New App-Pager

I saw an ad on the subway today for a new app called, "Pager". You download the app, input your info, and then you can report any symptoms you might be having, and get a doctor to make a house call within 2 hours.

That's right! The new innovation in medicine is house calls.

The app was designed by the same people who brought you Uber, the taxi summoning app. Which makes sense. In case you're interested, and I must say I'm intensely interested in this, here's a Wall Street Journal article about Pager from back in May.

But today was the first ad I'd seen for it, and I ride the subway every day.

I did the instant chat thing with Michelle from Pager when I checked out the site, because I was curious about a few things. Here are the screen shots:

Okay, so it's not foolproof, but they do have some way of addressing safety concerns.

I asked about safety because I remember my doctor making house calls when I was a kid, but this was someone with whom my family and I had a long-established relationship. Not a stranger.

I asked about Gyn just to be challenging. And I asked about Psych to see what they would say, and if I could potentially work there one day. Not that that's my current plan, but I do think this is a much more promising venue than telemedicine. These are real medical visits, with real physical exams. Wounds can be sutured, school physicals dealt with, flu shots given, labs ordered and followed up, prescriptions written.

I was thinking about this in comparison with Urgent Care centers, and for reasons I  can't really justify, I prefer this system. I somehow have the sense that if I walk into an urgent care center, I'll end up dealing with someone who has less training and knowledge than I do, and I'll be frustrated and walk out. I'm not sure why a doctor working for Pager would be any different, except that, at least according to the WSJ article, doctors do this to supplement their incomes, and to avoid the frustration of working at insurance based clinics. Somehow that seems more reasonable, or at least more in line with my approach. But I'd be interested to hear other people's thoughts.

Pager is $50 for a call or text that does not require in-person follow up, $199 for a weekday house call, and $299 for a weekend/evening house call. I believe it's only available in Manhattan, currently. I'm also not sure what the time limit is for a house call. Pager will provide you with appropriate bills to submit to insurance.

The site seemed reasonably responsible in weeding out emergencies, which was reassuring. It also seemed really suitable for someone visiting NYC and staying in a hotel.

Is this the future of medicine? Surely not the future of Psychiatry-house calls are kinda off limits for the way I practice. But Pager has an option for telemedicine, so maybe it could be tele-psychiatry, with an option for in-person follow-up if necessary. Sounds confusing, but better than run-of-the-mill distance psychiatry.

I did download the app. It required my name (false), email, cell number, and photograph, which it claims to need. It requires a credit card to set up an appointment, but not for plain old registration. I entered my office location, but I couldn't figure out how to access a list of local doctors without entering my current symptoms. Maybe I'll try that out.

Happy New Year

For those who celebrate the Jewish New Year, have a good and a sweet year. For those who don't celebrate the Jewish New year, also have a good and a sweet year.

Shannah Tovah!

Prozac "News"

This article was in the NYTimes.

It includes a retro report video which describes, in essence, Prozac's celebrity. The video leaves me kind of unsatisfied. It alludes to the unproven suspicion that Prozac increases suicidality, but drops the subject. It focuses more on the marketing of Prozac: "PRO" as in professional. "AC" as in action. And "Z" that sounds powerful, or techy, according to the article. They have quick videos of Elizabeth Wurtzel (author of Prozac Nation, also see this ghastly piece by her in yesterday's Times), and Peter Kramer (author of Listening to Prozac-check out the "before and after" of him with brown hair and with grey hair, and of the computers he uses). And it references the controversy of what Prozac is treating-is it "cosmetic"?, what is illness?, etc. All in 9 minutes.

I guess I expect a media video to be more interested in the controversies. There's a lot that could be said about the suppression of data. And the marketing guy they interviewed is satisfyingly slimy, so I can't really complain. Basically, it's a small capsule.

Learning New Things

I hope people are familiar with the Khan Academy. It's a wonderful resource created by Sal Khan, an MIT graduate who went on to work in business. While he was working, he started making little You Tube videos on the side, to teach math to his cousins. Then he realized that people who weren't his cousins were also interested in his videos. He thought about charging for his educational efforts, but then he remembered MIT's Open CourseWare.
There are a lot of online learning sites these days, including MIT/Harvard's EdX, Coursera, Codecademy, and Udacity, but Open CourseWare started it all. MIT decided to make all of its course materials, including syllabi, homework assignments, and lecture videos, available online, to the public, for free.

The Khan academy teaches a huge range of topics, from statistics to art history, from kindergarten level math to immunology. Recently, they even started offering test prep for standardized tests like the SAT, to level the playing field with students whose parents can afford private tutoring, and they have a college admissions section for some guidance.

