retirement – Go Retire Psychiatrist

Chef Jim Makes Pizza!

It had been around 3 years since I actually made a pizza (see YouTube video “The Path to Pizza.”) rather than just sticking a frozen one into the oven. Yesterday, Sena and I put together a video of me (with more than a little coaching from the boss) making a whopper pizza.

Sena bought a new pizza pan for the occasion. In fact, she got a few new cooking pans, saying firmly it was high time for a change. We used to call the old pizza pan “well-seasoned.” But it was out with the old and in with the new.

Because I’m a guy, it was safer to let me use a ready-made pizza crust mix. I was sort of used to that, anyway. It’s a Great Value brand and it was pretty good—after Sena jazzed it up with a few things like a little sugar, sea salt, garlic powder, and Himalayan Pink Salt preferred by all the Yeti chefs.

We used Classico Spicy Tomato & Basil spaghetti sauce, which I understand is legal.The spices we used were garlic powder, basil, fennel, red pepper flakes, salt and pepper, along with a couple dozen other things. You use what you like.

Sena also “suggested” different kinds of cheeses (“I woke up feeling the cheesiest!”) There was a shredded Italian variety made up of 3 different cheeses including parmesan, mozzarella, provolone, romano, and asiago. and we topped that with a different brand of provolone. Sena really likes added provolone.

MLK Week Redux for the New University of Iowa Psychiatry Fellows

I discovered the University of Iowa Dept of Psychiatry had a very successful match, filling key residency slots in Child Psychiatry, Addiction Medicine, and Consultation-Liaison fellowships. Congratulations! That’s a big reason to celebrate.

This reminds me of my role as a teacher. I retired from the department two and a half years ago. But I’ll always remember how hard the residents and fellows worked.

And that’s why I’m reposting my blog “Remembering My Calling.”:

Back when I had the blog The Practical C-L Psychiatrist, I wrote a post about the Martin Luther King Jr. Day observation in 2015. It was published in the Iowa City Press-Citizen on January 19, 2015 under the title “Remembering our calling: MLK Day 2015.” I have a small legacy as a teacher. As I approach retirement next year, I reflect on that. When I entered medical school, I had no idea what I was in for. I struggled, lost faith–almost quit. I’m glad I didn’t because I’ve been privileged to learn from the next generation of doctors.

Faith is taking the first step, even when you don’t see the whole staircase.”
Martin Luther King, Jr.

As the 2015 Martin Luther King Jr. Day approached, I wondered: What’s the best way for the average person to contribute to lifting this nation to a higher destiny? What’s my role and how do I respond to that call?

I find myself reflecting more about my role as a teacher to our residents and medical students. I wonder every day how I can improve as a role model and, at the same time, let trainees practice both what I preach and listen to their own inner calling. After all, they are the next generation of doctors.

But for now they are under my tutelage. What do I hope for them?

I hope medicine doesn’t destroy itself with empty and dishonest calls for “competence” and “quality,” when excellence is called for.

I hope that when they are on call, they’ll mindfully acknowledge their fatigue and frustration…and sit down when they go and listen to the patient.

I hope they listen inwardly as well, and learn to know the difference between a call for action, and a cautionary whisper to wait and see.

I hope they won’t be paralyzed by doubt when their patients are not able to speak for themselves, and that they’ll call the families who have a stake in whatever doctors do for their loved ones.

And most of all I hope leaders in medicine and psychiatry remember that we chose medicine because we thought it was a calling. Let’s try to keep it that way.

You know, I’m on call at the hospital today and I tried to give my trainees the day off. They came in anyway.

Giving Credit Where Credit is Due

Here’s another vintage post from around a decade ago after my former Psychiatry Dept chairperson, Dr. Robert G. Robinson and I published our book, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry” in 2010.

Blog: Who Gets The Credit?

When I think about peak moments, I remember this guy back in junior high school who decided to try to break the Guinness Book of World Records for skipping rope. I don’t remember his name but the school principal and his teachers all agreed to let him do it during class hours. They marked out a little space for him in our home room. He was at it all day. And he was never alone because there was always a class in the room throughout the day. We didn’t get much work done because we couldn’t keep our eyes off him. It was mesmerizing. The longer he jumped, the more we hoped. We were very careful about how we encouraged him. We didn’t want to distract him and make him miss a jump. And so, we watched him with hope in our hearts. It was palpable. As he neared the goal, we were all crowded around him, teachers and students cheering. He was exhausted and could barely swing the rope over his head and lift his knees. When he made the time mark, we lifted him high above our heads and you could have heard us yelling our fool heads off for miles. Time stood still. He was a hero and we were his adoring fans. It didn’t occur to us to be jealous. His achievement belonged to all of us.

