenon of road rage, with or without gunshots. What is the real source of your anger that is discharged by "losing it" at the driver who cut you off on the freeway? What is the real source of anger when you yell at your spouse or children? Who or what are you angry at when you punch a hole in the wall? The question is what the other person's actions symbolize to you or threaten that is of vital concern to you, and whether or not the anger is generated by your frustration at being unable to address the cause of your anger directly. As an aside, what damage has been done to your psyche when your parents have suppressed your need for anger so completely that you "never get angry"?
All mental health workers agree that the emotion of anger is a normal and natural one and only becomes a problem when it escalates out of your control, driving you to an action that you would never have done in a "normal" state. That is, in a state of anger, actions that would normally be egodystonic to you become temporarily egosyntonic, as if you are temporarily not the person you recognize as yourself ( "Dr Jekyll, let me introduce you to Mr. Hyde".) And why are there people who walk around in a state of chronic anger?
We often feel ashamed or embarrassed after such actions when we "cool down", and vow never to let such a thing happen to us again, much as an alcoholic vows to stop drinking after his/her first blackout or arrest for drunken driving, or really severe hangover.
It is as though we become temporarily insane, in that we lose conscious rational control of our behavior. We rant and rave and yell and strike at people or things both emotionally and physically. Who doesn't recall, for instance, the TV picture of Paul O'Neill, the all-star right fielder of the New York Yankees, kicking the water cooler or slamming his hat or bat down in the dougout whenever he made out? Was that due to his nature or his nurturing or a combination of the two?
If anger is a state of temporary insanity, to use that word loosely, is it that we slip the bonds of "civilized" behavior, or is it that there is a parallel being inside of us who is irrational and can erupt by escaping our control under certain emotional stimuli? There is no good evidence for either explanation. And we certainly have no idea why certain thoughts or ideas or concepts infuriate certain people and make them "see red". Very often our anger response is greatly out of proportion to the triggering incident. This is a sure sign that what/who we vented our anger at is not the true focus of our anger.
To Be Continued.....
Monday, November 14, 2011
Why There are and Will be Fewer and Fewer Primary Care Doctors
Of necessity, because "man is an economic animal" the different providers of medical care will have different opinions of any payment plan. Internists, psychiatrists, plastic surgeons, anesthesiologists, dermatologists, general surgeons, heart surgeons, orthopods, urologists, oncologists, interventional radiologists, just to name a few of the divisions of medical specialties. We should also add the question of solo or group practice (many fewer solo practitioners today), and practice as private entities or as employees of a hospital. The happiest doctors, of course, are the plastic surgeons and the dermatologists who do plastic dermatology (Botox injections, Restalen injections, etc.). They are not covered by any insurance plan, so they bill the patient directly, have no insurance forms to fill out, and they are free to charge whatever the traffic will bear.
The internist, who does no procedures (except for the occasional EKG) can only charge for his time, much as psychiatrists and pediatricians do. Medicare pays me three times as much for a rigid sigmoidoscope which takes only 5 minutes (and I could teach you to do in two days) than it does for a 15 minute office visit where a lot of diagnosis but no procedures are done. This is precisely why we are graduating fewer and fewer primary care physicians-----not only do they get paid less, but they also spend a lot of un-reimbursed time requesting permission for MRI's, or for a different drug, etc. Even if an internist drops out of all HMO's, Medicare and medical insurance plans, he/she will still be bombarded with requests to change brand name drugs to generics, or have to call up to find out why payment was refused for the drug he/she prescribed for the patient, or for the dosage.
Every month I am offered a chance to "increase your bottom line" by taking a weekend course in Botox injections and later, collagen injections. The Botox injections have to be repeated every 3 months, because otherwise the neuroparalysis wears off and the face sags, so you have an annuity from this patient of $300 to $500/every 3 months. I am also invited to take weekend courses to learn how to use a laser in my office to remove/reduce leg spider veius. Again, this makes a lot of money but does nothing to increase the amount or quality of primary care.
