Other Matters

An Old Sibling Issue That Still Hurts

Dr. E, guest blogger

Sibling rivalry I have one sibling, a brother three years older than I am.  As kids, we really had very little to do with each other.  Just being different genders was one reason, but there were others.

We had to change schools every three years because each school housed only three grades, so every time I entered a school, my brother exited, on his way to the next school.  And we had very different interests: my brother loved ham radio stuff, and I was into tropical fish and children's theatre.

So it's hard to say whether or not we got along, since we really didn't have much of a relationship at all until we got older.  My parents, however, created a problem that angered me to no end, while my brother seemed hardly aware of it.

At one point, our Dad, who loved new cars, got one just about the same time my brother got his driver's license, so instead of trading in the older car, our Dad kept it.  Before I got my license, my brother had exclusive use of the older car, of course, but when I got my license, I thought we would share the older car.  I was so wrong.

My brother considered the car his property and did not want me driving it, and my otherwise good parents, agreed.  Their thinking, they said, was that as a teenage girl, my dates would pick me up in their cars, but as a boy, my brother would need the car to pick up his dates.  But why I was not allowed to drive the car when my brother didn't need it for a date was a question my parents never answered.

I feel hurt and angry as I write this even though it was decades ago.  Call it boy over girl favoritism; call it older child favoritism; call it our parents deciding it was easier to argue with me than with him;  call it the erroneous sociological and parenting ideas of the decade (the 1950's); or just call it what it was...totally unfair. 

What could my otherwise good parents have been thinking!

I'm Dr. E, guest blogger.   For more information, click on the following resources:

 Studies in Sibling Rivalry

The Everything Parent's Guide to Raising Siblings:Tips to Eliminate Rivalry,Avoid Favoritism,and Keep the Peace  

Siblings Without Rivalry:How to Help Your Children Live Together So You Can Live Too 

Keep the Siblings,Lose the Rivalry 

Brothers:26 Stories of Love and Rivalry 

The Importance of Sibling Relationships in Psychoanalysis 

Making Brothers and Sisters Best Friends 

Brothers and Sisters:Developmental,Dynamic,and Technical Aspects of the Sibling Relationship  

Do Enhanced Medicare Programs Make Sense?

Dr. E, guest blogger

Medicare advantage I have an elderly relative in a nursing home.  She has Medicare, of course, and secondary health insurance provided by the state she lives in, a state with excellent health care coverage.

I recently got a phonecall from a social worker at the nursing home.  She told me that they had a few openings for residents to join, at no cost, an Enhanced Medicare Program available to nursing home residents and wondered if I'd like to sign my relative up.  "What are the pros and cons?" I asked.

The social worker seemed stunned.  Since she presents the option as a gift your relative has been chosen to receive, she is used to most people saying "thank you" and signing right up.    She was hard pressed to answer my question as well as others I asked.  She finally gave me the local and national information phone numbers for the Enhanced Medicare Program she was promoting.

What I learned from making those calls is that Enhanced Medicare Programs for nursing home residents are run by several different private insurance companies, who have persuaded the Federal government, with questionable and self-serving studies, that these programs reduce patient hospitalizations and thus reduce Medicare costs.  From what I've learned and seen, however, nothing could be further from the truth.  That insurance lobby in Washington must be way more powerful than we've been told!

 I was told that the way these enhanced plans work for nursing home residents is that Medicare pays a significant monthly fee to these companies.  In return, the only added benefit for my relative is that an outside nurse practitioner would visit my relative just once a month.  We do not know how long the nurse's visit is or what the qualifications of the nurse practitioner are.  And, I wondered, do the nursing homes get a fee for every resident they sign up?  The social worker seemed more like a saleswoman for the program than an informed patient advocate. 

But here is the main question:  since licensed nursing homes have nurses round the clock and aides who see residents 24/7, and since these nursing homes also have doctors who make periodic visits and are available for phone consultations 24/7, and since Medicare and secondary insurance pay for everything else, how can this brief, just once a month visit, which costs Medicare a great deal of money, end up saving Medicare anything?  

I did my part to reduce questionable Medicare costs incurred by insurance companies in this country: I declined enrollment in the plan for my relative. 

