reminiscence – Page 11 – Go Retire Psychiatrist

Thoughts On Laptop Computers

We bought a laptop computer. It has been years since I’ve used one. I forgot how exasperating a touchpad is. Luckily, we have a spare wireless mouse and a USB port. The laptop is slim and very light, like most laptops these days.

I remember the first “laptop” I had early in my career as a consulting psychiatrist. I think it weighed about 2-3 times what the modern ones weigh nowadays. I think I could have stopped a thief from taking it from me by whacking him over the head with it.

If I remember correctly, it had a slot for floppy discs and another for disc media. It developed a hardware problem which forced me to box it up and send it back to the manufacturer for repairs. I don’t remember how long I kept it after that.

The new laptops don’t have any internal optical drives built into them.

I read a tech article in which the author’s opinion about the gradual disappearance of internal optical drives and other physical media for laptops was probably the result of large companies finding out they could make more money by charging subscription fees for digital media.

Microsoft comes to mind.

In Memory of L. Jay Stein

I was thinking of one of the Johnson County judicial mental health referees I often worked with years ago. L. Jay Stein died in 2014. I looked up his obituary the other day and was a little surprised to find I had written a remembrance for him. I’d forgotten it.

“I will always remember my first encounters with Judge Stein. I was a first-year resident in psychiatry at The University of Iowa Hospitals & Clinics. He often presided at mental health commitment hearings at which I was often the nervous trainee providing “expert testimony” as the treating physician. Jay taught me and countless other psychiatry residents about the importance of procedure. His knowledge was prodigious. But it was his compassion, his fairness, and his inimitable sense of humor I will always treasure.”

Judge Stein’s vocabulary was impressive. Even his recorded telephone automatic replies sounded amusingly erudite. Occasionally, when I had a question about legal procedures in mental health I would call him but get his answering machine. These out of office replies were entertaining and sounded very much like the way he did during commitment hearings. I can’t remember all of it, but it began with something like, “Once again, your request has been denied…” It made me think of what I might hear at a parole hearing—not mine of course.

L. Jay Stein was wise and funny.

Thoughts on Down Time Activities for Land Survey Technicians

I was just thinking about the old-time land survey crews. When I was getting on the job training as a survey technician, the typical land survey crews were at least 2-3 persons. One rodman, one instrument man, and a crew chief who organized the job, which could be property or construction jobs.

Nowadays, you get by sometimes with one man doing the jobs using a theodolite that measures angles and distances. You don’t always need a physical measuring tape; you can use something they call “total stations.”

It’s cheaper for engineering companies to use one man survey outfits. On the other hand, one disadvantage is the lack of mentoring for learners who want to become land surveyors or civil engineers.

Mentoring from surveyors on the survey back in the day not only taught me such skills as how to throw and wrap a surveyor’s steel tape—it also taught me how to work well with others as a team. Of course, this was transferrable to working on the psychiatry consultation-liaison service in a big hospital as well.

It’s well known that playing cards in the truck while waiting for the rain to stop was an essential skill. I don’t know how they manage downtime nowadays. We didn’t play cards on the consultation service during downtime, partly because we didn’t have much downtime.

Anyway, as I mentioned in a recent post, we played Hearts in the truck on rain days. I always sat in the middle. At the time, I was a terrible card player in general. It was a cutthroat game and I had trouble remembering which cards had been played.

When you consider that the strong suit of engineers and surveyors is math ability, you’d think that survey crews would have figured out a way to play Cribbage during downtime. You can have a Cribbage game with 3 or 4 people although I’ve never played it that way. If there are 3 players, it can still be cutthroat.

The one problem I can see is that, the guy sitting in the middle would have to set the board on his lap. You’d almost need a special, custom-made board which would have a space for placing the cards to keep track of what’s been played. I think that might have made things easier for me.

The other drawback to one man survey crews is that pretty much the only card game you can play is solitaire.

What Kind of Mailbox Does the USPS Really Want from Us?

I just saw the latest headline about the United States Postal Service (USPS) new recommendation that we all get a nice, big mailbox. Huh?

I gather one reason for the suggestion is to cut down on mail theft. I don’t think I’m allowed to put a lock on a mailbox, no matter how big it is.

In fact, the only way I’ve seen to reduce (notice I said reduce, not eliminate) mail theft are those big mailbox clusters you see everywhere in neighborhoods nowadays. Those are the neighborhoods with Homeowners Associations (HOAs), which require you to paint your window trim with beige (not taupe, read my lips!) or face lawsuits.

