Uechi-Ryu.com

I cannot get to the original study by Fein in The Journal of Forensic Sciences (1999). But here's an NPR story that talks about it.

- Bill

Fame Through Assassination: A Secret Service Study

"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."

Here's your response: I don't really know what you're getting at. I am a person who is a physician, all the time. Is being a physician on my mind when I wake up? Frequently, yes; the alarm goes off and I'm wondering about my patients and scheduling my day in my mind. I recently dreamed I stayed in a martial arts class so long I had to attend a late morning sepsis conference in a gi. Other times, as a person, I'm consulted by family or strangers as a physician. I make diagnoses on the street and think about healthcare implications of restaurants and behaviors when out and about or exercising. And I'm a person at work, no matter what I'm doing. I'm curious to see what you're getting at.

Do you have replies to my questions?

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--Ian

"You presume the worst in me. Moreover, you're a jerk about it."

Everyone has their own perspective. From where I sit, I read your posts, I respond to your points, I try to agree with many of them and offer amendments rather than refutations where applicable. Your posts commonly come out vague and prone to being misread, whether it's saying that you only get "economy" healthcare which most people take to mean acceptable but not fancy, like seating on Southwest airlines, and presumably subsidized, followed by a clarification that means you only get what you pay for, which would be nothing, followed by an assertion that some kind of mental health program could and should reduce violence rates, which would mean sweeping increases in services to those who can't pay with a relatively limited societal payback in lives saved. I'm not dumb, and that's confusing to me, so either it was confusing or we have a severe case of VHS / betamax format incompatibility.

Why am I testy in my reply? You bring out Kuhn (for those reading along who are not familiar, the take home is that new scientific theories take a long time to be accepted and this often takes the literal dying off of older scientists who can't adapt) and that may have been a cajoling for me to consider new ideas in your mind. However, it really reads to me like the suggestion that you, with an as yet unspecified mental health plan, have a new paradigm that erases the old thinking like evolution trumped creation, and I'm just unable to get it. It seems better to start with a question--"what could be a better way?" rather than to suggest to that people writing in with long term experience and training aren't getting it. To me. We both seem to think we're being nice and or writing clearly, yet being treated unfairly.

This isn't the first time this sort of thing has happened. I started a thread about what I perceived was the injustice of DADT. Many posts went back and forth about all the possible problems before, somehow, the position I'd been espousing all along turned out to be just fine, and as it turns out, more cautious than the one that the legislative and executive branches selected, which has since caused no perceptible fuss. I'm sure there was some sense of importance to those replies about the problems with my thinking, and I'm fairly sure right now you're just thinking *I* was upset and the one with baggage, and still am. I'm sitting here wondering why you couldn't have just agreed because it was a very reasonable proposition I made, and what baggage you were carrying around since you can't let other seriously committed people borrow the word we use for "traditional" unions although it seems to be a free and easy concession to make to me. No, I don't want to revisit these issues; I want to emphasize that what seems like baggage and attack to one person are passionless reason and commentary to another.

Anyway--back to the issue.

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--Ian

1) "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.)"

2) "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."

Ah. You've dismissed the guy and you agree with him. What did he say? He said that you can't predict all future incidents of violence. To say anything else would imply omniscience and would be delusional. That's why you admit that in throwing out his idea (and saying anyone who states absolutes is DQ'd from argument) you accept this point. The fact is there are absolutes. Here's one: "we will not prevent gun violence in the USA." Here's another: "We will not prevent all cancer deaths." What does he say next? That while we can predict some events we can't predict all and we might not get most. You haven't presented any data to the contrary. All you've said is that predictive modeling will contribute, which is true, but I would contend that your lack of experience with psychiatry handicaps you as much as his lack of predictive modeling experience. No one has all the answers.

"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."

I actually haven't heard specific entreaties for solutions. In the last discussion on Cho, I heard comments that people dropped the ball, based on tidbits from the news and no experience with how life works in, say, their psychiatry clinic. Yes, I am still responding to that. As far as giving you excuses, it's really not a fair characterization. I don't consider it "an excuse" to explain the context of how psych holds work, how people go off their meds or can't be forced to take them, or how prediction of these events will always be imperfect; that's just an explanation. It is a counterbalance to posts you make where you suggest that anyone who says violence can't be 100% prevented isn't qualified to participate in the discussion!

"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 (etc)"

No argument from me. It is of course no secret whatsoever that schizophrenics are more prone to violence than regular people, nor is it a secret that prior events, going off meds, drug abuse, and having disturbing command hallucinations are risk factors for violence.

