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The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.

Katrina Blog Project

Katrina #3: Some Financial Lessons

Hurricane Katrina is considered the worst natural disaster in U.S. history. Although the death toll, which now stands at about 1,200, is certainly significant, we are very lucky to say that most of our losses were financial. After all, compared to the Indian Ocean tsunami of 2004, which killed 250,000, or the Kashmir earthquake of 2005, which killed 75,000, we got off pretty easy.

But the financial effects are a different story. Probably close to 2 million people suffered significant financial loss from Katrina. I, for instance, lost my home and my medical practice . Every one of the 70,000 people in St. Bernard Parish, LA lost their homes too, as well as the 14,000 or so residents of the nearby (and better publicized) Lower 9th Ward of New Orleans. I learned a lot in my financial travails after the storm. In some ways, my story was different from most because I am a doctor. But many of the lessons I learned apply to just about anyone, and I would like to share some of them with you.

  1. Always keep a few hundred dollars in cash around. In an emergency, you may lose access to bank accounts. There may be regional problems with computers, so your credit cards could be worthless. But cash is accepted everywhere. Despite what American Express says, cash is the thing you should not leave home without.
  2. Keep enough money for 6 months of expenses in easily accessible accounts for emergencies. This was one of the financial goals my wife and I agreed on shortly after we got married, and it was a very good thing. The reserve cash took a lot of pressure off us, since we never had to worry about running out of food or not having a place to live. It was the best insurance plan we had.
  3. A good insurance company is worth its weight in gold. Our insurance carrier was State Farm. Though State Farm was not the cheapest insurance carrier available to us, we picked it because it had a good reputation for paying off claims and a sound financial record. Though I did not dwell on this issue, it turned out to be one of the best financial decisions I have ever made. Unlike other insurance companies (whom I will not name), State Farm rapidly paid on its claims and gave us no problems whatsover. It settled on our house and car for what I thought was a very fair price and in a short period of time. My claim was in by the end of September and we had our money by the early Novemeber. This freed us up financially to start looking for a new home. Despite what the commercials on TV say about saving money, a good insurance company is worth the price.
  4. Try to keep all of your insurance plans with one carrier. One of the problems many Katrina victims had was that they had fire and dwelling insurance with one carrier, flood with another, and car with a third. Besides the fact that this triples the paperwork, multiple carriers make final settlements more difficult. The dwelling carrier says the damage is from flood and the flood carrier says the damage is from wind. They play a game of passing responsibility back and forth, each refusing to pay until the other has paid. This has created serious problems for many on the Gulf Coast. We, however, had everything with one company. This meant that the total settlement would be the same dollar amount, regardless of how much was flood or how much was wind. The insurance company understood that, and so went rapidly towards finalizing the claim, since it was a no-win situation for them.
  5. Don’t save stuff for special occasions. I get pangs of regret every time I think of all the stuff we lost that we were saving for special occasions. We had unopened bottles of wine, fine china, silverware, crystal, and many other things that we never used because the time never seemed right. Now all that brand new stuff is gone, and we wish we had used it. Life is short, and you never know what will happen. I wish we had enjoyed that things we had more. Sometimes we forget when we break a plate or stain our best sofa with wine that at least we are getting use out of them. Try losing something that you never used at all.
  6. Keep all your financial and vital records together in a container that you can take with you easily. We got out with all our credit card numbers, our bank and tax records. And we took things I am now very thankful we have, like our birth certificates and Social Security cards, my medical license, and the deed to our house. The only thing I lost that I really need are my diplomas. Electronic records are the best. Anything you can put on a CD-ROM is easy to take in an emergency. I wish we had had everything on electronic record. That will be my future goal.
  7. Education is king. The one thing you can’t lose in a disaster is your skills. No matter what, if you have a solid education and good work skills you can always get back on your feet. The people who are suffering the most are the ones without education, who live paycheck to paycheck on minimum wages. For them, rebuilding is going to be very difficult, because they have no educational foundation to build a new career on. The best way to prepare for life’s worst events is to go to school. Of course I understand that, and I will make certain that my children do also.


Depression and the Importance of Doctor Follow-ups

A recent article in the American Journal of Psychiatry looks at depression and how it is treated. The study discussed in the article, the STAR-D trial, looked at the treatment of depression with the drug Celexa in 2,876 patients. The STAR-D trial found that Celexa is effective, which is no big surprise, but it also found that the patients who went back to the doctor regularly for medication adjustments (what the study called “measurement-based care procedures”) had more improvement that those who did not.

This helps to confirm what many doctors know from experience – that the first dose of an antidepressant seldom does the trick. Almost always, the medication has to be adjusted several times to arrive at the optimum dose.

It is important that people who seek treatment for depression do not give up. If the first dosage dose not work, the medicine may have to be adjusted. Or it may be necessary to try another medication.

