Moving on

Well, I have arrived safely in Syracuse, NY. As you might imagine, things are quite hectic during a move and I am still living out of boxes and feel like I am playing the game "Memory" whenever I want to find something. Rest assured, the blog entries and additions to MedFriendly will soon continue, but I need to set up the new MedFriendly headquarters before that happens. It won't be long, so keep checking back for updates. Thanks.

Good night everybody!

Today was an exciting day for me as I completed the last day of a two year post-doctoral fellowship in clinical neuropsychology at SUNY Buffalo School of Medicine. This completes my formal training in neruopsychology which began as an undergradutate at Le Moyne College, continued as a graduate student at Nova Southeastern University, and then took me to the University of Oklahoma Health Sciences Center. It’s been a 12-year odyssey. Now, things have come full circle as I return to Syracuse (where Le Moyne College is located) to work as a neuropsychologist at SUNY Upstate Medical university.

It’s hard to imagine all that has happened in two years. There have been many ups and downs, but many more ups. I learned a ton, saw the birth of two beautiful children, published five journal articles and a book chapter, and formed important friendships that I hope will last a long time. I have many things planned for my career and this website and it will be interesting to see how it all shapes out. Tomorrow, I finally get to move out of this stupid apartment and into a house! As one of my supervisors here always said: “Good night everybody!”

Making it up

Once in awhile, psychiatrists consult me to assist with figuring out a patient’s diagnosis. This happened the other day. The referral involved a patient who was in jail who said he heard voices tell him to kill himself. The patient had been having lots of conflicts while in jail with the prison guards and apparently hated it there. Who wouldn’t hate prison I guess. Anyway, when the patient was taken to the hospital for psychiatric evaluation, the doctors began to question whether he indeed heard voices or just made the story up to get out of the prison for awhile. So I was called to evaluate whether the patient was really psychotic through the administration of a personality test.

Now, one thing to keep in mind here is that personality tests can be helpful, but it has to be combined with a good clinical interview so the results can be put into context and understood correctly. As it turns out, the personality test wasn’t very helpful. So I go into to meet with the patient, introduce myself, and say, “Remember when you told everyone that you heard voices telling you to kill yourself. Well, did you make that up to get out of prison?” The patient looked around the room for awhile, glanced back and me, and said, “Yeah. I made it up. Just wanted to get the heck out of there for awhile.” Case solved! Everyone suspected it, but I was the only one who asked.

Appreciate what you have

Today, a tragedy struck the National Football League, when San Francisco 49ers offensive lineman, Thomas Herrion, suddenly collapsed at his locker and died. He was only 23. The cause of death is unknown at this time.

This sad event highlights what I tell people all the time: appreciate what you have because at a moments notice, it can all be taken away. For example, my father exercised all the time and had a very healthy diet. He wasn’t overweight and took time to relax. Our family thought he was indestructible. One day, he noticed that when he was eating a banana, it kept getting stuck in his throat. Shortly thereafter, he was diagnosed with esophageal cancer and passed away almost a year later. He was only 60.

You never fully appreciate someone until he/she is gone. That is how it will always be I suppose. It’s human nature. However, if you take time each day to remind yourself how short life is, it can give you a greater appreciation for the people you love and improve the quality of your interactions with them. I do this every day. Lastly, don’t assume loved ones (or even yourself) are invincible. This means you should also take some time out for yourself to do things you enjoy. That’s right, treat yourself. You deserve it!

Sex change

How’s this for an interesting story? Today in Australia, a transsexual man, who believes he was wrongly advised to become a woman, has been given permission to sue the medical team which advised him to have the sex change. The doctors reportedly told the man that although he was a biological male, he had developed a female character identity.

Now, I feel bad for the guy that he had a sex change operation to become a female and is obviously unhappy with the results. But when it comes down to it, I don’t see how this is the fault of the doctors. Even if the doctors were wrong, the patient still has to listen to their opinion, decide whether or not he accepts it, and then make another major decision to have his reproductive organs removed.

The patient reportedly thinks he was falsely diagnosed after recently finding out about some personality testing in 1996 that showed he scored high on a masculinity scale. I just seriously doubt that if the patient knew this information that he would have decided against the operation, since it is so drastic that you really have to want that in order for doctors to go through with it. What say you?

