Sunday, April 29, 2012

Sometimes Church-State Separation Is Better for the Church | Almost Diamonds

Sometimes Church-State Separation Is Better for the Church | Almost Diamonds

International Academy of Law and Mental Health

International Academy of Law and Mental Health

XXXIIIrd Congress of the International Academy of Law and Mental Health
Amsterdam, Netherlands
July 14th-19th, 2013

The Dark Side of Personality | Psychology Today

The Dark Side of Personality | Psychology Today

The Dark Side of Personality

Is there a psychopath in your neighborhood, boardroom, or (egad) bedroom? Maybe it's more common than we want to think.


Psychopathy is among the most difficult disorders to spot. The psychopath can appear normal, even charming. Underneath, they lack conscience and empathy, making them manipulative, volatile and often (but by no means always) criminal. They are an object of popular fascination and clinical anguish: psychopathy is impervious to treatment.

Personality Disorders

Personality disorders are deeply ingrained ways of thinking and behaving that are inflexible and generally lead to impaired relationships with others. Mental health professionals formally recognize ten disorders that fall into three "clusters," although there is now known to be much overlap between the disorders, each of which exists on a spectrum.


Questions of personality have vexed mankind from the dawn of personhood: can people change? How do others perceive me? What is the difference between normal and pathological behavior? One's personality is so pervasive and all-important that it presents a clinical paradox of sorts: it is hard to assess our own personality, impossible to overlook that of others.

Crime and Punishment | Psychology Today

Crime and Punishment | Psychology Today

Crime and Punishment

Knowing what punishment to mete out is no simple feat. Some forms of punishment may send the wrong message. For example, is it okay to solve problems with more violence? Here are some thoughts on this tough topic.

Law and Crime

Psychology and the law intersect in the field of forensic science. Legal practitioners require a grasp of human motivation at its most basic and most debased in order to render fair judgment.


For a topic as subjective as morality, people sure have strong beliefs about what's right and wrong. Yet even though morals can vary from person to person and culture to culture, many are practically universal, as they result from basic human emotions. We may think of moralizing as an intellectual exercise, but more frequently it's an attempt to make sense of our gut instincts.

In Hopeful Sign, Health Spending Is Flattening Out

The New York Times - Breaking News, World News & Multimedia

In Hopeful Sign, Health Spending Is Flattening Out
The slowing of the growth rate is partly explained by the recession, but evidence suggests that changing behavior of health care providers and consumers also partly accounts for it.

Doctor Panels Urge Fewer Routine Tests -

Doctor Panels Urge Fewer Routine Tests -

Doctor Panels Recommend Fewer Tests for Patients

In a move likely to alter treatment standards in hospitals and doctors’ offices nationwide, a group of nine medical specialty boards plans to recommend on Wednesday that doctors perform 45 common tests and procedures less often, and to urge patients to question these services if they are offered. Eight other specialty boards are preparing to follow suit with additional lists of procedures their members should perform far less often.
Universal Images Group, via Getty Images
A doctor reading the results of a patient’s exercise stress test.

