All posts by shrinqueRap

About shrinqueRap

NYC psychiatrist Edward W. Darell's thoughts and commentary on current issues and developments in behavioral health.

TWITTER REVISITED

I quit Twitter years ago after a former colleague almost put me into a deep coma. A description of his breakfasts is what did it. Much more effective than Ambien. If only the meals that followed each other like tracer bullets were unique, unusual or even really disgusting. Anything but eggs, bacon, home fries, etc. What about salamander kidneys, I thought. Marshmallow meatballs, praying mantis a la Paula Deen, you get the idea. 

Recently, I returned to Twitterworld.  What a surprise! Even my colleague was tweeting with substance. No more French toast!  I saw how much the site and the number and variety of tweets had grown.  Even though one was still limited to 140 characters, so what? Tons of interesting ideas were being exchanged or debated.  Publications I had never heard of were quoted.  There was a much greater variety of tweeters, many brilliant, hilarious, or both.

Though I try to emphasize tweets related to my fields of psychiatry and psychology, I can’t resist sandwiching in some lighter stuff. I love humor, for example, but there’s the dilemma. I find no shortage of advice on the web that “professionals”, especially mental health professionals, should tweet only about professional matters and set up a separate account for the rest.

I still don’t feel that I can be an open book on Twitter, but I plan to lighten up and, hopefully, entertain as well as do my best to inform.

“IT IS BETTER TO LIGHT ONE SMALL CANDLE THAN TO CURSE THE DARKNESS

Thus spoke Confucius.

Below is a letter written by gastroenterologist Matthew Moeller and posted on
CaduceusBlog.  It was reposted on  LinkedIn as a topic for discussion in a managed care forum.  Below the rather lengthy letter is my response, also posted on LinkedIn.

DEAR LAWMAKERS:  THIS IS WHAT IT’S LIKE TO BE A DOCTOR TODAY

Matthew Moeller, MD | Physician  | March 20, 2013

I am writing this letter because I feel that our leaders and lawmakers do not have an accurate picture of what it actually entails to become a physician today; specifically, the financial, intellectual, social, mental, and physical demands of the profession. This is an opinion that is shared amongst many of my colleagues. Because of these concerns, I would like to personally relate my own story. My story discusses what it took to mold, educate, and train a young Midwestern boy from modest roots to become an outstanding physician, who is capable of taking care of any medical issues that may plague your own family, friends, or colleagues.

I grew up in the suburbs of southeast Michigan in a middle class family.  My father is an engineer at General Motors and my mother is a Catholic school administrator in my hometown. My family worked hard and sacrificed much to enroll me in a private Catholic elementary school in a small town in Michigan.  I thought I wanted to be a doctor in 5th grade based on my love of science and the idea of wanting to help others despite no extended family members involved in medicine.  Winning a science fair project about the circulatory system in 6th grade really piqued my interest in the field. Throughout high school, I took several science courses that again reinforced my interest and enthusiasm towards the field of medicine.  I then enrolled at Saint Louis University to advance my training for a total of eight years of intense education, including undergraduate and medical school.  The goal was to prepare myself to take care of sick patients and to save the lives of others (four years of undergraduate premedical studies and four years of medical school).  After graduation from medical school at age 26, I then pursued training in Internal Medicine at the University of Michigan, which was a three year program where I learned to manage complex problems associated with internal organs, including the heart, lungs, gastrointestinal tract, kidneys and others.  I then went on to pursue an additional 3 years of specialty medical training (fellowship) in the field of gastroenterology. The completion of that program culminated 14 years of post-high school education. It was as that point, at the tender age of 32 and searching for my first job, that I could say that my career in medicine began.

Over that 14 year time period of training, I, and many others like me, made tremendous sacrifices.  Only now as I sit with my laptop in the dead of night, with the sounds of my children sleeping, can I look back and see where my journey began.

