Saturday, March 31, 2007

Laughter is a drug

This started out as a comment to respond to some comments in Your Doctor is Making Jokes About You, but it got so long that I thought I'd post it. Midwife's comments (dang, I see she removed them but they deserved to remain) about being able to laugh at tragic circumstances provoked some anonymous comments about insensitivity, which is the other side of the coin to humor (all humor has this Janus quality... it is insensitive to laugh at that poor chicken's difficulty getting to the other side of the street). Mid wife apologized for inciting a riot.

There's no riot. This is a healthy discussion about what it is like to work in a job where one deals with human tragedy on a daily basis.

The problem, I believe, that the anonymous poster has trouble getting his or her arms around, is that physicians (and here I mean all health care "professionals") are not perfect. We do not possess some unique ability that shields us from anger, fear, depression, loneliness, despair. Yet, for some reason, there is an expectation that we are somehow above these human foibles.

We are not.

In the past week, I have dealt with near-lethal suicide attempts, single women who have had their children taken away from them (probably forever) because their brain illnesses currently prevent them from providing adequate parenting, people who have recently lost a loved one, a home, a job, their freedom. I have also dealt with people making more incremental steps of improvement in their life (another week of sobriety, making it to their follow-up appointment, getting a job, making a new friend).

And, I'm afraid, this is a typical week.

Just writing this comment, I feel tears welling up. That's fine. I'm in touch with my pain. I'm down with that. Woo. But I cannot be in touch with it all the time. That may work for some, but for me it would impair my ability to be effective.

So humor is my way of managing these emotions, both in me and in others. And I use it like I use a medication... with a particular dose to achieve a desired outcome (that is, in my work with patients and staff... at home, my humor is much more random... in my posts, it is somewhere inbetween, depending on the topic). (Mind you, I am not talking about "humor" where one laughs at another's misfortune in a way that is intentionally harmful/evil/superior to that person... that is not what I am talking about here.)

My intent is to heal... both myself and others. Just like a drug may have unintended side effects and be harmful, so might humor. I choose medication which I think is uniquely appropriate for a given patient. My patients do not get angry and hurt when a drug makes them have a dystonic reaction. A shot of Cogentin makes it better, and I avoid that type of drug again. They know my intent was to help.

Similarly, I choose the words I use intentionally for a given patient because it is important to use language that they often use. It helps us understand each other. When my humor has an unintended side effect and is experienced as harmful, my patients also do not get angry and hurt. An Apology makes it better, and I avoid that type of humor again. They know my intent was to help.

On the internet, when one stumbles onto a near year-long, extended conversation about psychiatry, mental health, blogging, ducks and fish, it is all too easy to jump right in, read some comments that appear hurtful or mocking, and take offense. This casual blog observer does not know what the intent is, unless they take the time to understand. Similarly, in the hospital, it would be easy to judge me, for example, as insensitive if I am administering one of my therapeutic aphorisms and someone walks past the door, only to hear "You gotta cut this shit out, Joe," or "So your right arm became paralyzed just after your boss told you that you didn't do a good job on the report that you've spent all month working on? I tell ya, it's a good thing it happened when it did, because if that woulda happened to me, I would have wanted to punch him right in the nose."

My approach (in life, but especially on the net) is to assume benign intent. This takes work, because I am, deep down, somewhat suspicious. But at the end of the day, I am convinced that this way of viewing the world makes the world a better place.

March Madness: Visitor Survey Results

Results are in. We put up a poll all month (March 2007) to see who visits our blog. PollDaddy was used, and duplicate votes were mimized via use of cookies.

> 20% physicians (incl 13% psychiatrists & 7% other docs)
> 9% nurses
> 7% psychologists
> 7% social workers and counselors

> A total of 43% of voters were (mostly mental) health care professionals.
> 29% were patients
> 29% were "others"

Just wanted to share these results with you all. Thank you for your interest in our inspired ramblings.

-The Management

[revised 3/31]


So last night, I went to "the movies." Actually, it was to a film with discussion, sponsored by The Baltimore-Washington Psychoanalytic Institute. The movie was a Russian film called The Return, about two teenage boys who venture off with a cold, oppressive father who has returned after a mysterious 12-year absence (--prison camp, maybe?). The movie was horribly depressing and to add to the somber, miserable feel it left, the discussant mentioned that one of the teenage actors died in a boating accident shortly before the release of the film-- my misery couldn't even be contained with "it's just a movie." I woke up still haunted.

Is it time to go back to work yet?

Friday, March 30, 2007

Dr. Fear Factor

Saw this on the APA site today. I sorta predicted this in Reality Therapy Vlog...

"A new TLC [The Learning Channel] show is looking for experts in cognitive behavioral therapy and anxiety disorder treatment to take on eight challenging patients in a groundbreaking television series to alleviate their phobias.

Everyone knows what it feels like to be afraid or to feel anxious, but there are some people who can be so debilitated that it interferes with the tasks of everyday life. Their friends and families try to understand, but the relationships are strained. Meet eight individuals who are prisoners of their own minds. In order to take back their lives from their overwhelming emotions, they will undergo a unique treatment directed by two of the country’s top anxiety disorder specialists. On a two-week journey of hope and self-discovery, eight individuals and two therapists will board a bus winding along Route 66, crossing eight states, and 2,400 miles with the aim of curing the neuroses for good. People on the bus will not only face their individual fears, but will also help each other through intensive group therapy.

The show will be an uplifting experience for the participants and the viewers. The patients will be challenged, yet always in a safe but dynamic environment. They will have the guidance and support of two exceptional therapists and their bus-mates, but they will be emboldened to take an active role in their own recovery.

The journey from incapacitating dread to dynamic vitality will be documented for The Learning Channel. The Learning Channel is a network dedicated to groundbreaking programming presented in a sensitive and educational manner. This program will be produced by LMNO Productions for TLC. Eric Schotz, Bill Paolantonio and Kathy Williamson are executive producers."
They are looking for two doctors -- a cognitive therapist and an anxiety disorder specialist -- to go on the road with them for 10 days. Any takers?

Thursday, March 29, 2007

Your Doctor Is Making Jokes About You

And Other Things You Don't Want to Know About Medicine

You deserve to know the truth. The truth is, your doctor may be telling jokes about you. Well OK, not necessarily about you, personally. But about medicine. About the experience of treating patients with common conditions in common circumstances. Stories about patients with unreasonable demands or unreasonable behaviors who come back repeatedly for repair after refusing to change the very things causing them problems. With regard to psychiatry, doctors who have been assaulted by a patient in seclusion may use humor to relieve the fear and anxiety associated with caring for a potentially violent person. In situations like this it's better to make a joke than to scream, throw up your hands and walk away.

