10 Ways Doctors Can Protect Themselves When Attorneys Try to Influence Patient Care

The prior blog entry discussed ways that attorneys try to control a patient’s medical care to win a case. Below are ten steps that doctors and other health care providers can take to prevent themselves being placed in such scenarios or deal with them more effectively when they occur despite attempts at prevention.

1. Awareness is key. When a  new patient arrives to the office or an existing patient arrives seeking medical treatment for a particular condition or injury, the first step is to determine whether the injury or condition is compensable in some way and whether the patient will be seeking compensation for it. In some cases, this will be easy to determine based on the insurance type (e.g., workers compensation, no-fault insurance) or if the patient acknowledges when asked that an attorney has been hired or that disability is being pursued. In other cases, a patient may deny pursuing compensation but plans to in the near future, is considering it, or is not being honest.  In such cases, consider the history. Was somewhat else alleged to be at fault for the injury (e.g., car accident) or is there someone the patient may blame for the injury/condition (e.g., a doctor misreading a brain CT scan in the ER as not showing signs of an acute stroke when it actually did, resulting in delayed care and worse signs, symptoms, and outcome)? Ask if the person is seeking disability.

2. Document acknowledged compensation seeking, receipt of compensation, and/or retention of legal counsel in the medical note. If the patient denies seeking compensation or having retained legal counsel, document this as well. This way, you have a record of what information was provided to you on this topic when treatment began. If the information changes at some point, document that as well.

3. Ask the patient whose idea it was for the evaluation. If the idea solely came from the attorney, explain to the patient that your practice (an insurance billing) is specifically designed for patients in which referrals originate from other health care providers or from the patient for the sole purposes of improving healthcare (as opposed to pursuing compensation). In other words, you perform clinical evaluations, not legal evaluations.

4. If the idea for the evaluation came from the attorney but was referred by another health care provider, contact that provider to discuss the issue. I have had several cases where I place such a call and the physician tells me. “I have no idea why I am sending the patient for the evaluation. She said her attorney wanted it, so I just ordered it.” In such cases, explain your position to healthcare provider and provide the patient and referral source with contact information of other providers in the area who perform medico-legal work (which is paid for by the attorney).  

5. If the referral was legitimately made by a healthcare provider but the patient is also pursuing compensation, explain that the medical records may be subpoenaed by an attorney/judge and used in a deposition, trial, or settlement negotiations. Explain that the findings may help the patient, have no impact, or negatively impact the compensation case. Explain that you will base your findings on scientific principles and methods and that your findings may be in perfect agreement with what the patients thinks is the problem and expects as a recommendation (e.g., disability status), may be in partial agreement, or that you may have a completely different take.
6. Go through the above information with the patient in an informed consent that you have the patient sign.  Make sure the form has a statement in it that says signing it means that the patient understands what is on the form, had the chance to ask questions, and that any questions have been answered to his/her satisfaction. Explain this out loud to the patient and provide the patient a copy when it is signed. This document can protect you in the future in case of a complaint. If the patient is unwilling to sign the form you can refer him/her to another provider.

7. While there is nothing wrong with clinically evaluating patients who are seeking compensation, make it clear that while you are open to hearing input that you are the one who makes the ultimate diagnostic and treatment decisions, decides how to word documentation, and what to say in a court of law. Be clear that this has nothing to do with ego or arrogance, but after all, you are the one with the health care license and health care degree.

8. While it is perfectly acceptable to advocate on a patient’s behalf, health care providers must be cautious to avoid blind advocacy in which there is an absence of evidence to validate compensation claims. This is especially the case when extensive attempts have been made to find such evidence. While it is true that absence of evidence is not always evidence of absence, many times it is.

9. Do not turn a blind eye to evidence that emerges which runs counter to the patient’s claims. In such cases, it is best to sit down with the patient, express your concerns, and adjust the case conceptualization and treatment plan accordingly. An example would include referring a patient for counseling if significant psychological distress appears to be the main problem as opposed to a mild injury. Do not send patients for indefinite treatments that show no improvement within reasonable time frames. Be sure to measure treatment progress over time.

10. If you eventually have to do a deposition or testify, try your best just to stick with the facts without getting caught up with trying to help one side win or lose the case. The outcome of the case is for the attorneys to handle and the jury to decide. The role of the witness is to assist the court/jury by providing honest testimony that is as objective as possible.

When Attorneys Control Patient's Medical Care to Win a Case

Consider the following scenario. A 40-year-old man arrives to your office seeking medical treatment for a mild personal injury suffered several weeks or months prior. Unbeknownst to you, the patient has hired a personal injury attorney who suggested that you evaluate him. Over the course of months to years, the patient reports no meaningful improvement in symptoms despite no objective biomarkers that any significant physical damage has occurred. In fact, the patient may even report getting worse despite all treatment attempts. 

Unbeknownst to the health care provider, the patient is regularly checking in with his attorney and receiving directives to request referrals for numerous therapy services (e.g., physical therapy, occupational therapy) to establish a record of a need for medical treatment to be used in settlement negotiations or an upcoming trial. Along the way, the attorney also directs the patient to make requests for diagnostic imaging (“Can you order an MRI?”), medications (“Can you prescribe me something for the pain?”), and specialty evaluations by someone known to the attorney (“Can you refer me to Dr. Smith?”). In health care, the attorney is said to be operating in stealth mode, although in other cases the attorney may be bolder and make these requests directly to the health care provider.

Unable to determine why the patient continues to report persisting symptoms, the health care provider accedes to these requests even though he/she may doubt that they will yield much, if any, benefit. Indeed, that is exactly what happens. For example, the therapists treat the patient but are also unable to provide any meaningful improvement and eventually inform him that no further treatment is indicated.  Within a few weeks, the therapists find out that the patient is back on the schedule for six more sessions, not knowing that the attorney instructed the patient to call the scheduling desk and do so.  The therapists see him again, as he now reports some new symptoms. Incidentally, when some of these patients are later asked why they continued to go to therapy sessions that were not helping, they will answer “Because my attorney told me I have to go.”

Eventually, the doctor who has been managing the patient’s care, receives a letter from the patient’s attorney, requesting a copy of all records and a time to talk on the phone to prepare for an upcoming deposition. The doctor may also be told something along these lines (taken from an actual email sent to me by a physician seeking my assistance on a case):

“The lawyer he (the patient) has hired told me that my response to a multi page letter from ‘independent’ reviewers needs to contain a rebuttal to their assertions that he has no claim. Whatever data I generate from the review of his file and references to papers will need to be made now because, if he does not win this appeal, only the information that I provide in a response can then be used in a subsequent law suit."

The doctor, wanting to advocate for his patient and not cause harm, writes a strongly worded rebuttal to the independent reviewers, clearing the language with the patient’s attorney before sending it in. A deposition, followed by trial testimony, is forthcoming.

The above scenario, and variations of it, occurs with alarming regularity and it is a major cause of increased health care costs, costing millions of dollars a year or more. In such cases, much of the patient’s healthcare outwardly appears to be directed  by the health care provider but is actually being directed by the patient’s attorney . Despite this, years of medical bills are sent to the patient’s insurance company as opposed to the attorney’s law firm.  In addition, the attorney has obtained a free expert witness, taking advantage of the health care provider’s fidelity to the patient and fear that not helping with the legal requests will cause the patient to lose the case, thus causing "harm.". The above scenario raises many obvious ethical and legal pitfalls, the most important of which is the potential for insurance fraud. The next blog entry will discuss steps that health care providers can take to prevent themselves from being placed in these situations or manage them better when they occur.

