reminiscence – Page 22 – Go Retire Psychiatrist

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.

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.

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.

Thoughts on the Song “Against the Wind”

A couple of days ago, while we were playing cribbage, Sena asked me who sang the song “Against the Wind.” I offered a name, which later turned out to be wildly wrong. It bugged her so much she got up from the cribbage game and went to the computer to look it up.

Of course, Bob Seger wrote the lyrics and sang it. She asked me what I thought it meant. I wasn’t sure at the time. I hadn’t thought about it for a really long time.

I read about it on the web. I didn’t know what the lyric “8 miles a minute” meant and found a forum message saying that it corresponds roughly to the speed of a cruising airliner which is about a “480 mph.” That’s technically more like 480 knots, which converts to about 550 mph.

Anyway, it’s really fast and might be a way of saying you’re moving through life at breakneck speed. In Seger’s case, it might have had a more concrete meaning, referring to flying all over from concert to concert.

The song was released in 1980, which was about the time we moved to Ames so I could go back to college at Iowa State University (ISU). It was a big change from working as a draftsman and land surveyor’s assistant in my hometown of Mason City.

If you extend the “against the wind” metaphor a little bit, Sena and I were both moving against the wind in terms of our place in society, income level, location and educational attainment. I thought I wanted to be an engineer at the time, mostly because I had worked for years for consulting engineers.

Backing up in time a little, I had done some undergraduate college work previously at an HBCU (historically black college/university), Huston-Tillotson College (now Huston-Tillotson University) in Austin, Texas in the mid-1970s.

That was also a kind of move against the wind. I grew up in Mason City, and often I was the only black kid in grade school. I got used to that, although the racism was more overt back then and it was difficult sometimes to bear up against that kind of wind. On the other hand, I felt like a fish out of water at H-TC. I just felt like I didn’t fit in. It was part of the reason I left Austin.

It was also challenging to fit in at ISU. I figured out quickly that I would never complete the engineering degree program. The math and hard science courses were tough from the beginning and only got harder. I realized I was going against the wind there.

So, I changed my major and settled on medical technology, which led to working in a hospital laboratory. But it took about a year to get a job after graduation. Looking back, It was a frustrating time and that really felt like pushing against a headwind. I don’t know what I would have done without Sena.

I finally got into medical school at the University of Iowa. Biostatistics and Biochemistry were brutal. I was very close to quitting before the 3^rd year of clinical rotations. I doubted I was cut out to be a physician. I thought about going back to surveying. But I didn’t.

Many deadlines, commitments, and struggles leading to brief forays from academia into private practice led me to think of myself as more of a fireman or a cowboy than an academician. Yet I spent most of my career at the University of Iowa.

Now I’m retired. Sena is my shelter against the wind. I guess if you look hard enough, just about anybody can relate to Bob Seger’s song. Let the cowboys ride.

Dumbphone Making a Comeback?

Here’s a side note on my recent post about using a smartphone to help you find where you parked your car. I just saw a few news items about something people are calling the “dumbphone.” I gather they’re making a comeback, and not just for old folks.

Hey, I used to have one of those. It was a flip phone. Several years ago, before I retired, residents rotating through the general hospital psychiatry consultation service suggested I graduate to a smartphone.

After I finally got one, I used it basically as a phone and did little else with it for a long time. It was my smart dumbphone.

I gradually added apps to it, including a step counter, epocrates, and whatnot. But I’m not constantly on it playing games and checking the news, mail, and so on.

The battery swelled up on it a couple of years ago, which worried me. But I took it to a cell phone repair shop where the battery was replaced and it’s been fine ever since.

I still use it mainly as a phone. However, I wonder what I’ll do, say, if the battery swells up again. I don’t know if it would make any sense to go back to the dumbphone.

The Kindness of Strangers in a Parking Lot

This is a post about how easy it is to forget where you parked your car in a big parking lot, say at the grocery store, and ways to help prevent it. This sometimes attracts the kindness of strangers, which is puzzling because it’s not very clear how helpful they can be in this situation.

But you want to say more than something like, “Oh, that’s too bad, hope you find it before the ice cream melts.”

The other day, Sena forgot where she parked the car at the grocery store. The circumstances were a little unusual. She parked near one entrance to the store and after getting the groceries, left from an entrance on the other side of the store way across the parking lot. The landmarks were all different.

This is how things started: she ran into a guy with his little boy. The guy actually couldn’t remember where he parked his car and was trying to use his car key fob remote to locate it. This is actually pretty common nowadays. I remember leaving the eye clinic a few months ago and hearing a small symphony of beeps from a number of people using their key fob remotes this way trying to find their cars in the large parking garage.

