reflections – Page 19 – Go Retire Psychiatrist

Thoughts on the Passing of Dr. Russell Noyes Jr.

I recently found the obituary of my mentor, Dr. Russell Noyes, Jr. MD. He died on June 21, 2023. This is the first time I’ve ever said that he was my mentor. I probably just didn’t realize it until I found out he passed.

Dr. Noyes was my teacher during the time I was learning consultation-liaison psychiatry back in the 1990s at The University of Iowa Hospitals & Clinics. His knowledge was vast. He contributed greatly to the scientific literature on anxiety disorders. He also wrote about near death experiences.

Dr. Noyes retired in 2002. As his students, we chipped in to get him a retirement gift. It was a large bookstand. We were just a little uncertain about whether a bookstand was the right gift for someone who was a tireless researcher and teacher. He was also an avid gardener and musician. He soon returned to work in the department, staffing the outpatient clinic. He also continued to regularly attend grand rounds and research rounds. Years later at a grand rounds meeting, someone asked him about his retirement. Dr. Noyes retorted, “I don’t believe in retirement.”

I remember I could hardly wait to retire. Since then, I’ve been ambivalent about retirement, but not so much that I ever seriously considered returning to work. I sometimes have dreams about being late for college lectures because I can’t find my way to them. A couple of times lately, I’ve had dreams about not being able to find my way through a hospital to conduct a consultation evaluation. I don’t know what that means.

I was an avid student of consultation-liaison psychiatry but I was not a scientist. That was part of the reason I left the university in 2005 for a position in a private practice psychiatry clinic. He cried at the going away party my students and co-workers held for me. I still have a little book in which well-wishers wrote kind messages. Dr. Noyes’ note was:

“Jim

We’re going to miss you. You are the consummate consultation-liaison psychiatrist and your leaving is a great loss to the Department. We wish you the best and hope to see you at the Academy meetings.

Russ”

His sentiment was one of the main reasons I soon returned to the department, only to leave again a few years later—and return again after a very short time. I came back because he was a consummate teacher and I wanted to learn more from this beacon of wisdom.

Many who knew him, including me, often saw him riding a bicycle on Melrose Avenue to and from work at the hospital. We wondered why he didn’t drive instead. His son James wrote a beautiful remembrance of him and posted it on the web in 2006. It’s entitled “My Dad (Russell Noyes, Jr).”

James says his dad was a terrible driver. This triggered a memory of how it was Russ’s wife, Martie, who drove the rental car when we rode with them from the airport to the hotel where an Academy of Consultation-Liaison Psychiatry meeting was to be held. I remember gripping the armrest and wishing we’d hired a taxi as Martie steered erratically through heavy traffic.

Dr. Noyes knew how to guide his learners through their careers. He also knew how to write and was a stern editor. Even as I wrote this remembrance, I could see how he might have critiqued it. I tried to do it on my own, and of course I failed. It will have to do.

Why Is It So Hard to Be A Human?

I wish I could have made the title of this post “Why It’s So Hard to Be a Human.” But that would mean I know why it’s so hard to be a human.

The reason this comes up is because of a song I heard last Friday night on the Big Mo Blues Show on KCCK radio in Iowa. The title is “Hard To Be A Human.” I’ve never heard of the vocalist, Bettye LaVette, who has been around a long time. A musician named Randall Bramblett wrote the song and he’s been around forever too, although I just learned of him as well.

I’m going to connect this song with the paranormal show I usually watch on Friday nights, “The Proof is Out There,” which I watch after I listen to the Friday Night Blues with Big Mo.

The show lives on videos from people who report seeing and hearing things like UFOs and Bigfoot or whatever that’s paranormal. There are a lot of fakes and conventional explanations uncovered on “The Proof is Out There,” including UFO videos sent in by contributors.

The reason I’m connecting the song “Hard To Be A Human,” to the paranormal is the letter “A” in the title. There’s another song with a similar title, but without the “A.” In my mind, leaving out the article “A” makes it clear that song is about humans for humans.

