Category: reflections

Thoughts on Doctors Going On Strike

I read Dr. H. Steven Moffic’s two articles in Psychiatric Times about the strike by mental health workers at Northern California Kaiser Permanente (August 16 and 26, 2022). So far, no psychiatrists have joined the strike.

However, this piqued my interest in whether psychiatrists or general physicians have ever gone on strike. I have a distant memory of house staff voicing alarm about a plan by University of Iowa Hospital & Clinics to reduce health care insurance cost support many years ago. It led to a big meeting being called by hospital administration to discuss the issue openly with the residents. The decision was to table the issue at least temporarily.

It’s important to point out that the residents didn’t have to strike. I don’t recall that it ever came up. But I think hospital leadership was impressed by the big crowd of physician trainees asking a lot of pointed questions about why they were not involved in any of the discussions leading to the abrupt announcement that support for defraying the cost of house staff health insurance was about to end.

That’s relatively recent history. But I did find an article on MedPage Today written by Milton Packer, MD (published May 18 2022) about what was called the only successful strike by interns and residents in 1975 in New York. I don’t know if it included psychiatric residents; they weren’t specifically mentioned.

In 1957, the Committee of Interns and Residents (CIR) in New York City and voted to unionize to improve appalling working conditions. They won the collective bargaining agreement, the first ever to occur in the U.S. because they went on strike, which hamstrung many of the city’s hospitals. Medical faculty had to pitch in to provide patient care.

After 4 days, the hospitals agreed to the residents’ demands. However, the very next year, the National Labor Relations Board ruled that residents were classifiable as “students,” not employees, which meant they weren’t eligible to engage in collective bargaining. This led to a reversal of the gains made by the strike.

Residents who are unionized voted to strike at three large hospitals in California in June of this year. They reached a tentative contract deal at that time. The news story didn’t mention whether there were any psychiatrists in the union.

There has never been a union of residents at The University of Iowa Hospitals & Clinics. I was a medical student and resident and faculty member for 32 years. I saw changes in call schedules and work loads that were the norm for the exhausting schedules that led to horrors like the Libby Zion case in New York.

Even as a faculty member on our Medical-Psychiatry inpatient unit, the workload was often grueling. I co-attended the unit for years and during the months I was scheduled to work there I shared every other night call with an internist for screening admissions. I was sometimes scheduled for several months at a time because it was difficult to find other psychiatrists willing to tackle the job.

If residents had wanted to unionize and voted to strike then, my internist colleague and I probably could have filled in for them.

But I would never have considered going on strike myself. It would have been next to impossible to find any other psychiatrist to fill in for me. And if other psychiatrists had gone on strike? We might have won a better deal—but only by hurting the patients and families who needed us.

I suspect my attitude is what underlies the impressions shared in Robert G. Harmon’s article, “Intern and Resident Organizations in the United States: 1934-1977,” in the 1978 issue of the Milbank Quarterly.

The house-staff choice of unionization as a formal process has disturbed some health professional leaders. One has pointed out that for a house officer to don another hat, that of striking union member, in addition to those of student, teacher, administrator, investigator, physician, and employee, may be a regrettable complexity that will further erode public confidence in physicians (Hunter, 1976). Others have seriously questioned the ethics and morality of physician strikes (Rosner, 1975). -Milbank Memorial Fund Quarterly/Health and Society, Vol. 56, No. 4, 1978.

When I graduated from medical school, I believed in the cultural view of the physician as a professional. My first allegiance was to the patient and family. I paid dearly for holding that stance. Sena reminds me of the times my head nearly dropped into my soup when I was post call. And I did struggle with burnout.

But I retired because I thought it was time to do so. I don’t think of it as a permanent strike. I hope things turn out all right.

59th Anniversary of MLK’s “I Have a Dream” Speech on August 28, 1963

Sena reminded me that today is the 59th Anniversary of Reverend Martin Luther King Jr’s “I Have a Dream” speech in Washington, D.C. After she reminded me about it, I found this anniversary mentioned in only a few headlines on the web.