I get periodic emails from them, and I recently received a link to this video, entitled, You Can Learn Anything:

For those who didn't bother to watch it, the video claims that no one is born smart, that learning requires struggle for everyone, and that this is a good thing. And ultimately, with enough effort, anyone can learn anything.

I applaud the notion that learning requires struggle. It casts frustration in a new light, and reminds people to persevere. But I don't believe that anyone can learn anything.

I studied math as an undergraduate, and for a miserable year in graduate school. And one of the few bits I've retained from all the math I learned and subsequently forgot is that math is HARD. Medical school was a lot of work, and what I do now requires intense effort and a certain kind of smarts. But nothing I've encountered comes close to the shear reasoning ability required for math.

Math beats everyone. Mathematicians, people who have chosen math for their professional lives, rarely produce new research past age 30.

One notable exception was the Hungarian mathematician, Paul Erdos (pronounced AIR DISH).

Paul Erdos

He produced new material pretty much until his death in 1996 at age 83. Erdos never married or had any romantic relationship that anyone was aware of, gave away all his money in contests he devised for young mathematicians, lived with his mother until her death, and subsequently by hopping from the home of one mathematician to the next ("Another roof, another proof"), and used amphetamines most of his life so he could spend 19 hour days working on math ("Plenty of time for rest in the grave").

To give you a little more flavor, he once wrote a letter to a fellow mathematician that went something like this:

Dear So and So,
Today I am in Australia. Tomorrow I leave for Hungary. 
Let k be the smallest integer such that...


Sure, Erdos never stopped learning. Math. But at what price? It's not clear that he was able to learn much of anything else. Certainly normal social interactions eluded him.

It's great that the Khan Academy has taken it upon itself to encourage people to learn. Learning is awesome! But I think there's a danger in encouraging the idea that anyone can learn anything, that the most difficult concepts are accessible to anyone with determination, regardless of innate talent or intellect. Because that isn't true. I will never be a Hall of Fame quarterback, or an Olympic sprinter, or even a mathematician like Erdos. And that's okay.

It all reminds me of a short story by Vonnegut, Harrison Bergeron (it was copyrighted in 1961, so I feel okay linking to it because it's been more than 50 years). The story takes place in 2081, when everyone is completely equal. Anyone who is exceptional in any way, be it dance, intellect, music, whatever, is subject to the Handicapper General, who plants noisemaking devices in people's heads to distract them from original thoughts, and attaches weights to anyone of physical prowess. All so no one will feel "less" then anyone else.

Chocolate

I'm addicted to chocolate. When I tell this to people, they usually smile, and I get that it's kinda cute. After all, chocolate doesn't impair my judgment, or make it hazardous for me to drive or operate heavy machinery. I won't go to prison for selling or using chocolate. Chocolate won't put me in rehab, or in danger of dying from overdose or withdrawal. And I won't spend my life's savings on chocolate.

It just tastes great and makes you feel good. But truly, I'm addicted. My longest clean time is one year, but I'm more typically on the wagon for a month or two.

Please understand, I am not making light of addiction. I genuinely have a problem with chocolate. I go on chocolate benders. I experience withdrawal with intense cravings and mood swings. In fact, probably the worst thing chocolate does to me is affect my mood. Or maybe it's the severe GERD. Either way, it gives me tremendous empathy for people suffering from addictions, and I'm just grateful that my substance of choice is legal and relatively benign.

Granted, some of it is about the taste. Because I won't consume just any chocolate. I'm extremely fussy. My favorite chocolate to just munch on or bake with is Callebaut. I'm particularly partial to their semisweet. And my favorite hot chocolate (not cocoa, NEVER cocoa-you can barely taste the chocolate) is the single origin Venezuela source by L.A. Burdick, which has stores in Boston, Cambridge, New York City (unfortunately, right across the street from my old office), New Hampshire, and nowhere else, as far as I know. I'm also partial to a store in the West Village called, The Meadow, which sells small batch chocolates, salt, bitters, and flowers. The guy working there told me he likes to eat dark chocolate ice cream out of a pink himalayan salt bowl, which sounds magnificently indulgent.

There's no question, at least for me, that eating chocolate feels good. It's soothing. It's calming, and it's mildly euphoric. Is it possible to isolate the elements in chocolate that cause those effects, and turn them into an antidepressant? Is it possible to keep those effects from wearing off quickly?

A paper by Parker et al (Summary) claims that while eating chocolate is a pleasurable experience, if eaten to help with a negative mood, it may provide short-lived relief, but then perpetuate the negative mood.

