Maggie's Farm

We linked a a paper in Scientific American a while back, Health Care Myth Busters: Is There a High Degree of Scientific Certainty in Modern Medicine?

We know, for example, that when a patient goes to his primary-care physician with a very common problem like lower back pain, the physician will deliver the right treatment with real clinical benefit about half of the time. Patients with the same health problem who go to different physicians will get wildly different treatments. Those physicians can't all be right.

Overall, physicians are said to get it wrong around 50% of the time. I suppose that is possible. I get it wrong on a regular basis. Dr. DB says he trusts no-one in medicine, including himself.

More from the Scientific American article:

Give surgeons a written description of a surgical problem, and half of the group will recommend surgery, while the other half will not. Survey them again two years later and as many as 40 percent of the same surgeons will disagree with their previous opinions and change their recommendations. Research studies back up all of these findings, according to Eddy.

I regularly get calls for consultations from people seeking disability for emotional complaints. If I fill out the lengthy state form, it's pretty much guaranteed that they will get some sorts of government checks forever.

I tell them to call somebody else. I won't do it. In the charity clinic at which I volunteer my time we have a blind fellow, a guy with no legs, and a paranoid schizophrenic lady working. They all get the admin work done. At my supermarket, my bags are packed by a gal with Down's. She is a sweetie.

The calls I get about this are, like, I have bad Bipolar or bad OCD, or bad drug addiction, or chronic depression with fibromyalgia. Being a Psychiatrist, I fortunately do not get calls from the people who say they can't work because their back hurts. Whose doesn't?

Giving up on a productive life means giving up on life and giving up on dignity. A colleague of mine will not work with anybody on any form of disability. His view is "If they have given up hope for themselves, why should I bother?" I tell him it's all about getting the money, not about hope. Scamming the system, or reverting to dependency.

This guy gets SSI,

In Sweden, you can get disability for this: Meet the woman allergic to electricity.

I doubt it's a deliberate scam. I suspect she is not insane, but probably half-crazy. It's easy to prove: just do some blind testing of her.

It reminds me of Multiple Chemical Sensitivity (a fascinating article).  People in the US can retire on this non-existent syndrome. The shame is that quacks are around to reinforce this sort of nonsense:

"Multiple chemical sensitivity" is not a legitimate diagnosis. Instead of testing their claims with well-designed research, its advocates are promoting them through publications, talk shows, support groups, lawsuits, and political maneuvering (such as getting state governors to designate a Multiple Chemical Sensitivity Awareness Week). Many are also part of a network of questionable legal actions alleging injuries by environmental chemicals.

Many people diagnosed with "MCS" suffer greatly and are very difficult to treat. Well-designed investigations suggest that most of them have a psychosomatic disorder in which they develop multiple symptoms in response to stress. If this is true—and I believe it is—clinical ecology patients run the risks of misdiagnosis, mistreatment, financial exploitation, and/or delay of proper medical and psychiatric care. In addition, insurance companies, employers, other taxpayers, and ultimately all citizens are being burdened by dubious claims for disability and damages. To protect the public, state licensing boards should scrutinize the activities of clinical ecologists and decide whether the overall quality of their care is sufficient for them to remain in medical practice.

Lyme Disease (which is a real and readily-treatable infection) presents another interesting situation in which crocks and quackery abounds.

I have always contended that the most severe mental disorders, eg Autism and Schizophrenia, were wiring problems rather than chemical problems.

Finally, it is becoming a major field of study: The miswired brain.

In my view, we all have different wiring, and we all have some loose wires and short circuits and sparking, but some loose wires cause more problems than others. Some will just make you more interesting, but some will burn your house down.

Between Arnold and The French Great Seducer, I am reading plenty of baloney about sex. Things about power as an aphrodisiac, things about "primitive men," that old feminist meme that it's about power and not sex, all sorts of nonsense.

Truth is, most people - men and women - have some or much desire for new sexual and/or romantic experiences. Novelty is exciting, flirting is fun, and seduction is exciting as hell. The French understand that side of the story.

The other side of the story has to do with consequences: The effects on family life, existing relationships, kids, spiritual life, conscience, financial condition and even legal issues. In other words, the grown-up side of the story.

Politicians and the rich and famous have no monopoly on adultery or promiscuity. They are common as dirt among both men and women of all social stations and, unless one tends to form "open" and "Don't ask, don't tell" relationships (which a surprising number of people do these days), they otherwise usually leave a trail of misery, shame, guilt, anger, distrust, and destruction.