A colleague of mine was lecturing to a group of 100 new physicians, all under the age of 35 about the intricacies of electronic billing systems. He asked for a show of hands of those in primary care. NO ONE'S hand was raised. This is terrible. Of course, if you want to make money and have a life then you don't want a specialty with night and weekend call and telephone calls at home and (sometimes) uncontrollable hours. Today about 50% of medical students are female. Following the above guidelines, if they want to be able to schedule their time and also have the time and a clear head to raise a family, their favorite specialties are (and I am NOT being misogynistic, just reporting the facts):
1) Dermatology (Botox, Restalen injections, Moh's surgery, face peelings, etc.)
2) Psychiatry---definitely pick your own hours.
3) Anesthesiology---no calls at home, and you are usually home before 3PM so you can welcome your children home from school.
4) Radiology---again few if any emergencies, no calls at home, no Sunday hours
5) Pathology-----dead bodies and chemical tests will never call you after hours, very low malpractice premiums, almost no weekend hours, no night hours at all.
6) Emergency Room----can be exciting and challenging, but well-defined 8 or 12 hour shifts, and when you leave you leave with no worries and no one calls you back.
7) Allergist---almost no emergencies, charge for all office tests and injections, virtually no phone calls at night and only occasional Saturday AM office hours if you so desire.
8) Geneticist----just counsel parents and prospective parents about disease linkages and inheritance and penetrance probabilities, again few night calls and no emergencies or weekend hours.
9) Plastic Surgeon for beautification----again tons of money and few if any night calls or weekend hours.
There was a book published about one year ago by an author who followed Dr. Craig Smith, the Chief of Cardiac Surgery at Columbia-Presbyterian Medical Center around for six months, and described his days, his work, etc. (Dr. Smith operated on President Bill Clinton, among others.) At the end of the book the author stated that Dr. Smith grossed $2 million, but the top grossing dermatologist at CPMC grossed $3.5 million. We all see where the goose that lays the most golden eggs is, and it is most definitely not in the field of primary care. So unless you are totally in love with the field, the odds are you will not enter it. I might also add that I raised three children and put them through college on my income as a solo internist. I do not net enough today to do that, so I cannot in good faith advise medical students to go into primary care unless they are independently wealthy, and that is a shame and a pity.
The internist, who does no procedures (except for the occasional EKG) can only charge for his time, much as psychiatrists and pediatricians do. Medicare pays me three times as much for a rigid sigmoidoscope which takes only 5 minutes (and I could teach you to do in two days) than it does for a 15 minute office visit where a lot of diagnosis but no procedures are done. This is precisely why we are graduating fewer and fewer primary care physicians-----not only do they get paid less, but they also spend a lot of un-reimbursed time requesting permission for MRI's, or for a different drug, etc. Even if an internist drops out of all HMO's, Medicare and medical insurance plans, he/she will still be bombarded with requests to change brand name drugs to generics, or have to call up to find out why payment was refused for the drug he/she prescribed for the patient, or for the dosage.
Every month I am offered a chance to "increase your bottom line" by taking a weekend course in Botox injections and later, collagen injections. The Botox injections have to be repeated every 3 months, because otherwise the neuroparalysis wears off and the face sags, so you have an annuity from this patient of $300 to $500/every 3 months. I am also invited to take weekend courses to learn how to use a laser in my office to remove/reduce leg spider veius. Again, this makes a lot of money but does nothing to increase the amount or quality of primary care.
A colleague of mine was lecturing to a group of 100 new physicians, all under the age of 35 about the intricacies of electronic billing systems. He asked for a show of hands of those in primary care. NO ONE'S hand was raised. This is terrible. Of course, if you want to make money and have a life then you don't want a specialty with night and weekend call and telephone calls at home and (sometimes) uncontrollable hours. Today about 50% of medical students are female. Following the above guidelines, if they want to be able to schedule their time and also have the time and a clear head to raise a family, their favorite specialties are (and I am NOT being misogynistic, just reporting the facts):
1) Dermatology (Botox, Restalen injections, Moh's surgery, face peelings, etc.)
2) Psychiatry---definitely pick your own hours.
3) Anesthesiology---no calls at home, and you are usually home before 3PM so you can welcome your children home from school.
4) Radiology---again few if any emergencies, no calls at home, no Sunday hours
5) Pathology-----dead bodies and chemical tests will never call you after hours, very low malpractice premiums, almost no weekend hours, no night hours at all.