But that’s no excuse. It doesn’t matter that I was just a small child on August 28, 1963. And when I hear the speech, it still makes the hair on the back of my neck stand up.

Memories and Condolences

I was thinking of my hometown, Mason City, for some reason today. Then I just happened to think of my childhood pastor, Reverend Glen Bandel. The last time I looked him up on the web was about a year ago and saw a news item dated in 2019. He was celebrating his 90th birthday.

I looked him up today. He died on June 3, 2022.

 My deepest condolences to the Bandel family. Reverend Glen Bandel was the definition of the caring family pastor in Mason City. He sat up in the chair with us nearly all night at our house when my mother was sick and my brother and I were little. He had a great sense of humor. The Bandels shared their home with us when times were hard.

They took us with them to visit a family up in Minnesota one winter. I don’t think my mother was with me and my little brother at the time. I think she was in the hospital and the Bandel family took us in.

The family in Minnesota lived and worked on a farm. They didn’t have indoor plumbing. I think Reverend Bandel had a particular reason to visit them. It might have been to try to persuade them to change the way they lived. They had several children.

I had to use the outhouse at night. I was too cold to move my bowels. My family was poor, but not as poor as this one.

I caught the father singing to his little baby daughter. I think the baby’s name was Dolly because he was singing “Hello Dolly” to her. I walked in on them while he was singing the lyric “It’s so nice to have you back where you belong.”

He was having a great time singing to her. But when he looked up and saw me watching him acting like a doting dad, he stopped and looked a little sheepish. I wished he hadn’t seen me.

Reverend Bandel was a hero in the eyes of the many people he served and in my eyes for sure.

I will remember him and the rest of his family for their kindness and generosity as long as I live.

Iowa State Fair Remembers Chet Randolph

The other day Iowa PBS remembered former Iowa PBS Market to Market host Chet Randolph with a flashback to his 1978 Reflections on the Iowa State Fair. His point about the Iowa farmers and the role of agriculture in this state is well taken. We enjoy the Fair because of Iowa farmers, who may enjoy it in a different way than most fairgoers.

According to Bob Quinn’s story in 2002 upon Randolph’s death, the icon of Iowa agriculture set a great example of how to respect the opinions of others while defending your own and be ready to accept “a better answer.”

Chet started out in Mason City, Iowa as a farm news broadcaster and in his early days, he made part of his show an offer to do chores for farm families who otherwise would never have had the time to take a vacation. He spent about 16 years (1975-1990) hosting Market to Market back when it was first called Farm Digest in 1974.

Picture credit of Chet Randolph “choreboy” Gene Champ.

All About the Potato Salad

I recently got a checkup for my retinal tear surgery about 4 months ago. My surgeon was pleased with the outcome. Partly based on my good outcome, he shared that he was guiding his trainees on the wisdom of not necessarily always going with the new surgical procedures for the disorder, which happens not infrequently in those over the age of 50.

In fact, the trend seems to be to do more than just the oldest operation, which is the scleral buckle, in favor of adding vitrectomy as well—a relatively newer approach. I got the scleral buckle.

Progress is good. But just because something is old doesn’t mean it’s outmoded.

We saw the Iowa State Fair episode on old farm machinery the other night. It showed how much progress has been made in farming over many years. However, those old machines replaced a lot of hard labor, so they were definite improvements back in the day.

You can learn something new and valuable by considering what is old. We saw a short film called The Foursome. On the surface, it’s about 4 old guys who have played golf together at an annual tournament for 50 years in Waukon, Iowa. Waukon is in the Northwest part of the state, close to the Mississippi River, which borders the eastern side of the state.

The show is not really about golf, of course. But before it came on, I almost decided not to watch it because of that misconception. The description gives it away, saying that it’s about friendship, small towns, golf—and potato salad.

I think it’s also about getting older. Not everybody ages gracefully and I’m including myself as a pretty good example. I’m not so sure about my memory or my hearing these days. I can stand on one leg for 20 seconds. But one day not too long ago I cracked an egg and instead of emptying the contents into the poaching pan, I dumped them on a paper towel on the countertop. I was mortified.

