She was 29 and I thought she was beautiful, although nobody else did, I am sure.  No normal scales in my clinic could weigh her, but I would put her between four and five hundred pounds.  Except for someone who brought her to see me ( I think, in the back of a pickup truck, but I did not press the issue) she did not leave the house. Others did her shopping, she had some kind of public assistance.

She was on the standard medication for her depression as well as her panic attacks; paroxetine (Paxil) 40 mg, to lower their intensity and frequency, and a little bit of Xanax, which is supposed to stop such attacks in their tracks.  She used it sparingly, hardly at all — no really — she did not use it.  It did not work.  The most addictive medication doctors give for this sort of thing and she didn’t even want it because it didn’t work.   I love this woman, I loved her candor.  She told me the last  psychiatrists had renewed these medications for the last six months,  even though they didn’t work.

What was wrong???

I took a medical history.  High blood pressure, getting worse, somewhat controlled by a vasodilator.  Not a bad choice. At least a medicine for blood pressure would open her blood vessels, and would not make her more depressed, as several medicines for blood pressure would have done.

Diabetes,  Type 2 (adult onset) also getting worse.  On insulin, immense doses.  Four injections daily, she had not brought her materials and could not quote exact scales, but she was single handily, via payments by the county, keeping at least two  makers of medical insulin comercially viable.

Back to the panic attacks.  We had to look for a pattern.  Subjects or stressors that brought them on.  Anything.  To find a pattern by journaling, if she could not think of it right away, would help us to fight this.

Her answer was not typical: “I get them every day at 7 AM and 3PM  whether I take the Xanax or not.”

And that told me the answer immediately — although no other doctor had ever put such elementary pieces together — They weren’t panic attacks.  They were, by the symptoms she described, hypoglycemia.   Her schedule of insulin types and injections seemed to be screwed up.

“Why didn’t my other doctors tell me that?” she asked.  It’s a normal reaction and I hear it all the time.  It makes me want to tear my hair out. I cannot answer as to why other doctors do the things they do — and I  never did hear from her physician or even her diabetes educator. 

There is an old paradigm I still practice by — Biological, Psychological, Social theorized by psychiatrist George L. Engel at the University of Rochester, and discussed in his 1977 article in the journal “Science” — and it works.

Marvelously — if I were a comic book hero, it would be my super power.

My inability to communicate with those who care for this lady medically will most likely undermine her prognosis. They have trouble accepting  me, and I’m afraid their shame and pride will adversely affect this patient’s chances of getting better.  But I have to believe that I took one step more  than any doctor has ever done for her, and somebody along the line, somewhere in this crazy system of public health we have cobbled  together, will realize that this is her best hope.

Oh, and one more thing.  She said she kept getting fatter, and she could not follow the diet.  It turned out she did nothing — absolutely nothing — in life aside from try to follow it.

She had no other life purpose I could discern.

“Think of anything but a blue horse,” I instructed her.

Like everyone I have ever tried that on, she thought immediately of a blue horse.

“Think of anything but your diabetic diet.”

She was obsessed and stuck with it.

What had she done for pleasure?  listen to music?  draw pictures? read?  Anything???

I told her to get on the internet, for like many people who have access,  she just never thought of constructive ways to use it.  After all, how many times can you watch the video of the kitty who plays  the piano and send it to all of your friends?

I suggested she find something she liked, like a hobby.  Could she  study it?  Maybe, someday, could she make money at it?

But I often ask too many questions at once.  I only get minimal access to people and I want to give them everything I’ve got.  What could I do? This is me, I see people for a little bit and I want to fix them yesterday.

But I saw that light bulb above her head — she got the idea.  She will  work past what she used to be.  She will figure out who she will be.

I think she will somehow be all right.  I have to.  It’s the only way  I can sleep at night.

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That is where I found an editorial about religion, purporting to explain why religion was necessary. I mean, the author — Oliver Thomas – thinks religion is as essential to life as oxygen and water. I was raised in the Jewish religion and spent a lot of time in temple, as my father was organist and choir director all of his adult life.  The only socializing my family did was at the temple, with breakfasts and holy day observances and things like that. I have always believed in a deity myself, not specifically in the way that the organized religions present it (as if to three-year-olds) and still have my own private rituals of prayer and meditation. That being said, this editorial disturbed me. Instead of ripping up the paper or making any attempt to answer it, I put it somewhere on the floor of the car hoping it would go away, but knowing that I would eventually have to deal with it in some manner. A lot of people seem to think that everything is in the world to support what they already believe.  Thomas, the author, is way far out — past the people who, for example, read Ford advertisements after they buy a Ford to prove to themselves that they have made the right decision. Thomas, a member of the USA Today board of contributors (I guess you have to be able to write enough to fill their quota of space) and author of a book titled “10 Things Your Minister Wants to Tell You (But Can’t Because He Needs the Job)” writes an editorial that asks an intriguing question, but does not answer that question or prove what he contends.

It’s obvious to me that Thomas must have at least perused the writings of Victor Frankl – a deep thinking gentleman,Holocaust survivor and founder of logo-therapy (a form of Existential Analysis) — who wrote about some people being more “decent” than others, and (to his credit) opining that decency is better.  But he did state, quite clearly, that this distinction had nothing to do with religion. As Rabbi Rami Shapiro (Murfreesboro, TN) pointed out in a letter of rebuttal to USA Today, printed Thursday, August 12, there is virtually no evidence that religion “makes us want to live.”  Anyone who actually knew anything about the history and phenomenon of religion, would notice that one of the serious functions of religion (some would argue its most important evolutionary function) is justifying death.  Funerals serve a spiritual as well as social function in the best of times.  It is comforting to “feel” that someone who has disappeared from physical existence and proximity is somehow still accessible, and will become more accessible. Many religions (anyone thought about suicide bombers recently?) actually teach that martyrdom is a Good Thing. Of course, some people do perfectly well without this particular set of beliefs.  Folks like the pure Ayn Rand Objectivists (as opposed to spin-off groups such as the Libertarian political party), are more in line with “this is it, folks” and do not see or need or want to see a world beyond. My guess is (I like them more and more) they would say that we can like the life we got.  We can go for biological immortality and try to keep what we got and there is plenty of science that can encourage people to move in that way. Perhaps building that science, making life as we know it the best it can be, is a really, really good purpose for life.  Maybe it is better than religion.

Incidentally, our friends at USA Today also published a response from an atheist who enjoys life just fine (you can read it on the same page as the Rabbi’s rebuttal letter), although he compares the state he has reached, from considering religion “mythology,” to his wife’s cat.  Lots of cats are pretty happy.  Life does indeed have plenty of purposes. So back to the article.  ”Religion makes it easier to be decent.” Gag me with a spoon here.  The core values here are “justice, forgiveness, and love of neighbor.”  I completely fail to see how religion facilitates this. I’m not the first — agnostics and atheists have long argued that morality does not have to rely upon religion.  This is called the principle of enlightened self-interest.  Your reason for NOT stealing or murdering might be because it is against God’s commandments — or it could just be that you don’t want to go to prison or get executed. That’s self interest. Religious morality basically rules by fear of punishment by a supreme intelligence.  Oh yes –  there are promised rewards, also.  Heaven sounds pretty good and hell pretty rotten, but our intrepid USA Today author goes out of his way to say behavior should not be governed by fear.  It is probably the only thing in that editorial with which I actually agree. If you have been burned out by the concept of  “Justice” in the US legal system (which our schools teach us is the very very best in the world and always works perfectly) by the trials of O.J. Simpson, Robert Blake and Michael Jackson, you shouldn’t expect any cosmic justice in the universe.

We all know that bad things happen to good people, and a lot of bad people end up with wonderful lives.  The purpose of Religion surely isn’t to make sure Justice prevails and Chaos is thwarted. Human Laws aren’t perfect but we got enough — most of which are common to many cultures — anybody can find their way without a few hours in church this week. “Forgiveness” is not a theological concept.  Say, for example, I establish a super relationship with a patient I am really helping deal with some major traumas of life.  Then I actually accidentally step on her toe.  She is likely to forgive me, because the larger aspect of our relationship has bountiful merit, so my transgression seems small
in comparison. If I step on her toe the moment I meet her, I may have trouble building trust and she may not be able to forgive the klutzy shrink lady.  The outcome of our session may not be favorable af all. NOTE: I want to assure you that I am a highly-trained and experienced professional and I seldom step on toes.  If I do, I’m usually able to recover the lost trust that such toe-trodding has cost.  Don’t worry. “Love Thy Neighbor?”  You have to take this in the context of the time it was written.  It doesn’t mean you have to extend your friendship or charity to those obnoxious frat boys next door whose week-night parties are still going strong (and loud) at 2 am — no matter how nicely you ask them to cool it. My definition of neighbors in this sense is “Fellow Traveler” who is part of my life — whether work or social — and with whom I have enough empathy to rely upon them and to help them when they need a hand. Organized Religion is a hierarchy — usually a bureaucracy — that devotes a lot of energy to perpetuating, maintaining and legitimizing itself.  Over the years my attitude has changed. When I was brought up in a culture of fairly traditional Judaism, I had no choice, as a child, but to soak it up.  I remember the joyous discovery — in public school — that children my age of other belief systems were more like me than different.

