Saturday, November 30, 2013

Organized Medicine Is a Real Trip,  Always Bashing the Clinician

Sending this letter. 


November 29, 2013

Chairman, Education Committee
Pennsylvania Psychiatric Society
777 East Park Drive
Harrisburg, PA 17111
1-800-422-2900 PH
717-558-7841 FX

        Re: Patient Safety and Risk Management 2013

Dear Doctor:
I am adding some missing commentary to the program. I hope you will share these comments with all faculty and attendees. The program was overly harsh,  negative, and unfair to the clinicians described, thus misleading. If you decide to provide your own corrections, let me know.

Internet.
All patients have access to the internet. This makes the process of informed consent automatic, and all patients now have a duty to Google. They may get as much information as any psychiatrist may have. They may look up information they cannot understand. So all claims about lack of informed consent are now frivolous, and should be automatically dismissed by the court.

There could also develop a duty to Friend, since patients will often communicate an intent to harm themselves and others on social media, and not tell the clinician until later, or never. The paranoid schizophrenic who shot people at a Batman movie in Colorado did so. The categorical prohibition of Friending patients as boundary crossing comes from silly transference concepts in psychoanalysis. The latter is a form of quackery, and psychiatric rules should not be based on such inferior conceptualizations. If a clinician harms a patient via social media, then boundary crossing has taken place.

Until the antiquated thinking of organized medicine has changed, it is a good idea to ask patients to Friend members of the family, as part of safety planning. This is similar in intent to the suggestion of informing family of urges o harm self or others, and to cooperate with eyesight supervision, as an effective alternative to hospitalization.

Safety Issues in Prescribing Hypnotics
1) A patient has an accident, and blood is taken. If it contains a benzodiazepine but no alcohol, the patient will get treated like a drunk driver. Patients need this warning.

While there is habituation of the brain to opiates and to benzodiazepines, the breathing center (http://en.wikipedia.org/wiki/Control_of_respiration) habituates to opiates but not to benzodiazepines. So the lethal dose of these drugs is the same as before the patient ever took any, with wide individual variability, and an unknown amount. See the death of Whitney Houston ( http://www.thedailybeast.com/articles/2012/02/13/whitney-houston-s-death-xanax-and-alcohol-deadly-duo.html). See the review in Postgrad Med. 2013 Jul;125(4):115-30.

Elements of a Med Mal Lawsuit

Four elements are listed. A fifth one is missing. It is of essential importance in cases of suicide. Its application should end almost all cases of malpractice for suicide of a patient.

5. Legal Causation. The fourth is Direct Causation: the patient’s damage is the direct result of the doctor’s negligence. Legal causation requires Direct Causation plus the total absence of “An Unforeseen Intervening Cause.” The definition is, An intervening act or event which overwhelms a defendant's antecedent negligence and prevents him/her from being liable. In every single case of suicide there is an intervening cause. In half the cases, the victim is intoxicated on alcohol or drugs. In the overwhelming majority of suicides, there are no prescription psychotropics in the blood, implying non-adherence with treatment. Treatment of ordinary psychiatric disorder is the single most powerful way to prevent suicide. Most victims have relationship problems driving their urges to kill themselves. Here is a long list of unforeseen intervening causes, covering 99% of suicides, http://www.suicide.org/suicide-causes.html. Each case should be analyzed for such, and no suicide case should prevail. Only cases of assisted suicide in states prohibiting it are justified. Even then one may make the case that treatment resistant depression is as bad as metastatic cancer, and that suicide may be a humane alternative.

Determining the Standard of Care. All listed items represent garbage science, and should not be allowed to be introduced. If they are, the defendant should file a cross claim against the authors, their publisher, and their supervisors in academia. Only an expert in the same field, and with the same credentials may describe the standard of care. There are no authoritative texts because any written advice is cookbook medicine, lacking the individualization of care required to meet any standard of care. The use of rating scales as part of any standard is also garbage science.

Unfortunae Truth. If you have not been sued, you will be.

Doctors should stop being crybabies. If a practice grosses $5 million a year, and has 4 lawsuits, doctors will get upset. A welding business or a store, or a service business grossing $5 million will have 400 lawsuits all the time. Walmart has 10,000 at any one time. Lawsuits are part of business in this county. The alternatives are much worse. One is a violent vendetta for 100 years. The other is government regulation. Only the tiniest fraction of malpractice acts are ever pursued in court, because they are not lucrative enough for lawyers, or the patient has undesirable personal characteristics, especially a mental illness. So things can only get worse wi th any change.  Even in judicial hellholes for defendants such as Philadelphia, physicians win two thirds of cases (http://www.pacourts.us/assets/files/setting-771/file-2715.pdf?cb=bd9d58).

Better Coping: Counterattack the plaintiff lawyer, to drive them from the business. Just about all behavior in a case has legal immunity. However, there is recourse inside the trial and from the court. Seek e-discovery on the plaintiff lawyer’s and on the plaintiff’s personal and work computers, seeking an improper motive for the suit, such as animus toward doctors. Any purpose other than money compensation for damages is an improper purpose. For example, “It’s not for the money.” “So it does not happen to others.” “Psychiatry is quackery.”

Look for any misstatement of fact by plaintiff witnesses and experts. Opinion is immunized by the First Amendment and by the litigation privilege. One may not lie about a fact, for example, I read this report, when the expert has not. A motion for a mistrial and for all legal costs to the assets of the witness should be filed. The judge may sanction perjured testimony from the bench at trial. This has been done.

This has not been done yet. The defense of Outcome Bias (http://en.wikipedia.org/wiki/Outcome_bias), an error made in evaluating the quality of a decision when the outcome of that decision is already known. Even defense experts cast blame when the outcome of a theoretical case is bad, and not when outcome is good, despite the fact that all procedures described are exactly identical. It is one of many established and well studied errors in critical thinking. The list should be reviewed for other biasing effects. (http://en.wikipedia.org/wiki/List_of_cognitive_biases)

The defense  lawyers who are supposed to be on the side of the doctor were overly harsh in their opinions, and insufficiently supportive of the doctor. Doctors must think of all out resistance as an investment in the future of clinical care. Lawyers learn from experience in court. If they win they come back over and over. The limp attitude of these lawyers was personally threatening to me, since they would encourage malpractice claim against others. Doctors should be encouraged to hire a personal attorney to manage and bully the insurance company lawyer. First, he paid very little, and must go to trial to make any profit. Second, he has failed to disclose that he gets his job, not from the client but from the plaintiff lawyer. So he will never hurt, scare, or deter the plaintiff lawyer, however much the client is screaming for more aggressive tactics. However, if the doctor asserts any demand, it will be laughed off. A lawyer malpractice specialist demanding zealous representation will not be laughed off.

Carefully Documenting. There is no correlation between quality of record and medical outcomes. Good records do not mean good care, nor do terrible records mean substandard care. As to electronic medical records, they should be resisted to the utmost because they force docors to become typists destroying productiveity, slowing all encounters, and slashing physician income.

No malpractice claim arising from a suicide has ever had any merit. Even in a Supermax prison, no one has enough control over the body to prevent suicide. There is no duty to commit involuntarily, and suicide is mostly caused by bad relationships, especially with the family scape goating the physician for their own guilt in the suicide.