Medical marijuana

People may soon have another reason to go to Hawaii as the Aloha state today announced the formation of a medical marijuana clinic. Marijuana, despite having some mind-altering properties, reportedly also has some medicinal properties such as stimulating the appetite, treating nausea and vomitting, and fighting pain. As you may know, the Supreme Court recently voted against the use of marijuana for medicinal purposes. The Court, in it's 6-3 decision, ruled against medical marijuana use because of social implications. In other words, the Court agreeed with the federal government that its anti-drug effort would be made more difficult if marijuana can be used by some patients.

What's my take on this? Well, I look for consistency in the argument. Why is marijuana illegal in the first place? Because it alters the mind in a way that can cause people to do dangerous things. OK, fine. But then why is alcohol legal? The government tried to ban alcohol once during the Prohibition, but people just defied the government and made their own alcohol in their bathtubs. Overall, it didn't work. Nowadays, you have so many people earning a living making alcoholic substances, that it is politically impossible to make alcohol illegal again. The bottom line is that there is a double standard in that alcohol is legal and marijuana is not. Because of this double standard, I don't see how you can ban marijuana, especially for medical purposes.

What do you think? I'd like to see some comments flowing on this blog.

Medical negligence

Today in Australia, a surgeon who allegedly caused the deaths of 88 patients reportedly wrote "untruthful" notes on medical charts to cover up botched operations. Although this case happened overseas, medical malpractice occurs in the U.S. as well. I once had a patient who was a physician that killed a patient out of negligence. He was so high on prescriptions he had written to himself and abused that he let a patient bleed to death during an operation in his office. This physician had also been doing some other unethical things, such as using carpenter’s glue instead of surgical glue on patients. Also, instead of surgical screws, he used screws from a local hardware store!

Someone asked me yesterday, “How do I find a good doctor.” One of the best ways is word of mouth. If you have a family member or friend of a family that is a doctor, try to find some way to get their advice on whom to go to for specific problems. If he/she does not know, they likely know a colleague who does. Another idea is to see if the doctor is board-certified. In other words, has the doctor been certified by a group of peers to be competent and highly skilled in his/her field. You can usually check if a physician is board certified in your insurance panel booklet. You can also use the following website: American Board of Medical Specialists and look up a doctor you are considering using.

Lastly, try searching if your doctor has published literature in his/her field. You can do this by searching at PubMed. Keep in mind though that there are some excellent doctors who do not do research and strictly see patients all day. Thus, there are many excellent doctors who have few, if any publications. However, if you find a physician who has published often, this can give you extra confidence that you are going to someone who is competent.

Back breaker

Many of you probably have a relative or know someone with osteoporosis (abnormally decreased bone density). I had a patient with this the other day who had a very serious complication that I had never heard of before – a broken back. We know that the elderly have an increased risk of breaking their hip from a fall because their bones are more fragile. And it makes sense then that if someone with osteoporosis is involved in a traumatic accident involving the back, that a spinal fracture can result. But this patient was different. What he did was try to lift a heavy household object and as a result, his spinal column shattered. I had never heard of that before, but wanted to post it on the blog because maybe some of you can pass it on to people you know and help prevent a serious injury.

There's a person under those covers

This morning I was consulted to evaluate an elderly gentleman for dementia. The man had numerous serious medical problems and was described in the chart as profoundly cachectic. This is doctor-speak for “very very sick looking.” So I walk in the room and I see someone shriveled up, lying flat on his back like a pancake, covered with layers of blankets. All I could see was his head, tubes coming out of him, and a pair of large wide eyes staring up at me. I introduced myself and honestly had no idea what to expect for a response, fully anticipating I may not even get a reply.

Sure enough, he responded appropriately and carried on a normal conversation. He was polite and even cracked a joke. When I walked out of the room, I wondered to myself how many people have walked by this person, looked at him, saw how sick he looked, and never tried talking to him. Even if you don’t work in a hospital, you may see such a patient one day when visiting a loved one in a hospital or at a nursing home. If you do, don’t be shy in trying to strike up a conversation because you may really make somebody’s day.

