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Monday, April 26, 2010

Better living through Chemistry?

It seems this one didn't make it into my latest copy of the Annals of Emergency Medicine.

Is it fact, fiction, or everything John warned us about? ;-)


Thai said...

For comments

Dr John said...

Oh boy do I have comments on this one but I want some others to take a crack at it first. Thai you just keep hitting them out of the park on your posts I think.

Thai said...

Is HSDD actually in DSM-V?

If it is, then I think I can speak for all of us when I say that sometimes your career is better than ours. ;-)

Dr John said...

To late my friend. It is already here

I do not do so much of this anymore as after I left the healthcare system I joined right out of training the dept. I was running fell apart. I told them I would come back but only if I had full budgetary control. Now I run a company where all the docs work for me. I am doing less and less clinical care all the time and mostly managing.

Anyway when I did do a lot of o/p clinical work I had many "depressed" woman as pts. It gave me an understanding of really how complex a woman's sexuality is. Men we are not that complex. We just want a pretty woman or at least a vagina to do it with. There are very few feelings involved aside from that animalistic drive. Although there are exceptions and yes a woman can want meaningless hedonistic sex like a man, that is just not natural for them.

I think this is where there is something to evolutionary psychology. Woman have all the energy and risk tied up in procreating. It makes sense for them to be selective and even tie emotional commitment to the act. This is exactly what I see in practice. At the bottom of almost every woman who has poor libido I found a woman who was angry at the man in her life and no longer had a strong emotional commitment to him. She just could not verbalize it right away.

Yes yes I saw otherwise healthy woman complain of low desire on certain meds or after menopause but these were the exceptions. I used to always say "we as men have sex with only just one woman because we love them but we could be having sex with lots of others despite it. Woman tend to give themselves to one man as part of that love" These are broad generalizations and perhaps I will be labeled a sexist. Society and the images we create have lead people including woman to see sex as something for pleasure and without cost to be participated in at younger and younger ages. I see this having devastating consequences on many levels.

A pill to make woman want more sex in my mind is the ultimate insult to a woman and the final act of objectification. I don't think woman are the problem. It is mostly the men in their lives. Most of the ones I know are dying to have sex with the right man. To paraphrase "They don't need no stinking pills."

Thai said...

This cannot be good.

JP said...

Dr. John:

"I used to always say "we as men have sex with only just one woman because we love them but we could be having sex with lots of others despite it. Woman tend to give themselves to one man as part of that love" These are broad generalizations and perhaps I will be labeled a sexist. Society and the images we create have lead people including woman to see sex as something for pleasure and without cost to be participated in at younger and younger ages. I see this having devastating consequences on many levels."

Lots of women were giving themselves to Tiger Woods.

That will likley change come the next "awakening".

Who knows what will happen then (about 2040?), but the 1960s are not coming back.

Of course, the next awakening could be worse.

Thai said...

By saying "awakening", are you referring to a generational dynamics concept?

JP said...

Not so much the "generational dynamics" concept as the generational concept itself.

There seem to be concentrated "spiritual events" that occur with distinct frequency.

Great Awakening, Second Great Awakening, 1960s., etc.

Generational dynamics is Xenakis's pet project. It's a derivative of general generational theory.

The boomers seem to have gone with the Free Love concept. Since there were lots of boomers (a large generation) and they are now in charge, we have lots of Free Love.

This causes distinct problems and will be changed (I hesitate to say "corrected") when the next big cohort generation hits with distinct ideas. I expect that to be in 2040 or so.

It's the Boomer's World these days.

Dink said...

(The following response will give some impression of far behind I am on SRCS)

Mike Royko was great. Why don't people use the term "hooch" anymore?

Physicians v. Mid-Level Practioners

Some sort of "Defcon" system makes so much sense. I was kind of surprised back in the H1N1 flurry that Thai had to see snifflers when he could have been sewing necks back together instead. Isn't there some sort of filtration system?

Relatedly, the Seattle Times published an article yesterday about Cisco's remote MD program for its employees. An experienced RN with some nice tech gadgets has a real-time video link up with an MD. MD diagnoses, prescribes, advises, or refers on to a higher Defcon. Seemed cool.

"I think this is where there is something to evolutionary psychology"

Agreed. I once read that the highest indicator of female lust likelihood was self-esteem. A true or "organic" ego is best for long-term consistency, but flattery might work for short-term results.

