The Problem With Checklists.....

I have critiqued the checklist approach to psychiatry in many posts on this blog.  Several like-mind psychiatrists have also added many comments in this area. I had recent experience with surgical checklists that leave a lot to be desired.  So much so that if I was not an MD - I might not be sitting here and typing this post right now.  For now, I will just post the bare bones sequence of events for illustrative purposes.  On April 14, I had an operative procedure that required antibiotic prophylaxis that consisted of a single intravenous dose of antibiotics given right before surgery. On July 31, I had a second operative procedure to address complications of the first procedure. Both procedures were done under general anesthesia (fentanyl and midazolam or Versed).  A laryngeal mask airway (LMA) was used instead of intubation.  The general sequence of events went like this.

1.  Preop physical exam - good for 1 month prior to surgery.  The exam is done by a primary care MD.  The surgery will not occur without it.  The goal is to identify and complicating or potentially contraindicating conditions.  Specific instructions are given to the surgeon and anesthesiologist based on this assessment.  Specific instructions are given to the patient about if they need to change up their medications at all prior to the surgery.  For example, it is common advice to hold aspirin and other anti-inflammatory medications (NSAIDs), and certain vitamin supplements for 1-2 weeks prior to the surgery.

2.  Hospital intake - over the hour or two before surgery there are intense meetings with a number of disciplines:

Pre-Op RN:  Reviews the medication list and confirms that all of the recommended medications and pre-op instructions were followed.  Assesses functional capacity as well as presence of eyeglasses, hearing aids, implants, pacemakers, CPAP mcahines and artificial joints.

Pharmacist:  Reviews the detailed list of medications and looks for potential drug-drug interactions as well as drug-anesthesia interactions.

Anesthesiologist:  Reviews the detailed list of medications and rationale.  Takes a detailed cardiovascular history. Examines heart and lungs.  Asks detailed family history and personal history for anesthesia interactions particularly malignant hyperthermia. In both cases this hospital trained nurse anesthetists who asked the same questions and administered the pre-op midazolam before leaving the pre-op area.

 OR Nurse:  Also interviews patient about concerns over the surgery and assures that all intravenous lines and devices that will be in the operating room (OR) are present and working.

That is the overall sequence of events.  Each of these team members has specific jobs and checklists that were entered into an EHR.  The primary care physician handed me a copy of my pre-op exam to take with me in case the faxed version was lost.  It was printed out from a well known enterprise wide EHR.

I have a condition called lone atrial fibrillation that is commonly seen in middle-aged (and now old) men who exercise too much.  It was originally thought to be associated with high levels of dynamic exercise like cycling and running, but epidemiological studies suggest it may also be associated with jobs that require a lot of heavy lifting - like furniture and piano moving.  I have also talked to power lifters in the gym who developed it when they continued the lifting into their 50s and 60s.  I take flecainide and it keeps me in a steady sinus rhythm and that has worked well for the past 8 years.  The problem with flecainide is that it is a fairly toxic medication if you have the wrong biological substrate or if you mix it with the wrong medications. A trial of flecainide in ventricular tachycardia was halted because of increased fatalities in the treatment group compared to placebo.  The last electrophysiologist I talked with suggested that I needed to get an exercise stress test done every year to make sure that the QRS interval was not widening due to the drug.  For the purpose of these surgeries my primary concern was not getting a medication that would interact with flecainide and result in a fatal arrhythmia.  I knew that this surgical specialty used fluoroquinolones preoperatively and if you search that interaction in any database this is a typical result.           

"Moderate risk - can cause QTc prolongation and should be avoided when possible. Increased risk for torsades de pointes and other significant ventricular arrhythmias.  Other factors (old age, female sex, bradycardia, hypokalemia, hypomagnesemia, and higher concentrations of the interacting drugs can increase risk for potential life-threatening arrhythmias."

I naturally wanted to avoid the fatal arrhythmia.

At every step in the above chain, I explained this drug interaction and advised the team members that I can safely take cephalosporins.  And here is what happened.

In both cases I had the same primary care MD doing the pre-op physical exam.  He was very focused on the pre-op checklist and in fact the rooming medical assistance reviewed the med list, vital signs, and review of systems that was entered into the EHR checklist before I saw the physician.  When he was done he asked me if I had any concern and I told him "Any antibiotic or anesthesia agent that interacts with flecainide - I do not want to take. I know that I can take fentanyl and Versed for general anesthesia so those are the preferred agents if they can use them for this surgery."  The first time he pulled up the interaction in the EHR, agreed and said - "I will flag this in my assessment so they see it."  The second time he said the same thing but reviewing the H & P he handed me it was not present.  It is possible it was transmitted on another form.

And so it went with every members of the preop team.  They all seemed surprised every time I brought it up.  They thought I was talking about an allergy as opposed to a drug-drug interaction. One of the pharmacists looked it up on her Smartphone app and confirmed.  There was a lot of confusion about the preop antibiotic right up until the time of administration.  Was there another drug that could be used? Would the doctor change the standard orders to administer another drug?  For the past surgery - I had to tell them to look up the April record and confirm that I was given 2 grams of IV cefazolin and not levofloxacin.

When it was finally clarified, it took two nurses to figure out how the levofloxacin could be discontinued from the standard order in the EHR so that the cefazolin could be given.  I was finally given the cefazolin, operated on and so far (barring another complication) things are going well.

The lessons:

1.  Almost everything you hear about the EHR and checklists increasing safety is a myth -  

In this case all of the professionals were using state of the art (and extremely expensive) EHRs containing checklists and forms that were dutifully completely and the ultimate check here was the patient who happened to be a physician who compulsively studies drug interactions and cardiac complications.  That is not a level of safety that I want to see for any of my family members or patients who are undergoing surgery.

