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Monday, November 14, 2016

Informatics coding update: DSM 300.4.DJT (F34.1.Trump)

 Saw this over at The Daily Beast:
This Election Had Medical Consequences—And I Gave Them a Name
I’m a sleep disorder specialist, and many of my patients couldn’t sleep because of the election—and the anxieties that underlay it.

Qanta Ahmed

For months now, I have left the exam room after a patient visit feeling unsettled- not by my patient’s clinical challenges but by the suffering of my fellow American. Dozens of my patients report fear, sleeplessness, dread, worry and dejection over “America,” “the future,” “what’s coming next?” or, in these past days, what happens “after Election Day.” Some are felled by the shock of the Trump presidency that will soon be a reality, and many have spent long moments sobbing, heartbroken in my office.

Countless are torn at the state of the country and having no choice. Noticing this so often these past months, I came up with a name for these symptoms: Election Dysthymia...
Interesting. She cites this book:

Anthropologist Hugh Gusterson and Catherine Besteman edited a fascinating volume of essays, The Insecure American: How We Got Here and What We Should Do About It. The book, with an eloquent forward by Barbara Ehrenreich, describes how Americans once believed themselves intrepid. But defeat in Vietnam, the energy crisis, our undeniable economic decline and wage stagnation changed all that.

Reading the book rings frighteningly true to me- my patients embody many of these essays. Every day I meet patients working sixteen-hour days or longer, married couples holding down four sometimes five poorly paid jobs between them struggling to make ends meet. And, after almost twenty five years treating Americans I am struck by their escalating poverty- both financial and in quality of life, despite their extraordinary work ethic, an ethic which all too often costs them their health...
"The book, with an eloquent forward by Barbara Ehrenreich..."

to wit,
Fifty or sixty years ago, the word insecurity most commonly referred to a psychological condition. Some people suffered from “insecurities”; otherwise, though, Americans were self-confident to the point of cockiness. Public intellectuals worried over the “problem” of affluence, which was believed to be making us too soft and contented. They held forums to consider the growing challenge of leisure, never imagining that their own children and grandchildren would become accustomed to ten-hour workdays. Yes, there remained a few “social problems” for sociologists to study—poverty, which was “discovered” by the nonpoor in the early sixties, and racial inequality—but it was believed that these would yield easily to enlightened policies. We were so self-confident that Earth itself no longer seemed to offer sufficient outlets for our energy and ambition. We embarked on the exploration of space.

It was at some point in the late 1960s or early 1970s that Americans began their decline from intrepid to insecure. The year 1969 brought the revelation of the massacre at My Lai and the certainty that the Vietnam War would end in disgrace as well as defeat. At the same time, the war was draining federal funds from Lyndon Johnson’s Great Society programs, vitiating health services and hundreds of community development projects. Then 1970 saw the first national observance of Earth Day and the dawning awareness that our environmental problems went beyond scattered cases of “pollution.” For the first time since Malthus, the possibility was raised that we might someday exhaust the resources required to maintain America’s profligate consumer culture.

American business, beginning with the auto industry, woke up, in the 1970s, to the threat of international competition and initiated its long campaign to reduce both wages and the number of American workers. By the 1980s, big business had started the dismantling of American manufacturing—sending the factories overseas and destroying millions of unionized blue-collar jobs. The white-collar workforce discovered that even they were no longer safe from the corporate winnowing process. In the old version of the American dream, a college graduate was more or less guaranteed a middle-class lifestyle.

In the emerging version, there were no guarantees at all. People were encouraged to abandon the idea of job security and take on the project of “reinventing” themselves over and over, as the fickle job market required—to see themselves as perpetual salespeople, marketing “the brand called you.”

Meanwhile, under both Ronald Reagan and Bill Clinton, the old confidence that we could mobilize collectively to solve social problems like poverty and racial exclusion was replaced by a growing mean-spiritedness toward the unlucky, the underpaid, and the unwanted. The war on poverty gave way to a war on crime, and when there were not enough crimes to justify this massive punitive enterprise, the authorities invented new ones—like the “crime” of drug possession and use. America achieved the embarrassing distinction of having the highest proportion of its citizenry incarcerated, surpassing both Russia and South Africa under apartheid.

Even into the new millennium, which brought the threat of terrorism and the certainty of global warming, we held our insecurities at bay with a combination of scapegoating, distraction, and delusion. Gays and illegal immigrants became our designated scapegoats, regularly excoriated by evangelists and cable news anchormen. War was at least a temporary distraction, even though it was the greatest non sequitur in military history: attacked by a group consisting largely of Saudi Arabians, the United States invaded Iraq. And then, at the personal level, there was the illusion of affluence offered by easy credit. If our jobs no longer paid enough to finance anything resembling the American dream of home ownership and college for the children, we could always borrow—take on a dodgy mortgage, refinance the house, sign up for more credit cards.