The bottom line is that there's no substitute for your being totally involved with your relative's health and care in a nursing home.  Call the relative daily, if possible; stay in  constant communication with the nursing home staff/doctors; and and make unannounced visits as often as possible.

I'm Dr. E., Ph.D.   For more information, click on the following resources: 

Medicare Meets Mephistopheles

Healthcare Fraud:Auditing and Detection Guide 

Medicare and Medicaid Fraud and Abuse,2009 ed. 

The Political Life of Medicare  

Reforming Medicare:Options,Tradeoffs and Opportunities

Amy Bishop:Should She Get Away With Murder?

Dr. Amy Bishop In 1986, when Amy Bishop was 20-years-old, she shot her brother after she had a fight  with her father as he was leaving their Massachhusetts home.  Her mother, the only witness, said her son's death was an accident.  Amy went on to marry, earn a Ph.D. at Harvard, have children and work.

People remember her as being quite a menace in their quiet Massachusetts neighborhood.  It is said that she tried to get her child's teacher fired and also successfully barred an ice cream truck from coming to her street because, she said, her children were lactose intolerant.  In 1993, she and her husband were suspects in an attempted pipe bombing of a doctor she had worked for at Boston Children's Hospital.  And in 2002, she punched a woman in a House of Pancakes and then fled with her family.  The manager wrote  down her license plate, though, so she was brought to court and convicted of assault.

Astonishingly and unfortunately, the administration at  the University of Alabama did not have any of this information when they hired Amy Bishop, but they denied her tenure recently.  Her research and publications did not meet high enough standards for tenure, and students criticized her for  being disorganized, not making eye contact, simply reading from a textbook and too often expressing her extreme political views with unsettling passion. Several weeks ago, during a department meeting at the university, Amy Bishop pulled out a loaded gun and killed three colleagues and wounded others.

It appears she was psychotic, most likely suffering from paranoid schizophrenia.  Having this mental illness, however, should not necessarily exonerate her from being convicted of murder and serving her sentence.  She planned the attack; she got a gun; she trained with it at a local shooting range; she brought the loaded gun with her to the department meeting; and she calmly got up and started systematically shooting her colleagues in their heads.

Having gotten away with so much all her life, she might have started to believe that she was invincible and that when all the facts were presented, she would be exonerated.  She may think that her powers of persuasion are so great and her genius so valuable, that she will go free.  She most likely convinced herself that she had been wronged and that the people she killed deserved it.  She probably believes that somehow, once again, she won't have to pay for the consequences of her actions.

What is certain, however, is that Amy Bishop should not get away with assault and murder this time. She knew what she was doing and knew right from wrong when she fired her loaded gun and killed and injured her innocent colleagues.

I'm  Dr. Blokar.  For more information, click on the following resources: 

Schizophrenia for Dummies

Surviving Schizophrenia:A Manual for Families,Patients,and Providers 

The Complete Family Guide to Schizophrenia:Helping Your Loved Ones Getting the Most Out of Life 

When Someone You Love Has a Mental Illness 

Schizophrenia,Causes,Symptoms,Signs,Diagnosis and Treatments  

Problems With Mixing Medications

This should not be taken Some foods and liquids, like grapefruits and alcohol, for example, should not be taken with certain medications, even non-prescription medications, because they may interfere with the drug's effectiveness, and some seemingly harmless over-the-counter medications and even herbal supplements can cause problems when taken together with certain prescription drugs.

Recently, for example, it was reported in a newspaper in England that women taking Tamoxifen (a drug given in order to stop the recurrence and spread of some breast cancers) together with certain antidepressants were more likely to die from breast cancer than those women not taking Tamoxifen with certain antidepressants.  These antidepressants, according to the research, seem to interfere with the metabolism of the Tamoxifen.

Another example is a thyroid medication used to treat low thyroid function that should not be taken with calcium tablets because the calcium interferes with the body's ability to absorb the thyroid medication which makes the thyroid drug less effective.  Since, in this case, the consequences do not create severe health problems, there are no red flags that would make the doctor or pharmacist warn you about mixing calcium and this thyroid medication.  Mixing may result in your having to take a higher dose of the thyroid medication, though, to get the desired result.

