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PostPosted: Sun Jan 09, 2011 8:45 pm 
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We've had these discussion before, Ian, per the mass murderer at Virginia Tech. And we politely agreed to disagree.
IJ wrote:

A psych hold requires that you be a risk to self, others, or unable to care for yourself.

Hence my ability to get two (2) people detained - for the good of themselves and/or the public. I understand the threshold, and know when and how to pull the rip cord.
IJ wrote:

Chronically hallucinating, feeling persecuted, fearing the government takeover, using PCP, training for armageddon = release to street.

In other words, pass the trash.

If it makes you feel better... And it is legal... And you have your excuse...
IJ wrote:

Threats to others have to be fairly imminent and specific.

Being 5 cards short of a deck was obvious even to this amateur, Ian. Read his writings, fercryinoutloud.

Caring enough to see that someone gets help is showing a sense of humanity. But of course I don't have that because I'm one of those free market extremists, right? ;) Sorry, my friend. I just enjoy chatting with you.
IJ wrote:

Unfortunately this guy was probably just a nut, one of many, and probably didn't rise to the level of forced confinement or treatment.

Dr. Obvious I presume...

See above.

You're talking to someone who's a professional in the field of health care predictive modeling. I'm building yet another one right now. (Can't tell you what it is... Industry secret and all that.) I understand the issues with predicting rare events.

But that's a red herring.

This guy needed help, and he was left to fend for himself. He was on the radar of the Army, the local community college, and local law enforcement. And it doesn't take government programs to solve the problem. It takes a caring community, and professionals whose tendency is to go the extra mile. They exist, Ian. But folks can sleep at night, knowing that they have an excuse.

Most probably nobody will lose a job over this. But wouldn't it be nice if this story was a non-story? I could be bashing Obama and you could be telling me how I'm an unrealistic purist. Think of all the precious free time we could be wasting!!

- Bill


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PostPosted: Sun Jan 09, 2011 9:21 pm 
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Now I think I know what you tried to say to me,
How you suffered for your sanity,
How you tried to set them free.
They would not listen, they're not listening still.
Perhaps they never will...


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PostPosted: Sun Jan 09, 2011 11:40 pm 
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Not that changes things but the Twitter posts by those who knew him fill in some back story. Bill, what kind of effects can alchohol poisoning have on a person?

http://blogs.phoenixnewtimes.com/valley ... hooter.php

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PostPosted: Mon Jan 10, 2011 11:21 am 
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Ian

Nice try, but...

No I did not suggest any of the wild and crazy things you suggested.

And no, I am NOT letting health care professionals off the hook. And guess what? Nonprofits which are developing the standardized metrics for health care process quality aren't either! (NCQA, AQA, NQF, etc.) Welcome to modern health care, where physicians and hospitals are held accountable for the care their patients get - REGARDLESS OF WHETHER OR NOT THEIR PATIENTS WANT SAID CARE. Because guess what? When we measure said process quality, we find that the results aren't random. IN SPITE OF the fact that it is ILLEGAL to force health care on patients, we find that some doctors are better at the game of behavior modification than others. And why is this? Go ask the doctors who consistently perform better.

My job in the health care system (among many) is to monitor process quality in health care (by any number of hundreds of national standard methods). I do so because I generally create the experimental design to test the effectiveness of interventions to health care populations. If the doctors can't do it by themselves - and they often can't - then "we" come in and apply this black art of behavior modification. And they actually let me do stratified random sampling and hold back control groups to see if something worked. And if it works? We keep doing it!

For what it's worth... There are literally tens of millions of dollars on the table for us in our Medicare Advantage population.

All of this is to tell you - once again - that I disagree with your attempts to make it seem like behavior modification is impossible. Impossible for some? Absolutely. Can't make a difference? BS. Some MDs most definitely do better than others, and some third party health plans do better than others.

For what it's worth, Ian... I'm not into making any number of things illegal. But I do believe you can encourage, insist, badger, cajole, and motivate a good number of people to do any number of things.

And as for the young lad in question... He was living at home with his parents, going to a community college. Translation? He had health insurance. Cost? His parents were ALREADY paying for his health care.

Do you think his parents preferred the alternative which is their son being nationally infamous and held in FBI custody with a chance of never seeing the light of day again?

How hard was that?

