Tic - toc......

Or why advising physicians on how to manage their time is not generally a good idea.

I will cut to the chase on this one.  The answer is two fold.  Medical practice is by its very nature inefficient.  Secondly, there are just too many people incentivized to waste physicians' time.   After reading another blog on this topic,  it is apparent that most people attempting to give advice to physicians either think that we are quite slow on the uptake or they have no appreciation of what medical practice is like.  The most misunderstood part is how much time physicians are forced to waste on work that is unnecessary to the work of patient care.

I preface my remarks by saying that in the many visits I have had to physicians of all specialties, I have never been seen on time and consider myself lucky to be seen within 30 minutes.  My all-time record was waiting about 30 minutes to be seen in the emergency department one day and then having to wait another 8 hours to be discharged by the physician who saw me for a rather uncomplicated problem.  So there is no expedited line for physicians in clinics, EDs, or hospitals.  We wait like everybody else.

The premise of efficiency in medical practice is a favorite of administrators and other salespeople pushing valuable time saving devices for physicians.  Primary among them has been the electronic health record or EHR.  I think there is finally a consensus on the fact that it has basically created a large pool of physician-stenographers that spend additional hours each day typing in documents that are designed for billing and coding purposes rather than enhancing the care of patients.  I will roll out my frequently stated comparison.  In 1981, two interns and myself could complete all of the daily documentation on a busy 30 bed neurosurgery service during the 2-3 hours that we were rounding with the senior residents and doing all of the other associated work that day.  Today it would probably take an additional 4-6 hours to do that work and it would mean less time in the operating room learning neurosurgery and attendings wondering about what happened to the team.  I have heard of some surgical services who hire retired surgeons to come in as scribes to do operative notes to reduce the paperwork burden.  The documentation burden is worse in primary care.  All of the advice on how to shift your time around to allow ample time for the documentation never considers the fact that time slots in clinic are rarely set in stone.  People show up 30 - 60 minutes late and expect to be seen.  Emergencies happen, and need to be dealt with while people are stacked up in the waiting area.  Labs need to be reviewed and all of the outgoing tasks (paperwork, phone calls, prescriptions, consults) need to be handled.  None of these are trivial tasks in terms of the time it takes to get them done.  Some of my friends in Endocrinology walk in on a typical morning and have over 250 test results stacked up in a computer queue that they need to review on top of the full patient schedule that day and do something about them - in some cases right away!

Outpatient clinics have certain routines every day depending on the specialties involved and the amount of staff available.  As an example, primary care clinics generally have many more staff to room patients, take vital signs, handle calls, and schedule patients than outpatient psychiatry clinics.  But even clinics that are more fully staffed can easily be overwhelmed by the demands placed on them.  There is no end to nonsensical ideas about how physicians can be more efficient, but there are always several facts that all of the advice givers typically ignore:

1.  There are mathematical laws called power laws that govern how many patients can be seen by physicians.  It is a mathematical fact.  All of the speculation about computers doing thousands of physician tasks per second are really meaningless at this point.  All of the administrators talking about "productivity" are as meaningless.  Productivity happens when real quality treatment occurs that changes a person's life.

2.  Despite all of the business focus on productivity, the business administrators in health care have done nothing but create obstacles to physician work.  Wasting hours every day doing tasks for insurance companies and the government is basically a case in point.  I would estimate at least 40-50% of all physicians time is wasted on these tasks.

3.  Every physician in this country who works in a clinic setting is an independent practitioner.  They don't need supervision, they just need to keep their license current and abide by the medical practice acts in each state.  The only time they are supervised is when they work in a clinic or hospital setting and suddenly they are vertically integrated into departments and placed under a supervisory hierarchy.  That hierarchy is by definition very inefficient.  A lot of time is wasted implementing the next great ideas of the supervisors and in some cases sitting in long drawn out meetings about the financial status of the department.  Apart from the administrators needing to demonstrate that they were actually doing something (that is frequently debatable) - these meetings were generally a waste of time.  I don't discuss all of my cases with business administrators - why would I want to read their spreadsheets?  How can putting 20 or 30 physicians in the same room for a meeting be anything but disruptive to clinic and hospital schedules?  The business and government initiatives to force physicians into these employment situations leads even less time to see patients.

4.  Physicians have been hit hard by the EHR and more.  Like many other jobs there is an implied 24/7 electronic access.  When physicians are not completing documentation after hours or at home,  they are answering e-mails and texts about patient problems.  It is not uncommon to start clinic and notice that is addition to a full schedule of appointments and labs to review that there are also 20 or 30 e-mails and messages through the EHR - many marked urgent.  If you are the first appointment in clinic that day and your physician said that she had to respond to an urgent problem - believe her.

I can understand that this post might elicit widely varying emotions.  Overworked and burned out physicians will see the obvious truths here and will wearily think: "Been there - done that."  There will be readers - like one who suggested that I drive a Porsche rather than a soccer mom van - who will be outraged that a rich doctor dares to complain about working conditions.  There will be readers who think that physicians should not complain on basic principles.  I guess they don't want physicians acting like other workers when this is supposed to be a privileged and noble calling.  They don't recognize that physicians are managed like production workers and not professionals.  There will be those trying to silence complaining physicians by suggesting it is "unprofessional" or characterizing legitimate complaints as "whining".  They generally have their own political agenda  that includes managing physicians like production workers.   It should be apparent that there is no extra time to manage.  There are many people who will say they are working as hard as doctors and therefore doctors don't have a legitimate point.  I would say that I don't doubt it at all that too many Americans are working long and hard hours.  The question is whether there is also a public safety consideration.  Most workers where there is an element of public safety have limitations on their hours.   Practically all physicians are running a huge time deficit that can't be overcome by gaining 5 or 10 minutes from the occasional appointment that goes well.