Sometimes in psychiatry you work with patients who aren't very nice to you. They may be angry and they may say things that are hurtful. As professionals it is our responsibility to take this dispassionately and allow the patient to be honest about their feelings. We cannot snap back or be retributive or let this influence our judgement. Psychiatrists must be dispassionate, supportive, sensitive and empathic.

Frankly, that's hard work.

Humor is one way of dealing with this. People who read this blog know that we use humor a lot. We tell jokes about medications, about diseases, about the pitfalls of psychiatric practice and about each other. (Well OK, usually about Dinah but that's just because she leaves herself so gosh-darn open to it. And because she takes it so well. Believe me, she can give it as well as she takes it.) According to our readers' comments one of the things people like about this blog is that it gives them a behind-the-scenes glimpse of the human side of psychiatry. That may be disturbing to folks who don't want to think about their psychiatrists in that way.

Every physician at some point in time has used humor to mediate stress and vent frustration. Heck, even an entire television series was based on this premise. The legendary Hawkeye Pierce used humor and practical jokes to highlight the idiocy of military (and medical) bureacracy all the while giving terrific patient care. I imagine my opthalmologist, my dentist, my primary care doc and even my gynecologist have their own brand of behind-the-scenes humor that I as a patient have never heard. (I have to admit I've come up with a few thoughts on my own while straddling the stirrups. And here's an informal survey: how many of you have gynecologists who post cartoons on the ceiling above the exam table?)

Personally, if it keeps my dentist sane and available for me and helps him be more tolerant of me as a patient I'm all for it.

I'll bet he's laughing at how I walk.


Warning: This blog features graphic scenes of psychiatric humor that may be disturbing to some readers. Reader discretion is advised.

Say What???? Part II


Managed Care Sources of Evil (and P4P, or Pay for Perdition)

Sandra blogged about Philip Zimbardo's post, Situational Sources of Evil, about Milgram's studies from the 1960s and the 10 behavioral methods or steps which are used to get good people to do bad things. As I read this, it made me think of the failed promise of Managed Care, and the next evolutionary change in U.S. medicine, Pay For Performance (P4P).

Here are my tangential thoughts about these 10 steps, as they relate to the whole managed care experience.


Managed Care (MC) involves establishing contracts with physicians and other health care practitioners, detailing what they can do and cannot do, in a manner which makes them look like poor sports if they do not comply (e.g., being
labeled a nonparticipant versus being part of a network of participating providers).


We health care practitioners strive to provide good care and most are in it to help people, not just for money; so the idea of making health care affordable makes sense. How could we be opposed to this?


Initially, there were rules limiting admissions to only those which were "medically necessary". Who wants to admit someone for a medical problem when it is unnecessary? Now, "medically necessary" is not what you think it is, but what the company defines it to be. Other rules get changed, and many have come to believe that "rules are rules and must be followed". Example: Dinah's previous point that Husband thought he must go to Lab B to get test done (even Lab A told him so), rather than paying the $12.68 and getting it done at more convenient Lab A.


"Managed care" rather than "managed costs".
"Authorization" rather than "rationed care".
"Medical necessity" rather than "only if we want to pay for it".
"Referral" rather than "gatekeeper".


Care is denied via a Review Committee rather than Doctor Jones. By requiring that patients or physicians jump through hoops, such as getting an authorization, waiting on hold for 15 minutes to speak to a reviewer, or filling out a 3-page treatment plan for 5 more visits, the guilt may then conveniently lie with you for not following the proper procedure, rather than the company for denying or limiting care.


It started out as simple as "You accept less of a fee, we will send you more patients." Then it progressed to "You must accept whatever we offer, or we will send you no patients." Now it is "You must practice the way we tell you to, or we will send you less money (and imply that you are practicing substandard medicine).

Provide the diagnostic code.
Provide the diagnosis and treatment plan.
Provide the diagnosis, treatment plan, and copies of your progress notes.
Provide the diagnosis, treatment plan, copies of your progress notes, and also various evidence of measures of "performance" to prove that what you are doing can be shown to have a measurable impact on visit-to-visit progress (the equivalent of focusing on quarterly shareholder profits rather the big picture of what is best in the long run).

We started out with "medical privacy", which is every patient's right. Then we passed a privacy rule, HIPAA, which makes your records "more private" by removing requirements for you to authorize their release under numerous conditions, and even requiring you to give them up to law enforcement officials, without a search warrant. And, if national security is invoked, y then it is illegal for you to tell your patient that, "Oh, the FBI came by to look at your records." We are all so confused that mindless obediance has been achieved (e.g., annual "Privacy Notices").

Try "opting out" of Medicare... it means you can't work for anyone who wants to bill Medicare for your service.

The Big Lie: We will pay you more for practicing evidence-based medicine, which results in better performance. (The Big Truth: We will pay you less for straying from our population-based, cookbook procedures. As Scott Aaronson says, "The plural of anecdote is not evidence.")

Wednesday, March 28, 2007

Walk Like A Psychiatrist

Roy, oh Roy, too many 'roids, it's Roy unleashed....
So Roy wrote these lyrics on the comment section of ClinkShrink's Comet post, and I just can't resist clipping and pasting them. Please, sing loudly, very loudly, to the tune of Walk Like An Egyptian!
All the old inmates in their cells

They do the Haldol dance don't you know

If they move too quick (oh whey oh)

They're gettin' a dose of Inderal

All the bizarre men have a file

They got a gray mouse for a pet

Seroquel smiles (oh whey oh)

They trade their pills for a cigarette

Freudian types with the hookah pipes say

Ay oh whey oh, ay oh whey oh

Walk like a psychiatrist

The big COs like to take their keys

They spin around and they cross the floor

They've got your back (oh whey oh)

You're in the clink so they guard the door

All the prisoners like to see the doc

If they do not then they are pissed

When the buzzer rings (oh whey oh)

They're walking like a psychiatrist

All the guards in the dining room say

Ay oh whey oh, ay oh whey oh

Walk like a psychiatrist

Every day's the same front and back

Noises make you miss the sleep you lack

Life is hard you know (oh whey oh)

So block the lows with your Prozac

If you want to please all the cops

Then stop before work at the donut shop

They sing and dance (oh whey oh)

They're keepin' peace down in the cell block

All the inmates dealin' with their nerves

No overdosin', no cuttin' wrists

And the nurses know (oh whey oh)

They walk the line like psychiatrists

All the cops in the donut shop say

Ay oh whey oh, ay oh whey oh

Walk like a psychiatrist

Walk like a psychiatrist!
And the best part? Sanjaya will be performing it on American Idol next week.

