Emery Dreifuss Muscular Dystrophy and Lipodystrophy

Public radio is a consistent source of content about medical problems that contain lessons for everyone.  I happened to hear one last weekend.  The program was This American Life and the story was called Do These Genes Make Me Look Fatless.   The story starts out with writer David Epstein describing the public reaction to his latest book The Sports Gene.  As part of the correspondence a 39 year old woman named Jill Viles sent him an illustrated letter and it contained the heading "Olympic Medalist and Muscular Dystrophy Patient with the Same Mutation."  The side by side photos of Jill Viles and Olympic sprinter  Priscilla Lopes-Schliep are side by side on the web page and I encourage anyone reading this to take a look at the comparisons and try to figure our how Ms.  Viles came to this conclusion.  Epstein was interested and replied getting a detailed scientific brief in return.  He got a second opinion from a geneticist that he consulted in the making of his book who concluded that Ms. Viles was probably wrong about the genetics.

From there the story goes into the incredible history of Jill Viles and how she started to research her illness.  After normal early developmental milestones she started tripping and falling at the age of 4.  She was taken to the Mayo Clinic and Jill, her brother and father were all tested and showed evidence of muscle damage.  They concluded that although it looked like muscular dystrophy, girls never got it and therefore she did not have muscular dystrophy.  Over the next 8 years her arms and legs got extremely thin,  she had a burning sensation in the legs, and all of the subcutaneous fat in her extremities disappeared leaving very prominent veins.  Within a few weeks she started to fall again and was no longer able to ride a bike or roller skate.  She regained her ability to walk and then began a very unusual research program to see if she could find out what was wrong.

She started by looking at tales of the supernatural - like poltergeists.  She reasoned that the people in these books she was reading could not explain what was happening to them and she might find an answer.  Then she went to college and started to study medicine on her own.  Her project involved reading textbooks and journal articles on muscle diseases trying to find one that matched her own experience.  She was reading an article on  Emery-Dreifuss  muscular dystrophy when she noticed the description "Popeye arms" and had an immediate association to the appearance of her father's arm.  As she read the description she noticed that she had features of the illness.  She took a number of the books home on break and her father discovered that he had both the muscular and cardiac symptoms with bradycardia into the 30 beat per minute range.  His doctors told him the symptoms were from exposure to a virus.  He was re-evaluated and a pacemaker was placed.

Jill went to a neurology clinic for confirmation of the diagnosis, but the neurologist there just make a diagnosis of Muscular Dystrophy.  She got angry and would change the diagnosis by writing in the chart.  The rationale was that women do not get Emery Dreifuss Muscular Dystophy (EDMD).  She eventually located a group of researchers in Italy specializing in the disorder and sent them blood samples of her entire family.  Four years later she had confirmation that she had the gene - a single base pain mutation on the Lamin gene.  According to the Universal Mutation Database the LMNA gene has 464 known mutations and 283 variants.  Some of the diseases are more well known than others.

At this point before I get into some additional details of the illness, this is clearly an inspirational story.  Jill is clearly a very bright person.  Transitioning from an explanatory paradigm that went from the supernatural to cutting edge DNA and genetic research within a few years while dealing with a significant chronic medical problem for  which there was no clear diagnosis or treatment is astonishing.  It is a testament to her intelligence, character, and mental flexibility.  In the process she her research also made a significant difference in her father's life and the life of Olympic sprinter Lopes-Schliep.  Hearing her speak about these details in the audio file is necessary to bring some of these details to life.

Jill got a job in a lab at Johns Hopkins combing the research for any reference to the lamin gene.  In the process she came across another photo that reminded her of her own appearance.  In this case the prominent feature was a loss of subcutaneous fat called partial lipodystrophy.  She maintained that she also had this rare disorder and was met again with denials - in this case based on the likelihood of having two rare genetically determined illnesses.  This time she believed the deniers.  She also started to get increasingly anxious in reading about  EDMD and the short life expectancy.  She stopped the research completely and started teaching at a local community college.  She got married and gave birth to a son who does not have EDMD.  She had more severe weakness after the pregnancy.  Jill's father died suddenly at age 63.  In the gathering at the familiy home her sister showed her pictures of Priscilla Lopes-Schliep.  She noticed the characteristic pattern of veins and muscle fibers.  Twelve years after she stopped researching EDMD she started to research lipodystrophy.  Eventually Jill arranged a meeting and they both  submitted samples to a world expert on the condition - Dr. Abhimanyu Garg.  He confirmed they both had the same rare type of hereditary lipdystrophy.  It turns out that the partial lypodystrophy mutation and the EDMD mutation are both on the lamin A/C gene LMNA.

Jill also reached out to Etienne Lefai a researcher studying SREBP-1, transcription factors that control muscle mass through protein synthesis.  Overexpression of these same factors can lead to muscle atrophy.  Dr. Lefai credits Jill with changing the path of his research when she reached out to him.  He described her a awesome and the only example of someone outside of the research community coming in and altering his basic path of research.    

I agree completely with Dr. Lefai.  Part of the story here is how much credence you give the theories that your patients have.  For a psychiatrist it is somewhat easier.  Good psychotherapy depends on finding out underlying theories, testing them and suggesting alternate theories at times.  It can be a trying process.  Sometimes your patient really is being followed by the FBI and figuring that out is a major decision in the diagnosis and treatment plan.  I have gone to some elaborate lengths to create an experiment and conferenced in some experts from other fields like electrical engineering to test a person's theory about how the  world  works.  In the addiction field it is very common to encounter people who have never had a chemistry course in their life and now consider themselves to be experts in pharmacology and organic chemistry.  I listen to all of these theories and carefully weigh them and consider their overall meaning.  It was interesting to read why the experts rejected Jill's correct theories and how they gradually came to accept them.          

Another reason for this post is that is also allows me to highlight what I consider to be the best resource on the Internet for musculoskeletal diseases and that is the Washington University Neuromuscular Disease Center. It is essentially a free online text in neuromuscular diseases ranging from the clinical presentation to pathology to molecular biology.  It is an immediate resource for any physician treating someone with a neuromuscular disease.  In the case of Emery Dreifuss MD, there is a comprehensive page with the genetics listed right at the top.  The National Organization of Rare Diseases has a web page on congenital lipodystrophies.

I often think about what research was like when I was in medical school.  My wife and I would head to the Medical Library and I would run around pulling bound journals while she copied the articles that I needed.  That was a lot of heavy lifting that is no longer necessary thanks to the modern flow of information.

I thought about that when the story described Jill lugging heavy books home in a backpack.  That was definitely another measure of her determination.


