science – Page 15 – Go Retire Psychiatrist

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.

Reminder: FDA VRBPAC Meeting June 5, 2024 on Covid Vaccines for Fall 2024

There will be an FDA VRBPAC meeting on June 5, 2024, 8:30 a.m.-4:30 p.m. ET to discuss Covid vaccines for this fall.

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.”

Rounding At Iowa: Smoking and Vaping

I just want to give a shout out to University of Iowa Health Care and the Rounding@Iowa podcast for an outstanding presentation on the hazards of smoking tobacco, vaping, and dabbing.

The program originally aired on May 14, 2024 and the guests included two ICU doctors who are pulmonologists I’ve worked with as a psychiatric consultant. They are very dedicated.

There was a third guest and he is a patient who vaped and suffered disastrous consequences leading to lung transplant surgery. His insights are invaluable.

Breathing is good; not breathing is bad.

87: New Treatment Options for Menopause – Rounding@IOWA

Join Dr. Clancy and his guests, Drs. Evelyn Ross-Shapiro, Sarah Shaffer, and Emily Walsh, as they discuss the complex set of symptoms and treatment options for those with significant symptoms from menopause. CME Credit Available: https://uiowa.cloud-cme.com/course/courseoverview?P=0&EID=81895 Host: Gerard Clancy, MD Senior Associate Dean for External Affairs Professor of Psychiatry and Emergency Medicine University of Iowa Carver College of Medicine Guests: Evelyn RossShapiro, MD, MPH Clinical Assistant Professor of Internal Medicine Clinic Director, LGBTQ Clinic University of Iowa Carver College of Medicine Sarah Shaffer, DO Clinical Associate Professor of Obstetrics and Gynecology Vice Chair for Education, Department of Obstetrics and Gynecology University of Iowa Carver College of Medicine Emily Walsh, PharmD, BCACP Clinical Pharmacy Specialist Iowa Health Care Financial Disclosures: Dr. Gerard Clancy, his guests, and Rounding@IOWA planning committee members have disclosed no relevant financial relationships. Nurse: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this activity for a maximum of 1.00 ANCC contact hour. Physician: The University of Iowa Roy J. and Lucille A. Carver College of Medicine designates this enduring material for a maximum of 1.00 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Other Health Care Providers: A certificate of completion will be available after successful completion of the course. (It is the responsibility of licensees to determine if this continuing education activity meets the requirements of their professional licensure board.) References/Resources:

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.

Submitted My Two Cents on Centers for Medicare and Medicaid Services Proposal to Minimize the Importance of the Delirium Diagnosis Code

I found out that the Centers for Medicare and Medicaid Services (CMS) is planning to reclassify the diagnosis code for delirium, making it less serious than encephalopathy. Many clinicians are challenging it and organizations of consultation-liaison psychiatrists and the like, including me, don’t understand or agree with the plan.

Even though I’m a retired C-L psychiatrist, I put my two cents in as a comment. I told them what I used to tell others who were either my colleagues or my trainees—that delirium is a medical emergency. I support classifying delirium as a major complication or comorbidity (MCC).

Since CMS asked for supporting documents, I included a pdf of Oldham’s article:

Oldham MA, Flanagan NM, Khan A, Boukrina O, Marcantonio ER. Responding to Ten Common Delirium Misconceptions With Best Evidence: An Educational Review for Clinicians. J Neuropsychiatry Clin Neurosci. 2018 Winter;30(1):51-57. doi: 10.1176/appi.neuropsych.17030065. Epub 2017 Sep 6. PMID: 28876970.

As the authors say, “Delirium always has a physiological cause.”

FDA VRBPAC Meeting on Covid Vaccines Postponed

The May FDA VRBPAC meeting on Covid vaccines, originally scheduled for this month has been rescheduled to June 5, 2024, 8:30 AM-4:30 PM EST.

Svengoolie Movie Trilogy of Terror!

Last Saturday we watched the movie Trilogy of Terror on the Svengoolie show. Well, we tried anyway. There were a lot of interruptions from severe weather warnings. We didn’t mind them because you ignore them at your peril. It’s hard to forget the 2020 derecho in Iowa, which affected a lot of Iowans, including us.