[insert photoshopped pic of Egyptian-walking Freud here... anyone?]

Tuesday, March 27, 2007

Advice For Comets

I watched a comet burn up this week. It was a most impressive flame-out, with raised voices, threats of legal action, hints of physical violence and tears.

The inmates, on the other hand, were relatively well-behaved.

I've seen many health care professionals come and go through the years. As the token employee assistance person (unofficial, uncompensated) I've provided supportive counselling (translation: been ranted at) by some of them. I struggle to know what to say, but over the years I've learned a few general principles.

When you're new to the correctional environment you have to go through an adjustment process that's analogous to the Kubler-Ross five stages of dying: denial, anger, bargaining, depression and acceptance.

1. "I'm working out of a bare cell? No way!"

2. "I'm not going to be treated like this!"

3. "If you want me to do X, you need to give me Y."

4. "Why do I stay here? I should just leave."

5. "It's pretty cool when my patient gets better."

Not all people go through all stages or in the same order, or sometimes it happens all at once pretty fast.

The main thing to know is that you're working in a bureacracy, and bureacracies are notoriously slow beasts to turn. You can't be a fighter pilot in a jumbo jet. Some professionals hit the bureaucracy with guns blazing, making a virtual declaration of war, and burn to cinders in the atmosphere within the first few months. If recent American politics can teach us anything, it's the importance of building a coalition prior to taking action. Your coalition is your team of co-workers. Now, your co-workers may (in your opinion) be inebriated incompetent dim-witted dickheads (I wish I were as eloquent as Shiny Happy Person. She would say this so much better than I could---I believe she'd use the terms 'fuck-wit' or 'git' which just don't get captured by American colloquialisms) but they are your battle-buddies and they're all that you've got. If you antagonize them they will let you go down in a hail of bullets. Or worse, turn weapons on you themselves. Your credibility depends upon tact and restraint. Translation: don't even try to start "writing people up" until you've been there a year or more.

At some point you're going to come to believe (or to witness) that this bureacracy rewards mediocracy and punishes malcontents. Once you hit this stage, you have three choices: you can throw up your hands and walk away, you can bury your head in the sand or you can change tactics. More importantly, you can take time off. You can cool down. You can go home and hug your kids (or your dogs or your cats). But the thing you should never, ever forget is:

We need you. You're smart. You care. And you've saved a few lives while you were here.

I hope that's enough to bring you back.

Overheard: "Are you a psychiatrist? You walk like a psychiatrist."

Monday, March 26, 2007

Say Cheeeeeese!

Look how pretty the posts are when one adds a pic!!!
(Hint to my dear Co-bloggers, especially the venerable ClinkShrink)

Say What???

OK, I'm not one to care about celebrity gossip and that's not the point of this post. I just saw this on CNN and it just struck me how far we still have to go about educating the general public about psychiatric issues. It would help if the media at least would get it right.

Here's a quote from the CNN coverage of Anna Nicole Smith's autopsy findings:

His death was ruled an accidental overdose of three antidepressant medications: methadone, Lexapro and Zoloft, according to forensic pathologist Cyril Wecht, who performed a private autopsy at the request of his mother.
Ouch. When did methadone become an antidepressant? And how will P4P reimburse for that?

Saturday, March 24, 2007


Roy is working on a very nice post about the newest trend in medicine, Pay-For-Performance. We went to an excellent seminar about it this morning, so I'll let him do the honors of a formal recap. I just thought I'd put up some quick knee-jerk reactions to the whole thing.

The idea of pay-for-performance is that doctors will be monitored with regard to various yet-to-be-defined standards of health-care delivery and rewarded (or not) in response to adherence.

First of all, the thing that struck me was that everyone agreed that doctors needed to be measured but so far no one can agree on a ruler. Multiple governmental agencies, health care businesses and professional organizations have a finger in this pie but so far no one has pulled out a plum. There were obvious things discussed like requirements for proper physical assessment or laboratory monitoring, patient education, continuing education and the like but as each aspect was brought up there were parallel problems involved with the assessment. My favorite example: a proposal to make family involvement in patient care a benchmark. OK, sounds good. In prison? The family involvement we get there is the accidental kind, where they happen to meet in a holding cell. Another benchmark: proper referrals for psychotherapy (got any therapists handy over there in maximum security?).

But the main issue as I see it is that the physician becomes the sole endpoint of a very complicated healthcare delivery system. Adherence to practice guidelines could be a useful measure of healthcare quality, but what if the patient doesn't want to take those medicines? Or if you've already been through the guideline decision tree (meant, after all, for the easiest case scenarios which are never the ones I get)? There are just too many 'what-if' scenarios to really tailor one quality measurement system---an inpatient unit is different from a partial hospitalization program, which is different from an outpatient clinic which is different from an emergency room. And none of the guidelines or benchmarks even considered the possibility of a correctional environment.

Consider this: the state saves money by not providing resources to the health care provider. They set the benchmarks, then fine the health care company for failing to meet the benchmarks that they have not provided the resources to obtain. A financial win-win situation for the state. Now comes pay-for-performance, the dynamic now trickles down to the level of the individual clinician. The question that I asked the presenters---and which brought the room to a dead silence---was whether or not the P4P approach would lead to any requirement that publically-funded health care systems actually provide the resources to meet their benchmarks. If so, sign me up.

In the meantime, I can't wait for my final benchmark: the patient satisfaction and quality-of-life survey. Of course, in my situation that would be the quality-of-life-sentence survey.

Friday, March 23, 2007

The Blogging Shrink Part II

I have to say, I never worry about my patients reading the blog. Which is not to say it's outside the realm of possibility---after all, prisoners use the Web to advertise for pen pals. Here's one who describes himself as:

"I'm a passionate, romantic, sincere friend who has ambitions and goals. I enjoy reading creative writings, studying the law, horseback riding, dining out, and going to museums. I like vacationing and taking romantic walks on the beach. Looking for pen pals..."
(link not provided because I'm not trying to encourage this sort of thing)

Theoretically somebody could be printing out my posts every week and mailing them inside the walls to my patients. Frankly, if anybody actually went through that much trouble I'd be rather flattered. And then maybe a bit alarmed.

