Let’s Get Ready to Rumble!

Let’s get ready to rumble! It’s an egg laying contest. The competition is underway and let’s face it—the house finch has the title tails down.

As of last Friday, the house finch had 5 white eggs in the nest, which is a typical clutch. The cardinal is probably going to end up with only two, after losing one egg somehow. Usually, the number is between 3-4.

None of the house finch eggs are the expected pale blue color—all creamy white.

But how many will actually hatch? And more importantly, how many will fledge? Also, it looks like the chipping sparrow will have some commentary about the matter because it continues to hang out and make a lot of noise.

Chipping sparrow has an opinion…

We’ll probably know the hatching result in another 12 days or so. Fledging numbers will take another couple of weeks. We can see the action in the house finch nest from our front window. We can peek into the cardinal’s nest from our back window. The competition is keen.

Anything can happen. Last year, I think a cat might have made off with at least one of the baby robins who hatched from a nest in the same tree the cardinals are in this year. We don’t know for sure if either of the two chicks actually fledged. I’ll keep you posted.

Bird Garden Update

I have some bird garden updates. As of a few days ago, we noticed a 4th egg was added to the front yard nest. I say that because there is a mysterious triad of birds now associated with the loosely woven and frankly untidy property.

I caught a fair snapshot of a house finch male and female which might explain the nest, although I’m still puzzled for a couple of reasons.

House finch male and female (female in the back and camera shy).

The eggs are white although I’ve read that house finch eggs are usually bluish. The other curiosity is the single chipping sparrow that hangs around and chirps up a storm whenever I get too close to the nest.

Chipping sparrow raising a ruckus (sounding an alarm?)

I can’t find another nest in any of the other front yard garden trees. What’s the motivation for the chipping sparrow? All three get really fussy whenever I’m out there messing around.

I can see the tree from inside our house through the window. I can’t get a clear picture of the bird sitting on the nest because there’s not enough light through the foliage. But every time it moves it’s head, I can see its beak, which looks sort of thick but it’s in the shadows—I don’t think that’s the sparrow.

Both male and female house finch have thick beaks. The male is pictured here; the female is brown with a heavily streaked belly.

As for the back-yard garden, there’s still only two cardinal eggs left in the nest. Mama won’t let me get too close when she’s sitting on them. She gives me that look, “Don’t you eye ball me.”

Don’t you eyeball me, boy!

Spring is for the Birds

Here’s an update on front-yard and back-yard birds, doing what birds always do in the spring–nesting. There were still only two cardinal eggs in the nest as of last Wednesday. There are no robin eggs in the nest; they would be blue. The parents are still pretty fussy (click on the images to see them better).

The front yard juniper (I guess it’s a juniper; it’s a skinny evergreen) has a Hoorah’s nest with 3 white eggs. The parentage of the eggs is tough to figure out so far.

I’m not sure what’ll hatch out of those eggs. The nest itself is pretty messy for a chipping sparrow. It’s loosely woven and has bits of what looks like white textile fibers strewn around the nest and scattered on the tree branches just outside. It’s about 5 feet off the ground.

Mystery eggs

I’ve seen a male house finch and what looks like a female chipping sparrow hanging around the nest. They both look like they fly out of the juniper when I approach. I’m no expert but I doubt house finch males are that promiscuous. They both fuss at me, but from different trees.

The eggs are non-descript. They don’t look like the chipping sparrow eggs we had in the spruce tree right next to the juniper about two years ago. Those eggs were definitely blue and the hatchlings were definitely sparrows. The only thing in that spruce now is what looks like it might be last year’s nest, from what I don’t know.

House finch eggs are usually “pale blue and lightly marked”, according to my Birds of Iowa Field Guide by Stan Tekiela (2000). Lightly marked with what? Don’t think about it.

My Mother

Sometimes I think about my mother, Ruby, who died 15 years ago. She reared me and my brother Randy. Those were hard times. She had a sense of humor but the years wore on her, making life a burden. She was a lifelong resident of our hometown.

 In early life, she worked as a waitress. She often spoke with great pride of her ability to carry more hot dishes barehanded from kitchen to table than anyone else she knew.

She was an avid card player. If you couldn’t remember what tricks were played in a game of 500 — Ruby had you for lunch.