Another peak moment occurred more recently, when my colleagues and I published a book this summer. It’s my first book. It’s a handbook about consultation-liaison psychiatry which my department chairman and I edited, and the link is available on this page. This time, the effort was collaborative with over 40 contributors. The work took over 2 years and often, being an editor felt like herding cats. But we worked on it together. Many of the contributors were trainees working with seasoned psychiatrists who had much weightier research and writing projects on their minds, I’m sure. Like any first book, it was a labor of love. The goal was to teach fundamental concepts and pass along a few pearls about psychosomatic medicine to medical student, residents, and fellows. The book grew slowly, chapter by chapter. And when it was finally complete, this time the achievement was ours and again it belonged to all of us.

I made a lot of long-distance friends on the book project and occasionally get encouragement to do something else we could work together on. I suppose one thing everyone could do is to propose some kind of delirium early detection and prevention project at their own hospitals and chronicle that in a blog to raise awareness about delirium—sort of like what I’ve been trying to do here. We could share peak moments like:

Getting the Sharepoint intranet site up and going so that group members can talk to each other about in discussion groups about how to hammer out a proposal, which delirium rating scale to use, or which management guidelines to use—and avoid the email storms.
Being invited to give a talk about delirium at a grand rounds conference or regional meeting.
Talking with someone who is interested in funding your delirium project (always a big hit).

That way if one of us falters, we always know that someone else is in there pitching. Copyrighting ideas and tools are fine. Hey, everybody has a right to protect their creative property. I’m mainly talking about sharing the idea of a movement to teach health care professionals, and patients about delirium, to help us all understand what causes it, what it is and what it is not, and how to prevent it from stealing our loved ones and our resources.

“It is amazing what you can accomplish if you do not care who gets the credit”-Harry Truman, Kansas Legislature member John Solbach, Ronald Reagan, Charles E. Montague, Benjamin Jowett, a Jesuit Father, a wise man, Edward T. Cook, Edward Everett Hale, a Jesuit Priest named Father Strickland.

Slow Progress with Juggle Behind the Back Trick

About a month ago, I made a YouTube video showing my miserable performance trying to do the throw behind the back juggling trick.

I have been practicing nearly every day since. I’m still not able to do the trick and integrate it into the 3-ball cascade. On the other, I’ve gone from zero percent to “maybe I can do this” when I try the 2-ball practice trick.

My latest video on the 2-ball practice trick alone still shows me chasing after dropped balls, obviously. But I catch at least one and sometimes both more often than I did last month.

The 2-ball practice throw behind the back trick has two components. They’re parts of the full trick which incorporates the trick into juggling a 3-ball cascade. I inferred this from the little manual I got with the Learn to Juggle kit I bought back in mid-October.

In one component, I throw the ball behind my back first with my right hand (the trick ball), then quickly throw the second ball up and—drop both on the floor. No, wait, the idea is to catch them both. This was easier a month ago then it is now because I quit practicing it to do what was harder.

The harder 2-ball practice component was to throw one ball up with my left hand first, then throw the trick ball behind my back. The object is to catch both, which I was unable to do at all until the last few days. It was a coin toss whether I would catch either ball or both. Most of the time, I dropped both.

I was amazed because it seemed like I went from being completely unable to do this to being marginally competent (luckier?) practically overnight.

I have watched demo videos of jugglers who can do the behind the back throw trick and it’s pretty impressive. At first, I thought I would be able to do this without as much effort as I put into doing the throw under the leg trick. They incorporate the same general moves, which includes throwing one ball a little higher than usual in order to make time for doing the trick throw and catching the next ball.

But the stickler for me is having to look behind me for the ball coming from behind my back—which means I have to take my eyes off the balls in front. When I do the under the leg trick, I’m looking at everything happening in front of me.

For a while, it seemed easier to throw the one ball before the trick a little lower rather than higher than usual. That doesn’t make sense, when I think about the timing, and yesterday it didn’t seem to matter exactly how high I tossed it. But I’m pretty sure that throwing it higher makes the trick easier.

Also, early on I thought you had to throw the balls perfectly to get the trick right. I do anything but that, which is why I’m good at ugly juggling. It’ll be a while before I incorporate this into a 3-ball cascade.

Old and Busted Juggling Balls

As you may know, I started juggling in mid-October. The Learn to Juggle kit came with 3 balls. After practicing for over a month and a half, they are old and busted.

The seams are splitting and the granules are flying out, as they smack my hands or hit the floor, computer, walls, and other objects. I hope I got most of them vacuumed up.

The old and busted juggling balls are retired now. For now, I practice with sticky ornamental balls that are not meant for juggling, but which will serve in a pinch.

University of Iowa Psychiatry Residents Get Shout Outs

Recently, University of Iowa psychiatry residents worked hard enough to get shout outs. One of them was exemplary performance on the consultation and emergency room service. The service was following over two dozen inpatients and received 15 consultation requests in a day. This is a staggering number and the resident on the service did the job without complaints. In addition, the resident was the only trainee on the service at the time. Other residents were working very hard as well.