"Generational dynamics is Xenakis's pet project. It's a derivative of general generational theory.

I've thought about this, disagree with it, and don't have time now to explain why. But I will later.

Dr John said...

Ugh more people going into "healthcare mang. science". You are right Thai. I don't see how that could be good.

I must do some reading on Generational Dynamics and Xenakis. I have not a clue as to what you guys are talking about?

Dr John said...

By the way JP, I know Woods had sex with lots of women. I never spoke to any of them but will speculate and bet you 10 bucks they did not have the same motivations that Woods had in that deal!

Oops, I forgot. Poor Tiger is an addict and not responsible for his affliction. I wonder if he is on the "sex" wagon now, completely dry like an Etohic staying away from the booze? No more sex forever just 12 step meetings proclaiming his powerlessness over the vagina.Serenity Now.

JP said...

Dr. John says:

"I must do some reading on Generational Dynamics and Xenakis. I have not a clue as to what you guys are talking about?"

When you read Xenakis, it's good to keep in mind a few things:

1) He thinks the economic system is going to experience a panic/crash sometime in the "near future". He has thought this for many years.

2) He also thinks that America is heading toward a genocidal "Crisis War" with China.

3) He thinks that intelligent robots will be running everything by 2040.

He's fun to read for current international events with a doomish spin to them.

He's at

He's a breakoff of the Fourth Turning chat boards at:

I need to remember how to link on here.

If you want a chemical engineer/amateur historian's perspective, it's better to read Mike Alexander's historical stuff.

Mike has a much more sober, data centric analysis of history and the "War Cycle" generally.

Thai said...

We have defcon in EDs. What do you think Triage is all about?

Plus the overwhelming % of the time in America, if you go to an ED (or an urgent care walk-in clinic now) for a runny nose, you will see an MLP.

JP said...

Thai says:

"We have defcon in EDs. What do you think Triage is all about?"

I spoke to a defense counsel for a hospital several months ago. Apparently the ED left a guy sitting in the waiting room for about 8 hours, at which point, he died.

I can't remeber why he died, whether it was his heart or dehydration (or something along those lines) but the defense counsel pointed out that there was no she could win that particular malpractice case.

Thai said...

I have a hard time seeing this war. Where I see it is between those who consume a ton of resources and those who do not.

There is simply too much pressure on those who produce to support those who do not AND worry about population pressures.

The issue of course is what are the kin boundaries people have under which they will split themselves up into rival factions.

I think nationalism is one (I am very patriotic) but I do not think this will be the fault line across which the war will be fought. It will be one of the fault lines, but I think the current inability of ethic/national conservatives to get a significant traction on the immigration issue (and don't get me wrong, it is a big issue but I don't see it as all encompassing as some others) suggests at least to me that this will not be the major fault line in kin warfare.

Remember, people tend to minimize how much abortion and delayed fertility with better infertility for those who do delay is changing the balance of this equation. Indeed, you could think of abortion as a kind of generation war as it were.

JP said...

Thai says:

"Remember, people tend to minimize how much abortion and delayed fertility with better infertility for those who do delay is changing the balance of this equation. Indeed, you could think of abortion as a kind of generation war as it were."

Under this line of reasoning, South Korea, Japan, and China have declared war on themseleves, with the result that they are winning the war.

Human fertility is generally dropping across the board.

Better birth control has a lot to do with this.

Thai said...

You are correct, they can't and that is the problem.

The cognitive dissonance on this issue is stunning so as long as everyone thinks the tooth fairy exists, the bubble will continue.

You have a bowl of water and have three variables you can play with to avoid water overflowing:
1. Water going into the bowl
2. Building a bigger bowl
3. Speed the flow of water out of the bowl

... I guess you can play with water density as well but so far we have not figured out how to do that.

1. No one wants to spend more resources
2. No one wants to increase risk
3. No one wants to earn less
4. No one wants to reduce their own personal utilization of resources
5. No one wants to give some of their resources to someone else
6. No one wants to lower quality of care
7. No one wants to lower documentation (now encompasses 66+% of all time a provider spends in their job... And FYI computers have increased the time providers spend documenting
8. etc... I could go on and on and on)

It is the unstoppable object hitting the immovable force- hence the bubble- and how it plays out no one knows.

Something has to give. And people can lower salaries but recruiting is already a significant issue in many parts of the country as we simply cannot keep up with the demand for all the providers needed to do all the nonsense they are required to do (I think I get at least one email every day like this and many days I get 3-5+/day).