She lived in the heart of the downtown area on Federal Avenue for decades — and loved every minute of it.

She enjoyed the noise of traffic, the city waking up, the city eating lunch, and the city having a hard time going to sleep at night.

She lived high above the street, and didn’t mind the stairs at all, even late into her seventies.

Ruby loved going out for coffee. She was a great talker, and thoroughly enjoyed hearing a good joke. She knew that sharing troubles and laughter were both healing. In her own way, she reminded us to cherish our blessings wherever we found them. We will remember.

I am very lucky to have some snapshots of my family, and even luckier to find one of her smiling brightly. She suffered to put it simply. Religious faith helped. We went to church regularly for some time. My father never went to church as far as I know, but for some reason, at one time I remember there was some hint that he might attend Sunday service with us. A new pastor had taken over and I remember he said flatly that he would never allow some “Black buccaneer” in his church.

Over the years, I’ve thought about whether the pastor’s emphasis was on my father being black or just a buccaneer. He was both. Anyway, he never showed up and that’s just as well because he surely was not welcome.

At Christmas, we used to get gifts of fruitcake from members of the church. I think that was one of the first times I learned how to lie from my mother who didn’t want to hurt anyone’s feelings who was making a gift to us during the holidays. I hated that fruitcake so much; I can’t even begin to tell you. But I told anyone who gave that stuff to us that I loved it.

Television was about the only entertainment we had. We used to watch Ed Sullivan, Lost in Space, and all those other shows you can see on MeTV nowadays. We used to play Old Maid with a pretty creepy deck of cards.

Mom could climb a lot of stairs without any problems, well into her eighties. I climb a lot of stairs too as a C-L psychiatrist in the general hospital, and I’m well into my sixties. We’re alike in many ways.

One of the differences was that she could play cards better than I ever will. I’m just not so good at remembering what cards have been played. However, I try and my wife and I occasionally play a game called Schnapsen, in which remembering what’s been played is critical to winning. I lose more than my share of games.

Mom was a fast walker. We often walked from our house to Central Park downtown, which was quite a distance. We didn’t have a car, so walking was the only way to get around. I take after her because I’m a pretty good walker. Ask any trainee who rotates through the psychiatry consult service.

When she got very old, her health worsened and her nerves got the best of her more often than not. I remember she made me promise I’d never put her in a nursing home. I did promise—and I eventually had to break it.

Mom and I were very much alike. I treasure our differences.


Cardinals vs Robins?

I’m not sure what to think about our cardinals. We saw the egg cache go from two to three—than back to two in the same day. No kidding, the nest gained a third egg in the morning and lost it in the afternoon.

I looked all over the ground and couldn’t find it. Before that, I was hunting around the web trying to learn more about cardinals and discovered that robins and cardinals will sometimes lay their eggs in the same nest. It’s not always clear why this happens, maybe competition or mutualism. Maybe they’re just swingers.

There was an article published about nest-sharing between cardinals and robins several years ago, published in The Wilson Journal of Ornithology. The authors observed cardinals and robins sharing a nest with mixed eggs in Polk County, Iowa of all places. Iowa is a happening place. Both species incubated the eggs; however, only the robins fledged.

“Govoni, P. W., et al. (2009). Nest Sharing Between an American Robin and a Northern Cardinal, BIOONE.

           Mixed-clutch nest sharing was observed between an American Robin (Turdus migratorius) and a Northern Cardinal (Cardinalis cardinalis) in Saylor Township, Polk County, Iowa in May 2007. The nest contained three American Robin eggs and two Northern Cardinal eggs, but only American Robin young were fledged successfully. This was not a case of brood parasitism, as both females were observed alternating incubation of the nest. Competition for desirable nest sites might be a possible cause for this type of interspecific behavior.”

Others speculate that robins will eat cardinal young. I’m not so sure about that. Based on what little I found on the web about it, it’s controversial whether robins actually raid cardinal nests to eat the eggs. They rarely will eat shrews and small snakes. Like me, they hate coconut. They eat a lot of chokecherries, often after they’ve fermented into wine, on which they get pretty drunk and could play pranks on cardinals (“Hey, let’s go cardinal-tipping and steal some eggs!”).They sure like worms and follow my wife around as she waters the lawn, snacking on them as they emerge from their flooded tunnels, gasping and frantically hunting for their flood insurance policies. They also ham it up for the camera.