Sena was sympathetic to the guy, but it was understandably really difficult to help him. He eventually found his car using the key fob trick.

Then the situations were reversed. Sena had trouble finding our car. She was roaming about the parking lot, pushing the grocery cart, obviously looking lost. This attracted 4 different persons (including the first guy she met) who were sympathetic and offered advice—mostly on how to use a key fob to locate the car by pressing one of the buttons (probably the lock/unlock although there might be a panic button). They demonstrated it by pressing the key fob button while standing right next to their cars. They suggested holding it far above your head.

This trick usually works best when you’re fairly close to the car because the key fob remote is a transmitter which uses low-power signals. The operating range may sometimes be limited. Sena was probably pretty far away from our car. She actually began to suspect our car had been stolen. She eventually found it by trial and error.

This episode resulted in attracting a number of people who were kind to her. That’ s encouraging since it looks like kindness is often in short supply. On the other hand, it’s not always good to be alone in a large unfamiliar parking lot, perhaps at night, looking lost and surrounded by strangers.

We can’t remember having this problem years ago before the era of keyless fob remotes, which I read was in the mid-1990s. And we didn’t have them until years after that. I guess we were just more careful about noting landmarks in large parking lots.

There are few things to do in order to avoid forgetting where you park.

You can try to find your car using your key fob remote, although the effective range of the signal might be too short to trigger the horn or the lights. And it might not work if the fob remote battery power is low. And if you’re surrounded by a lot of other people hunting for their cars using the same method, you might have a little trouble discriminating which beep is yours. This could become a YouTube meme, especially with different beep tones (like the 5 tones in the movie “Close Encounters of the Third Kind”).

You can pick a landmark which will make it easier to remember where your car is. Many parking lots have large signs with numbers and letters which can help you.

You can take a picture of your car’s location using your cell phone, including more permanent landmarks than just the other cars adjacent to it—which can be driven off by their owners.

You can also use a cell phone with Google Maps or another geolocation app to help guide you back to your car. Just about all smartphones have this feature. You can consult the owner’s manual for instructions for flip phones, some of which have this function. I don’t think car owners’ manuals typically have instructions for how to use the key fob remotes to find your car. At least ours doesn’t.

Good luck.

Update on James Alan McPherson Park Memorial Plaque

Sena suggested we send a message to Iowa City Mayor Bruce Teague inquiring about the proposed memorial plaque to James Alan McPherson, Pulitzer Prize winning author and longtime Iowa Writers’ Workshop faculty member.

I can remember only one other time in my life that I wrote a letter to an elected official. I wrote President Barack Obama in 2013, basically complaining about the Maintenance of Certification (MOC) program for physicians. I’m not sure what I expected him to do about it. Like many doctors, I was frustrated about the regulatory requirements from certification boards. I thought they were unnecessary and burdensome.

I received a reply which was completely off topic and probably not written by the President. The letter from “President Obama” didn’t answer or even come close to addressing the concerns about what I thought was regulatory harassment. In fact, I never kept the reply and forgot about it.

But the email to Mayor Bruce Teague was different. We just asked about the timeline on the memorial plaque for the James Alan McPherson Park, which was renamed last year. The celebration and ribbon cutting reveal of the new sign was in early August 2021. The memorial plaque was still in the planning stage. We’ve driven by the park several times in the last year looking for it.

Mayor Teague’s reply came the day after we sent our message. It was definitely pertinent and to the point. McPherson’s daughter Rachel is still looking over the wording on the mock-up of the plaque, considering what to include. After her approval, it would take about 10-12 weeks to complete.

Now that’s a quick and specific answer from a political leader. Mayor Teague also sings.

Ransom’s Cigar Store in Mason City

I was thinking yesterday about Ransom’s Cigar Store in Mason City, Iowa. There are actually a couple of reasons why it’s on my mind now.

The first thing about Ransom’s is that it’s an old pool hall on 120 North Federal Avenue. It looks like it has been there for a century. Decades ago, probably in the 1970s, I played a game of eight-ball with Bart Curran. Bart was the host of Bart’s Clubhouse, which I found out has a substantial Facebook following. Bart’s Clubhouse was a popular kids TV show back in my day and it aired on station KGLO (later KIMT) in Mason City.

Anyway, Bart and I played eight-ball (or was it nine-ball?) and drank a short beer. He was shorter than I imagined. He was a real nice guy. I think he asked me what my dad’s name was and when I told him it was John, he looked a little doubtful and said something like “Not the actor John Amos?” I don’t remember who won the pool game. It’s unlikely to have been me.

