University of Iowa – Go Retire Psychiatrist

Resident Physicians on Strike at Elmhurst Hospital in New York City

I read the news story about resident physicians at Elmhurst Hospital Center in New York City who went on strike this past Monday about low pay. The story doesn’t mention whether psychiatry residents joined the strike. The story did mention how difficult it was to work there during the Covid-19 pandemic in 2020.

I looked up the report from the consultation-liaison psychiatry department at Elmhurst during that time. Their report and many others were submitted to the Academy of Consultation-Liaison Psychiatry (ACLP).

The Elmhurst report was submitted April 1, 2020 by Dr. Shruti Tiwari, MD, Professor Consultation-Liaison, Icahn School of Medicine at Elmhurst Hospital Center, Queens, NY.

I read the report in order to figure out what I and my colleagues at University of Iowa Hospitals & Clinics needed to do in order to respond to psychiatry consultation requests in the setting of the Covid-19 pandemic. In general, we followed the Elmhurst suggestions.

I remember how difficult it was to operationalize the consultation protocol in light of the need to control spread of the Covid-19 infection. We worked with our IT department to use iPad devices with video hookups to evaluate patients in the emergency room. Early on, incredible as it may seem, there was limited supply of PPE for emergency room physicians.

We could do curbside consultations sometimes. Often, when I was on service, I found it difficult to use the iPad because of glitches in the device. In order to reduce the number of consultation team members huddling together, residents and I saw patients separately. Often, delirium with agitation demanded we evaluate the patient in person. There was an adequate supply of PPE with some limitations. Psychiatric consultants didn’t have access to N95 masks because of the shortage of them at the time. We wore surgical masks and face shields as well as gowns and gloves. We were not to see patients in the ICUs other than by video assisted means.

I couldn’t tell from the news story when the residents formed a union. One them was interviewed for the story and said that their immigrant status made working conditions more difficult as well as insufficient pay. The story also mentions that the last time doctors went on strike in Manhattan was in 1990.

It would have been difficult for physicians (including psychiatrists) to go on strike during the pandemic, probably impossible. I’ve written about physician strikes before and have given my opinion about that. I hope things work out for the Elmhurst resident physicians and the patients.

Earth Day 2023: Water What We Want to Grow

Happy Earth Day! Yesterday, Sena worked pretty hard out in the garden spaces. She has planted ten river birch trees. I did my usual spring lawn edging, which followed the first mow of the season a couple of days before by the lawn mowing service.

The vinca is coming up in the garden circle in our back yard. It reminds me of a time many years ago when I chopped a bunch of vinca out of a substantial portion of the back yard of a previous house. This became Sena’s first big garden. We’ve moved several times since then and there have been a number of other gardens.

True, vinca is invasive and I think it’s also called creeping myrtle or periwinkle. I found out later after I chopped out a few bushels of it that the plant has organic compounds called alkaloids which inhibit the growth of certain cancers. Vincristine and vinblastine are approved for use in the United States.

The reason I’m mentioning vinca is that way back early in my career as a consultation-liaison (C-L) psychiatrist at The University of Iowa Hospitals & Clinics, I dimly recall giving a short acceptance speech for winning a Leonard Tow Humanism in Medicine award from the Arnold P. Gold Foundation in 2006. I was nominated for it by one of the psychiatry residents and another faculty member.

Getting the Leonard Tow Humanism in Medicine pin

In my speech I mentioned cutting out all of the vinca (which I thought was a weed) in the back yard. I was pretty proud of getting that job done—until Sena got home and found out. She was less than thrilled about my accomplishment and explained that vinca was not a weed. In fact, she wanted it to grow.

I still have the speech and one of the points I made was, “…we water what we want to grow.” The speech is below:

Good morning distinguished guests including graduating medical students, Dean______.

Today we gather to reward a sort of irony. We reward this quality of humanism by giving special recognition to those who might wonder why we make this special effort. Those we honor in this fashion are often abashed and puzzled. They often don’t appear to be making any special effort at being compassionate, respectful, honest, and empathic. And rewards in society are frequently reserved for those who appear to be intensely competitive, even driven.

There is an irony inherent in giving special recognition to those who are not seeking self-aggrandizement. For these, altruism is its own reward. This is often learned only after many years—but our honorees are young. They learned the reward of giving, of service, of sacrifice. The irony is that after one has given up the self in order to give back to others (family, patients, society), after all the ultimate reward—some duty for one to accept thanks in a tangible way remains.

