books – Go Retire Psychiatrist

An Old Post on Breaking Bad News

I’m reposting a piece about a sense of humor and breaking bad news to patients I first wrote for my old blog, The Practical Psychosomaticist about a dozen years ago. I still believe it’s relevant today. The excerpt from Mark Twain is priceless. Because it was published before 1923 (See Mark Twain’s Sketches, published in 1906, on google books) it’s also in the public domain, according to the Mark Twain Project.

Blog: A Sense of Humor is a Wonderful Thing

Most of my colleagues in medicine and psychiatry have a great sense of humor and Psychosomaticists particularly so. I’ll admit I’m biased, but so what? Take issues of breaking bad news, for example. Doctors frequently have to give their patients bad news. Some of do it well and others not so well. As a psychiatric consultant, I’ve occasionally found myself in the awkward position of seeing a cancer patient who has a poor prognosis—and who apparently doesn’t know that because the oncologist has declined to inform her about it. This may come as a shock to some. We’re used to thinking of that sort of paternalism as being a relic of bygone days because we’re so much more enlightened about informed consent, patient centered care, consumer focus with full truth disclosure, the right of patients to know and participate in their care and all that. I can tell you that paternalism is not a relic of bygone days.

Anyway, Mark Twain has a great little story about this called “Breaking It Gently”. A character named Higgins, (much like some doctors I’ve known) is charged with breaking the bad news of old Judge Bagley’s death to his widow. She’s completely unaware that her husband broke his neck and died after falling down the court-house stairs. After the judge’s body is loaded into Higgins’ wagon, Higgins is reminded to give Mrs. Bagley the sad news gently, to be “very guarded and discreet” and to do it “gradually and gently”. What follows is the exchange between Higgins and the now- widowed Mrs. Bagley after he shouts to her from his wagon[1]:

“Does the widder Bagley live here?”

“The widow Bagley? No, Sir!”

“I’ll bet she does. But have it your own way. Well, does Judge Bagley live here?”

“Yes, Judge Bagley lives here”.

“I’ll bet he don’t. But never mind—it ain’t for me to contradict. Is the Judge in?”

“No, not at present.”

“I jest expected as much. Because, you know—take hold o’suthin, mum, for I’m a-going to make a little communication, and I reckon maybe it’ll jar you some. There’s been an accident, mum. I’ve got the old Judge curled up out here in the wagon—and when you see him you’ll acknowledge, yourself, that an inquest is about the only thing that could be a comfort to him!”

That’s an example of the wrong way to break bad news, and something similar or worse still goes on in medicine even today. One of the better models is the SPIKES protocol[2]. Briefly, it goes like this:

Set up the interview, preferably so that both the physician and the patient are seated and allowing for time to connect with each other.

Perception assessment, meaning actively listening for what the patient already knows or thinks she knows.

Invite the patient to request more information about their illness and be ready to sensitively provide it.

Knowledge provided by the doctor in small, manageable chunks, who will avoid cold medical jargon.

Emotions should be acknowledged with empathic responses.

Summarize and set a strategy for future visits with the patient, emphasizing that the doctor will be there for the patient.

Gauging a sense of humor is one element among many of a thorough assessment by any psychiatrist. How does one teach that to interns, residents, and medical students? There’s no simple answer. It helps if there were good role models by a clinician-educator’s own teachers. One of mine was not even a physician. In the early 1970s when I was an undergraduate at Huston Tillotson University (when it was still Huston-Tillotson College), the faculty would occasionally put on an outrageous little talent show for the students in the King Seabrook Chapel. The star, in everyone’s opinion, was Dr. Jenny Lind Porter, who taught English. The normally staid and dignified Dr. Porter did a drop-dead strip tease while reciting classical poetry and some of her own ingenious inventions. Yes, in the chapel. Yes, the niece of author O. Henry; the Poet Laureate of Texas appointed in 1964 by then Texas Governor John Connally; the only woman to receive the Distinguished Diploma of Honor from Pepperdine University in 1979; yes, the Dr. Porter in the Texas Women’s Hall of Fame—almost wearing a very little glittering gold something or other.