If Andy Williams Drank Tea Would He Still Be Alive?

Today, legendary singer Andy Williams (age 84) died of bladder cancer, a condition he announced being diagnosed with less than one year ago (November 2011).  He had received chemotherapy treatment. One of the first things people ask when finding out that someone they know (or know of) has died of an illness, is what the signs and symptoms were and if it could have been prevented.

For most people, bladder cancer presents with blood in the urine, a sure sign that something is wrong and that you need to see a doctor ASAP. However, the blood is sometimes only detected microscopically, which is why regular check-ups with the doctor are important because periodic urine analysis studies are typically ordered.  Painful and frequent urination are also symptoms of bladder cancer as is a feeling that one has to urinate but being unable to when trying.  It is worth noting, however, that bladder cancer is only one of many reasons why someone can experience these signs and symptoms, some of which are more serious than others (e.g., dehydration, kidney stones, urinary tract infection).

Diagnosis of bladder cancer is typically made via a biopsy of selected tissue. At this time, there is no clearly effective screening test for bladder cancer. Thus, the focus turns to prevention. Some risk factors are controllable such as smoking and not exposing yourself to harmful toxic chemicals such as arsenic and those used in various manufacturing plants (e.g., paints and dyes). However, many of the factors are beyond one’s control such as genetics and being an old white guy. That may sound humorous but indeed, old age, being white, and being male are all factors that increase one’s risk of bladder cancer.

As a result of such incontrollable factors, people often try to turn to diet to tip the odds back in their favor. Enter the world of tea consumption, which has been touted as being able to prevent bladder cancer. Individual studies on the topic have been inconsistent. When this happens, one of the best ways to gain more clarity on the subject is to perform a meta-analysis. In a meta-analysis, the researcher examines all of the best studies available on a particular topic, treats each study as if it was a research subject, and looks to see if the claimed intervention is actually effective.

A new meta-analysis on this topic was recently published in the World Journal of Surgical Oncology.  The authors selected the 23 top studies on the topic and found no association between tea consumption and decreased bladder cancer risk. This held true regardless of the type of tea consumed (e.g., green, black), gender, or the type of research design used. Incidentally, this meta-analysis replicated the findings of a prior one on the topic (Zeegers et al, 2001), yet included 11 more recent studies.  Overall, regardless of how much tea Andy Williams would have consumed, he would have very likely still passed away from bladder cancer.

References:

Qin J, Xie B, Mao Q, Kong D, Lin Y, Zheng X. (2012). Tea consumption and risk of bladder cancer: a meta-analysis. World Journal of Surgical Oncology, 10, 172-(ahead of print).

Zeegers MP, Tan FE, Goldbohm RA, van den Brandt PA (2001). Are coffee and tea consumption associated with urinary tract cancer risk? A systematic review and metaanalysis. International Journal of Epidemioogy, 30, 353–362.

Treating Tonsil Abscesses with Immediate Tonsillectomy

In the current issue of Acta Oto-Laryngologica, Drs. Nicolas Albertz and Gonzalo Nazar summarized 10 years of experience in treating patients with abscesses around the tonsil region (known as peritonsillar abscesses). An abscess is a well-defined collection of pus that has escaped from blood vessels and has been deposited on tissues or in tissue surfaces.

One or both tonsils can become infected and develop an abscess. These types of abscesses are actually the most common infections in the deep part of the neck. A common form of treatment is to cut into the abscess and drain the pus. However, Drs, Albertz and Nazar provide evidence that immediate surgical removal of the tonsils (tonsillectomy) is a safe and effective alternative treatment based on reviewing 10 years worth of patients (total =112 people, average age = 24 years) with this condition who had one tonsil (28 patients) or both tonsils removed.

Of the patients who received the surgery, none developed sepsis, which is a potentially deadly whole-body inflammatory response to infection. Only four (3.6%) of the patients developed bleeding after the operation and of these, two resolved spontaneously. Only 29% of the patients had enough pain that they needed to use a pump to self-administer morphine after surgery for pain relief. The average hospital length was 3.4 days. Of the 28 patients who had one tonsil removed, four (14.2%) developed a strept infection of the tonsils. Two of the 28 patients (7.1%) were admitted to the hospital again with inflammation around the tonsil area on the side that was not operated on. Only one of these patients required drainage and removal of the other tonsil. The authors concluded that the complication rate of the immediate tonsillectomy in these patients was similar to that of scheduled tonsillectomies in adults and that this should be considered a first-line treatment for peritonsillar abscesses.

Reference: Albertz, A. & Nazar, G. (2012). Peritonsillar abscess: Treatment with immediate tonsillectomy –10 years of experience. Acta Oto-Laryngologica, 132, 1102-1107.

Japanese and American Differences in Modesty Eliminated by Money

New social psychological research from Japan is shedding light on differences is modesty between people from American and Japanese cultures and shows the powerful effect of financial incentives on behavior. In the experiment, Japanese and American participants each completed two tasks: an embedded figure test and a trustworthy judgment task.  The Japanese participants were found to be modest (self-effacing) when asked to evaluate their performance compared to peers in their age range when no reason for providing the evaluation was given.

This was the case even though the responses were done via an anonymous questionnaire. By contrast, the Americans (especially the men) showed a self-enhancing tendency when evaluating themselves when no reason for providing the evaluation was given. However,  these cultural differences were eliminated when the participants were offered money for providing the correct self-evaluation. That is, the Japanese and the American groups both enhanced their self-evaluation ratings when offered a monetary awards. The findings show that the stereotypical differences in modesty between Japanese and American cultures were entirely dependent on context.

The authors believed that the results showed that modesty is a default reaction in the Japanese culture designed to avoid offending others. This default reaction was described as a social mandate that is advantageous to avoid being excluded from the group relations they encounter in everyday life. However, the study shows that default cultural behavior can be altered significantly with a monetary award because there is a strongly motivating factor present to override it.

Reference: Yamagishi, T., H. Hashimoto, Cook,  K., Kiyonari, T., Shinada, M., Mifune, N., Inukai, K., Takagishi, H., Horita, Y., Li, Y. Modesty in self-presentation: A comparison between the USA and Japan. Asian Journal of Social Psychology, 15, 1, 60-68. The entire study can be read here.

Want to Boost Your Health? Try Healthy Supplements

Are you looking to improve your health? You've probably started by getting more exercise and switching to a healthy diet full of fresh fruits and vegetables in order to get more nutrients from your food. This is a great start, but the reality is that it's extremely challenging to get all the nutrients your body requires from your food alone.


Fruits and vegetables derive their nutrients from the soil in which they are grown. Unfortunately, our soil is becoming depleted, which means that today's fruits and vegetables as well as other foods have lower nutritional content than in previous years. The animals that eat foods that are grown in depleted soil also have fewer nutrients available, which means that the pigs and cows that we consume in the form of pork chops and steaks also have a less favorable nutritional profile.

While obtaining nutrients solely from food is ideal, to get the rest of the nutrients your body needs, you can add nutritional supplements like the ones found on this site. Not only do nutritional supplements help build up your levels of important vitamins and minerals required by your body, they also provide complementary nutrients that help your body to better absorb and assimilate the vitamins that you are able to obtain from your foods.