George Dawson, MD, DFAPA




References:

1: Dessalle K, Euthine V, Chanon S, Delarichaudy J, Fujii I, Rome S, Vidal H,Nemoz G, Simon C, Lefai E. SREBP-1 transcription factors regulate skeletal muscle cell size by controlling protein synthesis through myogenic regulatory factors. PLoS One. 2012;7(11):e50878. doi: 10.1371/journal.pone.0050878. PubMed PMID:23226416.

2: Gnocchi VF, Scharner J, Huang Z, Brady K, Lee JS, White RB, Morgan JE, Sun YB, Ellis JA, Zammit PS. Uncoordinated transcription and compromised muscle function in the lmna-null mouse model of Emery- Emery-Dreyfuss muscular dystrophy. PLoS One. 2011 Feb 22;6(2):e16651. doi: 10.1371/journal.pone.0016651. PubMed PMID: 21364987.

3: Scharner J, Brown CA, Bower M, Iannaccone ST, Khatri IA, Escolar D, Gordon E, Felice K, Crowe CA, Grosmann C, Meriggioli MN, Asamoah A, Gordon O, Gnocchi VF, Ellis JA, Mendell JR, Zammit PS. Novel LMNA mutations in patients with Emery-Dreifuss muscular dystrophy and functional characterization of four LMNA mutations. Hum Mutat. 2011 Feb;32(2):152-67. doi: 10.1002/humu.21361. PubMed PMID: 20848652. 

4: Scharner J, Gnocchi VF, Ellis JA, Zammit PS. Genotype-phenotype correlations in laminopathies: how does fate translate? Biochem Soc Trans. 2010 Feb;38(Pt 1):257-62. doi: 10.1042/BST0380257. Review. PubMed PMID: 20074070.


Attribution:

Figure at the top is from National Library of Medicine Genetics Home Reference page on the LMNA gene.  It is the cytogenetic location of the LMNA gene.  It was generated with the NCBI Genome Decoration Page.  The copyright is Health and Human Services and I assume this is public domain.

https://www.thisamericanlife.org/radio-archives/episode/577/transcript

http://www.emerydreifussmd.org/genetics.html

Racing Thoughts?

From the DSM-5 under criteria B.4. for a manic episode: "Flight of ideas or subjective experience that thoughts are racing." (p.124). In a previous post I discussed how easy it was to make a reliable diagnosis of bipolar disorder because the patient needs to describe a clear cut episode of mania. The main problem becomes determining whether they are actually describing a manic episode or not. There are a significant number of confounding factors in that determination. The best way to illustrate what I am talking about is to focus on how the term racing thoughts is used in psychiatric evaluations by patients rather than psychiatrists. DSM technology gives surprisingly little guidance on what a racing thought is. In clinical practice that is very problematic, especially if psychiatrists are depending on the observations of untrained observers. People who appear to be hyperactive or agitated and hypertalkative are frequently described as having racing thoughts. In many cases when asked directly they will reply: "My thoughts are always fast." or "This is normal for me." or "What do you mean by racing thoughts?  I don't know what that means."  At the observer level, many observers have reported to me: "The patient states he is having racing thoughts" as though that is diagnostic.  It may be - but it also might not be.

One of the commonest scenarios for racing thoughts doesn't involve mania at all.  It involves anxiety and insomnia.  Initial insomnia is a case in point as in: "I try to fall asleep but as soon as my head hits the pillow my thoughts are racing and I am thinking about a million things. After a while I look at the clock and it is 2AM." In the sleep literature the experience of racing thoughts here is associated with the phenomenon of hyperarousal and it is the commonest form of initial insomnia.  In other words, when I go to bed to sleep at night - I have really trained myself to think about all of my problems for several hours before I fall asleep.  It is not about sleep at all. Subjectively a person may thinking about every hypothetical in order to prevent mistakes - a common cognitive error of the anxious.  Many people experience this high arousal and excessive worry state as racing thoughts, but the main difference is probably in the time domain. The insomniac experiences a compression of time.  The worry is continuous and at least initially there is some surprise that hours have passed and there is no onset of sleep.  When the insomniac wakes up in the morning the racing thoughts are probably not there. With an episode of mania the racing thoughts are usually phasic change until the manic episode resolves or a different cognitive process occurs like increasing incoherence and distractability.

One of the best modern sources of information on psychiatric phenomenology remains Andrew Sims' Symptoms in the Mind. His discussion of racing thoughts is more comprehensive than most and far superior to anything that you will find in the DSM.  I am sure that the DSM authors will point out that this is why psychiatric training is necessary to use the book and that the book is not a substitute for training in phenomenology. Without that training racing thoughts on the part of the patient or the observer is often anyone's best guess. The best example I can think of was a patient who was being presented to me as "histrionic and overly dramatic" who was in fact manic. It is difficult if not impossible to sustain a dramatic presentation of mania, racing thoughts and pressured speech for any length of time.

The Sims discussion of racing thoughts occurs in his chapter: Disorder of the Thinking Process. In it he uses what he refers to as Jaspers model of thought association.  As illustrated in the tables, people tend to proceed from one constellation of thought to another unless they have specific disorders of thinking.  Sims diagrams out the thought disorders using a very nice graphic to illustrate these clusters and how a person moves from one cluster to another.  I have included a couple of examples in the tables here and how the thoughts proceed as indicated by the red arrow.  As I thought about it there are some differences with anxiety and mania.  The anxious person will be operating form clusters of questions and doubt.  That leads to more and more branch points or worry.  The manic person on the other hand especially if they have grandiose and expansive mania is not operating from excessive worry or doubt but declarative statements consistent with their confidence level.  As I thought about both people trying to sleep, the anxious person would be laying in bed the entire time, probably with their eyes closed going through these constellations of thought.  One of the commonest sleep complaints they describe is: "I can't shut my mind off - it is racing."  

The manic person for the same time frame would undoubtedly be up and engaged in some activity late into the night - if not for the entire night while experiencing a rapid progression of thoughts.  They will often describe their thoughts as going too fast to describe and certainly too fast to speak, even though many can speak at a very fast rate.  A secondary phenomenon that I typically ask about is excessive thoughts with no progression or what Sims calls "crowding of thought."  His specific description is that thoughts are being passively concentrated and compressed in the head: "the associations are experienced as being excessive in amount, too fast, inexplicable and outside of the person's control."  Sims sees this as occurring in schizophrenia, but I have definitely asked that question to manic patients and had them agree that was happening to them.  Jaspers also describes flight of ideas as a massive flow of content without an increase in the speed of thinking. 

