Tuesday, August 15, 2017

The Google Memo





I decided to comment on the now famous (or at least viral) Google memo as an anchor point for social media on the blog. After making its way through the social media and into the mainstream media, I don’t think that it is necessary to say much about it other than it was written by a Google software engineer James Damore who was subsequently fired for the effort. I qualify my statements by saying that I do not know this engineer or anything about the corporate culture at Google other than what was written in his long memo. I do have 33 years of experience steeped in every aspect of medical culture. That includes working for corporations that have implemented many of the initiatives discussed in the memo. My overall take is that corporate politics can be dangerous to your health, but not because of major party politics.

The Memo presents a confusing introduction. The author states that he does not believe in stereotypes but proceeds to argue from that viewpoint. He discusses the predominate liberal atmosphere at Google and what that means in terms of liberal stereotypes. He refers to himself as a classic liberal, but at the same time complains about and refers to being discriminated against as a conservative. Despite the ample qualifiers, there is an implicit suggestion that due to inherently different characteristics – it may not be possible for a substantially male population in coding to be altered in material ways and that the programs in place to do an end run around this issue are not cost effective for the company. It is a strong argument to maintain the status quo.

As a kid growing up in the 1960s, female physicians were unheard of.  In the subsequent decades all of that changed drastically.  When I started in medical school, about half of the class was women, but women were substantially underrepresented in largely surgical specialties. There were clear problems with the transition. I can recall rounding where there were open arguments and verbal attacks based on gender by people at the same level of training. As a medical student I was privy to the private conversations of both sides and in those days it was all about gender. But thankfully only in a few areas. I had the opportunity to train with attendings and residents who were women and who were first rate physicians and academicians. Because of the gender based undercurrent, I also felt the backlash. Being an introvert is like being a projective test for some people. I got feedback from a male resident that the female attending on one of my rotations thought that I did not like women and that was just inaccurate. I attributed it and some other attitudes from a few women I encountered to biases they may have encountered along the way. I won’t say that did not have an effect on me – but it did not adversely impact my progress on the path to being a physician.

By the time I became a resident, half of my class was women. I viewed them as colleagues. They were all clearly as bright as I was. The farther I got into psychiatry, the more remote the gender biases seemed to be. I was eventually hired into a department that was largely women. It had a collegial atmosphere. In all areas of patient care, I never doubted that the work they were doing was at the level of my work. I would not hesitate to refer people to them or consult with them in tough situations and do so even today. In psychiatry, women are well represented in professional societies, scientific meetings and publications. I have never heard a male psychiatrist utter a word about women being less skilled or professional in psychiatry. It would be taken as an absurd statement.

The brief recap of my experience of gender representation in psychiatry has its limitations. It is my experience over 30 years in the field. It is in a field that is in short supply and may be dying – rationed out of existence by the government and managed care companies. For many years, interest in psychiatry was low. The problem has never been studied to my knowledge but my speculation is that enrollment by women in both medical school and psychiatric residency programs probably averted a much greater crisis. I can’t speak to the initiatives that got the enrollment in medical schools to go higher, but whatever it was – consider it highly successful.

That does not mean it was an easy transition.  Although I never personally witnessed it, I have no doubt that women and minority students were treated badly at some point in their medical training.  I base this on my own experience of being treated badly.  There were clearly attending physicians who were not interested in the education of medical students and were openly hostile.  I was ridiculed in front of one of my teams by the attending physician when he learned that I was going into psychiatry.  "You don't want to work Dawson?  Psychiatrists don't work as hard as other physicians and if I needed counseling I wouldn't see a psychiatrist".  All of that was presented with a congruent sneer. I held back at that time at the time, and did not tell him it would probably take years of psychoanalysis rather than a few counseling sessions.  

I observed in those days that the abusive cultures seemed to be localized in private institutions.  I naturally gravitated to the public ones - the County Hospital and Veteran's Administration Medical Center.  In these places there was a certain  esprit de corps.  There was a lot of work.  The staff were interested in caring for very ill patients with limited resources being available.  There was generally a wide sampling of specialists and everyone seemed accepting of medical students and residents as long as they pulled their own weight.  I met some of the best attendings and teachers in these settings.

The corporate takeover of medicine facilitated by the federal government created a hostile and authoritarian atmosphere.  Instead of being responsible for your own knowledge and how you took care of patients you were now burdened with totally subjective administrative standards.  The first was the new billing and coding standards.  Miss a bullet point in the document and get accused of fraudulent billing.  Send that bill in the mail and get accused of racketeering and go to Leavenworth.  People may find that humorous now, but I can assure you that in about 1996, every physician in my organization had to attend a seminar and that is part of what we were told.  As the feds transferred their power to intimidate to managed care organizations a whole new set of rules to intimidate and control physicians was put into place.  The "disruptive physician" concept was suddenly co-opted from physicians with clear personality disorders to just about anything that a physician did that somebody did not like.  In some institutions the accusations did not have to be witnessed or even factual.  Some institutions just adapted a "three strikes and you are out" policy.  In other words, if they collect 3 unsubstantiated, unwitnessed and (according to their rules) uncontested complaints - the physician could be fired.  That was a discretionary rule, I have seen physicians fired for just one complaint.  By the time the corporations had taken over, these rules were equally applied regardless of gender or race.  I personally know male and female physicians who were fired or who just collected a strike or two.  Equal oppression by the corporation may be the ultimate sign of egalitarianism.            

I am going to digress for a minute on the science of the memo, because the author seems to invoke this theme several times, even to the point of offering to send more references.  This memo is not a scientific endeavor, it is a political one.  In that process, even the extremes of liberalism and conservatism will be able to come up with scientific papers to support their extreme positions.  Even though there is a general consensus on climate change this is an example.  Not everyone agreed with Einstein's revolutionary theory and at the time his work was highly politicized based in part on his ethnicity.  The process of science is not designed to be taken in a political context.  The other aspect of the science of the memo has to do with measurement.  Measurement in the social sciences is a very approximate matter.  It requires individualized expert interpretation in a highly specific context.  I have lost count of the number of professional people that I know who were told by guidance counselors that they would never make it in college.  Measures of personality and intelligence have significant limitations.  They are not quantitative by any means.  One interesting conceptualization of the problem is Massimo Pigliucci's graph of empirical knowledge versus theoretical understanding.  On this graph, theoretical understanding of social sciences is definitely lagging.  Even though there is a well publicized reproducibility problem in social sciences, I consider that to be expected rather than a problem that needs to be solved.  In situations where the human conscious states is the subject of analysis, it is necessary to keep in mind that we have no adequate analysis of a very large number of possible states and how they overlap between men and women.  There is nothing to suggest that interracial differences at this level are significant.  Everyone has a somewhat heritable biological substrate, but in the case of the brain we have an infinitely plastic and complex organ that we are just beginning to understand.  It is easy to mistake the positive and negative effects of socialization for a biologically inherent trait.      

