I almost never write more than one post a day, but I’m pretty impressed with the blog post “The Perfect Balance” by The Goodenough Psychiatrist. It was very thought-provoking and the Stuart Ablon Ted Talk on Collaborative Problem Solving was refreshing.
A little over 3 ½ minutes into the video, Ablon says something interesting about conventional wisdom which helps cast doubt on blindly trusting it. When he remarks that conventional wisdom commonly fosters misconceptions including teaching that the earth was flat, it reminded me of a scene from Men in Black (I confess, one of my favorite movies). Agent K says, “A person is smart. People are dumb, panicky dangerous animals and you know it. Fifteen hundred years ago everybody knew the Earth was the center of the universe. Five hundred years ago, everybody knew the Earth was flat, and fifteen minutes ago, you knew that people were alone on this planet. Imagine what you’ll know tomorrow.”
His remarks highlight the challenge to those who break with conventional wisdom, which can sometimes be isolation.
I brought my camp stool home from my office at the hospital yesterday. For the past several years and up until the time of the COVID-19 pandemic, I used it while interviewing hospitalized patients as part of my job as a consultation-liaison psychiatrist in the general hospital. I stopped only when I wondered whether carrying around an object which could be contaminated with the virus was a safe thing to do.
A colleague lent me the little chair when he and his colleagues on the Palliative Care Medicine consultation service started using them. I asked him whether he wanted it back and he graciously said I could take it with me now that I’m retiring—and use it as a camp stool (in a way, saying “Please take your seat”). For many years prior to getting the stool, I had been finding a chair or sending my trainees to find one for me. I felt more comfortable sitting eye to eye with patients and I got the impression that my patients appreciated that as well.
I got a lot of positive feedback from patients, family members, and other hospital staff about the little chair. I think it helped break the ice with patients and was a great opener, especially if they felt well enough to express a sense of humor— “Hey, doc; you don’t need nunchucks; I promise I’ll be good!”
There are a few papers in the medical literature supporting the usefulness of sitting with patients. Most authors assert that it helps build rapport and increases the patients’ perception of how interested their physicians or other health care clinicians are in their welfare (see the reference list below).
Once, when my original little chair broke beneath me during an evaluation for catatonia in one patient, the stool abruptly became a novel catatonia assessment tool.
The patient was mute but there was little evidence otherwise for catatonia, one of the chief features of which is the inability to react to any stimulus in the environment. I was seated on the chair explaining in detail the intravenous lorazepam challenge test for catatonia (which often interrupts the episode of muteness and immobility).
I was sitting in front of the patient but facing the family and the consult service trainees while expatiating on the topic. As I was droning on, I heard a sudden pop—and I fell flat on my fundament as the chair collapsed beneath me.
My audience exploded in loud laughter, and pointed at the patient. When I turned to look at him, he was convulsed with silent mirth.
I considered this a negative test for catatonia in this case, though impractical for regular use.
My colleague gave me a replacement camp stool, more securely built. However, he mentioned he might give up using his as a result of my accident which, incidentally, befell (rimshot) another doctor on his team. I’m not sure whether I’ll use the little chair. If I sit on it too long, my legs go numb. I think that’s about 10-15 minutes, about the length of time mentioned in one of the studies below. It didn’t seem to influence the positive perception of the visit—but it did make me walk funny.
I probably spend about the same time with patients now that I don’t use the little chair. But I don’t feel right about it. I’m always reminded of what Hackett said:
“As a matter of courtesy, I sit down when interviewing or visiting patients. Long accustomed to the ritual of making rounds, many physicians remain standing as a matter of course. Standing, physicians remind me of missiles about to be launched, poised to depart. Even if that is not necessarily true, they look the part. Patients sense this and it limits conversation. In addition, when standing, the physician necessarily looks down on the patient. This disparity in height is apt to encourage the attribution of arrogance. Looking down at a patient who is prone emphasizes the dependency of the position. Sitting at the bedside equalizes station. Sitting with a patient need not take longer than standing with him.”—Thomas Hackett, in MGH handbook of general hospital psychiatry, 1978.