Kidney Damage from Lithium. In this case, addiction was rewarded with a settlement. It should be general policy to never do that. No permanent damage. No relationship between testing and damage, stemming from alcohol abuse. Get rid of experts, and shun them in the future. Damage was minimal. Standards for monitoring of medication are garbage science. This is unproven speculation. Real malpractice was entirely missed. Making a diagnosis of a mood disorder in an ongoing alcoholic. Proposed process will take many hours, and have no basis in any evidence.  Informed consent is a rolling process of experience and education. Patients now get package inserts, and have a duty to Google. All patients are non-adherent, especially if patient is an expert doctor in the field. Entire population would be terminated. Alternative is to persistently work with the patient.

Patient suicide. No case should be settled short of assisted suicide where illegal. Family far more to blame for the suicide. They should be mercilessly torn apart in deposition, to protect clinical care from scape goating.

Duty to Warn. There are 1000's of threats for every murder. Duty to warn based on garbage science.

Patient Suicide. Plaintiff expert promulgating garbage science. Seek a statement of a false fact under oath, then demand prosecution for perjury. File ethics charges against plaintiff expert. Move for a mistrial if found, with all costs to the assets of the expert. There is a duty to clinical care to deter fatuous, academic, purveyors of garbage science.

Metabolic Syndrome. Seen in those patients in the 1920's, caused by the disease, not the medication. Massive testing represents massive fraud against the federal government. For example, a surgeon puts a stent into every patient who has chest pain, would constitue fraud under the False Claims Act. The occurrence of metabolic syndrome is elevated in patients on these medications, 1 in 500, up from 1 in 1500. You will test 499 people to find one positive patient. This is fraud under the False Claim Act. The subject is not scientifically settled. The courts are not competent to rule on the subject. Medical controversy should not be settled in the court.

Never Events in Psychiatry.

Failure to adequately treat pain is illegal and patient abuse.

Expressing anger to patient can be appropriate sometimes.

Insider tips in the public domain are legal. “Pfizer is rolling out Viagra in three months. Time to buy. “

Sexual relationship with current patient allowed by Pennsylvania court, and affirmed at the Superior Court level. Such relationships may be protected by Lawrence v. Texas. I strongly opposed such relationship because our business is about the body, and we should remain trustworthy with it. The Judges slapped down the 3000 year old Hippocratic Oath prohibiting sex even with slaves who might be patients.

Self Disclosure is insane and unAmerican. It is an old trick. Confess to the Inquisition. Self criticize yourself to the Communist party of Stalin. Go to the stake or get shot. Silence is the best policy to protect clinical care from the lawyer predators besetting it.  We are at war with the lawyer profession, making their job easier is betrayal of clinical care. Joint Commission and AMA are total adversaries of the ordinary clinician. They are fully in collaboration with the lawyer profession.

I would never use the APA recommended insurer if these lawyers are setting policy. They are too pessimistic and dismissive of clincian interest. They will not be aggressive, nor ever counterattack the other side. Why? They owe their jobs to the other side and not to the doctor. They will never deter the other side.

I was personally sued for causing tardive dyskinesia in a child. The claim came after a half dozen successful lawsuits in New Jersey and Pennsylvania. Wach was for $5 million. I had to handle the total resistance. They lost. The plaintiff experts never testified again. The lawyer went out of the TD business. A patient with horrible TD said, no lawyer will consider my case up to 150 miles away. The resistance is an investment in the future of clinical care.        

I hope that if you plan to present the same namby pamby, half hearted review of the legal aspects of care, you let me know. I do not want to attend without the presentation of a lengthy rebuttal of your lawyers. However, they are telling only part of the story.

Sincerely Yours,




David Behar, MD



Monday, April 8, 2013

Clueless Academic Psychiatrist Attack Military Psychiatry

 http://www.nytimes.com/2013/04/07/opinion/sunday/wars-on-drugs.html?pagewanted=all&_r=0


April 6, 2013

Wars on Drugs

LAST year, more active-duty soldiers committed suicide than died in battle. This fact has been reported so often that it has almost lost its jolting force. Almost.
Worse, according to data not reported on until now, the military evidently responded to stress that afflicts soldiers in Iraq and Afghanistan primarily by drugging soldiers on the front lines. Data that I have obtained directly from Tricare Management Activity, the division of the Department of Defense that manages health care services for the military, shows that there has been a giant, 682 percent increase in the number of psychoactive drugs — antipsychotics, sedatives, stimulants and mood stabilizers — prescribed to our troops between 2005 and 2011. That’s right. A nearly 700 percent increase — despite a steady reduction in combat troop levels since 2008.
The prescribing trends suggest that the military often uses medications in ways that are not approved by the Food and Drug Administration and do not comport with the usual psychiatric standards of practice.
The military tests prospective enlistees with an eye toward screening out those with serious psychiatric disorders. So you would expect that the use of these drugs in the military would be minimal — and certainly less than in the civilian population. But the opposite is true: prescriptions written for antipsychotic drugs for active-duty troops increased 1,083 percent from 2005 to 2011; the number of antipsychotic drug prescriptions in the civilian population increased just 22 percent from 2005 to 2011, according to IMS Health, an independent medical data company.
The data suggest that military doctors may prescribe psychoactive drugs for off-label use as sedatives, possibly so as to enable soldiers to function better in stressful combat situations. Capt. Michael Colston, a psychiatrist and program director for mental health policy in the Department of Defense, confirmed this possibility. In an e-mail to me, Dr. Colston acknowledged that antipsychotic drugs have been used to treat insomnia, anxiety and aggressive behavior.
As a psychiatrist and psychopharmacologist, I am familiar with off-label use of drugs. Off-label use is, in fact, standard medical practice. Sometimes we use drugs off-label after we’ve tried and failed to treat various problems with other medications. Often we prescribe off-label on the basis of “class extension,” which involves deciding that if one member of a drug family is F.D.A.-approved for a certain disorder, it’s safe to presume that other members of the same chemical family will work as well.
It is conceivable that the trauma of war might be so psychologically damaging, even to those men and women who enter the service without a mental disorder, that innovative, off-label use of psychoactive drugs might be in order.
The trouble is that we have no idea whether it’s effective — or safe — to use antipsychotic drugs on a continuing basis to treat war-related stress or to numb or sedate those affected by it.

*********************************************************************************
 First, these medications are not anti-psychotic medications. They treat many symptoms of brain disinhibition, for example, hiccups, tics, nausea of chemotherapy, voices, paranoia, anger, sadness, self-injury. So any inappropriate brain disinhibited behavior demands a trial of this family of medication.

Second, Dr. Friedman, has no experience in the field upon which he is commenting, thus is devoid of credibility.

Lastly, academic doctors are most often verifiers of current practice, rather than innovators. Theirs is the medicine of 7 years ago. A desperate doctor faces a desperate patient. Finds a creative solution. It spreads around the world in months. Later, academics with their much less experience hear of it. They set up pilot studies, if really fast, taking a year. They apply for grants. Most are rejected. A small minority get funded. They spend 4 years carrying out the trial. They spend another year analyzing and publishing the data. Meanwhile, clinical doctors have moved on, and are doing little they were doing seven years before.