My experience in the workplace, at various levels of medical and scientific endeavor has made it very clear - irrespective of socialization or biology - men and women can function interchangeably doing the same tasks. The idea that one sex is intellectually superior or has personality characteristics that can lead to inherently better performance in the workplace is just plain wrong. I certainly can't speak to the workplace or political environment at Google, but I can say that the political environment in most real workplaces these days is dominated by corporate rather than major party politics. That corporate approach opens a number of avenues for the corporation to demand specific compliant behaviors from employees with possible penalties right up to termination.   Squabbling about major party politics at the water cooler pales in comparison.

It turns out that every corporation is an "ideological echo chamber" but that ideology originates at the level of the executives and the board of directors.  It is overwhelmingly focused on the best interests of the corporation and not the employees.  Attempting to impact that with a generally released memo like this one is a naive mistake and it misses the mark for many reasons.  The commentary from outside of the organization is predictable given the source, and of course entirely irrelevant to the intended purpose of the memo. And lastly, Damore's ideas about why men make superior software engineers is possibly accurate but I doubt it.  The women I have gone to school with and worked with were very bit as good as the men in those settings.  Engineers may be tempted to say that medicine is not software engineering and that is true, but for some of us there are a significant number of quantitative sciences and mathematics courses long the way.

And it was always obvious to me that we need as many women in those classes and professional schools as possible.



George Dawson, MD, DFAPA






Supplementary 1:  I could not work this into the main body of the post but the social media spin on this memo has been intense.  Spins saying that it has the science right and spin saying that it has the science wrong.  The author having to defend himself on the issue of whether or not he supports the alt-right.  He said that women aren't good at tech and he has said that there are women who are good coders at Google.  The reality is that women can do what men do and at no point in our history has there been more proof of that.  That is a much different issue from corporate governance or politics.
  


Reference:

1:  James Damore.  Google's Ideological Echo Chamber.  July 2017.

      It is available from several sites on the Internet.    





Friday, August 11, 2017

Computational Psychiatry

From Reference 1

In the 1970s I was reading a lot of science fiction in the Peace Corps. One of those books had a story about a scientist who had figured out all of the mathematical equations for human behavior. Although it was clearly fiction that thought stayed in my mind over the decades. When I was doing quantitative EEG work in the 1990s, I thought about it but it was apparent that the statistical models being used for that work were not remotely related to the observed behaviors that these devices were trying to classify – and there was always some clinical variable (eg. Did the subject have an alcohol problem or traumatic brain injury?) – that seemed to make the equations even more approximate. An electrical engineer that I was working with was able to apply a complexity measure to the output from a single electrode from an EEG and demonstrate the expected decrease in complexity with neural networks in Alzheimer’s Disease. That metric was interesting but not at the level where second to second behaviors could be examined. It was more of a brain state function.

That brings me to the recent article in JAMA Psychiatry entitled “Association of Neural and Emotional Impacts of Reward Prediction Errors With Major Depression”. Reward prediction errors are the difference between experienced and predicted rewards. The authors note that if the reward exceeds the expectation then “the value associated with the chosen option is increased, making it more likely to be chosen again.” As I read this, I thought about the case of chronic addiction where that is no longer the case and the maladaptive choice is made over and over again. I also thought about the subtler case of low frequency unexpected rewards. A common experience would be the “Aha” experience that universally occurs when problems are suddenly solved and exam questions answered after a unique insight is realized. As I tell my students, there is good evidence that if we put the person’s head into an fMRI scanner right at that instant that their nucleus accumbens would be lighting up. There does appear to be a lot more going on that the difference between experienced rewards and expected rewards.

This study looked at the issue of whether depression attenuates ventral striatal reward prediction errors (RPEs) in a task that did not involve a significant learning component. It was already known that there were attenuated RPE signals in the ventral striatum of people with depression during reinforced learning. It was also known that in healthy controls RPE variation explains momentary mood fluctuations.

The experiment itself consisted of two phases. In the first, a laboratory study looked at 34 subjects and 10 controls with diagnoses of depression after fairly rigorous exclusion criteria were applied at the clinical and fMRI level. The majority of the experimental group and half of the controls were women. It appears that all of the depressed patients were taking antidepressant medication. The subjects completed a risk decision task that did not require any learning and was designed so that performance by the depressed patients and controls was the same. The task consisted of 160 trials where the subject was asked to choose monetary gambles with two outcomes. The outcomes were given in real money. They were then asked to rate their happiness on an analog scale in response to the question: “How happy are you at this moment?” During the tasks, fMRI blood oxygen level dependent (BOLD) activity was measured. The MRI plane was optimized to view the ventral striatum. In the graphics both transverse and coronal MRI planes are depicted with the pixelated areas of interest in the ventral striatum.

In the second phase of the experiment, the risky decision tasks was translated to a smartphone app, The Great Brain Experiment (http://www.thegreatbrainexperiment.com). A total of 1833 participants completed 30 choice trials and 12 ratings. They were not compensated.

In terms of results, the depressed group and controls had similar earning on the probabilistic reward task ($7.75). Median reaction times and choice accuracy were also similar. Ventral striatal BOLD activity on the fMRI correlated with reward magnitude and did not differ between depressed subjects and controls. A lack of difference between these groups was also examined across reward magnitude, anhedonia, and antidepressant use and no differences were found.

In the smartphone sample, the momentary mood computational model (see above equation) correlated with happiness ratings. The model worked better is severe forms of depression. Anhedonia did not correlate with the impact of RPEs but other depression questions on the Beck Depression Inventory-II did.