Everybody knows that, but some people don't worry about consequences very much. They are too much devoted to "What I want to do" and too quickly forget that "Feelings aren't facts," "Character counts," and life is not meant to be free of struggle, conflict, disappointment, and frustration.

I advise patients that, if they are determined to have affairs or want to "go out," that they file for divorce first. And oh, I know - things do happen though. Having a trusting relationship with decent communication, commitment, and decent or creative sex is the best prevention but sometimes a few drinks at the hotel bar at a convention far away can undo even the best marriages.

One of the saddest things I see in my work are couples, after affairs or "indiscretions." Often, they begin to talk, to open up with each other, to become closer, more honest, and even to become better friends. However, it's too late to salvage the specialness that the relationship might have had. Something innocent dies whether they decide to stay together or not.

A few links on the topic:

Miss Attila: Power, and Its Privileges

Why Powerful Men (Like Arnold) Cheat

How to Tell If Your Partner Is Cheating

Pic is from the wonderful classic, The Seven Year Itch 

People are asking me about the IMF head's "problem".

If all the stories and rumors are true, he doesn't have a personal psychological problem (except his new personal political and legal problems). My guess would be that the issue is that people like him have no problem.

In other words, he just does whatever he feels like and doesn't give a damn because he gets away with it and his associates and his wife don't seem to care all that much. To diagnose that (eg Impulse Disorder, or Sex Addiction) is simply to excuse, or dignify, the sort of bad behavior that most people decide, often with great struggle, to limit to their fantasy lives. Everybody has illicit ideas and desires, whether consciously or unconsciously. That's why we are given the gift of the Ten Commandments.

Now that he has supposedly (as the gossip says) had his fun raping and/or seducing God knows how many attractive women and girls, and finally got caught, watch him now act the victim and seek help for a psychological problem. They always do, after they get caught. Clinton too.

From here:

The charges are roiling France, where Mr. Strauss-Kahn was the favorite to be the Socialist nominee for President next year and was even leading in the polls against Nicolas Sarkozy. The French are legendary for nonchalance toward the sexual appetites of their politicians, and they sniffed at Americans who disapproved of Bill Clinton when he lied under oath about sex. But we doubt even the French will be blasé about assaulting a hotel chamber maid.

Addendum, from France:

"Politicians ... enjoy a particular tolerance on this subject," he wrote. "Part of the shock comes also from the unusual scene, until now unthinkable here: police arresting a top-level politician on a matter of morals."

I think this article is baloney: Psychotherapy is Alive and Talking in Psychiatry.

A handful of pills and a few minutes of canned shrinkology is not enough to tend to a soul in turmoil and in pain. Take my word for it. People are complicated. For most people with troubles, sooner or later they have to face themselves, their flaws, and their self-defeating or destructive tendencies with honesty, and it is best done in the patient company of a decent soul who knows a thing or two about it all, and knows how to dig just deep enough to try to get to the heart of things; to gently drive a wedge through the devilish defenses to address the real "issues."

Some of us, or many of us, the Old Guard, are still here if you want to try to talk from the heart. Life itself is difficult enough, and having to struggle with one's own self just makes it harder for all.

It's an old topic, but always of interest. A Conversation With Dr Richard Kogan.

Many people, rightly or wrongly and for better or worse, reject Psychiatric medicines which can be remarkably helpful things at times, but also emotion-blunting at times. Fortunately, it's a free country.

Our post about hoarders the other day had me thinking about overeating. Overeating is hoarding fat cells. Once you create new fat cells, you can never get rid of them.

Odd and dysfunctional behavioral symptoms are all ways of dealing with uncomfortable internal states. Most people have at least one character defect or wiring defect which creates some sort of discomfort or uneasiness.

For some people, food is a center of existence and thus becomes a way of coping with being oneself, fending off boredom and a sense of emptiness - all of the cliches. In my line of work, we term this solution "orality." It works, in prosperous societies, and harms no-one but oneself.

For starters, this lady needs a physical job and needs to get out of the house. Her life is too easy, undemanding, and too dull. She'll end up on Disability, if she isn't already. Her son seems like a good kid, and wisely doesn't try to fix her. She has given up on life by taking on the victim role - she is a "victim of a food addiction."

I can tell you that some certainly are, some could care less, and some find it an abomination.

Porn, recreational sex, prostitution, rape, illicit seduction, perversions, etc. have been going on since there have been humans. That's a fact. Humans are endowed with the wackiest sex drives and wackiest imaginations of all animals and, depending on conditions and circumstances, not always the most mature or honorable behavior.