Irrespective of the emotional reaction to this post there is a very basic thought experiment that anyone can do.  It will highlight a suggested orientation to the problem.  The question is - when you see a physician do you want to see somebody who is burned out, fatigued from people wasting their time and trying to get them to do more busy work?  Or do you want to see a physician who is energetic, enthusiastic and has enough time to dedicate to you or your family member?

I personally will take the physician who is energetic, enthusiastic and has enough time to focus their energy on their family and learning more about their field.  That is not happening in many places today.      

And for all of those people who want to give physicians more advice on how to be more efficient in cramming 12-16 hours of work (much of it unnecessary) into 8 - here is a bit of advice for you.  Step back and let us do our work - we were doing quite well without you.

George Dawson, MD, DFAPA




Attribution:

Clock graphic by Dnu72 (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

Is Susceptibility To Terrorism A Developmental Risk?

I think it was about 1967 when I was playing football with my usual group of friends.  We played football every night for about 8 years.  One of them put on his Army jacket after the game and I noticed that he had a small solid blue button affixed to the lapel.  I asked him what it meant and he said "Students For A Democratic Society."  That was the very first time I had heard of the SDS.  In those pre-Internet days, the only access to radical literature was filtered through popular press in articles that were intended to sell copies.  There were some counter culture approaches like the Whole Earth Catalogue that advised on how to access non-mainstream forms of writing.  It was also possible to travel to one of the universities at the time that were the sources of radical thought and listen directly to what some of the student leaders had to say.

As I pondered that blue button, my next contact with radical thought occurred in the freshmen philosophy course of my liberal arts college.  I ended up in that class like several of my football playing colleagues.  The only reason I went to college was to play football and eventually become a football coach and physical education instructor.  My only disappointment so far was that the college did not have a PE major.  One of the texts for the philosophy course was Eldridge Cleaver's Soul on Ice.  The only thing making my life more complicated at the time was that the instructor graded on class participation.  If you didn't speak up, he would scan the list of names and call one out.  It happened that day in the fall of 1969 that he called my name and asked me what I thought of some aspect of Cleaver's radical text.  I was seated in the back row as 44 sets of eyes turned to stare at me.  My voiced cracked a little bit as I delivered a several minute interpretation.  I wish I could recall what I said that day because it was one of many turning points for me in college - but I can't.  All I can recall is the Professor's response:  "That is good Mr. Dawson.  That is very good."  From that point on, he knew I read the stuff and and could be counted upon for reasonable commentary.  When I sat down the introverted football player seated next to me - gave me a thumbs up.

The 1960s and 1970s were turbulent times.  The same guys I played football with - every day for years - were enlisting in the Marines and going to combat in Vietnam.  One of our group died over there and his name is on the Vietnam Memorial.  It was a very unpopular war and in those days protesting unnecessary wars was popular and became more popular as time went by.  My overall recollection was that information about the war was much more tightly controlled in those days than it is now.  That may have been part of the backdrop for protests, but there was more.  My home state of Wisconsin was a hotbed of radical political thought centered at the University of Wisconsin in Madison.  There were protests in the street and riot tactics used against the protestors.  At one point the windows were broken out of the stores so often on State Street that there were replaced with wood.  One of the retail pharmacies there eventually replaced their windows with bricks and mortar so that the store resembled a bunker with small windows up at the top.  It was an exciting place to visit due to the activity on campus and high level of emotion.  There are detailed descriptions of the history of what happened in Madison available around the Internet and I am not going to excerpt them here.  One of the references suggests that the three radicalized university campuses of that era were Madison, Berkeley, and Columbia.

The protesting in Madison seemed to peak on August 24, 1970 when 4 men blew up the East Wing of Sterling Hall.  That explosion killed a 33 year old physics researcher, injured 3 others, and destroyed years of research - in one case 25 years of research.  The apparent target was Mathematics Research Center because it was funded by the US. Army and the motive was to protest the war in Vietnam.  The 4 men involved ranged in ages from 19 to 23.   The same group was involved in an earlier attempt to bomb the Badger Army Ammunition plant in Baraboo, Wisconsin just down the road from Madison.  Depending on who you read, this bombing changed the course of war protests in Madison.  Many people left the anti-war movement when they realized it contained an element that were not concerned about the lives of others.  Even though many seem to agree that the incident seems to be forgotten, I think there are questions about whether the almost total lack of protests and radicalization today is not in part due to this lingering concern.  In his book Days of Rage, Bryan Burrough described the Sterling Hall bombing as having a transformative effect in that it refocused conversation from the Nixon administration to the bombers and assigned a larger responsibility to anyone who encouraged violence either directly or indirectly.