Calcium, as a matter of fact, is one of those seemingly harmless, over-the-counter supplements that can interfere with the absorption of many medications, so I recommend taking calcium supplements many hours apart from other medications.

Not all research is good research, so not every study requires us to panic or change our routines.  Always tell your doctor, therefore, about all the prescription, over-the-counter drugs and herbal supplements you are taking and ask about which can be taken together.  And ask your pharmacist the same question.   In the end, you must take responsibility for being informed  so you can make the right decisions for yourself. 

I'm Dr. Blokar.  For more information, click on the following resources:

Medication Errors

You:The Smart Patient:An Insider's Handbook for Getting the Best Treatment 

Taking Your Medicine:A Guide to Medication Regimens and Compliance for Patients and Caregivers 

Preventing Medication Errors and Improving Drug Therapy Outcomes:A Management Systems Approach  

The Search for Meaning in Our Lives

The meaning of When women in their twenties and thirties seek help from a therapist, the primary goal is to get help in finding and keeping the right mate.  For men in their twenties and thirties, the primary goal in seeing a therapist is to get guidance on career issues.

But when people seek the help of a therapist in their forties and older, no matter what the presenting symptoms may be, the underlying issue commonly involves the existential meaning of one's life.  Humans question why they are here and why our lives can be so easily replaced and forgotten after we're gone.  And no matter what our beliefs are, we are all frightened by the thought of what happens to us after death.  There are some literary works that explore the existential question of the human condition that are helpful.

A wondeful short and simple book is Viktor Frankl's Man's Search for Meaning.  Six decades after being published it is still in demand.

Leo Tolstoy's Anna Karenina is a great literary work in which the character Levin (basically Tolstoy himself) goes through a major crisis of meaning at the height of his career and the fulfillment of his personal dreams.  We can learn a lot from Levin's struggle.

Fyodor Dostoevsky"s Brothers Karamazov and Thomas Mann's Magic Mountain are also helpful. 

If you read these books in high school, it doesn't count.  You were too inexperienced, and these books require a mature and fertile mind in order to bear fruit.  These books are not easy literature, but life is not easy either.  Great literature, like life, is not clean-cut and linear.   It is messy and chaotic in spite of our best efforts to control it,  but life is intoxicating at times and even miraculous regardless of what we are feeling.

Do not be lazy.  After all, you have only one life to live, and in order to make it worthwhile, you need all the help you can get.

I'm Dr. Blokar.  For more information, click on the following resources: 

Finding Meaning in LIfe,At Midlife and Beyond:Wisdom and Spirit From Logotherapy

Passages:The Mystery of Death,Finding Meaning in Life 

Real Answers to the Meaning of Life and Finding Happiness 

Prisoners of Our Thoughts:Viktor Frankl's Principles for Discovering Meaning in Life 

Worldly Wisdom:Great Books and the Meaning of Life

Man's Search for Meaning 

Finding Meaning in the Second Half of Life:How to Finally,Really Grow Up 

Anna Karenina

The Brothers Karamazov

 Magic Mountain   


Post-Traumatic Stress Disorder(PTSD)

PTSD There are now many precise diagnostic tests available to many medical fields but not to psychiatry.  Many doctors have access to all sorts of new technologies that allow them to make precise diagnoses that can eliminate unnecessary surgery or, if surgery is necessary, these tools enable the doctor to be far more precise and have even allowed some surgeries to be done on an outpatient basis.

Psychiatric diagnoses, however, depend on the observational abilities of the examiner and, therefore, there is the possibility for error.  Even a skilled examiner brings his/her own blind spots and prejudices into the process.

There have been small breakthroughs in psychiatric diagnostic tools, but most laboratory test are too imprecise and cannot be used widely.   A new promising test using data collected with magneto encephalography (MEG), however, is able to pinpoint the existence of Post-Traumatic Stress Disorder(PTSD). 

PTSD is characterized by the re-experiencing of an extremely traumatic event.  One may be haunted in dreams or may experience so-called disassociated states during which the patient behaves as though experiencing the traumatic event at the moment. 

