Existential Dilemma (With the Usual Windy Discussion)

The past week or so, I've been experiencing an internal struggle. It's somewhat akin to a loss of faith, if you will, similar to what I experienced at age 19 when I became an agnostic (from Southern Baptist--trust me, that's a big leap). I've felt lost, confused, somewhat abandoned, and angry. While the acute crisis has mostly passed, I'm still feeling the aftermath and haven't decided yet what to do.

What was bothering me so much?

I have been confronted with evidence that a good portion of what we do in psychiatry is based on a) ineffective medication b) bad evidence on medication, sometimes even manipulated by drug companies c) made up as we go along. It just seemed to happen all at once, however, and kind of rocked me: can I "believe" in psychiatry, and practice in this field, if so much of what we "know" we don't actually know?

Some of you are going "WTF?" and some are going "DUH!" I'll try to list examples of what I'm talking about.

1) I've known for some time that the evidence for certain "mood stabilizers" like Depakote isn't very good. In fact, it sucks. In the study linked above, Depakote was no different from placebo in preventing mood episodes. Yet, we put every freaking bipolar patient on Depakote. It does seem to be effective in acute mania, but not quite so much in maintenance. And the whole term "mood stabilizer"? Doesn't it imply that the mood is "stable", or non-fluctuating? Even in trials with relatively good improvement over placebo, like this one with lamotrigine, show that the mean time to intervention for mood episode while on maintenance was 200 days (versus 93 with placebo). So by 6.7 months, the average patient on lamotrigine was going to have another episode. It may have reduced the risk of relapse, or prolonged the time to relapse, which is good, but I'd hardly call that a "stable mood".

2) A recent meta-analysis shows that overall, SSRI's aren't terribly effective in all but the most severe depression. Yet, we're taught in medicine that roughly 2/3 of patients will respond to the first antidepressant you try. It all comes down to your criteria, I suppose; remission vs response vs decrease in symptoms on a clinical scale, etc. Interestingly, the study above re-analyzed ALL the data submitted to the FDA to get these drugs approved, and came up with this answer. Uh, where was the FDA? Aren't they supposed to do that?

What really bothers me about this one, though, is that some of the efficacy data that was used to get these drugs approved in the first place was deliberately manipulated to make these drugs look more effective. After reading "Side Effects" recently, and looking at the study the book discusses, I'm angry. Wading through that study is tough, but you could still come out and think, well, it showed SOME benefit over placebo, and the side effects weren't too bad. Turns out, what was coded as "emotional lability" was actually likely to be suicidal behavior or self-mutilation. AND, several kids' data disappeared from the analysis. AND, the study was ghost-written. AND, GlaxoSmithKline deliberately had the writer word the study to show that "Paroxetine is generally well tolerated and effective for major depression in adolescents" because they knew it would hurt their bottom line to write that it wasn't! (That's not so shocking, really...)

Whether you believe that SSRI's cause/increase/exacerbate suicidal behavior or not (I've seen convincing arguments both ways), it is highly disturbing that the evidence we've been basing therapy on was so deliberately manipulated. Yet, we use this "evidence" all the time. It came directly from a drug company that expected to make millions to BILLIONS of dollars off this medication.

3) People ask me all the time if I'm going to become a child psychiatrist. After all, I love children, and (if I may say so) I'm pretty good at interacting with them. (Maybe I'm just childish?) However, my answer is usually "No." Why? Because I don't like the way we medicalize childhood problems and then medicate them.

Is ADHD a real disease? Sure, why not? I've met kids who were really impaired by their hyperactivity and impulsivity, across settings, with good, appropriately firm parents. I've also met kids who were totally out of control in the doctor's office while mom chats on her cell phone and then looks at me funny when I tell the kid not to hit their sister with the otoscope.

I have seen the number of kids diagnosed with ADHD go up dramatically in my lifetime, and (concurrently) the number of kids getting put on stimulant medication. What happened to behavioral modification? Or family therapy? I've not once seen those prescribed for a patient with ADHD (though my experience is still very small).

