10 Ways to Mismanage Your Patient's Heallthcare

Below is a satirical and easy to follow recipe to quickly and easily mismanage your patient’s healthcare. By following these steps, you too will be able to conceptualize cases improperly, misdiagnose people, and order improper treatments.



STEP 1: Overbook your patients: Schedule so many patients each day that you cannot possibly spend ample time with them or see them back for timely follow-ups. This step is not essential, but doing so allows the next steps to occur more easily.

STEP 2: Do not take a thorough history: Although a patient’s history usually provides essential clues to properly conceptualize cases, ignoring important aspects of the history such as family medical/psychiatric history, personal psychiatric history, history of substance abuse, and history of trauma helps get the interviews done faster so you can move on to the next patient. These topics are the easiest to discard because they are the most uncomfortable to discuss, despite the potential value they provide in understanding the current patient presentation. Do not obtain the patient’s medical records because this takes too much time as opposed to only relying on self-report.

STEP 3: Do not use any objective criteria for diagnosis: The diagnostic process is much faster and easier when relying purely on clinical intuition as opposed to a combination of intuition with objective diagnostic criteria. Doing so requires no standard and allows you to diagnose all sorts of conditions purely because you say so. This step also allows you to make up your own name for some medical conditions.

STEP 4: Prescribe unproven treatments: With no solid foundation for a proper diagnosis, you are now ready to move on to the step which involves prescribing medications, therapies, and use of various medical devices and techniques that have little to no scientifically validated evidence to support their use. If a proven treatment is available, ignore that and use the unproven one.

STEP 5: Do not coordinate care with other medical providers: If your patient is followed by multiple physicians, make no attempt to account for the patient’s numerous medications and the ways in which taking one can interfere with another or cause various adverse reactions.

STEP 6: Make no attempt to objectively measure treatment progress: Once the treatment is selected, keep it ongoing indefinitely and do not use objective measures it to check if it is successful. Simply rely on patient self-report and maintain the same general treatment approach if symptoms are still endorsed. Having no criteria for discharge is a bonus here.

STEP 7: Never alter case conceptualization: Once an initial diagnosis is settled upon (see step 3) do not alter it even if symptoms are reported indefinitely. Do not try to gather new information to figure out why this is happening but if new information arises, simply ignore it if it does not comport with the original diagnosis. Continue with the prior steps.

STEP 8: Do not refer to specialists: Since you already know the diagnosis and proper treatment, do not send the patient for evaluation by a specialist for a second opinion. This is the worst thing you can do because it may lead to an altered case conceptualization or different treatment approach. This is especially true if the specialist uses objective scientific approaches to patient care. The only exception to this rule is if you know of a specialist(s) who always agrees with you.

STEP 9: Make no attempt to measure symptom validity: Trust all subjective symptoms as accurate and make no attempt to measure (or refer to someone who can measure) symptom under-reporting or over-reporting in cases where the context would indicate it is appropriate to do so. Thus, if a patient has a severe medical problem but denies significant symptoms and wants to be released for certain activities, do this without considering reasons for why this may be the case (e.g., poor insight in a possible dementia case; desire to be normal again). Similarly, if a patient suffered a mild medical problem but reports severe symptoms grossly disproportionate to the event, make no attempt to assess for (or refer to someone who can assess for) why this may be the case (e.g., exaggeration to obtain medication and/or compensation benefits).

STEP 10: Do not keep up with the scientific literature or just ignore it: This step allows you to remain unaware of new scientific developments and maintain one’s accustomed way of doing things. If you become aware of research that suggests you should consider a different diagnostic and treatment approach, ignore it and continue with the old approach.

More Medical School Secrets Revealed

March Madness, Syracuse vs UNC Asheville, & the Science of Referee Bias

Tonight, during March Madness, the main story was about the game between the #1 seed in the East (Syracuse) and the #16 team, UNC Asheville. As a disclaimer, I am a HUGE Syracuse fan (LET’S GO ORANGE). Besides the possibility of the near upset that took place, the biggest aspect of the story was several calls by the referee that went against UNC Asheville that helped Syracuse.


This included a no goal tending call when goal tending seemed to take place, a lane violation call towards the end of the game that actually was correct, and the referees giving the ball back to UNC Asheville after the ball bounced off of Syracuse player, Brandon Triche, followed by a UNC Asheville player hitting into him. There was some question as to whether Triche was fouled before the ball went off of him, causing him to go out of bounds.

Ok, so what does all of this have to do with anything medical you ask? Good question. Nothing. But MedFriendly is a site that not only explores medical topics but psychological topics as well. Part of psychology is the study of bias. Some UNC Asheville fans believe that the officials were biased against them, which is what resulted in the calls above.

So, I tried to see if anyone had explored the notion of officiating bias scientifically in college basketball. I found one study, performed in 2009. The study examined officiating bias (in terms of foul calls) in 365 NCAA basketball games during the 2004-2005 season. Results indicated that officials are more likely to call fouls on the team with the fewest fouls, making it likely that the number of fouls will tend to even out during the game. The greater the difference of fouls between the two teams, the higher the probability that a foul would be called against the team with fewer fouls. The researchers found a significant bias towards officials calling more fouls on the visiting team (probability as high as 70%), and a bias towards foul calls on the team that is leading.

All in all, the evidence indicates that there was not bias against UNC Asheville by the referees because they met all conditions in the study by which one would expect bias to be in their favor as opposed to Syracuse. That is, they were losing at the time, had less fouls (Syracuse was in the bonus), and technically were considered the visiting team on a neutral court due to their lower seed and greater distance from their home geographical location. Ok Syracuse. Now go beat K-State!

American Idol, Coca-Cola, and Obesity

So, I am sitting at home and the popular show American Idol is on. Randy Jackson has a red shirt on, which is color coordinated with a large red Coca-cola cup. J-Lo is sitting by his side, also with a red Coca-Cola cup. Same with Steven Tyler.  When one of the artists takes the stage, there is a large red moving video banner promoting Coca-Cola. It’s called product placement and it has been going on for decades on television and the movies. There is nothing wrong with it of course, but in the case of Coca-Cola, the situation gets a little more interesting because some worry that such advertising may be contributing to the obesity problem in children.

In 2011, researchers from the Rudd Center for Food Policy and Obesity in New Haven, CT, published a study examining the number of food, beverage, and restaurant brand appearances within shows during prime-time programming examined by Nielsen in 2008. Items were analyzed by product category and company as well as exposure to children adolescents, and adults. They found that food, beverage, and restaurant brands appeared 35,000 times prime-time TV programming (60% of which were energy/sports drinks). It was noted that young people were rarely exposed to this type of advertising with on exception…

“Coca-Cola products were seen 198 times by the average child and 269 times by the average adolescent during prime-time shows over the year, accounting for 70% of child exposure and 61% of adolescent exposure to brand appearances. One show, American Idol, accounted for more than 95% of these exposures… Coca-Cola has pledged to refrain from advertising to children, yet the average child views almost four Coke appearances on prime-time TV every week. This analysis reveals a substantial, potential loophole in current food industry self-regulatory pledges to advertise only better-for-you foods to children.”

While this may make it sound like Coca-Cola has violated their pledge, they really have not when you read their pledge carefully. Here is the relevant section:

 “…we are committed not to directly market messages for any of our beverages to children under 12. We have historically not placed – and continue the practice today of not placing – advertising for any of our beverages on any media that is primarily directed to, and has an audience of 50% or more, children under the age of 12.”

