Category: History

The Intergalactic Angle on Your Point of View

I finally watched the movie “The Hitchhiker’s Guide to the Galaxy” the other night. It was released in 2005 and based on Douglas Adams’ book of the same title. In fact, he co-wrote the screenplay. A lot of it was not in the book. I thought a couple of scenes were noteworthy and pretty funny. I made connections to Dr. Martin Luther King, Jr. annual observance, which is this month.

One of them was the Point of View Gun. It’s probably unfortunate that the main prop was a gun, but hey, it was a ray gun. It didn’t kill anyone and in fact, it caused the person “shot” with it to be able to understand the perspective of another person. It was just temporary, but for a short while it enabled persons or extraterrestrials to understand another’s point of view. It was designed by the Intergalactic Consortium of Angry Housewives to influence their husbands to understand them better.

One of Dr. Martin Luther King’s main points was how important it is to try to understand and validate someone else’s point of view.

One drawback of the Point of View gun (besides the obvious associations with gun violence) was that the effect was specific to whoever was using it. So, when the ultra-maladjusted robot Marvin mowed down a gang of Vogons (hideous and cruel extraterrestrial bureaucrats who destroyed Earth in order to make room for an intergalactic bypass), they all collapsed from depression.

The other scene I thought was funny was the Vogon planet’s slap-happy encounter between the heroes and the creatures shaped like spatulas that popped out of the ground and smacked anyone in the face who had an idea.

I didn’t think the movie was nearly as good as Adams’ book. But I wonder if you could cross the spatula creatures with the Point of View gun that would take the perspective-taking power of the gun and give it to the spatula creatures who would slap you silly whenever you failed to even try to understand another’s point of view. I could use that kind of a slap sometimes.

It’s remarkable the connections you could make between Dr. Martin Luther King, Jr and The Hitchhiker’s Guide to the Galaxy.

Thoughts on “An Occurrence at Owl Creek Bridge”

Sena and I got to talking about a Twilight Zone show we saw over the holidays. It was a 1964 episode, not the regular program but short film that won a Cannes Film Festival award in the early 1960s, “An Occurrence at Owl Creek Bridge.”

The quick summary is that a Southern plantation owner is being hanged by Union soldiers for trying to set fire to the bridge to prevent the Union Army from attacking Confederate troops. The plantation owner seems to miraculously escape the noose, evades bullets and cannon fire, running all the way back to his plantation in an escape which lasts hours, finally almost rushing into his wife’s arms—but he can’t because at that moment his neck is snapped by the hangman’s rope. All of the action during his escape is a hallucination which happens in the blink of an eye.

It’s based on a short story of the same title by Ambrose Bierce. I vaguely recalled reading it years ago, possibly in a science fiction/fantasy anthology. At that time, I didn’t know the author’s background, which was that he’d been a Union soldier in the Civil War. He fought in a lot of battles and witnessed horrific injuries and death. He disappeared without a trace, and there is no explanation why or how.

As Sena and I talked about it, she wondered more about the details of the Civil War as context, while I thought the main point was about the time compression of a miraculous escape from execution that spoke of the nature and meaning of life and death.

When I searched the web to find out more about the story and the life of Ambrose Bierce, I saw her point.

I read the original story on the Internet Archive. It’s very short. Now, I’m not sure I ever really read it. I’m just a blogger and unworthy to really talk about it other than to acknowledge that it’s a work of genius. How the author’s spare and yet meticulous attention to every terrifying detail of war can be so ugly and yet so mesmerizing is beyond my understanding.

A Look Back at Intravenous Haloperidol for Delirium

I found one of my old blog posts about using intravenous infusions of haloperidol for delirium in the intensive care unit. The bottom line is it that it probably should not be used, in my opinion. This is sort of a follow up on my Christmas Eve blog post in which I mention talking to ICU personnel about using IV haldol for delirium. I’ve edited out a portion of the old post.

