Maggie's Farm

Memory is famously faulty. Just as politicians and journalists attempt to create stories and "narratives" out of data points, all humans do the same. Often, our conscious memory stories are designed to support our positive self-regard, to rationalize, blame, find excuses, and so forth. Temperamentally melancholy people tend to do the opposite and are often more honest with themselves.

Psychiatrists and Psychoanalysts know how to listen stories and information as "memory data" with all of the selection, distortion, factual accounts, mental constructions, etc. which are part of memory. We are trained to listen as if watching a movie. Since we are not judges or juries, "truth" is not necessarily our pursuit although we can be quick to call "bullshit" when needed because people lie and manipulate too. We are not truth-relativists, but our focus is elsewhere.

One of the fascinating things about Psychoanalysis is to see how memory narratives change during the process.

Even recent memories are subject to distortion: Trust your memory? Maybe you shouldn't.

That's the view of Dr. Alan Frances, and I tend to agree. However, I never liked the DSM 4 either. 

Psychiatry's New Diagnostic Manual: "Don't Buy It. Don't Use It. Don't Teach
It."

Related, from Dr. McHugh: DSM-5: A Manual Run Amok - It's time for psychiatry to drop its field guide and try to
learn about mental ills

We discussed salt last week. Here's The Bogus Public Health Attack on Sugar

Sugar in soda pop is no more fattening than any other carb, eg fruit, bread, milk, fruit juices like apple juice and orange juice. Nevertheless, it's not a "public health" issue, it's an individual choice issue. I like that light brown granulated sugar in my coffee.

It's brown, so it must be healthier, right?

The only thing new about Obamacare is its mandatory nature, its lack of choice, and its one-size-fits-all. It's antiquated thinking, like subsidizing mandatory buggy whips.

Government programs like this inhibit change, innovation, flexibility, and creativity, and hand control to government bureaucrats. When Prof. Mead discusses evolving alternatives to the old fee-for-service model of primary care, he might be forgetting that Obamacare has set it in stone just as Medicare did for the over-65.

Left alone, medical care would evolve according to markets and peoples' choices. As we have surmised before, Obamacare was designed to fail and to bring in single payer, also a blast from the past which would inhibit innovation.

Salt is one of those things that drive dietary cranks, control-freaks, and ignorant do-gooders nuts.

There really is no reason for that. Most of us docs have been saying this for years and I have made this point here in the past. Salt is an absolutely necessary nutrient for all animals, and very low levels of sodium chloride can make you sick or dead.

The average, normal human body contains around 50 quarts of salt water.

The reason people used to advise "low-salt" diet is because excess dietary sodium is a bad idea for people with kidney failure and congestive heart failure, and people with uncontrolled high blood pressure (with its associated higher risks of heart attack and stroke).

However, salt does not cause those things.

Significantly-high blood pressure is easily dealt with these days. Heart failure will likely kill you in time regardless of what you do (barring a heart transplant), but it is treatable with medicines and some salt restriction.

The new study from the CDC: No Benefit in Salt Restriction.

The American Heart Association is not up to date on the topic: Sodium is Your enemy.

If you have high blood pressure, get it under reasonable control with your doctor. If you have organ failure (eg kidney or heart failure), or have some other ailment, do whatever your doc says. If you're healthy, enjoy your salt. It makes food taste better.

One recipe tip: I always season a salad with salt and pepper. It makes rabbit food taste almost good. Don't get me on the topic of whether green salad is "healthy." (It's neither healthy nor unhealthy. It's just filler.)

Readers know that we do not approve of using mental health terms as ad hominems against those with whom we have honest disagreements on political, or other, topics. I have been guilty of sometimes opining that "big, benign government types" are indulging in infantile fantasies of ideal parents, and I should not do that.

World-views differ, as do views of human nature. It makes life interesting and interestingly-contentious.`

Still, once you get past the insulting title this is a good post: On the Arrested Development of the Left:

At some point, one needs to grow up. The fact is, the human quest for salvation, whether personal or social, cannot be left to the reckoning of children. Given the perilous condition to which progressivist utopianism is taking our country, its pubescent psychology deserves to be even more carefully scrutinized. The soft-focus, Pollyanna attitude of the left, which has come to be known as the therapeutic perspective on the world, is often accompanied by unmitigated savagery. Even if the assault on culture is not physical but legislative, its effects are almost universally devastating. The historical register shows that the effort to improve the world by revolutionary violence or by comprehensive and indiscriminate cultural revisionism — therapy gone wild — is practically guaranteed to cause far more misery than it attempts to alleviate.