ADHD for everyone! (part 2)

Continuing yesterday’s thread, ADHD (attention-deficit-hyperactivity disorder) is one of the most over-diagnosed conditions in the United States. In other words, there are tons of people walking around with the diagnosis of ADHD diagnosis that don’t really have it. A close second is bipolar disorder (formerly known as manic-depressive disorder) in which it seems all you need to do is have a mood swing before this label starts being tossed around. I’m being a little extreme here, but only to make a point.

Often, an ADHD diagnosis is made by the family physician after only a brief consultation. This can be done, because unlike more medically-based diagnoses such as cancer or strep throat, there are no diagnostic tests that can be used to say “Ah-ha. This proves without a doubt that this is ADHD.”

To properly understand why someone is exhibiting a particular behavior pattern, one needs to gather a detailed history of the current problem, detailed medical and social history, a mental status examination, and diagnostic testing (if necessary). When conceptualizing why a problem is occurring, I always use what is known as the law of parsimony, which is a fancy way of saying that the simplest explanation is likely the correct one. So is it more like that Little Jane is acting out at home because dad was just deployed to Iraq and that she has a history of being sexually abused, or should we attribute her problems “minimal brain damage?” I actually saw such a case and the person was diagnosed by the physician a having ADHD.

Many times, when I finish my evaluations and tell the patient or the parents that they do not have ADHD, instead of being met with happiness I am met with frowns. Why? Because this means they won’t qualify for special services at school and because medications may not be prescribed. It’s harder to work at the root cause of the problem than to throw medications at it. I am not someone who is anti-medication by the way. In fact, I often recommend medications in my reports. However, we need to be very careful that the medications are used appropriately and that we think twice before labeling people with certain diagnoses.

ADHD for everyone!

As I have mentioned before, I almost always begin my clinical interviews by asking the patient what his/her understanding is as to why he/she was sent to see me. Sometimes, I get this answer: ‘Because I know I have ADHD (attention deficit hyperactivity disorder) or “Because I know my son/daughter has ADHD.” So I ask if someone had diagnosed ADHD in the past. The answer I often get is no. So I then ask “Well, how is it that you know you have ADHD (or that your son/daughter has it)?” The answer I usually get is “Because I saw a commercial on TV about it from one of the drug companies and I have all the symptoms.”

The thing to keep in mind here is that the symptoms that the drug companies list are often vague and designed to make people wonder if they have a condition that may need to be treated with the medication they make. For example, these commercials usually say something like “Do you have difficulty paying attention or concentrating? Finding it difficult to find things around the house? Are you restless and fidgety? If so, you may have ADHD.” Well, who doesn’t have these things happen sometimes?!

People seem to forget the word “may” and it sometimes gets translated into “knowing” a disease/condition is present before it is diagnosed. Stimulant medicines for ADHD are prescribed left and right in this country every day and it is absolutely ridiculous. Why? Because there is no way that there are so many people out there that have a condition that used to once be called “minimal brain damage.” I’m not saying there are not people that have attention hyperactivity problems. But let’s stop a minute and think of what it is due to before we start stigmatizing people with labels and throwing potent medications at the problem.

Does Little Johnny have brain damage or could he possibly have attention and hyperactivity problems because his parents are divorced, his living situation is unstable, there are two other siblings, and he is unsupervised until 7pm at night until mom comes home from work? Might that distress a kid and make it difficult to pay attention? Maybe he is hyperactive because he is trying to get attention or needs an outlet for a lot of stress. I am going to try to keep each blog entry brief, so come back tomorrow for part 2 where I will discuss more of my thoughts on this topic.

The Mango Man

Ok. Time for a little bit of humor on the MedFriendly Blog. I figured I would reach back into the memory banks for a story from my graduate school days in south Florida. At the time, I had a patient with antisocial personality disorder. When the average person hears “antisocial” they think of someone who likes to stay by him/herself and does not like to socialize with others. But the diagnosis of antisocial personality disorder is something entirely different. Basically, it is someone with a longstanding pattern of flagrant violations of the rights of others which often includes lack of remorse. Such individuals often have a history of animal abuse, fire-starting, and bed-wetting.