And then there's the whole pediatric bipolar debate. Can a 4-year-old kid really be manic? I don't know. But apparently the FDA does, because they're willing to approve medications for use in pediatric bipolar, when even the DSM-IV doesn't have a criteria for it yet, because no one has agreed on what the criteria should be! And apparently Texas knows what it is, because 12% of 0-5 year olds and 2/3 of the teenagers in foster care are taking "psychotropic medication". Twelve percent of kids under 5, and we don't have any idea what these meds might be doing to their developing systems.

So no, I don't think I can be a child psychiatrist, unless I do only therapy, because a) there's very little evidence in kids, because who wants to do studies in kids? b) the studies we have may be flawed c) but we "have to do something" when little Johnny hits his sister, so here's your Risperdal, hope it doesn't zonk you out too much. Oh, it makes you too sleepy in the day? Well, we can try Concerta during the day! Side effects from the Risperdal? Take a Benadryl! We end up with young kids on 3-4 psychiatric medications, and we don't know what any one of them could do to these kids, let alone a combo of multiple.

4) We act like psych patients who are "non-compliant" are constantly wasting our time. I wonder, how many psychiatrists have ever taken, say, an antipsychotic? I've never taken Zyprexa, but I know people who have, and they were complete zombies (who got fat). We act like we're surprised that patients would prefer craziness to weight gain, or sedation, or extrapyramidal symptoms, or (god forbid) tardive dyskinesia. In reality, I think we're asking patients to make a tough choice. Schizophrenics don't get totally well on medication--there is no cure. So, they can have an improvement in their psychosis and mood with a ton of unpleasant side effects, and be quasi-functional, or they can be psychotic and flat and non-functional. This is a tough choice, and we need to appreciate that.
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I guess what's really been bugging me is the huge discrepancy between what we're being taught (in both med school and residency, now) and what is actually out there. We're so "evidence-based"--but so much of our evidence comes from drug-company studies. Or what we "know" is directly in conflict with the "evidence." I don't want to be taught how to dose a medication without knowing the evidence behind it. Is that too high a standard? I don't think so. Would it be any different in medicine or pediatrics? Probably not.

In so many ways, though, I feel like what we do in psych is far behind the rest of medicine. Look at how many options there are for treating hypertension: beta-blockers, calcium-channel blockers, thiazides, loop diuretics, salt restriction, potassium-sparing diuretics... Now look at our options for psychosis: typical or atypical antipsychotics. Possibly group or family therapy; hospitalization for "medical stabilization"; group homes for those whom we can't fix. For bipolar: anti-epileptic drugs, lithium, atypical antipsychotics, maybe SSRI's. When one med doesn't work, we just add more, despite having almost zero studies on combo therapy.

This is not what I wanted. I guess I wanted to feel like I could actually help people. Hopefully, by learning psychotherapy, I still can. I wanted to practice "evidence-based medicine"--how can I, when there's so little good evidence? I guess it's one thing to prescribe Depakote because "it's better than nothing" (although it may not be), because we don't have many better options, but I hate the sales job. Call it a "mood stabilizer" and you believe that it works. Your textbook says "used to prevent recurrence of mood episodes" and you see it as actually preventing episodes, as in all (or most) episodes, not delaying their occurrence by 100 days (like lamotrigine).

I really think basic pharmacology ought to have a segment where they examine (briefly) the best evidence for medications (like second-year med students need more to learn). I think we ought to be exposed to that stuff early. Like, study X showed a number needed to treat of 20 for cholesterol-med Y. Or if second year students can't do that, let's put it into the curriculum for clinical rotations in third year. Or in fourth year when we're lazing around on the beach. Or intern year.

I guess I wish someone had handed me a book that I could reference the actual numbers and studies used to say this drug works on this condition. To the best of my knowledge, no such book exists. Shame on us for not having such a book (and shame on me if there is something but I haven't found it.)

So I'm a little burned out right now. I'm getting plenty of sleep and I just had an easy month, so it's not that. I'm just concerned about my chosen profession and its integrity--scary, huh? And will it be enough for me to just "be with" patients (House of God) in the face of our inability to do much else?

Sign Failure

At the hospital the other day, there was a flyer posted in the elevator lobby:

"BAKE SALE: Urine Luck!!!"

I read further to see that the bake sale was to benefit the renal group's softball team, but all I could think was, I sure don't want to eat THOSE cupcakes!

I Love Kids...