Sunday, April 7, 2013

The Law Abiding Citizen and the Duty to Kill

In Shift, Police Advise Taking an Active Role to Counter Mass Attacks

The speed and deadliness of recent high-profile shootings have prompted police departments to recommend fleeing, hiding or fighting in the event of a mass attack, instead of remaining passive and waiting for help.
Jefferson County Sherrifs Office
After the Columbine High School shooting in 1999, some police departments began telling officers to act immediately rather than wait for backup.
National Twitter Logo.

The shift represents a “sea change,” said Chuck Wexler, executive director of the Police Executive Research Forum, which recently held a meeting in Washington to discuss shootings like those in Newtown, Conn., and Aurora, Colo.
The traditional advice to the public has been “don’t get involved, call 911,” Mr. Wexler said, adding, “There’s a recognition in these ‘active shooter’ situations that there may be a need for citizens to act in a way that perhaps they haven’t been trained for or equipped to deal with.”
Mr. Wexler and others noted that the change echoes a transformation in police procedures that began after the shooting at Columbine High School in 1999, when some departments began telling officers who arrived first on a scene to act immediately rather than waiting for backup. Since then, the approach has become widespread, as a succession of high-profile shootings across the country has made it clear that no city or town is immune and that police agencies must be prepared to take an active approach.
“We used to sit outside and set up a perimeter and wait for the SWAT team to get there,” said Michael Dirden, an executive assistant chief of the Houston Police Department. “Now it’s a recognition that time is of the essence and those initial responders have to go in,” he said, adding that since the Virginia Tech University shooting in 2007, the department has been training first responders to move in on their own when they encounter active gunfire.
Research on mass shootings over the last decade has bolstered the idea that people at the scene of an attack have a better chance of survival if they take an active stance rather than waiting to be rescued by the police, who in many cases cannot get there fast enough to prevent the loss of life.
In an analysis of 84 such shooting cases in the United States from 2000 to 2010, for example, researchers at Texas State University found that the average time it took for the police to respond was three minutes.

**********************************************************************************
The American male has been totally pussified by the feminist lawyer and its male running dogs. These internal traitors control 99% of the policy making apparatus of the US government. They will crush all self help. This feminization was a major factor in 9/11, and totally covered up by the lawyer dominated fatuous 9/11 Commission. When the American male acted, the third flight was stopped from its intended target. 9/11 would have been impossible on the airlines of nations with less pussified males.

Now, the police is coming around a little.

I take a bit farther. Arm all law abiding citizens, and require they try to shoot and kill all violent criminals on the spot, with total legal immunity for error. If a citizen on video recording, does not take out the weapon and try to kill, they should be issued a ticket for $100.

That would end crime, and the massive lawyer employment it supports. The reason for the pussification, and the persecution of self help is in bad faith. It is to promote lawyer rent seeking.
Malignant Suicidal Urges And the Son of a Celebrity Pastor

http://www.usatoday.com/story/news/nation/2013/04/07/pastor-rick-warren-matthew-warren-suicide/2060337/

Thousands are responding to Pastor Rick Warren's grief with compassion but others use the moment to attack him and his Christian message.

Pastor Rick Warren, the best-known name in American evangelism after Rev. Billy Graham, lost his 27-year-old son, Matthew, to suicide this week.
Uncounted strangers have joined the 20,000 congregants who worship at the megachurch network "Pastor Rick" built in Southern California, Warren's nearly 1 million Twitter followers and hundreds of thousands of Facebook followers in flooding social media with consolation and prayer.
But a shocking number are taking this moment of media attention to lash out at Warren on the digital tom-toms. The attacks are aimed at him personally and at his Christian message
Some unbelievers want to assure Rick and Kay Warren, his wife and Matthew's bereaved mother, that there's no heaven where they'll meet their son again.
STORY: Pastor Rick Warren's son commits suicide
You can find, among hundreds of comments on USA TODAY's news story on Matthew's death, comments such as the Cincinnati poster who says, "Either there is no God, or God doesn't listen to Rick Warren, despite all the money Rick has made off of selling false hope to desperate people." In another comment, the same poster counsels Warren to "abandon primitive superstitions and accept the universe for what it is — a place that is utterly indifferent to us."
Some rush to add pain to the Warrens' world because, in their view, he did not show sufficient compassion for the unremitting pain suffered by gay youths rejected by parents and peers. They were outraged when Warren took a political stand for Prop 8, which overturned legal same-sex marriage in California in 2008 and is now before the U.S. Supreme Court.
Others have appointed themselves 140-character theologians in a debate over whether someone once saved can lose his or her salvation if suicide is against God's law. These posters, rather than waiting for Judgment Day, have ruled for hell.
But Bruce Kwiatkowski of the University of Toledo posted on Facebook: "I appreciate what Pastor Ronald Cole said about the subject of Christian suicide. He said the Lord will say, 'We weren't expecting you yet...' "
John Schuurman observed on Facebook that celebrity culture makes everyone "fair game" and the anonymity afforded by social media that allows people to "send out hate flames without any consequence."
There are, however, people who won't let the vitriol unleashed on social media infect the little corners of the world under their own name.
John H. Armstrong fought back on Facebook, saying, "I just blocked someone that I do not know from my wall for saying that Rick Warren's son went to hell. What is it with people being so sure that they know God's final judgment? I fear for people like this. This man added that Rick Warren was being judged for being a 'false prophet.' Pathetic, cruel and reckless all come to mind. If I've seen the evidence of a false prophet this comes close."
********************************************************************************
Although an atheist to the extreme, I feel deeply embarrassed and apologetic for the atheists that exploited this tragedy to score unseemly, and disgusting atheist talking points. I recommend they receive the lash to teach them compassion and better manners. Disgusting. I am serious about subjecting these to 10 lashes of a bullwhip. I appreciate the benefits and purposes of religion, and am among the atheists that do not bash it. I am an "intelligent atheist," I suppose, compared to the "crude atheists" out there. Yet, anyone who cannot show sympathy to someone who has just lost a son is beyond the pale.

I use the word, malignant, in a manner similar to that used in cancer diagnosis. The cancer is of a type that will invade, spread, and kill the patient. Two treatments have usually been tried for malignant suicidal urges. One wonders if he had benefit of these, electro-convulsive therapy and powerful major tranquilizers all the way up to clozapine.

Sunday, April 8, 2012

NYT on the Rising Incidence of Autism

Autism causes a lag in language ability for mental age, social isolation from poor relatedness, and stereotypic movements (purposeless repetitive movements that go away when busy, such as hand flapping, or finger flicking).  One should think of it as a very broad final common pathway for likely hundreds of undiagnosed conditions. It is similar to the word, fever, or the phrase, mental retardation. It does not exist as a unified disease. Asperger Syndrome differs from autism in that that language is fluent, and the patient talks too much, lecturing on a narrow subject, even to people who are not interested.