Burrough goes back and does a good job of making sense of what happened in the 1960s and 1970s.  He covers all of the main radical groups and points out that terrorism (of a domestic kind) was much more widespread then than terrorism of all forms is now even though it was less lethal.  To cite a few examples, in 1972 there were 1900 domestic bombings in the United States.  Bombings were occurring daily and an FBI agent in the book referred to it as "commonplace".  One of the commonest sources of explosives for bombs was dynamite stolen from construction companies.  A Senate investigation in 1970 showed that the amount of dynamite being stolen from quarries and construction sites went from a total of 12,381 pounds in 1969 to 18,989 pounds in the first 5 months of 1970 (Burrough, p151).  By the end of that year most states had passed or were considering new laws limiting the sale of dynamite.  Radical groups also targeted police officers in their activity with several municipalities reporting several fold increases in assaults and homicides of police officers.      

Although Burrough's book is not written from the perspective of developmental psychiatry, there are important themes there that highlight what I think is the most plausible answers to both the recruitment of terrorists and some mass shootings that involve men in this age group with no clear mental illness.  First and most primary is emotional maturity.  Emotions  are both necessary for optimal decision making and at the same time can obscure clear decisions.  The factors that result in that optimal decision making are under delineation but brain maturity, the absence of intoxicants, and appropriate social context and boundaries are all important  aspects of the process.  It is clear from reading Days of Rage that the terrorists of the 1970s like many of their peers - lacked a lot of this.  Burroughs documents disagreements based on boundary issues within some of these groups and in some cases naive approaches to building solidarity within the group that was nothing more than sexual acting out.  Envy was a notable dynamic.  Many of the Weathermen were described as being envious of the Black Panthers.  Some of the radicals most notably the Weathermen were so naive in their quest to recruit and save the working class, that they did not realize that the working class did not want to be saved - at least by them.  The violent activity seemed to be driven at times by narcissism more than anything else.  Being the most violent person in a group of otherwise ambivalent terrorists conferred a certain status that seemed to last a long time.  Late adolescence and early adulthood is also the last great moment to be bonded to a group of your peers.  The next life stage for most people involves family units taking priority rather than peers.  Bonding around a life changing event like a revolution or even much less visible military service can be a powerful experience if it really happens.

History tells us that the revolution did not happen.  Several of the radicals from that time are interviewed and talk about being convinced at the time that it would.  The author refers to this thought as delusional at times, but it is more likely quasi-delusional - shared with such emotional intensity that a very low probability event seemed likely.  Some ponder their sparse legacy or rationalize a lot about what happened.  One interesting twist is that many of the radicals who were never convicted and even some who were completed their college degrees and even went on to professional school.  Some became lawyers and teachers.  One became a prominent psychiatrist.  That aspect of their transition from advocates for a violent overthrow of the system to being an integral part of it separates domestic terrorists from those who are involved in countries without that opportunity.  That may be what separates countries who may transiently have several hundred terrorists who fade away in a fraction of a generation to generations of terrorists living in an abandoned country like a revolution has happened.

There are experts in this area who have different ideas about classifying terrorists - but they are generally based on stable adult personality structures.  I  think that there is a lot to be said for a model that looks at susceptibility to recruitment into terrorist organization as a developmental predisposition and one of many decisions that needs to be made in the transition to adulthood.  That transition is fraught with bad decisions that are the product of the highly variable judgment that can be readily observed in adolescents and young adults.  That includes a prominent bias starting in adolescence that you are making the same decisions that adults would make or that you would make if you were slightly older.

What happened to the domestic American terrorists in the 1970s and how quickly they were forgotten is probably a case study in the problems with this process.  It is very likely that process continues to this day when young adults are recruited to work as foot soldiers in organizations that have similar violence-based ideologies that appeal to very few people.


George Dawson, MD, DFAPA     


Reference:

Bryan Burrough.  Days of Rage.  Penguin Press.  New York, 2015.

Note on the reference: If you lived through this time like I did,  this is the best reference I have found to help you figure out what really happened.

        


















Attribution:

FBI wanted posted image at the top of this post uploaded by Magnus Manske, via Wikimedia Commons - on April 12, 2012.


The following photos were taken of some of the historical locations mentioned in the above post in Madison, Wisconsin on Thursday October 22, 2015. 

Sign to commemorate Reform and Revolt just east of Sterling Hall. 

Sterling Hall Sign

Sterling Hall Main Entrance

State Street from the foot of Bascom Hill.

Watson Replacing Radiologists?

I like reading the Health Care Blog.  It typifies what is wrong with the management of the American Health Care system and I suppose blogs in general.  It is a steady stream of bad ideas and political rhetoric.  The best recent example was a little piece about radiologists called Will Watson Replace A Radiologist - Ask A Radiologist.  Radiologists either don't read this blog or they can't be bothered since the only comment at this point is from a rheumatologist on the necessary consultation and collegiality with radiologists.  The author of the main article is taking the perspective of being both threatening (Can the IBM Watson machine acquire the image reading capabilities of a human radiologist by "reading" a large set of clinical images and reading them at a much faster rate than a radiologist?) and advising (The only way that radiology will survive is to demonstrate their value to patients and colleagues by connecting with them?).  The author's conclusion is very explicit: Connect or be replaced.