First, as you can see, it is not correct to say that Coca-Cola has pledged to not advertise to “children.” Rather they pledged not to directly market their products to children under 12 with a specific audience make-up.  Secondly, I do not see how one can make the argument that a few Coca-Cola cups and a Coca-Cola banner on American Idol would be directly marketing to children. Direct marketing to children would be showing Bert and Ernie chugging down a Coca-Cola after singing the alphabet or Sponge Bob and Patrick singing about how good Coca-Cola tastes when paired with a Krabby Patty.

Third, American Idol, which was singled out in the study, gets about 25 million viewers. Of these, about 2 million are estimated to be in the 2-11 age range. That’s 12.5% in that age range which is far from the 50% number in the Coca-Cola pledge. Lastly, for other prime time TV shows, young children will not make up more than 50% of the demographic group because the shows are on too late at night. This is why children’s programming is predominant in the morning and the day. All in all, it seems to me that Coca-Cola has maintained their pledge and has not exploited any type of loophole.

March Madness Associated Deep Vein Thrombosis

March Madness officially started last night. In fact, as I am typing this I am watching Iona take on BYU (great comeback BYU!). This is a great time of year for any college basketball fan because you have several days in which most of the time is taken up with continuous games. This means lots of opportunity to sit or lay down for prolonged time periods. Remaining immobile for long time periods, however, can cause deep vein thrombosis (DVT), which is clot formation in a deep vein. If this clot dislodges, it can be fatal in about 3% of cases in which the clot came from the lower extremity.

While DVT formation can be caused by any form of prolonged inactivity, one group of clinicians at Walter Reed Army Medical Center reported a case of March Madness associated DVT formation in an 83-year-old man. One of the signs of a DVT is edema (swelling), which was first noticed in this man after a full day of sitting and watching March Madness. He had recurrent prostate cancer which was felt to be contributory to the DVT, but that prolonged sitting from watching March Madness was a significant contributory factor to clot formation. Patients with a hypercoaguable state (blood disorder leading to clot formation) increases the risk further. The authors recommended the following steps to prevent DVT formation: decreased alcohol and caffeine intake, drinking a liberal amount of water and fluids, and standing at regular intervals to stretch and promote circulation.

Reference: South Med J. 2005;98(3):396. March madness-associated deep vein thrombosis. Wilson RL, Ritter JB, Roy MJ

MedFriendly Website Recommendation #1: The Khan Academy

Tonight I stumbled across a very cool non-profit educational website that I wanted to share with you. It’s called The Khan Academy. Although it may sound like a place you send someone to learn karate, it is actually a website filled with thousands of micro lectures via video tutorials. The topics are very broad and include healthcare, medicine, biology, chemistry, and organic chemistry.

Examples of lectures in healthcare and medicine include one on diabetes, normal colon tissue, colon cancer, vitamin C, and drug pricing. There are many other topics covered outside of healthcare as well including math, the humanities (e.g., history, finances), and much more. The site is funded by donations, such as from Google and the Bill and Melinda Gates Foundation. So check out the site and I think you will find it a worthy bookmark.

Daylights Savings Time & Fatal Car Accidents

This weekend was daylights savings time, the one everyone dreads because you lose an hour of sleep. Sometimes, daylights savings time comes as a surprise to people who forgot about it or who did not realize it was coming.

Some people may know it is coming and adjust their clocks appropriately, but still wake up late because their bodies have yet to adjust. One potential risks of sleep disruption from spring daylights savings time is fatal car accidents. In the fall, you gain the much beloved one extra hour of sleep. There is some evidence for increased and decreased numbers of car accidents after fall daylights savings time. Increased car accidents after fall daylights savings time may be due to staying up longer than usual. Decreased car accidents after fall daylights savings time may be due to some people sleeping an extra hour that night.

An interesting study was performed in 2001 to examine the association between daylights savings time and fatal car accidents in more detail. The researchers examined data from 21 years of United States' fatal automobile accidents. The average number of accidents on the days at the time of daylights saving time shifts (Saturday, Sunday and Monday) was compared to the average of accidents on the matching day of the weeks before and after the shift. This was repeated for each daylights saving time shift.

The results of the study showed that there was a significant increase in accidents for the Monday immediately following the spring shift to daylights savings time. There was also a significant increase in number of accidents on the Sunday of the fall shift from daylights savings time. No significant changes were observed for the other days.

The authors concluded that sleep deprivation on the Monday following a shift to spring daylights savings time results in a small increase in fatal accidents. For fall daylights savings time, the authors concluded that the behavioral changes associated with anticipating the longer day on Sunday led to an increased number of accidents. This suggested an increase in late night (early Sunday morning) driving when traffic related fatalities are high possibly related to alcohol consumption and driving while sleepy.

The authors recommended that public health educators should probably consider issuing warnings both about the effects of sleep loss in the spring shift and possible behaviors such as staying out later, particularly when consuming alcohol in the fall shift. The authors concluded that physical and behavioral responses of the body to forced circadian rhythm changes (the body’s biological clock) due to daylights savings changes are important factors for sleep clinicians to be aware of.

Suggested reading: Daylight Savings Time Change May Increase Heart Attack Risk.

Reference: Varughese,J., Allen, R. (2001). Fatal accidents following changes in daylight savings time: the American experience. Sleep Med., 2(1):31-36.

Pink Slime in Your Children's Hamburgers

One of my favorite shows on TV is “Good Eats” with Alton Brown. If you have not seen the show, he focuses a half hour episode on a particular food product and he teaches you how to prepare certain meals from it along with interesting historical and scientific tidbits. Last weekend, I tuned into a show he did on hamburgers. He showed a very easy way to make your own burgers by purchasing fresh cuts of beef and grinding it yourself. If that sounds too time consuming, it isn't because you can easily do it with 10 pulses in the food processor. If you grind the beef yourself, you can feel much more comfortable about what is in your burger as opposed to purchasing the beef in an already ground up form.

The reason the above is important is because I have recently become revolted by the revelation that most ground beef products humans are eating (primarily from fast food restaurants) contain something known as “pink slime.” Pink slime (see above) is a nick name for a filler substance made from previously inedible cuts of beef that are made edible through a spinning separation process that involves treatment with water and ammonia. I used to add ammonia to a mop bucket and hot water when I mopped floors as a kid. It is not something that should ever be added to food. I used to think that I could trust the ingredients label on the package to know what was in my food, but as it turns out when pink slime is used, it is not listed and neither is the ammonia present. This is because the FDA does not view ammonia as an ingredient but part of a “process.” This makes no sense whatsoever because all cooking is a process and if a substance is being added to my food, especially if it is a chemical, I want to know about it. This is why I have dramatically changed my eating habits and that of my children after writing the blog entry called: Does Your Kids Cereal Contain BHT or BHA? – Mine Did.

Fortunately, many fast food chains now say that they are pulling “pink slime” from their food products. Unfortunately, many school cafeterias are still serving it to children and they use it as a filler as opposed to using originally edible meat. The FDA says pink slime is safe, but even if you believe that, why would anyone want to feed this to your children. Don’t get me wrong, enjoy a hamburger, but do it right and make sure the meat is actually real and do it yourself for the best results. The video below is really a must see for those who want to be educated more about this issue.