But distraction and delusion are not long-term cures for underlying anxiety. This book comes out at a time when more and more Americans are tumbling from insecurity into insolvency—bankrupted by medical debts, made homeless by foreclosure, ousted from their jobs by layoffs. The credit crisis that began in 2007, combined with stunning increases in the cost of fuel and ever-growing economic inequality, has created challenges not seen since the eve of the Great Depression. As I write this, the overwhelming majority of Americans believe that the country is “headed in the wrong direction” and fear that they will be the first generation to see their children live in more straitened circumstances than they have known.

The Insecure American would have been essential reading at any time in the last few years, but today it is indispensable. For the most part, we confront problems and issues only as they arise in the news cycle, taking them from sources usually short on facts and devoid of analysis. In contrast, the contributors to this book have been researching and thinking about their subjects—from militarism to health care, from foreign policy to poverty—for years. Many are academics who teach as well as write, and here they offer a powerful overarching lesson in clear and down-to-earth prose: that we can understand the forces that have robbed us of security, and—through understanding, combined with a renewed commitment to collective action—overcome them.

Barbara Ehrenreich
I extracted that from the Amazon "Look Inside" preview, which I also captured in full as a PDF. A fairly generous sample. One well worth your time. Notwithstanding that the book has a 2010 copyright date, it rings true to this election year and month. The takeaway is that "it's not like we couldn't see this coming."

And now we have this guy. Ugh.

"...more and more Americans are tumbling from insecurity into insolvency—bankrupted by medical debts, made homeless by foreclosure, ousted from their jobs by layoffs. The credit crisis that began in 2007, combined with stunning increases in the cost of fuel and ever-growing economic inequality, has created challenges not seen since the eve of the Great Depression..."

Yeah. I had a nano-role in the run-up to the FIRE sector crash of 2008, owing to my 2000-2005 tenure working in subprime risk analytics. Wrote about those experiences on another of my blogs. See "Tranche Warfare" and "The Dukes of Moral Hazard."

More Qanta Ahmed:
I am a sleep disorders specialist. People come to see me when they have trouble sleeping. Many of my patients have mental health issues that improve greatly when I treat their sleep disorders. While all my patients see me because they have sleep disorders, the intensity, the depravity and the relentlessness of the 2016 election cycle have resulted in an additionally corrosive assault on my patients...
I am getting close to finishing this book, which also delves into sleep dysfunction (mostly in the context of the adverse impact of 24/7 digital InfoTech obsessions).

Most of us will freely admit that we are obsessed with our devices. We pride ourselves on our ability to multitask -- read work email, reply to a text, check Facebook, watch a video clip. Talk on the phone, send a text, drive a car. Enjoy family dinner with a glowing smartphone next to our plates. We can do it all, 24/7! Never mind the errors in the email, the near-miss on the road, and the unheard conversation at the table. In The Distracted Mind, Adam Gazzaley and Larry Rosen -- a neuroscientist and a psychologist -- explain why our brains aren't built for multitasking, and suggest better ways to live in a high-tech world without giving up our modern technology. The authors explain that our brains are limited in their ability to pay attention. We don't really multitask but rather switch rapidly between tasks. Distractions and interruptions, often technology-related -- referred to by the authors as "interference" -- collide with our goal-setting abilities. We want to finish this paper/spreadsheet/sentence, but our phone signals an incoming message and we drop everything. Even without an alert, we decide that we "must" check in on social media immediately... - from the Amazon blurb
Will be reviewing it soon. For now a little snippet on sleep:
Research has also demonstrated that getting too little sleep can disturb memory in important ways. Of course, memory is a complex process that involves multiple areas of the brain, but one key component to memory is a solid cognitive control system without which the information would never get transmitted effectively or completely to memory centers such as the hippocampus. One study found that adults who routinely slept less than five hours a night were more likely to incorporate misinformation in their morning report of either photos or videos that they had observed before bedtime; some even reported that they had seen video footage of an event that never happened.

Gazzaley, Adam; Rosen, Larry D. (2016-09-16). The Distracted Mind: Ancient Brains in a High-Tech World (MIT Press) (p. 140). The MIT Press. Kindle Edition.
 "...reported that they had seen video footage of an event that never happened."

Anyone come to mind here? Say, a President-elect who prides himself on his manly 4 hours of nightly sleep?

BTW: There are implications for Health IT UX in The Distracted Mind. Stay tuned.


Excellent new post up on THCB:
The Age of Trumpian Uncertainty

The new Chief Executive Officer of the United States of America Inc. will take office January 20th and likely make good on his promise to repeal the Patient Protection and Affordable Care Act. It only requires a majority in both houses of Congress to pass and that’s assured based on the election results last week...
 Should healthcare in the United States be approached as a fundamental right or a privilege? In the constitution, life, liberty and the pursuit of happiness are guaranteed. Is access to a healthcare system a fundamental right for all in this country or is it reserved for those who can afford its services? In our system of government, we’ve concluded that education is a fundamental right for all. Is healthcare akin or different? And what’s included in that assurance: basic services for all, or exactly what?...