Over the past thirty years my experience with radiologists has been positive and in some cases outstanding.  That dates back to the early days of being the medical student or intern responsible for carrying a stack of heavy and awkward films around.  I remember not having a film on a Cardiology rotation and regretting it: "Mr. Dawson - what made you think it was not a good idea to have the chest x-ray of this patient with mitral valve disease?"  From that point on radiologists were my friends.  That was an era before there was a lot of managed care penetration and I always rotated at public  hospitals and VA hospitals anyway.  You could always find a radiologist back in the dark confines of a reading room.  The interns and residents had certain staff members that were the go-to staff in terms of teaching and also amazing observations.  They always pointed out what we were missing.  They collected teaching files and teaching cases for us to learn from.  Reading rooms could be bizarre places in those days.  Very large films clamped on reading boxes.  In some cases entire rows of films - 10 to 12 wide, could be rotated on a belt device.  The radiologist would need to recall when they saw the film and press down on a foot pedal until the correct film popped up.  On many days row after row of films would need to be surveyed to find the one you wanted.  In the early days of spinal CT, many films had to be viewed on each patient.

I did not forget my positive experiences as a resident when I became an attending physician.  All the images I ordered on my patients had to be seen.  I would still go down and pull the films and where necessary review them with the radiologist.  Now I had neuroradiologists to work with and they were excellent.  The medium was changing.  Eventually all of the films went away and when I went down to radiology, the reading room was still there, but now it was a computer terminal with two monitors.  The images could be immediately manipulated to show the best view.  It was no longer necessary to pull the film off the cassette and illuminate it with a bright light.  I could always ask them questions, but as time went by they were under a greater time crunch.  Now all of the dictated reports were available on the phone system and you were encouraged to listen to all of the reports.  Asking to review a series of films without listening to that report was frowned upon.  At one point in time we were all members of the same clinic, but soon all of the radiologists were spun off into a different company.  They were the same people,  just no longer affiliated with our clinic.  By  that time managed care was trying to get everyone on a productivity scale and radiology seemed like an ideal speciality to crank up the productivity expectations.

In addition to the direct experience with radiologists, the author here also seems to not recognize the value of a human brain as a processor.  I teach neurobiology to students, residents, and physicians.  Part of the job of any lecturer is to help people stay awake.  Just before I delve into the frontal cortex and its connections to the ventral striatum, I put up a slide with a fact from one of my IEEE journals:

"Equivalent computing power (depends on the simulation) using today's hardware may require up to 1.5 gigawatts to power and that is equivalent to 0.1% of the US power grid or the output of a small nuclear power plant..."   IEEE Spectrum 2012

I ask the students to speculate on how the human brain has such a tremendous amount of processing power and how it is different from computers.  Even though the audience is generally tech savvy young physicians or students, I have never heard the correct answer.  One of the correct answers is the fact that the human brain is an unparalleled pattern matching device.  There are papers where it has been estimated we can each recognize about 80,000 unique patterns.  I start to go down the list and end with studies of radiologists, dermatologists and ophthalmologists demonstrating superior pattern matching and pattern completion skill.  But I also point out, it is why that you can't learn medicine from a textbook.  It is why you need clinical exposure before you can safely practice.   You need to acquire those skills.  To my knowledge, there have been no good papers written on available pattern matching in human diagnosticians compared with the cognitive tasks they face.  For example to be a good radiologist, how many unique patterns and variations do you need to be able to see - 10,000, 50,000?  The answer to that question is critical and yet we do not know the answer for radiology or any other medical specialty.  If the number if less than 80,000 (and we don't really know this confidence interval) - Watson may have the speed but not necessarily the accuracy.  Will Watson be analogous to the current ECG computer - a general normal/abnormal reading, a reading on measurable dimensions, and then not much on equivocal cases?  Only time will tell.

So I think this Health Care Blog post has the valuable lessons of most of their posts.  I don't know the author, but it is clear that he has not worked with radiologists as long as I have.  Not just the consultations backlit by reading boxes, but the telephone conversations about the best possible test to use to investigate the problem.  If he had worked with radiologists he would know that they have always been connected throughout the careers of most physicians.  The only obstacle to that connection has been corporate medicine.  The author's seemingly friendly advice is disingenuous.  If the business administrators who run health care really wanted radiologists connecting - they would get reasonable productivity compensation for that activity.  They would not need to connect and then run back to their terminal and read enough films to make up for the period of time they were in a conference or informally teaching residents from other specialities.  I think that the admonition to connect probably means to connect with the business administrators running the health plans.  Come back into the herd and let us tell you how many images to read, just like we tell other physicians how many patients they have to see.  Advising physicians on how to behave is also a well known strategy to manipulate them.

The real message is come back to the herd or be replaced, because there is nothing that would make an administrator's day more than replacing physicians with machines - especially physicians that they have no direct control over.

IBM knows that and I know that........

An equally important question is why Watson can't replace business administrators?  They seem to have the requisite lack of technical expertise and creativity.  They need a very basic level of pattern matching to do the job, certainly no training in it.  It would seem that a very basic program to optimize the working environment for physicians, health care workers and patients would be more ideal than dabbling in an area where real expertise and collegiality is required.  I can only conclude those concepts are alien to the ever expanding group of administrators whose reason for existence seems to be managing people - whether they need it or not.


George Dawson, MD, DFAPA


Supplementary:  Although I could not work it into the above post another insidious effect of corporations on medicine has been taking teaching out of the loop.  Radiology teaching files and teaching rounds were always a rich source of learning for students and residents.  It is a required skill on most board exams.  I recall approaching an administrator about preparing teaching slides for the residency in-training exam.  It is quite easy to copy de-identified images onto PowerPoint slides for review and these images routinely appear in all major medical journals.  I will never forget the response:

"Dr. Dawson - why would we want our images to appear on teaching slides?"