Robin hamming it up and probably three sheets to the wind.

My wife has spied a robin or two flying around the back yard. It raises questions about competition because robins nested and raised a brood last year in the same tree and in the exact same spot where the cardinals are settled this year.

It’s hardly prime real estate in my opinion. We’re always out in the back yard, making noise and flinging water and grass clippings. And we’re continually nosing around the nests, which makes the adult birds pretty nervous and fussy, putting up Do Not Trespass signs and privacy fences.

If robins ate the third egg, they had excellent table manners. There’s no trace of shell or yolk anywhere. I wondered if the cardinal had carried off one of the eggs out of impatience with our continual spying on their nest. But how? The eggs look too big for a bird’s beak. Can they carry it in their feet? Or do they own luggage?

And where would they take it? I supposed it’s possible they could be taking it to another nest they previously built—but it would be occupied by a previous brood. Cardinals nest more than once a season; the male feeds the young while the female builds another one, according to Birds of Iowa Field Guide by Stan Tekiela (2000).

I have no idea what’s going on with these birds. I’ll keep you posted as the situation develops.

Oops, We Missed Earth Day 2019

Well, we missed Earth Day this year, which fell on April 22nd. The theme was to protect threatened and endangered species. One excuse is that we’ve been too focused on the cardinals building a nest in our back yard this spring. They are neither threatened nor endangered. I would call them fussy, especially when we get too close to the nest in our evergreen tree.

My other excuse is that April 22, 2019 was the day I had my last official work-related CPR recertification. It’s valid for two years but I’ll be retired next year. CPR is very important and I take the class seriously. I always seem to have a problem getting the bag mask tight enough on the mannequin’s face to get a good breath in.

This year there was an electronic device to monitor the quality of your chest compressions. It lights up green to let you know when they’re adequate. Orange lights means you have to fix your technique. That was new for me and I was probably not letting up enough to let the heart fill. Imagine that. I’ve probably had poor technique for years.

 Getting back to the cardinals, we’ve noticed that there are two eggs, off white with brown speckles. We’ve never seen eggs like that and we can distinguish them from the eggs of robins and chipping sparrows. The cardinal parents chirp pretty loudly at us whenever we get too close to the tree.

Northern Cardinal eggs…we’re pretty sure.

Also, it’s Hosta planting time in the back-yard garden, a job my wife does because my form with a shovel is just as bad as my chest compressions and bag breathing on the CPR mannequin.

Last year, we got out for Earth Day and I found an old polaroid camera while we were out on the Clear Creek Trail. I’m not sure how harmful it was to the environment. Judging from its condition, the environment was more harmful to the polaroid.

Polaroid in good condition.

On the other hand, we did spot a plastic bottle, which is harmful to the environment. We did the appropriate thing by dropping it in the proper trash receptacle.

Plastic goes in the trash.

Today is National DNA Day, which celebrates the discovery and understanding of DNA and the scientific advances that understanding has made possible. About the only thing important to me about it is that there are a few things that are definitely not in my DNA:

Cooking—unless it’s sticking a frozen pizza in the oven.

Planting Hostas.

Bag breathing the CPR mannequins.

Reading, listening to, or watching political news.

Eating shredded coconut.

Sitting in a psychiatry outpatient clinic, waiting for no-shows.

Waiting in airports.

Shopping for anything.

Removing or spreading mulch.

It’s an incomplete list, of course. Happy DNA Day!

Back on My Soap Box about MOC

I’m back on my soap box about Maintenance of Certification (MOC) again. Sidney Weissman, M.D. remarked in a letter to the editor of Psychiatric News (April 19, 2019 issue, Vol. 54, No. 8) on the rising numbers of graduating medical students who match in psychiatry residency slots. Many will graduate from these programs into private practice clinics which will emphasize seeing large numbers of patients primarily for medication management. Psychiatric hospitalists like me are uncommon, which tends to decelerate the movement toward integrating medical and psychiatric care and limits the application of psychotherapy which psychiatrists have historically done but which has been replaced by medication management.