The second thing is, I searched Ransom’s Cigar Store on the web and found a couple of links to something called Ransom’s Pleazol. I can’t find the word Pleazol in any dictionary, including the Scrabble Dictionary. If anyone knows what that means, please drop a comment.

Thoughts About Guns

I think there a lot better places to read about viewpoints on mass shootings than my blog. I recommend you check out Dr. George Dawson’s post “Gun Extremism Not Mental Illness,” posted on May 31, 2022, then read the editorial in Scientific American, “The Science is Clear: Gun Control Saves Lives,” posted on May 26, 2022.

I’m going to chime in mainly to show a few graphics I found which I think send a clear and simple message. Before I get to that, I just want to mention a few anecdotes to show how little hands-on experience I have with guns.

My earliest memory of any contact with firearms is in early childhood. My dad and a friend came home from a hunting trip with some rabbits for dinner for the family, which included my younger brother and my mother. I don’t know who cleaned or cooked them. I’m pretty sure my mom would not have had anything to do with them. I got my first taste and didn’t like it and said so to my dad. He introduced me to the word “gamey.” I didn’t know meat could taste gamey. The other thing I got from that meal was a mouthful of buckshot. I silently vowed I would never eat anything like it again while I lived.

My next encounter with guns was a YMCA program for kids to learn how to shoot. I might have been in my early teens, maybe even younger. We were given BB guns and instructed to do some target shooting. The paper bullseye targets were set up several yards away. I took many shots and collected my target to show the instructor.

I thought I hit it once and pointed to the hole. The instructor looked at it critically for a few seconds and then told me kindly that the hole was where the pin was stuck to fix the target to the wall. I never touched another gun.

Fast forward to when I was a third-year medical student getting through my clinical rotations at the University of Iowa. In 1991, a physics graduate student named Gang Lu shot and killed 6 people on campus including himself, wounded another rendering her paralyzed from the neck down, all apparently because he was not chosen to get an award for his dissertation. I remember feeling shocked when I read about it in the newspaper.

Now let’s move to some graphics I found at a website maintained by The University of Sydney, GunPolicydotorg, International firearm injury prevention and policy https://www.gunpolicy.org/. It makes it easy to put together comparison statistical graphics on things like gun violence. I compared the United States to New Zealand, Australia, and Canada. Click the next few links in order to get the message. In my opinion, I think the last one is a consequence of the first few.

I guess now it’s up to Congress. God help us all.

Jumping Worms Joke

The jumping worm invasion is the big news these days. This is a follow up to the post I wrote on May 19, 2022. I found this article, “Invasive jumping worms now in 34 states—including Iowa.” It was posted by an Indianola, Iowa outdoorsman named Tom Charlton.

The most interesting thing about this article is the jumping worm joke at the end. I’ll have to do this in stages. First, he prefaces this joke with the one about “What’s worse than finding a worm in your apple?” And I can’t help but think he’s got a different version than the one I know. He says “Of course, we all know what’s worse than biting into an apple and finding half a worm.”

I don’t know what would be worse than finding half a worm. In fact, this actually happened to me. I was a young man living at the YMCA in Mason City, Iowa. That was back in the days when you could rent a single occupancy sleeping room there on the cheap. There was an old snack vending machine there and I got a Butterfinger. I bit into it and found—half of some kind of little worm. Spoiler Alert: the worm half was doing something typical for worms. The answer is below.

By the way, that Mason City YMCA was placed on the National Register for Historic Places in 2002 and has been renovated into the River City Apartments, a low-income housing resource. I don’t know if it still has snack vending machines.

I also can’t think of anything worse than finding half a worm. One worm joke site says “Two worms.” Somehow, it doesn’t have the zing of the “half a worm” version.

I thought the joke (which has been found in print since 1911) went more like: “What could be worse than biting into an apple and finding a worm in it?” The punchline is “finding half a worm in it.”

In the next sentence, Mr. Charlton writes: “…but do you know why the young boy thought the jumping worm would taste like chewing gum?”

I really didn’t get this. I googled it and couldn’t find anything about it. Then my wife, Sena, did a web search on Bing and solved the riddle immediately. She gave me a hint which helped: think of a brand of gum.

It’s actually an old worm joke. It’s very similar to Mr. Charlton’s joke, except it leaves out the word “jumping.” Think of a brand of chewing gum and you’ll get it. It’s not Trident.

The punchline is “Because they’re Wrigleys.” I got sidetracked into overthinking it because it was about jumping worms.

That should have made coming up with the punchline easier. Thank you, Mr. Charlton!