As an example, you probably drink milk in order to meet your body's daily calcium requirements. Unfortunately, without enough vitamin A and vitamin D, your body is unable to properly use the calcium that is found in your milk. While milk is often fortified with these vitamins, they are typically not enough. According to a study published in the Archives of Internal Medicine, vitamin D deficiency is dramatically on the rise and is being blamed for an increase in such diseases as cancer and diabetes.

Additionally, if your digestive system isn't working properly, you will have difficulty absorbing nutrients properly. Many supplements contain ingredients that help your digestion run smoother so that you can get more benefit from the foods that you eat. Adding a supplement containing probiotics to your diet is a great way to boost your gut health. Probiotics help restore the natural flora of your gut, which is easily damaged by taking antibiotics yourself or by eating meat that has been overly treated with antibiotics.

Adding nutritional supplements to your diet is a great way to improve your health. When your body is properly nourished, you will look and feel your best.

This entry is a guest blog entry.

How Too Much Exercise Can Harm You and Your Heart

A regular normal amount of exercise is known to reduce many diseases and improve heart health. However, some people have taken the “Let’s Move” and exercise suggestions to the extreme. Examples include running hours a day and training for grueling marathons and triathalons. By all means, people should feel free to do this if they want to, but they should do so knowing that there are potential serious health risks involved.  People may be surprised to hear this, especially after hearing day after day about the need to exercise, exercise, exercise. This has led some people to believe that if exercise is good, then very high amounts of exercise must even healthier. But that is not always the case, as recently pointed out in a review article in Mayo Clinics Proceedings (reference below) that did not receive much media attention.

The authors of the review paper found that long-term exercise endurance can cause abnormal structural changes in the heart and large arteries. This is especially true for people who train in marathons, ultra-marathons, ironman distance triathlons, and very long bicycle races. Initially, this could cause short-term overloading of the heart, decreased heart pumping efficiency, and elevations on blood tests that are indicative of heart damage. The good news is that these transient effects return to normal in one week.

The bad news is that if this process of excessive repetitive exercise continues over months to years, it can lead to heart disease such as abnormal thickening of the heart valves and abnormalities in the heart muscle leading to stiffening of the heart tissue.  This can also lead to abnormal heart rhythms. Other problems that can be caused by excessive exercise include coronary artery disease and stiffening of large arteries.  Some of the risk factors are considered hypothetical and like most research areas there are some inconsistent findings. However, it is probably wise to consider the words of the ancient Greek philosophers to do things in moderation.

Reference: O'Keefe JH, Patil HR, Lavie CJ, Magalski A, Vogel RA, McCullough PA. (2012). Potential adverse cardiovascular effects from excessive endurance exercise. Mayo Clin Proc., 87, 587-95.

Also of Interest: How Jogging Can Kill You

Can Hyperbaric Oxygen Therapy Improve Achilles Tendon Tears?

Hyperbaric oxygen therapy (HBOT) is the application of 100% oxygen in a specialized chamber to treat medical conditions, most commonly decompression sickness. Decompression sickness is  the formation of gas bubbles in the body from being exposed to extreme depths or heights.  However, scientists continue to research whether hyperbaric oxygen can be used to treat other medical conditions.

In a new study referenced below, researchers attempted to find if HBOT could improve early healing after Achilles tendon tear and subsequent repair, in rats. The Achilles tendon attaches the calf bone to the heel bone and is often torn as a result of athletic activity. The researchers took two groups of rats (28 per group) , surgically tore the tendons, and sutured them. Before surgery, one group’s Achilles tendon was injected with a steroid medication (betamethasone ) and the other group’s Achilles tendon was injected with a saltwater solution. Fourteen rats from each group were treated with HBOT and the others were not. The Achilles tendons were removed, evaluated for how well  they moved, how strong they were, and what their features were like under the microscope 11 days after surgery. The researchers found that the group treated with HBOT showed improved healing of the Achilles tendon in terms of movement, strength, and formed more fibrous connective tissue.  The results cannot yet be generalized to humans because it is based on rats but many will view the findings as promising.

Reference: Kuran, F.D., Pekedis, M.P., Yildiz, H., Aydin, F., & Eliyatkin, N. (2012). Effect of hyperbaric oxygen treatment on tendon healing after Achilles tendon repair: an experimental study on rats. Acta Orthopaedica et Traumatologica Turcica, 46 (4).

Improving Sleep in Intensive Care Units

Intensive care units (ICUs) are not fun places to be. By definition, people placed on such a unit need intense medical care for a serious medical condition (which is often life-threatening). While on the ICU, the body needs to rest in order to heal and the best way to do that is through the restorative powers of sleep.

 RECOMMENDED BOOK: Say Good Night to Insomnia

With worse sleep in the ICU, it will take longer to leave the ICU, the patient may develop delirium, and worst of all, the chances of dying increases. Delirium is a state of fluctuating mental confusion that develops over a few hours or days. Some studies have shown that people in ICUs have sleep problems characterized by frequent awakening, abnormal biological clock rhythms, and/or a decreased length of time in the 3rd and 4th stages of sleep.

To address this problem, treatment of sleep disorders in critically care patients are needed. However, in a newly published review article in the medical journal, Acta Anaesthesiologica Scandinavica, researchers found that there was not good scientific evidence that existing treatments of sleep disorders in the ICU setting worked. The authors suggested large multi-center studies to address this problem with larger groups of patients that were more alike as a group.

The authors also suggested some specific possible changes such as: 1) improving the ICU setting, 2) not using as many medications known to cause sleep problems, 3) use of melatonin pills (a chemical that is used naturally in the body to promote sleep), and 4) using more types of mechanical ventilation to improve synchrony between the patient and the ventilator.

Related blog entry: Treating Sleep Problems in Multiple Sclerosis: An Update

Reference:  Boyko, Y., Ording, H., Jennum, P. (2012). Sleep disturbances in critically ill patients in ICU: how much do we know? Anaesthesiologica Scandinavica, 56, 950-958. 

Michael Clarke Duncan Turns Vegetarian, Loses Weight, and Dies of a Heart Attack

On 9/3/12, famous actor, Michael Clarke Duncan, died after complications from a heart attack that he suffered on 7/13/12. Some people may not be surprised because they remember him from his roles as an imposing figure in The Green Mile. Duncan was 6 foot 5 inches tall but before he became famous, he weighed up to 315 pounds.

I have yet to see anyone comment on the irony of his death given that he became a vegetarian in 2009, lost about 45 pounds, and became a spokesperson for PETA, touting the health and strength benefits of vegetarianism. As I have made clear many times on this blog, I have no objections at all to people wanting to be a vegetarian. However, I don’t like when people continuously try to convince and badger others that they should not eat meat if they are perfectly content doing so.

As I have also pointed out, the notion that eating a diet full of fruits of vegetables is going to provide some sort of guarantee against sickness and death is completely misplaced. In Duncan’s advertising campaign for PETA, he pointed out how elephants are powerful and strong despite only eating vegetables. However, the real King of the Jungle is the lion and the lion feasts on meat.  I also once saw a nature show documenting a group of hungry tigers attacking and eating an elephant when provoked by hunger.

The bottom line is that there are pros and cons to vegetarian and non-vegetarian diets and each person needs to make their own individual choice. However, the choice should be made based on realistic expectations. In other words, if you really love meat but chose not to eat it because of reported health benefits, you may regret not having the occasional hamburger or hotdog after being diagnosed with a terminal illness and should not be surprised if this occurs. If you truly love being a vegetarian though, won’t regret it when facing your own mortality, and won ‘t be shocked if you are diagnosed with a serious illness (e.g., cancer) then enjoy those fruits and veggies.