References:
Johnson RL, Sadosty AT, Weaver AL, Goyal DG. To sit or not to sit?. Ann Emerg Med. 2008;51(2):188‐193.e1932. doi:10.1016/j.annemergmed.2007.04.024
Swayden KJ, Anderson KK, Connelly LM, Moran JS, McMahon JK, Arnold PM. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ Couns. 2012;86(2):166‐171. doi:10.1016/j.pec.2011.05.024
Strasser F, Palmer JL, Willey J, et al. Impact of physician sitting versus standing during inpatient oncology consultations: patients’ preference and perception of compassion and duration. A randomized controlled trial. J Pain Symptom Manage. 2005;29(5):489‐497. doi:10.1016/j.jpainsymman.2004.08.011
Orloski CJ, Tabakin ER, Shofer FS, Myers JS, Mills AM. Grab a Seat! Nudging Providers to Sit Improves the Patient Experience in the Emergency Department. J Patient Exp. 2019;6(2):110‐116. doi:10.1177/2374373518778862
Merel SE, McKinney CM, Ufkes P, Kwan AC, White AA. Sitting at patients’ bedsides may improve patients’ perceptions of physician communication skills. J Hosp Med. 2016;11(12):865‐868. doi:10.1002/jhm.2634
While we were out for a walk on the Terry Trueblood Trail today, for a change, my wife gave me the idea that we should just let nature speak. The frogs were in full voice. It was impressive. As we walk, we usually start off by talking a lot. We point out interesting birds and flowers and comment on all we see and hear. The further we go on the trail, the quieter we get. Pretty soon, we don’t talk much at all. We walk at a slower pace. We just listen.
Usually, after we return home, I make a video and try to match it with some kind of music. Nature has its own music, though. Today, we just let that happen.
Happy Mother’s Day! The blog post for today is a little unusual because it’s about a “mother” robin who built a nest on April 9, 2019 and is still sitting on it as of today. It’s unusual because she’s been sitting on the nest for at least a couple of weeks now even though there have been no eggs in it. We can’t figure why she’s sitting on an empty nest.
Things got started relatively well. In fact, after building the usual sloppy nest, the mother robin laid two eggs in it. That was the largest number of eggs we ever saw. The number went down from two eggs to one to none over a couple of days or so.
“And then there were none.” I never read Agatha Christie’s book by the same name or saw the TV miniseries on which it was based several years ago. On the other hand, death played a role—a natural one—in the case of the very devoted mother robin.
The robins built their nest in an evergreen tree right below one of our windows. What was nice about that was that I never had to creep up on them, see them thunder out of the tree, mess with the branches around the nest, snap photos—and leave a scent trail for large predatory birds.
Now, speaking of predatory birds…I never saw any of them this time. I know last year I heard a heavy flapping noise (like bedsheets on a clothesline) outside of my office window and opened the blinds just in time to see a huge crow or turkey vulture take off from our front yard tree. Its beak was full of house finch nestlings. I swore I would never again engage in monitoring bird nests in that way.
This time there was only circumstantial evidence of nest robbery. My wife saw broken egg shells on the ground under the tree but it’s not clear exactly when she saw that.
But mother robin still sits on the nest. I have not been able to find any information about this behavior in nesting birds.
It’s not that birds never display odd nesting behavior. One of E.B. White’s essays, “Mr. Forbush’s Friends,” published in the Essays of E.B. White (White, E. B. (1977). Essays of E.B. White. New York [etc.: Harper and Row), describes a great number of these peculiar behaviors. One quote: “Had pair of Carolina wrens build nest in basket containing sticks of dynamite. No untoward results.”
I did wonder why our mother robin built a nest so visible from the sky. That was as bad as building a nest in a basket of dynamite. I know we have a tendency to anthropomorphize animal behavior, but I’m having trouble explaining this mother robin’s persistence in sitting on an empty nest. There are no new eggs; yet she acts as if eggs are there. Is she grieving? Is she hallucinating? How long will this go on?
