Category: reflections

Stop Me If You Heard This One Before

I saw one of my favorite X-Files episodes the other night. It’s titled “Monday.” Mulder goes through the day repetitively doing the same things, including fumbling his chance to thwart a bank robber who blows up the bank and everyone in it, including Mulder. See the Wikipedia for a full spoiler alert but I’m going to spill the beans here anyway.

A lot of people think the idea was stolen from the movie “Groundhog Day,” which I’ve never seen. Actually, it was stolen from a Twilight Zone episode called “Shadow Play,” which I have seen.

“Monday” got good reviews overall, which is saying a lot. I never got the part about how a bank robber (Bernard) who can only land a job mopping floors would be smart enough to build a bomb jacket.

That said, the scenes are mostly everybody going through the day doing the same things over and over. Mulder and Scully both meet Bernard and his girlfriend Pam, who was always waiting outside in the getaway car and is the only one who remembers what has happened each and every time, which is about 50. Pam thinks Mulder is the key to disrupting the endless cycle. She has been trying to get Mulder to change what he does every time he walks in the bank just to cash a check and interrupts Bernard in the process of robbing the bank.

Mulder never gets it right away, but does wonder aloud that he’s getting a sense of déjà vu. Déjà vu is the sense that an experience is something you had before but could not have. The medial temporal cortex triggers the false memory and, normally, the frontal lobe says, “No, this is not a memory.”

Eventually, Mulder gets the idea of repeating to himself over and over that Bernard has a bomb and changes his approach by giving his gun to Bernard and telling him he knows he has a bomb. This approach is based on the assumption Bernard will walk out without setting off the bomb because Mulder will let him go without trying to arrest him.

Then, Scully brings Pam into the bank, and Bernard almost surrenders to Mulder, until he hears police sirens—and tries to shoot Mulder but instead kills Pam because she steps into the path of the bullet. He gives up and doesn’t set off the bomb. Pam changed the ending and notices just before she dies that it never happened in any of the previous enactments.

There’s the brain-based definition of déjà vu and then there’s a more mundane definition, both of which are in the Merriam-Webster dictionary on the web. The mundane definition is “something overly or unpleasantly familiar,” mainly about situations that happen repeatedly (“here we go again”).

We all recognize the second definition. We sometimes say or do something which we would not if we just recognized that it’ll trigger a pattern of events we would like to avoid. Something has to change in order to interrupt the pattern.

Psychiatrists and psychotherapists are usually experts in helping people change repetitive, maladaptive patterns of thought and behavior.

Medications can be helpful, for example in the repetitious thoughts and behaviors of obsessive-compulsive disorder (OCD). Some cases of that may respond better to a combination of psychotherapy and medication.

One of the challenges is that there are not enough helpers to help those who need it. Another challenge is that the ones who need help often don’t recognize they need it. That’s called lack of insight.

The cycle of lack of insight and unpleasantly familiar, repetitive patterns sometimes resulting in explosive consequences is ubiquitous in our society.

Can somebody please bring Pam into the consulting room?

This is National Suicide Prevention Week

Thanks to Dr. H. Steven Moffic for his Psychiatric Times article, “A Psychological Autopsy on My Only Patient Who Died by Suicide.” In it he describes his own experience with a patient who committed suicide. He also reminded us that this is National Suicide Prevention Week. It’s also National Suicide Prevention Month.

The quote I’m familiar with about psychiatrists and patients who die by suicide Moffit is by forensic psychiatrist, Robert Simon:

“There are two kinds of psychiatrists—those who have had a patient die by suicide and those who will.”

I have been through that experience. It led me to focus on my role as an educator to psychiatry residents and other trainees to learn as much as I could about the process of suicide risk assessment.

On the other hand, my first experience with someone who died by suicide happened long before I became a psychiatrist. It was in the early 1970s and I was working for a consulting engineer company. I was just a kid, learning on the job to be a drafter and surveyor’s assistant.

One of my teachers was a man I would come to respect a great deal. Lyle was a land survey crew chief and part time photographer. He was gruff, but kind and had a great sense of humor. We all liked him.

