Loss of Psychiatric Beds in Vancouver

From the Nanaimo Daily News in Canada:

"VIHA said they had to shut the [psychiatric] unit for as long as a year because they cannot find a replacement for a departing psychiatrist. It's hard to believe that VIHA has allowed itself to end up in this position.

In fact, Alberni-Qualicum MLA Scott Fraser is right when he says, "It's not acceptable . . . . It's not an option. You cannot shut down essential services."

To add to Fraser's incredulity, closing a mental health ward approaches irresponsible if not outright negligent.

VIHA might argue they have no control over the comings and goings of doctors, but it's pretty hard to believe that they did not or could not foresee this long enough ago to take appropriate action.

Either way, the fact that they could not negotiate to have the current psychiatrist remain until a replacement could be found, or that they were caught by surprise, indicates something is wrong within VIHA.

What this also seems to indicate is that the health authority has little regard for those in need of mental health care."

This story says a lot about the way many hospitals view psychiatric treatment... as a community service that is somehow "optional."

The Psychoanalysis of Oliver Sacks

First, a couple of plugs:

Since we're still talking about the Shrink Rappers' trip to APA, I'd like to steer you to Peter Kramer's piece on what psychiatrists actually do at big psychiatric conventions.

Nothing to do with APA, but we received a nice note from a psychiatrist, and he has a site for quickly looking up DSM-IV-TR codes. Unlike Roy, I actually can't remember all the codes, so check out : doctorcodes.com.

Okay, so Oliver Sacks. I heard him speak just briefly at APA at the Convocation of Fellows. He talked about musical hallucinations, and as he gave his talk, he mentioned that he's been in twice-a-week psychotherapy with a psychoanalyst for 42 years. That's a lot of decades of therapy. Roy's comment: "Kinda weird." Here's what else I know about Dr. Sacks -- I heard him talk on an NPR show a few weeks ago. He was born in England in 1933. His parents were physicians and, more specifically, his mother was a surgeon. When he was a boy, he said on the NPR show, his mother would bring home fetal body parts for him to dissect. His brother does not think he should talk about this. Dinah's comment: "Kinda weird." I'll say it tongue-in-cheek, but this alone might cause one to need decades of psychoanalysis.

Before I say any more, let me add a disclaimer. I've heard part of an NPR's Fresh Air (Listen Here) -- oh, he has a Great NPR Voice. I've read The Man Who Mistook His Wife for A Hat. I've heard him speak for roughly 15 minutes at APA. I think I saw the movie Awakenings with Robin Williams. I've never met Dr. Sacks, I've never e-mailed him, I have no knowledge of his life beyond what I've heard him say in public. This post borrows from him, but I have no idea why Dr. Sacks has spent decades in therapy, and please don't take my fantasies as reality.

I don't know if Dr. Sacks suffers from a mental illness. Perhaps he does, and perhaps that alone warrants all these years of treatment. But maybe he doesn't; so, now we can digress into my fantasies. Dr. Sacks lives in New York City, a place where many of the worlds' psychoanalysts practice, a place where the practice remains alive, and where therapy is still accepted (or was when I was a med student there) as a means to gain self-awareness and maximize one's ability to live life to the fullest. It's not necessarily about curing illness; it's sometimes about a vaguer, more self-actualizing goal, one that may be an on-going process and one without a specified end.

To divert a bit, I once had a supervisor who volunteered to me that he'd had decades of therapy. Unlike Oliver Sacks, he wasn't a stranger, and I didn't have to speculate: I asked why. He told me his therapist served as a surrogate father, helped him to process his work, and that after he finished analysis, he wanted to continue to see him weekly rather than just bumping into him from time to time.

Personally, I believe that psychotherapy is a personal endeavor--- if it's helpful to you, do you need to justify it? Of course not, but in ways, society asks us to do this. It's expensive, it's regulated, there are not enough psychiatrists to provide care to the mentally ill, so is it right that someone who is not in active distress should take up the precious time of physicians who might be better used elsewhere? I'm told that there are only a handful of psychiatrists in Afghanistan -- perhaps we should ship these psychoanalysts there to help the chronically mentally ill Afghanistan citizens.