There are three reasons why inmates express
curiosity about someone---for flattery, for intimidation or just out of boredom. They wonder where I'm from when my accent slips out ("Charm City, but not originally."), why I don't wear a wedding ring ("I don't bring jewelry into the institution.") and whether or not to wish me a happy Mother's Day ("Thank you."). Rarely I get a direct personal question, and then I just give a direct response: "I don't talk about myself in here. This is your time." They accept this.

I have run into my patients after release (their release, not mine. I don't see myself being released for quite some time). Usually they recognize me first since once they're out of the standard-issue too-big or too-small jeans and grey t-shirt they just don't look the same. Only once have I run into a former inmate who didn't acknowledge me or seem to recognize me, and I understood that. I doubt anybody would necessarily want a reminder of an unpleasant place.

So I really don't think about it too much. And honestly, when it comes to finding out about someone through the Internet they have a lot more to worry about than I do.

Thursday, March 22, 2007

The Blogging Shrink

In the comment section of ClinkShrink's Max & Me post, some of the commenters have started a discussion about what it is one does or doesn't want to know about one's shrink and what it might be like to read the blog of one's very own shrink. I've been thinking about this for a couple of days now, and I thought I'd turn my response into a post.

For those who haven't been here since the beginning to hear about my blogging angst, I started the blog last April after feeling a bit overwhelmed by the winter. I'd returned in November from a brief time in Louisiana with the Katrina Assistance Project, I had a bunch of patients who'd been having problems, I was feeling demoralized with my lack of success in getting my novels published, and I wanted a forum to express some of my thoughts -- more about psychiatry but a little about my own life-- and I wanted to engage interested parties in discussion about topics in psychiatry. My field, it seems, lacks consensus on much of anything, I'm not always very comfortable with uncertainty, and it's fun stuff to discuss. For me, a lot of it is about the writing. I asked ClinkShrink and Roy for help, and have been thrilled that they embraced this project with so much enthusiasm and investment. One of the best things about Shrink Rap is that my friendships with both of these wonderful people have grown, both on-line and in Real Life. Shrink Rap is now a part of my life, it occupies my thoughts in a stimulating way, I love the discussions we have here, and I've enjoyed "meeting" the readers who engage us in both intellectual and entertaining conversation. The blog has been a really good thing.

When we began, I debated using my own name, and initially used my full name. ClinkShrink and Roy were clear on the matter-- they were using pseudonyms. Though, as time and the My Three Shrinks Podcast have moved on, they are both aware that anyone who wants to figure them out, can. I had already published a novel, I'm very active in our local professional organization, here and there I've had a non-fiction rant published that people comment on. In the psychiatric community, I'm not particularly low-profile, and anyone who really wants to Google me can read about my thoughts and my life in a variety of forums. So why not? --and our blog bears my first name.

I've been proud of Shrink Rap. I ask my friends to read it, I mentioned it in our family Holiday card, I tell other shrinks, I have the URL on my C.V., even my big brother subscribes. I am who I am, and with my name plastered to it, I'm happy to talk about my thoughts about psychiatry, to let the people I know in a bit on my emotional life, to rant, to be a little sarcastic (couldn't we call it Witty?), to be playful and have fun. Some of it's a bit intimate, but nothing here is terribly personal-- aside from the dog Max and his friend Tex who have been mentioned by name and pictured-- I keep anything I don't want the world to know off the blog. The fact that it holds my real name serves as a constant reminder that I'm accountable for what I say and to me this feels right. A bit of writer's narcissism mixed in as well.

So what about my patients? This has been a complicated issue for me and it comes to life again as readers comment that they would be distressed to know so much about their shrink. Ultimately, in my life in a variety of roles-- wife, mom, dog owner, shrink, novelist, ranter, exerciser at a gym where some of my patients go, grocery shopper, restaurant patron, and the list marches on-- I've been left with the "I am who I am" conclusion. I suppose I'd rather my patients didn't read my blog, mostly because I don't want to upset anyone, and so far I'm not aware that anyone has. I don't tell them I have a blog (or a novel for that matter), and it doesn't readily pop up by googling my name. There are actually a bunch of people with my name out there and for the record, I'm not a dietitian in Dallas.

In the office, I offer little about myself. I wear a wedding ring, but don't have photos of my family. I offer little about myself for two reasons: psychotherapy is about the patient and everyone is more comfortable (me especially) with some boundaries in place. A handful of patients know about my novel, a few have read it. The novel makes Shrink Rap look like a fairy tale and has been a bit upsetting, I believe, for the patients who've read it. I can't, however, come to terms with the idea that I shouldn't write, or should do so only undercover, because it might upset my patients. There are many things in life that psychiatrists do that would upset their patients, I suppose the question is how much of oneself is the shrink obligated to mask in the name of being who their patients would like them to be? Outside the office, in ways that don't immediately impinge upon the lives of patients, I believe a psychiatrist is entitled to be whoever he or she is.

So, if my patients hunt my blog down, that's fine. I write with them over my shoulder, I'm aware the possibility exists, that the probability even is that some will find this. If a patient wants to tell me they've read Shrink Rap and use it a focus for a therapy session (or many sessions), that's fine. If a patient wants to read Shrink Rap and never mention it, that's fine too. If it's too much, too intimate, then I'd hope that patient would simply not read.

Wednesday, March 21, 2007

Medicines: The Good, The Bad, & The Ugly



So humor me while I talk a little about medicines.

The Good


The Bad:


The Ugly:

So what do I tell patients?


Monday, March 19, 2007

Giving up my day job!!

Woo-woo! We made ten bucks! Some kind, anonymous reader (I think it is the one who's been yankin' our chain lately... thanks, bud!) made a donation in our virtual tip jar for 10 bucks. I really didn't expect anything to come of this. (Excuse me but gotta go use my steroid nasal spray... allergy time.)

Some of you may have noticed that I added an Amazon Giving button at the bottom of our sidebar a few weeks ago. This is a nifty way for people to contribute to a website they like, even as little as a dollar.

