DR. BOB'S MUSINGS

Leakage of a draft opinion of the majority in the case of Dobbs v. Jackson Women’s Health Organization has resulted in a consensus that the US Supreme Court will likely reverse the decision of Roe v. Wade, and undo its protections for women and their health care providers to determine the best course of care.

In my opinion, physicians, including psychiatrists, have a duty to advocate for patients who we counsel and treat based upon the best medical evidence. Roe has been settled law assuring women access to a standard medical procedure for almost 5 decades—or so we thought.

Click here to read the full article at PsychiatricTimes.com

The U.S.A. has a problem with guns. About 40.000 people will die of gunshot wounds (GSWs) in America this year. Most victims will commit suicide, while others are murdered or are shot accidently. For every GSW victim who dies, about two others survive. Approximately 10,000 people are shot across the U.S. each month. The costs, financially and psychologically, are enormous.

In May 2021 a mass shooting at a light-rail facility in San Jose left the perpetrator and nine GSW victims dead. While unique to the victims and their families, mass shootings have become common occurrences in America. According to the Gun Violence Archive, thirty-three to eighty-six mass shootings took place each month in America during 2021. (A mass shooting is operationalized as four people shot.) In a given day, one to three mass shootings take place in our country.

I have recently evaluated a dozen employees who survived another Bay area mass shooting that occurred in San Francisco in 2017. These horrific critical events don't just go away tomorrow. They are life-changing events. Now, one city in America is poised to say, "Enough is enough." According to San Jose's mayor, about $40M is spent annually on emergency services related to gun violence in that municipality. When one considers total cost of gun violence to that community, it's estimated to be in excess of $440M.

The City of San Jose has recently approved an ordinance that will require gun owners in San Jose to carry liability insurance and pay an annual "gun harm reduction" fee. The ordinance doesn't restrict gun ownership, yet sets policy based upon the financial consequences to a community resulting from firearm use.

My father was a combat medic assigned to a U.S. Army engineering unit in Burma during WWII. He was awarded the Bronze Star in recognition of his valor. Unlike my dad I didn’t have to travel to a distant land to witness weapons of war taking human life. It’s happening here at home, every day with no end in sight.

Doctors for America (DFA), with 20,000 physician and medical student members, believes we can make a difference by the clinical work we do in hospitals, ERs, clinics and private practices. DFA is also committed to bringing our fight for common sense gun safety laws to the attention of city officials across the U.S. Our message is simple. Follow the lead of San Jose. We want gun owners in New York City, Chicago, Miami, New Orleans, San Francisco and all major cities in the Land of the Free, the Home of the Brave to shoulder some of the cost for the damage caused by firearms. Perhaps we are at a moment when public health and safety may prevail over the obsession America has with guns.

In 1974 when I began my training at Northwestern University Medical School, a state-of-the-art women’s hospital was scheduled to open on that campus in Chicago. It was designed with an entire floor dedicated to cases of sepsis. You might ask how large numbers of adult females could end up with infections in their circulatory system. It’s quite simple, illegal abortions. As a result of the decision in Roe v. Wade, an entire floor of a major hospital was obsolete before it opened. Does anyone of good will want women to rely upon illegal procedures?

Women are understandably concerned about access to healthcare and reproductive options. (See The New Mexican, Rally for Reproductive Rights, 10/3/2021.) The “Right to Choose,” more graphically termed access to abortion, remains the wedge issue in America. From this physician’s perspective, there is no good alternative. No one likes abortion, not even the woman who has decided to terminate her pregnancy. However, no one can force anyone to carry an unwanted pregnancy to term. The result of eliminating safe, legal abortion for many will be a surge of infectious disease, hospitalizations, chronic pain and infertility, and deaths in women of reproductive age.

If the pope can say, “Who am I to judge,” then what decent person wishes to be the first to cast a stone at a desperate fellow citizen? There are a multitude of reasons why pregnancies are terminated by victims of sexual assault & incest, teenage girls, married women with too many kids, single females with abusive partners, and the list goes on. Do we really want hospitals in Chicago, New York, Dallas, Miami and all other major cities to have Sepsis Wards?

Those supporting elimination of abortion do not envision what fate will befall the poor. Some folks who cloak their views as consistent with a “right to life” will make sure their wife or daughter has access to the care denied others. Let’s call this what it is, hypocrisy. My intention is not to insult or anger the many people on the other side of this debate. I wish to inform all about where things could end up.

