Intentional Complications

Empty suit

Because THAT helps to explain this:  the fundamental devolution of the practice of medicine, psychiatry and nursing with the concomitant declining health and welfare of the citizenry in the US.

Truth?  Whose truth?

Branding?

Market share?

Global leadership?

Cui bono?

Harvard.

Controlling healthcare costs

Despite trying to engage in distractions and diversions during every waking moment and engaging in supposedly cognitive and memory stimulating reading (I can’t concentrate, can’t comprehend and can’t retain much info, so consider everything I write with a healthy dose of skepticism), I am increasingly experiencing noticeable memory lapses and episodes of confusion.  The memory lapses are annoying and disheartening.  The confusion is frightening.  Because no one was interested in learning about those problems and instantly dismissed them as “due to the depression”, I am left to my own devices to manage them. Enter Google.  There are self-assessment tools which purport to distinguish between dementia and depression in memory loss.  I tried them out and came away with a 100% alignment with depression.  However, these tools, and the physician feedback I received, conflated correlation with causation.  The real answer is that no one knows. After a winter of experiencing much more back and joint pain, the inability to self-plan and perform even a basic yoga practice, and a months long stretch of not leaving the bed except for bodily functions needs, I find myself so fatigued, dull, and slow that forcing myself to stay alert, attentive and mobile is a monumental task.  And really, since I do not have any obligations to work, socialize or contribute in any way, no one cares or is affected, which brings me a perverse sense of relief of not failing anyone.  When all of society yanks those away and sends you off to a life of dying and social death, this apparently is the benefit. (For all of you psychiatrists who found your “EBM” on that most medically scientific principle of false hope and optimism serving as a default component of “insight”, this is it for optimism and flexible thinking.  Insight I’ve got in spades.) I have struggled to attend scheduled volunteer activities.  But I think I am bringing a poor benefit/risk ratio to the organization.  I can’t perform much of the physical work, and sometimes I can’t remember the very simple instructions to carry it out. The people I’ve met are seriously smart, wise, witty, knowledgeable and committed to the goals and work.  The leaders lead well (coming from me, that’s the equivalent of the Nobel Peace Prize).  Two of these people are dealing with immediate end of life issues, and I try to be a reliable and comforting presence.  That, at least, I can offer and carry out. So back to self management.  I started looking around again for resources and strategies to try.  Because I root around in PubMed, am located in a city where a vast amount of clinical research is occurring, and have a sense of what I need in the way of outcomes, I called the HMO and asked to speak with the mental health case manager.  The marketing and sales people weren’t happy with that.  The person I spoke with was sullen and only after repeated requests and my refusal to give her clinical info was I transferred.  And I got the same woman who when I first called to find a psychologist with expertise in both PTSD/trauma and depression gave me four names where either the person was no longer in the plan or was outside my ability to travel. When I called to report this and ask for appropriate options, she became belligerant and defensive, and so I ended the call since I had already been through the provider list and discovered that there weren’t any at all who met the above criteria. This time, I asked her if she knew of any research or clinicians who dealt with ketamine for severe depression, or with rapid responses to severe depression.  She started in on the spiel that it wouldn’t be paid – it was experimental.  After a few minutes of this abuse – no referrals, no answer,  I told her I’d had enough and hung up. Ten minutes later the police were at my door.  Luckily, my computer screen was on and open to the complaint and disenrollment line, the coffee pot was full, and no weapons were    in sight (that last one is a joke).  The sergeant grilled me about what I had said that “would make her call”.  I explained about inquiring about the ketamine research.  I offered him the phone number to call the woman.  He couldn’t get past the telephony.  I had to sign a form declining emergency transport to the ED. The officers declined coffee, inquired as to the rent I pay for this attic dump, rolled their eyes at the response, and then changed the conversation to “we have to do our jobs.” I replied that experiencing public humiliation (lovely lights, multiple police cars and ambulance in the drive and street) and terror (nothing like having 5 uniformed and armed men on your doorstep banging on the door and demanding to be let in.  NOW.) was obviously what the HMO’s objective was, and they agreed. Which is just the latest experience which illustrates why I still have no health support, no trusting relationship with anyone, and no hope of finding same. What I ended up doing was perusing the research studies for chronic pain and finding several that are non-pharmacologic and low risk to enroll in. I was assigned to the treatment arm of two, and two more are simply looking at different biomarkers and immune responses.  I’m an easy stick, so I’m happy to donate a little serum to that cause.  However, one study requires a combo PET/MRI along with an arterial lineinsertion.  Having been on the managing end of those before as a critical care nurse, I think receiving one (they are uncomfortable at best) is a dose of my own former medicine. I wasn’t permitted to disenroll from the HMO.  The abusive case manager is still a “valued employee”, and I effectively have no health insurance, because there I will not provide any information to, use any provider affiliated with, or voluntarily use any aspect of that HMO’s products and services.  They really have the keeping costs controlled portion covered.  Abuse, terrify and threaten enrollees, collect their premiums and watch the profit margin soar. And the research compensation (for “subject “expenses”) will pay for dental and vision exams.  At least those don’t come with threats of imprisonment and assault and battery. (Optimism and hope, psychiatrists.)

