Category: reminiscence

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:

  1. 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.
  2. The patient’s ability to understand her medical condition and the risks and benefits of the main and alternative medical interventions proposed as treatment.
  3. 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.
  4. The patient’s ability to reason through her choices regarding treatment.
  5. 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]:

  1. “Efficiency model” scenario
    1. Incompetence is presumed.
    1. Psychiatric consultant is expected to remove legal barriers expeditiously to obtain a surrogate decision maker.
  2. “Pseudoconsultation” scenario
    1. Consultation requestor lacks the patience, interest, or time to do an assessment.
  3. “Persuasion” scenario
    1. Psychiatric consultant is expected to persuade the patient to reverse his refusal of needed treatment.
  4. “Protection” scenario
    1. Psychiatric consultant is expected to provide documentation to protect against potential litigation.
  5. “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.

The Dirty Dozen on Delirium in WordPress: A Shortcode Presentation

When I was a consultation-liaison psychiatrist I taught trainees in different ways. One of them was what I called the Dirty Dozen slide sets. They were on various basic topics that are important for psychistrists to know. I tried to put the most important points on only a dozen powerpoint slides.

After I started blogging about C-L Psychiatry around 13 years ago, the WordPress blogging platform started offering a way to post slide presentations using what is called shortcode. Presumably, you didn’t really have to know anything about coding language but the instructions weren’t very helpful.

I think I started trying to make slides using shortcode shortly after it was first introduced around 2013. I had to contact WordPress support because I couldn’t learn shortcode. A lot of bloggers had the same problem.

I think my main reason for getting interested in shortcode was so I could cut down on how many powerpoint slides I had to convert to images, which can take up a lot of space on a blog site after a while.

Anyway, in the past few days I tried to pick up the shortcode but couldn’t get the hang of it again. I finally found a WordPress help forum in which I found a blogger’s solution. She made it so clear.

Anyway, the Dirty Dozen on Delirium is below. A few pointers: click in the lower right hand corner of the slide if you want to view the slides full size. Use the directional arrows on your keyboard to click through the slides. You can also just use the arrow handles on the slides if you don’t want to see them full size. . When you click the URLs on the delirium websites, right click and open them in a new tab.

This slideshow could not be started. Try refreshing the page or viewing it in another browser.

Jim Has a 27-Year-Old Shirt!

I have a 27-year-old shirt. It’s denim with a plaid pattern on the front. I wore it when we went on vacation to Hawaii in 1997. In the featured image, I’m wearing it as Sena and I pose for a photo after we got off the plane. We and a lot of other vacationers were festooned with leis as we entered the airport.

That makes this shirt 27 years old—at least. I’m sure I had it for a while before we went to Hawaii. I don’t remember where I got it. Sena says she probably bought it for me at Target.

I looked it up and found an identical shirt for sale on eBay—but it was advertised as being for ladies. The description is “VTG 90s Ladies Greatland Denim Flannel Shirt Size M Pocket Streetwear Grunge.

My first thought was: I’m wearing a lady’s shirt that sells for about twenty bucks on eBay? I couldn’t find one labeled for men. I asked Sena about it and found out for the first time that the buttons on a man’s shirt are on the right side and on a women’s shirt the buttons are on the left.

Then I looked at the eBay picture of the shirt again. The buttons are on the right. I guess the woman selling them doesn’t know the rule of right and left side buttons as it pertains to shirts for men and women.

Well, I guess I can stop being insecure about it. I don’t think anyone really knows why that gender-based rule about right and left side shirt buttons exists. I looked at a couple of web pages and they tend to repeat the same reasons and then end up saying nobody knows and it doesn’t matter.

The other thing to consider is whether my shirt could be considered vintage. According to some experts, anything between 20 and 99 years old can be vintage. I guess that makes me and my shirt vintage.

Biggish Events in Iowa in 1982

We’ve been watching for the house finch eggs to hatch sometime soon here. Remember they’re the ones who are nesting in the artificial Christmas tree on our front porch.

The 2023 edition of the book Birds of Iowa Field Guide, written by Stan Tekiela says the house finch was first seen in Iowa in 1982. That makes it a big year for house finches and for Iowa.

It got me to wondering what other big things happened in Iowa in 1982. A number of events as it turns out.

Terry Branstad was first elected governor of Iowa in 1982. He was 36 years old and at the time was the country’s youngest chief executive. After that, it seemed like he never stopped being the governor—even when he wasn’t, which was seldom. He was governor for 22 years. He was notable for being the nation’s longest-serving governor in history as of 2016.

In 1982, the University of Iowa Hawkeye football team went to the Rose Bowl—and lost to Washington 28-0. Coach Hayden Fry was not happy. The biggest thing about it was the long running party before the game.

While we were in Ames in 1982, there was evidently a big fire that destroyed the Iowa State University Alpha Iota chapter fraternity house. We don’t recall it. One of the members of the fraternity named Steve Shamash, wrote a five-page story about it. One quote (author unknown at the time by Shamash) is worth sharing about how the fire affected the fraternity:

“Adversity exasperates fools, dejects cowards, draws out the faculties of the wise and industrious, puts the modest to the necessity of trying their skill, awes the opulent, and makes the idle industrious.” In short, that fire gave our chapter a swift kick in the butt.