Just another sign of the apocalypse.










      

Current Treatment of Respiratory Viruses - More Homilies

With Permission: SIB Swiss Institute of Bioinformatics,
Philippe Le Mercier, ViralZone.

My Facebook feed got me going today.  I get the Mayo Clinic feed since I consider their clinical care and some of their research to be the best in the world.  Of course social media is much less rigorous and sometimes it comes down to just advertising and promotion.  That was my assessment of the link to this document this morning.  It is a business document that purports to give advice on how to decrease your chances of a respiratory infection this winter.  Some of that advice is given by a Mayo Clinic Infectious Disease specialist and a Cleveland Clinic family physician.  There was one number I had not seen before and that is the Number Needed to Treat (NNT) for the flu vaccine is 40.  Forty people need to be vaccinated to prevent one case.  The advice is the usual set of homilies about respiratory infections including get the flu vaccination, wash your hands, sneeze into your sleeve, take care of yourself and stay home of you are sick.  In other words, there is no way in hell that you are not going to get sick at least once this winter.

Our continued 1950's approach to viral infections remains a mystery to me.  Certainly there are technical problems with trying to design vaccines for over 200 viruses that can cause the common cold.  But the reality is, vaccine design for influenza virus - easily the most lethal of these viruses is obviously not so hot.  As far as I know, vaccines for the most common of the cold viruses - Rhinovirus - is non-existent.  Anti-viral medications for respiratory viruses are more controversial.  Looking at the most popular one Tamiflu or oseltamivir.  The NNT to prevent one death may be 1,800 - 3,200.  The NNT to prevent one hospitalization may be 97 to 142 depending on criteria.  The NNT group suggests somewhat better NNTs of 36 and 83 for preventing a culture positive case of influenza and preventing pneumonia respectively.    Contrast that with the NNT for antidepressants of 5-10 as determined by Leucht, et al (2) in their comparison to other medications for various medical conditions.  And you thought antidepressants were ineffective?

Infectious disease respiratory virus research is a goldmine for all of the Luddites out there.  There are a number of web sites that provide free access to just about everything you ever wanted to know about every virus known to man.  The viral particle shown at the top of this page is the order that contains Rhinoviruses one of many common cold viruses and one of the viruses that may be responsible for the expression of asthma in predisposed individuals or exacerbations of asthma in asthmatics who are asymptomatic.   This illustration is from the ViralZone, one of many free online databases with detailed information about the molecular biology and genetics of viruses.  If I was an aspiring Luddite wanting to be provocative about the field of medicine being stuck in the 1950s despite the availability of all of this advanced information - this would be a logical place to start.

In previous posts here I have also critiqued the lack of attention given to environmental approaches to respiratory viruses and the fact that the airborne nature of some of these viruses is not acknowledged - possible because airborne viruses are not contained by hand washing and other direct contact techniques.  It s well know that viruses can be collected in the heating and air conditioning systems of public buildings and that altering the humidity and air flow characteristics in those buildings can change the viral concentrations in the air.  Whenever I have mentioned this to the administrators of buildings where repeated respiratory epidemics swept through the staff - I got the same response that I received from an airline after I reported a severe respiratory infection after one of their flights: "We are really sorry that you had flu-like symptoms after your flight and look forward to your future comments to help us improve our service."

What?!

 Time to get serious about respiratory infections and come up with some effective interventions.  Effective medication to prevent viral replication and spread in the infected and to create barriers to infection would be ideal and so would environmental methods to reduce the infection rate.  Considering the strong incentives in America to work while sick and considering that the average worker is going to get 2 to 3 respiratory infections per year that can last up to 3 weeks in duration means that very few of us and the patients that we treat are not going to be exposed and infected.  With the current advanced knowledge of the pathogens and modern heating and air conditioning systems it seems like a lot more could be done right now.


George Dawson, MD, DFAPA


References:

1:  Postma MJ.  Re: Tamiflu: NNT to prevent a pandemic flu death may be a million.  BMJ 2005; 331:1203.

2:  Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012 Feb;200(2):97-106. doi: 10.1192/bjp.bp.111.096594. Review. PubMed PMID: 22297588.


Attributions:

Graphic at the top of this post is courtesy of: SIB Swiss Institute of Bioinformatics, Philippe Le Mercier, ViralZone.  http://viralzone.expasy.org/  licensed via Creative Commons Attribution- NonCommercial 4.0 International License.

Does Publicizing Mass Shooters Benefit Anyone?

I ran across this perspective posted on the Kottke blog.  It is basically a journalist writing an opinion piece about why the names of mass shooters should be used in the media.  I think it is a reaction to the banning of the use of the names and details of mass shooters by some law enforcement and the media.  The Sheriff in the most recent mass shooting incident refused to release the name of the shooter.  The argument against releasing the name of the shooter goes something like this.  At least part of the motivation of some of these shooters involves the fame and publicity that they will achieve based on the incident.  The mass shooting incidents have been in my estimation fairly compared to terrorist incidents where the victims are killed in some of the most horrible and sadistic ways possible as part of the media campaign by these organizations.  It enhances any kidnaping and extortion threats that they may have and also enhances their image as a ruthless and single-minded entity.  Until recently that behavior was also a ticket to widespread international media exposure.  When the media cycle becomes knee jerk in response to mass shootings or terrorist events it is predictable no-cost publicity to both types of perpetrators.

