PREFACE: If you are a sworn peace officer, I support you - and since this has become such a "trite" and meaningless "monkeyphrase - let this be specifically interpreted to mean that a number of my colleagues & myself feel & have felt compelled, without thinking, to come directly to your assistance when your safety was jeopardized.

Having said this for the purpose of context, and contemplating the nomination of Maria Sotomayor amidst an already shitty week, I was surprisingly stopped and questioned, à pied, because I "appeared to be weaving" on University Avenue at approximately 10:00 pm. Oddly enough, what flashed through my mind like a short film of David Lynch was a, surprisingly cogent recollection of my father; and that would, albeit, have been during better "better times."

I basically have no explanation for the limited, "factual" (i.e. corroborated) information I have of my father. And this is despite the fact that he was literally present - actively pushing air - though divorced from my mother. Likewise, it's probably better that what I have "memorialized" about him - if only to be able to suggest a "relationship" as I now understand it - originates from my young age when things could be, indeed, be corroborated. At the same time, the truth is that every virtue I am able to memorialize about him, he seemed to have committing himself to minimizing; and I have no reason to believe this sourced from humility. And please, if any of this strikes as overkill, I would refer you to any child, of most any age, head in hands, who cannot consistently and/or reasonably predict what might emanate from the lips of a sick parent. Both God & John Bowlby are on the same team when it comes to the juxtaposition of detachment & childhood resiliency. But it seems God alone appreciates the devistation which seems to escape other family member "obvservants."

The issue at hand is this: at a too young and and during extraordinary circumstances, my father became a most noble Четници a defender of God, Motherland, the King, and the people. But captured.This, at least, I am able to verify from independent photos & writings. Secondly, I am also to corroborate that he spent the final years of WWII in the Dachau Nazi Concentration Camp in company with the Blessed Saint Nicholai (Velimirovic) of Ochrid & Zicha, and the Serbian Orthodox Patriarch Gavrilo, all of whom suffered tremendously. As a child at bedtime, I didn't want "bedtime stories," but for him to repeatedly describe the glorious and joyous day when US troops, mainly African-American, "liberated" them from Dauchau. He came to this country with the greatest respect for our Constitution, for liberty, for religious freedom, and each every and any right afforded by our Constitution. At the same time, he was equally intolerant and outraged at those who "demonstrated" anything he believed as disrespect and ingratitude as, conceptually, incomprehensible, unimaginable. "If you could have seen..." Two examples were demonstrative: When John Kennedy was assassinated, he was absolutely devastated, and I vividly recall on that Friday night in our church, as a child, in the dark candles and incense, clinging to his leg, attempting to understand his sobbing and sorrow. And secondly, during our times of American civil "unrest," he bought a flag, a pole, and a shotgun. He set the pole in concrete, raised his flag with pride, and placed the shotgun inside the front door, stating simply, "Let anyone tough my flag." It never crossed my mind that he would actually harm someone, but it was merely an expression of the veracity of his belief. That he later had close friends who were judges and volunteered for youth probation were insignificant, by comparison. My respect was formalized and "memorialized." And so, I fully believe that I am constitutionally required to identify myself to a peace officer when requested, and to show respect and to cooperate in the exercise of their duty. When I finally, politely asked if I might now leave, he tossed some cheap "Why? Is there something you don't want me to know?" questions at me. What I wanted to say was "you broke my father's heart."

So, while administering the customary "gleaning" of an otherwise monotonous batch of junk mail, I open a message forwarded from POTFP; always a pleasure and a virtual "visitation"... Whatever... The text was, shall we say, casual, bordering on the downright colloquial:

Heya, how are you doing recently ?
I would like to introduce you a very good company which I knew. Their company homepage is www.im-a-low-life-thief.com. They can offer you all kinds of electronical products which you need, such as motorcycles, laptops, mobile phones, digial cameras, TV LCD,xbox, ps3, gps, MP3/4, etc. Please take some time to have a look at it, there must be something you'd like to purchase.
Their contact E-mail: imalowlifethief.com
MSN : www.im-a-low-life-thief.com
Hope you have a good mood in shopping from their company!
Regards.

So, I'm amused as to even visit, immediately directed to the crook's site with a URL ending in .cn, which would be China. Funny, though I've personally never considered a motorcycle an electronical product, and I must concede that I've never ventured further east than, well, the west coast (despite having a first cousin quite renowned in the east), I can't seem to find motorcycles as advertized. But wait. WTF! A Gibson Custom Shop 50th Anniversary Sunburst guitar - listed at $4,999.00 at my local purveyor - only $380!!! AND, Free Shipping if you purchase more than one! POTFP's daughter plays guitar...

As I battle the urge to actually read their "Payment Policy," I Google the "company" to find a flood of identical reports of "Chinese hacking my Gmail account, deleting all my messages, & sending [the same message as shown above] to all my contacts from my 'vacation' setting." Oh, oh... I email my friend, only later to receive the simple response, "I got hacked."

I am reminded of the time my checking account was gutted - an event, I report with some irony, that I discovered immediately upon returning from a visit with my friend and his family - in a series of ATM withdrawals by a thief to my south. The bank turned out to be quite conciliatory, immediately restoring my funds, but making the odd request that I be so kind as to file a police report. Possessing, in fact, an unlikely "association" with law enforcement, I (apparently) naively inquired, "Do you think they'll go looking for them?"

My concluding thought here is two-fold: 1) This has befallen a most-undeserving victim; and 2) If you, perp, are, in fact, in China, live your life ill at ease, sleep with one eye open. Trust me on this...

Several evenings ago, I spoke to a friend who is a new attending at an out-patient psychiatry clinic associated with a major east coast medical school. She told me that she conducted an initial screening of a man who was a walk-in to the clinic, checked the schedule, and gave him an intake appointment with the first available resident the following week. She then went on a scheduled trip to Europe and returned approximately six weeks later. Upon returning, she was told that the patient, with whom she had spent approximately 30 minutes, had committed suicide. She was referred to an affiliated psychiatrist to "process" the event, and attended 2 group therapy sessions for clinicians with a similar experience. For her part, she could not even remember the patient. Now, I do not report this because it is ironic - and I struggled not to say absurd - but rather to contrast what happens when you are affiliated with funding. If you have access to funding, you can, apparently "err" on the side of well... what's right. And on one of the saddest days of my life, as I was writing case notes after a group therapy session, a colleague came in and told me that the Medical Examiner's office had just called to inform us that a patient of mine was found in a hotel room, having completed suicide. They connected him to us by a prescription bottle they found with him.

Because I have the reputation of working with a specific patient "demographic," I will get calls that usually begin with, "Hey, I have this wo/man who lost his/her insurance and can't continue at this clinic..." Hey, always good to hear from you too. Right. Nevertheless, a patient who has actually had commercial health insurance, in my experience, presents with some significant "protective factors" personally, and "advantages" administratively. Paradoxically, in my experience, these patients nearly always result in administrative conflict, probably because they can be incorporated into treatment in a expedited process (i.e. disrupting the protocol).

I find that patients who have actually had health insurance tend to be in a better state of over-all health, generally, than the typical off-the-street public clinic patients. Secondly, they generally are "well-documented," preceded by a medical chart that sometimes includes an accurate medication & medical history, and sometimes (sorry) a psycho-social assessment conduct by a reliable clinician. Oorah.

And so, the patient in question here came to me because he had been laid off from, "not just a job, but my vocation," based solely on "seniority." In fact, he was a much-valued, well-acknowledged, and well-compensated employee. He had a significant history of a moderate major depression; a history of both child physical & sexual abuse; was in recovery from alcoholism - extended & continuous; and was acting-out sexually to the point of "devoting" hours each & every day to cruising his gym, a bathhouse, and Craig's List for "hook-ups." His affect was markedly depressed & anxious, but he reported his mood as "a little depressed, but hopeful." I will forgo detailing our actual work together. When he did not appear for his scheduled appointment - the first ever - I called, and we rescheduled for the next day. The next day, when he neither showed nor called, I again called, & when I got his voicemail, expressed my concern, asked him to call me immediately, and re-enforced a point in our treatment contract: no attempting self-harm or suicide without first calling me, 911, or the Emergency Psychiatric Unit. He had checked into a nice hotel that afternoon, and the Medical Examiner estimated that he died early Sunday morning.

No one in clinic, from the Program Manger to the supportive staff, said anything to me; everyone was gone by the time I had completed my notes and returned the charts. No one. I locked the place up & went home. If you are a clinician & reading this, it is my sincerest hope that this never, ever happens to you. I spent the entire night scrutinizing, me. What did I do wrong? What did I miss? I poured over my notes from beginning to end; attempted to "recall" the specific details of every session described. WHY? By morning, I was overwhelmed. I sat through the staff meeting, and the suicide was never even mentioned. When enough was enough, I simply stated, "I am devastated, and I going to our "Employee Assistance Program" (EOP). Perhaps POTFP could explain such programs, as he is truly a pioneer & expert regarding the topic (and be sure to click over there regardless) - but one aspect of an EAP is to be a confidential (even to your employer) source of referral assistance for situations like I have described. I can say that my perception was that the sponsoring organization of my clinic - who didn't really advertize the availability of the EOP (alright, they never mentioned it after the initial hiring session) - pretty much resented paying for 6 "free" therapy sessions. Now go back & read the opening to this post... All said, may he rest in peace.

I generally experience the term "minority" as a pejorative, often "masking" term for disdain. There are, however, times when I could not be paid to abandon my "vilification." Microsoft, according to surveys, took an old-fashioned ass-kickng at the hand of Apple's "I'm a Mac, I'm a PC" advertizing campaign. Somehow thinking it wise to retaliate, MS has embarked on a campaign of corporate dis'. Now, there are those rare times when you are unexpectedly (and I'm going to presume inadvertently) provided the opportunity to actually delight in witnessing someone shooting themselves in the foot, cutting off their own nose to spite their face, laying a trap for others & falling in themselves:

POW! And there you are. No, baby, you are not cool enough for a Mac.

Finally, these are Holy Days, which explains Vladyka Lauras of blessed memory featured at the top of this post. While I cannot explain it, around 11:00 pm last night, I gathered up some big-ass bags of my recyclables (returnable cans & bottles) - which I am altogether negligent in returning, even for the cash refund - and went out walking. For me, selection in such matters is totally subjective, and probably for the better. I'm sure I looked quite crazy - or perhaps completely, "contextually" acceptable taking into account that it was, after all, me - to the evening hipsters heading to the clubs and restaurants. I passed any number of "qualified" & otherwise worthy individuals, but without a feeling of appropriateness. Spontaneously turning into a poorly lit alley, I eventually encountered a small man approaching me, and the closer he got, the fact that he and his clothes were absolutely filthy became increasingly obvious. Upon me, I asked if he could use some cans & bottles, and this man absolutely lit up.! He was so happy, repeatedly saying, "Oh, man! Thanks!" as I helped him gather up these big-ass bags, that I was laughing and smiling right along with him. The reality, however, was that the smell of this guy was triggering my already hyperactive gag-reflex, and as he repeated, "Oh man!" I moved on. Walking in the front door, my roomate said, "What's up? You're smiling?" All I could say was, "These are Holy Days."

Sunday was Easter, and an exceptionally temperate & beautiful day, & upon returning from a walk on the harbor, I'm stopped at a traffic light where 6-8 young men were dressed in pastels and wearing "bunny ears." They are also wearing t-shirts emblazoned with the words: "YOUR God made me this way!" As you might imagine, they are provocative, engaging with traffic whose drivers were of varying degrees of "acceptance." You couldn't pay me to live in the suburbs...