The authors conclude that their results demonstrate that there is no impairment in “basic reward-related neural and emotional processes in depression in a non-learning context”. The dopaminergic RPE signal was the same in the depressed group and controls. They make the further arguments that dopamine signaling in the ventral striatum is complex and other factors are involved. They discuss a model from the literature that discusses the cognitive deficit in depression as one of goal directed reasoning based on a model of the causal structure of the world. They imply that dopamine at least in the studied reward systems may not have a central role in depression.

The authors discuss a major limitation of their study in that only 9/32 subjects with depression were unmedicated. They discuss how they examined some parameters that suggests this effect was not significant. An ideal study would look at both the effects of severe depression (PHQ-9 score here was 15.8 [SD 4.7]) , no medications, and patients who have never been medicated. It might be useful to consider more rigorous elimination of other disorders affecting the ventral striatum. All things considered it is a useful look at an experimental paradigm that demonstrates the utility of brain imaging in applications that can be used on a wider population basis and whether or not they may be valid.

The accompanying editorial by Rabinovich and Varona was interesting.  They make the argument that the global conscious state is too complex to be described by mathematical equations but various components are not.  They go on to describe their own model of global brain networks and how they interact with one another.  They suggest that brain networks are very similar and vary only in content and the complexity of their content.  As an example in the creativity process, the channels stay the same whether the process involves music, poetry, or mathematics.  They suggest the same processes are active in psychiatric disorders and illustrate cognitive and ritual heteroclinic channels in obsessive-compulsive disorder.  They suggest that these dynamic systems in the brain can be determined and can be quantitatively characterized by various means like the value of the Kolmogorov-Sinai entropy. Mathematically modeling the brain as dynamic systems has been around for some time.  I will have to review this work but it seems that it may not incorporate enough of the physical characteristics of the systems into the mathematics.

Finally, I would be remiss if I did not mention the excellent review by Wang and Krystal (3) and well as many of their other articles on computational psychiatry.  Their definition of computation psychiatry is a discipline that seeks to incorporate the computational mechanism from a real neural network into its role in psychiatric disorders and the way a person actually functions.  This is an exciting approach because it represents the ultimate integration of all of the anatomy, physiology and pharmacology that we study into a real working system. It is exactly where the field needs to be heading.  I think there is a natural overlap with the study of human consciousness.

These are exciting times and computational psychiatry is adding to that mix. 


George Dawson, MD, DFAPA



References:

1:  Rutledge RB, Moutoussis M, Smittenaar P, Zeidman P, Taylor T, Hrynkiewicz L, Lam J, Skandali N, Siegel JZ, Ousdal OT, Prabhu G, Dayan P, Fonagy P, Dolan RJ. Association of Neural and Emotional Impacts of Reward Prediction Errors With Major Depression. JAMA Psychiatry. 2017 Aug 1;74(8):790-797. doi: 10.1001/jamapsychiatry.2017.1713. PubMed PMID: 28678984.

2:  Rabinovich MI, Varona P. Consciousness as Sequential Dynamics, Robustness, andMental Disorders. JAMA Psychiatry. 2017 Aug 1;74(8):771-772. doi: 10.1001/jamapsychiatry.2017.0273. PubMed PMID: 28564683

3:  Wang XJ, Krystal JH. Computational psychiatry. Neuron. 2014 Nov5;84(3):638-54. doi: 10.1016/j.neuron.2014.10.018. Epub 2014 Nov 5. Review. PubMed PMID: 25442941

4: Keller K, Mangold T, Stolz I, Werne J. Permutation entropy: new ideas and challenges. Entropy 2017, 19(3), 134; doi:10.3390/e19030134

Contains a section on Kolmogorov-Sinai Entropy and a discussion of EEG applications.

5: Donoso M, Collins AG, Koechlin E. Human cognition. Foundations of human reasoning in the prefrontal cortex. Science. 2014 Jun 27;344(6191):1481-6. doi: 10.1126/science.1252254. Epub 2014 May 29. PubMed PMID: 24876345
I included this reference as a great example of the network in the frontal cortex that are active in reasoning and activation of the ventral striatum during good decisions (the "aha effect").

6: Piray P, Toni I, Cools R. Human Choice Strategy Varies with Anatomical Projections from Ventromedial Prefrontal Cortex to Medial Striatum. J Neurosci. 2016 Mar 9;36(10):2857-67. doi: 10.1523/JNEUROSCI.2033-15.2016. PubMed PMID:26961942.

7: Jarbo K, Verstynen TD. Converging structural and functional connectivity oforbitofrontal, dorsolateral prefrontal, and posterior parietal cortex in the human striatum. J Neurosci. 2015 Mar 4;35(9):3865-78. doi: 10.1523/JNEUROSCI.2636-14.2015. PubMed PMID: 25740516.


Monday, August 7, 2017

Why There Are No Bipartisan Solutions To Exorbitant Healthcare Costs In The USA




I happened to see Face The Nation yesterday.  Governors John Kasich and John Hickenlooper were on, talking about their attempted bipartisan solution to health care reform.  Their basic idea is that they and their staffers should be able to compromise and come up with a better proposal and possibly model cooperation for all of the uncompromising members of Congress.  Things did not look very well after the opening question by host John Dickerson:

"And we have seen in Washington both sides say they don't want to give up much of anything.  Give me your sense of what Republicans should back down on and what Democrats should back down on just as a preliminary good-faith effort to show that people are, on the health care question, committed to maybe working together."

I took out the key statement for both responses and included them in the above graphic.

The statements are very telling in terms of political rhetoric disguised as political philosophy.  Kasich seems to believe that there is a free market at work.  Hickenlooper seems to be more focused on the insurance principle of adverse selection - in this case the buyers of insurance with health problems are more likely to buy health insurance than younger healthy people without health concerns.  That leads to a concentration of buyers who increase the risk for the insurance company paying out and in the worst case a loss for the company.  Translation - the Democrats should give up on the idea of mandatory health insurance and the Republicans should give up on the idea of repealing mandatory health insurance.   That is quite a compromise.