My family generally tolerated me less as I questioned more. The cultural heritage of my ancestors, I hold in reverence. The intertwined history and mythology, I put in context.  I read some near Eastern philosophy in college, like most of my peers did at that time (late 60s and early 70s). My family felt I had somehow culturally degenerated.  I felt I had widened my thoughts, sharpened my intellect, expanded my mind. Knowledge was my drug, and I was an addict from an early age. When I first came into a context where folks asked me about child rearing, I basically told them there was nothing wrong with teaching religion to children, but to expect all they were doing was giving their children a structure that might be rejected as they matured For me, a turning point was the reformed Jewish congregation in Minneapolis that determined what my cost of participation would be and basically presented me with a bill.  They must have thought I was already a successful neurosurgeon, when I was simply a poor resident physician.  On my meager salary, I couldn’t afford to be devout (with them).  They wouldn’t budge from their assessment, and I decided to make my religious observances my own private business. Later, I saw a crystal clear difference between public profession of faith — which is more a social and political expression — and private belief.  I still think it is a “cheap shot” when a president of the United States– any president regardless of party, as they all profess to be born-again Christians — prays for the camera. At the time of this writing, Pres. Obama is under fire from those who believe he is a Muslim (about 1 in 5 people) and not Christian.  As such, his staff is occupied with getting the news out about how often the President prays each day, and how frequently he goes to church.  It’s important, they think, to establish his Christian “bonafides” since most of those same Americans believe we are at war with Islam and religion and politics are joined at the hip. Remember how I started out by saying that this is the most religious country in the world? Now, after thirty years of practicing medicine, I have never once heard a patient say that their faith was their exultation, their joy, their well-being.  I have heard that it is help with some issues such as abstinence from addictive substances, but only with relapse, which is a frequent problem with or without religion.  Brief comfort, dreadful relapse.

The religious community often becomes a “surrogate family” but one with the same problems as a biological family.

I hear about guilt, manipulation, everything that is bad about human institutions.

I have had patients sign releases for me to speak with religious institutions.  Perhaps the most serious situation I can think of, was that of an anorectic in her early forties who had been pushed into manic exhaustion by volunteer demands for a church bulletin.  Not once but twice I called the minister from the church she would not leave and told him to lay off for the sake of her heart health.  He gave me a lecture about how important her contribution to the church mission was.

Ultimately she got a better job, better insurance, and left me.

If the “mythology” of religion that science has not replaced has value, it gets harder for me to find, the longer I practice, the more woes I hear. The key is in this notion of “interpretation.”  Just yesterday, at a restaurant,my husband and I (accidentally) sat in a booth next to and overheard an obviously senior religious education professional telling a younger student type that a good religious education is needed so that the Bible can be taught in a non-ambiguous way, and so one can lead the flock well. After all the many years I spent in education, I have never heard such concern over such trivial knowledge — The Misguider leading the Misguided. Unless someone understands ancient Hebrew and Greek, they have no right telling anybody what the Bible says, for translation errors abound.

Greek may be little more than a distant memory, and if I told you what I know about Hebrew translation, maybe the world would explode. This was the perfect example of the hierarchies spending most of their energy preserving themselves.  Back to the author of the USA Today piece — Rev. Thomas seems to be comfortable with his hierarchy.

No matter what else you believe in, all religious institutions are run by humans, who mess up these hierarchies at least as much as they do hierarchies of other sorts, like the military and government. But with its easy-to-assimilate mantle of a questionable “divine,”  I have started to wonder if organized religion is not the easiest and most secure refuge for those who simply do not apply reason. Or — to paraphrase Dr. Samuel Johnson — “the last refuge of scoundrels.”

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Shrek is bored with the non-ogre like life as a father of a family with Fiona, his own true love.  So much so that he signs a pact with Rumpelstiltskin – who seems to have purchased the embodiment of evil franchise from Satan.  This launches him into a plot that is essentially the same as Jimmy Stewart in “It’s A Wonderful Life” (and if you’ve never seen that movie, just wait until Christmas season and it will be on every TV channel night and day for a month).

Shrek has some pretty hair-raising adventures, and – rest assured — ends up happy to be the father of a family again by the end of the picture. So the “meta-message” is that the best thing to be is what you already are, even if it is disagreeable on some level.  Yes, diapering bratty, farting babies has its own rewards, and sure beats being lonely and battling witches.  In other words – CHANGE.

The power of the meta-message might have missed me entirely if it were not for a lavish commercial that proceeded the movie, that showed that Americans were a nation of craftspeople. (Don’t you just love going to the movies and sitting through a half hour of commercials?) The commercial’s message was “the things that we made, made us.”  Actually, the message was, “buy a new car – our brand, of course.”  The visuals treated us to great parades of people working in factories to make high quality stuff. Great.  I don’t even remember what brand of car the commercial was for.  I was enraged. Why was I enraged?  Maybe it’s just me, but I would rather be the person who designed the car or owned the company, and lived in a better house than everyone else.  An affluent person who sold ideas instead of handiwork.  Clearly, neither the commercial, nor the movie, was really meant to appeal to me. So I talked to my husband about what the movies were and have become. Sequels are conservative investments, and the movies are as much a money business as anything else, maybe more.  People want assured successes – a return on their investment. 

I have never heard anyone say this before, but this probably has something to do with congratulating people for being as they already are, making them feel satisfied and comfortable with their lot in life.  Sure, everybody has fantasies — men love explosions, so we get to see explosions and car chases and  good-guy buddies putting a stop to the bad guys. 

Hollywood gives the audience what they want.  Blockbusters can get made only because they are sure to make money. Now for someone like me, who is not a celebrity follower, who goes to the movies with her husband as a respite from vicissitudes of life, the great subculture of movies and how they get made remains very confusing.  It seems like an old boys club(and maybe now there are some old girls) who plays with money like candy-canes, who speak in high-faluting terms about dreams and vision, but still mostly make movies where things blow up.  Or maybe, on a good day, chick flicks where people get physically intimate within a context that makes it good and right.

Maybe there are no accident, but as luck would have it, we recently watched a documentary: “Overnight.” It is the true story of someone from the part of Boston my family so carefully kept me from as a child –  a rough-at-the edges Irish bartender/bouncer type who lived on the knife edge of senseless violence, and had the ambition to write a screenplay about it.  He also performed in a rock band – who were purportedly talented, but not exactly to my taste in music.  He came up with the right script at the right time, and got accepted by mainstream Hollywood – The William Morris Agency and Miramax Pictures.  The young man – Troy Duffy – was going to be the next big star – like Sylvester Stallone was with “Rocky” 40 years earlier.

The movie itself is a formula revenge flick, about two brothers who go after the bad guys, shooting, crashing cars, exploding – making lots of noise. The rock band got the contract to provide songs for the soundtrack.  In addition – to really sweeten the deal – Miramax was going to buy the bar where Troy worked and give him 50% ownership (Miramax was going to own half of a bar).

As a native of Boston, I am interested whenever a program has some kind of a message about that city, and senseless violence, maybe even about the levels of pseudo and real sophistication of Boston society and scheming that make Boston such a wonderful base for stories.  However, there is a TV series called “Leverage” that does it so much better.

The point of the documentary was how success spoiled Troy Duffy and he frittered away the best deal anybody could dream of – if you are a dreamer with Hollywood aspirations.  It was filmed by his closest friends, who set out to document the meteoric rise of a nobody to a somebody – but ended up as a cautionary tale that could have been subtitled “Don’t Count Your Chickens Before They Hatch.” He started out as the goose that laid the golden egg, but some cross between Hollywood Politics and the fact that Troy has some kind of a severe personality disorder — something with a healthy dollop of narcissism — meant that nobody is could work with him.  Not Hollywood, not the buddies from the ‘hood:” nobody.

There are painful scenes of Troy on the phone cursing at his agent and at MiraMax studio representatives before the movie is even off the ground.  He thinks his movie deserves Robert DeNiro and other top-caliber talent.  His ego has run away with him. Troy’s film got scrapped by Miramax but eventually made at a fraction of the budget by a ninth-rate studio who moved the filming to Canada (parts of which could realistically pass for Boston). “Boondock Saints,” never got wide distribution theatrically.  It played less than a week in half a dozen theaters.  The soundtrack album of Troy and his band sold a total of 700 copies.