A Letter to Editor – “Santa Fe New Mexican” – pub. July 10, 2021 

I’d like to suggest some neologisms (new words) for parents like the Olivers, who lost their son, Joaquin, in a school shooting. “Childreft” as in bereft of child. “Formrent” as in former parent. “Minorless” describing a household having no children. “Gunvictamily” as in gun victim’s family. Perhaps other wordsmiths might suggest their own neologisms. Write to The New Mexican with your descriptor for parents and families who have become victims of gun violence. Get your friends in other communities across the U.S. to do the same in local media. Only through action will this epidemic be curtailed.

Doctors For America is an organization of physicians and medical students that advocates for changes in policy for a number of issues affecting the health of our fellow citizens. Preventing gun violence is one of those issues.

DFA and many other organizations support background checks for firearm purchases. About 90 percent of voters and the majority of gun owners do as well. Let’s start with background checks and then move on to address red-flag laws, ghost guns, and assault rifles.

Dr. Bob Larsen, Santa Fe

A Letter to Editor -  "Boulder Daily Camera" - pub. April 2, 2021   

While watching CU’s team lose to Florida State, I was told, “Now is not the right time,” when bringing up the King Soopers shootings during a break in the action.

After graduating from CU (B.A., MCD Biology, 1973), I did scientific research before completing medical school (MD, Northwestern, 1978), psychiatric residency (UCSF, 1982), public health training (MPH, UC, Berkeley, 1984) and a health policy fellowship (Stanford, 1984). As an occupational psychiatrist, I help employees with work-related tragedy. Last week, I evaluated five UPS employees following a 2017 mass shooting at a San Francisco worksite. These critical incidents don’t go away overnight.

Our nation’s flags were at half-staff following the shootings in Atlanta when ten people died in Boulder. In the past eight years, America has averaged two mass shootings per month. Pray tell, when would be the right time to discuss another act of senseless violence?

Sandy Hook and Columbine are known for their death tolls, not their curriculum. In response to shooting incidents, SWAT teams deploy with military-style precision. Grief counselors console the victims. The pattern repeats itself. If America brought this same impotent approach to fighting Smallpox and AIDS, people would be dying at epidemic levels.

My state of New Mexico has a “red flag” law. The Boulder shooter’s family could have restricted his access to firearms with such a law. A Federal background checks bill (HR8) passed the House in 2019. 90% of the electorate support the bill, including most gun owners.

Doctors For America (DFA) has proposed the formation of the National Bureau for Gun Safety, akin to the National Transportation Safety Board. My colleagues and I need your support for gun safety laws addressing background checks, red flags, safe storage, assault rifles, and a National Bureau. Now is the time to eradicate our gun violence epidemic.

Dr. Bob Larsen

CU graduate; marching band,1970

This month we celebrate women's history & throughout the world on Monday, which happens to be my daughter's birthday!

In Chapter 17 of Wounded Workers, the tale of a young immigrant who gets a job in a meat processing plant after college is told. "I Am Unlovable" will break your heart, before you cry out for joy. This is a tale of hardiness & resilience in a woman who travels from victim to VICTOR in her journey. 

Enough said, get the book at Amazon Books.

And remember to honor the strong women in your life. Thanks.

The GOOD news is Wounded Workers will be available on Amazon in March! This long-awaited treatise on the plight and resilience of American workers can be yours for the asking. Just go to the book’s website https://workingmansshrink.com & click on the “Be the First to Know” or “Contact Me” to sign up for the details of the launch.

It’s been years since I began writing Wounded Workers. I wasn’t sure where it would end up. I had written journal articles, chapters in textbooks, letters to the editors of newspapers, op-eds, obits, and other written products for consumption by professional audiences and the general public. I thought writing a book would be a logical next step.

Not so. Producing a book is more like building a house than writing a position statement, an editorial or a chapter in a textbook. It’s the difference between a room addition and new construction. You might be able to do a renovation on your own. It takes a construction team to build a house.