2.  Patients or competent family members are the best safeguards for safety at this point -     

I have worked with very bright and insightful nurses who told me that they have a rule that they accompany hospitalized colleagues and check everything that is going to happen to them as well as what medications are administered to them.  On the other hand I have asked patients what medications they take and been told: "You tell me doc.  I just put them in a pill container.  I don't know the names, doses or what they do."

There is a lot of talk about patient empowerment, but it has to be built on a solid foundation of patient literacy.  I certainly realize that a lot of people do not want to know, but I have also talked with many people having less than a high school education who could tell me every drug they took during a complicated course of cancer treatment that included a bone marrow transplant.  Reading and understanding the pharmacy printout given with a medication is a basic prerequisite for the literacy I am talking about. 

3.  This is a systems problem and not a personnel problem -  

Let's face it - all of the personnel in the system are highly competent licensed professionals. They are all focused on their tasks and they do a good job of it.  The problem is that all of these very competent individual assessments are not synthesized into a useful safety plan.  Experts have been writing about the importance of checklists in industry (like the airline and automotive industries) for decades but medical information is individualized complex, and not redundant.  Any adverse outcome of the sequence of events that I described is likely to be something like this:

"Well Dr./Nurse X - did you fail to read all of the narratives in the chart and the patient stating that he had concerns about drug interactions with flecainide?"

Any response to the effect that the EHR is difficult to read and in some cases incoherent and should have flagged this concern automatically is likely to be met with:

"Well that's our EHR and we have to live with it. Our focus groups with the nurses and the manufacturer have been working on fixes for the past 5 years."

Translation:  somebody has to take the blame and it won't be the EHR.

4.  Why doesn't the EHR/checklist approach work? 

It failed miserably - not just once but twice in my case and I was advocating at every level to flag flecainide and not give me any interacting drug.  Having worked with EHRs now for nearly 20 years I can speculate on a few things.  First, there is very little intelligence built into EHRs.  In this case the EHR will do a comprehensive drug interaction search on the current list.  But there is probably not an automatic search on the standard preop antibiotic.  If there is - physicians are numbed to dismissing so many false positive drug interactions that could have happened as well. Second, any discussion of the patients concern or doctors advice is buried in documentation that is prioritized for billing, rarely read, and not translated into any rational action. An intelligent EHR would convert the concern about flecainide interactions into what is called a hard stop. That means the potentially offending drug could not be ordered until some further action was taken - like a discussion between the physician, pharmacist, and patient.  In this case, my discussion with 10 people was not beneficial and the only reason I did not get levofloxacin was that I was in a hospital bed about 6 feet away from where the nurse was working and I was a physician who has worked for years to prevent these kinds of problems.

It is hard to believe that such extremely expensive and heavily lobbied systems can't provide a basic level of safety.  I was not surprised to read that having the same primary care physician for years is probably a better assurance of longevity.

For the non-medical person reading this - know your medications, what they do, and what the potential safety concerns are when you are in a situation where those medications are being changed. Ask your pharmacist and physician to do a drug interaction search to make sure these transitions can be safely made. Refuse any medication unless a sound rationale can be provided to you about why you are taking the drug and how safe it is to take with your current prescriptions.

George Dawson, MD, DFAPA

     
Graphics Credit - the graphic at the top is from Shutterstock per their standard licensing agreement.

The Abuse Potential of Gabapentinoids

I first started prescribing gabapentin in the 1990s, as part of an early attempt to see if it worked for bipolar disorder.  It was an off-label approach and did not have that indication.  At the time anticonvulsant approaches to bipolar disorder (valproate, carbamazepine) were being heavily used.  I was following a number of people who could not take lithium and on anticonvulsants and they seemed to do surprisingly well.  Gabapentin seemed to have significant advantages in terms of toxicity, it was well  tolerated by most people.  Unfortunately, it was completely ineffective for bipolar disorder and I stopped trying it almost immediately.

The next off label application that surfaced was for chronic pain.  Any psychiatrist is exposed to a number of patients with chronic pain or chronic pain and addictions, and it became apparent that it was being used successfully for chronic back pain, chronic headaches, and post herpetic neuralgia.  Over the next decade, gabapentin and then pregabalin was prescribed for chronic pain indications and people seemed to do reasonably well with it - even at relatively high doses.

At some point, physicians working in detox and the addiction field started to use gabapentinoids for chronic pain, anxiety, and withdrawal.  It is not uncommon to see patient with all of these problems who is not able to tolerate antidepressants for those symptoms or who needs more immediate relief.  In fact, in residential addiction treatment it is common to see patients come in on high doses of gabapentin for chronic back pain.   They are there for treatment of an opioid use disorder, but during that time have not escalated the gabapentin dose.

In the literature reports of gabapentin misuse have been surfacing over the past 5 years (1-7).  A large review (4) suggests that 1.3% of the treated population is at risk for gabapentinoid misuse with the number being much higher is some populations such as opioid users.  There is a report (3) that patients with opioid use disorder will attempt to augment the eurphorigenic effect of methadone in a similar way that they use benzodiazepines.  Benzodiazepine use with methadone in methadone maintenance clinics is a chronic and at times lethal problem.  There is a report from Norway (5) that gabapentinoids may be useful is reducing benzodiazepine use.  The report generally suggests that the abuse potential is low and greater for pregabalin than gabapentin.  There is an insurance database report (6) that looks at an overuse metric comparing gabapentinoids to other abused drugs.  Goodman and Brett (7) comment on the epidemiology of gabapentinoid prescribing, specifically an increase in gabapentin prescriptions from 39 million in 2012 to 64 million in 2016 with an associated doubling in the sales of pregabalin during the same period.  They attribute the increase to attempts to treat chronic pain without opioids in primary care, suboptimal non-opioid medications (acetaminophen and NSAIDs). They cite mixed evidence in clinical trials, side effects, misuse or diversion, and an excessive focus on pharmacological measures for pain as being concerns.       