6) Emergency Room----can be exciting and challenging, but well-defined 8 or 12 hour shifts, and when you leave you leave with no worries and no one calls you back.
7) Allergist---almost no emergencies, charge for all office tests and injections, virtually no phone calls at night and only occasional Saturday AM office hours if you so desire.
8) Geneticist----just counsel parents and prospective parents about disease linkages and inheritance and penetrance probabilities, again few night calls and no emergencies or weekend hours.
9) Plastic Surgeon for beautification----again tons of money and few if any night calls or weekend hours.
There was a book published about one year ago by an author who followed Dr. Craig Smith, the Chief of Cardiac Surgery at Columbia-Presbyterian Medical Center around for six months, and described his days, his work, etc. (Dr. Smith operated on President Bill Clinton, among others.) At the end of the book the author stated that Dr. Smith grossed $2 million, but the top grossing dermatologist at CPMC grossed $3.5 million. We all see where the goose that lays the most golden eggs is, and it is most definitely not in the field of primary care. So unless you are totally in love with the field, the odds are you will not enter it. I might also add that I raised three children and put them through college on my income as a solo internist. I do not net enough today to do that, so I cannot in good faith advise medical students to go into primary care unless they are independently wealthy, and that is a shame and a pity.
Sunday, November 6, 2011
Why Evidence-Based Medicine and Government Guidelines are Impractical
There have been many articles written recently about how the application of the results of "evidence-based" medicine to patients will both save money and make them healthier. We are also bombarded with many guidelines from the government as well as from various national medical groups as to how to diagnose and/or treat various diseases. I will not discuss the obvious problem that arises when different medical groups produce opposing guidelines (viz. the AMA, American Urological Assn., American College of Physicians, National Public Health Service, American Cancer Society) as to the proper timing of or the utility of PSA testing, or mammograms, or colonoscopies, or-------.
One problem that the public does not appreciate is the impact these "suggestions" and "guidelines" have on the work time of physicians. Time is our least fungible resource. But every time you deviate (for good reason) from a recommended HMO or government guideline, you end up having to explain yourself in writing, either in the chart, or in response to a letter from an HMO or Medicare, and this takes up time. Also, sometimes it is necessary to deviate from the guidelines to shield you from a malpractice suit or to reduce your chances of losing one. The fact that a test you did not do was not indicated in the guidelines will not help you if a malpractice lawyer can convince a jury that application of the possible results of the test might have prevented permanent harm to your patient. And please remember that a doctor much prefers to avoid being sued than to be "right" and win the suit, because defending a suit takes time, energy, and time away from the office.
When we look at evidence-based results, the first question a doctor asks is if his/her current patient fits the characteristics of the study group as to age, sex, race, economic standard of living and geography. For instance a recent article published in the New England Journal of Medicine on the use of cytisine for smoking cessation did have an equal number of men and women, and married and unmarried. However, all the participants were white, lived in Europe, were between 40 and 60 years of age, and smoked between 10 and 30 cigarettes a day, and your patient is a 25 year old Mexican immigrant who smokes 40 cigarettes a day, and wants to stop smoking. You don't even know the proper dosing regimen because you don't have any data on how rapidly or slowly Mexicans clear cytisine from their blood compared to white Europeans.
A recent study in Lancet showed that treatment with Augmentin was "not inferior" to surgery for uncomplicated acute appendicitis. The study group was equally divided between men and women and covered ages 18 to 68. But all were white, all lived in Europe, no mention is made of marital status or use of cigarettes, or even the other medicines they were taking, no one was obese, and no mention is made of prior abdominal surgery.
Let us say you have a new patient with reflux esophagitis. There are very clear guidelines about treatment and the sequence of adding more drugs for control and which tests and procedures to do. (Although there is no mention of urecholine, probably because it has been generic for so long that no one even thinks about it.) But your patient is also on medicines for heart failure, diabetes, and hypertension, and no one in the GERD treatment group was on these medicines. So some of the GERD medicines may be absolutely contra-indicated in your patient, but it will take time to explain this. Some doctors just write in the office or hospital chart: "This patient refuses to take the following medicines and tests" if the doctor does not think that those particular medicines or tests are either not indicated or might be harmful. This saves him/her from having to answer many letters, and no one from the HMO is permitted to question the patient about this because to do so would violate HIPAA rules. I might also note that the American Assn of Family Practice, the American College of Physicians, and the American Gastroenterological Assn. all have different recommendations about which procedural (i.e. invasively performed by a gastroenterologist) tests should be done to diagnose and follow GERD.