It helps to be able to laugh at yourself.

1. Twain, M., et al., Mark Twain’s helpful hints for good living: a handbook for the damned human race. 2004, Berkeley: University of California Press. xiv, 207 p.

2. Baile, W.F., et al., SPIKES-A six-step protocol for delivering bad news: application to the patient with cancer. Oncologist, 2000. 5(4): p. 302-11.

Giving Credit Where Credit is Due

Here’s another vintage post from around a decade ago after my former Psychiatry Dept chairperson, Dr. Robert G. Robinson and I published our book, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry” in 2010.

Blog: Who Gets The Credit?

When I think about peak moments, I remember this guy back in junior high school who decided to try to break the Guinness Book of World Records for skipping rope. I don’t remember his name but the school principal and his teachers all agreed to let him do it during class hours. They marked out a little space for him in our home room. He was at it all day. And he was never alone because there was always a class in the room throughout the day. We didn’t get much work done because we couldn’t keep our eyes off him. It was mesmerizing. The longer he jumped, the more we hoped. We were very careful about how we encouraged him. We didn’t want to distract him and make him miss a jump. And so, we watched him with hope in our hearts. It was palpable. As he neared the goal, we were all crowded around him, teachers and students cheering. He was exhausted and could barely swing the rope over his head and lift his knees. When he made the time mark, we lifted him high above our heads and you could have heard us yelling our fool heads off for miles. Time stood still. He was a hero and we were his adoring fans. It didn’t occur to us to be jealous. His achievement belonged to all of us.

Another peak moment occurred more recently, when my colleagues and I published a book this summer. It’s my first book. It’s a handbook about consultation-liaison psychiatry which my department chairman and I edited, and the link is available on this page. This time, the effort was collaborative with over 40 contributors. The work took over 2 years and often, being an editor felt like herding cats. But we worked on it together. Many of the contributors were trainees working with seasoned psychiatrists who had much weightier research and writing projects on their minds, I’m sure. Like any first book, it was a labor of love. The goal was to teach fundamental concepts and pass along a few pearls about psychosomatic medicine to medical student, residents, and fellows. The book grew slowly, chapter by chapter. And when it was finally complete, this time the achievement was ours and again it belonged to all of us.

I made a lot of long-distance friends on the book project and occasionally get encouragement to do something else we could work together on. I suppose one thing everyone could do is to propose some kind of delirium early detection and prevention project at their own hospitals and chronicle that in a blog to raise awareness about delirium—sort of like what I’ve been trying to do here. We could share peak moments like:

Getting the Sharepoint intranet site up and going so that group members can talk to each other about in discussion groups about how to hammer out a proposal, which delirium rating scale to use, or which management guidelines to use—and avoid the email storms.
Being invited to give a talk about delirium at a grand rounds conference or regional meeting.
Talking with someone who is interested in funding your delirium project (always a big hit).

That way if one of us falters, we always know that someone else is in there pitching. Copyrighting ideas and tools are fine. Hey, everybody has a right to protect their creative property. I’m mainly talking about sharing the idea of a movement to teach health care professionals, and patients about delirium, to help us all understand what causes it, what it is and what it is not, and how to prevent it from stealing our loved ones and our resources.

“It is amazing what you can accomplish if you do not care who gets the credit”-Harry Truman, Kansas Legislature member John Solbach, Ronald Reagan, Charles E. Montague, Benjamin Jowett, a Jesuit Father, a wise man, Edward T. Cook, Edward Everett Hale, a Jesuit Priest named Father Strickland.

Blast from the Past Blog

I thought I’d re-post something from my previous blog, The Practical Psychosomaticist, which I cancelled several years ago. The title is “Face Time versus Facebook.” I sound really old in it although it appeared in 2011.

I’m a little more comfortable with the concept of social media nowadays and, despite how ignorant I was back then, I later got accounts in Facebook, Twitter, and LinkedIn. I got rid of them several years later, mainly because all I did was copy my blog posts on them.