It turns out that my "porn industry" patient came upon the industry by chance (if you believe in such matters). His mother had put him out because his "life" consisted of television and marijuana: "She said, ' If I don't put you out, you'll never leave.'" As customary, his affect betrayed nothing; a continuous variation on "diastole." Was this a good move on her part? "I'm out. Even I was afraid I'd never go." Current arrangement? His "boss" befriended him, offered to take him in, give him his own room, meals, buy his clothing, provide a limited amount of actual cash, etc. in exchange for his described work. "And <insert euphemism for masturbation> every night before he goes to bed." WTF. "He's older. He has AIDS. I wear a glove. He gets lonely & I help him out. He doesn't want to have sex with me; never asked me, never pressured me." Were you surprised at the 'industry?' Were you shocked?" "No. I just see it as a business." thump-THUMP. Well, is it (was it ever) arousing? Sexually stimulating?" "No. I pretty much am bored with it all." thump-THUMP. Diastole. Yeah, passivity - and let's distinguish projective identification (where, paradoxically, one can experience the feelings of another as one's own) from counter-transference, which is an unconscious phenomenon - is particularly difficult for me.

To digress for a quick moment. I had the incredible opportunity, back in the day, to train at the Ackerman Institute for the Family on E. 78th St. in Manhattan. I emphasize that Ackerman trains family therapists in an intense & rigorous (make that, for the clinician-in-training, terrifying) manner: every session was observed by a team behind a large mirror in the room & everything was videotaped for later "scrutiny." I raise this issue because one concept that was continually emphasized was self-awareness: how do you appear to the patient. Remedies? Utilize a mirror to see yourself; I was told once to try sitting on my hands to preclude my "physical demonstration" detracting from my spoken words. I raise this only to say that I would love to see the expression on my face when a patient, for example, tells me he masturbates his boss nightly as a function of his work. How would you word that on a resumé? One benefit of working in prison: little direct eye-contact. Wow, I am easily distracted...

Let me again clarify: I'm no scholar, philosopher, "exegete," or classic translator - once, having actually enrolled in a under-grad course entitled "On the Translation of Poetry," one meeting and a few days of sobriety quickly revealed the wisdom of that decision - and while I didn't dream up or invent, I will be emphatic in utilizing bald-face interpretations that serve my argument. But then again, it is my argument. I will say that I have some "unfounded" theories here (i.e. I am only able to support this by a mixed literature), and like any scientist with a "vague" notion, will conclude with the suggestion that "further investigation is necessary." Science is, indeed, sweet. You have been warned.

The Greek word "pornia" πορνια, the "root" of "pornography" (and note that while "graphia" γραϕια frequently is interpreted as "writing" - e.g. think biography - I believe it is better understood in terms of "conveyance," in the sense of "a greater" truth," as opposed to simply "setting pen/pencil to paper") apparently means a lot of things to a lot of people, one-and-all as potentially bald-faced and self-serving as my own: fornication, pervert(ion), and plain old immorality. And the wonder of the internet provides me some (I force myself to limit it to two) ultimate distractions: the truly unexplainable UM " "?. ITY O. PORNIA SAN DIEGO HANDFUL OF EXOTICS, and my support for the Minister, forced by both irony & dumbass parents to tread the way of this life as the Rev. Eddie Pornia (not Ed or Edward, mind you, but "Eddie"). Who am I to suggest a standard for morality (though I'm sure we could agree on some universals), so for my purposes, I will interpret pornia as something contrary, in opposition, to my already-posited position of Evdokimov, below. Contrary to what I suspect to be a highly "rationed," infrequent human experience, pornia suggests to me a lack of transcendence, and so it shall be defined.

The psychiatric literature of pornography is slim to non-existent, save some, for example, fMRI & hormonal studies on sexual arousal and the like. Further, limit your search to studies in regard to industry "performers,"^* and I could find nothing I would consider significant or, for my purposes, helpful. I would point out a notable researcher, the late Robert J. Stoller, MD, Professor of Psychiatry at UCLA, who wrote several "insider" (behind the scenes) books related to the production of movies and videos. While noting a significant caveat that his material is dated, as near as I can tell (and you can bet I'm not laying out Yale University Press' outrageous price to specifically find out), Dr. Stoller seemed to find very little "pathology" among industry participants. Curiously, however, while concluding that "most porn scripts are not 'simply anti-female' . . . these stories are often full of freedom--women depicted having a marvelous time,"a Publisher's Weekly review summarizes his position as "anger or rebellion against one's parents and society underlies most pornography, that it exploits men as well as women and that a desire to degrade or be degraded is an element of pornography." Um, I don't know, kids, but without the science, this conclusion - and there are an abundance of similar conclusions - strikes me as too, too simple.

Ennui is generally translated from the French as "boredom." However, if one were to pursue Camus, Sartre, du Bouvier, and Genet, for example, ennui has a profound meaning in the nomenclature of existential thought. I will suggest "indifference founded in meaninglessness" is more likely an appropriate definition than, "this blog entry is boring the living hell out of me." Purpose, "meaning," utility. Satre cloaked the whole mess into the word Nausea: "Nausea [is] dull & inescapable, [which] perpetually reveals my body to my consciousness... a desacrilization of the romantic torment and the transforming of it into nausea of ennui" (emphasis mine).

OK. Contrast the patient's statement, "I'm pretty much bored with it all," with Ms. Randall's lament,"What happened to the good old-fashioned, passionate sex scenes?" ENNUI! Why do I seek out the scariest, most gruesome and vilifying horror movies hitting the market in record number? ENNUI! To feel something when nothing feels. To relieve the "dullness," to diminish the desacrilization, to... Um, kids, does this sound too, too easy? I'm stopping at maybe.

I thought I'd be done here, but I am notably verbose & connot summarize my thought in toto. And somehow, I can't leave out my female "talent," whose interaction with began with, "I just got out of jail. All I remember immediately before that is that I was so pisssed that I went into a bar across the street to clear my head..." Further investigation is necessary. You should have seen it coming.

Jo says she'll do you for the cost of weed, but there's more to it than that.
She'll want to talk. Sometimes an hour, sometimes more.
Camus, Sartre, Beauvoir - over and over.
Next thing you know, you're both grinding away under the sheets.
Your mind's been elsewhere, worthless in all this screwing.
You try to catch up, but she rolls you over. She's finished.
And you look down - so are you.
Let me tell you: Existential ennui makes lousy foreplay, but I think she gets off on this whole thing.
She puts out, and yet, she keeps it to herself.

^* I will simply footnote my fundamental lack of understanding of the "industry" distinctions regarding "amateur," "performer," and "actor/actress." My immediate thought is that it is a "distance-providing" ego defense - like trying not to identify with a "cadaver" as a human being in Gross Anatomy. And in case it crossed your mind, here is an explanations as to why "acting" in pornography is not prostitution, at least in California. I have got to re-consider law school...

First, I decided to use my own photographs whenever possible (regardez), and when I have accumulated enough randomness I will try to lay it to rest:

In the past 2 weeks, I have been literally flooded by phishing email. If you don't know about phishing - and you absolutely should - you can get the complete explanation here. But a quick description is that thieves construct websites of financial institutions that can be virtually indistinguishable from the legitimate sites, to the smallest detail, then send mass emails that, for example, inform you that your bank account has been "frozen" because of a security problem: you need to immediately follow the link they have provided to resolve the matter. When you click the link, you are transported to the fraudulent site that appears to be the legitimate site. You are then asked to sign in with your username & password, and to provide, depending on the scam, everything from your Social Security number to your shoe size. When finished, you are kicked out to the legitimate home-page of the financial institution, while they go about taking as much from you as possible until discovered. As far as scams go, this is pretty ingenious, leading me to imagine that it was contrived by somebody in prison, devoting their psychopathic "mother of invention" to no good. Now, being a certified dumbass, if I were to be phished, it certainly would be because of the "randomness" of the email; you just don't get these every day. That is until last Thursday, when, through the course of the day, I received 7 (yup, count 'em, seven) separate emails, specifically from my bank. Do you take me for a fool? Don't answer that... My best advice? Song #1, Buddy Guy: "You got my nose open, baby, but I got my eyes on you."

Continuing the thought, my all-time spammers are those (purported) sites peddling Viagra, Cialis, and every variant available in the pharmacopoeia. As I write, I have 75+ Gmail spam from such sordid characters as othell Atyl, Qycima, Abe Christensen, Charity McDonald, Jane Dalia, Shawn Jule, Kas, Racquel Mitchell, Pufue Jonid, Somer Thi, and 20 from the ubiquitous "me"; one & all concerned about my ability to "get the job done." Kazuw Citun writes, "I worry about you.. [yeah, that would be 2 periods] Offline for so long," while Coa Qnu is beside him/herself, "Called you 7 times! Damn:" Some of these folks are clever as well, telling you to reply "Unsubscribe" if "you no longer wish to receive" their email; respond, of course. and you have opened the gates of spam hell. Hey, and how about those Nigerian 419 scammers! Directly from today's email:

United Nations Compensation Commission (UNCC) In Affiliation With Barack Obama Campaign to Assist Scammed Individuals In The Settlement Of Disputes Through ZENITH BANK NIGERIA PLC .

Attention:

How are you today? Hope all is well with you and your family?You may not understand why this mail came to you but kindly read for your perusal and follow the giving procedures for your claim.

The United Nations Compensation Commission (UNCC) was created in 1991 as a subsidiary organ of the UN Security Council.Its mandate is to process claims and pay compensation for losses and damage suffered as a direct result of Internet Fraud. This email is directed to all the people that have been scammed in all parts of the world, the UNITED NATIONS in affiliation with Barack Obama Campaign have agreed to compensate them with categorical payment sum of US$ 100,000 each. In its decision 17 of 24 March 2006, the Governing Council established basic principles for the distribution of compensation payments to successful claimants.

The Governing Council therefore devised a mechanism for the allocation of available funds to successful claimants that gave priority to the three urgent categories of claims and which, within each category, would give equal treatment to similarly situated claims. Only when each successful claimant in categories "A","B"and "C" had been paid an initial amount up to US$2,500 would payments commence for claims in other categories. Accordingly,the first phase of payment involved an initial payment of US$2,500 to each successful individual claimant in categories "A" and "C". However,for humanitarian reasons, all category"B"claims will be paid in full of a total US$150,000. A total of US$3,252,337,997.09 was made available to 1,498,119 successful individual claimants in categories "A", "B" and "C" under the first phase of payments.

You are advised to contact Mr. Jim Ovia of ZENITH BANK NIGERIA PLC , as he is our representative in Nigeria, contact him immediately for your approved bank draft of USD$150,000. This funds are in a Bank Draft for security purpose, so he will send it to you and you can cash it in any bank of your choice.Therefore, you should send him your full Name, telephone number and your correct mailing address where you want him to send the Draft to you. Contact Mr. Jim Ovia immediately for your Bank Draft.

Thanks and God bless you and your family. Hoping to hear from you as soon as you cash your Bank Draft.

Making the world a better place.

Regards Ban Ki-Moon.

(UN Secretary-General)

Apparently, my ship is in but, for humanitarian reasons, I always seem to fall into Category B. It appears I was never destined to be an "A."