There is additional evidence in the personal effects of many of these shooters and well as evidence from the staging of the events that publicity is a strong motivating factor.  The shooters often have computers and written statements about the motivation for their acts, and some of that material describes the event as something for the world to see.

The counterargument from the journalist seems to be that it is important for the public to hear all this information.  He makes the expected argument of the press that all of the news needs to be reported.  He also spins the political angle and suggests that conservative gun advocates including the sheriff involved in the most recent incident and then Fox News have elected not to name the perpetrator and connects this with the right wing tendency to talk about mental illness being the problem and not uncontrolled access to firearms.

I am at the point where I cringe when reading these highly politicized arguments probably because that is all that I hear when it comes to psychiatry.  The general form of the argument is that people taking a certain position have a certain ideology and therefore the conflict of interest issue reigns supreme.  Because a news service or a sheriff have been identified as being right wing and supporters of continued open access to firearms, anything they say about maintaining the anonymity of the perpetrator can be discounted based on conflict of interest.  In other words, by maintaining the anonymity of the shooter and focusing on the mental state of the shooter, the focus is shifted inappropriately away from more functional legislation to reduce firearm access.  The writer acknowledges that part of the motivation of some of these shooters is publicity or infamy whether they survive or not.  It is hard to deny because a review of the personal effects of some of these shooters makes it explicit.  The author takes the view that denying this publicity essentially gives the appearance that something is being done and this is bullshit.

First off, that does not meet my definition of bullshit from the definitive essay by Frankfurt.  According to Frankfurt, the main differentiating point between bullshitters and liars is that bullshitters have a blatant disregard for the truth.  The truth in this case is that irrespective of political motivations it is highly likely that denying these men the publicity that they seek will result in fewer of these crimes.  It might even provide a public health path to treatment for many of these individual instead of acting out.  I would suggest statutes that address the issue of how mass shooters should be handled in the event of any incident and would not only see anonymity as being important, but also confiscating property and all of the written material and images from the perpetrator and making them available for academic study, but not for the evening news.

The author also seems blind to the role of journalists in this process.  Every massacre triggers the standard response from journalists that I have written about on this blog many times.  All of the shocking details, the interviews with the aggrieved, the response from politicians, and the "profiling" of the perpetrator.  Then after a few days, the President comes on and we are all told to move on.  It seems that the President in his latest address has questioned the value of this process before members of the press have including this author.

My conclusion is that there has to be obvious progress in the area of gun control (yes - I said control).  But I have also accepted the fact that the power structure in this country does not have to yield to public opinion.  My decades of treating violent and aggressive people have also led me to understand that this is also a public health problem and as a public health problem - multiple measures need to be in place.   Restricting wide spread publicity for the perpetrators is one of many logical options.

There is also the issue of contagion.  Does a large incident with a lot of news coverage trigger copycat crimes?  There have been some anecdotal reports that copycat crimes occur in the specific area of school shooting.  The authors of a recent PLOS article (2), analyze the USA Today Mass Killing database and the the Brady Campaign School Shooting database.   The original databases and any modifications to them are available at this link.  The authors comment that a contagion model has been applied to several natural events like the financial markets, burglaries and terrorist attacks.  The authors specify the model they are using and go on to show that according to the USA Today database there was a mass killing (involving 4 or more people killed) every 12.5 in the US.  For the Brady database school sooting occurred every 31.6 days.  The authors illustrate there is a contagion effect for mass killings involving firearms but not mass killings that do not involve firearms.  They also show correlations between state prevalence of firearm ownership and mass shootings, but the authors note that mass shooters commit suicide 48% of the time and that is much higher than the expected suicide rate by perpetrators committing a single act of homicide (5-10%).  Mass shooters who commit suicide also kill 22% more people than mass shooters who do not.  The graphics and statistics in this article are great and I highly recommend a look at the graphs showing what part of the data is due to the contagion effect.  I also applaud the authors efforts to publish essentially public health research in an area that has been actively suppressed by Congress.  Scientific research on firearms policy is apparently incompatible with the Second Amendment.

So it turns out that there are probably legitimate reasons for withholding the identity of mass shooters and decreasing the disclosures about the incident and in some cases the audiovisual material that they have produced to promote their activity.  There is a well known journalistic tendency to wrap themselves in the flag when it comes to their not having complete access and the ability to disclose information, but the process is far from perfect and in many cases they defer to national security.   In the case of the databases involved there is clear asymmetry in terms of which incidents get publicity and which do not.  This is an opportunity for them to provide some news about public health interventions to prevent violence and mass shootings.

I don't think the importance of the notoriety or contagion factors in motivating mass shooters can be cancelled out by a conflict of interest argument.  But the conflict of interest card seems to be played like it is the trump card these days.

I also don't accept the "we as a society have made our choice" argument.  It's not really them it is us.  That argument is a stark contrast to how our government runs.  "We" are no more responsible for a society flush with guns that "we" were for three unnecessary wars based largely on fictional threats.  That oligarchy can function primarily with the full cooperation and lack of critical analysis by the American press.  The fact that late night comedians can produce more analysis of these issues than mainstream journalists is an indication of how much serious reporting is lacking.

There is probably no better example of reporting deficiency than how mass shooting incidents have been handled for decades.


George Dawson, MD, DFAPA


1:  Josh Marshall.  The Great Evasion.  TalkingPointsMemo.com  October 2, 2015.

