Squeezed: Four Decades of the Juice Myth

Matt Freeman DNP, MPH

Tamara

I used to live down the street from a juice stand named “Tamara.” The juice was mouth-watering: whatever combination you could imagine. The passion fruit had a perfect tang, the grapefruit was sour, the oranges were ripe and sweet. Situated at the corner of Dizengof Street and Ben Gurion Boulevard, “Tamara” was the ideal location in Tel Aviv. It was easily accessible en route to the beach, on the way back from the beach, or while out for a stroll.

“Don’t you wish we invented, Tamara?” asked my friend, Ariel. “They just have a shack, some fruit, and they hire good-looking students to serve up the juice for the equivalent of US $6.

Ariel and I would chuckle at the juice bar across the street, which was staffed by a schlubby guy. He ne never had any customers. The Tamara brand exuded refreshing youthfulness.

Tamara never claimed to be anything but a juice bar. They served juice that tasted good; just a refreshing treat. They offered no illusion that they were serving some sort of magical elixir. To my knowledge, Tamara does not serve wheat grass.

An acquaintance, Nadav, made an odd claim about Tamara. “It’s a good place for smokers,” he explained. “They need the anti-oxidants so they do not get cancer.” Although not a smoker himself, quitting smoking did not seem to be on Nadav’s radar as a disease prevention strategy. And that’s when I started to think more about juice.

 

“I’ve gone back to juicing.”

I greeted one of my patients recently, and I asked how he had been feeling. “I’m in much better shape. I’ve gone back to juicing.” Paging Nadav.

In fact, many have embraced versions of Nadav’s scientific misconceptions. Oprah Winfrey, Mehmet Oz, Gwynneth Paltrow, and others have extolled the virtues of “juicing” as the key to a healthy weight and a healthy life. Forget flu vaccine, hand washing, seatbelts, or other self-explanatory measures to protect one’s health. The answer lies in juice.

Where does this appeal come from? Why has it been so sustainable?

Juice and Cleansing

Juicing—retail or homemade juice consumption—is frequently associated with the notion of “cleansing.” There are pervasive references for the need to cleanse the liver and colon.

Amid other functions, the liver converts fat-soluble toxins into water-soluble versions, which can be tossed into the colon via bile or into the kidney for excretion in urine.

The colon removes water and absorbs some nutrients, particularly vitamin K, B12, thiamine, and ribovlavin.

The liver and colon do this regardless of what one eats or drinks. In fact, the concept of “detoxifying” the liver is not a possibility. The liver itself detoxifies, so it cannot be detoxified by an external source.

Catherine Collins, a National Health Service dietitian at St George’s Hospital in London put it best. “It’ll probably give you a chance to reassess your drinking habits if you’re drinking too much. But the idea that your liver somehow needs to be ‘cleansed’ is ridiculous.”

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The liver would actually be dysfunctional if it were to be detoxified.

Cleansing advocates argue that toxins accumulate and line the interior of the colon. Moreover, these invisible toxins are weight-bearing and cleansing therefore leads to weight loss.

This is false. The colon is actually full of perhaps trillions of microbes: bacteria, fungi, and protozoa. In fact, the bacteria in the colon serve to produce a small but significant proportion of vitamins.

Bowel obstructions can form from a variety of sources, but this is really just a version of constipation: not an accumulation of “heavy toxins.” A total detoxification of the colon would be disastrous in terms of eliminating beneficial bacteria (so called “normal flora.”) Microbes, by definition, are “microscopic,” and so they just cannot be large enough to contribute to body weight.

 

The Origins of Fruit- and Juice-Based Diets

According to restaurant analyst Andrew Freeman, the most significant introduction of juicing in popular culture was the Beverly Hills Juice Club in 1975. (I know Andy Freeman. He is a great guy. But we are not related—at least as far as we know.) Coincident with a resurgence of American “vitamania” in the late 1970s, juice became allied with the notion that it is a gateway to missing nutrients, and thus a ticket to better health.

The Beverly Hills Juice Club also shortly predated the “Scarsdale Medical Diet,” introduced in 1978. A bestseller, the Complete Scarsdale Medical Diet was the first “ultra low calorie diet.” Although not juice-specific, the Scarsdale Medical Diet permitted “sliced fruit: as much as desired.”

 

The Complete Scardsale Medical Diet

The Complete Scardsale Medical Diet was the invention of Herman Tarnower MD, a cardiologist. Whether deliberate or not, Tarnower’s low-carbohydrate, low-calorie, but fruit-permissive diet was remarkably reinforcing. Diet followers enjoyed significant weight loss at the beginning of their adoption of the diet plan. It is, in fact, the same technique used by pretty much any popular diet: caloric restriction. By swapping half a grapefruit for a meal, Scarsdale dieters were limiting themselves to fewer than 1,000 kilocalories per day.

The body responds with as one might expect in a state of starvation: it digs into energy stored as glycogen. Glycogen itself is connected to water, so there is a substantial fluid loss during the first week or two. The grapefruit or unlimited sliced fruit are not magic: it is just fluid loss.

One of Tarnower’s diet followers was his girlfriend, Jean Harris. Headmistress of the Madeira School in McLean, Virginia, Harris was losing extra pounds on the Complete Scarsdale Diet.

There was one additional element that “completed” the diet: amphetamines. Tarnower was prescribing speed for Harris, which undoubtedly led to further weight loss. The drugs also contributed to her shooting Tarnower to death in 1980. (Not to name drop again, but Jean Harris and I grew up on the same street.)

Over the coming decades, various reincarnations of The Complete Scarsdale Medical Diet surfaced. All of them followed the same caloric restriction model.

Fruit and juice, however, came to the forefront with The Beverly Hills Diet.

 

The Beverly Hills Diet

Introduced in 1996, the Beverly Hills Diet was another bestseller. The diet was the invention of Judy Mazel, who had no formal education or credentials in nutrition or the health sciences.

The first ten days of the Beverly Hills Diet are limited to fruit. The diet actually encourages diarrhea, claiming that it is a sign that the diet is working. Just like the others, the fluid loss from diarrhea provides an immediate—but not sustainable—weight loss. The starvation-based approach of The Complete Scarsdale Medical Diet seems benign in comparison with a diarrhea-based diet. According to the World Health Organization, diarrhea is the seventh leading cause of death worldwide (1.5 million deaths per year.)

I cannot help but recall my friend Kristen’s stories from med school. She had gone on some sort of educational program to Ecuador. She referred to a particular item at the breakfast table as “diarrhea juice.”

The Beverly Hills Diet later gave way to the Atkins, South Beach, and Paleo diets, all of which are variations on the caloric restriction theme.

 

Juice as a Nutritional Superpower

The combination of fruit-based diets and the Beverly Hills Juice Club evolved into the idea of “juicing.” This became an accessible option as household juicers became more affordable and retailers began selling wider varieties of juice combinations. Pomegranate/açai/blueberry smoothies are available at convenience stores. A countertop juicer sells for under $50.

No longer the domain of the Beverly Hills Juice Club, “juicing” became an option for everyone.

Authors of diet books were quick to capitalize on the availability of juice. One name emerged above all others: Joseph Mercola DO.

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Dr. Mercola and the Juice Miracle

On his web site, http://www.mercola.com, Joseph Mercola extols may benefits of juice, particularly how it is preferable in comparison with whole fruits and vegetables. Mercola claims that juice is preferable because, “most people have impaired digestion as a result of making less-than-optimal food choices over many years.” Mercola does not explain the pathophysiology behind his claim: would French fry consumption in the past lead to an inability to digest a banana?

Mercola’s argument is that juice permits one to “pre-digest” nutrients thereby facilitating their absorption. The notion of “pre-digestion” plays upon the same idea that previous dietary indiscretions are irreparable, and that one must consume nutrients in liquid form only.

Mercola has some particularly bizarre claims about juice. He states that it increases energy by “optimizing” the body’s pH. The acid/base balance in the body is complex and constantly adaptive system. The stomach’s buffering mechanisms allow juice to remain acidic in the stomach, but this does go beyond the stomach. If the stomach could not buffer juice, our bodies would be in miserable acidic states. Optimal pH is maintained by the body regardless of what one eats or drinks.

Mercola’s acid/base claim connects with his even more curious assertion that juice provides the body with “structured water,” and “living water.” In an insult to those who have studied the most basic chemistry class, Mercola explains that juice comes as H2O2 not H2O.

H2O2 is hydrogen peroxide. If one were to drink it, it just turns to foam, and eventually just to water. Water does not come in living or structured forms; water is always one oxygen atom and two hydrogen atoms.

 

Juice and Immunity

Mercola argues that juice “supercharges” the immune system, implying that a hyper-responsive immune system is favorable.

Immunity actually only comes two ways: deficient and adequate. There is no “supercharge” to the immune system. In fact, an inappropriately responsive immune response occurs in autoimmune diseases, in which the body attacks itself. These include systemic lupus erythematosis, scleroderma, Hashimoto’s thyroiditis, and others. The “supercharge” is to one’s detriment. Allergies, for example, a result of a “supercharged immune system.”

Commercial juice retailers are a bit more subdued. Jamba Juice argues that its Zinc and Antioxidant Boost “helps support your immune system” with a footnote, “These statements have not been evaluated by the FDA. These products are not intended to diagnose, treat, cure, or prevent any disease.” Tropicana omits the disclaimer, stating that an eight-ounce glass of its orange juice, “helps to support a healthy immune system.”

The only plausible way to argue “immune system support” from orange juice is that one might be spared from getting scurvy.

Mercola has a strange an futuristic explanation: “…juice supercharges your immune system” with “phytochemicals and biophotonic light energy.” I do not even know how to respond to that other than by asking, “what?”