And finally, on Monday I stopped by the state university in this town to visit with a friend of mine who is the single psychiatrist for this entire university. Nice gig, but he hardly comes up for air. And so it goes... After, as I approach my car, the phone rings & it's my friend. Hey, the iPhone even shows you your contact's picture & plays an "unique" ringtone. His? Rage's Bullet in the Head. Psychiatrist, bullet in head... Forget it. Anyway, he abruptly says, "You need to go and get a haircut now. I know you and you even looked crazy to me." "OK, I'll take care of it..." "No, right now." So, as I do trust my friends, & even despite the fact that it was 15 minutes from the start of the NCAA basketball final, I made a quick call and within another 15 minutes commenced the shearing. I must say, even I was stunned: enough hair was removed to carpet POTFT (always a Category A, by the way) and at least 2 of his brothers (and trust me, we're talking about considerable territory), and it still remains "substantial," albeit markedly neat & "groomed." Whether I continue to appear "crazy" remains to be seen. And on top of it all, I was able to watch the ballgame live on the iPhone. What a country.

I feel compelled to make a preliminary comment in regard to "cockroach-longevity" spam - in my case, in the form of a truly astonishing number of (purported) sites employing an astonishing variant of the human name attempting to avoid filtering - who make my email an object of considerable annoyance. And so it goes... But standing out from among this clutter of detritus is a (purported) MD, Ph.D., GR, who "raves" at my blog content (thereby immediately making himself a focus of suspicion), and offering to make me something of a net healthcare celebrity. As near as I can tell, his deal is attempting to sell "traffic" to your site as a pitch to assume your content. Once (and once only) I was, in fact, polite in rejecting his offer. Now that I have removed the hook from my lip for ever responding & thereby opening Pandora's Box, I conclude this short rant by stating, "Dr. GR, fuck you and the horse you rode in on." Perhaps now he will conclude (if he has ever read this blog at all) my content is unsuitable for his vast readership. Desperate measures...

In my mind, the details of sexual activity is a sensitive, uncomfortable issue. I do not mean to imply that I am "prudish," or "squeamish" around the discussion of sexuality: as a practice, I always inquire if a patient is sexually active, if they have been tested for STD's (notably HIV/HCV), and if they employ safe sexual practices; and likewise, I always inquire if a patient (male or female) has experienced sexual abuse. I find that all of this information is essential to good clinical practice, but is rarely "offered" unless specifically asked. Nevertheless, I have long believed in what has been so dramatically, elegantly, and profoundly elucidated by the Russian philosopher/theologian Paul Evdokimov: sexuality is defined in intimacy, and conversely, intimacy is defined in sexuality. And in fact so intimate as to be a literal act of human transcendence (the paucity of such events, it would seem to me, makes it difficult to argue) as to be placed beyond simple "scrutiny." Mind you, please: I am neither a philosopher, theologian, a particularly "deep" thinker, nor did I ever meet Evdokimov. I can reasonably imagine he might conjecture "deviance" or "aberration" as inconsistent with a "transcendent intimacy" - but I cannot speak for him - nor will I speak to the "conditions" (read the book!). Nevertheless, I strongly suspect he would not be surprised at the level of angst and/or ennui we so frequently observe in clinical practice as relates to issues sexual. As a clinical instructor noted, "Sex will fuck you up." And so, to the termination...

My "adult film industry" patient is only the third I have accepted into treatment (which is generally 3 more than any of my colleagues) and which also includes two which I did not, but I make no claim to be knowledgable. And apart from an attempt to fathom a definition of intimacy within the context of "the industry" (and all five referred to the "players" in a general cloak of "the industry" and "the talent"), the dynamics do not interest me particulalry. Further, my pursuit into this context, frankly, left me feeling a touch foolish and naive; managing, I suspect, to elicit every stereotype I ever had rearding the "production" of pornography.

My gentleman presented as markedly depressed in affect and demeanor. He walked in a sort of stooped way, avoided direct eye-contact, and though quite young, fell into the chair with a sigh of breath. In a good-natured opening (and God knows I'm good-natured), I explain that it is my practice for physician & patient to "interview" one another, and in the end attempt to come to some conclusion as to whether the patient believes I might be of help, and, likewise, if I believe I might be helpful. As with a good 60-65% of new patients, he indicated, "I don't exactly know why I'm here." I believe I then, imperceptibly, sighed. The work begins. As a clinical instructor once reported, "I ask enough questions until an image of what I believe the "issue(s)" might be begins to crystallize, and I continue until I have a working hypothesis." OK.

This gentleman reports a "dead end," going no where" lifestyle that he perceives makes him unattractive to would-be companions, and he is lonely for a "real relationship." "What does this mean?" "Well, I work in the adult film industry." And here begins, at least in my mind, a blowing of the dust off every stereotype I have gleaned from Boogie Nights; 2 documentaries relating the stories of porn "actresses," otherwise "girls-next-door" types who, in a frenzy of drugs, sex, and disillusion, complete suicide; a Rolling Stone biography/obituary of a spectacularly-endowed "pioneer" of porn who succumbed to drugs and AIDS; a "panel" of actors/actresses on a "talk show";and the biography of a male porn actor, required reading for a course on Human Sexuality that, to this day, I perceive as seduction rather than education; we won't go there.

The patient before me bears absolutely no resemblance to any of my stereotypes: virile; attractive; (at least for the camera) out-going & uninhibited; comfortable with himself & his sexuality (though I'm not exactly sure what this means); and, seemingly, enjoys his work. Well, it turns out that my patient is not an "actor," but on the "production side" of gay pornography (an "industry" I assumed flourished farther north in Los Angeles): greeting potential "talent" (Semper Fi, indeed), making them "comfortable" ("They're pretty much always nervous when they arrive") and preparing them for the shoot" (No, I didn't ask); adjusting lights and "scenery"; and "cleaning up" (you knew somebody had to do it). Pointedly, the patient stressed that, despite engaging in "activities" relevant to the task at hand, "I am not gay or bi." Thus, with the summation of the facts, while I am confused, he, apparently, is not, and that is all that is important. Or is it?

What shall we make of the word angst, and does it have have a place in psychiatry? While I do not believe you will find it in the DSM-IV or Kaplan & Saddock, it is certainly a familiar concept in psychiatry. From my reading (and acknowledging a limitation in translation) angst seems, in the vernacular, to infer both "anxiety" and "panic." If I read Kierkegaard correctly, angst is a: "byproduct of drifting, or more specifically, the absence of rules, form, and shape that accompany it [and thus "panic"]. There is a hegemony of rules & shapes and laws precisely because we feel chillingly uncomfortable without them." Later, "This dread is explicitely connected with freedom and choices, with the uncertainties and lack of boundaries that freedom entails..."

Deep within every human being there still lives the anxiety over the possibility of being alone in the world, forgotten by God, overlooked by the millions and millions in this enormous household.''

Now, if you're like me, you hear a profound echo - freedom inextricably bound with anxiety & panic - and know it to be Irvin Yalom in Existential Psychotherapy: yes, the primitive drives, plus the terror of death and the dilemma of freedom. Freedom, the drifting with an absense of rules, boundary, and laws, by a seeming paradox, unhinge us. Ironically, while lacking the fundamental curosity of Kirkegaard or Yalom, and, without my pejorative intent, I suspect without even appreciating the content, porn filmaker Holly Randall writes about the "pornographic angst":

With high-end productions pushed to the side to make way for amateurish, extreme content, we created a market for what I call the Porn Olympics. It wasn't about the beauty and sexiness of the girl anymore, it wasn't about the chemistry between the performers, or the setting, or the quality of the production. Now it was a question of how far you could push the envelope: how many men can you have sex with in one film, how many ***** can you fit in your orifices, how many ways can you eat ***? In the attempt to one-up the last guy, scenarios I couldn't even dream up became, well, somewhat normal.

What happened to good old-fashioned, passionate sex scenes? You know, the ones with the beautiful women, the gorgeous settings, the beautiful clothes and superior lighting? Oh that's sooo boring…. I mean, who can get off to a scene if someone's head doesn't get pushed into the toilet while getting ****** from behind?

Better we move on to ennui and sum up my observations...

After a month of no contact, I have finally concluded that I terminated with a relatively new patient - "new" in the sense that I had seen him 8-9 times. Factually, he terminated with me in that he could not verbalize (at least to me) even a theoretical basis for continuing. As is my customary practice, I will openly & frankly discuss "termination" with any patient, sharing, theoretically, what I believe is the presenting "problem," and, theoretically, how continuing treatment may or may not be helpful. And if you decide today not to continue, I'll promise not to administratively discharge you until I must (30-days of no contact). Go ahead, find a car dealer who would make you a similar offer. Relax, that's a joke...

Trust that I am well aware of those who believe psychiatry to be a pernicious and manipulative process of engagement by less-than-subtle implication, innuendo, or "baiting: "I know something (and imagine your worst underlying fear) about you, and you are a coward not to continue" (ominous pipe organ music for effect); or "You need medication - which will keep you coming back... (insert video of marching zombies)." This "stringing along," theoretically, continues until you reach the limit of your insurance, and when the out-of-pocket fee is your car payment x4 per month, you get a referral to the "sliding-scale" facility - worn carpeting, 2nd hand chairs, lasy year's magazines - to see the chimp that figured out how to type Shakespeare. Well, kids, I am that chimp.

I play no role in your financial arrangement; I'm paid whether you keep your appointment or not; pharmaceutical reps are not allowed past the receptionist (I steal their pens from the drug store); and medications, for the vast majority of patients, come with little or no cost. And without belaboring the point another two paragraphs, if I don't think I am or can be helpful, I will tell you; I will tell you I plan to discuss this with the treatment team (and on occasion have brought a patient to treatment team); I can have a colleague sit in on our session or watch a video of our session; or I can have you meet with a colleague. While, thankfully, this process has nearly always resolved the problem - and I can also honestly admit that, on occasion, the "problem" has turned out to be me (and that issue is worth a post in and of itself!) - I would like to believe that I neither string nor am strung. I would like to believe...

So, I just wanted to get this initial issue of engagement out of the way, because my interest in this particular patient began with examining the intake forms, finding occupation to be, "Adult Film Industry." What the... well, you know.

This otherwise non-descriptive image is of a building that exists on the quiet end of a major street in my town, and I cannot imagine the number of times I have passed it without notice. There is no address, no sign, absolutely no indication of what lies inside. In passing, it seems quite limited from the street, but upon investigation, this is the entrance to a substantial facility. I recall on occasion noticing that, with the front door propped open, you catch a glimpse to the left of black & white tile and what seem to be lockers. I also recall thinking it to be a private health club or spa. But a patient pointed out to me the other day that this is, in fact, a "bath house"; and if you're thinking removing urban grime by "soaking in warm, scented luxuriance," think again.

If you even spent a moment with the above reference, you find that gay bathhouses are certainly nothing new, and, in fact, historically served a supportive social and psycho-sexual function for a significantly repressed and oppressed body of the community. But if you also lived and worked in healthcare in NYC in the 1980's & 1990's, the notion of "support" frighteningly morphs into a vision of the Prophet Micah: unmitigated contagion and holocaust. HIV & AIDS silently struck the core of a community that believed it had fought for and earned its right to "exist." For the decade and more that followed, the rest of us stood by, literally, with nothing to offer but what we now so euphemistically refer to as "palliative care." And the epidemic, so tragically, so shockingly, and so brilliantly recorded by Randy Shilts and Paul Monette seemed, individually and collectively, unforgettable.