While the match numbers continue to grow in psychiatry, the dissatisfaction with regulatory pressures from certification boards like the American Board of Psychiatry and Neurology (ABPN) also continue to frustrate psychiatrists who are compelled to oppose the Maintenance of Certification (MOC). Indeed, another prominent story in the psychiatric news is the class action lawsuit against the ABPN filed by two psychiatrists, alleging that the MOC requirements are illegal and anticompetitive. See the story in the April issues of Clinical Psychiatry News and Psychiatric News.

Along with the increasing numbers of psychiatrists who are retiring (more than 60% of psychiatrists are over the age of 55), and I interpret the increasing Psychiatry match numbers with cautious optimism at best.

I have always advocated for the principle of life-long learning for physicians and opposed MOC because, in my opinion, it’s a drag on the progress of fulfilling the principle. The reason is that there is very little evidence supporting the certification boards’ assertions that MOC makes better physicians.

I have supported the position of Dr. Paul Teirstein, MD, one of the leading physicians spearheading the National Board of Physicians and Surgeons (NBPAS), and I’ve recommended that the University of Iowa Hospitals and Clinics (UIHC) consider accepting NBPAS as an alternative to the American Board of Medical Specialties (ABMS) MOC. Three Iowa hospitals already do so.

I’ve been in phased retirement and expect to be fully retired by 2020. Because of that, I decided not to seek continued certification through either NBPAS or ABMS. I chose not to pay the fee required by the American Board of Psychiatry and Neurology (ABPN) to sit for the recertification examination. Consequently, that resulted in my being identified as “Certified” although “Not Meeting MOC Requirements.” This was data about me as a physician which was readily available to the public and other organizations. I think it’s unfortunate that this practice tends to convey the impression some physicians are less qualified than others based on their certification status alone.

My current listing on the ABPN web site.

Now I’m listed on the ABPN as “Not Certified” of course. Ironically, my Performance in Practice (PIP) module on delirium, the Delirium Clinical Module is still there. You can find it just by typing the word “delirium” in the search field. In my previous blog, The Practical C-L Psychiatrist, there was virtually no interest in such a module, at least judging from my far from scientific poll about 6 years ago. Yet it’s one of the few modules available on the ABPN website that C-L psychiatrists would welcome.

Low interest in an ABPN MOC Delirium PIP activity in 2013

I’m aware that declining to sit for what would have been the last MOC recertification examination in my career might not be viewed as much of a protest, especially since I’m retiring.

I’m also aware that many physicians are not in a position to decline participation in MOC. Some organizations and health insurers demand it, prompting several physicians and state legislators to collaborate toward adopting or consider adopting laws to discourage it.

To be fair, MOC is often not the only criterion that organizations use to ensure patients are getting the best health care available. And there are many who work diligently to improve the MOC process and believe it works. Enhancing the motivation for physicians to participate in MOC is complicated and we need to consider different practice environments, physician burnout, and financial incentive programs which have typically attracted few physicians overall.

It’s difficult to find much information on PubMed about MOC, whether you search using the Most Recent or the Best Match filter. In both, I found a paper by a doctor which appeals to my sense of humor as well as to my sense of fair play. It was written by a Singapore physician, for whom the dollar cost of recertification was over $10,000. His nerves took a beating as well as his bank account. Speaking of banking, here is the authors’ final observation:

Physicians should be able to choose a programme that best fits their scope of practice. However, it is likely that, besides the efforts put in by physicians themselves as a commitment to professionalism, the economic price will be borne by patients in the name of public assurance of medical competence and safety. If the burden becomes too onerous, one can always become a banker. — Teo, B. W. and S. Subramanian (2015). “Maintenance of certification: the price of medical professionalism is $10,108.05, two weeks leave and five white hairs.” Singapore Med J 56(4): 181-183.

I’m a very busy consultation-liaison psychiatrist in a large academic medical center. I think there are alternatives to MOC which don’t waste my time with modules and tests which typically are not relevant to my practice.

For example, I have followed the model of the practice-based learning and improvement competency at the University of Iowa by using what Drs. William R. Yates and Terri Gerdes called the “problem-based learning” case conference. The abstract for their paper describes it:

“Problem-based learning (PBL) is a method of instruction gaining increased attention and implementation in medical education. In PBL there is increased emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education. A weekly PBL conference was started by a university consultation psychiatry team. One active consultation service problem was identified each week for study. Multiple computerized and library resources provided access to additional information for problem solving. After 1 year of the PBL conference, an evaluation was performed to determine the effectiveness of this approach. We reviewed the content of problems identified, and conducted a survey of conference participants. The most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%). Computerized literature searches provided significant assistance for some problems and less for other problems. The PBL conference was ranked the highest of all the psychiatry resident educational formats. PBL appears to be a successful method for assisting in patient management and in resident and medical student psychiatry education.”