 As a result of PTSD, the patient tries to avoid any stimuli and situation associated with a trauma.  One develops an overall numbing of one's general emotional responsiveness which often results in social withdrawal and markedly diminshed interest in previously enjoyed activities.  This is often accompanied by a feeling of detachment and estrangement from others including the inability to have loving feelings.

In spite of detachment and a seeming lack of interest, there can be a heightened excitability -- exaggerated startle repsonses, being on guard and hyper-vigilant about possible danger, difficulty concentrating, outbursts of anger and frequent difficulties with sleep. 

These symptoms of PTSD may lead to severe incapacitation in every area of one's life including learning, loving, working and socializing. Often the patient feels hopeless about his/her prospects for the future or even his/her longevity.

Although skilled clinicians are able to diagnose and treat PTSD, it involves lengthy evaluations which do not always result in an accurate outcome.  With the new and welcome MEG test, when in doubt we will be able to diagnose PTSD faster and then patients can be quickly triaged and directed into the most effective treatments.

I'm Dr. Blokar.  For more information, click on the following resources:

The Post-Traumatic Stress Disorder Sourcebook:A Guide to Healing,Recovery,and Growth

Conquering Post-Traumatic Stress Disorder:The Newest Techniques for Overcoming Symptoms,Regaining Hope,and Getting Your Life Back  

Post-Traumatic Stress Disorder for Dummies 

Healing From Post-Traumatic Stress 

I Can Still Hear Their Cries,Even in My Sleep:A Journey Into PTSD  

My Opinion of the Proposed Health Care Reform

Health care I, and many other doctors I know, breathed a sigh of relief when Speaker Pelosi announced that the Health Care bill passed in the Senate would not be approved by the House.  At least for now, the Health Care bill seems dead, in spite of  President Obama's remarks to the contrary after the recent election of a Republican Senator in Massachusetts.

As an immigrant physician who chose America based on the knowledge and perceptions I acquired while visiting the United States, I shivered at the thought that an enormous bureaucracy would make decisions that should be made between a doctor and a patient.  In addition, having some experience with state bureaucracy in a former communist country of my origin, I know how stifling and inefficient such a bureaucracy can be.

It was not uncommon for people to circumvent the bureaucracy by offering bribes in return for quality medical care, while physicians were forced to accept these bribes in order to support their families because the state paid them so poorly.

In my opinion, when bureaucrats run the system, individual talent and initiative suffer.  Everything is reduced to its lowest common denominator and all share equally in poor care.  Yet somehow highly positioned bureaucrats, politicians and the privileged always find ways to exploit the system while the average person is left with no recourse but to accept the state's largess.

I'm Dr. Blokar.  For more information, click on the following resources:

The Healing of America:A Global Quest for Better, Cheaper, and Fairer Health Care

Health Care Will Not Reform Itself:A User's Guide to Refocusing and Reforming American Health Care 

Cured! The Insider's Handbook for Health Care Reform 

The Truth About Health Care:Why Reform Is Not Working in America 

A Second Opinion:Rescuing America's Health Care  

When Children Have a Chronic Illness

Children with chronic illness Chronic illness may have devastating effects not only on a child's physical development but also on a child's psychological development.

Ill children are often treated differently by their peers who see them as dissimilar and fragile.  Frequent absences from school can prevent a child from forming strong relationships and being an integral part of the school community. 

A chronically ill child is treated differently in the family, too.  Some parents may overindulge their sickly child trying to overcompensate for the unjust hardships and deprivation the child may face.  Parents may be understandably overprotective and unnecessarily shield the child from every challenge.  Puberty is a particularly difficult time.  It is the time when the child strives for independence and detachment from the family, but for a child with chronic illness that leap towards independence is often thwarted by the dependence on others that is necessasary because of the chronic illness.

There are also effects on other family members.  Parents can become overwhelmed by and resentful of the enormous demands their child's illness causes.  Siblings may be resentful because the sick child requires more time and care, invariably taking time and care away from them.  When family members feel angry and resentful while at the same time feeling guilty about their misplaced and inappropriate emotions, there is conflict.  These conflicting feelings are communicated to the ill child and influence the ill child's sense of self.