The Academy of Psychosomatic Medicine (APM) to which there is a link in the old post below, later changed its name to the Academy of Consultation-Liaison Psychiatry (ACLP), which made good sense. I still have the email message exchange in 2016 with Don R. Lipsitt, who wrote the book “Foundations of Consultation-Liaison Psychiatry: The Bumpy Road to Specialization.” It’s an excellent historical account of the process.

Don liked a post I wrote, entitled “The Time Has Come for ‘Ergasiology’ to Replace ‘Psychosomatic Medicine?” It was a humorous piece which mentioned how many different names had been considered in the past for alternative names for Psychosomatic Medicine. I was actually plugging his book. I don’t think ergasiology was ever considered; I made that part up. But it’s a thing. It was Adolph Meyer’s idea to invent the term from a combination of Greek words for “working” and “doing,” in order to illustrate psychobiology. Don thought “…the Board made a big mistake…” naming our organization Psychosomatic Medicine. He much preferred the term “consultation-liaison psychiatry.” We didn’t use emoticons in our messages.

The Don R. Lipsitt Award for Achievement in Integrated and Collaborative Care was created in 2014 to recognize individuals who demonstrate “excellence and innovation in the integration of mental health with other medical care…”

I don’t think the ACLP uses Facebook anymore, but they do have a Twitter account.

I also included in the old post a link to the Neuroleptic Malignant Information Service (NMSIS). I used to call the NMSIS service early in my career as a consultation-liaison psychiatrist. I often was able to get sound advice from Dr. Stanley Caroff.

Blog: Face Time versus Facebook

You know, I’m astounded by the electronic compensations we’ve made over the years for our increasingly busy schedules which often make it impossible to meet face to face. Frankly, I’ve not kept up. I still think of twittering as something birds do. If you don’t get that little joke, you’re probably not getting mail from the AARP.

The requests for psychiatric consultations are mediated over the electronic medical record and text paging. Technically the medical team that has primary responsibility for a patient’s medical care contacts me with a question about the psychiatric management issues. But it’s not unusual for consultation requests to be mediated by another consultant’s remarks in their note. The primary team simply passes the consultant’s opinion along in a request. They may not even be interested in my opinion.

I sometimes get emails from people who are right across the hall from me. I find it difficult to share the humor in a text message emoticon. And I get more out of face-to-face encounters with real people in the room when a difficult case comes my way and I need to tap into group wisdom to help a patient. These often involve cases of delirium, an acute confusional episode brought on by medical problems that often goes unrecognized or is misidentified as one of the many primary psychiatric issues it typically mimics.

The modern practice of medicine challenges practitioners and patients alike to integrate electronic communication methods into our care systems. And these methods can facilitate education in both directions. When professionals are separated geographically, whether by distances that span a single hospital complex or across continents, electronic communication can connect them.

But I can’t help thinking there are some messages we simply can’t convey with emoticons. By nature, humans communicate largely by nonverbal cues, especially in emotionally charged situations. And I can tell you, emotions get involved when physicians and nurses cue me that someone who has delirium is just another “psych patient” who needs to be transferred to a locked psychiatric unit (although such transfers are sometimes necessary for the patient’s safety).

So, when do we choose between Face Time and Facebook? Do we have to make that choice? Can we do both? When we as medical professionals are trying to resolve amongst ourselves what the next step should be in the assessment and treatment of a delirious patient who could die from an occult medical emergency, how should we communicate about that?

As a purely hypothetical example (though these types of cases do occur), say we suspect a patient has delirium which we think could be part of a rare and dangerous medical condition known as neuroleptic malignant syndrome (NMS). NMS is a complex neuropsychiatric disorder which can be marked by delirium, high fever, and severe muscular rigidity among other symptoms and signs. It can be caused very rarely by exposure to antipsychotic drugs such as Haloperidol or the newer atypical antipsychotics. The delirium can present with another uncommon psychiatric disorder called catatonia, and many experts consider NMS to be a drug-induced form of catatonia. Patients suffering from catatonia can display a variety of behaviors and physiologic abnormalities though they are often mute, immobile, and may display bizarre behaviors such as parroting what other people say to them, assuming very uncomfortable postures for extended periods of time (called waxy flexibility), and very rapid heart rate, sweating, and fever. The treatment of choice is electroconvulsive therapy (ECT) which can be life-saving.