The interesting aspect of focusing in only on the conscious experience of racing thoughts is that there is not necessarily an associated pressured speech.  Andreasen defined 18 different thought disorders in her early work and one of them was pressured speech.  She defined pressured speech as a rate of at least 150 words per minute. (3).

From a clinical standpoint a number of syndromes present with self descriptions of racing thoughts including anxious and agitated depressions, some forms of attention deficit~hyperactivity disorder, various intoxication states.  Racing thoughts is often the first phenomenon described by people who are under a lot acute stress and in some cases physical illness.  Many people become delirious for one reason or another and describe what amounts to a state very similar to pre-sleep reverie as racing thoughts.  The recent literature on racing thoughts supports the observations in this post and suggests that thought overactivation that includes both racing thoughts and overcrowding is a common phenomenon in mood disorders including unipolar states.  It also highlights an inherent limitation of the DSM - despite an abundance of descriptors it is inherently weak on phenomenology and this needs a lot of work with trainees who may be too focused on the DSM as a system for indexing rather than a comprehensive diagnostic system.  The criteria of racing thoughts certainly seems to lack specificity at several levels and clinicians encounter a broad spectrum of people who describe racing thoughts and do not have mania.  

Rather than a central feature of the diagnostic process, I would speculate that most experienced clinicians find that racing thoughts are an elaboration down the mental checklist after they have a detailed history of mood, activity level, and sleep changes.  At that level most of these clinicians are matching patterns of hundreds or thousands of people treated rather than specific written criteria.


George Dawson, MD, DFAPA



References:

1:  Andrew Sims. Symptoms in the Mind. Third Edition.   Elsevier Limited, Philadelphia, USA, 2003: p. 149-155.

2:  Karl Jaspers. General Psychopathology. Volume I.  John Hopkins University Press.  Baltimore, Maryland, 1997. p. 210-213.

3:  Andreasen NC. Thought, language, and communication disorders. I. Clinical assessment, definition of terms, and evaluation of their reliability. Arch Gen Psychiatry. 1979 Nov;36(12):1315-21. PubMed PMID: 496551.

Abortion, Women's Mental Health, and Politics...

Let me preface this post by saying that I am not a member of a political party and I do not endorse any political views about abortion.  The only interest that I have in abortion is what women tell me about it in the context of a psychiatric evaluation and treatment.  I also do not want to see women's mental health become a surrogate end point for the political debate on abortion.  In the state where I practice the Minnesota Department of Health mails a report on the number of abortions in the state with a number of warnings about the legal requirements of reporting abortions (p 51-57 of this report) despite that fact that 99+% of all physicians and 100% of psychiatrists do not perform abortions.  I bristle when I get that politically motivated report each year.

I am writing this post to examine whether or not any objective research on the mental health effects of abortion can be done.  This examination was precipitated by a post on a forum of the Time story "Abortion Doesn’t Negatively Affect Women’s Mental Health: Study".  Whenever I see an article like that I think of two things - the life experiences that women have told me over the years and where abortion fits in.   I also try to think about how I would do a study of this issue.  What would constitute mental health?  Most large studies don't depend on interviews anymore and that typically means a checklist or some sort of psychometric instrument.  There are typically cutoff scores and comparisons of cutoff scores between the research subjects and a control group.  Correlations are made with come psychiatric diagnosis or psychological construct to determine mental health.  With that kind of technology the underlying assumption is that these are good measures of mental health and that it covers all of the possibilities.  Human consciousness covers a lot of ground and there are generally subtle problems that don't get covered by these gross measures.

The study in question (1) is based on telephone interviews semiannually over a period of 5 years of a cohort of women selected for having an abortion, having a first trimester abortion, being turned away from access to an abortion and giving birth and being turned away from access to abortion and not giving birth.  In their results section, the authors plot the results of 11 interviews, but they point out that the subjects participated in an average of 8 over the 5 year period.  The women who received an abortion presented within 2 weeks of the clinics gestational limit for abortions (N=452).  Women with pregnancies up to 3 weeks past the gestational limit were turned away.  The turnaway group either gave birth (N=161) or had an abortion or miscarried (N=70) as possible outcomes.  Based on those outcomes they were identified as the turnaway-birth and turnaway-no-birth groups.   The first trimester group (N=273) was included to study whether or not the psychological outcomes differed if a woman had an abortion early or late during the pregnancy.

The test metrics were all Likert scales.  The depression and anxiety ratings came from the Brief Symptom Inventory (BSI) a 53 item rating scale of various psychological symptoms.  There are grouped ratings for 9 different symptom constellations including anxiety and depression.  All subjects are asked to rate their level of distress due to a symptom on a severity score ranging from 0 (not at all) to 4 (extremely).  For anxiety and depression their are 6 items each and subjects were identified as a "case" of anxiety or depression if their aggregate score were 9 of the total possible score of 24.  

Life satisfaction was determined by one item from the Satisfaction with Life Scale: "I am satisfied with my life."  One item was also included for self esteem.  Both were rated on a 5 - point scale from 1 (not at all) to 5 (extremely high life satisfaction/self esteem).

Using these variables, the trends were best illustrated in graphics of depressive cases versus time and depressive symptoms versus time (figure 1 above) and similar graphics for anxiety, self esteem, and life satisfaction.  The general trend was for less anxiety and depression slightly higher self esteem and life satisfaction over the 5 year course of the study.  I think analysis of the latter two elements was limited by the the single items 5 point scale and a regression toward the midpoint of the rating.  There is the usual extensive statistical analysis of what I would see as fairly limited data.  The turnaway groups and the near limit group generally had more depressive and anxiety symptoms and cases and lower self esteem and life satisfaction that the first trimester abortion group.  Their statistical analysis is consistent with those observations.

The authors conclude:  "Our findings add to the body of evidence rejecting the notion that abortion increases women’s risk of experiencing adverse psychological outcomes. Women who had an abortion demonstrated more positive outcomes initially compared with women who were denied an abortion."  In their secondary analysis they show that a history of previous mental health problems or psychological trauma correlated with adverse outcomes and may have worse outcomes if they are denied an abortion.  They discuss the importance of individualized care and recognizing the response to an abortion or in this case denial of abortion.  One trend that I did not see any specific comments on was the turnaway-no-birth group and the fact that it seemed to have the best outcome at 5 years in terms of depressive symptoms/syndromes and higher self esteem and life satisfaction.  In their overall conclusion the authors believe that their study shows that there is no necessity for laws warning women about the adverse psychological consequences of abortion and that being denied an abortion is potentially more detrimental.  