Notes on Pharmacology for the Treatment and Prevention of Delirium: IV Haldol Infusions

“I ran across the Canadian Coalition for Seniors’ Mental Health guidelines for the management of delirium in elder adults. You can access them for free at the at this link, CCSMH – Canadian Coalition for Seniors’ Mental Health. I was a bit surprised to read the following recommendation:

“For those who require multiple bolus doses of antipsychotic medications, continuous intravenous infusion of antipsychotic medication may be useful.“

Note: I read this in 2011. I’ve rechecked the website of CCSMH, which shows the same recommendation when I reviewed it on December 27, 2023.

The recipe for continuous infusion of haloperidol was in a paper by Riker and I thought it was of historical interest[1]. Essentially, if the delirious patient had not responded to 8 consecutive 10mg bolus injections of haloperidol, you asked the intensivists to start a haloperidol drip at 10mg an hour. It usually didn’t work and despite the puzzling tendency for experts to claim that extrapyramidal side effects (EPSE) such as dystonias, parkinsionism, and akathisia occur at a lower rate when haloperidol is infused intravenously, the dissenting opinion from experienced psychiatric consultants including me is—if you do this enough times you’ll see EPSE. I’ve witnessed everything from trismus to opisthotonos, on one occasion all in one patient as I stood there and watched him over minutes while the intravenous (IV) haloperidol was infusing.

The idea that IV haloperidol infusions seems to stem in part from a 1987 paper by Menza[2]. There were only 10 patients total in that study.

My comments: I remember a presentation at an Academy of Consultation-Liaison (ACLP) meeting many years ago reporting that EPS (extrapyramidal side effects such as dystonia) had been reported to occur after IV administration in 67% of normal humans given a single dose, in 16-74% of adults with medical illness including burns, migraine, and Human Immunodeficiency Syndrome, and in 37% of psychiatric inpatients. EPS occured after IV administration of other dopamine blockers including the anti-nausea agent Reglan and there were at least 6 case reports of Neuroleptic Malignant Syndrome (the “ultimate EPS”) following IV administration of haloperidol.

The presenter reporter that no EPS occurred in several cases of reported very high dose IV Haloperidol, e.g., 945mg/ in 24 hours; and 1155mg in one day (from his own case report in 1995). It may have had something to do with delirium itself being a highly anticholinergic state.

There have been improvements in the management of delirium in the ICU since then. The best example I can give would be what Dr. Wesley Ely, MD has been doing for years at Vanderbilt.

1.            Riker, R.R., G.L. Fraser, and P.M. Cox, Continuous infusion of haloperidol controls agitation in critically ill patients. Crit Care Med, 1994. 22(3): p. 433-40.

2.            Menza, M.A., et al., Decreased extrapyramidal symptoms with intravenous haloperidol. J Clin Psychiatry, 1987. 48(7): p. 278-80.

Testament to Testiness on Liaison Psychiatry

The other day, I got an email message from the Academy of Consultation-Liaison Psychiatry (ACLP). It was from the Med-Psych Special Interest Group (SIG). It was an intriguing question about a paper somebody was looking for and having trouble getting it through the usual channels.

The paper was “The Liaison Psychiatrist as Busybody” by somebody named G.B. Murray and published in the Annals of Clinical Psychiatry in 1989. The person looking for the paper mentioned that there was a note from the editor that the paper was of a “controversial nature.”

I was immediately intrigued after doing a search of my own and finding out that the full note from the editor was as follows:

“Editor’s Note: We are aware of the controversial nature of this communication and invite responses from psychiatrists in practice as well in academic settings.”

Nothing is as exciting as holding something out to us and at the same time hiding it from us. Why was it unavailable through the usual channels? Nowadays “usual channels” means accessing the digital copy over the internet from the journal.