2:  Towers S, Gomez-Lievano A, Khan M, Mubayi A, Castillo-Chavez C. Contagion in Mass Killings and School Shootings. PLoS One. 2015 Jul 2;10(7):e0117259. doi: 10.1371/journal.pone.0117259. eCollection 2015. PubMed PMID: 26135941.

The Problem With Benzodiazepines.....

I want to thank David Allen for the inspiration for this post when he commented that as an addiction psychiatrist, I was probably seeing a skewed sample of people addicted to benzodiazepines and that might be why I have such a jaundiced view of them.  I use the above bubble diagram to illustrate how benzodiazepines are prescribed by docs like me with a strong bias toward preventing addiction compared with physicians who have no such bias.  To make sure that we are on the same page, benzodiazepines are all technically tranquilizers or sedatives.  They marked a therapeutic advance from the earlier barbiturate class  in that their therapeutic index (ratio of the drug that produces toxicity in 50% of patients to the dose that produces a therapeutic response in 50% of patients) is much greater than earlier tranquilizers like barbiturates.  The practical measure is that it takes much higher doses to produce respiratory arrest and death.  Despite the increased safety these drugs are addictive.  People can develop a tolerance and in some people they produce a euphorigenic effect, very similar to the effect of alcohol.  Some people describe benzodiazepines as "alcohol in a pill."  Unfortunately we do not know the percentage of people where that occurs or how to detect them. There are many common clinical situations where the safety margin of benzodiazepines is cancelled out by other factors.  Mixing them with alcohol and opiates are two of the most common dangerous situations and if you are treating addiction - you see that happen all of the time.

Rather than list the entire table of benzodiazepines, I am going to list the commonest ones that I see being abused.  In order from the most frequently abuse that group would include alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), and diazepam (Valium).  Of those compounds Xanax Bars or 2 mg alprazolam tablets seem to be the most commonly abused by far.  The maximum recommended dose of alprazolam is 4 mg/day and I frequently have seen people taking 8-20 mg/day in combination with other street drugs.  Benzodiazepines have all been generic for a long time so they are very inexpensive to purchase if you have a prescription.  If you don't have a prescription and acquire them illegally the "street value" of a drug is a sign of abusability.  The average street value of alprazolam is about $5 for a 2 mg bar.  The immediate risk of using benzodiazepines excessively is accidentally overdosing on the single drug or in combination with alcohol and other drugs of abuse.  There is also a significant seizure risk from abrupt withdrawal when the supply of medications have been used.  The abuse of benzodiazepine like compounds that are more typically used for sleep like zolpidem (Ambien) or eszopiclone (Lunesta) does happen but it is more likely to occur in combination with alcohol for alcohol related insomnia.  A common example would be a person with alcohol dependence who takes zolpidem at night so that they can sleep through the entire night.  Without it they would predictably wake up at 2 or 3 AM from the withdrawal effects of alcohol.  Chronic use of benzodiazepines whether by prescription or acquisition from illegal sources can lead to tolerance and chronic withdrawal symptoms that can last for months if the drug or medication is stopped.  That fact alone should be considered as part of the risk of taking benzodiazepines - even in the situation where the person does not have an addiction and has anxiety that they do not believe can be treated by any other means.  In my experience, I am not sure that kind of anxiety exists.

Another common problem with benzodiazepines is that they can be psychologically debilitating, even if the person affected never takes the pill.  It is all part of the behavioral pharmacology of addicting drugs.  It usually starts out with a panic attack.  That panic attack can result in people going to the emergency department once or twice because they believe they are having a heart attack.  Somewhere along the line a physician prescribes alprazolam to take "in case of a panic attack."  That starts to happen and even if the panic attacks are rare, brief, and situational - the person affected starts to believe they need to carry alprazolam around with them wherever they go "in case" of another panic attack.  They may not have had a panic attack in years, but they are more anxious about whether they are carrying a pill when they get on a plane, cross a bridge, etc.  The pill have taken on Talisman-like features based on their using it for a condition that for most people fades away over time.  Some  who don't know the sequence of events might suggest "what's the harm" if somebody develops such a belief system around a pill.  In my estimation the harm is that the person's normal conscious state has been transformed and they have exchanged one form of anxiety for another.  The debilitating effects of anxiety depend on the illusion that your life needs to be modified in a certain way to accommodate it.  Proving to yourself that is not true is one of the best ways to adapt.        

Despite those reservations, I have prescribed a lot of benzodiazepines in my career.  They are very good medications to use in controlled environments for acute alcohol and sedative hypnotic withdrawal, acute seizures, catatonia,  akathisia, and various agitation syndromes associated with acute psychosis and mania.  The goal is typically to get the patient off the medication before they are discharged and to avoid treating patients with addiction with benzodiazepines.  Benzodiazepines are also useful for the first month in treating panic attacks, but that typically takes a lot of work.  The work involved is convincing the patient that a medication that seems to work rapidly is not a good one to take for the long haul.  The other dimension that is operating here that is rarely commented on and never explicit is whether the person receiving the benzodiazepine enjoys taking it.  Medications that are potentially addictive lead to an array of problems that are not there with drugs than are not addicting.  The main one is that they tend to be viewed as solutions for everything.  Instead of just anxiety or panic people will take them for insomnia, stress, or just to wind down at the end of the day.  Medications that reinforce their own use have the problem of inventing new uses that they were never prescribed for and that can lead to escalating doses of the medication.  In some complicated situations benzodiazepines are added to treat anxiety.  They have been used in psychiatric patients with multiple problems and been shown to add no benefit.  They are commonly added to multiple medications including opioids in patients with chronic pain with no additional benefit.