Substitutions

I follow food and nutrition science to some extent.  This caught my attention:

It’s been a profitable venture for the drug companies, as well as for the professors and their universities. Agriculture schools increasingly depend on the industry for research grants, a sizable portion of which cover overhead and administrative costs. And many professors now add to their personal bank accounts by working for the companies as consultants and speakers. More than two-thirds of animal scientists reported in a 2005 survey that they had received money from industry in the previous five years.

Yet unlike a growing number of medical schools around the country, where administrators have recently tightened rules to better police their faculty’s ties to pharmaceutical companies, the schools of agriculture have largely rejected critics’ concerns about industry cash. Administrators have set few limits on how much corporate money agricultural professors can accept. Faculty work with industry is governed by confidentiality rules that veil it from public view.

In certain ways, the close relationship between animal scientists and pharmaceutical companies has never served the public well. Few animal scientists have been interested in looking at what harm the livestock drugs may be causing to the cattle, the environment, or the people eating the meat. They’ve left most of that work to scientists outside of agriculture, consumer groups, and others who take interest.

But with the introduction of Zilmax, the situation may have reached a tipping point. Critics say some academic animal scientists have become so closely tied to the drug companies that they may be working more in the companies’ interests than in those of farmers and ranchers—the very groups that land-grant universities were created to serve.

Substitute patient for beef cattle and psychiatrist/primary care physician for animal scientist and voila! Patients growing enormous and iatrogenically ill and diseased on second generation antipsychotics, and their physicians so entangled with pharma and medical device industries that they fail to serve patients’ interests.

The Chronicle of Higher Education isn’t usually where I find in depth whistle-blower investigative reporting.  Read the entire article.  It will (or should) make your hair stand on end.

Ethics and malfeasance, anyone?

Social contract. In pieces.

Letters to Children and Other Juveniles

A little while ago, I dropped in at one of the many libraries in the area that sell books and ephemera.  A nondescript thin unmarked cover demanded closer inspection. In muted gold script, the title emerged, Letters to Children by Beatrix Potter, Harvard University Press.

Inside were several otherwise unpublished tales embedded in very kind and respectful letters to children that Potter had written.  Like another favorite author, Madeleine L’Engle, she was careful to get out of her own way and write of salience and thought-provoking ethics which all ages could enjoy and take away the gifts of essence.

It occurred to me that the ever louder and defensive whining tales of woe coming from self-proclaimed “good” psychiatrists might benefit from a session or two with Potter’s and L’Engle’s stories.

Here are some of the take aways for them:

1. Who is the subject of the tale?  Patients (others) or self (psychiatry and psychiatrists)

2. Who is the hero? See #1

3. Who and what constitutes the villain?  Patients, insurers, third party reimbursers, employers (hospitals, institutions, jails, prisons, lawyers, universities, patients), laws, regulations, society, colleagues, non-psychiatrists health professionals

4. What needs to happen for the hero to triumph? Patient compliance, better financial renumeration, more professional power, greater professional autonomy, more prestige (all this assumes psychiatry is the hero)?  Or in the case of patient as hero, recovery, respect, successful societal integration, independence, personal autonomy, belonging, self-efficacy, prestige, greater financial renumeration?

5. What are the dangers interfering with hero triumph? What are the resources the hero brings to bear on the dangers?

OK, so with that in mind, have fun re-reading your childhood favorites.  And take a gander at two recent posts penned by psychiatrists who define themselves as “good guys”, but do not specify exactly what that means for readers. The Steve twins – Drs. Moffic and Balt, have a go and try to engage with commenters who self identify primarily as people who had experiences as psychiatric patients and family of psychiatric patients. Refer to the list above and see if you can’t help them out in their obvious confusion and self-contradictions.

Hint: psychiatry’s subject is supposed to be patient well-being and health derived from a respectful and trust-based relationship with patients

 

Riffing off A Powerful Message

A week’s worth of (medicated) sleep, and my noggin can at least process a few thoughts, here and there. 1 boring old man published an important post titled, A Powerful Message.  He chronicled the increasing clamor of psychiatry to use a neural circuitry model as evidence of psychopathologic causality and therefore an avenue for research and treatment.  I had noticed this, too, with increasing alarm and a sense of deja vu. I yammered a bit in a comment:

As a long time critical care nurse and educator, I witnessed an enormous transition in thinking about the care and treatment of myocardial infarctions (heart attacks). Care and treatment initially and historically was focused on complete bed rest and inactivity – up to and including only allowing room temperature food and drink lest cold irritate the vagus nerve. As the plumbing and electrical circuitry interface with the muscle stimulation and perfusion became more well known, treatments became more aggressive – getting patients up and moving right away, reperfusing coronary arteries and stenting them, ablating lesions, etc. Then the focus spotlighted statin use for prevention, concomitant with pharma DTC advertising and KOLs. Only recently has any of this been questioned, and lo and behold, stenting and preventive statin use may not do anything at all in terms of disease prevention.