Anyway, soon enough somebody found a copy of what turned out to be Dr. George B. Murray’s presentation of the paper with the title “The Liaison Psychiatrist as Busybody” at the American Psychiatric Association (APA) meeting in 1983 in New York. It looked like it was copied from the Annals of Clinical Psychiatry journal where it was published in 1989.

The paper was one of four APA presentations (p. 76) in a symposium entitled “The Myth of Liaison Psychiatry.” The titles and presenters including Murray’s:

  1. Teaching Liaison Psychiatry as Medicine at Massachusetts General Hospital—Ned Cassem MD, Boston, MA
  2. The Liaison Psychiatrist as Busybody—George Murray MD, Boston, MA
  3. Liaison Psychiatry to the Internist—John Fetting, MD, Baltimore, MD
  4. The Hazards of “Liaison Psychiatry”—Michael G. Wise, MD, Baltimore, MD

Before I get to the paper itself, I should mention that it was my wife, Sena, who gets the credit for actually finding out that “G.B. Murray” was George B. Murray, a distinguished consultation psychiatrist at Massachusetts General Hospital.

I purposely omitted the word “liaison” from “consultation psychiatry” because he was said to have “loathed the word ‘liaison’.” This was according to the blogger (Fr Jack SJ MD) who posted an in-memoriam piece on his blog in 2013 shortly after Father George Bradshaw Murray died. He had been a Jesuit priest as well as a psychiatrist. Fr Jack SJ MD also noted that Murray ran the consult fellowship at Mass General, saying:

“George’s fellowship was unique.  He founded it in 1978 and directed it full-time until a few years ago.  By the time he retired he had trained 102 fellows mostly on his own.  His didactic methods would be frowned upon by politically-correct, mealy-mouthed, liberals of academe (bold face type by J. Amos).  His fellows thrived.  George turned us, in the words of Former Fellow Beatriz Currier, MD, “into the kind of psychiatrist I wanted to be but didn’t know how to become.”  We worked hard.  Many consults per day.  Vast amounts of reading for which he expected us to be prepared.  But he worked even harder for us.”

So, right about now, to quote one of my favorite Men in Black movies character, Agent J: “That grumpy guy’s story’s starting to come into focus a little bit here.”

I’m not going to dump big quotes from Murray’s presentation, but I can say that it’s understandable to me now why it has been described as controversial. He just sounds a little testy.

Getting back to the New York symposium, I noticed that the chairperson was Thomas P. Hackett, and the co-chair was Ned Cassem, both of Mass General, the latter also a Jesuit priest. I never met either of them, but they are legends. Hackett died in 1988 and Cassem died in 2015.

I’ve read what Hackett wrote about the difference between psychiatric consultation and psychiatric liaison:

“A distinction must be made between a consultation service and a consultation liaison service.  A consultation service is a rescue squad.  It responds to requests from other services for help with the diagnosis, treatment, or disposition of perplexing patients.  At worst, consultation work is nothing more than a brief foray into the territory of another service, usually ending with a note written in the chart outlining a plan of action.  The actual intervention is left to the consultee.  Like a volunteer firefighter, a consultant puts out the blaze and then returns home.  Like a volunteer fire brigade, a consultation service seldom has the time or manpower to set up fire prevention programs or to educate the citizenry about fireproofing.  A consultation service is the most common type of psychiatric-medical interface found in departments of psychiatry around the United States today.

A liaison service requires manpower, money, and motivation.  Sufficient personnel are necessary to allow the psychiatric consultant time to perform services other than simply interviewing troublesome patients in the area assigned.  He must be able to attend rounds, discuss patients individually with house officers, and hold teaching sessions for nurses. Liaison work is further distinguished from consultation activity in that patients are seen at the discretion of the psychiatric consultant as well as the referring physician.  Because the consultant attends social service rounds with the house officers, he is able to spot potential psychiatric problems.”—T. P. Hackett, MD.

