Category: science

Looking Back on Gunslingers and Chess Masters

I was looking at an early version of the handbook of consultation-liaison psychiatry that eventually evolved into what was actually published by Cambridge University Press. I wrote virtually all of the early version and it was mainly for trainees rotating through the consult service. The published book had many talented contributors. I and my department chair, Dr. Robert G. Robinson, co-edited the book.

In the introduction I mention that the manual was designed for gunslingers and chess masters. The gunslingers are the general hospital psychiatric consultants who actually hiked all over the hospital putting out the psychiatric fires that are always smoldering or blazing. The main problems were delirium and neuropsychiatric syndromes that mimic primary psychiatric disorders.

The chess masters were those I admired who actually conducted research into the causes of neuropsychiatric disorders.

Admittedly the dichotomy was romanticized. I saw myself as a gunslinger, often shooting from the hip in an effort to manage confused and violent patients. Looking back on it, I probably seemed pretty unscientific.

But I can tell you that when I followed the recommendations of the scientists about how to reverse catatonia with benzodiazepines, I felt much more competent. After administering lorazepam intravenously to patients who were mute and immobile before the dose to answering questions and wondering why everyone was looking at them after the dose—it looked miraculous.

Later in my career, I usually thought the comparison to a firefighter was a better analogy.

The 2008 working manual was called the Psychosomatic Medicine Handbook for Residents at the time. This was before the name of the specialty was changed back to Consultation-Liaison Psychiatry. I wrote all of it. I’m not sure about the origin of my comment about a Psychosomatic Medicine textbook weighing 7 pounds. It might relate to the picture of several heavy textbooks on which my book sits. I might have weighed one of them.The introduction is below (featured image picture credit pixydotorg):

“In 2003 the American Board of Medical Specialties approved the subspecialty status of Psychiatry now known as Psychosomatic Medicine. Long before that, the field was known as Consultation-Liaison Psychiatry. In 2005, the first certification examination was offered by the American Board of Psychiatry and Neurology. Both I and my co-editor, Dr. Robert G. Robinson, passed that examination along with many other examinees. This important point in the history of psychiatry began many decades ago, probably in the early 19th century, when the word “psychosomatic” was first used by Johann Christian Heinroth when discussing insomnia.

Psychosomatic Medicine began as the study of psychophysiology which in some quarters led to a reductionistic theory of psychogenic causation of disease. However, the evolution of a broader conceptualization of the discipline as the study of mind and body interactions in patients who are ill and the creation of effective treatments for them probably was a parallel development. This was called Consultation-Liaison Psychiatry and was considered the practical application of the principles and discoveries of Psychosomatic Medicine. Two major organizations grew up in the early and middle parts of the 20th century that seemed to formalize the distinction (and possibly the eventual separation) between the two ideas: the American Psychosomatic Society (APS) and the Academy of Psychosomatic Medicine (APM). The name of the subspecialty finally approved in 2003 was the latter largely because of its historic roots in the origin of the interaction of mind and body paradigm.

The impression that the field was dichotomized into research and practical application was shared and lamented by many members of both organizations. At a symposium at the APM annual meeting in Tucson, AZ in 2006, it was remarked that practitioners of “…psychosomatic medicine may well be lost in thought while…C-L psychiatrists are lost in action.”

I think it is ironic how organizations that are both devoted to teaching physicians and patients how to think both/and instead of either/or about medical and psychiatric problems could have become so dichotomized themselves.

My motive for writing this book makes me think of a few quotations about psychiatry in general hospitals:

“Relegating this work entirely to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods.”

“All staff conferences in general hospitals should be attended by the psychiatrist so that there might be a mutual exchange of medical experience and frank discussion of those cases in which there are psychiatric problems.”

“The time should not be too long delayed when psychiatrists are required on all our medical and surgical wards and in all our general and surgical clinics.”

The first two quotes, however modern they might sound, are actually from 1929 in one of the first papers ever written about Consultation Psychiatry (now Psychosomatic Medicine), authored by George W. Henry, A.B., M.D. The third is from the mid-1930s by Helen Flanders Dunbar, M.D., in an article about the substantial role psychological factors play in the etiology and course of cardiovascular diseases, diabetes, and fractures in 600 patients. Although few hospital organizations actually practice what these physicians recommended, the recurring theme seems to be the need to improve outcomes and processes in health care by integrating medical and psychiatric delivery care systems. Further, Dr. Roger Kathol has written persuasively of the need for a sea change in the way our health care delivery and insurance systems operate so as to improve the quality of health care in this country so that it compares well with that of other nations (2).