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An antioxidant “boost” is not just dubious, it is dangerous. Nadav’s “smokers need juice” theory is problematic because antioxidants can actually exacerbate lung cancer and increase the risk of death from cardiovascular disease. Antioxidants were long believed to reduce certain activity on the surface of cancerous cells. It seemed like a good idea until the Carotene and Retinol Efficacy Trial (CARET), in which people who were at high risk for lung cancer (smokers, those with a history of asbestos exposure) were given beta-carotene supplements. The CARET trial stopped before its planned end date because those participants who received antioxidant supplements had more cases of lung cancer. (Sorry to break the news to Nadav.)

 

Juice and Alzheimer Disease

Mercola states on his web site, that juice can “Support your brain health. People who drank juices (fruit and vegetable) more than three times per week, compared to less than once a week, were 76 percent less likely to develop Alzheimer’s disease, according to the Kame Project

On the surface, the Kame project looks like a powerful endorsement for juice. In a study of 1,836 Japanese Americans in King County, Washington, who were followed for nine years. Those participants who drank juice once or twice per week had a hazard ratio of developing probable Alzheimer disease of 0.26. Those who did not report juice consumption had a hazard ratio of 0.84.

But a hazard ratio isn’t a measure of relative risk. Relative risk is the probability of an event occurring in an exposed group (juice drinkers) compared with an unexposed group (those who did not drink juice twice a week). For example, smokers have a relative risk of 20 of developing lung cancer: their risk twenty times that of nonsmokers.

Hazard ratios express the rate of an event occurring in one population (juice drinkers) versus a control population (non juice drinkers.) A test subject in a group with the higher hazard ratio has greater odds of reaching a specific endpoint first. In other words, the juice drinkers in the study had lower odds of developing Alzheimer Disease before those in the non-juice drinking group. A hazard ratio does not explain the extent of treatment benefit, so the dose of juice was not explained.

Furthermore, the Kame study only controlled for tobacco and alcohol use and a particular genotype found in Alzheimer Disease (ApoE). It did not control for significant predictors of dementia like family history or head trauma.

As an epidemiologist, one looks for certain key elements in research, such as a dose-response relationship and biologic plausibility. Mercola and the Kame study do not offer either of these core components of robust research.

Mercola’s claim that juice prevents Alzheimer Disease is not supported by the Kame study. The only possible claim is that there is evidence in one trial that drinking juice twice per week might forestall Alzheimer Disease in a specific population.

 

Joseph Mercola, the Questionable Advocate for Juicing

Perhaps Mercola is not the best advocate for juicing. Mercola was censured by the US Food and Drug Administration (FDA) in 2005 for making illegal claims about supplements. He then received a warning one year later, and the FDA warned him again in 2011. One would think that a single action form the FDA would lead one to back off, but Mercola’s supplement and book sales must be so lucrative that he is willing to look beyond censure.

Although his license remains active without sanctions, Mercola reputedly had a three-year battle with the Illinois Department of Financial and Professional Regulation, and he stopped practicing in 2012. In addition to his juice claims, Mercola opposes fluoridation, screening mammography, dental amalgams (fillings), and vitamin K administration to newborns. Although there are some debates about the appropriate ages and intervals for mammograms, these are not controversial subjects in public health.

Mercola’s allies are similarly problematic. His endorsements from a Dr. Andrew Saul are worrisome. Saul claims to have a “nontraditional PhD in ethology.” His other colleague, a Dr. Abram Hoffer, supported the use of niacin to treat schizophrenia. The research was later discredited because the diagnostic test to establish a diagnosis of schizophrenia was called into question.

Perhaps the juice industry would benefit from solid research rather than “expert” opinion from supplement profiteers like Joseph Mercola.

 

Is Juice Healthy?

Juice is not exactly a low-calorie, low-carbohydrate choice compared with soft drinks.

250 mL Serving Size

Carbohydrates kCal
Apple juice 28.97 110
Coca-Cola 35.18 105
Orange Juice 27.20 118
Pineapple Juice 32.18 140

 

One could argue that juice contains vitamins, which are not found in soft drinks. But a serving of apple juice, for example, contains only four percent of the recommended daily allowance (RDA) of vitamin C. It really is just sugar and water. It is true that other juices fair better in terms of vitamin C content, but vitamin C is found in a wide range of other foods contained in the typical Western diet.

Fresh-squeezed juice, however delicious, is also troublesome from a food safety standpoint. In fact, one of the first cases I was assigned as an epidemiology student was an outbreak of salmonella at a Florida resort. The CDC referred to outbreak location as “Theme Park A” (no prizes for guessing: it is in Orlando and has a mouse mascot.) The acid in juice was deemed to be protective, but the sweeter nature of fresh-squeezed orange juice meant that it was less acidic and thus less likely to contain salmonella. Outbreaks of Escherichia coli 0157:H7 and cryptosporidia have struck apple juice and apple cider. So much for “detoxification.”

 

Make no mistake, juice is delicious. I love fresh-squeezed juice from Tamara, I take the risk and buy unpasteurized orange juice—enjoying a small glass with my coffee in the morning. But it is not a detoxifying superfood. It is a nice dose of sugar when I wake up. But I am under no illusions. I could just as easily have Coca-Cola, it is not going to lead to weight loss, and it certainly is not going to detoxify anything.

 

 

References

Barrett S. FDA Orders Dr. Joseph Mercola to Stop Illegal Claims . Quackwatch. 6 September 2015. http://www.quackwatch.org/11Ind/mercola.html Retrieved 20 December 2015.

Cassell DK, Gleaves DH, The Encyclopeida of Obesity and Eating Disorders: Third Edition. New York: Facts on File. 2006.

Cook KA, Dobbs TE, Hlady W, et al. Outbreak of Salmonella Serotype Hartford Infections Associated With Unpasteurized Orange Juice. JAMA. 1998;280(17):1504-1509. doi:10.1001/jama.280.17.1504.

Dai Q, Borenstein AR, Wu Y, Jackson JC, Larson EB. Fruit and Vegetable Juices and Alzheimer’s Disease: The Kame Project. The American journal of medicine. 2006;119(9):751-759.

Fatsecret.com https://www.fatsecret.com/ Retrieved 23 December 2015.

Jamba Juice. http://www.jambajuice.com/menu-and-nutrition/menu/boosts/boosts. Retrieved 20 December 2015

Kelm H. A Reply To The American Psychiatric Association Task Force Report on Megavitamin and Orthomolecular Therapy in Psychiatry: The HOD Test” Orthomolecular Psychiatry 1978: 258–262.

MacVean M. Juicing Trend Still Going Strong in 2015. The Los Angeles Times. 29 January 2015. http://www.latimes.com/health/la-he-juice-20150131-story.html. Retrieved 19 December 2015.

Mercola J. Health Benefits of Juicing. http://articles.mercola.com/sites/articles/archive/2015/04/11/health-benefits-juicing.aspx

Mercola J. Juicing : How Healthy is It?http://articles.mercola.com/sites/articles/archive/2014/04/19/juicing-benefits.aspx Retrieved 20 December 2015.

Mercola, Joseph. Malpractice settlement 23 December 204, $387,925. https://www.idfpr.com/Applications/ProfessionProfile/ProfileDetails.aspx Retrieved 21 December 2015.

Mohammadi D. You can’t detox your body. It’s a myth. So how do you get healthy? The Guardian. 5 December 2014. http://www.theguardian.com/lifeandstyle/2014/dec/05/detox-myth-health-diet-science-ignorance. Retrieved 20 December 2015.

Omenn GS. Chemoprevention of lung cancers: lessons from CARET, the beta-carotene and retinol efficacy trial, and prospects for the future. 2007. European Journal of Cancer Prevention. 16:184-191.

Saul, A. http://www.andrewsaul.com/bio/. Retrieved 21 December 2015.

Tropicana. http://www.tropicana.com/#/trop_healthbenefits/hbMain.swf Retrieved 20 December 2015.

Watson R & Hodgekiss A. Fruit juice should not count in our five-a-day because some versions ‘contain as much sugar as fizzy drinks. Daily Mail. 10 February 2014
http://www.dailymail.co.uk/health/article-2555758/Fruit-juice-NOT-count-five-day-versions-contain-sugar-fizzy-drinks.html#ixzz3vCiNcpyB. Retrieved 23 December 2015

Wilson J. Juicing Pros and Cons. CNN 11 April 2014. http://www.cnn.com/2014/04/11/health/juicing-pros-cons/ Retrieved 20 December 2015.

World Health Organization. Top Ten Causes of Death http://www.who.int/mediacentre/factsheets/fs310/en/ Retrieved 20 December 2015

 

All images public domain

©2015

 

 

Meg Ryan is Making Me Sleepless

Matt Freeman

Annie Reed (Meg Ryan) is the romance-enthused journalist in Sleepless in Seattle. Driving between Baltimore and Washington, Annie becomes infatuated with Sam (Tom Hanks), a lonely widower bearing his soul on a radio show. With daring speed, Annie abandons her boyfriend, Walter (Bill Pullman), and becomes entangled in a slightly saccharine romance with Sam.

In the Christmastime setting of the film, Annie seems somehow reasoned in her actions. Annie (and the audience) have a distaste for Walter. Walter is a downer. He seems perhaps detached, less intense than Sam. But his fatal flaw is a humidifier at his bedside.

Humidifier
Walter would have been fine—even marriage material—but not with that humidifier and those allergies. Thank goodness Annie stalked Sam and dodged that Benadryl-laced bullet! A humidifier? Walter might as well have been in Boko Haram. Good riddance!

Quietly judging Walter for decades, my life took a turn of events in which Walter’s humidifier took center stage.

Ever since graduate school, I was told that I snore. Some neighbors in Stockholm once mentioned that they could hear me from next door. A roommate on a school ski trip was hopelessly annoyed. I figured that this was a function of fatigue and alcohol, both of which are cornerstones of graduate studies.

In paramours that involved frequent overnight stays, I had some snoring complaints, but these were usually joking or just for eye rolling. There were no threats of Annie Reed-style departures.