Addressing the tough realities of the real world, and the depressing limits of one's own self, are the best vitamins.

Mr. Solway references Rieff's challenging book, The Triumph of the Therapeutic: Uses of Faith after Freud.

I've mentioned here several times that the DSM is no "bible" for me or for most of my colleagues. We rarely find our patients in there, or human beings, for that matter. When the premise is wrong (that surface symptoms and complaints lead directly back to a neuro-chemical abnormality), then the entire endeavor is only useful for completing insurance forms (with a handful of partial exceptions).

A few relevant and interesting links:

- The Real Problems With Psychiatry - A psychotherapist contends that the DSM, psychiatry's "bible" that defines all mental illness, is not scientific but a product of unscrupulous politics and bureaucracy.

Not to mention the pharmaceutical industry. Always question Authority!

- Psychiatry’s Guide Is Out of Touch With Science, Experts Say in the NYT via 1 Boring Old Man's Groundhog Day

- How Scientific Is Psychiatry?

Like many fields of endeavor, good Psychiatry is part art, part science, but mixed with much life experience, much interpersonal experience, and as much painful self-knowledge as the doc him- or herself can handle to "sharpen the scalpel" as it were. We are called upon to be experts in real life, relationships, religion, the brain, the mind, the body, and the soul. It's a tall order which is why it is often termed "the impossible profession."

Readers know that I have trademarked the term "psycho-utopianism" to refer to the naive and reductionistic notion that, if all our our chemicals and all of our neurons were straightened out, and if we docs could fix it all by a cookbook, we'd all be some kind of "normal" and some kind of moral and some kind of "happy" of a serene, bourgeois sort. It ain't never gonna happen, and it's for the best that it cannot.

It would not be human, and it would not be real life. I recently was referred an evaluation for depression. Patient fit the DSM perfectly, but it didn't "smell right" to me so I took a chance and ordered her a total body MRI. She had an undiagnosed gastric cancer.

As an MD Psychiatrist and Psychoanalyst, I agree entirely with the sentiments of Gary Greenberg.

I do not have time to go into it now, but I tend to think that the whole thing is a pseudo-medical charade, designed for the drug industry and for the insurance industry's convenience.

If "mental health" cannot be defined, how can you draw lines to define "mental illness"? You can, at the extremes, but otherwise you can't. Everybody is a little nuts.

I never have done so even though stretching makes you look like a serious athlete. Reasons Not to Stretch

Jumping Jacks or Jump Rope are excellent warm-ups, if one wants it.

Executive decision-making is a skill. Good executive decision-making seems to be a talent. These are neither skills nor talents that I was blessed with, but that's probably just as well. I've never been much of a leader, and never a good follower either. My major life decisions have always made me nauseous. Medicine has been the right field for me. Independent work, endlessly interesting, and cautious, careful, conservative decision-making comes easily to me.

From Harvard Biz School, "While elevated narcissism and self-promotion has been shown to result in quicker promotion early in one's career, its negative impacts are revealed in positions of higher authority."

As in the sports world, in the biz world, if you cannot produce winning decisions consistently and with integrity, you will eventually go down. It's rough out there. I hear all of the stories and all of the excuses, but the most talented and honest do pretty well and never make excuses for their disappointments. Competition is a big part of life, and an exciting part of it.

Reflections of a Medical Ex-Practitioner - The glow of the personal relationship with patients is being extinguished:

 When I graduated from medical school in 1962, the profession of medicine was for many graduates an opportunity to provide care—as distinguished from, though aligned with, treatment—and to provide it to individuals, not to populations or governmentally specified groups. Young doctors hoped to establish an independent business, enjoy lifelong intellectual excitement as knowledge and therapies expanded, and have an income sufficient to live decently and support a family. There have always been some who entered medicine, as with any vocation, to maximize income. Yet most of us who came into the profession in the early 1960s had modest financial aspirations and substantial social commitment...

There is no "should". This foolish and, I think, exhibitionistic piece in the WSJ, How Often Should Married Couples Have Sex?, has been getting attention all over. I don't think it is very illuminating. Sexual frustration, however, does make both guys and gals cranky, and tends to make them want to look elsewhere for their instinctual romantic and sensual drives (which normal people do anyway, but even more so).

In my professional opinion, younger guys seem to be OK and relatively calm with sex twice daily. They are monkeys. Older fellows seem to get by with anywhere from daily to 3-4 times/week, depending on how hard and long they work at their jobs. Women are an entirely different topic, but my general advice to women is to remove the TV from the bedroom. Not to worry ladies - they will put it back in our bedrooms 24 hrs/day when we're demented widows in the nursing home. We can catch up with our shows and movies then. Carpe diem.