For me, it began in college, taking rigorous pre-medical courses against a large yearly burden of tuition:  $27,000 of debt yearly for 4 years.  I was one of the fortunate ones. Because I excelled in a competitive academic environment in high school and was able to maintain a position in the top tier of my class, I obtained an academic scholarship, covering 70% of this tuition.  I was fortunate to have graduated from college with “only” $25,000 in student debt. Two weeks after finishing my undergraduate education, I began medical school.  After including books, various exams that would typically cost $1000-$3000 per test, and medical school tuition, my yearly education costs amounted to $45,000 per year. Unlike most other fields of study, the demands of medical school education, with daytime classes and night time studying, make it nearly impossible to hold down an extra source of income. I spent an additional $5000 in my final year for application fees and interview travel as I sought a residency position in Internal Medicine.  After being “matched” into a residency position in Michigan, I took out yet another $10,000 loan to relocate and pay for my final expenses in medical school, as moving expenses are not paid for by training programs.

At that point, with medical school completed, I was only halfway through my journey to becoming a doctor.  I recall a moment then, sitting with a group of students in a room with a financial advisor who was saying something about how to consolidate loans. I stared meekly at numbers on  a piece of paper listing what I owed for the 2 degrees that I had earned , knowing full well that I didn’t yet have the ability to earn a dime. I didn’t know whether to cry at the number or be happy that mine was lower than most of my friends. My number was $196,000.

$196,000. That was the bill, for the tuition, the tests, the books, the late night pizza. $196,000 financed through a combination of student loans, personal loans, and high interest credit cards, now consolidated, amalgamated, homogenized into one life defining number for my personal convenience.

I then relocated to Michigan and moved into a small condo in Ann Arbor, where I started my residency. As a resident in Internal Medicine, I earned a salary of $39,000. All the while, interest continued to accrue on my mother-lode of debt at the rate of $6000 per year due to the high debt burden.  Paying down this debt was not possible while raising two children. My wife began working, but her meager salary as a teacher was barely enough to cover day care costs. During residency, my costs for taking licensing examinations, interviewing for specialty training positions, and interest on the large loan ballooned my debt further, now exceeding $230,000, all before I began my career as a “real doctor”.

Relatives and friends often ask me, “now that you are a ‘real’ doctor, aren’t you making the big bucks?” While I am fortunate to now be making a higher salary, some basics of finance make my salary significantly less than meets the eye (very in-depth article on how this is so). First, I was 32 years old as I began training and I now had over $230,000 in debt. Had I invested my talents in other pursuits such as law school, I would not have built up this level of debt. Also, as I did not start saving when I was younger, financially speaking, I have lost the past 10 years without the ability to save and invest to earn compounding interest.  In addition, as physicians, though we make more money than many others, we are not reimbursed for many of the services that we provide.

We do not “clock” the number of minutes as attorneys do when we talk with patients.  We do not hang up the phone as attorneys may do if they are not going to get paid. No, we listen to patients and answer their questions, however long it may take.  Even if it is the thirty-second straight hour of work, which happens very often, we listen, respond, and formulate a logical plan.  If it involves calling a patient at home after I just worked 30 hours in a row and just walked in the door to see my family, I do it. I never come “home” from work.  As physicians, we are always available, and have to respond in an intellectual way using the $230,000 rigorous education that we received.   And if we don’t do our work well, we don’t just lose business, but we can lose our livelihood through lawsuits.

You may ask why do we do all of this?  It’s because we have pride in what we do.  We truly care for the well-being of the human race.  We have been conditioned to think, act, talk, and work as a very efficient machine, able to handle emotions, different cultures, different ranges of intellect, all to promote the health of America.  We are doctors.

In reading this letter, one may think that one has to sacrifice a significant amount to become a great physician.  You may think we face physical and mental stress that is unparalleled.   You may begin to think that doctors not only have to be smart, but they have to know how to communicate with others during very emotional times.   You may think that we must face adversity well and must develop very rough skin to handle all walks of life, especially when dealing with sickness and death on a daily  basis.

Now that you see this additional aspect to our career, you may think that we have a tough job to tackle several tasks at once, demanding much versatility.  You may think someone needs a great work ethic to do what we do.  You must think that not only do we have to know science extremely well, we also have to know other areas such as writing, history, math, even law given the multiple calculations we go through in our heads on a daily basis and conversations we have with families. And finally, you must think we know finance, as we have to try balance a $230,000 loan while making $50,000 at age 30.