There are also other possible developments. A new study might be done after the guidelines were published which either introduced a new and better drug for an old problem (Singulair for asthma, dabigatran for anti-coagulation) which can either add an intermediate step to the treatment step-ladder (Singulair before oral steroids) or are safer than an older drug (dabigatran instead of Coumadin). Sometimes a guideline has an unintended result: Many years ago Medicare decided that no one needed to be transfused just one unit of blood. They started to sanction doctors who did so. Immediately many patients who a doctor thought should have one unit of blood was transfused two units, thereby doubling the patient's risk of a reaction to the transfusion, e.g. an infection with a disease not screened for in the transfused blood, such as Chagas' Disease.
Then we have the problem when the government recommendations directly contradict the clinical evidence. What comes immediately to mind are the many studies that have shown that the antibodies induced by the flu vaccine are useful defensively for only about 6 months. There was even a recent study published in the New England Journal of Medicine that showed that an injection of 4 times the usual dose of flu vaccine provided useful antibody levels for 12 months. It would therefore follow, from elementary pharmacology, that the cheapest way to provide year-round flu coverage would be to immunize every patient with a single dose every 6 months. Yet no insurance plan, HMO, or Medicare will pay for this. Why not? Doesn't the government believe the results of its own clinical tests? Don't they want to keep people as healthy as possible?
The real problem is that each and every patient is unique, not only in his/her DNA, drug clearance ability, level of hormones, etc. but that each patient has different underlying diseases, is on different drugs, and takes different over-the-counter supplements. They may be smokers or vegetarians. They may be fat or thin. They may be very old or very young. They may be male or female. They may be pregnant or have the possibility of becoming so. They may be on birth control pills (patients on BCP's are never in a study group to test a new drug). They may be black or brown or yellow or white. They may be on cancer chemotherapy or on medicines to treat heart failure. They may not want to be on "too many" drugs. Outside of a blood transfusion for severe anemia and supplemental oxygen for hypoxia (and be very careful with the amount of oxygen given to premature babies!) there are few treatment recommendations that can be applied uniformly, especially when it comes to prescription drugs.
Finally, almost all guidelines apply to a patient with a given disease or symptom. None of them takes into account that a patient may already have four other diseases/conditions for which he/she is being treated, and that the guidelines to treat this fifth disease will almost certainly conflict with some of the requirements of other guidelines. The typical 60 year-old patient is on 6 or more prescription drugs, and NO guideline has studied a group of patients on the patient's particular group of drugs.
So it comes down to medicine being an art as well as a science, but you cannot subjugate art to check boxes on a computer's template, or note the reaction of a patient to a question, or tell the computer that the spouse insisted on being in the room with the patient and that therefore all the answers may not be true, or that the patient requested that certain answers not be entered into the office chart.
One problem that the public does not appreciate is the impact these "suggestions" and "guidelines" have on the work time of physicians. Time is our least fungible resource. But every time you deviate (for good reason) from a recommended HMO or government guideline, you end up having to explain yourself in writing, either in the chart, or in response to a letter from an HMO or Medicare, and this takes up time. Also, sometimes it is necessary to deviate from the guidelines to shield you from a malpractice suit or to reduce your chances of losing one. The fact that a test you did not do was not indicated in the guidelines will not help you if a malpractice lawyer can convince a jury that application of the possible results of the test might have prevented permanent harm to your patient. And please remember that a doctor much prefers to avoid being sued than to be "right" and win the suit, because defending a suit takes time, energy, and time away from the office.
When we look at evidence-based results, the first question a doctor asks is if his/her current patient fits the characteristics of the study group as to age, sex, race, economic standard of living and geography. For instance a recent article published in the New England Journal of Medicine on the use of cytisine for smoking cessation did have an equal number of men and women, and married and unmarried. However, all the participants were white, lived in Europe, were between 40 and 60 years of age, and smoked between 10 and 30 cigarettes a day, and your patient is a 25 year old Mexican immigrant who smokes 40 cigarettes a day, and wants to stop smoking. You don't even know the proper dosing regimen because you don't have any data on how rapidly or slowly Mexicans clear cytisine from their blood compared to white Europeans.