Apropos of the topic, I saw that Glenn Reynolds linked this book: Lube Jobs: A Woman's Guide to Great Maintenance Sex. Library journal commented about it, "Most people spend the largest part of their adulthood slogging through committed relationships, and they need books like this." 

Good cozy marital snuggles can make up for a lot of troubles. But "slogging"? If you're slogging, it's your own darn fault. I have patients deep into their 70s and 80s with quite satisfying and jolly sex lives even when they know far more than they want to know about their spouses, and when their equipment is not what it once was. We are, in part, biological beings.

Have Americans lost the sense of evil? I don't really think so. Some say that, nowadays, the cognoscenti can only use the word ironically, but I don't agree with that entirely either. After all, I have read too much vitriol from the Left directed towards people like me, labeling us (non-ironically) as evil.

In other words, I think "evil" has been secularized or politicized. At the same time, attempts are made to psycho-babbleize it away.

Without writing an opus on the topic, I'll make just a few points about evil (from a non-religious standpoint). Evil thoughts and impulses exist in everyone, to varying degrees, whether consciously or unconsciously. It never appears in pure form. 

A normal human conscience, along with social pressures, fear, a desire not to be destructive, etc. permit most of us to live without enacting very many evil deeds. Some people, in denial of their own dark sides, project evil into others. Some people attempt to deny the existence of evil anywhere. Some people try to erase the presence of evil by what we call "identification with the aggressor", of which the Stockholm Syndrome is an extreme example.

To look upon evil, wherever it is and however banal it may appear on the surface, is frightening. In the movies it can be exciting, but in real life it is deeply scary. Thus thoughts like this: St. Louis U. student asks, “Why don’t we talk about evil anymore?” and this: Why Does Evil Make Liberals Stupid? A quote from that:

This piece in The Atlantic is a good exemplar of the mushy liberal commentary that has proliferated in recent days. Authored by one Megan Garber, it is titled: “The Boston Bombers Were Muslim: So?” Before taking a close look at Ms. Garber’s article, let’s advise The Atlantic not to put away that headline. It could come in handy so often. “The Cole Bombers Were Muslim: So?” “The Embassy Bombers Were Muslim: So?” “The First World Trade Center Bombers Were Muslim: So?” “The September 11 Bombers Were Muslim: So?” “The Madrid Bombers Were Muslim: So?” “The London Bombers Were Muslim: So?” “The Shoebomber Was Muslim: So?” The Underwear Bomber Was Muslim: So?” “The Fort Hood Shooter Was Muslim: So?” “The Beslan Child-Murderers Were Muslim: So?” “The Times Square Bomber Was Muslim: So?”

And this one:  Jihad Will Not Be Wished Away - But willful blindness remains the order of the day.

I am sorry to say that Mukasey has it right:  Make No Mistake, It Was Jihad - Let's hope the administration gets over its reluctance to recognize attacks on the U.S. for what they are.

All sorts of things can help unleash the cruelty and destructiveness in people, but I won't get into all of that now because I only want to mention one of the things: communal support of evil. If only 7% of Muslims are inclined to active Jihad, that's 100 million people. That's no mob - that's a large nation of killers and would-be killers of infidels and they are all on the same page.

Jihadists believe the West is evil. "Submit or die." They are convinced of their virtuousness, but they are as wrong as can be because all that we in the West want is to be left alone and to truly "coexist" peacefully.

Here's an interesting 1996 book by Columbia Prof Andrew Delblanco: The Death of Satan: How Americans Have Lost the Sense of Evil

Bombs filled with ball bearings in my Boston Town. It's like a bad dream. What evil and/or insane person or persons did this to our gentle, Liberal town and our world-wide guests?

In the absence of information, it's a Rorshach of peoples' hopes and fears, and on the teevee, talking heads attempt to instill their prejudices to gullible low-info voters according to their preferred narratives. No info? A chance to write something onto their blank slates that might stick to their emotions.

Meanwhile, we have a mass murderer on trial in Philly, a knife-man attacker in a school, and 4 killed in Chicago just last weekend with illegal handguns. We know those details.

Evil exists everywhere and no laws can eliminate evil. Stay strong and calm and carry on. See human history. Our thanks to all of the first responders everywhere, and to all of the good civilians who pitch in when help is needed and run towards trouble instead of away from it.

We will never be free of trouble, but strong men and women will always run to the sound of the guns.

I have been saving two links about Tallis' 2011 book, Aping Mankind: Neuromania, Darwinitis and the Misrepresentation of Humanity, until I found time to say something interesting about the ideas. I could not add anything, as it turned out, because Mark Signorelli says it so well in his review.