An ethical framework is probably a better one to start from.  As I argued in a recent post - if your ethical priority from a political perspective is to allow people to have a choice - then give them choices when it comes to health care.  No choice is not an ethical option.  If your ethical priority is the value of human life - then universal access is necessary.  If the ethical priority is making sure that the resources being used by people who need health care services is finite and needs stewardship - then by all means make the entire system more cost effective for society at a whole.

All of the suggested ethical approaches cannot occur when the level of financial conflict of interest is large like it is in Congress.  Members of the US Senate get on the average $438,000 in donations from the Health care sector (PACs and individual contributions in the 2015-2016 election cycle).  That is a powerful incentive to keep making arguments about free markets and insurance markets that do not make any sense.  They make even less sense when it is clear that these same politicians are being lobbied to maintain the status quo - even though it is the most expensive and most inefficient health care system in the world.  The following graphic on the accumulation of administrators relative to the increase in physicians is just one illustration of that point.

Personal Communication David Himmelstein with his permission - July 2017.



So the next time you hear about the need for compromise and results from Congress, keep this scenario from Face The Nation in mind. Unless you have a reasonable assessment of what the problems really are, there is no starting point for compromise or consensus building. Policy makers in Washington are so far removed from an accurate assessment of the problem bad policy after bad policy is the logical outcome.


In discussing the problem with them a fair question is why the United States is incapable of coming up with effective health care at a reasonable price when all health care is currently rationed by for-profit companies.

It does not take single payer to get a better result, but it does take a government that is for the people rather than big health care business.



George Dawson, MD, DFAPA


References:

1: Face The Nation Transcript from August 6, 2017: Guests included Tom Cotton, John Kasich, John Hickenlooper, Jeh Johnson, Susan Page, Reihan Salam, Jennifer Jacobs and Jamelle Bouie. (Accessed on August 6, 2017).



Monday, July 31, 2017

The Charlie Gard Case - Why Political Rhetoric Can Never Be Ignored...

  Charlie Gard died three days ago after his life support was withdrawn.  He was a British infant born less than a year ago with infantile onset encephalomyopathic mitochondrial DNA depletion syndrome.  There are three genetic subtypes listed on OMIM and I those linked in the Supplementary material below.  Note that the capital letters in the titles is a convention of OMIM and not my addition.  The medical details as well as the basis for the legal decision is available online.  In this case the court sides with the Great Ormond Street Hospital in deciding to withdraw life support because of Charlie Gard's terminal medical condition.  In the summary an American physician is mentioned who apparently suggested that nucleoside therapy might be tried even though it has never been tested for this condition in humans and it has never been tested in a mouse model of the human disease.  The judge refers to the culture around these issues in the USA as being "slightly different" in that anything might be tried.  This court document was apparently written before Charlie Gard was examined by the American physician Michio Hirano, MD who offered Nucleoside Bypass Therapy an experimental treatment for mitochondrial diseases.  The parents of Charlie Gard ended their legal case to bring him to the United States for experimental treatment on July 24, 2017 - four days before he died.  In the language of contested court cases - their attorney said that new tests confirmed that the experimental treatment would not help.  In fact, there was no real evidence that the experimental treatment would have ever helped.

The conflict between Charlie Gard's parents and the Hospital began after they successfully raised enough money to take him to the USA for treatment in January.  The Hospital's argument at the time was that it was not in the best interests of their patient and subsequently that the treatment being offered was unlikely to be of benefit.  The court documents describe their opinions included the opinion of an expert in mitochondrial diseases who had authored 140 scientific papers and book chapters. He is described as a person with grave neurological disease who is maintained by life support and the in the opinion of the Hospital staff the life support should be removed and he should be allowed to die.

From a political standpoint, the right wing in the United States picked up on the case as a case of a socialist health service against the rights of the parents or as Brook Gladstone (On The Media) said: "a martyr to statist tyranny."  On that same show, Melanie Phillips a conservative blogger and writer for the Times of London described the conservative commentators position in the US as "ignorant and ideological".  She describes their writing about the case as something that could be used in the fight to repeal of Obamacare.  She points out that conservative commentators in the UK are not invested in portraying the National Health Service as a killer.  She points out that right to life activists and that agenda only exist in the US.  It is part of a long succession of political rhetoric that suggests that the risk of a more openly government run system is that it puts the government between the patient and the doctor and the decisions are more likely to be consistent with what the state wants.

I decided to read and footnote one of the articles from the right (5) on this dilemma. In her article on Fox News Health, Penny Young Nance makes the case that the problem is really big government and socialized medicine and that no government can take away God given rights.  The counterpoint to this opening premise is that the political right generally does not view health care as a human right.  They view it a a business and something that must be earned based on merit.  Her second premise is that American healthcare is cutting edge and driven by cure as opposed to National Institute for Health and Care Excellence in the UK that is driven by profit.  Both elements of that second premise are erroneous.  I don't think that there is any evidence that the UK uses less technology and irrespective of how they use it their outcomes are better at a fraction of the cost than the most expensive medical system in the world in the USA.  I also don't know how socialized medicine is making profits (and for who) by denying unnecessary care.  The third premise is that technological advances like the eradication of smallpox requires a free market approach to innovation so that mistakes can be made.  In actual fact, smallpox eradication was a long effort of physicians, academics, public health departments, some private industry, and the World Health Organization.  That is hardly a free market effort. It could easily be argued that it would not be profitable enough for American companies to enter.  She goes on to critique the Independent Payment Advisory Board (IPAB) under ObamaCare as being similar to NICE as a health care rationing body.  NICE is not a rationing body and this opinion leads me to question if she ever viewed their extensive web site of some of the best medical evidence collected in the world.  She conflates IPABs ability to control prices as "shoving us in the direction of single payer health insurance." Every more successful and far less expensive health care system in the world has cost control mechanisms.  Her summary statement connects the Charlie Gard case and IPAB:

"We should heed Charlie’s case as an example of gross government overreach and repeal IPAB immediately."

Only the political right wing in America can draw such a connection.

The rhetoric of the political right, is basically rhetoric that is thinly disguised as concern about individual rights.  It requires a complete suspension of the current reality in health care. Those realities include the following.

1.  Medicine is best practiced by physicians especially the ones taking care of you: 

In Charlie Gard's case he was assessed and treated by experts from multiple specialities in the UK.  No reasonable American physician would doubt that he received expert care and care that is probably available in a small minority of medical centers in the United States.