One may ask, why do this? One answer might be that we water what we want to grow. We say to the honorees that we know that what we cherish and respect here today—was not natural for you. You are always giving up something to gain and regain this measure of equanimity, altruism, trust. You mourn the loss privately and no one can deny that to grieve is to suffer.

But what others see is how well you choose.

I didn’t write down the anecdote about the vinca. I think I was also trying to make the point that vinca can be thought of as an invasive “weed” as well as a pretty garden plant. Furthermore, while the vinca alkaloid (for example, vinblastine) can be an effective treatment for some cancers, it can also cause neuropsychiatric side effects, which can mimic depression. That’s where a C-L psychiatrist could be helpful, showing how medicine and psychiatry can integrate to move humanism in medicine forward.

Anyway, ever since then, vinca has often been a part of Sena’s garden, including the one where we live now. And, whenever we walk on any of the trails in Iowa City or Coralville, we always notice it carpeting the woods.

We can probably apply the little law “we water what we want to grow” to many things in life. We can choose to apply it to the world in which we live by creating a safe home to shelter a happy family, doing useful work in the garden while practicing kindness, gratitude, and patience.

We can start by planting an idea like a tree.

Hello, I’m Dr. James Caramel Brown

I read Dr. Moffic’s article, “The United States Psychiatric Association: Social Psychiatric Prediction #4”. I think the rationale for renaming the American Psychiatric Association makes sense.

However, it also got me thinking about the names of other associations connected to the APA (here meaning American Psychiatric Association). One of them is the Black Psychiatrists of America, Inc. We make up about 2% of psychiatrists in the United States.

It also reminded me to once again do a web search for the term “Black psychiatrists in Iowa.” It turns out the results would lead to a repeat of my previous post “Black Psychiatrists in Iowa” on May 7, 2019. Nothing has changed. My colleague Dr. Donald Black, MD is still coming up in the search. Just as a reminder, he’s not black.

It probably comes as no surprise to readers of my blog that this also reminds me of a couple of Men in Black scenes.

Video of Men in Black scene, Dr. Black and Dr. White quotes.

And my post still appears high up in the list of web sites. There has also not been published a more recent edition of the Greater Iowa African American Resource Guide than the one in 2019. You can still find my name and that of Dr. Rodney J. Dean listed in the 2019 edition as the only black psychiatrists in Iowa.

In case you haven’t noticed, I’m retired. I have never considered changing my name and title to Dr. James Caramel Brown. If you noticed that the “Caramel Brown” part is from Men in Black 3 (Agent J talking about what Agent K should say about his skin color in his eulogy for him), give yourself a pat on the back.

Agent J: Can you promise me something, if I go first, you’ll do better than that at my funeral? Yeah, something like, uh: “J was a friend. Now there’s a big part of me that’s gone. Oh, J, all the things I should have said, except I was too old and craggy and surly and just tight. I was too tight. Now, I’m gonna just miss your caramel-brown skin.”

Agent K: I’ll wing something.

Anyway, I’m not sure what to do about renaming the American Psychiatric Association. But I think whoever is in charge of google search results for the term “black psychiatrists in Iowa” could improve on the current situation.

Random Connections

Today, I read Dr. George Dawson’s blog post, “How I ended up in a high-risk pancreatic cancer risk screening clinic.” As usual I was impressed with his erudition, scientific literacy, and rigorous objectivity, even as it pertained to a deadly disease which runs in his family genetic history. I couldn’t help admiring his courage.

And, whether this is a random connection or not, this somehow led to my remembering Dr. George Winokur, a giant in the scientific study (including genetics) of psychiatric diseases, especially mood disorders. He died of pancreatic cancer shortly after he was diagnosed with it in the spring of 1996.

Dr. Winokur was chair of the University of Iowa Department of Psychiatry from 1971 to 1990. He remained on faculty, actively involved in research and teaching up until the day of his death in October of 1996.

I was a resident in psychiatry at University of Iowa from 1992-1996 and I have a clear recollection of meeting with Dr. Winokur in his office during my last year, when I was preparing for job interviews. I knew he had been diagnosed with pancreatic cancer.

He had been actively recruiting me to accept a position in the department and did so even as we spoke briefly. I remember noticing that he gripped an electrical conduit on the wall next to his desk so tightly that I wondered if he were in pain.

He was the main reason I stayed in Iowa. He had a great sense of humor. All of us residents loved him. There was even a list of his “commandments” all new residents received when they began their residencies at Iowa.