Readers’ Comments

"I order what I consider unnecessary tests all the time because of malpractice fears. The art of medicine died when the lawyers got involved."
john credico, Toledo
The recommendations represent an unusually frank acknowledgment by physicians that many profitable tests and procedures are performed unnecessarily and may harm patients. By some estimates, unnecessary treatment constitutes one-third of medical spending in the United States.
“Overuse is one of the most serious crises in American medicine,” said Dr. Lawrence Smith, physician-in-chief at North Shore-LIJ Health System and dean of the Hofstra North Shore-LIJ School of Medicine, who was not involved in the initiative. “Many people have thought that the organizations most resistant to this idea would be the specialty organizations, so this is a very powerful message.”
Many previous attempts to rein in unnecessary care have faltered, but guidance coming from respected physician groups is likely to exert more influence than directives from other quarters. But their change of heart also reflects recent changes in the health care marketplace.
Insurers and other payers are seeking to shift more of their financial pain to providers like hospitals and physician practices, and efforts are being made to reduce financial incentives for doctors to run more tests.
The specialty groups are announcing the educational initiative called Choosing Wisely, directed at both patients and physicians, under the auspices of the American Board of Internal Medicine Foundation and in partnership with Consumer Reports.
The list of tests and procedures they advise against includes EKGs done routinely during a physical, even when there is no sign of heart trouble, M.R.I.’s ordered whenever a patient complains of back pain, and antibiotics prescribed for mild sinusitis — all quite common.
The American College of Cardiology is urging heart specialists not to perform routine stress cardiac imaging in asymptomatic patients, and the American College of Radiology is telling radiologists not to run imaging scans on patients suffering from simple headaches. The American Gastroenterological Association is urging its physicians to prescribe the lowest doses of medication needed to control acid reflux disease.
Even oncologists are being urged to cut back on scans for patients with early stage breast and prostate cancers that are not likely to spread, and kidney disease doctors are urged not to start chronic dialysis before having a serious discussion with the patient and family.
Other efforts to limit testing for patients have provoked backlashes. In November 2009, new mammography guidelines issued by the U.S. Preventive Services Task Force advised women to be screened less frequently for breast cancer, stoking fear among patients about increasing government control over personal health care decisions and the rationing of treatment.
“Any information that can help inform medical decisions is good — the concern is when the information starts to be used not just to inform decisions, but by payers to limit decisions that a patient can make,” said Kathryn Nix, health care policy analyst for the Heritage Foundation a conservative research group. “With health care reform, changes in Medicare and the advent of accountable care organizations, there has been a strong push for using this information to limit patients’ ability to make decisions themselves.”
Dr. Christine K. Cassel, president and chief executive officer of the American Board of Internal Medicine Foundation, disagreed, saying the United States can pay for all Americans’ health care needs as long as care is appropriate: “In fact, rationing is not necessary if you just don’t do the things that don’t help.”
Some experts estimate that up to one-third of the $2 trillion of annual health care costs in the United States each year is spent on unnecessary hospitalizations and tests, unproven treatments, ineffective new drugs and medical devices, and futile care at the end of life.
Some of the tests being discouraged — like CT scans for someone who fainted but has no other neurological problems — are largely motivated by concerns over a malpractice lawsuits, experts said. Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation.
Still, many specialists and patient advocates expressed caution, warning that the directives could be misinterpreted and applied too broadly at the expense of patients.
“These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder. “This kind of one-size-fits-all approach can be a real detriment to good care.”
Cancer patients also expressed concern that discouraging the use of experimental treatments could diminish their chances at finding the right drug to quash their disease.
“I was diagnosed with Stage IV breast cancer right out the gate, and I did very well — I was what they call a ‘super responder,’ and now I have no evidence of disease,” said Kristy Larch, a 44-year-old mother of two from Seattle, who was treated with Avastin, a drug that the F.D.A. no longer approves for breast cancer treatment. “Doctors can’t practice good medicine if we tie their hands.”
Many commended the specialty groups for their bold action, saying the initiative could alienate their own members, since doing fewer diagnostic tests and procedures can cut into a physician’s income under fee-for-service payment schemes that pay for each patient encounter separately.
“It’s courageous that these societies are stepping up,” said Dr. John Santa, director of the health ratings center of Consumer Reports. “I am a primary care internist myself, and I’m anticipating running into some of my colleagues who will say, ‘Y’ know, John, we all know we’ve done EKGs that weren’t necessary and bone density tests that weren’t necessary, but, you know, that was a little bit of extra money for us.’ ”
This article has been revised to reflect the following correction:
Correction: April 5, 2012

An article on Wednesday about a move to recommend that doctors curb the use of 45 common and often unnecessary medical tests and procedures misidentified the organization that was issuing the advisory. It is the American Board of Internal Medicine Foundation, an organization that promotes physician professionalism — not the American Board of Internal Medicine, the specialty board with which it is affiliated.


Share your thoughts.

The DSM's impact on mental health practice and research.

Medical Specialists Will Try to Reduce Excessive Diagnostic Testing

A caution against preventive psychiatry
An article in the New York Times on April 4 describes a wonderful new initiative that may substantially improve the quality of US health care, while simultaneously also cutting its costs. Nine medical specialties have joined forces in a concerted and long overdue effort to reduce unneeded diagnostic testing and treatment. Although the US spends much more per capita on medical diagnosis and treatment than any other country in the world, we don't come close to getting our money's worth. Because unnecessary testing and treatment eat up a whopping one-third of all medical expenditures, we wind up spending a fortune for poor results on most national health outcome measures.
The new initiative by the medical specialty groups recognizes that many medical tests and procedures are not only wasteful, but also cause more harm than good. The American Board of Internal Medicine and Consumer Reports will jointly sponsor an educational program called 'Choosing Wisely', aimed at changing the attitudes and habits of physicians and patients. Among the commonly overused tests that will be the target of re-education are: EKG's, mammograms, prostate studies, and MRI, CT, and stress cardiac imaging.
Education is a much needed first step. When it comes to medical care, people too often people think that more is necessarily better. They fail to appreciate the harm that follows when promiscuous screening leads to unneeded and aggressive treatment. But education won't be enough. Things have gotten so far out of hand because of perverse financial incentives that make unnecessary procedures very profitable and also because of pervasive physician fears that leaving any test undone will invite a malpractice suit. We need to change the incentives in the system, not just the attitudes of the participants.
How does this initiative from other medical specialties apply to psychiatry? The dis-infatuation with ubiquitous screening in the rest of medicine should provide a needed check on the premature and unrealistic DSM-5 ambition to achieve a 'paradigm shift' toward psychiatric prevention. DSM-5 plans to introduce many new diagnoses that straddle the heavily populated boundary with normality. The DSM-5 rationale (consciously borrowed from what has been tried with such mixed success in the rest of medicine) is to screen early and treat expectantly in order to reduce the lifetime burden of illness. This would be a wonderful goal if only there were available tools to realize it. Truth be told, psychiatry does not now have any method to allow for accurate early diagnosis and we also have no preventive treatments of proven efficacy. If DSM-5 doesn't come to its senses, millions of people will be misidentified, over-diagnosed, and over-treated with medicines that can cause very harmful complications.
It is sadly ironic that DSM-5 has caught the early screening, prevention bug precisely when other specialties were already discovering its risks and dangerous unintended consequences. We should learn from, not copy, painfully earned experiences in the rest of medicine and avoid expanding our boundaries before we can safely do so.
And, on another note, cautions about overuse of existing laboratory testing should also be applied to the long awaited and much hyped biological testing for Alzheimer's dementia. An Alzheimer's profile is still only a research tool, at least a few years away from being ready for clinical practice. But even when ready, the risk/benefit and cost/benefit analysis of widespread Alzheimer's testing should be given the kind of searching scrutiny that is only now revealing the risks and limitations of excessive screening. The lesson learned- it is not always a good idea to screen for something just because we have a test that lets us do so.

