Back in November 2022, while on our way to the Stanley Museum of Art, we saw the two murals on the East Burlington Street Parking Ramp. It was the first time we saw them in person although photos were available last fall. The Little Village article published an article about them on September 30, 2021. It’s the Oracles of Iowa mural project, conceived by Public Space and the Center for Afrofuturist Studies partnered with the artists, Antoine Williams and Donte K. Hayes. The artists sought to stimulate a conversation in the community about how black and white people relate to each other.
The murals are painted on parking ramp at two locations along East Burlington Street. One says “Black Joy Needs No Permission” and the other says “Weaponize Your Privilege to Save Black Bodies.”
The Little Village article points out that a survey of public perception of the murals revealed that 64 percent of white respondents supported the murals while only 40-50 percent of minority respondents supported them. The stickler for minorities was the use of the word “weaponize” and the phrase “Black bodies,” which were thought to raise impressions of “violence” and dehumanization.
Because I’m a writer, retired psychiatrist, and a writer, the word “weaponize” made me wonder what other word might have been chosen in this context. The only definition of “weaponize” that I can find which makes sense to me is from Merriam-Webster: “to adapt for use as a weapon of war.”
I’m a retired physician, so I have a perspective on the “privilege” to “save” lives, and by extension to enhance health and well-being. I’m also Black. I grew up in Iowa and I can recall getting bullied and being called a “nigger.” I can remember my psychiatry residency days, which includes a memory of a patient saying “I don’t want no nigger doctor.” I didn’t have the option to switch patients with another resident. When I saw the patient on rounds, I did my best and every time the “nigger” word erupted, I left the room. It was one of a few episodes which were marked by frank racist attitudes.
I was given the University of Iowa Graduate Medical Education Excellence in Clinical Coaching Award in 2019, one of several esteemed colleagues to be honored in this way. Many of those who nominated me were white. It was one of many joyful experiences I had before my retirement in 2020, when the pandemic and other upheavals in society occurred, including the murder of Black persons, resulting in many consequences prompting the creation of the murals.
I have other memories. I was privileged to be given a scholarship to attend one of the Historically Black Colleges and Universities (HBCU) in this country, Huston-Tillotson College (now Huston-Tillotson University). It’s one of the oldest schools and is the oldest in Austin, Texas. The scholarship was supported by one of the local churches in my home town of Mason City. I don’t think it had any black members. Although I didn’t take my undergraduate degree from H-TU, it was one of the most valuable learning experiences in my life. It was the first time I was ever not the only Black student in the class. It was marked by both joy and a struggle to learn where I belonged.
The murals did for me what the artists hoped it would do. It stimulated me to reflect on the meaning of racializing life. They stir me to seek perspective on whether joy has any color and why anyone needs permission for it. And I believe I would rather exercise my privilege to respect and care for others than to weaponize anything, including my sense of humor.
I noticed Dr. H. Steven Moffic, MD had written another article in Psychiatric Times asking whether it’s time for psychiatrists to consider going on strike. Often the issue triggering discussions about this is the rising prevalence of physician burnout. I’ve already given my personal opinion about physicians going on strike and the short answer is “no.”
One of my colleagues, Dr. Michael Flaum, MD, recently delivered a Grand Rounds presentation about physician burnout. The title is “Everyone Wins—The Link Between Real Patient-Centered Care and Clinician Well-Being.”
Fortunately, I and other are able to hear the substance of his talk on the forum Rounding@Iowa. During these recorded presentations (for which CME can be obtained), Dr. Gerry Clancy, MD interviews clinicians on topics that are of special interest to medical professionals, but which can be educational for general listeners as well.
I remember meeting Dr. Flaum when I was a medical student. At the time, he was very involved in schizophrenia research. He’s been a very busy clinician ever since. As he says, while he may be Professor Emeritus now, he’s definitely not “retired.” He’s still very active clinically.
Dr. Flaum identifies both systems challenges and physician characteristics as important in the physician burnout issue. Interestingly, he bluntly calls the systems challenges as virtually unchangeable and focuses on bolstering the physician response to the system as the main controllable factor. His main tool is Motivational Interviewing, which is more of an interview style than a separate kind of psychotherapy.
I think the kind of approach that Dr. Flaum recommends, which you can hear about in the Rounding@Iowa presentation, is what most psychiatrists would prefer rather than going on strike. See what you think.
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[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.
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.
Similar to my previous post on the role of civil commitment and catatonia, I’d like to share my thoughts on what little is known about Factitious Disorder and civil commitment.