Maybe some of you know what this is all about and I welcome your comments. Until then, it looks like for this robin, Mother’s Day is endless.
The robins are building their Hurrah’s nests in our back yard again. That’s about the only thing that has not changed. The COVID-19 (C-19) pandemic has changed just about everything else in our lives.
I wear a face shield now at the hospital. We’re told to wear it as much as possible, like putting on our clothes in the morning. Don’t we leave them on all day? The shield keeps you from touching your face, which is why it’s better than a face mask. However, I’ve noticed something about wearing the face shield for much of the day. Before I describe it, let me give you analogy: If you’ve ever worked detasseling corn when you were young a long time ago, you might remember what happened when you closed your eyes at night and tried to go to sleep. I saw corn fields—miles and miles of corn fields. When I opened my eyes, the vision would disappear. But as soon as I closed my eyes again, I saw the vast corn fields.
It’s crazy, but I have a similar sensory after-effect when I doff my face shield–sometimes I still feel the headband. The pressure of it is just the same as if I were still wearing it. I suppose it’s because I cinch it too tightly. But if I don’t, it slips down my brow, pushing my eyeglasses down my nose.
Another change—I’m a Consultation-Liaison (C-L) Psychiatrist, so I’m used to washing my hands in between patients in the hospital. Now, I’ve got something I’ve never had before–alligator hide patterns on the backs of my hands. They’re dry and cracked. I don’t count the number of times I wash my hands, but it’s a lot more frequent than I used to do. It’s not uncommon for health care professionals to wash hands 75-100 times a day in the C-19 era. I have to use hand cream conscientiously—something I almost never did.
I’m less comfortable being closer than several feet away from people. I tend to hug the walls and corners in stairwells, where I now encounter more people than I ever have before. I guess the message everyone hears is “Stand by me—six feet away if you please.”
I don’t shake hands anymore. The lines into the hospital sometimes lead to crowding while we wait to have our temperatures taken and answer the screening questions about whether we’ve had fever, cough, shortness of breath, etc. It’s perfunctory most of the time, because virtually always the answer is “no” and everybody is in a hurry.
I don’t carry my little camp stool with me anymore, which allowed me to sit down with patients and have face to face, eye level interaction. I’m distinctly uncomfortable standing over them because I haven’t done that in years. If there is a chair in the room, I’m hesitant to use it because, like the camp stool, I worry that it might carry C-19 virus on its surface.
I used to evaluate psychiatric patients in our emergency room by simply going there and seeing them face to face, either in their rooms or, when it was really busy (which is most of the time), in the hallways.
I just used a remote telehealth interface platform using an iPad the other day, which allows me to interview patients from my office, in order to avoid the risk of contagion. It was a little slow and awkward, and I was uncomfortable that a health care professional had to be in the emergency room to hold it up for the patient—who was covered in blood. I felt a little guilty.
I used to round with medical students and residents on our patients. We were the movable feast, a sort of MASH (Mobile Army Surgical Hospital) unit, more like Mobile Unifying Shrink Hospital (MUSH). Unifying means unifying medicine and psychiatry. The medical students are not permitted on the wards now, in order to protect them. It’s awkward rounding with only one resident at a time, although another resident can do other things like chart review and telephone relatives for collateral history. I get in the hospital earlier nowadays, and see many non-C-19 patients alone without trainees, preparing for the C-19 surge when I expect we’ll get many more consultation requests to help care for C-19 patients with delirium and depression. It’s a one-man hit-and-run psychiatry consult service and efficiency is mandatory to meet the demand.
I see patients by myself for another reason. Try as we might, C-19 positive patients will slip through the screens. Many are asymptomatic but contagious, and any test will have false negative results. The idea is to expose the least number of health care front line staff members as possible. Faculty capacity is stretched pretty thin, which is pretty much the situation everywhere. I have to choose. I’m older. I’m weeks from retirement. I’m afraid.
But robins don’t have the burden of choice. They obey their instinct every spring, just the same.
Today we took a break from the intensity of the pandemic and went out for a walk on the Terry Trueblood Trail. We were a little surprised at the crowd. There were more people there than we’ve ever seen before.