Are there biases in these report?  There certainly are.  I don't have access to the full text of the most comprehensive paper (2), but I would be interested in looking at the actual numerator and denominator for their numbers and how much was based on actual pharmacovigiliance/pharmacosurveillance as opposed to case reports, case series and reports of complications.  The other issue is that all of these papers seem to come from the same publisher.  I have not encountered that before.

The only study that I could find that looked at the direct question of concomitant use of opioids and gabapentin came from Canada (8).  It studies a large group of patients on a database that records the prescriptions and looked at all opioid users that died of opioid related causes between 1997 - 2013.  The big picture is that there were a total of 2,914,971 opioid users during the study time frame and 6,745 died of opioid related causes.  Then by selection criteria they identified 1,256 cases and matched them to 4,619 controls. They defined gabapentin exposure as concomitant gabapentin use in the 120 days preceding the index date.  They also looked for a dose response relationship of gabapentin doses considered as low (<900 mg daily), moderate (900 to 1,799 mg daily), or high (≥1,800 mg daily).  They also did a comparison with nonsteroidal anti-inflammatory drugs (NSAIDs) used as an adjunctive pain medication instead of gabapentin.  Their results are summarized in the following tables excerpted directly from the article (click to enlarge):

 
As noted from the data and analysis, 12.3% of the controls and 6.8% of the cases were prescribed gabapentin in the 120 days, representing a 50% increased risk of death in the gabapentin treated cases.  In the case/control comparison both groups have roughly the same levels of mental illness but the case group had higher utilization of antidepressants (all types), benzodiazepines, and other drugs/CNS depressants. They were also taking substantially more high dose opioid therapy (>200 MME).  Higher dose gabapentin nearly doubled the risk. There was no added effect from NSAID use.  The authors conclude that caution needs to be exercised in deciding to prescribe this combination (opioids + gabapentin) and that if that decision is made it needs to be carefully monitored.  From my perspective I had some concerns about the controlling for benzodiazepine use in the case/control comparison and did not see any risk attributable to benzodiazepines.  The authors do cite a reference that led to FDA warnings about the benzodiazepine-opioid combination. 

Given the concerns about gabapentin why use it at all?  The main reason is that it is effective for some of the most difficult problems in medicine.  It is very difficult to see people with extreme anxiety and insomnia go for weeks without sleep and experience continuous panic attacks all day long.  When a person stops taking benzodiazepines that they have been taking for years that is a frequent result.  The same is true for people who have decided to stop drinking and suddenly have very high levels of anxiety and insomnia now that their baseline anxiety is back.  More to the point, unless something can be done to provide them with timely relief, relapse to drug and alcohol use is certain.  Finally does high levels of abuse by some patients with addictions suggest that the medication is unsafe?  It is probably safer then other medications in this population and extremely safe outside of those populations.  In either case safety depends on whether there is a physician involved or the medication is acquired from nonmedical sources.   

Standard practice with gabapentin should be to tell all patients (in addition to the usual discussion and detailed information) the following information.  I point out here that I do not prescribe pregabalin:

1.  Take this medication exactly as it is prescribed.
2.  Do not accelerate the dose of the medication.
3.  Do not mix this drug with alcohol or any other intoxicants or street drugs.  If a relapse occurs call to discuss and set up a plan as soon as possible.
4.  Do not stop the medication abruptly it needs to be slowly tapered.  There is a seizure risk if it is not.
5.  This medication is potentially addictive to some people. If you notice any tendency to take more of this medication than prescribed contact me immediately.
6.  This medication is monitored on the state Prescription Monitoring Program and all prescriptions are recorded even though it is not technically a scheduled drug at this time.

At least that is the way that I think it should be handled.  If I was still seeing a lot of patients with chronic pain on moderate to high doses of opioids I would add in a line or two about the the Canadian study (9) and greater chances of death from the gabapentin + opioid combination.  In my current practice, psychiatric treatment is split off from buprenorphine detox and maintenance treatment - but I still see a lot of patients on buprenorphine + gabapentin and can attest to the fact that in a controlled environment we have not observed the complications suggested by the Canadian study over a period of months.  None of these patients receive benzodiazepines or sedative hypnotics beyond a period of detox.  In fact, doing that study might be a significant contribution to the research.  It also probably means that those patients when they are discharged should hear that the risk of taking that combination may increase substantially in the outpatient setting.

There is plenty of politics and confusion surrounding the gabapentinoids issue.  It should not be surprising that this medication is showing up in the toxicology of opioid overdose victims. It should not be surprising that some people try to get "high" on it, even though the people doing that do not have typical ideas about the utility of medications. It should not be surprising that people try to use gabapentin like benzodiazepines to augment the effect of what they are using to get high especially opioids.  It should not be surprising that when some people decide to stop buprenorphine or methadone that they will buy somebody's gabapentin to try to treat withdrawal effects.  It should not be surprising that in some areas it is currency on the street (What can I get for a month's worth of gabapentin?).  It should not be surprising that it has become a political football in the social media on pain ("See it's not opioids as the problem - it is gabapentin") or the social media on weed ("See these are Big Pharma solutions, marijuana is much safer").  It should not be surprising that you can read about it on drug culture web sites where everyone is an expert pharmacologist and provides you with anonymous advice on how to get high. It should not be surprising that you can buy it online and have it delivered to your door, although you can never really be certain that it is the same stuff you get at Walgreens.  I am always amazed at how easy it is to sell some Americans drugs, if they think there is the slightest possible chance they can get high on it. That is also why it should not be surprising that children and teens will take it out of medicine cabinets - use it to get high and brag about it even though there were probably not high at all.