I now realize after years of individual effort at organizing the material and writing the stories in Wounded Workers that only got me through the permit process of book building. Just as architectural plans are updated and revised, so too is a manuscript edited, proofed and put through design review. You start out thinking a good idea and an empty lot are all that’s necessary to build a great residence. With time, you realize you are part of a team. An architect designing his, or a general contractor building her, dream home doesn’t work alone. Good authors need editors, proofreaders, graphic designers, research assistants, gifted printers and other talented artisans.

So, please come to my house warming. Get a copy of Wounded Workers. Write a review, if you are so inclined. You’re invited to share the website & the book’s availability with a friend. Maybe give a copy as a gift to someone you know who will identify with the employees honored by the tales that the book tells.

I look forward to hearing what tales spoke to you. Many thanks in advance, Dr. Bob

 “In the end, we are not defined by the particular product or service we create, but rather by the manner in which we affect those we serve. If you are engaging in meaningful work, those for whom you provide service will decide your value.”  

“From the last chapter of Wounded Workers. For availability go to Contact Me for updates.”

The president, the first lady and Hope Hicks have all tested positive for COVID-19. There is no surprise here. Optional masks, no social distancing and attending indoor mass gatherings have consequences. These public health strategies work, even if they are sometimes controversial.

They are not alone. What do seat belts, vaccinations of schoolchildren and motorcycle helmets have in common? They are all required by law, with some exceptions. These health and safety measures are based upon safety tests, epidemiology and advice from safety experts.

Like wearing masks or social distancing, these health and safety laws have met with public resistance. Personal freedom and infringement upon individual rights are cited by citizens opposing mandated health and safety policies. Motor vehicle mortality rates have plummeted since federal law requires their use. Many childhood illnesses such as measles, mumps and whooping cough no longer occur at epidemic levels in our country because of the vaccinations of schoolchildren.

The first universal motorcycle helmet law was enacted in 1966. As of 1975, 47 states and Washington, D.C., had universal helmet laws. After federal penalties were eliminated, half of the states repealed their laws. A review of 61 studies by the Cochrane Collaboration found helmets to reduce mortality by 42 percent and head injuries by 69 percent in motorcycle accidents. Currently, only 22 states, the District of Columbia and Puerto Rico have universal motorcycle helmet laws.

Costs to the health care system and society are enormous when personal freedom trumps proven safety equipment and effective, preventive medical intervention. As a physician with a graduate degree in public health and five years of experience working in a county hospital emergency room, I bring a certain perspective to the current debate over the use of facial masks during the coronavirus pandemic. My advice is quite simple: Wear the mask. In my public health training, we were taught, “Plan for the worst and hope for the best.” Unfortunately, our country’s response to a highly contagious virus has been in large part to support personal freedom over implementing sound health policy. Our country leads the world in COVID-19 deaths, hospitalizations and infection rates. Is wearing a mask too much to ask of Americans?

A Washington Post article published in The New Mexican (“CDC: Nearly 11,000 exposed on airplanes,” Sept. 21) cites an investigation of 1,600 passengers by the Centers for Disease Control and Prevention where almost 11,000 people were potentially exposed to COVID-19. The article reports that a public citizen called upon the Department of Transportation to mandate mask-wearing on planes. Currently, mask-wearing is at the discretion of airlines or individual passengers. Any wonder why America leads the world in COVID-19 cases?

Aside from misinformation about the virus and inconsistent policy across levels of government, leadership at the highest level hasn’t modeled mask-wearing, social distancing and avoidance of large gatherings. Response to a pandemic should not be politicized.

To perhaps better understand why Americans have responded as we have to this pandemic, the blame cannot be directed solely toward the president and his administration. We all have responsibility to protect our fellow citizens. Minors and young adults have never seen a person acutely infected with measles, much less polio or smallpox. Americans have heard of AIDS but often don’t know anyone who died of that disease. Ebola devastated areas of Africa, yet we were spared witnessing fellow humans bleeding to death. If more Americans experienced the havoc viruses can bring to an individual or a community, we’d gladly wear a mask. Residents of Santa Fe and elsewhere in America are well advised to follow the advice of doctors, epidemiologists and public health experts. It’s not complicated if we work together and respect this elegant, deadly coronavirus.

Dr. Bob Larsen has devoted his career to evaluation and treatment of injured workers with serious trauma. His book, Wounded Workers: Tales of a Working Man’s Shrink, is scheduled for publication in early 2021. He and his wife live in Santa Fe.