2.  Medical ethics can easily be politicized but their foundation is more sound than politics: 

There are two relevant concepts here - futile care and experimental treatment.  In this case the best summary appears to be that there was really no evidence that the experimental care would do anything to alter the course of Charlie Gard's terminal neurological illness.

3.  Political opinions on ethics don't have to be consistent:

There are striking inconsistencies in the positions offered by the political right.  At the level of personal choice they make it seem like there is a panel that will be taking healthcare choices away from Americans.  In fact, the panel will be addressing prices and cost containment.  The political right also seems to have completely ignored how health care is rationed by health care companies and subject to racial and socioeconomic disparities. We are currently in the midst of a very inadequate system of mental health and addiction care based on 30 years of rationing by private American companies.  If you are elderly and have a significant illness in an American hospital managed by an American company, you or your family is likely to be approached about the idea of palliative care or hospice care.  It might be recommended that you forgo certain diagnostic tests or procedures because of your illness and transfer to a hospice setting. Nobody discusses the fact that these recommendations are aligned with the financial interest of the hospital.  If you stay there too long or use too many resources - they lose money.  This is the current system of care in the United States. As most people know - you don't have to worry about the government.

You do have to worry about the the corporations making profits by charging you plenty of premiums and copays and deciding how they will not have to pay that out in services.  That is the rationing that occurs millions of times a day in the US.  

4.  How is a market system that appoints private businesses as proxies for rationing services and  that ignores the health of tens of millions of people ethical?

As noted above - as millions of people are uncovered, tens of thousands die and more suffer.  If your ethical priority is choice - these people do not have a choice.  If your ethical priority is the sacred nature of life - these people have immediately been devalued.  Unless I missed it - these seem to be the main ethical arguments of the political right.

On the whole idea of the government getting between you and your doctor - there are currently two people standing between you and your doctor in the United States.  The first is your health care company.  The second is the company that manages your pharmacy benefits.  If either of these companies does not want to act on your preferences or your doctors orders - they can make life miserable for both of you.  The level of misery can extend from a flat denial of service or medication to saying that you don't meet their medical necessity criteria for a service.

The only logical conclusion here is that American healthcare is highly flawed from an ethical perspective and right wing opinion clearly wants their constituents to believe that it is something that it is not.  We are certainly technically competent to provide care.

The political right has elaborate rhetoric to cover the flawed ethics and the balance tipped in favor of corporations rather than people.  That keeps Americans from getting to the same level of performance as the other, less expensive systems in the world.  That includes the National Health Service in the UK as evidenced by the life expectancy graph at the top of this post.


George Dawson, MD, DFAPA




References:

1:  Melanie Phillips.  Why America Got the Charlie Gard Tragedy So Wrong, July 29, 2017.  http://www.melaniephillips.com

2:  On The Media. July 27, 2017. WNYC studios - The Charlie Gard story is near the end of this podcast.  

3:  Lori Robertson.  Dying from a lack of insurance. The Wire. September 24, 2009.

4:  Truog RD. The United Kingdom Sets Limits on Experimental Treatments: The Case of Charlie Gard. JAMA. 2017 Jul 20. doi: 10.1001/jama.2017.10410. PMID: 28727879

5:   Penny Young Nance.  Charlie Gard: Why his struggle may soon be ours.  Fox News Health. July 10, 2017



Supplementary:

MITOCHONDRIAL DNA DEPLETION SYNDROME 9 (ENCEPHALOMYOPATHIC TYPE WITH METHYLMALONIC ACIDURIA); MTDPS9

MITOCHONDRIAL DNA DEPLETION SYNDROME 5 (ENCEPHALOMYOPATHIC WITH OR WITHOUT METHYLMALONIC ACIDURIA); MTDPS5

MITOCHONDRIAL DNA DEPLETION SYNDROME 13 (ENCEPHALOMYOPATHIC TYPE); MTDPS13

RIBONUCLEOTIDE REDUCTASE, M2 B; RRM2B



Saturday, July 29, 2017

Where Are All of the Pizza Shamers?





On the drive home tonight I was listening to a radio piece about the new White House Press Secretary.    Anthony Scaramucci, was apparently a banker and hedge fund manager before he accepted the new role.  He was the head of SkyBridge Capital LLC and sought approval in January to sell this fund to a group of Chinese investors.  He could make as much as $125 million off of the deal.  The deal requires approval of the Committee on Foreign Investment in the United States (CFIUS) since it potentially involves national security issues.  Another interesting aspect of this sale is that the President can apparently veto CFIUS decisions, although that has never happened in the past. Several commentators have discussed the role of White House Press Secretary as being a critical role in the administration.  From an ethical standpoint, the relevant question is - should anyone with a pending large sale to a foreign power that is under review by an agency of the federal government be placed in such a position?

Similar questions and others have been a constant consideration with President Trump and his administration.  He has refused to distance himself from his businesses by placing them in a blind trust like previous members of the executive branch.  That is the most glaring problem even though elected officials apparently get a pass relative to non-elected employees who have to adhere to Standards of Ethical Conduct for Employees of the Executive Branch.  Additional criticisms include the foreign and domestic Emoluments Clauses, prohibiting elected officials from accepting gifts or making a profit from their elected position.  Those criticisms have included hotel deals by foreign concerns in staying at the President's hotels or golf clubs and whether investments by government employee retirement funds in the President's businesses constitute violations of these clauses.  An encyclopedic look at these potential conflicts of interest are included in reference 3 below.  The only offsetting factor in terms of the potential to make money from some of these areas was an analysis in the Economist  - suggesting that the President's business is mediocre and not very dynamic.  That author thought that it would be several years before any profits could be realized due to these constraints.

The lack of transparency for the President and the Executive Branch is stunning, but I think consistent with what could be expected from placing a businessman in the White House.  Americans have general amnesia when it comes to the mistakes of history.  Despite a Hollywood movie, most people forgot that in the financial sector engineered financial crisis of 2008, only one top banker went to jail and that was for concealing hundreds of millions of dollars in mortgage backed securities losses at Credit Suisse (5).  The way around financial conflict of interest is to design a system where everyone's financial security is at risk all of the time and to let the investor know that absolutely nothing can be depended upon.  Pages and pages of boilerplate illustrate this concept.  Lose everything and it always comes down to your lack of due diligence, not the financial adviser who is selling you stock and shorting that stock at the same time.  What do Americans expect will happen when they elect a President from that ethos?        