An article in How Stuff Works claims that chocolate contains caffeine, cannabinoids, and Pheylethylamine, the "love drug", technically classified as a hallucinogen. It also causes the release of dopamine and serotonin. The article goes on to claim that these chemicals are present in chocolate in amounts to which we've become habituated in things like coffee, so they don't have much effect on people. I don't smoke, I don't use any illegal drugs, I drink maybe a glass of wine a month, and I don't consume caffeine, except in the form of chocolate. Maybe that's why it effects me so intensely.

Anandamide is an endogenous cannabinoid also found in chocolate. Its effects are mediated by the central CB1 cannabinoid receptors, and the peripheral CB2 receptors. A metabolite of acetaminophen, AM404 is a weak CB1 and CB2 agonist, as well as an anandamide reuptake inhibitor. This may explain some of the analgesic effects of acetaminophen.

Anandamide is degraded by the fatty acid amide hydrolase (FAAH) enzyme, as is AM404. However, an analogous, synthetic compound, AM1172, also inhibits anandamide reuptake, and is not degraded by FAAH. AM1172 is a candidate for the treatment of anxiety and depression (Royal Society of Chemistry, Fegley et al).

Phenylethylamine is sold as a dietary supplement for its purported mood effects. However, it undergoes extensive first pass metabolism by MAO-B, and as such, would need to be ingested in extremely high doses to have any significant effect on mood.

In writing this, I've pretty much exhausted everything I remember from Chemistry, so I'm gonna stop with the technical stuff. But with all the talk about there being nothing in the pipeline in antidepressant development, what happened to these guys? Does anyone know?

I'll leave you with a recipe for the world's best brownies. It's my adaptation of a fantastic recipe from Smitten Kitchen. In my opinion, they taste best frozen.

3 ounces unsweetened chocolate, roughly chopped
1 stick unsalted butter, plus extra for pan
1 cup (packed) dark brown sugar
2 large eggs
1 teaspoon vanilla extract
1/2 teaspoon flaky sea salt
2/3 cup all-purpose flour

Heat oven to 350°F. Line an 8×8-inch square baking pan with parchment, extending it up two sides, or foil. Butter the parchment or foil or spray it with a nonstick cooking spray.

In a medium heatproof bowl over gently simmering water, melt chocolate and butter together until only a couple unmelted bits remain. Off the heat, stir until smooth and fully melted. You can also do this in the microwave in 30-second bursts, stirring between each. Whisk in sugar, then eggs, one at a time, then vanilla and salt. Stir in flour with a spoon or flexible spatula and scrape batter into prepared pan, spread until even. Bake for 25 to 30 minutes, or until a toothpick inserted into the center comes out batter-free.

Let cool and cut into desired size. If desired, dust the brownies with powdered sugar before serving.


*non-linked info from Wikipedia

A Duck!

Not talking about emotional support ducks, here. Nor am I referencing Shrink Rap's mascot, cute as it may be. I'm talking about the collaborative care model. I enthusiastically checked out "new and interesting clinical updates from UpToDate", the psychiatry section. And this is one of the things I learned:

Collaborative care for patients with depression and medical illness (May 2014)

Collaborative care that integrates mental health specialists and case managers into primary care practices is an effective way to treat depression and may also improve general medical outcomes. In a meta-analysis of seven randomized trials that included 1895 patients with comorbid depression and diabetes, both depression scores and glycemic control demonstrated greater improvement with collaborative care than with usual care.

Having written about this exact topic a little while back, I wasn't sure where they were drawing their conclusion from. So I went to the link and found this:

 Many studies demonstrate that collaborative care improves depression outcomes:

●A meta-analysis of 37 randomized trials (n >12,000 depressed patients) found a significant but clinically small effect favoring collaborative care over standard primary care, which persisted for up to five years; heterogeneity across studies was moderate.

●A subsequent meta-analysis of 79 randomized trials (n >24,000 depressed patients) that compared collaborative care with usual primary care (eg, pharmacotherapy alone) found that after six months, response (reduction of baseline symptoms ≥50 percent) occurred more often with collaborative care (relative risk 1.3, 95% CI 1.2-1.4); heterogeneity across studies was large. The benefits of collaborative care persisted for up to 24 months.

●In meta-analyses of randomized trials that compared collaborative care with usual care in depressed patients with chronic conditions (eg, arthritis, asthma, cancer, coronary heart disease, diabetes, and HIV), improvement of depressive symptoms, psychosocial functioning, and mental and physical quality of life were greater with collaborative care that usual care. However, other analyses found that diabetic control and all cause mortality were each comparable for the two treatment groups.

I'm not sure how this demonstrates improved glycemic control.