There is not much to say, in brief. In fact, many writers can find a lot to say about the other interesting clinical features of Factitious Disorder. That includes me. I wrote the chapter on factitious disorder and malingering in the book I and my former University of Iowa psychiatry department chairperson, Robert G. Robinson, co-edited (Amos, 2010).
The gist of the definition of this disorder is that patients lie about medical or psychiatric symptoms to health care providers to adopt the sick role presumably because they crave attention, especially from doctors. It is distinguished from malingering by not defining malingering as a disorder and identifying external incentives as the major reason to fake medical or psychiatric illness, e.g., escaping penalties or obligations such as incarceration or military service, or obtaining entitlements.
In the DSM-5 it was placed in the Somatic Symptom Disorder Category:
Factitious Disorder Imposed on Self
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, assoc. w/identified deception
B. Presenting oneself to others as ill, impaired, injured
C. Deceptive behavior evident even in absence of obvious external rewards
D. Not better accounted for by another mental d/o like delusional d/o or other psychosis
It can be further specified into single or recurrent episodes. There is also another category, Factitious disorder imposed on another (by proxy in DSM-IV).
Regarding civil commitment, obtaining an order can sometimes be difficult when the standard in a jurisdiction is imminent danger to self, or when judges require a treatment plan for a disorder for which there is little evidence of consistently effective treatment— (Eastwood, S. and J.I. Bisson, Management of Factitious Disorders: A Systematic Review. Psychotherapy and Psychosomatics, 2008. 77(4): p. 209-218.)
The legal climate is further complicated by patients with the disorder who have filed malpractice lawsuits against the doctors who failed to recognized their factitious behavior. Patients have been sued for false claims to insurance companies.
A recently published case report (which makes up the majority of papers published about the disorder) mentions the Eastwood and Bisson review (see above), which indicated that 60% of these patients either refused or failed to appear for psychiatric follow-up. Civil commitment is limited to those with imminent suicide risk, clear evidence of danger to others, or inability to provide for basic self-care needs (Sinha A, Smolik T. Striving to Die: Medical, Legal, and Ethical Dilemmas Behind Factitious Disorder. Cureus. 2021 Feb 9;13(2): e13243. doi: 10.7759/cureus.13243. PMID: 33585147; PMCID: PMC7872498.)
Patients with factitious disorder can self-induce illness in ways that result in severe disfigurement or death, often from unnecessary medical interventions. And they have successfully sued physicians who unwittingly caused iatrogenic harm for failing to recognize their disorder—despite denying the true nature of their feigned illnesses in the first place early on. The cost of their excessive health utilization has been estimated to run in the millions of dollars. Their subterfuge can also result in the physician ignoring genuine disease.
General management principles involved include:
Assess severity, potential for imminent life or limb threat
Thoroughly document evidence
Involve hospital administration/attorneys/ethicists early
Psychiatric consultation early
Treat depression, psychosis, addiction
Confrontational v. nonconfrontational approaches
One published case report described obtaining a commitment order based on the patient’s demonstrated dangerousness from self-induced illness (Johnson, 2000). Another case report described “house arrest” as the intervention (Elmore, 2005). Yet another report discussed an interesting non-coercive “Hospital Management” approach which used “paradoxical free access to the hospital with a designated permanent bed on a medical ward for 1 year—which was apparently successful (Schwarz, 1993). The list of successfully treated patients under court order is short and the likelihood of sustained recovery is probably low.
The civil commitment approach is confrontational and there are proponents for a nonconfrontational approach because it’s difficult to get a court order for involuntary psychiatric hospitalization and often, once a patient with Factitious Disorder is admitted to a locked psychiatric ward, the self-induced illness behavior often simply stops. And there are supporters for the development of a “therapeutic discharge” plan in which hospital administration and clinical staff collaborate to conduct a safe discharge:
Consider involving hospital administration and all health care personnel in a therapeutic discharge plan if it can be done safely
Taylor, J. B., S. R. Beach and N. Kontos (2017). “The therapeutic discharge: An approach to dealing with deceptive patients.” Gen Hosp Psychiatry 46: 74-78.
Kontos, N., J. B. Taylor and S. R. Beach (2018). “The therapeutic discharge II: An approach to documentation in the setting of feigned suicidal ideation.” Gen Hosp Psychiatry 51: 30-35.
Beach, S. R., et al. (2017). “Teaching Psychiatric Trainees to “Think Dirty”: Uncovering Hidden Motivations and Deception.” Psychosomatics 58(5): 474-482.
References
Amos, J. (2010). Managing factitious disorder and malingering. In E. b. Robinson, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry (pp. 82-88). New York: Cambridge University Press.
