Re: "What the Republican Plan Gets Right"

To the editor:

Mark Siegel (5/6/17, What the Republican Plan Gets Right) makes an absurd argument to justify the Republican plan to charge higher premiums to some patients and not others.  He speaks of a patient who 'insists' on seeing him too frequently for her seasonal allergies and asks 'shouldn't a patient who continues to see me unnecessarily pay more?'  

No. The physician is not an indentured servant.  If his treatment is  'unnecessary' why is he delivering that care? And how is the insurance company paying for treatment that is not medically necessary? Dr. Siegel points to the patient's low copay supporting this misuse but he places too little responsibility upon himself for taking his time and the insurance company's money to 'reassure', apparently without success, his patient.

Patients with a tendency to over utilize the health care system often suffer from an undiagnosed psychological problem - typically an anxiety disorder or depression.  Perhaps if reassurance is not effective, Dr. Siegel should  suggest his patient see a physician who can more effectively treat her worry.

Respectfully submitted,

Larry S. Sandberg MD

Re: "Video Games Aren't Addictive"

To the editor:

Doctors Ferguson and Markey (NY Times, 4/2/17; 'Video games aren't addictive') point to a large scale study about internet gaming to prematurely conclude that video games are not addictive but a 'normal behavior' that for some may be a 'waste of time.'  In clinical practice, there are some patients whose gaming activities profoundly interfere with the work and social demands of living.  For some individuals it manifests itself as part of a severe depression, social anxiety, or incipient psychosis; that is, it is symptomatic of another primary psychiatric diagnosis. For others, it appears to be consistent with a pattern of addictive behavior. It seldom surfaces as a complaint by the individual. 

Given that tens of millions of people engage in gaming, one would not expect this behavior to be pathological for the majority who engage in it. Time will tell whether or not it makes sense to make gaming addiction a formal psychiatric diagnosis or to refine the diagnostic criteria so that it is more sensitive in revealing pathology.  It will also take more time to discern if there are adverse developmental consequences for young people whose game playing is increasingly in the virtual world.

While the research the authors report is reassuring, it is premature to make a definitive clinical judgment about the health effects of gaming.

Respectfully submitted,

Larry S. Sandberg MD

Re: "Why It's OK for Doctors to Participate in Executions"

4/22/17

To the editor:

 It is only with twisted logic that Sandeep Jauhar (4/21/17, Why It’s OK for Doctors to Participate in Executions) can argue that physicians have a rightful role in participating in the executions of convicts sentenced to death.

 It is absurd to equate the suffering of a terminally ill patient with a death-row inmate. The former is being destroyed from within; the latter by the state. Alleviating the suffering of a dying patient by offering end of life care is not the same as choosing to be a tool of the state. Such complicity not only violates the Hippocratic Oath to do no harm; it masks the barbarity and inhumanity of taking a life.

 A physician’s refusal to partake in enforcing capital punishment creates a necessary impediment to its implementation. Dr. Jauhar opines that more crude means of execution – like death by firing squad – may gain in popularity. If so, perhaps that will lead more Americans to ask why we are the only Western country to use the death penalty.

Respectfully submitted,

 Larry S. Sandberg MD

Re: "Trump Digs in on Wiretap, No Matter Who Says Differently"

To the editor,

President Trump's struggle to grasp reality should be of great concern to all Americans.  His reliance on unsubstantiated claims on Fox news that former President Obama wiretapped his phones using British intelligence shows that he is grasping at straws not the truth.  As you report, (NYT, 3/16/17, Trump Digs In on Wiretap, No Matter Who Says Differently) 'Much like his longstanding assertion that Mr. Obama was not born in the United States, Mr. Trump dismisses contrary information with undiminished surety.'  As a psychiatrist and psychoanalyst, I am in no position to offer a diagnosis of President Trump's underlying mental condition.  But this mode of thinking, whatever its cause, puts our country in harms way.  President Trump poses a risk to our national security and patriotic Americans, regardless of party, should speak out for love of country.

Respectfully,

Larry S. Sandberg, M.D.

Re:

To the editor

Allen Frances (NYT, 2/15/17), an eminent psychiatrist, contradicts himself by chastising those psychiatrists who have diagnosed President Trump from afar.  He asserts that President Trump while a 'world class narcissist' does not suffer from a personality disorder because one criterion, subjective distress and impairment, is not present. 

Not having examined President Trump personally, how can he exclude the presence of subjective distress?  Moreover, independent of President Trump's diagnosis, how can he exclude 'impairment' given the obvious trouble he has displayed in carrying out his functions as President?

Dr. Frances is correct that ultimately it is a political solution that is needed.  But it is neither stigmatizing to people with mental illness nor inappropriate for experts on the mind to offer their perspective and insight into the current turmoil facing this country.