We’re social creatures. After a while, we get a little tired of everything being about coronavirus and making homemade masks out of bandanas and rubber bands. I made one of those—but I didn’t wear it out on the trail. Most people didn’t.
Sena bought me short sleeve shirts so I can be bare below the elbows at the hospital. I’ll think about it tomorrow.
Today we listened to the Eastern Meadowlark’s song and watched Tree Swallows kiss each other on the beak. We saw American Coot up close for the first time.
They were catching bass in the lake. Nobody wants to clean them so they just throw them back. The frogs are cheeping.
We found a little American flag laying on the walkway. We stuck it in the ground and watched it wave. The Tree Swallow nest boxes were stamped “Made in America.”
I wondered how all of these things came together on a sunny afternoon in the spring. I can’t figure it but it sure was nice.
I remember when we were kids, we used to get gifts of fruitcake from well-meaning older ladies in our church. I think that’s where I first learned how to lie. If my little brother and I didn’t praise the weaponized loaf of glazed, syrupy candied fruit studded with rotten walnuts, we caught hell from Mom. Lying gets a bad name, I know. But if you don’t learn this essential social skill early in life, you end up with a sore backside from the paddle in the corner of the family room. Ironically, the paddle was a repurposed paddle ball toy we got for Christmas—which was always the time the old ladies from church would gift us with fruitcakes from outer space, obviously via wormhole vortex.
Speaking of friends, we occasionally had dinner with an older couple, RellaMae and Ray, who owned a gargantuan mongrel dog, part bull mastiff and part mastodon. His name was Moose. When he was tied to a post out in the back yard, he spent a lot of his time barking and snarling at anything living that passed by, especially the paperboy. On the other hand, he played like a puppy with me and my brother. At the dinner table, he would lay his head on my knee, mournfully staring at every forkful and leaving a pond of drool on my pants.
RellaMae was tickled to death with her old Chrysler which had a push-button transmission. I bet you thought that was a modern invention. I know next to nothing about cars, but Chrysler made some of these in the 1950s and 1960s. We went for a drive in it and I half-expected it to fly. It was pink, if I recall correctly. Ray was a cab driver with bad heart disease who chewed on but did not smoke cigars the size and consistency of Black Angus bull turds. The cab dispatcher where he worked had a singular talent. The phone was always busy but because she was the only dispatcher, she had to make her bathroom breaks very speedy. The legend was that she could be in and out in less than a minute.
The push-button Chrysler reminds me of a car my wife and I owned for a while sometime in the 1980s to 1990s which talked to you. I believe it was a New Yorker. It said things like “A door is ajar” which everyone made jokes about (When is a door not a door? When it’s ajar). Har! That chatty car got me across Iowa, Missouri, Illinois, Michigan, Indiana, and Ohio when I was interviewing for residency. I got stranded along with a lot of other motorists at a rest stop on the way back from Ohio because of a snowstorm. That was brief, uneventful, and we were on our way after the plows went through in a couple of hours.
But that does remind me of another time I got stranded in Wyoming on my way back home from college in Texas. I traveled by bus back in those days and me and my fellow passengers were stuck in a hole in the wall sandwich and gift shop at the bus depot. A couple of us sat at one of the tables and were entertained by what sounded like tall tales from a couple of local guys bragging about their criminal exploits. One of them finally pushed up his sleeve, exposing his arm which was covered with about a half dozen or so wristwatches—which he hinted were stolen and he was trying to sell.
You can tell when somebody is in his anecdotage. Anybody out there with a story?
I began rereading the book Invisible Man by Ralph Ellison today, which is Leap Day. Given what little I know about Leap Day and Leap Year in general, there isn’t a connection.
I first read Invisible Man well over 40 years ago. It was a paperback and I took it with me to Huston-Tillotson College in Austin, Texas (now Huston-Tillotson University), one of the historically black colleges and universities (HBCUs) in the United States.