Here’s the thing. This quote comes from Hackett’s chapter in the 1978 edition of the Massachusetts General Handbook of General Hospital Psychiatry. But I tended to gloss over what he wrote right below it:

“Once organized, a liaison service tends to expand. Most liaison services are appreciated and their contribution is recognized. Sometimes this brings tangible benefits such as space and salary from the departments being serviced. However, even under the best circumstances, the impact of a liaison effort seldom lingers after the effort is withdrawn. Lessons taught by the psychiatrist need constant reinforcement or they are forgotten by our medical colleagues. In a way, this is an advantage since it ensures a continuing need for our presence. Conversely, it disappoints the more pedagogical, because their students, while interested, fail to learn. I believe we must be philosophical. After all, our surgical colleagues do not insist that we learn to do laparotomies. They insist only that we be aware of the indications.”—T.P. Hackett, MD.

You get a clear sense of Hackett’s sense of humor as well as a practical appreciation of what can and maybe cannot be done when you try to apply liaison principles in a formal teaching approach.

So, what does Murray say about liaison psychiatry that seemed cloaked behind the term “controversial”? He starts off by admitting that his remarks will be “inflammatory” and makes no apology for it. He starts with three main statements:

  1. What all nonpsychiatric physicians appreciate, and what, in fact, works, is the medical model of consultation psychiatry.
  2. Liaison psychiatry is more myth than reality.
  3. The liaison psychiatrist is to a great extent a relatively high-status busybody.

It’s difficult to pick out excerpts from Murray’s presentation—so much of it is integral to the main message and entertaining as well that I hate to omit it. Here’s my pick anyway:

“There is a certain Olympian quality surrounding liaison psychiatrists. It is as if they will teach others the wonders of the labyrinthine biopsychosocial factors involved in patient care. The other Olympian feature centers on the so-called consultee-oriented consultation. In hearing discussions and reading the literature one can get a downwind whiff of antiphysician feeling. There are remarks made, for example, of the insensitivity of surgeons, of patient “harassment” and how little the attending physician understands this hysteric’s or sociopath’s inner dynamics. This attitude is snobbish, unhelpful, and in semistreet parlance, “chickendip.” It does not seem to bother liaison psychiatrists that there are no liaison cardiologists, liaison endocrinologists, and so forth—another clue to the vacuity of liaison psychiatry.”

He is testy and with good reason, if you define liaison in this way. His paper is uproarious. And there are lots of controversies in medicine. I’m still not sure why this one seemed hidden from public view.

I opened up the door by saying “…if you define liaison in this way.” There are other ways to convey useful information to “consultees.” For example, I had better luck talking in a casual way about what I could for a MICU medicine resident about how to help manage a very agitated delirious patient on a ventilator who was in restraints because of the fear of self-extubation (a common problem psychiatric consultants get called about).

We were sitting in the unit conference room and the unit pharmacist was present. I don’t remember if the attending was there. I started to describe what had been studied in the past, which was continuous intravenous infusions of haloperidol lactate (there are several studies which do not support the use of haloperidol for treating delirium). There was no way to administer oral sedatives. In fact, the patient was being given heavy doses of intravenous benzodiazepines and opioids.

I notice that the more details I shared about the intravenous haloperidol, the wider the pharmacist’s eyes got. Long story short, the MICU resident decided to try something other than psychiatric medication. Indirectly, you could say I was using a motivational interviewing technique to teach. But Murray would have described that as Olympian and in any case, I didn’t consciously do that. All I had were facts and I told the resident what they were. A matter-of-fact approach and tact can be part of a liaison approach, but that’s not what Murray was concerned about and probably not what he saw from most liaison psychiatrists.

And I had to work hard not to display testiness (much less loftiness), which I’m afraid I didn’t always do.