And people think lowering salaries will help that 9 hour wait?


Of course if we did not have to do so much "stuff" we would not need so many providers and high salaries to pay these providers in the first place and salaries would therefore plummet on their own accord. But right now the bubble is spiraling in the wrong direction where everything is "more more more".

So your hospital will pay god knows how many millions settling the lawsuit and the cost will simply be passed on to either a "different" consumer or made up in one of those endless classic left pocket-right pocket government subsidies they always give to the hospitals when the hospital comes up short.

We cannot solve this problem by doing more, period. It can ONLY be solved by doing less and until people realizes this, they harm mostly themselves.

... Of course you and I have a job in the mean time.

But no one wants to hear: "stop doing all low value this nonsense!"

Trust me, the person in health care preaching this message is the least popular person in the room and the one accused of wanting babies to die in the waiting room.

We have created a noose for ourselves we are slowly hanging our-self by. As I say, health care is in a bubble.

... Sorry for the rant. ;-)

Thai said...


Thai said...

And "yes" better birth control does have a lot to do with it, but so does improved life expectancy, lower infant mortality, better education of women (to a point), etc...

Also, the disproportionate birth of boys in Asia compounded on top of their lower fertility rates will create a kind of secondary drop in birth rates, etc...

E.g. it only takes one man in a harem to produce lots of children but the reverse is not also true, etc...

So depending on how you define the term "war", and how you define your kin boundaries, there are lots of conflicts which can lead to a particular outcome without an actual war ever coming to pass.

Thai said...

Remember, it is a fractal where the sum of the parts creates a whole that is the same as its parts and more and looks the same and looks different. Lots of building blocks weaved together iterating over and over to create larger and large similar issues.

Thai said...

And at every level the parts are either cooperating or synchronizing with the other parts on the same and higher and lower levels or they are competing.

Right now it is lots of competition

Dr John said...

Great posts. I agree Thai. I keep trying to get the institution I work with to close psych beds which are really expensive and mostly filled by people we do nothing for regardless if they pay. So far I got one unit in the system closed but they opened 4 beds without really listening to me in the other hospital. I profited handsomely by providing services but it was not what I wanted for all the reasons you point out. It is very bad in the end. Good rant.

Thai said...

And JP, please in no way take my comments as somehow saying an 8 hour ED wait is acceptable or that in the midst of 8 hour waits, the triage nurse has a pass and does not need to recognize who is so ill they need to jump to the front of the line and simply be brought back regardless of everything else.

Indeed, the battles between physicians and nursing over the entire issue of whether we should let patients wait in the waiting room at all vs. simply bring them right back into the main ED and put them in chairs in the halls if there is no space is a legendary battle in my specialty.

To be fair there are at least two sides to the issue as the logistical problems around bringing patients back right away and the issues it causes are significant.

Still I'm firmly in the "bring them right back" and put them in a chair in the hall if you have to camp (seems better than a chair in the waiting room).

But we all need to cooperate as a team and physicians are not the only ones that control this issue.

Longer ED wait times have clearly been linked with higher mortality in numerous studies all over the globe.

FWIW- If you think 8 hours is bad (and don't get me wrong, I certainly think it is. None of my facilities are near that), look at Canadian ED wait times, I dare you. ;-)

But the longer waits are caused by all the factors I list above, and in particular, the big issue in the US is what we refer to colloquially in emergency medicine as "boarders"

E.g. - the biggest problem EDs have controlling patient flow is in patient outflow or discharging them out the "back door".

Patients arrive but we cannot get them out of the ED as they simply "sit" and occupy their ED bed for long hours waiting to be admitted to the hospital. And as they take up space, time and RN resources (as well as additional physician resources to a lesser degree) EDs get bogged down and cannot care for the new patients which arrive.

We call this "boarding" since after the patient is admitted to the hospital, they sit or "board" for hours in their ED bed as they waiting to go to upstairs.

It is kind of like a car accident causing a traffic jam and bringing the whole flow of traffic to a halt.

Many ED's have proposed simply sending admitted patients to a bed in the hall upstairs in the hospital while they wait for a more permanent real room/bed.

And there are even a few hospitals that tried this with significant improvements (at least in ED waits and crowding) but you can imagine how popular it is with the nurses upstairs. ;-)

Our old friend externalities and the tragedy of the commons which is health care in a nutshell ;-)

Thai said...