Okay, so the question gets even more complicated: should the long-term analysand without a mental illness pass the bill along to her insurance company? This again gets foggy -- I see patients who've rapidly recovered from a Major Depressive Episode -- if they continue to come for appointments, should the bill be passed along to the insurance company even if the patient has no active symptoms of depression at the time of the visit? Not every patient walks into every appointment in distress, and some people go up and down. I imagine ( I don't know) that over the course of 42 years, Dr. Sacks has good weeks and bad weeks, whether or not he has a psychiatric disorder.

There are many who feel that with limited resources, our society should not pay for therapy for people who don't have mental illness; subjective distress is something you should pay for on your own, and self-awareness is the same. Socrates told us that the unexamined life is not worth living; he didn't tell us who should pay to examine it.

The Shrink Rappers Go To APA

First, congratulations to Clink on her new job and her new appointment to a professional society's board. Way to go, girl!

I learned a lot at APA this year, some of it useful, some of it simply interesting (but useless).

Where do I start? ClinkShrink already told you that we met some readers.....Hi, Sophizo, Hi, "Shrink Rap," and if you read the comments to Clink's post, well, there were others in the audience. It was fun. I didn't freak and faint. Thanks to Roy for setting this up and for including me. When is he coming to organize the rest of my life? Who is TigerMom?

So at our presentation: I learned about the Psycho-babble bulletin board and met Dr. Bob. I've always wondered about this because when I've Googled myself I've come upon posts to this psycho-babble board by someone with my name. Sort of a weird coincidence, and this funny idea that people (my patients included) who would think this was me posting...stuff I can't control, and the poster has my exact full name. Very weird, but there's nothing I can do about this, and now I know what Psycho-babble is. I, like Clink, loved hearing the very brave patients talk about how this on-line community has provided support, encouragement, and healing. And then the third part of our workshop included a talk about on-line virtual gaming. I wasn't sure what to make of this-- I have a kid who sometimes plays sports on-line, but I'm not aware that anyone I know lives an average of 8 hours a day (3000 hrs/year) in a virtual world with millions of players, hierarchies of players, the exchange of money for virtual 'property.' I'll have to start asking.

I heard Oliver Sacks talk about musical hallucinations. Dr. Sachs has been in twice a week psychoanalysis for 42 years (or was it 46). I had the sense that it was with the same analyst. This probably deserves it's own blog post.

John Greist talked about OCD--- I'm not sure I learned much new, but it was good to know I wasn't totally out of touch. Dr. Greist is an amateur race car driver.

I went to a very good symposium on treatment for substance abuse. For cocaine addiction, people are using antabuse (disulfuram), modafinil (I hope I have that right) and d-amphetamine: this brought the predicted questions from the audience about addiction. Marijuana dependence is a rapidly growing reason for seeking treatment-- especially in older folks (meaning people in their late 40's, and 50's) as well as adolescents. Marinol is the pill-derivative form of THC. There were talks on methadone and buprenorphine, and on motivational interviewing.

I didn't learn as much as I wanted to about the metabolic syndrome. One studied showed that people gained less weight (on average) on zyprexa if they also took modafinil (provigil). They still gained weight, and the study only went 3 weeks out.

Max missed me, the judge enjoyed coffee with my husband, and everyone liked the wind-up walking brain I brought home. I had lunch and dinner and cocktails and overall I felt like The Bernstein Bears and Too Much Conference. Happy to be home.

How To Say Goodbye

In a few weeks I will be less of a ClinkShrink than I currently am. I'll still be a ClinkShrink, I'll just be doing it in fewer prisons. It feels odd to schedule my patients for followup knowing that I will no longer be there for their followup appointment. I am faced with the question of how to say goodbye to my patients, some of whom I've treated over multiple incarcerations in the last fifteen years.

Patients come in and out of my life fairly quickly. With a caseload of at least 150 patients or so, there's no way I can specifically remember each one. Often they disappear without warning, released to parole or transferred to other facilities. Sometimes I read about them in the newspapers later, either arrested or killed. That bothers me. I used to think that inmates didn't get attached to prison doctors because they move quickly through the system and see someone new at each pretrial facility. Generally though once they get into the sentenced side of the system, the prison side, this settles down and you have a chance to develop some longterm relationships. And the longer you work in the system the more inmates you get to know. Dinah thinks that when you're 'only' doing med checks the therapeutic relationship isn't important, but I can tell you it is. I'm going to miss (not all, but many) of these guys. If it matters to me, I'd be willing to bet it's going to matter to (not all, but many) of my patients.