An Old Blog Post About My College Days in Texas

There’s something embarrassing yet fascinating about reading my old blog posts from years ago. The one I read yesterday is titled simply “I Remember HT Heroes.” I make connections between my undergraduate college days at Huston-Tillotson College (now Huston-Tillotson University (an HBCU in Austin, Texas) and my early career as a consultation psychiatrist at The University of Iowa Hospitals & Clinics (now rebranded to Iowa Health Care).

My first remark about getting mail from AARP reminds me that organization is sponsoring the Rolling Stones current tour, Hackney Diamonds. And the name of my specialty was changed from Psychosomatic Medicine to Consultation-Liaison Psychiatry in 2017.

The photo of me attached to the original post reminds me of how I’ve gotten older—which also makes me hope that I’ve gotten wiser than how I sound in this essay. The pin in my lapel is the Leonard Tow Humanism in Medicine award I received in 2006.

I Remember HT Heroes

Getting membership solicitations in the mail from the American Association of Retired Persons (AARP) is a sure sign of aging, along with a growing tendency to reminisce. Reminiscence, especially about the seventies, may be a sign of encroaching senility.


Why would I reminisce about the seventies? Because I’m a baby boomer and because my ongoing efforts to educate my colleagues in surgery and internal medicine about Psychosomatic Medicine, (especially about how to anticipate and prevent delirium) makes me think about coming-of-age type experiences at Huston-Tillotson College (Huston Tillotson University since 2005) in Austin, Texas. Alas, I never took a degree there, choosing to transfer credit to Iowa State University toward my Bachelor’s, later earning my medical degree at The University of Iowa.


Alright, so I didn’t come of age at HT but I can see that a few of my most enduring habits of thought and my goals spring from those two years at this small, mostly African-American enrollment college on what used to be called Bluebonnet Hill. I learned about tenacity to principle and practice from a visiting professor in Sociology (from the University of Texas, I think) who paced back and forth across the Agard-Lovinggood auditorium stage in a lemon-yellow leisure suit as he ranted about the importance of bringing about change. He was a scholar yet decried the pursuit of the mere trappings of scholarship, exhorting us to work directly for change where it was needed most. He didn’t assign term papers, but sent me and another freshman to the Austin Police Department. The goal evidently was to make them nervous by our requests for the uniform police report, which our professor suspected might reveal a tendency to arrest blacks more frequently than whites (and yes, we called ourselves “black” then). He wasn’t satisfied with merely studying society’s institutions; he worked to change them for the better. Although I was probably just as nervous as the cops were, the lesson about the importance of applying principles of change directly to society eventually stuck. I remember it every time I encounter push-back from change-resistant hospital administrations.


I’m what they call a clinical track faculty member, which emphasizes my main role as a clinician-educator rather than a tenure track researcher. I chose that route not because I don’t value research. Ask anyone in my department about my enthusiasm for using evidence-based approaches in the practice of psychiatry. I have a passion for both science and humanistic approaches, which again I owe to HT, the former to Dr. James Means and the latter to Dr. Jenny Lind Porter. Dr. Means struggled to teach us mathematics, the language of science. He was a dyspeptic man, who once observed that he treated us better than we treated ourselves. Dr. Porter taught English Literature and writing. She also tried to teach me about Rosicrucian philosophy. I was too young and thick-headed. But it prepared the way for me to accept the importance of spirituality, when Marcia A. Murphy introduced me to her book, “Voices in the Rain: Meaning in Psychosis”, a harrowing account of her own struggle with schizophrenia and the meaning that her religious faith finally brought to it.


Passion was what Dr. Lamar Kirven (or Major Kirven because he was in the military) also modeled. He taught black history and he was excited about it. When he scrawled something on the blackboard, you couldn’t read it but you knew what he meant. And there was Dr. Hector Grant, chaplain and professor of religious studies, and champion of his native Jamaica then and now. He once said to me, “Not everyone can be a Baptist preacher”. My department chair’s echo is something about how I’ll never be a scientist. He’s right. I’m no longer the head of the Psychosomatic Medicine Division…but I am its heart.


