Should Doctors Feel?

There was an article in today's New York Times called "When Doctors Grieve."  Leeat Granik mentions her mother's long battle with cancer and the family's relationship with her oncologist.  She is now a health psychologist and has just published an study done by interviewing 20 Canadian oncologists.  While I know nothing about the methodology she discusses, I found her conclusions, as she summarized them for the NYTimes, to be thought provoking:

We found that oncologists struggled to manage their feelings of grief with the detachment they felt was necessary to do their job. More than half of our participants reported feelings of failure, self-doubt, sadness and powerlessness as part of their grief experience, and a third talked about feelings of guilt, loss of sleep and crying.

Our study indicated that grief in the medical context is considered shameful and unprofessional. Even though participants wrestled with feelings of grief, they hid them from others because showing emotion was considered a sign of weakness. In fact, many remarked that our interview was the first time they had been asked these questions or spoken about these emotions at all.

The impact of all this unacknowledged grief was exactly what we don’t want our doctors to experience: inattentiveness, impatience, irritability, emotional exhaustion and burnout.

Even more distressing, half our participants reported that their discomfort with their grief over patient loss could affect their treatment decisions with subsequent patients — leading them, for instance, to provide more aggressive chemotherapy, to put a patient in a clinical trial, or to recommend further surgery when palliative care might be a better option. One oncologist in our study remarked: “I see an inability sometimes to stop treatment when treatment should be stopped. When treatment’s futile, when it’s clearly futile.”

I wondered if  one or two (or a few) psychotherapy sessions might help doctors who deal with death or other difficult patient issues?  Might brief psychotherapy give these doctors a chance to  express and explore difficult emotions in way that might make them more comfortable with their feelings --even social or culturally unacceptable feelings-- and be more aware of how these feelings are impacting their work?  It's just a moment of wonder.  I don't want this to be read as a wish to medicalize normal emotions or to suggest that all oncologists need long-term psychotherapy, or that such a thing even be required, it's  just a question of 'what if' such a venue were easily available in a non-stigmatizing environment?  What do you think?  Maybe it's just the sort of thing one should feel comfortable talking with colleagues, or a nice spouse, about, though I think the point of the article was that it isn't okay to talk about these things without being seen as weak or troubled.

A Pill for Alcoholism?

When I was at APA earlier this month, I heard an excellent talk by Dr. Bankole Johnson on the treatment of alcoholism.  I'm currently reading a book called Hooked, by Lonny Shavelson, about an effort by the San Francisco Department of Health to provide drug-treatment-on-demand to all comers in 1998.  The book, a great read even if it is a bit out-of-date, talks about how drug treatment gets divided into camps of those who insist on total abstinence versus those who will settle for a decrease in use as part of the "harm reduction" model.  Dr. Bankole made the point that if you look at total abstinence for alcohol, the numbers are low and one could get very discouraged trying to treat alcoholics.    And he is all in favor of trying medications to reduce craving for alcohol.  Which brings me to an article in the NYTimes by Douglas Quenqua called "Drugs Help Tailor Alcoholism Treatment."  So Dr. Johnson is quoted in this article, and since I enjoyed his talk, I'll mention the article.  It talks about medications that help some people with their cravings-- both on label and off label-- and the question of using a pill to treat an addiction.

Books and Ducks

Life is quiet here as we get ready for summer.  Nothing has struck me as particularly urgent to blog about, but Sarebear sent us a link to a mystery writer's blog with a post about shrinks in mystery novels, so I thought I'd share that: http://www.mysteryreaders.org/Issues/Shrinks.html#white


We haven't been able to find time to podcast, it seems we're never around all at the same time.  Clink is off touring nature sites and playing with her new camera.  Maybe she'll post a pic?  Roy is busy with all thinks geeky, and I'm happy that I finished a grant application today-- my first ever.  I've been fiddling some with my old fiction, and I'm thinking of putting one of my old novels up as an e-book on the free amazon kindle site.  Has anyone done this?  Do you have any wisdom to share with me?  Oh, and speaking of e-books, I just got a copy of Lowell Handler's new e-book, Crazy and Proud.  Do check out his website.  I haven't read the book yet, but the photography is compelling.

So I thought I would check out Facebook advertising.  My cousin used it to get thousands of fans for her website, Motherrr.com, about mother-daughter relationships, so I wanted to see how it worked.  I ran the ad for 2 days with our book cover as the graphic and only got one click-through.  I changed the graphic to a duck, and there were 6 clicks in following 24 hours.  I feel like I'm turning into Roy with all this number tracking.  It's just an experiment to see how it works (another Roy-type thing to do).

Finally, the graphic above was sent to me from a blogger at a site called Grass Fed Ducks, which I think is mostly about food (specifically Korean Food), but there is a duck/mental health tinge as well.

Shrink Rap Ads for NAMIWalks Donations

Click image to Donate.

Shrink Rap is walking for NAMI's Donation Walk tomorrow, Saturday May 19, at Baltimore's Inner Harbor (Rash Field), at 11am. Looks like medical blogger, Dr Val Jones, will also be joining us. Roy and Dinah will be there (I think Dinah; she said she might). Clink will not be able to join us.

But, as you can see on the left, we have only hit 21% of our goal. Sure, it's $300 more than last year and I probably over-reached, but I'm not giving up yet.

Here's the deal. If anyone donates at least $200, we will donate one week of advertising on Shrink Rap, right in the header where the lime green ribbon is now. That's about 8000-10,000 pageviews and potentially 300+ click-throughs. (No pharma, no distasteful ads. Sorry if this seems cheesy but it's for a good cause.)