Respectfully

Larry S. Sandberg MD

Re: "Bannon Says News Media Should 'Keep its Mouth Shut'"

To the editor:



Stephen Bannon (NYT, 1/27/17, Bannon says news media should ‘keep its mouth shut’) unsurprisingly fails to recognize and respect the crucial role of journalism in our democracy. His unapologetic contempt is chilling. What exactly does he mean when he says of the NY Times ‘They got it 100% wrong?’ Presumably he is referring to the polls predicting a Clinton victory.  What else?  What we are currently witnessing with President Trump is thoroughly in line with the in depth substantive reporting by the vast majority of news outlets, including the New York Times, leading up to the election.


The fact that so many Americans were uninterested in the facts, pinning their hopes on a motto of making American great again and informed by fake news says more about the electorate than journalism.  Our democratic way of life is being assaulted and journalists are in the front line fighting for our democratic way of life.



Respectfully



Larry S. Sandberg

Re: "A Lie by Any Other Name"

To the editor:



Charles Blow (‘A lie by any other name’, NYT 1/26/17) is right to insist that President Trump’s lies not be euphemistically downgraded into something more benign.  The problem is that President Trump believes his own lies. He seems unfazed by the fact that to most rational minds his false assertions are preposterous.  Rather than recognize that it is only the truth being spoken (albeit a painful truth), President Trump sees labeling his statements as lies as an attack against him. To bolster his misconception he orders an investigation as if that will legitimize his belief.  I think this is what Barack Obama had in mind when he deemed Trump unfit to serve.

I hope that patriotism will take priority over partisanship as members of both parties recognize their role in the balance of powers.  I hope the media will not be bullied and will flourish during these trying times. And I hope that Americans, including those who support President Trump, will make their voices heard and insist that the truth govern the important decisions that need to be made.



Respectfully,



Larry S. Sandberg

Re: "Meeting With Top Lawmakers, Trump Repeats an Election Lie"

To the editor:

Re. Meeting with top lawmakers, Trump repeats an election lie (NY Times, 1/24/17): I applaud the NY Times for calling President Trump out for lying in his assertion that he lost the popular vote because unauthorized immigrants voted for Hillary Clinton.  Unlike the sociopath whose lies are an intentional effort to manipulate others, all evidence suggests that above all President Trump is telling himself a lie because the basic facts are simply too painful for him.  He seems unfazed by the fact that to most rational minds his assertions are preposterous. 

I hope that patriotism will take priority over partisanship as members of both parties recognize their role in the balance of powers.  I hope the media will not be bullied and will flourish during these trying times. And I hope that Americans, including those who support President Trump, will make their voices heard and insist that the truth govern the important decisions that need to be made.

Respectfully,

Larry S. Sandberg

Re "Putin Led Scheme to Aid Trump, Report Says"

1/7/17

To the editor:

There has been too  much focus on the role of Russia in its covert efforts to influence the outcome of the past Presidential election while ignoring an inconvenient and worrisome fact (NYT, Putin led scheme to aid Trump, report says, 1/7/17). The Russians have a treasure trove of RNC emails that they can choose or not choose to leak at a moments notice. Hillary Clinton lost the election by a minuscule amount when looking at the three swing states that gave Donald Trump the election; we now will have a President in office whom Russia is capable of blackmailing at any time.

Respectfully

Larry S. Sandberg

Re: "Sorry Liberals. Bigotry Didn't Elect Trump"

To the editor:



David Paul Kuhn (Sorry liberals. Bigotry didn't elect Trump, NYT 12/27/16) cites numerous statistics to bolster his claim that bigotry, while more prevalent among Republicans, was not a cause of Trump's victory. He further suggests that to evoke such an explanation is to engage in stereotyping.

Bigotry, like implicit bias, impacts decision making often outside our conscious awareness. We are all vulnerable. The studies reported by the author do not eliminate bigotry as a 'cause' of Trump's victory. 

As hate crimes are on the rise and Trump continues with his divisive rhetoric we blind ourselves to the appeal of an 'us versus them' mentality at our own peril.

It is naive to conclude thatTrump won only because of bigotry. Trump won for many reasons. Appealing to man's - and woman's- more base instincts was one of them.



Respectfully 


Larry S Sandberg

Re: "Going Beyond 'Do No Harm'"

11/5/16

To the editor

Haider Javed Warraich (Going beyond 'do no harm') rightly encourages the medical profession to rethink its attitude towards assisted suicide for the terminally ill.  He notes that the often evoked worries around this intervention (encouraging 'eugenic sterilization', harming the vulnerable and uninsured, avoiding palliative care) have not been borne out based on all evidence.  However, he leaves out the most important clinical consideration: the presence of a major depression that exists alongside a terminal medical illness.  A careful clinical assessment by a psychiatrist is crucial to make sure the patient's wish to die is not part of a treatable psychiatric illness.