The features about the gabapentinoids that make sense to me is that they are medically useful  and have low toxicity, for people with nearly impossible problems in desperate situations.  It is a less toxic drug on the street than those mentioned in the above paragraph. Even then these drugs need to be carefully prescribed and closely monitored.  And even then some people will escalate the dose. There are no perfect solutions in medicine and in this area in particular - nothing seems to be coming down the pike.  The probability statement is always - does the use of gabapentin result in more people with improved symptoms, better quality of life and less addiction?  At this time unless presented with compelling evidence I would say that it does with the qualifier that its application needs to be carefully done by a physician who knows what they are doing and is aware of the potential for misuse. In  the current era, that can all be subject to the next social media fad.

There is not a big push by the pharmaceutical industry at this time to discover a drug that has limited toxicity that can be used for severe chronic pain, insomnia, and anxiety associated with addictive disorders.  There is also the question of what medications are being used for these problems if not gabapentin.  The answer is atypical antipsychotics (mostly quetiapine), hydroxyzine (a first generation antihistamine), and clonidine (primary use is hypertension and opioid withdrawal).  If the comprehensive toxicology of overdoses is available I would expect to see these compounds listed.  In any search of drug interactions both quetiapine and hydroxyzine are flagged as potentially affecting cardiac conduction. Clonidine can cause hypotension if used excessively and rebound sympathetic symptoms (tachycardia, hypertension, diaphoresis).  Looking at that group of medications gabapentin would appear to have the preferred side effect profile.

There also appears to be a big push to make gabapentin a controlled substance according to the Controlled Substances Act (CSA).  Pregabalin is currently a Schedule V drug (see page 14) or considered to have the lowest abuse liability.  Getting on that list depends on how the DEA currently sees the addictive behavior towards gabapentin versus pregabalin.  Putting a drug on Schedule V will probably have no impact on how it is used in medical practice or out on the street.  The fact that pregabalin is ranked so lowly is a sign of regulatory opinion on abuse liability.

That's my current opinion on the topic.  I may add more to this post in the future or to a post I am working on about the basic science of gabapentinoids.


George Dawson, MD, DFAPA


References:

1:  Schifano F. Misuse and abuse of pregabalin and gabapentin: cause for concern? CNS Drugs. 2014 Jun;28(6):491-6. doi: 10.1007/s40263-014-0164-4. Review. PubMed PMID: 24760436.

2:  Chiappini S, Schifano F. A Decade of Gabapentinoid Misuse: An Analysis of the European Medicines Agency's 'Suspected Adverse Drug Reactions' Database. CNS Drugs. 2016 Jul;30(7):647-54. doi: 10.1007/s40263-016-0359-y. PubMed PMID:27312320.

3:  Baird CR, Fox P, Colvin LA. Gabapentinoid abuse in order to potentiate the effect of methadone: a survey among substance misusers. Eur Addict Res. 2014;20(3):115-8. doi: 10.1159/000355268. Epub 2013 Oct 31. PubMed PMID: 24192603.

4:  Evoy KE, Morrison MD, Saklad SR. Abuse and Misuse of Pregabalin and Gabapentin. Drugs. 2017 Mar;77(4):403-426. doi: 10.1007/s40265-017-0700-x. Review. PubMed PMID: 28144823.

5: Smith, R. V., Havens, J. R., and Walsh, S. L. (2016) Gabapentin misuse, abuse and diversion: a systematic review. Addiction, 111: 1160–1174. doi: 10.1111/add.13324.

6: Bramness JG, Sandvik P, Engeland A, Skurtveit S. Does Pregabalin (Lyrica(®) ) help patients reduce their use of benzodiazepines? A comparison with gabapentin using the Norwegian Prescription Database. Basic Clin Pharmacol Toxicol. 2010 Nov;107(5):883-6. doi: 10.1111/j.1742-7843.2010.00590.x. PubMed PMID: 22545971.

7: Peckham AM, Fairman KA, Sclar DA. Prevalence of Gabapentin Abuse: Comparison with Agents with Known Abuse Potential in a Commercially Insured US Population. Clin Drug Investig. 2017 Aug;37(8):763-773. doi: 10.1007/s40261-017-0530-3. PubMed PMID: 28451875.

8: Goodman CW, Brett AS. Gabapentin and Pregabalin for Pain - Is Increased Prescribing a Cause for Concern? N Engl J Med. 2017 Aug 3;377(5):411-414. doi: 10.1056/NEJMp1704633. PubMed PMID: 28767350.

9: Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W.  Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case-control study. PLoS Med. 2017 Oct 3;14(10):e1002396. doi: 10.1371/journal.pmed.1002396. eCollection 2017 Oct. PubMed PMID: 28972983; PubMed Central PMCID: PMC5626029.

Graphics Credit:


Figure 2 about is excerpted directly from the work in reference 8 above per the Creative Commons Attribution License.  The authors are listed as the copyright holders.


Supplementary:

Publication from the above content?  If you are a psychiatrist or pharmacologist and think you can rework the above article into a publication.  Contact me and let's write that paper!

Cycling Tips From A Psychiatrist

I have been a serious cyclist for longer than I have been a psychiatrist.  At midnight on Labor Day in 1972, two friends and I took off on a trip that we hoped to accomplish the same day.  I was riding a CCM 10-speed bike built around Reynolds chromoly tubing.  We were traveling to a town 164 miles away.  My first friend dropped out at 57 miles.  The second made it all the way but for the last third of the trip he was falling asleep on his bike.  That trip and several others taught me valuable lessons about cycling.  The picture at the top of this post is me stepping off the bike after my initial test cruise yesterday.  When I was slightly younger, I would have been out biking as soon as the snow melted.  Less than 5 years ago I was out biking down the Gateway Trail on a mountain bike and I hit a patch of ice and went down hard.