Since NMS is rare, many consulting psychiatrists are often not confident about their ability to diagnose the condition. There may not be any colleagues in their hospital to turn to for advice. One option is to check the internet for a website devoted to educating clinicians about NMS, the Neuroleptic Malignant Syndrome Information Service at www.nmsis.org. The site is run by dedicated physicians who are ready to help clinicians diagnose and treat NMS. Physicians can reach them by telephone or email and there are educational materials on the website as well. I’ve used this service a couple of times and found it helpful. The next two electronic methods I have no experience with at all, but I find them intriguing.

One might be a social network like Facebook. In fact, the Academy of Psychosomatic Medicine (APM) has a Facebook link on their website, www.apm.org. Psychosomaticists can communicate with each other about issues broached at our annual conferences, but probably not discuss cases. Truth to tell, the Facebook site doesn’t look like it’s had many visitors. There are 3 posts which look like they’ve been there for a few months:

Message 1: We have been thinking about using Facebook as a way to continue discussions at the APM conference beyond the lectures themselves. Would anyone be interested in having discussions with the presenters from the APM conference in a forum such as this?

Message 2: This sounds great!

Message 3: I think it’s a very good idea

It’s not exactly scintillating.

Another service could be something called LinkedIn, which I gather is a social network designed for work-at-home professionals to stay connected with colleagues in the outside world. Maybe they should just get out more?

Email is probably the main way many professionals stay connected with each other across the country and around the world. The trouble is you have to wait for your colleague to check email. And there’s text messaging. I just have a little trouble purposely misspelling words to get enough of my message in the tiny text box. And I suppose one could tweet, whatever that is. You should probably just make sure your tweet is not the mating call for an ostrich. Those birds are heavy and can kick you into the middle of next week.

But there’s something about face time that demands the interpersonal communication skills, courtesy, and cooperation needed to solve problems that can’t be reduced to an emoticon.

Listen to Dr. Wes Ely, MD on Talk Radio Europe Discuss His Book: Every Deep-Drawn Breath

Listen to Dr. Wes Ely on the show Talk Radio Europe as he talks about the devastating consequences of severe disease that results in admission to critical care units, specifically in the context of the Covid-19 Pandemic.

The title of the presentation is “Understanding the Long Shadow of COVID and ICU Care.”

Taming the Juggling Balls

As of November 7, 2022 it has been 22 days since I purchased the Learn to Juggle kit from Barnes and Noble. So far, my learning experience reminds me of a story by Mark Twain, “Taming the Bicycle,” which was published posthumously—obviously after he succumbed from his injuries in the attempt to ride the high-wheeled bicycle in the early 1880s.

Just kidding of course, about his death from the bicycle riding adventure. He did mention using about a barrel of something called Pond’s Extract, which was a liniment for scrapes and other wounds.

Twain was writing about learning something new—a thing all of us are called on to do many times in our lives. He didn’t try to learn to ride the bicycle until he was over 50 years old.

I didn’t try to learn how to juggle until was well past my mid-sixties. How do you account for decisions to embark on new hobbies, adventures, and other nonsense at an age when most people would be content vegetating on the porch or in front of the TV?

I just answered the question, in case you didn’t notice.

Anyway, I am making some progress as juggling, although it’s uneven. It’s hard to believe, but sometimes I think I juggle better as I wander around. I think it might be because there is a natural tendency to throw the balls away from you. That way, I look more adept simply because I’m making a frequently observed beginner’s mistake. But I seem to be steadier even when I walk backward a few paces.

When I stand firmly in one place and attempt to juggle, I can often barely make it past half a dozen throws. Wandering a little, I have made thirty throws.

But then, randomly, the opposite occurs and the theory fails.

Counting the number of each throw seems to help—occasionally. I also notice that unscheduled, short practice episodes for 10 minutes or less work better than struggling along for a half hour or so at set times.

I don’t dread the practice sessions; in fact, I have a sort of itch to juggle at various times during the day. Sometimes I believe I do it to help me collect my thoughts, to keep my hands occupied, or just to pass the time.