Sena covered for me and brushed it off, saying it was because we had been talking about the finer points of poaching eggs and I just got distracted, and some hogwash about how she’s done that too. Maybe.

In the film, one of the Foursome was showing some of the artwork he has on the walls at his home. He stopped at one and seemed to fall into some kind of reverie. The camera operator had to sort of whisper to the guy that he needed to move on.

Let’s change the subject and talk about potato salad. They filmed the wife of one of the guys making this potato salad, the recipe for which you can get for free on the web. She used Miracle Whip instead of Mayonnaise. I pointed this out to Sena, who said nothing. Miracle Whip has been around since the 1930s and I grew up eating it on sandwiches at home. I favored it over Mayonnaise.

There has not been a jar of Miracle Whip in our house in almost 45 years—which is how long we’ve been married. I have learned to like Mayonnaise.

This reminds me of one segment on the film showing the wife of one of the other guys shopping for food (including burgers, chips, and whatnot as well as potato salad fixings) for the cookout, a part of the annual golf outing for the four guys. She said it really didn’t matter what she got because “They’ll eat anything you put in front of them.”

Some of them will eat nothing but the potato salad.

There is something poignant about the irascibility alternating with poignancy in the film. Their friendship is deep enough to move one of the four guys to tears. At least that’s what it looked like.

They have the usual flaws men have, including the tendency to be stoic in the face of oncoming frailty and the specter of death.

I don’t know if I’ll age as well as they do. But I do know I will never take up the game of golf. And I wonder if you can substitute Mayonnaise for Miracle Whip in that potato salad.

One thing I’m sure of, Sena is my best friend.

Iowa State Fair Musings

We’ve never actually been to the Iowa State Fair, but we really like listening to the Iowa Public Broadcasting TV shows about it.

The first show covered a lot of activities. Food at the Fair is always intriguing.  We know there are a lot of foods on a stick, but we didn’t know you could get a rattlesnake corn dog—with venom sauce! It’s pretty good according to the food guy, Travis Graven. You probably won’t find it in your local grocery store.

The big animals are impressive. I always wonder why the handlers sort of guide some of the animals (like that huge boar) using those little boards.

The lemonade stand was a little thought provoking. Dad’s Old-Fashioned Lemonade stand sellers aren’t out there to make money. They do it for the nostalgia. I’m sure they do it for the tradition as well.

That’s a nod to keeping tradition alive. One of those is the 4-H program. According to the Iowa State University 4-H Youth Development web page, the 4 H’s stand for:

Head for thinking, planning, and reasoning

Heart for being kind, true, and sympathetic

Hands for being useful, helpful, and skillful

Health for taking care of yourself and your community

The Iowa State Fair is a longstanding tradition. It started way back in 1854. It was on hold in 2020 because of the Covid-19 pandemic and that was the first time since World War II it was cancelled and only the sixth time in the Fair’s 166-year history.

A tradition is defined as the transmission of a culture’s customs, beliefs, knowledge, skills and more from generation to generation. In order to do that somebody has to do the passing down of all of that. And somebody has to pick it up.

You can store some of it in electronic archives, but a critically important part of it relies on institutional knowledge in the hearts and minds of the culture’s older people. It’s a two-way street; the young listen, accept some, and improve more if we’re lucky. It’s more than facts and figures—it’s the wisdom we want to preserve.

And we want to keep the rattlesnake corn dogs, with venom sauce.

Holes in Our Heads

I remember getting a trephination of my fingernail a long time ago when I was working as a surveyor’s assistant. We were out taking elevation shots with a level and a rod measuring the depth of sewer pipes.

This required us to remove the manhole covers, which are very heavy. I got one of my fingers pinched and man that hurt. My crew drove me to the emergency room where an ER doctor drilled a tiny hole in my fingernail. The immediate pain relief resulting from the release of the subungual hematoma pressure felt miraculous.

That was trephination of the fingernail. I’ll bet some of you thought of my skull when you read the word in my first sentence, though.