- Bill


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PostPosted: Wed Jan 12, 2011 1:06 am 
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MikeK wrote:

Bill, what kind of effects can alchohol poisoning have on a person?

Cutting to the core of your question...

The results of twin studies suggest that these types of mental health conditions are part nature and part nurture in origin. In other words they run in families and one can inherit a propensity to be stricken the same way BRCA1 and BRCA2 can put a woman at risk for getting breast cancer. And... things we do - LIKE SUBSTANCE ABUSE - can trigger those genetic factors.

I do not believe that alcohol poisoning alone did it. But in a case above that I referred to where (after some considerable effort) I was able to get someone help, her brother developed his schizophrenia shortly after a "bad LSD trip." And further investigation revealed evidence of schizophrenia on the maternal side of the family. So there we have both factors coming into play.

One really interesting factor I've seen suggested as causal is the mom contracting influenza while pregnant. Apparently the child born of that pregnancy has a higher risk of developing schizophrenia. This is why I have a running experiment right now that is comparing 4 different interventions (against a control group) to get people with chronic illnesses and/or who are pregnant to get their influenza vaccines.

- Bill


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PostPosted: Thu Jan 13, 2011 6:10 am 
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Bill, I'm well aware of efforts to improve delivery of patients to care that are outcome oriented. You're also aware that there is a lot of work being done to make sure these measures don't penalize doctors working with difficult populations or in resource strapped communities. You may or may not be aware that many of these measures include an "out," for patient refusal or are compliance free--such as measures for tobacco cessation (advice provided) or beta blockers at discharge after MI (prescription given OR contraindication noted).

"All of this is to tell you - once again - that I disagree with your attempts to make it seem like behavior modification is impossible. Impossible for some? Absolutely. Can't make a difference? BS. Some MDs most definitely do better than others, and some third party health plans do better than others."

Great. Hearing about your from a distance experience with quasi related work is nice. I also know about your two referrals for mental health evaluations (and how one worked). But I've been actually trained to do capacity evaluations, and I've been involved with them in clinical medicine now for eleven years, six as an attending physician. I spend much of my time surrounded by psychiatry--my partner and half of our friends--and these issues are discussed constantly. I have been involved in as many psych-hold situations (as a practitioner) just TODAY as you have (as a lay person) in your life. I know I was an 18 year old kid when you met me, but seriously--what amazes me here is your willingness to tell me how these things work rather than ask me.

I did indeed have flashbacks to your Va. Tech comments when you started writing here. Then, it sounded pretty much like you faulted individuals who didn't hold or treat the guy, but... gosh how many times can I say it?... we're not. allowed. to just hold. anyone we want. You have to be pretty freaking disturbed to be on a hold. We HAVE to let untold numbers of totally psychotics roam the streets (and truth be told, most of them do fine, and/or are a threat to no one other than themselves, be it from suicide or substance abuse).

I am perfectly aware that mental health treatment (or anti-retroviral compliance, or heart failure management, whatever) can be done effectively, or ineffectively. Where we differ is that you seem to think the higher performing groups are going to effectively, substantially, reduce these events, or as if it's clear that this one could have been stopped; you write as if someone clearly dropped the ball. Yes, there are great models for active mental health teams that go into the community, monitor intensively, provide lots of therapy and followup, and do better than others. These teams are funded by someone, and they're given certain amounts of authority too. Where there is no team set up, well, it's not as good. Where funding has been slashed, well, it's not as good. Dur.

Go ahead and say you're not letting "health care professionals" off the hook, but what you should be saying is that you wouldn't let mental health systems (legislatures to judges to police to health systems to families etc) off the hook (entirely). Talking about the individual professionals makes about as much sense as saying it's some ER doctor's fault a cardiac arrest patient died at Denny's. She can't control the presence of an AED. She can't control bystander education on CPR. She can't control 911 services. A mental health professional can't just go into the community looking for cases to treat; they deal with what they're brought. Was this guy brought to "health care professionals" attention? Hmm? So what are they supposed to do? And he may be a total whackadoo, but that doesn't make him holdable or force-treatable. We have to impress a judge for that stuff (other than temporary emergency). I have heard he was nuts and the college students thought he was a potential risk, but I haven't heard anything convincing he's said that would make him holdable (but please fill me in). Maybe the college shoulda had the police pick him up. Maybe a student shoulda called the police on him. His parents (I don't know all the details but they apparently tried to help in reasonable ways). Someone shoulda forced an eval to at least keep him from buying a gun so easily. Shoulda Shoulda.

