Go Retire Psychiatrist

I reminisce once in a while on my early days running the Psychiatry consultation service at University of Iowa Health Care. I was involved in a delirium prevention committee back in 2011. The old blog post below shows my frustration with how slow progress seems to be in committees. I used to watch Hogan’s Heroes on TV when I was a kid. It’s on the MeTV network nowadays, but I watch Svengoolie B movies instead. I compare how easy it is for Hogan’s Heroes to get things done to how difficult it is to change how things run in hospitals.

“Blog: Hogan’s Heroes and the Delirium Project Committee

Remember the 1960s TV sitcom Hogan’s Heroes? I suppose mostly baby boomers would recollect the show about the exploits of 5 main prisoners of war in Stalag 13 during World War II. They were Hogan, LeBeau, Newkirk, Carter and Kinchloe. Their prisoner of war status was just a cover for their sabotage of the German war effort using a variety of clever communication devices and secret tunnel systems which allow them almost unlimited access to cash, travel, and uniforms.  Of course the enemy was portrayed as gullible and incompetent, like Sergeant Schultz (“I see nothing, nothing!”), and camp Kommandant Klink (“No one has ever escaped from Stalag 13!). The heart of the show was the byzantine but unfailingly effective ruses the prisoners created and enacted to be successful in their missions. In fact, everyone escaped from Stalag 13 through the elaborate underground railroad-like system of tunnels and outside contacts.

So that you don’t think I’m minimizing the horrors of WWII, the Stalag 13 TV episodes were not based in a POW camp styled after those run by the SS or Gestapo. The prisoners invariably won the day in the end. I don’t recall anyone getting even slightly bruised.

Sometimes I have a little daydream about being as clever, resourceful, and powerful as Hogan’s Heroes. Hospital organizations and committees can be stifling occasionally in my opinion. And it’s challenging to be patient enough to let the wheels grind slowly. In my heart of hearts I believe in the careful and considered approach that the delirium project committee is taking. And I would never undercut it just for the sake of speeding things along. If I did that, there’s a real chance that patients and families, doctors and nurses, and hospital administrations would not be well served in the long run. Still, we need to think both/and about the complementary roles of spirit and structure in program development.

There’s no denying I have a problem staying in my own backyard, which leads to the occasional smack-down from my collaborators. Part of the reason for that is the nature of my job as a psychiatric consultant in a large academic medical center. It’s basically crisis management. Our consult service is a fire brigade, putting out minor and major behavioral conflagrations around the hospital. I learned to do medication management and meatball psychotherapy on the run because I had to. There was no sit-down, classroom, or mentoring service available to prepare me for the jungle. Like many consultants, I had to use my own ingenuity and wits to make up solutions on the fly. My team, consisting of me and a few trainees, is a hit and run movable feast in that I can’t keep my head down because I’m so visible. People take bites out of me in the hall, on the ward, in the lobby, and I have long ago given up trying to make it to conferences because I have no schedule. It’s a miracle I can even make to delirium project meetings.

Ironically, the reason my days are so hectic is because I’m so frequently asked to evaluate what doctors think are cases of depression, anxiety, mania, and psychosis—but which turn out to be cases of delirium more than half the time. Medical students and resident physicians get to see this several times during their rotation on the consult service when I’m on duty (which is most of the time). When a consulting physician (often a resident) is trying to tell me that a patient is behaving oddly because they’re manic or depressed, I pull out my crude clock-drawing task I administered while I was interviewing his patient and show it to him. It’s usually a mess, indicating the patient’s profoundly impaired cognition pointing to delirium being the real problem. It’s a lot like pulling a rabbit of a hat. Everyone gets to see the resident’s usual reaction: jaw drops, eyes dilate—and he shuts up.

A light goes on. It’s a neat little show but it’s time for something more systematic and scientific, automated, and smarter so that someday I won’t continually have to run a dime store magic act, fun as it may be sometimes.

No wonder I’m having trouble getting used to committees. I’m geared for dramatic, mobile, top speed, thin-slicing, commando MacGyver-style guerilla operations while committees sit down at scheduled meetings and define, measure, analyze, improve, and control using tools I’ve never heard of like Gantt Charts, FMEA Analysis, Pareto (isn’t that a chicken spice?) and SWOT Analysis.

I’m used to a different kind of SWAT team.

 That’s why I sometimes get a little impatient and fire off a few rounds into the air or smuggle a few educational pearls out of the camp under Kommandant Klink’s nose.

I hope I may be forgiven for it.”