July 2019 – Go Retire Psychiatrist

Moaning and Groaning About Deck Maintenance

We’re pretty dedicated to maintaining everything about our property, including deck maintenance. Check that; actually, my wife is dedicated. I’m usually hard to find when it comes to chores like that. When it’s time for deck cleaning and sealing, there is always some emergency I need to address on the other side of town or I’ve been temporarily abducted by aliens.

Sena is usually not one for moaning and groaning about these jobs, but painting the deck rail spindles is an exception—each and every spindle, separately and painstakingly swabbed with a brush so that every tiny spot is covered with sealant.

The right kind of sealant is critical. She usually likes water-based sealant, but the local hardware store salesman managed to sell her an oil-based product that was on sale. There’s debate about the relative merits of water-based vs oil-based sealants.

In general, the water-based products are a lot easier to work with and provide excellent deck protection. Oil-based sealants have been around a lot longer, penetrate better, and naturally repel water. Most of them nowadays have a low risk rating as volatile organic compounds (VOC), meaning they are environmentally safe. On the other hand, Sena is finding it takes more than one coat of the oil-based product to get adequate coverage, and she has to use a brush instead of a pump pressure sprayer. It takes longer to finish the job—which elicits more moaning and groaning.

We’re not 100% sold on the assurance by experts that either one puts down a finish that will last for several years. We live in Iowa and shovel the deck several times a season, so moaning and groaning about this could happen pretty much every two or three years.

Just for the sake of full transparency about my role in this job—I was banned last year for reasons which would normally remain opaque but who cares?

That cleaning and sealing chore last year was a major challenge. I somehow had to figure out how to reach the yard side of the spindles to cover them with sealant. The trouble was that I was not tall enough to reach them. I think it is to my credit and possibly my eternal fame that I immediately came up with an ingenious solution—a boom lift truck. I have some simple instructions to pass on to those who learn certain skills quickly and don’t mind spending a little time in a state penitentiary.

Now, we didn’t own one but it just so happened that across the street there was a lot of construction going on in a new subdivision development. The average boom lift truck with a cage or bucket would have made a pretty big dent in our bank account.

You should pick a weekend day to successfully pull this off—I mean execute this procedure. Usually the construction crews are short-handed and they’re too busy smoking cigarettes to pay much attention to what’s going on around them.

Pick a two-story house under construction, which is more likely to need a boom lift truck for applying various exterior features like windows, cedar shakes, shingles and escape hatches. It’s likely to be left running with the key in the ignition. There might be a couple of construction guys hanging around, which you can get rid of by shouting “Hey look, there goes Elvis!”

This always works—pretty much. While they raced off, fumbling with particle board scraps which they could possibly get an autograph scribbled on using lumber crayon, I climbed into the nearest boom lift truck.

There’s usually a button to start it. The one I found was already running. Reverse gear was difficult to find; it was just as easy to hit the gas and dislodge the portico cover on the way back to the street. By this time, a couple of construction workers and a rottweiler had spotted me and were racing back across the lot, yelling and barking.

This was not a problem. I managed to get the rig up on two wheels and whipped around. I contributed to their cardio workout as they sprinted back the way they came. I finally caught all of the pursuers including the dog in the basket. It didn’t take me long to figure out where to dump them. There were plenty of basement holes dug. They were making quite a bit of progress in that subdivision!

I made it back home in time for lunch. I had to eat fast because I could hear sirens up the street. I could get only a few rail spindles covered before I discovered that I might have to quick like find a hideout—I mean alternative living quarters.

Anyway, you’ll have to do some calculations to figure out how much progress you can make with this method. I’ve refined it in several ways and I plan to post an update on these instruction when I’m out on parole—I mean back from vacation.

In any case, I think Sena is doing a great job. She’s been a tireless gardener, hospital volunteer, and the best wife a guy could ask for.

Suicide Risk Assessment Update 2019

I updated my suicide risk assessment presentation today in light of new data on suicide risk assessment stratification. It turns out that using such tools might not be supported by the research evidence. That’s not going to stop the use of such tools, which include the Columbia–Suicide Severity Rating Scale, which is in wide use.

I found criticism of these scales in a recently published article in Clinical Psychiatry News, published June 21, 2019, “Why we need another article on suicide contracts,” by Nicholas Badre, MD and Sanjay S. Rao, MD.

For many years now, psychiatrists and other health care professionals have learned that trying to use no-suicide or no-self harm contracts are controversial and don’t prevent suicide. Badre and Rao sound like they’re easing away from that contention although they still say that a thorough clinical suicide risk assessment out to be done.

Until I saw this article, I was not aware of a recent review of 70 studies showed that: “no individual predictive instrument or pooled subgroups of instruments were able to classify patients as being at high risk of suicidal behavior with a level of accuracy suitable to be used to allocate treatment.”