These features overlap with the negative symptoms of schizophrenia, another likely very broad syndrome. They are reliable predictors of a poor, outcome, unified by the lack of social interest or relatedness. One should think of all these patients as mentally retarded. Even if the autistic person has an IQ of 110, he will always come from families with IQ's of  140, and is thus mentally retarded for that family.  All of the high IQ patients operated markedly below their expected level of tested function.That was the traditional way to make the diagnosis.

How did the rate go from 1 in 2000 to 1 in 100?

1) Services attracted parents to school districts. Open a program, and the autism rate will shoot up. Do not investigate the water, just the school system for a cause of increased rates. 

2) Doctors are making the diagnosis in merely immature children, often with ADHD. It is not well known that 20% of boys will not have spoken by age 3. So they get enrolled in expensive special education programs, with rich parents hiring aggressive lawyers to intimidate school systems for more services at taxpayer expense. Come age 5, these kids become chatter boxes, and the aggressive bullying now appears to hav been justified. It is just spontaneous onset of speech. The most famous of these children was, of course, Albert Einstein. He did OK for himself.

3) The assault on the American family by the feminist lawyer is nearly victorious. Bastardy is associated with out of control child behavior. The immaturity and poor socialization is misdiagnosed as a serious condition because of the massive benefits of this diagnosis, compared to the criticism of the mother's promiscuity and the bastardy of her offspring. Such criticism is taboo, and would result in the firing of any child welfare worker. The reason is that bastardy and its huge increase in social pathologies generates massive government make work jobs. Any criticism of the mother would threaten government jobs, and there is zero tolerance for it. Thus the absence of this most likely of all causes in the article.

Monday, February 6, 2012

It’s not Ritalin That Has Gone Wrong, It is the NY Times That Has Gone Wrong

I suggest an instant increase in credibility for all left wing extremist propaganda outlets. Have a brief counterpoint box inserted into the article so people can see there two sides to the discussion. The author is a psychologist who bemoans the lack of funding for the psychological aspects of Attention Deficit-Hyperactivity Disorder (ADHD). He fails to disclose he is arguing in the economic interest of his specialty. This piece is to pressure the government to increase funding for psychological research, and self-dealing. I have no argument with self-advocacy as long as it is transparent and disclosed.

The author has no idea what ADHD is. We move around while alive. We move the most around age 2. The amount of movement steadily declines with age to 100 years old. This decline happens to parallel the loss of dopamine neurons of about 1 half percent a year.  One may therefore think of a 12 year old boy with ADHD as someone who moves like a normal ten year old. Put a six year old in a class of 12 year olds, and she will appear hyperactive, inattentive, easily distracted, and impulsive. This is despite being a normal 6 year old. At puberty, nearly all children lose the hyperactivity part of the disorder, and retain the inattention and impulsivity parts, most into adulthood. The best judge of this deviation from age based standards is the teacher observe a class of kids the same age, engaged in the same activity.

Activity level has a great deal of environmental input. Are you praying or running a foot race?  So case controls are tough in the absence of a similar environment, such as being classmates. That makes the teacher the best judge of the deviance from norms. That is not mentioned in the article.  The teacher is also the real consumer of the medication, because without it, the child cannot be controlled and no one else is able to do any learning. No mention of the deleterious impact of the untreated disorder on the entire class or family. Other children shun them, as well.

Everyone agrees insulin is a miracle drug. It controls diabetes, it does not work, “long term.”  Why hold Ritalin to a higher standard than the miracle drug insulin. It markedly changes the quality of life day to day, and that is pretty good. Parents have to choose to give it daily. The idea that an academic psychologist knows more about the interest of their families or their chid has no validity, just arrogance.

About 20% of children have a small slowing of their height growth. Stopping the drug in the summer restores these children to their pre-treatment growth line. So growth effects are temporary if unusual.

Why is a stimulant given to children who are impulsive and hyperactive? In low doses, it stimulates the parts of the brain that quiet the other parts of the brain down. That is why children do not feel much on these medications. Their own brains are quieting other parts down.

There is a tolerance to the medication, and to the side effects. One may increase doses. Then, try to stop the medication in the summer. If the child has not grown out of the disorder, restart at the lower dose.

There is a rebound hyperactivity at the end of its effect in the evening. Small doses will stop that form of drug withdrawal. However, there is no feeling sick from drug withdrawal.

All medical conditions have a response to the environment, such as stress. ADHD is no exception to the long list.

As far as habit forming. No. The opposite is true. Kids do well, have no side effects, have improved grades, are popular on medication ad the opposite off medication. They are likely to refuse to take it. If there is an opposite to addiction, kids with ADHD have it Int heir oppositionality, they refuse to take medicine and must be coerced into doing so. Why refuse if grades are high, adults are praising the work. Friends are willing to play with the patient again? Because it is a noxious feeling to not be yourself anymore, however popular and successful.

So how are motorcycle gang members getting high? They are injecting a full day’s high dose intravenously. If they ever took a prescribed dose, they would slow down, treat their old ladies better, clean up, pay the bills, and become responsible.

The data make the case for even more prescriptions to under-treated kids, and for a low quality of life off these medications.

Saturday, February 4, 2012

Yes. It is an Excellent Idea for Middle Aged Professionals to Attend Law School

I recommend attending law school, and staying in one’s field of expertise.
Workers know a lot about their field, not much about the law. Lawyers know law, but nothing about nothing else.
1) The powers of the animal that is an expert in a field and knows some laws is yet unknown. So the boss may send a contract to a lawyer who knows nothing about his business, and has to explain the basics, or to a co-worker with a law degree. What a difference that will make.
2) One is less likely to be puzzled and intimidated during legal actions. One can predict the tactics of the other side and craft replies. 
3) One can bully adversaries with credible legal threats. That advantage has returned several times the cost of tuition of attending internet law school.
4) One can supervise and force one’s lazy, stupid personal lawyer to better assert one’s legal rights in legal disputes.

Sunday, November 13, 2011

After Every Adverse Communication from a Health Plan

After every adverse decision or letter from a Health Plan, a letter of complaint about the Medical Director should be sent to the licensing board. Let them spend their time being investigated, and their money hiring lawyers. As they make it tough to do our jobs, so should we return the favor. Here is an example.

State Board of Medicine
P.O. Box 2649, Harrisburg, PA 17105-2649
Phone:             (717) 783-1400      
Fax: (717) 787-7769
ST-MEDICINE@pa.gov

RE: Unprofessional Conduct; X, MD; Medical Director,
Y Health Plan,
Dear Doctor:
I enclose a copy of a letter from Dr. X. I request that it be investigated for its unprofessional conduct. The blacked out areas have a single patient name. General opinion, commentary, and criticism have First Amendment immunity. This letter’s specific demands, criticisms, etc., represent the practice of medicine, because they are about a specific patient. They are therefore under your jurisdiction.

1) Y is a quasi-governmental organization with the ability to punish doctors. Its actions require a fair hearing. That was not granted nor even offered.

2) I believe Dr. X is not a qualified psychiatrist. He is therefore criticizing doctors outside his scope of knowledge or experience, two psychiatrists. I am board-certified in psychiatry. The Mcare Act requires that any governmental medical action be based on the opinion of an expert with qualifications equal to mine. This letter violates that statute.