Winokur’s 10 Commandments

Thou shalt not sleep with any UI Psychiatry Hospital patient unless it be thy spouse.
Thou shalt not accept recompense for patient care in this center outside thy salary.
Thou shalt be on time for conferences and meetings.
Thou shalt act toward the staff attending with courtesy.
Thou shalt write progress notes even if no progress has been made.
Thou shalt be prompt and on time with thy letters, admissions and discharge notes.
Thou shalt not moonlight without permission under threat of excommunication.
Data is thy God. No graven images will be accepted in its place.
Thou shalt speak thy mind.
Thou shalt comport thyself with modesty, not omniscience.

I never got the impression that George Winokur recruited me because I was black, although it was pretty obvious to me that I would be the first black University of Iowa psychiatry department faculty member. He had too much class to make that an issue.

I’ve known a few classy psychiatrists. Maybe the connection is not so random.

Catatonia Education Resources

I noticed what is, for me at least, a new educational resource for catatonia. There’s an aricle about it in the March 2023 issue (Vol.51, No. 3) of Clinical Psychiatry News. The resource is available at University of Rochester Medical Center website. They include pdf files and training videos for assessment of catatonia.

There are also links for information about catatonia:

Catatonia Information Center

University College London

The University of Rochester presentation has has demo videos using a standardized patient (a physician, Dr. Joshua Wortzel) and a teacher, Dr. Mark Oldham.

I saw cases of catatonia while I was a consultation-liaison psychiatrist at The University of Iowa Hospitals & Clinics and they often had medical causes. My YouTube video lecture on Catatonia, Neuroleptic Malignant Syndrome, and Serotonin Syndrome is still getting views after 4 years.

Fathers Can Be a Pain in the Ass

I’m going to talk a little bit about fathers. Mothers are important too, but I’m a guy and I can talk about mothers another day. Because it’s a touchy subject, I’m going to begin with a Men in Black (MIB) joke, like I always do when I’m being defensive. There’s this MIB 3 scene in which Agent K and Agent J have this exchange:

Agent K: I used to play a game with my dad, what would you have for your last meal. You could do worse than this (explanation for this: they’re sitting in a restaurant and an eyeball in Agent K’s soup swivels around and stares at him).

Agent J: Oh, okay, I used to play a game with my dad called catch. Except I would throw the ball and it would just hit the wall, cause—he wasn’t there.

Agent K: Don’t bad mouth your old man.

Agent J: I’m not bad mouthing him, I just didn’t really know him.

Agent K: That’s not right.

Agent J: You’re damn right, it’s not right. A little boy needs a father.

On one level, this scene is just another way of showing the father/son, teacher/student, mentor/mentee relationship Agents K and J had with each other. By extension, their interaction says something about what happens in similar real-life relationships—in the shallow, cliché ways that movies always do.

I sometimes think about the relationship I had with learners when I was a teaching consultation-liaison (C-L) psychiatry. Often, I say to myself that I never had a mentor and I was never a mentor.

That’s not true. Although I never had a mentor who was formally assigned to me, there was more than one faculty member in the psychiatry department with whom I had an informal mentor/mentee relationship. And I was an informal mentor to at least a few trainees.

However, I was middle-aged by the time I entered medical school, which probably set the stage for awkward relationships with my fellow students and some teachers, partly because I was either the same age as or older than them.

That doesn’t mean I was wiser than them. It just means that I was conflicted about them. Later, in residency, I learned about transference and countertransference. In fact, I focused on the psychodynamic as well as the medical issues in teaching trainees. In the first C-L manual I wrote (the forerunner to the book I and my co-editor published later), I devoted a large section to psychodynamic factors relevant to doctor-patient relationships.

So, if you’re wondering when I’m going to start bad-mouthing my old man, you can stop wondering. I’m not going there. He wasn’t a hero, like Agent J’s father was (you need to see the movie to get this angle).

My dad was funny. I don’t think I got my own sense of humor from him, but it makes sense why I would have one—and just because “he wasn’t there” doesn’t explain everything. It never does.

Fathers can be a pain in the ass, not just because of dad jokes. Fathers can be a pain in the brain, too. Ask anybody who was a latchkey kid; I was one of those. We really don’t belong to any specific generation.

We also can’t just up and time travel like Agent J and find out about the father we never really knew. Mostly, it’s just bits and pieces, like a matchbook with a name and address from somebody on your paper route. The path it can lead to doesn’t always mean you find out that “Your daddy was a hero,” like a young Agent K tells young James (who becomes Agent J in the future) after he neuralyzes him to shield him from the hard truth about his father.