Elmore, J. L. (2005). Munchausen Syndrome: An Endless Search for Self, Managed by House Arrest and Mandated Treatment. Annals of Emergency Medicine, 561-563.
Johnson, B. R. (2000). Suspected Munchausen’s Syndrome and Civil Commitment. J Am Acad Psychiatry Law, 74-76.
Schwarz, K. M., et al (1993). Hospital Management of a Patient With Intractable Factitious Disorder. Psychosomatics, 265.
I got a wonderful holiday greeting from one of my favorite past residents, Paul Thisayakorn, MD. He’s running a top-notch Consultation-Liaison Psychiatry (CL-P) Service and a brand-new C-L Fellowship in Thailand. I could not be more excited for him and his family. His wife, Bow, runs the Palliative Care Service.
He and Bow answered our holiday greeting to them. In it I remarked about my brief episode of mild delirium immediately following my eye surgery for a detached retina and mentioned a nurse administering the CAM-ICU delirium screening test. One of the questions was “Will a stone float on water?” I answered it correctly, but joked in the greeting message that I said “Yes, but only if it really believes.”
His remark was priceless: “We actually did a CAM-ICU in the morning when I received this email from you. I told my fellow and residents about you and what you taught me how to be a practical psychosomaticist. They also learned about how stone floats on the water.”
Paul made an awesome contribution to the Academy of C-L Psychiatry knowledge base during the height of the Covid-19 Pandemic. Things were tough there for a long time. Paul tells me they are still practicing some elements of the Covid protocol. Thailand is gradually opening back up.
This is the second year for his C-L Psychiatry fellowship program at the Chulalongkorn Psychiatry Department. They graduated their first C-L fellow and there are now two other fellows in training.
Under Paul’s strong leadership, they’ve gathered a group of interested Thai psychiatrists and founded the Society of Thai Consultation-Liaison Psychiatry just this past October.
And he was given an assistant professor position at the university. Paul and his team are in the featured image at the top of this post. Paul’s the guy wearing glasses in the middle.
He’s not all work and no play, which is a wonderful thing. He jogs and meditates and he has the most beautiful family, two great kids growing fast and a wife who is both a devoted partner and the leader of the Palliative Care service.
As a teacher, I couldn’t ask for a better legacy. I still have the necktie with white elephants that he gave me as a gift. In Thai culture, the white elephant is a symbol of good fortune (among other things), which is what Paul was wishing for me. Of course, the feeling is mutual.
I wish Paul well in the coming new year. And to all those who read my blog, have a happy new year.
Recently, University of Iowa psychiatry residents worked hard enough to get shout outs. One of them was exemplary performance on the consultation and emergency room service. The service was following over two dozen inpatients and received 15 consultation requests in a day. This is a staggering number and the resident on the service did the job without complaints. In addition, the resident was the only trainee on the service at the time. Other residents were working very hard as well.
This high level of performance is outstanding and raises questions about health care system level approaches to supporting it.
I read the abstract of a recently published study about Mindfulness Based Stress Reduction (MBSR) compared to medication in treating anxiety in adults (Hoge EA, Bui E, Mete M, Dutton MA, Baker AW, Simon NM. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry. Published online November 09, 2022. doi:10.1001/jamapsychiatry.2022.3679).
On the day I read the abstract, I saw comments which were cringeworthy. The commenter is an outpatient psychiatrist in private practice who had some criticisms of the study. He thought the report of results at 8 weeks was inadequate because symptoms can recur soon after resolution.
Another problem he mentioned is worth quoting, “A course of treatment that requires as much time as the MBSR course described in the study would be out of the question for most of my patients, most of whom are overworked health care professionals who don’t have enough time to eat or sleep. Telling people who are that overworked they should spend 45 minutes a day meditating is the “Let them eat cake” of psychotherapy.”
That reminded me of a quote:
“You should sit in meditation for twenty minutes every day—unless you’re too busy; then you should sit for an hour.”
Zen Proverb
I know, I know; I should talk—I’m retired. Actually, I took part in an MBSR course about 8 years ago when I noticed that burnout was probably influencing my job performance on the psychiatry consultation service. I thought it was helpful and I still practice it. I was lucky enough to participate in the course after work hours. The hospital supported the course.
The residents who are being recognized for their hard work on extremely busy clinical services may or may not be at high risk for burnout. They are no doubt extra resilient and dedicated.
And the University of Iowa health care system may also be offering a high level of system support for them. I don’t see that University of Iowa Health Care is on the list of the American Medical Association (AMA) Joy in MedicineTM Health System Recognition System, but that doesn’t mean they aren’t doing the kinds of things which would merit formal recognition.
Go Retire Psychiatrist 