"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.

Again, there's no argument from me. I add only the caveat that "violence" in this context has to be rigorously defined. It turns out that many of the "attacks" medical workers suffer are from confused elderly who hit us. Similarly, when we talk about schizophrenics being violent, much of this means being restrained by police or psychiatry workers, or some fisticuffs. I'm not at all minimizing the gravity of these events, just distinguishing them from organized, highly lethal mass murder which is vanishingly rare. We also must consider that substance use may reflect severity of schizophrenia as well as worsen it primarily. But it's a valid risk factor to consider.

"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.""

Again, no argument from me. Of course there is value to USSS or FBI profiling. These people may have similarities. My caveats are that we MUST consider the denominator. Let's say that almost all people who murder have antisocial traits. Great! How many million people in the USA have antisocial traits? How many are holdable? Force medication-able (incidentally no meds work for antisocial PD)? How many can be barred from owning a gun (before their first big act of violence)? How many people are available to police this population? Who pays them?

From WSJ:

"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."

From Ian:

"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."

"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."

I have also repeatedly championed the provision of carefully rationed services to those in need; your statements on this matter have at times said little more than if people can't pay they might not get treatment, and this refusal to encourage dependency might enhance their dignity.

From Ian's highlighted quotes:

"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."

From Bill:

"He isn't qualified to speak to the matter. (His statement of absolutes pretty much is a giveaway.)"

"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."

"Checkmate, Ian."

Ok, now you've utterly lost me. I have never, ever, once come to these discussions and said that we can't help schizophrenics or prevent some episodes of violence. Of course we can and I'm the one who's voiced support for expanded (but rationed) coverage on these very forums. I'm the one that's bemoaned the defunding of AZ health services; I'm the one who bemoaned the defunding of San Diego mental health services; I'm the one who works with dozens of psychiatrists who deal with the half absent "safety net" for these people who are severely disturbed through no fault of their own.

I specifically say that we should try, set high expectations, and acknowledged the success of many active, outgoing mental health community teams. How, on earth, is your WSJ quote a "checkmate?" Your WSJ quote is my manifesto: support these teams, fund the healthcare, but admit that it's not going to be perfect or easy. It is 100% consistent with my prior statements.

Your WSJ quote is a checkmate to your comment about their previous expert; you go disqualify an expert from the discussion because he is absolutist and says prevention won't be perfect, and then you go and quote, as your coup de grace an authority who clearly states that these events are absolutely impossible to completely eliminate.

_________________
--Ian

And now, some reflection:

Has this entire thread been about my being offended and reminded of your critiques of clinicians who saw Cho, because you launched into a "no excuses" mode on these events instead of just starting off by recapping how difficult these events are to predict and suggesting using predictive modeling to increase our yield? I would have said super let's do it and make sure there's a mental health service network and added that who needs predictive modeling when this guy had to be seen by police on several occasions and was tossed from college because everyone thought he was a time bomb.

Sigh. Hey here's one thing I have going for myself: I regularly admit that I'm argumentative and critical, and in fact I tell my teams about ways I've overcome those tendencies at least at work. I have definitely written some snappy posts here. Let's review some of what undid the control systems:

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

Bill: "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."

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

Bill: "In other words, pass the trash. If it makes you feel better... And it is legal... And you have your excuse..."

Me: "Threats to others have to be fairly imminent and specific."

Bill: "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? Wink Sorry, my friend. I just enjoy chatting with you."

Me: "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. Bill: "Dr. Obvious I presume..."

In this reply, you accused medical people of passing the trash. This is highly insulting. It's also misleading. We desperately want to hold on to some of these people, and we want to force meds on them. But we CANNOT because of the legal system. This is analogous to gun control. People want to take your guns to reduce crime, and whether that is valid or not, they cannot, because you have rights. People also have rights not to be medicated or confined. You placed physicians who want to help and are left helpless by our legal system in the category of people who just shoo someone along to shoot up a Safeway down the road because it's easier and they'll be excused. And you do this without demonstrating how sick someone has to be to be held, all the while claiming expertise because you've gotten two people evaluated. To someone who was truly horrified by these shootings, and who's read, several times, the haunting accounts of the shooting and the grim triage at the hospital,including the desperate open heart massage and extended CPR on an innocent 9 year old girl, this was hurtful, and I responded curtly as a result.

Listen, I've got problems. I do not recall you EVER acknowledging that a post of yours was vague or confrontational, however, and the lines above are pretty darned insulting to my peers, and suggest I don't care either. I may need to improve the civility in my posts, and I admit that, but I am not alone.

