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Good job, Senators

After all the waiting and political posturing, today the U.S. senated voted no on a straight repeal of the Affordable Care Act (commonly known as Obamacare).

In the days leading up to this you heard many, including POTUS, urged the senators who had campaigned on repeal of the ACA to step up and deliver on their promise.

Today, the U.S. Senate voted not to repeal.

For those who had campaigned on the promise of repeal but decided to vote No because it hurt your constituents, I respect you.

Campaigning for something and then trying to follow through blindly despite learning how it hurts those you represent is — well to me, it isn’t doing your job at all.

The ACA isn’t perfect.

But a full repeal that would result in coverage loss for millions of Americans with no answer in sight is downright wreckless.

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The Event — It’s Time to Clean This House

Let’s ignore the details — for a moment — of what has happened in the city of Ferguson from the day Michael Brown was shot until the decision of the grand jury not to indict Darren Wilson was announced. Let’s compress it into a singular event.

Essentially, that event seems to have thrown open this nation’s closet door. It’s the closet into which we have thrown all our racially charged skeletons for the sake of appearing tidy, clean, and welcoming to guests who may come to visit — or the nosy neighbors who might peer through open windows. It’s a closet that has been stuffed full and whose contents burst out as soon as that door cracked open. But the Event didn’t crack the closet door open; it violently flung it open and exposed our darkest secrets to a watching international audience.

Whether or not you believe that the Event was motivated by racial undertones or not, it has pulled back the covers to reveal a deep pain, anger, and mistrust that was conveniently pushed aside or ignored for a very long time.

It’s time for this House to have an honest, deep, rip-the-carpet-out, fix-the-bannister, get-rid-of-all-the-termites type of spring cleaning. Or else watch as this House crumbles from the inside.

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The Almost-Kamikaze American Pilots

I can’t believe it’s been 10 years since the Twin Towers fell. In these last few days there have been numerous articles about that day and of memorials being held in NYC. For the most part I have stayed away from them. While I do think it is important for us to remember what happened, I think I just wanted to avoid it this week.

But one article caught my attention and I couldn’t help but click on it. It told of the two pilots who were ordered to intercept Flight 93. Back in 2001, there were no fighter jets that were armed and ready to take off to intercept planes. It was a different time.

When the order came to intercept Flight 93, the two pilots, Lt. Heather Penney and Col. Marc Sasseville, could not wait for their planes to be armed. They took off with only 105 lead-nosed bullets and the knowledge that those bullets wouldn’t do the job.

From the article:

“It was decided that Sass and I would take off first, even though we knew we would end up having to take off before our aircraft were armed,” Penney, among the first generation of American female fighter pilots, said to C-SPAN.

Penney said each jet had 105 lead-nosed bullets on board, but little more.

“As we were putting on our flight gear … Sass looked at me and said, ‘I’ll ram the cockpit.’ And I had made the decision that I would take the tail off the aircraft,” Penney recalled.

Both pilots thought about whether they would have enough time to eject before impact.

“I was hoping to do both at the same time,” Sasseville told the Washington Post. “It probably wasn’t going to work, but that’s what I was hoping.”

Penney, a rookie fight pilot, worried about missing her target.

“You only got one chance. You don’t want to eject and then miss. You’ve got to be able to stick with it the whole way,” she said.

The pilots chose their impact spots in order to minimize the debris field on the ground. A plane with no nose and no tail would likely fall straight out of the sky, its forward momentum halted, Penney said.

I read the article and was just amazed and reminded about what our men and women in uniform are willing to do for us each day.

Source: MSNBC.com

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Doctors & Nurses

Unfortunately, it seems that many nurses have a bitter feeling towards doctors. I can’t say I know why. But only because I don’t know their perspective. I can only speculate. But I’d venture to guess that at the core, it is an issue of feeling unappreciated and disrespected by doctors. Those feelings can then easily turn into resentment.

Are those feelings unwarranted? Sadly, no. I’ve seen too many instances where a doctor brushes off a nurse. I’ve seen times when the nurse feel slighted about something a doctor has done. Most of the time, at least I hope, it was not intentional on the physician’s part. But these little things add up over time on a mental score card that is not always unbiased.

They say that $h!t flows downward. This is especially true for hierarchies. In the grand scheme of things, whether you like it or not, the doctor is often at the top. Their signature, their orders. So when an attending mistreats a resident, the resident has a bad day. The resident snaps at a nurse. The nurse has a bad day. The scared medical student asks for help and the nurse glares back.

But the problem is that medical students don’t stay students forever. They remember feeling marginalized by the nurse that had a bad day. And it’s that much easier for them to brush of nurses when they earn their stripes. The cycle needs to stop.

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Book Review: Doctor Confidential — Secrets Behind the Veil

Doctor Confidential
Last month I received an advanced copy of this book. This book, Doctor Confidential: Secrets Behind the Veil by Dr. Richard Sheff, was released this past Sunday (May 1).