By contrast, the song with the article “A” makes me think of extraterrestrials. “A human” could imply that there might be some other life form aside from humans. Of course, there’s no such song as “Hard To Be An Extraterrestrial” (or, if you’ve read Douglas Adams’ book, “The Hitchhiker’s Guide to the Galaxy,” maybe “Hard To Be A Vogon”). Insert “Martian” if that makes thinking about this any easier, which it probably won’t.

There is a song entitled “Hard To Be Human,” which I think is really about how difficult it is to be human, without considering whether there could be any other beings besides the human ones.

Just adding the specific article “A” in front of the word “human” led me to wonder if you could interpret the song in a galactic sense. Now, I have no problem admitting that all this is probably just because of the temporal juxtaposition of the song and the paranormal TV show.

On the other hand, I have this thought. While I couldn’t find the full lyrics to “Hard To Be A Human,” I could understand some of them. I could discern underlying themes suggestive of Christianity. There are definite references to the Bible, such as walking in the garden “apple in my hand”, the lyric “I’m just another life form,” and “First He made the mountains, then He filled up the sea; but He lost his concentration when he started working on you and me.”

I’m willing to concede that the “just another life form” phrase might have been restricted to just the life forms on planet Earth. However, might it suggest that God made beings (and mistakes) on other planets and their inhabitants?

I hope these references are familiar to at least some readers, because I think the point of the song might go beyond the everyday struggle of being human. I think there might be an attempt to raise the notion of trying to compare the sense of being a human with that of some other kind of being not from this planet.

The older I get, the less sure I am that a human is the only kind of being in the universe. It’s a big universe. If we’re not the only life form in the universe, could life be harder for other life forms?

Probably the answer is no. I don’t see extraterrestrials in millions of flying saucers blotting out the sun in a desperate attempt to move here. Inflation is outrageous. And, after all, it’s pretty hard to be a human.

Costa Rica Tarrazu Coffee Notes

Sena bought a bag of ground Costa Rica Tarrazu coffee the other day. It brings back memories. We savored it along with some piano music from George Winston, may he rest in peace.

You can gas about coffees a lot. You can call Tarrazu a thing which has a certain complexity of notes, a balanced flavor, a spicy character and whatnot. I guess appraising coffee can be similar to judging wines. I don’t like wine and know nothing about it. I don’t know much about coffee, either.

But there’s a coffee connoisseur who made a YouTube video evaluating the Tarrazu we have. He said it has “coffee notes.” I should hope so. He gave it a so-so rating, 6.1. I guess there’s a 10-point rating scale. I think he takes subtle sarcasm to a new level. He had some kind of fancy coffee filter I’ve never seen before. He compared Tarrazu to coffee you get from Denny’s restaurant—as though Denny’s is a highbrow establishment. He also said it has chocolate notes. I actually noticed that years ago.

We first tasted Tarrazu at the World Market in Madison, Wisconsin many years ago. The drive from Iowa City to Madison was a pleasure. We took the more scenic route, which was Highway 151. Just in case you read this and make the trip yourself, I’ll say this: what is scenic to one is boring to another.

I remember we sampled Tarrazu from those little white Styrofoam cups in the World Market store. It was the smoothest coffee we ever tasted. We were hooked and bought a bag.

There’s a lot to do in Madison, which is not to say there’s not much to do in Iowa City. There’s just more of everything in Madison. Every day there was some new attraction to explore. Tarrazu was also a new experience.

We had a lot of fun in Madison. We went up to Wisconsin Dells and darn near froze to death on an open boat ride in the early fall. Part of the “fun” of the ride was mainly for the driver, I think. He would rev the boat at rocket speed and splash us with water, which could have had a thin skin of ice notes over it, judging from the shock. We saw the House on the Rock in Spring Green. We relaxed at the Sundara spa. We rode the horse-drawn wagon on the Lost Canyon tour and still have a deck of playing cards from the gift shop.

We’ve bought Tarrazu a couple of times since our adventure in Madison and found that, somehow, the flavor wasn’t quite as bright, not as smooth. On one bag, the name was spelled “Terrazu” rather than “Tarrazu. Sure, it had “coffee notes,” but not the chocolate notes. And it didn’t evoke memories of Wisconsin.