This is now called the Clinical Problems in Consultation-Psychiatry (CPCP) and trainees from medical students to residents participate as presenters. The format is also used as a framework for the Consultation-Liaison Psychiatry Interest Group at Iowa. There are lively discussions at these meetings, to which colleagues from other medical specialty departments are invited. The model for this was adapted from that reported by Puri and colleagues.

Yet these and other creative practice-based learning efforts which are relevant to our practices are not on the approved product list for CME and Self-Assessment at the ABPN.

To be sure, one Performance in Practice (PIP) clinical module (mentioned above) that I and one of our residents submitted to ABPN was approved. This was the Delirium Clinical Module, for which we received congratulations from leaders of the Academy of Consultation-Liaison Psychiatry (ACLP). This is a clinically relevant exercise which could be useful to many medical specialists, not just psychiatrists. It would also be important for enhancing patient safety—which is the whole idea of practice-based learning.

I have worked with the Iowa Medical Society (IMS) to get resolutions adopted as IMS Policy which support the principle of lifelong learning and which oppose both MOC and Maintenance of Licensure (MOL).

The idea that if doctors don’t develop a system for monitoring continued competence in psychiatry, other groups will do it for us likely comes from what are essentially cases of medical malpractice. This was probably what was meant by the ABPN response to my criticisms of the MOC process several years ago, which was that part of the reason for MOC was the public’s demand for a way to hold physicians accountable for harming patients.

One of the papers citing this problem was by Shaw and colleagues. The authors mention “damaging high-profile cases” one example of which triggered the Bristol Inquiry in the United Kingdom leading to the “development of a compulsory integrated regulatory program with oversight in all levels of medical care from hospital systems to the practice of individual physicians.

This is the United Kingdom’s revalidation program, which is similar to MOC or perhaps more properly, MOL.

The irony is that the American Board of Medical Specialties (ABMS) and member specialty boards including the ABPN claim the American version of MOC is a voluntary program and that this is “self-regulation.” It’s not clear who else would “do it for us” though—some government agency? It’s hardly necessary when, as Dr. Paul Mathews reported recently, some private insurance payers require participation in MOC. He’s a voluntary board member of the National Board of Physicians and Surgeons (NBPAS), which is a newly established alternative to the ABMS which doesn’t require MOC participation:


As a volunteer board member of NBPAS (no compensation or honorarium as opposed to the salaries of ABMS board members, which can range from $300,000 to greater than $800,000), I have often wondered why private payers require MOC when Medicare does not require board certification or MOC. The answer is quite disturbing. Private payers actually participate in certification, which is issued by the National Committee of Quality Assurance (NCQA). Margaret E. O’Kane is the founder and president of the NCQA, and she is also a member of the ABMS Board of Directors. The NCQA requires private payers to require physicians to participate in MOC in order to be NCQA certified. Thus, anyone contracting with a private payer will require MOC. In the conflicted case of Ms. O’Kane, she profits from the NCQA requiring private payers to require physicians to participate in MOC, and then she profits again from her ABMS position when said physicians must pay to comply with MOC requirements”

This raises another concern about MOC, which is the ever-present cloud of suspicion the ABMS and some of the member specialty boards are under, especially the American Board of Internal Medicine (ABIM).

According to Charles Cutler, M.D., M.A.C.P., in the winter 2016-17 issue of Philadelphia Medicine, Philadelphia County Medical Society, in an issue entitled “Is The ABIM Too Broken to Fix?” article “A Message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires,” reforms should in fact include doing just what the title says and much more.

Board executives, especially CEOs, make what appear to be enormous six-figure incomes from the MOC programs, including Dr. Larry Faulkner, M.D., the President and CEO of the ABPN who earned over $900,000 in 2014 according to IRS Form 990.

