APA Blues

The American Psychiatric Association meeting in San Francisco this year has left me depressed. The vast majority of my colleagues are either believers or shruggies. Academics I respect and admire feel that fighting quackery is a bad idea.

I related my problem with MDs promoting chelation and other unproven therapies for autistic children to Paul Applebaum. He agreed with my statement to parents, that experimental or unproven therapies must be done in the context of a registered clinical trial so we can learn more about their safety and effectiveness. But when I asked how we as a profession might fight quackery, he shook his head. "I don't know about 'fight'," he said. He seemed to feel that it's enough to limit one's own practice to science-based therapies.

I had a similar conversation with Howard Zonana, who said that there have always been promoters of fringe ideas in medicine. What counts as evidence can be a matter of opinion.

Yes, I said. There are gray areas. But some ideas contradict established basic science. For example, homeopathy-- with remedies so dilute no active ingredient is present-- if it works, we need to re-write physics and chemistry. For that reason we can reject it.

Zonana pointed out that homeopathy was pretty useful in its day when medicines were often quite toxic. He mentioned that the osteopaths, who once held some pretty odd beliefs, have become mainstream.

I started to argue that the shift in osteopathic practice was no natural evolution but the result of the Flexner report.

Zonana interrupted, saying the Flexner report was devastating to a lot of communities. "It closed all the black medical schools. The AMA was politically powerful and really, pretty awful toward blacks."

The implicit point in all this seemed to be: political battles against bad ideas can have unintended, negative consequences.

Chill. Be a lover not a fighter, they seem to say.

And yet Applebaum quite effectively fought against psychiatric involvement in coercive interview settings with military detainees. He said, "not ethical," and snap! Case closed.

Oh, if only. If only he'd take a look at autism quackery and say, "not ethical," in the same way.

Makes me weep. Srsly.

MOC: WHERE IS THE RAGE?

The new system for maintaining physician board certification is called "MOC," short for "Maintenance of Certification." One particular component of MOC irks me, the "feedback modules."

The description of the feedback modules sounds like the business management "performance review and development" or "PRD" system that is now ubiquitous. Example here.

Companies hand out forms to employees for self-assessment, documenting several performance measures (quality of written work, meeting deadlines, arriving on-time, teamwork, etc.) using a 1-5 scale:

5. Outstanding: Exemplary performance in all areas of the job.
4. Exceeds Expectations: Surpasses the standards and established performance expectations in many important areas of the job.
3. Meets Expectations: Good performance. Consistently meets standards and established performance expectations in important areas of the job. Performs duties at an expected level.
2. Below Expectations: Performance does not meet expectations in some important areas of the job; below expected levels of performance. Improvement needed.
1. Unsatisfactory: Performance falls below expectations in many areas of the job; substantial improvement critical.

The employee hands the completed form to a supervisor, who also grades the employee using the same scale. Both parties sign the form, which is then added to the employee's file.

Looks reasonable enough, eh? So why is this system hated by worker-bees everywhere?

Cuz it's bullshit, that's why.

PRD's unspoken purpose is to get the employee to agree, in writing, that his or her performance in certain areas is sub-standard. The documented confession provides the employer with a significant advantage if any conflicts over termination, advancement, or pay raise, ever arise.

Note that there's no similar system for grading the employer on relevant measures, like providing resources or ensuring adequate coverage when staffing shortages occur.

Those in power seek to create systems where everyone is guilty of something. Keeps the serfs docile and compliant.

Physician-patient relationships used to be fairly personal and intimate. That's changed over the past two decades as healthcare has suffered the invasion of wankers with MBAs who refer to patients as "consumers" or "stakeholders."

I was trained to avoid using my patients for personal gain aside from payment for my time. This ethical value is common among psychiatrists, who sometimes refer to it as "neutrality."

There have been occasions where it might have been to my advantage to ask my patients to advocate for my interests with some agency or insurer. But I refrained, feeling the request might violate my position of neutrality.