In their own discussion of the limitations of the study, loss of subjects over time was significant - 43% over 5 years.  They discuss the methods they used to limit bias due to loss (potentially of subjects with mental illnesses).  They discuss their alteration of the BSI and point out that it is really a screening instrument so that the identified cases in their study would require additional screening for an actual diagnosis of an anxiety disorder or depressive disorder.  

I had several thoughts when I read this study.  Women don't generally come in to psychiatrists and say they are depressed or anxious as the result of an abortion or a denied abortion.  That might be different in psychiatric clinics that specialize in women's health issues.  They often don't discuss the issue at all in the initial diagnostic evaluation.  They disclose these details along with other sensitive issues after a relationship has been established with a psychiatrist.  In that context there can be discussions about thoughts, images,  and feeling states related to abortion into other forms of psychopathology.  An example would be intense guilt, rumination, and self criticism about the abortion during an episode of depression.  When any person gets depressed it is a common experience to scan past personal history for stressful events from the past that lead to the same emotion.  There can be daydreams and fantasies of what the child would have been like.  There can be brief episodes of depression or anxiety related to self criticism, doubt, shame, or interpersonal conflict about having had an abortion.  Many of these thoughts can occur at a future date when the history of an abortion can take on new meaning such as a new committed relationship.   Any life event that impacts person's conscious state and causes them distress is significant to me, whether it is picked up by rating scales or not.  I would see these reactions as being part of normal emotional life rather than anything pathological.

Equating the mental health of women to a DSM diagnosis  or psychometric construct is a mistake.  The DSM is a product of looking at the 5% of people who are outliers and trying to characterize their problems with with categories or continua.  That approach removes human consciousness from the equation and that should no longer be acceptable to psychiatry or anyone interested in the conscious life of real people.  An event with as much potential meaning as abortion can never be adequately characterized as a psychiatric diagnosis or a psychometric scale.  The reactions are too diverse and nuanced.  Suggesting that abortions or the lack of abortions does or does not affect women is more of a political statement than a statement that takes into account the most important aspect of the human psyche - the unique conscious state of every person.  That conscious state is unique because what happens over the course of your lifetime matters and some events matter more than others.

My conclusion from practice is that abortion is one of many events that has the potential to significantly impact the conscious state of a woman.  That should be the consideration in the case of contraception, pregnancy prevention, and abortion and not whether or not it causes mental illness or symptoms.  A woman's unique conscious state should also be considered in the case of unplanned pregnancies and why that decision is much more complex than a list of social variables or whether or not contraception is used.  A more appropriate focus on conscious state rather than mental illness or symptoms would yield a more realistic idea about the effect of life events like abortion.  That result will be anything but simple and that is why simplistic political solutions or response to those solutions do not apply here.

I have a secondary conclusion about the place of politics in both the research and clinical care of women.  It has no place at  all.

It is as obvious as an annual vaguely threatening letter about abortion reporting to a psychiatrist from the state government.  When politicians practice medicine nothing good happens, but this letter goes way beyond that.


George Dawson, MD, DFAPA


References:

1:  Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women's Mental Health and Well-being 5 Years After Receiving or Being Denied an Abortion: A Prospective, Longitudinal Cohort Study. JAMA Psychiatry. 2016 Dec 14. doi: 10.1001/jamapsychiatry.2016.3478. [Epub ahead of print] PubMed PMID: 27973641.

Attributions:

1:  Graphic at the top is from Reference 1 with permission from the American Medical Association - Order Number 4024950066424

2:  Thanks  to Pearson Assessments for sending me a sample copy of the Brief Symptom Inventory.  www.pearsonassessments.com

Do Businessmen Dream Of Medicine Without Doctors?

You bet they do.

My first exposure to the business-driven dystopian future of medicine occurred in Fort Lauderdale in 1994.  I was the Public Affairs rep for the Minnesota Psychiatric Society.  The APA decided that it would be a good idea to bring all of the Public Affairs and Legislative reps of the local district branches (DBs) to Florida for a conference.  On the surface it was supposed to be focused on getting solutions into the hands of the DBs.  In retrospect it was a shocking introduction to how the managed care industry would lay waste to the field of medicine in the decades that followed.

The keynote speakers for that conference were Governor Arne Carlson from Minnesota and a business consultant.  Minnesota has always been a hotbed of managed care activity and for the past three decades any physician practicing here has been a witness to what can happen when government and business bureaucrats practice medicine.  The end result of rationing psychiatric services over that period of time has been a system of care that is so fragmented and that provides such poor service to patients and family members that the current Governor Mark Dayton recently called for massive reform.  The result of that Task Force is quite unremarkable but that is another story.  In 1994 Governor Carlson was there to brag about MinnesotaCare, a government insurance scheme for the working poor and the Health Care Provider Tax on all health care providers in the state to finance it.  He was describing them as major breakthroughs but over the years they have proven to be very suboptimal programs.  The Provider Tax in many years acts as another revenue source for the State and that revenue is not directed at anything to do with health care.  I have never witnessed any of my working poor patients get on MinnesotaCare.  It appears to be rationed as tightly as a managed care option.  Some members of the audience were less than receptive to these ideas and the Governor did what he could to put them in their place.  The precedent of never telling a politician that they are wrong about their supposed health care reform was easily established.

The consultant provided an even clearer picture of the business agenda. He bombastically presented the first wave of fake news that helped establish managed care.  That fake news was - "Nobody needs specialists anymore.  There are too many of them and they are too high priced.  We are going to buy them out and put them out of business.  The only doctors we need are primary care doctors."  He focused on orthopedic surgery as a case in point, but he pointed out that the same was true of any medical specialty.  It was an implicit threat to all of the psychiatrists in the audience. Of course his statement was pure fabrication.  There is no way a businessman is going to spend a dime to buy practices when he can just manipulate them out of business.  It was the beginning of the full court press to manipulate physicians into doing whatever the business types wanted them to do.  In the following 2 decades - physicians and patients were manipulated into using primary care physician offices for a gatekeeping function for everything while simultaneously reducing reimbursement to those physicians to the point that they needed to see 30 to 40 patients a day to keep the doors open.

I was working for an altruistic multispeciality clinic at the time.  I say altruistic because one of our goals was to see all people presenting to our hospital or clinic irrespective of their ability to pay.  We had to work harder as a result, but were generally quite content.  The physicians were high quality and we were all collegial.  I never trusted any group of physicians more.  The work environment resembled the training environments that I had worked in - county hospitals and VA hospitals and clinics.  Billing, coding, and reimbursement were far removed from the work.  We had billing and coding specialists who came by, read our notes, and submitted the billing documents - totally unseen by us. All we had to do was focus on the practice of medicine.  Anyone working in those days would tell you that was more than enough.