And, if you are in town, feel free to join us Saturday morning. Registration begins at 10am. Thank you.

(Also, thank you to our recent contributors: Lawrence, Dave, Julie, Dinah, Elise, Carol, Elizabeth, Amy, John, Colleen, Michael, Valeria, and several Anon's.)

Conversations About Bipolar Disorder

Sara is a blog reader who wants to write about bipolar disorder.  She's interested in talking to people who have the condition, and she's started a blog called "Conversations about our Condition."
If you wouldn't mind talking to her, do visit her site!

Fatter and Fatter

I have some questions about America's obesity epidemic.

The New York Times has an article about a mathematician who has been looking for the causes of obesity-- In a A Mathematical Challenge to Obesity, an interview with Carson Chow, Claudia Dreifus  notes that the average person weighs 20 pounds more now than in the 1970's.  I was alive then and it was the hey-day of processed food back when skinny people fed their skinny kids white bread with butter and sugar.   Mayonnaise (or rather Miracle Whip, what ever substance that might have been) was on everything, and oh for  twinkies, ring dings, chef Boy-r-Dee, and scooter pies....those were the days.

The mathematician proclaimed that the answer is that there is more food.  More is grown, more is available, it's cheaper and cheap food allows for the existence of fast food, something you can't have if the food costs a lot.  What I've noticed is that food is everywhere.  All the push to make school food healthier, get rid of soda machines, and encourage children to be more active (ah, the kids I know, even the heavy ones, are doing 3 hours a day of sports after school, it's no guarantee you'll be slender), but it seems that every day is a "special" day....a fund raising bake sale, someone's birthday, end of year party, weekly advisory where the kids rotate bringing baked goods, language class meal, trip to restaurant, snack parent at every sports game, followed by dinner, and when you go out, the servings are huge, and I, for one, find it hard to stop eating really good tasting food if I'm hungry and it's on my plate.  So I'll believe that food availability is the reason why people are fatter.  

So here's my question.  Obesity researchers study obese people and how they differ from normal weight people.  Why isn't everyone obese?  Why are only 1/3 of Americans  obese and only 1/3 are overweight?  Why aren't they studying the people who remain thin despite the fact that they are surrounded by food? Okay, so some people have very fast metabolisms, but others are don't seem to have any desire to overeat.  There may be lots of available food, but they don't want it, or they want it when they're hungry, but they have some and that's enough, a 'stop eating' mechanism kicks in at a point that keeps their weight low.  Why don't they have the desire to eat more when food is available?  And finally, there are those people who want more food, but for the sake of their health or their appearance, they limit their eating.  I've heard it said, "Well, if she really wanted to be thin, she'd eat less."  I don't buy it, I think there are differences between people besides a simple desire, or a weakness of character that makes self-control harder for some then for others.  I want to know why some people have faster metabolisms, less desire to eat, or more will power.  Okay, Dr. Carson, how does your mathematical model work for that one?

I'm not an alcoholic.  It's not because alcohol isn't available-- at any given time my house is stocked with an assortment of beers (I keep dark on hand because Roy likes it) and wines.  It's available, but most days, it's just not on my radar.  It's not because I have great willpower.  I like a drink or two, but after that I get very tired, and it's not fun to be out with people just wishing I could lie down.  I'm not an alcoholic because I'm not wired to want  to drink very often or very much.  I tend to think it's the same with obesity: some people crave food, or the wrong food, or way too much food, and others don't.  Availability may make it easier, but there are still thin people, and isn't it interesting that in more affluent socioeconomic circles, where food has always been readily available, obesity rates are lower.


As a society, we've made the statement that if you're fat, it's your fault.  The obese are the last group of people that it's okay to pass judgement on.  "Exercise more, Eat less."  It's a simple recipe.  Dr. Chow tells us there's no magic bullet.  It's stigmatizing to take weight loss pills or have bariatric surgery.  I've heard morbidly obese people say it's their own fault, as though they don't deserve to be thin, and they loathe themselves for eating too much.  I sometimes wonder if our prejudices about obesity hinder pharmaceutical research because-- if anyone wants my vote-- there should be a magic bullet. 

Crossing Over: Treatment Rights of Transgendered Prisoners

Over on Clinical Psychiatry News I've put up a column on the evolving treatment rights for prisoners with gender identity disorder.

In the CPN post I cover about thirty years worth of changes in prison policies and standards, up to where we are today: individual inmates suing prisons to provide sex reassignment surgery. So far no inmate has ever been given surgery, but at this point it's just a matter of time.

I think the topic is interesting in part because it traces out how correctional standards of care develop: first the courts decide if a condition "counts" as a serious medical or mental health disorder that mandates treatment, then over time an accumulation of individual cases carve out the boundaries and limitations of that care.

So why aren't doctors the people deciding this instead of judges?

Well, they are to an extent. The institutional clinician assesses the condition and makes a determination of treatment needs. Outside clinicians acting as court consultants or correctional experts offer opinions about what the standard of care should be, and professional organizations also weigh in. Courts take in all of this information, weigh it against the interests of the facility, and issues an opinion about whether or not there is a constitutional right to treatment.

This is the same process that took place in the 90's when protease inhibitors were invented to treat HIV. Correctional facilities initially balked at giving the meds because of the cost, but now this is standard and accepted.

Feel free to post questions or comments in either place (CPN or Shrink Rap).