PS: I still am not sure exactly what kind of healthcare system you would fund for the poor or mentally ill despite asking a half dozen times; you just cryptically tell me it's in your prior posts and call me out for misinterpreting or not reading. See also my two largely unanswered recent questions.

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--Ian

http://www.latimes.com/news/nationworld ... 8622.story

Yet, in 2010, Brewer agreed to cut in half state funding for the Department of Health Services, reducing services to about 14,000 mentally ill Arizonans.

Brewer's reluctant acquiescence to the cuts reflects not only the state's dire budget crisis — it must fill a $1.2-billion budget chasm this year — but the tough battle mental health advocates face in securing funding for such services.

Across the country, mental health advocates say, cash-strapped legislatures have been chopping services for the anxious, depressed and schizophrenic. Since 2009, states have shaved more than $2 billion from such programs and axed more than 4,000 inpatient beds, said Michael Fitzpatrick, executive director of the National Alliance on Mental Illness.

About one-fifth of states have passed or proposed cuts in mental health budgets for the next fiscal year, according to the National Conference of State Legislatures.

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--Ian

Are you all so brilliant that you are all insane?!? Because that's exactly what you all sound like..
This is a Forum to help discuss veiws about Karate Do.. You guys have turned it into a Circus,,,

Forrest Gump was Stupid... But at least he was funny... You guys are no Forrest Gump..

ROTFLMAOOL!!!

What he said...

FWIW, I don't mind seeing these two get into a good argument, though I must admit to skimming posts that don't fit on a page. It's a productivity habit I've developed from 20+ years of forum participation.

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Mike

.... we do seem to be hashing alot of Panther's "Difficult Questions" turf right here on the Roundtable. For better or worse. I personally don't mind, but could see others taking issue. Then again, it's Bill's house.

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Life begins & ends cold, naked & covered in crap.

Wow! Et tu Panther?

As Jason stated...

What he said...

As for Stevie's post, I've responded here.

- Bill

Getting Bill going always has entertainment value!

Besides, it's not like a lot of strictly MA threads have been opened on here lately, gotta have some filler during those slow times.

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Glenn

I was just tweeking you a bit Bill-Sensei... It's in part because we think alike a lot of the time, in part because I was laughing so hard at Steve B's post, and in part because I really haven't/don't have time to fully contribute more than lurking since I was laid-off and started new work which requires ~55-60 hrs/wk doing actual work.

Regardless, no worries mon ami... just poking a little fun.

Besides you are so brilliant that sometimes to us "ordinary folk" you sound insane! (and, imnsho, that's something to be proud of...)

Hey.... I resemble that remark!!

Glad to hear you are working. In this economy, that's a very good thing. You can't take anything for granted.

- Bill

So true, so true. I was told the beginning of October that funding was up on the project I was working on. They were trying to figure out how to tell me they couldn't afford me anymore (after 4+ years) and I ended up saying, "Lay me off, it's your only choice. Just the way it is in this economy." I spent the rest of the meeting telling them my part of the project was basically complete anyway and I'd be fine, not to worry. I really think they were shocked when I had new work lined up in ~4-5 weeks. THe good, the bad & the ugly are:

Good: I make more on an hourly basis.
Bad: I went from "full-time, permanent employee with full benefits" to contract where I have to cover all my own benefits.
Ugly: The place where I'm at now wants me to do 3 people's jobs in six months and no more than 50 hours/week average. (I'm averaging between 55-60 right now, but I plan on taking a week or so off later.) It started that I was told how things were and when I actually got going I found that they weren't nearly as far along as they said... I've already told them that I'll do my best, but I seriously doubt this will get done in 6 months regardless of the hours put in. It started out as a single chip design, but has grown to 3 different designs with a little bit of core that stays the same.

Tell me something (Bill or anyone that cares to answer), why do managers always think everything is "a drop-in" or "quick & easy"... when the truth is that is (almost) never true. One of the managers had told one of the senior engineers that something should take ~20 hours to do, so the engineer said, "I'm REALLY busy, so why don't you just crank that out." Surprisingly the manager agreed to do it and... after nearly 7 months, it still doesn't work and still isn't done. The engineer is pretty smug about it now... and rightly so. But management still acts the same way on a daily basis. It doesn't really impact me, because I'm getting other contract job calls about 3-4 times a week still. I've been telling people to call back in about 4 more months.

Anyway, contract work like this can be pretty hard, but the money is pretty good too. All depends. Things will be a lot easier when I'm out of here and living closer to you! Hopefully by the time this contract is over!

Later my insane friend!