Trephination is just the word for the medical procedure of making a hole in the body for some reason. In order to relieve pressure and severe pain from getting your finger mashed, a doctor can make a hole in your fingernail.

Trephination can also mean making a hole in your skull to treat brain injuries or to let the evil spirits out. That was done thousands of years ago, but making burr holes in the skull for other medical reasons is still being performed, including to relieve pressure.

It’s the origin of the old saying, “Well, I’ll be bored for the simples,” where the term “simples” means feeble-mindedness and “bored” refers to the obvious treatment.

Anyway, boring holes in either your mashed finger or your head can relieve certain kinds of pressure and pain.

Figuratively speaking, we can feel under pressure in our heads for all kinds of reasons. In fact, we’re born with several kinds of holes in our heads that can lead to the pressures of anger, anxiety, sorrow and fear.

Our eyes can fool us, even to the point of making us believe we see Bigfoot when all we’re really seeing are pictures or videos that are very blurred and pixelated. I didn’t say nobody ever sees Bigfoot. I’m saying that there’s a term for some forms of visual misperception, one of them being pareidolia—the tendency to perceive meaningful images in random or ambiguous visual patterns.

Our ears can also fool us. Mondegreens are misperceived song lyrics. One of the most common mondegreens is a line I was very embarrassed by for years, “Wrapped up like a douche, another runner in the night” from the song Blinded by the Light by Manfred Mann’s Earth Band. It’s actually “Revved up like a deuce, another runner in the night.” A deuce is a kind of automobile that was often converted into a hotrod in the 1930s, usually a Ford.

Those are just a couple of examples of how holes in our heads can sometimes lead to trouble getting along with each other. All you have to do to prove this is to look at news headlines. Everybody’s slamming each other.

There’s no magic cure for interpersonal conflict, although there have been plenty of efforts to help us understand how it may arise from misperceptions and misunderstandings, often arising from missteps in communication. I doubt making more holes in our heads would be helpful.

For example, I could have chosen to show you a picture of which one of my fingers got pinched in a manhole cover. How I might have done that could have been unnecessarily provocative and even offensive—even if I only meant it as a joke. A prominent scientist recently published a picture on social media of what he called a new star he said was taken by the Webb telescope. It later came out it was actually a picture of a slice of chorizo, which is a sausage. Many people didn’t think it was funny, but that was his explanation for the post.

I don’t have to say anything more to convey the message that being mindful of what and how we are communicating is vital to making ourselves understood while remaining respectful and kind.

Practicing mindfulness is one way to facilitate clear communication that can help solve problems without hurting the feelings of others and triggering vengeful counterattacks. We’ve all been there.

Not everybody gets the idea about mindfulness. I think the blogger thegoodenoughpsychiatrist does a great job discussing it in the post “Reflecting on DBT and Mindfulness.”

As the blogger says, “Sometimes, you just need to be brought back down to earth.”

And if that doesn’t work, we can always try trephination.

TV with Heart

The other night I watched a show I’ve seen 3 times and it still makes me want to cry. It’s the Heavy Rescue 401 episode with Bear the heavy wrecker operator with the Ross company who lets an 8-year-old boy diagnosed with cancer hold the steering wheel and pull the horn as they take a drive around the farm where the family lives.

They hug and it’s tough to tell whether Bear is comforting the boy or the other way around. I guess it’s both.

I saw a Facebook page about the boy, who succumbed to cancer a few years ago. People are still leaving warm messages.

I watch a fair amount of TV and I make fun of most of it, including the paranormals. They’re pretty formulaic, re-investigating decades old cases that never get solved about alien visitors in spaceships, leaving behind evidence that goes missing from government storage warehouses. Because it gets lost, nobody has to explain why there is a notable lack of any convincing evidence for what most UFOs are and who might be flying them.

I can’t generate much emotion for the paranormals. I mostly laugh at them. How can you lose or throw out physical evidence of UFOs and aliens so many times?

“We need to make more room in here; can we toss something in the trash compactor?”