While I will always entertain the argument, I do not consider myself naive. If only by virtue of working in corrections & reading the epidemiological data - as frequently as a weekly review - I am aware of trends, anecdote among clinicians, and activities in the community. Patients describe quick "hook-ups" through Craig's List, cruising specific areas in town, certain bars and clubs, blah, blah, blah. But I must admit the poigniancy, the shock I continue to feel at the revelation of the "bathhouse." Pursuing the issue, I found a published interview with the owner (manager?) of the bathhouse who indicated he was "scrupulous" in making condoms "available" (and one patient told me of a "punch bowl") and did not permit nor condone the use of methamphetamine (emerging as the single-most significant risk factor for unsafe sexual practices in this community), he concluded, as I suspect we all must, "You just can't force people."

The Centers for Disease Control's most recent publication of data regarding HIV & AIDS in the US is from 2007 (and comparing the period of 2003-2007), and was released on 02/18/09. I do not intend to make this an extensive analysis of a report you can read and/or download to read on your own but, it is striking that "From 2004 to 2007, there was a 26% increase in estimated annual HIV/AIDS diagnoses among [male-to-male sexual transmission]." And while noting that "incidence" (i.e. new infections) may be partially attributable to more accurate surveillance by the CDC, "[male-to-male sexual transmission] increased all four years of the analysis, with the largest occurring in the last year" (emphasis mine).

Further, the CDC released a report on 01/28/09 examining the effect anti-retroviral therapy (i.e. medications) had on the sexual transmission of HIV; meaning, if you are already infected with HIV, actively taking anti-retroviral medication, and apparently having unprotected sex, are you less likely to infect your sexual partner? "Observational studies" and "models" were inconclusive, with the notable exception of those persons with "complete viral suppression," but this was qualified with "as might be achieved by more potent and tolerable regimens [of ART]," obviously speaking to the ART of the "future." Finally, the CDC issued new guidelines for the prevention and treatment of oportunistic infections in HIV/AIDS on 03/28/09. If you need to address pretty much any horror occurring from the degradation and collapse of the human immune system, you'll likely find it there.

As near as I can tell, all of this voluminous data - so ironically reminiscent of Saramago's All the Names - is mockingly and pathetically summed up by the CDC in a "new" publication of 12/28/08:

Laboratory studies have demonstrated that latex condoms provide an essentially impermeable barrier to particles the size of STD pathogens.

Overall, the preponderance of available epidemiologic studies have found that when used consistently and correctly, condoms are highly effective in preventing the sexual transmission of HIV infection and reduce the risk of other STDs. Consistent and correct use of male latex condoms can reduce (though not eliminate) the risk of STD transmission. To achieve the maximum protective effect, condoms must be used both consistently and correctly.

I believe we discovered this 30 years ago.

Sometimes, people can be pushy. Sometimes it's necessary.

I noted in the post directly below that the reclining gentleman is a metaphor for an attempt at "longer-term" employment. It would be easy to interpret what is portrayed below as one in a long line of "negative outcomes" - and trust you'll find no argument from me - but I have also suggested it is endemic to this particular population. I can live with that fact, and apparently it seems necessary to significantly adjust clinical expectations in relation to a predictably and increasingly morbid process; necessary if you don't want to "melt-down." In my mind, this means that "satisfaction," personally & professionally, is determined by training, self-scrutiny, and integrity. Obviously, I over-simplify an intensively personal process, but is it possible to "get the numbers" and be a slacker at heart? Duh.

I can't imagine anyone enjoys being scrutinized, even knowing that it is the basis of education, skill-building, and practice. And I must admit that, for me, it is next to impossible to separate the personal from the "professional." I believe I have mentioned the violation I filed on a child sexual perpetrator who was screaming "You fucking quack!" at me, without my ever uttering a word, in front of 80 locked-down super-max prisoners. But within the context of education and supervision - and ask anyone who has been in "live observation" or video-taped for "critique" by colleagues - though uncomfortable, is somehow eventually "palatable." But this philosophical license does not extend to employment interviews.

If you have read Snakes in Suits by Dr. Robert Hare, psychopaths should be expected in the workplace. Likewise, I suspect that, with the current "financial scandals," ranging from Bernard Madoff to the AIG bonuses, Dr. Hare's observations have become more poignant. In this context, hiring must be an unusually harrowing task. Gone are the days of simply relying on a resume, personal interview, and simply providing references upon request. Today, Google et. al is everyone's friend and/or nemesis, and HR is trained in structured analysis and parametric testing. Or, if you will,

Returning to the issue at hand, I was one of two viable candidates for a position focusing exclusively on "dual-diagnosis" out-patients, meaning psychiatry patients with a diagnosis of mental illness and a chemical dependency. I digress for a moment to point out that this "buzzword" is annoyingly redundant in that all substance-abuse disorders are contained in the DSM-IV as "mental disorders." Let it ride... Now, the only thing worse than a job interview is multiple interviews that exponentially add persons steps above in the hierarchy. What did I say last time? Am I contradicting myself? My head spins... And now to the actual beheading. At a given point in a very relaxed "conversation," I was asked my opinion of administering psychotropic medication to individuals who continue to actively "abuse" alcohol & other mood-altering drugs. Perhaps it was the "conversational" character of the meeting, perhaps I assumed they really wanted my opinion, and it is here I stepped in front of the bus.

First, I began by expressing my experience, which seemed significant in that, given the limited resources in the county, patients, quite literally, rotate among clinics as if one milling body: it was the rare, statistically insignificant, and anomalistic patient whose cessation of drug/alcohol use could be directly correlated with the administration of a psychotropic med. I could not think of a single example. But most importantly (and you knew this was coming), the literature does not support the practice. Several recent examples:

• 01/09 Of 149 patients enrolled into the open-label [VPA & LICO3] acute stabilization phase, 79% discontinued prematurely (poor adherence: 42%, nonresponse: 25%, intolerable side effects: 10%). Of 31 patients (21%) randomly assigned to double-blind maintenance treatment, 55% (N = 17) relapsed (24% [N = 4] into depression and 76% [N = 13] into a manic/hypomanic/mixed episode), 26% (N = 8) completed the study, and 19% (N = 6) were poorly adherent or exited prematurely. CONCLUSION: A small subgroup of patients in this study stabilized after 6 months of treatment with lithium plus divalproex. [That would be 8 patients]
  
  
• 11/08 While a growing number of studies suggest that second-generation antipsychotic medications may have beneficial effects on the treatment of co-occurring substance use disorders [though I cannot locate them], this review suggests that the literature is still in its infancy. Few existing well controlled trials support greater efficacy of second-generation antipsychotics compared with first-generation antipsychotics or any particular second-generation antipsychotic.


• 02/08 Substance use disorder is the most common psychiatric comorbidity in schizophrenic patients, with prevalence rates of up to 65%. Recommendations for antipsychotic pharmacotherapy in schizophrenia are based on studies that excluded patients with this dual diagnosis... In conclusion, there are more theoretically based arguments for the preferential use of SGAs in schizophrenic patients with comorbid substance use disorder while the empirical evidence is weak.


• 09/06 Only recently have studies examined the impact of various psychiatric medications on alcohol use among patients with these disorders. Evidence supporting the benefits of antidepressants for co-morbid alcoholism and depression continues to mount. Although these studies have demonstrated benefits in terms of quantitative decreases in the volume and frequency of consumption, the benefits in terms of remission from alcoholism have yet to be shown conclusively.
  

We could go on (and on), and if you'd like citations, ask.

The tension in the room was palpable; eyes were averted; mice were heard sloppily consuming cheese. I then heard the playing of "Taps" and felt the life-raft drifting away. The chief psychiatrist quietly stated, "Prescribing these medications is our practice." Said the program director, "We'll be in touch." The inevitable phone message thanked me for applying and indicated they were "moving in a different direction," but would keep my CV on file.

Factually, have I worked in similar situations where identical treatment philosophies were practiced? Yes. Did I agree with the practice? No. Did I ever resign or quit over such practices? No. Why object now? Because I just felt like it. Because I couldn't take it. Because I'm a dumbass in tough economic times.

Hey! Google my ass. I hope you land on the unconscious fellow below, undoubtedly pumped full of some grossly expensive SGA and who knows what else, which he summarily washed down with a nice chianti.

So, I went out yesterday, a beautiful, sunny March day, intent on mailing a letter, running some errands; the ever-present camera at hand. I randomly looked across the busy street and happened to see a former patient, sitting casually on the bus stop bench, legs comfortably crossed, drinking from a paper bag. Why did I remember this guy? Frankly, he dwelt among the nameless, vaguely-familiar "cohort" that wandered into our clinic for a variety of reasons - and in my estimation - the least of which was psychotropic medication. But what distinguished this gentleman, actually, was his ZZ Top-bearded side-kick (street-christened, "Smokey"), who upon initial contact with me, pulled from his pants pocket and back-pack 2 massive knives that he pointedly banged on the counter in front of me, thereby heeding the worn sign that forbade "weapons" within the clinic. Now, if you are familiar with the persistently homeless, they tend to "hoard" a tremendous amount of I'm-not-exactly-sure-what in trash & other bags, frequently tied to bicycles and shopping carts. Who, exactly, would inspect these "belongings?" But it was the response of the gentleman in question to my, apparently, amusing reaction to the knives that I recall: being already "unsteady," he laughed so hard he fell down. Approximately 40 minutes later, as I returned to the area, I found him as you see above. Without ranting, the scene is a very busy commericial area, and I am just not surprised to see such a sight so blatantly ignored by the hundreds walking past. Two guys literally cut through the bushes, stepping over the man, to tape signs on a lightpole. He was shallowly breathing, twitching, but otherwise unresponsive to me. Gross spider angioma of the face; swollen hands and ankles; bright red palmar erythema, obvious flexion deformity of the hands, and deformity of the nails & nail beds. Comment of the Chief Resident: "Why are you bothering me with this shit? Banana bag him in the hall & let him sleep it off." I sit on the bench & call 911 who seemed more interested in identifying me - three complete attempts at spelling Starfish - before switching me to paramedics who wanted to instruct me in counting the rising & falling of the gentleman's chest... Thankfully, a police officer, pulling on his blue surgical gloves to the sound of the ambulance but blocks away, sort of mumbled thanks on behalf of the citizenry, and as I moved on, never went closer than 2 yards to my former patient.

And believe it or not, this will all lead to an explanation of how I talked myself out of a job...

I have been enjoying the eclectic, significantly stress-reduced lifestyle unassociated with the slings and arrows of a maximum-security corrections facility, and liking it. Probably too much. I've given a few guest lectures, done some "per diem," some "consultations," and even turned down some opportunities to re-join mainstream clinical work doing things I really don't want to do. And I must stress the triomphe of actually rejecting things I really don't enjoy. Not exactly rock-climbing, but different enough... At the same time, I cannot possibly imagine how anyone could possibly survive on $480 of unemployment compensation per week, the most California allows. My heart still aches for my single-parent ex-colleagues. And so it goes. But a friend called and suggested I look into the opportunity of replicating some of my previous work in corrections - completely on the "outside" - on a county level. In this manifestation, however, you need to take a civil-service "examination," and this set off a series of peculiar events.

It is the custom of my friend & cohort, POTFP, to send a family Valentine in lieu of other "seasonal" greetings. And because Madame is a real photographer and artisan, these cards are breathtaking portraits of their children (and one unfortunate, yapping canine). And, it generally arrives late. For the holiday. At least to me. Nevertheless, after, again, being stunned, I set the card down & sent an email suggesting that an argument could reasonably be made for parthenogenesis. I concluded my chiding with a mention that I was taking a civil service exam on Saturday morning.