Why do we -- three U.S.-trained, working physicians -- want to panhandle on the internet for pocket change? We can afford $5 per month for the bandwidth costs (Siteground: 900GB per month!! Best deal on the Net!), or a C-note for a microphone (insert affiliate link here). I wasn't really sure why I did it, but I think I figured it out. It's like putting money in the hat of a street performer.

But then I saw this interview on Rocketboom. The two guys who dreamed up lonelygirl15 -- one is an attorney (Greg Goodfried) and the other a surgeon (Miles Beckett) -- left their safe, professional, paying jobs so that they could devote all their time to, their new website where visitors can interact with Bree (lonelygirl15) and other not-real characters. For this they expect to eventually be able to cash in bigtime, with their 1.5 million views per week (hey! we get 1.5 thousand, so watch out Greg & Miles).

So I am now in-f'n-spired. I have handed in my resignation as Chairman of the Department of Psychiatry at Bigtime Medical Center so that I can devote all my time to That's right! In two weeks, I'll be unencumbered so that I can spend all my time devoted to improving our $ite for our loyal readers. So start clicking that button, folks. Every 108 minutes.

Oh, sure, Wife was surprised. Even a little upset (I think she's jealous). But then I showed her how just by clicking a button, millions of readers can contribute $1, $2, even $10 each. That really adds up. I could tell by the look on her face that I convinced her that this is the real deal. In fact, she's on the phone right now, even as I'm typing this, calling her attorney (probably to get advice on how to handle the coming tidal wave of cash).

Maybe I'll add some virtual shrinks for visitors to talk to. Like lonelyshrink42. Or Eliza. Or Max. We'll do a daily videocast, like Dr. Anonymous did (but talk faster, with shorter pauses).

This is gonna be big! Look at those visit counters spin.

What's that, Wife? Someone's here for me? Whoa, check that out! There's a car with flashing lights outside... probably my police escort to the bank or something. Man, word gets around fast!

Gotta go, folks. Thanks for the tips! (no, really, thank you) (better not forgot my steroid spray...this stuff is great!)

Life is Full of Risks

The next time you step into your car, stop and think for a moment about the risks. The following things might happen. You could have a fender bender or bump into an inanimate object, causing damage to your car, someone else's car, or some one's property. It will be expensive to repair, your car insurance rates might rise and if it happens repeatedly you may become uninsurable. You could have an accident in which you are injured--perhaps with broken bones that will take months to heal, internal bleeding which may require emergency surgery and cause organ damage, or anatomically unnoticeably muscle or nerve injuries which could cause you years of chronic pain and disability. You could have injuries which leave you scarred and disfigured, you could become paralyzed and never walk again, never have use of your arms, require a respirator to breathe. You could die. And even if you're a very safe driver, there is no guarantee that someone else on the road isn't intoxicated or simply careless. And maybe you're not a great driver, and in a moment's distraction while you fiddle with the radio or respond to a child's request, you are at fault in an accident that disables another human being. You may be sued. You may have to live with a lifetime of guilt for the distress you've caused others in a moment too short to contain an ounce of bad of intent.

And while the likelihood of something bad happening is low for any given trip to the store, in the course of driver-lifetime, it is not an unlikely thing. Nearly everyone has had a fender bender; many many people have been in car accidents resulting in some form of injury to someone, thousands of people die in motor vehicle accidents in a given year-- nothing about the risk is anything but in your face.

And still, you will get in your car, just as I will soon get into my car. It's important to get to work, we all need to pay the mortgage. And we're out of chocolate sauce, what is ice cream without the topping? The kid really should learn to play guitar, gotta get him to those lessons. We take the risk because we do it so much, we've extinguished our anxiety about a very real danger. We take the risk because we've decided the quality of our lives is better if we do. And there are a whole host of reasons why every car doesn't simply have the very best safety rating and why someone would purchase any car that isn't the absolute safest one available.

This was a long way of saying, when you take a medication, there are risks. The prescribing doctor should tell you those risks, even if the patient is also a doctor, even if the patient really needs the medication but won't take it if he's told of the one in a million shot of death. The risks may be immediate, they may be long-term, they may be unknown, especially for the medium and long term. Each doctor decides what risks to tell patients, and honestly, these decisions are colored by some very non-scientific things. If the doctor took the drug and it didn't work for him or he had an unpleasant side effect, if he just saw a patient who had a dramatic bad effect even if it's known to be rare, if the last seven people walked in thrilled with how much better Drug X has made them feel, all with words of praise for the wonderful prescriber. No doctor tells a patient every possible side effect-- we simply can't remember them all, time doesn't allow for such lengthy discussions, many patients don't want to hear it. And while a patient should be warned of the more common side effects, will be told of any potentially life-threatening possibilities as deemed by the fated Black Boxes, many are coming for treatment because they are in pain or anguish, physical or mental-- they want the distress to go away and it's obvious that there is risk involved-- they're willing to accept at least some risk in exchange for the possibility of relief.

Stayed tuned for the next post: The Good, The Bad, & The Ugly -- more about medication. But first, I need to run to the store.

Sunday, March 18, 2007

Economist Suggests Changes to our Health Care Delivery System: P4P vs P4V

I posted briefly about Pay-for-Performance (P4P) efforts earlier, describing them as the next step in attempts to reduce health care costs while wrapping it up in a package to make it look like an attempt to improve quality.

I remain skeptical that this is the wrong approach. Insurance company bureaucrats will have us "teaching to the test" in the same way that primary education has gone... and with the same disastrous outcomes, I fear. Kids can answer the questions, but can they think? Do we want doctors who just focus on keeping hemoglobin A1C's down, speeding up the time that you get the first antibiotic during abdominal surgery, and counting up the number of cardiac patients they have on beta-blockers? Will we get lost in the forest, just tending to the trees?

Harvard economist, Michael E. Porter, in last week's JAMA, addresses P4P and broader health care delivery issues in a manner which I find very appealing. It places physicians back at the table, while holding us and others accountable for adding value by collaboratively focusing on patient outcome (not process) to improve patient care while controlling costs. In the article, How Physicians Can Change the Future of Health Care, he describes an approach to competitive, cost-effective health care that places the patient back in the center (isn't that what it's all about?), while teams of health care providers work together in parallel (not serially) to address each patient's needs as a connected team, not as an assembly line product. This is apparently what M.D. Anderson and Mayo have been doing for some time.

Take a look at this article and see what you think. If you can't get access to the whole document, email me at mythreeshrinksATgmailDOTcom, and I could send you a few pertinent paragraphs for educational purposes only (for the purpose of comment and criticism). (Or, get his book.)