Now imagine, if you would, having $230,000 dollars in debt with two young children at age 30 and listening to the news with lawmakers saying that doctors are “rich” and should have their pay cut.  Or that “studies show that doctors lack empathy”.

Unfortunately, we physicians do not have much of a voice on Capitol Hill.  There are not enough doctors in Washington D.C. who can give the insight of this letter while you in Washington, D.C. discuss health care reform.   You may hear from leaders of the American Medical Association, but these are not the doctors on the front lines.   These are the older political voices who were physicians when the times were different, when doctors did get reimbursed fairly for their work, when student loan debt was not this high, and when lawsuits were less prevalent. Many of the loudest voices in the healthcare debate are those of lawyers and lobbyists for special interests. They do not care about the well being of patients; that is what doctors do.

I want to make it clear that this letter is not just another story about the difficulties of becoming a doctor and being successful in medicine.  I do not want you to think I am complaining about how hard my life is and used to be.  In fact, I love my job and there is no other field I would ever imagine myself doing.   My true wish is to illustrate the sacrifices doctors do make because I feel we are not represented when laws are made. These sacrifices include a lack of quality family time, our large student loan debt, the age at which we can practically start saving for retirement, and the pressure we face with lawyers watching every move we make. Yet we make these sacrifices gladly for the good of our patients.

I want to challenge our leaders to address the points I have made in this letter, keeping in mind that this is an honest firsthand account of the personal life of a newly practicing physician.  It is a letter that speaks for almost all physicians in America and our struggles on our arduous yet personally rewarding life.  It is not just a letter of my own journey, but one that represents most physicians’ path on our way to caring for America’s sick.

You may ask how I had the time to write this letter?  As I’m sure many of you do, I made time.  It is now 3:00 am on my only day off this month.  I considered this a priority.  I hope you feel the same.  I just finished my 87 hour week.  Time for a short rest.

Matthew Moeller is a gastroenterologist.  This article originally appeared on CaduceusBlog and  was reprinted on LinkedIn as a topic for discussion in an managed care forum.

MY RESPONSE:

I am a physician in private practice, and read Dr. Moeller’s letter with interest.  With respect to the summary of his training, the consequent late start as an earner, the debt incurred along the way, and the demands of the profession among other things, my own experience is mirrored.  However, the  letter has a grandiose and entitled tone that I found off-putting.  Dr. Moeller is going a bit far in stating that his opinions represent those of a majority of physicians.  The use of the royal “we” only underscores the fact that he does not represent me.

 Physicians had been glorified for so many years in this country as the “I play one on TV”, Marcus Welby types that the current trend towards doctor-bashing is jarring, especially to older doctors. 

One problem is that, at least when I was in medical school in the 70′s, we were not taught a single thing about the economics of medicine, how to set up a practice, etc.  Doctors were not questioned,  they could keep patients waiting forever.  The average patient was passive, and many physicians did not deign to discuss their fees, leaving that chore to their billing person.  

With the advent of  managed care,  physicians’ practices came under greater scrutiny and insurer’s gained power.  The nation’s health care expenditures grew and grew, to the point that it is projected that by 2021, they will approach 20% of GDP.  There are many reasons for this. Time and space do not permit me to address them.

Physicians are “supposed” or expected to hold to a higher moral standard than other professions, such as the law.  Yet medicine is a business in a capitalist economy.  U.S. physicians, even under the current circumstances and constraints, earn far more than their counterparts in the rest of the world.  Nobody is entitled to anything in this world. If Dr. Moeller wishes to get the attention of “leaders and lawmakers”, he would have been well-served by elaborating just a bit, in his letter, on what the problems are on a national level, and what these people should be doing about it.  Mostly, what he plans to do to solve the problems,  other than throw himself a bang-up pity party.  

The noted philosopher Albert Camus wrote that man takes control of reality through action.  Complaining is not action.  It’s just complaining.             

PHYSICIAN, HEAL THYSELF

On the 12th anniversary of 9/11, my fading memories of the World Trade Center bombing came back into clear focus. 

I was on the subway when the first plane hit.  Clueless, I got out and walked to my midtown office building.  Outside the lobby doors, I saw a group of well-dressed people talking on their cell phones. 