But what about the ladies? A teen gal recently told me that somebody said to her, in the bathroom after a frat party, "I am so pissed that I didn't get any dick tonight." How times have changed. Or have they?

I have looked at internet porn. I prefer love. Is porn bad? Pride and Prejudice and Porn

Rules of Misbehavior - Dan Savage, the brilliant and foul-mouthed sex columnist, has become one of the most important ethicists in America. Are we screwed?

The man is not Ann Landers. Holding sexual pleasures and adventure as the centerpiece of life, he seems to have come up with a simple ethic: Let them know what you are doing before you do it.

Good luck with that.  

Antisocial Personality. I miss it all the time. I am posting this in the hope that this will help deter me from missing it in the future.

AVI claims you can tell criminals by their faces, but I am not talking about serious criminals. I am talking about the effective manipulators, seducers, schemers, and deceivers and not the obvious violent and stupid people who end up in jails.

I get burned by such people on a regular basis. I like to think it's because I tend to think the best of people, but it's really probably my naivete.

Not all people with antisocial traits are axe-murderers. Most are ordinary liars, users, con-artists, self-servers, etc., and they often do not realize themselves that they are off base and living in their own amoral reality with all of their rationalizations for their behavior. The problem with the personality disorders is that people with them think they are normal. Sociopathy is a very common personality disorder, and often associated with glibness and a sort of disarming appeal that many people fall for.

Yes, everybody lies sometimes. I am not talking about that. I am talking about deceit and conniving as a way of life. Politics, for an example.

I always get suspicious when they call me "Doc" at first. I take it as an intrusive presumption of intimacy which I have not invited. Do not call your physician "Doc," except on the golf course. "Doctor" is OK.

The only real cure is religion, but that is only if, and after, they have somehow come to realize how off-base they are in their take on life, their relative indifference to others, and their self-centeredness.

In recent years, we have learned that Antisocial Personality traits derive as much from upbringing as from genetics. I think we wanted to believe it was all genetic. How it all works, I do not understand. All I know is to Beware, because these people will turn around and hurt you without thinking twice about it.

Bruckner subtitles his essay in City Journal: The Western cult of happiness is a mirthless enterprise. It's a short history of the idea of "happiness." One quote:

What is needed is a renewed humility. We are not the masters of the sources of happiness; they ever elude the appointments we make with them, springing up when we least expect them and fleeing when we would hold them close. The excessive ambition to expunge all that is weak or broken in body or mind, to control moods and states of soul, sadness, chagrin, moments of emptiness—all this runs up against our finitude, against the inertia of the human species, which we cannot manipulate like some raw material. We have the power to avoid or to heal certain evils, yes, but we cannot order happiness as if it were a meal in a restaurant.

The Western cult of happiness is indeed a strange adventure, something like a collective intoxication. In the guise of emancipation, it transforms a high ideal into its opposite. Condemned to joy, we must be happy or lose all standing in society. It is not a question of knowing whether we are more or less happy than our ancestors; our conception of the thing itself has changed, and we are probably the first society in history to make people unhappy for not being happy.

Readers know that, much as I value whatever joy and contentment come my way, I find "happiness" difficult to define and, furthermore, do not view it as a particularly meaningful or important goal of life as if is often defined. For example, if performing painful or sacrificial duties is what is satisfying to you, then how can you construct a universal definition of "happiness" when the word may mean "ease and comfort" to another person?

Excellent post by Dr. Sheurich, Interesting Times for Psychiatrists.

Yes. It used to be that Psychiatrists were the only ones who would talk to a distressed person with some depth of understanding. Nowadays, everybody can be a "therapist," and the "New, Improved" Psychiatrists don't want to get to know who you are. They want a symptom for the right pill.

I'm with 1 Boring Old Man:

I kept going on doing what I knew how to do anyway – just kept "doing what I did before and what I loved." I was a late arriver, having had another career first, so I was never around for the days of wine and roses to "go backwards, moneywise, in [my] career." I’m retired with "the lifestyle that my wife and I have been living for the last 40 years." I live in a log cabin. We travel and buy the things we want. It was a modest life with a modest retirement. I wouldn’t have had it be much different. I get calls from Therapist friends often who want me to help them find a "good Psychiatrist" who will do their "meds." I don’t even know what to say. Good Psychiatrists don’t "do meds," they treat people.