Those with a low opinion of the adage about “…the wise old doctor who improves with experience…” should probably be shared with those board leaders who made the arbitrary cutoff date for requiring participation in MOC, grandfathering physicians board certified prior to 1994, thereby exempting them from the program.

Participation in MOC would make more sense if there were credible research evidence that it improves patient outcomes. However, the studies tend not to support this conclusion.

And MOC is not supported by most physicians, according the results of a Mayo Clinic Proceedings survey, indicating that “Dissatisfaction with current MOC programs is pervasive and not localized to specific sectors or specialties. Unresolved negative perceptions will impede optimal physician engagement in MOC.”

Finally, any suggestion to sign up right away for MOC probably should be preceded by another important action, which is to first check with your institution to see if MOC participation or, indeed, board certification itself, is a condition of employment. It may not be.

What are the alternatives to the MOC approach? They depend on one’s level of attachment to keeping some sort of certification status.

There is the alternative National Board of Physicians and Surgeons (NBPAS), which was launched in 2015 and offers board re-certification without MOC or recertification examination requirements. There is a nominal fee and CME requirement. A previous ABMS certification is also required, but if that has lapsed one can still obtain certification by submitting a higher number of CME credits.

NBPAS leaders are very much aware that certain private insurance payers require MOC participation. It was the top priority for NBPAS in 2017. See their website for full details about their re-certification process.

Physicians could simply forgo MOC or alternative certifications, which would probably raise more anxiety. For example, if one simply stops sending money to the ABPN toward MOC requirements and declines to sit for the recertification examination, then after the general board expires one would be identified as “Certified-not meeting MOC requirements.” But after the examination date passes, you’re Not Certified. The prudent diplomate should first check with ABPN for clarification of specific details and should check their employer’s expectations and insurance payer rules about MOC.

In my opinion, there ought to be a choice to participate in MOC or some other vehicle for fulfilling the principle of lifelong learning. Those who want MOC should keep it. Those who don’t should be allowed to continue using the method they’re most comfortable with for maintaining their knowledge and clinical skills, including CME and other creative methods for staying current with the medical literature.

Our patients deserve at least this much.

“It is far better to light the candle than to curse the darkness”—attributed to William L. Watkinson in a 1907 sermon according to Quote Investigator.

William L. Watkinson


Pato, M. T., et al. (2013). “Journal club for faculty or residents: A model for lifelong learning and maintenance of certification.” International Review of Psychiatry 25(3): 276-283.

Brooks, E. M., et al. (2017). “What Family Physicians Really Think of Maintenance of Certification Part II Activities.” J Contin Educ Health Prof 37(4): 223-229.

Tieder, J. S., et al. (2017). “A Survey of Perceived Effectiveness of Part 4 Maintenance of Certification.” Hosp Pediatr 7(11): 642-648.

Stoff, B. K., et al. (2018). “Maintenance of Certification: A grandfatherly ethical analysis.” Journal of the American Academy of Dermatology 78(3): 627-630.

Glover, M., et al. (2017). “Participation and payments in the PQRS Maintenance of Certification Program: Implications for future merit based payment programs.” Healthcare.

Teo, B. W. and S. Subramanian (2015). “Maintenance of certification: the price of medical professionalism is $10,108.05, two weeks leave and five white hairs.” Singapore Med J 56(4): 181-183.

More References:     

1.         Boland, R., MD, Maintenance of Certification, in Psychiatric Times. 2017, UBM Medica.

2.         Knoll, J.L., IV, MD; Cotoman, Dan, MD, Maintenance of Certification and Self-Mortification, in Psychiatric Times. 2017, UBM Medica.

3.         Shanafelt, T.D., L.N. Dyrbye, and C.P. West, Addressing physician burnout: The way forward. JAMA, 2017. 317(9): p. 901-902.

4.         Bright, R.P. and L. Krahn, Value-added education: enhancing learning on the psychiatry inpatient consultation service. Acad Psychiatry, 2015. 39(2): p. 212-4.

5.         Yates, W.R. and T.T. Gerdes, Problem-based learning in consultation psychiatry. Gen Hosp Psychiatry, 1996. 18(3): p. 139-44.

6.         Puri, N.V., P. Azzam, and P. Gopalan, Introducing a psychosomatic medicine interest group for psychiatry residents. Psychosomatics, 2015. 56(3): p. 268-73.