You know about those clusters, they’re a block away from your house. And you know how small your mailbox is there, yet the postal service is also big on recommending that you use them, probably because it makes their job easier. Which is it? Big mailbox with no lock or big locked mailbox cluster with small boxes?

Is the postal service in charge of maintenance on those mail cluster boxes? Of course not. We’re responsible for clearing away the ice and snow. And is theft not a problem with the cluster boxes? Scan the web for stories about armed bandits who hold up the letter carrier for the key. It happens.

Bigger mailboxes are not the answer to the postal service problems. They can attract the Halloween pranksters showing off their Hank Aaron batting skills (look him up!) and sadistic city snowplow drivers who like dragging your mailbox into the next county after plugging your driveway.

I can remember when the letter carrier walked the delivery route pushing a cart filled with mail. He stopped at every house in the neighborhood to put your mail in the mailbox, which was attached to the front of your house, or to drop it in the mail slot in your front door.

I’m not saying mail theft was not a problem in those days, but I don’t recall hearing about it on the news broadcasts or reading about it in the newspaper—which I hand delivered, sometimes risking injury from big dogs. The only theft I recall was by customers who avoided paying when I tried to collect:

“Do you have change for a hundred-dollar bill, sonny?”

“I’m a paperboy, not a banker!”

“Come back next week.”

Here’s an idea. What if some scientist invented a mailbox which contained a device which would trip only after your mail was delivered? This device would spray concentrated poison ivy resin all over the inside of the mailbox, teaching thieves a lesson. Of course you would have to wear gloves to collect your mail.

Another idea is to make your own mailbox, which would be big enough for a Ninja warrior to hide inside. That would surprise the crooks! I think you can get a Ninja for a fair price on eBay.

Big Mo Pod Show: “In Search of Good Company”

When I listen to the Big Mo Pod Show, I tend to almost free associate to memories which the songs sometimes evoke. The 5 songs this week came from, as usual, his Big Mo Blues Show this past Friday night. The theme of the pod show was “In Search of Good Company.”

I’m not so sure about good company thoughts, but the comments about Muddy Waters song “Long Distance Call” reminded me of something way back in my past. Big Mo talked about making long distance calls a long time ago, which he connected with pay phone booths.

I don’t think I’ve seen an actual pay phone booth in decades, since the invention of cell phones and that kind of technology. But the conversation about phone booths reminds me of my youth.

I used to live at the YMCA and the rooms didn’t have phones. No cells phones were available back then because it was well before the 1980s. The only way you could place a phone call was to use the one phone booth in the building, which was on the second-floor landing. The rooms were on the third floor, and they were for men only, of course.

Also on the third floor was an old snack vending machine and I’m pretty sure I’ve told this story before as I recollected while writing this post.

I got a Butterfinger candy bar from that vending machine one time. I took a bite out of and saw half a worm wiggling around in it. You don’t want see a worm at all, but half a worm has a whole different meaning.

I was worried and used the pay phone to call the local emergency room. I think I paid less than a quarter to place the call.

I guess I would have been relieved to hear the ER doc tell me that I would be OK—if he hadn’t been laughing so hard. Good thing it wasn’t a long distance call.

Reminiscence of My Younger Days

The other day we had some stormy weather roll across central Iowa, although it was not as bad as the tornado that swept through Greenfield. We hope the best for them. We didn’t actually get a tornado, but I remember wondering why the siren went off about 6:00 a.m. It woke me up and I wondered what was the matter. Turns out it was a tornado warning and we had to sit in the basement for a little while. It was a little scary, but the storm moved east pretty quickly northeast out of our area.

For whatever reason, this eventually led to my reminiscing about my younger days. Maybe it was because of a temporary scare and increased awareness of our mortality.

I used to work for a consulting engineers company called WHKS & Co. in Mason City, Iowa. This was back in the days of the dinosaurs when it was challenging to set stakes for rerouting highways around grazing diplodocus herds.

I was young and stupid (compared to being old and stupid now by way of comparison). I lived at the YMCA and took the city bus to the Willowbrook Plaza where the WHKS & Co. office was located on the west side of town.

I usually got there too early and stopped for breakfast at the Country Kitchen. The waitress would make many trips to my table to top off my coffee while I sat there waiting for the office to open. That was fine because I had a strong bladder in those days. I left tips (“Don’t cross the street when the light is red”).

My duties at WHKS & Co. included being rear chain man and rod man, at least when I first started. A “chain” was the word still being used for a steel tape for measuring distances. It was well past the days when land surveyors used actual chains for that purpose. You had to use a plumb bob with the chain to make sure you were straight above the point (usually marked by a nail or an iron property corner pin) you measuring to and from.