It was very hot in Austin in my freshman year and the students didn’t have air-conditioned dormitories in those days. It must have been over 90 degrees. The glue melted on most of my paperback books, including Invisible Man. I suppose that’s why I eventually threw the book away, because it was falling apart.
After all these years, I bought a hardcover edition. We have air-conditioning now. I was motivated to read it again after I read Invisible Hawkeyes: African Americans at the University of Iowa during the Long Civil Rights Era, edited by Lena M. Hill and Michael D. Hill. See my blog posts, Milestones, and The Iowa River Landing Sculpture Walk, for background.
When I was a young man, I identified with the protagonist in Invisible Man. The Prologue still strikes a chord.
On the other hand, I googled my name today and found a few links that made me feel less invisible. Probably the most surprising link was to an interview with me entitled “James Amos, MD,” which you can read here. The piece evoked memories of a past version of me—which has not changed much since then. It mentions my former blog The Practical Psychosomaticist which I later renamed The Practical C-L Psychiatrist (C-L stands for Consultation-Liaison) after the flagship organization, the Academy of Psychosomatic Medicine changed its name to the Academy of C-L Psychiatry in response to a poll of its membership asking whether the name should be changed.
This biography makes me more visible, at least on the web. On the other hand, the blog no longer exists, due in part from my concerns about the General Data Protection Regulation (GDPR), which was enforced in 2018. I posted a lot of educational material about C-L Psychiatry on the blog along with pictures and presentations of my trainees. In a way, I did not protect their privacy and I was uncomfortable about that.
Other web pages surfaced during my self-googling. They included my article on delirium, “Psychiatrists Can Help Prevent Delirium,” posted on Psychiatric Times in 2011.
I also found my blog post on physician burnout, “How I left the walking dead for the walking dead meditation,” published on the Gold Foundation web site in 2014.
And there was my other Gold Foundation post about rude doctors, “Are doctors rude? An insider’s view,” posted in 2013.
There are a couple of petitions left over from years ago as well, about the controversial Maintenance of Certification (MOC) and the closure of state mental hospitals in Iowa several years ago.
I also found my review of Dr. Jenny Lind Porter’s book, The Lantern of Diogenes and Other Poems (published 1954).
The book seller’s note to me when Porter’s book was delivered in 2011 read as follows:
“Thanks for your purchase! It’s rare to find a book of this age that when you open the pages, it creaks like it is unread. I guess someone liked the way it looked on their bookshelf! Haha! Enjoy the book and Happy New Year, Rob J.”
An unread author is an invisible author. The first poem in the book is below:
The Lantern of Diogenes
by Jenny Lind Porter
All maturation has a root in quest.
How long thy wick has burned, Diogenes!
I see thy lantern bobbing in unrest
When others sit with babes upon their knees
Unconscious of the twilight or the storm,
Along the streets of Athens, glimmering strange,
Thine eyes upon the one thing keeps thee warm
In all this world of tempest and of change.
Along the pavestones of Florentian town
I see the shadows cower at thy flare,
In Rome and Paris; in an Oxford gown,
Men’s laughter could not shake the anxious care
Which had preserved thy lantern. May it be
That something of thy spirit burns in me!
Dr. Porter’s house in Austin, Texas was demolished a few years ago. There were plans to build a house there reminiscent of the architectural style of her original home and also a remembrance of her published work. I just noticed a satellite image of the property. There is no visible evidence that anything of that nature was ever built. Dr. Porter is, in a sense, invisible although her lantern still burns.
Visibility is a relative term. My advancing age and approaching retirement sometimes lead me to feel like I’m becoming invisible, gradually vanishing from the landscape of consultation-liaison psychiatry and general medicine.
Ralph Ellison’s book Invisible Man is a visible legacy. My legacy is small—yet the flame flickers, visible after all.
I’ve seen the news warning us about how facial hair can interfere with the N95 respirator mask seal. It’s connected with the concerns about the novel coronavirus which you no doubt have heard unless you live under a rock. The Centers for Disease Control (CDC) reiterated their warning about how certain beard and mustache styles can interfere with the recommended mask for helping protect you from infection.