He was so tough that, while perched high in a tree and trimming a large branch to enable a line of sight for the instrument man running a theodolite (used to measure vertical and horizontal angles)—he accidentally cut a significant gash in his hand. We on the ground were aghast because blood was dripping from his hand.

He just laughed and said, “I don’t sweat the small stuff.”

One day, he told me and another survey crew member that his girlfriend left him, saying she was tired of picking up after him. He was crying. We felt sorry for him and didn’t know what to say. We never saw him cry before. This image was strikingly different from the tough guy persona he usually had.

As I look back on it, I wondered why he didn’t think the breakup was just more “small stuff.”

The next day, one of the leaders of the company made a short announcement, saying that Lyle had “passed away,” the night before, by suicide. A little later, the rest of the story gradually emerged. Lyle had shot himself in the chest. One of the guys said that it took a long time for him to die, that somebody found him early the next morning, and all Lyle could say was “It hurts.” At first, I thought he meant physical pain. Later, I wondered if he meant physical and emotional pain.

About a week later, one of the survey crew members was planning to pick me up and drive us to Lyle’s funeral. He never showed up.

Of course, I could not have foreseen Lyle’s suicide based on his being so upset about a breakup with his girlfriend. I was just a kid.

When I became a psychiatrist, I saw this quite a lot. I learned, a few times the hard way, how to make the best judgments I could about what might happen to a patient describing physical and emotional pain.

22nd Anniversary Commemoration of 9/11 Attacks

The 22nd Anniversary Commemoration of the 9/11 attacks and the 1993 World Trade Center will be observed today.

I remember where I was on September 9, 2001. I was climbing the stairs at the hospital on my way back to my office. I was on duty on the psychiatry consultation service. I happened to glance at the television in the lobby from the landing. A news story was showing one of the Twin Towers on fire.

I couldn’t believe my eyes. The rest of the day there was talk of the attack on America.

We visited New York City in 2017 and viewed the Memorial & Museum Plaza. We saw the Survivor Tree, the Callery Pear.

It seems like there is almost nothing else to remember about the date except the disaster and the tragedy.

But one of the local fire stations not far from our house has a Flag of Honor on the wall. It honors those killed in the terrorist attacks on 9/11.

Even if we can’t go to the Memorial in New York City, we can remember it and honor the brave.

Should Doctors Be Funny?

I ran across an interesting Medscape article, “Should Doctors Be Funnier? These MDs Are Real Comedians.” I don’t know if they should be funny, but it probably wouldn’t hurt.

I think a sense of humor is a good thing for anyone to have and it’s probably not that hard to develop. There’s even a Wikihow article on how to develop a sense of humor.

I usually look for the funny edge in most things that happen to me. I was always very nervous about presenting Grand Rounds when I was on staff at the hospital. I would try to come up with a good case example illustrating both medical and psychiatric features. It was pretty challenging.

I often used humor to help me get through my stage fright. I didn’t tell jokes, but I did clown around a bit. One day, I arrived too early for the Psychiatry Dept. Grand Rounds and accidentally walked in on another scheduled event in the conference room that was obviously not for psychiatrists—only not immediately obvious to me. I got a few chuckles from the audience just from having to back out. Later, during the real Grand Rounds I clowned about my mistake as a sort of opener to my presentation.

Unfortunately, I then had to stumble through my PowerPoint slides (every presenter’s worst nightmare) because I evidently had not organized them correctly. I survived by joking about it. That resulted in a digital award from the residents for being “Improviser of the Year.”

Humor can get you through some pretty sticky situations.

Another Blast from the Past

Today is Labor Day, and I was looking at some of my old blog posts from my previous blog The Practical Psychosomaticist. I found one that I think I haven’t reposted on my current blog called “Going from Plan to Dirt.”

It’s a funny post, at least I think so. It draws a comparison between blue collar and white collar work, similar to what I did the other day (“Why Can’t I Wear Blue After Labor Day?”).

I wrote it in 2011, when I was on a hospital committee to improve detection and prevention of delirium in the general hospital.