Respectfully,

Larry S. Sandberg MD

Re: "Intimacy for the Avoidant"

10/7/16

To the editor:

Donald Winnicott, a Britiish pediatrician and psychoanalyst, spoke of the endearing objects young children often have a special attachment to - raggedy stuffed animals or dolls, blankets held onto on their last thread - as 'transitional objects.'  These things soothe children by creating a bridge or link to the most important person in a child's life during periods of separation - typically one's mother.  Over time, these objects are given up having outlived their usefulness.  The child's secure attachment to her mother is internalized and forms the basis for building healthy intimate relationships.

David Brooks (NYT, 'Intimacy for the avoidant', 10/7/16) describes a perverse form of this phenomenon for individuals with a 'phone addiction.'  Perverse because the 'security blanket' of the smartphone is not a link to a deeply loved other; rather it is a poor, superficial substitute.  Perverse because it is not transitional; it cannot be relinquished as there is no deeper attachment to replace it. 

Technology, as David Brooks notes, can be a valuable tool to build relationships . But for some the seductive appeal of distance, relative invulnerability and, sometimes anonymity, can inadvertently convert the tool into an impediment to intimacy. I think we are all vulnerable to this addictive behavior.  Caution is warranted in the use of these devices especially with young people whose brains, minds, and social capacities are being actively developed.

Respectfully,

Larry S. Sandberg MD

Re: "Trump's Latest Birther Lie"

9/17/16

To the editor:

As Trump continues to be Trump (NYT, 9/17/16, 'Trumps latest birther lie'), Hillary Clinton repeatedly gets attacked for being such a weak candidate asserting that any other reasonable opponent would have buried Trump in the polls by now.  But it should be remembered that it was Trump who buried a field of over ten other Republicans some of whom possessed the character and potential competence to be President.  

Hillary Clinton's description of many of Trump's supporters being the the 'basket of deplorables' was insulting to a large part of the electorate. But his popularity begs the question: how can someone whose comments are, by and large, deplorable be acceptable to so many people? How can he be so appealing to so many people? 

I am sure the answers are complex but I think it is naive to believe that people support Trump in spite of his duplicity and hostility towards so many sectors of the population.  It is even more naive to believe that 'if only' there were a less flawed candidate running against him Trump's popularity would dwindle. 

Respectfully submitted,

Larry S. Sandberg

Re:

9/16/16

To the editor:

Buried in the today's paper (NYT, 9/16/16) Trump is said to be in 'excellent' health in new doctor's note while noting his calcium score was 98 in 2013 and his blood sugar level is 99.  The previous day we learned (albeit absent in his 'doctor's note') that based on his BMI he is obese.  The calcium score measures plague build up in the coronary arteries and, if it has risen minimally since 2013, would put him at risk for a cardiovascular event.  Per the Mayo Clinic: 'A score of 100 to 300 — moderate plaque deposition — is associated with a relatively high risk of heart attack or other heart disease over the next three to five years.' Why was the test done in the first place?  Has it been repeated?  Has he had a stress test?

The article also points out that Trump's glucose is teetering on being considered 'pre-diabetic'.  A measurement of hemoglobin A1C is a more sensitive marker but none is reported.

Donald Trump may be in good health or even very good health.  But the judgment that he is in excellent health is contradicted by the few objective facts that have been released. All politicians running for the highest office should be held to the same standard of disclosure about their underlying health.  And we should not take at face value the judgment of a personal physician when that judgment is at odds with much of the sparse data that judgment seems to be based upon.

Respectfully,

Larry S. Sandberg MD

Re: "A Fatality Forces Tesla to Confront its Limits"

To the editor:



While the cause of the accident that killed a driver in a self-driving car (A fatality forces Tesla to confront its limits, 7/2/16) remains to be determined, the assertion by Tesla that data is 'unequivocal' supporting the enhanced safety of self-driving should be strongly challenged. 

Driving conditions in the real world are incredibly complex. When is the benefit of 'decreased workload' offset by inattention? When does the relative passivity encouraged by Autopilot decrease reaction time? In what ways might the driver non-consciously become a 'back seat driver'? 

As a psychiatrist who appreciates how sophisticated the brain is I would argue that safe driving is no doubt enhanced by some technology. However, we risk losing ourselves - literally and figuratively- in becoming overly reliant on technology. Energy, time and money would be better spent teaching our youth the dangers of using technology while driving rather than chasing a grandiose dream.



Respectfully,



Larry S Sandberg

Re:

1/24/16

To the editor:

Sally Satel and Scott Lilienfel (NYT, 1/24/16) criticize American culture for promulgating the idea that shame ‘is … a damaging, useless emotion….’. They criticize efforts to ‘eradicate’ shame (by likening drug addiction to cancer) for those with addictions worrying such individuals will see their ‘habits as unalterable.’