Dr A Tags Us w/Thinking Blogger Award

Dr. Anonymous tagged us with the Thinking Blogger Award. I'm glad we make people think. Or smile. Or laugh. Any of these will do.
Here are my 5 tagees: Omni Brain; Corpus Callosum; NeuroFuture; Health Care Renewal; and ClinPsyc. Tag, you're it!

UK Doctors Protest NHS Fiasco

This whole British MMC thing is just out of control. If you've been following along on some of the UK blogs in our blogroll (like the Psychiatrist Blog or Trick-cycling or DrCrippen) then you know about how the government has set up this new system, akin to the US "Match", to connect young doctors with training sites. However, they've really botched it, and it seems more like the military, where you go where you are sent. Yesterday, twelve thousand junior doctors marched in protest about this crappy system. It is amazing that this many docs got together to do this. It says a lot about how messed up this is.

"They fear the Government's Modernising Medical Careers (MMC) scheme, designed to speed up the training process to become a consultant, will split families, drive some doctors abroad and force others to leave the profession.

Some 30,000 are competing for 22,000 posts allocated under a computer-based system, plagued by technical problems, that critics say takes scant account of the suitability and experience of candidates.

Concerns about the new system, which was introduced in January, came to a head after The Daily Telegraph gave a voice to angry and dismayed junior and senior doctors."

Max & Me

I've been off the blog for a bit of housesitting at Dinah's B & B, caring for Max the Magnificent. I must say it's been rather nice being away at a place with no Seroquel discussions, no one accusing me of abusing my "god-like powers" (I think I missed that class in medical school) or going on about how abusive and useless my profession is in general to my patients.

I haven't missed that. Besides being complete and utter poppycock (insert your own international colloquialisms here) it is just rather poor manners to come to a blog purely to insult the bloggers. I enjoy a good conversation but not when it turns to accusatory harangues.

If you don't like psychiatry or psychiatrists you are free to choose another healing paradigm if you wish. If you disagree with the parens patriae role of psychiatry you may go the legislature and change the civil commitment or involuntary treatment laws. Heavens, there are a couple states here in the US that have even authorized physician-assisted suicide.

I'm caring for Max now because he's afflicted with the condition of being a dog. Now maybe being a dog isn't a disease, but he still needs someone to look out for him and I've enjoyed doing it. I scratch Max's butt because that's what he wants. He comes to me regularly for it and I do it even though there is no scientific evidence whatsever that it will be helpful or therapeutic and I can't guarantee there won't be side effects or unforeseen harm from it. I've never forced a butt-scratching on him. I do things to prevent him from coming from harm even if that sometimes frustrates his wishes. These are just the basics of what you do when you're responsible for caring for another living creature.

Being willing to care requires no apology.

Wednesday, March 14, 2007

A Perfect Mess: The Hidden Benefits of Disorder

I read about this book in Newsweek. It describes data that suggests folks spend way too much organizing, and that sifting through chaos has its benefits.

That's my kind of story.

Tuesday, March 13, 2007

Why I Still Prescribe Seroquel

In my post below, Things I Wish I Knew, I talked about how I'm uncomfortable with uncertainty, in particular when I'm the one to make decisions for other people and don't really have any way to know the full consequences of the decisions I make for them.

I mentioned a number of things I wish I knew, most didn't draw much attention, but two topics did: The consequences of allowing children to watch video games, and the issue of prescribing novel antipsychotic medications off-label, as opposed to Xanax.

Enough about VideoKid--Spring sports have begun and he'll have gobs of homework as the school year ends, he's looking for a job, thinking about college, learning to drive, it's soon to be a moot point. We're doing our best here and it's an imperfect world, what can I say.

Instead, I'll tell you why I'm more comfortable prescribing a very low dose of a second generation anti-psychotic (usually either 25mg of seroquel or 2.5 my of zyprexa) off label when someone is subjectively distressed---let me call it agitated, it's hard for me to say because I'm not inside their skin. Often these are folks who have bipolar disorder or have an agitated major depression, and the dose of the antipsychotic is given on an as needed basis (determined by the patient) until something else kicks in. I don't think I've ever given this as the sole agent unless the patient has simply refused other medications.

To put it simply, I give these medications instead of Xanax because they are easy to stop. No one gets stuck on them, no one makes me uncomfortable by demanding that I continue to prescribe something that is no longer needed. People take them When Needed (usually a handful of times, or a few times a week). Xanax helps, and people take it a few times a day, maybe it helps so much they take it a few times every day, maybe it helps so much they take it a more than I suggested, and they don't want to stop, and if I refuse to continue to write for it they become demanding, or call repeatedly in distress insisting I MUST give them something, and I'm faced with the issue of refusing to write for it and risking that they'll withdraw and possibly seize, or writing for a medication on on-going basis that I'm not comfortable with, sometimes after it's been escalated to doses where I wonder if the FDA will hunt me down. This just doesn't happen with low-dose anti-psychotics.

Okay, in reality, I never use Xanax, so this has only been an issue when seeing patients that other docs have started and maintained someone on (up to 8mg a day, chronically, ouch!). But if the same patient as above shows up and there is no reason not to, I may use Ativan (lorezepam) or Klonopin (clonazepam) in the same way. I agree, if they can be used in the short term, and if someone doesn't become addicted to them or physically dependent or tolerant, the risks are less. So, I weigh it in my head: Is there a history of addiction? (yes-- no benzos). Is there a history of or current alcohol abuse (punt). Does the patient get distressed when I tell them they can't drink on this medicine? If there is no history of alcohol or benzodiazepine abuse or dependence (they are cross reactive), if the patient has been on a benzodiazepine before and had no trouble coming off, if they drink sometimes but have no history of alcohol abuse, then I feel comfortable prescribing a benzodiazapine. I give a small amount, and I tell them it's a crisis medication, not for regular use. I warn that it can be sedating, that it can be addicting. Most people worry about that: it's a good sign. It's the person who assures me that he won't get addicted that I worry about.

When I use a novel anti-psychotic, I tell the patient that it is a low dose and that the medication is associated with precipitating/fast-forwarding the onset of diabetes, lipid dysregulation, and weight gain. I suggest they take it only when needed and that they stop as soon as possible (there is no withdrawal to low doses). One of our commenters said that even low doses cause difficulties, even "kill" (I assume this means weight gain, diabetes, dyslipidemia)-- this may be, but in my personal experience, I have not seen problems with periodic low dose medication. Maybe I've simply been lucky to date.