Tallis, a neurologist (and amateur and impressive philosopher) wrote the book as a critique of biological and evolutionary reductionism. 

Here's a brief review from the WSJ.One quote:

 In his vigorously argued "Aping Mankind," Raymond Tallis takes on what he calls "neuromania" (the belief that we are our physical brains and nothing more) and "Darwinitis" (the insistence that our consciousness can be reduced to evolutionary terms) in a robust defense of the unique nature of human consciousness. Mr. Tallis, a doctor and researcher in clinical neuroscience, believes that most contemporary accounts of human consciousness fail to understand the lived experience of individual minds. Reducing man to simply another animal in a real sense de-humanizes us, with disastrous effects in areas from social policy to the interpretation of art and literature, which the author touches on in engaging asides.

Aping Mankind is negative research. While most popular-science writers attempt to weave compelling stories from the latest neuroscience experiments to explain 'why we are the way we are', Tallis attempts to show why these stories simply cannot be true. If you are skeptical of media--and scientific journal--headlines such as "Researchers discover the location of love in the brain", then you may enjoy Aping Mankind. In this work Tallis exposes the odd proclivity of scholars, from biologists to literary critics, to anthropomorphize pieces of matter while simultaneously dehumanizing human beings. In effect we are systematically transferring our humanity to matter, and this may not be good for our health--just like vitamins.

Returning to Signorelli's impressive review which opens like this:

I can recall very clearly the moment at which the spread of Darwinian ideology became a matter of concern for me. Previously, I had been acquainted with such ideology, and recognized it as but one more strain of fashionable cant, promoted by a set of persons quite obviously unfamiliar with elementary philosophical reasoning. Having attended college in the late twentieth century, I, like many of my generation, simply became accustomed to dwelling in an intellectual atmosphere poisoned by noxious dogmas, whether deconstructionist, multi-cultural, or what have you; Darwinism was evidently just such another doctrine, and so I took no great alarm at its prevalence. That changed one evening when, surfing idly across the internet, I came across the late Denis Dutton’s article on “Aesthetics and Evolutionary Psychology” in the Oxford Handbook of Aesthetics, an article which proposed the advantages of applying evolutionary theory to our inquiries regarding the arts and literature. This was the first time I had encountered Darwinism in such a context, and when I looked into the matter subsequently, I found that Dutton was by no means alone in his project; quite a body of literature had amassed by that point, purporting to offer evolutionary accounts of poetry, dance, and painting, among other things. Now I became alarmed, and greatly so. Literature (understood in the broad sense of learning, or letters) has been everything to me, the source of all my consolation, and all my self-understanding. To see it threatened by this dirty little creed, with its invariable tendency to degrade whatever comes under its purview, was deeply worrying to me. So I began writing against it, with that same defensive urgency that motivates a man to fight for kin and country.

I am a big fan of AA as a help with addiction and as a method for personal growth and maturity.

It's not the only way, but it might be the best way for those who have trouble with it. Recently, people have recommended two books by Allen Carr:

The Easy Way to Stop Drinking

Allen Carr's Easyway to Stop Smoking

This simple problem, offered by a reader, doesn't (I think) require Bayesian methods:

Suppose some one person stole some money and there are a hundred possible suspects. You use a lie detector, which has a 99% chance of a positive if you are guilty, and a 99% chance of a negative if you are innocent. Someone tests positive. What are the chances the person is guilty?

As with medical tests, this deals with rates of false negatives and false positives. Please explain your answer in the comments.

I found this piece, with this example with some good discussion:

10 out of 1000 women at age forty who participate in routine screening have breast cancer.  800 out of 1000 women with breast cancer will get positive mammographies.  96 out of 1000 women without breast cancer will also get positive mammographies.  If 1000 women in this age group undergo a routine screening, about what fraction of women with positive mammographies will actually have breast cancer?

The answer is 7.8%. That's why needle biopsies are done, but they can be read wrong too. Some error is always unavoidable.

She says doctors themselves generally get such stats wrong. Here's another example:

Here is a simple example, based on Mike Shor's Java applet. Suppose you have been tested positive for a disease; what is the probability that you actually have the disease? It depends on the accuracy and sensitivity of the test, and on the background (prior) probability of the disease...

It's worth reading both brief presentations. The current thinking seems to be that Bayesian is the only reliable approach for data these days, and, if data has not been subject to it, it might not be worth much.

In my field of mental illness, the data is always so squishy to start out with that I am a skeptic about everything I read anyway. I have seen very few reports in Psychiatry which have been subject to Bayesian analysis and are thus probably not worth much. 