But there was fear in the air.  Over the next several years the physicians in my group were talking about how the local managed care companies were going to put us out of business.  Since were were the largest provider of medical and psychiatric services in the east Metro area and had the market cornered on poor reimbursement,  I dismissed it as hysteria.  Over the next several years we were acquired by one of the three managed care companies that provide the bulk of medical services in Minnesota.  In the process our self funded malpractice fund disappeared.  The provision of care also started to change.  There was no longer an acute care Neurology service.  Stroke care was going to be provided by "an internist with an interest in strokes."  The internal medicine consulting service became the hospitalist service and primary care physicians no longer saw their patients in the hospital.  The decisions were not discussed.  There was no consensus.  Department heads were let go.  Physicians were just told what to do.  At some point my request to talk with the wizards behind the screen was met with a simple answer.  There was now a "firewall" between physicians and the administrators and there was no way that I would ever question their decisions or talk directly with them.  

The administrators began to proliferate.  An endless series of administrative ideas began to be put on the physicians.  Physician were no longer practicing medicine all day long.  Suddenly there were plenty of feel good meetings for administrators.  And so it went.    Outright bombastic contempt for physicians was no longer necessary.  The administrators had won.  Additional mechanisms were put in place to suppress any dissent.

The contempt is still palpable in some of those dissent suppressing situations.  These days - all it takes is a complaint against a physician to activate what is typically an airtight mechanism to scapegoat them within the organization.  It doesn't matter if the complaint is real or not.  In many organizations, a physician's annual evaluation actively solicits anonymous complaints about them.  It is part of a general effort by administrators to illustrate that physicians are really deficient human beings, only able to function in the context of a beneficent organization and supervision by a business person.  Some organizations have a "three strikes and you are out policy" and they don't want to debate the merit of any complaints.  They just list it as a strike.

This is how being a physician devolved from being a fairly autonomous profession to one that is clearly under the boot of the managed care industry and the government and everything that entails.  It was largely an exercise in fake news and rhetoric on the part of the business community and a complete lack of response from physicians or their professional organizations.  That practice is alive and well today.  There is no science involved in business management and no standards.  That alone would create some suspicion about how medicine is currently managed - but there are very few critics.  Physicians as a group have never been able to grasp one of management's unscientific techniques referred to as pushback.  Instead of standing there like deer in the headlights pushback against all of the fake news generated by these managers.

If that ever caught on with my colleagues - we would all start pushing now and keep it up for the next 30 years to just break even.


George Dawson, MD, DFAPA




Supplementary 1:  Businessmen here is used as a generic form of businessman or businesswomen.  There are clearly plenty of female managers who also do not know what they are doing.

Supplementary 2:  A few words about pushback.  According to William Safire writing in the New York Times - pushback the noun began to surface in business journals near the end of the 20th century.  In my experience it started to show up in medical meetings about a decade later.  The current Merriam Webster definition is "resistance or opposition in response to a policy or regulation especially by those affected".  That does not really capture the business application of this term.  In a business meeting for example, the strategy might be to exert some kind of pressure on a group or subgroup of people affected by the business and see if there is any pushback.  In some cases, no pushback is expected because the employees are fairly expendable.  I heard a business story about retail stores that use a clopening strategy where the same employee closes the store one night and has to open it in the morning.  That is very inconvenient if you are that employee and trying to coordinate daycare for children or a second job, but pushback is not really anticipated.  In the case of professionals who are required in certain positions pushback might be anticipated with certain mandates.  I have been in meetings where the question was asked: "Has there been any pushback from the doctors or nurses on that?"  If there is none, the leverage is typically increased until there is.  In the case of physicians it rarely (if ever) happens.  There have been numerous explanations for the lack of assertiveness on the part of physicians.  The general explanation is that it is unseemly behavior that is inconsistent with the professional image of the physician.  I think the real mistake is that physicians assume that the business manager class has the same degree of professionalism and values when they clearly do not.  Any physician being pushed around or bullied by business managers knows exactly what I am talking about.  They do not think or act like physicians.  It is time to stop acting like they do.

Ref:

William Safire.  Pushback.  New York Times.  January 14, 2007.    


Supplementary 3:  From Orwell's 1984 as O'Brien interrogates Winston Smith and plants the idea that the only way man can assert power over another is by making him suffer and goes on to detail how that is done.  He concludes:  ".....Always, at every moment, there will be the thrill of victory, the sensation of trampling on an enemy who is helpless.  If you want a picture of the future, imagine a boot stamping on a human face--for ever."

That is exactly where the business world and the government want the medical profession.

Ref:

George Orwell. Nineteen Eighty-Four. A novel. London: Secker & Warburg (1949).

Attribution:  Image from this post is downloaded from Shutterstock  per their standard licensing agreement.  Image number 59502138 by Stokkete (photographer).

Americans Can't Do The Basic Health Care Arithmetic

A minimum of $300 billion dollars saved.  That is what I thought could be achieved by eliminating insurance companies from the American health care system.  It turns out the savings are a lot bigger than that.  Just looking at countries where the per capita health care costs are at least $2500 and comparing the USA to Switzerland - the country with the next highest per capita health care costs we get the following equation:

$2640 (the difference) x 320 million (current population the the US) = $844.8 billion

That is what converting the US health care system to single payer would involve.  No more managed care companies (MCOs)  pretending to be efficient.  No more pharmaceutical benefit managers (PBMs) rationing medications in order to make profits.  No more outrageous Obamacare premiums that seem to be rising with no end in sight.  No more MCOs, and PBMs making your doctor's life miserable and burning him or her out.  The writing should be on the wall by now for all Americans.  The US Congress and their healthcare lobbyists fully intend to continue the unsustainable health care bureaucracy to every American until the last possible moment.  That is as true for Republicans as it was for Democrats.

What do I mean by unsustainable?  According to KFF.org in 2016 employer purchased health insurance policies averaged $18,142 per year ($12,865 paid by the employer and $5,277 paid by the employee).  For retirees the situation is even more stark.  I used the AARP calculator to look at estimated health care costs only in retirement for a theoretical couple retiring at 66.  The result was an estimated $225,463.  Of that total only $121,529 was covered by Medicare and that left a shortage of $103,934 in out of pocket costs.  To me that means the average Social Security dependent senior citizen in this country cannot cover their health care costs even with Medicare.  Some of them are telling me their supplemental policies are as high as $20,000 to $25,000/year.  For any couple trying to stay in their own home in retirement - health insurance premiums and property taxes will easily absorb most if not all Social Security income.  The gross estimate by this calculator varies from state to state but some sources have given the gross average amount for a retired couple to be about $260,000.