 This commentary from Dr. Bob also appeared in the "Santa Fe New Mexican" on October 3, 2020  

Whether working in person or from home these days, we are all part of a team. This holds for solo practitioner attorneys as well as claims examiners working for large insurers with offices throughout the state and perhaps the nation. Your team encompasses many more individuals than your manager, your supervisees and you. Your team includes people that are not even co-workers. In a world in which important tasks are outsourced to independent contractors and other partners, our team and yours include the UPS driver, the janitors, building maintenance staff, building security, a website designer, an accounting firm, pension plan experts and others necessary for producing your company’s goods and services. In a time wherein we attempt to maintain normalcy while nothing seems normal, supporting your team is more important than ever.

Supporting your team is simple. By doing so you remind yourself and others that no one works alone. We humans are social creatures. Your team provides needed interchange with others. 

There are three easy steps that you can take during The Time of the Pandemic to support your team. 

1. Be mindful who is on your team. Don’t take co-workers, contractors and other partners at work for granted. Begin by making a list of all the people who help you get the job done.
2. During these challenging times begin conversations with members of your team by asking, “How are you doing?” That is usually enough to show that you share a connection with each other.
3. Give thanks and show gratitude for accomplishments that are not merely your own. You may be amazed at how good it feels to be magnanimous.

Testing, please

We need testing.

We need more testing.

We need more readily available testing. (Do I have to be symptomatic to be tested?)

We need more reliable testing. (Am I positive/negative when the test says so?)

We need more informative testing. (My test is positive. Am I contagious or immune?)

Then we can move forward.

This commentary from Dr. Bob also appeared in the "Santa Fe New Mexican" on May 14, 2020 

When recently going through a number of cases seen in our office, I found myself thinking about all those individuals who have had tragic experiences while at work. Doctors sometimes identify with our patients. However, that is not unique to the medical profession. Attorneys, claims administrators, case managers, union representatives, vocational consultants, judges and all those providing support related to claims of work-related conflict and injury are also affected by the tales we hear.

While of course it is far worse for the individual who is traumatized than for those who work with them, it is only human to be affected by stories of resilience or alternatively victimization. Severe burns, amputations, assaults, head injuries, robberies and unforeseen acts of God affect the people who come through our doors. Their tales affect us all. 

It really is important to find some balance between managing the troubling tales of others and having a life outside of work. My words of wisdom are simple. Enjoy friends, family and life. Don’t let the months pass by without recharging your batteries.

There is no cheerful way of having a discussion about gun violence.

Unfortunately, the subject does not take a break for the holidays. During the past two decades, gun deaths have increased by 20 percent in our country, according to the U.S. Centers for Disease Control and Prevention. Almost 40,000 Americans will die of gunshot wounds this year, while several times that number will survive with physical and emotional injuries that may never fully heal. The cost to our society is enormous.

Consider the resources that address our epidemic of gun violence. Law enforcement personnel include patrol officers, SWAT teams, crisis negotiators, commanding officers, sheriff’s deputies, detectives, investigators, forensics experts, bailiffs, correctional officers, parole and probation officers and, unfortunately, coroners.

It doesn’t end there. Legal resources become necessary to deal with criminal and civil matters. These include prosecutors and district attorneys, defense attorneys, paralegals, and judges. Ancillary personnel come into play as well. Bondsmen, insurance company representatives, mediators and morticians are part of the labor pool needed to address the carnage.

I and many of my colleagues lend our expertise to victims, dead or alive, and their family, co-workers and neighbors. The medical team involves emergency physicians, trauma surgeons, orthopedists, physical medicine experts, plastic surgeons, internists, pathologists and psychiatrists like me. Other necessary clinical components are paramedics, EMTs, nurses staffing the emergency room, operating room, medical/surgical units and home visits, hospital technicians and orderlies, occupational and physical therapists, prosthetists, psychologists and counselors.

The financial costs to our society are enormous just in terms of the labor needs required to respond to the frequent instances of gun violence. Meanwhile, the politics of firearm ownership divide us into adversarial camps. The lack of political will has left us with a hodgepodge of laws at the local, state and national levels that are often inconsistent and ineffective in dealing with this public health crisis.