Finally, getting back to the Tarrazu we have now. The taste is miraculous, just like it was so many years ago. It takes me back to the Styrofoam cups at World Market, the speedboat in the frigid water, the Sundara bedsheets stained by previous guests with mud notes from the spa, the Infinity Room in Spring Green, cheese curds and chili.

Those are my Tarrazu notes.

My Two Cents on the Involuntary Treatment of Tuberculosis and Psychiatric Illness

By now many of us have seen the news headline about the person in Washington state who was arrested and sent to jail for noncompliance with a court order for treatment of tuberculosis. This led to my searching the literature about the connection between court-ordered treatment for psychiatric illness and court-ordered treatment for tuberculosis in Iowa. I’m not assuming that the person who is the subject of the news story has psychiatric illness.

I’m a retired consultation-liaison psychiatrist and the issue of how to respond to patients who refuse treatment for tuberculosis arose maybe once in my career. When the Covid-19 pandemic began a few years ago, I thought of the Iowa code regarding involuntary quarantine of patients infected with Covid-19 infection. I thought it was a situation similar to that of persons infected with tuberculosis. That was an issue for the hospital critical incident management team to deal with.

I found an article relevant to both internal medicine and psychiatry. It is entitled “Can Psychiatry Learn from Tuberculosis Treatment?” It was written by E. Fuller Torrey, MD and Judy Miller, BA and published in Psychiatric Services in 1999. The authors point to the directly observed therapy (DOT) programs in place in several states, including Iowa. Such programs can include positive reinforcement incentives such as fast-food vouchers and food supplements, movie passes and more. They credit the New York experience using DOT with reducing the tuberculosis rate by 55%.

Torrey and Miller point out that many psychiatric treatment programs didn’t offer as many incentives as DOT programs for treatment of tuberculosis. They also say that a “credible threat of involuntary treatment, essential for the success of DOT” often is absent from psychiatric programs.

I was puzzled by their view because of what I saw from our own integrated multidisciplinary program of assertive community treatment (IMPACT) at The University of Iowa Hospitals & Clinics, which started well before they wrote the article. My impression is that it has been very successful. The Iowa Code covers the role of involuntary psychiatric hospitalization in the event of noncompliance as a result of uncontrolled psychiatric symptoms leading to danger to self or others or inability to provide for basic self-care needs.

On the other hand, because of my background in consultation-liaison psychiatry, I wondered about how we might treat someone with both tuberculosis and severe psychiatric illness, the latter of which could make treatment of the former difficult or even impossible.

We can use long-acting injectable antipsychotics to treat those with chronic schizophrenia. They’re not uniformly effective, but they play an important role in acute and maintenance therapy.

But I also forgot about how tuberculosis treatment could be administered to those unwilling to take it voluntarily. I rediscovered that tuberculosis treatment can be given by injection, if necessary, although it’s usually intended for treatment-resistant disease. On the other hand, scientists created a long-acting injectable drug for tuberculosis which was effective in animal studies and which could be a delivery system for non-adherent patients.

And I thought about who would be the responsible authority for administering tuberculosis medications on an involuntary basis. It’s not psychiatrists. It turns out that in most states, including Iowa, the local public health officer is in charge. The CDC has a web page outlining suggested provisions for state tuberculosis prevention and treatment.

Patients with tuberculosis who refuse treatment can be confined to a facility, although it’s not always clear what that facility ought to be. Certainly, I would be concerned about whether a jail would be the best choice.

I don’t have a clear answer for an alternative to incarceration. Would a hospital be better? General hospitals are not secure and there would not be an ideal way to prevent the patient from simply walking away from a general hospital ward. If the patient has a comorbid severe psychiatric illness that interferes with the ability to cooperate with tuberculosis treatment, then maybe a locked combined medical-psychiatric unit (MPU) would be the better choice. Arguably, while an MPU might not be the best use of this scare resource, it’s probably more likely to have a negative pressure isolation room for a patient with both tuberculosis and psychiatric illness. I co-attended with internal medicine staff on The University of Iowa Hospital’s MPU for many years. There are rigorous criteria for establishing such units. The best expert in integrated health care systems I know of would be a former teacher and colleague of mine, Roger Kathol, MD. He is currently the head of Cartesian Solutions.