I hunted for the author of the quote and I think it’s by Orison Swett Marden who wrote How to Succeed or, Stepping-Stones to Fame and Fortune. The full quote is:

“Adversity exasperates fools, dejects cowards, draws out the faculties of the wise and industrious, puts the modest to the necessity of trying their skill, awes the opulent, and makes the idle industrious. Neither do uninterrupted success and prosperity qualify men for usefulness and happiness. The storms of adversity, like those of the ocean, rouse the faculties, and excite the invention, prudence, skill and fortitude of the voyager.”

One of the biggest things was the Grateful Dead concert at the University of Iowa Field House. We never went because we were living in Ames at the time. I was an undergraduate at Iowa State University. You can hear the songs at the Internet Archive. The only one I recognize as being by the Grateful Dead is “Truckin.”

Sena surprised me by reminding me she bought me a colorful Jerry Garcia necktie while I was a resident in the Psychiatry Department at the University of Iowa in the mid-1990s. I don’t remember that at all, probably because my brain was fried from being post-call most of the time.

Our Solar Eclipse Day: A Happening on Terry Trueblood Trail

Yesterday, we went out to Terry Trueblood Recreation Area to see the solar eclipse. It was a gorgeous day for it, although a bit chilly. When we got there about 11:30 AM, the parking lot was pretty empty and only a few people were there. We even ran into a few on the trail who didn’t know about the eclipse at all.

However, as the day went on, more visitors showed up, although by no means a crushing crowd. Sena and I were testing out our pinhole and cereal box viewers, and I practiced using the solar filter with my smartphone. While we were doing that, a woman approached us and we struck up a great conversation about the eclipse, which she was looking forward to as well.

As the time approached for the big event, others took up positions around the park. It didn’t take long for us to share stories with others. A woman shared her pinhole viewer with us. She also shared her eclipse glasses (Sena did as well) with another couple who had a NASA live feed on their large screen smartphone. They in turn shared the NASA live feed with us. The irony was the couple didn’t have eclipse glasses and couldn’t safely look up at the partial eclipse right where we were in Iowa City.

And that’s how we all got to share our experience of 4 eclipses, 3 of them total eclipses (albeit vicariously by the NASA live feed by smartphone) with Carbondale, Illinois as well as Arkansas and Texas. The videos were mesmerizing.

As the eclipse progressed, we noticed it got colder and darker. The birds stopped singing. On the NASA live feed, we heard a reporter excitedly remark that the bats were flying out of the caves because they thought it was nightfall. The Terry Trueblood Park lights turned on it got so dim; then they came back on as the eclipse reversed.

The eclipse itself was spectacular. Even more fascinating was how it brought some of us together with others to share it. It reminded me of an old term “the happening.” It was coined in the 1950s and, although I think it originally referred to artistic events, you could apply it to a lot of big and cool events—like eclipses. It was a happening.

Svengoolie Triggers Memory Lane Trip to the Drive Ins

Both Sena and I stayed up to see the cheesy 1972 horror flick The Gargoyles last Saturday night. No kidding, Sena stayed up for the whole thing! The show runs from 7-9:30 PM but the actual movie is only a little over an hour long. It’s about a clan of gargoyles that every 500 years hatch from eggs and wage war on humans to take over the planet. They never get the job done, probably because humans have all the guns and all the gargoyles have are claws and flimsy wings which you don’t see used until the very last scene. Like all of the Svengoolie movies, all of the jokes are so bad they’re good.

You can ask a fair question, which would be what else is on in addition to the movie? There’s a lot of commercials, of course, as well as the corny jokes and skits. But the other features last Saturday were excerpts from the Flashback Weekend Chicago Horror Con, in August 2023. I think it’s an annual historical horror convention that takes place in Rosemont, Illinois.

One of the attractions was a panel presentation about the history of the 90th anniversary of the drive-in theater hosted by Svengoolie and Joe Bob Briggs. It was arguably better than the feature flick. I have heard the history elsewhere about how the drive-in theatre began (I think it was on the travel or history channel).

The most interesting part of the history is how the Covid-19 pandemic influenced the recent history of the drive-in theaters. The point was that, when the pandemic hit the country, all indoor theaters closed, leaving the drive-ins the only place to watch movies for several weeks. They did pretty good business.

Moreover, horror movies and drive-ins go together like cheese and crackers (see what I did there, cheese as in cheesy movies?). OK, fine.

Anyway, horror films were mainly linked to low budget projects that big stars and big directors avoided like the plague. Mainly, those movies were played at the drive-ins—which is how they got a tarnished reputation. That led to cherished stories by older people who used to sneak their friends into the drive-ins by stowing them in the trunks of their cars. That probably did happen, even in the old Mason City Drive-In Theater in Iowa where Sena and I grew up. It was demolished in 1997.

As far as The Gargoyle movie goes, the one thing I couldn’t find out was exactly why Bernie Casey, who played the head gargoyle, didn’t voice his own lines. The web references I found just mentioned briefly that it was because his natural speaking voice didn’t fit the character. They were dubbed in by Vic Perrin who did the voice-over for the introduction to The Outer Limits.

Maybe the funniest scene was when the head gargoyle placated and playfully slapped the fanny of the female head breeder gargoyle after she noticed he was flirting with the human woman he kidnapped. The breeder was obviously really jealous. Maybe this means that the battle between gargoyles and humans will always come to a stalemate because we’re too much alike.