So this particular patient comes in one day and tells me that he is sick and tired of his neighbor’s animals pooping on his lawn. His solution: injecting industrial-force insecticide into the mangos that these animals eat in the backyard. Mango trees are very common in Florida. Needless to say I tried to discourage this type of behavior. Well, the next week, this guy comes back and I get a call that he is in the waiting room. When I went out there, he says “I have a present for you.” Both of his arms were extended and in each hand were two large mangos! He didn’t understand why I refused to take them and to this day, I wonder if he poisoned them.

Quality of life

I recently had a patient with Parkinson’s disease. As you might expect from a disease that can literally cause muscles to stop working, severe stiffness, and/or uncontrollable tremors, depression is common in this illness. Indeed, about half of all people with Parkinson’s disease suffer from depression. The thing that really upset my patient’s spouse was that they had seen many physicians and whenever the topic of depression was brought up they were met with comments such as “Well, yes, of course she’s depressed. She has Parkinson’s disease.” The family felt that she was basically being told that this is a part of the disease and were frustrated that no treatment was offered.

As a result of the above, the patient went years without treatment for depression and by the time I see her she is suicidal and severely depressed. Now, I am not saying that if intervention such as anti-depressants and/or psychotherapy were begun earlier that she would not be depressed. But she would probably be a lot better of than she is now. So one of my goals was to emphasize to the physician that this person can enjoy improved quality of life if depression is treated. I have marveled at patients with severe disabilities who go on to enjoy life no matter what. It can be done, but some health care providers need to have a greater awareness of this. Have you had similar experiences of feeling snubbed in your doctor’s office? If so, post them here.

Out in the open

So I get off the elevator in a hospital the other day and as I start walking down the hallway I see a large desk with numerous sealed containers of bodily fluid. Some were cups of urine, other were vials of blood, and others were who knows what. Some of the specimens were inside plastic bags. This is not the first time I have seen this at this particular hospital. And it’s not like I am on some secret floor or something. This is a patient floor we are talking about so both the general public and hospital staff are walking by all the time.

How on Earth is it acceptable to leave vials of bodily fluids out in the open? First of all, what’s stopping someone from causing mischief and stealing the containers or switching them around? What if someone knocks into it and it falls on the floor? Now you have potentially infectious material spread out in the open. At least these containers were on a high counter so at small child could not reach it. Needless to say, I will be issuing a complaint about this. We’ll see what happens.

Roadside wrongdoings

I was driving home on Interstate-90 last night when I received a call from my brother telling me that he just drove by a guy walking on the shoulder of a busy highway, as close as possible to traffic. If anyone reading this has been out of the car on the shoulder of a highway, you know it is scary. The cars, which are going about 80 miles an hour, feel like they are going 800 miles an hour when they zoom by with tremendous force. You don’t realize how fast you are really traveling on the highway because everyone is normally traveling at the same speed as you.

On the rare occasions that I have had to stop on the shoulder of a highway, I always make sure to wait for a break in traffic before exiting the car. Then I proceed to the passenger side of the car so I am further away from traffic. To do otherwise is very dangerous. I distinctly remember a patient I had several years ago who pulled over on a very busy highway to change a tire. As he was doing this, another car pummeled into him, causing a prolonged coma and severe brain damage. My wife, who is a nurse, also saw a patient who was standing in back of his car on a highway and was struck by a passing car. Both his legs were chopped off in the accident and he bled to death.

The overall point here is that it is very dangerous to walk or be on the shoulder of the road, especially when you are on a busy highway. Even sitting in the car on the shoulder can be dangerous because another car can come barreling into you and cause severe physical injury. Ask any police officer about that. It is incorrect to assume that other drivers will be as cautious as you are because the highway is littered with people who are drunk, under the influence of illegal drugs, sleep deprived, driving without a license, or too physically disabled to drive. So be smart when on the road, carry a cell phone to call for help in emergencies, and if you could at all afford it, sign up with AAA
for emergency road side service.

Sexual predators, part 2

Yesterday, I wrote about ways to protect children from sexual predators, a topic that was spurred on based on a patient I had a few days ago who had molested his teenage daughter. As many people know from the heinous sexual abduction stories reported in the news, sexual predators often have long histories of committing similar crimes. There is no doubt we need some better laws to help protect our children from these people. What can be done?