Carter, G., et al. (2017). “Predicting suicidal behaviours using clinical instruments: systematic review and meta-analysis of positive predictive values for risk scales.” Br J Psychiatry 210(6): 387-395.

This was even more interesting because we recently changed our practice regarding suicide risk assessments on the psychiatry consultation service based on relatively new recommendations from the Joint Commission on Accreditation of Hospital Organizations (JCAHO). The Joint Commission favors the risk assessment tools.

Of course I’m not going to second-guess the Joint Commission but after 27 years (counting residency) of struggling to assess suicide risk, I’ve learned that it can hardly be reduced to any single rating instrument.

I have often said to patients that I don’t use no-suicide contracts because they’re too much like promises—and promises are broken every day. That segues into what I prefer which is to work with the patients on developing a safety plan, which I compare to no-suicide contracts by saying “a plan is better than a promise any time.”

Working on the safety plan with patients gives me another way of assessing the strength of my alliance with them and a way to improve it as well as a method for evaluating their ability to formulate a workable way to stay safe that emphasizes their individuality.

On the other hand, the safety plan is no guarantee of safety, any more than the no-suicide contract.

But often enough I’ve gotten the sense that some patients and I have even had a little fun working on suicide safety plans—ironic as that sounds. I find how important pets are, hear little anecdotes about a favorite hobby or goal, aspirations, hopes, and memories of better times when they coped really well.

Listening for understanding to someone who is contemplating suicide or who has attempted suicide is never easy. It’s the hardest thing I do. I can’t say that I’ll miss it when I retire. I have great faith in the next generation of doctors.

New suicide risk assessment presentation

If You Can’t Stand the Heat…

We saw this rabbit in our front yard today, stretched out on the grass under our crabapple tree. It’s 117 degrees this afternoon with the heat index and we won’t get out from under the Excessive Heat Warning until later this evening. Thank goodness for air conditioning. Rabbits don’t have air conditioning and can’t escape the heat.

Sena stands the heat better than I do; she waters the lawn and garden, keeping it beautiful. On the other hand, I felt body-slammed just walking out to get the mail.

The old saying goes, “If you can’t stand the heat, get out of the kitchen.” It means you if you can’t take the pressure of a situation, then you should move and let somebody else take over. It was popularized by President Harry S. Truman, who said the originator of the proverb was Judge Buck Purcell of the Jackson County, Missouri Court—whoever he was.

Anyway, I’m on call this weekend and got to talking with a colleague who is thinking about retirement. We go back a long way in our education and careers. He asked me about what phased retirement is like. I told him I thought if I’d tried to retire outright, I probably would have just come back to work.

That’s a twist on standing the heat. As a psychiatric consultant, I’m like a fireman (get it?) in the general hospital, putting out fires, so to speak, all over the hospital. Most often the problem still tends to be delirium, an acute change in mental status that should be considered a medical emergency rather than a psychiatric problem per se. It’s just one of many crises that I encounter every day. Over 23 years (not counting residency), I learned how to stand the heat in that kitchen. When I retire, somebody else will have to get in there and cook. Speaking of cooking—I still can’t.

I guess I’m mixing my metaphors (fireman and kitchens, etc.). So what? I’m a retiring geezer and I guess I’ve earned the right to mix my metaphors as much as I want.

But in my first year of the 3-year phased retirement contract, I felt a different kind of heat–the heat of trying to find something to do with my unstructured time. It was a struggle for a guy who’s accustomed to being in almost constant motion, climbing up and down 20-30 floors (I hate waiting for elevators) and covering 2-3 miles a day.

The only trouble is—I can’t get out of the kitchen of retirement. I’m getting up there in age and even though most of the time, I seem to leave some of the trainees huffing and puffing getting up the stairs, I know they’ll replace me someday. But I can’t find a replacement to do my retirement time for me.

I have 11 months to go before I retire. I can feel the heat.

Whatever Happened to the Janus Head Logo for ACLP?

I got an email from Don R. Lipsitt, MD yesterday which reminded me of the Janus Head logo for the Academy of Consultation-Liaison Psychiatry (ACLP). It was changed to another sort of nondescript logo several years ago for reasons I didn’t understand.

Dr. Lipsitt is a luminary in C-L Psychiatry and recently published a definitive history of the field, Foundations of C-L Psychiatry: The Bumpy Road to Specialization (2016).

I posted a blog or two about Don and his book in a previous blog, The Practical C-L Psychiatrist. We’ve never formally met. A few years ago, he noticed that I had written about him and his book. I had sent him an email message about it at around the same time the APM was considering the name change for the organization, telling him that I had plugged his book and asking him what he thought of the name change. Incidentally, he thought both of our books made a great package, so I guess I’m allowed to plug mine, strangely titled Psychosomatic Medicine: An Introduction to C-L Psychiatry, editors James Amos and Robert Robinson (2010).