What you're hoping (no data--I mean, 5 minutes ago you were saying we shouldn't expose people to the true cost of healthcare because there wasn't proof and the benefit would be marginal--WTF) is that an awesome system might have gotten the guy on treatment or locked him up. That's all possible. Especially in some imagined setting where the psychotics can be forcibly medicated (not in the USA, no they can't). This might have reduced the risk, in retrospect. So now what?

Going forward, you can't just treat the one person who will shoot up a crowd every 5 years-no one knows who they are. You need a comprehensive healthcare system that gets to all these people (the mentally ill) so that only the noninsane proceed with mass killings (which they will). So who's funding this comprehensive mental health safety net? Again, 5 minutes ago, you wanted a healthcare system that's "pay or pray," and whether this dude had insurance or not, many to most of these schizophrenics do NOT, and states with crushing deficits are cutting services not increasing them. Here in San Diego, they basically ceased funding for psychiatry to see all mentally ill poor people unless they were basically in crisis, pushing all psych care of stable schizophrenia and bipolar and depression to community clinics when 1) these people don't have PCPs and 2) the PCPS are not equipped to deal with these patients, they aren't psychiatrists. Beds at County Mental Health are hard to come by. So how do you address that minor problem?

In an effort to make your head explode, I went looking for something from Salon on the matter. I found an interesting article from a reasonable sounding psychiatrist who among other things diagnoses the guy with probable schizophrenia, excuses the media of responsibility, points out that hindsight is 20/20, advises us that the laws in AZ make it relatively easy to force evaluations of potentially mentally ill people, compared with other states, and explains that yes, dur, coverage matters:

"During media coverage of stories like this, we often hear that we should take mental health seriously in this country. What would that mean, exactly?"

"It would mean you would actually have the resources to do something we haven't done yet, which is get people treatment. We have been very good at emptying the hospitals. What we haven't done is to offer treatment once people are out of the hospitals. In Arizona, for instance, they closed down most of the hospital beds. They are next to last in the United States in the availability of hospital beds for the population, and they have closed down some of the outpatient clinics. If you want to get serious about mental illness, then you need to provide the resources so people can be treated."


Remember, this is AZ, where they recently defunded programs that will be required to save currently identified individuals due to debt. Those people are going to die prematurely as a result. Are we going to imagine that they'll fund a comprehensive plan to treat thousands of these people in the hopes of preventing a future attack? We'll see. :popcorn:

http://www.salon.com/life/feature/2011/ ... index.html

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PostPosted: Thu Jan 13, 2011 1:02 pm 
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I am troubled by your post, Ian.
  • Too many excuses.
    Ian wrote:

    Going forward, you can't just treat the one person who will shoot up a crowd every 5 years-no one knows who they are. You need ...
  • Repeated mischaracterizations of my position.
    Ian wrote:

    5 minutes ago you were saying we shouldn't expose people to the true cost of healthcare

    ***

    Then, it sounded pretty much like you faulted individuals who didn't hold or treat the guy, but... gosh how many times can I say it?... we're not. allowed. to just hold. anyone we want.
  • Too much energy spent antagonizing.
    Ian wrote:

    Hearing about your from a distance experience with quasi related work is nice.

    ***

    In an effort to make your head explode, I went looking for something from Salon on the matter.
  • Little demonstrable effort to move forward with the idea that - yes - we can learn from mistakes made in the past.
I have a book for you, Ian. Let me know if you get around to reading it.

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George Bernard Shaw wrote:

You see things; and you say, 'Why?' But I dream things that never were; and I say, 'Why not?'

I guess that's why I'm in R&D. If it's already done, it doesn't interest me so much.

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- Bill


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PostPosted: Thu Jan 13, 2011 2:01 pm 
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IJ wrote:

I know I was an 18 year old kid when you met me, but seriously--what amazes me here is your willingness to tell me how these things work rather than ask me.

Sometimes you make me smile.

My first karate instructor used to beat the #&@%!!! out of me in class. It didn't take many days of practicing before I noted that he was leaving the slackers alone, and doubling down on the handful of people in the class who were working their booties off. In other words... he made my path of learning hell not because he disliked me or wanted me to quit, but rather because he saw someone he felt he could bring to another level. It was little consolation at the moment. But with 20/20 hindsight, I can see he indeed had a lasting and positive effect on me.