It is my experience that patients who seek treatment for depression and anxiety often expect too much too soon from the medication. They think popping one pill will turn their lives around, and this is simply not the case. Antidepressives do work, and study after study has shown that, but making them work requires a little effort. If the medication does not seem to be working, or is working a little but not enough, it is vital that the patient discuss this with his doctor. With the proper re-evaluation, a good doctor can refine the treatment until the patient get the results he is looking for.


The Strange Case of Charles Cullen

Over the holidays, I stumbled upon a remarkable news story. A nurse in New Jersey, serving a life sentence for murdering 29 of his patients, has agreed to donate a kidney to an acquintance.

You can check out the story for more details, but I will outline the basics. The nurse, Charles Cullen, decided several years ago that he wanted to be New Jersey’s answer to Dr. Kevorkian. So he began killing older and weaker patients, people he thought were suffering and would die anyway. He did this by overdosing them on medication, typically insulin or digoxin.

In a brief review of Cullen's life, twothings stand out. First, Cullen is a deeply disturbed individual. He as attempted suicide on many occasions and has a documented history of spousal abuse and alcoholism. Divorce records indicate that he also has a history of animal abuse, and most psychologists regard animal abuse as a marker for severe mental distrubance.

Secondly, Cullen got away with his murders for years because again and again medical facilities hired him, unaware of his background. In fact, Cullen was dismissed from several hospitals and nursing homes under the suspicion of having harmed his patients. Although reporting laws have been strengthened since Cullen’s conviction in 2004, it remains remarkable how easily a healthcare professional can move from job to job despite a very poor work record, or even suspicion of malfeasance.

Which brings us to Cullen and the kidney. We usually think of organ donation as the most altruistic of actions – giving up a part or our own bodies and taking a health risk (surgery) to do it, all for the benefit of another. Here is a man who killed at least 29 people and yet wants to help save a man’s life.

Is Cullen just irrational? Or does he think he was doing a kindness by ending the lives of chronically ill people, and thus, the kidney donation is simply an extension of his desire to decrease suffering? One thing is for certain. If Cullen does have some sense of ethics he certainly has them out of order. It is not important simply to have values. A person must have the right priority of values. For instance, it may be ethical to be patriotic. But if a government asks a person to torture an innocent person because it is patriotic to do so, a moral person should at least pause. What is more important, patriotism or the right of an innocent person not to be tortured?

Values do not exist in a vacuum. They sometimes come into conflict (and this is often the case in medicine), and when they do, the people involved have to consider not just what their values are, but also which values take precidence in a given situation.

In the case of Mr. Cullen, perhaps he understood the value of not prolonging unnecessary suffering. But he missed the value of a patient’s right to live, even in suffering, if the patient wants to. It is a conflict of values that a balanced mind would not be likely to miss.

Aside from simply pointing out this very peculiar case, I would venture an observation. It is easy for us to see that Cullen, in his effort to relieve suffering, was doing the wrong thing. He, in his mentally ill state, stumbled over the conflict in values between relieving suffering and respecting a patient’s right to live. The fact that he would want to donate a kidney tells me that he really does have values, albeit very warped by his mental illness.

It is easy for us to see the faults in Cullen’s thinking. But there are tougher moral choices out there than the ones Cullen made. I wonder if our society is warped in its thinking, if we are making terrible moral choices but cannot see them, just as Cullen cannot see his. Our society once condoned slavery, and wife-beating, and lynching, because our ancestors stumbled over value conflicts our modern eyes now see as easily as we can see Cullen’s mistakes. There is no reason to think, having cast aside a few errors of the past, that we are now perfect, though it may be perfectly satisfying for us to be so kind to ourselves.


New Year's Day 2005

The past has claimed another year, and it goes without saying that for those of us from the Gulf Coast it is a year we would rather forget. It is the one mercy of the passage of time that a terrible event, once it has occurred, can only recede.

I was in New Orleans again for New Year's weekend and again impressed at how things improve, slowly but relentlessly, no matter how bad the local government is and how much the federal government drags its feet. But this is the way people always are. The most surprising thing is that anyone doubted it would happen. People plan. They look forward. They always have, or else how would Europe have survived the Black Death in the Middle Ages? A quarter of Europe died in the plague epidemic then. But people just got up and kept on going. As did the world after two devastating world wars, and China after a hideous revolution and Mao's purges thereafter. They all still stand.

A month ago, New Orleans Parish had 80,000 people. On New Year's Day, the new estimate is 135,000. It is predicted that that number will rise to 225,000 in a year. Even more impressive, the metropolitan area, once less than 250,000 shortly after Katrina, now stands at 930,000, and is expected to reach 1.1 million next year. Less than 2 weeks ago a New York Times editorial pronounced New Orleans a dying city. Though the city has many, many problems, far from being moribund, it is again one of America's 40 largest cities.

The hard work of life is not done by politicians, or newspapers, or pundits. It is done by countless, nameless people who make decisions every day. The leaders have a lot less to do with it than they think they do.