Don expressed his opinion about the name change:

“I feel I have dealt with that at some length in my book. I still feel C-L is most fitting and that the Board made a big mistake naming it PM. Who were they? Any C-L psychiatrists among them? Any Psychosomaticists? Why are not the “complex medically ill” a special population? And why is APA now offering courses on “integrated” care (which is what C-L psychiatry has always been about? The notion that C-L was not declared a specialty because it was considered a skill of ALL psychiatrists (with minimal training), then how do geriatric or child psychiatry become specialties (that all psychiatrists also have training in)? Don’t get me started.”

He considered his book, in large part, a “polemic” against the name “Psychosomatic Medicine.”

Anyway, the ACLP was formerly the Academy of Psychosomatic Medicine (APM) until a couple of years ago when the organization responded robustly to the membership (of which I was one at the time) to abandon the term “Psychosomatic Medicine” and adopt what rank and file practitioners preferred—Consultation-Liaison Psychiatry.

It was a kind of rebranding and it was not the first time the academy had considered a name change. I and a lot of other C-L Psychiatrists cringed at the term “psychosomatic,” not so much because of the word itself in terms of its true denotation, but because of the unfortunate negative connotations it had acquired.

Another luminary of C-L Psychiatry, Dr. Thomas Hackett, MD, wrote about the term “psychosomatic” in the Massachusetts General Hospital: Handbook of general hospital psychiatry: edited by Hackett and Ned Cassem (1978):

“The term ‘psychosomatic service’ has had a variable history. The term generally leaves a bad taste in the mouths of physicians. It reminds them of the 1930s, 1940s, and 1950s, when various psychosomatic schools espoused doctrines linking specific psychological conflicts or unique personality profiles with diseases designated as psychosomatic. Compounding this misunderstanding has been the term’s abuse by the general public, who regard anything psychosomatic as either imaginary or nervous in origin. As a consequence, most people believe that a psychosomatic disease is not to be taken seriously.”

Well, anyway, because of my anecdotage, I’ve strayed a little from my original story about the Janus head logo.

I already mentioned that the logo was abandoned in favor of something that looks like waves and could lead to seasickness. I inquired about the history of the use of the Janus head logo.

In addition to my curiosity about why the logo was changed, I also wondered why it was chosen in the first place and when. According to Don, it was part of the organization’s journal, Psychosomatics, in the late ‘60s and ‘70s. What was interesting is that it was already in use by the Journal of Geriatric Psychiatry when the Psychosomatics editors started using it. However, a conflicting view was that it was not introduced to the cover until 2010. Hmmmm.

I saw the 2012 issue of the APM Newsletter had a pretty funny picture of Drs. Shuster and Rosenstein posing as Janus and the statement “Thank you, Janus. You served us well for over 50 years.” That might put the origin of the logo, at least, around 1962 although my understanding is that APM was started in 1953 (TN Wise, A Tale of Two Societies, Psychosomatics 1995).

Time to say “Hello, again, Janus?”

It’s just my opinion, but because Janus is the ancient god of beginnings and transitions, gates, doorways, endings and time, and typically depicted as two-faced because he looks to the future and the past, I think the symbol is a better image for what C-L Psychiatry has been through over the years.

Anyone for re-rebranding and go retro back to the Janus head logo?

Hoofing it Around the Hospital

Again today, I hoofed it around the hospital. I put 43 floors and a little over 4 miles on my step counter.

I don’t like waiting for elevators so I take the stairs. And a Consult-Liaison Psychiatrist is like a fireman, running all over putting out fires.

I did other things today. I gave the usual lecture on delirium and dementia to the medical students. I notice that as I have gotten older, I tend to tell more anecdotes about my experiences managing delirium in patients on the medical side of the hospital.

I’m in my anecdotage, as I told the students today.

I also lamented the decision by the powers that be to copyright the Montreal Cognitive Assessment (MoCA). The medical students will be able to use it for free, but faculty won’t.

I think that’s ageism. I won’t pay so I won’t use the MoCA anymore.

Back in the Saddle

Well, I’m pretty tapped out, so it’ll be a short post today. I’m back in the saddle, running around the hospital on the psychiatry consult service. This is my last year of phased retirement and in 11 months—I’ll be fully retired.

I put 36 floors and 3 miles on the step counter. I’m feeling every one of those. Sena bought me some banded collar shirts and I’m wearing those instead of a shirt with a necktie. I don’t need a tie bar.

And I don’t worry about a delirious, violent patient strangling me with my necktie.

We had a small scare tonight. We were looking at my total compensation statement (the last one) and got the Sharp Elsi Mate EL-505 vintage calculator out to crunch some figures. The calculator went dead.

I put some new batteries in it, hopeful. It still didn’t work. We’ve had this calculator for over 30 years and it ran more than a decade on the first set of AA batteries.

I tried another pair of batteries. It worked! The vintage calculator lasted longer than the batteries. It’s nice to know that just because something’s old doesn’t mean it’s useless.

That’s all I got.