You’ll have to watch the movie to get that one.

University of Iowa Stanley Museum of Art Wins Prestigious Master Builders of Iowa Award

The University of Iowa Stanley Museum of Art, won the highest Master Builders of Iowa Award. See the Russell Group Inc. website for more details about the award.

It’s a very impressive space and a must-see marvel when you visit Iowa City.

Behind the Mask Policy

Tomorrow I’ll get to see how the new Covid-19 face mask policy works at the University of Iowa Hospital & Clinics. It goes into effect today. I’m going to see the dentist, as I have periodically for years, even during the Covid-19 pandemic. Of course, the idea of masked dental patients is ironic.

The rule change about masks being sort of optional is a little confusing.

It’s sort of optional because it looks like it’s not optional for unvaccinated health care employees. They still have to wear masks.

I wrote about this back in May of 2021, “Unmasked Means Fully Vaccinated?” That was back when bandanas were acceptable as face coverings.

So does being masked mean “not vaccinated?” It’s confusing because if masking is optional for patients and visitors, why are health care workers the exception? I’m not sure how anyone would enforce the policy.

If you can wear a mask just because you want to do that, how does that separate you from the unvaccinated person?

If masks are optional, then why are the entrance and exit policies not changing, including screening of patients, visitors, and staff? I didn’t see the guidance about what to do if anyone says they are symptomatic or unvaccinated and prefers not to wear a mask, other than to offer a mask (which is free!).

If it’s disrespectful to ask a patient or visitor to put on a face mask, why is it not disrespectful to require an unvaccinated health care worker to do so? There is one bullet point in the question-and-answer section about whether you can ask anyone to wear a face mask which says you can’t ask anyone, including “employee, colleague, patient, visitor, etc.” In the same section is the statement: “Whether or not to wear a mask is a personal decision that each person must make for themselves and for their own reasons.” Does that apply to getting a Covid-19 vaccine as well?

That said, I’m a staunch supporter of everyone getting a Covid-19 vaccine, if they don’t have medical or other exemptions. They don’t make you magnetic!

And I don’t think the recent Cochrane Review results on face masks really means they’re useless, which some news stories tend to convey. I think the Cochrane review does what most such reviews do, which is point out the problems with some controlled studies. And the reviews themselves may have unintended biases.

What’s the most important part of all this? Well, maybe the predicted snowstorm coming to Iowa tomorrow will prevent my dentist from getting to the clinic. And if that doesn’t work, maybe I could just exercise my right and privilege to wear my mask as a barrier to any nefarious procedures.

Face Masks Optional at University of Iowa Hospitals & Clinics Starting March 8, 2023

As of March 8, 2023, face masks will be optional for visitors, patients, and employees at University of Iowa Hospitals & Clinics.

More On Taming the Juggling Balls

I’ve been juggling for about 5 months now and reflecting on my progress. I think I’m doing OK for a geezer. Sena would call me a hot dog although I would still call it ugly juggling by any standard.

What’s striking, at least to me, is the little bit of science I can find on the web about juggling. I hear the term “muscle memory” when it comes to learning juggling. Actually, there’s some truth to that. There are different kinds of memory. For example, most of us know about declarative memory, which about memorizing facts, because we use it to prepare for exams. Those of us who went to medical school remember the agony of taking tests for the basic sciences.

But so-called muscle memory, or the memory for learning new skills like juggling, takes place in the brain. There was a study published in 2009 which found changes in both gray and white matter of subjects before and after learning to juggle (Scholz J, Klein MC, Behrens TE, Johansen-Berg H. Training induces changes in white-matter architecture. Nat Neurosci. 2009;12(11):1370-1371. doi:10.1038/nn.2412).

The study about correlation of the inability to stand on one leg for 10 seconds with higher mortality in older patients, which I relate to the ability to do the under the leg juggling trick, was published last year (Araujo CG, de Souza e Silva CG, Laukkanen JA, et al. Successful 10-second one-legged stance performance predicts survival in middle-aged and older individuals. British Journal of Sports Medicine 2022; 56:975-980.)

I talk a lot about juggling as though I’m a teacher. I’m not a juggling instructor by any means. You can find better juggling teachers on the web. But my approach to talking about juggling in terms of it being a hobby for me is really not different from how I talked about consultation-liaison psychiatry before and after I retired. I’m still a teacher—just evolving in retirement.