Category: Psychiatry

Random Connections

Today, I read Dr. George Dawson’s blog post, “How I ended up in a high-risk pancreatic cancer risk screening clinic.” As usual I was impressed with his erudition, scientific literacy, and rigorous objectivity, even as it pertained to a deadly disease which runs in his family genetic history. I couldn’t help admiring his courage.

And, whether this is a random connection or not, this somehow led to my remembering Dr. George Winokur, a giant in the scientific study (including genetics) of psychiatric diseases, especially mood disorders. He died of pancreatic cancer shortly after he was diagnosed with it in the spring of 1996.

Dr. Winokur was chair of the University of Iowa Department of Psychiatry from 1971 to 1990. He remained on faculty, actively involved in research and teaching up until the day of his death in October of 1996.

I was a resident in psychiatry at University of Iowa from 1992-1996 and I have a clear recollection of meeting with Dr. Winokur in his office during my last year, when I was preparing for job interviews. I knew he had been diagnosed with pancreatic cancer.

He had been actively recruiting me to accept a position in the department and did so even as we spoke briefly. I remember noticing that he gripped an electrical conduit on the wall next to his desk so tightly that I wondered if he were in pain.

He was the main reason I stayed in Iowa. He had a great sense of humor. All of us residents loved him. There was even a list of his “commandments” all new residents received when they began their residencies at Iowa.

Winokur’s 10 Commandments

  1. Thou shalt not sleep with any UI Psychiatry Hospital patient unless it be thy spouse.
  2. Thou shalt not accept recompense for patient care in this center outside thy salary.
  3. Thou shalt be on time for conferences and meetings.
  4. Thou shalt act toward the staff attending with courtesy.
  5. Thou shalt write progress notes even if no progress has been made.
  6. Thou shalt be prompt and on time with thy letters, admissions and discharge notes.
  7. Thou shalt not moonlight without permission under threat of excommunication.
  8. Data is thy God. No graven images will be accepted in its place.
  9. Thou shalt speak thy mind.
  10. Thou shalt comport thyself with modesty, not omniscience.

I never got the impression that George Winokur recruited me because I was black, although it was pretty obvious to me that I would be the first black University of Iowa psychiatry department faculty member. He had too much class to make that an issue.

I’ve known a few classy psychiatrists. Maybe the connection is not so random.

Catatonia Education Resources

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:

Catatonia Information Center

University College London

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.

Fathers Can Be a Pain in the Ass

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.

You’ll have to watch the movie to get that one.

Thoughts on Regrets

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 Got The Greatest Shout Out Today

I just got the greatest shout out from one of my heroes, Dr. H. Steven Moffic, MD. The link to one of his regular Psychiatric Times web (PT) articles, mainly on what’s in the daily news that impacts psychiatry or vice versa, is on the menu of my home page.

The title of the PT article in which I get a shout out  is “A Tale of 3 Retirements: Football Star Tom Brady, Black Psychiatrist James Amos, and Me.” He got my retirement date wrong by 20 years, but what the heck; no big deal. He did his homework otherwise just fine.

In fact, I didn’t know that Dr. Moffic even noticed that I had a blog. I have written articles for PT in the past. You can still find them by searching my name on the web site. One was on stress and the psychiatrist and another was on how consulting psychiatrists can be helpful in recognizing and managing delirium.

And today, Psychiatric Times (PT) contacted me to make a video about my juggling hobby. I gather it’s a regular series about what psychiatrists do outside of their work/practice. Imagine that; PT wants to see ugly juggling! How did PT know about that? Dr. Moffic mentioned my name.

In return, I’d like to give a big shout out right back to Dr. Moffic and also to other psychiatrists. One is Dr. George Dawson, who writes the blog Real Psychiatry. Another is TheGoodEnough Psychiatrist. These are featured on the main menu on my blog. I can name another who also writes for PT and this is Dr. Ronald Pies.