This book is not a textbook. It is not a source for definitive, comprehensive lists of references about all the latest research. It is not a thousand pages long and does not weigh seven pounds. It is a modest contribution to the principle of both/and thinking about psyche and soma; consultants and researchers; — gunslingers and chess masters.

In this field there are chess masters and gunslingers. We need both. You need to be a gunslinger to react quickly and effectively on the wards and in the emergency room during crises. You also need to be a chess master after the smoke has cleared, to reflect on what you did, how you did it—and analyze why you did it and whether that was in accord with the best medical evidence.

This book is for the gunslinger who relies on the chess master. This book is also for the chess master—who needs to be a gunslinger.

“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat”—Sun Tzu.”

References:

1.        Kathol, R.G., and Gatteau, S. 2007. Healing body and mind: a critical issue for health care reform. Westport, CT: Praeger Publishers. 190 pp.

2.        Kornfeld, D., and Wharton, R. 2005. The American Psychiatric Publishing Textbook of Psychosomatic Medicine. Psychosomatics 46:95-103.

Will A Stone Float On Water?

I told the little story about a postop nurse asking me a CAM-ICU question (Will a stone float on water?) after I got back to the recovery room following my retinal detachment surgery last week. I got that one right by answering “No.” But for a split second—I had to think about it.

Sena was there and remembers the nurse also asking me if I knew the day of the week. I don’t remember that question, although Sena says I got it right.

I think I was a little hazy and probably was less than fully attentive because I got some sedation during the procedure (thank goodness).

Sena found a couple of videos that challenge the notion that the answer to the question about whether or not a stone floats on water has an obvious answer. It turns out that it all depends—on what kind of rock we’re talking about and whether a scientist is answering the question.

The CAM-ICU questions about thought disorganization have been outlined thoroughly, as in the picture below:

They’re in section 4: Disorganized Thinking, where you’ll see the question, “Will a stone float on water?” and others. According to the directions, you could make one “error” here and be judged not delirious.

Sena found a couple of YouTube videos that showed some rocks will, in fact, float on water. Volcanic rocks like pumice will float.

And then there are scientists like Neil deGrasse Tyson who can talk circles around you about this issue of why some kinds of rocks can float under certain conditions.

I think I was mildly delirious. But everybody took really good care of me.

To Boost or Not to Boost?

To boost or not to boost? That is the question. I’m still thinking about whether or not it’s important for me to get the second booster for the COVID vaccine. What might help me decide is a little bit more information from University of Iowa Hospital epidemiologist Dr. Daniel Diekema, MD.

The Omicron subvariant, BA.2, is much more transmissible than most past variants. According to Dr. Diekema, it’s responsible for more than half of all Covid-19 cases in Iowa. On the one hand, it doesn’t cause more severe disease than the other variants, and it’s just as responsive to the current vaccines.

On the other hand, just because I’m older makes me more susceptible to severe disease and less responsive to vaccines. That’s according to studies done by Stanley Perlman. MD, PhD at the University of Iowa.

So even if the first booster dose is effective against severe COVID-19 disease, I may be better off getting the second booster sooner rather than later.

It’s also important to continue wearing a mask and practicing social distancing as well as good hand hygiene.

The Path to Asapiprant: Perspiration or Inspiration?

I just found a University of Iowa Health Care announcement about a potential novel treatment to protect older patients from the ravages of Covid-19 infection. According to the announcement:

“An experimental drug that counters immune aging, effectively prevents death in older mice with severe COVID-19, suggesting it may have potential as a therapy to protect older people who are most at risk from the disease. The new findings by researchers with University of Iowa Health Care were published recently in the journal Nature.”

The experimental drug is called Asapiprant. I’m far from knowing anything much about immunology but the path to this discovery reminds me of the work of Ed Wasserman who wrote a book I’ve not yet read but probably should, As If By Design: How Creative Behaviors Really Evolve (2021, Cambridge University Press).

I first found out about Dr. Wasserman from an episode of The University of Iowa’s virtual events of Uncovering Hawkeye History. The title for this one was “Endless Innovation: An R1 Research Institution (1948–1997).” This event series was designed to highlight notable elements of UI’s 175-year history.  