I’m aware that just because someone refuses treatment for tuberculosis doesn’t necessarily mean a psychiatric illness is present. The critical issue then could become whether or not the patient has the decisional capacity to refuse medical treatment. The usual procedure for checking that would include assessing understanding, appreciation, reasoning, and the ability to make a choice. You don’t necessarily need a psychiatrist to do that. Further, there are nuances and recent changes in the decisional capacity assessment that can make the process more complicated. The New York Times article published in early May of this year, entitled, “A Story of Dementia: The Mother Who Changed,” makes that point based on a real-life case in Iowa, involving psychiatrists at The University of Iowa.

It occurs to me, though, that just because a person is able to pass a decisional capacity assessment doesn’t necessarily make a decision to refuse tuberculosis treatment OK. Letting someone expose others to infection when effective treatment is available doesn’t sound reasonable or safe.

That’s my two cents.

Quenard F, Fournier PE, Drancourt M, Brouqui P. Role of second-line injectable antituberculosis drugs in the treatment of MDR/XDR tuberculosis. Int J Antimicrob Agents. 2017 Aug;50(2):252-254. doi: 10.1016/j.ijantimicag.2017.01.042. Epub 2017 Jun 5. PMID: 28595939.

Most Birds Forget They Ever Met

Some birds pair for life, like swans and bald eagles. Most backyard birds pair up for a season. Mourning doves sometimes mate for life, but their name doesn’t relate to grief when they lose a mate. Their instinct is to procreate and ensure the survival of the species.

They forget each other after every season. But when you just watch them, it’s easy to imagine they’re in love.

Thoughts on Gaming Disorder

I just read an interesting article in the latest print issue of Clinical Psychiatry News, Vol. 51, No. 5, May 2023: “Gaming Disorder: New insights into a growing problem.”

This is news to me. The Diagnostic and Statistical Manual lists it as an addiction associated with the internet primarily. It can cause social and occupational dysfunction, and was added to the DSM-5-TR in 2013 according to my search of the web. I’m not sure why I never heard of it. Or maybe I did and just failed to pay much attention to it.

There are studies about treatment of the disorder, although most of them are not founded in the concept of recovery. The research focus seems be on deficits. One commenter, David Greenfield, MD, founder and medical director of the Connecticut-based Center for Internet and Technology Addiction, said that thirty years ago, there was almost no research on the disorder. His remark about the lack of focus on recovery was simple but enlightening, “Recovery means meaningful life away from the screen.”

Amen to that.

That reminded me about the digital entertainment available thirty years ago. In 1993, the PC game Myst was released. Sena and I played it and were mesmerized by this simple, point and click adventure game with intricate puzzles.

Of course, that was prior to the gradual evolution of computer gaming into massive multiplayer online role-playing and first-person shooters and the like. It sounds like betting is a feature of some of these games, which tends to increase the addictive potential.

Sena plays an old time Scrabble game on her PC and other almost vintage age games. I have a cribbage game I could play on my PC, but I never do. I much prefer playing real cribbage with Sena on a board with pegs and a deck of cards. We also have a real Scrabble game and we enjoy it a lot. She wins most of the time.

This is in contrast to what I did many years ago. I had a PlayStation and spent a lot of time on it. But I lost interest in it after a while. I don’t play online games of any kind. I’m a little like Agent K on Men in Black II when Agent J was unsuccessfully trying to teach him how to navigate a space ship by using a thing which resembled a PlayStation controller:

Agent J: Didn’t your mother ever give you a Game Boy?

Agent K: WHAT is a Game Boy?

Nowadays, I get a big kick out of learning to juggle. You can’t do that on the web. I like to pick up the balls, clown around, and toss them high, which occasionally leads to knocking my eyeglasses off my head. I usually catch them.