You and the lead chain man had to pull hard on each end of the chain to make sure it was straight. It was challenging, especially on hot days when my hands were sweaty and the chain was dirty. Callouses helped.

The rod was for measuring vertical distances and an instrument called a level was used with that. One guy held up the rod which was marked with numbers and the guy using the level read the elevation. Another way to measure both horizontal and vertical angles used a rod and a different instrument that we called a theodolite (older instrument name was “transit”).

We worked in all kinds of weather, although not during thunderstorms. In fact, when it was looking like rain out in the field, a standard joke for us sitting in the truck waiting for rain was to draw a circle on the windshield (imaginary, you just used your finger although if your finger was dirty which it always was, you left a mark) and if a certain number of drops fell in the circle, you could sit in the truck and play cards.

When we played cards, it was always the game Hearts, which I could not play skillfully at all. I always lost. But it kept us out of the rain. If a big thunderstorm blew in, we just headed back home.

We never got caught in a tornado.

Consultation-Liaison Psychiatry as a Supraspecialty

I just rediscovered this old blog post below from 2010 in my files. The literature citations are dated, of course. I just wanted to reminisce about how I used to think through issues in consultation-liaison psychiatry. The post is old enough to contain the former term for the field-Psychosomatic Medicine.

“At the annual Academy of Psychosomatic Medicine (APM) meeting this year held on Marco Island, Florida, I heard Dr. Theodore Stern call Psychosomatic Medicine (PM) a “supraspecialty”. Usually it’s described as a subspecialty. I couldn’t find the word in Webster’s although “supra” comes from the Latin for “above, beyond, earlier”. One of the definitions is “transcending”. I tried to Google “supraspecialty” and came up empty. So I guess it’s a neologism. The context was a workshop on how to enhance resident and medical student education on Psychosomatic Medicine services. Dr. Stern coined the term while talking about the scope of practice of PM. As he went through the long list, it gradually dawned on me why “supraspecialty” as a title probably fits our profession. It’s mainly because it makes us, as psychiatrists, accountable for aspects of general and specialty medical and surgical care above and beyond that of Psychiatry alone.

As a member of this supraspecialty, we wrestle with some of the most intriguing questions about the core competencies of clinical care, interpersonal and communication skills, professionalism, medical knowledge, systems-based practice, and practice-based learning and improvement. These core competencies are a set of commandments, as it were, that teachers and learners are supposed to quantitatively assess in the service of producing competent doctors. While acknowledging the importance of qualitative assessment of the core competencies, Dr. Stern had the courage to criticize the assumption that quantitative assessment is even practicable. A qualitative assessment would probably be more practical.

For example, how would one assess a trainee’s ability to digest, critically evaluate, communicate about, and integrate into local practice systems the small but growing knowledge about psychopharmacologic prevention of delirium? I am a bit surprised at the general enthusiasm among PM practitioners about pretreating patients with antipsychotics in an effort to prevent postoperative delirium. One of the more recent examples of a very small set of studies is the randomized controlled study by Larsen et al which showed that using Olanzapine prevented delirium in elderly joint-replacement patients[1]. The caveat that everyone seems to ignore is that the patients who got Olanzapine endured longer and more severe episodes of delirium. Dr. Sharon Inouye (who designed the Confusion Assessment Method or CAM for diagnosing delirium) has quoted George Washington Carver, “There is no shortcut to achievement”, cautioning against oversimplifying non-pharmacologic approaches to preventing delirium[2]. By extension, I’m suspicious of any recommendation that would reduce an intervention for preventing a syndrome as complex in etiology and pathophysiology as delirium to the administration of a single dose of a psychiatric drug either pre-op or post-op or both. Given the complexity of this issue, is there a quantifiable assessment method for core competencies that suffices? What I’d really like to see is how a trainee thought through the complex issues involved.

One other issue that would influence our ability to assess core competencies is the recent appearance of evidence which seems to show that selective serotonin reuptake inhibitors (SSRIs) when given with beta-blockers may increase mortality in heart failure patients[3]. The bulk of the research evidence in the last couple of decades impels psychiatrists and cardiologists alike to have a low threshold for prescribing SSRIs to patients with heart disease in order to prevent depression. Again, in this context, is there a suitable quantifiable assessment for gauging whether or not a trainee has mastered the core competencies adequately? I would rather hear or read a trainee’s reflections on how to decide for oneself what the safest course of action would be under particular circumstances, and then how to convey that to our colleagues in Cardiology.

And is there a reliably quantifiable way to assess how a PM consultant (trainee or not) evaluates and recommends treatment for an ICU patient who develops catatonia postoperatively in the context of abrupt withdrawal of previously prescribed benzodiazepine, in the face of recent evidence that Lorazepam is an independent predictor of delirium in the ICU[4, 5]?