Iowa State University African American Science Graduates

I was thinking about what to write for the first day of Black History Month, which starts today on February 1, 2023.

As usual, I started to reminisce about my time at Iowa State University (ISU) in Ames, Iowa. I usually don’t talk about my undergraduate days. In fact, I had a little trouble finding my diploma. It was in storage in the first place I should have looked. I graduated from ISU in 1985.

The Iowa State Daily ran a story, “Black scientists from Iowa State,” published on February 4, 2021, obviously in honor of Black History Month. Of course, it featured ISU’s most illustrious graduate, George Washington Carver, who earned his graduate degree in 1894. Carver also loved poetry and painting, which I didn’t know.

This work is in the public domain in the United States because it was published (or registered with the U.S. Copyright Office) before January 1, 1928

Carver was a scientist and put it to practical use. It fits with the ISU motto, which was short and to the point: “Science with Practice.”

I transferred credit to ISU in the mid-1970s from one of the country’s Historically Black Colleges and Universities (HBCUs), Huston-Tillotson College (now Huston-Tillotson University). I submitted a poem to the college’s annual student poetry contest sponsored by one of the English Professors, Dr. Jenny Lind Porter-Scott. My poem didn’t make the cut, but many students got their work published in the little book, Habari Gani (Swahili for “What’s Going On”), which published the best poems.

Part of the reason I went to ISU was the encouragement I got from my bosses at WHKS &Co, consulting engineers. I was a surveyor’s assistant and drafter. I was the only African-American employee working there.

The idea behind going to ISU initially was to pursue a degree in engineering. That didn’t happen because frankly, I didn’t have a head for the mathematics. On the other hand, I got interested in biology, chemistry, and zoology and finally ended up in medical school at The University of Iowa in Iowa City. The rest is history, as they say, which allows the usual cover up of a multitude of sins.

At the time Sena and moved to Ames in the early 1980s, it was a quiet little town, except during VEISHEA, an annual spring celebration on campus. The event got out of hand many times and it was finally banned in 2014.

Back in the days of George Washington Carver, African American students were not allowed to room with other students who did not have black skin on campus. By the time we moved to Ames, the most uncomfortable racial incident I can recall personally was being the butt of a “nigger” joke at a barbershop. I had to find another place to get my hair cut.

I still had a lot of science to digest at ISU after switching my major from engineering to the life sciences. I remember a chemistry professor who looked like the typical hippie who demonstrated how electrons get excited by stacking chairs on top of the counter in front of the chalkboard (which teachers were still using) and climbing to the top and nervously doing a shaky little dance showing what an excited electron he was. I think all of us collectively held our breath, waiting for him to tumble to the floor.

I really had a tough time learning organic chemistry. You had to draw diagrams showing how the molecules and atoms connected after each reaction. I will never forget an Asian Teacher’s Assistant who patiently tutored me, despite my having a very bad cold and a bad attitude to boot.

I graduated and then returned to get more credits to try getting into medical school after finding it very difficult to find employment with my Bachelor of Science degree. It took about 9 months before I finally landed a job in the clinical lab at one of the hospitals in Des Moines. The lab director worked there for a very short time while I was there, and then left to go to medical school.

That was my cue. I think it worked out for the best. By the way, the engraved crystal in the featured image is an appreciation gift from The University of Iowa for my years of service.

And I guess that’s about enough reminiscence for now.

Exercise or Weaponize My Privilege?

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.

MLK, Jr and me

More Thoughts on Physicians Going on Strike

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.

MLK Week Redux for the New University of Iowa Psychiatry Fellows

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.

An Old Post on Breaking Bad News

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

Blog: A Sense of Humor is a Wonderful Thing

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

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

“Does the widder Bagley live here?”

“The widow Bagley? No, Sir!”

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

“Yes, Judge Bagley lives here”.

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

“No, not at present.”

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

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

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

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

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

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

Emotions should be acknowledged with empathic responses.

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

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

It helps to be able to laugh at yourself.

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

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