Early Saturday morning, I arrived outside of a county facility to join a cadre of similarly "milling mad wo/men," before a sign indicating, "The door will open at 8:00." So, with a few moments on my hands, I sent off an iPhone email to POTFP, reporting on the (customary) observation that I appeared strikingly different than those with whom I waited; and that would be "professional" and/or like a cop. Noting that this is a touch anxiety-provoking, I concluded with something like, "WTF, all aboard."

I digress for a moment to say that San Diego County's civil service exam bears some solid warnings about revealing the contents of said exam. I will not defy this signed oath by divulging specific information, but it seems reasonable (and somehow necessary) to comment on the content. For reasons I have discussed previously, I appear a dumbass in regard to spelling. Alright, I am a dumbass in regard to spelling. In my estimation, San Diego county is inordinately concerned with spelling. Enough said. Fortunately, I am considerably more fluent in regard to grammar... I think. We were offered the opportunity to "dispute" the validity of any exam question(s), and I felt compelled to make a notation that, at least in the example given in question #8, the NY Times Manual of Style would suggest that "who" is equally acceptable as "whom" in modern usage.

Exam concluded, I turned in my materials, turned on my phone, and headed out to the car. Immediately a number of "chime" notifications issued from the phone indicating email & voicemail. Taking the email first, POTFP responded to my earlier mail with, first, "What?" and then a short succession of "What is happening????" Turning to the voicemail, POTFP is distressed, requesting an immediate callback. Huh? I'm thinking, "Could he be that concerned about my considering a return to corrections?" I dutifully call, only to leave a voice message. Later, I'm on the highway & hear the phone; without the headset, and driving directly behind the highway patrol, I pass. It's illegal here. When I stop, I listen to the voicemail and finally understand the proceedings: apparently, POTFP "glanced" at the email I sent without reading that I was taking the test. So, reading that I was "standing in front of a county building," on a Saturday morning and the seemingly cryptic, "all aboard," suggested to POTFP that I was "taking hostages" and on the brink of a Saturday morning induced-halocaust. Mild-mannered me? Madonna mia, Pal, get yourself a decaf!

And now, a "proof-of-concept." As I mentioned in my discussion with the OG, I can find no reasonable explanation for the pronunciation of "heroin" on the street. But perhaps, should you not have believed me, listen to Rodney King & Seth Binzer, from a "reality show," to which I shall return later. The Newcastle Brown will still bring you down.

King HAIR-on

Regardless of my stated intention, I'm am not returning to the issue(s) of the previous posts. Were you holding your breath? Yeah, me either. Who cares? No one. So, I thought I might stop for a moment - and with all due respect to the Cardinal depicted at the left, from the USD campus, a warm metal head is asking for trouble - and take a moment to "tie up" some loose ends, finish some stories, and commit some shit to the trash.

It certainly bears repeating - and repeating and repeating - that what I've written, and notably in regard to interaction with patients, is "disguised" in order to comply with the prevailing laws and regulations protecting patient privacy. And I would add that, even in consideration of the law, it is both ethically & morally indisputable. This is not to say that this is an exercise in "fabrication" or "fictionalization," but disguise. Finally, having said that, I must reiterate that the point of beginning here in the first place, was to understand me, and patient interactions are merely illustrative; a way of my understanding my own thoughts & perception in context.

I am amazed in a "transcendent" sense at the fact that the unexplainable frequently breeds the unexplainable. I so distinctly recall concluding my comments about Jennifer, looking & speaking to her father, wishing that by knowing the comfort Jennifer had brought to my mother, it might bring comfort to them as well. In a silent hall, from across the room, he said to me, "It does. Thank you. It does," as if we were the only ones present. And not even a year later, he too succumbed to this horrible disease. Russians pray for a place where, "sickness, sorrow, and sighing are no more," but I can only think of a wife & mother, driving endlessly between oncologists & medical centers, futilely attempting to elude a master thief.

I (and perhaps you) will sleep better knowing that this gentleman (and in this case gentleman is a grossly charitable euphemism for "psychopath" who was one of the few to actually unnerve me) was back in "local custody"; meaning that he was re-arrested and was being held in a county jail awaiting a parole revocation hearing. What are the positive "rehabilitative indications" in this example? He substantially improved his actual release time from three hours to three weeks in a mere 8 years. That must count for something...

And just to prove that I am no sore loser, and perhaps (and let me emphasize perhaps) acted as a clinical "hack" (or was that a "wank," POTFP?), the last person described here went door-to-door safely on the Compton Express; reported to the Out-Patient Clinic as directed; and even dutifully followed my written directions on securing postpartum medical care for herself. Wow. But while I am not a betting man, I'd put 5 on it that all she will ever recall about me personally is that I refused her the phone.

You may recall that I have mentioned the pleasure I derive from photography, but be careful in assuming a correlation between deriving pleasure & actual talent. But like with everything, I do what I can. Having initiated the use of Apple's Aperture to catalog & manage my photos, a thorough "scouring" of my mixed media revealed 7,000+ photos. WTF! So, I'm starting small & creating some limited "galleries" based on situations I've described here. Gallery One is general, "When Did We See You?" referring to Matt. 25:37; the Second contains the reason for my visitation from the FBI; and the Third is A Tale of 2 Cities, a passion of witnesses.

You'll need a recent, free Flash player, and I would note that, as I am still "tuning" the code, shit happens. What can I say? Just reload & everything should work. Because the music is "buffered" to prevent gaps, it may take a minute to load. For now, you need to reload to change the song. It's BETA, baby... Click here, scroll down to the crosswalk (please watch for traffic), and click on the 4th box. Be sure to visit the Gift Shop... OK, there is no Gift Shop, but feel free to leave a comment, suggestion, or aspersion (only if necessary).

Ultimately, this is a business of outcomes. And a step further, it really is a business of positive outcomes. More so than I actually imagined, given the "venue," and certainly more than I liked. A "gentler," more reliable form of science would be the non-political, non-grant /prestige/notoriety-seeking form of science to which I had been uncomfortably become "accustomed." .

CHORUS: WTF. When did he become so cynical?

HARTMAN
Joker!

JOKER
Sir, yes, sir!

HARTMAN
Forty-two-twelve, Basic Military Journalism.
You gotta be shitting me, Joker! You think
you're Mickey Spillane? Do you think you're
some kind of fucking writer?

JOKER
Sir, I wrote for my high school newspaper, sir!

HARTMAN
Jesus H. Christ, you're not a writer, you're
a killer!

JOKER
A killer, yes, sir!

At its most fundamental, science sources from a place of evidence and observation. The approach, then, to "unusual" observations - deviations - from what has been historically observed is to assume that, without "evidence" that specifically corroborates or refutes our historical observation, we will assume the "unusual" observation is random & insignificant. This is the hallmark of science. Quick example. In my email today was a new "abstract," or summary, of a study that indicated that if you have a specific "genetic variant" (i.e. differing from most people), you will not respond as well to the medication Plavix^TM. And relying on the best information available - that being the TV commercial - Plavix prevents blood platelets from "sticking together," thereby forming a blockage in an artery. How would you go about proving this? Well (and I'm obviously oversimplifying), getting together a significant group of people who meet the diagnostic criteria for prescribing Plavix with the genetic variant, and a second significant group of people without the genetic variant ought to do it. Prescribe both groups Plavix, and compare the results. The results would constitute your "evidence," and determine your outcome.

A likely source of my most recent "conflict" with this whole process began when we were informed that our department had been given access to state data that could track patient "outcomes," associated with individual clinicians. I had to assume this referred to a single, basic calculation: how many patients who met with you were returned to custody, or simply put, had a "negative" outcome? My immediate question was to clarify to what end such a calculation might be made, because I suspect you know what I was thinking: some dumbass will take this data and attempt to make a conclusion as to an individual clinicians "effectiveness" based on outcome data. In other words, if I saw 100 patients, 87 of whom were returned to custody within a year, but the woman across the hall saw 100 patients, 55 of whom were returned to custody, it's apparent I SUCK. Now, you may have reasonably concluded that I was paranoid about the whole matter, but...

In 1994, the NY State Health Department began publishing a report on Adult Cardiac Surgery Outcomes, in the interest of patient consumers. "Outcome" here is a euphemism for "survival." Not only does this report clarify historical "trends" (this year, in reporting data from 2003-2005, "outcomes" are consistently better), but it breaks down the outcome data to each specific hospital certified to conduct cardiac procedures, and still further, the outcome data is broken down by each individual surgeon in the state. So, put yourself in my position: your mother needs an aeortic valve replacement to correct a congenital defect. You dutifully download the report, only to find that her proposed surgeon is batting .250, while the cardiac surgeon in the university-affiliated medical center on First Avenue (and undoubtedly, as a direct result of this report, finds him or herself listed as a Best Doctor in NYC) is batting .850 with 3-4 times as many completed procedures as your proposed surgeon. If you're like many, you see that report & starting phoning the "top five" for an appointment.

The "problems" with this data & report were first brought to the public's attention by Elizabeth Bumiller in the NY Times in 1995, to be renewed each time the state issues a new report. Simply put, the surgeons at the lower end of the report are generally from public hospitals & medical centers, with a patient demographic markedly bearing no resemblance to their "First Avenue" counterparts: older; in a generally poorer state of general health; lacking consistent medical care and management of chronic disorders endemic to the demographic; and finally, they arrive at a significantly more advanced state of cardiac disease. And for these reasons, their "outcomes" are poorer, and their survival & mortality rate is skewed. A friend who was Chief of Cardiology at a Westchester County medical center told me, "Those 'Top Ten' surgeons are not seeing patients whose first "intervention" is an ER admission when they're crashing." On paper, these surgeons SUCK. But they are not, by any means, necessarily poorer or inexperienced physicians. They are simply treating sicker patients.

And so, this argument has come full-circle, back to me. And, hey, why in the hell should it not. I own the joint, after all. I have one more post to complete my "whining trilogy," and then I'm done. I conclude, again, by stating that, post-analysis of the "data-analysis" of the outcomes that didn't take place reveals: on paper, I SUCK. Back in the day, in NYC a parking ticket always included the option of pleading, "Guilty, with an excuse." Let's be clear here: excuse differs from rathionalization, and here we will begin anew & anon.

My office is off-campus, located in the "village" of La Jolla. You can see the Pacific Ocean looking out the window. Today was heavily overcast, approximately 60 degrees at the shore. Right before noon, I was sitting with two colleagues in an office facing away from the shore when there was the rush of a jet engine. In my mind, it sounded, from inside, like a commercial jet, and we all looked outside. Nothing. Just the sound. One colleague said, "That's unusual." "I said, "They must be rerouting flights from Lindbergh Field because of the weather." The second colleague said, "Let's go to lunch."

At about 2:30 pm, the first colleague came to me office and said, "Did you hear about the crash?" "What crash?" "A military jet crashed into UTC (University Town Center)." "What?" "Do you think it was the jet we heard?" "When did it crash?" "Around noon.The pilot ejected"

I have no idea if we heard that plane. The crash occurred six miles from our door. At about noon. Two people, a mother & child, are known dead; another two, a grandmother and another child, in the same house, are missing. They are being referred to as, "civilians." Several houses are destroyed and the neighborhood was evacuated. The pilot was transported to the Naval Medical Center. He was twenty years old, commanding a $48 million aircraft. He apparently was attempting to guide the plane into a nearby canyon. He apparently ejected at the last possible moment, coming to rest in a tree in the canyon. High school students having lunch nearby saw the pilot eject and watched the plane crash.