Benzodiazepines are a big problem in primary care.  The NSDUH survey illustrates that most people with an addiction are not aware of it and further that only a small minority seek treatment and find it.  That same survey suggests that about 1.5 million Americans start using tranquilizers and sedatives (they do not have a unique benzodiazepine category) for non-medical use very year.  Even if it is apparent to a primary care physician and their patient that an addiction to benzodiazepines exits, there are significant obstacles to reversing the process.  Although there are protocols for slowly tapering the medication on the Internet, it takes a very highly motivated person and ideal circumstances to accomplish this.  Outpatient detox from urgent care, the emergency department or an outpatient clinic is problematic because the same medication that the patient is not able to control is being given to them to self administer at home.  It is common that the detox medications are all taken the same day or in some cases at once.  Structured detoxification in the American health care system is practically impossible to find, especially in the case of benzodiazepines that require careful attention to seizure prevention, the prevent of withdrawal delirium, and adequate treatment of chronic withdrawal symptoms when they emerge.  Some primary care clinics are taking the preventive approach of not starting benzodiazepines in the first place.

Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.

There is a lot of resistance to the ideas of addiction docs when benzodiazepines and their long term effects are discussed among physicians.  There is always a physician who claims that they have successfully treated a person with an alcohol use disorder with benzodiazepines or they have people who have stayed on low doses for decades in order to treat their anxiety.  I see the failures.  It leads to the question of how many people are capable of staying sober, not developing a tolerance to benzodiazepines, and not experiencing a negative impact on their life.

As far as I know there are no good studies that address that question and I would not expect that there will be.  Any study that allowed subjects to mix alcohol, opiates, and benzodiazepines would be unethical and should not be approved by any Human Subjects Committee.


George Dawson, MD, DFAPA


Supplementary:

This article was subsequently edited and modified for the Psychiatric Times.  The edited version reads better.

Is President Obama Reading This Blog?

Not really, but you can find the mass shooting links on this blog at this link.  They extend back three years and they overlap with a number of posts on homicide prevention.  They also overlap in many areas with the President's speech.  This was President Obama's 15th address to the nation following a mass shooting incident.  A couple of other landmarks - this was the 40th time this year that a gunman opened fire in a school and the 294th mass shooting incident this year.  Both of these markers illustrate how tragic but absurd this problem is in America.  How can responsible people allow this to happen?

The President is coming to the only logical conclusion that a person can come to about mass shootings and the relationship to firearms.  That point in this speech was when he said that our thoughts and prayers for the families and survivors are not enough.  We cannot keep making these pat statements in response to continuous mass shootings as though nothing can be done to prevent them.  We cannot treat mass shootings like they are routine:

"Earlier this year, I answered a question in an interview by saying, “The United States of America is the one advanced nation on Earth in which we do not have sufficient common-sense gun-safety laws -- even in the face of repeated mass killings.”  And later that day, there was a mass shooting at a movie theater in Lafayette, Louisiana.  That day!  Somehow this has become routine.  The reporting is routine.  My response here at this podium ends up being routine.  The conversation in the aftermath of it.  We've become numb to this."

 The familiar refrain about condolences to everyone and now it is time to move on needs to stop.  With governments that regulate what a lot of us do at work every day - right down to how we cross the Ts and dot the Is - it is difficult to believe that more functional gun control laws cannot be passed.  In his speech he points out that this is possible and there are laws that have been shown to work in other countries and in specific counties and municipalities in the United States.

At one point he speaks to the mind of the perpetrator:

"We don't yet know why this individual did what he did. And it's fair to say that anybody who does this has a sickness in their minds, regardless of what they think their motivations may be. But we are not the only country on Earth that has people with mental illnesses or want to do harm to other people. We are the only advanced country on Earth that sees these kinds of mass shootings every few months."

People tend to get hung up on whether specific perpetrators have a diagnosable mental illness and whether it is treatable.  They tend to get hung up on whether the behavior of violent individuals can be predicted over time.  They tend to be very pessimistic about the nature of the problem and whether insightless people will ever be able to get the kind of help that they need to prevent mass shootings.  It might be easier if there was some education about the types of situations that lead to these problems and the fact that in most of those cases, help is available.  That specific help will prevent homicides and prevent the unnecessary loss of lives of both the perpetrators and the victims.  

The President ended with a comment on the political process and an appeal to gun owners on the issue of whether they are being supported on this issue by an unnamed organization or not.  It was a compelling speech and the arguments are powerful.  As a politician, he is focused on political action and on common sense gun safety laws.  I have stated that it might be best to proceed from a public health standpoint and a focus on violence prevention and forget about legal approaches largely because there has been no political will on this issue.  President Obama has given one of the most compelling speeches on this issue that I have ever witnessed and it will be interesting to see the result.

From the medical and psychiatric side, our advocacy still needs to be on the public health side of the equation.  For me that comes down to seeing the problem to a significant extent as violence and homicide prevention.  We need more public education on the predisposing mental states and how to get assistance when these states are recognized.




George Dawson, MD, DFAPA


References:

Statement by the President on the Shootings at Umpqua Community College, Roseburg, Oregon.  October 1, 2015.  Transcript