Doctors for America proposes a new program to confront the issue of gun violence. A new government agency called the “National Bureau for Gun Safety” should be established. The NBGS would be staffed by experts in public health, medicine, law enforcement, engineering and communications. It would oversee research into behavior, safety technologies and legislative priorities to save lives at risk from gun injuries. The NBGS would work with the Bureau of Alcohol, Tobacco, Firearms and Explosives. A synergistic approach would be brought forth with respect to research, technology, public awareness and legislation.

In 1966, our government responded to the challenge of increasing mortality on roadways by passing the National Traffic and Motor Vehicle Safety Act. The National Highway Safety Bureau was created. The NHSB systematically addressed the problem through research and technology, which brought about seat belts and later airbags. Public education and legislative change were part of that process. The result was a drop in the motor vehicle death rate by two-thirds over subsequent decades. Doctors for America is calling for a similar response to gun violence as was apparent five decades ago to the problem of motor vehicle accidents and associated injuries.

The proposed agency, as currently conceived, would have shared goals with the Second Amendment Foundation and the National Rifle Association, which have a history of advocating for gun safety.

At the same time, doctors and other health professionals must lead the way in protecting the public health. This is our job, our calling and our lane. The NBGS concept can potentially change the national conversation on gun violence by placing the focus upon health. The goal should be preventing violence, injury and death as opposed to dealing with the victims when it is often too late.

Bob Larsen, M.D., is a member of Doctors for America and the National Steering Committee on Gun Violence. He lives in Santa Fe. This commentary also appeared in the "Santa Fe New Mexican" on December 14, 2019

This is a two-pronged message which is both personal and universal. First: We are all more human than otherwise and thus vulnerable. Second: We should all count our blessings, give thanks.

Last month I had the good fortune, in retrospect, to have the same cardiothoracic surgeon who saved my life more than a decade ago do so once again. After contracting a heart infection, i.e. endocarditis, my aortic valve began to malfunction. In 2008 the valve was replaced during a hospitalization at California Pacific Medical Center. Some years went by during which time my cardiac function was periodically monitored. Over time the pig valve which had been implanted began to fail as well. Rather than put things off I opted to undergo open heart surgery once again, only this time at El Camino Hospital. Last month a team led by Dr. Vincent Gaudiani replaced the defective aortic valve and reconstructed my ascending aorta. I am now more bionic than ever. I am doing amazingly well with long walks and bicycling having resumed as regular activities. I plan to be back conducting evaluations at the Center in December.

Like you I am human, mortal and vulnerable. Like me you have things to be grateful for. I know this Thanksgiving I will be counting my blessings when I am with family and friends.

Let me end by wishing you good health, and absent such, excellent healthcare. My advice to patients, family and friends is simple. “Be your own best advocate. Trust your doctor or get a new one.” 

By the way, the rumors of my demise have been greatly exaggerated! 

    Public safety officers represent a population of workers who often come to the attention of mental health practitioners. Police officers, firefighters, paramedics and other first responders routinely are exposed to critical incidents on a singular or cumulative basis. 

As an early career physician I spent five years working emergency services at Highland Hospital in Oakland where paramedics, deputy sheriffs and police were tasked with bringing trauma victims. More than three decades ago I accepted the invitation of then Captain Mike Hebel to tour the San Francisco Police Academy. Following the events of 9/11, I met with N.Y. firefighters at a firehouse that lost eight colleagues. 

Whether first responders, long term employees or not, I believe doctors should humanely listen to and report the stories of persons with “mental injury” claims. We should be advocates for systems designed to protect workers while maintaining neutrality in complex human stories.

  The Bureau of Labor Statistics keeps data on fatal occupational injuries on an annual basis. Information on non-fatal yet serious injuries is also maintained. Loggers, construction workers, taxi drivers, police officers and iron workers are at high risk for serious if not fatal injury when compared to the average American worker. 

Not uncommonly such injury events involve claims for both physical and mental injury. An agricultural worker losing a limb will understandably have some psychological problems. An iron worker impaled by rebar may experience a fear of heights when later returning to a jobsite. A trash collector witnessing a co-worker run over by a garbage truck may well experience high anxiety when working around heavy machinery. The psychological injuries related to serious physical injuries and work-related deaths are real.