Why I Don't Go to the Doctor on My Birthday

Today is my birthday and I am NOT going to the doctor. You may be wondering why I am mentioning this, but there are a subset of people who go to the doctor on their birthday, despite the fact that most people try to avoid doing so. This applies not only to regular doctor visits but also to surgeries – most people try to avoid doing this on their birthday. Dr. Stuart Handysides (terrific name by the way) decided to study why some people decide to go to the doctor on their birthday and published his findings last year in the British Journal of General Practice (full reference below). He looked back at his files for 10 years (2001 to 2010) to identify such individuals and tabulate the reasons.

Dr. Handysides identified 30 people who did this, ranging in age from 1-90 (16 males, 14 females), with a modal age of 50 to 59 years. As it turns out, most of the people (10 of the 30) went in for an acute medical problem. As the author points out, if you have an acute medical problem you usually seek help when you need it, regardless of the day. However, such patients often express disappointment that their birthday has been taken up by a medical appointment. That being said, not every person seeks medical care the same day of acute symptom onset so Dr. Handysides speculated that a presentation to a doctor on a birthday signifies a more serious problem. Alternatively, he suggested that it may reflect a desire for reassurance that everything is ok on their special day. Another possibility, however, is that some people don’t care too much about their birthday and may not care about going to the doctor on a birthday.

It is interesting to note that in the study, that birthday consulters visited their general practitioner about 6.5 times a year which is almost double the normal average. Three people died on the year they consulted on their birthday, one of whom was the only patient in the study who consulted on two birthdays. The death rate of the birthday consulters was twice as high as non-birthday consulters. Interesting stuff and it may all be coincidence but I am happy that on my birthday, I am not going to the doctor. Special thanks to Dr. Handysides for sending me a copy of his article.

Reference: Br J Gen Pract. 2011 Sep;61(590):575-6.Characteristics of patients who consult their GP on their birthdays. Handysides S.

Move over Lite Brite...Child Swallows 37 Buckyballs

I remember when I was younger and I accidentally swallowed a Lite Brite peg, which was a small peg-shaped piece made of hard plastic. Fortunately, it was only one and there were no serious problems or complications that resulted. No one really uses Lite Brite anymore unless you have one of these relics in your attic. Instead, kids these days play with virtual Lite Brite, one of the iPad app. None of those kids will swallow any plastic pegs. But instead of Lite Brite pegs, parents now have something new to be careful about --Buckyballs.

If you have not heard of Buckyballs (or Buckeycubes), they are high powered colored magnets (pictured above) that can be connected to make all sorts of artistic designs and objects. Although they are not children’s toys, their color and shape makes them look appealing and fun to play with for children. Children have been known to put these objects in their mouth, perhaps because they look like some types of colored candies. Older children put them in their mouth to simulate a tongue piercing. Overall, 22 children are reported by the Consumer Product Safety Commission to have ingested small magnets.

In Oregon, a 3-year-old girl recently swallowed 37 Buckyballs, which then connected together in the child’s intestines. Because the magnets were so strong, when they connected they tore three holes in her intestines and one in the stomach. This required surgery to remove the Buckyballs and fix the tears. She is fortunately expected to make a full recovery. Signs and symptoms of magnet ingestion includes pain, nausea, vomiting and diarrhea. Of the 22 children who ingested magnets, 11 needed surgery. Don’t let the next one be your child. Keep these small objects away from the little ones if you have them.

My First Book Available for Pre-Order on Amazon.com

I am happy to announce that my first book (Mild Traumatic Brain Injury: Symptom Validity Assessment and Malingering) is now available here for pre-order at Amazon.com and will be released on 7/1/12. The entry lists a brief description of the book, which was co-edited by my colleague, Dr. Shane Bush. Amazon does not yet list the Table of Contents, but a sneak preview is presented below. A final version of the cover should be ready soon, with the picture to the top left showing a prior version.


Preface

1. Introduction: Historical Perspectives on Mild Traumatic Brain Injury, Symptom Validity Assessment, and Malingering

2. The Role of Clinical Judgment in Symptom Validity Assessment

3. Ethical Considerations in Mild Traumatic Brain Injury Cases and Symptom Validity Assessment

4. Differential Diagnosis of Malingering

5. Noncredible Explanations of Noncredible Performance on Symptom Validity Tests

6. Providing Feedback on Symptom Validity, Mental Health, and Treatment in Mild Traumatic Brain Injury

7. Research and Symptom Validity Assessment in Mild Traumatic Brain Injury Cases

8. Free-standing Cognitive Symptom Validity Tests: Use and Selection in Mild Traumatic Brain Injury

9. Use of Embedded Cognitive Symptom Validity Measures in Mild Traumatic Brain Injury Cases

10. Psychological Assessment of Symptom Magnification in Mild Traumatic Brain Injury Cases

11. Strategies for Non-neuropsychology Clinicians to Detect Non-Credible Presentations after Mild Traumatic Brain Injury

12. Assessing Non-credible Attention, Processing Speed, Language and Visuospatial/Perceptual Function in Mild Traumatic Brain Injury Cases

13. Assessing Non-credible Sensory-motor Function, Executive Function, and Test Batteries in Mild Traumatic Brain Injury Cases

14. Functional Neuroanatomical Bases of Deceptive Behavior and Malingering

15. Cognitive Performance Validity Assessment in Mild Traumatic Brain Injury, Physical Pain, and Posttraumatic Stress

16. Symptom Validity Assessment of Mild Traumatic Brain Injury Cases in Disability and Civil Litigation Contexts

17. Symptom Validity Assessment and Sports Concussion

18. Symptom Validity Assessment of Military and Veteran Populations Following Mild Traumatic Brain Injury

19. Symptom Validity Assessment with Special Populations

Walt Disney World and the Obesity Controversy

I have always loved Walt Disney World ever since I was a little kid. I recently went back for a trip with my family. I am not sure if I am just old enough to realize something I missed when I was a kid but as an adult it is easy to see that the Disney Corporation is trying to take on social causes that they believe will appeal to the majority of their customer base, even if the message is contradictory. For example, on a rainy day, my family and I were stuck in Epcot’s The Land exhibit and to pass some time, we watched a movie called Circle of Life: An Environmental Fable -- obviously designed for those who are passionate about the environment. In the film, the cartoon characters lament how terrible mankind is for knocking down trees and entire forests for development, which would include business expansion. At this point, I could not help thinking, “How do you think Walt Disney World was built?!”

More recently, Walt Disney World found themselves under attack from The National Association to Advance Fat Acceptance for allegedly being insensitive in another cartoon by reinforcing stereotypes that obese people eat junk food and watch TV too much television. Regardless of the merits of that argument, I object to Disney’s argument on other grounds. The fact is, people do not become obese from eating junk food or watching too much TV. You can become obese from eating excessive amounts of any type of food, regardless of whether it is junky or not. Also, you can watch all of the TV you want, but watching TV does not cause obesity. If Disney wants to promote any type of message about obesity, it should simply be this: if you take in more calories than you burn, you gain weight. Not too hard to understand. Even Dumbo can understand that. If you want to add something to it, you can say that eating too much, often combined with too much inactivity can cause obesity. People should not feel vilified for eating candy bars, drinking soda, or being a coach potato once in awhile. It’s all a matter of balance and doing things in moderation.