On two occasions, I saw sleep specialists to ensure that I did not have some sort of correctable deformity. Both offered reassurance.  I did not smoke, was not a heavy drinker, unexceptional of figure, and did not have some sort of problem with nasal or oral anatomy. If I snored, so what?  My dog snores.

I experimented with every possible remedy: an “oral appliance” that essentially inflicted enough pain so that one never falls asleep. I tried costly anti-snore pills of dubious origin. There were nasal sprays, nasal strips, nostril inserts. They all made their way to the rubbish bin quickly.

SnoreStop

For reasons I cannot entirely explain, the symptoms worsened over a short span of time: less than one year. I had moved countries, gained a few pounds, deeply stressed, and was working absurdly long hours. I noticed that I would somehow hear myself snore and awake myself at night. My fatigue progressed, and I was nodding off while driving. I drew the line when I almost wrecked my car while a friend was in the passenger’s seat. I’d rather not be a homicidal driver.

Again, I sought medical advice. I was told the obvious: I worked too hard; and thus when I slept, it was both insufficient and of poor quality.

I argued again of my concern for sleep apnea. I knew from my own practice that it is underdiagnosed, undertreated, and deeply dangerous. I had probably ordered 100 sleep studies in the past year or two. “A-ha!” I would think to myself, “A wise diagnosis. You have helped the patient and protected the public! Bravo!”

Little did I know that I was creating Walters. (In the film, it is most likely a humidifier, but a 2017 Walter would be sleep apnea material.)

The sleep study itself was conducted at home. It was comparatively benign: a small nasal cannula that fell out constantly, pulse oximeter on my finger that slid off every few minutes, and an awkward chest strap. Since I usually sleep on my stomach or side, it was oddly painful, but I endured.

HST

A sleep study in the “comfort” of your own home. What could possibly get in the way of good night’s rest?

The results came soon, and I was told I had severe sleep apnea. I was mortified. But I had the idea that if I treated it, life would be so much better. The stress of work would dissipate, I would be overcome with renewed energy, libido, and my world would be like some sort of television ad for detergent: everything refreshed and renewed.

The ads for sleep apnea equipment were compelling. Erstwhile continuous positive airway pressure (CPAP) had given way to the gentler “autopap”. The machines were heated, humidified, and easily transported. It would be like a user-friendly iPod that would ensure a brilliant night of rest, and greater joy during waking hours.

DreamWear

The language in the ads referred to “dreams,” “pillows,” and “rest.” Through the genius of modern science, I would glide into bed, warm and humidified air granting me peace, resilience, and vigor.

The ads never mention Walter.

The “Dream Machine” was far larger than I had expected. Although it looked innocuous, that changed as soon as one attached the tubing. The cheery saleswoman had assured me that this machine would be effortless and unobtrusive. Using a nasal mask, it would be the least cumbersome. Moreover, it would “ramp up,” leading to increased pressure over time, adapting to my own tolerance. I fell for it.

I brought all the equipment home, and I made room for it at my bedside.

The machine would also report my adherence to my phone, so that I could see my “grade” for the previous night. If I did not feel judged enough for having the machine, I could feel judged by the machine itself.

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The minute I put on the mask, I thought of an oral surgeon. Perhaps around age seven or eight, a dentist told my older sister and me that we would both need to have six teeth removed simultaneously. This was somehow a prerequisite for orthodontia, which is a painful experience to share some other time.  (I am sure that Walter had braces well into is 30s. He probably still has them.)

The tooth extraction was not painful, but it was terrifying. The oral surgeon had a strange, alien demeanor. He was accompanied by a disinterested assistant with flaming red hair. He put a nasal mask on me that fed oxygen. Without warning, he pressed his whole hand over my mouth and jaw, then switching the line to oxygen mixed with nitrous oxide. I wanted to fight back, but I was powerless.

I had nightmares for years about that experience; and I still think about it now. I suppose gaseous induction of anesthesia spares the drama of putting IV lines into children, but there must be a better way to than to hold my mouth and jaw shut until I was rendered unconscious.

I told myself that the lovely, quiet, “Dream Machine” contained nothing but air and water; I would not be held restrained against my will. Soon I would just see the stars twinkle and the Man on the Moon would grin in approval.

The “Dream Machine” was at its lowest setting. It smelled like ozone (the machines are cleaned through ozonolysis.) It jammed air into me with jarring force. I adjusted every setting to reduce it to “gentle breeze” rather than its default, “tornado outbreak.”

CPAP

I did eventually fall asleep, intermittently taking the mask on and off.

Sensing distress, my dog jumped on to the bed, licking my hands. If he could speak, I’m sure he would have said, “Master, this is a bad idea.”

On about the fourth night, I slept only 90 minutes.

The next morning, I found myself lost in mid-sentence, a patient asked me if I had narcolepsy. I fell asleep at my desk, waking up to a screen full of commas.

Over the course of the first week, I had hit my head multiple times on the shower door, the tap, and almost yanked an entire towel rod off the wall. I’d woken up on the bathroom floor and on the couch in my living room.

Every morning, I would fall asleep and hit my head on a water glass or cup of coffee. I would wake up when the drink spilled. Each morning meant wiping off the spilled liquids and cleaning the carpet.

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Poor Walter.

Not only did he lose Meg Ryan, but he would no doubt be stuck with a “Dream Machine,” shoving air down his throat with breakneck pressure.

I asked a friend, “Who would wear one of these?”

“People who want to live,” he suggested. Point taken.

Again, thinking of Walter, I pointed out that nobody famous or attractive would be relegated to a “Dream Machine.”

“Ryan Gosling, Ryan Reynolds, and Ryan Phillipe do not have CPAP machines.” I quipped. “Zoe Saldana: definitely not a CPAP owner.” “Do you think Emma Stone goes to bed at night with one of these? Emma Watson?”

“Prince Harry does not have a CPAP machine.”

“You don’t know that;” my friend replied.

“Can we call Buckingham Palace and ask? What about Kate Middleton?”

Instead of pestering Buckingham Palace, I turned to Google. “Celebrities CPAP,” I entered.

The Ryans and the Emmas were not on the list. If Nicole Kidman wore a CPAP, she was keeping it under wraps. There was no mention of Idris Elba, Alexander Skarsgård, nor Amal Clooney.

The list featured Roseanne Barr, Rick Perry, and Rosie O’Donnell.

This was not uplifting news.

Right now, I am dreading even entering my bedroom. I have a beautiful, big bed with fluffy pillows, and layers of pressed white sheets. I now associate that room with the suffocating ozone smell of the “Dream Machine.”

Although I will consult with my own doctor, I am taking my dad’s advice: “Why don’t you lose a few pounds and not think about it so much?” He went on: “If the mental anguish of the machine is that bad; don’t use it.” And—of course—“hitting your head so frequently is probably not so good for your health.”

Indeed, I tried a night without the “Dream Machine.” I fell asleep in an instant, delving into all of the REM sleep I had been missing. I awoke calm, awake, and steady. And unlike my nights with the machine, I awoke without a headache.

walter_sleepless_in_seattle

Annie Reed, I know you’re fictitious, but you should have been kinder to Walter. I am sure that he was unhappy with that machine at his bedside.

© 2017

All images designated as public domain

Suicide is Crazy: The Irrational World of Seeking the End

Matt Freeman

 

A few months ago, a young man came to see me. He was depressed. He had far exceeded typical depression. His speech and manner were slow. His eye contact was minimal. He seemed so sad as if tears were too much effort to shed.

This patient seemed to have a reasonably decent quality of life: otherwise good health, favorable finances, a stable job, and a loving family. He had a recent breakup with his girlfriend, but this was not excessively traumatic. On the surface, he did not seem to have reason to live in such pain.

He told me that he wanted to die.

He evaded questions about any specific plans. I worked with him and his counsellor frequently, and he is now doing well, living in another city.

 

I recognized his words and how he appeared. His hopelessness and emptiness were all too familiar. Some years ago, I came within a few minutes of taking my own life.

Just as it seemed crazy that this guy would die at an early age; it now seems just as crazy that I had walked in the same shoes.

 

Theories of Suicide

Psychologist Thomas Joiner described the suicidal individual as one who is overcome with isolation and a sense of burden upon others. Emile Durkheim characterized suicidal people as emotionally dysregulated: either removed from society or so altruistic that they fear burdening others.

According to Durkheim, a suicidal person could be either too broken as to ignore a moral compass, or conversely tightly bound to crippling perfectionism.

Aaron Beck wrote how those who succumb to suicide are “sensitized” to the notion of killing themselves by suicidal experiences, thereby making the final act somehow more accessible.

There are perhaps a dozen more theories, all trying to explain what leads a person to end his or her own life.

 

Theories of suicide may provide comfort to the bereaved, guidance for therapists, and a framework for suicide prevention. But the theories perhaps try to explain the inexplicable.

One of my favorite colleagues, a clinical psychologist, took a more straightforward approach. “Think of it in terms of problem solving. A person is suffering, so he or she seeks a list of possible solutions. Somehow suicide ends up on the list, even though it makes no sense to an outsider.”

I am writing about suicide as a release from emotional pain and mental illness, not the planned suicides of those with terminal diseases. These are controlled, programmed journeys to the end of life. It is an understandable escape from pain and indignity.

I write instead of suicide that makes no sense. Suicide is not necessarily an act of logic. The hopelessness and emptiness that surround the will to die are muddled, indistinct infections of the mind.

 

Where Burnout and Depression Meet

I knew what depression was. I had experienced its grip, but a commitment to suicidality was different. Although everyone experiences it differently, depression felt like a frustration and conflict with life. Suicidality felt that life was immaterial.

There is increasing attention to burnout among healthcare providers. Not enough attention, but at least a bit. I found myself working inconceivably long hours—sometimes out of necessity; sometimes to escape from an otherwise empty existence.