The patients it will matter to are the ones who ask for me by name when they get arrested, the ones who insist on getting on the phone to say 'hi' when the nurse pages me for medication orders, the ones who honk and wave when they drive by me on the street, or run up to me in the recreation yard to tell me how they're doing. These are the patients who prove to me that kindness and a good rapport counts, even when you're 'only' doing med checks.

So I've been saying goodbye this week, not without a fair amount of guilt. Eventually I will be replaced but not right away, not for the full amount of time, and likely by someone with little or no correctional experience. I have sympathetic anxiety pains for the new clinician who has no clue what he's walking into, as well as for the inmate who sees the new face and has to start all over again.

But starting over is what the correctional experience is all about, for patients and sometimes also for physicians.

It Was Nice Meeting You

So Dinah, Roy and I ventured down to Washington DC to the American Psychiatric Association conference to talk about the use of computers in psychiatry. I was hoping to get a picture of our feet under the panel table, but that didn't happen. What did happen was that various Shrink Rappers met a couple Shrink Rap readers, and we appreciated the feedback you gave us. I hope our fellow psychiatrists enjoyed all the presentations at that session as much as we did. I personally enjoyed hearing patients talk about how online discussion boards helped them get better. That was pretty cool, and not something you hear every day. I thought it was pretty brave of them to put their histories out there in public, and I appreciated their willingness to do this for the education of psychiatrists.

Thanks again.

My Creepy Shrink Is On the Wall Street Journal Blog

Check out the Wall Street Journal Health Blog-- Thanks to Scott Hensley for writing about those mean psychiatrists. Most aren't, just so you know. But Cruella.....

My 15 minutes of Blog Fame, though I am quite glad that Cruella is well-disguised.

The Shrink Rappers are off to APA. The blog may be quiet for a few days.

Note to my co-bloggers: Clink, all my emails to you bounce back. And I dropped my phone into the toilet tonight...the SIM card is saved and I could transfer it, so you can call me, but most of my numbers haven't transferred, and I haven't figured out how to text on the temp phone. Call if you need me.

My Therapist is a Creep

Pic removed when I looked at it more closely and realized what it was--I am so sorry to all. I will look more closely at what I'm posting...oy.

Vaguely confabulated, but.....

So an acquaintance (let's call her Marsha) mentioned she'd been in therapy with a psychiatrist (let's call her Cruella) I know through professional channels. I shivered, oh did I shiver. "How'd it go?" I might have asked if this really happened. "Awful." No surprise there. Therapy with Cruella sounded to be just as I'd imagined; she was weird, kind of nasty, and just the thought of talking to her about my deepest darkest or looking to her for comfort made me ...well... shiver.

Many people think psychiatrists are weird. Maybe we are. The truth is that most of the psychiatrists I know are at least kind, well-meaning, interested, and want to help people. Cruella does not fit this mold, she's weirder than any TV shrink I've seen, prone to outbursts, and doesn't relate well to people; I've seen her cut people with words, I've watched her hold the room hostage. My opinion, of course, and my best guess is that Cruella has nothing nice to say about me. So be it.

I forgot to mention that Cruella is very smart, and I'm sure she's a very competent psychopharmocologist. But this is the thing-- I would never refer anyone to her. Why? Because she's weird and not nice.

What's this got to do with anything? The truth is that people all have fantasies about their real life psychiatrist-- one is the supposition that the psychiatrist is a nice person who's life is vaguely in order. Did you want to see a marriage counselor who's on his fourth marriage and has three children who've been placed with foster parents for abuse? I don't think so. And while I know many psychiatrists with their own long stories, many of them I would still refer patients to-- they are good at what they do despite the Whatever in their lives.

I think if I walked into Cruella's office I would run the other way at breakneck speed. Marsha stayed for a while, looking for hope or something good. She didn't find it and eventually left, soured by the experience, but it took a while for her to figure out how not-nice Cruella was.
Can you be a mean person and be a good therapist? I don't know, but I don't think so.

Grand Rounds Smack Down!

Doc Gurley from Posts From an Insane Healthcare System has pounded out a true heavyweight Grand Rounds this week.  Check it out.

Now I Remember

So in my post from yesterday I talked about the normal process of memory and forgetting. Right after I published that post I started thinking about all the weird little things that I remember.