The standards for physicians are much different.  Physicians can be reported to a database and listed on that database for accepting a meal worth as little as $10.  In the heyday of drug representatives trying to convince physician to use their products the common currency was pizza.  I used to see these reps dragging large boxes of pizza through the hospital where I worked usually to a Grand Rounds.  People would pick up a piece of pizza and eat it during the noon presentation and then go back to work.  Eventually arguments were made that even a single piece of pizza would bias a physician into prescribing a drug from the pharmaceutical representative who purchased that pizza.  Examining the database of physicians who accepted payments shows that the vast majority on on the list because they were pizza eaters or they were listed for attending a company sponsored continuing education event.  Research was presented to prove that pizza or an equivalent trivial reimbursement led to the expected pattern of prescribing.  Psychiatrists were criticized far more than other physicians.  I have posts on this blog that highlight the poor quality of these arguments and the associated research.  Those posts include clear data that refutes the basis for pizza shaming and suggesting that there was something unique about psychiatry.    

The Institute of Medicine argument is that since it is hard to tell the difference between and appearance of conflict of interest from true conflict of interest - in the case of physician they must be considered the same thing.  The IOM rationalizes their opinion as necessary to maintain public trust because of the traditional role of the physician.  Coincidentally their opinion makes sanctioning bodies like the IOM and other organizations that purport to tell physician what to do and how to behave even more important and central to the medical profession.  After all what would physicians possibly do without the IOM and other sanctioning bodies meting out these sacred opinions? The short answer of course is what they have been doing since sometime around the 4th or 5th century BCE and Hippocrates in Epidemics: "As to diseases, make a habit of two things—to help, or at least to do no harm."  The writings are considered the foundation of the main elements of modern medical ethics.

Rather than considering ancient history - ask the question - what is the the larger conflict of interest - a $5 piece of pizza provided by a pharmaceutical company or millions to hundreds of millions of dollars in trading profits? What is the appearance of conflict of interest versus actual conflict of interest in those two scenarios?  In other words, if the party questioned denied they were influenced by a piece of pizza or a million dollars - who is the most likely to be lying? Keep in mind - the pizza is gone after you eat it.  No matter how good it was the benefit is transient and overall trivial.  Most people would not say that about a million dollars.

Considering more realistic  numbers for Congress rather than the Executive Branch, the average donation to a member of Congress from the pharmaceutical industry is $46,579 (averaged across members of both houses).  What will have more impact, the money to a Congressman who is writing laws and regulations that govern the industry or a piece of pizza to a physician who may or may not write a prescription for that company's drug?

Taken at another level, the idea of physicians being so important in society that they must be held to a standard that few other citizens are makes sense in terms of individual health care.  It does not hold at the level of society in general.  It takes relatively few politicians to make decisions that affect the lives of tens of millions of people.  Those decisions can result in mass casualties and result in generations of people living in armed conflict and poverty.  Political decisions can result in large segments of society being actively discriminated against.  Economic decisions can transfer wealth from citizens to favored industries at a large cost to individuals and their families.  For all of these reasons - the idea that physicians should be reported for accepting pizza at a conference and members of the executive branch talking to potential business partners when they are supposed to be representing the best interests of the American people is more than absurd - it is an outrage.

Where are all of the pizza shamers when they can really make a difference?  Why aren't they focused where they should be?


George Dawson, MD, DFAPA                





References:


1.  Reuters.  Scaramucci Awaits U.S. Approval for China Deal.  July 21, 2017.

2.  Adrienne Hill.  Scaramucci's hedge fund sale to Chinese firm could pose a conflict of interest.  Marketplace.  July 27, 2017.

3.  Jeremy Venook.  Trump’s Interests vs. America’s, Pensions Edition.  The Atlantic.  July 27, 2017.

4.  The Economist.  Donald Trump’s conflicts of interest.  November 26, 2016. (Contains an infographic of the Trump organization's estimated value).

5.  Jesse Eisenger.  Why Only One Top banker Went to Jail for the Financial Crisis.  New York Times Magazine.  April 30, 2014.



Attribution:

Pizza slices are from Shutterstock per their standard licensing agreement for non-commercial use.
Stock photo ID: 122225896 Cheese Pizza with white background, close up - by Hong Vo.  Accessed on 7/28/2017.

Monday, July 24, 2017

A New Perspective on Dreaming


From: Reference 1 with permission.


A friend of mine insists on telling me his dream.  He knows I am interested:

"So I am in this old house.  I have the feeling it is my Grandmother's house, but it is really a house I have never been in before.  There is a gathering on the main floor and there are two people there.  I know that one of them is supposed to be my grandmother but it doesn't look at all like her.  There is a guy there who is apparently dating my grandmother.  I know that he is supposed to be a handyman that my brother introduced to my Grandmother but I have never seen him either.  They look like they are in their 70s.  But in reality as you know - my grandmother has been dead for over 20 years."

"Suddenly I am no longer at the party.  I am in the house and I am in an upstairs bedroom.  For some reason, I think it is my grandmother's bedroom.  I don't know why I'm there but all of a sudden this guy comes down the hallway.  He is one of the commentators from TMZ that Hollywood gossip show (let's call him Bob).  I look to the floor next to the wall to my right and there are two small bowls of M&Ms - a bowl of green M&Ms closer to him and a bowl of red M&Ms closer to me.  They are in those Anchor Hocking glass bowls without the blue plastic lids.  Anyway - I grab a small handful and start eating them.  They are dark chocolate M&Ms.  I look at Bob and say: "That's what they're there for" and he starts eating a few."  He asks why I am there and I say: "I heard there was a mouse in here and I need to kill it."