Children with or without chronic illness learn who they are from their parents and others closest to them.  Loved children feel lovable; abused children often believe they are bad and deserving of abuse; and children of depressed parents often feel inadequate because they fail to make a parent happy. 

Family therapy might be very useful in helping the family of a child with a chronic illness to develop  well, without maladaptive character traits or, worse, a character disorder.  Once that happens, treatment is much more difficult.

I'm Dr. Blokar.  For more information, click on the following resources: 

Helping Children and Adolescents with Chronic and Serious Medical Conditions:A Strengths-Based Approach 

Extreme Parenting:Parenting Your Child with A Chronic Illness 

Parenting Children with Health Issues 

Families Living with Chronic Illness and Disability:Interventions,Challenges, and Opportunities 

In Sickness and in Play:Children Coping with Chronic Illness  

Avoiding Mistakes with Prescription Medications

Prescription pills We have all heard of mistakes made with prescription medications, even in hospitals.  Some prescriptions sound and are spelled so similarly that it is easy to see how mistakes happen.  But even though drugs may have similar spellings and sound alike, they are often used for very different purposes which makes these mistakes dangerous, sometimes even fatal.

A friend ordered a six-month supply of her antidepressant from a Canadian pharmacy, where she saved money.  About a month later she realized that something was not right.  She felt anxious, "blue," and easily frustrated with a short fuse.  When she looked again at the supply she had received from Canada, she discovered that she was not taking her antidepresssant at all but a medicine used for stomach/digestive problems. At a glance, the medicine started with the same first three letters as her antidepressant and contained the same 20 mgs dosage, but it was a very different medication used for very different illnesses.  While in this case there was no immediate or long term danger, the consequences of prescription mix-ups can be fatal.

There are many sources of medications abroad that are less expensive (but not regulated or under the supervision of a known and trusted pharmacist), and the potential  for  mistakes is enormous.  But even at your own neighborhood pharmacy, you must take responsibility for being informed about what  medications you take, in what dosages, and what they are for. 

Human error is always possible everywhere. For your own protection, always check that no mistake has been made on your order. 

I'm Dr. Blokar.  For more information, click on the following resources:

Medication Use:A Systems Approach to Reducing Errors

Medication Errors 

Medication Errors Guidebook 

Medication Errors:Lessons for Education and Healthcare  

Where Is the Confident and Courageous America I Love?

The american flag Coming from a totalitarian state with practically everything controlled by the government (your job, your apartment, your retirement age and your mobility), I had an image of America as a place in the sun. 

As a young medical doctor, I first came to the USA while working on a ship that besides carrying cargo also carried 13 American tourists.  During my three week trip I discovered that America was also unexpectedly and exceptionally generous.  I met people  who looked very young for their age, who engaged in their second, even third, careers, and I, too, wanted to live and thrive in a country where you can be young at 50 and where your prospects seem endless.  That was 32 years ago. 

What I see now, though, worries me. The 1993 bombing of the World Trade Center, in spite of subsequent bombings of US targets abroad, was not taken seriously enough.  September 11, 2001, however, changed everything.  It finally focused the public's attention on the dangers of terrorism...for a while. 

 Many of my friends and patients express doubt about our government's ability to protect us from man-made disasters.  They're resigned to whatever fate awaits us, hopeless especially after the attempted downing of an international Detroit-bound Northwest Delta plane on Christmas Day.  The symbolism was not lost on those who wish us harm, and many lament the shortness of our collective memories.

The government appears to be complacent at times, if not unintentionally complicit.  The fear of making value judgements or offending particular groups appears to paralyze the authorities constrained by the straightjacket of political correctness.

If psychodynamic concepts are applied to a nation, then America is behaving like an abused, despised child who concluded that it must be deserving of the hate it encounters.  Once you incorporate the hatred of those who are attacking you, you stop fighting the attackers.  Instead, you exaggerate your imperfections in order to justify their behavior towards you.

Where is the bold and courageous America I once knew with people who are generous, but not in denial, and who are confident in the future?

I'm Dr. Blokar.  I wish all of you a very Happy New Year, and may God bless America.