3) Assume nothing was wrong with the procedure of Y. This doctor is still giving specific, technical, medical advice about a patient he has never met, nor whose clinical record he has reviewed.

4) His allegation of multiple prescribers of a psychotropic drug over 45 days fails to acknowledge that Dr. Z and I work for the same clinic. We are providing coverage for each other, using the same facility, reviewing the same chart, and seeing the patient when follow up visits are due. There is therefore good continuity of care, not multiple, unrelated prescribers. Clozapine is prescribed to patients who have failed to respond to multiple neuroleptic tranquilizers, and remain dangerous to themselves and to others. Not seeing such patients regularly is substandard care. He is also receiving Seroquel, to reduce the dose of required clozapine, a desirable goal given the side effects of this medication.

Weasel clauses in the standard insert do not detract from the seriousness of the allegation of medical mismanagement being made by this quasi-governmental organization.

Sincerely Yours,

David Behar, M.D.

Monday, October 10, 2011

Request for Advisory Opinions Sent to Licensing Boards

Sent to three licensing boards. 

I am licensed in medicine by your board. I request advisory opinions on the following scenarios with patients. To make things easier for you, I request that you rate the conduct described as unprofessional (U) or acceptable legally and regulatorily (A). You should expect that any opinion you send will be shared with others.

1) A child patient has behaved well with parent earlier, and during an exam. Doctor gives him a lollipop, saying, “This is for your good behavior today.” The cost of the lollipop is 50 cents.

2) A state mental hospital doctor pays an eager mental patient $10 for washing his car, while the car is in the state hospital parking lot, during work hours. Both parties are satisfied by the result.

3) Patients in a program are raising money for an activity. They organize a bake sale or a car wash. A doctor who works there pays $100 for a cake with a $5 charge tag, or a car wash costing $10.

4) A doctor needs computer services. A current patient is unemployed, and desperate for any income. The doctor pays his full fee, for a contract worth $10,000, mutually benefitting both parties. There is no contract dispute, where abuse of private knowledge can be used.

5) Same as 4), but there is a private, not a public contract dispute. The doctor uses personal knowledge about the weak spots of the patient to bully a favorable settlement from the patient.

6) A doctor “friends” a patient on Facebook.

7) As a Facebook “friend,” he sees messages on the page of the patient that he has begun drinking alcohol again, and stopped his blood pressure medication. The patient does not reveal these changes, actually denies them,  during a routine visit to the doctor. The doctor confronts and berates the patient (politely, yet firmly) about non-adherence to treatment. This is a reverse scenario as a violation of confidential health information. It uses public information in a private medical encounter.

8) As a Facebook friend, the doctor sees the patient plans to commit suicide or to kill his parents. The patient also says, he has collected a number of working guns. These intentions are denied in medical follow up sessions. Is there a duty to warn under the Tarasoff doctrine? Again this is the use of public information, superceding confidential denials during medical visits in the office.

9) The doctor and a patient fall in love. The doctor refers the patient to another doctor in the same specialty. They have sex, and eventually get divorced from their respective spouses and marry each other. (Please, review this question in light of two cases, Lawrence v Texas at the Supreme Court of the US, and Long v Ostroff decided at the Pennsylvania Superior Court).

Tuesday, September 20, 2011

Wrongfulness of Lawyer Licensing, Discipline, and Self-Regulation

The current arrangement of lawyer licensing and discipline violates the separation of powers, and is unconstitutional. It is not even rational, since no group of human beings has ever properly regulated itself in the history of mankind. The results are unfair self-dealt immunities, and countless virtual self-dealt immunities.

There are countless statutorily enumerated duties to the adverse third party in the Rules of Conduct, of Evidence, of Civil and of Criminal Procedure, not to mention case law over 1000 years. Yet, the lawyer is totally immune from liability for damage done to the adverse third party by misconduct. He is almost 99% immune from legal malpractice from his own client. The victim of malpractice must win a double verdict, that malpractice and damage took place, and second that he would have won the original case but for that lawyer malpractice. Next, he must prove that the original defendant was not judgment proof, and that he could have collected from the original defendant. Lastly, he must overcome the defense of the litigation privilege, where faulty judgment is privileged.

If liability is a substitute for violence, then violence against lawyers, and judges has full moral intellectual, and policy justification.

Next, there is no recourse for the public at the licensing level. Almost no civilian complaint is ever investigated properly nor taken seriously. Mostly complaints from judges are.

Writing the The Rules of Conduct is a legislative act. Yet it is done by the Supreme Court of a state. It often plagiarizes these rules from a professional society, the ABA, whose aim is to promote the interest of the lawyer, and not that of the public.

Next, a self-styled prosecutor investigates and prosecutes complaints against the lawyer. That is an executive function. Yet, the Disciplinary Counsel is an employee of the Supreme Court, and claims onto itself all discretions and immunities of a prosecutor, despite not being a real one.

Lastly, the Supreme Court of a state listens to the Disciplinary Counsel's case, the case of its own employee, and a person well know to the court. It then considers the arguments of an outside defense counsel. It is likely to favor which side, that of it s own employee, using all the buzz words provided by the court over time, or that of an argumentative stranger? So the procedural due process right to a fair hearing of the accused lawyer is brazenly violated.

Monday, September 19, 2011

Recovery Movement

Recently, a local agency was forced to adopt new Mission Statement, Philosophy Declaration in order to keep its referrals and public funding. Many other agencies have been forced to as well by government funding sources. Progress toward recovery is also expected in the documentation, so staff is forced to lie. Say a patient has not spoken in group for 6 months in a partial program, that is not progress toward recovery. So staff has to make stuff up about his improvement.

To argue by analogy, my agency treats paralyzed people. Could the goal not be adaptation to their condition, teaching of new skills to get around, and encouragement to get to wherever they want? This would be the rehabilitation model.

Does the goal for everyone have to be to walk again, and to lie about their progress when they cannot walk at all? Recovery in this context would be impossible, offensive, and cruel as unattainable.

This recovery movement, promoted at the highest levels of the federal government, as well as by bullying, inter-meddling state ideologues requires one thing. Staffing. It is in bad faith, to grow government and to plunder the tax payer without evidence of any benefit to the patient, or the family, or the neighborhood.

Sunday, August 28, 2011

Insane Restrictions on Physical Control of Ultra-violent Mental Patients

The consequence is sever injuries to anyone who works in these facilities. Left wing ideologues in capital cities are using false or incomplete  data to support the elimination of restraints, or other physical measures of control of ultra-violent mental patients. Some have been expelled from Supermax prisons as unmanageable.

So what if a patient is going on a rampage in the TV lounge. Staff: well we clear the lounge until the patient is finished three hours later.

OK. What if the patient is choking another, and the other is turning blue? Then we do put our hands on him, and everyone has to lie on the report of the incident.

Why would irresponsible, slow witted, pro-criminal, biased, left wing extremist, state officials seek to go "restraint free?" What is the alternative to physical controls of ultra-violent mental patients? The answer is, more staffing. The main aim is government enlargement, and increased staffing and costs of these institutions. The money motivation makes the rules enactment one in bad faith, to make more money and expand the size of government.