A recent study in Lancet showed that treatment with Augmentin was "not inferior" to surgery for uncomplicated acute appendicitis. The study group was equally divided between men and women and covered ages 18 to 68. But all were white, all lived in Europe, no mention is made of marital status or use of cigarettes, or even the other medicines they were taking, no one was obese, and no mention is made of prior abdominal surgery.
Let us say you have a new patient with reflux esophagitis. There are very clear guidelines about treatment and the sequence of adding more drugs for control and which tests and procedures to do. (Although there is no mention of urecholine, probably because it has been generic for so long that no one even thinks about it.) But your patient is also on medicines for heart failure, diabetes, and hypertension, and no one in the GERD treatment group was on these medicines. So some of the GERD medicines may be absolutely contra-indicated in your patient, but it will take time to explain this. Some doctors just write in the office or hospital chart: "This patient refuses to take the following medicines and tests" if the doctor does not think that those particular medicines or tests are either not indicated or might be harmful. This saves him/her from having to answer many letters, and no one from the HMO is permitted to question the patient about this because to do so would violate HIPAA rules. I might also note that the American Assn of Family Practice, the American College of Physicians, and the American Gastroenterological Assn. all have different recommendations about which procedural (i.e. invasively performed by a gastroenterologist) tests should be done to diagnose and follow GERD.
There are also other possible developments. A new study might be done after the guidelines were published which either introduced a new and better drug for an old problem (Singulair for asthma, dabigatran for anti-coagulation) which can either add an intermediate step to the treatment step-ladder (Singulair before oral steroids) or are safer than an older drug (dabigatran instead of Coumadin). Sometimes a guideline has an unintended result: Many years ago Medicare decided that no one needed to be transfused just one unit of blood. They started to sanction doctors who did so. Immediately many patients who a doctor thought should have one unit of blood was transfused two units, thereby doubling the patient's risk of a reaction to the transfusion, e.g. an infection with a disease not screened for in the transfused blood, such as Chagas' Disease.
Then we have the problem when the government recommendations directly contradict the clinical evidence. What comes immediately to mind are the many studies that have shown that the antibodies induced by the flu vaccine are useful defensively for only about 6 months. There was even a recent study published in the New England Journal of Medicine that showed that an injection of 4 times the usual dose of flu vaccine provided useful antibody levels for 12 months. It would therefore follow, from elementary pharmacology, that the cheapest way to provide year-round flu coverage would be to immunize every patient with a single dose every 6 months. Yet no insurance plan, HMO, or Medicare will pay for this. Why not? Doesn't the government believe the results of its own clinical tests? Don't they want to keep people as healthy as possible?
The real problem is that each and every patient is unique, not only in his/her DNA, drug clearance ability, level of hormones, etc. but that each patient has different underlying diseases, is on different drugs, and takes different over-the-counter supplements. They may be smokers or vegetarians. They may be fat or thin. They may be very old or very young. They may be male or female. They may be pregnant or have the possibility of becoming so. They may be on birth control pills (patients on BCP's are never in a study group to test a new drug). They may be black or brown or yellow or white. They may be on cancer chemotherapy or on medicines to treat heart failure. They may not want to be on "too many" drugs. Outside of a blood transfusion for severe anemia and supplemental oxygen for hypoxia (and be very careful with the amount of oxygen given to premature babies!) there are few treatment recommendations that can be applied uniformly, especially when it comes to prescription drugs.
Finally, almost all guidelines apply to a patient with a given disease or symptom. None of them takes into account that a patient may already have four other diseases/conditions for which he/she is being treated, and that the guidelines to treat this fifth disease will almost certainly conflict with some of the requirements of other guidelines. The typical 60 year-old patient is on 6 or more prescription drugs, and NO guideline has studied a group of patients on the patient's particular group of drugs.
So it comes down to medicine being an art as well as a science, but you cannot subjugate art to check boxes on a computer's template, or note the reaction of a patient to a question, or tell the computer that the spouse insisted on being in the room with the patient and that therefore all the answers may not be true, or that the patient requested that certain answers not be entered into the office chart.
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