In the assessment of suicidal risk, the unfortunate term “trigger” is the first item on the list. It could be a loss of a loved one or friend, an illness, a divorce. In my case, it was the all-too-common threat of a dysfunctional and menacing workplace.

The abyss deepened as a recognized the venom of work. Concealed beneath the veneer of a “we’re all family here” façade, I was mired in politics and backstabbing that driven by a culture pervasive with hatred, secrets, and seemingly constant dismissals. Characteristic of a sick workplace, employees would disappear overnight.

It is a story told quite frequently in America: there have been front-page articles about Amazon, Microsoft, and—of course—Enron. I lived in constant fear of being berated and dismissed despite my popularity with my own supervisors, colleagues, and my patients.

Depleted of all energy, crushed with loneliness, and a biting work environment left my life feeling not just depressed but entirely unworthy. Although worthlessness is a symptom of depression, this was not just “I’m no good,” it was a total and all-encompassing feeling that life had no value. No medicine, no workbook, no cognitive exercise could extricate me.

 

Legend Versus Practicality

There is a glossed, almost benign nature to legendary suicides. One’s mind turns to Sylvia Plath’s oven or Socrates’ sprigs of hemlock.  These were undoubtedly violent—even disgusting deaths. But the gore is washed away. I thought of the The Aokigahara, Japan’s “Suicide Forest” or the Golden Gate Bridge. These seemed like misty outposts for a quiet exit rather than nightmarish sites of early death.

When my last stages of planning were underway, there was no poetry, no drama. Suicide was a remarkably practical endeavor. I ensured that my patients’ charts were suitable for someone else to take over, that my apartment was tidy, and I had made careful plans for my dog to be at a kennel. I even emptied my refrigerator as to ensure that the smell of spoiling milk would not disturb the neighbors.

The plan I had selected also made every effort to prevent me from being found. I did a couple of “dry runs” to make certain that I could get it right. I did not want anyone to stumble upon a decaying body, nor did I wish for any sort of funeral. I just wanted to disappear from this earth. Swiftly, quietly, in a cold, rainy night.

I also wanted to be certain that I did not end up in lace-less shoes playing musical chairs with meth addicts and schizophrenics on a locked psychiatric unit.

The questions I asked myself were not related to life or death. I wondered if I should leave my door unlocked, where to leave my car keys, and if I needed to take my wallet. In the loss of rational thinking that characterizes the most immediate of suicidal thoughts, “Should I do this?” was not on the checklist.

 

The Mask of Professional Identity

The deepest irony was that I spent much of my work dealing with suicidal patients. I taught classes on suicide assessment, I visited patients and families in crisis centers and psychiatric units.

Perhaps once a week, I found myself conferring with colleagues about the potential suicide risk of a patient. I even earned ironic praise for handling the suicide of a patient with grace and calm.

While talking with patients who expressed suicidal thoughts, I often found myself thinking, “Oh, you’re definitely not suicidal. I am suicidal.” Maybe it was my own escalating will to die that made it so easy for me to convince others that that they were not in such dire condition.

In a bit of macabre humor, I found myself taking suicide risk inventories. In my perfectionist, over-educated world, I wanted a grade. I never seemed to score that high. I was not physically ill, I did not fall in the right age ranges, I lacked a substance abuse problem, and my finances were not in jeopardy. I was failing the suicide tests.

 

The Note

Comedian Sam Grittner wrote about the strange task of writing a suicide note. He stumbled over font choices and he ran out of ink for his printer. I was fortunate enough to have a laser printer with adequate toner; and I was pretty set on using Palatino.

Although I wrote several drafts, they never seemed to say anything other than “I’m sorry.” I felt like including a few “fuck you’s.” It occurred to me that those I would mention were such sociopaths that they would be unlikely to be moved or even saddened by a suicide. I was not really interested in teaching anyone a lesson.

I never printed the note. I kept wondering where to put it, and if anyone would bother reading it. What purpose would it serve? I did not want anyone thinking, “Oh if only…” I did not want anyone thinking of me at all. I wanted my life erased.

One of the most frustrating lines is, “It was such a selfish act.” Suicide is a desperately-needed escape from a life too painful or meaningless to continue. Selfishness implies indulgence, diversion of resources to oneself. Suicide feels like the opposite of siphoning off the assets of others. It is one less mouth to feed, one less salary to pay. I even thought it would be a benefit to the healthcare system: one less patient availing himself of costly benefits.

 

An Unhealthy Dose of Guilt

It seems like human nature to seek comparisons. I was beyond the point of reflecting on my life, but I would sometimes get flashes of world news. “You could have ALS,” “You could be living amid genocide, war, appalling poverty… So many people have it worse than you do.”

This only adds to the damnation of suicide as “selfish”. The imminent will to end one’s life has nothing to do with Darfur or Donetsk. It is neither reassuring nor helpful to imagine squalor and pain elsewhere in the world.

“Count your blessings” has a pop psychology, Dr. Joyce Brothers superficiality. If one is truly committed to dying, “counting blessings” sounds like a childish diversion. Flip as it may sound, it would be the equivalent of saying, “I have an iPhone and I do not have cystic acne. Wow! This is fantastic! I should stay alive after all!”

It is also similar to saying, “It can’t be that bad.” In those last days and hours, there is no “bad” or “good”. It is only a matter of, finding an end. The pain is suppressed; one’s focus is just to make life disappear.

 

The Particular Burden of Professional Licensure

The most heartless and sinister aspect of being a healthcare provider struggling with suicide is that many state laws require investigation, oversight, and practice restrictions on doctors and nurses who “get caught” admitting to suicidal thoughts. In a misguided effort to “protect the public,” licensure boards crack down on those most in need of help, punishing anyone who reaches out at the last moment before leaving this world.

The boards tacitly endorse suicide: it is far easier to be dead than to have to suffer a public disclose one’s most painful, innermost thoughts repeatedly for the remainder of one’s career. Had I been hospitalized, the law would have required that the licensure board issue a press release, warning the public that I was mentally unwell. Any member of the public would be able to read the most intimate details. I would spend the rest of my career providing documents of my mental instability to insurance companies.

 

Reverse Course

I paused. I do not know why. I doubt I will ever know why.

To paraphrase Sam Grittner: “Pro Tip: always call your therapist before pulling the trigger.”

“Pro Tip: always call your therapist before pulling the trigger.”

I had a psychologist. A wise, warm, and clever professional. He was deeply caring with an unmatched sense of humor.  Trying avoid alarm, I did not call from a bridge, nor did I bother him in the middle of the night. I spent the remainder of that night agitated and foggy, and waited for his office open.

His response was what only the most confident and caring professionals would know to do: he gave me a huge hug, struggling to keep back his own tears.

There was no need for him to demand my shoelaces or submit me to the indignities of hospitalization. Without words, he was saying, “No. That’s not where this is going. You’re not doing this.”

He also knew to meet me in a place I knew well: the snarky gallows humor of medicine. We talked about how one particular attending psychiatrist was almost always on service at the nearby hospital. He was famous for being as arrogant as he was incompetent. If I somehow did not die from suicide, I could awake from a coma with that imbecile at my bedside.

I was deeply unwell, but made every effort to fake it. I got up went to work, and buried myself in routine.

I eventually moved on from the battles of my former job. Although it seems inconceivable, I just somehow did not feel like dying anymore.

 

Retrospect

Sufficient time has passed that I can think somewhat clearly about that dark 48 hours. The lesson I wish I could impart the most to others is that suicide makes no sense. One can read theory upon theory, but it is inherently irrational. I cannot explain why I did not kill myself.

Suicide assessments also try to impart some sort of method where there is no algorithm or equation. I did not score high enough on any of the “validated” suicide measures. There is thus a danger to suicide awareness campaigns and to clinicians who might turn to some sort of psychiatric inventory.

As I knew, the most lethally suicidal patients keep their mouths shut. Except at the very end; I said nothing. Although there is an art to working with more vocal patients, and their cries should not go unheard, it was a function of good luck that I happened to have a psychologist, and that he was both available and perceptive.

 

I think I am a better clinician because of my own experience. I obviously maintain boundaries and do not talk about myself. Like the patient in the introduction, I can at least feel a deep sense of empathy, and I try to take after the psychologist who looked after me.

Only the most monstrous of licensure boards would punish me for expressing my recollections here. I am no danger to myself–years have passed; and I was never a danger to others. I ended up avoiding the hospital, and thus would not meet the threshold for some sort of investigation.

 

Taking a cue from the “Make It OK” program and “The Hilarious World of Depression” series, I felt that sharing my own experience might just help someone else.

If that person is you, and you are reading this, do me a favor: wait a day. Call the person most likely to help you. I wish you a hug, honesty, and hope.

© 2017

for BB

Window Seat

 

Matt Freeman DNP, MPH

 

“Come with us.”

A soft-spoken airline agent gestured toward me.

“You don’t want to miss this.”

She saw me sitting alone, my eyes wandering out the window. Perhaps seven or eight airline employees gathered by massive floor-to-ceiling windows. “We always watch the sunset together,” she explained.

Several snapped photos with their phones.

The sun grew and glistened, the planes shimmering in neat rows. The endless crowds, congestion, and noise of LAX disappeared. It was just a few moments of collective appreciation of the planet. From there, flying took on a renewed, human quality. I took off that night, staring out at the stars from the window seat. It was a sensation of immeasurably profound calm.

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Fear and Fascination

The first time I was old enough to remember a big trip, I was sitting with my mother at Kennedy Airport. Only the nose of the 747 was visible from the window. It seemed like an improbable means to take flight, and I wondered if the “real” plane was hidden behind it. This was all some illusion.

Nobody had told me that the flight would take place at night. It seemed like an immensely bad idea. How would we find our way? How would we avoid bumping into another plane?