In this age of home video, “Boondock Saints” found success and made a healthy amount of money for it’s studio – but Troy’s agent didn’t negotiate any percentage of home video or cable TV sales so Troy was back at the bar, checking IDs at the door and bouncing rowdy drunks.

But I digress — Back to movies in general.

Now if you went to my grandmother of blessed memory, and asked her what her favorite movie of all time was, she would probably say the “Life of Emile Zola” starring Paul Muni. My husband took less than ten seconds to explain to me why a movie of that sort could never be made again.  Something about the old Hollywood studio system when the stars were under contract, the studios had standing sets and lots of costumes, and they also owned the theaters so they had to pump out tons of movies and an audience that had no TVs at home was anxious to see any pictures that moved and had sound. Now granted, my grandmother had a crush on Paul Muni, whose real name was Muni Weisenfreund.  He had been a star of the Jewish theater in New York and she said she saw him perform there in person before he made it in Hollywood.  But there were other things.

Emile Zola had been basically exiled from France and came back; he voluntarily took on hopeless political struggles.  The grandiosity of the theme of the movie was so intense; well, my grandmother of blessed memory knew about Dreyfus, the Jewish officer downed by prejudice, and how an older Zola took on the cause and wrote “J’accuse”  (I accuse) and had vindicated Dreyfus.

This she somehow linked to reasoning that it was all right for me, Jewish Estelle, to go to medical school in France because of Paul Muni. My life has been directly enhanced by this movie, which I didn’t see until many years later on one of those classic movie cable channels celebrating the birthday of Paul Muni.  Never mind that Paul Muni played a non-Jew, he helped a Jew, so he was one of my grandmother’s heroes, like Harry Truman who recognized the state of Israel. My grandmother was struggling with English, I would not have classified her as an intellectual.  But something in that movie did uplift her.

We are not making movies like that now, and we are not going to.  The only movies that get made are star vehicles – Brad and Angelina, Tom Cruise, Denzel, Streep, Will Smith and others who can assure a crowd at the box office.  Or maybe remakes of old movies (as I write this The Karate Kid is popular once again with Jackie Chan and Will Smith’s son starring and Disney’s Tron will soon be released). Or sequels like Shrek and Toy Story.  Or comic book, toy and video game spin-offs like Iron Man or Transformers.

Then the film must be vetted by focus groups – after which new endings might be shot, or scenes might be eliminated.

In other words, Hollywood wants assurance of the economic acceptability of a movie before it is shown in the theater. 

Paul Muni and his peers – from Clark Gable and Gary Cooper to Barbara Stanwyck and Joan Crawford – were under contract and were assigned a script to shoot at a flat salary.  Today, movies are sliced up and everyone gets a piece of the pie – actors, director, writer.  Instead of a studio system, there are networks of friends, like Ben Stiller’s string of movies, and Will Ferrell and Adam Sandler with their cronies.

But through the years and the changes in Hollywood, one thing is still the same – the meta-message.

TV, Movies and most other kinds of mass entertainment have always tried to make the public believe that we all have to be the same.  That our rebellions have to be lockstep.  That we have to have the same things that everybody else does, that we need to copy the looks and the actions of the celebrities.

I grew up in a world where any boy (girls were not yet allowed in the game) could grow up to be President.  I had a classmate in the third grade, for the brief time I was in public school, who wanted to be President.  His father was an alderman or something, but that boy was going into politics and we all knew it.  I think he actually became something in local politics. I remember seeing his name in the newspaper when I returned home years later, and a picture of him smiling.  I had not thought him to be excessively bright.  We all know by now that is not a prerequisite for politics. The programming by his folks was.  There is no programming discernable in the society that surrounds us to be extraordinary, to be an achiever, to be a leader.  We are taught not to question authority.  Anyone who breaks out of this indoctrination does so on his or her own – seeking truth and justice and The American Way. But by the time we are formed – and it is very early in life — everyone has internalized a group identity which includes low self esteem.

Me, I don’t think I could fit in with a crowd if I tried. In my heart I believe if we each have one life, it should be spent being true to ourselves, which is likely to be labeled eccentricity and perhaps even criticism.  But this is the only chance of leading to greatness. Movies do not now seem poised to tell us that.  If anything is, it should be the parents and family.  This is one thing I think my folks got very right.  I frankly do not know anyone else who does. I certainly do not know any current hit, really popular movies, about extraordinary people, that make us want to be extraordinary people.

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Huh? 

Like I could do one like you saw in the art museum. 

Huh?? 

My well-meaning teacher told me to draw the kind of princess I wanted to be. 

Huh??? 

I already knew that somehow I was going to end up working for a living. 

“Draw something from Disney,” she said, or something to that effect. Fast forward to a certain Southern California clinic which will remain nameless.  They had the good sense to hire me to consult (meaning — clean up their mess and get them back on track).  A nurse who, like many nurses in many similar clinics, was convinced that her agenda was more important than mine just happened to be wearing (under her scrubs) a Tinkerbell T-shirt. She is explaining to me things I do not need nor want to hear.  This is, alas, typical nursing behavior. People do not understand what Tinkerbell stands for.  She is a brat. She is powerful.  Not just the kind of power that comes from flying and using fairy dust.  She is a brat who knows how to get her own way.

In this case, she is another nurse who should have gone to medical school instead. It is no accident that one of Paris Hilton’s cutesy little purse-size barfy dogs is called “Tinkerbell.”  There is a message here about power.

No you do not need a Wikipedia article to know about Paris Hilton.  I have heard of preadolescent girls who claim they “love” her, of names coined to describe what she is, and I hear entirely too much press coverage of what a “bad girl” she is. She is our brat made heroine.  Our living Tinkerbell.

First, let it be known there are parents who do not like Tinkerbell.  And it is true that you can go all the way back to the original material, the 1904 play, and find out that she tried to kill Wendy a couple of times. I have the feeling I have fallen upon some kind of Jungian archetype, Some kind of mythologized ideal that people love to love. I do remember it being singularly power-less, being a little girl. This seems to be a fantasy people hitch on to.  Whether your magic is magic (like Tinkerbell) or relatively real (like the unimaginable wealth of Paris Hilton) there are some people in many places, mostly female, who can’t hear enough about beautiful little girls behaving badly. Everybody agrees Paris is attractive by current standards.  She is thin and blonde — that’s about all it takes today (and can be accomplished by surgery and bleach). Tinkerbell, drawn by the Disney staff, has that same exaggerated hour glass figure that got Barbie into trouble once when some claimed that her figure represented an unreachable ideal that could encourage young girls into eating disorders.

Tink (if you will excuse the familiarity) was designed to fit the commonly accepted standards of “cute.” But neither Paris nor Tinkerbell has the body of a prepubertal girl.

The Bratz have been controversial too.

Both the Bratz and Tinkerbell, I think were intended to be little girls.  Characteres are usually formed to be similar to the target audience for the movie or toy.

But if we are looking at a Jungian archetype here, we are looking at the early borderline personality disorder.  Yes, there was even an Urban Legend that Tinkerbell was copied at least in part from the body of Marilyn Monroe, that well known borderline personality disorder.

Borderline personality disorder is a mental disorder with criteria and presumed treatment, but it is also the stuff that fantasies are made of.  Pretty much all of the great heroines of history and fantasy and fiction fit the criteria for this disorder. 

I once actually tried to look and this is all I found.  Perhaps the archetype of modern times is Gustave Flaubert’s Madame Bovary, who is of course drop-dead gorgeous  (they all are, evidence perhaps of a Creator’s sense of humor). Borderlines are remarkably unstable in terms of emotions and relationships and can render even the most confident heterosexual male into just so large a bowl of helpless Jello.  The borderline is a person who threatens suicide if she can’t get her way, throws tantrums (and perhaps plates and vases) when angry — and then breaks down crying and begging forgiveness and one more chance.

For example, Mme. Bovary has one lover with her and is waiting for the arrival of another and says she feels lonely and empty.  I mean, only a borderline personality disorder could come up with that one.  The story by Gustave Flaubert is as fresh and real today as ever.