"A mouse runs between me and Bob and I tell him to kill it.  He misses it and it runs at me and I kick at it and knock it into the corner.  Bob is still reluctant to kill it.  The mouse runs at me again but this time it is as big as a rat.  I kick it into the corner of the room again.  This time it runs back out at me and it not longer looks like a rat - it is as big as an otter.  I kick it again - but this time I am shaken awake by my wife.  She asks me if I was having a bad dream.  She said I was kicking my legs like I was running and punching my arms in the air for a few seconds.  My heart was pounding like I was really in a fight with this thing.  What was all of that?  What  does it mean?"

There are a few things about this dream that are striking.  The first is the amount of detail recalled right down to what appear to be the product placements.  Most people telling me about their dreams rarely recall this level of detail.  Often they recall only the emotional tone of the dream and the vague idea that something happened.  The second is the overall content of the dream.  By the dreamer's report it is illogical - none of the events really happened or are likely to happen.  With the exception of the TV celebrity, none of the people in the dream were really who they were supposed to be.  Strangers were supposed to be his grandmother and his grandmother's boyfriend but in reality - there was no such relationship.  There is the movement.  The dreamer is thrashing about the bed until his wife wakes him up.  A final consideration that I like to think about is the processing power necessary to create this experience either de novo or from existing elements.

Dream interpretation is still alive and well in psychiatry - at least the way I practice it.  It is not quite the detailed analysis of all of the elements that Freud thought were important but a combination of a look at the predominate affects and what might be called a synthesis of what is supposed to happen in dreams.  It is also not quite where we need it to be from a neuroscientific perspective.  For example, for the most part we are still operating on a model that suggests more dream activity occurs in REM (rapid eye movement) sleep and that NREM (non-rapid eye movement) sleep contains very little.  We know from dream studies that is not completely correct because both REM and NREM sleep have EEG correlates and we can wake research subjects up during dreams and determine if they are dreaming or not.  Based on those studies there is a rough correlation - but there are still dreams occurring during NREM sleep and REM sleepers without dreams.  Various theories have been advanced about why that occurs, but there is no comprehensive theory.  The other issue is that dream content needs a better explanation.  The simplified explanation is that illogical impossible dreams like the one described here are REM dreams and that NREM dreams are more like plausible events.  Finally - movement during REM dreams is not possible suggesting that the dreamer in the above example was not in REM sleep or he has a neurological problem to account for the dissociation between his motor activity and the fact that he should be paralyzed in REM sleep.  These thoughts about REM and NREM sleep are so pervasive in our society that I routinely interview patients who tell me why they think they are (or are not) getting enough REM sleep.

I was lucky to have found a recent paper (1) on the subject that if correct may prove to be a landmark study about the neural basis of dreaming and possibly consciousness.  One of the advantages of this paper is that is it written from the perspective of consciousness researchers with an interest in the neural correlates of consciousness.  In this study the authors ran three experiments looking at the question of dream reports and high density (256 channel) EEG.  They used a serial wakening model in which subjects were awakened and asked to report if they were dreaming and could recall some of it (DE = dreaming experience) or if they experienced something but could not recall (DEWR=dreaming without recall of content).  A third option was no experience of dreaming (NE = no experience).  They were asked to characterize any content further according to protocol.  There were two groups of research subjects.  The first was a group of 32 subjects who underwent few awakenings - 233 total.  The second was a smaller group of 7 subjects who had many (815) awakenings.  In a third experiment 7 subjects were studied with 84 awakenings to see if the results of the first two experiments could be predicted.

The initial section of the paper reports on the results of DE versus NE experience in the low frequency (1-4 Hz) power spectrum.  The authors were able to identify what they describe as a posterior cortical hot zone (bilateral parieto-occipital area including the occipital lobe extending to the precuneus and posterior cingulate gyrus superiorly p. 873).  DE occurred when there was decreased low frequency power in this region.  That condition occurred in  both REM and non-REM states.  This finding across distinct sleep stages appears to be highly significant.

The next section of the paper reports on DE versus NE in the high frequency power spectrum (20-50 Hz) that corresponds with high rates of neuronal firing.  Some of the results are summarized in Figure 3 at the top of this post.  In the DE experience condition increased high frequency power was noted in the same parieto-occipital regions that were associated with decreased low frequency power but it was more extensive. DE with recall of content was associated with more widespread extension of the high frequency map than DEWR (no recall of content).  Additional observations were made of the high frequency maps with regard to specific recalled dream content.  The results here are extremely interesting in terms of the specifics of content.  The authors comment on the "perception versus thought" content of dreams.  Some recalled content is an isolated thought or emotion and other content is very vivid imagery including full conversations like the example at the top of this post.  In their experiments, the authors note that there appears to be an anterior -> posterior gradient for high frequency activity with thought content mapping out over frontal cortex and perceptual content mapping out over posterior cortical regions.  They looked at dream content involving facial recognition and noted an increase in high frequency activity over the right fusiform gyrus - a structure noted to be involved in facial recognition during wakefulness.  Dream content that involved spatial imagery was correlated with increased high-frequency activity in the right posterior parietal cortex and area with that expected function during wakefulness.  Additional correlations were noted with movement and speech.

In the final phase of the experiments, the authors sought to find out if the markers identified in the initial sections of the paper could be used to predict where or not a person was dreaming just based on their EEG data.  They were able to accurately predict dreams 80.7 to 91.6% of the time (87% accurate across all states).  

I consider this to be a potentially critical paper to any psychiatrist interested in sleep or dreaming.  If replicated it illustrates that there is a posterior cortical hot zone that correlates with dreaming across REM and NREM sleep stages.  That in itself explains the lack of tight correlation of dreams with REM and NREM sleep.  From a theoretical standpoint they point out the the low delta activity (1-4 Hz) that correlates with dreaming also corresponds to alternations in neuronal depolarization and hyperpolarization that causes a breakdown in cortical communication.  High delta activity  corresponds to states of diminished consciousness including some forms of delirium and loss of consciousness.  They suggest that posterior cortical activation should be studied in patients with disorders of consciousness to see if there may be consciousness without responsiveness based on activity in this area. They also discuss the broader implications of dreaming as a model for the study of consciousness.

That is a good point to end this post.  I will continue to monitor the work of these authors and have been following some of them for some time.  Dr. Tonini for example is probably one of the top experts (and theorists) on consciousness and the only psychiatrist who I am aware of who is doing this work.        