You are one of the brighter people I know, Ian, just like Justin has one of the bigger hearts I've sensed. It is why I spend so much time debating the both of you. It is a process... 8)

- Bill


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PostPosted: Thu Jan 13, 2011 10:20 pm 
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Bill Glasheen wrote:
You are one of the brighter people I know, Ian, just like Justin has one of the bigger hearts I've sensed.


r u say me dum?

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- Justin Powell


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PostPosted: Fri Jan 14, 2011 12:55 am 
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He's saying he's just mentoring his students who aren't at his level, but phrasing it in a slightly nicer way than being completely patronizing.

Hey that Kuhn text is a classic. I'm glad I read it in the early 90's. I wish YOU would read my posts and notice that I'm harder on the health care system and on physicians and a bigger proponent of quality and pay for performance than anyone here or anyone I know, for that matter. If you were you could see I don't need to reread it.

As for positions and mischaracterizations, why not... state your case clearly and not risk it? Specifically,

1) How would you say this incident should have been prevented?
2) Exactly what changes / programs are you endorsing to prevent violence by the mentally ill in the future?

Then we'll have something besides an outsider's view that someone dropped a ball s/he was never holding :)

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PostPosted: Fri Jan 14, 2011 6:24 am 
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"Moreover, it is nearly impossible to predict whether any given individual is going to become violent, say psychiatrists. "We will never be able to anticipate all acts of violence and perhaps not even most acts of violence," says Paul Applebaum, a professor of psychiatry, medicine and law at Columbia University.

--Today's WSJ.

I'm not saying we don't try. I'm not saying we don't have high expectations. I'm not saying it won't be better if we do.

I am saying:

1) Most people who are assessed as mentally ill threats to themselves or others would not have committed any dangerous acts
2) Many unsuspected people will complete deadly acts
3) The people who will turn out to be dangerous overlap in many ways with nondangerous people and civil rights issues will always be at odds with safety concerns (both for the individual patient and for the public)
4) The search will be almost completely fruitless given that there are 2.4 million schizophrenics in the USA and these events are extremely rare--a bit like a luggage search at the airport--worthwhile perhaps, but labor and cost intensive for the yield
5) if people want it done better and to expand mental health coverage they ought to describe their plans to cover it, House Republican Pay-Go style
6) It is not helpful and almost always inappropriate to lay any blame at the feet of well intentioned people after the fact, just because we need to make sense of tragedy and the retrospectoscope has spotless vision.

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--Ian


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PostPosted: Sun Jan 16, 2011 2:58 pm 
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IJ wrote:

As for positions and mischaracterizations, why not... state your case clearly and not risk it?

I do, Ian. It's all in the thread that you read but don't give the appearance of having read. And then you accuse me of not reading what you wrote.

I want to replay an exchange here.
Bill Glasheen wrote:

You are one of the brighter people I know, Ian, just like Justin has one of the bigger hearts I've sensed.

Justin wrote:

r u say me dum?

Quote:

He's saying he's just mentoring his students who aren't at his level, but phrasing it in a slightly nicer way than being completely patronizing.

Here's my read, Ian.
  • I say something nice AND factual. No pretense.
  • Justin responds in a humorous fashion. Touché! And my take is that Justin has taken the complement well. A similar piece of humor is when someone calls you a broken down old alcoholic and you respond back that you are NOT that old. And FWIW, his comment is an allusion to another famous saying. But that's a rabbit hole to explore on another day. (I get it, Justin. ;))
  • You presume the worst in me. Moreover, you're a jerk about it.

Before I go farther - and I will - please explain how we can continue in an intelligent dialogue when you bring baggage to a discussion. Your modus operendum is to assume something negative based on what I said, and then to attack it. Should I just respond to your lengthy posts with "Strawman!" and change the subject?

And for the record...

I've never been afraid to associate with and debate people far more intelligent than I am just as I was never, ever afraid to spar with someone who I knew was about to kick my ass. In fact... I seek it. At the end of the day, the best ideas and the best techniques win, and we all enjoy it.

Or at least *I* enjoy those kinds of exercises...

I've also never, ever been intimidated by having students who were brighter, stronger, or more emotionally intelligent than I. In The Book of Bill, that's a true teacher's dream.

