I’m just puzzled lately over what seems like a contradiction between two ideas I’ve seen in the news and in TV commercials. It’s all about body odor.
There is this study that was recently published about stinky armpit odor possibly making the practice of mindfulness meditation more effective.
This contrasts with the usual meaning of body odor, which is that it’s to be avoided and prevented at all costs. And, the newest total body odor eliminator product is getting heavy rotation in TV commercials and its name rhymes, (possibly fittingly) with “looney.” I’m just going to frankly admit that I can’t stand watching the commercial.
There is this old timer product called Ex-Odor that was marketed in the early 1900s by a company called Gordon Gordon, Ltd. The label said it “Removes All Body Odors.” It was touted as “safe, sure, lasting” and it cost only ten cents. The original label actually did italicize the word “All.” On the other hand, Looney is a lot more expensive—just sayin’.
The armpit odor study and Looney definitely send opposite messages about body odor.
In fact, there is a psychiatric disorder marked by an intense preoccupation with smelling bad. I think it’s still called Olfactory Reference Disorder (ORD). Almost any part of the body could stink and could lead to showering several times a day or visits to ENT doctors to get “infected” and therefore smelly tonsils removed. The disorder not uncommonly gets requests for consultation-liaison psychiatrists to get involved.
Olfactory Reference Disorder can lead to severe, even disabling, social anxiety. It can lead to beliefs that have delusional intensity.
Often, those with ORD firmly believe they emit a foul odor, often from armpits, or inguinal, anal, and oral areas. Some seek surgical treatment. There are many other disorders which consultation-liaison psychiatrists need to remember in order to distinguish ORD from them. Combined cognitive behavioral therapy, possibly along with medication can be recommended as treatment.
Suggested screening questions include:
“Are you very worried or concerned about your body odor in any way?
Do you believe that other people are also aware of the way you smell (your body odor) and take special notice of it (e.g., make comments about the smell)?
Is there anything you feel an urge to do often and repeatedly in order to lessen your worries about your body odor? (e.g., repeatedly brush your teeth, wash or change clothes frequently, smell self or ask others for reassurance)
Do you avoid any situations or activities (e.g., sport/dating) because of this body odor?
Do these worries about the way you smell negatively affect your mood (e.g., cause shame, depression, anxiety, suicidal thoughts) or your daily life (e.g., relationships, work, school, social)?”
I’m not trying to make any value judgments about either the study or the Looney product. Well, maybe a little. It does remind me of a few lines from the Grinch song:
You’re a foul one, Mr. Grinch, You’re a nasty wasty skunk, Your heart is full of unwashed socks, Your soul is full of gunk, Mr. Grinch.
The three words that best describe you are, and I quote, “Stink, stank, stunk”!
Thomas, E., et al. (2015). “Olfactory Reference Disorder: Diagnosis, Epidemiology and Management.” CNS Drugs 29(12): 999-1007.
Lim, L. and Y. M. Wan (2015). “Jikoshu-kyofu in Singapore.” Australasian Psychiatry 23(3): 300-302.
McKenna, P. J. (1984). “Disorders with overvalued ideas.” Br J Psychiatry145: 579-585.
Santin, J. M. and F. M. Galvez (2011). “Overvalued ideas: psychopathologic issues.” Actas Esp Psiquiatr 39(1): 70-74.
Mullen, R. and R. J. Linscott (2010). “A comparison of delusions and overvalued ideas.” J Nerv Ment Dis 198(1): 35-38.
Miranda-Sivelo, A., et al. (2013). “Unnecessary surgical treatment in a case of olfactory reference syndrome.” General Hospital Psychiatry 35(6): 683.e683-683.e684.
I noticed what is, for me at least, a new educational resource for catatonia. There’s an aricle about it in the March 2023 issue (Vol.51, No. 3) of Clinical Psychiatry News. The resource is available at University of Rochester Medical Center website. They include pdf files and training videos for assessment of catatonia.
There are also links for information about catatonia:
The University of Rochester presentation has has demo videos using a standardized patient (a physician, Dr. Joshua Wortzel) and a teacher, Dr. Mark Oldham.