George Dawson, MD, DFAPA


References:

1:  Siclari F, Baird B, Perogamvros L, Bernardi G, LaRocque JJ, Riedner B, Boly M,Postle BR, Tononi G. The neural correlates of dreaming. Nat Neurosci. 2017 Jun;20(6):872-878. doi: 10.1038/nn.4545. Epub 2017 Apr 10. PubMed PMID: 28394322; PubMed Central PMCID: PMC5462120



Attribution:

Figure 3 at the top used with permission from Nature Publishing Group - License Number 4154981341951.  The figure is from reference 1.



Supplementary:

As I have previously posted - I have experience with standard array quantitative EEG (QEEG) and its limitations.  I am a little skeptical of being able to determine the EEG spectrum in the fusiform gyrus by standard surface electrodes in what I imagine is a cap array.  But time will tell.




Tuesday, July 18, 2017

The Anarchist Cookbook




I am a child of the 1970s and I am still trying to figure out what happened back then.  Most people think that the history has already written, but that is not what generally happens in the USA.  The real history isn't typically written until after the major players are dead.  Usually until they are dead for a long time.  It was in that spirit that I watched a Netflix documentary about William Powell a few days ago.

William Powell wrote The Anarchist Cookbook in the 1970s when he was 19 years old.  In the documentary that single act was a thorn in his side for practically all of his adult life.  The documentary is set in the home of Powell and his wife Ochan Powell.  Ochan participated in the interviews.  They were living in France and Powell had no inclination to return to the USA but his wife did.  The interviewer asks Powell about his early life, the writing of the book, how his authorship had plagues him at times in his life, his knowledge about how it had been used and whether or not he had any regrets. Powell is introspective to a fault.  In many cases it is clear that he is trying to find the correct words and I think it is natural to speculate about whether or not he is being defensive.  He is confronted by the interviewer who is asking him tough questions about widely known incidents like terrorism and school shootings where someone happened to find a copy of the Cookbook in possession of the perpetrator(s).  The New York Times obituary is a summary of the Netflix documentary.  Please read that to determine if you want to see the film. I will focus on a few points in it that were under emphasized.

The depiction of his early life, emphasizes a pathway to alienation.  A Long Island born boy goes to England due to his father's occupation where he is viewed as an outsider.  The family then returns to the US where he is viewed again as an outsider and mocked for having a British accent.  He is sent to boarding school where he is molested by a teacher and at that point leaves and goes to New York City where he decides to write the Cookbook.  In journalistic (and documentary) style these conditions are all presented as sufficient for him to write this document.  I think an argument can easily be made that a large number of boys and men are alienated from society for various reasons and they eventually find a way to join the rest of the herd.  I would not find it too surprising that at some level it is related to brain maturation processes that we now know extend into the 20s.  There is another group of boys and men who are fascinated with weapons and explosives.  The vast majority of these boys are not dangerous in any way to other people.  Some of them are dangerous to themselves and end up getting killed or disabled by some of their experiments with explosives or setting up explosions.

Powell's description of how he wrote the Cookbook, by going to a public library and sitting in the military section that contained all of the material he needed is totally plausible.  I have some of these very books in my library and they were purchased off of Amazon.  As early as elementary school, I was being taught to use the Encyclopedia to write reports and a good deal of technical information was available in those general volumes.  You could find the general recipes for gunpowder, nitroglycerin, and even a detailed drawing of the inner workings of an atomic bomb.  All of this material was openly available in 1960s Encyclopedias.  Powell makes this argument a couple of times in the documentary as well as the disclaimer in the Cookbook that what he is presenting is general information.  At no point does he or the interviewer touch on the notion that putting generally available information into the political context of anarchism and revolution, although the interviewer does consistently push for some level of accountability.

At some point in his early life Powell found a calling - teaching emotionally and developmentally delayed children and teaching teachers about how to engage those children. There seemed to be a brief thread about how some of the school shooters may have had these problems.  In the course of his career he was boycotted for various positions when parents discovered that he had written the Cookbook.  He described a scenario where there was some initial concern and he e-mailed every parent to let them know that he had written the manual and was willing to answer any questions about it.  They did not have any additional questions.  During some of the interviews, his wife commented that he went through difficult times because of his association with the Cookbook.  Like most documentaries, editorial license is involved.  In the final shot Powell is asked a questions bout some of the parallels between his life and some of the alienated people who read his book.  The scene fades at that point and we never hear his response.  I am sure that he had one.  The final announcement was that he died unexpectedly on July 11, 2016.

The central point of the documentary from the interviewer's standpoint was the effect that knowing the book was found in the possession of some infamous perpetrators of violence had on him and whether he felt he had any responsibility.  He was very clear that he was responsible for writing the book but not how people used it.  He acknowledged that he did feel badly about these associations and it did cause him to try to take action to get it removed from print.  On Amazon, he has published a detailed letter about how he came to write the book and the fact that he no longer believes that violence is an acceptable way to cause political change.  He refers to it as a "misguided and potentially dangerous publication which should be taken out of print" after discussing how he attempted to get his original publisher to take it out of print.  He also wrote a detailed letter to the Guardian on December 13, 2013 that was apologetic requested that the book go out of print and that is available on their web site.    

In the end I was left with the impression that William Powell had done something that he regretted at age 19 and spent the rest of his life trying to make up for it.  Unlike those of us who made similar mistakes, he was able to find a publisher that resulted in his big mistake being put into print.  If I look back on those times, revolutionary rhetoric was commonplace and only rarely acted upon.  Rebellious youth found no level of public support for a wide scale revolt.  Most Americans then as now just want to put in a day of work and go home to their families.  The other interesting aspect of trying to hold an adult man far removed from his rebellious teenage years accountable for that person is that it is developmentally incorrect.  At a wider philosophical level, much more dangerous information is now available both in books and over the Internet.  Anyone still reading the Anarchist Cookbook has not done much research.

For me the developmental questions always linger.  Why the fascination with explosives and violence?  It seems to be an area that is consistently ignored.



George Dawson, MD, DFAPA




References:

1:  American Anarchist. Netflix documentary: https://www.netflix.com/title/80143794

2:  Richard Sandomir.  William Powell "Anarchist Cookbook" Writer Dies at 66.  New York Times March 29, 2017.