If you have any doubts, Woody Allen, in his wonderful short story “the Kugelmass Episode,”  took Emma Bovary out of the book and brought her to modern New York City, where she seems to waste no time getting a cute black velvet pantsuit at Bergdorf Goodman and taking acting lessons. I have always respected Woody, who must have read everything ever written. Borderline personality disorders (99.9% are women) do not generally tell the truth.  Let’s face it, Tinkerbell does not exactly have a growing nose like Pinocchio.  And as for the self-contradictory nature of Paris Hilton’s interviews, let us say simply that the links are too many for me to list. Many men have been seduced by wildly attractive women who withhold and then occasionally distribute their favors according to an agenda that defies description, then always seem to get their way, even though they seem so fickle it may be impossible to determine what their way IS until it has already changed. 

Whether opera or the movies, these seem to be the people we choose for our heroines.  Women want to be them.  Men want to have them.  Whether they are John F. Kennedy and Marilyn Monroe or one of my male patients who had a woman prostitute steal his money and drivers’ license.  The looks and the lies seem to do it, and they do it well, generation after generation. I saw a study long ago that suggested this was a hereditary disorder. I have certainly known enough mothers and daughters who fit the criteria so that I can believe this.  I can also believe the reputed frequency, about one in three daughters having this strange entity. Rarely, I have seen it in males.  More often, males who do not often tell the truth seem to be criminals of some sort (Anti-social personality disorder and/or Narcissistic).  But these women are infuriating, and I have dealt with many.  For me, obviously the physical attractiveness part means little, and yet they tend to bat their eyelashes and play coy — as if to bring out a mothering instinct in me.  In Paris, I see an icon of many, who is not known for integrity and who seems to get away with behavior such as drug use — which I would not recommend to anybody.  Yes, it bothers me that little girls “like” or even envy her.

Me, I look at her and think, with that kind of money and power, she could embrace causes.  She could push social change.  I think of examples such as Paul McCartney and what he has done for vegetarianism. The best message I have for worried parents is that liking Paris or Tinkerbell does not necessarily mean their little girls would turn out that way.  We suspect and have somewhat proven that personality disorders are largely genetic. No, we don’t really want to value these ideals.  But few girls get what I got — a mother who told me once when I was attempting to put on make-up that I would never get by on my looks, so I ought to concentrate on studying. What mother values in the home may be more likely to stick than what is seen or wished for on the silver screen. Most girls are more concerned about low self-esteem in the competitive heap.  I do not think there are a lot getting into trouble by pretending to be Paris Hilton, but I really don’t know. The question is — Mothers, what are you telling your daughters?  Spend enough time with them to tell them something, and make it as good as you can, because they will remember.

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Unfortunately, we will all eventually suffer such a great loss and the grief that it brings.

Believe it or not, a properly trained professional can help minimize the grief and help those sufferers to cope. Much of this horrible experience can be truncated, if not removed, by people who know what they are doing.

But it seems that most people don’t believe this, and some people will never learn.

Patrick Swayze was a beloved figure in Hollywood, a dashing romantic lead in “Dirty Dancing” and a macho action hero.  He died a very public death of pancreatic cancer, his decline chronicled on the front pages of the supermarket tabloids for all to see.  And of course his eventual death made headlines and was featured in every major news broadcast.

Throughout the decline and even after his death, Swayze’s wife of 34 years, Lisa Niemi, stood by him and became the family’s interface with the media and the public. She suffered what married people fear most — watching the one you love most slip away and feeling helpless to do anything about it.

Perhaps to help herself and others cope with such a colossal tragedy, Lisa participated in a round table discussion on Grief, Healing and Resilience at the Women’s Conference 2009 in Long Beach, CA. Elizabeth Edwards and Susan St. James, both of whom suffered the loss of children in accidents were among the participants.

I definitely believe in patient empowerment and there may be something constructive about a bunch of women getting together in a conference to talk about what loss of a loved one can do to people.  But there is something that the public has never understood.

Support is not treatment.

Here was a group of celebrity women who apparently gathered to offer each other support, and by doing so, demonstrate to the non-celebrity public how to deal with this type of loss. But nobody offered anybody any kind of healing.  

Women suffering together and offering mutual support is NOT, nor should it be, taken as the state of the art way to deal
with grief.

I have colleagues who specialize in grief counseling.  They take special training and learn special techniques to give the victims of loss comfort AND healing.  When professionalism is disregarded, well-meaning amateurs can make things worse.

The best example I have concerns the Oklahoma City Bombing.

I started my first private practice after leaving the academic life in Oklahoma City in the early 1990s. At that time, I was a standard-type of psychiatrist — not the Renegade Doctor I became later on.

During my years in Oklahoma City, I developed my outpatient practice, but I also had inpatient privileges at several of the major hospitals.  I made the rounds, and took care of the seriously disturbed patients in the locked wards.

That’s what I was doing at 9:00 a.m. April 19, 1995 when a home-grown terrorist named Timothy McVeigh unleashed a truck bomb on the Alfred P. Murrah Federal Building in the heart of downtown.  The results are a part of history — 168 people killed, 700 more injured.  To compound the tragedy, the building held not only the federal courthouse and offices of the IRS and the ATF, but a daycare center.  Of the fatalities, 19 were children under the age of six.

As part of my activities in those years, I had a radio show.  On Saturday nights, I hosted “Dr Goldstein’s Housecall” on the local NBC radio affiliate.  Immediately after the bombing, I went to the station every spare minute I had when not attending patients.  Every evening and on the weekends, the station opened the phone lines to an open-call format and I sat in the studio taking calls with a general practitioner MD and one of the local on-air personalities — a typical Midwest Bible-Belt conservative pundit of the “Fox Network” variety like we see today.

NBC ran the Oklahoma City broadcast throughout their entire network for the next couple of weeks.  We had calls from all over the USA and even from some foreign countries.  I remember one call from Ireland where a puzzled gentleman asked why we Yanks would blow each other up (since he knew we didn’t have the same troubles as Ireland had in Belfast).

Our in-studio pundit was quick to note on the air that he didn’t see why we had to have a bunch of psychologists sticking their hands into this mess (he either didn’t know the difference between psychologist and psychiatrist or he was trying to show his contempt for the field).

“Why don’t you just go talk to your bartender?” was his advice.

Professionalism is not respected — much less understood.

I’ve done many serious attempts to help people address grief.  Not long after starting my practice in San Diego, I was invited to be one of the presenters in the program series at the Unitarian church.  They had a group comprised mostly of widows and widowers who had been getting together for a long, long time.  

In other words, nobody seemed to be making progress in working through their grief.

It was one of the most difficult seminars I have ever done, because people came at me with belief systems that were totally contrary to getting well.  There were no ways to answer them.

The single one who was more cutting than the others was: “God intends me to suffer for her death.  I am going to continue to suffer every day of my life, because our love was so great.”

Such a belief — believing that healing does not even exist — simply amounts to self-torture, in my opinion.

“I have got to go through this.  I have to grieve.  It is suffering, but it is something people have to do,” another explained.

Not much better.

You see how I was reminded of this when reading about the celebrity women’s conference in Long Beach.  It was not much better than the Oklahoma City pundit or the Unitarian grief society.  I have trouble with celebrity worship anyway, but I have lots more trouble when celebrities do things that nobody should do, and then get copied, because they are celebrities.  I can imagine a room full of women who think it is all right to walk around in pain because celebrities that they respect are in pain.

NO.

There are plenty of mental health professionals to help with both the biological and psychological aspects of pain.

This is not technically a clinical depression.  The official psychiatrist manual (DSM-IV TR) calls it an “adjustment reaction.”  You may not need medication, and you probably should not accept prescriptions that may be offered to you because of the side effects they may have.

Mainstream doctors tend to jump into prescribing antidepressants in cases like this. Of course, there is a whole list of natural substances that can help with anxiety and sleeplessness and appetite changes.  People who are suffering have no reason to continue to do so when there are biological methods that do a very good job of truncating the pain.

Only false belief systems seem to keep people stuck in pain.  Many believe that religion is helpful here, but some systems buckle under the weight of “tradition,” or even the false belief that the more someone has been loved, the more the person left behind needs to suffer.  These are among the most destructive traditions and beliefs known to me.

This is where, if someone is really tied to a religion, the religious counselor who truly believes in a deity of infinite mercy and love and forgiveness, who believes that comforting the mourning is the greatest good deed of all, should be the person who leads the victim to comfort and healing.

Unfortunately, this is not always what happens and I find myself in the role of spiritual counselor — sometimes opposed to the “OFFICIAL” spiritual counselor — forced to deal in universals instead of aspects of faith that may be helpful or familiar.  I can do it, I have done it, but it makes me very uncomfortable.

I don’t have the answers to the great eternal questions and all I can do is try to make things better in the “here and now” for the physical body.  Spiritual guidance is out of my specialty.