I didn’t know it back in the seventies, but my teachers at HT would be my heroes. We need heroes like that in our medical schools, guiding the next generation of doctors. Hey, I’m doing the best I can, Dr. Porter.

Another Look at an Old Blog Post on Psychiatric Case Formulation

I just had a look at a blog post on case formulation I wrote about 12 years ago. Aside from sounding a little pompous, I decided to check on the title I gave it back then: “What Kind of Disease Does the Person Have And What Kind of Person Has the Disease?”

I looked at the web site that researches who said what as far as quotes go. It’s Quote Investigator and their conclusion is that the above quote should be attributed to Henry George Plimmer, a lecturer on Pathology and Bacteriology at St. Mary’s Hospital Medical School. He said:

“You will have to acquire, too, for any success to be given you, an accurate knowledge of human nature, and you will find that it is quite as important for the doctor to know what kind of patient the disease has for host, as to know what sort of disease the patient has for guest.”

Anyway, the post is below; the cases are all fictional:

I recently had the pleasure of evaluating one of our junior residents using the new clinical skills exam format. These evaluations are taking the place of the oral board examinations for certification in Psychiatry. The oral board exams have been the bane of examinees for many years in part because of the extreme anxiety they provoke. Preparing a resident in psychiatry involves a rigorous educational program over 4 to 6 years and they must master a vast amount of content knowledge just to become certified as safe and competent practitioners as defined by regulatory organizations. Elements of the clinical skill exam include interviewing skills, a mental status exam, case presentation, and case formulation.

Case formulation is the most demanding element. There are many references trainees can Google on line to find. A classic paper often cited is the one by Perry and others[1]. It helps doctors and patients by balancing the focus on both what kind of disease the person has, and what kind of person has the disease. Case formulation is an essential skill which takes years of practice to master and I’m inclined to give a lot of latitude to trainees in their ability to demonstrate it, especially in the first year of residency. Formulations can be used by psychiatrists in every subspecialty, including Psychosomatic Medicine, as the fictionalized examples will demonstrate.

Making useful case formulations can be frustrating for both trainees and experienced clinicians. On the other hand, if it’s not, there’s a good chance that oversimplification is becoming a problem. One pitfall that ironically comes with experience is dashing off a formulation that sounds deep using “psychobabble” but which misses the mark in describing the patient’s problems in the real world. Striking a balance between over inclusiveness and superficiality takes practice. Often, tying the formulation to only one model seems constrictive.

In general, making an integrative synthesis of the relevant factors in a patient’s clinical situation (abstracted from the history) is easier than making an integrative inference about why her problem exists. It helps to look for clues in the form of repetitive themes in a patient’s life which lead to conflicts that are resolved in maladaptive ways. There is no standardized format, and so there may seem to be as many formulation strategies as there are clinicians. Starting with a manageable framework can help. The phrases in bold type are the connectors that guide thinking and writing about the patient and help keep the focus on central issues:

This is a  age, employment status, illness state (acutely v. chronically ill), marital status, male/female, with  psychiatric symptoms list, duration of,  complicated by,  head injury, substance abuse, medical syndromes, that we were asked to evaluate because of  consult requestor question.  She meets criteria for Diagnostic and Statistical Manual-IV-TR diagnosis.

Her psychiatric symptoms can be associated with or precipitated by medical diagnoses. They are also known to have familial pattern, affected/exacerbated by drugs, environmental triggers.

The current behavior may have been determined by a developmental background marked by abuse, neglect, conflict in family of origin, maintained longitudinally by pattern of maladaptive management of relationships and situational stressors.  Although cross-sectional exam cannot typically confirm one central conflict, she may have difficulties with independence v. dependence, intimacy v. isolation, generativity v. stagnation.

Typical defenses may include acting out, denial, reaction formation, etc., which appears to be interfering with medical management, not an issue on the ward, and may be predictive of chronic noncompliance with therapy, conflict with caregivers, eventual return to adaptive coping, etc.