By Atul Gawande

How dependent are our fundamental values—values such as decency, reason, and compassion—on the fellow we’ve elected President? Maybe less than we imagine. To be sure, the country voted for a leader who lives by the opposite code—it will be a long and dark winter—but the signs are that voters were not rejecting these values. They were rejecting élites, out of fear and fury that, when it came to them, these values had been abandoned.

Nearly seventy per cent of working-age Americans lack a bachelor’s degree. Many of them saw an establishment of politicians, professors, and corporations that has failed to offer, or even to seem very interested in, a vision of the modern world that provides them with a meaningful place of respect and worth...

As the new Administration turns to governing, the mismatch between its proffered solutions and our aspirations and ideals must be made apparent. Take health care. Eliminating Obamacare isn’t going to stop the unnerving rise in families’ health-care costs; it will worsen it. There are only two ways to assure people that if they get cancer or diabetes (or pregnant) they can afford the care they need: a single-payer system or a heavily regulated private one, with the kind of mandates, exchanges, and subsidies that Obama signed into law. The governor of Kentucky, Matt Bevin, was elected last year on a promise to dismantle Obamacare—only to stall when he found out that doing so would harm many of those who elected him. Republicans have talked of creating high-risk insurance pools and loosening state regulations, but neither tactic would do much to help the people who have been left out, like Jim Young’s family. If the G.O.P. sticks to its “repeal and replace” pledge, it will probably end Obama’s exchanges and subsidies, and embrace large Medicaid grants to the states—laying the groundwork, ironically, for single-payer government coverage...


Some remarks I recently posted on Facebook.
Those of us who opposed and voted against Donald Trump are now members of the "loyal opposition." But, it is critical to continue to focus on that to which we are properly to be "loyal." The Constitution, yes. But more importantly, the ideals of equal justice for which it ostensibly stands.

Loyalty to the Constitution presupposes loyalty to the office of President it sets forth in Article II. But, that is a separate consideration from unreflective, unquestioning deference to the person who holds that office at any given time irrespective of how he (and, still a "he") behaves once in power.

To the extent that the new President Trump comports himself within the established confines of the Constitution, fine. We will continue to have the First Amendment right to peacefully disagree vocally with specific policy proposals and actions (which always happens, and is to be expected in a free society), but Mr. Trump should never be permitted to forget that loyalty is a two-way street.

It may become necessary for someone to read the Declaration of lndependence to him, given the voluminous record of autocratic, belligerent statements he has left us with thus far. That perhaps he doesn't actually believe all that crass, incendiary campaign shit is no less of a cause for concern.

Going to be an interesting year, my friends.
Also, Trump has made opaque pander-to-the-Fundies allusions regarding having Roe vs Wade overturned.
With respect to human reproduction (in particular the "life begins at conception" canard), the contribution of the male begins and ends with the sperm's successful delivery of the polymer molecules comprising ONE copy of the male's DNA that constitute his 23 chromosomes. Everything that takes place thereafter, starting with the ensuing division process begun by the single cell sperm-fertilized ovum, is a function of the female's gestational biology. all of the subsequent biological reproductive effort, and all of the medical risk.

The assertion that [1] a fertilized ovum is instantly a "person," and, [2] men should be able to declare for themselves "equal reproductive rights" tantamount to a veto over what a woman does with her body once pregnant are the most ignorant and arrogant things I've ever heard. It has nothing to do with "reverence for the sanctity of life," it has everything to do with reverence for dominant male power. Period.

Moreover, take men out of the picture, just to advance the argument a step further. The notion that some women should be able to use the force of law to deny other women the right to control their biology is equally specious. For starters, it violates the Equal Protection clause of the 14th Amendment.
Don't like abortion? Don't have one.
Then there's the issue of "dismantling regulations."
Consistent with his broad ignorance, Trump has no clue regarding "regulations." He claims he will just get rid of 75 to 80% of all federal regulations. First of all (beyond the fact that doing so is the purview of Congress, not the President), an apt analogy to law and regulation is the corporate "policies and procedures" we also all hate.

Laws tell us "what" and "why," and subsequent regulations tell us "who," "how," and "when" (the operational details). Regulations at the federal level are published in draft as Federal Register proposals, which undergo a prolonged period of public review and comment before they are finalized. Moreover, they cannot exceed the scope of the parent law. To the extent they do they are very quickly challenged in court and either overturned or scaled back. The various stakeholder groups are vigilant with respect to proposed regulations. We may not like the volume and complexity of them, but that's simply a function of the way legislation works in a nation of 330 million people.

I have worked in highly regulated environment for 30 years. EPA, NRC, OSHA, OCC, FDIC, and HHS. In my last job, I was the team lead on our staff for writing policies and procedures that were compliant with HIPAA medical privacy and security regulations covering our statewide Nevada Health Information Exchange. I know a thing or two about how this stuff works.

It's maddeningly tedious and complicated and imperfect. But, human affairs get regulated one way or another.

You want polluted water and air, toxic drugs, unsafe vehicles, poisoned foods, airplane crashes routinely?

Fine, do away with regulations.

The first new job created by the incoming Trump® Administration.


More to come...

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