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Fatigue must have set in, and I nodded off.

I awoke next to my father, my ears popping. As I stared out of the window, I was transfixed. The wing had moving parts that extended and screeched. Wafts of mist shot across the wing surface. Fog and clouds spirited past the window. Beneath us lay something even more extraordinary: houses, electrical wires, grass, cars, road. We were landing in Milan, but I had no idea what to expect. I was dumbfounded that Italy had certain familiarities from home.

 

The Foreign and the Surreal

A couple of years later, I visited Heathrow Airport for the first time. The experience of flying took on a particularly enthralling mystique. Unlike anything I had seen before, digital signs heralded flights to Harare, Bratislava, Caracas, and Leningrad. There were planes from “forbidden” port of call: an Illyushin jet from Aeroflot taxied into a nearby gate.

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The next morning, we sat outside at the New Stanley Hotel in Nairobi. My family pointed out that the crew from British Airways was at the table next to us. It was like seeing a primary school teacher at the movies or supermarket. They were in casual clothes, having a beer in the African sunshine. It made little sense. In my boyhood imagination, these people lived on the 747. They would not wear anything other than deep blue uniforms adorned with ties and scarves styled after the Union Jack. Everything became even more magical and mysterious.

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My family was quick to indulge my fascination. My uncle would send me unused invitations to the business class lounge in Bucharest (aware that I was unlikely to have a Romanian holiday anytime soon.) My grandfather would take me to the airport to see the rare appearance of a DC-10 from JAT, an erstwhile Yugoslav airline. A neighbor who worked for El Al would tell me stories of his own travels on employee tickets. My grandmother shared stories of the furious immigration officer at Sheremetyevo Airport in Moscow.

 

The Joy Fades

Somehow the sparkle became routine, a hassle, bourgeois cocktail conversation. As I grew older, flying became about hassles, garnering points, and dodging high fares. As I grew larger and more discriminating, the size and pitch of the seats became bothersome, the food avoidable rather than interesting. I was once fascinated by the stamps and carbon copies by ticket agents, this gave way to endless crowds, and frustrating hassles.

As aviation terrorism resurged on US shores, I lost my interest with the unusual security procedures overseas, I developed particular fury with the nonsensical, humiliating, and seemingly endless absurdity of the Transportation Security Administration.

It took a moment that evening, standing and watching the sunset at LAX, to find the mystique and passion from the jumbo jets we board every day.

 

Re-Imagining Magnitude

The anxious clenched fists I felt as I stepped aboard a 747 as a little kid are best explained by the unthinkable scope of what it means to travel today. It is both mundane and astounding.

As an adult, I was sitting next to my father on flight from Newark to São Paulo. “How many dishes and plates do they go through?” He asked. I do not have an answer other than “a lot.”

 

Flight 85 is the most familiar to me. Every day, a Boeing 777-200 takes off from Gate C9 in Tel Aviv just after noon, arriving at Newark just after 5:00 pm, usually somewhere on the “C” concourse. Depending on the time of year, the flight takes about 11 and half hours.

Shortly after 9:00 am, the check-in counters open. Two hundred sixty-seven passengers are interviewed by the Israeli Airport Authority, their bags are weighed and tagged then screened. The passengers walk downward through a security checkpoint, immigration control, and then to a massive rotunda of 24-hour, seven-day duty free shops.

natbag

About 90 minutes later, roughly 18 crew arrive, having spent the past 24 to 30 hours asleep, on the beach or touring Israel. There are typically two pilots, two “relief” pilots, at least four plain-clothes Federal Air Marshals, a purser or “Inflight Service Director,” about three Hebrew-speaking flight attendants, and five international flight attendants.

From the upper level of Ben Gurion Airport, the 777 is not particularly imposing. The airport is full of jumbo jets in the Middle Eastern sunlight. Unlike my fear of the 747 at JFK, the plane looks airworthy. From such a height, one can hardly perceive its 64 meter length (210 feet), and even greater wingspan. The engines themselves are seven meters (24 feet) in diameter. It seems implausible, but four of me could stand head-to-toe inside the engine.

As the ground crew starts preparations, the 777 will require about 220,000 pounds of fuel. This is measured in pounds in part for convenience. It is roughly the equivalent of 1,493,800 gallons. (5,654,648 liters). According to indexmundi.com, the cost of fuel would be $1.30 per pound or $286,000 for the flight. That does not account for the likely higher cost of Jet-A fuel in Israel. At $1071 per passenger just for fuel, suddenly the actual cost of the airfare does not seem quite so extortionate.

 

Roughly 45 to 60 minutes before pushback, a mix of crews from Quality Airport Services (QAS) and United Airlines start loading the 267 passengers: checking passports, asking few security questions mandated by the US government, and a glance at hand luggage to ensure that passengers comply with US laws about liquids. In an astounding 45 minutes, each wheelchair is stowed, each stroller is collapsed and tagged, each forbidden water bottle is discarded, and passengers negotiate with their neighbors to swap seats.

In the mid-day heat, the 777 uses the longest runway, a breathtaking 13,327 feet (4,026 meters).

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Despite endless web sites full of vitriol and ratings, the cabin on flight 85 offers the unimaginable. Passengers plug in to electrical outlets, log in to WiFi, flip through page after page of “on demand” movies and television shows.

In business class, a stainless steel cart passes through the aisle with the crew offering port and gourmet cheeses cut to the passenger’s taste. This is followed by another stainless steel cart with ice cream, warmed chocolate fudge, and liqueurs.

It is easy to forget that this is occurring at 560 miles per hour (901 kilometers per hour.) This is just about three quarters of the speed of sound.

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All of the Above Quadrupled

Perhaps the most remarkable fact is that a sister flight, number 91, will take off with another 267 passengers just under twelve hours later. Meanwhile, their counterparts (84 and 90) are flying from Newark back to Tel Aviv. Every day.

That means 1,068 passengers per day, every day, on just one route. In the roughest estimates, that is 2,136 hot meals, 5,000 paper napkins. If just half of the passengers participate in a frequent flyer program, more than three million miles will be earned.

Six days per week, the same route is replicated by El Al Israel Airlines, carrying at least an additional 279 passengers per direction.

That is one route on one day of the week.

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Finding Meaning

The hassles are seemingly endless: high fares, confusing web sites, strange fees, long lines, absurd security, delays, cancellations, diversions….

Look out the window.

ua-wing

There is both joy and peace to be found amid the clouds. The views are unparalleled, particularly the sunsets.

There is a certain shock if one considers what constitutes a “routine” flight. It is so complex that one’s mind cannot begin to imagine 5,000 napkins.

Take a cue from the enamored staff at LAX: look out the window; snap a photo of the sunset.

 

©2016

All images designated for non-commerical redistribution

The Martha Mitchell Effect

Matt Freeman DNP, MPH

 

“It’s all happening. It’s happening now.”

I could smell a hint of whiskey or bourbon on my patient’s breath. His knee bounced up and down with anxiety; his eyes scanned the room. His speech  was forced hard to follow.

“She’s in the waiting room now. She could be calling them. I don’t know. She has been checking my phone. She eavesdrops. She knows people.

The patient had a long and complex story about how his criminal history prevented him from owning a business. Therefore, everything was held in his wife’s name, and she had been threatening to turn him in: to the police, the FBI, and ICE (Immigration and Customs Enforcement.)

His speech grew louder, he fumbled for words, occasionally losing himself mid-sentence. He stood up, paced, eventually sitting back down.

I assured that my patient was not in any immediate danger to himself or others, but I struggled to figure out how I could help him. I was happy to listen, but it seemed like he needed a divorce lawyer, maybe an immigration lawyer, perhaps treatment for substance abuse.

Naturally, I wondered about hyperbole. Was this man wanted by the FBI? Did he have a crippling criminal past? Was this a delusion?

 

One phrase stuck in my mind: “The Mouth from The South.”

In one of his interviews with David Frost, Richard Nixon remarked, “If it hadn’t been for Martha Mitchell, there’d have been no Watergate.”

Martha Beall Mitchell (1918-1976), was former schoolteacher from Pine Bluff, Arkansas. Her second husband was John Mitchell, former Attorney General under Nixon and subsequent head of the Committee to Re-Elect the President. The Mitchells ironically lived in the Watergate Building.

Julie_Nixon_Eisenhower_with_Martha_Mitchell_-_NARA_-_194649Martha Mitchell with Julie Nixon

 

Amid marital spats, prescription drug abuse, and alcoholism, Mrs. Mitchell called Washington journalists, often late at night. She spoke with Helen Thomas, Carl Bernstein, and Bob Woodward. Although the exact conversations were not recorded, Mitchell reportedly revealed her husband’s complicity in “dirty tricks” operations of the Nixon administration, particularly her husband’s Committee to Re-Elect the President (CREEP).

The phone calls famously came from her pink “princess phone.” Her Arkansas twang earned her the nickname, “The Mouth from The South.”

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Martha Mitchell became a celebrity, posing for television interviews and magazine covers such as People and New York.  She called for Nixon to resign, clarifying that the public was well aware of Nixon’s misdeeds. Her histrionic demeanor could have been inherent, a reaction to her husband’s efforts to silence her, or a function of alcoholism.

Mrs. Mitchell stated, “I’ve been persecuted more than anyone since Jesus Christ.” She made it clear that she wanted to be known as “Martha Mitchell, not Mrs. John Mitchell.” Her draw for attention was famously exemplified by her clothes. “What I wear,” Mitchell said, “nobody else would buy.”

Her motivations were not political. Although she clearly detested Nixon and CREEP, her “phone capers” erupted after learning that John Mitchell was reportedly dating one Mary Gore Dean. A snub to her ego and image pushed her to pick up the “princess phone.”