Men are never convinced of your reasons, of your sincerity, of the seriousness of your sufferings, except by your death. So long as you are alive, your case is doubtful; you have a right only to your skepticism.

Albert Camus, The Fall

Does this seem reasonable to anyone?

So, today is my boy's birthday. St. Nicholas' Day, you remember? Unfortunately, they never seemed to appreciate this fact in Crown Heights where he was born. Leopold, in English, but his mother always called him "Lev" (ly-OV) (as in Tolstoy), whom he has grown to resemble.

The police called me this morning; said they found him wandering the Lincoln Tunnel, muttering to himself, "When I think of it . . . all these years . . . but for me . . . where would you be . . . You'd be nothing more than a little heap of bones at the present minute, no doubt about it." He always seems to knowingly pause, waiting for the response. "Your line! You forgot your line!" he shouts. Patience had always eluded him. And try as he would, he was never handy.

"1^st Ave. at 27^th?" the cop asked me in a low voice. "Nah," I said. "Take him to the Jersey side, buy him an authentic Mexican meal, and take him home." "Just like last year?" "Yeah, just like last year." "Just like the last ten" "Hah! Many more to come, my friend. Many more to come." Even over the phone, I hear the snap of the cuffs. "May the cat eat you, and the devil eat the cat!" I hear in the distinct, angry brogue. How ironic it is that I have come to associate St. Nicholas, the patron of cops, with the long march to Brooklyn.

What gets into a man's mind on days like this? Makes a man regret not accepting the gerenontology Fellowship after all.

Well, I would only ask that, should you have a free minute, stop over and leave a kind word for a for a truly aged soul. Tell him I sent you.

In passing, I turned the corner to see that someone(s) had desecrated my wall. And of all stupid things, the chicken-foot juju you see hanging was put there to specifically bring GOOD FORTUNE. So much for hoodoo, juju, or voodoo:

(Yeah, that would be Salt n Pepa)

So, as this whole deal winds down, I randomly gathered data - and as you will see, I use the term quite loosely - on approximately 3,500 inmates of the total I have seen over an approximate period of five years. I would note that, from the beginning, we were told that the CDCR forbids analysis of "their" data. And while I have since found this to be untrue, I suspect they would exert a significant amount of control over those researchers they actually allow access. For the record, you will find no "analysis" or conclusions here.

Understand my job: 1) to provide a contemporaneous examination (think Kaplan & Sadock, Chapter 7) of an inmate with a mental health classification, already approved for parole (i.e. I played no role in the approval process); 2) examine the medical record for current meds, historical meds, public health matters (e.g. Tuberculosis, HIV, HCV), current diagnosis, etc.; 3) examine the Central File - the criminal record - noting criminal history, specific "notable" crimes (e.g. involving violence, arson, sex offense, escape, gang affiliation) and registrations (e.g. sex or drug offenders, arsonists); and 4) explain the "special condition of parole," mandatory participation in the Parole Out-Patient Clinic. I then cap off this visit from Peter Pan with a mandatory "invitation" letter to join POC on a specific day & time. Straightforward, no?

The theoretical basis for for what I have done, as was explained to me, is that, on the whole, parolees with a mental health classification who actually arrive at POC have significantly better "outcomes" than those who abscond. One obvious reason might be that they are provided psychotropic medication at no cost; and, as one could reasonably predict generally, medication compliance - the bete-noir of psychiatry - is critical. Following this logic, the intent of my work was to increase the actual number of individuals who "arrived."

You can find a million places where it is duly noted that "outcomes" in psychiatry generally bear no resemblance to "outcomes" in medicine as a whole. For example, if are diagnosed with a community-acquired pneumonia, you are given the appropriate antibiotic until the infection is gone; outcome, "cured." If you are diagnosed with Schizoaffective Disorder, however, "outcome"is not measured by resolution of the disease process, but rather an improvement in or stability of the quality of life (and if you haven't read The Center Cannot Hold: My Journey Through Madness by Elyn R. Saks, I highly recommend it). While there are some "objective" indications of improvement (i.e. observable by others), in the end, the patient subjectively determines the "outcome." Now, contrary to this generalization, I had the concrete, simple, and "objective" measure of outcome: recidivism. If you did not re-offend or abscond & return to jail, your's was a "positive outcome." And ultimately, this will be reflected in the data. OK, in this case, will is elusive, so let's say, "should."

I have long questioned the utility of associating "outcome" to a specific clinician (or facility, or both) without examining all determinable variables that might impact the outcome. For example, if you are dealing with the sickest patients, it would seem reasonable to predict substantially poorer outcomes, whether you are speaking of coronary by-pass procedures, or the persistently mentally ill being housed in correctional institutions. But, again, this should be reflected in the data. So what about the data?

The data itself is (and I'll avoid the term shit as unscientific, but you know what I mean), at best, misleading; and if it's funding you're after, my opinion is that it is not inaccurate to state that it is deceptive. In this system, "outcomes" are pretty much according to these designation:

1. Deceased (Well, not exactly what I'd choose, but you can't argue the significance of the variable).
2. [Parole] Revoked, generally meaning that you had your chance (and more often than not, chances,) and a Parole Board or Judge has seen enough of your sorry ass. If you were playing Monopoly^TM, you know where you're headed, without passing GO or collecting $200 (ironically enough, the same amount CA puts in your pocket when you leave).
3. Re-Incarcerated (Yeah, buddy, but you won't have me to kick around).
4. Local Jail Confinement (a mere stone's throw from the Big House).
5. Parolee at Large (PAL) - "How long? Not long!"
6. Of the same genus, Did Not Keep Appointments.
   
7. Receiving Treatment Elsewhere - Now, I might jump on this as a "positive" sign (e.g. at the VA, community clinic, etc.), but it is in the realm of possibility that this is a "write-off."
8. Transferred Out of State - gratefully, destined to screw up someone elses' numbers.
   
9. Parole Discharged - we'll come back to this.
10. And my personal favorite, Maximum Benefit Received.
    

The final two designations are interesting in that they may imply one thing (i.e. a positive final outcome - likened here to graduation), but actually refer to something quite different. If you do not re-offend (i.e. violating an aspect of parole is not a new offense) eventually, you will have served all the possible time the state can have you serve for your crime. At that point, you "discharge your number," and you're off parole. You have paid your debt in full, but we will (most likely) be awaiting you with open arms. Any number of patients have attempted to pass themselves off to me as "first termers," because when you return, you get a shiny new number.

When I worked in out-patient psychiatry in the community, "maximum benefit received" was generally an occasion where the patient and I agreed that they had worked to a place of stability, and probably needed to go it alone. I am identifying this to be a positive therapeutic outcome. On the other hand, my list is brimming with those malingerers who took meds to get better housing & a lower bunk, or those markedly ill individuals who stopped meds AMA, telling me, "I really believe I can make it this time without meds." No bookie on this earth would give you odds on the former, and it breaks your heart to imagine what might happen to the latter. After all that hip-hop, even I want to play on Sarah McLachlan. Alright, I lied. But it is truly disconcerting.

I'll get back to you on my outcomes. Prelude: I suck.

I started to "comment" on the comments to the previous post from Midwife With a Knife & Ladyk73, but it got too "windy," So, as I personally believe the issue & the comments are significant, I decided to comment here, for the increasing hundreds who follow this blog. That was a joke, kids...

My frequent intention here has been to acknowledge - good, bad, or questionable - the differences between medical & mental healthcare in the community and in correctional facilities. As I've written here many times, control of the entire medical delivery system of CA state prisons was placed into the authority of a federal court appointed "Receiver," because the court found the conditions to be "unconstitutional." And for Ladyk73, this series in the NY Times regarding NY prisons was brilliant (and be sure to either scroll all the way down to "next page," or click "printer-friendly format" because it is long article). Having said that, I emphasize that I make no judgment as to parity, "worthiness," or financial burden; and I cannot justify in my mind purposefully withholding necessary medical care because of such a factor. Now, have I ever had the thought, "You are being prescribed these grossly expensive medications when I know you're malingering, you rat bastahd, and people who need the med can't get it." Sure. That would be "yes," affirmative, "aye-aye" (for my friends in the military), and that would be more frequently than I would like to admit. But nevertheless, "worthiness" has never been a reasonable criterion for medical care.

I would note here before continuing that, working in the Mental Health Delivery System, I had rare interaction (count them in one hand) with physicians in medical, non-psychiatry departments (even when I was injured!). There are non-psychiatric policies & procedures I have sought out (e.g. treatment protocol for HCV & HIV), but on the whole, my direct knowledge is limited to what has been announced to be "defective" and/or corrected by the Receiver, reviewing medical records, or discussion with clinical staff.

Both commentators asked about "routine" screening: HIV & baseline colonoscopy at age 50. It appears that basic bloodwork is done routinely when an inmate enters a reception center. And it seems likely that a digital rectal exam is routinely "offered," as the presence of a signed "refusal" is nearly universal in men's medical records. Using this same logic, that any significant refusal is documented, I have never seen the refusal of a baseline colonoscopy, never had an inmate report an offer, and never found results of a "routine" (i.e. not based on a medical indication like FOBT) baseline colonoscopy in a corrections medical file; and because any but the most rudimentary procedures are conducted "off-site" (generally there is an arrangement with a local community hospital), they are generally well-documented. To my knowledge, the only "routine" screening of all CA inmates is a yearly PPD (and/or CXR) for tuberculosis. It appears a PPD is mandatory, but treatment for latent tuberculosis infection is not. I'm would like to believe that every medically indicated test is ordered & conducted, but it is impossible to corroborate.

Since 2006, the Centers for Disease Control has recommended "HIV screening as part of routine medical care for all persons 13-64," and "new strategies are warranted to increase HIV testing, particularly persons who are disproportionately affected by HIV infection." And who are disproportionately affected? IVDU's; minorities ("HIV prevalence rates for blacks & Hispanics were, respectively, 7.6 & 2.6 times the rate for whites"); sexual partners of high-risk individuals; and from the November, 2008 issue of Pediatrics, "All pregnant women in the United States should undergo documented, routine HIV antibody testing [to prevent MTCT of HIV]." Wow. That would certainly seem to justify "routine screening," if for any reason, cost-effectiveness alone. What I forgot to mention in the previous post is that, by the numbers, these individuals are returning to prison at a rate greater than 70%. If I see no lab results for HIV/HCV in the chart, I always recommend that an inmate seek screening on the outside, but so many do not stay out long enough to do so. We are, then, likely to be treating them in prison at a later stage of illness and in generally poorer over-all health than those on the outside. So, where there is HIV there is increasingly HCV & tuberculosis (the most significant factor for the activation of latent tuberculosis infection? HIV), but, thankfully, no correlation to colon cancer that I can find!

As far as I can tell, the CDCR officially admits to very little sexual activity or drug use within correctional facilities. But as a taxpayer, would you be interested in hearing to the contrary? I would be fascinated to see a longitudinal study as to inmates contracting HIV/HCV while incarcerated, but it is hard to imagine it happening in CA. And to raise the stakes, as CA provides for conjugal visits for all sexual orientation, an August, 2008 article in the journal AIDS education and prevention : official publication of the International Society for AIDS Education, entitled, "Bringing it home: design and implementation of an HIV/STD intervention for women visiting incarcerated men," notes that "Women with incarcerated partners reported low rates of condom use and HIV testing combined with a lack of information about prison-related HIV risks."