I remember learning to ride the bicycle for the first time when I was a kid. I fell down a lot, just like Twain did—until I got the hang of it. Maybe juggling will turn out to be the same.

But I won’t need Pond’s Extract for juggling mistakes—as long as I don’t try juggling while climbing or descending stairs.

Sena Grows Peonies!

Sena has a peony shrub growing dazzling red blossoms. The red ones are said to symbolize love, respect, and honor. The peony genus classification is Paeonia, which is taken from the Greek word Paean. At least a couple of flower web sites say the origin of the name peony comes from a Greek myth involving a deity called Paean (pronounced “Bud”).

According to the flower web sites version of the myth, Paean was the physician of the gods. He was a student of Aesculapius or Asclepius, whose friends just called him “Bud.”

Paean used a peony root to heal Pluto, which was the Roman name of the deity Hades. I don’t know what was ailing Pluto. Maybe it was the gout. Anyway, Aesculapius got wind of Paean’s treatment, and became really jealous. He tried to kill him, but Zeus wasn’t having any of that baloney, intervened and turned Paean into a peony.

I couldn’t find this version in any scholarly source of Greek mythology. In fact, Edith Hamilton, a Greek scholar who wrote a book entitled simply, Mythology, says Paean was just another name for Apollo or Aesculapius, also known as Asclepius—or “Bud.”

In fact, a paean is a song of thanksgiving or triumph addressed to Apollo.

Hamilton’s version is kind of a soap opera. Greek gods always seemed to be having torrid affairs with humans, often leading to drama involving the transformation of humans into various plants, animals and whatnot—and maybe even destroying them.

This is what happened to a human female named Coronis, who had a fling with Apollo who got her pregnant. She snubbed him for a human guy, which annoyed Apollo so he killed her. However, he saved his baby by tearing Coronis open and plucking him out right out of the womb—really extreme.

Apollo than adopts the kid out to an old fart of a Centaur named Chiron. Apollo ordered Chiron to name the child Aesculapius, or Asclepius, “Bud” for short. He was never named Paean, according to Hamilton.

Chiron was pretty slick with healing arts and taught Bud everything he knew. Then Bud got too big for his britches and brought a guy back from the dead. I can’t recall exactly who got resurrected; it was either Hippolytus or Elvis. Gods got mad about it because making zombies is their business, not Bud’s.

Consequently, Zeus killed Bud by slinging a thunderbolt at him. Contrary to flower shop lore, Zeus never even considered turning him into a peony. In his opinion, you had to teach these pups a lesson.

How do you think Apollo felt about this? How would you feel? What would you do? Apollo got on the phone with his lawyer, and before you could say “peony,” he got a court order authorizing Apollo to kill the Cyclops who were manufacturing all of Zeus’s thunderbolts.

If you think it ended there, you’re wrong. Zeus, not to be outdone, sued Apollo, who lost big time and was sentenced to slavery to King Admetus for one to nine years in solitary confinement.

Bud, on the other hand, even though he was slain, was honored by thousands for hundreds of years. Those who came to his temples were invariably healed of various ailments including but not limited to the gout. Snakes were involved in the treatments, though, and some preferred to live with the gout, so declined to sign the informed consent forms.

Hamilton and other scholars don’t ever mention Bud getting turned into a peony. But Sena’s peonies are still beautiful.

Reference: Edith Hamilton, Mythology, Little, Brown and Company, 1942.

The Written Word is Blurred

I ran across this quote the other day: littera scripta manet. The English translation is, I think, “the written word endures.”

Not to dwell too much on the prosaic side of the issue which is that, for me, often the word has been blurred because of problems with my vision. I just had retinal detachment surgery a little over a month ago and I’m making a good recovery. But early on I had a lot of trouble with blurry vision, tearing, and light sensitivity.

Just the other night though, I was able to read a section of a book without having as much blurred vision as I did before the surgery when I looked up from the page at something distant. I’ve been wearing progressive lenses for many years and it probably got worse because of the detached retina, which was chronic or maybe acute on chronic.