“Sure, get rid of those photos of military personnel taking selfies with aliens driving UFOs and drinking beer. That’ll make room for the 400-page binders of the syllabus for the graduate school course ‘Effect of Chimpanzee Eyebrow Dandruff on Prime Interest Rates During the 20th Century.’”

One of paranormal shows did an extensive review of the Kecksburg, Pennsylvania UFO, the one shaped like a macadamia. No wait, it was shaped like an acorn. It was dark and brooding, full of intrigue, veiled threats, and an alien pilot. As usual, evidence was lost.

Did you know Kecksburg throws an annual UFO-themed party? They just had the 17th Kecksburg UFO Festival just last month, replete with something called a burnout contest, fireworks, and crafts. The people of Kecksburg aren’t letting the government conspiracy get them down. They’re more than happy to let the paranormal producers visit because it gives the town leaders a chance to draw more tourists to the area.

I get a kick out of Men in Black (MIB) too, and I won’t tell you how many times I’ve seen the first one and the first two sequels. In Men in Black, Agent K shows the new recruit, Agent J, a special universal translator and says MIB is not even supposed to have it and says, “I’ll tell you why. Human thought is so primitive it’s looked upon as an infectious disease in some of the better galaxies.”

That’s why it helps to watch some other TV shows, the ones with heart where real people who are not acting but living do the mundane things which are seldom the most treasured of miracles. They remind you of the better human qualities like humor, kindness, love, generosity, gratitude, and the experience of sorrow that can sometimes humble a species which often suffers from overweening pride.

It can sometimes make you cry.

The Mundanity of Some Yellow Things

We went out for a walk on Scott Boulevard and saw a lot of yellow things. We were looking for Goldfinches. We saw mostly yellow flowers.

Compass flowers were everywhere. It looked like most of the flowers were facing east. However, it turns out that it’s the leaves that point east.

Black-eyed Susans competed with the Compass Flowers. Both made it more difficult to spot the male Goldfinches, which are brilliant yellow. We never got a snapshot or video of any of them, though we could see them flitting about at lightning speed.

We also saw a yellow airplane flying repeatedly around and around above fields and over the land surrounding Scott Boulevard. It seemed to be painted both yellow and black, raising the question of whether it’s linked to University of Iowa. It seemed to fly in ellipses from east to west and back. It was a mystery.

Later, my romanticizing imagination led me to think maybe the pilot was drawing a massive compass flower in the air, tracing the path of each petal.

Eventually, Sena said several times she thought the plane was crop dusting, which I pooh-poohed.

After we got back home, I took a close look at the videos I shot of the yellow plane. Using my video editing software, I could mitigate the camera shake artifact and sharpen the still images I got from the best clips.

I found one image which displayed a number on the tail, N942QC. The tail number is an alphanumeric code which identifies a specific airplane. I looked it up on the FAA Registry.

The plane was probably not drawing fanciful ellipses. It belongs to a company called Thompson Aero Inc, which operates in Amana, not far from Iowa City. It’s been in operation for 38 years. The business description says: “This organization primarily operates in the Crop Spraying Services business/industry within the Agricultural Services sector.”

Once again, Sena is right about the importance of mundanity.

Overdiagnosis of Psychiatric Disorders Still Happens

I read an excellent article in Clinical Psychiatry News recently in the Hard Talk section. The title is “A prescription for de-diagnosing” by psychiatrists Nicholas Badre, MD and David Lehman, MD in the July 2022 issue (Vol 50, No. 7).

The bottom line is that too many psychiatric patients have too many psychiatric diagnoses. A lot of patients have conflicting diagnoses (both unipolar and bipolar affective disorder for example) and take many psychotropic medications which may be unnecessary and lead to side effects.

It takes time to get to know patients in order to ensure you’re not dropping diagnoses too quickly. Discussing them thoroughly in clinic or in the hospital is an excellent idea. And after getting to know patients as people, it makes sense to discuss reduction in polypharmacy, which can be quite a burden.