Of course, biology is not everything, by all means.  People do not and should not try to “forget” a deceased loved one and keep moving along. As the last survivor of a very close family, I have a great many reflections — daily, or even hourly — of the loved ones who I can’t see or talk with any longer.  I have my moments of grief like any other human.  Being a doctor doesn’t immunize one to the realities of death.

The term used here is generally the “completion” of a relationship.  Sometimes we have the luxury of working with someone whose death was expected, as with Patrick Swayze. More often the death has already happened.  Sometimes I actually use techniques that include “imagining” the deceased still alive, and acting out resolutions to past conflicts.  It works, since the source of such conflicts is not the person who lived and died, but rather the image of that person that survives and remains in the head of the one who grieves.

Regular readers of this blog know that I rely upon Emotional Freedom Technique (EFT) for delicate situations, and it has been of enormous use in cases of grief resolution.

The fact that “accidents happen” or “parents never live as long as children” are no comfort.  The strongest comfort here is a sense of purpose.  When someone dies, the book is closed.  Physical immortality is simply not a reality at this time and even the most devout have times when they question spiritual immortality.  

One of the more dramatic cases of mourning I have dealt with was a woman who was nearly forty, and whose young son (in his twenties) had died in an act of senseless violence in prison.  Various doctors issuing multiple antidepressants over a period of three months had not helped her significantly.  There was some improvement in sleep and appetite but she was just “going through the motions” of her daily activities. I had done some neurolinguistic programming (NLP), to little avail, and had not yet learned EFT.  

But the searing pain remained.  

She started healing only when I suggested that she join a prison reform group.  She started to have a sense of power over her pain and to actually believe that she could change the circumstances that had caused her son’s death.  She was able to donate some money to the group, and a lot of volunteer effort, lobbying local government and the like.  We actually saw some real improvement.  When last I saw her she was doing well indeed.

Patrick Swayze’s wife called a friend at 2am, she said.  It would surely not dishonor his memory if she were sleeping.

Grief is not supposed to go on forever, nor are people supposed to “stuff” bad feelings and pretend they do not exist and go through the motions of life.

The loss of a loved one to death is the most profound pain anyone can live with on this earth.

We must search for meaning in death and comfort in life.

A professional who knows what they are doing can help plenty.  There is no belief system that validates avoiding comfort.  To magnify suffering is a perversion of any belief system that values human beings.

Like the lady who decided to work for prison reform, I urge the griever to memorialize the dead in a way that feels comfortable and right.  This can include anything from a memorial photo album, to a charitable donation in the name of the deceased, to anything or everything done to further a cause that was dear to the deceased.

When my beloved younger brother died, my husband suggested we buy an inexpensive bronze tag and engrave the words “Donated by the family of Harry S. Goldstein,” affix the tag to his television, and donate the TV to the day treatment center where he spent most of his final days (as an autistic adult).  This inexpensive gift was greeted by the care center as a valuable treasure and it occupied an important place in the commons room where the residents could watch their favorite programs.  It was our way of memorializing Harry, and helping our own grief heal by helping others.

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I first found out about this list of so-called “Influential Doctors“ in the USA Today newspaper and did not finish the article before I became aware of two powerful realities: 1. This list does not sound like it will help people who need a doctor, but more likely it will benefit someone else in the health care industry.  2. Nobody compiling a list of influential doctors is going to add me because I’m a professional pain in the rear-end of the other doctors on the list.

It sounds like one of those times when somebody is making money from patients pockets by marketing drugs or services, via insurance companies or drug companies. 

Hello “parasite!”  Hello person-making-money-from-sick-people without adding “value” to healing them.

Hmmmm …. who could be behind this? Marketing? Pharmaceutical marketing?

Pretty transparent stuff.  Let us look a little closer at what is going on.

This “Influential Doctors” database is written up in the newspaper subsequent to two interviews with Alzheimer’s experts.

The first interview is with Ron Peterson, “a leading researcher” who runs Mayo Clinic center, talking about the way to diagnose Alzheimer’s.  The article labels this “a problem critical to solve.” 

Somebody gives this doctor a title as “a leading researcher” (where? In the US?  In his specialty?  In the Mayo Clinic?)”

And the project they are working on is labeled “a problem critical to solve.”

Please don’t think I’m unsympathetic to what is generically called “Alzheimer’s” — broadly applied to diminished cognitive function at any age.  I’ve worked with it extensively and consider it a very serious consideration for everybody who expects to live to a ripe old age.

My pet peeve is with the usage of labels.

Labels.  Every mature adult has a decline in cognitive ability.  We measure it starting at 30 or so when people start forgetting where they parked their car at the mall.  I have learned recently that in Japan it is considered to start at 20 or so.

We know that people who are genetically “chosen” to be more likely to get a more rapid decline exist, and we can test for this genetically. Insurance has never paid for this test — to my knowledge — although the test is not extremely expensive (a few hundred bucks for an admittedly imperfect but reasonably predictive result).

The fancy, impressive medical term is apolipoprotein E allele testing.  I have offered this test to plenty of patients, and never found a single one who actually followed through on it.

What Alzheimer’s means, when it is diagnosed, is that attention, memory and some other things we group into “cognitive functions” are slipping away faster and more acutely.  So we get the prescription drugs, which are not without risk — headaches, confusion, dizzyniess, fatigue and sometimes hallucinations –and sometimes the drugs work, but sometimes they don’t.

When the patient continues to decline and becomes psychotic and/or aggressive, the next line of medications given is usually antipsychotics.

Ironically, the main risk from these medicines (besides cerebrovascular events and movement disorders) is –cognitive decline.

Alzheimer’s is largely preventable, or at least it can  be delayed enough so that the patient ends up dying from something else first.

I know I don’t qualify for it as a diagnosis, but I am not going to sit around waiting until I meet this set of criteria, if I ever do.  Everyone who discusses this issue with me usually gets my favorite quote from the poet Dylan Thomas:“Do not go gentle into that good night; rage, rage against the dying of the light.”

Age can be fought, with both efficacy and panache, with everything from new activity menus to over the counter supplements.  We all have cognitive decline to fight, and there are lots of reasons, from traumatic brain injury to prescription medications, that cognitive loss is a problem — a big social problem.

The USA Today article also included a brief interview with Dr. Julie Schneider of the Rush Alzheimer’s center in Chicago.  Patient are referred to her because their doctors are unsure of the diagnosis.

AAAAUUUGGGHHH!!!!

Doctors today seem notoriously bad at diagnosis.  That probably accounts for the popularity of the TV series “House, MD.” Every episode of that show for the past six years has been a race to find a correct diagnosis — while plowing through a dozen or so wrong diagnoses.

The most common question I get from a new patient is “Why didn’t my last doctor (or all my other doctors) know that/find that out/tell me that?” And then they tell me I am a real-life Dr. House.  (Except I’m nice and touchy-feely instead of crochety and sarcastic).

This reminds me of my beloved brother-in-law of blessed memory.  He was a man in the mold of a young John Wayne — a macho, rugged man who loved re-enacting frontier life and portraying a mountain man.  His hobbies included shooting guns, sharpening large knives, and throwing tomahawks at targets.

But the last time I saw him, he was a shadow of himself, dying from colon cancer.  His chemotherapy had caused him great pain and anguish (as if the cancer had not provided enough) and I offered him some alternative treatments that — if not able to actually cure the cancer — could ease his pain and help the horrible side-effects of his treatment.

He declined.  He said he figured he was getting along pretty well, since his doctor told him he was coming along about as they expected.

As far as I could figure, that meant that he was dying according to schedule. 

He trusted his doctor and declined any other treatment as graciously as he could, leaving my husband and me feeling devestated.  He lived his last days stoicly, as John Wayne did in the movie where he died defending The Alamo.  He died right on schedule and the doctors must have thought they had another success.

I never cared about his progression (or was it a digression?).  The doctors tracked the stages of his illness and charted various vital signs and blood tests.  Their only worry was to keep him alive as long as they could — not to make him better or to make the quality of the rest of his short life any better.

Jump forward a few years to today — when we have “influential doctors” who have to do cross-cultural tests to see when a label of Alzheimer’s is appropriate appropriate to hang on a patient.

I trained in an era when a “real” diagnosis of Alzheimer’s could be made only by brain biopsy (I did some) or autopsy.  I can tell you, after seeing the pathology (microscope slices from suffering brains) several times, the difference between what we call Alzheimer’s and what we call cognitive loss for age is only one of degrees.  The lesions, the brain changes, are exactly the same.

I have worked with some cracker jack neuropsychologists who can diagnose the intensity of a cognitive loss for age — that is, tell the difference between aging and “Alzheimer’s — with pencil and paper tests.  Luckily we don’t see too many examples of honest-to-goodness Alzheimer’s as Alois Alzheimer first described it, in the mid-fifties.