As a health care worker, I’m required to be fit tested annually for the N95 respirator mask. “Fit” is not an acronym, by the way; it just refers to how well the mask fits. It’s a twenty-minute test in which a technician or nurse uses a special machine to check for how tight the seal is around the mask in order to ensure protection from airborne particles, including viruses.
I passed my fit test.
I saw the graphic yesterday of all the different facial hair styles that pass muster—most of them don’t. I’ve never heard of half of them. Believe it or not, I didn’t know that little tuft of hair under my lower lip is called a “soul patch.” I guess maybe I’m the one who’s been living under a rock.
I’ve read that some experts think that any facial hair is bad and recommend that you have to be clean shaven. I think some places won’t even allow fit testing on anyone who has facial hair.
However, I found a PubMed study published in the latter part of 2018 which showed that you can pass a fit test “even with substantial facial hair in the face seal area;” the abstract is below:
Floyd, E. L., et al. (2018). “Influence of facial hair length, coarseness, and areal density on seal leakage of a tight-fitting half-face respirator.” J Occup Environ Hyg 15(4): 334-340.
BACKGROUND: OSHA regulations state that an employer shall not permit tight-fitting respirators to be worn by employees who have facial hair that comes between the skin and facepiece seal. Studies have shown that facial hair in the face seal zone can increase penetration and decrease the fit factor (FF), although the relationship between the amount and characteristics of facial hair and the increase in penetration is not well quantified. This article examines the influence of facial hair length, areal density, and coarseness on FF for one model of half-face elastomeric negative-pressure air purifying respirator. APPROACH: Quantitative fit tests (QNFT) were performed on 19 subjects with beards initially 0.500-in long and subsequently trimmed to 0.250, 0.125, and 0.063 in, then after a razor shave. Three fit tests were performed at each of the 5 lengths, for 285 total tests. The average diameter and areal density of cheek and chin hair were measured. Penetration was modeled as a function of hair length category, beard areal density, and hair coarseness. RESULTS: FF decreased with beard length, especially beyond 0.125 in. However, passing FF scores were achieved on all tests by all subjects at the smooth shave and 0.063 in conditions, and 98% of tests were passed at 0.125 in; seven subjects passed all tests at all conditions. Chin and cheek areal densities were significantly different and were only weakly correlated. Beard hair diameters were normally distributed across subjects (mean 76 microm, standard deviation 7.4 microm). Beard length and areal density, but not coarseness, were statistically significant predictors of fit using an arcsine transformed penetration model. FF decreased with increasing beard length, especially beyond 0.125 in, although FF with a “stubble” beard did not differ significantly from a smooth shave. FF also decreased with increasing areal beard hair density. CONCLUSION: Beard length and areal density negatively influence FF. However, tight-fitting half-face negative-pressure respirator fit tests can achieve adequate fit factor scores even with substantial facial hair in the face seal area.
I generally have a stubble circle beard. When I don’t use the stubble guard on my trimmer for a while, I supposed my chin whiskers could lead to what some have called the “goatee leak.”
The CDC web site posted a funny article in 2017 on their web site entitled, “To Beard or not to Beard? That’s a good Question!” That facial hair chart is in the article. They also remind you check your mask seal every time you use it, no matter what your facial hair status is.
There’s a pretty funny YouTube video about this issue. The title is “The Bearded Guide to N95 Respirator Fit Testing.” My video is below.
I’m a little late for Valentine’s Day, but you could give me a break because I’ve been a little busy being retired. Don’t throw things at me because I’m getting too old to duck. And I did get my wife a card, flowers, and some candy on time.
It was something else I forgot. It’ll take a few days before I can tell you what it was.
We made a Valentine’s Day wish by breaking a chicken wishbone the other day. I believe that was before Valentine’s Day. In fact, it was about a week prior.
I don’t know if there are any rules about how to you’re supposed to hold the wishbone. Some will probably say our technique was poor when they see the video.
I think if you talk about what you wish for, you’re liable to break the spell and you won’t get what you wish for. I believe you’re allowed to hint, though. Pay close attention to the video.
Go Retire Psychiatrist 