Related Blog Entries:

1. When Fruits and Vegetables Kill
2. How Fruits and Vegetables Killed Steve Jobs
3. Exercise and Eat Fruits and Veggies All You Want: You're Still Going to Die

EXTREME Body Parts: Part 4

The most popular feature of the MedFriendly Blog is back: the world's most extreme body parts. If you have not seen this interesting feature, see the original article, part 2, and part 3. Without further ado, here is part 4.

1. World's Largest Hand: This is the hand of Lui Hua, who suffers from a condition known as macrodactyly. This rare condition is defined as abnormally large fingers or toes from birth due to overgrowth of underlying bone and soft tissue. The left thumb was 10.2 inches and the index finger was close to 12 inches. In July 2007, he underwent radical surgery to have 11-pounds of flesh removed.

2. Most Fingers and Toes: Another abnormal condition that can affect the fingers and toes is polydactylism. There are two people known to have 25 fingers and toes (Pranamya Menaria, Devendra Harne). Devendra is shown below:

3. World's Largest Female Beard: This is Vivian Wheeler, a woman born as a hermaphrodite. The longest hair was 11 inches and 27.9 centimeters.

4. World's Longest Eyebrow Hair: This record goes to Frank Ames from Saranac, NY, who has a 3.7 inch eyebrow hair.

5. The World's Largest Tongue: The world's longest tongue belongs to Steven Taylor from England. It measures 9.8 cm (3.86 cm). For the female record for the longest tongue, see here.

Ten Ways to Avoid the Death of Your Baby or Child

There is nothing sadder than the death of a child. Some deaths, such as due to pediatric cancer, are unavoidable. But other deaths are avoidable as shown by these recent examples in the news:



1. August 2012: A baby in Utah was killed after his father straddled him between himself and a gas tank while riding a motorcycle too fast, losing control, and throwing the baby off the vehicle.

Lesson: Never ever allow a baby to ride with you on a motorcycle.

2. August 2012: A baby in Indiana died after falling asleep on his grandmother’s chest.

Lesson: Allowing a baby to fall asleep on your chest can be deadly because the baby can die from accidental suffocation since they are primarily nose breathers.  This is why doctors recommend always lying babies on their backs in a crib and not keeping other items in the crib (including blankets and pillows) when the bay is sleeping.

3. August 2012: Eight children across the U.S. died when left unattended inside hot vehicles.

Lesson: Look before you lock! Never leave a child unattended in a car, especially in hot temperatures with the windows closed.

4. August 2012: A two-year-old child died in Utah after falling out of a three story window, tumbling through the window screen.

Lesson: If you have small children, keep the bottom aspect of windows locked (even if a screen is in place because children can easily rip through it) and only open the top part of the window (if out of the child's reach) for fresh air.

5. August 2012: An eight-year-old child died in Toronto when his father reversed his car and backed into him.

Lesson: Never reverse your car when your child is behind you. Know where they are at all times. Preferably have the child in the car before reversing or make sure the child stands to the side of the vehicle while reversing.

6. August 2012: A three-year-old child died in Atlanta when playing in a shallow area of water in a park. There was a shallow drop off to a deep area, where the boy fell in. No one in the area could swim well to save the child, including the parents.

Lesson: Even in shallow areas, small children should not be in the water without close physical assistance and supervision. Children can fall and drown in just a few inches of water.

7. August 2012: Making the point I made in the lesson above, a 11-month-old child died after being placed in the bathtub with her 4-yearold sister by her father. The father then fell asleep on the couch.

Lesson: Again, children should not be left unsupervised by adults in the water, even a bathtub lightly filled with water. Also, young children should not be left to supervise other young children, which is what sounds like may have happened here.

8. July 2012: A one- year-old child dies in San Antonio, Texas, when trying to climb furniture, causing the dresser to tip, resulting in a 32-inch television crushing him to death.

Lesson:  Don’t let your children climb furniture, particularly furniture that can easily tip over.

9. April 2012: A 6-year-old boy from Connecticut died when he was pulled into a wood chipper while placing wood inside the machine. He was helping his father on a landscaping job when his father turned his back.

Lesson: Don’t let your children place items into a wood chipper and never turn your back if your child happens to be near power tools.

10. April 2012: A 2-month-old boy in South Carolina was killed after being dismembered by the family dog while the mother was away and the father slept.

Lesson: Do not leave small children unattended with animals, particularly dogs. Even dog breeds you would not expect to be violent sometimes can be. The dog in this case was a retriever.

How Jogging Can Kill You

It continues to amaze me how some people jog for health benefits while simultaneously placing their bodies (and those of others) in peril. Not that I have anything against jogging, and have done it myself innumerable times, but I have to shake my head when I see people jogging on busy roadways with 55 to 65-mph speed limits, not paying attention to their surroundings, jogging in extreme heat or cold, not wearing reflective gear at night, jogging first thing in the morning in poor visibility,  or jogging with the flow of traffic  (meaning they have no way to see if a driver may be veering off the road towards them so they can at least try to get out of the way).  It’s as if some people think that the very act of jogging insulates them from being harmed along the way.  It doesn’t.

I pointed the perils of exercising dangerously in a November 2011 blog entry. Unfortunately, deaths from jogging continue to mount. So, it’s time for an update to try and bring some more awareness to this issue and hopefully prevent needless deaths or injuries related to jogging. Remember, all of these people went out for a jog to live longer and they wound up getting killed in the process. It’s a sad and terrible irony.

1. August 2012: A man in British Columbia died while jogging on the side of a highway after jumping a barrier and landing on the rocks below.  The jogger tried to get out of the way of a truck approaching him from behind, leaped over the concrete barrier at the end of the highway, and fell down the steep 30-foor drop on the other side. 

2. August 2012: A 21-year-old woman was critically injured in Corpus Christi, Texas, after running across a street (she was not on a cross walk) and being struck by someone driving an SUV.

3. July 2012: An experienced runner died in England while jogging and accidentally running into a low-hanging high voltage cable.

4. July 2012: A teenage jogger in England died while listening to his headphones and not hearing an approaching freight train which killed him.

5. July 2012: A 20-year old jogger is killed on Rte 507 in Pennsylvania while she is struck from behind by a pick-up truck. 

6. July 2012: A jogger in La Quinta, California was hospitalized with moderate injuries after being struck by a motorist who suffered some type of medical emergency while driving and went into cardiac arrest.

7. July 2012: A 22-year-old woman jogging in an atmospheric temperature of 113 degrees in Arizona collapsed and died. She was dehydrated and her body temperature was 109 degrees.

8. July 2012: An 84-year-old man jogging in Hempstead, New York, was critically injured around 7:45 am after being hit by someone backing out of their driveway with a Jeep.

9. July 2012: A 21-year-old woman in New York was critically injured after being struck by a driver who fled from the scene.

10. March 2012: In England, a 52-year-old jogger was killed by a truck driver driving dangerously.

I have not even included all of the cases of women who have been physically and/or sexually assaulted while jogging alone on jogging trails, often late at night.  Please use common sense while jogging and if you know a jogger, please pass this on.  Whenever you jog next to fast-moving vehicles, you are putting your life (and the lives of people in the car) in jeopardy. But wherever you job, you have to be aware of your surroundings, which includes the weather, to stay safe.