Not for nuthin’ has clinical depression been found to coexist and correlate with heightened morbidity and mortality with of heart disease.

Patient stays in critical care units for heart attacks (MIs) went from 7-10 days to 1-2. Of course, patient education, diet teaching, stress management, socioeconomic assessment went out the window. In other words, self management and quality of life factors were ignored and abandoned. Patients are sent home with prescriptions, stents, pacemakers, automatic internal defibrillators and all manner of coronary hardware, and sometimes followup appointments. They are not linked to case managers, community resources and psychosocial supports.

The forces of capitalism, free markets and decreasing corporate regulation have converged to erode worker protections, environmental protections, food safety, community development (corporations receiving tax breaks, outsourcing jobs to other countries and pulling up stakes, leaving communities dying on the vine), and overall, contributing to the deterioration of social life and community throughout the US.  Vicious and poisonous politics have contaminated the well of civil discourse.

Whither health and well-being?

Here, my collegiate roots show.  Case Western Reserve University’s Frances Payne Bolton School of Nursing and the Department of Nursing Education, Teachers College, Columbia University, both were founded on the critically important work of nurses who established, grew, and nurtured public health and psychiatric nursing theory and practice.  My education was based on the principles and practices of Lillian Wald, Hildegard Peplau, Virginia Henderson, Isabel Hampton Robb (yes, the Robbs of Johns Hopkins and later, Lakeside Hospital of Case Western Reserve – this hospital was noted by Flexner in his famous Report on Medical Education, for serving as an exemplar), and Mary Adams, pioneer in gerontologic nursing and later a Dean at her home state, South Dakota’s State University School of Nursing.  These names will mean nothing to almost all members of the public, physicians, and sorry to say, nurses.

But I hope you’ll click on the links because their work has critical importance and influence on the individual, family and community health and well-being of Americans today. What you will see is their universal concern with the immediate and larger social and community environments which affect health and well-being of the targeted patient populations.

Physicians, nurses and indeed, all members of the (licensed, ergo, regulated) helping professions have an obligation to address, influence and lead policy and programming which are congruent with and supportive of a healthy environment and social life.  Those include wages which allow adults to work a single job and provide for safe shelter, clean water and air, nutritious fresh whole foods, reliable transportation, access to education and natural recreational facilities and adequate protective clothing for themselves and dependents.  It means assuring clean air and potable water.  It means assuring access for all to basic communicable disease prevention: vaccines, safe food, zoonoses prevention.  It means worker protections which promote tolerable physical and psychological stress levels.  It means protections for whistleblowers – rewarding workers for upholding ethical business, research and professional ethics.  It means promoting civil discourse and discouraging ostracism – whether that be racism, bullying, intimidation or any other type of behavior which is exclusionary.

Embracing the classical virtues and publicly upholding the inherent worth of every person will lead more to health and well-being than any pill, potion, invasive treatment or state of the art assessment tool.

The bottom line:  Each and every member of a helping profession by the social contract is an agent for social change.  Without that, patient treatment is devoid of care. And treatment will only palliate and blunt symptoms, rather than address disease and distress causality. Futile, impotent and, ultimately, destructive. Like this, perhaps:

Chasing Tails

Thomas Joiner’s interpersonal theory of suicide is one I refer to often here.  However, even he doesn’t move upstream to look at distress causality.  Exhibit the last:

J Psychiatr Res. 2012 Apr 2. [Epub ahead of print]

Behaviorally-indexed distress tolerance and suicidality.

Source

Military Suicide Research Consortium, United States.

Abstract

Research indicates that distress tolerance exhibits a complicated relationship with risk factors for suicidal behavior. Specifically, low self-reported distress tolerance has been linked to perceived burdensomeness and thwarted belongingness. Contrastingly, high self-reported distress tolerance has been linked to the acquired capability for suicide. Given the frequently discrepant findings between self-report and behavioral indices of distress tolerance, we sought to expand upon prior findings by testing these relationships utilizing a behavioral measure of distress tolerance. Additionally, in an effort to further clarify the role of distress tolerance relative to painful and/or provocative experiences in the acquired capability, we examined whether distress tolerance serves as a moderator. Results revealed no significant associations between distress tolerance and burdensomeness or belongingness; however, distress tolerance was positively associated with the acquired capability. Furthermore, the interaction of distress tolerance and painful and/or provocative experiences significantly predicted the acquired capability, with the strength of the association increasing at higher levels of distress tolerance. Results highlight the potential importance of perceived versus actual ability to tolerate distress with respect to suicidal desire. In contrast, the results reflect the importance of actual persistence in the acquired capability.