My Medical Remake of Dr. Seuss's ABC Book

Theodor Seuss Geisel (affectionately known as Dr. Seuss) was born today in 1904. His books have delighted children and parents for generations, include my own. Thus, I pay tribute to Dr. Seuss with a medical version of his famous ABC book. I hope you enjoy it. If so, please share with others.


Big A
little a
What begins with A?
Aunt Aunnie’s angiography.
A..a..A

Big B
little b
What begins with b?
Basophil
baby
bone scan
and a
biopsy.

Big C
little c
What begins with C?
Cancer on the colon
C..c..C

Big D
little d
Dr. Dominic Doo
dreamed
a dozen discharges
and
a dentist too.

ABCDE..e..e
e. coli
edema
eosinophil
e
e
E

Big F
little f
F..f..F
Four fetid feces
on a
Fiber-feffer-feff

ABCD
EFG
Gram
Girl
Gynecologist
G…g…G

Big H
little h
Headache head
HEY!
Halloween is here
Hooray! Hooray!

Big I
little i
i..i..i
Intestines
are
irritable.
So am I.

Big J
littlej
What begins with j?
Jimmy Jolly’s
jaundice
and janiceps
begin that way

Big K
little k
kilogram-aroo
Kick a Kaposi's
sarcoma
and
Korsakoff’s too.

Big L
little l
Little Liter Lopp
Left loin.
Lower neuron
lacrimal drops.

Big M
little m
Many MRIs
are making
multiple sclerosis
and the myelin
mighty bright

Big N
little n
What begins with those?
nine neuropsychologists
and a neutrophil
and a nose.

O is very useful
You use it when you say
“Ophelia’s ophthalmologist
owns
an orange optometer today.”

ABCDEFGHIJKLMNO…P

Pregnant Preeclampsia
Plasma in a pail
Peter’s poisoned poulty
And now
Protein’s in the pail.

Big Q
Little q
What begins with Q?
The quad
Queen of Quadriceps
and her
quadriplegia too.

Big R
Little r
Rosy Rehab Ridth
Rosy’s going running
With a low red cell distribution width.

Big S
Little s
Silly Shelley Smith
Saw a squamous lesion
And got
sick sick sick.

T…..T
t…..t
What begins with T?
Ten tired tapeworms
On the trunk of a tree.

Big U
little u
What begins with u?
Unmyelinated axons
and an
ultrasound too.

Big V
little v
Vera Vermis Vinn
is
very
very
very awful
taking vitamins.

W..w..W
wrinkle Wally Woo
washes Wendell Wiggins
who’s on the
Wall of Fame too.

The X chromosome is useful
if you want
to be a girl
X-rays comes in handy
All throughout the world.

Big Y
little y
Young yellow skin.
Yvonne did yoga
With the yang
But not the yin.

ABCDEFGHIJKLMNOPQRSTUVWXY..and…
Z
Big Z
little z
What begins with Z?
I do.
I'm a
Zinc Zafirlukast
as you can
plainly see.

A Follow-Up to The Psychological Profile of TJ Lane

Yesterday, I posted a psychological profile of Chardon school shooter, T.J. Lane (pictured to the left). As always happens, the day after such incidents, more detailed information emerges about the shooter. So far, everything I have read confirms the information I posted yesterday. Lane has already confessed to prosecutors that he shot his victims at random and did not know them (although he apparently knew one in middle school). 

This is consistent with the pattern of many school shooters, and the theory that he was lashing out against a “system,” be it society, government, the educational system, or all three. This type of behavior actually transcends school shooters and fits into a broader category of mass murderers who commit terrorist acts. For example, I remember walking through the Oklahoma City Memorial and seeing the tiny shoes of the babies who lost their lives after Timothy McVeigh bombed the federal building. McVeigh did not view the babies as innocent individuals who he had a personal problem with but saw them as necessary casualties of war in his fight against the government. In this sense, the victims are actually symbolic representations of a much larger system that the aggressor is upset about.

Although violence prediction is difficult, for Lane’s lawyer to say that this could never have been predicted is simply not true. Lane clearly was in a high risk category for this type of behavior based on what was noted yesterday. Part of this high risk comes from a troubled family life. More specifics regarding this have emerged that fits yesterday’s profile. Specifically, Lane's father has been arrested several times for violent crimes against female acquaintances, including his mother. For the first two years of Lane's life, his parents (who divorced in 2002) were both arrested for domestic violence against each other. His father also served prison time for assaulting a police officer and was charged with holding another woman under running water and bashing her head into a wall. He has been charged with kidnapping, felonious assault, attempted murder (eventually dropped), and disrupting public service. His father had been warned by law enforcement officials to stay away from him on multiple occasions. Thus, Lane clearly had a role model in life for violent behavior as a means to solve problems and lacked proper parental role models.  

It was noted yesterday that Lane attended an alternative H.S. and that this made it likely that he had academic and behavioral problems. Information disclosed today revealed that his alternative H.S. was a place for "at risk" students who are "reluctant learners" with problems such as "substance abuse /chemical dependency, anger issues, mental health issues, truancy, delinquency, difficulties with attention/organization, and academic deficiencies." Thus, there clearly were concerns that people had about him but it is unclear yet if any mental health professionals evaluated him and if anyone made any connections between his family background, belief systems, and tendencies for aggressive behavior.

On the 911 tape, Lane was described as a quiet kid who did not really talk to anyone, which, according to one friend, was associated with a Goth phase he became involved in as a freshman. Neighbors described him as very sullen, rarely showing his face and always wearing a hoodie, the latter being yet another symbol of alienation from society (when interpreted in the context of everything else that is known about him) as the hood can serve as a shell for him to hide in. It is noted that he wore a gray hoodie (again note the absence of bright colors) on the day of the school shooting based on 911 witness accounts. Another student noted that he would sit in the lunch room and no one knew he was there. That is interesting considering that the shooting occurred in the lunchroom. The school lunchroom is one of the most stigmatizing locations in school because this is where the student body becomes segregated into cliques. Students sitting by themselves in the lunch room (either by choice or through not being accepted) can be another sign of social alienation. Thus, he may have chosen an area that symbolized his social alienation as an area for the school shooting. The large availability of students to chose from in the lunchroom setting may have also played a roll.

Suggested Reading: Without Conscience: The Disturbing World of the Psychopaths Among Us

A Psychological Profile of Chardon School Shooter, TJ Lane

Nowadays, it seems like a school year does not pass by without a school shooting and the death of innocent children. When I was younger, the most other kids had to worry about was the school bully or maybe a gang, but no one ever feared that they could get killed in their classroom. It is difficult to say why school shootings have become so common these days.

It is likely some combination of increased access to firearms, worsening forms of bullying (such as cyberbullying), the influence of violent revenge themes in the media and entertainment venues (e.g, music, movies, video games), the breakdown of the family structure, and the increased availability of subculture movements such as Gothic and Emo that foster a sense of alienation from mainstream society. None of these factors by themselves is likely to trigger a school shooting. For example, there are many Gothic children and people who play violent video games who do not commit school shootings but the more of these variables are present, I believe that the likelihood of a school shooting increases.