My experience is a better teacher which is, I suppose, sort of Bayesian.

It's been far too long since I studied, or used statistics other than to read medical journal articles. Everybody talks about Bayesian Statistics nowadays. They are the new old thing, almost 100 years older than Fisher Statistics (Fisher was an interesting fellow).

In my youth, I learned to be always skeptical about any research results, but I am told that running data through Bayesian methods is a good test of data.

Can somebody explain the concept to me in simple English? I don't intend to use it, just to get the ideas (I can do the math, but I want something conceptual for starters.) Most Liberal Arts students learned basic Stats in college, the p and the t-test, etc., but the Bayesian is new to me.

Reading Buzz Bissinger's confession, My Gucci Addiction, I would have to seriously consider the Bipolar possibility were I his doctor:

In the past few years, I've bought eighty-one leather jackets. Dozens of boots and leather gloves. I've purchased pants that cost $5,000. I own a $22,000 coat. This winter I took a tour of Milan's Fashion Week (all expenses paid by Gucci, in appreciation of my many, many purchases), where I spent tens of thousands more and began to seriously grapple, once and for all, with a compulsion that could cost me more than just my life savings. My name is Buzz Bissinger. I am 58 years old, the best-selling author of 'Friday Night Lights,' father of three, husband. And I am a shopaholic.

Not everybody who does crazy things has a diagnosis, but unless Mr. Bissinger has inherited $100 million, somebody ought to try to stop him before he blows himself up. It does not sound like his wife is likely to do that.

I saw a nice lady for consultation a few years ago. She was distraught, wanted help in rebuilding her life and her emotional strength. Her husband, age 54, had, after an evening of good sex with her, informed her that he had realized that he was gay, and needed to leave her to pursue a gay life style because he did not want to deceive her or betray her.

They cried together and held eachother. She cried for two weeks. After that, she began having panic attacks. He moved out, and the legal aspects of the divorce proceedings had been easy and mutually agreeable.

Six months had gone by and she still felt shattered. The reality of her life had been exploded. I told her that grief takes at least a year.  Mind you, this was a sophisticated urban woman who had once been in the fashion business and who assured me she could readily identify gay guys at a distance. He had always been a loving, sexy, loyal husband with no hyper-macho ways, and no stereotypical gay interests or mannerisms. Good father, too. He worked in finance.

In the six months apart, she told me that he had seemed to transform himself from an ordinary fellow into a flamboyantly gay man who drinks too much, dyes his hair, spends weekends in Provincetown and weeknights in gay bars. He told her it took him 40 years "to find his inner fag." He says he'll love her forever, support her and the kids, but now has found his real self and feels happier than he ever had.

I thought to myself "That was a real gay marriage." I also wondered whether he was Bipolar, but it didn't matter because it was over and her challenge was to write what I term "a new chapter."

I had seen this a number of times before, in mid-life men and in women too. I can't say I understand it. Nobody really does, but I do understand the grief. Agonizing. I also understand the horror of wondering whether much of one's life has been fraudulently-lived in a fake reality.

In my line of work, I encounter plenty of people who live in fake realities of their own construction, but it's not ordinarily about sexual matters. It's usually about other things. I carry the burden of a thousand stories in my soul, but don't feel sorry for me. It's a privilege, and I get paid to carry them.

(nb: real details of this story are totally altered and combined - fake but true)

If marriage is primarily a legal contract, then why can't two elderly sisters marry? It might very well be to their advantage, and they may love eachother deeply. Or does marriage have to involve sex? If so, who from the government is going to check to make sure that sex is happening? God knows, the world is full of sexless marriages.

And, yes, what about polygamy? Why not? It's not Christian but it is Old Testament Jewish and it is modern (quietly) Mormon - and Islam. How many wives did David have? I read that Solomon had 200 wives and 800 concubines, or maybe the other way around. I do not know when the Israelites gave up polygamy.

The whole topic becomes more and more absurd and confusing as cultural traditions are undermined. Gays can get married while the heterosexual people are now up to 50% childbirth out of wedlock. Crazy world. It's called cultural change.

Then I noticed this: Kagan ’09: ‘There Is No Constitutional Right To Same-Sex Marriage’. That statement signifies to me that she is an unwise person. The Constitution does not set up government to dole out rights to the people, but rather to protect the mostly-unlimited rights of a free people. But I am repeating myself.

Freedom and privacy require no "penumbra." Back to the US Constitution, the American social contract:

• 
  

  This list of rights should not be read to limit in any way any other rights of the people.