Now to get beyond trivialities, I saw the quote above in an issue of the University of Iowa publication, Iowa Magazine. It was in the last Old Gold column of University Archivist, David McCartney. He retired in March of this year. The title was “Old Gold: The Enduring Power of the Written Word.”

He notes the Latin expression is on the seal of the U.S. National Archives and Records Administration. McCartney’s point is that technology can undermine as well as strengthen the power of the written word. He identities Horace as the originator of the expression, “the written word endures.”

I went pecking around the internet and found out that a lot of people think an educator named Neil Postman was the originator of this quote. What makes me doubt this is that the original is in Latin, which suggests a much older origin. He was born in 1931 and died in 2003. Interestingly, Postman criticized the effect of technology on thought and culture.

A website that seems dedicated to explaining English translations of Latin indicates that the quote comes from a longer expression: Vox audita perit, littera scripta manet, which translates to “the spoken word perishes, but the written word remains.” One contributor says the originator was Horace. Another insists that “littera” does not mean word at all, although concedes that the proposed translation is correct, nevertheless.

Further, there is a Wikipedia entry which cites the Latin expression differently, “verba volant, scripta manent,” which in English is “spoken words fly away, written words remain.” The author says the proverb originated from a speech of senator Caius Titus to the Roman Senate.

Anyway, McCartney points out that the world is becoming increasingly digitized and that the average website lasts only a little over two and a half years. Some important digital records have been lost, unreadable (blurred?) because of improper management.

My previous blog survived about 7 years but is lost. Maybe that’s not such a bad thing. My current blog is a little over 3 years old. So far, I’m beating the odds as far as typical longevity, but is it worthwhile?

Both written and digital records have strengths and weaknesses in terms of durability. And deciding what to preserve and how is essential to any society. We need good stewards to help us decide.

Good luck in your retirement, David McCartney. I’m sure the University of Iowa treasures your stewardship. Let the written word endure unblurred.

Looking Back on Gunslingers and Chess Masters

I was looking at an early version of the handbook of consultation-liaison psychiatry that eventually evolved into what was actually published by Cambridge University Press. I wrote virtually all of the early version and it was mainly for trainees rotating through the consult service. The published book had many talented contributors. I and my department chair, Dr. Robert G. Robinson, co-edited the book.

In the introduction I mention that the manual was designed for gunslingers and chess masters. The gunslingers are the general hospital psychiatric consultants who actually hiked all over the hospital putting out the psychiatric fires that are always smoldering or blazing. The main problems were delirium and neuropsychiatric syndromes that mimic primary psychiatric disorders.

The chess masters were those I admired who actually conducted research into the causes of neuropsychiatric disorders.

Admittedly the dichotomy was romanticized. I saw myself as a gunslinger, often shooting from the hip in an effort to manage confused and violent patients. Looking back on it, I probably seemed pretty unscientific.

But I can tell you that when I followed the recommendations of the scientists about how to reverse catatonia with benzodiazepines, I felt much more competent. After administering lorazepam intravenously to patients who were mute and immobile before the dose to answering questions and wondering why everyone was looking at them after the dose—it looked miraculous.

Later in my career, I usually thought the comparison to a firefighter was a better analogy.

The 2008 working manual was called the Psychosomatic Medicine Handbook for Residents at the time. This was before the name of the specialty was changed back to Consultation-Liaison Psychiatry. I wrote all of it. I’m not sure about the origin of my comment about a Psychosomatic Medicine textbook weighing 7 pounds. It might relate to the picture of several heavy textbooks on which my book sits. I might have weighed one of them.The introduction is below (featured image picture credit pixydotorg):

“In 2003 the American Board of Medical Specialties approved the subspecialty status of Psychiatry now known as Psychosomatic Medicine. Long before that, the field was known as Consultation-Liaison Psychiatry. In 2005, the first certification examination was offered by the American Board of Psychiatry and Neurology. Both I and my co-editor, Dr. Robert G. Robinson, passed that examination along with many other examinees. This important point in the history of psychiatry began many decades ago, probably in the early 19th century, when the word “psychosomatic” was first used by Johann Christian Heinroth when discussing insomnia.