In retrospect I now realize that a number of the jobs that I had as a young man were quite risky. In Chicago I witnessed a more experienced dock worker crushed between two trucks. I later worked in research laboratories with chemicals so toxic that if you smelled them you would die. My shortest career path was as a roofer which lasted one day. That work in Florida was hot, heavy and fraught with hazard. In each of these job positions some years ago I earned the princely sum of less than $5.00 per hour. 

Exposure to falls, hazardous substances, dangerous machinery and transportation incidents account for many work-related fatalities. Let us not be surprised that there are psychological consequences to those events. For more information go to www.bls.gov/iif/. 

Let us all be grateful when someone else is able and willing to take on dangerous work. When considering the most odious aspects of our own work, think about what cops, cab drivers and power line workers deal with on a daily basis.

Most folks referred to Dr. Bob for evaluation come with some type of bad story. Not uncommonly they are dealing with debilitating physical illness, intrusive recollections of acute trauma such as armed robbery, or burnout from a long career involving high demands and minimal gratification. A frequently asked question is, “Why me?” Perhaps an existential question best left to philosophers or spiritual leaders rather than mental health practitioners. One of my goals in the course of a consultation is to help interviewees ask, “What can I do to make a difference in my situation?”

The point is to move people away from passive victimization and toward active re-involvement in improving their lives. For some they are encouraged to consider pursuing a job transfer with their long-term employer. For others reduction in reliance upon narcotic pain medication is needed. For those who do not see themselves returning to the workforce there are opportunities to volunteer and mentor persons who are even more wanting.

A few years ago my wife and I became victims of identity theft. A parcel containing copies of our bank records, tax returns, and financial statements was stolen before it could reach its intended source. After returning from vacation we learned that purchases had been made, applications for new credit cards had been accepted, and lines of credit had been approved. It took many months before all the banks and retailers involved became a part of the solution and not the problem.

I did not care for having to be labeled as a “victim” of identity theft after filing a report with the San Francisco Police Department. That turned out to be the only way of resolving numerous transactions that had occurred without our knowledge. That whole process gave me some appreciation for what the people that I see at times must feel when labeled by others as merely injured, disabled or victims. However, when we treat others with respect the victim role is lessened. Simply put, hope can take root when we see ourselves as empowered and not victimized.

   As professionals involved in the workers' compensation system in California we have all become familiar with the processes of Utilization Review and Independent Medical Review of recommended industrial treatment. The concept places an emphasis upon evidence-based treatment guidelines. 

I would like to tell you a brief story which involves a recommendation for an unusual form of treatment for an admitted psychiatric injury. Some years ago I evaluated a woman of Haitian origin who had developed phobic symptoms in response to having been physically injured at work. Counseling services had been provided by the insurer with no significant change having come forth. The applicant was wary of taking psychotropic medication. 

The injured worker was aware that there was a practitioner of the dark arts located in her community whom she was convinced could help her. A treating mental health practitioner had recommended an additional one dozen outpatient psychotherapy sessions. My recommendation was that the insurer instead pay for three sessions with the voodoo practitioner. Surprisingly the insurer consented to cover such costs with an acceptable outcome coming forth and the applicant’s claims being brought to a satisfactory conclusion.

This vignette points to the importance of cultural issues. I recognize such as the son of an immigrant mother who was born in Italy. My mom though quite intelligent was highly superstitious. Without her ever having read the works of Freud, she placed great weight upon the interpretation of dreams in foretelling the future. I recognized those same beliefs in the applicant who had been born in Haiti. 

No doubt the Utilization Review process and the Independent Medical Review assessment of that claim would never have approved the healing intervention that worked. To the extent that it is possible, my advice is for administrators to maintain some flexibility with respect to treatment authorization in light of the characteristics and mindset of each injured worker. 

Let us all give some weight to the power of belief systems and the cultural values of fellow workers and our own families. 

“The Five Keys to Happiness”

1. Release hatred from your heart, it does you no good.
2. Let go of worry from your mind, you can’t fix it all.
3. Live more simply, you don’t need that latest device.
4. Give back more, there’s always somebody that needs it more than you do.
5. Expect less not of yourself, but for yourself.

I chose psychiatry as my career path more than four decades ago. While in medical school I was asked at an interview for a residency training program why I was interested in psychiatry. My answer was I wanted to help people be “happy.” Perhaps a bit naïve at the time yet looking back on that answer I’d like to think that we all could do worse than assisting others in becoming content.