Archive for June, 2014

The sad Gangsta

Posted: June 17, 2014 in Uncategorized

The patient appeared just like any other young male I had seen during my residency at an innercity clinic. His hair was kept very short, he wore an excessively baggy red shirt that hung past his elbows and had a matching red handkerchief stuffed in his back jean pocket, but this was different.

Normally the complaint would be some vague pain along with allergies to anything non-opiate, or maybe a new onset diabetic who is having trouble understanding his disease, or someone complaining of a new rash, but this was different.

While looking down at the floor and in a low steady tone he calmly told me how depressed he was, how he has trouble waking up each day, how he can’t bear to think of the future, even if its only a week ahead, and how he  had no interests in drinking, hanging out without friends, or even sex. Before he came to see me he recognized that he was at a desperate time in his life was and had gotten rid of all his firearms at home, but there was one catch. He stated that his job, doing air quotes with his hands, frequently required the use of a firearm. He also had fear about his “coworkers” who may turn on him if they learned how depressed he was. He was afraid because there was no “retirement plan” as he put it, the only way out being death of one sort or another.

I didn’t know what to do as they don’t teach you how to deal with suicidal gang members in medical school. How can I keep someone safe who is a danger to himself, but if he seeks help others become a danger to him? I offered to help him get admitted to a local mental hospital – which he refused out of fear of his coworkers.  I suggested maybe moving away – but he said “they will find me anywhere I go, we have eyes everywhere and in every city.” We ended up deciding on trying an anti-depressant, which he could hide from coworkers, and a return visit in one month to see how he was doing.

But I never saw him again, and I wonder what fate he suffered. Did he take his own life? Did his acquintances turn on him as he feared? Maybe, just maybe, he was able to escape and get the treatment that any human – gangsta or not – has a right to.

While reading over some articles I found one about physician suicide – which is of course an issue close to my heart. From there I started looking at other articles talking about physician suicide. This is gives me some relief as I am not alone but at the same time scares me as I fit some of the descriptions of a successful physician suicide “to the T”. In a career dedicated to helping others, it seems we fail at helping ourselves as evidenced by “the overall physician suicide rate cited by most studies has been between 28 and 40 per 100,000, compared with the overall rate in the general population of 12.3 per 100,000”  which is 2-3 times the rate of the normal population! In an era of physician shortage, about 400 physicians successfully complete suide each year which “would take the equivalent of 1 to 2 average-sized graduating classes of medical school to replace.”

I wondered if any specialities would be a highest risk – you would think oncology – with so much death and sorrow, or maybe neurosurgery – which are overworked and in constant high stress situations. In my situation, one of my worse clinical rotations was the medical ICU as I started feeling down, thinking very negative and was having trouble with dealing with other people being happy/content. I soon realized that we were averaging a death a day and it was taking a toll on everyone.  The answer suprised me – “there has been multiple studies since the 1960s trying to breakdown this in specialities, and they tend to point to psychiatrists as having the highest suicide risk – although studies done later have found no difference in specialities.” Although maybe dealing with constant mental illness, depression, and anxiety starts to effect oneself.

The risk factors for physician suicide are a lot like the general population – which upset me because I fit so many. For example, rates are found to be “higher among physicians who are divorced, widowed, or never married,” and having been recently divorced…  Another statement describes the personality qualities of a physician who completes suicide “as driven, competitive, compulsive, individualistic, ambitious, and often a graduate of a high-prestige school,” – I don’t think I am too competetive – but of course I am individualist(do autistic people have a choice in this regard?) and driven(which has gotten me to where I am). Another study showed personality factors “including self-destructive tendency, depression, and guilty self-concept” – which basically describe my mindset for the past 20 years – using these attributes psychiatrists were able to review a past medical class and pinpointed the 8 successful suicides without prior knowledge of the class! A 1980s study linked suicides to “having slightly more difficult or emotionally draining patients than other physicians, both throughout their careers and in the final 2 years of their lives” which is not too suprirising.

One of the other reasons possible for such a high success rate in physicians may be our knowledge of drugs and lethality, this has resulted in a “higher completion to attempt ratio”, especially in females. I can appreciate this as I think of my previous attempts when I was a teenager – how unlikely my change of suceeding would be with the methods I had used..


Miller, et al. The Painful Truth: Physicians Are Not Invincible, “Southern Medical Journal”, 2000

Facts About Physician Depression and Suicide, American Foundation for Suicide Prevention

Andrew, L, et al. Physician Suicide,, 2012

Colic and Probiotics

Posted: June 10, 2014 in medicine
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For anyone who hasn’t had a child, one of the things that be very stressful is colic, aka “Cry fuss behavior”. Colic is a poorly understood constellation of symptoms which there is no effective treatment, yet it puts the caretakers under great stress and is a common reason for ER and primary care visits.

To start off, there are different definitions of colic depending on what criteria you use but they all rely on a certain amount of time (usually over 3 hours a day on a frequent basis) and an infant who is healthy (meaning ruling out other causes) for a colic diagnosis. Examples of this include the “Rome III criteria” and the “Wessel Criteria”.

There is no one accepted theory that explains colic, and it is most likely a combination of social and physical causes, but most theories focus on the GI system (specifically around milk digestion), biological factors (like smoke exposure), and psychosocial (the babies tempermant).

The history and physical focus on ruling out diseases that CAN be treated, such as metabolic disease and GI disease, and the workup would be dependent on if you think one of the other disorders exist (this includes labs, radiology studies).

The usual recommended treatment of colic focuses on supportive therapy (soothing the baby) and with adjusting feeding techniques. Other treatments include removing lactose from the diet (for suspected lactose intolerance) to herbal remedies.

One of the secondary treatments that has been gaining some interest is treating with probiotics. A review of RCT(randomized control studies) in 2013 found inconclusive results regarding probiotics. Multiple other reviews occured in 2013, which showed confilicting results (some positive, some showing no effect)

A new paper, by Indrio, et al. “Prophylactic Use of a Probiotic in the Prevention of Colic, Regurgitation, and Functional Constipation: A Randomized Clinical Trial”, published 2014 in JAMA pediatrics adds to this existing knowledge.

This is a somewhat small study (n=238 in the treatment group) for a short peiod (90 days), but it is structued as a “double blind” study. The secondary outcomes used include the number of medical visits, ER visits, and the number of parent work days lost, were much less in the treatment group. This makes both a difference to the parents along with reduced healthcare costs. The authors mention that longer studies are needed, as are ones comparing the different probiotic formulations – which would be interesting if they were designed in a similar way.

This provides an interesting alternative if the methods of feeding adjustment and soothing do not work and you are left with a very frustrated parent.


Uptodate –

Indrio F, Di Mauro A, Riezzo G, et al. Prophylactic Use of a Probiotic in the Prevention of Colic, Regurgitation, and Functional Constipation: A Randomized Clinical Trial, JAMA Pediatrics. 2014;168:228-233

A renovation

Posted: June 10, 2014 in Uncategorized

A lot has gone on since I started this.. I have finished my family medicine residency, I have moved, and I am going thru a divorce..

I think I may continue the use I originally intended this for (life thru the eyes of high functioning austism) and in addition include articles/research studies I find interesting.

I am very open to people asking questions or having me talk about certain effect of HFA on medicine/life.