Juggling is a lot more fun than playing Myst. I would prefer it to any massive multiplayer online game. I never had a Game Boy.

Celebrate Teacher Appreciation Week!

Teacher Appreciation Week this year started on May 8, 2023. I found my old report cards from Lincoln Elementary School in Mason City, Iowa. Lincoln was torn down many years ago to make room for expanding the Post Office. But I have my memories. I rediscovered reasons to celebrate the dedication of teachers. I don’t know how many people keep their grade school report cards. My mother kept mine along with old elementary school photos, including class pictures.

Jimmy!

Brief remarks on my grade cards remind me how supportive my teachers were—and how they expected me to buckle down. I was kind of a handful and there are indications that I had difficulty focusing my attention. My fifth-grade teacher, Mrs. Cole, was instrumental in identifying my near sightedness, which helped me to get my first pair of eyeglasses.

It wasn’t a bed of roses. My third-grade teacher, Mrs. Myrton (who always smelled like cigarettes), once slapped me so hard it made my nose bleed because I bumped into her when I was running around the classroom. I don’t remember why I was doing that. She was really sorry for slapping me.

And there was the time me and another kid got caught throwing snowballs on the playground (I can’t remember what grade I was in), which led to the usual penalty levied by the school Principal, Esther Ahrens. We each had to draw really small circles (signifying snowballs) to fill a sheet of paper.

We (meaning the kids) thought Ms. Ahrens was a witch. On the other hand, on a really hot day shortly before summer break, my 4^th grade teacher, Ms. Hrubes, started acting really strange and was sort of wobbling at the open window in the classroom. There was no air conditioning in the school. Ms. Ahrens happened to be walking by the room and rushed into the room just in time to catch Ms. Hrubes as she was falling backward in a dead faint from heat exhaustion.

But other than that, along with the usual physical and psychological cuts and scrapes of elementary school, I remember those years as instrumental in turning me and other kids into smarter, nicer people and better citizens. We also learned how to make really tasty homemade ice cream the old-fashioned way, using nested containers, the larger of which had a mixture of salt an ice and a hand crank.

The notes and letters with my report cards often had illuminating comments:

“Jimmy has done well in Physical Education class. He has excellent aim and can hit a moving car’s windshield with a rock (yelling ‘bombs away’) with fair accuracy.”

“During this quarter, I was able to dissuade Jimmy from trying to fly like superman from the second-floor window of the classroom.”

“Jimmy reads well. He could apply himself more carefully in science. We were finally able to remove all the exploded paint from the gymnasium. It took only a few weeks this quarter.”

“Jimmy’s command of spatial relationships has improved a great deal! He can figure out how to fill his emptied milk carton with spinach in seconds, often without attracting the attention of the lunchroom monitors.”

I’m giving a great big thank you to all the teachers! You deserve it!

Racial Affinity Group Caucusing Separate But Not Equal to Segregation

I read the New England Journal of Medicine perspective article “Racial Affinity Group Caucusing in Medical Education—A Key Supplement to Antiracism Curricula.”

I did not see the word “segregation” anywhere in the paper, although the Daily Mail news item used it frequently in a manner that I suspect was intended to incite indignation over separating White and Black, Indigenous, People of Color (BIPOC) medical students into Racial Affinity Group Caucuses (RAGC). This was for the purpose of ultimately integrating them with the goal of defeating racism.

Words matter. The word “segregation” used in the way some news reporters did is bound to conjure up 1960s images of the effect of Jim Crow laws and remind those old to remember it the speech of Alabama governor George Wallace pledging “Segregation now, segregation tomorrow, segregation forever.”

Separating people into groups for the purpose of working out a solution to racism can be called segregation only in the strictest sense of the definition. If you can separate denotation from connotation, I think you have to question the use of the word in the news article, which was heavily freighted with negative connotations.

When I was a student at Huston-Tillotson College (now H-T University, one of the Historically Black Colleges and Universities) in the 1970s, the Greek fraternity and sorority pledges were segregated from those who chose not to pledge, including me. I was really happy to be segregated when I witnessed the hazing of the pledges.