Another study that I know of, by Katon, et al, and published in NEJM in 2012, looked at collaborative care for patients with depression and co-morbid diabetes and/or coronary heart disease. This study found significant blah blah blah. It also changed its primary outcome measures during the course of the study:

The initial primary outcome was the percentage of patients achieving disease control at 12 months on all three disease-control measures...This outcome was changed in August 2009 (before study data became available for analysis in November 2009)...

I assume they're telling us the outcome measure was changed before study data became available so we won't think there was any bias. They didn't know the outcome yet, right? Well then, why change the outcome measure?

NEJM. Oh, yeah.

This is an excerpt from the description of the study intervention, just so we can establish what goes on in a collaborative care model.

The intervention combined support for self-care with pharmacotherapy to control depression, hyperglycemia, hypertension, and hyperlipidemia. Patients worked collaboratively with nurses and primary care physicians to establish individualized clinical and self-care goals. In structured visits in each patient's primary care clinic every 2 to 3 weeks, nurses monitored the patient's progress with respect to management of depression (according to the PHQ-9 score), control of medical disease, and self-care activities. Treatment protocols guided adjustments of commonly used medicines in patients who did not achieve specific goals...First-line agents included...citalopram or sustained-release bupropion for depression. Nurses followed patients proactively to provide support for medication adherence.

Using motivational and encouraging coaching, nurses helped patients solve problems and set goals for improved medication adherence and self-care...Patients received self-care materials, including The Depression Helpbook, a video compact disk on depression care, a booklet and other materials on chronic disease management, and self-monitoring devices...

Nurses received weekly supervision with a psychiatrist, primary care physician, and psychologist to review new cases and patient progress. An electronic registry was used to track PHQ-9 scores and glycolated hemoglobin, LDL cholesterol, and blood-pressure levels. The supervising physicians recommended initial choices and changes in medications tailored to the patient's history and clinical response. The nurse communicated recommended medication changes to the primary care physician responsible for medication management.


This is a link to the supplementary appendix. It includes, among other things, the power point they used to teach the nurses the study intervention. It's too upsetting to describe. Take a look, if you have a strong constitution. 

About the same time I got the UpToDate email, I read an article in the July 4th edition of Psychiatric News, The First and Last Word in Psychiatry. (It's the APA). It's by Jurgen Unutzer, one of the pioneers of integrated care, and it's entitled, Case Study: Heartbreak and Lessons Learned. In it, Dr. Unutzer laments the abandonment of a collaborative care model by a clinic, the Federally Qualified Health Center (FQHC). It was a 3 year program that worked spectacularly in its first two years. But then there were staff changes, and poor financial planning, and the program was abandoned. "Most importantly, the organization never fully integrated the program into its overall mission, vision, and clinical operations." The poor, lost, misguided souls.

Reading this made me think of the duck.

"Why is collaborative care like a duck?" you ask. Not for the same reason a raven is like a writing desk. 

It goes like this:

Patients seen in primary care clinics often have poor access to mental health care. 
We know that most prescriptions for antidepressants are written by primary care doctors. 
Therefore, all patients seen in a primary care setting should be administered a PHQ-9.
The best treatment for those who qualify as "depressed" is a care manager.
Psychiatrists are trained to treat patients with depression, and should therefore have no contact with the patients in a collaborative care program.
The care manager will administer sequential PHQ-9s via phone contact, to determine if the patient gets better on the medication that is recommended by the psychiatrist and prescribed by the primary care provider. 
When these patients say they are more satisfied with their lives because of the collaborative care model, this means that their diabetes has improved. 
Therefore, all psychiatric care should be practiced via the collaborative care model.


I suspect the reasoning is based on the following logical sequence, from the witch scene in Monty Python and the Holy Grail:

Terry Jones: There are ways of telling whether she is a witch.
Rabble: Are there? What are they? Tell us!
TJ: Tell me, what do you do with witches?
R: Burn them!
TJ: And what do you burn apart from witches?
R: More witches!
R: Wood!
TJ: So, why do witches burn?
(Confused pause)
R: Cuz they're made of...wood?
TJ: Good!
TJ: So, how do we tell whether she is made of wood?
R: Build a bridge out of her!
TJ: Ah, but can you not also make bridges out of stone?
R: Oh, yeah.
TJ: Does wood sink in water?
R: No, it floats. It floats!
R: Throw her into the pond!
TJ: What also floats in water?

Rabble:
Bread!
Apples!
Very small rocks!
Cider!
Gravy!
Cherries!
Churches!
Lead! Lead!

Graham Chapman: A duck!
TJ: Exactly. So, logically:
R: If she weighs the same as a duck, she's made of wood!
TJ: And therefore?
(confused pause)
R: A witch!