First of all, the sentences for sexual crimes need to be much much greater than they are now. My position is that anyone who rapes a child should be put in jail for life so that there is no chance another child will have to suffer long-lasting psychological harm from a repeat offender, or worse, an early death. Some may even take it a step further and advocate the death penalty for sexual perpetrators who rape children. I’m certainly not opposed to this idea and some states have such a law.

If the sentencing does not get tougher, we need a much better way to notify parents that a sexual perpetrator has moved in or near their neighborhood. One should always check the state sex offender registry websites. However, I think the states should automatically send us a notice in the mail informing us a sexual predator has moved in, complete with a picture and other types of detailed personal information available on the websites.

One of the problems with sexual perpetrators released from jail is that they often do not report their real address to the state authorities. Sure, a warrant goes out for their arrest, but by the time this all gets figures out, the sexual predator has left the state and the police have no way to find him. My solution to this is that all sexual predators should be implanted with tracking devices so we know where they are at all times.

The argument against what I am saying is that this interferes with the freedom of sexual predators to live their lives after release from prison. My answer to that is simple: those freedoms were lost as a consequence of committing a sexual crime against a child. I’d like to hear your opinions out there, so write in with your thoughts.

Sexual predators, part 1

Yesterday I assessed a patient who told me he sexually molested his daughter when she was a teenager. Coming face to face with such an individual led me to think about ways we can protect our children from sexual predators. I am going to use the term sexual predator here instead of sex offender because I think that more accurately describes their actions.

Sexual predators have been in the news lately, especially since the recent death of 9-year old Dylan Groene and the abduction of his sister Shasta. This happened at the hands of someone who had an outstanding warrant for failing to register as a high-risk sex offender. So not only did they release this guy on bail for molesting a 6-year-old boy in Minnesota but they had no way of tracking him when he did.

You don’t have to be a psychologist like myself to know that there is no effective treatment for sexual predators. Although there may be a handful of rare exceptions, for the most part they will repeat again. So how do we protect our children?

The most practical thing to do is to talk to them and let them know that there are some very bad people in this world who like to do bad things to children. Although this may scare the child, that’s partly the point. Granted, you don’t want the child to live in fear all day, but you need to instill some degree of fear so they are cautious, alert, and think twice when a guy pulls up to them on their way home from school and asks them if they want to come for a ride to get some candy or play video games.

The second thing to do is emphasize to children that although strangers should be avoided, people they already knows cannot be trusted 100%. Sadly, this includes priests, neighbors, teachers, and even family members. Many sexual predators know their victims before the crime is committed and use a superficial relationship to gain access to them.

Third, monitor your child’s computer activity. There are many sexual predators that use on-line chat-rooms to lure children to a desired meeting place where a sexual crime is committed. The popular website, Yahoo just got rid of all of its chat rooms for this very reason. Check out the popular program, Spy Buddy to monitor your children’s activity. I do not receive any money from promoting this product..

Another thing to do is to find your state’s “sexual offender” homepage to find pictures and addresses of sexual predators in your area. For example, if you live in New York, like I do, go here: NY Sex Offender Registry. Now, in my opinion, a big mistake people make is they type in their zip code, see that there are sex predators in their area, maybe print out the address and name, and leave it that. I would take it a step further and show the picture of the sexual predator to your child so they know to stay away from that person. You should also show your child where this person lives so they know to stay away from that area.

Please share your tips on the blog and come back tomorrow when I will discuss a few ideas I have for legally dealing with child sex predators. Click here for the next post

Despicable

Sometimes, I come across situations in the course of my job that I truly find despicable. I’m sure I will outline each of these situations as the blog progresses, but for now, I’m going to touch on something that I have seen pop up numerous times in the past month. I often assess patients who are very very sick. This may be due to physical illness, mental illness, and often times both. These patients often have few financial resources and their only source of income is Social Security. Many of them are so ill and have such severe cognitive impairment that they lack the capacity to live safely and independently.

When people lack capacity to live safely and independently, they need to live in a supervised setting. That can be with family or it can be in a group home, such as a nursing home. Family can remove patients from group homes if they sign a form promising to provide adequate care and if no red flags are immediately obvious to the staff which indicate otherwise.