“Our work on the Delirium Early Detection and Prevention Project reminds me of my early formative experiences working as a draftsman and land survey technician starting in 1971 with an engineering company, Wallace Holland Kastler Schmitz & Co. (WHKS & Co.) in Mason City, Iowa. I remember being amazed at how a drawing on paper could be turned into a city street, highway, bridge, or airport runway. They have a website now. I can now find written there what was modeled for me then:

“WHKS & Co. is committed to the continuous improvement of the quality of service provided to our clients.”

Then and now WHKS & Co. worked hard to create the infrastructure that we depend on and then put it into the world in a “safe, functional, and sustainable” way. Out in the field we sometimes joked about how a designer’s drawing was flawed if we couldn’t go from plan to dirt.

It’s common to believe that engineers and land surveyors deal with complex mathematical formulas, structural materials, things instead of people—an applied science in which the emotions and motivations of people play a small role. Nothing could be further from the truth.

I was 16 years old when WHKS & Co. hired me. I had no idea what engineers and land surveyors did, had no experience, and I was at a crossroads in my life. They didn’t hire me because I had any talent or asset they needed. They hired me because they were as committed to the people in the community, not just to things.

And if you think land surveying doesn’t have anything to do with people’s emotions, consider property line disputes. The survey crew I was attached to had been sent out to find the property corners of two neighbors. This involves locating iron pins that mark the corners of the lots that houses sit on. Little maps or “plats” are used as guides and let me tell you, often enough we found the map is not the territory.

Anyway, while we were out there in the back yard of one of the neighbors, they both came outside. One of them was a diminutive elderly lady and the other was a tall, big-boned elderly man. They started arguing about the boundaries of their lots and it got pretty heated. Pretty soon they were yelling in each other’s faces and the lady reached down in the garden in which we were all standing. She picked up the biggest, juiciest rotten tomato she could find and it was clear to us what she planned to do with it. They were both pretty old and neither one of them could move very fast. My crew chief, sensing that something violent was about to happen, moved in between them (a decision I still can’t fathom to this day).

What followed seemed to happen in slow motion, in part because the combatants were so old. The man could see the lady was about to hurl the rotten tomato at him. Ducking must have been beyond his power, probably because of a stiff back. He bent his knees and leaned forward. She cocked the tomato as far back as she could and let fly, screeching, “You’re nothing but an old Norwegian!” My crew chief probably caught a seed or two. Amazingly, the tomato only grazed the top of the man’s head.

I think the altercation took a lot of both of them. They both went back in their houses after that.

It’s not hard for me to see the connection between my past and the present. WHKS & Co. was and still is committed to continuous improvement. And they were and still are all about finding a practical way to do it. If we’re going to improve the quality of care we provide patients and we propose to do it by preventing delirium, we’re going to have to use the same principles that my first employer used. And we’re going to have to be just as practical about how to go from plan to dirt.

We’re still trying to refine the charter for our delirium detection and prevention project, which is a kind of map, really. And even though the map is not the territory, it’s still a necessary guide to remind us of the goal.”

The AARO Finally Has a Website And is it Part of a Zero-Sum Game?

The All-Domain Anomaly Resolution Office (AARO) finally has a website—more than a year after it was formed.

It looks like there’s an intriguing message in the section “Coming Soon: US Government UAP-Related Program/Activity Reporting.” It says AARO will accept reports of UAP from current government employees who know of any programs or activities related to UAPs dating back to 1945.

One sentence tells you “This form is intended as an initial point of contact with AARO; it is not intended for conveying potentially sensitive or classified information.  Following the submission of your report, AARO staff may reach out to request additional detail or arrange for an informational interview.”

Several other sections provide further information and pictures and videos on UAP.

I wonder if all this is a reaction to the House Oversight Committee Hearing on UAP on July 26, 2023. Either the website has been under construction for all of last year and was just finished a couple days ago or it was just thrown together recently.

