Medicine Trial and Error: Missouri Turkey Shoot

Psychiatric Medication Context Notes

Yes, you may recall: I sent out this post the weekend before the Va Tech tragedy. Just didn't seem appropriate at the time with all the shooting going on, so pulled it back into the drawer. I am sending it our again because we do have so many psych tragedies occurring [though less catastrophically] everyday. Targets are often not defined adequately, and sloppy thinking can have terrible results.

The proliferation of Black Box warnings by the US FDA address the same specificity/target issues. In this particular corner of psych medication use the FDA has a point.

When we are sloppy with meds, years, indeed lifetimes, can be lost.

Blasting Away With Medications
So consider the Missouri Turkey Shoot:

Blasting At The Barn

How do you feel when a doc says: “I don't know what's going on here, let's give this a shot.”  Sounds like a Missouri Turkey Shoot to me.

Take Notice: The Clinical Targets and Medication Titration Strategies Have Changed!

By now you know that I am a medical target shooter, and don't agree with loading up any shell and simply blasting away at the unknown with my metaphoric arsenal. But blasting away is a big problem with meds, simply because of the rapid evolution of the *science of targets.*

Now just what does he mean by target? Hint: the target is smaller than a barn. We have more targets to identify, more specific tools to use.

When I was a kid we hunted rabbits out in Missouri and Indiana. Two wonderful Beagles loved to chase any rabbits thru woods, over the railroad tracks, and down in the “swales.” I was a country kid and, hey, it put meat on the table, and took my father, brother and me into the woods together.  We reloaded our own shells, and I was the chief skinner and cleaner. Could clean a rabbit in less than 3 minutes. But back to the Turkey Shoot…

Turkeys and Medical Targets

Hit What You Aim For

Occasionally in the Missouri fall the local hunting group held a Benefit Turkey Shoot. We all put on blaze orange hats, they guys set out beer and drinks out on picnic tables and the women brought wonderful food. Sorta like a very red neck tail gate party. Loved it. It was a hunter/family bonding thing wherein we could all tell dog and rabbit stories.

The Benefit Turkey Shoot:
The sponsors would put up a large piece of brown butcher paper between two trees with a turkey painted in outline. The contest? Drink some beer, load up a shotgun shell [with 00 buckshot], boom one shot at the paper bird, and go back to bragging. Shotgun smoke fills the air, everyone is happy.

You paid to take the shot, and the collected dollar pot went to the benefit, and the guy with the most holes in the paper bird [count them], won the prize: case of beer, dog collar, can't remember.

What am I talking about? We have a problem, *benefit targets* have changed dramatically in 50 years. Reasonable neuroscience practice is no longer just a Turkey Shoot.

Let's take off our hats and stop keeping score by counting blind hits. [Managed care does disagree. They want a cheap shot, and want us to miss  two times before we are permitted to take precise aim with the best system. Unbelievable where we are with psych meds in '07, more later.]

The Turkey Shoot problems are multiple:

1. No clear specific target, like shooting geese at night: Honk!… Bang!
2. Multiple blind shots all in one large cloud of pellets can both miss and complicate the target
3. Winning is by chance alone
4. This practice is pervasive on both sides of the philosophic fence: Traditional med folk see depression and blast away, and functional medicine folk send them out the door with 30 supplements.  Different  pellets, same process.

Systems medicine is evolving: The target can be more precise so let's get more specific evidence with some [very brief overview] of these tests:

1. Sputum for Hormones [more soon]
2. Precise Neurotransmitter Measurements
3. Thyroid with TPO and rT3 [more soon]
4. Comprehensive Metabolic Panel [see in earlier post]
5. Iodine clearance testing [more soon]
6. Celiac testing [more soon]
7. Heavy metals [more soon]

Let's take more care with patients, and use the best meds, delivered with full respect for specific clinical objectives. Not every depression is just depression.

Stay tuned as we tell you about these tests and their relevance for the chronic “psychiatrically impaired' exhausted, fatigued, depressed, withdrawn patients.

Blasting away was the only way years ago, now we must identify specific targets for specific outcomes.

And don't wear your blaze orange hat to the next scientific meeting, it would not be lucky.

If you don't look, if you don't measure, you can't hit the target precisely. Let's not simply load up and do the Turkey Shoot.

cp