Obviously, these "connections" & correlations seem endless, and unless I stop writing now, I fear they will rise up and slay me (and that's a line directly stolen from Lewis Black). Aye.

I strongly suspect that the type of work I've been doing for the past 5 years is considerably annoying to the actual treating physicians of the patients I examine. Imagine, someone basically unknown to you shows up and is reading your case & medication management notes. And thinking who knows what... Basically, facility physicians on the whole (but I must add that I have met some exceptional psychiatrists in prison) give me the look like, "You owe me money." And while it makes for a "tense" experience at times, insecurity is, generally speaking, not a big issue for me.

Bearing in mind that diagnosis should be a process of elimination (i.e. ruling out possibilities until only the "reasonable" possibility(-ies) remain), psychiatric diagnosis can be significantly more complicated than, say, internal medicine, in that the presenting symptoms on any given day, week, or month may vary or be absent altogether (rapid-cycling bipolarity, for example, comes to mind): patients with schizophrenia present as stable & lucid; an episode of major depression has, for the moment, resolved. Likewise, psychiatric symptoms can be emergent, only revealing themselves over time and observation (e.g. personality disorders). It is not unusual, then, to see disorders listed in an initial diagnostic assessment as "rule outs"; sometimes based on history, self-report, or there are not enough presenting symptoms to meet diagnostic criteria.

But I have mentioned an anecdotal observation that the prevalence of HCV in CA prison's is remarkable. Now, there are many studies suggesting that the prevalence of HCV in the general population is "overestimated," but let's lean on the Centers for Disase Control & Prevention:

The prevalence of anti-HCV in the United States was 1.6% (95% CI, 1.3% to 1.9%), equating to an estimated 4.1 million (CI, 3.4 million to 4.9 million) anti-HCV-positive persons nationwide; 1.3% or 3.2 million (CI, 2.7 million to 3.9 million) persons had chronic HCV infection. Peak prevalence of anti-HCV (4.3%) was observed among persons 40 to 49 years of age. A total of 48.4% of anti-HCV-positive persons between 20 and 59 years of age reported a history of injection drug use, the strongest risk factor for HCV infection. Of all persons reporting such a history, 83.3% had not used injection drugs for at least 1 year before the survey. Other significant risk factors included 20 or more lifetime sex partners and blood transfusion before 1992.¹

As you probably would have imagined, this study consisted of "civilian, non-institutionalized," subjects in a "nationally representative household survey." But what about CA prisoners:

The prevalence of HCV infection was 34.3% overall (95% confidence interval [CI], 30%-38%) and was 65.7% among those with a history of injection drug use (IDU), compared with 10.2% among those with no history of IDU (odds ratio [OR], 17.24; 95% CI, 10.52-28.25)².

Quelle difference! But simply for the sake of contextual reference, in a September, 2008 report of the American Lung Association, lung cancer,

"has been the leading cause of cancer deaths among men since the early 1950’s and, in 1987, surpassed breast cancer to become the leading cause of cancer deaths among women in the United States. Lung cancer is expected to cause an estimated 161,840 deaths in 2008, accounting for 29 percent of all cancer deaths."

And the prevalence rate of lung cancer in the US? That would be 1,332 per 100,000 people (highest incidence in KY - to-BACC-o - and the lowest in Utah), or significantly less than 1%. Not enough context, you say? In the last published (2007) statistical analysis of cancer in the US, the overall incidence of colon cancer appears to be 58.2 cases in 100,000 (50.5 per 100,000 in CA). My conclusion: WTF!

Now, CA's CDCR has a protocol for treating HCV, and to be honest, I've read it, but not compared it to a non-correctional protocol. I do, however, suspect it is congruent (or I'll give them the benefit of the doubt). Assuming this to be true, they would be treating patients pursuant to the expected natural history of HCV over an established, graduated protocol for a non-incarcerated cohort. [NOTE: For the sake of brevity, I'm over-simplifying here:] As for the B vitamin complex, without over-complicating the issue, homocysteine is an amino acid cited to do a briefcase of lame things in the body: "In chronic hepatitis C, preliminary data have shown that hyperhomocysteinemia [elevated levels] is an independent risk factor for steatosis [an abnormal accumulation of lipids - think "fatty liver"] or even fibrosis [let's just say an accumulation of "junk" that will lead to cirrhosoi/portal hypertension and eventually the need for transplant]."³ I know this is getting windy, but hyperhomocysteinemia is associated with poorer outcomes with the most effective treament for HCV to date (peginterferon alfa-2a and ribavirin)⁴. And finally, B vitamins are demonstrated to decrease the levels of homocystein⁵. Is this the appropriate treatment for CA inmates with HCV? I have no clue.

So, not to my surprise, a study appears in the November, 2008 journal Hepatology entitled: Treating hepatitis C in the prison population is cost-saving⁶. Wow. Though significantly more expensive than a B vitamin complex, the yearly cost of PEG-INF & ribavirin is less than half the cost of treating hepatocellular carcinoma (a too frequent complication of HCV) or palliative (end-of-life) care:

If the decision to treat is based on pharmaco-economic measures, however, the results of our analysis suggest that treatment is cost-saving and should not be withheld in U.S. prisoners with hepatitis C. Because the efficacy of treatment is diminished by relapse of injection drug use and reinfection, this treatment strategy must be coupled with educational and substance abuse programs. Furthermore, because mental illness is widespread in the prison population and can often be exacerbated by treatment, careful mental health screening and follow-up would be required.

She sat down across from me, in her 18th month down, exhibiting some classic signs of EPS: the "grimacing" of a dystonia, stereotypical movements of her arms & hands, and the "jumping legs." "Too much meds, I think." That would be as good a guess as any. "What are you taking?" "Haldol." An excellent guess. "I have a "co-pay" appointment (inmates must contribute from their "earnings" for extra medical appointments) with the doctor tomorrow." Good. As is customary, I question regarding IV drug use, HIV, & HCV. "I've used needles for years & my boyfriend uses needles and sleeps around when I'm in jail, so I'm nervous. I've asked to be tested, but nothing happened."

It didn't take me but a split-second to suggest, "When you see the psychiatrist tomorrow, why not ask if the tests can be scheduled before you leave?" "That's a good idea. Thanks." "That's why I'm here." And the echo of the future: "Who is that arrogant dumbass, interfering with my patients?" Ok, dumbass I'll accept, but...

¹ Fox RK, Currie SL, Evans J, Wright TL, Tobler L, Phelps B, Busch MP,
Page-Shafer KA Hepatitis C virus infection among prisoners in the California state
correctional system. Clin Infect Dis. (2005) 41 (2), 177-86.

² Ruiz JD, Molitor F, Sun RK, Mikanda J, Facer M, Colford JM, Rutherford
GW, Ascher MS. Prevalence and correlates of hepatitis C virus infection among inmates
entering the California correctional system. West J Med. (1999) 170 (3), 156-60.

³ Roblin X, Pofelski J, Zarski JP. Steatosis, chronic hepatitis virus C infection and homocysteine. (In French). Gastroenterol Clin Biol. (2007) Apr;31(4):415-20.

⁴ Borgia G, Gentile I, Fortunato G, Borrelli F, Borelli S, de Caterina M, Di Taranto MD, Simone M, Borgia F, Viola C, Reynaud L, Cerini R, Sacchetti L. Homocysteine levels and sustained virological response to pegylated-interferon alpha2b plus ribavirin therapy for chronic hepatitis C: a prospective study. Liver Int. (2008) Jul 24. [Epub ahead of print].

⁵ Nenseter MS, Ueland T, Retterstøl K, Strøm E, Mørkrid L, Landaas S, Ose L, Aukrust P, Holven KB. Dysregulated RANK Ligand/RANK Axis in Hyperhomocysteinemic Subjects. Effect of Treatment With B-Vitamins. Stroke. 2008 Nov 13. [Epub ahead of print].

There are times when you just walk past something so many times, that by the time you look up, it's already gone raggedy-assed. Prime example should be noted above. Now, I have repeatedly identified myself as a New Yorker, and on the other coast such a display might attract a bit of interest. But in sunny SoCal, my thought is that - between the feet & the heat - WET WHEELS! A playground for everything fungal. But the truth of the matter is that popular they are here, and corrected I stand.

So, sometimes, people, you just NEED to pay some tribute to your one & only subscriber (and you know who you are), perhaps with a Chin Check (and look it up cuz ya too young to 'rememba):

I'm a smoke where I wanna smoke
I'm a choke who I wanna choke
I'm a ride where I wanna ride

Indeed. I'm a ride for my side in the C.P.T. and God bless the memory of Eazy-E. But hey, most importantly, never forget it's what's in the boots that make the lady!

I'm outta hea'.

PROP 8: ELIMINATES RIGHT OF SAME-SEX COUPLES TO MARRY. INITIATIVE CONSTITUTIONAL AMENDMENT.

Changes California Constitution to eliminate the right of same-sex couples to marry. Provides that only marriage between a man and a woman is valid in California. Fiscal Imapct: Over next few years, potential revenue loss, mainly sales tax, totaling in the several tens of millions of dollars, to state and local governments. In the long run, likely little impact on state and local governments.

---

Everyone has been touched in some way by breast cancer. And recoiled from the touch. No family should lose a mother prematurely. Or a dear friend, sister, wife, daughter, co-worker. No one of us, just diagnosed, should have to look at the mirror in the morning and say: Will I survive? Everyone deserves a lifetime: We feel it deep in our bones. Allow yourself to imagine a world without breast cancer.

If you had the idea that this rant is about or regarding sexual orientation, same-sex marriage, or a meditation on the landmark that is Brown v Topeka Board of Education, Or, that this might be related to inequality, a comparison or quantification of issues, or worse, analogy, complex or simple, I strongly suspect you will be disappointed. Read this statement as many times as needed: this is a reflection on contrast.

Yesterday as I was out walking - customarily taking photos down crazy alleys where I don't belong - I emerged onto the street and ran into a group of people distributing fliers announcing a protest rally at the downtown Manchester Hyatt Hotel. The issue: apparently the Hyatt Corporation is actively "marketing" the gay community, yet Doug Manchester of this particular franchise, donated $125,000 toward Prop 8 (as cited above) - and that would be his hotel with the word "BOYCOTT" projected upon it from across the street - which passed in the General Election. In summary, and despite Hyatt's statement that this is an individual proprietors' decision, not a corporate decision, the group Sleep with the Right People believes this to be hypocrisy on the part of Hyatt Corporate. I, not being G, L, B, nor T, do (as you may have read here) possess a strong sense of justice, and so, camera in hand, headed downtown at the appointed hour.

This was, in my estimation, a somber, sad, culturally rich & diverse gathering of disaffected souls, who are staring into the face of, not "disagreement," but outright hate every bit as ugly and despicable as this country continues to experience regarding race and immigration. In fact, commentators in cars rolling down Harbor Drive, fairly equally shouted references to the Bible as they did racial obscenities. The San Diego Police apparently considered this to be a benign enough affair that necessitated four (count 'em, four) officers, who did not appear to be enjoying the assignment, and frequently chatted among themselves, seemingly oblivious to what transpired. While the talk, the chant, the singing spoke of hope and eventual triumph, I, for one left this even feeling anything but.