This high level of performance is outstanding and raises questions about health care system level approaches to supporting it.

I read the abstract of a recently published study about Mindfulness Based Stress Reduction (MBSR) compared to medication in treating anxiety in adults (Hoge EA, Bui E, Mete M, Dutton MA, Baker AW, Simon NM. Mindfulness-Based Stress Reduction vs Escitalopram for the Treatment of Adults With Anxiety Disorders: A Randomized Clinical Trial. JAMA Psychiatry. Published online November 09, 2022. doi:10.1001/jamapsychiatry.2022.3679).

On the day I read the abstract, I saw comments which were cringeworthy. The commenter is an outpatient psychiatrist in private practice who had some criticisms of the study. He thought the report of results at 8 weeks was inadequate because symptoms can recur soon after resolution.

Another problem he mentioned is worth quoting, “A course of treatment that requires as much time as the MBSR course described in the study would be out of the question for most of my patients, most of whom are overworked health care professionals who don’t have enough time to eat or sleep. Telling people who are that overworked they should spend 45 minutes a day meditating is the “Let them eat cake” of psychotherapy.”

That reminded me of a quote:

“You should sit in meditation for twenty minutes every day—unless you’re too busy; then you should sit for an hour.”
Zen Proverb

I know, I know; I should talk—I’m retired. Actually, I took part in an MBSR course about 8 years ago when I noticed that burnout was probably influencing my job performance on the psychiatry consultation service. I thought it was helpful and I still practice it. I was lucky enough to participate in the course after work hours. The hospital supported the course.

The residents who are being recognized for their hard work on extremely busy clinical services may or may not be at high risk for burnout. They are no doubt extra resilient and dedicated.

And the University of Iowa health care system may also be offering a high level of system support for them. I don’t see that University of Iowa Health Care is on the list of the American Medical Association (AMA) Joy in Medicine^TM Health System Recognition System, but that doesn’t mean they aren’t doing the kinds of things which would merit formal recognition.

Anyway, they all get my shout out.

What Would Make Psychiatry More Fun?

I just read Dr. George Dawson’s post “Happy Labor Day” published August 31, 2022. As usual, he’s right on the mark about what makes it very difficult to enjoy psychiatric practice.

And then, I looked on the web for anything on Roger Kathol, MD, FACLP. There’s a YouTube video of my old teacher on the Academy of Consultation-Liaison Psychiatry (ACLP) YouTube site. I gave up my membership a few years ago in anticipation of my retirement.

I think one of my best memories about my psychiatric training was the rotation through the Medical-Psychiatry Unit (MPU). I remember at one time he wanted to call it the Complexity Intervention Unit (CIU)—which I resisted but which made perfect sense. Medical, behavioral, social, and other factors all played roles in the patient presentations we commonly encountered with out patients on that unit where we all worked so hard.

Dr. Kathol made work fun. In fact, he used to read selections from a book about Galen, the Greek physician, writer and philosopher while rounding on the MPU. One day, after I had been up all night on call on the unit, I realized I was supposed to give a short presentation on the evaluation of sodium abnormalities.

I think Roger let me off the hook when he saw me nodding off during a reading from the Galen tome.

Dr. Dawson is right about the need to bring back interest, fun and a sense of humor as well as a sense of being a part of what Roger calls the “House of Medicine.” He outlines what that means in the video.

What made medicine interesting to me and other trainees who had the privilege of working with Roger was his background of training in both internal medicine and psychiatry. He also had a great deal of energy, dedication, and knew how to have fun. He is a great teacher and the House of Medicine needs to remember how valuable an asset a great teacher is.

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.

Countdown to Hot Water Heater Replacement

Well, even though our hot water heater was temporarily fixed, there is no guarantee that it won’t fail again between now and later this week. That’s when we’re scheduled to have the new water heater installed

That will cost approximately 10 billion dollars. This item will be the major selling point for our house because we’ll have to sell it immediately in order to move to the poor house.

We have insurance of course. We know what our deductible will be, although we’re not exactly sure how much the insurance company will pay. Maybe they’ll want to know whether we tried to “fix” the water heater first.

Technically, we did that although it could go out again during a shower. That could mean a trip to the emergency room for treatment of rapid hypothermia including surgical removal of icicles from various bodily orifices.

There may be an upside to that. Flash freezing could mean we could preserve ourselves for the future when scientists figure out how to slow down or even stop the aging process.

In fact, that reminds me; Sena saw a news item indicating that there may be a class of medications called “senolytics” that could allow humans to live up to 200 years.

The article doesn’t say what kind of shape you’d be in around that age. What are the implications for retirement age? Would that have to be postponed until you’re over a century old? What would it be like to be that old? Maybe we could ask certain entertainers who are making a living in Branson, Missouri.

How much would senolytics cost at the pharmacy? Probably about 10 billion dollars per pill.

How about extending the working life of water heaters?

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.