In my view, all docs should treat people, not diagnoses and not symptoms. People aren't "cases" - not even to good surgeons and anesthesiologists. No two "cases" are the same. Medicine is a humanistic, humanitarian art as much as it is science, and people are too complicated for simple formulations - unless they are bleeding out in the ER or some such. As I read the medical literature, most people don't even take their prescribed medicines.

I take note that the current head of the American Psychiatric Association, Dr. Carol Bernstein, has problems with the DSM model.

So do I. I have some hope for it too, but believe it to be of limited utility. It's largely pseudo-scientific, and pseudo-certain. "Sex Addiction"? Give me a break.

As 1 Boring Old Man says, "Don't mistake the pointing finger for the moon."

I would add, "Don't treat a test result." I have seen that end badly many times. 

I wrote yesterday about how Psychiatry is tending towards treating symptoms rather than people. Perhaps it is a general tendency in medicine today to retreat from the personal to the technological. See Treat the Patient, Not the CT Scan.

Medical care is not science. It is applied science - and an art. No checklist of symptoms, blood tests, and CT scans can sum up what is ailing an individual human, whether physically or mentally.

It must be clear by now that the dehumanizing trend in Medicine is something that I deplore. Good docs have to be more than good technicians who follow consensus protocols.

More on that in a letter to the New York Times here.

No, Virginia, there is not a little pill to fix everything that ails your heart and soul. It's the new fad, however. Your soul isn't troubled: you just have a little chemistry problem. Better living through chemistry!

In the New York Times, Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy.

It's not just about money. It's more complicated than that, but it's all very sad, in my opinion. I will not go into all of the reasons now other than to say that any doctor, Psychiatrist or not, who doesn't take the time to know you, and just wants to know your disease, isn't worth your time or your hard-earned money.

OK, now I'm depressed by my profession. Where's the pill for that?

Read all about Ashley Madison:

After spending several years as a sports agent at Chicago's Interperformances, Biderman founded Ashley Madison in 2002, naming the company after the two most popular names for baby girls that year. A large chunk of his work as an agent involved helping professional basketball players juggle their wives and mistresses, so when he read somewhere that 30 percent of users of Internet dating services were pretending to be single when they weren't, a light went on, pointing the way to an underserved online niche market. What would happen, Biderman thought, if cheaters had a website all their own?

Clever entrepreneurs, but I wonder how Biderman's Mom and Dad feel about his business.

The natural desire for novelty and excitement in romance and sex is always with us. It takes a while to realize that the new one is, well, just another deeply flawed person too. And for them to realize the same about you.

In my work, I tend to deal with the grim fallout of such adventures so I tend to be biased against acting on romantic temptations. Unlike the "sophisticated" Europeans and Asians, Americans tend to expect vows to be deadly serious. Especially church vows.

I say "tend to." Here are some US infidelity stats. Relatively few American marriages survive adultery, and those that do have some permanent damage.

Another data point, from this site:

Medical field(s) with the highest divorce rate: Psychiatrists and marriage counselors. Ouch.

Unless you cover them up too much, men always glance at them. They can't help it. (Women often furtively glance at men's junk too.)

Readers would be amused by the ways Psychologists and Psychoanalysts talk about men's curiousity about our boobs. Very deep and academic, things about mothers and breast-feeding and regressions and so forth.

More to the point, I think, is this explanation from a guy that I found somewhere, and which I recently quoted in a talk:

Why do we like breasts? Cause they're warm and snuggly, bouncy and soft, friendly and cute, playful, kissable, hot and nasty, pointy and happy, round and curvy, squeezable - and there's two of them!

I know two Oncologists who are being pushed out of private practice by Medicare price controls. Why are they losing money on their practices? Medicare price controls on their services, despite the huge costs of chemotherapies.

As I understand it, chemotherapy administered in a hospital can be charged at a higher rate than in an office. Thus it is viable for a hospital to take over a private practice and make money, or at least break even, on it.

Interesting article on government medical care price controls: Confessions of a Price Controller. A quote:

Medicare ignores the market, setting prices for physician services based on an academic theory with its roots in the Soviet Union and implemented by the American Medical Association. Those prices do not reflect the value patients receive from their care, and they do not reflect shifts in the demand for particular kinds of services (such as primary care) as the population ages or as more people have health insurance.

Here's what I do: I teach, for free. I work at an urban charity clinic where I donate my time. (I have no idea whether, if, or how the clinic is compensated.) I have a private practice in which I adjust fees in order to consult anybody who is referred to me. I accept no insurance plans, no Medicare, no Medicaid. All I have to worry about is covering my monthly bills.