This reminds me of the Single Question in Delirium (SQiD), a test to diagnose delirium by simply asking a friend or family member of a patient whether their loved one seems to be more confused lately. It’s a pretty accurate test as it turns out.

This also reminds me of the difficulty in making an accurate diagnosis of bipolar disorder. I and a Chief Resident wrote an article for The Carlat Report in 2012 (TCPR, July / August 2012, Vol 10, Issue 8, “Is Bipolar Disorder Over-Diagnosed?”) which warned against overdiagnosis of bipolar disorder. Excerpts below:

Some argue that bipolar disorder is actually under-diagnosed. They have support from abundant literature showing that bipolar disorder tends to present more often with depression than mania or hypomania (Judd LL et al, Arch Gen Psychiatry 2002:59(6):530–537). As many as 10% of patients with unipolar depression ultimately are shown to have bipolar illness instead, according to some experts (Goodwin GM et al, Eur Neuropsychopharm 2008:18(7):535–549). (See this month’s Q&A with Claudia Baldassano for more on this.) In addition, a new emphasis on subthreshold mood symptoms and more rapid mood shifts has led some psychiatrists to promote the concept of a “bipolar spectrum disorder” (Youngstrom EA et al, Curr Psychiatry Rep 2010;12(6):479–489).

While it’s important to remain vigilant about a history of manic and hypomanic symptoms, we think the problem of over-diagnosis is probably greater. For instance, in a 2008 study, Zimmerman and colleagues performed a comprehensive diagnostic interview on 700 patients, nearly 21% of who self-reported a history of “bipolar disorder.” However, when using the gold-standard SCID (structured clinical interview), only 13% had the diagnosis; they also had more first-degree relatives with bipolar disorder than the others (Zimmerman M, Ruggero CJ et al, J Clin Psychiatry 2008:69(6):935–940). The authors hypothesized that over-diagnosis of bipolar disorder might be a consequence of efforts to improve recognition of it and avoid under-detection. In fact, the same authors studied 40 depressed patients previously diagnosed with bipolar disorder and found that, by the SCID, they had specific phobia, PTSD, drug abuse/dependence, or a personality disorder instead (Zimmerman M et al, Compr Psychiatry 2010;51(2):99–105).

Over-diagnosis can also occur when apparent mood episodes are defined as psychiatric when in fact, they have a different etiology altogether. Decreased need for sleep, disorganized or racing thoughts, increased activity and agitation, and delusional thinking, even when they occur together, can represent a sort of “final common pathway” for medical conditions and other syndromes. The manic phenotype can occur in patients with agitated delirium, brain tumors, corticosteroid treatment, and of course substance intoxication (Bunevicius A et al, CNS Spectr 2008;13(11):950–958; Brooks JO and Hoblyn JC, Am J Psychiatry 2005;162(11):2033–2038). These other phenotypes can be distinguished by recognition of key features such as the fluctuating nature of consciousness in delirium, neuroimaging findings, and positive urine drug screens.

Unfortunately, physicians may also be susceptible to diagnostic shortcuts. When faced with limited time for diagnostic interviews and the pressure to prescribe by patients and their families, well-meaning clinicians may give the diagnosis after a single brief interview. Not uncommonly, we find that it was diagnosed on the basis of mood fluctuation over minutes, temper tantrums, and fleeting insomnia. The rapidly expanding repertoire of medications approved for bipolar disorder, and their relative ease of use, may also contribute to over-diagnosis. Unfortunately, in some cases the treatment may be worse than the symptoms themselves (Iordache I and Low NC, J Psychiatry Neurosci 2010;35(3): E3–4).

I was accustomed to asking what I called the Single Question in Bipolar (SQiB). I frequently saw patients who said their psychiatrists had diagnosed them with bipolar disorder. I would ask them, “Can you tell me about your manic episodes?”

Often, they looked puzzled and replied, “What’s a manic episode?” I would describe the typical symptoms and they would deny ever having them.

The article by Drs. Badre and Lehman is a bit disappointing in that it doesn’t look as though we’ve improved our diagnostic acumen much in the last decade.

We need to try harder.