It seems to me that if you could invent some kind of "rapid rule out" protocol, like we have for chest pain, where if you proved that 6 hours of observation is just as predictive as 3 days in predicting suicide, then you could patent it and rule the world.

The money saved on this is simply stunning.

At one of our hospitals, where we do not have inpatient psychiatric services and so need to transfer all our psych admissions (yet I kid you not, we have a 7 bed psych ED- it's a big ED), some of our transfers can have 3 day lengths of stay.

Think about that 3 days on a little ED gurney waiting to see you.

Several times my director has called the governor's office to get movement... And you can imagine how popular this is with hospital administration. Do it too often and you will definitely find yourself looking for a new job as problems with the quality of your care suddenly materialize in ways you never understood before ;-)

Imagine all the issues around this and of course, often it is for a patient who was binging on cocaine for 5 days and in a crash is suicidal, etc...

You can't make this stuff up!

Dink said...

"We have defcon in EDs. What do you think Triage is all about?
Plus the overwhelming % of the time in America, if you go to an ED (or an urgent care walk-in clinic now) for a runny nose, you will see an MLP."

Sure, triage to assess how acute the patient's situation is, but I assumed everyone eventually got MD time no matter how ridiculous issue. I've never had to go to an ED now that I think about.

So being naive, I thought of EDs as places one goes because either 1)something drastically bad has happened that can't be handled by your primary doc, or 2) its four am and your primary doc's office is closed. In either case, long waits seem odd because you'd either bleed out or it would be morning and your primary doc would be open again.

This idea of EDs as sanctuaries for the uninsured seems a bad idea. Shouldn't some public space like a football stadium open MASH tents at night?

Anyway, did you notice that Homo Sarcasticus commented on Sudden Debt today?

Thai said...

No, I haven't gone to the new post yet.

re: homo

Well well well ;-)

Thai said...

I think you notions of the ED are correct Dink.

The problem with health care finances and emergency departments in particular is people tend to think of them using:

1.linear logic
2. as personal consumers of care, 3. From the viewpoint of the bill in front of them they actually pay

These are all valid ways of thinking about EDs, but they lead to some very misleading myths that are very hard for the average person to overcome.

Remember, the ED at some level is everything for everyone.

But at some level, the big growth in ED volume in recent years has actually been driven by people like yourself, whom I assume is employed and has insurance.

For EDs are actually very efficient places to provide care in the later hours of the evening/night as they are already open and have all the equipment you could ever want.

They are less cost effective during the day but even this is a complex issue as it depends on one of those "how you want to split the atom" discussion- e.g. discuss a part of the whole and they look bad, discuss the whole and they can still look pretty good.

Discussions of $ in health care since it is still all about how you are defining the system under discussion and what the level of service is that you are going to provide to people and what/how you will subsidize others and where this subsidy comes from.

Thai said...

Sorry lots of typos

mean to say:

"Discussions of $ in health care can be very confusing since to a large extent it is all about how you are defining your system under consideration for discussion and what the level of services are that you are going to provide to people and what/how you will subsidize others that need assistance and where this subsidy will comes from."

So it is often easier to look at things globally and then take it down to the individual/personal, in order to understand you and your role and relationship to the system. Call this method A for looking at health spending

It is just as valid to follow the trail from yourself to the global but it can be much harder to see the relationships that way. Call this method B for looking at health spending.

Naturally, most people use method B and as a result then end up getting confuses when the issues are actually rather simple to understand, just difficult in their moral implications.

If this helps

Dr John said...

Thai, this is why I do not see our hospital closing psych beds and why I am popular with your ER Dr brethren.(Even though many know what we do is bad) If I have a bed they go right up. I barely ask questions. I know my job is to relieve the ER. They have no place to send them. Who wants to discharge a pt they have NO PREDICTIVE ABILITY WHATSOEVER on.

This will never be fixed until there is collapse. The standard of care in psychiatry has NOTHING to do with outcomes. This is what frustrates me about psychiatric malpractice and my own profession. I admit I do things every day that make no sense at all.

Standards of care have no basis on actual outcomes. You don't need to demonstrate you did anything that resulted in a bad outcome. All the lawyer needs to do is imply I deviated from a standard of care.These are so vague in psychiatry as to be almost meaningless. On top of this my personal opinion is that what exists as the current standard of acre in treating such problems is veterinary medicine and malpractice itself. The community does not have to assume any risk, only the institution and the Dr.