And where does all of that money go?  That is easy.  It goes to bad management.  In a country that has fewer doctors and fewer hospital beds than most countries in the above graph - it should be obvious that rationing medical care to make profits for Wall Street does not work.  Two recent experiences will illustrate the problem.  I heard a presentation given by a speaker from one of the major physician run medical clinics in the  US.  For some reason she started talking about the ratio of administrators to physicians in their organization.  The number given was 50 administrators to every physician.  That is an absolutely stunning number.  With that number of people in hospitals and clinics - it should raise the question "What are they doing there?" and "Why does it take this many people to administer the most accountable professionals in the US?" Not only that but what has all of this administrative oversight accomplished?  The answer is in the graph at the top of this page - the most expensive and most inefficient health care system in the world.  It is basically an expensive jobs program for managers and bureaucrats, and bad technology.

The second scenario was a physician talking with me about his speciality clinic of 5 physicians.  He recently learned that they were being administered by 15 mid level administrators reporting to a single higher level administrator.  When he questioned this practice, he was asked why he was concerned about the number of administrative staff.  I guess according to the previous estimate he was doing quite well with a ratio of 16 administrators for 5 medical staff.

The real impetus for this post occurred as I was doing some exercises at home before work this morning.  The Today show was playing in the background.  Matt Lauer and Katie Couric were interviewing Trump advisor Kellyanne Conway about a number of issues.  I heard the question: "Have they (Republicans) come up with something to replace Obamacare?"  Ms. Conway responded with the typical free market solutions - buying insurance across state lines, health savings accounts, etc, etc.  None of these are solutions to bad management and what is basically corporate welfare for the army of healthcare administrators in this country.  The only correct response to that question is:

Single-payer health insurance.

Get rid of the unnecessary managers and save a trillion dollars in mismanagement.



George Dawson, MD, DFAPA


Attribution:

The figure on per capita health care spending is from the Kaiser Family Foundation accessed on January 1, 2017 and this is their citation:

OECD (2016), Health spending (indicator). doi: 10.1787/8643de7e-en (Accessed on 01 January 2017).

 I have no affiliation with the Kaiser Family Foundation or the OECD and their graphic is used here per their terms of use for non-commercial, non-profit sites.


Supplementary 1:

I would be remiss in not pointing out the mountain of fake news that goes into getting Americans to believe that some kind of government led "reform" that concentrates market power into a few for-profit proxies is a good idea.  There is the associated fake news from both parties that just happens to leave the pricing power to private industries,  In that context the fake news by Ms. Conway this morning is all part of an unmistakable 30 years of nonsense stretching back to the Clinton administration and their idea about "managed competition".  We have had nothing but mismanaged competition ever since.  The dynamic in health care is an obvious parallel to the financial services industry and their guaranteed profits from the work of Congress.  In both cases, all Americans foot the bill.


Supplementary 2:

Let me remind the free market advocates that there is not now and there will never be a free market in health care or anything else in the USA.  It is (largely) a Republican fantasy.  The major markets in the US all depend on government intervention and the sector with the best lobbyists gets the most favorable deals.  It is the only way to explain a trillion in waste, just based on "free market management" not including other boondoggles like a highly regarded electronic health record that is less functional than 1990s database software and paying $300 for 29 cents worth of epinephrine.

Breakfast With My Old Mentor

I have some other posts ready to go, but I wanted to end the year on a positive note.  I could not think of anything more positive than my old mentor being back in town and suggesting that we meet for breakfast.  I would not be where I am today without mentors.  Mentors who told me what to do and silent mentors who I could just identity with.  Both types have been invaluable to a guy who did not have a clear idea of what he wanted to do in life.  When it comes to people who carefully plan their life and people who are on kind of a random walk - I was firmly in the latter camp until some time after college.

The only reason I went to college was to play football.  I got a scholarship.  It did not take long to discover that was a bad idea.  That discovery was facilitated by a gangrenous appendix.  During the hospital stay, one of my professors came in to visit.  He basically told me to snap out of  it, drop the idea of coaching and a physical education minor, and do something more rigorous academically.  He literally told me that I was wasting my time.  He was very animated about it.  When he left I wondered why an unpopular professor with a reputation for eccentricity would visit a freshman who he had only known for about a month and tell me that my life trajectory was wrong.  And why would I immediately see that he was right?

It was not long before I had met chemistry and biology professors that I could identify with.  I also had very positive experiences with the English and Philosophy professors.  That led to increasing motivation and academic rigor.  Medical school was not much different.  It was natural to gravitate to neuroanatomists, biochemists, neurosurgeons, neurologists, internists, endocrinologists, nephrologists, cardiologists, and infectious  disease specialists.  Learning medicine and psychiatry in medical school and residency was an exciting immersive educational experience.  Not all of the professors were stimulating or inspiring.  I did not consider those fields for a second.  After the computer match of several specialties psychiatry was the next step.

I met my mentor  in my PGY2 year in 1984.  He had just left private practice to do research.  There was never any doubt that he was extremely knowledgeable in psychiatry.  At the time there was an active debate between the so-called biological psychiatrists and the psychiatrists who were more psychotherapy oriented.  The biological psychiatrists were basically phenomenologists in search of biological paradigms at the time.  Some of the more prominent paradigms at the time were psychopharmacology, genetics, primate research and neuroendocrinology.  In many cases, residents were split by identification with some faculty or alienation from others.  My mentor was comfortable in all areas.  We could discuss biological theories and then how to introduce and conduct psychodynamic psychotherapy.  He explained how he did it and it made things possible.  He highlighted our discussions with with examples from his own experience.  He asked me questions about what it was really like to be a psychiatrist: "Suppose you are at a cocktail party and a person approaches you.  That person appears to be acting out.  Do you react to them like psychiatrist or not? Do you think that you can put being a psychiatrist on hold?"  Questions that most PGY2s have not had time to contemplate when doing night call on psychiatric units full of transplant patients - many with difficult to control diabetes.  All of this was worked in between seeing patients and doing the usual patients presentation in the clinic and the hospital.

I moved on to a different program  for the last two years.  The same biological psychiatry versus psychotherapists going on in the new program where interestingly there were biological researchers with strong interests in both psychodynamic and behavioral therapy.  It was the only program where I have ever seen pharmacotherapy contingent on whether or not the behavior therapy was attempted or successful.  Even more psychiatrists with the same orientation as my original mentor.