I saw cases of catatonia while I was a consultation-liaison psychiatrist at The University of Iowa Hospitals & Clinics and they often had medical causes. My YouTube video lecture on Catatonia, Neuroleptic Malignant Syndrome, and Serotonin Syndrome is still getting views after 4 years.
I’m going to talk a little bit about fathers. Mothers are important too, but I’m a guy and I can talk about mothers another day. Because it’s a touchy subject, I’m going to begin with a Men in Black (MIB) joke, like I always do when I’m being defensive. There’s this MIB 3 scene in which Agent K and Agent J have this exchange:
Agent K: I used to play a game with my dad, what would you have for your last meal. You could do worse than this (explanation for this: they’re sitting in a restaurant and an eyeball in Agent K’s soup swivels around and stares at him).
Agent J: Oh, okay, I used to play a game with my dad called catch. Except I would throw the ball and it would just hit the wall, cause—he wasn’t there.
Agent K: Don’t bad mouth your old man.
Agent J: I’m not bad mouthing him, I just didn’t really know him.
Agent K: That’s not right.
Agent J: You’re damn right, it’s not right. A little boy needs a father.
On one level, this scene is just another way of showing the father/son, teacher/student, mentor/mentee relationship Agents K and J had with each other. By extension, their interaction says something about what happens in similar real-life relationships—in the shallow, cliché ways that movies always do.
I sometimes think about the relationship I had with learners when I was a teaching consultation-liaison (C-L) psychiatry. Often, I say to myself that I never had a mentor and I was never a mentor.
That’s not true. Although I never had a mentor who was formally assigned to me, there was more than one faculty member in the psychiatry department with whom I had an informal mentor/mentee relationship. And I was an informal mentor to at least a few trainees.
However, I was middle-aged by the time I entered medical school, which probably set the stage for awkward relationships with my fellow students and some teachers, partly because I was either the same age as or older than them.
That doesn’t mean I was wiser than them. It just means that I was conflicted about them. Later, in residency, I learned about transference and countertransference. In fact, I focused on the psychodynamic as well as the medical issues in teaching trainees. In the first C-L manual I wrote (the forerunner to the book I and my co-editor published later), I devoted a large section to psychodynamic factors relevant to doctor-patient relationships.
So, if you’re wondering when I’m going to start bad-mouthing my old man, you can stop wondering. I’m not going there. He wasn’t a hero, like Agent J’s father was (you need to see the movie to get this angle).
My dad was funny. I don’t think I got my own sense of humor from him, but it makes sense why I would have one—and just because “he wasn’t there” doesn’t explain everything. It never does.
Fathers can be a pain in the ass, not just because of dad jokes. Fathers can be a pain in the brain, too. Ask anybody who was a latchkey kid; I was one of those. We really don’t belong to any specific generation.
We also can’t just up and time travel like Agent J and find out about the father we never really knew. Mostly, it’s just bits and pieces, like a matchbook with a name and address from somebody on your paper route. The path it can lead to doesn’t always mean you find out that “Your daddy was a hero,” like a young Agent K tells young James (who becomes Agent J in the future) after he neuralyzes him to shield him from the hard truth about his father.
I’ve been juggling for about 5 months now and reflecting on my progress. I think I’m doing OK for a geezer. Sena would call me a hot dog although I would still call it ugly juggling by any standard.
What’s striking, at least to me, is the little bit of science I can find on the web about juggling. I hear the term “muscle memory” when it comes to learning juggling. Actually, there’s some truth to that. There are different kinds of memory. For example, most of us know about declarative memory, which about memorizing facts, because we use it to prepare for exams. Those of us who went to medical school remember the agony of taking tests for the basic sciences.
But so-called muscle memory, or the memory for learning new skills like juggling, takes place in the brain. There was a study published in 2009 which found changes in both gray and white matter of subjects before and after learning to juggle (Scholz J, Klein MC, Behrens TE, Johansen-Berg H. Training induces changes in white-matter architecture. Nat Neurosci. 2009;12(11):1370-1371. doi:10.1038/nn.2412).