The women and men students at H-TU who lived on campus were segregated into male and female dormitories. This did not stop certain activities like dances and fraternity events.

I recall reading news stories a year or two ago about some black college students wanting to be segregated into different dormitories at predominantly white college campuses. I don’t agree with the idea, but it sounded like some black students preferred it.

I like my socks segregated from my dress shirts. But that’s just me.

May is Mental Health Month

May is Mental Health Month. This would be a good month for me to practice giving myself and others grace. Here’s a link to a very nice article about grace. It’s really about giving each other a break from slamming one another and letting go—sort of like what you need to do in juggling. The author of the article on grace suggests a short list of ways to practice grace. They’re just the guidance I welcome for Mental Health Month and any other month for that matter.

The one about compassion and forgiving myself and others is difficult to do. I should do it anyway.

Buttoning my lip before criticizing, complaining, or venting other harsh utterances is a nice way to avoid the slamming mode I see in the news every day.

It’s tough not to expect the worst from others, especially when you read the news. Hey, let’s stop reading the news.

I don’t get much recognition, and that’s actually a good thing. Sometimes the last thing I need is attention.

I can think of many persons who have probably gently and silently helped me over the years.

While it may feel good to get my digs in on people I don’t agree with, it’s not satisfying for very long. People do remember how you made them feel.

Let’s give each other grace. We all need a break.

Gardening Works as Mindfulness Meditation

When I think of Sena learning to juggle and find her juggling balls on the floor where she drops them after a 2- or 3-minute practice, I now think of her gardening.

I wondered if gardening could be a form of meditation and did a web search like I did yesterday for juggling. It turns out many people think of gardening as a kind of mindfulness meditation. It’s another one of those moving meditations, kind of like the walking dead meditation as I and some of my peers described it at a mindfulness retreat 9 years ago.

Sena has been gardening for a long time. I remember she turned our back yard into a park many years ago.

She is always on the lookout for something new to plant. I don’t always remember the exact names of them, but they’re very pretty. And the Amaryllis house plant stem is 22 inches tall!

I found one article on Headspace, “How to practice mindful gardening” which laid it all out about the subject. The key takeaways about mindful gardening:

Being fully present in the garden can help improve mood
In this setting, we might also become more aware and accepting of change
Check in with your senses before getting your hands dirty

Sena can work in the garden all day, sometimes in 100 degree plus heat—which I don’t recommend. On the other hand, she really gets a charge out of digging holes in the yard, pulling up turn to make room for more flowers and shrubs, and tilling the soil. She has kept the Amaryllis stalk thriving; it’s 22 inches tall! She’s not sure what to do yet with the Easter Lily plant, but she’ll figure something out.

I still do sitting meditation, which is what I learned from the Mindfulness Based Stress Reduction (MBSR) class. And I now have begun to think of juggling as a kind of moving mindfulness meditation.

On the other hand, I’m not keen on gardening in any sense, including mindfulness. Partly, it’s because a fair amount of dirt is involved.

I think it would be difficult for me to do gardening all day like Sena does. I could stick it out for about as long as she practices juggling—about two or three minutes. I would put my tools away, though.

I’m beginning to think of juggling practice as a kind of meditation, especially since I started to learn the shower juggling pattern. Doing that for more than 15-20 minutes at a time usually doesn’t result in much improvement—at the time. But I think I sprout more brain connections as I’m doing it because I notice gradually smoother timing and coordination.

In sitting meditation, counting your breaths is generally frowned upon. On the other hand, counting my throws (especially out loud) during juggling actually helps me focus my attention. I see each throw as sort of like a single breath. I still have to consciously adjust my posture so that the “horizontal” pass doesn’t end up being more like an underhand throw. And when I modify the throws so they stay in the so-called jugglespace (not so close the balls bounce off my head, not so far out front I have to lunge for them), and space the balls out just right, I find it’s easier to get more throws in.

I don’t think Sena counts the number of dirt clods she tosses aside.