It’s not pretty and it’s extremely incapacitating.

There are great prevention programs available.  My personal regimen is wildly effective, and I’m staking my most valuable resource (my razor-sharp mind) on a bunch of supplements and “brain games” validated by scientists.  My mental workout is tough stuff, but my brain stem cells are working overtime replacing those dead cells and re-establishing neural pathways that might have gotten tangled or lost.

Of course I have given elements of such a program to my patients, although I can’t say who listens and does what I say unless they stay in my care.

But I’m mostly aware of results when I’m looking out for Number One.  My brain; according to my self-tests, it is getting younger — something which amuses me no end.

I will not sit around and wait for a diagnosis, nor rely on treatment.  I “rage against the dying of the light” every day, every chance I get. 

Every patient is more like their doctor than different.  In the case of mental illnesses (I still consider Alzheimer’s under that moniker) us doctors and treating personnel, we live twenty or thirty years longer than our patients.

That is not fair.  Patients have to ask us what we are doing, at least.  They have to get informed, try harder, realize they may be serving a system, not themselves.

I suppose that when the diagnosis is made, people get more home health care and other kinds of benefits, but with an implied prognosis that things won’t get much better.  I am sure that somebody gets something.  I am also sure that the gold standard that people really want is clarity of diagnostic criteria to justify the prescription of the drugs, or else there would not be pharmaceutical folks working on the list.

I had not been a doctor for very long — as a matter of fact I was still a student — when I assimilated the concept of “working diagnosis.” You get to know people better sometimes; you may have to, as a physician, before you can tell if they really fit criteria.  You try to find truth.  I have surely tried, and there have been times it did not work.

In the Qforma list, it sounds — at least from these most influential doctors — as if we are looking for meeting of diagnostic criteria, and as if the reason for doing this has something to do with pharmaceutical marketing, which seems to be financing the research both of these “influential” doctors are doing.  They are part of institutions, and one could argue it is part of their jobs.

I have a strong memory, early in my professorial career, at a Midwestern university of a particular patient. He was in his early twenties and living on the streets.  He ended up in my clinic because he couldn’t get treatment anywhere else — he no money, no insurance and didn’t qualify for any of the welfare programs.

His symptoms were pretty generic –treatment-resistant depression with a little paranoid psychosis. I did a neurological exam but I could not get a phone call back from the neurological clinic.  They refused to see him because nobody would pay.

Given his homelessness and age and his grab-bag of symptoms, everyone assumed his problem was drugs.  That wasn’t a diagnosis — just a stereotype to put a label on his peculiarities.

It was an older nurse who took my hand and walked me to the front desk of the neurology department.  They asked me for the diagnosis.  She motioned to me that I should be quiet.  I thought diagnoses were, well, a doctor thing, but she was old and mad and powerful so I shut up.  She said his diagnosis was “rule out muscular dystrophy” and he was given a clinic appointment immediately.

As soon as we got out of that office I told her there was nothing — I mean nothing — wrong with his muscles.

She told me “If we say there is, he is one of Jerry’s kids, and if he is one of Jerry’s kids, they will pay for the workup.  So you are going to shut up and they probably won’t even bother telling the chief you are a rotten neurologist, because they think all psychiatrists are rotten neurologists, but this is the only way this workup is going to get done.”

Okay, so they are diagnosing, and that is their pressure and their choice.  Doctors covering their tushies, looking for data to justify insurance payments for drugs.  I cannot read this group, and what these people say, any other way.

Look, I had an Alzheimer’s type patient recently, in her 80s, recent decline.  With nothing but supplements, daughter told me I had “rolled back her life” ten years and she was gardening, going out with groups, and having a grand old time.  Another daughter insisted on insurance and mainstream medicine, removed my supplements, and gave prescription drugs.  Within a week the patient had declined and was messing her pants.  She had gone from winning at canasta to wearing diapers.

Of course, the daughter who had consulted me and trusted me was heartbroken, and we mourned together.  But finances being what they are, this is what life is like.

You won’t find me on any “influential” list.  Like most of the profession I was once proud of, these folks have become parasites on needy and hurting people.

I can’t be “influential” — I’m considered a renegade doctor.

And PROUD of it!

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This seems to be the era of backwards-definitions.  “No Child Left Behind” means a diminished budget and fewer programs for child education. “Compassionate Conservatism” means cutting programs for the unemployed, the medical indigent and the hungry. “Strategic Defense” means a full-speed-ahead attack.

The “Innovative Programs” article talks about are mostly supplied by The Greenfield group, where improved medical care is provided if people  fork in some cash to get it.  Also “Harvard Vanguard,” who loves to be the first to do things.

Since there is nothing but Harvard hospitals on the reality TV show  Boston Med, I wonder if the Harvard Public relations people have descended to some all-invasive biological state, to infiltrate all media, and to try to get us to believe that they do things medically and surgically that are more advanced than other providers. 

This is not necessarily always the case…

After inspecting, organizing and participating in a variety of public clinics over the past ten years, I can tell you that no matter where I go — urban or rural, East or West Coast or Midwest — the practice of medicine is a hodge-podge of over-worked, burned-out employees including some scoundrels who try to get away with whatever they can to avoid work and get a paycheck for the time they occupy space rather than for the specific tasks they do.

The exceptions to this generalization are shining stars — saints, in my book — who actually care what happens to the patients left in their charge.

It is common to have a flooded waiting room — which insures that there will be NO confidentiality required by law — without an organized system to actually get the patients into one of the doctors (or more likely, “health extenders” who are de-facto doctors practicing without a license).

Just as common is to have a chief administrator who is either a secretarial person who was promoted for all the wrong reasons or a doctor who is trained to practice medicine and not keep a clinic functioning smoothly.

Doctors are slaves to the administrators — who are often the secretarial people at the front desk who answer phones and put calls through while a doctor is trying to deal with a patient, or who schedule a parade of patients popping in every 7 to 10 minutes and then shuttled off for three months before coming back for another few minutes.

Doctors are expected to sign the billing papers, and that’s about it. Prescriptions can be fudged and often are (using rubber stamped signatures or pre-signed pads distributed by the chief administrator to people the doctor has never met).

As our government has taken over more of the health-care payment, the clinics are enticed to bend the rules — double billing, having authorized people sign off on patients they haven’t actually examined, and other shenanigans.  With payments being reduced every few months, the clinics need to pull such stunts to keep their cash flow.

In the past year, I’ve been invited to evaluate several clinics that are NOT government (local or state) funded, but who contract to the government and bill them for services.  In each case I see the same mistake over and over. They try to build a private, for-profit clinic using the same model as the government welfare clinics.

There are certain things doctors can get paid for and a great many that they can’t get paid for.  I’ve worked in clinics where they only time I could bill for was “face time” with the patients. All the doctors in the clinic put in two to three hours of unpaid overtime per day just to keep their charts current. Phone calls to a pharmacist or a referral specialist were likewise “on the house.”

In one HMO known for aggressive cost cutting, the doctors had to supply their own pens and pencils, scotch tape and paperclips.

The biggest problem, though, is that doctors seem to be asked to make  more decisions with less patient contact. 

Now medicine has changed since someone told me this, early in my (American) surgical career, but I was told, from some study in the Midwest, that the average physician had to make the average medical decision on 70% of the “reasonably necessary” information.   There are, of course, reasons for this: patients forget.  Patients lie. You’ve probably heard that from Dr. House.

Some “Innovative” proposals are ludicrous.

Group appointments.  Wow, like that is really innovative.  I can’t imagine how many patients they had to interview before they found someone who said they enjoyed hearing how other people solved their own problems.

There is a word for this phenomenon.  It is called a “support group,” and does not usually welcome any presence from a professional.  I found out the hard way, as an overly-enthusiastic resident who decided to sit in on an AA meeting to observe.  I was told to get lost unless I wanted to go on a binge and become impaired.  The group was  extremely hostile to medicines, since they considered all drugs evil.

That being said, many cost-cutting organizations try to shed their needy patients by referring them to 12-step groups.  Medically speaking, “support” is not treatment, and this practice is unconscionable.

In real life, I have worked at several agencies that wanted their physicians to develop group appointments.  Before that, in mental  health, the notion of groups is one consecrated by use.  Plenty of examples, and admittedly some serious ways to help patients.  Institutionally, even within my residency training, I think (I was often a “cotherapist,” a secondary therapist present) I learned plenty.  But once I made the leap into private practice, I must admit I have not once heard any therapist, however noble and idealistic, discuss the idea of group therapy without talking about improving income.