Does Medicine Discourage Gay Doctors? -

Does Medicine Discourage Gay Doctors? -

Does Medicine Discourage Gay Doctors?

Doctor and Patient |
| April 26, 2012, 11:56 am 221 Comments
Keith Negley
During my surgical training, whenever the conversation turned to relationships, one of my colleagues would always joke about his inability to get a date, then abruptly change the subject. I thought he might be gay but never asked him outright, because it didn’t seem important.
But one morning, while we working at the nurses’ station with several of the other doctors-in-training, I realized it was important, because at the hospital, he really couldn’t be himself.

Doctor and Patient
Doctor and Patient
Dr. Pauline Chen on medical care.

That morning, one of the senior surgeons stormed over. He had found one of his patients feeling slightly short of breath, no doubt because of an insufficient dose of diuretic overnight.
“Which of you idiots,” he growled at us, “gave my patient a homosexual dose of diuretic?”
It took me a moment to understand what the surgeon was trying to say. But when I finally did, I couldn’t help but glance at my colleague. He stood mute, his face ghost white.
Later that day, the group of us would rant against the surgeon and even make fun of him. But none of us, including that colleague and me, ever confronted him directly or reported the egregious remark. We were too scared. Doing so, we felt, would have been tantamount to saying we were gay or lesbian ourselves. And it wasn’t hard to realize that in an environment where senior doctors felt free to equate homosexuality with incompetence, such an admission would have clearly been a career-ender.
In a recent issue of the journal Academic Pediatrics, Dr. Mark A. Schuster, head of general pediatrics at Children’s Hospital Boston, lays bare the experience of being gay in medicine and the constant struggle to “choose between being a doctor and being openly gay.” The prose is riveting, but it is also difficult to read. For it delivers unflinching, evenhanded descriptions of a profession that is committed to helping others, yet is also capable of treating some of its own as aberrant.
Does medicine discourage gay doctors? Join in the discussion below.
Dr. Schuster describes being a medical student at Harvard in the 1980s, searching for guidance at a time when discussions on gay health were sandwiched between lectures on prostitutes and drug addicts. He hears about high-ranking medical school faculty members who actively block job or residency applicants they suspect to be gay. Another gay man, a law student he happens to know, is trotted into one of his medical school lectures as “a real live one” who would “tell us what it was like.” One of the few open faculty members finally advises him to remain closeted until after at least his first semester grades. That way, she explains, the school won’t be able to trump up academic charges as a reason for expelling him.
Most poignant, however, is what happens to Dr. Schuster toward the end of medical school. A powerful figure in the specialty he hopes to pursue quickly becomes a father figure, doling out advice to the young man and volunteering to write glowing recommendation letters for residency training programs. One day, Dr. Schuster decides to reveal to his mentor that he is gay. “I felt I had to,” he recalls. Residencies wanted leaders, and his most important experiences as a leader to date had been with a gay group. Moreover, he writes, “I didn’t want him to hear from someone else and think I didn’t trust him.”
His mentor’s reaction is silence. And a few months later, with only weeks to go before the deadline for submitting residency applications, he tells Dr. Schuster he will no longer write a letter of support.
“I felt blindsided; and there were no policies, no grievance boards and no mechanisms in place to protect us,” Dr. Schuster said when I spoke to him last week. There is no anger in his voice when he talks about his experiences. “It wasn’t just me, nor was it just the places where I was learning and working. There were a lot of doctors who had the same experiences as I did all over the country.”
Five years ago, Dr. Schuster was recruited back to Harvard after working for many years on the West Coast. Much has changed. The medical school and hospital where he was once encouraged to remain in the closet has now embraced him, as well as his spouse and his children. There is now an active support group for lesbian, gay, bisexual and transgender patients, families, employees and clinicians; Dr. Schuster originally delivered his essay as the featured address for its major annual event. In the wider culture, popular Web sites like the “It Gets Better” campaign feature LGBT doctors talking openly about their lives to help young people get through their teenage years.
“I have been very lucky that I can live and work in a place that is supportive,” Dr. Schuster said. “But I wrote this essay to help people remember. Because the world has changed so quickly, it’s become easy to forget that for many clinicians and patients who are lesbian, gay, transgender or bisexual, things haven’t changed at all.
“My experiences wouldn’t seem so quaint to them.”