7.         Shaw, K., et al., Shared medical regulation in a time of increasing calls for accountability and transparency: comparison of recertification in the United States, Canada, and the United Kingdom. JAMA, 2009. 302(18): p. 2008-14.

8.         Mathew, P., MD, MOC and Physician Burnout: Treating the Cause, Not the Symptoms, in Practical Neurology. 2016.

9.         Cutler, C., MD, MACP, A Message to the ABIM: Reign in Spending and Stop Turning Staff into Millionaires, in Philadelphia Medicine: The Official Magazine of the Philadelphia County Medical Society Philadelphia Medicine 2016, Hoffmann Publishing Group, Inc.

10.       Gray, B.M., et al., Association between imposition of a Maintenance of Certification requirement and ambulatory care-sensitive hospitalizations and health care costs. JAMA, 2014. 312(22): p. 2348-57.

11.       Hayes, J., et al., Association between physician time-unlimited vs time-limited internal medicine board certification and ambulatory patient care quality. JAMA, 2014. 312(22): p. 2358-63.

12.       Cook, D.A., et al., Physician Attitudes About Maintenance of Certification. Mayo Clinic Proceedings, 2016. 91(10): p. 1336-1345.

My Brother

Sometimes I think about my brother Randy, who died 19 years ago. His last days were made immeasurably easier by the caring staff at Hospice of North Iowa. He worked at a local artificial ice company for many years. He died when he was 43 of cancer, before either of our parents died.

He will always be remembered for his generosity, kindness, and infectious sense of humor. A sense of humor ran in the family, despite hardships. He had a raw, honest, and often boisterous passion. We treasure everything he gave us.

Even the courageous way he let go of his life was a gift. He died as he lived, in the arms and in the hearts of the people who loved him.

I learned a valuable lesson about that. On his last day in the hospice, I was determined to be with him up to the moment he died, staring down death in his face. I’m still not sure why I wanted to do that.

Then a couple of his long-time friends stopped by to see him. Death watch was interrupted as we visited in his room. I faced them, reluctantly taking my eyes off him. They talked to me, sharing their memories of him while he was alive. I soon became painfully aware that there were many who knew Randy in ways that I did not know. He was a dear friend and even a surrogate father to many.

They talked; I listened and learned. I lost track of the time. When there was a break in their discourse, I quickly turned back to Randy. He was already gone. He had slipped away while his friends, his other family, were sharing something with me far more important than my death watch. I learned more about humility that day than I can recall learning ever since. There is a brick in the driveway of Hospice of North Iowa on which is etched the message, “He ran his race.”

Randy was a track man in school. He could outrun just about anyone. He was also pretty fast on his gold flake Schwinn Stingray bicycle. I notice there are vintage Stingrays going for thousands of dollars these days. He could fishtail and wheelie like nobody’s business.

My father used to say that the only difference between me and Randy was that he could cook and I couldn’t. There were a few other differences.

Jimmy and Randy (I’m in the wagon)

Through an unfortunate circumstance that I still don’t understand, Randy was my patient on our Medical-Psychiatry Unit in the late 1990s, shortly after he was diagnosed with cancer. I would never have done this by choice, but it seemed there was no one else to cover the unit at the time.

He was delirious, probably from an accidental overdose on opioid pain medicines during a difficult stage in his cancer treatment. It’s really not possible to describe the conflict I had about being both his brother and his doctor. It should not have happened—but it did. He didn’t recognize me. He mumbled. He twitched. He drifted in and out of awareness. I knew all the signs; I saw delirium every day in the hospital.

But this was different because this patient was my brother. I will never forget. After that, I had a much better understanding of what families goes through when they witness delirium in a loved one. I will not miss this part of my job when I retire.

Randy was my best man at my wedding in 1977. I bought him a nice pocket watch, which was buried with him. I do not visit his grave not because I don’t love him, but because I would rather remember him as he was.

Who is Harry Dumpty?

My wife and I spent a few months living in Madison, Wisconsin back in 2008. I had taken a new job as a psychiatrist there. It was the second of two blunders moving from academic medicine to private practice, the first being a move to Illinois, also very short-lived.

We really liked Madison and sometimes dream of moving back there after I’ve retired. It’s an interesting city with many sights to see and things to do.