The study about correlation of the inability to stand on one leg for 10 seconds with higher mortality in older patients, which I relate to the ability to do the under the leg juggling trick, was published last year (Araujo CG, de Souza e Silva CG, Laukkanen JA, et al. Successful 10-second one-legged stance performance predicts survival in middle-aged and older individuals. British Journal of Sports Medicine 2022; 56:975-980.)
I talk a lot about juggling as though I’m a teacher. I’m not a juggling instructor by any means. You can find better juggling teachers on the web. But my approach to talking about juggling in terms of it being a hobby for me is really not different from how I talked about consultation-liaison psychiatry before and after I retired. I’m still a teacher—just evolving in retirement.
However, you can find much better resources for learning how to juggle at the following websites:
I’ve been thinking about Dr. Moffic’s article on regret, posted on February 16, 2023 in Psychiatric Times.
I’ve dwelt on it long enough that I feel compelled to inject humor into the subject. It’s one of my many defenses.
There’s a quote from Men in Black 3 involving a short telephone conversation between Agent K and Agent J:
Agent K: Do you know the most destructive force in the universe?
Agent J: Sugar?
Agent K: Regret.
You could probably sense that joke coming. Whenever there is talk of regrets, I always recall maybe one or two remarkable episodes which led to lifelong regret. Because regret is pretty corrosive, as noted by Agent K, I need something to counter it.
My trouble is that I have many regrets. Am I so different in that regard?
Sometime in mid-career, a very important leader told me, frankly and calmly, “You’ll never be a scientist.”
Well, by then it was far too late for me to change life course. It was true; I’ve always been the rodeo clown, never the matador.
On the other hand, I know one thing I’ve never regretted and that’s my retirement. At least I think I haven’t regretted it. I have this recurring dream. It’s not every night, but often enough to make me wonder what I should do about it.
In the dream, I’m late for an exam or class and I fear I’m going to flunk. I look for the building where the exam is going to be held. I can never find it. Hallways appear and look vaguely familiar, but as I wander about looking for the bookstore or classroom or exam room, I feel like I’m in a maze, climbing stairs, almost like an Escher drawing.
That reminds me. Incidentally, several years ago, one of the medical students rotating on the psychiatry consult service drew a picture entitled “The Practical Psychosomaticist” which contained images of stairs running in different directions similar to an Escher drawing (see the featured image). It was really just her expression of how I got around the hospital. I avoided elevators and always took the stairs.
Anyway, I’m carrying several notebooks and loose papers keep falling out. I get lost in this jumble of halls and stairways, never finding my destination.
The dream is probably just me telling myself I’m failing at something in my waking life. It’s not like I need a dream to notify me.
This is a long way of saying I have many regrets, and that I may not know exactly how many. Some of them are less important than others. Take the “I’ll never be a scientist” theme. I’m not terribly broken up about it.
After all, rodeo clowns do pretty important things.
I discovered the University of Iowa Dept of Psychiatry had a very successful match, filling key residency slots in Child Psychiatry, Addiction Medicine, and Consultation-Liaison fellowships. Congratulations! That’s a big reason to celebrate.
This reminds me of my role as a teacher. I retired from the department two and a half years ago. But I’ll always remember how hard the residents and fellows worked.
And that’s why I’m reposting my blog “Remembering My Calling.”:
Back when I had the blog The Practical C-L Psychiatrist, I wrote a post about the Martin Luther King Jr. Day observation in 2015. It was published in the Iowa City Press-Citizen on January 19, 2015 under the title “Remembering our calling: MLK Day 2015.” I have a small legacy as a teacher. As I approach retirement next year, I reflect on that. When I entered medical school, I had no idea what I was in for. I struggled, lost faith–almost quit. I’m glad I didn’t because I’ve been privileged to learn from the next generation of doctors.
Faith is taking the first step, even when you don’t see the whole staircase.”
Martin Luther King, Jr.