Anyway, in a nutshell, Wasserman’s theory is that innovation is often more about perspiration rather than inspiration. He says it’s often a combination of the 3 C’s: Context, Consequence, and Coincidence. And while I was noodling around on the web, it struck me that this might fit how the Asapiprant innovation developed.

To be sure, the University of Iowa was a critical part of the story of how Asapiprant eventually became an important agent to protect the elderly from immune system aging and thereby decrease the mortality from Covid-19 disease.

I found out the agent was originally called S-555379. It was developed by Shionogi & Co., Ltd as a possible treatment for hay fever several years ago. I think that would be the Coincidence.

But in 2011, Stanley Perlman MD, PhD, professor of microbiology and immunology in the UI Carver College of Medicine, published a paper, which I think is part of the Context:

Zhao J, Zhao J, Legge K, Perlman S. Age-related increases in PGD(2) expression impair respiratory DC migration, resulting in diminished T cell responses upon respiratory virus infection in mice. J Clin Invest. 2011 Dec;121(12):4921-30. doi: 10.1172/JCI59777. Epub 2011 Nov 21. PMID: 22105170; PMCID: PMC3226008.

This paper was cited by Shionogi in the company’s announcement of their license agreement with BioAge Labs, Inc., posted on January 26, 2021:

“It is known that age-related declines in immune function are significant risk factors that increase morbidity and mortality from infectious diseases2. Therefore, it has been suggested that restoring immune function may reduce the severity of various infectious diseases, including COVID-19. The DP1 receptor has been identified as a drug discovery target that improves age-related declines in immune function in an original AI-driven analysis of longitudinal omics data in humans conducted by BioAge. In addition, in a study conducted at the University of Iowa by Dr. Stanley Perlman in which an existing DP1 receptor antagonist was administered in an aged mouse model of SARS coronavirus (SARS-CoV) infection, the mortality rate of mice was improved and a significant decrease in viral load in the lungs was observed3. Based on these exciting study results, we have concluded a license agreement in expectation of development of this compound as an immunopotentiator for the elderly by drug repositioning.”

And I think part of the Consequence is that BioAge, Inc. has announced that the drug, the name of which was changed to BGE-175 and now called Asapiprant is about to undergo Phase 2 clinical trials for treating older patients hospitalized with COVID-19.

Whether you call it perspiration or inspiration, I think it deserves our admiration.

Featured image picture credit: Pixydotorg.

Third Video in the Uncovering Hawkeye History Series: “Endless Innovation: An R1 Research Institution (1948-1997)”

Here’s the video recording of the third session in the Uncovering Hawkey History Series: Endless Innovation: An R1 Research institution (1948-1997).” Enjoy!

Video of UI Breaking Barriers: Arts, Athletics, and Medicine (1898-1947)

Here is The University of Iowa video of the presentations from the February 8, 2022 Uncovering Hawkeye History series (2nd in the series), celebrating the 175th anniversary of the University of Iowa beginnings in 1847. The audio is fine on this one.

Thoughts on Near-Death Experiences

There is a very interesting Medscape article on Near Death Experiences (NDEs), “Young Doctor Explores Near-Death Experiences – Medscape – Jan 13, 2022.” The story was written by Stephanie Lavaud. It was a transcript of an interview with a general practitioner from, Francois Lallier, MD, PhD, from Reims University Hospital in France. He conducted a retrospective study on NDEs for his general medicine dissertation. He discussed the results in his book, Le mystere des experiences de mort imminente (translation: The Mystery of Near-Death Experiences).

It has so far collected several interesting comments. I submitted a couple.

One of them was about a teacher and colleague of mine, Dr. Russell Noyes, Jr, MD, Professor Emeritus University of Iowa. He published several articles about NDE related to traumatic accidents, mainly in the 1970s. Lallier used the Greyson Near-Death Experience Scale for his study, and this scale was based on the work of Noyes and others.

He also participated in a Iowa Public Radio Show in 2018. Dr. Noyes collected over 200 personal accounts of NDEs but declined to publish them. I don’t recall that Dr. Noyes ever discussed his interest in this area with me.

My other comment was a correction to a mistake in my first comment, in which I said no patient I saw in my career as a consult-liaison psychiatrist ever reported a Near-Death Experience to me. I remembered one later. It occurred decades ago but I had forgotten about it. I included the patient’s NDE self-report in a grand rounds presentation, which was not mainly about NDEs.