John Mitchell
John Mitchell subsequently served 19 months in prison

 

Motivations aside, Mitchell was billed by some as a hero. She spoke openly and publicly about a corrupt political administration. Coming across as a deranged and attention-seeking, Mitchell incited even greater interest in journalists, eventually leading to the downfall of the Nixon Presidency.

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The Martha Mitchell Effect

The Martha Mitchell effect in psychology and psychiatry refers to a failure of a clinician to verify potentially plausible claims of a seemingly delusional patient.

When I took abnormal psychology in 1994, I remember my professor, a clinical psychologist, citing an example. A patient of his claimed that he was being followed by the FBI. In attempt at reality testing, the psychologist and the patient sat together as the psychologist called the FBI. He inquired if his patient was under investigation. Indeed he was under surveillance.. The patient had written a threatening letter to Lyndon Johnson. The patient may have been paranoid, even struggling with a thought disorder, but he was still being followed by the FBI.

 

The patient who came to see me with stories of his wife, ICE, the FBI, was under the care of a psychologist. I relayed to her his concerns, and therefore left it up to her to pursue any investigation into the veracity of his claims.

Was his anxiety and paranoia due to an actual pursuit by the government, or was he delusional? I will never know.

 

The message is critical for any clinician: We all hear outrageous or bizarre claims of persecution, spying, and other threats. Even a patient under the influence of alcohol or drugs, even a psychotic patient, even a patient with a personality disorder can still be telling dangerous truths.

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References

John N. Mitchell Dies at 75; Major Figure in Watergate. The New York Times. 10 November 1988. http://www.nytimes.com/1988/11/10/obituaries/john-n-mitchell-dies-at-75-major-figure-in-watergate.html?pagewanted=all

Maher B. Anomalous experiences and delusional thinking: the logic of explanations. In Oltmanns and Maher B (Eds.) Deulsional Beliefs. Chichester: Wiley. 1988.

Martha Mitchell speaks out about Nixon, Watergate. 15 June 2012. BBC News. http://www.bbc.com/news/world-us-canada-18436516

McLendon W. Martha: The Life of Martha Mitchell. New York: Random House. 1979.

 

This blog entry was originally a lecture I gate at Pacific Lutheran University.

All images designated as public domain

© 2016

 

On Being a Patient

Matt Freeman DNP, MPH

“Can I help you?” The receptionist rolled her eyes, hidden behind bullet-proof glass. “What is your problem? I can’t hear you!” she snapped. I offered by identification and insurance card. “I don’t need that,” she retorted. “Someone will help you later.”

The waiting room was covered with admonishments about not using mobile phones, commitments to “excellence in customer service,” and a bizarre  poster about sleep apnea awareness.

A triage nurse eventually emerged. No pleasantries, no introductions. Instead, she just shamed me for not coming to the emergency department sooner.

I had the misfortune of suffering from an embarrassing and painful problem that was not improving with medication. (It did not involve a foreign body stuck into me, just in case that is where your mind was headed.)

After exchanging chat with another nurse about their boredom, I was escorted to an almost vacant emergency department. The staff were lounging; one brought her four small children with her.

Another nurse emerged without introduction. She offered similar shaming commentary. I did not reveal my profession, but I had the urge to say, “I’m here now; why shame me?” She fussed with a computer, not asking if I was in pain or cold (I was freezing and very much in pain.) She wandered off.

A chilly and detached physician emerged. He at least knew to introduce himself. With cold efficiency, I was filled with needles and chemicals.

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Perhaps the overwhelming sense was feeling so cold. I was without clothes, without a pillow, on an oddly small gurney. The only clothing on me was a bar-coded bracelet. The door swung in and out to the public area, featuring little kids and a lot of loud discussions about food.

The frigidity did not instill confidence. I got the impression that I knew more than the physician did. But he did not seem to do anything absurd. I was prepared, however, to jump in at any moment.

Eventually, after drugs, an unpleasant medical procedure, and some observation, I was deemed stable enough to leave. Now, a few days later, I’m just sore and tired… hoping to vanish the memory to some sort of protective repression.

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That afternoon, I went to work. I felt no benefit from sitting at home, and I wanted the distraction.

A young patient came in with an unpleasant and sensitive condition that required treatment with liquid nitrogen. I instinctively patted him on the back, saying “You didn’t do anything wrong. This is going to be okay, and I’m going to be with you the whole time.” I would periodically stop and ask how he was doing. It was not some overabundance of compassion; it was common sense.

I thought back to my education. I had fond memories of my emergency department rotations. My favorite attending physician and nurse were perfect role models. Even when a patient was in the midst of a heart attack, there was a certain casual but caring approach. “How are you doing over here?” How’s the pain? Can I get you anything?” Despite the gravity and urgency of the situation, the patient was still our guest.

There was also a certain automatic assumption of the emotional response to an emergency. I recall one attending physician saying, “I’m sure that this is anxiety-producing, but it’s not going to take too long.” His calm confidence reinforced a sense of stability and safety.

Gown

There are any number of books about doctors facing serious illnesses themselves. David Biro’s One Hundred Days: My Journey from Doctor to Patient is unforgettable. Kay Redfield Jamison’s The Unquiet Mind opened my eyes to bipolar disorder. Although I would not with a serious illness on anyone, there is boundless insight to be gained from professionals who have the experience of illness themselves. The absurdity, indignity, uncertainty, and fear are miserable for anyone; perhaps even more agonizing for those who are used to being on the other side of the examination table.

 

What can students and clinicians gain from the experience?

  • The experience of being patient can be painful, immodest, and demeaning. It is so easy to forget that in clinical practice.
  • Despite the many classes and assignments on clinical skills, patient rapport, and sensitivity, such attention disappears in the impersonal world of the hospital.
  • Names are deeply meaningful. I certainly do not expect to be called “Dr. Freeman” as a patient, but I wished someone had used my first name. Instead, I was spoken about in the third person. One time I was called, “The gentleman.” It would have meant so much to use my name, just for a moment, to remind me that I am still a person, not naked on an uncomfortable and freezing cart.
  • Although there are debates about the kindness versus barriers of touch between clinicians and patients, a handshake, a pat on the back, or—if necessary–a hug or hand holding—bring humanity and connection to an otherwise inhumane environment.
  • Hospitals are not hotels, but it is not extraordinary to ask, “Can I get you anything?” I dreamt of asking for socks or a blanket, but I felt powerless… as if I would have been an entitled, squeaky wheel, treating the hospital “like a Holiday Inn” if asked for the simplest of comforts. The power dynamic is such that I was there as a body, not a person.

 

If anything, I hope that this week’s experience will make me even a more sensitive clinician and role model for students. Medical and nursing education can be fragmented, there can be eye-rolling about the so-called “touchy feely” aspects of patient care. In fact, sensitivity and dignity are integral parts of patient care.

For now, I hope to not be in the hospital (as a patient) for a long time.

 

©2016

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An Ounce of Prevention and a Pound of Greed: Insurance Barriers to Preventive Care

Matt Freeman DNP, MPH

 

The Cough

There is an infectious disease that is more contagious than Ebola. Every year, there are an estimated 16 million cases of pertussis (whooping cough) and 195,000 people die every year from it. The United States hit a peak of pertussis cases in 2012 with 48,277 cases; the largest number since 1955.

PertussisBoy struggling with pertussis
Centers for Disease Control Public Health Image Library

It is unthinkably painful to watch a child gasp for air from whooping cough. There is an unmistakable, strident cough. The kid turns blue from lack of oxygen. Some survive; some do not. In adults, the disease is not usually deadly, but it is agonizing: a so-called “100-day cough” leading to loss of work and school, but—above all–infection to others.

It is easily prevented by a safe, effective vaccine.

 

The Cancer

Eleven thousand American women are diagnosed every year with cervical cancer, the most common cancer among young women. Four thousand four hundred will die every year from the disease. It is a painful, tragic death at a young age. Almost all of the cases are attributable to human papilloma virus (HPV).

The viral strains that cause cervical cancer are easily preventable with a series of three safe, quick vaccines.

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A newlywed, who passed away at age 26 from cervical cancer
Caters New Agency

The Virus

The most recent statistics from the Centers for Disease Control and Prevention (CDC) are from 2013: there were an estimated 47,352 new cases of HIV, and 13,712 deaths from HIV/AIDS. Although deaths from HIV have declined, it is still a life-threatening chronic illness, with widespread complications to multiple body systems.

Although not a vaccine, HIV infection can be prevented by a daily pill, tenofovir/emtricitabine (Truvada,) which is profoundly effective at preventing viral transmission. Deemed no more toxic than ibuprofen, tenofivir/emtrictiabine can be prescribed as “pre-exposure prophylaxis” or PrEP. It has the power to end the gruesome deaths from AIDS and the costly and complicated life of living with HIV.

Mathematical models indicate that the cost per quality-adjusted life-year (QALY) gained was $160,000, a cost saving of $740,000 with a number needed to treat of only 64 patients.

5226171134_137becb684_bThe National AIDS Memorial
Photo by Steve Rhodes 

 

Defining Prevention

Pertussis vaccine, HPV vaccine, and PrEP are all forms of primary prevention. This is “golden” form of preventive medicine: taking action before a disease actually strikes.

Secondary prevention refers to screening for a disease in order to intervene sooner. An example might be screening a patient with for cervical cancer test to see if the disease has already struck. You are till to late, but you can hope to intervene before she suffers.

Tertiary prevention refers to mitigation of the effects of an illness that has already set in. This might mean preventing the adverse effects and complications of a ventilator used on a child struck with pertussis.

 

The Surprise Barrier to Primary Prevention

Most healthcare providers I know have pulled their hair out because of “anti-vaccine” efforts that prevent vulnerable patients from receiving vaccines they need. Despite my frustrations with “anti-vaxers,” I have taken a lesson from pediatrician and vaccinologist Paul Offit MD, who urges compassion. Anti-vaccine advocates are presumably genuine in their fears. They have been misled by unscientific, groundless but convincing information.