I have had several cases recently in which family members have very sick family members live with them for the sole purpose of stealing their income. One patient’s family member, for example took her out of a group home to live with her. Social workers found out later that the family member never gave the patient her medicines or cared for her properly, and stole her monthly Social Security check to buy drugs! This is ”family” we are talking about. I have seen other people perform this scam not to support a drug habit, but merely to put a few extra dollars in their pocket. Any family member that does something like the above should be prosecuted to the fullest extent of the law since they are neglecting seriously ill patients who can die as a result.

Medical mistakes

Medical mistakes happen. You’ve heard the stories of people having the wrong body part surgically removed, getting misdiagnosed because vials were mislabeled at the lab, or a pharmacist filling the pill bottle with the wrong medications. Medical mistakes are all too common and they kill about 100,000 people a year.

I am not the type of doctor that performs surgery or prescribes medicine, but today I was involved in a situation in which a serious medical mistake was almost made. I was called to evaluate an inpatient on one of the medical units. When I arrived, the patient was not in her room. This can mean several things: the person has been moved to another floor, the person is off the floor for tests, or the person is somewhere else on the floor.

So I asked two staff members where the patient was. They pointed to someone sitting by a telephone and said that was her. Now, I always check the wrist identification bracelets to avoid identification mix-ups, but this patient didn’t have one, which was frustrating. So I asked her if she was the patient I was looking for and she said she shared the first name but reported a different last name.

It’s important to keep in mind here, that the patient I was looking for had a known psychotic condition. So when she said her last name was different, that is something that can occur in psychosis. It’s called a delusion. Nevertheless, I went to the same staff members and double-checked: “Are you sure this is the same person because she is saying she is someone else?”

“Oh yes” was the reply I got, “She does that. It’s part of her psychosis.” So I took the person into her room to do the interview and before I did, I triple checked her identity with another staff member. “Yep, that’s her” was what I was told. So I finished my evaluation and walked out. As I left, I ran into the referring physician and started describing some of the things the patient was telling me. I was met with odd looks and he could not believe I was talking about the same person.

Turns out, all three staff members identified the patient incorrectly because two patients had similar sounding first names on the unit. I said the last name when I asked for the patient, but all the staff focused on was the first name.

If I didn’t bump into the referring doctor when I left the unit, I would have generated a completely wrong report. He was naturally upset with the staff and questioned why on Earth the patient did not have her identification bracelet on. Mistakes are always going to happen I suppose. Good thing this one was caught before anything serious happened.
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Communication and the captain

When I first started this blog I was worried I might run out of things to discuss. Fortunately that has not happened and new things keep popping up each day. Today I want to tell you about a family I recently saw who was dealing with an elderly individual that had a very serious neurological disease which often causes memory problems. (As is the case with all anecdotal information I share on this blog, I have to be somewhat vague to protect confidentiality).

Most family members will monitor the medication usage of an elderly family member with memory problems by administering the pills themselves, having a home nurse administer them, and/or placing the medications in a pill box so the patient does not need to sort out the medications. I am speaking here about elderly patients who live at home. Considering that it is not uncommon for the elderly to be on 12 prescription medications, it is no wonder some assistance is needed.

Imagine my surprise when I found out that the family was allowing the patient to tell them what medications he was taking. Although they described prominent memory problems in other areas, they said the patient seemed confident about the medications. When I asked if they had a list from the doctor about what the actual medications were, they said no.

So I dug a little deeper to find out what was going on here. Turns out, there were about seven different family members taking care of this person. No one really knew what the other was doing. For example, when the patient’s functioning dramatically declined after a medication change, no one had notified the physician. As a result, the patient was still in a compromised state. In social psychology, this is known as diffusion of responsibility. Multiple people are involved, there is poor communication, and each person thinks the other will take the lion share of responsibility. As a result, nothing gets done.

If you have a family member who is sick, and multiple caretakers are involved, someone needs to be designated as a captain who will be mainly in charge of things. That person can delegate tasks to others as needed. The captain role should switch from time to time because caretakers can easily get burned out. Lastly, communication is the key. That goes for communication between family members and communication to the doctor’s office when something goes wrong.