One of the interesting sights we saw was a mysterious bronze sculpture that I’ve only just today found the explanation for. It looks like Humpty Dumpty of the familiar nursery rhyme and riddle. I found out a lot more about Humpty Dumpty and his odd brother Harry Dumpty, who is actually the subject of the sculpture found in front of the Madison Municipal Building just south of the intersection of Martin Luther King Jr. Boulevard and East Doty Street.

Harry Dumpty

I never knew the sculpture was Harry Dumpty. It sat above a large concrete wall with an inscription on it which I just assumed was connected to the sculpture and probably still sits there although we couldn’t find it in 2012 when we returned for a visit:

“David James Schaefer, 1955-2004
was a phenomenal phenomenon. Though plagued by the progressive debilities of cerebral palsy, “Schaefer” was an uncomplaining and generous friend to many. Disability Rights Specialist for the City of Madison in three different settings, his death of a heart attack in September 2004 made a hole in our community which cannot ever be filled.
Erected by the Friends of Schaefer at private expense.”

It turns out Harry Dumpty has no connection to David James Schaefer. In fact, Harry is one of several similar sculptures created by artist Brent George, who made him in 1997, saying he’s Humpty’s brother. If you look closely at the book sitting open next to Harry, it’s entitled “Harry Dumpty.” Brent George’s name is below it. Brent’s phone number is on the front of the wall. Evidently somebody called him and asked about the sculpture. Brent says there’s no connection between the sculpture and the inscription.

A copy of Harry Dumpty sits outside of the Dekalb Public Library in Dekalb, Illinois. Brent moved from there to Madison, Wisconsin. In the local online newspaper, the Daily Chronicle, news editor Jillian Duchnowski wrote a couple of stories about it in 2014 which eventually led to the proposal of a contest to find a rhyme for him similar to Humpty’s. I couldn’t find the results. One newspaper speculated that Harry is less well-known because he never fell off a wall.

In the online news website, Isthmus, a staff writer named David Medaris wrote a few paragraphs about Harry in 2008, which we somehow missed back when we were first learning about Madison. Medaris comments that this kind of irreverent art is common in Europe and is a marker for cities where “…people who have a sense of humor live with gusto.” He identifies Brent George as the artist but never mentions David James Schaefer.

There has been a lot of speculation about deep political and scientific meanings for Humpty Dumpty, but it’s likely just a nursery rhyme and riddle.

On the other hand, there’s very little written about Harry Dumpty. If anyone knows the results of the Dekalb, Illinois poetry contest mentioned above, please let me know.

My Father

Sometimes I think about my father, who died about 17 years ago. He was known in his neighborhood as “Johnny Hots.” He moved to Milwaukee, Wisconsin when he was in high school. He enlisted in the Navy when he was in the 11th grade and served his country during World War II.

His obituary also says he was happiest when he kept busy. After he retired he helped with maintenance of the apartment building where he lived during his last years. He liked working crossword puzzles. He also had a pretty good sense of humor and liked to laugh.

I like working crosswords. I like to clown around and laugh. And I like to keep busy. I was never in the military although I tried to enlist. That didn’t work out.

He talked about the great time he had in Milwaukee. He said it was the best time of his life. My wife and I vacationed there a few years ago. It was fun. One of the residents interviewed for a C-L Psychiatry fellowship at Medical College of Wisconsin recently. She was wondering about places to site-see so I made a little video about it for her.

Milwaukee, Wisconsin

He was a talented carpenter and built our kitchen cabinets. I remember struggling a little in Shop Class to make a wooden dice pencil holder. Mr. Rodomeyer, a man built like a bull, called my class the biggest bunch of characters he’d ever seen.

That was back in the days when the boys went to Shop Class and the girls went to Home Economics (Home Ec). Maybe that’s one of the reasons I don’t do so well in the kitchen. Anyway, that’s what I blame it on.

However, my father was pretty handy in the kitchen and could cook up a tasty barbecued anything.

He walked everywhere and he walked more slowly as he got older. I have always walked pretty fast. I think I picked up that habit when I was a young man working for land surveyors. When I walk around the hospital and up and down the stairs, the trainees tend to lag behind me.

I didn’t see much of my father while I was growing up. We have a few things in common. I am thankful for our differences.

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