These situations tax the medical and psychiatric knowledge, treatment and communication skills and wisdom of master and learner alike. Is it possible to mark a check box on a rating scale to assess performance? And would that give us and our patients the ability to tell whether a doctor has the wherewithal to discern what kind of disease the patient has and what kind of patient has the disease, to do the thing right and to do the right thing?

All of these examples make me wonder whether or not quantifiable assessment of every core competency in the supraspecialty of PM is realistic or even desirable.

1. Larsen, K.A., et al., Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics, 2010. 51(5): p. 409-18.

2. Inouye, S.K., et al., NO SHORTCUTS FOR DELIRIUM PREVENTION. Journal of the American Geriatrics Society, 2010. 58(5): p. 998-999.

3. Veien, K.T., et al., High mortality among heart failure patients treated with antidepressants. Int J Cardiol, 2010.

4. Brown, M. and S. Freeman, Clonazepam withdrawal-induced catatonia. Psychosomatics, 2009. 50(3): p. 289-92.

5. Pandharipande, P., et al., Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 2006. 104(1): p. 21-6.”

Old Blog Post on Decisional Capacity Assessment

I just found a blog post I wrote about assessing decisional capacity. It’s over 13 years old and you can tell I was a little frustrated when I wrote it. It was back in the days when consulting psychiatrists were called psychosomatic medicine specialists. Here’s to another blast from the past.

Blog from 2011: Thoughts on Assessment of Medical Decision-Making Capacity

Listen very carefully to what I’m about to say. A patient’s ability to make decisions about her medical or surgical treatment does not depend on knowing her surgeon’s name.

Let me put it differently. Simply because you can recall your surgeon’s name doesn’t mean you have the decisional capacity to give or not give informed consent to have surgery.

If that’s too obvious to most of you, then maybe I can stop worrying that it isn’t to so many doctors, who sometimes misunderstand or are simply unaware of the basic principles of assessing decisional capacity regarding medical treatment. Believe it or not, some physicians actually believe the above is part of an adequate decisional capacity assessment.

Psychosomaticists are frequently called to assess decisional capacity to participate in the informed consent discussions that are such an important part of the doctor-patient relationship today. Many non-psychiatric doctors simply don’t feel confident that they can do it themselves. And when they try, their description of the process often indicates an alarming deficit in their medical school education about this basic skill.

In order to give informed consent, you need to have enough information from your doctor, be able to voluntarily make a decision without undue pressure from others (including your doctors), and be competent to decide. Exceptions to obtaining informed consent include but are not limited to “incompetence” (the inability to decide) and medical emergencies.

In a nutshell, the basic elements of assessing decisional capacity are:

Any physician can do it; a psychiatric consultation is not obligatory though it may be helpful in difficult cases in which delirium or other mental illness may be substantially interfering with decision-making.
The patient’s ability to understand her medical condition and the risks and benefits of the main and alternative medical interventions proposed as treatment.
The patient’s appreciation of the nature of her medical condition and the potential consequences of the treatment options or no treatment in the context of her values and wishes.
The patient’s ability to reason through her choices regarding treatment.
The patient’s ability to express a choice.

Notice that nowhere in the above list is recall of the surgeon’s name even mentioned. Remembering your surgeon’s name may be flattering but it’s not essential to the assessment of decisional capacity.

There are several reasons to assess decisional capacity including but not limited to an abrupt change in the patient’s mental status. This is commonly caused by delirium, which by definition is an abrupt change in affect, cognition, and behavior that fluctuates and is by definition related to medical causes.

Any physician can conduct a decisional capacity evaluation, yet a psychiatric evaluation is frequently requested. The reason for that may arise from the assumption that the Psychosomaticist is a sort of “informed consent technician”[1]:

“Efficiency model” scenario
1. Incompetence is presumed.
1. Psychiatric consultant is expected to remove legal barriers expeditiously to obtain a surrogate decision maker.
“Pseudoconsultation” scenario
1. Consultation requestor lacks the patience, interest, or time to do an assessment.
“Persuasion” scenario
1. Psychiatric consultant is expected to persuade the patient to reverse his refusal of needed treatment.
“Protection” scenario
1. Psychiatric consultant is expected to provide documentation to protect against potential litigation.
“Punishment” scenario
1. Stigma associated with psychiatric evaluation is used unconsciously to punish treatment refusal behavior.

In all fairness, psychiatrists are sometimes just as guilty of this buck-passing; for example, when we request a cardiology consultation to “medically clear” a patient for electroconvulsive therapy to treat life-threatening depression.