Shame, as a universal social emotion, serves an evolutionarily adaptive function. It is also extremely painful and often dealt with by hiding. Contrary to the authors’ assertions, I believe our culture tends to stigmatize people with addictions– to wit the authors use the pejorative label ‘addicts’. Such individuals often avoid treatment because of shame and destroy themselves in the process.

The role of agency is complex in illness whether dealing with addictions or illnesses the authors categorize as ‘biological.’ For example, a patient with lung cancer who smokes is a different patient than a nonsmoker. Regardless of the condition it is critical to mobilize the healthy part of the patient to take responsibility for his or her health. This has more to do with mobilizing self-love in the setting of shame.

Diminishing the stigma attached to addictive illness may help some people more readily enter treatment and come out of hiding. Twelve step programs intuitively integrate this into their philosophy by encouraging people to accept being powerless (i.e., to not ‘lose face’) in relation to their addiction while proceeding to do a moral inventory where reparation is an essential part of recovery.

Respectfully submitted

Larry S. Sandberg MD

Re:

11/27/15

To the editor:

'Turn the volume down on drug ads' (NYT, 11/27/15) glosses over the significant shift that occurred in the mid-1990's leading to the proliferation of direct to consumer advertising (DTCA).  At that time,  the FDA came increasingly under attack in its efforts to regulate the drug industry fueled, in large part, by the Republican Party's taking control of Congress in 1994. House Speaker Newt Gringrich called the FDA the 'no. 1 job killer' and the pressure to deregulate was intense. In 1997, the FDA, under pressure, clarified that drug companies could advertise their drugs as long as consumers were referred elsewhere (a website, a toll free number, a physician) for complete product information. The result? Between 1997 and 1998 television DCTA spending more than doubled; total DCTA advertising jumped from $1.3B in 1998 to $3.3B in 2005. For the pharmaceutical industry, this was also an effort to mitigate the growing role of managed care in encouraging the use of less expensive drugs.

Respectfully

Larry S. Sandberg

Re: "Believing What You Don't Believe"

To the editor:

Jane Risen and David Nussbaum (11/1/15, Believing what you don't believe) problematically argue that intuition is at the heart of certain behaviors that are either superstitious in nature (using a lucky charm) or reflect statistically unlikely judgements in decision making (an 'ill timed' sacrifice bunt). They suggest that the 'slow system' for information processing may be able to detect errors without correcting them. 

Emotion is a critical dimension in decision making even at high levels.  It may contribute to tragic outcomes  - look at what's going on in the Middle East - or acts of heroism.  A coach making a high risk call is not making an error; he is introducing an element of surprise into his decision making in an effort to win and to fool his opponent.  As for the lucky charm this too is not an error in thinking.  It is a token that helps create an illusion of power and control (and diminishes our anxiety ) and comes in handy, especially when your team is struggling. What the authors call intuition is the emotional dimension of life from which we cannot divorce ourselves.

Respectfully,

Larry S. Sandberg

Re:

10/20/15

To the editor:

New approach advised to treat schizophrenia (NYT 10/20/15) highlights the value of combining talk therapy and medication for patients with first episode psychotic illness.  But, as the article points out, this is not a new approach; nor is it a discovery as much as it is a rediscovery.  Similar programs have been in place in other countries for decades.  In most simplistic terms, the distinction is between treating the patient as a person having an illness as opposed to being the illness.  The former approach is compassionate and humanizing while helping patients manage reality - the core problem in psychosis - while minimizing the serious side effects of anti-psychotics. The latter approach leads to massive non-adherence as the article points out.

The finding is important because it highlights, for better or worse, the place of evidence based medicine in shaping the standard of care. On a practical level it is reassuring that the authors found that such care is within reach of this most vulnerable population.

Respectfully,

Larry S. Sandberg

Re: "A New Way to Tackle Gun Deaths"

To the editor:



In an otherwise powerful piece encouraging responsible gun policy (A new way to tackle gun deaths, 10/4/15), Kristof labels America's mental health care system a 'disgrace' both devaluing the hard work and effort of those of us treating mental illness and implying that an improved system would somehow reduce or eliminate such tragedies. Meanwhile, Kleinfeld and colleagues (Mass murders fit profile, as do many others who don't kill, 10/3/15), in reviewing the available data,  illustrate just how difficult it is to predict who will act violently.  An isolated, socially withdrawn, vengeful individual who sees himself as a victim is not the kind of person who seeks out mental health services. Whatever shortcomings exist in our mental health care system, the real disgrace is that our elected officials have sold out to the powerful gun lobby and no longer represent the will of the people.



Respectfully,



Larry S. Sandberg