Docs with high overheads - large staff, machinery, materials, high rents, high malpractice insurances, etc. do not have the luxury of operating as I do.

I count myself as very fortunate to be able to have an old-fashioned practice. I can do whatever I chose to do, and I like it that way.

1 Boring Old Man has a good post (one of a series) about current trends in Psychiatric diagnostics. One quote:

To my mind, the resulting evidence-based psychiatry seems like a tautology from my  college logic class. A tautology is neither a proof nor fallacy. It’s the situation where the premise and the conclusion are just different ways of saying the same thing. Instead of experience informing, refining, or changing our new classification, practice was being designed to reaffirm and solidify it, since the only admissable evidence is group validation by clinical trial. No matter the outcome of the study, the validity of the group is affirmed. It depersonifies our patients - their diagnoses becomes bigger than their lives or experiences, and it locates the seat of knowledge outside the clinician/patient dyad, putting it in the hands of key opinion leaders who look at the studies and create the algorithms. The resulting relationship moved from doctor/patient to expert/diagnostic_group. I wish I were overstating this, but I don’t think I am by much.

Because human nature is so variable and strange and complicated, and because my field is still in recovery from an overdose of "Biological Psychiatry" (in which the "mind" plays no role), many of our Experts have seen fit to categorize people according to their symptoms.

Pursue sex too avidly? You got a sex addiction. Work too hard? You got OCD. Nervous about something? You got an Anxiety Disorder. Put stuff into your underpants at WalMart? You got Kleptomania.

To my mind, these things are not diagnoses - they are what we term in Medicine "Chief Complaints" - we scribble "cc -".

To my mind, surface emotional symptoms frequently say little about what is ailing or bothering a person, just as saying that a patient has a fever tells you little about what is wrong. It just tells you that something is wrong. I find it to be challenging, helpful, and always interesting to probe into what is really the matter rather than slapping a label on somebody.

A label is not a diagnosis. I had my training from the best, and they certainly agree. (We need to re-post my series on diagnosis one of these days.) I'd like to go on at length about the topic of depth Psychology and Psychiatry vs. cheap and superficial Psychiatry, but I can't do that right now.

Seems to me that one must define the term, first.

Be Not of Good Cheer - We defer genuine joy and its corresponding pain in favor of a safe, steady intake of "well-being."

From the review of the book "Perpetual Euphoria" in the WSJ:

Instead of rehearsing the usual explanations about the rise of science and technology, Mr. Bruckner claims that the Christian attitude to pain contained the seeds of its own undoing. Many Christians naturally desired to hasten the coming of the Messiah, who would deliver them from their earthly torment. During the French Revolution, this urgent desire was secularized into utopian designs—as when idealists like Robespierre tried to eliminate the misery of the ancien regime and remake society in accordance with republican virtue. But for Mr. Bruckner, as much as for Edmund Burke, any attempt to usher in a reign of felicity will be marked by folly—and may well create new forms of misery. He notes that the more secular Western societies have become, the more sensitive they are to suffering that is no longer justifiable as part of a divine plan.

The reviewer concludes:

Mr. Bruckner himself comes across as neither a stoic who advocates giving up on happiness nor a sentimentalist who thinks pain has some intrinsic or artistic value. We are only happy, he believes, in spite of the suffering around us, and only for rare, unexpected and often inexplicable moments. Happiness, he implies, may not be as important as qualities like lucidity and dignity. But if you really want it, the best way to find it is not to care too much about it.

I could write about this topic for hours, and find some happiness - or pleasure - in doing so. But I won't. I have other things that need doing.

Psychiatry made a wrong turn when it tried to turn its back on the heart and soul, and appeared to decide that it was better, or easier, or most cost-effective, or more "medical"-sounding, to view humans as bags of chemicals and containers of symptoms.

In his "Reflections on Sacred Texts," the Boring Old Man sees it pretty much the way I see it  (h/t to Dr. X). I have a similar aversion to the DSM. My "sacred text" is the individual with the problem. Most patients I see do not fit neatly into any box, and I do not try to squeeze them into one.

The good doctors of most patient-oriented specialities - Internal Medicine, Family Practice, Surgery, etc. - seem to take more personal interest in understanding their patients and their lives than many "Biological Psychiatrists" do these days.

Psychiatry spans a broad range of problems, from pure brain abnormalities to regular difficult life problems, with complicated mixtures being the most frequent.

Fortunately for our patients, some us are still interested in getting to know them and in figuring out what ails them beyond their symptom checklist.