They say that our brains try to make sense of limited information by constructing the most likely scenario based upon past experience.  My brain said, “Ah, a group of tourists phoning home”.  Suddenly, a clean-cut young man in a business suit took off running.  He was heading south.  I thought little of it. 

A day or two passed. I sat in front of the T.V. with my wife.  Images of the planes hitting , the buildings collapsing.  Over  and over.  I felt shock, disbelief, anger and helplessness. I wanted to do something.   I needed a catharsis.  Being a psychiatrist, I thought that  perhaps  I could provide some comfort to persons affected by the tragedy.  I put my name on a few volunteer  lists, but didn’t get a call.  Angrier and more frustrated than ever, I searched for an alternative.  I found an ad posted by The Church of Scientology, seeking volunteers to work at a counseling center close to Ground Zero.  I attended a brief tutorial on crisis intervention techniques.  They gave me a white plastic hazard suit, a helmet, and a mask. I concealed a smile at the irony of being recruited by one of psychiatry’s most bitter enemies. 

It was a Saturday, four days after the bombing. They bussed a number of us to a “treatment center” about a quarter-mile from what had been the WTC.  Nobody came for help. I was so frustrated that I was ready to just go home. Then they asked for volunteers to move closer to the site to hand out food and drinks to the men and women working there.  We were not to be allowed onto the site itself.  No “civilians” wanted, only construction workers at that point. 

After handing out nourishments, I did a little exploring.  I entered the World Financial Center, which was intact  except for a large metal beam that had struck and penetrated the brickwork. Inside, everything was covered with a fine white dust.  On the ground floor was a snack bar with plates of uneaten food sitting on the counters and tables.  I went upstairs.  There was a gym.  Rows of treadmills and exercise bikes, all completely white.  I thought of Pompeii, frozen in time.    

I had a goal in mind.  I wanted to get to the site itself, to the foot of that enormous, smoldering mountain of debris surrounded by partially destroyed buildings and that iconic twisted steel lattice.  I snuck in when a police guard’s eyes were turned away and inserted myself into a  bucket brigade of masked and helmeted construction workers.  They were passing large pieces of debris, mostly twisted metal, along a chain leading to a  collection area.  As I handled these objects to which I still felt no human connection, I occasionally looked at the ground. 

There I saw pieces of debris, few larger than a foot in diameter.  Most were fragments  of electronic  equipment.  Smashed computers, monitors, wiring, keyboards, and small, unidentifiable objects,  some charred.  During a lull, I picked up a piece of paper.  It was a reservation list for the restaurant, Windows on the World, that had been at the top of the North tower. Feeling guilty, I picked it up and put it in my pocket anyway.

A piece of one of the jetliners passed through my hands.  I still felt so numb inside that, to me,  it was just another chunk of metal, not a fragment of a vessel that had carried so many innocent  people to their deaths. 

I dropped out of the line and started home.  As I walked along streets covered in dust and debris, I saw fire engines and cars flattened into amorphous lumps of  steel  a foot or two high.  One of the vehicles was a UPS delivery truck.   I noticed a construction worker staring at it.  I heard him say to a companion, “So that’s what happened to the package I sent!” They laughed, and so did I. That shared laugh was the first human connection I had made all day.  Black humor, yes.  But I felt a bit better.

Influenced by Freud, surrealist André Breton had coined the term “black humor” in 1939. He agreed with the premise that grim jokes help us overcome fear, and quoted Freud: “The grandeur in (black humor) clearly lies in the victorious assertion of the ego’s invulnerability… It insists that it cannot be affected by the traumas of the external world.”

I returned to the site the next morning.  The rules were even stricter.  No more construction workers. Police officers only.  I snuck in again and rejoined the bucket brigade. I saw disciplined teams of rescue workers  from all over the country making their way up the mountain,  stopping here and there to dig through the debris.  Cadaver dogs sniffing away.  Every once in a while, human remains were discovered and shielded from view by the workers before being brought out in black body bags.  