In order to be a doctor you have to have a pretty good memory. You start out by memorizing muscles and bones and nerves and blood vessels, and work your way into the body by memorizing types of cells and cell processes and biochemical reactions. (How many of you remember how many molecules of ATP are produced in the Kreb's cycle?) The comedian who played Father Guido Sarducci on Saturday Night Live used to have this bit where he'd advertise for the Five Minute College. By sending him lots of money and taking his Five Minute College course, you could get a college degree while learning everything a college graduate remembers five minutes after leaving college.

I'm always surprised by the little factoids and trivia I remember, both in day-to-day life and from college days decades ago. I remember my friend's apartment number because it's the same as the year Jamestown was founded. I remember my childhood phone number (OK, that's an easy one---it's two digits repeated two or three times) as well as the addresses for all the apartments I've ever lived in.

Remembering things too well is rarely a problem for people. When it happens it's usually in the context of unpleasant or horrible memories, memories that intrude on day-to-day life and are upsetting or interfere with one's ability to function, as in post-traumatic stress disorder. These situations are usually managed with therapy, although now people are also experimenting with the use of medications to prevent the formation of intrusive memories after traumatic events. This is still too experimental to be practically useful, however.

Of course, we know that memory is not always a reliable thing. We remember childhood events differently than our older siblings, or not at all. In the 1980's following years of a movement for the treatment of trauma survivors we learned both that bad memories can be repressed, but also they can be created through false memory syndrome. The amazing thing is that false memories can be just as convincing to the individual as real ones.

Speaking of false memory syndrome, here's a practical example. When I started writing this post I was feeling rather pleased with myself that I remembered how many ATP's were produced by the Kreb's cycle. I was wrong. See if your memory is better than mine by checking out this link here.

I Forgot

I was driving home from work the other day and I heard a piece on National Public Radio about professional musicians who forget their instruments. I didn't hear the whole thing, but they mentioned stories about symphony musicians who leave expensive instruments somewhere (the Stradivarius left in the cab, for instance).

They asked a mental health professional who also happened to be a musician why people do these things. The mental health talking head said it happened because the musician was "hyperfocussed" or so concentrated on the upcoming performance that everything else was driven out of the mind. He also speculated that performance anxiety was expressed as an unconscious wish to lose the instrument. What he didn't mention, but the first thing that popped into my head, was sleep deprivation or just simple absent-mindedness.

We all do absent-minded things at some time in our lives. We lock our keys in the car, or ourselves out of the house, or we forget to pay a bill or to mail a bill that's already been paid. We forget birthdays and anniversaries and other important dates that we (and our loved ones) really expect us to remember. Fortunately, we also forget anniversary dates of things that are better left forgotten, although I think it will be a long time before anyone forgets dates like 9/11. (Do young people know the date 12/7? Isn't it amazing what we, as a collective national memory, forget?)

Yet we don't consult mental health professionals about why these things happen. Remembering things, and forgetting, are a natural mental process that happens continously outside our awareness. If the problem becomes too severe---if we start forgetting the names of our spouses or children or where we live, or if the memory problem becomes associated with other brain problems like writing or reading or talking, then it becomes a disease.

Age-related memory changes may concern older people, but they are not necessarily a sign of progressive disease. It can also be a sign of clinical depression, in which case memory problems are temporary and reversible.

Of course, none of this explains why I keep forgetting to take my iPod out of my my car when I get home. It must be an unconscious fear of listening to My Three Shrinks. What I want to know is, what's the unconscious wish for forgetting to pick up your kid?

Disturbing Things

I received the following e-mail from a friend. Copied without permission:

I get some of the craziest emails but this one is short and pretty good. I mean, we're all a bit nutty…but really.

Psychopath Test

Read this question, come up with an answer and then scroll down to the bottom for the result. This is not a trick question. It is as it reads. No one I know has got it right.

A woman, while at the funeral of her own mother, met a guy whom she did not know. She thought this guy was amazing. She believed him to be her dream guy so much, that she fell in love with him right there, but never asked for his number and could not find him. A few days later she killed her sister.

Question: What is her motive for killing her sister?

[Give this some thought before you answer]




Answer:

She was hoping the guy would appear at the funeral again. If you
answered this correctly, you think like a psychopath. This was a test by
a famous American Psychologist used to test if one has the same
mentality as a killer. Many arrested serial killers took part in the test and
answered the question correctly.