As the 2015 Martin Luther King Jr. Day approached, I wondered: What’s the best way for the average person to contribute to lifting this nation to a higher destiny? What’s my role and how do I respond to that call?
I find myself reflecting more about my role as a teacher to our residents and medical students. I wonder every day how I can improve as a role model and, at the same time, let trainees practice both what I preach and listen to their own inner calling. After all, they are the next generation of doctors.
But for now they are under my tutelage. What do I hope for them?
I hope medicine doesn’t destroy itself with empty and dishonest calls for “competence” and “quality,” when excellence is called for.
I hope that when they are on call, they’ll mindfully acknowledge their fatigue and frustration…and sit down when they go and listen to the patient.
I hope they listen inwardly as well, and learn to know the difference between a call for action, and a cautionary whisper to wait and see.
I hope they won’t be paralyzed by doubt when their patients are not able to speak for themselves, and that they’ll call the families who have a stake in whatever doctors do for their loved ones.
And most of all I hope leaders in medicine and psychiatry remember that we chose medicine because we thought it was a calling. Let’s try to keep it that way.
You know, I’m on call at the hospital today and I tried to give my trainees the day off. They came in anyway.
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:
“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. 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.
There was a countdown on Sunday for the new season for Highway Thru Hell. That’s the explanation for the featured image. The show has been on a while; this is season 11.
Season 11, for the first few episodes will deal with the catastrophic floods that devastated British Columbia in November of 2021. It took a huge toll on everybody, including the tow truck businesses. That’s one reason why I think, out of the plethora of reality shows that are faked on TV—Highway Thru Hell is not.
There are times when I wondered about the show’s authenticity, of course. One episode featured a potential new hire named “Jack Knife,” which brings to mind what the heavy tow trucks do, which is to drag huge jack-knifed semi-trucks out of ditches along the highways. The episode actually showed a segment of Jamie Davis, the owner of the major tow truck business on the show, in which he confirms that Jack Knife is the guy’s real name. It doesn’t look like he was hired.
There is a kind of irony about the kinds of jobs I’ve had and how similar or not they were to the Highway Thru Hell type of work.
You’d think that when I was working as a survey crewman back when I was a young, I would think it was similar to Highway Thru Hell. In fact, I worked for professional consulting engineers. I had a regular schedule with set hours. I had the right equipment for the right job. When work slowed down, meaning the company didn’t have a big contract for a highway relocation or whatnot, I and other guys would fill the time and to look busy, we would tie up redheads.
I’ve set up that joke before. We didn’t tie up red-headed women. You tied red ribbon as flagging around nails to use as measuring points for property or airport runway lines and the like. It makes them easier to see. If you were lucky and had some drafting skills, like me, in the winter months you’d work on drawing up survey plots and other plans for blueprints. I worked in pretty bad weather sometimes, in the winter. I never had to do anything that was dangerous. I got plenty of sleep.
But I never worked as hard as tow truck operators. When it’s slack time for them, some are laid off, which is never a good thing. But when they’re busy, they’re up all day and sometimes all night. The calls to haul trucks out of the ditch are unpredictable. And the conditions are always dangerous.
The irony is that it wasn’t until after I graduated medical school, got my medical license, and finished my residency in psychiatry that, as I look back on it now, that my work sort of resembled the chaos of workers on Highway Thru Hell. And being on call as a resident did sometimes result in my face nearly falling in my dinner because of sleep deprivation.
Like Highway Thru Hell, working as a psychiatric consultant was a lot like being like a fireman, which is similar to towing. I got called, often to emergencies, and had to work in conditions which were dangerous, mainly because of violent patients. Like towing, the work load was feast or famine. The job often called for creative solutions to apparently impossible challenges.
Much of the time, the Highway Thru Hell workers’ worst enemy was Mother Nature, just as it was in during the catastrophic floods of November 2021. For many psychiatrists and other physicians, it seems like the worst enemy was burnout, especially during the Covid-19 pandemic.
There is no quick fix in either case. We can work together and help each other.
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.
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.