This makes me think of a couple of things, one is Dr. George Dawson’s blog post “Is This An Episode of the X-Files?” The other is an X-Files episode itself, “Zero Sum” which Sena and I just saw a couple of nights ago. We don’t remember seeing it when it first aired in 1997. You can read the Wikipedia article about the episode.

The gist of it is that Assistant Director Skinner makes a deal with the Smoking Man in which the latter will save Agent Scully’s life (she’s dying of cancer related to alien experiments) if Skinner hides the death of a postal worker who was killed by a swarm of bees carrying smallpox. This is part of a complex plot by a group called the Syndicate which is either trying to work with extraterrestrials to either exterminate the human race or save it (depending on which episode you watch) by using bees as a vehicle to transmit either smallpox or a vaccine to cure the Black Oil, which screws you up pretty bad. Part of this is my interpretation because the storyline sometimes is not clear about this to me.

Anyway, the back-and-forth actions and reactions of the characters, especially Skinner and the Smoking Man, are pretty good examples of a Zero-Sum game, loosely defined in that neither gets much of an edge on the other as they both try to counter each other’s efforts in what is probably just a power struggle from the Smoking Man’s perspective and a desperate effort to save Scully’s life from Skinner’s perspective.

Anyway, I wonder if the UAP reporters and the government (including the AARO) might be in some kind of zero-sum game. UAP reporters try to get the government to admit that Extraterrestrial Biological Entities (EABs) and Extraterrestrial spacecraft exist. But the government denies it. Neither side ever seems to get much further ahead of the other.

Why Can’t I Wear Blue After Labor Day?

I have a few thoughts on the upcoming Labor Day weekend. It occurs to me that Labor Day often evokes images of blue-collar workers. On the other hand, I think in a broader view of the holiday, most of us can think of ourselves as working toward improving our society no matter whether our jobs are in the white-collar or blue-collar sector.

Many eons ago, I was a blue-collar worker. I was a surveyor’s assistant and drafter for a consulting engineers’ company in Mason City, Wallace Holland Kastler Schmitz & Co. (WHKS & Co.). I got attached to my job because it was the first real job I ever had.

I was proud of what I did, even though I didn’t make much money. I had to travel around the state a lot. I lived at the YMCA and ate all my meals in cafes because I was often out of town on jobs and when I was not, there was no kitchen in my tiny sleeping room at the Y.

I wore blue jeans and tee shirts, flannel shirts when I wasn’t out in the hot sun. I liked being outside except when the ragweed was out in the late summer. I had bad hay fever. I tried desensitization shots, but all they did was make my arm swell up. Winters were cold, especially if I had to stand in one place for a long time, either holding up the rod or running the gun.

I was mostly a rear chain man and rod man early on, but moved up to “running the gun” which meant operating the level and theodolite, the former for measuring elevations and the latter for measuring angles. I was proud of my job.

It took me a while to transition from blue-collar to white-collar mindset. In college, I often returned to work for WHKS during the summer breaks. That was where I formed my identity.

Some aspects of the job were simple. You hammered a stake, an iron property marker, or a frost pin if the ground was frozen. Measuring distances, angles, and elevations were often repetitive tasks, yet satisfying because they marked progress toward a concrete goal, like building an airport runway, establishing the outline of a tract of farmland, or raising a bridge. As one of my bosses on the survey crew put it, the work helped you see “the lay of the land.”

Land surveying, mapping, and drawing up plans set my perspective on life when I was a young man. At one time, that perspective made me think I wanted to be an engineer. I respected engineers because they built the subdivisions, highways, dams, and other real things from ideas.

I respected my teachers at WHKS, but couldn’t do the math. And they respected my change of heart.

I eventually became a doctor, after a short stint as a medical technologist in clinical laboratory medicine. You’d think, given my hands-on background, I would have become a surgeon, but I wasn’t made for that either.

I learned basic things at WHKS like being steady, reliable, and focused. I had to learn other things to be a doctor, especially a psychiatrist. On the other hand, in this white-collar environment, especially in a research-oriented academic medical center, I often looked and acted more like a blue-collar worker.