As I was dusting myself off, I recalled a story from a gastroenterology colleague of mine who is about 10 years older than me.  He would always ride in the Minnesota Ironman,  a spring ride that is designed to be a century (100 mile) ride but also can be broken up to shorter rides.  It is scheduled this year for April 26th, with options to ride 14, 27, 29, 60, and 100 miles.  The problem in Minnesota at this time of the year is the weather.  My GI colleague told me he was sitting there waiting for the ride to start.  It started to rain and sleet.  By starting time, he was soaked, cold and his shoes were full of ice cold water.  He got off the bike, walked over to the van that would be at the finish line with T-shirts, picked up his T-shirt, and went home.  I guess the lesson there is that at some point, you realize that you can enjoy cycling and not be miserable doing it.  It is a lot easier to ignore misery when you are younger.

When you are younger, your physiology is also a lot better.  I was doing pretty well until about 7 years ago when I had an episode of atrial fibrillation.  By pretty well, I mean essentially unlimited exercise potential.  I could go as hard as I wanted for as long as I wanted up until that point and even after that point for a while.  But eventually I realized that even exercise induced tachycardia predisposes a person to atrial fibrillation.  I had to tone my very high heart rates down into a more conservative range in order to prevent episodes of atrial fibrillation and the conditions that predispose to atrial fibrillation.  Now when I am out in the country, I am always watching a heart rate monitor instead of my speed.  That is somewhat depressing and it has an impact on self image when you have to go from unlimited exercise capacity to somewhere on the deterioration spectrum.  My goals have varied over the past 30 years from biking 200-250 miles per week to doing more speedwork for racing.  My fastest race time occurred when I would do 2 - 50 mile rides on the weekend and 4-18 miles rides during the week.  For half of the 18 milers I would try to ride as fast as I could.  These days my goals are a lot more conservative and these are my modest goals for 2015.

That may be a little optimistic but for comparison I watched Fabian Cancellara lead the peleton at what appeared to be a leisurely pace into a small French town a few years ago.  They were doing 30 mph on the flat and his heart rate was 130 bpm.

I thought that I would share a few observations here about some other things I have learned over the years about cycling that might be useful.

1.  Use good gear and keep it in good working order:

The kind of bike you ride is highly subjective.  When I first started cycling, high end bikes could only be assembled from components.  I used to ride Vitus frames that were aluminum tubes that were glued together.  The mechanical components were made by Campagnolo, Shimano, and SunTour in various prices ranges.  My all time favorite components were SunTour Superbe Pro.  They seemed so light and effortless.  I just liked the way the gears changed.  It seemed like there was just a lot less rolling resistance.  But SunTour just went out of business one day.  I currently ride a Trek bike with a carbon fiber frame after riding aluminum frames for over 20 years.  Bikes today are so much better in just about every way than they used to.  If you bike a lot, it pays to ride the best bike that you can afford and go to a shop where people can explain it to you and fit you to the bike.  Don't ride a bike that gives you consistent pain in any part of your body.  You should always feel stretched out and ready to go.  Don't hesitate to buy a bike that you think looks cool.  Don't hesitate to buy as many bikes as you want.  These are both strong motivators for riding.

2.  Be safe and stay alive: 

Biking is in many ways like getting into an open Land Rover and driving out into the Serengeti among the predators and large animals.  Anything can happen and you have minimal protection.  Just pulling out of my driveway I always double check the air pressure (it should always be at the max) and I make sure my front wheel is not ready to fall off by pounding on it with my fist.  I am riding high pressure tires with tire liners to prevent a blowout.  I don't have time to fix flats out on the road.

And then I become hypervigilant......

I was screaming down a hill in Duluth one day and all it took was a split second for a large black Labrador to run out of a bush and right under my front tire.  Hitting that dog was like hitting a tree stump at that speed and I went right over the handle bars and onto the shoulder.  I personally know too many cyclists who were killed or became quadriplegic in accidents like this.  It is the main reason I continue to do a lot of upper body strength training to provide some elasticity in the event of a crash.

In another close call,  I was heading south on Cty Hwy 15 from Square Lake Trail just north fo Stillwater, Minnesota.  Washington County has the highest per capita income of any county in Minnesota and that is reflected in the state of their roads and what happens to the roads at the county line (they get worse).  It is the ultimate biking territory because most of the roads have 5 - 10 feet of pavement  to the right side of the white line.  That is a lot of biking space compared to most county highways.  Coming north in the other lane was a truck pulling a boat on a trailer.  I heard some scraping and saw some sparks.  Suddenly the boat and trailer reared up, disengaged from the back of the truck and was headed right at me.  It cut in front of me by about 5 feet.  I think I was saved by the ultra-wide shoulders in Washington County.

I always stay to the right hand side of the while line by as wide a margin as I can.  All it takes is this little experiment to prove to yourself that this is the best place to ride.  Count the number of cars out a hundred that you see crossing that line in proximity to you when you are riding.  The number I get is about 6% and that is when they see that you happen to be riding next to them.  Hopefully the new car designs with lane deviation alerts will train people to stay in the driving lane.  But it is going to be a long time before everybody has them and let's face it some of those drivers may be intoxicated even in the light of day.

3.  Stay as competitive as you want to be:

I was never a big time racer.  I rode only in an annual unsanctioned 40 mile event.  It was kind of a free-for-all and it was pretty dangerous.  It was a pack style race but in the end, some of the riders were using aero handlebars (ouch) and there was always a massive crash at about the ten mile mark.  Some of the riders were Cat 2 and rode in it for practice.

 I can recall reading Greg Lemond's book about the attitude to have as you get older - basically that you have more responsibilities and more time commitments away from cycling.  That is also true.  Ever since I left Madison, Wisconsin in 1986 - I have been a solo biker.  The only exception was a play date that my wife arranged.   He was a tri-athlete and the husband of one of her health club friends.  The plan was to do a 60 miler from Mahtomedi to the Chemolite plant in Hastings back up to Square Lake Park via Stillwater and back to Mahtomedi.  This guy took off like he was time trialling and I did not catch him until the 20 mile mark.  By then he had hit a wall and his speed started to fall of precipitously.  The last third of the way he was down into the 10 mph range and eventually fell off his bike and fractured his wrist.  The last few miles into Stillwater I was riding next to him trying convince him to stop so that I could call his wife and get him picked up.