  
  


• 
  

  The powers not specifically granted to the federal government by the Constitution, nor prohibited by the Constitution to the states, are reserved to the states respectively, or to the people.

  
  

Two confused thoughts:

1. Marriage. Everybody is writing about the gay marriage topic. How is marriage defined? Is the Supreme Court being asked to be a dictionary? To revise the dictionary? That's above their pay grade.

2. Is there a "right" to gay marriage? Isn't that the wrong question? The Federal government was never assigned the power to determine such personal things in a country in which the presumption of local and, most importantly, individual liberty is the centerpiece. We do not have, or need, delimited rights. Government has delimited powers (supposedly). I guess the issue had to become a federal case because marriage is not so much about a relationship, but, maybe unfortunately, about a legal status with many legal implications.

Obamacare isn’t forever, but what’s next is worse

Charles Krauthammer, MD, gets it. He always did. Our money- and power-greedy government has always drooled over the idea of control of medical care because so much emotion and money is involved. Votes, power, control.

Believe me, personal care does not lie in the future. At that point, I will give up. I will give up charity care too, if there is any of it left. I did not enter Medicine to be an employee or a peon. If that is what the people want, they can have it.

For me, it's a calling but I will not do it as a government peon.

If psychotherapists "screw up" their children any more than anybody else, I haven't seen the data. (My own kids, BTW, are perfect.) Biggest issue with parenting these days? Trying to be friends with the young. They can be pals when they grow up and achieve independence but, until then, make your own friends.

It's a perennial topic, however. If therapist-types do, I think it comes from being over-attentive, over-protective, overly-empathic, and not respecting kids' resilience and adaptability.  How Therapists Screw Up their Children.

It's important for therapist-types to put their work hat on before work, and to take it off after work.

This on parenting is related: Please Do Not Adjust Your Child

Unlike, it seems, some or many of the young women in Medicine today (50%), I never had any interest in being anybody's employee.

The Doctor Won't See You Now. He's Clocked Out. ObamaCare is pushing physicians into becoming hospital employees. The results aren't encouraging.

My freedom in practice is to see people anytime I want or can, to work whatever hours I want to, to follow no imposed treatment protocols, to set my own fees and to provide as much charity as I wish, and to help anybody I chose to.

Nobody tells me what to do or how to do it. Maybe I'm a dinosaur. I'll see patients on a Saturday or Sunday if need be.

A quote from the article:

Once they work for hospitals, physicians change their behavior in two principal ways. Often they see fewer patients and perform fewer timely procedures. Continuity of care also declines, since a physician's responsibilities end when his shift is over. This means reduced incentives for doctors to cover weekend calls, see patients in the ER, squeeze in an office visit, or take phone calls rather than turfing them to nurses. It also means physicians no longer take the time to give detailed sign-offs as they pass care of patients to other doctors who cover for them on nights, weekends and days off.

Most hospitals exacerbate these strains by measuring the productivity of the physician practices they purchase in "Relative Value Units." This is a formula that Medicare already uses to set doctor-payment rates. RVUs are supposed to measure how much time and physical effort a doctor requires to perform different clinical endeavors.

A quote:

Under Obamacare, more and more doctors are becoming employees of large hospitals, where there will be more control over how they practice medicine. Hoover Institution Senior Fellow Dr. Scott Atlas fears this will cause a brain drain in medicine. "Really smart people want autonomy, and when you take that away it's naive to think you're going to get really bright people becoming doctors," says Atlas. "The best doctors could excel at any profession, so why go into medicine if they won't have the opportunity to be their best?"

The people interviewed practice the same way I, and plenty of my colleagues, practice. No insurance, and thus no back office staff and low overhead. No boss, practice exactly the way I want to as I decide with my patients.

Amateur addicts always have an excuse, but those who are honest with themselves will admit that it just makes them feel good and that they have addictive tendencies.

There's a Reason That Addicts Say Yes to Drugs.

Emerson College's Insurer Will Cover Transgender Student's Transition Surgery.

These people who seem to believe they are the spawn of aliens, animals inside a human body, boys who believe they are girls, and all the other sorts of silly fantasy lives that people put on display today, are people with only the slightest grip on reality.

I would never claim that we shrinks and psychoanalysts have the power to change such unfortunate fantasies/delusions, but seeing other physicians collude with such fantasies disturbs me more than a little bit.

Many rightly criticize Psychiatry for over-pathologizing human variation, but normalizing total weirdness is another matter. Strange is strange, and nobody should be afraid to say so in fear of the Thought Police.

He has a new book out, about what he learned from the Harvard lifetime study. He is delightful. The podcast is here.

Why we have our best ideas in the shower: The science of creativity.