I think 2006 will be the year that New Orleans and the Gulf Coast will move on, without the politicians. The good folks down there, including several of my family members, will continue to rebuild, and work, and fight, no matter what the leadership says they should or should not be doing. If the leaders will just see to it that the levees get rebuilt and upgraded, we will see the rest come together, slowly, but almost magically.

The prognosticators need to get over themselves. Katrina was an act of God. Recovery is not an act of Congress; it is an act of the people.


Political Thoughts at Year's End, 2005

I have partisan political views, but for the purpose of this website, I tend to keep them to myself. But this being the end of the year, the time of reflections, it seems like a time to break some rules. We can set things right again next year.

Through the year, with the problems of Iraq, the renewal of the Patriot Act, and now the recent stories about the President ordering eavesdropping on private phone calls in the U.S. without a warrant, there has been a recurring theme. Exactly how much power should a president have? We live in a time when national security, especially from terrorism, is a very great worry for most of us. How much of our civil rights should we be prepared to give away for our safety?

At the heart of this issue is a longtime struggle for power in Washington – the struggle between Congress and the Chief Executive for leadership of America. We all know that the framers of the Constitution created three branches of government, the Executive, the Legislative, and the Judicial branch. It is understood that by dividing power among the three, and giving each branch the ability (and the duty) to check the other, that government will proceed more democratically.

That part is clear to everyone. What is equally important, but I think is less obvious to many, is that the Founding Fathers did not expect the three branches to share power equally. Congress was expected to take the lead.

We can easily see this intent in the first presidency. George Washington maintained a strict policy as President never to comment on legislation before Congress. He believed, as most Americans then believed, that the President’s job was strictly to enforce the laws on the books. He did not submit budgets. He had no “domestic policy” or “economic policy,” as presidents do now. Washington did not even think it was his right to veto legislation simply because he did not agree with it. For Washington, the veto was reserved solely for laws that he felt were unconstitutional. His Presidency was small, and unobtrusive, and it never would have occurred to him that it was his job to set the national agenda. That job fell to Congressional leadership.

Things have changed greatly in 210 years, mainly because of the arrival of the Fourth Branch of government, the Media. As the media in this country became larger and more important, it began to affect national politics. The media can pick and choose among major issues of the day, and in doing so, select which issues will catch the attention of the public. Note for example how Terry Schiavo became so famous that Congress tried to pass a law to save her, while a patient of mine in a New Orleans nursing home with identical medical issues died unnoticed.

Since the media can set the national agenda, this greatly empowers the individuals who can manipulate them. The President is one man. As an individual, he is a simpler focal point for the media than Congress. It is easy to cover the movements and statements of one man. Congress, on the othe hand, has 535 voting members, every one of whom has his or her own opinions and policies. It is much tougher to sum up Congress in two minutes than it is the President. So, over time, the President has been able to dictate the national agenda with increasing ease. He has become more powerful than Congress.

The relative primacy of the President is not necessarily a problem as long as Congress has the strength and the gumption to continue to check the President when he grabs for more power. The real danger emerges when Congress stops thinking it is its job to say no to the Executive Branch.

This has happened. It has happened because half of Congress, the half in the same political party as the President, has decided that it is more in their interest to support the growth of presidential power than it is to defend the traditional turf of Congress. I am not blaming the Republican party here specifically, because it has not been above the Democrats to do the same from time to time, especially in state legislatures. It just so happens that the Republicans have been in power lately, and lately this problem has been getting more serious.

From the point of view of the common citizen, it is critical that Congress and the President regularly butt heads. The Founding Fathers intended this. They also thought that Congress could and should win most of the time because it can make all the laws and is in charge of the money. To them, and to me, this is desirable. Every citizen has direct representation in Congress, and because members of the House stand for reelection every 2 years, Congress tends to be more sensitive to the public will. In general, in a democracy, we want a government that is sensitive to the wishes of the people.

The media have changed this balance. Because the President commands the immediate attention of the media 24 hours a day, because he is both the spokesman for government and the largest celebrity on Earth, singular influence tends to swamp the more divided forces of Congress. Thus the President leads the government nowdays. The members of Congress see that, and those in his party line up on his side, magnifying the power of the executive and reducing the legistative power. They do this because they are more interested in power than they are in keeping Congress separate and intact as a major force in public life.

How I wish the same pains taken to keep Church and State separate were employed to keep President and Congress independent!

We need a strong and independent Congress. Everyone likes to make fun of Congress, to deprecate it as a confused, pandering, illogical institution. Next to it the President looks firm, focussed, and calm. But we need Congress. If Congress is not strong, the voters are not strong. No one is immune to the tempation of power, and if Congress lets the President take all he wants, little by little he will be tempted to do it.

The Founding Fathers were afraid of the presidency. They thought it naturally engendered the characteristics of royalty and dictatorship, and they took great pains to limit it. Today, that job falls to Congress, and we need to make sure that our leaders are up to this important task.