As a boss I sought out workers who were the best and were self directed, and not ones who would do what I told them to do. One former direct report (and now good friend) is the current Virginia State Health Commissioner. If I want to have an ego in the matter (Nooooo, not me!!! :roll:), I'll do it by saying "She once worked for me!" My favorite mentors were that way. I learned my lessons well. 8)

- Bill


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PostPosted: Sun Jan 16, 2011 5:26 pm 
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Please respond to this in its own post, Ian.

Are you a physician first or a human being first?
  • When you wake up in the morning.
  • When you are on the job.
  • After hours.

- Bill


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PostPosted: Mon Jan 17, 2011 12:41 am 
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IJ wrote:

"Moreover, it is nearly impossible to predict whether any given individual is going to become violent, say psychiatrists. "We will never be able to anticipate all acts of violence and perhaps not even most acts of violence," says Paul Applebaum, a professor of psychiatry, medicine and law at Columbia University.

--Today's WSJ.



Well it's in the Wall Street Journal, so It must be true!!!!

:multi: :multi: :multi:

But it's not. I read the comment when it came out, and dismissed it outright. Consider the source, Ian. He can be a professor of psychiatry, medicine, law, pottery, and basket weaving for all I care. But he doesn't do predictive modeling for a living, does he? That's a very special expertise. He isn't qualified to speak to the matter. (His statement of absolutes pretty much is a giveaway.)

I do predictive modeling in health care for a living. Talk to people who have the academic training, the industry training, and the field experience. No, you can't create a model that will predict the time, place, and act for each and every individual in a population. But you absolutely can predict the likelihood that any one of a number of events might happen. Over time, you can refine what it is you are predicting (making the findings "actionable") and refine what it is you'll do about the information that any model or set of models will tell you (making the entire process more practical). It's an iterative, never-ending process.
IJ wrote:

It is not helpful and almost always inappropriate to lay any blame at the feet of well intentioned people after the fact, just because we need to make sense of tragedy and the retrospectoscope has spotless vision.

Your first mistake - a mistake you continue to make over a period of years - is to get defensive. We are not in a court of law. I am asking for solutions, and you keep giving me excuses. And I will not accept that kind of response.

More later.

- Bill


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PostPosted: Mon Jan 17, 2011 1:05 am 
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I'll give you a taste of what my work would start with, Ian. This can also be found in the Wall Street Journal (January 15, 2011).
WSJ wrote:

{snip}

The most recent systematic review on this subject, published in the journal PLoS Medicine in 2009 and involving over 18,000 subjects in 11 countries, found that individuals with schizophrenia were more likely, as compared to the general public, to commit acts of violence, regardless of how violence was measured. This increase was typically two to five times higher in men with schizophrenia and over four-fold higher in women with schizophrenia. As one expert commented, clinicians have to face up to this "unpalatable" evidence "for the sake of our patients." A similar review on bipolar disorder and violence from 2010 found similar increases in risk.

{snip}

It may be that schizophrenia is simply a marker for other factors that increase the risk of violence. Of these factors, one of the strongest is alcohol and drug abuse. Estimates from the U.S. indicate that around half of patients with schizophrenia also have problems with substance abuse. One study in American urban centers found that nearly a third of patients who were discharged from the hospital and also diagnosed with substance abuse were violent within one year.

{snip}

Three other factors consistently increase the risk of violence in mentally ill patients. The first is the overall extent of their psychotic symptoms—the worse the symptoms, the more likely the risk of violence. Another is a history of antisocial behavior, usually manifested in problems at school, previous arrests or fighting. A final risk factor is a family history of criminality, suggesting possible genetic and early environmental contributions to violence.

{snip}


I'm watching a 60 minutes show as I type, Ian.

The United States Secret Service has studied eighty-three (83) such individuals. And by the account of the reporters on 60 Minutes, the similarities with Laughner are "alarming." Expert after expert is saying how these violent acts "are not impulsive, random events."

More from the same article...
WSJ wrote:

What can be done to reduce violence in the mentally ill? Several kinds of interventions should be considered.

{snip}

None of these strategies would necessarily have prevented the Arizona shooting, and they certainly will not eliminate the possibility of similar occurrences in the future. But they would reduce their likelihood and, at the same time, substantially improve the lives of one of the most disadvantaged and misunderstood patient groups.

Checkmate, Ian.

- Bill


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