Today, I began to hear repeated blaring car horns, shouts, and cheering, accurately perceived something was up, grabbed the camera, and headed up the street. There I meet a literal stream of humanity - hundreds, eventually seemingly thousands - of women in varying costumes, all with some variation of pink. Vans with large signs identifying them as "Titty Buses" offered rides to the weary or injured, three miles from their eventual goal. Cars passed, honking, "thumbs up," greeted with waving and cheering; some cars blaring music clearly intended to inspire and promote dancing.

The San Diego police - all men as far as I could see - were on bicycle, numerous, dressed in pink shirts and riding along and beside the stream of women. At one point, a new pick-up truck parked along the route, labeled "HONK FOR HOOTERS!!!" included pink-clad officers, prominent with firearms, dancing and waving from the pick-up bed, encouraging passing traffic to honk in support. Families with children stood on the street cheering, adorned with such t-shirts as "I love boobs!" But likewise, there were far, far too many carrying signs & pictures of loved ones ravaged and taken by this disease, and undoubtedly far too many undocumented "stories" and grief: "We miss you!," "We love you!"

I devoted a little over an hour to each event, and not until I walked away from the second, observing a pitifully atrophied young man in a wheelchair, digging in the trash for cans & bottles, a million miles away from the "hope" that literally paraded past him yards away, was I overwhelmed. And I sat down under a tree next to the stinking smell of fast-food & cried. Fortunately, neither my heart nor my head is large enough to suffer everything I see. But apparently just enough to remain human.

While I had yet to even convince myself that I have accomplished something in the seemingly unstoppable river of tears, we were served with the notice that we are "indefinitely laid off" as of 12/30/08. As I read the data, a small cadre of brave, at times startlingly insightful, but most frequently unappreciated band of clinical hooligans, were able to affect change. That would be by the data.

Now, I have been forced to admit to my dearest friend that the "seepage" of the "evidential basis for efficacy," so prized in medicine, - and let's talk tragedy as a recent example - has not served me particularly well in my personal life. And if you're thinking, "Whatever..." I share the sentiment. But what is mystifying is that - perhaps being the only one trained in medicine - the question as to why the data indicated an inducement of change never seemed to interest anyone but me. Pretty much seen as an extraneous matter (as near as I can tell), as far as such matters actually go. Unfortunately, funding does seem to rest upon such extraneous matters. I was never asked, so here I leave my head at the door.

The fact of the matter is this: sometimes, the writing is actually on the wall. I hope you have been following the journeys of ClinkShrink and the Midwife With a Knife, because they have both been greatly appreciated lessons to me in perspective,. But then again, I am more Private Joker than Pliny:

Sgt. Hartman: Private Snowball, you're fired. Private Joker is promoted to squad leader.

Snowball: Sir, aye-aye, sir!

Sgt. Hartman: Private Joker is silly and he's ignorant, but he's got guts, and guts is enough.

And thus, in the end, I am proved to be what I had imagined: a nobody, merely whispering to deaf ears. Now, do not mistake this as some form of self-deprecation, because it most certainly is not. Do I believe anyone can perform the function I did better than me? Absolutely not. I defy anyone to find a dozen patients who will say that they left my presence without a message of possibility - what Dr. Irvin Yalom so simply, but brilliantly referred to as the "installation of hope." While the data would suggest that most eventually returned to jail, I did what I could.

And so it goes. I slowly settle into this with as much sadness as disappointment, and the operative defenses appear to be suppression & humor. It's even crossed my mind to take a vacation...

My average day is comprised of a walk with some of the sickest, most beligerent, dispicable, loathsome, and utterly rejected beings that humanity has to offer. Like many who share this same circumstance, it is not particularly troubling. That would be in the moment.

I am always cautious, and I am always aware of my surroundings: Is it even possible that an experienced clinician would be stupid enough to leave a stapler or a two-hole paper-punch - for punching holes in documents to be inserted into medical records - on the desk where a psychotic inmate would have easy access? Acess because you politely but firmly said, "No, you may not use the phone to call your mother" (which, of course, they already knew, but you're a new face & presumed to be a "sucker" until proven otherwise).

And having previously experienced violence (which is a euphemism for saying I got in a kick-ass, knock down fight with a psychotic man), I am "hyper-vigilant," always aware of who & what is going on around me - some would refer to this as "post-traumatic stress," whereas I see it as a gift. Or how can I explain the dramatic psychological, philosophical, and psychic shift from one taught to "restrain" the "patient" to, as a psychiatrist explained to me my first week in a level-4 "super max" facility, "Grab anything at hand - grab the chair you're sitting on - and beat that motherfucker as hard as you can, for as long you can, until either help arrives, or they are no longer a threat." Wow. Me?

Late last night I got an email saying, "You probably already heard that the chief psychiatrist in Region whatever had some issues (and don't we all), locked himself in his office with enough drugs & alcohol to kill a small army, setup a delayed email informing staff he would "miss them," assuring that no one would find him until, if I may quote the Coroner of Munchkinland:

As Coroner, I must aver,
I thoroughly examined him.
And he's not only merely dead,
He's really, most sincerely dead.

And I say to myself, "What could he have been thinking? He was a psychiatrist, for God's sake!" And then I remember: you are merely a step ahead of the demons. Why him and not you? Intelligence? Doubtful. Less stress? Right... Better "coping" mechanisms? Well, apparently so far... More frustration, disappointment, "disenchantment," discouragement at every turn? Absolutely impossible.

And for two consecutive nights I have headed out onto the dark streets to cope in the best way I know how: take my camera and record the carnage. From the streets, to AdSeg, to the office of the Chief Psychiatrist, I can't imagine any of these consciously chose this path to destruction. Do I "absolve" them because they are/were "ill?" Hell no. But I would be satisfied knowing why.

And tonight at 2:30 am, walking through a quiet but deserted shopping center in the "Uptown District," where I had earlier sat on some stairs watching the annoyed drivers of very expensive cars honk & yell at a homeless man - too oblivious with his own tormentors to notice them - the police rolled up on me with that blinding light directly in my face. It took all my energy not be a complete asshole when they asked, "What are you up to?" Rather than say "I am heartbroken," I merely said I couldn't sleep. And when one checked the ID around my neck and said, "You don't look like a doctor," all I could say was, "May I leave now?" "Go home. It's dangerous out here."

Pal, you couldn't even imagine how dangerous it is out here.

The Capitol Television News Service (Sacramento) reported today:

At a hearing in San Francisco yesterday, a federal judge ruled that the state will have to pay Federal prison inmate health care receiver $250 million dollars to start building new inmate health care facilities by November 5th, or the Governor will be held in contempt of court at a hearing the next week. Receiver J. Clark Kelso is seeking a total of $8 billion dollars to build and operate new inmate health care facilities, after the same judge ruled the state's current inmate health care system is constitutionally inadequate.

The Governor in contemp? Oh, oh.

I opened the chart of what was to be the first patient of the day, only to find that she would not be joining me because she was hospitalized. As I continued to read, she was not being held in a psych unit, but a medical unit. Apparently, she had been reporting a "chronic cough," dyspnoea" (an increasing shortness of breath that left her gasping, resolved only by lying down on her side), which eventually led to the hypoxemia (or a lack of oxygen saturation of the blood - did some one say Capillary Refill?), which is frequently characterized by disorientation, anxiety, confusion, and restlessness. Psych diagnosis? WTF, pick the NOS you prefer, but be sure it's characterized by disorientation, anxiety, confusion, and restlessness. Are you with me so far? 'Cause I'm thinking, all well & good, but how do we account for the cough? Simply put, she was a three-pack-a-day-for-thirty-years mentally ill cigarette smoker with an invasive, advanced squamous-cell carcinoma of her right lung that had basically cut off her right main bronchus before anyone even decided to take a chest xray. Oh, oh.

The Lieutenant Governor of California, ah... I'l bet his own mother can't remember his name, defended the State's choice to defy the Federal Court's order by suggesting that "the taxpayers have a right to know how their taxes are being spent." Two questions immediately come to mind: (1) does U.S. District Court Judge Thelton Henderson actually have the guts to lock up these two arrogant "public servants" (and you know damn well they would not be 214 Upper & 214 Lower (as in bunk), and (2) how many hours would the Governor(s) last in "the cooler" before calling for a pen to sign Mr. Kelso's check?

Next followed the chart of a young woman who, likewise, had been taken to the hospital a week earlier. And, likewise, she too had been taken off-site to a medical facility for an endoscopic examination of her gut. Reason being? Suspected of swallowing "foreign objects." Suspected objects? Razor blades; the ones you can tear out of a disposable razor. Appropriately sedated, they "snaked" her gut like a yellow pages plumber (and don't mistake those cloners for the real yellow pages), only to reveal "abrasions & cuts suggestive of a razor" (Seriously, how could they tell with such precision? Perhaps a "clean" shave?). But alas, said "foreign objects" had moved on (read that as DUCOLAX^R), if you know what I mean. The interesting part is that in the course of ultrasounding her belly, they chanced upon "hepatomegaly," an enlarged liver. This, in turn, led someone to actually "scrutinize" her liver function panels, conducted over an approximate period of 9 months, that clearly indicated something was "amiss": A/G ratio, ALT, AST, all pointing to what even a dumbass like me had already figured: HCV. Treatment offered? A daily B vitamin supplement.

Now, you know I could fill page after page of anecdote that accurately depicts & describes the inequity & indifference to services in this lunatic system. But I can also tell you that medication prescribed to my own mother - the only medication that is effective - is not covered by her Medicare supplemental insurance. Let me repeat: it is the only medication that is effective, and her paid insurance carrier refuses to cover it. My advice to her: you and your buddies should rob a couple of liquor stores ("Quick getaway?" Right. The cops won't even break a sweat). I'll bet you get that med in prison...

But, hey, at least we're not China, leaning on our prisoners to facilitate the save the rich white tourists travel industry (You thought I was kidding?). No, if you are mentally ill and stole food and clothing on the streets of sunny CA, we'll just put you in a wheelchair that looks like the boys from Jackass rode it down the stairs of the Library of Congress, and regale you with lessons in compassion. But then again, the Chinese know how to work the yard.

Come on, tell me you've been reading my boy...

Well, I spent some time in a manner that nearly - and I emphasize nearly - embarrassed me. I randomly came across the phrase, "l'homme sandwich," or alternately "homme-sandwich." And thus began the lunatic search of what this could possibly mean. I begin with "state the obvious":

A junior member asks, "Comment diriez vous "homme-sandwich" en anglais. Merci d'avance!"

A senior responds, "Wikipedia translates that as Sandwich board (to which I would have responded, "I could have looked it up on Wikipedia, international authority on language, myself).

Two senior members then respond identically: "Simply 'sandwich man.'"

If there is a better "state the obvious" response, I'd like to see it. But having thought, "Could that be it? Is it that simple?" I thought, what the hell is a Sandwich man? A man who makes, delivers, eats, or is known for his sandwiches? Consider the possibilities. While junior member is grateful & satisfied, I, for one, am not. And if you're like me, and I suspect the likelihood is dismal, you may hit all the translation sites, concluding, as I did, that this is, perhaps, an idiomatic expression, despite the "simple" interpretation of the senior members.

And now, the cumulative result my relentlessness: Mon Dieu, a video. And my now friend Deni, may he live forever.

Sometimes, you can only conclude the obvious: Je suis un Dumbass.