"An Atascadero State Hospital psychiatric technician suffered head trauma and a fractured eye socket after a Wednesday night beating -- just one day after lawmakers convened in Sacramento to consider the violence plaguing the state's five psychiatric facilities and to try to come up with solutions, Sen. Sam Blakelee's office said today.

Blakeslee (R-San Luis Obispo) learned of the assault Thursday and has met with the hospital's  executive director for a briefing. His office also spoke to employee groups about the attack.
At Tuesday's hearing, Blakeslee had called on Department of Mental Health officials to expedite the creation of special units for the most violent patients and to send those who are too violent to treat to prison.
"The offender responsible for this attack had made explicit threats against this employee and had a well-established record of violence," Blakeslee said in a statement Friday. "This week’s assault underscores the urgent need for reforms to ensure the most dangerous offenders will be swiftly returned to a correctional facility once violent and assaultive behavior becomes evident.”

A statement provided by the Department of Mental Health to Blakeslee said only that the female employee was assaulted at 8 p.m. and hospitalized in moderate condition. A psychiatric patient was booked into the San Luis Obispo County jail on counts of battery using force likely to cause serious injury. The hospital has initiated a proceeding to have him returned to prison.

Blakeslee learned more during his meeting at Atascadero on Friday. According to chief of staff Christine Robertson, employee groups reported that the assailant had "made it known that his goal was to be returned to prison, so he had been engaged in threats and attacks" and had previously threatened the victim. The patient was in restraints and asked to go to the bathroom, where the psychiatric technician either "loosened or removed the restraint and with the free hand he beat her."

Tuesday's hearing touched on the need to distinguish between predatory violence that is intentional and violence spurred by psychosis-related delusions. Staff members have pushed for a more punitive approach toward those who knowingly commit violence. About 92% of the state's hospital patients have either been arrested or convicted of a crime related to their mental illness. Many are vulnerable and regularly victimized. Others, meanwhile, possess a "prison mentality" and are prone to prey on others."

Sunday, August 21, 2011

Coping with Plaintiff Expert Witnesses

Nice review of the subject at the above link.

"Most state medical boards have the authority to discipline doctors found to have provided unethical witness testimony, said Lisa Robin, chief advocacy officer of the Federation of State Medical Boards. However, each board's process of investigating complaints and enacting discipline differs. Whether states have jurisdiction to punish out-of-area doctors also varies, Robin said.
The American Academy of Emergency Medicine publishes expert witness testimony online.
In Mississippi, doctors from out of state who give deceptive testimony can be prohibited by court injunction from testifying in future cases. The state medical board also can revoke the licenses of doctors who provide false testimony and charge physicians up to $10,000 for investigating a case."

The litigation privilege will trump any licensing authority sanctions, and will be reversed by the courts. The courts want witnesses to be immune for their testimony, however false. This privilege is supported by the Supreme Court in a case where a police officer could not be sued for lying on the stand and sending an innocent defendant to prison for a few years.  Little hope for doctors if the immunity is that extreme and even covers the crime of perjury.

Doctors should still report unprofessional conduct to all the licensing boards of the witness. It is just a moral obligation, and a legal one in some states, where there is mandated reporting of unprofessional conduct. Take each shady statement, and report it to each board once a month, so that the h witness remains under investigation for years. I am not aware of any statute of limitations for licensing board reporting.

Some boards will reply that testifying at a malpractice trial is not an act of medicine. It most definitely is. It is an act of super-medicine. It tells the doctors of the state what the standard of due care in a medical matter is.

2) Most of the recourse against plaintiff experts has to be found inside the trial itself. Defense counsel has a conflict of interest making money from having a rial. So they will resists acting against plaintiff experts. One must hire a second private attorney to terrorize the insurance company lawyer into acting a bit different, attacking the expert and seeking to end the trial before it begins.

3) Disqualify the expert.

4) Find a false fact uttered by reading every word uttered by the expert. Demand a mistrial and all legal costs assessed to the personal assets of the expert. Opinion has the protection of the First Amendment. False testimony about facts is perjury and not privileged. For example, the expert claims to have read a document and has not. He claims to have researched an article and has not.

Rapid Change in Consciousness from Low Dose Tramadol

A patient did not take any prn Ativan that day, took half a tramadol 50 mg. for pain. She woke up chained in an ambulance with no recall of the following. She fell asleep, drifted into the grassy divider of a highway, and eventually came to a stop. Luckily, she did not cross into oncoming traffic. Police  arrived, she was in a rage and agitated. She had to be restrained and tied to the gurney. That is what she was told, because she has no recall prior to waking up in the ambulance ride. Most disturbing, this effect was not preceded by gradual sedation. It was sudden. Nothing could be done to prevent it, such as drive onto the shoulder of the road until it passed.

Next day, she tried this experiment,  at her house. She did not take any Ativan. She took 25 mg of Tramadol at the same time of day. Within a half hour, she was nodding off and could not be awakened by her family for an hour.

She then spoke to her mother. Mother had the exact same experience with tramadol. This sensitivity to this one drug runs in her family. Her other meds are at ordinary medium doses.

She is on an antidepressant, but had no evidence of a serotonin syndrome, nor of a seizure.

I suggested she get together with her prescribing doctor, get the ER records, and fill out an FDA Adverse event form.

Monday, July 4, 2011

What I Got From my Internet Law School Education

There are 1.3 million lawyers in the USA. No more is needed, since this number exceeds the number needed by 500,000. When there are excessive lawyers, crime goes up, as the lawyer protects the criminal from citizen self help, the best remedy to crime. The tort lawyer deters not just defendants but entire segments of the economy. Without the lawyer, our growth would be 10% a year. There would be no economic crisis. The lawyer forced banks to lend to irresponsible minority members without ability to pay, just to consume and destroy property values. The family would still be thriving, and not on its last ropes.

So established professionals should forget becoming full time lawyers.

The modern law is based on supernatural core doctrines copied from the Catechism. In order to make modern students accept such supernatural concepts, indoctrination emthods are used in law school, rather than straight teaching methods. Lawyers are welcome to try to fit their law school experience to these methods of changing minds, and indoctrinatin fits best.


1) The basic "science of the law today is Scholasticism.  This is a philosophy mostly abandoned by even the Church. It sought to prove the existence of God by observation in nature.

2) One method of Scholasticism was the disputation to arrive at the answer to some important question. That was the likely origin of the adversarial system.

3) The core doctrines of the law were copied from the Catechism.To its credit the Medieval Church attributed these supernatural powers to God, in accordance with their faith. The lawyer believes that people are capable of these supernatural powers.

4) The lawyer  believes that minds can be read (intent for every element of a crime), that the future can be forecast (forseeability as the basis of duty).

5) No lawyer today understands the real meaning of the word, reasonable, the central and most important word in the law. One has to wonder why it is the central word, and not any alternative. This obliviousness would include Harvard Law grads with PhD in Medieval Legal History. The indoctrination has been that good.