In the elevator today, a mom and her adorable little boy stepped in. He looked to be about 4, and he was in a very cheerful mood. I stepped in, and a crusty-looking old doctor stepped in after us.

We arrived at the little boy's floor and his mom said "This is our floor, time to go have your picture taken!"

Little Boy: "Oh boy, I LOVE X-rays!"

*giggles in the elevator*

Crusty Old Doctor: "So do I, it's my department." (I hadn't noticed that his white coat said 'Department of Radiology' on it, and he was old enough, it could BE his department.)

*more giggles in the elevator*

When Your Students Get Bad Grades...

...why, just lower your grading standards! Which is exactly what the Dallas Independent School District's board has just mandated that all of its teachers do. Dr. Eliu Hinojosa, the superintendent, backs the new rules, which will mandate that teachers accept late homework, give retests for failing tests, and (my favorite) not allow teachers to accept grades on homework that would drop the student's average.

WTF?

So, your average in a class can only go up? What if your average in the class is a 98? Do these people even know how to calculate an average, which includes points both above and BELOW the mean? I guess it wouldn't matter, since these students have zero incentive now to actually DO their homework, anyway, since the teacher can't penalize them for not doing it. Dr. Hinojosa: "We want to make sure that students are mastering the content [of their classes] and not just failing busy work," he said. Oh, so now all homework is busy work? I highly doubt I'd have learned geometry or calculus without practicing at home, and (though I was highly self-motivated) it helped me slog through all those problems knowing I'd get a good grade. I'm sure I wouldn't have been quite so motivated to finish 30+ calculus problems a night if there had been no penalty for not turning it in.

It gets better. Dr. Hinojosa cites research that shows that ninth-graders who are failing 2 or more classes in the first 6-weeks of ninth grade are "doomed" to become dropouts. This is probably accurate, because if you're already failing in the first 6 weeks then clearly the subject matter is over your head or you aren't trying very hard (or both).

Why do I say the subject matter is over your head? The article I linked above goes on to say that teachers are saying the real problem isn't that ninth grade teachers are grading too hard, it's that these kids can't freaking read!

In 2007, 80 percent of them scored below the 40th percentile in reading on the Iowa Test of Educational Development. Yet the promotion rate out of eighth grade for that class was 98 percent. (Dallas Morning News)

So, the majority of these new freshmen read at a below average level for eighth graders. If you can't read well, you can't possibly pass high school courses. Math classes require reading. Science classes require reading. Hell, even drafting, shop, home ec, health, and agricultural classes are bound to require some reading.

This says a TON about the quality of education in the DISD, I think. If 80% of your ninth graders are below average readers, then the quality of your reading program is likely to be--wait for it--BELOW AVERAGE.

So the DISD's answer to their failing freshmen? Lower the standards further. Never mind that nearly 50% of college freshmen from Texas high schools are requiring remedial courses to catch up to their peers. Never mind that the same panel reported that the standards on the TAKS test are so low already that passing this test doesn't reflect that the students are ready for college. Never mind that business leaders are concerned that many Texas high school graduates aren't prepared for the workforce, either.

Let's ignore all of that for a second, and pretend that the problem is that high school is just too hard. Then yes, the answer is to make it easier! If you made a bad grade, we'll just throw that one away!

The real victims, of course, are the students in DISD. Let's take students who are badly prepared by their school to read at a high-school level, and let's give them extra incentives to be lazy. They're going to be told that it's okay not to turn in assignments, okay to make bad grades because they don't count, and then when they hit the "real world" of college or trying to go to work, they're going to be totally stymied. Some of my college classes had 300+ students--do you think that prof gave a crap if I was having a bad day and didn't feel like turning my assignment in on time? And even people who work at McDonald's or a grocery store have to have basic reading skills.

Random data: DISD paid Dr. Hinojosa $327,600 last year. DISD contains 160,000 students currently, 38,586 of whom were in high school in 2007-2008. If 80% read below an eighth grade level (I'm assuming that no further reading instruction was given, so those students reading below the average eighth grader continued to do so through 12th grade), then 30,869 high school students in DISD have poor reading skills and are set up to do badly in high school and beyond. Over the next four years, as those 30,000 students are released on Texas colleges and business as high school graduates (or dropouts), I think we'll see that Hinojosa's rather large salary is a pittance compared to the cost all Texans will pay later for these poorly educated students.