One of the Family Medicine residents who rotated on the psychiatry consultation-liaison service left me a gift of a fireman’s helmet. It fit my head and my approach to psychiatry in the general hospital. What I did mostly was put out the fires, metaphorically speaking, of behavioral eruptions related to delirium which were caused by medical problems. Often, I had to apply blue-collar approaches in a white-collar world. So, can I wear blue after Labor Day?

Happy Labor Day.

“I Have a Dream” Speech 60 Years Later

Today is the 60th anniversary of the Reverend Dr. Martin Luther King Jr’s “I Have a Dream” speech at the Lincoln Memorial in Washington D.C.

I was too young to remember it. However, I have a deep appreciation of the meaning it has not just for Black people, but for all of us. It’s not difficult to broaden the implication for all people.

My personal reflection about this started this morning with a look at one of my primary school class pictures. I’m the handsome guy 2nd from the left in the top row. The other kids of color in the photo are Latino.  

The photo shows not just a group of kids. It also illustrates, just by chance, pretty closely the percentage of black persons in the state of Iowa as of the 2021 U.S. census, about 4%. Historically though, in the county in which I was living at that time, the percentage of nonwhite persons was listed at 0.4%. This was a 28% drop from the previous decade. In 1980, the percentage of Black people in the state was only 1.8%. As near as I can tell from the web, the current percentage of Black people as of the most recent data is 3.74% (possibly as of 2021).

My father was black and my mother was white. In Iowa, the law against miscegenation (marriage between blacks and whites) was repealed in 1839. On the other hand, my parents got their marriage license in 1954 in Watertown, South Dakota—which was 3 years prior to when that state repealed its law against interracial marriage. Right below the license, though, is a certificate of marriage marked State of South Dakota in Codington County. It certifies that my parents were married in Mason City, Cerro Gordo County in the state of Iowa.

I’m not going to try to puzzle that one out. My mother kept a lot of old photos and legal records that anchor me in my personal history.

I have photos of my father with me and my brother, Randy. I also have photos of my mother with me and my brother.

What I don’t have are photos of all of us together. It’s understandable to ask why. I wonder if it has something to do with the culture and mindset of the time. Why was it not possible to find someone, black or white, to snap a family photo of us together?

We can pass legislation repealing anti-miscegenation laws as well as other laws to protect civil rights. That is a necessary (but perhaps insufficient) step toward non-exclusion of certain groups of people from basic human rights.

Ashley Sharpton, who is an activist with the National Action Network and daughter of Reverend Al Sharpton, said that Americans need to “turn demonstration into legislation.”

I agree with her. On the other hand, I also wonder what more has to happen in the minds of all of us to turn legislation into transformation—of our personal implicit biases, which are not in themselves always bad or inescapable.

And since we’re into rhyming, what about asking another question? Can we turn demonstration into legislation while encouraging transformation without bitter confrontation?

The Thing About Identity

I was searching on the web for something about my co-editor, Robert G. Robinson, MD, for our book Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry, published in 2010.

The reason I was searching for something about him was that I’ve had difficulties finding anything on the web lately about doctors I had worked with years ago and admired—and the search revealed they had died. It has been a little jarring and got me thinking about my own mortality.

My search didn’t turn up any obituary about Dr. Robinson, but I found a couple of interesting items. One of them is, of all things, a WordPress blog item, the About section. It’s dated April 2012. I’ve seen it before. It’s supposedly about a person named Dr. Robert G. Robinson, MD and the only thing on it is his name and affiliation with The University of Iowa Carver College of Medicine. Every WordPress blog has an About section. I have one and I’ve been blogging since 2010.

There’s no entry in the About section for him on WordPress. However, there was another item on the web that looked like it was a blog (It’s another blogging site called About.me), and it was labeled as an About section.  It was a biographical summary of his academic and scientific career. Of course, it was impressive. At first, it looked like he was planning to write a blog, which could have been very educational because he’s an extremely accomplished psychiatrist with a very long bibliography of published articles about psychiatric research, a lot of it about post-stroke syndromes.