How Too Much Exercise Can Harm You and Your Heart

A Psychological Profile of Wade Michael Page: The Sikh Shootings

Only a few weeks after the mass shooting in Aurora, Colorado, the U.S. experienced yet another mass shooting in a public place, this time a Sikh worship center in Wisconsin. As has been profiled here in the cases of movie theater shooter, James Holmes, and school shooter, T.J. Lane, the people who commit these crimes have often lost their connection to society and become recluses. When crimes like this occur, it is common to hear discussions of the need for improved gun legislation to prevent crimes like this from occurring again. While improved gun legislation may help, there needs to be a greater discussion of ways to reduce such crimes by preventing people from developing the mindset that they need to take revenge against society by mass killings of random people (or any people for that matter).

The shooter in the Wisconsin killings was Wade Michael Page, who has now been widely identified by the media as a white supremacist.  It is important to keep in mind that Page was not born as a white supremacist just like alleged Canadian Icepick killer, Luka Rocco Magnotta, was not born evil. After all, Wade’s step-mother, Laura Page, recalled him as being “precious child” who was “kind and gentle and loving” and who loved to do normal child activities such as playing with his dog and camping.  Early childhood pictures show someone who appeared to be happy and normal.

Although I, and any other sensible person, unequivocally condemns Wade’s actions, an important issue for society is to determine how and when someone transforms from a happy normal child to a reclusive member of society who goes on a mass shooting rampage. The reality is that the transition is usually not one that occurs over night, but typically results from years of negative life experiences combined with poor coping resources and vulnerability to extremist influences. In the case of Wade Page, his step-mother has said that she has “no idea” where he changed. However, the early history provides some answers of how the process of social alienation unfolded. None of these factors alone are sufficient to explain a mass shooting rampage, but putting them together can sometimes culminate in a tragic event.

The first clearly relevant negative event identified in Page’s life is that his mother died from lupus in 1985 (age 13). This is difficult for any child to deal with and Page was reportedly devastated.  His father re-married when he was  10-years-old and at that point his mother and step-mother shared joint custody of him.  It is likely that the divorce was difficult for him as well. He reportedly did not get along with his father. His father and step-mother later moved from Colorado to Texas, leaving him behind in Colorado to split time living with his aunt and grandmother while attending school. While he reportedly developed a close bond with the latter, we now have a child whose parents divorced, whose biological mother is dead , and whose father and step-mother moved away from him.  Essentially, his childhood was marked by tragedy and an unstable home life. His school grades are unknown but it would not be unusual for a child with this type of history to have academic struggles.

It seems that Page lacked focus and direction as a teenager because according to his step-mother he claimed that this was what joining the army at age 20 provided him.  He did this after moving in with his father and step-mother after H.S. and trying to work in a convenience store. Whatever discipline he learned in the military was not sufficient because he had continued alcohol-related problems, which likely reflected a maladaptive way to cope with stress. Specifically, at a pool bar in 1994, he kicked large holes in sheetrock with his boots, and was charged with criminal mischief.  He was demoted and discharged from the army in 1998, reportedly for showing up drunk.  He was demoted and discharged from the army in 1998, reportedly for showing up drunk.  He was not allowed to re-enlist and received a general discharge, which is a level below an honorable discharge.  He was also arrested for a DUI in 1999, the same year his mother and step-mother divorced.

It is at this point that his family began to lose contact with him and he began a new chapter in his life…joining the white power movement in 2000. He had reportedly expressed white supremacist views in the military and was covered with tattoos by 1995, some of which identified his views. One example is his tattoo of the Celtic cross on his left arm with the number 14 inside of it. The Celtic cross is a symbol of a German Neo-Nazi  group and the #14 reflects the number of words in the white supremacist rallying slogan.
By 2000, it seems that Wade tried but failed to fit in with society through normal routes. He no longer had a biological mother, was disconnected from many in his family, had been rejected by the military by his behaviors, and sought a way to feel connected to something else. In Page’s case, the white power movement provided that sense of family and meaning, just like a gang provides the same for many inner city youth from broken households. 

Overall, Wade Page was not happy with society, which he has referred to as sick and hypocritical in a previous interview about his heavy metal band, End Apathy. He began the group in 2005. The name of the band arose from his desire to enact change and served as a way to direct his anger.  He was also the member of a band called Definite Hate. His music helped vent his feelings of anger and frustration.  People outside of his group were referred to as “dirt people.” With such views, non-whites become dehumanized and a mindset develops that allows one to commit a heinous mass murder.

However, even within his own sub-culture, Page could not fit in. A girlfriend reportedly cheated on him with a band member, resulting in the band dismembering about a year ago. In early June 2012, a girlfriend reportedly broke up with him and he moved out of his residence with her. A friend described him as emotionally upset and hurt.  He was fired from multiple jobs (e.g., truck driver, parts coordinator) over the years, once because he did not want to take direction from a female co-worker.  He lost his house in February 2012 when the bank seized it after a foreclosure.

Essentially, Wade Page seems to be a person who grew up in the face of tragedy and instability, tried to fit in society but failed, identified with the white supremacist subculture but had a falling out there as well. His life had fallen apart and he took out his anger on the society he disliked, focusing on those he had completely dehumanized. He may have been planning his rampage for a few weeks because when he moved out, he lived alone and rarely left his residence. He did not return a call from his father three weeks before the shooting. He barely made eye contact with people and did not want to be engaged. He was blasting aggressive music from his radio, which was likely channeling his anger. He was avoiding human connections perhaps because he did not want to have any such feelings should they interfere with his plans. Of course, this is speculative, but clearly, he was angry and upset at the time.  While people recognized he was acting strange, no one felt concerned enough to contact police.

As a society, we need to do everything possible to maintain stable families and living situations for children. In cases of divorce and/or death of a parent(s) we need better societal resources in place to help children cope, which includes mental health outreach and community outreach programs to reduce feelings of isolation and reclusiveness (for adults and children). There should be a more rigorous follow-up of people discharged from the military for conduct problems, particularly if they are known to be reclusive or engage in hateful activities. There is no way to prevent all cases of mass violence, but when I look back at Walter Page’s history, I cannot help but think that his life (and by extension the lives of the people he killed) did not need to turn out this way.

Stupid Diets: Infesting Yourself with Tapeworms

It’s amazing the types of things people will try to do to lose weight without dieting or exercising. On this blog, one of biggest scams to reduce obesity was previously covered.  However, one of the more unusual obesity “treatments” is found in an old ad stating that you could eat sanitized jar-packed tapeworms (beef tapeworms).

The ad specifically claims there are no ill effects, that they are easy to swallow, and hey, no exercise or dieting required!  Ads like this were common in the United States between 1900 and 1920. However, these were the days before the Food and Drug Administration (FDA) so it is not clear is whether the companies advertising tapeworms actually put them in the product.  In other words, it could have been false advertising.

Despite the claims, it is not safe to ingest tapeworms, as is detailed in the extensive MedFriendly entry on tapeworms. These worms can grow up to 30-feet in length and can cause various signs and symptoms of illness. If someone ingested tapeworms to lose weight, it could result in weight loss (1 to 2 pounds a week) but this is due to harmful side effects (e.g., diarrhea), interference with digestion due to substances secreted by the tapeworm, and the tapeworm absorbing many of the calories consumed  (which is why people could continue to eat what they want). The main problem though is that tapeworm infestation could result in blockage of the intestines and death.  A related complication is tapeworm infestation of the brain, known as neurocysticercosis (click link for pictures). Tapeworms can also infest the spine, liver, and eye. They can also cause cysts, malnutrition, and stomach swelling (the latter of which defeats the purpose of weight loss).  Of note, pork tapeworms are even more dangerous than beef tapeworms.