Psychosomatic Medicine began as the study of psychophysiology which in some quarters led to a reductionistic theory of psychogenic causation of disease. However, the evolution of a broader conceptualization of the discipline as the study of mind and body interactions in patients who are ill and the creation of effective treatments for them probably was a parallel development. This was called Consultation-Liaison Psychiatry and was considered the practical application of the principles and discoveries of Psychosomatic Medicine. Two major organizations grew up in the early and middle parts of the 20th century that seemed to formalize the distinction (and possibly the eventual separation) between the two ideas: the American Psychosomatic Society (APS) and the Academy of Psychosomatic Medicine (APM). The name of the subspecialty finally approved in 2003 was the latter largely because of its historic roots in the origin of the interaction of mind and body paradigm.

The impression that the field was dichotomized into research and practical application was shared and lamented by many members of both organizations. At a symposium at the APM annual meeting in Tucson, AZ in 2006, it was remarked that practitioners of “…psychosomatic medicine may well be lost in thought while…C-L psychiatrists are lost in action.”

I think it is ironic how organizations that are both devoted to teaching physicians and patients how to think both/and instead of either/or about medical and psychiatric problems could have become so dichotomized themselves.

My motive for writing this book makes me think of a few quotations about psychiatry in general hospitals:

“Relegating this work entirely to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods.”

“All staff conferences in general hospitals should be attended by the psychiatrist so that there might be a mutual exchange of medical experience and frank discussion of those cases in which there are psychiatric problems.”

“The time should not be too long delayed when psychiatrists are required on all our medical and surgical wards and in all our general and surgical clinics.”

The first two quotes, however modern they might sound, are actually from 1929 in one of the first papers ever written about Consultation Psychiatry (now Psychosomatic Medicine), authored by George W. Henry, A.B., M.D. The third is from the mid-1930s by Helen Flanders Dunbar, M.D., in an article about the substantial role psychological factors play in the etiology and course of cardiovascular diseases, diabetes, and fractures in 600 patients. Although few hospital organizations actually practice what these physicians recommended, the recurring theme seems to be the need to improve outcomes and processes in health care by integrating medical and psychiatric delivery care systems. Further, Dr. Roger Kathol has written persuasively of the need for a sea change in the way our health care delivery and insurance systems operate so as to improve the quality of health care in this country so that it compares well with that of other nations (2).

This book is not a textbook. It is not a source for definitive, comprehensive lists of references about all the latest research. It is not a thousand pages long and does not weigh seven pounds. It is a modest contribution to the principle of both/and thinking about psyche and soma; consultants and researchers; — gunslingers and chess masters.

In this field there are chess masters and gunslingers. We need both. You need to be a gunslinger to react quickly and effectively on the wards and in the emergency room during crises. You also need to be a chess master after the smoke has cleared, to reflect on what you did, how you did it—and analyze why you did it and whether that was in accord with the best medical evidence.

This book is for the gunslinger who relies on the chess master. This book is also for the chess master—who needs to be a gunslinger.

“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat”—Sun Tzu.”

References:

1. Kathol, R.G., and Gatteau, S. 2007. Healing body and mind: a critical issue for health care reform. Westport, CT: Praeger Publishers. 190 pp.

2. Kornfeld, D., and Wharton, R. 2005. The American Psychiatric Publishing Textbook of Psychosomatic Medicine. Psychosomatics 46:95-103.

The Chicken Finally Lays An Egg

Below is an old post from a previous blog that I published on June 6, 2010. Although the title in my record is simply PM Handbook Blog, there must have been another title. Maybe it should have been more like The Chicken Has Finally Laid an Egg (you’ll get the joke later).

There are two reasons for posting it today. One is to illustrate how the Windows voice recognition dictation app works. It’s a little better than I thought it would be. The last time I used it, it was ugly. I’m using it now because I thought it might be a little easier than trying to type it since I still have problems with vision in my right eye because of the recent retinal tear injury repair. So, instead of doing copy paste, what you’re seeing is a dictation—for the most part.