In an ideal world, a decisional capacity evaluation would be requested in and accepted in “the true spirit of dialogue as the result of a genuine evaluation of the patient’s mental state as a whole”[1].

We don’t live in an ideal world. So when a doctor is truly stuck and needs help with decisional capacity evaluations, she can confidently call a practical Psychosomaticist in the true spirit of collaboration as a result of the genuine appreciation of the importance of the patient’s medical and psychiatric care as a whole.

1. Zaubler, T.S., M. Viederman, and J.J. Fins, Ethical, legal, and psychiatric issues in capacity, competency, and informed consent: an annotated bibliography. Gen Hosp Psychiatry, 1996. 18(3): p. 155-72.

Another Look at the C-L Psychiatry Pecha Kucha

Back in 2018, one of my emergency room staff physicians asked me to do a Pecha Kucha on what a consultation-liaison psychiatrist does. If you know what a pecha kucha is, you can understand why it was challenging for me to put it together and present it.

Although you may have seen the video I made of the pecha kucha 5 years ago on this blog, I think it’s OK to present it here again.

Briefly, PechaKucha is Japanese for “chitchat.” It’s a presentation format using 20 slides displayed for 20 seconds each. It took a while to rehearse to get it right.

I think it’s also worth emphasizing because most of the ideas in it are still relevant to consultation-liaison psychiatry. See what you think.

Thoughts on Copyright Issues Related to Consultation Psychiatry and Dad Jokes

I want to gas; I mean talk about copyright as it relates to consultation psychiatry or telling dad jokes. By the way, those aren’t the same.

I used to teach medical students and residents how to do certain quick bedside cognitive tests for delirium and dementia. Over the years the instructions about how to administer them (and the restrictions over using them at all) have changed slightly. The major point to make is that they have been copyrighted, which usually means you have to pay to play.

One of them, the Mini Cog, despite being copyrighted, does not require you to pay for the privilege of using it. The video below shows part of it. I didn’t do a comedy bit about the short term recall of 3 objects. The video also flickers when I show the delirium order set; just pause it to stop the flickering.

There used to be a cognitive assessment called the Sweet 16, which started off being non-copyrighted, but then became copyrighted. At first the Sweet 16 mysteriously just disappeared from the internet. You can now download it from the internet, but it’s clearly marked as copyrighted.

The reason the Sweet 16 became unavailable is because a company called Psychological Assessments Resource (PAR) acquired the copyright and then started enforcing it. I found out about this when I could not obtain the PAR version of a cognitive assessment very similar to the Sweet 16 called the Mini Mental State Exam (MMSE) unless I forked over at least $100.

I then started teaching trainees how to use the Montreal Cognitive Assessment (MoCA) because it was free to use without any strings attached. Then it also was copyrighted although you can use it under certain conditions.

Moving right along to telling dad jokes, I found out that dad jokes (and indeed, any joke) can be copyrighted, at least in theory. In fact, it’s hard to enforce the copyright on jokes, even when you can prove originality. Here’s an example of a dad joke I think I made up:

What do you get when you cross marijuana with a Mexican jumping bean? A grasshopper.

Note: this joke may become more important now that the DEA, according to news agencies, plans to reclassify marijuana from Schedule I to III in the near future.

Sena thought it was funny (the joke, not the DEA), which probably means it’s not, technically, a dad joke. That’s according to the authority about dad jokes, Dad-joke University of Humour, (DUH). I’m far from a joke teller at all, as Sena (and anyone else who knows me) would assert. On the other hand, I did graduate from DUH and have a diploma to prove it. You can now give me money.

Furthermore, I also investigated whether something called anti-jokes can be copyrighted. According to the internet, the answer seems to be no. Here’s my attempt of the anti-joke:

Knock, knock.

Who’s there?

The doorbell salesman.

See what I did there? In case you didn’t know, experts say that Knock-Knock jokes are among the hardest to copyright for reasons I suggest you look up later. If you also frame the Knock-Knock joke as an anti-joke (stay with me here), the literalness and mundanity of the so-called punch line makes it virtually impossible to copyright. And, like the dad joke, it’s usually not funny—although there can be exceptions.

Just for the sake of incompleteness, I’ll mention the concept of copyleft, which is not the same as open-source. Although this is usually applicable to computer software, you could broaden it to include dad jokes—I think. Copyleft could mean you can use or modify a dad joke (or anti-joke), spread it freely at parties and whatnot as long as it’s bound by some condition. This includes paying me (no personal checks, please).

What pet do inventors have a love-hate relationship with? A copycat.

You’re welcome.