Reason in Scholasticism is the ability to perceive God. It is the most reliable guide to making moral decision. Intellect is subject to being misled by the Seven Deadly Sins, resulting from the Fall from Eden. The most reliable guide to moral decisions is the New Testament, so St. Thomas Aquinas argued. The reasonable person must be fictional. If any juror bases a decision on a real person, no matter how high functioning, a mistrial will be called. The reasonable person must be fictional, in order to be "objective."What is not said is the the New Testament is the story of Jesus Christ. And the reasonable person is really a stand in for Jesus Christ.

So the adversarial system, the core doctrines, the extensive use of Latin, and the standards of conduct are all derived from the Medieval church methodology.  That makes them all violate the Establishment Clause, as much as any legal system based on Sharia might.

One could overlook this violation if the law were effective.

6) Every self-stated goal of every law law subject is in utter failure. Why? Because tgher eis noting from the 13th Century that is in any form acceptable as a practice in the modern world. This is explained by its extreme atavism, and use o Medieval doctrines.

Sunday, May 29, 2011

Alternatives to "Life After a Lawsuit"

The AMA is a trip. This article describes helplessness and victimhood. It says nothing about another side of being sued for malpractice. That is the duty to protect clinical care from the vicious predators coming at it from all sides, including hate filled, scapegoating, entitled, greedy plaintiffs, who are real scum.

Some Perspectives

Doctors are Spoiled and Nearly Immune from Tort Liability

1) Say a practice makes $5 million a year. It gets all upset if it has four lawsuits of any kind. If it were a $5 million welding business, it would have 400 lawsuits all the time, permanently, as long as in business.  A large business, such a s Walmart, has 10,000 lawsuits at all times. This predatory practice is a huge heavy anchor on our economy, where a criminal cult enterprise, the lawyer profession, has total control of government, and uses it to enrich and empower itself by plundering all productive entities. This criminal cult knows doctors are crazy and violent once angered, so they stay away, mostly. (See Al Qaida, the Cuban Revolution, Ethnic Cleansing in Serbia,  for examples of doctors getting angry.) Doctors are a privileged group, almost immune.

2) When a lawsuit is filed, it fails at a rate of 80% at every stage of litigation. So, the smallest fraction of claims ever reach trial. Once at trial, jurors like doctors and give them the benefit of the doubt. Even in judicial hellholes, the verdicts favor doctors 75% of the time.

3) When spectacular losses make the newspaper, they are misleading. Baby makes $58 million, the headline may say. Baby really makes almost nothing is the reality. They baby will get the limit of insurance, such as $2 million. After the lawyer has taken out expenses and contingency fees, only a pittance is left for the baby. Greedy, low life parents are often shocked by this principle of no "Blood Money."

The Doctor has No Friend in Court Save the Jury

1) The defense lawyer is a traitor working only for himself. He will always want to get to trial because that is the only way to make a profit on a medical malpractice defense. He will allow his client to go through the wringer in a frivolous case to generate the profits from the rial. He does not need the client. He will never do anything that might scare, deter, or even inconvenience the plaintiff bar. He will never go after a biased judge. These are all duties to the client.

2) The doctor must hire, at his own expense,  a legal malpractice specialist to terrorize the insurance provided defense lawyer, looking out only for himself, and always orchestrating the case so a trial happens to enrich himself. There should be no pity shown this traitor. The malpractice lawyer must force the defense lawyer to file for motions to dismiss, for motions to disqualify  the lawyers, the judges, and the experts. Try to destroy the case as early as possible.

3) The process of discovery must brutalize all the enemies of clinical care, including the pro-lawyer biased judge, a hack, only slightly more morally upright than the felons passing thorugh his court. The judge is scum, and must not be spared any pain possible. Judges must come to pee their pants whenever a doctor enters the court, rather than the other way around. The judges are base cult criminals, sworn enemies to clinical care, scum who allow frivolous cases to proceed and refuse to punish irresponsible plaintiff lawyers. Demand all out e-discovery on the plaintiff, his entire family, the plaintiff lawyer for an improper motive, on all the named experts, and on the judge for his anti-doctor bias or pro-litigation bias. A full search for content in social networks should be done for all the adversaries.

This is  a proper motive for the tort claim: to make the plaintiff whole with money damages. Period. Every other utterance should result in a motion to dismiss, or to disqualify. For example, "It is not for the money." An improper motive. To prevent this from happening to others. To find out what happened. To send a message to the health care system. Any utterance indicating frustration or hate for the doctor. All improper motives. Use all appearances in the media as evidence of improper motive, since these are to get attention and notoriety, to embarrass the defendant into offering a settlement. All depositions should be relentless in their search for these case ending statements.

No Courtesies Nor Civility During the Trial

1) The malpractice lawyer must second guess every move or failure to make a move by the defense lawyer.

2) Ask the judge to question the jury in mid trial, whether any has used any electronic means to independently research any aspect of the parties or of the case. This is irresistible. It will be true at nearly every trial. Demand a mistrial and legal costs.

3) Use every utterance of every adversary, including those of the judge as a basis for many ethics complaints, using a specific Rule of Conduct from the applicable law covering professional ethics. This may generate dozens of complaints against the plaintiff lawyer, the experts, the judge. Generate dozens of investigations against each, so they all live in uncertainty, and not just the defendant, as in this article cited above. These investigations may have to be carried out for months after the end of the case. They have driven the targets from the field.

4) File cross claims against all other defendants. If one decides to settle, he will need your consent. You would not let anyone out unless they paid you or your wanted to. People will settle, and leave to suffer a trial alone. Do not allow that without thinking hard about it.

5) A doctor in the article sued the plaintiff and the lawyer for misuse of a civil procedure. This measure after the trial is a waste of time. The legal system is rigged airtight to encourage litigation and lawyer employment. One must possess proof in the form of a writing or recording of the lawyer confessing that the case was filed with knowledge of its lack of merit or confessing an improper motive. Impossible.

Alternative to the Misuse of a Civil Procedure after the Trial

The sole remedy to the frivolous claim must be found in the trial. The trial judge has limitless powers to punish the attorneys with costs, jail time, and seizure of personal assets, even dismissal of the case for misconduct (generating a legal malpractice case by the client). Make the defense lawyer traitor demand sanctions against the expert for any misstatement of facts (opinion is immune), against the plaintiff lawyer for misconduct (the doctor defendant should study the Rules of Civil Procedure to make informed demands of the defense lawyer.

6) The tort defendant has  procedural due process rights, the Supreme Court affirmed in reversing excessive punitive damages against an insurance company. One such right under is a right to a fair hearing. The defendant should take this list of biases, use it as a checklist, and see if any apply to the case, and demand a motion to dismiss if found (as early in the case as possible). Here is the list of biases.  The most important in medical malpractice are hindsight bias and outcome bias. The defendant may even blame himself and harbor an outcome bias against himself. This bias can be demonstrated to exist in defense experts. These are no more acceptable than other biases such as those against minorities.An argument using cognitive bias has never been made, let alone tested in a medical malpractice case, so the defense lawyer will resist it as having no precedent.

Deter the enemies of clinical care. Personal destruction has good moral validity. It is indeed a duty of the doctor defendant, to protect clinical care from its relentless enemies.

Sunday, April 3, 2011

Nursing Home Litigation Not Related to Quality

According to the article, litigation increased in the 1990's. That happened to coincide with the greater funding of nursing care. The best correlate of litigation is assets not quality. The tort system is a really a system of lawyer plunder.