We ordered breakfast and settled in.  It was the first time we would be talking for an hour in 32 years.  I had talked with him briefly outside of a lecture that he was getting ready for at an APA meeting.  He brought me up to speed on what he was doing.  He got in on the ground floor of psychiatric research in a particular specialty and it was apparent that he knew most of the field cold.  He e-mailed me several papers later.  We discussed a few medical problems and the morbidity of the aging process.  We discussed some issues that come up teaching residents and I remembered some of the things he told me about my personality and style that were dead on.  We talked about my concern over the FDA contraindication for bupropion in active or resolved eating disorders and what needed to be done about that.  We discussed the historical development of the DSM and its limitations.  He told me something I had never heard there - organized psychology tried to come up with an alternative to the DSM-III and failed.  I informed him about the Psychodynamic Diagnostic Manual (PDM) and my experience discussing it with some East Coast clinicians.  We made a few jokes - technically we were peers, but he was always easy to relate to.  As the hour wound down we settled on a few truths that we had come to over the years about psychiatry and I thought I would include them here as a positive jumping off point for the new year:

1.  It is all about the biology -

I have always reflected on my teachers of clinical psychiatry and concluded that I was very fortunate to be taught by the best from two very different programs.  That all started with my mentor.  About two thirds of the way into our conversation he made this statement and I found myself in complete agreement.  When I was in medical school psychiatry was in a very primitive state and a lot of that was due to the nature versus nurture argument.  The psychiatric assessment and mental status exam has not changed since that time.  There are generally 200 - 300 data points gathered in a standard assessment and the goal is to come up with a formulation of the problem and a separate list of diagnoses.  If you are a resident of course they need to be DSM diagnoses.  The  problem then as now is that the explanatory power of the formulation is not necessarily robust.  At the end of that presentation somebody in the crowd could always say: "So is it nature or is it nurture?"  On either end of that spectrum the formulation could encompass - "Who cares if it is nature or nurture - I just prescribe medication for specific diagnoses." to  "I only do psychotherapy - this is repressed narcissistic rage.  I prescribe a little amitriptyline if needed for sleep."  Hardly robust explanatory paradigms and the old Popperian baggage that psychoanalytic theories were not falsifiable.

The biggest missed opportunity during residency was not capitalizing on the neuroscience of the day.  The academic centers where I was studying were firmly into primatology, neuroendocrinology, and psychopharmacology.  Nobody seemed to pick up on Kandel's early work for about a decade.  There was much debate about what biological psychiatry was and the definition I was picking up on at the time was treatment with medications.  There was a focus on neurotransmitters and neural transmission.  But my entire residency occurred before the advent of selective serotonin reuptake inhibitors (SSRIs) and atypical antipsychotics (AAPs).  The most effective medication for the indication was lithium and that is still probably the case.  Over the intervening decades neuroscience has taken off.  We now have an early appreciation of the complexity of the brain and nervous system with advances  every year.  We are very close to the point where we are able to investigate putative neuroscience based mechanisms for stress, psychological trauma, environmentally determined epigenetic changes that cause important changes in behavior, common psychiatric syndromes, genetically determined changes in drug metabolism, and primary genetic transmission of mental disorders.  There has been an explosion of information about the molecular biology of addiction and dementias.  It seems that many people have discovered in the last 10 years what Kandel was writing about in 1979 - psychotherapy changes biology.  How else would it work?  All of this information is immediately relevant for psychiatrists.  

2.  The last thing that we need is another research proven psychotherapy -

I found that I had psychotherapy training in residency that was second to none.  As a resident that occurred primarily as one hour of direct supervision for every hour that I was in session with a patient and that was about 450 hours per year for three years.  The psychotherapy supervisors were diverse in terms of their orientation.  I picked up additional training on inpatient services from psychoanalysts and others.  It seemed obvious to me that you have to say something useful to people when you see them and that typically flowed from one form of therapy or the other.  In psychiatry due to the severity of the problem and the general lack of medical care - flexibility was necessary.  I can recall making a diagnosis of probable partial complex seizures in a patient I thought that short term psychodynamic crisis oriented therapy might be useful.

Over the years, psychotherapy research led to more manuals for standardized approaches.  I remember getting an early copy of Linehan's Dialectical Behavior Therapy mailed directly to me from the inventor herself.  I accumulated a library of psychotherapy texts on supportive, psychodynamic, behavioral, cognitive behavioral, and the more recent modifications.  But the problem with psychotherapy was never a lack of useful models.  There was fairly good evidence that psychotherapy may not be all that specific.  Therapists from different schools could both get good results.  There was a general lack of adequate research of psychodynamic/psychoanalytic therapy.  There were also some clinical trials that may have left the wrong impression.  I recall an early partially negative trial of psychotherapy in schizophrenia that seemed counter to older anecdotal literature.  More recent cognitive behavioral therapy of schizophrenia and other severe mental illnesses seems to correct the idea that psychotherapy is not useful.

In our discussion of psychotherapy we both agreed that there is really no research based psychotherapy available largely due to managed care environments.  I thought the average number of sessions for most managed care patients was 3.  He had just read an article suggesting it was 1.  Either way the practical limitations for psychiatrists in these settings is that they are scheduled for brief medication focused visits and long intervals.  A person with a severe mental illness who is not in a crisis situation may be seen every 3 months for 15 - 20 minutes.  But even in that rationed and sparse setting, I worked with a psychiatrist who established incredible relationships with people.  I had people asking me for years after he left, if I knew what had become of him.   

We both agreed that it was futile to keep doing psychotherapy research on heterogeneous populations and inventing different psychotherapies when the results are generally the same (and probably limited by varying subject characteristics) and research proven psychotherapy cannot be provided due to managed care rationing.  The therapeutic alliance and useful discussions with patients need continued application.  Nothing useful tends to happen unless the patient believes they are clearly understood and that is communicated by the psychiatrist.


3.  Residents have to care about the DSM - we don't -

Through all of the fake news about the release of the DSM-5,  I maintained that all of the hype was hardly necessary for a very imperfect classification system that is slightly important to psychiatrists - but nobody else.  We agreed it was useful for residents to learn but really not that important for practicing psychiatrists.  The basis of that agreement and the need for the residents to learn it is that we know all of the deficiencies and the few strong points better than anybody else.  It caused me to recall the electronic medical record that I use.  Each major diagnostic category has about 240 listed diagnoses or nearly the total in the DSM-5.  There are so many that I can have difficulty finding the correct one.  Like most psychiatrists, I am using about 1/4 of the diagnoses and recognize the limitations not only of those diagnoses - but limitations of the idea that simple verbal descriptions can parse the most complicated organ into a large number of useful diagnoses.