I saw a piece of flesh at my feet no more than two inches long.  I saw a priest blessing the bodies of three firefighters.  I looked into the face of the police officer next to me.  He looked back at me suspiciously.  He’d probably figured out that  I was not a cop.  Perhaps he felt that I didn’t belong there.  I couldn’t have cared less. I’d done nothing requiring any skill, nothing heroic, just moved some junk along, but felt more at peace. I’d started to heal. The enormous mountain of debris that was once the World Trade Center kept on smoldering.

More on Dr. Drew: Diagnosing on TV is Easy, Just Like Predicting the Weather

As a psychiatrist with over 30 years experience, I have a couple of things in common with Dr. Drew. Being a psychiatrist is not one of them. He is an addictionologist. More on that later.

Having been on staff at the same two hospitals in Pasadena, California as Dr. Drew was, albeit well before him, I’m (almost) experiencing a fuzzy sense of kinship with America’s Addictionologist. In fact, at times, I feel myself basking in a few scattered rays of the good doctor’s starlight just by having shared those experiences with him.

When I saw Dr. Drew explaining to an awestruck CNN interviewer why it’s no big deal diagnosing people via their televised images, I felt like running to the bathroom and yodeling into the old porcelain phone. Had I done so, Dr. Drew would have diagnosed my reaction with 99.99% accuracy as acute nausea. (Nobody’s perfect).

Dr. Drew, Renaissance man that he is, recently gave an addictionologist’s diagnosis of Charlie Sheen’s apparent psychiatric problems based upon his public behavior, and recommended treatment. Immediate hospitalization, no less.

I was gratified to hear from Dr. Pinsky, in the course of the CNN interview, that medicine and, by extension, its subspecialty, psychiatry, are on a par with political and weather commentary in terms of appropriatness for media consumption. Even as a psychiatrist (though I did go to med school), I could say that a mole-like lesion on someone’s face big enough to show up on TV was probably a mole. Unfortunately, I’m having a hard time seeing how Dr. Pinsky, without referring the person to a dermatologist for further investigation, including a biopsy, could say for certain that it wasn’t a potentially fatal melanoma.  Instead he seems to be saying,    “That was easy!” (Apologies to Staples).

Dr. Pinsky’s smug view of his capabilities as Doc-in-a-La-Z-Boy makes little sense with respect to the diagnosis of mental illness, his most recently acquired area of expertise.  It’s so much more complex than a zit.  I’ll bet he’s scaring the hell out of plenty of folks out there who now want to hospitalize Aunt Gertrude just because she got a little giddy from that margarita and called herself the Wicked Witch of the West.

If Dr. Pinsky, as he professes, really wishes to educate,  he should do so.  Within his area of expertise.  But, I would urge him to be wary of the ethical standards that govern many of the health professions. These expressly state that thou shalt not diagnose without thoroughly examining a patient first and making sure that you have his or her permission to share your opinion. No wonder Charlie challenged Dr. Drew to a fistfight.  (The Warlock versus the Drewminator).  When it comes to a punch-up, I’d probably bet my clams on Charlie,  but if it were a grandiosity contest…

Woody Allen once said that the late Normal Mailer pledged to donate his ego to the Harvard Medical School. I can just see Dr. Drew’s up there on a shelf,  marinating in the next jar to the left.

Here’s the relevant link:  http://drdrew.blogs.cnn.com/2011/03/28/%ef%bb%bfdr-drew-talks-envy-celebrity-rehab/

Doctor, First Diagnose Yourself, and Do No Harm (First published on Technorati, 3/17/11)

You might imagine that Charlie Sheen, given the number of people who have commented upon his recent activities, has a fairly lengthy shit list. But, so far, he’s only publicly challenged one person to a punch-up: Dr. Drew, AKA Drew Pinsky, M.D., addictionologist to the stars. Said Charlie: “I think me and Pinsky should jump in the ring and he can see how unstable these fists of flaming fury really are. I’ll show you how unstable I am. Bring it! Bring it little man!”

So what’s Charlie’s beef? He has taken issue with Dr. Drew’s armchair diagnosis, made on Hollywoodlife.com, that he was in a manic state, and should be hospitalized on an emergency basis.

Dr. Pinsky is not the first physician to draw broad conclusions about a public figure from few established facts. Years ago, psychoanalyst Dr. James Brussel, author of the book, “Instant Shrink: How to Become an Expert Psychiatrist in Ten Easy Lessons” (take note, Dr. Drew), was asked to profile the notorious “Mad Bomber” who terrorized New York City in the Forties and Fifties. 