I don't always agree with him, but this time, LawDog has gotten it. Thanks to his site for running this story first.

Grand Rounds

Go check out this week's medical Grand Rounds at sixuntilme, a blog about all things diabetes from a sufferer of type I. She's organized the posts into a form of the Dewey Decimal system on the advice of an evil card catalog in her nightmare. Just because I find that hilarious does NOT make me a huge nerd. Really.

Weight

I've been thinking a lot lately about weight, both mine and other people's. I was made very happy last week when this article received a lot of media attention. Basically, the authors looked at data on 5,440 adults over the age of twenty, including their height, weight, and some lab tests. They also used self-reports of smoking and exercise habits. Overall, they found that inactivity, not weight, correlated with heart disease; so did age, smoking and waist circumference. In their study, 51% of overweight patients (BMI 25-29) had normal blood pressure, cholesterol, triglycerides, and blood sugar.

It's not exactly time to go out and rejoice by eating a gallon of Blue Bell, but this makes sense to me. Our BMI scale takes into account 2 things: height and weight. There are an awful lot of other factors that go into a person's build: gender, bone structure, muscle tone, fat density, etc. Just by BMI, many basketball players and other athletes considered to be in excellent physical shape fall into the overweight or obese categories (of course, I'm not referring to 300-lb linebackers here). Other studies have shown the importance of waist circumference in determining cardiovascular risk. I've seen a lot of people with skinny limbs and a big ol' gut.

This study also shows the other end of the spectrum: the unhealthy but skinny person. I'm sure we've all had thin patients with hypertension, hypercholesterolemia, diabetes, and coronary artery disease. I had a friend in high school who was genetically blessed and very thin. Other girls would (jealously) ask her why she worked out or ate salads--"you don't need to, you're so skinny!" We have this perception that only the fat people need to exercise, that the skinny ones have "made it" somehow, they've won the big prize and can eat cookies dipped in butter all day while sitting on the couch.

This study fits nicely into my personal belief, then: healthy people are active, regardless of weight. They probably eat better, too; not necessarily dieting all the time, but eating balanced healthy meals.

Can runners get coronary artery disease? Sure. I think nothing is truly impossible within the span of humanity (except, perhaps, a man who leaves down the toilet seat). Just as there are marathon runners who are fat (rare, but it can happen), I'm sure there are people who could leave me in their dust, only to have a big MI. It's all about adjusting your risk, just like everything we do in medicine.

Now, this study was just a cross-sectional observational study. The authors didn't follow the overweight people to see if that 51% stayed healthy or if they developed problems later on; they just took a snapshot of a group of people at one time. Just as these authors are cautioning that correlation does not equal causation, that obesity may be correlated but may not cause health problems, so might they be reaching the wrong conclusion.

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I think the heavier you are, the harder it is to be healthy. I can share that I am 5'1" and have weighed as much as 158 lbs, putting me at a BMI of 29.9, which is almost to the obese category. When I couldn't fit into my interview suit from med school to interview for residency, I decided it was time to act, and I hit the gym. I was really appalled at how badly I performed (although I was also having a lot more asthma trouble at that time, too). Still, it's hard to move well with jiggling areas and extra pounds. Every step I took on the treadmill or elliptical, I lifted more weight than a woman my height should (unless she's wearing ankle weights). In other words, my system had to work harder to do the same amount of work as someone with a "normal" weight.

That was around September last year. I worked out and worked out and worked out and eventually noticed I was a little less winded on the elliptical. I'd also lost about 5 lbs, and fit into my interview suit in time, which was my first goal. Over the spring and through my trip to China, I ate a little less, and lost another 5 lbs. This time, I had to buy new pants in a size 10, so now I have a huge motivation not to gain the weight back (if I lose more, I'll have them taken in).

Losing weight is really hard, and I haven't really lost that much. Enough that people noticed; enough that I went down a dress size; enough that my midsection is noticeably smaller (I have an hourglass shape, so most of my weight is on my lower half). I really, really like the way I look now, and I'm having to work hard enough to stay this weight that I'm not sure I'm ready to try to lose more. It's funny, but the first time I weight 148-lbs I felt awful about it. Now, coming down to 148, it feels great. My resting pulse is lower, my blood pressure looks good (it wasn't high, but now it's even better), and my cholesterol looks better (though still a little high).