Also in real life, whether we are talking mental or general health, patients get attached to their doctors.  There are studies that a patient will choose to wait longer for “their” perceived personal doctor than anyone who happens to be free.  Add to that the fact that every single patient known to me with whom I have discussed the idea of group patient visits has told ME exactly the same thing.

Basically, they say that telling the doctor everything that is going on is hard enough, and they would find it hard or impossible to do with people they did not previously know in the room. 

This doctor-patient thing is precious, and I have seen it diluted beyond recognition with “doctor extenders” and the like.  I suspect there are many people who feel some variant of these feelings.  I must admit the patients I have asked about this have usually seen me with nobody but the two of us in the room, and would look at any kind of a group meeting as a “stepdown.” One could always bring in new patients and train them to expect less. Lower cost doctor extenders tend to spend more time with patients and on patient polls, often appear more “caring.”  They may be able to answer common questions.  After all, common problems are, well, common. 

Me, I have re-diagnosed patients (and actually made them better) in several cases.  I could not have done this without spending a big hunk of adulthood in training in various specialties involving the brain, thereby omitting the hell-raising and failed marriages of my colleagues.  Moreover, thirty years of experience, well, it gotta be worth a few bucks.  There are some things a patient needs someone like me for and I do them pretty darn well.  I am also good at nurturing doctor extenders, and at teaching anybody who wants to learn. (“teacher” is what the word “doctor” means in Latin).

More people are looking for more doctor extenders.  Is anyone surprised?

I can name at least one job, where I was told my performance was “outstanding,” where they hired a nurse practitioner later as consultant instead.  Saved a lot of money, too.

Quality can never compete with cost — at least in the public health market.

However, nurse practitioners are now demanding — and getting — about the same money as a medical doctor.  In many cases, they have virtually the same duties and privileges, so why not?  Although, in some cases, they are over-reaching their authority.  The institutions probably rationalize this by thinking that paying a fine or two is cheaper than hiring the High-Priced help.

Okay, enough of that.  I continued to read my USA Today and found, also Monday August 16th, 2010, also on the front page (Health is no longer in Life section, for it is always on the front page now) “Grants to aid states vs health rate hikes.” Yep, there is an insurance “boost” coming and $46 million is coming so states can figure out how to regulate this.

Basically, the states in which this kind of authority does not even exist, are looking both for the authority to enforce something about these concerns over insurance rates, as well as personnel who actually know what is good and what is not. Since I have been unable to find any education on the internet that gives someone any education on — let alone any credential on — the determination of insurance rates, the best I seem to be able to do is to find people who are supposed to be experts on this and they seem to get their credentials from–insurance company.  Everybody got a rate determination system.

This is going into the void, to develop multiple state regulatory agencies from zero.  To tread where no minimally trained insurance man or woman has trod before.  (I you can hear the Star Trek theme in your head.)   I am not optimistic.  We have found a Brand New Way to spend money on  medical care without doing a single thing to improve the quality of that care. We have found a new way to build the bureaucracy, that can only increase building more bureaucracy.

People are dying.  People write columns in local newspapers reporting their doctors have told them “there is nothing we can do for you.” — Not due to any medical problems, but because they have no insurance or (worse) they DO have insurance, but it doesn’t cover that condition for some reason or another.

When I was a surgeon, we would determine a patient wasn’t a good candidate for a procedure if their heart couldn’t stand the surgery or they might not survive the anesthesia or there was some other type of serious medical risk.  We NEVER based our decision on ability to pay until the early to mid 80′s.

We need to be using most effective treatments, give people (like me) who have devoted their lives to taking care of people a chance to reach the people who need them.

Instead we are building a thicker and more impenetrable wall — a wall of people who make money from health care but add no value to the healthcare experience.

In the famous words of President Ronald Reagan, “Mr. Gorbachev, tear down this wall.”

Substitute the appropriate person for Gorbachev.

What I’m getting at is the need to tear down the financial wall between people and health care.  I do not care at all what kind of politics it takes.  Left, right, center, whatever, are only words.  People are dying, other people are making money off them and not helping.  These are not honest or decent ways to make money.  These people are parasites on the system, no better than thieves, and we are facilitating them in a consistent manner.

Would it be appropriate to say, “Mr. Obama, tear down this wall.”

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After more than one internet search, the only mention I found of what is going on online is this one, in what seems to be a Seattle tabloid.

I strongly suspect that this is a road that has been travelled more than I know.  After all, I am not exactly a celebrity watcher. Nevertheless, from what we already know about folks like Michael Jackson, and from what Dr. Nathalie Maullin seems to have said under oath, I think we have a pretty good idea of what it is like to be a drug-seeking celebrity.

First, I think it worth noting that Dr. Maullin was on staff at Cedars-Sinai at the time. Now putting aside the PR of the latter (it is allegedly the best in L.A.; they have ads and some top notch publicity firm–) Cedars Sinai is a hospital.  I can testify that to be on staff at any clinic or hospital, they do a background check. 

I am squeakly clean to the point of nausea — 30 years with no complaints, no challenges to my status, no malpractice suits.  Arguably, that is at least as much from my charm as from my unbridled hyper-competency (I work hard to keep it) but this is someone whom we can say has been pretty much free from serious medicolegal problems to get where she is or was.  Besides, I agree with a lot of her opinions, as far as this info goes.  I guess this is one place I am pretty mainstream.  See, I want my patients to stay alive, and I think she did, too.

Here is the road:

1. Celebrity patient has pain and requests drugs.  With benign back pain, assuming she did not have cancer in a bone or something horrific we do not know about, most (qualified and reasonable) doctors would have dived for the ibuprofen, maybe something to protect the stomach (since ten thousand people a year die from non steroidal inflammatories, of which ibuprofen is one; it causes stomach ulcers, can hit a blood vessel and make someone bleed out). This is not wildly effective, but a lot of people (especially those in county clinics) live with this and exercise, like swimming, and make do.

 2. A celebrity seems to want more, demanding freedom from pain, asking for something that does more.  Now a “normal” doctor can’t usually be bothered with this.  Most cases of back pain have no vertebral bone with cancer in it, or anything else that could conceivably be called a “lesion.”  Anyone who read literature would know the best chance for help with back pain would include psychotherapy or even medications or a way to address underlying stresses. These things work.  Although I’m a former back surgeon, I’ve “cured” many back pains with non-drug and non-surgery methods.  Some people like the results of physical therapy; many, like John Sarno, MD of NYU think it useless; whatever.  People get better without drugs  if they are willing to try, to participate in the therapy.

3. Although reasonable attempts may have been made, no celebrity known to me (again, I am no celebrity expert) except Anne Bancroft — who was Sarno’s most famous patient — has ever followed this kind of therapy.  Even relatively wealthy and powerful people with whom I have worked have said “just give me the pills” in pain situations, even if I warn seriously how dangerous and rotten the pills are.  Celebrities do not like to “participate in…treatment.”  Dr. Maullin noticed this problem with Anna Nicole Smith during her hospitalization. Celebrities have money and believe themselves to be important. Presumably, so do their completion bond guarantors and God knows who else. Addiction can be asymptomatic before people get messed up.

Celebrities would be expected to ask for higher and higher doses of addictive drugs and they get them.  Besides the cases reported in the media, there are LOTS of gossipy anecdotes that you hear about in the L.A. area.  Many doctors accept money and get in trouble.  Clearly the temptations are great.  The proximity to the famous.  The cash rewards from the rich.  Although I do wonder a bit when I hear people condemn all of us, I would be the first to admit that there are plenty of doctors out there who are enough to make me ashamed to be a medical doctor.

4. The patient gets in trouble.  Big trouble; life threatening or death.  Thanks to Dr. Maullin’s testimony, we have a clear description of at least one of Ms.Smith’s troubles. Nobody who actually knows what they are doing would ever, ever, take someone on both methadone and Xanax off both during pregnancy; a horrific decision which Ms. Smith made on her own, as she recounted to Dr. Maullin.  Doses and medical details are omitted here for obvious reasons, and this is the only reason I could disagree with Dr. Maullin. Sudden stopping of Xanax could cause seizure and maybe even lead to death. If someone is convulsing, this can seriously disrupt the circulation of the placenta/embryo/fetus depending on how far along the baby is.  We are talking dying dead. Was Ms. Smith not told?  Would she not listen?  Was she already so compromised she could not give an adequate informed consent?  Again, God knows; not the doctors. Incidentally, Dr. Maullin said that addiction problems could only be treated in a facility. Detox, maybe, but there are concierge practices and other alternatives available — especially to the wealthy. Problems are made for treatment; or better yet, prevention. There are lots of ways to do this.

There were more troubles.  We are grateful to whatever people believe in that she brought the baby through somehow, for she left the hospital and went home and had home visits from the same doctors who had been giving these things through pregnancy. Many docs, including me, will not prescribe these things without birth control in place.