If you didn't answer the question correctly, good for you. If you got the answer correct, please let me know so I can take you off my email list. (ha)

-----------

So I got it right....I promise I haven't killed anyone, but apparently I'm off Harry's e-mail list. The picture, by the way, was stolen off Fat Doctor's blog. Psychopathic cows for sure. Clink, any thoughts here?

Fat. So?

Oh, a while ago I wrote up a review of a book by Gina Kolata, a New York Times science writer. I never did anything with it, so why not, I'll post it here.


Rethinking Thin

In the mid 1980’s, I worked as a research assistant at the University of Pennsylvania’s Obesity Research Group. It’s been a long time since I’ve had any interest in the details of obesity research, but it got my attention when I saw that Gina Kolata, a New York Times science writer, wrote Rethinking Thin. This is a book which pulls together decades of human and animal research on the causes, treatments, and repercussions of being overweight. In the book, she followed four patients enrolled in a two-year research study at Penn’s Obesity Research Group, now called the Center for Weight and Eating Disorders. The group’s name has changed, some of the researchers however, have not, and it’s always fun to read a book when I can put faces and stories to the names.

The book itself is the history of obesity research, coupled with glimpses of our views about weight in the last century or so. Is it complete? I really don’t know. What I do know is that as I read the book, I was inspired to reconsider certain beliefs I’d held about weight and weight control. I also, however, could think of many examples of people who defied the principals that the author puts forth as new truths.

Kolata begins with the discovery of Jean Anthelme Brillat-Savarin, a French lawyer, who published The Physiology of Taste in 1825. Brillat-Savarin wrote that the treatment of obesity mandates, “a more or less rigid abstinence from everything that is starchy or floury.” This was a preview of the Atkins diet, nearly 200 years ago, and perhaps the start of an endless series of diet fads. Kolata moves on to discuss the practice of “fletcherizing,” named for Horace Fletcher, also known as “The Great Masticator,” who advocated that chewing food one hundred times per minute was the key to the perfect weight and all-around good health. After years of chewing, America was introduced to calorie counting by Fisher and Fisk in their 1916 book How to Live. Around this time, Americans became consumed with being thin and young girls started to diet and exercise to lose weight. The stories continue: the first obesity surgery occurred in 1911 when a Philadelphia surgeon removed 12 pounds of adipose tissue from a patient’s abdomen. The 1920’s saw skinny flappers and the first bathroom scales and full-length mirrors. The diet club, TOPS, was started in 1948. There were diet drinks, diet pills, diet contests-- Kolata describes it all.

Almost every woman wants to be thinner, the author tells us. Miss America has gotten taller and thinner. Jennifer Anniston weighs in at 110 pounds, too light for her 5’5” height. And it’s hard to be fat: fat people make less money and are treated with shame and disgust, sometimes being subjected to public humiliation. Their medical problems are all attributed to their weight. 91 percent of formerly fat people in one survey chose having a leg amputated (hypothetically!) over being obese again.

Kolata continues with a careful look at more recent research in the field—both human studies regarding the etiology, transmission, and treatments of obesity, and animal models in search of chromosomes and hormones that contribute to or control both appetite and body weight. She reports on twin studies, diet studies, research on those who’ve been starved and those made to gain weight.

The four patients/research subjects in the Penn study are revisited throughout in short chapters. There weight loss progress is noted, their optimism waxes and wanes as the pounds drop and come back. They are here, I believe, to make the book more palatable to the lay reader; it is otherwise a recital of research studies with a fair number of pages devoted to the search for a fat mouse gene and hormones which might, but so far don’t, hold answers to the problem of obesity. The Penn patients’ stories are dealt with rather superficially. They weren’t particularly distinctive or compelling and they blended in the author’s desire to show that sustained weight loss is a nearly hopeless goal.

Dr. Albert J. Stunkard, the Director Emeritus of the center, gets his own chapter in Rethinking Thin. He is presented as intelligent, insightful, determined, and inquisitive in his nearly 50 year- long quest to understand obesity. It’s good to know he hasn’t changed since my days as his college student.

Kolata wrote this book with what appears to be clear agenda, she has a message she wants to get out there. It goes something like this, and I’ll list it as bullet points:

· Obesity is not caused by underlying psychological problems or a lack of motivation to be thin.