That incident captures some of the problems of biking with other people.  What are the mutual expectations?  If it is some kind of competition is it at least a benign competition?  The skill level has to be in the same ballpark as well as the overall expectations of the ride.

What about people that you encounter along the way?  During my time of unlimited exercise, my rule was not to be passed (within reason).  I  would also try to catch anyone on the horizon, but to do it in the most unassuming manner possible.  As aging has taken its toll I have to pick my battles.  Two years ago I was out biking towards an average sized hill when I noticed a pack of about 8 guys quite a bit younger than me closing fast.  I naturally assumed that their social brain worked like mine and they were trying to trounce the old man going up the hill.  By this time I was trying to stick to my heart rate rule of not exceeding 130 bpm and I looked down and I was already at 120 bpm.  I increased my speed to match their figuring that some of them were maxed out trying to close the distance.  At the bottom of the hill I shifted to a bigger gear and hit it as hard as I could.  The group caught me halfway up the hill and then seriously faded.  I was the first guy up and over the top.  I won't tell you what my heart rate was at the time.  I was somewhat elated, especially when the last rider in that group looked over at me and said sarcastically: "Nice work Lance".

Some people view competitiveness as either a character flaw or the most desired personality characteristic.  I see it as neither.  To me it is the embodiment of training and study in the field as well as the third dimension of how long you can put off the ultimate deterioration of your body.  When I win these little competitions that I devise for myself, it is not about the anonymous opponents who I will never know.  It is a battle against my own death anxiety and mortality and a good way to stay physically fit in the process.

4.  Drivers are either not paying attention or they are trying to kill you:  

If you bike long enough or even pay attention to the newspapers, cyclists are always getting killed.  Seven hundred and thirty two cyclists are killed every year and 49,000 injured, but it is possible that the police only record about 10% of the injuries.  In my town it is about 1-2 people per year.  That suggests to me that the fatality estimate is also too low.  I personally know both experienced and inexperienced cyclists who were killed and seriously injured.  In one of the most noted cases a driver mowed down three cyclists while trying to adjust her CD player.  The only defense against the inattentive and/or drunk driver is to be as far to the right of the lane marker as possible and try to avoid sharing the actual traffic lane whenever possible.  There are some additional helpful approaches.

Avoid riding in traffic until you know what you are doing.  The basic skill requirement is to be able to bike in a straight line and not veer all over the road.  That seems easy but it is not.  Any type of distraction including talking with your fellow riders and looking over your left shoulder can cause you to drift into the traffic lane.  Don't ride in traffic if you are drifting all over the road for any reason.  Don't ride in traffic until you can glance over your left shoulder and not drift into the traffic lane.  If you know you can't do that - stop the bike completely, put your feet on the ground and look behind you.

Bike with people you know and trust.  If you are biking distances at speed you have to know that the person in front of you is not going to pull up all of a sudden without warning and cause a crash or lead you to veer into the traffic lane.  Ride single file most of the time,  except where you have enough shoulder surface to comfortably ride side by side.  You should have enough confidence in your fellow riders that you know they will not make any contact with you.

In some cases, the nature of the ride is just plain dangerous.  I can recall riding out of Aspen to Independence Pass.  The shoulder on that road gets down to 6 inches wide as it winds up to the pass.  The day that I did it, there was constant Airstream trailer traffic.  The vehicles pulling those trailers were all outfitted with very long side view mirrors to see around the trailers and they were dangerously close.  To make matters worse,  I was aware of a cyclist who was hit from behind by one of these mirrors.  That image of a mirror imprint on my back made the ride up a lot less enjoyable than it should have been.  Sometimes your cycling goals take you into dangerous territory in spite of everything you know about safety.

Aggressive drivers are an entirely different problem.  They come in several classes that I would described as the appropriately angry driver,  the enraged driver and the personality disordered driver.  There is a significant overlap between the personality disordered driver and the enraged driver and that depends on the assumption that a person can have defects in emotional reasoning in the absence of major character pathology.  As far as I know that study has not been done.  Prevention is always the best initial approach and by that I mean not doing anything to piss drivers off.  It does not take much.  After all they are in a two ton vehicle obligated to adhere to the rules of the road or risk legal penalties and suddenly the cyclist in the oncoming lane buzzes right through a stop sign.  That action is enough to cause the mild-mannered banker who you personally know to start pounding his steering wheel with both hands while screaming epithets out the window (Don't ask me how I know that).  Simply put you will anger fewer drivers by adhering to the same rules that they have to.  That will not prevent all angry encounters because there remains some ignorance about traffic laws.  For several weeks I encountered an angry young woman cycling toward me in the wrong direction on my side of the road.  She was riding against the traffic.  She was aggressively swearing at me and telling me I was going the wrong way until I politely told her to read the drivers manual.

But obeying all of the traffic laws will not keep you out of the cross hairs of our various personality disordered citizens.  I was biking up Myrtle Street in Stillwater, MN one day.  It is quite a haul and most road bikes don't come with small enough chainrings to make it up that hill very comfortably.  I was 2/3 of the way up when suddenly a young man in a large 4WD pick up truck (not that there is anything wrong with that) pulled up next to me and started to harass me all of the way to the top.  His basic heckle with the expletives removed was: "Yeah you're not so tough now are you?"  Wait a minute, I am the 55 year old guy riding up this hill on a bike and you are the thirty something guy sitting in a 400 horsepower truck going up the same hill and I'm not so tough?  Harassment like that can be disorienting, I flipped into my mindfulness mode and thought about all of the times I have biked this hill - while keeping an eye on how close the truck was to me.