The surprise barrier is not from “anti-vaxers,” it is from health insurance companies.

Under the Patient Protection and Affordable Care Act (PPACA) of 2010, most health plans must cover preventive service without a copay, coinsurance, or deductible. Even a patient with a high deductible health plan need not worry about a pertussis vaccine or HPV vaccine because these services are covered at no out of pocket cost to the patient.  PrEP is slightly different because some patients have a deductible for medication costs, but the pharmaceutical manufacturer offers generous subsidies to cover out of pocket costs. The bottom line is: cost should not be a concern.

There is one massive snag: insurers may not reimburse the healthcare provider or may not offer enough “in network” providers to cover the costs.

 

Vaccine Reimbursement

Human Papilloma Virus (HPV) vaccine is sold to healthcare providers for $178.04 per dose. A healthcare provider stocks HPV vaccine in the refrigerator, administers the vaccine when necessary, and sends a bill to the patient’s insurance company. The insurer then reimburses the healthcare provider for the cost of the vaccine.

Insurance companies maintain reimbursement “schedules,” which generally cover the cost of the vaccine. For example, one insurer that covers half of the market in my state reimburses $187.03 for an HPV vaccine. The extra $8.99 can cover shipping, the cost of the needle, alcohol, the extra time to administer the vaccine, and perhaps the cost of submitting charges. It is fair enough.

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But the insurer does not actually have to follow its state “schedule.” In my case, this insurer’s contract states that they will pay 80 percent of the reimbursement schedule for all services. But that’s not where it stops. One insurer knocks off another 20 percent if the vaccine is ordered by an advanced practice nurse rather than a physician.  That means that the reimbursement went from $187.03 to $112.22.

My office loses  up to $65.52 per dose and we lose $197.47 per HPV vaccine series.

It would be unethical and a breach of our contract to bill the patient for the balance.

When we discussed this issue with the “network coordinator” for the insurance company, she said, “That’s why most people just give up.” I wonder how she would feel if a loved one died of pertussis or cervical cancer.

There is no regulation on vaccine reimbursement to healthcare providers. The insurance companies’ primary responsibility is to their shareholders, not public health. They are required to make certain that vaccines are covered but not required to make certain that it is financially feasible for doctors’ office to make the vaccines available.

One could ask, “Shouldn’t these patients go to a health department or some other office?” Most of my patients are covered by commercial insurance, and are therefore ineligible for subsidized vaccines under the “Vaccines for Children” (VCF) program available by some health clinics and health departments.

When my office spoke with the same networking representative, we inquired about sending patients to a pharmacy to receive vaccines. She explained that most pharmacies would not cover these patients as they were not “in network.” Network relationships aside, it seems absurd that we could not just administer the vaccine sitting in our refrigerator.

 

Network Participation

The preventive service mandate of the Affordable Care Act requires that the service be rendered by an “in network” provider. This means that the clinician: (physician, physician assistant, advanced practice nurse) has been deemed worthy of participating in the insurer’s network and has been granted a contract.

As discussed here: https://medfly.org/2016/01/02/in-and-out-of-network-900-million-every-year-on-unnecessary-administrative-healthcare-costs/ network participation is complicated and expensive.

The law in my state requires that an insurer have an adequate network to offer preventive services within 60 days. One insurance company claimed that they are “closed” and do not need any more providers, so my office tested their claim:

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On the insurance company’s web site, there were 24 listings available when I said I wanted to see a male primary care provider who is accepting new patients. That sounds promising.

Take a second look: five of those listings were duplicates. Nine were not actually in primary. Since these clinicians had completed internships and residencies in internal medicine prior to their fellowships, they are listed as “internists,” but some are cardiologists, nuclear medicine specialists, even one pathologist. They are not serving in a primary care role.

Only four were accepting new patients, and the wait time for an appointment was six weeks for a “sick visit” (state law requires insurers to guarantee a 15 day maximum wait time for a sick visit.)

If you are enrolled in that particular insurance plan, and you want to obtain preventive services from an “in network provider,” you are going to be waiting a long time.

In some cases, insurers have said that they will cover a preventive service such as a vaccine or routine physical examination. My office has been skeptical, called the insurer advance, received the name, time, date, and a “call reference number” stating that the service would be covered. Then the patient got a bill for $350. When asked why the service was not covered, the insurer just says “no.” It is an expensive problem for a patient who is trying to protect his or her own health, yields fury toward our office, and we can end up “writing off” the cost of vaccines because the insurer said that they would cover the cost, but then changed their mind.

Patients complained bitterly, hoping to see me. They wrote to the local networking representative, the State Department of Insurance, and the national ombudsperson for the insurance company. A representative from the “Resolution Office” for the insurer told me that I was lying, and that patients “will never hear back from us.” I asked if she was willing to go “on record” with that statement. “Yes, but I wouldn’t phrase it that way,” she replied.

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The Case for PrEP

Since it is a comparatively new feature of preventive medicine, PrEP is prescribed by only a handful of clinicians. In fact, fewer than ten percent of infectious disease specialists stated that they had prescribed it. But infectious disease is also the wrong place for those who are not infected. PrEP is a primary care preventive medicine responsibility, and thus should be in the hands of a competent primary care provider.

In the case of the insurer with only four available primary care providers, none of their office representatives said that they offered PrEP.

When we asked the insurance carrier where to send patients who did want PrEP they had no answer.

Like vaccines, PrEP cannot be offered as an “out of network” service since it is preventive in nature. It just is not available.

Ironically, the insurer has built a national marketing campaign regarding LGBT health, a bold move in a conservative business. But their actions defy their marketing. Patients in my city of one million people have to drive 161 kilometers (100 miles) every three months if they wish to see an “in network” provider who offers PrEP.

 

What does this all mean?

The failure to make preventive services like vaccines and PrEP financially feasible and readily available is a failure of our public health infrastructure. We have legislation requiring that insurers cover these services, but coverage is not the same as availability. Furthermore, if the cost to the healthcare provider is so extreme, preventive care can be so costly that fewer healthcare providers will be available and willing to provide the service. As a consequence, more people will be infected with infectious diseases, morbidity, mortality, and costs will skyrocket.

It is a tragedy that insurers are so morally bereft that they would suggest “just giving up,” and that patients should never expect a response to their concerns. Insurers do not need to care. As long as their revenues please their shareholders, nobody is going to stop them.

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What are potential solutions?

  1. Narrow networks may save money for insurers, but drastically prevent access to care. Insurers blame doctors for failing to update their “demographic information,” but any outsider looking at the provider directory can see that the insurance company is inattentive to the availability of primary care providers. A network can be so narrow that it is useless.

    Since legislative action, such as “any willing provider” laws would take a glacial pace, it is up to healthcare consumers to speak out against insurers and to launch class-action litigation.
  2. Preventive care should not be limited to network participation. This is stop-gap measure until the networks are opened, and possibly an “easier pill to swallow” for insurance companies.
  3. Vaccine reimbursement must never be “discounted.” This is a fixed cost. It is unreasonable to ask any healthcare provider to bear a $194.47 cost to immunize a young person against human papilloma virus. It is profoundly morally bankrupt for the insurer’s response to the problem to be, “just give up.”Although vaccine manufacturers have laws preventing negotiations with insurers over reimbursement, I would bet that Merck would want to facilitate the availability of its HPV vaccine. They have shareholders too.
  4. If an insurance company does not have an “in network” provider offering an essential preventive service like PrEP, they have an ethical duty to make certain that this service is available. They also have a financial responsibility: PrEP saves money, so it seems contradictory to make it unavailable to those who wish to take it.Since legislation and government oversight is likely to be weak on a good day, the pressure should come from the pharmaceutical manufacturer. After all, the patients were told that they would “never hear back” from their insurance company.

 

 

References

Chen A & Dowdy DW. Clinical effectiveness and cost effectiveness of HIV pre-exposure prophylaxis in men who have sex with men: risk calculators for real-world decision making. PLOS One. 6 October 2016.

Conniff J & Evensen A. Preexposure Prophylaxis (PrEP) for HIV prevention: the primary care perspective. Journal of the American Board of Family Medicine. 29:1; January-February 2016.

US Centers for Disease Control and Prevention. Pertussis. http://www.cdc.gov/pertussis/fast-facts.html. Retrieved 18 April 2016.

US Centers for Disease Control and Prevention. HPV. http://www.cdc.gov/hpv/hcp/clinician-factsheet.html. Retrieved 18 April 2016.

US Centers for Disease Control and Prevention. HIV in the United States At a Glance. http://www.cdc.gov/hiv/statistics/overview/ataglance.html. Retrieved 18 April 2016.

US Department of Health and Human Services. Preventive Services Covered Under the Affordable Care Act. http://www.hhs.gov/healthcare/facts-and-features/fact-sheets/preventive-services-covered-under-aca/. Retrieved 18 April 2016.

©2016

All images designated as licensed for non-commercial reuse.

 

Warning Fatigue: Chatter and the Stress of Flying

Matt Freeman DNP, MPH

A trip through the terminal at Galeão/Antonio Carlos Jobim Airport in Rio de Janeiro is mundane, if not a bit grim… unless  you start listening. The steaming, sultry, deep voice of former newscaster Iris Lettieri is used to make announcements. Since 1977, Lettieri’s passionate voice has been used in Rio, and has since expanded to other airports in Brazil.

Every time I have flown in Brazil, I have been caught off guard by the sense of mystery and romance in her recorded voice.

If you have never been to Brazil, or have forgotten Lettieri’s voice, this NPR interview will introduce or reacquaint you. You will not be disappointed.

http://www.npr.org/templates/story/story.php?storyId=8976813

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Iris Lettieri is the exception.

Amid the many stresses of air travel, the overuse of announcements is grating, counterproductive, and exacerbates an already anxiety-producing experience.