I don't insist that anyone take any medication they don't want to take. Nor do I recruit patients, I'm an outpatient doc, people come to me, often asking for medication. I have never said to a patient "If you won't take this medication, I won't treat you." I tell them what the studies show, I tell them what I think they should do, if they don't want meds and they still feel helped by coming to see me, I see them.

We live in a society that values the right to make choices, even bad choices. We allow people to smoke and to drink alcohol, despite the fact that the risks they expose themselves (and others) to are both huge and certain, the cost to society exorbitant. It is unfortunate, perhaps even tragic, that we don't have medications with no side effects or ugly adverse effects and I wish that weren't so, it would make my job so much easier. But given the options we have, when I see someone in distress, I'm faced with what I know-- and that is full of uncertainty . Will this medicine make you sick? Will you have a recurrence of your illness without it? Will you have a recurrence anyway AND get sick if you take it? Given that there is no free ride, the other option is to refuse to prescribe, and that carries with it lots of other risks, the denial of something that often helps, and the message of there is no hope if you can't be patient-- and honestly, therapy alone, even great therapy, doesn't always do it. Mostly, I'm left to share what I know with the patient-- including statistics if I have them and if it's appropriate-- but ultimately the decision belongs to the patient, and when they leave it to me, I cross my fingers and do my best.

So no one wanted to comment on the rise in teenage suicide following the black box warning?

Monday, March 12, 2007

got cocoa?

The news is abuzz with the latest research, suggesting that chocolate -- specifically, one of the ingredients, epicatechin -- is one of the most important medical discoveries since penicillin.

Why? Apparently, folks in the Kuna tribe, near Panama, have incredibly low rates of stroke, hypertension, heart disease and cancer. They also drink an average of 5 cups of cocoa per day.

The stuff appears to be a great antiinflammatory drug, as well as an immunomodulator which helps to prevent cancer. What the hell... let's say it's a great antidepressant, antipsychotic, and antianxiety treatment. We three shrinks are going to open up a posh, inpatient psychiatric program, called The Cocoa Retreat, where i.v, i.m, and p.o. forms of chocolate flow ad lib. You can bathe in it, too, because (of course) it prevents wrinkles. We will only take cash (or its equivalent in cocoa).

Sunday, March 11, 2007

Between A Rock And A Hard Place

I want to thank Michael (see his comments on my 'No You Don't' post) for sending along a link to a very interesting case. Even if you don't work in corrections people should really read this; it provides a revealing description of the hard place correctional facilities & personnel get stuck in when working with very difficult inmates.

The case is a complaint to the United Nation's human rights committee filed by an Aboriginal juvenile in an adult Australian prison. The 16 year old detainee was involved in a riot in a juvenile facility and took someone hostage. He was transferred to an adult correctional facility (following a conviction for armed robbery) where he was placed on segregation both for institutional security and for protection from adult inmates. While there he attempted suicide and threatened self-harm if not removed from segregation. While being placed on suicide precautions (which involves removing the inmate's clothes) he kicked an officer in the head. To make a long story short, he had repeated episodes both of self-harm and aggression toward officers. He was given at least two additional prison sentences for convictions related to assault on correctional staff. He was prescribed an antipsychotic medication (what's 'Largactil'?). In the complaint it's alleged that the inmate was prescribed the medication without an examination, and that when the examination took place it did not support any diagnosis requiring medication (or so I'm reading a rather obscure quote). The inmate admittedly took the medication voluntarily after a period of involuntary treatment.

I'm obviously not familiar with the legal procedures for transferring Australian juveniles to adult facilties, but regardless the meat of the claim appears to be that once in an adult facility the inmate had no effective legal means of challenging his punishment or alleged inappropriate treatment. He could follow an administrative appeals process but this apparently didn't provide for damages or any judicial power of intervention. (Correct me if I'm wrong, but that's how I read it.) The human rights court found that most of the interventions did not violate the inmates rights except as regards certain episodes of length of confinement (going more than 72 hours without out-of-cell time) and removal of his clothing. It specifically found that giving an antipsychotic medication did not violate the International Covenant on Civil and Political Rights (see point 9.5 under 'discussion of the merits'). It also doubted the utility of a tort claim due to lack of clear damages.

In free society American physicians adhere to certain protocols when giving orders for the use of seclusion. American prisons also have policies and procedures for this; failure to follow policy has been the ground for Department of Justice intervention.

Does Anybody Here Really Know What Time It Is?

I guess it began a few weeks ago when my good friend ABF began complaining that her husband had to work all the time. All the time: like around the clock on his vacation week. He's a computer geek and his company was preparing to deal with the DST issue. For those of you still in the dark--that's this year's rearrangement of Day Light Savings time such that we sprung ahead today, three weeks earlier than the world here in the Eastern Time Zone of the USA usually springs. I'm assuming that psychiatrically this will be for those with Seasonal Affective Disorder prone to winter depressions, and time will tell--sooner rather than later--if spring time manics will be dancing earlier.

I thought about it again when a patient mentioned he was overwhelmed at work--another computer systems guy getting ready for the change.

I didn't think it was about me.

The first hint came yesterday morning when an e-mail arrived from Palm: I had to go their website and do something so my Palm Pilot would remake itself into a properly sync-ed sort of machine. Great.

8:50 AM, the phone rings (it's Saturday and I am not a morning person, please wait until 9, but okay, I was up and drinking coffee). It was my friend Camel (see previous posts), on the way to the office to update her Palm. Did I do this? Did I want to do this together (she lives an hour away, but hey, what are cell phones for). I was off to the hairdresser, then to watch videokid play baseball (like in real life, not on a screen), it would have to wait.

I visited Palm's website. I would have to visit Microsofts website and I might (might?) have to download two updates (no, I don't have the microsoft updates automatically downloaded). It didn't say Which two updates --would that be too much to ask? One was obvious--something to do with DST/2007. Oh, but first I needed to download ActiveX. My screen didn't do what it said to do. I went to the baseball game.

Fastforward: note first that videokid's team won both games of the all-day tournament. Okay, we now have ActiveX. I think the second update was for Outlook to update to 2007. But it wouldn't download and I don't use Outlook.

I returned to the Palm site. It warned me Don't Download This If You Haven't Downloaded the Microsoft Updates. It still wouldn't tell me Which updates. I hit Download. It downloaded. Mission complete?

