Saturday, February 16, 2008

Co-Blogger Battle of the N=1 Post


OMG, I'm gonna kill her. Clink complained that I posted over her post, the one she put up to break up my monotonous In Treatment posts. So I re-posted her N=1 post with my intellectually stimulating comments at the beginning and the end in an effort to renew interest in this stimulating topic. This was at 1 AM after the 3 Shrink Rappers had been screaming at each other for 4 hours over a project unrelated to the blog. I got up this morning to see that at 6 AM (when do you sleep, girlfriend???) Clink removed my comments, remade them into another post, placed under the original post, given a similar name. Even I don't know what's flying here.

Some people are never happy.

[Note: This is Dinah's response to my N=1 post. They were originally put in my post, at the beginning and end, but I took them out and moved them here so it would be clear who was saying what. ---ClinkShrink]


We're getting mixed reviews on In Treatment. I'm sometimes enjoying the show, I think it brings up some real-life therapy issues, and I've been trying to talk more about those and less plot synopsis. ClinkShrink hates it, Roy is oblivious, and some of our readers say they miss the old Shrink Rap. It's not the old Shrink Rap, we've got a lot of Life Gets in The Way issues going on, one is that Clink's internet is on the fritz, and we're all involved in some other projects. I've given Roy a "To Do" list which includes posting the last podcast we did-- and we're not even married. We spent the whole podcast screaming about when, who, or even IF, benzodiazepines have a place in clinical practice, so if you've like the Xanax controversies on Shrink Rap, stay tuned and maybe put on your armor.

Okay, and ClinkShrink put up this post the other day to stimulate conversation about the role of doctors and patients in keeping down healthcare costs. It's not about the TV show. Ah, but I posted over it, so if you didn't read it, by all means.... and maybe Comcast will let Clink respond some day.....

So I read this and thought, wait, you don't think people should prescribe benzos for anxiety--they get people addicted, and you don't think people should take expensive meds like Seroquel, off-label for anxiety.....what do you want them to do?

Ah, but Clink says that's not the point of the post, the point is that we all have a role in helping keep down costs. I'm not sure what to do with that, when I have a patient in my office who is suffering-- I think best not cheapest. What's it worth dollarwise for a good night's sleep, or to stop those delusions, or to prevent an episode of mania, or to stop feeling suicidal? To make it so a patient only triple checks the locks? And what constitutes suffering??--Seroquel is perhaps okay if you're hearing voices but not if you're in the midst of an awful panic attack? Or people use it for insomnia, and isn't this an expensive treatment for insomnia, but what if it's the only thing that works or that isn't contraindicated. So we have these medicines, or expensive diagnostic procedures, we're left to ask how to ration them. Easy to blame the insurance companies for not forking over the bucks, or the docs for not being more diligent about cost-containment. But when I'm with a patient, I try to figure out what best helps the patient. Cost is in my head only if there are cheaper options that don't compromise care, have higher risks, or lower efficacy. Might be a little easier not to blame the insurance companies if we weren't reading articles like this from Boston.com:

November 19, 2007

RE "BLUE Cross gave chairman $16.4m in retirement pay: Van Faasen still on salary at insurer" (Business, Nov. 16): At a time when the cost of health insurance and the numbers of uninsured are rising, all sectors of the healthcare community must exercise prudent management of every healthcare dollar. This responsibility cannot be borne solely by the provider sector while the insurance industry passes expenses on to subscribers and employers.

Blue Cross and Blue Shield of Massachusetts voted its CEO a total of $19.4 million in salary and benefits while retaining him as chairman. Because Blue Cross-Blue Shield is a not-for-profit entity, Massachusetts considers it a public charity. As such, the insurer, its board of directors, and the state officials charged with the oversight of public charities should be held accountable by the citizens of the state for better guardianship of the public trust.

Dr. GERALD B. HEALY
Chicago