Like many people, I am always interested in learning more about the shooter and the specific motive(s) behind the attacks. Before I know anything about the individual, however, there are a few things that I can usually make some safe assumptions about: 1) The person feels angry with and alienated from his peers and society (especially when the shooters attack people at random), 2) There were traumatic events (e.g., bullying, abuse, significant family dysfunction) in the person’s past that led to these feelings (which is not to excuse the shootings of course), 3) There is usually something in the person’s appearance (e.g, style of dress, physical characteristics) that shows that they are different in some way from their peers, 4) The person usually sends some signal ahead of time that the shooting was to occur. As it turns out, it seems that all of these criteria appear to have been met in this case. The reader should know that I have never met T.J. Lane and that I am not a professional criminal profiler. The profile of Lane that I put together is based on what I could gather from his Facebook page, early media reports (some of which may later be modified), knowledge of clinical psychology, and common sense.

When I first saw the picture above of the shooter, TJ Lane, my first reaction was that it fit the psychological profile I have of these shooters. The picture comes from his Facebook profile. Of all the pictures, he could choose, he picked one that was black and white, thus devoid of color. Color symbolizes positive emotions whereas black and white symbolizes the absence of such emotions and conveys a sense of despair and alienation, especially when other themes associated with this are present. This dark theme goes along with his black jacket, which may be related to the Gothic culture he became involved in. Note how he is looking to the side and not to his audience (Facebook friends). In this picture, he is showing that he does not want to look at you or have to look at you because he does not feel connected with you. The side profile picture also bears resemblances to side profile mug shots. You will notice that he is not smiling but instead looks disninterested, annoyed, and possibly angry. Self-esteem is likely low, which accompanies feelings of insecurity. His hands are in his pockets. Hands and fingers symbolize a sense of control (since we mostly control our environment with our hands and fingers) and thus hands in the pockets may indicate that he feels a loss of control in his life. Taking a gun and shooting people is a maladapative way to re-exert control and gain attention, which can improve his own feeling of self-importance. He is thin and one is left to wonder if he was picked on for his appearance, which was later confirmed via media reports. Other pictures on his Facebook page showed him shirtless with his arms folded and a defiant look on his face and he is never smiling. Thus, the only times where he does look at his audience, he is conveying a sense of anger. The profile picture was updated last, however, indicating a growing sense of alienation from others.

Initial media reports stated that Lane had family problems, was being constantly teased by many of the kids in school (e.g., about his hair, clothes, quiet demeanor), often had a sad look in his eyes, was upset about a girl in school, was quiet, very guarded, and a loner who did not belong to any particular group.  Some students assumed he was normal but admitted they did not know much about him. One student stated he got into the Goth phase in the 8^th grade. He lived with his grandparents, his older brother was in prison, and he attended an alternative school, which indicates he had a history of academic and/or social emotional difficulties requiring alternative school placement. He may have had a split with a girlfriend on Valentine’s Day and may have been upset that she was dating a former friend. In fact, on 2/17/12, he posted a song on his Facebook page entitled “Blood on the Dancefloor” that centered around an angry male figure with a demonic Gothic appearance trying to break the spell of a female lover. This included lyrics such as “Now is the time, now is the hour. To take back my heart, to take back my power. This is the moment to break your spell. I see right through you... Burn in hell witch.”

Review of Lane’s Facebook page showed that he claimed to work for a non-profit organization called “Free the Slaves,” which claims to liberate slaves around the world and attack the systems that allow slavery to exist. Note the phrase “attack the systems” which generally refers to governmental systems (which includes school). He could have taken this phrase literally in carrying out an attack against “the system.” This may sound like wild speculation, but consider the following. He clearly seems to have felt alienated from the educational system as indicated by the fact that under “College” he listed “We don’t need no education.”  Even more troubling was that under High School, he wrote “We don’t need no thought control.” Thus, he seems to have believed that his school was controlling his thoughts, all of which sounds eerily similar to the video of Jared Loughner walking through Pima County College, ranting about mind control, loss of freedom of speech, the school’s control of the grammar, and his “genocide school” before he shot, injured, and killed several people at a governmental event.

The phrases “We don’t need no education” and “We don’t need no thought control” come from the famous Pink Floyd Song, “Another Brick in the Wall” which partly has to do with a protest against rigid schooling. Incidentally, Pink Floyd is listed as one of his favorite music groups. The music video for the song portrays a teacher reprimanding a young student (who bears some resemblance to Lane) for writing poems in class, which Lane liked to do (see end of this blog entry). The child then engages in fantasies of destroying the school and killing his teacher.

This begins to suggest the possibility of a psychotic disorder in which one is detached from reality. This is again speculation, but further suggestive of this was that he listed one of his favorite philosophers as David Icke, who has described himself as being the most controversial speaker in the world based on his belief that a secret group of reptilian humanoids called the Babylonian Brotherhood is controlling the world. Icke’s worldview is replete with conspiracy theories, which is common among people with paranoid belief systems.

Lane also listed Credo Mutwa as a favorite philopher. Credo Mutwa is a Zulu sangoma (spiritual healer) who is know for his writings against the African government in his pursuit to see the “truth.” In Mutwa’s own words, “I am one of the scums of this earth, a creature dejected and ridiculed by university professors” and “I have been scorned; demonise lied about by conspirators…” This is another reference to alienation and anger towards educational systems. Interestingly, Credo Mutwa writes about listening to David Icke. One of Lane’s favorite books listed was David Icke’s “Guide to the Global Conspiracy and How to End It.”

Another book Lane listed as a favorite was “Alice in the Country of Hearts.” The book centers on an insecure main character (who Lane likely identified with) in a strange world named Wonderland and is forced to interact with the inhabitants. Everyone in Wonderland is reckless as to who lives or dies, everyone distrusts each other, and has an instinct to kill. Sound familiar? Continuing with Lane’s seeming immersion into a bizarre fantasy life was that another favorite book listed was the “Death Note” series, which centers around a high school student who finds a book called the Death Note that allows the reader the ability to kill anyone whose name and face they know by writing the name in the book and picturing their face. To date, several students across the country have been caught and disciplined for possessing Death Note books containing the names of other students. I will not be surprised at all if Lane had one as well.

In terms of movies, Lane listed the movie “Let Me In,” which tells the story of an adolescent boy who is continuously harassed by bullies, neglected by his parents, and develops a relationship with a vampire child (re: Gothic association).  He also liked “Fight Club,” which is a violent movie that was designed to serve as metaphor for the conflict between the younger generation and the traditional values of society. Lane’s sense of disconnection from society is emphasized by him writing that one of his interests and activities is “wandering aimlessly.”

Lane’s Facebook page also contained dark poetry that he wrote in class and posted on 12/30/11: "In a quaint lonely town, sits a man with a frown. No job. No family. No crown. His luck had run out. Lost and alone. His thoughts would solely consist of “why do we exist?” His only company to confide in was the vermin in the street. He longed for only one thing, the world to bow at his feet. They too should feel his secret fear. The dismal drear. His pain had made him sincere. He was better than the rest, all those ones he detests, within their castles, so vain. Selfish and conceited.” He goes to discuss how the castle kept the peasants at bay and did not keep the enemies away and how he castle’s every story “was just another chamber in Lucifer’s laboratory.” The story continued to attack society and desires for the castle to fall. He wrote about going through the castle, past guards, and making others beg for mercy and ending with "Feel death, not just mocking you. Not just stalking you but inside of you. Wriggle and writhe. Feel smaller beneath my might. Seizure in the Pestilence that is my scythe. Die, all of you."

This story is clearly the writings of an angry and insecure individual who has strong revenge fantasies. The castle was likely a metaphor for his school and he was foreshadowing events to come. Unfortunately, as in many similar cases, no one put the pieces together before hand. In fact, four of his Facebook friends liked the story and 49 shared it with other friends. No one wrote a public comment of concern or disapproval. For a follow-up to this blog entry on TJ Lane, click here.