So I opened my Palm software. Everything looked fine. Oh, except that Mrs. Jones always comes at noon on Friday, and for the next three weeks, it seems she's coming at 1. Huh? In four weeks, once the regular world resumes on the old DST, Mrs. Jones will be resuming her noon appointment. Hmmm, seems everyone shifted an hour later.

I called Camel (her husband is also a computer geek). No answer. No answer either on her emergency life-or-death-line (yes, I called it). I called my husband, which oddly enough through today's technology means that from the third floor of our house in Baltimore, I dialed a number in Philadelphia to reach his blackberry, to ask that he come upstairs to help me (he and the Philadelphia blackberry were on the second floor of the Baltimore house). He was clueless. I called my brother, yet another computer geek, who told me how he'd spent the last 16 hours working on his hard drive. He thought the problem might fix itself at 2 am with the official time change.

"So it will be fine in the morning."

"I give it 50-50."

Great. In the meantime, I didn't hot-sync (Clink will tell you how stressful an experience that is for me anyway).

I woke up this morning at whatever time it was in whatever time zone I live in. I went up to the computer, pleased to see it had set itself to the right time. I fixed the clock on the wall, which oddly enough has a battery and winder. I opened my Palm software on the computer, and you guessed it, Mrs. Jones it still set for 1 on the next three Fridays. In my unsynced Palm handheld, she remains scheduled at noon.

I can't be the only one.

Saturday, March 10, 2007

No You Don't

I think Dinah raised an interesting topic in her last post. Can psychiatrists ever refuse to treat someone, or to treat them only under certain conditions?

I'll leave Dinah and Roy to talk about the free society way of handling that; I can address what happens inside the walls.

The patients I treat get locked up because of persistent misbehavior or persistent high-risk behavior. (I don't call it 'self-destructive' behavior---even though it is---because inside the walls that term has a very different connotation.) I don't really ever have the option of not treating someone. My clinic is never too full to accept new patients and our jail/emergency room never goes on 'fly-by' status due to lack of bed space. So, I get all comers.

That being said, I do have certain limits. By the time I get my patients they are generally ready to accept the idea that their behaviors are getting them into trouble. The biggest issue is how to handle the interventions from that point on.

The biggest trick with treating substance abusers is that there's a big difference between what they say they want and what they actually want. They say they want to be drug or alcohol-free, to give up 'fighting the system' and to get themselves together. But at the same time they want to be in control of treatment, in control of their environment and to have it all done on their own timeline.

This is a setup for frustration.

Fortunately, it's all manageable. The key is to be upfront about expectations and limits and to be true to your word. Inmates can accept a 'no' but it's a very very bad idea to imply you can or will help them with something you have no control over. I don't make housing or cellmate changes, I don't order lower bunks or special diets, I don't make phone calls or transmit messages for inmates. That's pretty much the easy part.

Occasionally inmates aren't happy about that. Very rare inmates may escalate their requests along a continuum that I can pretty much predict: a hint for a favor turns into a direct request which turns into a demand which turns into a threat. Once you reach the demand/threat point treatment stops.

So getting back to the idea of conditional treatment, my only real condition is the requirement for safety. Once a patient gets to making a threat of violence to me, to himself or anyone else, treatment stops and safety interventions begin. That's really the only way to get things back on track.

Thursday, March 08, 2007

Things I Wish I Knew

We come to day with day with a list of Shoulds we take at face value (--where would you like me to begin? Don't smoke, don't drink excessively, don't be overweight, exercise, take your meds, ingest enough calcium, don't shoot heroin, stay out of jail, don't quit too many jobs, get your screening colonoscopy at 50, yearly mammograms after 40, wear a condom, sunlight is good, sunlight is bad, sunscreen is good, sunscreen is bad, coffee is good, coffee is bad....) only to have them rethought time and again. Roy is now finally off his HRT or so I'm told, he still doesn't look post-menopausal to me.

A few things I find myself wishing I knew the answers to:

Will my children be damaged by all the video-game playing I allow?
Will my relationship with my children be damaged if I don't allow them to play video games and survive the inevitable fights it will cause.

If they go out to ride their bikes instead-- nice healthy exercise--will I wish they'd stayed safely home playing video games if they get hit by a truck?

Why didn't my children come with instruction manuals?
--Inspired by yesterday's snow day and my patient today who is consumed with guilt and a sense of perfectionism with regard to her parenting. Something it's easy to distance myself from during a psychotherapy session, but sometimes strikes a bit close to home.

Will some awful consequence of Gardasil (the new HPV vaccine) be discovered 20 years down the line?

If obesity is so fatal, why, since the 1950's are there so many more obese people and why is the average lifespan 10 years longer?

Why do some people seemed to be unscathed by decades of smoking marijuana?

When my patients chronically misbehave and are completely uninterested in changing (for example, young people who enjoy spending their time drinking to excess in bars, others who repeatedly and without regret sleep with strangers, those who consume large doses of prescription narcotics prescribed by someone else, or people who just won't entertain the idea of abstaining from marijuana)-- am I wrong to continue to treat them on their terms?

If I simply refused to treat them unless they get treatment for their addictions, would they a) stop coming, b) stop telling me about their bad behavior, or c) get treatment and clean up their acts?

When a patient complains of intolerable feelings of agitation or other vaguely defined distress, and gives me the "walk a mile in my shoes" talk, is it wrong that I sometimes offer a prn very low dose of an second generation anti-psychotic, along with the warnings about possible induction of diabetes and dyslipidemia, and let them make the decision about whether to take it? Is it funny that I never ask myself if I should offer that script for very low dose prn Xanax which is what they really want?

And what about the patient whose last depressive episode (of many) lasted nearly a year and who has never been able to tolerate lowering her zyprexa, should I stop it given that her risk factors for diabetes and heart disease are screaming in my face (they preceded the zyprexa, but it can't be helping)? How do we know the worst of two evils?

Were those 250 extra children who died of suicide in 2003 compared to 2004 (see Pediatrics, annual vital statistics, death figures on page 13), children who were not taken for mental health care, or not offered anti-depressants because of the Black Box Warning added to anti-depressants by the FDA?

Sometimes I wish I had a crystal ball that worked, one where I could fine tune it to ask the subtle what-ifs. When it comes to the long-term prognosis for diet Coke and hair chemical abusers, well, there are some things I just don't want to know.