"High-quality nursing homes get sued almost as often as low-quality nursing homes, a new study shows. Researchers say the finding illustrates that litigation, or the threat of litigation, doesn't lead to improvements in patient care. Nor does it appear that better nursing homes are rewarded for superior care in terms of fewer lawsuits."

Read More .

Sunday, March 13, 2011

NYT Article Bashes Modern Emphasis on Psychopharmacilogy

 Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy

Richard Perry/The New York Times
“I had to train myself not to get too interested in their problems, and not to get sidetracked trying to be a semi-therapist.” DR. DONALD LEVIN, a psychiatrist whose practice no longer includes talk therapy.
DOYLESTOWN, Pa. — Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and second marriage falling apart, the man said he needed help.

But the psychiatrist, Dr. Donald Levin, stopped him and said: “Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.”

Like many of the nation’s 48,000 psychiatrists, Dr. Levin, in large part because of changes in how much insurance will pay, no longer provides talk therapy, the form of psychiatry popularized by Sigmund Freud that dominated the profession for decades. Instead, he prescribes medication, usually after a brief consultation with each patient. So Dr. Levin sent the man away with a referral to a less costly therapist and a personal crisis unexplored and unresolved.


Medicine is rapidly changing in the United States from a cottage industry to one dominated by large hospital groups and corporations, but the new efficiencies can be accompanied by a telling loss of intimacy between doctors and patients. And no specialty has suffered this loss more profoundly than psychiatry.
Trained as a traditional psychiatrist at Michael Reese Hospital, a sprawling Chicago medical center that has since closed, Dr. Levin, 68, first established a private practice in 1972, when talk therapy was in its heyday.
Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

Dr. Levin has found the transition difficult. He now resists helping patients to manage their lives better. “I had to train myself not to get too interested in their problems,” he said, “and not to get sidetracked trying to be a semi-therapist.”

Brief consultations have become common in psychiatry, said Dr. Steven S. Sharfstein, a former president of the American Psychiatric Association and the president and chief executive of Sheppard Pratt Health System, Maryland’s largest behavioral health system.

“It’s a practice that’s very reminiscent of primary care,” Dr. Sharfstein said. “They check up on people; they pull out the prescription pad; they order tests.”



*******

It is impossible to do psychopharmacology without cognitive advice and content. The latter is a form of rehab, similar to physical rehab and exercise after an orthopedic operation. It is indispensable to the successful orthopedic operation. No surgeon would denigrate, short change a patient on it without hurting his outcomes.

For example. One has to say this or fail in treatment.

Your Abilify will reduce your impulsivity and will solely give you 5 seconds to think before acting. It does not give you the correct answer about what to do, nor coping skills, nor skills in getting what you want and need.

A year later, patients say, I have been doing it for months. Abilify taught me to think first. I can do it on my own. They stop the Abilify with their doctor, and many are right. They no longer need it, duplicating its effect with irreversibly learned skills.

Those skills are the rehab, the exercise of the operated limb. Does an orthopedic surgeon berate herself for not doing rehab, but for merely prescribing it for others to do? No. Nor should we berate ourselves for not doing extensive psychotherapy. The surgeon may briefly describe the exercise needed for success of the operation to the patients, and so may we. But sitting there practicing repetitive rehab is not the best use of time.

As to conflict of interest evidenced by withholding the possibility of response to psychotherapy.

All professions have a conflict of interest in making more money, the more people have problems, and less the more problems are solved. Professionalsim, pride in craftsmanship, and need to enhance reputation are all motivations for accuracy of advice, rather than trying to rip off the patient.

But try to give a bereaved person anti-depressant instead of counseling, they get a bunch of side effects, do not return, and bad mouth the psychiatrist to the referring family doctor or pastor. No psychiatrist will want that.

Wednesday, March 2, 2011

Eat a Sandwich from a Drug Rep, Get Reported to the IRS

I understand that drug companies will begin to send 1099's to doctors and others accepting meals. I wanted to get an opinion letter from the IRS about this practice. I believed those were gifts, not income. For example, I come to your home. I bring your wife flowers. Do I have to 1099 your wife at the end of the year? I thought the flowers were a gift. She did not work for me.

My accountant straightens me out:


"The following significant increases in user fees will apply: 

... The fee for a private letter rulings will increase from $7,500 to $10,000, except as provided for certain reduced fees explained below. A private letter ruling is a written statement issued by the IRS Associate Office to a taxpayer in response to its written inquiry about the tax effects of its acts or transactions or its status for tax purposes before the required filing of returns or reports.

Under the new fee schedule, taxpayers with gross income of less than $250,000 can request a private letter ruling for a reduced fee of $625 while a fee of $2,500 will apply to requests from taxpayers earning from $250,000 to $1 million. Currently, a $625 fee applies for a request that involves (1) a personal tax issue from a person with gross income of less than $250,000 or (2) a business-related tax issue (for example, home-office expenses, residential rental property issues) from a person with gross income of less than $1 million. 

... User fees for information letter requests are imposed for the first time, at $2,000. Information letters provide a general discussion of the law on a subject, not directed to any particular set of facts. Such letters can be issued when the taxpayer has asked for a letter ruling, but for some reason the Chief Counsel could not issue it. The taxpayer cannot rely on information letters.

In answer to your question, if you are deducting the flowers for my wife, a bottle of wine, or a box of chocolates, it is considered a business gift. Such gift are limited to $25/year to any single recipient [Code Sec. 274(b)].

If you buy a patient or colleague a meal, as long as there is a bona fide business discussion before, during or after the meal, you can deduct ½ of the cost. If you want to deduct 100%, the patient or colleague needs to pick it up as income. It appears that is what is happening here. The pharmaceutical companies are probably deducting 100% of the costs and making the Doc’s pick up the meal fair market value."

Wednesday, January 12, 2011

Many Medical Malpractice Claims Motivated by Anger. This is an Improper Motive

What the doctor is trying to say is the evidence points to personal animus as motivating most malpractice claims. Such a motive is an improper motive and represent lawyer malpractice if it is the real reason for the lawsuit, and the alleged deviation from standards of care and its alleged harm is just a legal pretext. The filing of such a retaliatory claim is an improper use of a civil procedure and itself a tort. The subject of anger should be deeply explored in any patient and family deposition. Then the doctor should file a countersuit against the lawyer, the plaintiff and any family member who encouraged the claim. An attempt should be made to get an injunction from a higher court against any judge allowing such venomous claims to proceed beyond first pleading to dismiss.

The overwhelming majority, perhaps up to 80%, of medmal claims are weak claims. They fail at every stage of litigation. The innocent doctor should not settle, and should consider countersuing the lawyer predator. To deter.

Because there is a first duty to survive and to stay open, the cover up is the most common response of any health entity to medical error. All investigational material will be subject to discovery and may ruin the health entity. One may conclude that these weak, hate filled, retaliatory lawsuits result in the shut down of investigations into systemic improvements that would eliminate medical errors. Every preventable medical error may therefore be caused by the medical malpractice lawyer, with no exceptions.