Suggested Reading: Without Conscience: The Disturbing World of the Psychopaths Among Us
 
Related blog entries:
A Psychological Profile of Wade Michael Page: The Sikh Shooter
A Psychological Profile of James Holmes: The Joker Killer
Cannibal Icepick Killer Luka Magnotta was Not Born Evil.

Restaurant Impossible Shines Light on the Need for Health Department Reform

A TV show I enjoy tuning into is Restaurant Impossible. To those who may be unfamiliar with it, the show revolves around all-star chef, Robert Irvine (pictured to the left), who goes to failing restaurants and tries to save them in two days with a $10,000 budget. This often involves improving customer service, redesigning menus, improving kitchen cleanliness, improving marketing, and/or redesigning restaurant.

One of the patterns I have noticed on the show is that many of these failing restaurants have filthy kitchens. But last week, I saw the most extreme and appalling version of filth when I watched the episode called “Anna Maria’s” in which Chef Irvine tried to fix a restaurant that bears this name in Dumore, Pennsylvania. Among the problems noted during the show were a) layers and layers of food and grease covering stove tops, pots, overhead vents, and kitchen appliances (which included a pot on the stove that was caked in so much black grime it looked like something you would find in a dungeon); b) bacteria, slime, and old food on the floors, and behind/under/on restaurant equipment, c) filthy refrigerators with open containers of food, and c) a basement with food (e.g., flour) stored next to chemicals. Of all the shows, I never saw Chef Irvine so upset. He nearly vomited in the kitchen on screen and suggested that he actually did vomit later in the show. I could go on describing the horrors of this kitchen but you really have to see the show to believe it.

The advertisement for the show on my DVR said that the kitchen had not been cleaned in about 25 years. I am not sure if that was hyperbole, but regardless, the kitchen clearly had not been cleaned in a long time. When I heard this and saw the state of the kitchen, I was shocked and upset that the government could allow a restaurant to continue to serve food to the public like this and put them at risk of food poisoning (e. coli). But I was even more shocked when I read an article stating that the restaurant actually passed a health inspection nine months prior. The restaurant owner’s son claims that the Food Network exaggerated the state of the restaurant for the purposed of TV.

While I am fully aware the not everything on TV is how it seems, it simply stretches all credulity for me to believe that the Food Network planted the dirty pots, coated the kitchen equipment with bacteria-laden slime, made the refrigerators filthy, planted old food behind equipment, and brought food in the basement to put it next to chemicals. There is too much evidence the other way, such as that a) the chef (Rudy) said on camera that the kitchen had been in that condition for four years, b) the owner and her son allowed Irvine to send customers home after he tossed out a filthy stove vent for them to see, c) the owner and son admitted that the kitchen had fallen into an embarrassing state, d) the show normally does not spend this much time focused on kitchen clean-up needs, e) no one has sued the Food Network over false presentation, f) Chef Irvine genuinely appears to want to help people, and g) the visual evidence of the state of kitchen clearly indicates this was a process that took a very long time to create.

It is all too easy to blame the Food Network for exaggerating the state of restaurant as part of some type of conspiracy theory. How about two alternative and more parsimonious explanations: 1) The restaurant owners are embarrassed and understandably concerned that no one is going to come to their new restaurant after seeing an expose of it on television (which is a public relations disaster) and so they blame the Food Network for exaggerating it as a form of damage control; 2) The Health Department is not doing their job.

Explanation number one does not need a further explanation, but consider number two a bit further. Not only did this restaurant pass health explanation nine months prior, but not a single violation or risk factor was found. How can that possibly be true? It is possible that the inspection was either never done but signed off on or that an inspector signed off on the report knowing there was a deficiency. Why would that be? Sometimes, restaurant owners have political connections with health inspectors that allows the process to be circumvented. This is more likely to be the case in small cities such as the one this show was filmed in.

All in all, I now have no confidence that health inspections mean anything and have become increasingly careful about the types of restaurants I frequent, preferring to go to ones with an open kitchen that I can see for myself or ones where I can peak into the kitchen. If I cannot see the kitchen, then I use proxy indicators such as how clean the bathrooms are, floors, tables, walls, ceilings, the dining ware, the staff, and the food as an indicator of the state of the kitchen. State, county, and city governments need to revisit the health inspection process to make reforms so that the process works as intended and the public can once again have confidence in how the system works. I also believe there should be a law that allows customers to view the kitchen of restaurants before placing an order.

Cookie Monster Is Not Autistic

In 1984, an article was written in the publication, Children Today, in which Cookie Monster was labelled by children with disabilities as autistic because he ate messy and only said "Cookie." Scientific understanding of this condition has greatly improved since then and at this point, I do not believe Cookie Monster would meet diagnostic criteria for autistic disorder (also known as autism).

RECOMMENDED BOOK: Autism: A Practical Guide for Parents

One of the essential criteria for autistic disorder is that the affected individual has a qualitative impairment in social interaction. This can be manifested by at least two of the following: a) marked impairment in nonverbal behaviors to regulate social interaction, b) failure to develop peer relationships appropriate to developmental level, c) lack of spontaneous seeking to share enjoyment, interests, or achievements with people (e.g., by pointing out objects of interest), or d) lack of social or emotional reciprocity.

Cookie Monster clearly demonstrates adequate social interaction. For example, in the interaction below with Kermit The Frog, he uses very good eye contact and hand gestures to facilitate communication. He clearly demonstrates social reciprocity in playing the guessing game with Kermit and it is clearly established in Sesame Street that he has developed good relationships with other Muppets such as Kermit, The Count, and Prairie Dawn.



The next criteria that would need to be met is a qualitative impairment in communication. This would be evidenced by at least two of the following: a) delay or total lack of the development of spoken language, b) marked impairment in the ability to initiate or sustain a conversation with others, c) stereotyped and repetitive use of language or idiosyncratic language, or d) lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level.

While Cookie Monster does have some problems speaking with proper grammar (e.g., “Me Want Cookie!”) he does not truly meet any of the criteria mentioned above. Someone may want to make an argument that his language is idiosyncratic and that he can sometimes be repetitive (e.g., “Om, om, om, om, om”) when he eats a cookie, but I just chalk that up to him being extremely happy that he is eating cookies. Clearly, Cookie Monster is very capable of carrying on lengthy conversations, initiating them (as he does in the video clip with Kermit), and sustaining them.

Lastly, to meet criteria for autistic disorder, Cookie Monster would need to have a repetitive or stereotypes pattern of behavior, interests, and activities, as manifested by at least one of the following: a) an encompassing preoccupation with one of more stereotypes and restricted pattern of interest that is abnormal in intensity and focus, b) an apparently inflexible adherence to specific, nonfunctional routines or rituals, c) stereotyped and repetitive motor mannerisms, and d) persistent preoccupation with parts of objects.

Cookie Monster can be said to meet some of the latter criteria (a and b) because he is clearly pre-occupied with cookies to an abnormal degree and it seems that he has to eat his cookies each day and is not too flexible on the matter. However, anyone can meet one or two criteria of various mental health disorders without having the condition of interest due to not meeting full diagnostic criteria. That is the case with Cookie Monster. I have not seen any convincing evidence that he meets criteria c or d.