In other words, if I'm healthy at 148, or a BMI of 28, then that's okay with me. Sure, I'd love to be a size 4, but with the junk I've got in this trunk, it's never going to happen. To get a BMI of 25, back in the "normal" range, I'd have to get down to 132 lbs. I'd really like to get there, but I don't want to end up a yo-yo dieter. I'd rather stay peacefully in one spot than get yanked all over the place. Besides, I really like cookies.

So, I'm really trying to base my personal health assessment on how I feel, what my vitals and cholesterol look like, rather than my BMI. I figure, if I can get on the elliptical for 45 minutes, then walk a mile at a steep incline, and then do a few weights, how bad off can I be? My next goal: to jog a whole mile without stopping or being severely winded. In 26 years, I've never accomplished this; I may never accomplish this, but by god I'm going to try. It would be nice if achieving this goal also got rid of my double chin or made my legs less jiggly, but I'll try not to let that be my only measure of success.

Of course, internship is seriously getting in the way of my personal fitness crusade, but hey, we wouldn't want this to be too easy, now, would we?

JUNK SCIENCE

Today at Fat Doctor's blog, she has a post about a patient who seems to firmly believe that his high cholesterol will have no impact on his life, and that not only does he refuse treatment but he feels "sorry that [she has] been duped." By clicking on the link on her blog, you can visit the website of a physician who uses the term in the title frequently and always in all caps. I'm not going to put his link here because, frankly, I don't want to give his site any more traffic. If you want to visit, go to FD's blog and click her link. Basically, he promotes not exercising, eating tons of red meat, and pretty much doing whatever you want, so long as you take his "cheap" supplements.

Now, does this patient have the right to believe whatever he wants? Of course. If he wanted to believe that little aliens in his bloodstream were doing battle with the bad cholesterol with argon laser beams, he has that right. Does the patient have the right to refuse intervention? Absolutely. Cholesterol-lowering drugs are not benign therapies. Statins can cause rhabdomyolysis, most cholesterol meds can cause elevated liver transaminases, most (if not all) can cause GI upset, and of course, they all cost money. Without insurance, Lipitor can cost $100 per month (I'm having a hard time finding a good estimate online, so forgive me if that is inaccurate). There will always be patients who don't want what Western medicine offers, and that's okay.

The problem is that this guy claims to be a kind of maverick doctor hero, set against the pseudo-science of mainstream medicine, offering treatments that only he knows about. For example, he claims that only low cholesterol is unhealthy and that even the American Heart Association agrees. He says that patients with low cholesterol can be just as prone to heart disease as those with high. You know what? I don't have exact numbers, but it's true that patients with low cholesterol and no known, accepted risk factors can have heart attacks. It's also true that people with high cholesterol may never have a heart attack. Finally, it is true that other factors are involved that we don't know much (or anything) about. Homocysteine is one; the "pattern" of LDL is another; apolipoprotein subtype ratio is yet another. Cholesterol level is not the only predictor of heart disease.

Yet, total cholesterol, LDL and HDL levels are all well-correlated with cardiovascular disease in multiple, multiple studies. There may be a lot to this picture we don't fully understand, but we do widely accept that elevated total cholesterol and LDL and/or a low HDL level puts you at risk for heart disease. We do have good study data that shows that lowering LDL and raising HDL reduces risk of heart attack and death even in those who had a previous heart attack. It's a risk reduction, not a guarantee, not a promise of no future heart attacks, but a better chance for not having another one. And, though I cannot get the AHA website to load for me today, I'm pretty sure their guidelines for cholesterol have not changed since last month when I was on neurology and we followed their guidelines for lowering cholesterol.

One problem with evidence-based medicine (of which I am only a novice at best) is that we can only say what the evidence tells us. If we don't have a study, then we can't say yea or nay. When the Women's Health Initiative shocked everyone a few years ago by showing increased cardiovascular events in women on hormone replacement therapy, the best available evidence at the time was to stop all HRT. Now, the picture is much muddier, as more and more studies try to tease apart the risks and benefits of HRT. What does the evidence tell us? It's really hard to say. All I know conclusively is that HRT lowers symptoms of menopause. So, ob/gyns prescribe it for that. Who knows about the increased risk breast cancer or heart disease or DVT or decreased risk of colon cancer? Is it worth it to increase the risk of breast cancer to decrease the risk of colon? Who knows? (I'm obviously no expert in HRT, and I will leave a more detailed discussion to those who are).