In a previous incident, I was at the bottom of this hill when an elderly driver decided to turn right into me as we came up to the third or fourth cross street.  Luckily she was going at a low rate of speed and I was at the right place where I could slam my hand down on the roof of her car and spin myself and the bike out of the way.  She was oblivious to the whole situation and kept driving.

One of the worst things that you can do with the enraged or personality disordered driver is to escalate the encounter.  It took me a while to figure this out.  The best example I can think of involves being harassed by a motorcycle club on day toward the end of my ride.  I doubt that they were 1%ers, but they were all young very muscly guys wearing sleeveless motorcycle jackets and seeming quite intoxicated.  As I rode by one of them had climbed the cyclone fence that surrounded this establishment and started to shout "Wheelie! Wheelie! Wheelie!......" as I pulled up to a stop sign.  Several of his peers caught wind of this and started to do the same thing.  It was a scene out of a biker film from the 1970s.  Clearly they were expecting a response from me.  In the old days, I might have said something and it would have been off to the races.  Today the exchange went something like this:

Me:  "I can't do a wheelie."
Intoxicated Biker: "Why not?" (angry tone)
Me:  "Because I am too old!"
Intoxicated Bikers: Explode into laughter.  As I ride away they are reassuring me that I am not too old to do wheelies.

So the bottom line is that some of these ugly confrontations can be defused with humor.

5.  Fantasize your brains out:

Psychiatrists don't talk about fantasies any more.  I think that an active fantasy life can be very adaptive.  I have fantasies that I can pull up in any terrain.  In the hills or mountains I can imagine myself riding between the Schleck brothers in the Alps.  On level ground or into the wind, I can see Miguel Indurain time trialling in front of me and I am just trying to maintain the correct spacing between us until I can pull out and pass him.  The weeks of the Tour de France are generally the times of peak fantasy for me.  There is always the case of a solo rider who breaks away from the best cyclists in the world and stays away.  I can't think of anything as exciting in all of sports.  I am waiting to watch that clip and incorporate it into my fantasy world.  I can hear Phil Liggett calling out my name.....

6.  The cognitive versus the emotional aspects of life:

I have decades worth of meticulously detailed training information - all handwritten.  Distances and times, routes, intervals, heart rates, etc.   In the 21st century, none of that stuff is necessary.  You can automatically record all of that data and download it to your computer after the ride.  You can study whatever parameters that you want.  But don't get too lost in the details.  I live for the time during the year when I am cruising along in a fairly steep gear and can put my foot down and go.  Bam!  I am sure that any coronal section of my brain on fMRI at that point would show my nucleus accumbens lighting up, but the subjective experience is most pleasurable.  It can occur only with the right distribution of power and weight and I notice that it is advanced on in the season.  If it ever disappears, I know that I will miss it.    

7.  Wear the most radical clothing you feel comfortable with:

Most non-cyclists don't understand the utilitarian nature of cycling clothing.  I was speedskating one night and came off the ice with some biking gear on.  One of the hockey dads decided to give me a rough time and commented how I must think that I was pretty cool because I had special speedskating clothing on.  Keeping in mind that he had several kids with about a thousand dollars worth of hockey gear on,  I said:  "Well no, this is my cycling clothing."  On top of thermal underwear of course.

I have been in pursuit of the perfect biking shorts and saddle for the past 30 years.  When I find a pair that seems to meet the criteria, it doesn't take long for the manufacturer to change the design or the chamois.  It is a basic fact that you cannot expect to bike every day if your perineum is trashed or you develop saddle sores.  The best way to do that is to think that you are going to ride more than 10 miles in a pair of cotton Bermuda shorts over boxers.  I am currently trying out some very high tech shorts.  They were so high tech that I had to send an e-mail to the company.  I was concerned about what kind of chamois lubricant to use, because of all of the high tech materials used in the short.  Their reply was totally unexpected.  Don't use anything.  Wear these trunks dry.  So for the first time in 30 years I don't have some kind of lubricant between my ischial tuberosities and my bike saddle.

Live and learn.

8.  Inclement weather:

I don't bike in the rain or snow anymore.  I will also not be biking up to Independence Pass again unless they ban Airstream trailers.  I have an ergometer in my basement and I try to match the outdoor conditions.  I know that at many levels that is an illusion.  I do however always bike in extremely hot weather and in the wind.  It takes a certain mindset to overcome those conditions.  You have to be able to feel that you are going with the wind and benefitting from the temperature at some level.

This is a long post and that's all I can think of for now.  So the next time you see some old dude out on the road biking - he may be a narcissist wrapped in Lycra, but it is more likely he has a lot on his mind and he is trying to live the best way that he can.


George Dawson, MD, DFAPA




Supplementary 1:     

Disclaimer:  I am not a cycling coach or expert.  The point of this post was to look at some of the unspoken psychological aspects of biking from the standpoint of individual consciousness.  Don't take any of this as advice on how to cycle or live your life.  Follow the advice of your personal physician on all matters related to exercise especially if you have decided to start a new program or alter your intensity.


Supplementary 2:

I am a guy so this is written from a male perspective.  I know that women are as dedicated and serious about biking as I am, but I can't speak to their conscious state.  If you are a female cyclist feel free to comment about your conscious state in the comment section below.  Or better yet, send me an essay and I will post it as an invited commentary by a distinguished guest.  I am very interested in your motivations, cycling fantasies, and daydreams about cycling and any insights that you have developed as a result.  Not everyone can keep riding and I am very interested in the ways that people do.