Many people reading this who are pet owners are already aware of the dangers of tapeworms because you try to keep them away from your pets.  Tapeworm infestation in pets and humans is treated with specific medications designed to kill the worms.  In people who use tapeworms for weight loss, once the tapeworm is killed the weight returns because no lifestyle changes have taken place.  There is no guarantee, incidentally, that the tapeworms will easily be destroyed with medication.

Contrary to some rumors, famous opera singer Mary Callas did not lose 80-pounds from tapeworms or die from tapeworm dieting. In fact, she attributed her weight loss to a regular diet of salad and chicken. While Callas had been afflicted with tapeworms, this was because she sometimes ate raw meat, which is prone to tapeworm contamination.

These days, it is illegal to import or sell tapeworms in the U.S. and the FDA has banned tapeworms for dietary purposes due to the dangers the pose. There are places in Mexico where people can pay about $1200 to $1500 to infest themselves with beef tapeworms, supposedly identified microscopically.

Cord Blood To The Rescue

As science continues to evolve, there have been a number of advancements that help treat certain medical conditions. Behind a large number of medical advancements is a substance that is often overlooked or misunderstood: cord blood.


If people will learn more about this important resource, it has the potential to change the medical industry. What exactly is cord blood and why is it important in the medical field?

What is Cord Blood?

Cord blood is blood is taken out of the umbilical cord shortly after a child is born. The cord blood is different from regular blood, and it has a number of substances inside it that make it a natural disease fighter.

Medical Benefits

Cord blood has an impressive variety of different medical uses. The stem cells from the cord blood can be taken and used to treat more than 80 different life-threatening diseases. A number of different types of leukemia can be treated with cord blood. Stem cell disorders can be treated, as well as several plasma and immune system deficiencies.

One of the reasons that cord blood is so attractive is because it can be taken without any risk to the baby or to the mother. It can then be stored in a cord blood bank, so that it is available at any time in the future for any family member who needs it. Another nice feature of using cord blood is that the blood types do not have to be a perfect match in order to use it. This means that anyone in your family should be able to use it without having to worry about matching up perfectly with the source.

Using cord blood also comes with a lower risk of viral infections compared to other types of transplants. Many of the common viruses and infections that come with transfusions do not apply with cord blood.

Cord blood is also commonly used in the area of scientific research. With the help of cord blood, scientists have developed cures to many different diseases, and they are working on more every day.

If you are thinking about whether or not to store the cord blood of your child, consider all of the potential ways that it could be used at some point in the future. It could save your life, the lives of your kids, or the lives of family members who need help at some point.

The entry above is a guest blog entry.

A Psychological Profile of James Holmes: The Joker Killer

In watching and reading the media coverage of The Batman movie killings in Aurora, Colorado, it is frequently stated that the killer’s behaviors are incomprehensible, not understandable, beyond belief, etc. Taken figuratively, I understand what these people are saying since there a very few people who would walk into a crowded movie theater, throw down chemical bombs, shoot and kill 12 people from ages 6 to 51, and wound 58 others. Taken literally, however, I disagree, because there are reasons why people behave the way that they do and those reasons are indeed discoverable.

The first thing I noticed about the alleged killer, James Holmes, that I have not seen anyone discuss yet, is that the school picture of him looks quite awkward. While clean-cut and properly dressed, what stands out from the picture is a vacant stare. Try staring at the picture and making a connection with it. You can’t. The smile also seems forced. In a video of him when he was age 18, note how when he speaks to the audience in front of him, he mostly looks at the presentation screen or at the floor, and when he does look in the audience’s direction, his eyes go out to right, preventing him from properly connecting with them.  He also never seems to directly turn and face the crowd in the clips shown.

The vacant stare, forced smile, and difficulty emotionally connecting with others is consistent with the repeated theme that has emerged in media reports from people who knew him (or knew of him) which is that he was shy, introverted, aloof, socially inept, stubborn, quiet, that he stayed to himself, and was easily forgotten.  This information, combined with other information below, makes me wonder if he has Asperger's syndrome, a condition manifested by qualitative impairment in social interaction and restricted repetitive and stereotyped patterns of behavior, interests and activities.

It seems that Holmes was teased, probably related to his social awkwardness, and that he did not know how to handle it and held his emotions in.  For example, a H.S. classmate said, "He was the kind of person that if you teased him, he would sit there and smile and really not do anything about it."

Many have remarked about his lack of on-line presence, at least under his real name. He apparently does not have a Facebook or Twitter account. Although he had a MySpace page, he either never had any friends or the friends were deleted due to an inactive account. Note how in his MySpace picture that both eyes are closed, apparently at a restaurant,which seems strange. He appears to have had more recent account with the website, Adult Friend Finders, and another profile with Match.com. This indicates, given the other information that has come out about him, that he was having trouble finding a sexual partner using normal behavioral methods (e.g., introducing himself to someone, dating, etc) and was trying to bypass that by going directly to an exclusive sex dating site and swinger service. By this time, he had dyed his hair orange and was asking “Would you visit me in prison?” In a picture of him on Match.com he again seems awkward, with a strange smirk, one eye almost closed, and his head tilted to side. Maybe the sun was shining in his eyes, but all of the pictures seem odd for one reason or another.
Despite stellar grades, Holmes was unable to find a job. One wonders if it was due to his social awkwardness and extreme rigidity and stubbornness that caused him to perform terribly during a computer  programming summer internship. He had been giving off social cues, at least recently, that there was something seriously wrong with him. For example, it was recently discovered that he had a “bizarre, guttural, freakish” sounding answering machine message. It seem like he was struggling to fit into society and recently decided to withdraw from his PhD program. He was trying to pay for college by working part-time at McDonald’s, which obviously is not going to work. Some say he seemed depressed. He would not acknowledge people in his apartment complex who said hello. At some point,  it appears that he had enough. People who decided to shoot members of the public at random can get to that point by being convinced that the world (or a particular society) is the enemy and needs to experience retribution. To someone who thinks this way, there are no more individuals. Each person is simply viewed as a reflection of the society as a whole that the person despises.

In the case of James Holmes, such feelings may have been brewing for some time. It has been said that he always rooted for the bad guys to win and loved to play fantasy role playing computer games.  While there is nothing wrong with that, it seems that Holmes eventually had difficulty detatching fantasy from reality and eventually over-identified with the Joker character, most like Heath Ledger’s award winning version.  The Joker is known to take his anger out against the world through violent means, which sometimes involves using explosive devices and guns in public places. This may account for the dyed hair (although it is strange he did not dye it green) and would account for why he committed this crime during a Batman movie, identified himself as The Joker when police arrived, and is reportedly still carrying out the role in prison.

Note: The comments above are based on early media stories, are preliminary, and partly speculative. Also, I have never evaluated Mr. Holmes.

Related Stories: Cannibal Icepick Killer Luka Magnotta was Not Born Evil
                         A Psychological Profile of Chardon School Shooter, TJ Lane
                         A Psychological Profile of Wade Michael Page: The Sikh Shooter 

Why I Contributed to New York's Psychology PAC

In advocating for psychology, a quote I have often passed on to colleagues is that “if you are not at the table then you will be on the menu.” This quote has been around since about 2000 as a Washington D.C. political saying. From a professional perspective, being on the menu in psychology is analogous to having something adverse occur to our profession on a state or national level resulting from a legal or regulatory action.