Although the scaffold looks unwieldy and long, in practice (and with practice) it can be tailored to fit the clinical need. Certain neuropsychiatric problems seen by consultants don’t require any detailed analysis of defenses, e.g., uncomplicated drug-induced deliria in patients without any psychiatric histories. But just because someone does have a complicated psychiatric history doesn’t imply that the formulation must be long and detailed. The goal is always to succinctly summarize the central issues that describe and explain the patient’s current problems so as to guide recommendations for management.

Example case formulations:

  • 44-year-old multiply divorced, alcoholic, unemployed white male without formal psychiatric history, but with acute subsyndromal depressive symptoms without suicidality in the context of recent diagnosis of diabetes mellitus after being hospitalized with diabetic ketoacidosis. His father (who also had diabetes) died of suicide when the patient was 9 years old. Consult triggered by patient refusing to get up to toilet himself, crying, insulting the nurses, yet constantly on his call light. Depression is known to be associated with Diabetes Mellitus and can run in families. He may be conflicted between dependence and independence or struggling with stagnation developmentally, given his social and occupational marginalization. Regression appears to be major defense. Tolerance of nonthreatening behavior and allowing him control over non-essential features of his care may facilitate face-saving return to more adaptive coping with grief. Monitor for development of a more well-defined depressive syndrome; supportive approach with encouragement of affect but engage effective coping by modeling; query into past successful problem solving.
  • 37-year-old divorced white female teacher aide with abrupt onset of medically unexplained slow, garbled speech. Previous psychiatric history notable for one brief hospitalization in her mid-teens after impulsive overdose over a breakup with boyfriend. Temporal association of dysarthria with her discovering her current boyfriend in bed with her teenage daughter (reported by a friend). Her presentation is consistent with conversion reaction. Major conflict is desire to confront boyfriend but fear of rejection and abandonment. Major defense is somatization. Confrontation generally contraindicated; suggest that recovery will be fairly rapid; no invasive procedures or specialist referrals needed and the condition is not dangerous. Quick follow-up in mental health clinic scheduled.
  • 57-year-old disabled man who had a liver transplant and who has polysubstance dependence in remission and longstanding antisocial behavior referred for subsyndromal depression and anxiety along with insomnia. Recently arrested for shoplifting. Also engaging in reckless driving and fistfights, neither of which he’s done in decades either. No organic brain disease identified that could explain the behavior. Possibly struggling with generativity v. stagnation because of chronic unemployment leading to regressive acting out. Refer to psychotherapy, although resistance expected with more acting out and non-adherence.
  • 49-year-old woman with Hepatitis C (HCV) on interferon (IFN) for last 3 months and with gradually increasing symptoms of syndromal depression, personality change with marked irritability, and somatic complaints. Previously diagnosed recurrent depression in the context of Cluster B personality traits complicated by alcoholism and cocaine abuse, now in sustained full remission. Consult triggered by her erupting in the GI clinic at the gastroenterologist’s suggestion that cutting interferon dose might be recommended in light of her psychiatric status. She thinks that this means she’ll get cirrhosis, be denied liver transplant because of her drug history, and be condemned to die of liver failure. She blames doctors for missing the HCV diagnosis for years, yet feels stigmatized by everyone because of the diagnosis, and at the mercy of doctors who control the only effective treatment. Several cognitive distortions could be the issues in her depression including personalization, catastrophizing, control fallacies and blaming. Interferon is also known to be associated with depression and cognitive impairment. Cognitive Behavioral Therapy (CBT) intervention may be influenced by the latter side effect; antidepressants are an effective drug treatment of IFN-induced depression.

1.       Perry, S., A.M. Cooper, and R. Michels, The Psychodynamic Formulation: Its Purpose, Structure, and Clinical Application. Focus, 2006. 4(2): p. 297-305.