· Weight is genetically determined (or at least not environmentally determined) and this is supported by adoption and twin studies. Individuals have a narrow weight range, a set point per se, and it is difficult for them to vary from this by either gaining or losing weight; it is even more difficult, if not close to impossible, for them to maintain a weight either above or below the set point range.

· There is are organizations, including diet industries, academic centers, and federal agencies which are invested in propagating the belief that it is unhealthy to be overweight and imperative that Americans eat less, eat healthful foods, and exercise more. Kolata quotes Eric Oliver, a University of Chicago political scientist, “If you are on the political right, obesity is indicative of moral failure. If you are on the left, it means rampaging global capitalism.”

· People are fatter. No one knows why, and interventions aimed at changing diet and behaviors do not change weight. Kolata repeatedly mentions a $20 million, intensive 8 year study done with high-risk Native American children—the study, she says, has mostly been ignored.

· Studies that broadcast the health risks of being overweight are flawed and it seems that overweight people have decreased mortality according to more recent studies. As Americans have gotten taller and heavier, they’ve also gotten healthier with longer life spans and fewer chronic illnesses.

The Penn Study finished after two years on a low note. The dieters had long ago stopped losing weight and had regained much of what they’d lost. They were disenchanted and disappointed though perhaps transformed to a better place of acceptance.

And the book itself? It was a quick and entertaining read. I did have the sense that the author was on a mission to change our views and preconceptions about weight and all that we believe to be unquestionably true about the evils of obesity. At moments, Kolata swerves towards sensationalism, and it’s clear she’d like us to decide that fat is beautiful.

Maybe she’s right and maybe we will.

Two Years Of Shrink Rap Tomorrow: Anniversary Post

On April 21st, Shrink Rap will be two years old.

It's no longer ruining my life. I still love having a blog with my two terrific friends, Roy & ClinkShrink. I still love that her blog name is ClinkShrink.

Ducks and chocolate and podcasts with or without prestigious guests,
readers who read and those who comment. Hummus and Cake and Pizza and Beer. And they help me with computer problems and listen to my teenager stories. And people in South Africa and Australia read my random thoughts, they get stirred up or they simply ignore me. What could be better? More chocolate of course, but I don't run like Clink, so I'll watch it (go down....).

So, for lack of anything more brilliant to say: I'm reposting my first blog post. I have to say that Shrink Rap has now become so big and bulky that it's hard for me to find and navigate it. It's not a blog you could really start from the beginning and read through. I found my first post, and two years of psychiatric progress have not outdated it.

The post is called "Plan: Continue Treatment, Return When?"

Our hypothetical patient enters the office; he's never seen a psychiatrist, and he's here because he is overwhelmed with sadness after being laid off from work. He isn't sleeping well, he's lost ten pounds, he's having trouble organizing his job search, he's irritable and arguing with his wife. He is clearly a bright guy, but tells us he's lost jobs before and feels he isn't living up to his potential. He's not psychotic, he's not dangerous. A full evaluation is done and some decisions are made about what type of treatment to begin. So here's my question: When do we have him return for the next visit? Is that a silly question? And do I really want an answer? You want to ask more questions about our patient, talk about how you would treat his depression, or his adjustment disorder, wonder why he repeatedly loses jobs and is there perhaps a personality disorder as well? And no, I don't want an answer, what I want to do is throw out the idea that there probably is no consensus among us about how often patients should be seen. If our patient is seen in a clinic, he may well be started on an antidepressant and told to return in three to four weeks. In a private office, perhaps he'll be told to return in a few days, or maybe not for week or two or three or four. And if there isn't enough disagreement on how often to see patients at the beginning of treatment, what happens if he has a good response to a medication, his symptoms are alleviated, but he still fills the sessions talking-- do we continue to see him daily/weekly/biweekly/monthly if he isn't asking to come less often and if he's paying his bill?

Okay, nostalgic rambling. Come back to Shrink Rap...oh later today or maybe tomorrow.


[Roy here...]  Nostalgia, huh? Okay, here's a link to my first post, which was sort of a Tom-Kat-Scien-tology post called Tom Knows Psychiatry.  We made a very short podcast yesterday (about Virginia Tech, which we podcasted about last year) for the 2-yr blogiversary, but the recording mysteriously disappeared so there will be none this week.  We did take a picture of the carrot cake that Clink got for the occasion, which I've put up top.

And here's Clink's first post on Recertification Exam Fees.