The more I become involved in professional advocacy/lobbying efforts, the more I have realized that being at the table is necessary but not sufficient to avoid being placed on the menu. You must also have strength when you are at the table.

There are four main ways to obtain this strength. One way is having a strong argument – but that is not enough. The strong argument has to deal with an issue that is publicly and politically beneficial for a politician or political appointee to support and ideally should have some type of emotional appeal. The second way is to have friends in powerful places – those who are closest to making the important decisions. An example of this that has nothing to do with psychology draws on my love of cinema. When Paramount chief Bob Evans was making the film “The Italian Job” he needed to film in Turin, Italy, and have the city shut down. He happened to know the most powerful man in the city who had the police and other government officials give Paramount everything they need to make the picture. Evans has remarked how that connection enabled him to do in one day what the President of the United States could not have done in one year.  The third way to obtain strength, at least with politicians, is by making a financial contribution to their political campaigns. This is how you maintain existing political friendships and make new ones.  Lastly, another way to gain strength at the table is to move yourself into a position where you play a major role in the important legal and regulatory decisions that are made.

In an ideal world, strength of argument alone would be enough to allow psychologists to obtain successful professional advocacy results. However, the real world simply does not work that way. We have already seen in New York where state regulators banned the use of psychology technicians and where legislators limited return to play decisions in concussion management to physicians only (thus no longer allowing psychologists with expertise in this area to perform this function). State regulators then followed this up by only naming school nurses as health care professionals who could perform cognitive testing in concussed athletes. Psychologists in New York were caught off guard in the former circumstance but were at the table for the latter. The problem is that we did not have enough strength at the table. Other professions did.

So, what can you do about it? One of the most important things you can do is to make a donation (however small) to PLANY, which is New York’s political action committee (PAC) for psychologists.  The PAC is expressly designed to allow special interest groups access to legislators so we can have a meaningful say in proposed legislation.  Politicians love donations from PACs because they do not need to spend any money soliciting the donation. The larger the PAC, the more influential it is. The PAC becomes larger and more influential with more donations. 

This is where YOU come in, if you are a psychologist reading this. For example, if you want the limited liability company laws (LLC) in New York State amended so that psychologists could be authorized to form LLC partnerships and corporations with physicians on a co-ownership basis, you should donate to PLANY to help get this done. This change is very important because it aligns what we know about best practices and would enable for the first time the creation of corporate partnerships between psychologists and physicians, putting psychology on an equal footing with medicine in our state. With health care reform here, this is something we cannot miss out on.

I want to challenge every psychologist reading this to donate to the psychology PAC in your state, even if it is a small amount.  Doing so would be a great way to help advocate for your profession. To donate to PLANY, please go to this link above for more information.

The Medical History of Coca-Cola You Never Knew

Long before the modern day Coca-Cola beverage existed that billions of people drink around the world today, there existed a drink known as coca wine. Coca wine was sold in the 1800s alongside many other beverages at the time that contained cocaine. While this may sound shocking to some people today, back then, cocaine was a commonly used medicinal substance and it was not illegal.

For example, see the prior blog entry on the use of cocaine tooth drops.
Coca wine contained 30 grains of Erythroxylum coca per ounce of wine. Erythroxylum coca is one of two species of cultivated coca and is used to make cocaine (a stimulant drug). When wine is combined with cocaine, it creates a substance called cocaethylene. When ingested, it is almost as strong as cocaine.

Below are pictured two images of a coca wine bottle from Metcalf’s Coca Wine (click to enlarge).  As you can read from the back of the bottle, manufacturers of such drinks marketed them based on medical claims, leading consumer to believe that coca wine could cure just about any sign or symptom (i.e., “…a remedy for every malady…”). It was advertising as treating headaches,  anxiety, fatigue, depression, and fever, soothing  the vocal cords, aiding digestion, and more. However, these drinks were also used for pure pleasure seeking purposes.  It was specifically marketed to children, elderly, and people who were in a stage of healing, as you can see written on the back of the second bottle.



Metcalf’s coca wine was not the only one on the market (Vin Mariani was a famous brand in Europe), but it was one of the most popular. The manufacturers claimed that a medium dose of their wine produced a slow and sustained effect different from the excitation caused by any other wines. The dose? Three wineglasses a day! It is because of questionable medical claims such as these and the lack of dose modification for children versus and adults that stricter regulations over pharmaceutical substances later came to pass. It is interesting to note the marketers claiming a benefit of a slow and sustained release because it reminds me of the present day and age when drug companies market slowed release forms of stimulant medications (e.g., Ritalin) to treat children with attention deficit hyperactivity throughout the day.

Metcalf’s coca wine was run by Theodore Metcalf (1812-1894), a pharmacist who ran a widely known pharmaceutical business, selling products all over the world. His store was a mecca for famous people such as Charles Dickens and Oliver Wendell Holmes. Millions of prescriptions were filled by the company, written by some of the greatest physicians of the time. When Metcalf retired, he transferred the store to others. 

Eventually, John Pemberton of Atlanta, created his own version of coca wine, based on the Vin Mariani beverage. He called it Pemberton’s French wine, sold it in a pharmacy, and promoted it as a stimulator of the sexual organs. Once the Prohibition began in 1886, Pemberton replaced the wine in coca wine with sugar syrup and Coca-Cola was born. He marketed it as “the temperance drink” and once again, it is seen in the ad below that it was promoted as a cure for all nervous conditions even though this is obviously not true. Coca-Cola initially contained cocaine. Due to growing concerns about drug addiction in the U.S., cocaine was removed from Coca-Cola  in 1904 (except for trace amounts), but the cola leaf remained.  Now days, there is no cocaine in Coca-Cola at all. Cola wine no longer exists today in legal form but it led to a drink that almost everyone has tasted.

Reference: Mason, B. (1908). The Metcalf Pharmacy in Boston. Bulletin of Pharmacy.  I (XXII), 279-82.

How New York Fumbled the Ball on Concussion Management

Below is a copy of a letter I sent today to Deputy Commission Ken Slentz at the Office of P-12 Education at the NY State Education Department (SED). The letter concerns opposition to aspects of the Concussion Management and Awareness Act.


The letter also addresses opposition to aspects of the concussion management regulations published by the State Education Department (SED) due to concerns that the safety and well-being of children are being put at risk, despite the best of intentions. The law excludes psychologists with expertise in concussion management and evaluations (e.g., neuropsychologists) from making return to play decisions in children who have suffered concussions. The subsequent regulations do not do enough to recognize the important role that neuropsychologists play in concussion evaluation and management.

If you are as concerned as I am about this issue, parents, students, health care professionals, and others should a) forward this letter to others, b) spread the word via social media and other media sources, and c) contact Senator Kemp Hannon, Assemblywoman Catherine Nolan, and those copied at the end of this letter to voice your opposition and advocate for the amendments to the law and regulations listed below.

Historical background:

Since 7/12/10, the New York State Association of Neuropsychology (NYSAN) and other state and national psychological/neuropsychological organizations have been in contact with multiple sponsors (i.e., Senators Hannon and Stachowski, Assemblypersons Nolan and Benedetto) regarding the Concussion Management and Awareness Act. Through these contacts, we advocated for reverting to the language in an earlier draft of the bill (S07572) that specifically allowed for “a licensed health care provider trained in the evaluation and management of concussions” to make decisions about return to competitive play and physical activity after a known or suspected concussion (mild traumatic brain injury). This would have allowed for our profession to continue in this role, which helps ensure the safety and well-being of children.