I always figured that it's because there were no distractions, same as driving alone with the radio off (which I recommend).

Do the nanny-staters and busybodies want stores to sell food that people don't want to eat?

Here's an amusing response to that widely-linked NYT piece:  Sweet savage food marketing at the New York Times

Moss' hystrionic NYT article complained about food that panders to the human taste appeal of salty and sweet foods. Well, guess what - the human sense of taste is limited to sweet, salty, and bitter (and sour). So why didn't Moss complain about the pickles with the burger too? Or is sour OK with him?

Unsurprisingly, the appeal of fatty food is not taste, but textural and olfactory. However, as I have preached here many times, fatty food is good stuff and is required for health, vigor, and mental functioning.

Just skip those carbs if you wish to stay slim.

I entirely agree with the comment:

Wakes and funerals already exist to serve the immediate needs for mourning and recognition of the loss. Participation in normalizing rituals is probably far more helpful than therapy in the immediate aftermath of a such a loss.

We all agree that human monogamy is not "natural" in any animal sense. It's a stretch.  If marriage matters to you, and you've been married over a year or ten, this could a pretty useful talk, and takes the topic further and more intelligently than the supermarket magazines ever will.

Just one of the secrets seems to be experiencing one's spouse in different situations and seeing them being effective or impressive in different ways - socially, professionally, intellectually, adventurously, morally, humorously, physically, talent-gifted, etc. We can never know everything about another person and it is much easier to become familiar with a spouse's flaws than with their varied strengths, many of which may be hidden from us.

For one example, when on occasion I have barged into my husband when he is deep in prayer, I do see him with new eyes. For another, when I see him regaling people with wacky stories at a party.

The secrets to desire in a long-term relationship:

As the man says, "their definitions expel me and, in fact, most mental health professionals."

I like to claim that the DSM is an Obsessional Disorder.

We learned about an interesting center for evaluation and training for kids with autism, mental retardation, and developmental disorders: The May Institute.

Walter Mead linked to Brill's article in Time, Bitter Pill: Why Medical Bills Are Killing Us:

A quote:

I got the idea for this article when I was visiting Rice University last year. As I was leaving the campus, which is just outside the central business district of Houston, I noticed a group of glass skyscrapers about a mile away lighting up the evening sky. The scene looked like Dubai. I was looking at the Texas Medical Center, a nearly 1,300-acre, 280-building complex of hospitals and related medical facilities, of which MD Anderson is the lead brand name. Medicine had obviously become a huge business. In fact, of Houston’s top 10 employers, five are hospitals, including MD Anderson with 19,000 employees; three, led by ExxonMobil with 14,000 employees, are energy companies. How did that happen, I wondered. Where’s all that money coming from? And where is it going? I have spent the past seven months trying to find out by analyzing a variety of bills from hospitals like MD Anderson, doctors, drug companies and every other player in the American health care ecosystem...

Tort reform is an easy place to start. I think 90% of CAT scans are defensive, and are billed at anywhere between $600 and $3000.

Second might be an acceptance of the inevitability of death. No, I do not mean death panels. I just mean acceptance. Death is not an enemy.

Daniel Greenfield asks the question Who Needs The Family?

That's easy for me to answer: I do, and I always did. A person without family, tribe, and community is a person adrift, a lone wolf, a lost soul. Governments have nothing to do with it. He says of socialist schemes:

    The state replaced the family. It told men and women that they no longer needed to make permanent commitments to each or to their parents and children. So long as they paid their taxes, the state would bear the burden of their commitments. And so men and women gave up on each other, parents gave up on their children and children gave up on their parents, the family fell apart and now the state that took its place is also falling apart.

    A building cannot be built on nothing...

At best, the merger of
romantic love and marriage is relatively recent and relatively localized.

We have posted in the past about the history of romance being converted into covenant marriage. Marriage has always been in transition, and, for better or worse, it is in transition now.

As I have said countless times here, I don't know how people can run an orderly, complicated, and productive life without a committed partner, much less create a family with all of the things family entails - finances, traditions, social life, stability, values and religion, disciplines, etc. The very wealthy always could do that, but not otherwise.

I never forget the story of how Thomas Lincoln (Abe's father, a prosperous and prominent Kentucky farmer and real-estate investor at the time) hopped on his wagon and drove to the nearest city, leaving the kids in charge of themselves, to quickly fetch a new wife after Nancy died. I believe he fetched the first widow he could find, Sarah.

Today, he would be arrested for leaving the kids on their own.

Thanks to all for all of the interesting comments on my PTSD post.