So what does our furry little blue friend have wrong with him? Obsessive compulsive disorder (OCD) is technically possible in which his compulsive cookie eating may be a way to relieve anxiety caused by recurrent and persistent thoughts to devour cookies. However, to answer this would really require a good clinical interview with him to see if he meets all the criteria of true obsessions and compulsions. Furthermore, he would need to engage in compulsive cookie eating for more than an hour a day and we do not know if he does that. Another possibility is bulimia nervosa, in which someone binge eats a large amount of food and then uses inappropriate mechanisms to prevent weight gain, such as vomiting or laxative use. We have no idea if Cookie Monster is running to the bathroom afterwards but if he is trying to prevent weight gain, it does not seem that it is working as he does seem overweight.

My impression is that Cookie Monster has impulse control disorder not otherwise specified.  This is a failure to resist an impulse, drive, or temptation to perform an act that is harmful (e.g., causing obesity, diabetes mellitus) to the individual or others. Most people with this condition feel an increasing sense of tension or arousal before committing the act and then experience pleasure, gratification, or relief at the time of committing the act.

Related Blog Entry: Why Kermit the Frog Rules.

Whitney Houston Death Photo Is No Surprise

A major controversy has erupted over the National Enquirer publishing a supposed death photo of Whitney Houston on the cover. Some people are upset because they believe that it is disrespectful to the dead to publicize such photos. However, so many people have a fascination with death and morbidity that even though they may agree that there is something wrong with publicizing the photo, they will look anyway.

RECOMMENDED BOOK: Remembering Whitney

This is why people rubberneck at car accidents. They don’t really want to see an injury or death, but they look anyway. This public fascination with death is why we Michael Jackson’s death photos can be found on the internet, why there was a public broadcasting of the dead bodies of Saddam Hussein’s adult children, why the documentaries The Faces of Death were so popular, why horror movies are popular, and why there was a clamoring for the release of Osama bin Laden’s death photos, the latter of which the U.S. government did not release.

But back to Whitney Houston and the National Enquirer. This was all so predictable. It is well known in psychology that past behavior is a great predictor of future behavior. In 1977, the National Enquirer posted a death photo of another famous singer, Elvis Presley. As you can see from the photo below, even the same exact catch phrase (“The Last Photo”) was used on the cover:

A Doctor's Touching Experience on Ash Wednesday

Today is Ash Wednesday. Whether you are religious or not, below is a touching story of one medical doctor’s (Dr. Richard Pesce’s) experience on Ash Wednesday with a patient named Drew.

Entering the intensive care unit (ICU) to begin rounds after a weekend off call, I found a patient of mine had been admitted in respiratory distress. We had known each other since his coronary bypass surgery several months earlier. This surgery had been followed by multiple complications, including sternal breakdown due to staphylococcal infection. This was followed by four sternal repair attempts and finally omental flap closure before Drew could be weaned from the ventilator. The repairs were more difficult than usual because he had received radiation therapy to his mediastinal area for Hodgkin's disease many years before. This left him with a compromised blood supply to the sternum and a restrictive cardiomyopathy. After 2 months and many hours of worry on both sides, he could finally be discharged to home. He had been at the office a half dozen times since to control his pleural effusions by thoracentesis. The effusions finally began responding to combination diuretic therapy. The last time I saw him prior to admission he had improved and, although still weak, he was beginning to enjoy life and being with his family.

As I entered his ICU room I saw that things had quickly deteriorated. Staphylococcal endocarditis, acute and bacteremic, had taken hold. Drew looked gray, he was barely able to whisper, and his breath sounds were hardly audible.

"Drew, I have to help you breathe!"-he nodded in response. As we laid his head down for intubation he calmly submitted. I could not use any sedatives because of his hemodynamic instability. I needed to place an endotracheal tube and obtain venous access, but sternal surgery had caused contraction of his neck muscles, so no usual access was available. I continued, however, through radiation-toughened skin, and with care because his clavicles were out of alignment. I was able to obtain a femoral artery blood gas and place a femoral intravenous line. But I saw that this had caused him discomfort despite local anesthetic.

"My God," I thought. "I am taking part in a crucifixion." This man lay in front of me awake and suffering. I was unable to relieve his pain just then and had to continue to do procedures to stabilize him.

Drew's family had arrived, and quick exchanges took place. We had met many times before and had discussions regarding the "what ifs" of his condition. His family was wonderful and supportive. There was not anything they would not try to accomplish for their father and husband. His daughter asked if anything else could be done, knowing what the answer would be. (Even during his first surgery his aorta could not be cross-clamped because it was so friable. To attempt valve replacement was not possible.) As the patient's pressure continued to fall, episodes of bradycardia began. He would respond to boluses of epinephrine and then fade again. His wife asked that their priest be called to administer the Sacrament of the Sick and that comfort measures be taken.

They were. Father Mike arrived quickly. He had known this family for many years and had been in school with some of the children. As he began the service, Drew's family gathered at his bedside and prayed out loud the Lord's Prayer. Each person told Drew that he should feel free to go to his reward, thanking him for having loved and cared for them so well. As the priest continued the annointment, I could see the heart monitor record slower and slower beats. They all then kissed him goodbye. At the end of the last word of the last prayer the monitor became flatline. At 9:20 AM, it was over.

As the family said their last goodbye, each one thanked me for trying to help Drew. I was speechless. Seldom had I witnessed such closeness in a family, and seldom had I felt so powerless to do anything that may have been of benefit. Yet to have these people thank me was more than I could bear.

Later that morning, I attended the Ash Wednesday service at the hospital's chapel. Drew's family was there and Father Mike was saying the Mass. Ash Wednesday is the day most Christians begin to spiritually prepare themselves for the celebration of the death and resurrection of Christ on Easter Sunday. It culminates in the placement of ashes on the forehead to remind us that we are from the earth and shall return to it when we die. It is a time of sacrifice and reflection. I was the last person to receive the ashes. Father Mike looked at me and said, "From dust thou art and to dust thou shall return, Doctor."

As I acknowledged him, I thought, "Yes, I will accomplish this. But have I accomplished my mission 'To cure sometimes, alleviate suffering often, and comfort always'?" At that moment, Drew's wife approached me: "Thank you for always being there for us, you will always be in our prayers." At that moment my question was answered and doubt resolved.

On this Ash Wednesday, I felt the uplifting spirit of a family's love for their father and husband and the hope for a better life. I have been privileged. Thank you, Drew.

The above article is publicly available here.

Did Abraham Lincoln Have a Genetic Disorder?

February is a month where we not only celebrate the birth of George Washington, but also Abraham Lincoln. In a recent blog entry, I discussed some fascinating aspects surrounding Washington’s death. Today, attention turns to Abraham Lincoln. Unlike Washington’s death, many people are aware of Lincoln’s untimely demise via assassination.

FEATURED BOOK: Abraham Lincoln: Vampire Hunter

Many people are also aware that Lincoln had a distinguished yet unusual look about him. As you can see from the picture above, Lincoln’s distinguished look consisted of hollow eye sockets, long thin lips (with an m-shaped curve on the upper lip and a blubbery lower lip), and a long drawn out face. He was also tall (6’4), thin, and had large feet.