Another problem with evidence-based medicine relates to the studies. One study says that drinking 1 glass of alcohol daily lowers your risk of heart attacks, so the media gets excited and tells people to drink. Then, the next study says it's red wine, not just alcohol. The next says the level is 2 drinks for men. The next says it's so many per week, and if you don't drink that much, then just don't bother. Some studies don't show a benefit to drinking at all, or point out the liver toxicity and risk for dependence. We have different studies that advocate, in turn, low-fat, high-fat, Mediterranean, Atkins, South Beach, low-salt, low-meat, high-meat, low-carb, high-carb, low-protein, high-protein diets. Everyone was shocked recently that the Atkins diet wasn't shown to increase cholesterol. A Mediterranean diet (lots of olive oil) has been shown to be more favorable than the tradition low-fat AHA diet in some studies.

But I digress.

This guy's website is a hodgepodge of truth, incorrect facts, and flat-out lies. Truth: drinking 8 glasses of water per day is a healthcare myth. In terms of hydration, you can get enough water from food and other liquids (even coffee, tea, and soda) to keep you hydrated. Lies & half-truths: the AHA warns that low cholesterol can lead to the deadliest kind of stroke known as the "massive stroke". First, I don't remember learning about the "massive stroke" when they taught us about ischemic versus hemorrhagic, cardioembolic versus large-vessel, etc. Second, is he referring to total cholesterol, or to HDL?

My final problem with this guy's site, before I quit reading it because I was so angry, was right at the top. Next to his link "Find Out What Your Doctor's Not Telling You" is a link "Recommended Products". Here's the key to this guy: he's selling all the supplements he recommends. It's his website that the link goes to. His proprietary "NATURAL HORMONE THERAPY" will only cost you $29.95 for one month, the same price for his "ULTIMATE DAILY SUPPORT". I'm sure he would argue that this is no different than any other doctor prescribing Lipitor, because everything costs money. Sorry, bud, but Pfizer wasn't knocking on my door to give me a big paycheck every time I wrote a script for atorvastatin on neurology (and often, we used the generic simvastatin unless there was a reason to use Lipitor specifically). $0 in my pocket versus $30 in his from the sale of his supplement. (Of course, there are doctors who are getting $$$ from drug companies to hawk products, and shame on them, too).

There's a pretty fine line between a "physician" and a "quack". Those who do their best, slog away learning the best available data, try to read a JAMA or two at the gym, go to CME conferences, and generally try to stay afloat the most recent data represent the current ideal of American medicine. Western medicine doesn't have all the answers. Some of our treatments don't work, and others will be outdated in 5 years. It could be that in 20 years we'll look back and laugh at our current understanding of cholesterol metabolism and atherogenesis. I'm hoping that our knowledge in medicine will be much more personalized by then, so we can more accurately assess a person's risk for bad outcome from a disease and tailor a therapy just to them. For example, the recent PSA outcry has people wondering, how can we tell which men have a favorable, non-lethal tumor, and which have an aggressive tumor which needs removal?

But there's still a difference between trying to keep abreast of the best medical advice, and making up your own "science" in order to sell a vitamin supplement. When drug companies do this, we cry foul, and many patients are wise to this scheme. Unfortunately, when doctors do this, patients may be unaware. It's one thing to buck traditional medical science and point out its many flaws; it's another entirely to just start making stuff up on your own so you can sell books and pills.

And yet, I'm still bothered. I guess I need to believe that in medicine, we're not perfect, but we're doing the best we can. Guys like this exploit the weak points of medicine and rub it in our faces by using inflammatory language. It's rather like a schoolyard bully singing "nyah, nyah, nyah-nyaaaaah, nyah". You can look at it for what it is, you can cover your ears and say "go away!", you can know fully that it's just a stupid song, "a tale told by an idiot, full of sound and fury, signifying nothing"--and yet that song still gets under your skin. Sometimes, when I acknowledge just how much we don't know, and how limited science actually is, I feel like there are fewer differences between "physicians" and "quacks" than I would like to admit.