Trilogy of Terror had some psychiatric aspects to it that reminded me how Hollywood frequently gets it wrong when portraying them in films—but sometimes hits the nail on the head.

Although we missed parts of the first and second parts of the movie, it wasn’t difficult to figure out the psychological angle. Both “Julie” and “Millicent and Therese” made me think of antisocial personality disorder (ASPD). The male college graduate student was a pretty good example of a predatory guy lacking any conscience and feeling no remorse for his bad behavior against his apparently meek and defenseless teacher, Julie.

But then the tables were turned and it was Julie who was actually the convincing, coldly calculating and remorseless psychopathic serial killer. She kept a scrapbook of the newspaper stories about her many victims.

One of my colleagues wrote the book about ASPD. Dr. Donald Black, MD, is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy). In it he recounts the story of serial killer John Gacy. He was diagnosed with ASPD at the University of Iowa. He collected a great deal of data about antisocial men and also acknowledges that women can be diagnosed with ASPD. He has also co-edited and published the Textbook of Antisocial Personality Disorder.

The “Millicent and Therese” part of the movie displayed how a woman can be diagnosed with ASPD. This was the character Therese—who was also Millicent, a very strait-laced alter personality, which makes this also a case of what you could call dissociative identity disorder (DID), which may be related to severe trauma. This used to be called multiple personality disorder. What was interesting about this part of the movie was that both identities were being managed somehow by a family physician, not a psychiatrist—which is not at all plausible.

The last part of Trilogy of Terror is “Amelia,” in which Amelia buys a Zuni fetish doll (named “He Who Kills”) which she intends to give to her boyfriend. However, she’s in a hostile, dependent relationship with her mother who controls her and interferes with every aspect of her life. Of course, the doll comes to life and tries to kill her.

The struggle between Amelia and the doll makes me think about her internal struggle with angry and probably murderous feelings about her controlling mother. Amelia finally internalizes the doll’s rage (actually her own) when he emerges from the oven where she shoved him in an apparently futile attempt to burn him to a crisp. What it looks like is that she inhaled the smoke, finally owning her own rage by internalizing the doll’s smoky remains. This transforms her into a vengeful killer (now grinning with the sharp teeth of the doll) who calls her mother to invite her over to her apartment with the obvious plan to cut her to pieces with a large knife.

This is probably not a movie for kids or sensitive adults, which Svengoolie acknowledges several times during the show. This is why I like the segment with Kerwyn, the dad joke telling chicken with teeth who is voiced by Rich Koz, who also plays Svengoolie. Usually during that segment he tells a series of jokes, repeating the lines a couple of times, seemingly in an effort to teach you how to tell dad jokes. There’s also a Kerwyn joke of the week event, in which he tells a joke submitted by a fan. The joke video takes a few seconds to load, so be patient.

Yet Another Study Affirming Stair Climbing Is Great Exercise!

There is yet another study showing that climbing stairs is great exercise and could help you live longer. It’s not yet published in a peer-reviewed journal, but it was presented at the recent scientific congress of the European Society of Cardiology (ESC) Preventive Cardiology.

Conclusions were that, compared with not climbing stairs, doing so was associated with a 24% reduced risk of dying from any cause. There was a 39% reduced risk from dying of a cardiovascular disease.

One news story about this finding linked to an American Council of Exercise (ACE) article on an international sport called tower running. I’ve never heard of it before.

This could help get you ready for chasing extraterrestrials as shown in the famous fitness documentary Men in Black. Officer Edwards may have had “a real problem with authority” (ironic since he was a New York City cop). But as Agent K pointed out, “So do I. But this kid ran down a cephalopoid on foot, boss. That’s got to be tough enough.”

The point being: if you really know what’s good for you—you’ll take the stairs.

Carver College of Medicine Health Sciences Research Day!

Heads up! The Carver College of Medicine Health Sciences Research Day is on April 26, 2024. The event is open to the public. Find your way to the Medical Research Facility (MERF) by google map.