Despite our repeated advocacy and educational efforts, the bill states that only physicians are allowed to make return to play decisions after concussion, thus removing part of a psychologist’s scope of practice in New York and creating unnecessary health risks for children (see below). Ironically, the profession (i.e., neuropsychology) that has contributed the most research on understanding the effects of concussions, developed the cognitive assessment tools and symptom checklists now promoted by SED, and led the way in operationally defining a mild traumatic brain injury* is now not legally permitted to pull or return athletes from play in New York after suffering a known or suspected concussion. Meanwhile, physicians whose primary area of expertise is not directly related to neurological functioning (e.g., cardiologists and pulmonologists) are performing cognitive evaluations of such patients and provide return to play clearance.

NYSAN raised the above concerns with the Governor's Office before Governor Cuomo signing the bill into law but the office was non-responsive to our concerns. Senator Hannon (sponsor of the bill) informed me (and others) before the bill was passed that psychologists might be added through an amendment but after the law was passed it is our understanding that there are no such plans at this time. It was suggested to us through Senator Hannon’s and Assemblywoman Nolan’s office that psychologists could have a role in developing the regulations that were published by SED on the practical implementation of the law.

Opposition to Aspects of Current  SED Regulations:

Dr. Dominic Carone served as the New York State neuropsychology representative to SED (by their request) regarding the development of their concussion regulations, but the feedback and edits provided about adding neuropsychology more prominently in the document were essentially ignored and removed. The edits were not intended to change the law regarding who could provide return to play clearance (which we hoped to do with an amendment) but were designed to recognize the important role of neuropsychologists in concussion management and evaluations.

In the final version of the regulations, which were not released to us before they were finalized, new language was added stating that it is a role of school nurses to provide neurocognitive baseline evaluations and similar assessments with concussion patients to aide the physician in understanding the status of the child. This was the only profession specifically singled out to perform these evaluations. While a for-profit test company may provide a certificate to various health care professions to use such tests, this does not equate to the training and education on concussion management and evaluation provided through formal education and professional training in the neurosciences. The most qualified health care providers to provide this service are neuropsychologists due to their formal education and training in cognitive assessment, neurosciences (e.g., neuropathology, neuroanatomy), statistics, emotional pathology, symptom validity assessment, and other factors that are crucial towards interpreting test scores and patient presentations.

While NYSAN agrees with many aspects of the legislation and regulations, we believe that they unintentionally place children at risk of harm due to the problems noted above. As such, Dr. Carone requested that his name be removed as an advisor to these regulations and the request was granted. Neurocognitive evaluations can easily be misinterpreted by those who do not have formal expertise in this area, causing children to be cleared to return to play too early which risks further neurological injury. Another risk, which is rarely discussed in the media but often encountered in clinical circles, is withholding players from most physical activity and/or school for excessive periods of time, resulting in emotional pathology, declining academic performance, over-medication, and development of the sick role.

Action Points:

Our organization strongly recommends an amendment to the state law and regulations to be inclusive of our profession. Legally, this means broadening the language as we originally requested to be consistent with that of so many other states. In terms of regulations, this means specifically recognizing the important role of psychology/neuropsychology in the Concussion Management Team. Please note that neuropsychologists are included on the staff of NHL and NFL teams to aide in making return to play decisions after concussion. In addition, the National Athletic Trainers' Association recommends that a neuropsychologist should ideally be part of the sports-medicine team when evaluating players who have sustained a concussion (Guskiewicz, et al. 2004).Why would New York State not afford children that same layer of safety, protection, and expertise that are afforded to professional athletes?

I have copied Senator Hannon and Assemblywoman Nolan and request a personal meeting (separately or together) to discuss ways to move forwards on an amendment process. I will be happy to discuss this information further and my contact information is listed below.

*Note: Dr. Thomas Kay, a New York neuropsychologist, was the senior contributor of the American Congress of Rehabilitation Medicine’s operational definition of mild traumatic brain injury used throughout the world today. See the attached document for more contributions of neuropsychology. 

Reference: Guskiewicz, et al. (2004). National Athletic Trainers' Association Position Statement: Management of Sport-Related Concussion.  J. Athl Train. 39: 280-297

Sincerely,
Dominic A. Carone, Ph.D., ABPP-CN
Diplomate, American Board of Clinical Neuropsychology
NYSAN Past-President

cc: Mr. Ken Slentz, Deputy Commissioner,Office of P-12 Education,NYS Education Department, 2M West EB,89 Washington Avenue,Albany, NY 12234
The Honorable Senator Kemp Hannon, The Capitol Room 420, Albany, NY 12247
The Honorable Assemblywoman Catherine Nolan, 836 Legislative Office Building, Albany, NY 12248
Doug Lentivech, Esq., Deputy Commissioner, Office of the Professions, New York State Education Department, 89 Washington Avenue, Albany, NY, 12234

How Ripley's Believe It Or Not was Used by Big Tobacco

In the early 1980s, I used to love watching the Ripley’s Believe It or Not TV show with Jack Palance. There were and still are many Ripley’s Believe It or Not books, filled with all sorts of strange images, similar to these pictures on extreme human body parts. I also remember playing a Ripley’s Believe It or Not trivia game at the time, with the purpose being to tell whether or not what was stated on one of the cards was true or not. They also had questions like this on the TV show too.

Ripley began publishing brief panel articles in The New York Globe in 1918 featuring odd news and facts from around the world. In 1929, the famous publisher, William Randolph Hearst, began running these panels in his papers (syndicating them in 17 papers worldwide), increasing their exposure and popularity. In the 1930s, Ripley expanded into radio, short films, and opened a museum. In 1936, he was voted by New York Times readers as the most popular man in America.  As such, his endorsement was highly coveted by advertisers, including the tobacco industry.

Below (click to enlarge) you will see what is actually an advertisement for Old Gold cigarettes (established in 1926) designed to look like one of the Ripley panels. Old Gold is a cigarette brand of Lorillard Tobacco Company. Note their common advertising phrase at the time “Not a Cough In a Carload” features in the ad.

In the ad, the reader is informed about a “public test” of four cigarette brands in which Old Gold is reportedly chosen by otolaryngologists (ear, nose, and throat doctors or ENTs) as the best cigarette, leading to the eye catching headline.

Note that not a single one of the doctors are identifiable in the ad. The person in the dark suit is Ripley. Using ENT’s  was purposely designed to enhance the credibility of the sales pitch. After all, if cigarettes are believed to cause irritability to the nose and throat area, what better doctors to endorse a cigarette purporting not to cause such ill effects. Ripley claims to have run a blind experiment but unlike descriptions of true experiments, the reader is not told how many ENTs tried the cigarettes or what the cigarettes were that they were being compared against.

The ad also claims that there was a “decisive ratio” of 2 to 1 in favor of Old Gold but the reader has no idea if this is truly significant from a statistical perspective. Old Gold received 50% of the votes, two other brands received 25%, and another brand received no votes. To illustrate how misleading these percentages can be, if there were only four ENTs, and two picked Old Gold and one picked two other brands, then 50% liked Old Gold and 25% liked one of the other brands. But if there were only four ENTs in the test, the numbers are misleadingly inflated.

For those interested in learning more about how ENTs were used by the tobacco industry to cover up tobacco’s link to cancer, see this paper (the title says it all): The price paid: manipulation of otolaryngologists by the tobacco industry to obfuscate the emerging truth that smoking causes cancer. Believe it...or not.