Dr. Sheff is a family physician with over 30 years of experience in practice. In this book, Sheff eloquently and openly shares stories that have stayed with him through the his time as a student, then as an intern, then a junior resident, and finally as a senior resident. Readers who are unfamiliar with the world of medicine will be happy to know that this book should be understood by the lay person. When the story being recounted requires the use of medical jargon, footnotes offer a clear explanation.

As a medical student, I couldn’t help but smile when reading through portions of the book recounting Sheff’s medical school experiences. At times, I had to remind myself that Dr. Sheff attended medical school a couple decades ago. Yet some things never change — and other things change very little.

One piece of advice that a senior medical student shared with Sheff, and that Sheff subsequently shares with his readers, is to remember that “Medicine is a bottomless pit. You can pour all of yourself into it, seven days a week, 24 hours a day, and still not fill it up — still not do enough for your teachers or for your patients. Only you can decide when you’ve done enough.” It is short. It is brief. But it is profound. And those who have gone through medical school will likely agree with this statement. It is a pity that many hear this later than necessary. As I began reading the book, it was nuggets of wisdom like these that kept be going.

As the book continues, Sheff describes the slow, gradual change from student to doctor through many memorable stories. They are poignant stories that question the system of healthcare and healthcare education we have in place in America, and ultimately accomplishes what the book set out to do — to reveal the “secrets behind the veil.”

If you are interested in getting a look behind the scenes, I’d recommend this book. And if you are a medical student like me, I think you will enjoy reading someone eloquently express many of the feelings we experience during our clerkship years.

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In The News: Mom Withheld Meds, sentenced to 8-10 years

I just got home from taking the Psychiatry NBME Subject Exam and logged onto MSNBC.com and saw this story. It’s a story of a mother, Kristen LaBrie who withheld chemotherapy medications from her autistic son for at least 5 months. He died at the age of 9 in 2009. A judge has sentenced her to 8-10 years.

I don’t know what she was thinking. A quote from the news story:

“If I could do it differently, I would, because I certainly miss my son, and I think about him every day and I wish he could be with me and my family,” she said.

Labrie, handcuffed in the courtroom, after receiving he sentence. Photo Credit: Cheryl Senter/AP

Her son was diagnosed with non-Hodgkins lymphoma in 2006. The tragedy is that her son’s oncologist believed that he had a cure rate of about 85-90% under an intensive two-year treatment plan.

But for whatever reason, she stopped giving his medication.

Source: MSNBC.com – Mom who withheld son’s cancer meds gets 8-10 years

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Re: Major Depressive Disorder (MDD)

This morning I posted the following on my tumblr1 account (link to original post):

MDD is associated with a mortality rate of 15% — suicide.

50% of people with MDD receive no treatment.

What other disease has a 15% mortality rate, yet we do so little to get them help?

 
It was subsequently reblogged by myvonne with her “rant” (her words). Here is the link to her full response, unadulterated by my annotations.

Now, I don’t know myvonne at all. It appears she reblogged me through another reblog. So she may or may not ever read this response. But if she does, I want her to know this:

  1. I understand that your own personal life experiences have shaped whatever strong views you hold that must have fueled that rant.
  2. If we, the medical profession, have wronged you or your loved ones, I am sorry. That probably means nothing coming from a stranger over the Internet who hasn’t even graduated medical school yet, but still… I’m sorry. The profession isn’t perfect. We have made mistakes. And too many of us are socially awkward enough that we might not always communicate very effectively. I have strong opinions about they way doctors communicate with their patients. Quite frankly, I think that we have done a poor job.
  3. Please don’t take this response personally. I don’t mean to attack you in any way. My response is to the words you wrote. If we were sitting across from each other, talking face-to-face in a patient-doctor conversation, I probably wouldn’t disagree with you at all — at least not for a while. Because I’d sit there and ask questions about what makes you feel the way you do. But the context is different here. And again, I don’t even know if you will ever read this.

With that being said, I felt compelled to respond to a few things I read in the reblog of my original post. The quoted sections below will be from the post mentioned above.

I’m just gonna say. I HATE labels like this… I wish doctors and psychologists would stop labeling a people as something that they feel they have to live with forever.

 
Love them or hate them, labels aren’t going away. In fact, I believe that labels are essential to our success as human beings. Childhood learning is full of labeling. We label, we categorize, we generalize. It helps us learn. We look at a ball learn about it. The next time we come to a spherical object, we assume it has similar properties with the first ball we saw. Labeling helps us learn.

In this case, I assume that you are referring to “Major Depressive Disorder” when you say that you “HATE labels like this.” But labeling things like this helps physicians who are treating a patient. I will be the first to say that I am not the biggest fan of the DSM-IV, affectionately known as the Bible of Psychiatry. Sometimes the labels make no sense. But more often than not, in medicine and psychiatry, labels help to dictate the next step in the management of a patient.

We don’t label for fun. We don’t call someone “obese” to be mean. Statistically, those over a certain BMI have an increased risk of unhealthy consequences down the line. We don’t differentiate between pre-hypertension, stage I hypertension, and stage II hypertension because we are bored. Knowing what kind of hypertension a person has will direct the therapy of that individual. Ideally, the delineations like these are there to help guide treatment.