This means EVERY "suicidal" pt for the most part gets admitted. They have to cycle through 3-4 times in a several month span and get loads of documentation as "players" to be rejected. On top of this almost none of the psychiatrists I work with ever want to label anyone a malingerer. I mean the ward clerk can see these people for what they are 2 mins after being admitted but the Dr is trying to give them Depakote for their crack addiction and rage episodes. I don't know if they are stupid or their cognitive dissonance is too great for them to confront this.

To do so leaves one hopeless and cranky like me. Thanks for saying the nice things about my paper. Psychiatrists were not so excited about it.

Thai said...

Re: "The standard of care in psychiatry has NOTHING to do with outcomes."

Actually, I really think this applies to most of medicine and you see a uniqueness to the problems of psychiatry that really doesn't exist.

Further the concept of bad outcome itself is a moving target that is constantly re-defining standard of care.

Whereas once it was the norm to take a watch and wait approach to see if things deteriorated. If they did, then we would intervene. Today this idea of deterioration itself is the bad outcome by which the standard has become defined.

But it is an endlessly circular problem of "if the disease worsens, then it is get closer to the point of no return, so we need to avoid worsening, etc..."

Soon the notion that deterioration is to be avoided at all cost becomes the goal, instead of looking at what deterioration really means and how it is really a non-linear problem. E.g. there is deterioration and there is DETERIORATION!!, etc...

I see this every month in Peer Review and simply shake my head in amazement.

And so a new standard of care is endlessly recreated causing us to chase our tails more and more.

It's crazy

When will people wake up?

So I totally agree with you. If we are going to destroy lives and use the system as some form of punishment, there should at least be some kind of absolute benchmark from which standard of care derives.

Yet nothing could be further from the truth.

... And if we are going to be using the system to compensate people for injury???

Well you and I know that no system could be further from achieving this goal.

It serves only the occasional lucky lawyer who hits the jackpot in a kind of lottery mentality- e.g. it feeds the John Edwards of the world (a man whom in my opinion can truly go to bed at night knowing he made the world a worse place as he almost singlehandedly increased the rate of Cesarean sections in America yet made no positive impact on the rate of fetal injury)

... And he is a hero to some?

We have lost our marbles

Dr John said...

I know this disease pervades all of medicine Thai but I stand by my assertion it is worse in psychiatry. At least you have the comfortable delusion of semi-objective tests to fall back on. I got nothin.

By the way have you been over to Carlat recently? I read a lot of the posts on an article he wrote for the Times. You had said it is impossible to get a man to think a certain way if his pay depends on him thinking the opposite. You can pretty much tell exactly what the credentials are of the person posting without looking at their names. Psychiatrists maintaining how great meds are despite evidence to the contrary and both groups talking about how long periods of training are so critical to psychotherapy outcomes again despite any evidence.Everyone in healthcare has to spend all their wind justifying how critical to the system they are. There is not a drop of skepticism in anyone.

I think I said my piece and have given up there. John

Thai said...

Perhaps your right. I don't walk in your shoes.

As for Carlat, I think you can tell from some of my comments that it's not the right place for me. I like much of what he has to say (not all) though I'm not a regular reader. I just came across it as I like to read different medical blogs and I thought Deb might like it there. Most of the medial blog reading I do is not psychiatry focused.

Further I'm not so fond of the idea that somehow we physicians are the heroes of this story but the drug companies and insurers are the villains. This cliche is simply too much to stomach anymore.

It's like the cliche that fat people should blame McDonalds. In a twisted way it is a truth, but it is not the only version of the truth and it eliminates any concept of free will in even commonly understood ways we mean free will.

I do see a number of the points Carlat makes about some of the practices which go on in the pharma industry, honest... Though I think Carlat and many others on the blog apply a double standard to pharma they do not apply to themselves and which I keep meaning to write a post about.

And I do think many of the physician comments on Carlat give themselves a pass for the very real impossible difficulties they face without admitting that people everywhere including pharma face most of these exact same impossible no good solutions situations as well. They are simply part of life and we all face them because we live in a fractal world.


And yes, I agree the medical profession is full of itself (not quite so true of us EM physicians if I may stereotype). But also "yes", some of our patients want us to maintain this facade. I think it is not controversial to admit that there is healing in ritual and I have to keep reminding myself to wear my white coat- which I hate wearing and is always covered in coffee stains. ;-)

Be well

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