Psychologists in the United Kingdom analyzed how repetitive announcements result in “warning fatigue.” Professor Judy Edworthy and Plymouth University described how listeners will “habituate” to a stimulus, and it will eventually be ignored.

There is a reasonably simple principle of neuroscience behind this: action potentials from a constant stimulus will decrease over time. As a physiology professor taught me as an undergraduate: this is why you do not smell your own perfume or cologne after a while.

 

Looped, Pre-Recorded Announcements

Edworthy’s argument is perhaps most evident in pre-recorded announcements. Journalists from The Telegraph identified twenty-seven public safety announcements during a 30-minute period at a London railway station. These included messages about using the handrails, using an elevator instead of an escalator if one has suitcases, and so on.

A spokeswoman for the railway company said that the messages were “for the safety of our passengers because we have had accidents.”

Lisa Lavia, a representative of the Noise Abatement Society, felt differently. “…the public really hate these announcements but feel powerless to do anything about them. But as the science is now showing, these nightmare messages are no longer just a nuisance–they don’t even work.”

 

Relevance

Perhaps the most baffling of looped, pre-recorded announcements advises passengers in US airports of restrictions on liquids and gels in hand luggage. This announcement is played repeatedly in the “sterile” area of the airport, after passengers have passed through a security checkpoint.

The irrelevance tacitly advises listeners, “These announcements do not apply to you. You have nothing to gain by listening.”

Anything significant, such as “the airport is now on fire,” would run the risk of being lost amid the frequent and meaningless other announcements.”

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Mass Confusion

During my first job after college, I attended a workshop on dealing with crowds and lines. One of the core lessons was: never, ever shout instructions at a large group. The typical responses are:

“What was that?”

“What did he say?

In a check-in hall at an airport, yelling “Anybody going to Chicago?” will likely create mass confusion. “Did he say Chicago? Was that our flight?” Then someone will yell from the back, “Chicago! That’s us!” The commotion escalates.

It is far easier to walk along side the crowd and ask, “Are you headed to Chicago?” Or, perhaps more productively, “Where are you headed today?” Although the illusion is that it might take longer, it is actually far more expeditious. One can identify the Chicago-bound passengers and direct them to the right place—calmly, personably. In the process, you might find that you have people in the wrong queue for the wrong airline and correct that problem too.

 

The Transportation Security Administration (TSA) has developed a reputation for so-called “barkers,” who shout instructions at groups of people waiting in line. The stressful experience of airport security is exacerbated by a barrage of repeated and blurred shouts.

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I recall one security checkpoint that was strictly for passengers transferring off of international flights. “Folks, you are about to enter a security checkpoint!” shouted the “barker.” It would be hard to imagine that anyone would be confused by the scene before them: x-ray machines, metal detectors, body scanners. After all, everyone in the queue had just gone through the same experience several hours prior. The remaining instructions were garbled, and certainly unhelpful to those who did not speak English.

I witnessed one TSA agent go against the trend. She smiled, stayed calm, and politely gestured to those who did not speak English to remove their coats and shoes. Unsurprisingly, she had the line moving far more quickly and without agitation. Furthermore, other passengers witnessed her polite demonstration, so the message propagated down the line. Without words and with a gentle smile, she silently had everyone on their way.

 

Shame and Admonishment

“We have a lot of material to cover today.” I remember far too many teachers and professors who would start off their classes with this warning. It was never helpful. After all, the professor wrote the syllabus, so it was his or her idea as to how much material would be covered in the designated instructional time. The initial pressure of “we have a lot to cover today,” just added stress without discernable benefit. What could students have done differently?

The same applies to “this is a very full flight.” This announcement precedes just about every commercial flight I have taken in or to the United States in the past few years. It is an introduction to the flight by admonishing and shaming passengers who have done nothing wrong; they just happen to be flying that day.

“We are expecting a very full flight” adds the same stress as, “We have a lot to cover today.” There is nothing I can do differently if the flight is full or empty: my hand luggage is the same size; my own height and weight have not changed. All I can expect is that I will feel perhaps more cramped than usual.

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Asking for the Impossible

Boarding is invariably the most stressful time for passengers and crew. There is the struggle to fit everyone’s hand luggage in a small space, find seats, relocate families who have been separated, and still get the plane out on time.

Instead of a self-regulating environment, passengers are bombarded with instructions to “step into [their] row” thereby leaving the aisle open for other passengers. Amid the chaos of fitting 150 people into a small space, the announcement just creates noise. If passengers self-regulate: moving and accommodating for one another, they need not pause to listen to an unnecessary announcement.

There is also the impossibility of “stepping into your row.” In a crowded single-aisle aircraft, one has to be patient as everyone else shuffles themselves and their belongings. Stepping into one’s row is not always an option. The announcement thus creates more disruption, and it asks passengers to accomplish the impossible.

 

Significance versus Fine Print

Gate agents and flight attendants read from announcements from smartphones, booklets, or from computer printouts. The longwinded nature of these announcements makes the fundamental error of mixing marketing, regulatory, and logistical information with the same cadence, length, and mixed in a single string of data. There is little sense of priority, and much of the information is superfluous.

 

Category Example Priority Can this be excluded?
Regulatory “Children under the age of 15 may not sit in an exit row.” Important
It is a federal law, but does it need to be announced?
Maybe. The gate agents and flight attendants could check this without an announcement.
Logistical “The flight time will be 3 hours, 25 minutes.” Intermediate relevance:
useful information for most passengers
Maybe
Logistical “We accept credit and debit cards with the Visa, MasterCard, and American Express logo.” Low relevance.
A passenger attempting to purchase something in cash might be informed of this only if such a situation arose. Why announce it?
Yes
Marketing “We are a founding member of the Star Alliance.” Minimal relevance
since passengers already purchased their tickets and boarded the flight.
Yes

 

Parsimony

Federal law (FAR Part § 121.317) requires that illumination of the “fasten seatbelt” sign have an accompanying oral instruction. This is not necessarily a bad idea, particularly for passengers who have vision impairments, or who might not speak English.

In reasonable situations, a crew member just says, “Seatbelts, please.” On a flight to Germany, the American captain just said, “Seatbelts, please. Bitte anschellen.” Four words. An unequivocal message is delivered in both languages, and there is compliance with US law.

Sadly, the four word announcements are rare. I often fly to and from Tel Aviv. The airline I often fly has a blaring, pre-recorded announcement. A woman’s voice at 10 out of 10 volume arouses one from sleep on an overnight flight saying, “Ladies and gentleman, the Captain has turned on the ‘fasten seatbelt’ sign. Please return to your seat and fasten your seatbelt.” This is followed by a Hebrew-speaking crewmember repeating the same message. Twenty words in English followed by 16 in Hebrew. The length of the announcement detracts from the core message: “seatbelt.”

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Redundant Information

In airplanes with video equipment, most airlines present safety information through a video presentation. These films are reviewed by the FAA, and the language has to be specific to meet regulatory requirements. As ridiculous as it seems, the law is clear that passengers must be shown how to buckle and unbuckle a seatbelt. (The idea is that airplane seatbelts operate differently than those in cars.)

Problems arise when crew restate information already in the film. This is particularly true of announcements regarding mobile phones and smoking. One could argue that this information needs to be reinforced to ensure adherence. “Nobody watches the film, so we have to announce it.” Another option is never presented: during the mandatory walk-throughs or “compliance checks,” the crew could just ask passengers individually to correct any reclined seats or obstructive luggage.

Instead of worrying about inattention to the video or announcements, why not just correct the safety problems as they occur?

 

Goal Setting

“Did you not hear the announcement?” is no longer a reasonable argument. There are so many announcements that one can easily become sidetracked. Furthermore, flying is tiring, rules vary, and some airlines and security checkpoints are stricter than others.

The TSA staff or airline crew would be wise to ask, “What is our goal?” Is the goal to have one’s announcements heeded, or is the goal to ensure that passengers are safe?

 

Moving Forward

The first question is, “How much of this information needs to be conveyed?” Aside from federally-mandated announcements, air carriers would be wise to explore passenger comprehension. During the roughly 60 minutes it takes from beginning boarding to reaching the runway, how many announcements are made? Of those announcements, what is the overall comprehension level?

Some of these issues are hard to measure. One cannot conduct a “placebo controlled” study to determine if repeated overhead announcements about leaving luggage unattended actually lead to greater attention to security. The decision to cease the announcements has to be based on principles of neuropsychology: repeated announcements will be ignored over time.

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Dialing it Down. How Can We Limit the Cacophony?

Since the “announcement culture” is ingrained in American air travel, it may take scientific analyses to argue for fewer announcements.
1. Measure Passenger Stress

Passenger stress can be assessed through psychological inventory or biological measures. Researchers could evaluate the magnitude of passenger stress as a function of the number of announcements (safety, logistical, and marketing.)

 

2. Measure Passenger Adherence

Some announcements are federally-mandated, but one could experiment with optional announcements.

  1. Conduct a trial in which one TSA checkpoint has an agent announces repeatedly that laptops must be removed from hand luggage; make no announcement in another checkpoint. See how many passengers remove their laptops between the two lines.
  2. Ask airline crews to measure the number of passengers who attempt to pay in cash as a function of a pre-flight announcement. Does the announcement actually affect adherence?

 

3. Measure Passenger Satisfaction

Airlines routinely collect extensive survey data. It would be easy to determine if passengers have greater satisfaction with their airport experience based on stressful announcements like, “This is a very full flight.” An air carrier could compare satisfaction surveys from flights where such language is prohibited to the status quo.
There are solutions to a calmer, quieter trip both on the ground and in the air. Although it would be pleasant to have the rich voice of Iris Lettieri all over the world, there is an obvious need to “dial down” the barrage of announcements.

 

 

References

Copping J. & Ljunggren H. Annoyed by public address messages? Now experts say they don’t even work. The Telegraph. 2 October 2011.

 

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©2016