Asking patients to write letters on my behalf to the American Board of Psychiatry and Neurology rankles. It will feel awkward and absurd. It will create tension if the patient agrees but doesn't follow through.

How many bad doctors will this novel, intrusive, and time consuming intervention weed out?

What is the number needed to treat here?

Who are these colleagues of mine who believe I need even more administrative overhead?

Pink Lady's Slipper

A few weeks ago my husband said he'd found a patch of wild orchids near a small pond hidden in the woods. Not being much of a flower or plant person, I said, "oh that's nice," and went on with whatever I was doing.

Then yesterday he took me on a hike to see the pink lady's slippers for myself. They are indeed unique (click pic to enlarge).



Hey, get yer mind outta da gutter! It's a lady's pink slipper!

If you happen upon an orchid, don't touch it. They are fragile things. And if the flower dies, the plant itself will die.

Where be the titmouse?

In the bowels of the Moscone Center taking a board review course for MOC.

MOC or "maintenance of certification" is a new invention by an organization know as "the Board." Docs a little older than me are exempted from MOC.

Lucky bastards.

MOC is a set of on-going tests over a ten-year period, repeated every ten years until death or retirement. The tests include:

-an expensive day-long examination in an inconvenient location
-an essay regarding why one would like to become Miss America
-waterboarding
-a confession of sins
-penance, as documented by "feedback modules":

B) Feedback modules (Patient/Peer* Second Party External Review)
• Feedback modules require each diplomate to solicit personal performance feedback from at least five peers* and five patients concerning the diplomate’s clinical activity over the previous three years.
• Each diplomate must then identify opportunities for improvement in the effectiveness and/or efficiency in their practice as related to the core competencies and take steps to implement suggested improvements.
• Within 24 months, each diplomate is required to solicit feedback from at least another five peers* and five patients to see if improvements in practice have occurred. If a diplomate participates in peer review in his/her clinical setting, that institutional activity may also fulfill the PIP Feedback Module criteria.

In other news: Anonymous out front protesting the Scientologists. The weather is warm and they're fanning each other with their hand-held signs to stay cool. Friendly bunch.

moot winz teh internets!

Anonymous crashed the Time 100 on-line poll.

Marble cake allegedly present.

Oh, and The Game.

BRB, soup.

Why aren't more violent crimes committed by ice cream men?

I mean really.

There's an ice cream truck circling the neighborhood presently. It outputs one song on a loop, a midi version of Scott Joplin's, "the Entertainer."

Third time by my building today; parked next door the past twenty minutes.

It's so mechanically cheerful.

It's killing me in my skull.

Which CAM Practice is Most Stupid?

Homeopathy is a top contender for the stupidest of CAMs. But there's a newer variety of CAM that might be even dumber: energy patches.

Energy patches are fancy stickers you attach to your skin or perhaps to certain items. The patches ward off ebil and promote teh goodness.

Example:

"The Aura Patch is a small metalized energy patch that attaches to the body and presents a field of supportive and restorative energy back into the body’s energetic field. The AuRA patches are an energy delivery system. They provide specific energy patterns that are found in people with abundant good health. By restoring these energy patterns, we have observed a positive change in people’s health. The patches are programmed with completely natural frequencies with no negative side-effects. There is no chemistry that passes through the skin. This is the same energy that is found inside the healthiest people on earth. "

LOL!

Maybe I'll cash in with my own brand of healing patches. I'll have them inscribed with the lucky Chinese proverb: "Wa ta goo siam."

My Toes. Let Me Show You Them.*

Pied billed grebe awesomeness #1: dinosaur toes!

The toes are not webbed; they're lobed. When the grebe pulls its foot forward through the water, the toes fold up. Then when it pushes back the toes open. Pretty good swimming idea. Yet it can't paddle as quickly as the ducks. It actually swims faster below the water than at its surface.

I'd love to watch the grebes during the breeding season. The male's call sounds like laughter. Sadly, they're endangered in my state due to habitat loss.

Stay tuned for more pied billed grebe goodness...
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*If this is your pic, let me know so I give proper credit.

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