Dr. Brussel quickly painted a detailed portrait of the Bomber, George Metesky, that included a strong likelihood that he favored double-breasted suits. When apprehended at home, Metesky was wearing pajamas, but, (Aha!) changed into a double-breasted suit for his trip downtown. Dr. Brussel was praised to the heavens.

In a 2007 New Yorker piece on criminal profiling, Malcolm Gladwell wrote: “If you make a great number of predictions, the ones that were wrong will soon be forgotten, and the ones that turn out to be true will make you famous… It’s a party trick”. 

My point? Today’s armchair diagnosticians, enabled and empowered by a celebrity-obsessed culture, are, like Dr. Brussel and Dr. Pinsky, performing party tricks. Why not impress and entertain a credulous public with fancy medicalese and psychobabble, while getting to bask in the reflected glow of their celebrity targets?  

As a psychiatrist, I am most familiar with the American Psychiatric Association’s  position on diagnosis at a distance, although other professional organizations take a similar stance. “It is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization for such a statement.” 

Diagnostic labels, particularly in the highly sensitive fields of mental health and chemical dependency, are scarlet letters that stick, and they should not be recklessly applied to public figures by mediagenic, attention-seeking, gossipy types who end up perpetuating negative stereotypes of their chosen professions while serving little constructive purpose.

My Views on Proper Attire for Boomers: letter to the New York Post 3/6/11

Tracey Jackson needs to lighten up (“Hey Baby Boomers, Grow Up!” PostScript, Feb. 27).

As a so-called Baby Boomer, I take issue with her opinion. Jackson appears rigid and conventional in her thinking, expressing views that seem out of touch with the times.

Older people are being increasingly spared the invisibility, prejudice and stereotypes that have prevailed for years in our youth-oriented culture. Plus, many are forced to continue working years beyond retirement age and are living much longer.

People should be permitted to wear whatever they wish, whatever their age, even if it’s a Marilyn Manson T-shirt or plumber’s butt pants. I can’t help but imagine that, at 65, Jackson would prefer seeing me in dress trousers belted at the chest and white shoes with big gold buckles.

The admonition to “grow old gracefully” is ageist and nonsensical. One of the blessings of getting older is not caring so much about what others think of you and being free to express yourself, verbally or otherwise.

Here’s the link to the article in question: http://www.nypost.com/p/news/opinion/opedcolumnists/hey_baby_boomers_grow_up_VGP1IaaYxVukUacpQuoLvO

My Response to a Psychiatric Times Blog Entry by Psychiatrist Carol A. Paris M.D. Concerning the Tribulations of Working with Health Insurance Companies

It seems to me that this kind of criticism of the insurance industry misses the more important point. As a psychiatrist, I am not enamored of piles of paperwork, debating with peer reviewers, and feeling that my patients are sometimes denied important services on the basis of cost. But, many physician complaints about the system seem, to me, narrow in scope, if not downright self-serving.

I was practicing in California when managed care arrived in the mid 80′s. I hated those calls from insurance companies that made me feel that my competence and judgment were being questioned. Then again, some of my colleagues were keeping patients in the hospital until their insurance ran out, declaring them cured, and discharging them. And there’s the psychiatrist I knew who was billing for psychotherapy with a patient in an ICU who was in a coma. I accept the few bad apples theory, but physician greed certainly contributed to the backlash that occurred.

At the present time, over 16% of our population has no health insurance, yet we’re spending an almost identical proportion of our gross domestic product on health care, and bankrupting our system. All the complaining in the world won’t change the fact that something’s got to give. We can blame overpaid CEO’s, an excess of mid-level managers at the companies we revile, lawyers and politicians, but let’s look at ourselves. All too often, we think of our patients, our income, all the rewards we were promised for staying up all night studying or working 72 hour shifts as house officers, piling up debt while our friends were working for a decent wage and having fun.

We’re not entitled to anything. Nobody is. Let’s accept current realities or work to change them instead of holding pity parties for ourselves.

Link to original blog:  http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1707756