It has long been suggested that Lincoln had Marfan syndrome. Marfan syndrome is a genetic disorder of connective tissue which causes unusual tallness, long limbs, and long thin fingers and toes. Cardiac problems are common, with shortness of breath during exertion. While Lincoln was tall, he was not abnormally tall.  His fingers seemed proportional to his body (as is seen in the picture to his left) but did not look as long as what fingers typically look like in Marfan syndrome (see picture to the right). He was known as an excellent axeman, rail fence builder, and wrestler, which would have required good cardiac functioning. Geneticists now think it is unlikely that Lincoln actually suffered from Marfan syndrome.


More recently, a new theory emerged from Dr. John Sotos in a book known as The Physical Lincoln. The theory is that Lincoln actually suffered from a different genetic disorder that has skeletal features almost identical to Marfan syndrome, known as multiple endocrine neoplasia type 2B (MEN2B). Individuals with this condition tend to be tall, thin, with a long face, and protruding blubbery lips. All patients develop benign tumors of the mouth, eyes, and connective tissue that supports mucous membranes throughout the body. Cancer of the thyroid almost always occurs and cancer of the adrenal grand occurs in about half of the cases. Chronic constipation is a common symptom.

Lincoln clearly was tall and thin, had a long face, and protruding lips. Other characteristics Lincoln was known to have that occur in MEN2B include constipation, low muscle tone, lumpy lips, and possible cancer. The right cheek mole, facial asymmetry, droopy-eyelids, and depressive-like symptoms were also considered to be consistent with the diagnosis. Lincoln may have also grown a long beard later in life to cover up benign facial tumors. People with the condition usually die young, which is the main challenge to this theory. However, Dr. Sotos believes that Lincoln would have died within a year from cancer if he was not assassinated at age 56.

Genetic testing can confirm a diagnosis of MEN2B. The “problem” is that no one is going to allow for a U.S. President’s body to be exhumed (especially not someone as iconic as Lincoln) to test such a hypothesis. In addition, Lincoln’s coffin was encased in steel and concrete after a theft attempt and the last wishes of his family was for Lincoln’s body to be left alone. However, there is one other possibility where a DNA sample can be taken from: a blood stained Lincoln relic. One option was the bloodstained pillow (pictured below) that Lincoln laid on after being assassinated, which is stored in a Philadelphia museum. The museum eventually denied a request to test it.

Dr. Sotos eventually joined forces with a geneticist at the Cleveland Clinic (Dr. Charis Eng) and they were able to secure a sample of a dress worn by Laura Keen. Keen was an actress who rushed to Lincoln’s side after he was shot, causing blood stains to transfer to her dress. After months of work the testing was only able to find some genetic mutations that could be minor contributors to MEN2B but no conclusive evidence that he had the disease. Only by obtaining further samples from other sources will it be possible to come to a definitive answer.

Did Physicians Kill George Washington?

President’s Day, also known as Washington’s birthday, is a celebration of the life of George Washington. While it is well known that he was the first U.S. President, crossed the Delaware River, and helped defeat the British, many people do not know about the noble and fascinating medical aspects surrounding his death (see comparison story on Abraham Lincoln).

On December 12, 1799, Washington had been riding his horse at Mt. Vernon for a prolonged period of time (10:00 am to 3:00 pm) in cold weather and precipitation. He came in and ate dinner without changing his clothes. Washington denied that his clothes were wet but his secretary, Tobias Lear, stated his neck seemed wet and that there was snow in his hair. At night, he reportedly appeared well.

The next day, it snowed heavily. Despite developing a cold and sore throat, Washington still went outside to do some yard work. According to George Washington Custis (a relative), Washington came inside, developed chills and nausea in the afternoon, changed his wet clothes, and continued to work. At night, he did not feel well and drank a cup of tea to soothe his hoarse throat, which had worsened. Lear told him to take something for his cold at night, but Washington declined. He tried to rest at night, but he tossed and turned with fever and pain. He awoke his wife between 2 to 3 am to say he was sick. He could barely speak and had labored breathing. Despite his discomfort, he did not want outside help to be called because he did not want to disturb anyone else’s rest.

On 12/14/79, Washington allowed for help to be sought at dawn. Lear came to the scene and stated he could hardly utter an intelligible word. He requested that an employee be called to help him by bloodletting. Bloodletting was a common medical practice for over 2,000 years and involved drawing blood out of the patient’s body (usually through a vein in the arm or neck) with the hopes that it would cure or prevent disease by removing the offending agent. This ancient medical practice was based on the belief that a woman’s menstruation purged the body of bad substances. Despite the good intentions of bloodletting, it was usually harmful to patients. As such, it was not helpful to Washington and his conditions worsened.

A molasses-butter-vinegar mixture was prepared for his sore throat, but he could not swallow it. Any attempt to do so caused distress, convulsions, and near-suffocation. He was bled again. His wife tried to intervene, questioning whether this was appropriate treatment, but Washington insisted more blood be let out. After half of a pint of blood was removed, the blood letting was stopped as it provided no relief and his wife remained uneasy.

Since oral intake was impossible and the standard treatment of the day (bloodletting) was not working, his throat was gently bathed with a salve. His feet were bathed in warm water. neither treatment helped. Another doctor tried to treat his throat with a blister of Cantharides, more blood letting, and inhaling steam from water and vinegar. He almost suffocated when trying to gargle. As the day progressed, Washington did not speak much but stated he was very ill. He was bled two more times. The blood came out slow and thick at this point, but he did not faint. His multiple doctors then treated him with calomel and tartar emetic.

A book in 2002 entitled Doctors Killed George Washington alleged that doctors took a “mild” complaint and bled Washington to death. It has been suggested that the focus of bloodletting may have killed Washington by preventing a search for other remedies. However, Washington did not have a mild complaint, but had clearly been severely ill before the bloodletting. He likely became ill in the first place by making his body more vulnerable to illness after prolonged exposure to the winter elements. Third, other remedies were indeed tried as noted above and by Custis:

“The medical gentlemen spared not their skill, and all the resources of their art were exhausted in unwearied endeavors to preserve this noblest work of nature.”

While the bloodletting was clearly excessive and would not be done today, doctors were treating Washington with the limited medical techniques of colonial times and should not be accused of killing him anymore than doctors of today should be accused of killing patients who have incurable diseases with current technology yet attempt to treat it with methods that will be considered outdated hundreds of years from now.

At 4:00 pm, Washington provided instructions for his will and wake. He was in great pain and distress in the afternoon, had difficulty breathing, and was restless. When his secretary tried to reposition him for comfort, he was concerned about causing his secretary fatigue. He thanked his doctors and others for help but asked that they let him die in peace. Regardless, at 8:00 pm, the doctors tried to treat him with a hot medicated cloth and applied wheat brain to his legs and feet.

Custis describes Washington’s very last moments in such an elegant way that it would be a disservice to paraphrase it. As you will read, the founding father left the world between 10 and 11pm that evening in the noble way that he lived it,

“The patient bore his acute sufferings with fortitude and perfect resignation to the Divine will, while as the night advanced it became evident that he was sinking, and he seemed fully aware that 'his hour was nigh.' He inquired the time, and was answered a few minutes to ten. He spoke no more - the hand of death was upon him, and he was conscious that 'his hour was come.' With surprising self-possession he prepared to die. Composing his form at length, and folding his arms on his bosom, without a sigh, without a groan, the Father of his Country died. No pang or struggle told when the noble spirit took its noiseless flight; while so tranquil appeared the manly features in the repose of death, that some moments had passed ere those around could believe that the patriarch was no more."