As a consultation-liaison psychiatrist, I saw many patients with severe medical illness and I can recall only one patient who described an experience of NDE. Delirium was a common syndrome in most of the patients I saw, especially those in the intensive care units.

I think it’s possible that some of the cases of NDE might be attributable to delirium. Vivid and compelling hallucinations and delusions are common symptoms of delirium. The catatonic variant of delirium, which can be caused by severe benzodiazepine withdrawal and other psychiatric disorders can lead to the rare Cotard’s syndrome, marked by the nihilistic delusion that one is dead or even paradoxically immortal, has lost one’s body, is rotting internally or is without limbs and other body parts. The line between NDEs and neuropsychiatric disease can sometimes be thin. However, I don’t categorically dismiss NDEs as mental illness.

Dr. Noyes was very familiar with delirium. He was one of my first teachers in the practice of consultation-liaison psychiatry. He taught me and countless other trainees and early career psychiatrists about anxiety, somatoform disorders, and delirium. He knew the difference between neuropsychiatric illness and NDEs.

In the National Public Radio interview, he explained that after consulting with an attorney who cautioned about the possibility of lawsuits related to breach of confidentiality (obtaining releases of information consents after so much time had passed would have been next to impossible), he decided against publishing his collection of personal accounts of NDEs.

The Medscape article author pointed out that many doctors usually take little interest in the issue of NDEs with patients. Lallier said this is because it’s not normally a part of medical school curriculum. On the other hand, one doctor pointed out in the comment section that he had been conducting NDE research for a decade and had published a series of articles in a peer-reviewed journal. Dr. John Hagan III reported that the articles were included in a medical textbook for physicians in 2017, The Science of Near-Death Experiences, copyrighted by the Missouri State Medical Association (MSMA). Dr. Hagan added that the MSMA passed a resolution which was sent to the national US medical organizations asking that all medical school curricula include education on NDEs.

Even the titles of the books I mention in this post are interesting: The Mystery of Near-Death Experiences and The Science of Near-Death Experiences. The mystery vs the science—or the mystery and the science? They seem almost analogous to bookends, or maybe the Janus head, which is fun to speculate about.

The Janus head used to be the logo for the Academy of Consultation-Liaison Psychiatry (ACLP). It was replaced by some nondescript design for reasons I don’t understand. It reminds me of waves, which could lead to seasickness.

Janus was a god in Roman mythology and is typically represented as having two heads, each facing opposite directions. Janus was the god of doors, gateways, and transitions. He held a key in one hand to open gates and a staff in the other to guide travelers. He is said to represent the middle ground between the abstract and the concrete, between life and death—and perhaps between mystery and science.

Update on “Endless Innovation: An R1 Research Institution (1948-1997)”

Last night’s webinar on Uncovering Hawkeye History, “Endless Innovation: An R1 Research Institution (1948-1997) was fascinating for us.

Dr. Bruce Gantz kicked off the first presentation about his work in cochlear implant surgery. Business picked up for him as far as these procedures in the last year and a half partly because of the pandemic. We were stunned to learn that the demand was driven because so many people were wearing masks—which prevented the deaf from lip-reading.

Kevin Washburn was next up and highlighted the great performance of the UI Law school’s stunning list of 4 student-led law review journals. They rank extremely high in the country, up there in the company of Yale and Harvard. I’m off on a tangent here, but Washburn’s status as a citizen of the Chickasaw Nation (which is based in Oklahoma; there are no Chickasaw tribal members in Iowa despite there being a Chickasaw County, by the way) reminded me of a guy who was a year behind my class in medical school. His name is Orrenzo Snyder and he’s a urologist in Oklahoma. Orrenzo and several other fellow students founded the American Indian Student Association (AISA) in 1989, which was later renamed the Native American Student Association (NASA). The University of Iowa Pow Wow was established in 1990. The 26th Annual Pow Wow is scheduled for April 2, 2022. Give it up for Orrenzo!

Anyway, Washburn mentioned one of the many stars in the UI Boyd Law school: Willard (Sandy) Boyd (for whom the college is named) who became one of the youngest University of Iowa presidents to take office and did so during a rowdy time of student unrest—in 1969. He raised a lot of money for the institution and was an advocate of human rights. He was appointed first chair of the University of Iowa’s Human Rights Committee.