Gratitude to Pastor Robert Stone

I came across a couple of items that prompted my renewed gratitude. One of them was an article in Bloomberg on the web, “US Medical Schools Grapple With First Admissions Since End of Affirmative Action” by Richard Abbey, Ilena Peng, and Marie Patino, published on December 14, 2023. It’s about how hard it is for black students to get into and graduate from medical school. Just getting to college is a major hurdle.

The other item is an obituary of one of the most important persons in my life, Pastor Robert Leroy Stone. He authorized scholarships for two years of my undergraduate college education, which were at Huston-Tillotson College (now Huston-Tillotson University, one of the HBCUs) in Austin, Texas. That was back in the 1970s, ancient history now. The issue of Affirmative Action was widely discussed during that time.

As usual, I’m dumbfounded by how often I miss the passing of the critically important people who made my success in life possible. And there is this astonishing connection which followed me even to Iowa City—but of which I was unaware. After he retired, Pastor Stone moved from Mason City to Iowa City in November of 2001. At that time, I had graduated from The University of Iowa College of Medicine, finished my residency in psychiatry in 1996, and was on staff in University of Iowa Dept of Psychiatry. I never knew he was so close. He died in 2002.

Pastor Stone was a Board Member and Chair of the Mason City YMCA, where I lived for a while. He was also a Member of the Board of Chemical Dependency Services of North Iowa as well as the Mental Health Center of North Iowa.

Although I didn’t graduate from Huston-Tillotson College, I was able to transfer credit to Iowa State University. And from there I went to medical school at The University of Iowa.

I’ve read other stories about how hard it is for Black students to get into and finish medical school. My path was indirect and not easy, but Pastor Stone made it possible. And for that, I am grateful.

Kindness Is Still Out There

The other day, Sena and I were talking about growing up in Mason City, Iowa. As kids, both of us were the ones who lugged the groceries home. That was back in the days of paper sacks and, for me and her, food stamps. The food stamp program got started during the Great Depression. The goal was to keep people from starving and farmers from going under. In other words, it was kindness.

Food stamps were a sign of hard times and I don’t think that has changed much, except now I think you get a debit card instead of stamps.

I did grocery shopping at Fareway Store, which got its start in Boone, Iowa. Sena did hers at Grupps Food Center.

When it comes to shopping, I followed what my mother put on a list. I got the items and paid with food stamps. I can’t remember ever coming up short. I think I just gave them the cashier the stamps and they took what was needed to cover the price. I walked to Fareway and then I just walked home carrying two or three paper sacks of groceries. It was about a mile trip up and a mile back. My arms were pretty sore when I got home.

On the other hand, Sena came up short on stamps one day. It was embarrassing enough to have to pay using food stamps. But it was awkward as hell when you didn’t have enough to pay. At that time, the cashier was a guy named Bud Grupp. Bud was Carl Grupp’s son. Carl bought the store in the early 1960s.

Bud counted out the stamps and had to tell Sena that there wasn’t enough. She didn’t know what to say. People were lined up behind her and they could probably tell something was wrong. Bud just said “We’ll put you on credit,” and that was that. He sacked all of the groceries like there was nothing out of the ordinary. Sena didn’t know what was done about the balance on credit, whether it was ever settled or it became just a running bill that never got paid off.

Sena also had to walk home carrying bags of groceries. One winter day during a light snowfall, she dropped all of the bags in the snow. They got wet and all torn up. A woman saw it, came out of her house with some bags and helped Sena get the groceries sacked up again. She got home alright.

About a year ago, Sena was in line waiting to check out groceries. An elderly woman was ahead of her and came up short on money to pay for her few items. She fished in her purse and looked embarrassed and pathetic. Sena was thinking about paying for them herself but just before she could, a guy behind her handed the cashier his credit card and told her he would cover it.

Regardless of what you see in the news, kindness is still out there. Our Christmas cactus is already blooming.