On the other hand, I’m still having to proofread what I dictate. And I still find a few mistakes, though much fewer than I expected.

The other reason for this post is to help me reflect on how far the fellowship has come since that time. It did eventually attract the first fellow under a different leader. That was shortly after I retired. It was a great step forward for the department of psychiatry:

“Here is one definition of a classic:

“Classic: A book which people praise but don’t read.” Mark Twain.

When I announced the publishing of our book, Psychosomatic Medicine, An Introduction to Consultation Liaison Psychiatry, someone said that it’s good to finally get a book into print and out of one’s head. The book in earlier years found other ways out of my head, mainly in stapled, paperclipped, spiral bound, dog eared, pages of homemade manuals, for use on our consultation service.

It’s a handbook and meant to be read, of course, but quickly and on the run. As I’ve said in a previous blog, it makes no pretension to being the Tour de Force textbook in America that inspired it. However, any textbook can evolve into an example of Twain’s definition of a classic. The handbook writer is a faithful and humble steward who can keep the spirit of the classic lively.

We must have a textbook as a marker of Psychosomatic Medicine’s place in medicine as a subspecialty. It’s like a Bible, meant to be read reverently, venerated, and quoted by scholars. But the ark of this covenant tends to be a dusty bookshelf that bows under the tome’s weight. A handbook is like the Sunday School lesson plan for spreading the scholar’s wisdom in the big book.

Over the long haul, the goal of any books should mean something other than royalties or an iconic place in history. No preacher ever read a sermon to our congregation straight out of the Bible. It was long ago observed by George Henry that there will never be enough psychiatric consultants. This prompts the question of who will come after me to do this work. My former legacy was to be the Director of a Psychosomatic Medicine Fellowship in an academic department in the not-so-distant past. Ironically, though there will never be enough psychiatric consultants, there were evidently too many fellowships from which to choose. I had to let the fellowship go. My legacy then became this book, not just for Psychosomatic Medicine fellows, but medical students, residents, and maybe even for those who see most of the patients suffering from mental illness—dedicated primary care physicians.

My wife gave me a birthday card once which read: “Getting older: May each year be a feather on the glorious Chicken of Life as it Soars UNTAMED and BEAUTIFUL towards the golden sun.” My gifts included among the obligatory neckties, a couple of books on preparing for retirement.

Before I retire, I would like to do all I can to ensure that the next generation of doctors learn to respect the importance of care for both body and mind of each and every one of their patients. That’s the goal of our book. And may the glorious chicken of life lay a golden egg within its pages to protect it from becoming a classic.”

Chicken picture credit: Pixydotorg.

Scrabble Babble

The other day Sena and I played a close game of scrabble—close that is until I challenged her play of the word “Xi.” I lost a turn because in our brand spanking new Scrabble dictionary it’s defined as a Greek letter.

Later, I knew better than to challenge her play of “Ka,” which I looked up after the game. It means the spiritual self of a human being in Egyptian religion. I ended up losing the game.

She plays a Scrabble video game and got a Bingo recently, which got her 80 points. On the web a Bingo is defined as playing all seven tiles, and you get 50 points. I guess that’s the difference between playing the video Scrabble game and playing a human being, whether of the Egyptian religion or not.

We also used a brand-new Merriam-Webster’s Collegiate Dictionary, Eleventh Edition, during a different game. We used that and I challenged her play of “dic.” I guess you know what’s coming.

As you can probably guess, “dic” is not a word, but those of us with dirty minds know full well that “dick” is a slang term that can mean penis, detective, or surprisingly, nothing. The nothing definition reminded me of the Men in Black scene in which the soon-to-be Agent J is riding down the elevator with Agent K, explaining that because he was chosen by the MIB organization, that means they recognize all of his skills. Agent K makes the deflating remark that all of his skills mean “precisely dick.”

I know you’ll be fascinated to learn that the nothing meaning of dick is not in the Scrabble dictionary nor is it in the Merriam-Webster’s Collegiate Dictionary.

So, remember that the next time you play Scrabble. On the other hand, if you don’t play Scrabble, this means precisely—detective.