5.  The doctors attempt to justify themselves. They could not manage a case where the patient seemed to be doing the managing. They say the use of pain medication was needed because of the enormity of the pain. If they were not complicitous in the death, any physicians involved were certainly guilty, especially if the doses were on the high side, of prescribing to a known addict.  Nothing good could have happened here.  The celebrity was in control and the doctors were collecting money.

I do not have another step here, except there is lots of tabloid press coverage, and secrecy that reveals what I say above to have been pretty much true.

Not all doctors are drug pushers, not all of them treat the patient like a cash cow, not all physicians try to take the easy way out at the expense of the health — or life — of their patients.

But if even one of them does so and makes international headlines, it injures the entire profession.

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I am not sure that it is the stuff people should spend their whole careers on.  But a single association  between neurochemistry and holding hands has been enough for a previous posting.

Now the association between feelings of gratitude and lowered cortisol has delighted me so there is a smile on my face. I guess this is because it validates some of the pure observation from life kind of anecdotal advice that my grandmother of blessed memory would come up with.  Things like “Roughage is good for you,” which later became “eat
fiber.”

The idea that gratitude is good for brain chemistry is so delightful and potentially validating for otherwise not too tough to validate behavior, that it has been joyously co-opted by coaches.  They are an entrepreneurial lot who never bother with footnotes, not any more than they do with credentials.  I mean, there is no regulation known to me about using the nomenclature “coach.”  But on the other hand, they build careers and get paid with the results of their ministrations, a situation which I believe would send a fair amount of physicians to the poorhouse.

The only literature I have located so far that looks more like science than hearsay is nicely summarized by someone delightfully named “The Positivity Company.”

There is a questionnaire study, the kind people get to do and publish when they don’t have the required credentials to check bodily fluids a lot.

(They seem to know statistics a lot and do a pretty good job with experimental designs and such.)

One checks salivary cortisol and DHEA (dehydroepiandrosterone) and the salivary cortisol levels (which are well known to be excellently correlated with serum levels) are definited decreased, although the DHEA levels are more significantly increased.  The method that differed between the groups studied was heart rate variability management, which has been shown solidly to lower stress.  Gratitude correlation is not wildly evident to me, as it seems to have been to the person who wrote this page.

The third one talks about positive emotions undoing negative.

There is something good here, and there seem to be ways to use the “heartmath” paradigm to lower serum cortisol.

This seemingly knowledgeable social worker traces it through the “core heart rhythms” or “heartmath” paradigm.

Here is what looks like serious research, but a little bit too commercial for me to take without some salt.

Nevertheless this thing makes cosmic sense.  That which relaxes you must at some point bring down your stress markers.  I remember the Hans Selye original definition of the circumstance some years ago, when it was a cornerstone of basic medical school courses.

We were steeped in the “general adaptation” theory, which led to the cortisol-rise-associated “Fight or flight”syndrome. Some how or other, at some point in my career, I started telling patients how when Fred Flintstone met a sabre-tooth tiger, he either had to fight and destroy or run for the cave.  It was definitely the cortisol that got him physiologically ready to do either.

If Fred Flintstone were, say, in downtown Oklahoma City, he might have a panic attack if he saw someone who seemed threatening.  Enter the Rx drugs.  Enter now, new forms of relaxation treatment.

Enter corporate coach, telling people to thank and appreciate employees, presumably lowering cortisol.  This link opens up a PDF file.

This one becomes an encouragement of “active appreciation,” a method of increasing positive thought, and a sales piece for the “biodot,” a sort of miniature hassle-free mood ring.  Not the worst technology, but a bit dated.

This one sounds a little more like science and it tells people to hold the gratitude for 15-20 seconds.   Positive thoughts to get rid of negative ones; quantified here at three.  In The Secret, it says one positive thought is as strong as seven negatives.  Go figure.  No footnotes, no links, anywhere, anymore.

I have a great visual memory, but I can’t usually tell people where I read things.  Finally it is trust.  This is admittedly a realm of science where small samples and contradictory results are definitely part of the landscape.

All right, so I mentioned “the secret," which nobody has accused of being excessively scientific.  But I can tell you that the Secret, like many emotional texts, insists on “gratitude” as part of the plan.
 
Lack of gratitude has been accused of many a self-sabotaged success plan.  From Claude Bristol, WWI veteran to the present, it is a factor.  To his credit, Bristol makes a concerted effort to steer clear of religion, and to report findings that are as scientific as possible; something you would certainly expect from a “hard boiled” reporter.

I will certainly admit that gratitude feels good.  It does raise the self-esteem of the person to whom it is expressed, and that sort of interchange doubtless feels darn good both for the person doing the thanks and the person being thanked.

This is a good practice by any measure, as long as it is sincere and real.  I remember wonderful feelings when I found a school teacher who had ignited some feelings about art or science some years later. Teachers being generally underpaid and under acknowledged, this is a good place to start.

It is harder to do with closer or more complex relationships, because there is always a sort of constellation of both good and bad feelings involved.  But it is worth it, once this “thank you” saying is good for you mentality returns to consciousness, to do it.  There is a sense of joy and peace, what has been, for me, a sort of “whoops, there slides the cortisol” feeling.  For instance, my husband is a man talented in many spheres.  When I thank him for his knowledge and/or actions, realizing what I am doing.  I see him happy and know I have made him happy.  It can only be good.

No matter what the numerical ration between positive feelings and negative ones, or even positive statements and negative ones, there is something to be said about dragging the tone of a conversation positively.

I suspect we will not and cannot and maybe even should not finance great gobs of research for the correlation between neuroscience and everyday life.  I usually decry the application of common sense to neuroscience, which is neither common nor makes much sense, but here the small bit of biochemical correlation we have is plenty here. Mainly because it goes with one of those magnificent if common grand feelings that validates.

We must be careful about letting religion co-opt this one.  Prayers of thanks are present in any religion known to me. Religion has a way of using any concept to validate itself. As I age, I become increasingly suspicious of any hierarchy that spends a lot of energy in self-validation.  My husband (although sometimes I suspect Mr. Right of being Mr. Always Right) is certainly not God.  But the warm glow I feel when I am grateful to him, for existing, for acting kindly towards me, does not seem to be, to me, more or less correlated with whatever secretory events are happening in my life than a prayer of thanks to any kind of external intelligence that may be a little harder to visualize than the man sitting at the computer.

This gratitude thing is good.  Like most feelings, I have a feeling it needs to be real.  I certainly cannot imagine how it could be even minimally harmful, unless it were incorporated into a stress reaction.

I remember being “forced” to write thank you letters, as a child, to a grandparent whom I considered such a pain in the neck that the pain he caused was far greater than my gratitude for any gift.

I know my grandfather meant well.  He was a character, thought himself a bit superior, and certainly relished any authority that came with his age.  He recounted the same anecdotes so many times I knew them all by heart.  My mother told me to shut up instead of finishing the ones my grandfather started.

I mean, apologies to the memory of my blessed grandfather, my mother’s mother who liked to drive a road without traffic so he drove to visit us, starting his two hour drive across the state at 4am and waking us at 6am on a Sunday morning and of course, nobody even thought then of going out for breakfast, as it was too expensive.  Not only did I have to dress before coming downstairs to see him, but I had to listen to him berate my mother for being overweight, diminish my father any way he could think of, and telling me (I was somewhere between sentiency and age 7 when he got too tired to visit) that it was never too early to comtemplate a secure future in marriage. 

When he brought me a radio, even though it was a lovely short wave one and I could hear faraway countries and distant lands, I put off writing him the requisite “Thank you” letter until my mother’s anger was no longer tolerable for me.  When I did write it, I am quite certain it raised my cortisol.  I actually felt relieved when my grandfather of blessed memory was institutionalized for his Alzheimer’s.  Since then, I have taken special joy in going back to bed after breakfast on Sunday mornings.

Emotions are a gauge of feelings, and a fairly reliable one in the honest and (relatively) fearless.  They are, at best, a fairly reliable compass to help someone get their thoughts back on track.  We are all ruled by emotions more than we want to believe, but with awareness of them, I have no doubt that we can adjust a legion of brain chemicals. Certainly more of them than anyone can study directly.

So it is nice to know that something that feels good can actually be good for you. Raised cortisol has been correlated with a seemingly infinite list of both medical and psychiatric problems.

My advice — say “thanks” in any way you can think of, but use yourself as your own emotional measure.  This is one place where the gesture is harmless enough that I think it possible to say, with our current level of feeble if amusing biochemical knowledge, if it feels good, just do it.

And if it does not, just don’t –  and keep moving.

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