All in all it was a good breakfast.  I was happy to see my mentor and he was happy to see me.  Along the way I think I evolved into a competent clinical psychiatrist with a very similar skill set (except the extensive research).  I know that the other residents in my class did the same.

I feel privileged and elevated by acquiring those skills directly from my mentors and colleagues along the way.  It transformed my early random walk into academics into a focused professional life.

And I am very grateful for that.      


Happy New Year!

George Dawson, MD, DFAPA




Attribution

Eggs Benedict picture at the top is By balise42 (http://www.flickr.com/photos/ipalatin/5261997126/) [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons at https://upload.wikimedia.org/wikipedia/commons/2/2b/Eggs_benedict.jpg

The Moral Dilemma Of Alcohol Exposure

Before anyone schools me about Prohibition - I give lectures on Prohibition. I know it doesn't work and I know the reasons why. I also know that talking about restricting intoxicants in any way is counter to the current zeitgeist of liberalizing their availability.

I also treat alcoholics and I know how that works. When I see Minnesota's largest and most famous retailer opening up large and attractive liquor stores where there used to be not so attractive foods courts and positioning it right across from the cash registers - I know that will be a problem for a lot of people trying to stay sober. I know that for many people in recovery - an attractive liquor store in their favorite retail store or grocery store creates a very high probability of relapse - even if they know that relapse may result in death or severe disability. In Minnesota liquor stores hours is another issue. In states where liquor sales are prohibited like Minnesota, it is incentive to drive across the border into bordering states in order to buy alcohol. A modification is the availability of low alcohol content beer from grocery stores and gas stations.

Another proxy measure for relapse risk would be the total number of bars in each state.  That data is harder to get.  I have information from a tavern owner that the business organization representing them sets the maximum number at 1 tavern or bar per 500 people, but the actual limits are subject to local jurisdiction.  In reality the maximum tavern/bar concentrations occur in North Dakota, Montana, Wisconsin, and South Dakota ranging from 1621 - 2268 people per tavern/bar.  At the lower end Virginia ranks 50th at 64,773 people per tavern/bar. (US Census Bureau Data per The Forum).

Are retailers that desperate that they all need to compete in this low margin business? Why are governments in this business at all? I know that there are vocal people everywhere who argue for their unalienable right to intoxicants. One of the main arguments has always been that the vast majority of people can drink and not incur any problems from it. What about the people who cannot? Binge drinking, alcohol poisoning, and excessive alcohol use are all major public health problems according to the CDC. The direct and indirect cost of excessive drinking in the US is about $249 billion in direct and indirect costs.

One of the main arguments of cannabis advocates is how dangerous alcohol is. Alcohol costs $1.90 per drink according to the CDC in complications from drinking. That cost is probably artificially low because treatment and detoxification from alcohol is rationed and most people don't get anywhere near the level of treatment they need. In Twin Cities metro hospitals - drug and alcohol use can account for up to 60% of admissions. Potential consumer advocates in this case belong to an organization that values anonymity and as far as I know has not been very politically active.

The CDC (Community Preventive Services Task Force) suggests that alcohol excise taxes need to be increased, alcohol outlet density needs to be decreased, hours of sales need to be decreased rather than increased, and retailers need to be held liable for damages caused by underage or intoxicated drinkers. The tax suggestion reminds me of the general theory of sin taxes and why they really don't work from a governing standpoint. It basically generates money for politicians to spend and is typically diverted away from any stated use that involves treating complications of the activity.

To me the alcohol issue is much bigger than who sells it, but governments have a big problem at the moral and public health levels. Just carrying forward the CDC recommendations invites rhetorical response about prohibition or temperance. I have found myself in illogical arguments with both individuals and families about the right to drink oneself to death. Make no mistake about it, the issue was not suicide - just continuing to drink with advanced liver disease and repeated hospitalizations for bleeding problems and encephalopathy due to advancing liver disease and the associated anatomical and physiological changes.

At its base, the alcohol problems and tolerating excessive alcohol use is a cultural problem. In the Midwest where binge drinking is most prominent, teenagers start drinking in middle school. In many areas it is a rite of passage. Even though the majority of people don't drink. It is very difficult to find social settings that are alcohol free. Alcohol use in most settings is promoted as the social norm with the exception of a few subcultures. Barring a widespread cultural movement that promotes moderation or abstinence, it appears that the usual educational measures about the dangers of alcohol use will be the primary intervention point. Secondary and tertiary prevention depends on a robust system of care for alcohol use and that currently does not exist. In some cases close monitoring by the correctional system for people with DWI infractions can be effective, but that does not address either the group of people who do not come to legal attention or those for which legal intervention is not a deterrent.  It also does not provide long term solutions to the problem of continued alcohol use.

Despite all of the current hype about how some intoxicants are wonder drugs and the ongoing arguments about legalization of all or most intoxicants - I can't help but see this as another moral dilemma. The will of the many basically writing off the serious problems of the few. This often plays out in families where one member clearly has a severe drinking problem and the others (usually a spouse) refuses to not drink in front of them or not have alcohol available in the home.  It all comes down to the rationalization that everyone can control their drinking or that drinking can be seen as bad behavior and that is obviously not true.

The moral dilemma of increasing alcohol availability or the government sanctioned availability of any intoxicant is the same.  It is based on the theory that people in general can use these intoxicants without damaging other members of society or themselves to the point that they do not become a cost to the rest of society.  That essentially writes off the group of people with uncontrolled use who cannot do that.  American society traditionally handles that problem by punishment and rationing availability of treatment and detox services.  Functional detox services staffed by physicians are practically unheard of.  Contrary to that guy in your freshman philosophy course who doubted the meaning of everything - moral philosophers can also add a perspective here.  Consider this quote from Blackburn about the nature of moral knowledge:

"There are countless small unpretentious things that we know with perfect certainty.  Happiness is preferable to misery, and dignity is better than humiliation.  It is bad that people suffer and worse if a culture turns a blind eye to their suffering.  Death is worse than life; the attempt to find a common point of view is better than a manipulative contempt for it." (1).

The availability and treatment of alcohol related problems in American society on one hand and the motivation to profit from it on the other hand seems to stand Blackburn's quote on its ear.  In the US there is a clear blind eye approach to alcoholism.

It may be time to come up with a better plan for living.


George Dawson, MD, DFAPA


References:

1:  Simon Blackburn.  Being Good - A Short Introduction To Ethics.  Oxford University Press. Oxford, UK. p. 134.


Graphic:

Liquor store density is from Health Indicators Warehouse at www.healthindicators.gov and is in the public domain.  This graphic was generated on that site. (click to enlarge)