You can also discover other facts, such as in 1839 the Iowa Territorial Supreme Court ruled that Ralph, a slave brought into free territory, must be released from slavery, in 1846; Iowa was admitted to the Union as a “Free State;” and in 1868 In Clark v. Board of Directors the Iowa Supreme Court ruled that the Iowa Constitution guarantees the right to public education to all citizens. The plaintiff parent was Alexander Clark, Sr., who later graduated from the Iowa Law School (possibly the first African American to do so at UI). Justice Chester C. Cole wrote the opinion for the case.

University Archivist David McCartney also mentioned 1969 as a noteworthy year because that was the year of the Apollo 11 moon landing. There’s an Iowa connection to the Apollo 11 mission and that is State University of Iowa professor James A. van Allen in the Department of Physics, who warned of the danger to astronauts of the radiation belts encircling the earth (these were later renamed the Van Allen belts).

And I would add that African American women helped put astronauts on the moon in 1969.

Ed Wasserman expounded on his scientific work with pigeons and humans, comparing them on how they use their brains to solve problems. Are we better than pigeons? Maybe. Wasserman also gave many examples of how trial and error led to some surprising advances and innovations: the Ponseti method for treating clubfoot, the butterfly stroke in swimming, and Field of Dreams. His point is that the 3 Cs: consequence, context, and coincidence, play the larger role in many great achievements.

In other words, just keep pecking away at it.

Next Episode of Uncovering Hawkeye History Today

Get ready for the next episode of The University of Iowa’s virtual event of Uncovering Hawkeye History this evening from 4:30-6:00 PM. The title for this one is “Endless Innovation: An R1 Research Institution (1948–1997).” According to the official announcement, “This event series is designed to highlight notable elements of UI’s 175-year history and includes readings you can do in advance, notable guest speakers during each class, and the opportunity to ask questions each week.” You can register here.

Today’s zoom class again features university archivist David McCarty and 3 of the UI’s most talented innovators:

Bruce Gantz: 68BS, 74MD, 80MS, 80R), otolaryngology professor, the world’s first doctor to perform a robot-assisted cochlear implant surgery

Kevin Washburn: N. William Hines dean, College of Law

Ed Wasserman: experiential psychology professor

Sena and I plan to join the event this evening. I’m looking forward to hearing from Ed Wasserman, who has been studying the origins of innovation for decades. He studies pigeons to find out what really goes on in the ability of humans to come up with new ideas. Wasserman thinks it may have more to do with simple processes like trial and error then eureka type flashes of genius. In other words, we’re a lot like pigeons.

For some reason, this reminds me of an essay by James Thurber, “There’s an Owl in My Room.” It’s published in a book entitled The Thurber Carnival. The essay is all about Thurber’s impatience with a poem about pigeons written by Gertrude Stein. He thought it made pigeons way too complicated. I realized that I had never read the poem, so I went hunting for it on the web. I found a lot of comments about how ridiculous many people think “pigeons on the grass” is:

“Pigeons on the grass, alas. Pigeons on the grass, alas. Short longer grass short longer, longer shorter yellow grass. Pigeons, large pigeons on the shorter longer yellow grass, alas, pigeons on the grass.”—Gertrude Stein.

I had no trouble finding a short excerpt of Thurber’s scathing essay about it on the web.

Thurber’s closing sentence is “No other thing in the world falls so far short being able to do what it cannot do as a pigeon does. Of being unable to do what it can do, too, as far as that goes.”

You can see why some people might be offended by being compared to pigeons. On the other hand, he has written a book about the origin of the notion of creative genius, As If by Design: How Creative Behaviors Really Evolve (2021, Cambridge University Press).

I read an article on the web claiming that, scientifically speaking, there’s no difference between doves and pigeons. Sena and I have observed pigeons/doves with missing toes. That might indicate the trial and error of attempts to make nests with string, which gets wound around their feet, leading to auto-amputation. Some call it stringfoot, although it might just be bad judgment (see my YouTube description).

I can imagine what he might think about Ancient Aliens theories about how humans might come up with innovative inventions. Aliens seem to be particularly prone to crashing their space ships on our planet, making it easier for us to reverse engineer the working parts left strewn all over the ground. There’s something ironical about that. How can they be smart enough to manipulate our DNA and leave us clues about how to create inventions that advance our civilization when they can’t even stop falling out of the sky? On the other hand, maybe we just stole their technology right out from under their very small noses and slapped patents on them. So much for genius.

I’m sure Wasserman thought of all that.