It Is Cold Outside

I was driving into work this AM. I drive a six year old Toyota Van. The thermometer on my rearview mirror hovered between - 20 and -21 Fahrenheit, but every bank I passed said -24. Before I left home this morning I added a layer of polyester, packed additional headgear, and wore my Sorel boots. This is serious weather even if you are born and raised here and you need to be prepared for the worst. Standing outside for even a few minutes without adequate cover can result in frostbite or worse. The Governor of Minnesota closed down all of the schools today to prevent frostbite injuries and so far there have been no arguments with that decision.  The drive home at night was slightly warmer at -16 degrees.  The sky was so clear it was like being in outer space.  I had to stop for gas and the driver's side door froze open.  I had to hold it shut for about 6 miles until it thawed to the point I could slam it.

Apart from the pragmatics of winter survival, the cold weather also triggers a lot of associative memories - starting with my Sorels. I got these boots originally in 1971 in order to do a Limnology experiment on Lake Superior.

A friend of mine helped me and we went out onto the ice for a about 5 hours and pumped about 200 gallons of lake water through a plankton net to look at the winter plankton population. It was about -5 degrees that day. A few years earlier he had a case of frostbite after walking about 10 blocks to school wearing nothing but a pea coat.  Like a lot of people in the northern US and Canada, I have found that these boots absolutely protect your feet in subzero weather.

I lived in Duluth, Minnesota for a while and can recall trying to speedskate when it was -10 to -15 degrees. At that temperature, a skate blade cannot compress and liquefy the ice enough to support much glide so the skating motion and its mechanics are seriously disrupted. I was wearing two layers of polyester, a layer of Lycra, and a layer of fiber.  Unlike Sorels - speedskates even with neoprene boot covers don't protect much against the cold.  When I got home I had to lay on top of a radiator under a blanket for 30 minutes in order to warm up. The coldest I have ever been in the winter usually happens after falling through the ice. I can recall walking across a creek and just getting ready to step up onto the far bank when I fell through the ice up to my chest in icy water. The sensation that occurs when that happens is incredible. Your breathing stops for a while followed by rapid gasping as you struggle to get out of the water. That is followed by the desperate run home. In my case it was only about 7 blocks and by the time I got there my clothes were frozen solid.  A friend of mine was skating on Lake Superior and fell through the ice catching himself only by his fingertips. He ran home about the same distance but he had been totally submerged.

My more recent memories are about how the cold has been a factor in my role as a psychiatrist. Most psychiatrists in the Midwest have first-hand experience with the complications of cold weather. We have seen people with frostbite injuries both on burn units and after they have been transferred. We know many of the people who are caught in the endless inpatient unit -> emergency department -> homeless cycle that seems like a permanent artifact of our managed care inpatient and county mental health systems. We have seen the human interest stories that tend to run in the papers when the potentially lethal cold weather hits and the temporary concern about whether or not there are enough shelter beds.

Weather this cold does not allow you to make a lot of mistakes. Sometimes all it takes is the idea that you can run out to the trash can without putting on a jacket and finding that you have locked yourself out of the house. People with memory problems and disorientation can wander off and get lost. People with drinking problems can pass out or just take too long to get home. All it takes is a decision that keeps you out in the subzero weather for minutes too long and you can be in serious trouble.

Potentially lethal cold weather is also an integral part of treatment decisions. You can't really watch people coming in to appointments wearing summer clothing in this weather without doing an assessment for cold weather safety. It becomes part of the discharge decision making. Exactly how stable is the person's housing and how likely are they to keep themselves safe? Can they walk 10 blocks from the hospital to their apartment wearing a sweat suit, basketball shoes, and no hat?  Should they be discharged to the street, even if they want to be?  Should they be discharged if a managed care reviewer says that they should be discharged?  We are generally talking about people who have chronic problems with insight and judgment.  What about people with suicidal ideation? What about the person with chronic drug problems who has a history of drug induced blackouts and waking up on park benches?  What about the person with Alzheimer’s disease who does not have 24 hour supervision?   

How do you make an unbiased decision in that context?  I can say that you don’t.  You don’t because as a psychiatrist you are aware of all of the adverse outcomes.  The continuum of severe frostbite injuries to the hypothermic who could not be resuscitated to those who were found frozen to death.  You don’t want to see that happen to anyone.  You don’t care if somebody wants to call that paternalistic.  You don’t really care if it costs a managed care company or (more likely) a hospital a few bucks.  You have been there yourself and you know you cannot take any chances in subzero weather.  It’s not about a fear of being sued, it’s about concern for a fellow human being.

There are implications for the imminent dangerousness standard that is commonly applied to involuntary holds.  I have argued with enough county attorneys over the years to understand that the standard itself is purely subjective and arbitrary.  No matter how it appears on paper you will hear ten different interpretations from 10 different county attorneys.  There are a few states where a gravely disabled standard applies.  That standard states that a person may have problematic judgment to the point that it potentially impacts their ability to secure adequate food, medical care, or housing.  That standard probably generally applies in these situations, but if you happen to be in a state where there is no statute or the county courts ignore it for convenience or financial reasons it may not be available for use.  

Those are the kinds of things I think about when it gets this cold.  I do get the occasional lighthearted thoughts – making sure I recall the thermodynamic equations that show my car battery dependent on temperature and telling myself that I am going to call Columbia and ask them if they make some type of expedition wear that is warmer than my current Titanium coat.  But mostly – I hope the most vulnerable among us get the help they need and nobody gets injured or killed.  Hopefully someday people will think about the fact that some people have a hard time protecting themselves - irrespective of the air temperature.

George Dawson, MD, DFAPA

Andy Rathbun.  Regions Hospital Sees "Record-Breaking" Number of Frostbite Cases.  St. Paul Pioneer Press.  January 6, 2013.

From the article:

"Most of the people that come in with severe frostbite are "in some way compromised," he said. A small number are physically or mentally disabled, but a majority are people who have consumed too much alcohol or were abusing drugs and didn't realize how cold it was outside, Edmonson said."