But when I looked at the social media links on the WordPress page, it led to a picture of someone who is definitely not the Robinson I know. This person was a “Certified Rolfer.” Remember Rolfing? It’s a form of deep tissue massage developed in the 1970s. The Dr. Robinson I know was never involved in Rolfing.

I’m not sure what happened with the WordPress and other blog items, but it looked the WordPress section was a case of mistaken identity. The most recent genuine item on the web about him is a 2017 University of Iowa article about his receiving the Distinguished Mentor Award.

I hope somebody doesn’t get confused by that WordPress mistake.

Then, I happened to come across an article that, at first, I didn’t recognize. The link on the search page listed Dr. Robinson’s name. It’s on the Arnold P. Gold Foundation website for humanism in medicine. The title is “Are doctors rude? An Insider’s View.” It didn’t have my byline under it. It took me a minute, but I soon recognized that I wrote it in 2013. At the bottom of the page, I was identified as the author.

At first, I thought it was a mistake; there was a place for an icon that at one time had probably contained a photo of me, but it was missing. It’s my reflection about a Johns Hopkins study finding that medical interns were not doing basic things like introducing themselves to patients and sitting down with them.

This was not a case of mistaken identity. But I got a little worried about my memory for a few seconds.

Anyway, I was reminded of my tendency to have trainees find a chair for me so I could sit down with patients in their hospital rooms. I later got a camp stool as a gift from one of my colleagues on the Palliative Care consult service. It was handy, but one of my legs always got numb if I sat too long on it. It broke once and I landed flat on my fundament one time in front of a patient, family, and my trainees. The patient was mute and we had been asked to evaluate for a neuropsychiatric syndrome called catatonia. The evidence against it was the clear grin on the patient’s face after my comical pratfall—and because of the laughter that we could see but not hear.

One of the points of this anecdote is that it’s prudent to be skeptical about what you see on the internet. The other point is that parts of your identity can hang around on the web for a really long time, so it’s prudent to be skeptical about how permanent your current identity is.

How the Metta Prayer and the Shower Juggle Are Alike

I’ve been practicing mindfulness meditation since 2014, when I became uncomfortably aware of how unpleasant I was becoming on the job and elsewhere. I called this “burnout.” The word still works as an explanation although it was and is sometimes still an excuse.

I learned about the Lovingkindness meditation or the Metta Prayer during the Mindfulness Based Stress Reduction (MBSR) course I took almost a decade ago.

I used to pray when I was a child. I read the Bible and prayed. I viewed the act of prayer as a request to God back then. And I still probably regard the Metta Prayer as a kind of bargain between me and the cosmos or whatever it is I think of as a higher power.

Just because I say the Metta Prayer doesn’t mean that anybody’s going to treat each other differently. It doesn’t make people get up and square dance together. However, the caution about not expecting others to change just because you say the Metta Prayer doesn’t mean that the practice would not enhance a sense of community—if enough people did it.

There are dozens of scripts for the Metta Prayer easily accessible on the web. The part of it that is directed to those with whom I’m having a difficult time is tricky. Often enough, my goal is to use it as a way of somehow changing the person I’m having difficulty with. It’s the same way I used prayers as a child.

That’s a mistake, but at least I’m aware of it. Prayer is not a request for God or the cosmos to intercede on my behalf so that life won’t be so difficult for me sometimes.

I have trouble remembering that I’m not really a role model, especially nowadays. I’m just an old retired guy who was difficult to work with and needed to change, despite my status as a psychiatrist. I tell dad jokes and clown around but I’m still an old guy with problems—like just about every other old guy.

So, I’m still off and on practicing the Metta Prayer. I’ve noticed that practicing mindfulness is a lot like practicing juggling, which I’ve been doing for almost a year now. I still can’t do certain tricks, like the shower juggle. I can do about three or four throws and drop the balls, sometimes on my head (which is why I wear safety goggles!). And I still tend to use prayer like I’m negotiating a deal to get rid of my faults and troubles.

But I haven’t given up practicing the shower juggle. And I haven’t given up on the Metta Prayer.