A second reason for these labels is insurance purposes. But I only mention this to acknowledge it. I believe that labeling is important for the reason I’ve written above.

If you are THAT unhappy, there is someone in your environment causing it. You may even have a physical illness (undiagnosed). People will stay in the most horrible situations or with people who are constantly belittling them in some way and not see that as a source of or part of the problem. Sometimes the depressed person is doing something that he knows is wrong … or doing something someone else SAID was wrong… with the resultant self-loathing. To get up, get some balls and actually do something about one’s life takes courage and I know that when you’ve been beaten down for a long time courage is hard to come by.

 
Sure, there are many reasons a person might be depressed. You are correct that a physical illness can be the cause. There is a diagnosis in the DSM for that — Mood disorder due to a General Medical Condition (DSM-IV 293.83). We also have other diagnoses like “substance-induced mood disorder” or “minor depressive disorder” or “mood disorder not otherwise specified.”

But I will disagree with a blanket statement saying that if someone is “THAT unhappy” then there is “someone in your environment causing it.” It may contribute to the depression for some, but I wouldn’t call it the cause.

There are many theories as to how depression comes about. But one thing is clear — there are definite differences in the brain of a person suffering from depression. There is decreased metabolic activity and PET scans show decreased blood flow. The endocrine system is also affected; depressed patients seem to have specific dysregulation in certain hormones. This is not explained by just “someone” in the environment. There are biological differences.

I wish I could tell the depressed patients I see to grow a pair and DO something. But I can’t because it doesn’t work. Depressed people hear pleas to DO something all the time. Sometimes people need more help than a pep talk.

Life is a battle at worst and a fun game at best. Either way, it takes courage and skill and a willingness to fight or play with all your might. Change of venue, change of friends, change of husband or wife, change of attitude is much more beneficial than a label!

 
I agree. Life is a battle. There are ups and downs. And a change of venues/friends/spouse just might do the trick. But sometimes, change just cannot happen right away.

The last few weeks I have been on the Adolescent Psychiatry unit. What do you tell a child who is depressed and suicidal due to their own traumatic events? There are kids who have been abused. Kids who don’t have healthy parental support around them. You can’t tell them to just get up and make a change.

Life sucks. Sometimes you can’t make the changes you’d like change. And these depressed patients often need to learn coping skills to deal with the situation they find themselves it.

If you have just lost both legs in Iraq or your child has died or some other genuine horror has befallen you, then okay, I’ll give you some longish time to come to terms with it…otherwise… whatever.

 
I don’t know what is considered to be a “longish” time. I’ll forego putting into words my initial response to this paragraph; it wouldn’t be helpful. But Iraq was brought up. During my time at the VA, I saw old men who suffered from PTSD. These were hardened, combat veterans. Tough guys. But 30 years later, they still suffer from flashbacks, nightmares, avoidant behavior, hyper-vigilance. Labeling these proud men with PTSD is the first step in getting them the help they need. Ignoring it can be disastrous.

So you don’t like your job or you just ‘feel sad’, go to work, work hard, do something that interests you, run a marathon, create a some art but don’t label yourself and then be that the rest of your life. I know this sounds harsh but the whole label thing really bugs me.

Okay, I’m done with my rant.

 
Finally, if someone were only “feeling sad” and able to run a marathon, create art, and do things that are enjoyable to them… well, then by definition, that wouldn’t be Major Depressive Disorder. MDD affects a person’s daily living. Anhedonia (or lack of interest in things they used to find enjoyable) is present in nearly all adults with MDD. They don’t find anything interesting.

Now, are there people who are incorrectly diagnosed as MDD? Sure. Diagnoses evolve as we learn about a patient. And yes, I’m sure there are patients who will take their diagnoses of MDD (whether correctly or incorrectly given) and use it as a crutch. They use it as an excuse for themselves or their inactivity in life. However, I don’t think this is a problem of “labeling.” In my view, it is a problem with defense-mechanisms or coping skills. They are basically using avoidance to get out of something they find uncomfortable.

Also, and I feel bad for sticking this in at the end, I think there is a confusion with the diagnosis of MDD. A person who has one major depressive episode can technically be diagnosed with MDD. But a major depressive episode can last for as little as 2 weeks. After that time, they can be back to normal and fully functional. Others, though, will have recurrent episodes of major depressive episodes that last for months (or longer) at a time.

This has been quite the lengthy post. But essentially my points are:

  1. MDD is real. We need to be more vigilant in getting help to those who need it.
  2. Labels like MDD are useful because they help us decide on treatment. It can be quite an effective tool.
  3. Many people with true MDD will benefit from treatment.
  4. Some people do use their diagnosis as a crutch to avoid things, but the problem is not the label. The problem is poor coping skills.
  5. MDD does not mean someone always has a depressed mood. It only means they have had periods (or episodes) of major depression.

If anyone would like to add their $0.02, please feel free to do so via the Contact Me link or in a comment below. You don’t have to agree with me. And I know that some of the people I follow have battled with depression. If your experiences have been totally off, please tell me. Hearing your views will only help me be a better doctor someday.

  1. My tumblr account is usually pretty silly. It is where I post light, non-medical related posts. []