I just hope that as our science gets better, the gap between the two gets wider.

It's Genetic, I Swear...

Email from my dad this morning:

"So if the Russians invaded Georgia, is Alabama next?"

Email response I sent back:

"It's Shermanov's March."

I couldn't help it.

Wow

I would just like to say that I didn't expect all the positive comments. I'm afraid if I get anymore, my head will get so big it will actually explode, which would be messy. Seriously, many thanks for the support.

I haven't quite figured out what I'm going to do. I feel like I'm probably going to do a little blogging about residency and what I'm doing, since (as Midwife with a Knife pointed out), the First Amendment still applies to me. I will try to avoid writing about patients as much as possible, though, since I'd hate to violate someone's privacy. Writing about other people, particularly patients, brings a whole other level of complexity to this equation.

It puts me in a bit of an awkward situation at work, though. I'd like to participate in some kind of discussion about blogging, but just by doing so it threatens my anonymity at work. Right now, the only person at work who knows I blog is an upper-level resident whom I confided in, so now I'm in a weird spot, since he's the one who forwarded the email to me about blogging. If I continue blogging about work, and he's the one who told me the policy is not to do so, then in essence I'm lying to him, or at least betraying his trust. As ridiculous as it may seem, I've considered contacting a lawyer (or at least, a friend who happens to be one) to get legal advice on this issue. After all, this is my current job and future career that could be at stake.

I really would miss blogging terribly, though. I love having a reason to write. I've never been good at keeping a diary or journal, but I've managed to write a little bit in this for nearly 3 years now. That's something to be proud of, no matter how poor the writing is sometimes (or most of the time), or how many times I simply degenerate into curse words. And all joking aside, I was really moved by all the positive comments. Thank you, thank you, thank you.

Quote of the Day

"Tropical Storm Edouard? Spelled with three vowels, O-U-A? Oh my god, how gay can you get???" --said a gay friend of mine today

In no way related to the sexual preference implied by the name Edouard, this was one wussy tropical storm, IMHO. A friend in Houston called and said they only got 2 inches of rain. Where are the broken trees, the blown-off roof tiles? The videos of guys riding their bikes through flooded streets saying "This ain't so bad"? Geez!

Changing It Up

I suspected that this day would come, but even so I wasn't entirely prepared for it. In discussions with my chief resident about how I was dealing with my patient's death, I blurted out "Oh, I blogged a little bit about how I felt about it, which seemed to help."

Big, huge mistake.

Apparently, the organization where I'm doing my residency sent out a "cease and desist" email last year to resident bloggers, asking/telling them to immediately stop blogging about anything to do with patients or residency. I was forwarded a copy of this email. It would seem that the reason they are concerned is that a blog could be used in court as a medico-legal document. I'd say that is ludicrous, but most of us still remember what happened to Flea.

So now I'm trying to figure out what to do.

I think I'll leave up previous posts written during residency, as they were all written before I'd gotten the word. If you notice something you feel is a HIPAA violation (keeping in mind I try to change personal details and deliberately keep things vague), shoot me an email at tinyshrink77@gmail.com so we can talk about it. I'm afraid I'm going to have to quit writing this blog, though, as I really don't have much of a life outside of residency. Even if I never posted anything about a patient, ever, the email specifically says "and residency". If I were a great cook, or could write discerning article reviews in psychiatry weekly, or had something else interesting to say, it would be different, but I don't.

Partly, though, it made me a little angry. Another resident told me he writes fiction and non-fiction (I'm assuming with the intention of publishing), and he takes similar precautions to change patient data, so if his book were published how is that different from my blog? It could still be used in court, right? Even a diary, if its existence is known, can be admissible in certain cases, so how is that any different? Could a draft of a manuscript be admissible? I think the program took the "just stop it now" step with the intention of examining its policy later, but it doesn't seem that any actual discussion has taken place. If it had, surely they would have made this an official policy instead of just an email, sent out before I joined the organization.

Ugh. I haven't posted since I found out because I didn't know what to say. I'm not in any trouble with my program, and I'd like to keep it that way.