Here is an interesting link: How We Were Lied to About Health Care

I have made the case here, in the past, that PTSD is not so much a disease or "disorder," but a normal variant in response to disturbing events. The mental health field, these days, is pathologizing everything and everybody.

I have seen persistent PTSD complaints in all sorts of people, far more civilians than military. Life affects us deeply, and can shatter us, unless we are heavily armored or lacking in emotional response. I have seen them in sudden announcements to divorce, spousal death, deaths of a child, job loss, fatal car crashes, young police officers, and witnesses to the 9-11 jumpers.

We Westerners live in a mostly safe world, insulated from so much of the pain, distress, and horror which were routine in past generations. An ordinary snowfall, or a loss of electric power, is now a really big deal, a tragedy. We are so safe and comfortable that we have lost the tools to cope with tough situations, scenes of horror, and painful memories. These things do, indeed, change us. Comfort and safety have made us innocent, in a way. Police and doctors deal with these things routinely, and develop thick skins, professional distance.

I read this today: Government Can Do More to Treat Veterans with PTSD. The number of returning veterans afflicted with Post Traumatic Stress Disorder has reached crisis proportions.

By government, they mean the VA. "Qualifying" for disability is a terrible idea. Getting into life is the best plan, whether one wants to or not. No matter what happens, it's best to buck up and get on with it.

There is no treatment, no cure, for being human. There is no cure for PTSD complaints other than the old-fashioned "tincture of time." Entrepreneurs out there sell cures which are snake oil. All we Psychiatrists really have to offer these people is care, emotional support, help with substance abuse, and, if they wish, emotion-blunting medicines. There is no magic cure for life's horrors and misfortunes other than alcohol and drugs, and they tend to make things worse in the end.

Some psychoanalysts like Kohut and Kernberg have theoretical ideas about it. Sometimes I think that the word, and whatever idea exists behind the idea, is a sociocultural construct more than anything else.

That is not to say that we are not individuals with our own personality tendencies.

Here's an essay: The Self in Self-Help - We have no idea what a self is. So how can we fix it?

From The Last Psychiatrist, No Self-Respecting Woman Would Go Out Without Make Up.

He covers a lot of ground in his post, including firearms and Goldman Sachs.

As I have often said, there is no useful general definition of happiness. Unhappiness and misery are much more easily defined.

Do all people need a sense of mission or purpose to be "happy" - other than the basic mission of survival and comfort? I very much doubt it. The wonderful psychiatrist Victor Frankl was indeed sustained by his search for meaning in the camps, but that is far from ordinary life and he was far from an ordinary man.

Here's Emily Esfahani Smith's There's More to Life Than Being Happy. I am not sure what I think about that report.

For me, contentment is a good, loyal husband, a good love life, good work, enjoyable if sometimes difficult kids, good friends and good acquaintances, exciting hobbies and sports, integrity and a clean conscience, a dog, a relationship with God, and books to read. Changing the world is a fool's errand for crazy people and narcissists who do not want to focus on the substance of their own brief lives. Can't do without them, though. Part of the fabric.

Mass killings, and serial killings, are in decline. Murder overall, in fact, is in decline except for in some (Blue) cities like Chicago and Detroit which nobody seems to get excited about very much. 

Everybody is seeking scapegoats for mass killing, especially when it's white suburban kids instead of the slow mass murder of inner city black kids, and everybody hops onto the hobby horse they want to ride. Movies and video games, firearms, bomb ingredients, the mentally ill, etc.

The problem is that these mass events are so rare as to be utterly upredictable. We cannot put an armed guard at the door of every classroom. And trust me, you cannot lock up, indefinitely, every paranoid or angry person who has thoughts of killing people. You'd have to lock up half the commenters at Daily Kos. Thoughts about killing, like thoughts of suicide, are very common.

Furthermore, mass killers like Timothy McVeigh and serial killers like Ted Bundy were not even mentally ill in any usual sense. Evil, not ill. Not to mention Nidal Hasan, the Fort Hood killer. A military Psychiatrist, no less (and a presumed Jihadist). Or the 9-11 killers.

Terrible events are black swans and probably not preventable. Dangerous people rarely seek help with their problems anyway, and criminals ignore laws. Nobody who is hell-bent on mass killing is likely to tell anyone.

From the NYT yesterday,  Focus on Mental Health Laws to Curb Violence Is Unfair, Some Say.

Here is Top 10 Myths About Mass Shootings

I posted about epigenetics a few weeks ago: Epigenetics in Metazoans.

Here's a good example from pigs: Why Cloned Animals Aren't Identical.

I entirely agree with 1 Boring Old Man.

Here's another: DSM5 Dead on Arrival!