University of Iowa – Page 5 – Go Retire Psychiatrist

Old Doctors vs Young Doctors

I ran across a recently published web article that originated from the Wall Street Journal (WSJ), to which I don’t have access because I’m not a subscriber. The title is “Do Younger or Older Doctors Get Better Results?” and it’s in the form of an essay by Pete Ryan.

It’s been picked up by over 130 news outlets and is actually based on an open access study published in the British Medical Journal (BMJ) in 2017, (BMJ 2017;357:j1797): Tsugawa Y, Newhouse J P, Zaslavsky A M, Blumenthal D M, Jena A B. Physician age and outcomes in elderly patients in hospital in the US: observational study BMJ 2017; 357:j1797 doi:10.1136/bmj. j1797.

I had a quick look at the rapid response comments. A couple resonated with me. One was from a retired person:

“I did not see specific patient age statistics vs physician age groupings. Wouldn’t older patients, whose risk of dying soon was higher, want to see their own older doctors? Lots of uncontrolled variables in this study… I also agree with one of the other comments that a patient who knew the end of their life was near would seek care from an older physician that would tend to be more empathetic with a patient of their own age.”

Another was from an emergency room physician, Dr. Cloyd B. Gatrell, who entered the comment on June 8, 2017. Part of it echoed my sentiments exactly:

“The authors’ own statements call their conclusion into question: “Our findings might just as likely reflect cohort effects rather than declining clinical performance associated with greater age….”

I suspect most of the web articles spawned by the study didn’t really talk about the study itself. They probably were mainly about your attitude if the doctor who entered the exam room had gray hair or not.

The study involved internal medicine hospitalists and measured mortality rates comparing physicians were in different age ranges from less than 40 years to over 60.

It got me wondering if you could do a similar study of younger and older psychiatrists. Maybe something like it has been done. I’m not sure what an appropriate outcome measure might be. If you focus on bad outcomes, completed suicides are probably too rare and can involve psychiatrists of any age. The quote that comes to mind:

“There are two kinds of psychiatrists—those who have had a patient die by suicide, and those who will.”
Robert Simon, MD, forensic psychiatrist

I doubt they would fall into any particular age category more often than any other.

Anyway, on the subject of physicians who are getting older and required to retire at a specific age, recent news revealed that Scripps Clinical Medical Group agreed to pay almost $7 million to physicians to settle an age and disability discrimination charge filed with the U.S. Equal Opportunity Commission over a policy requiring them to retire at age 75.

And this reminds me of an article in Hektoen International A Journal of Medical Humanities: Jean Astruc, the “compleat physician.” He was a doctor in the Age of Enlightenment and was a geriatrician. An excerpt from the article:

Jean Astruc had a special interest in geriatrics and in 1762 gave a series of lectures that were taken down by one of his students. He described how in old age the skin becomes thick and hard, the hair and teeth fall out, there becomes need for glasses, respiration becomes labored, urine escapes, there is insomnia, and people forget what they have done during the day but remember every detail of what they have done in the distant past. He recommended diet, some wine to help the circulation, exercise, long sleep, and “a life from bed to table and back to bed.”

I think there is a contradiction in Astruc’s recommendations.

I retired voluntarily a little over 3 years ago. It just so happens that one of the reasons was the Maintenance of Certification (MOC) program, which the BMJ study authors mentioned in the first paragraph of the introduction:

“Interest in how quality of care evolves over a physician’s career has revived in recent years, with debates over how best to structure programs for continuing medical education, including recent controversy in the US regarding maintenance of certification programs.”

That reminds me that I got an email a few days ago from Jeffrey M. Lyness, MD, the new President and CEO of the American Board of Psychiatry and Neurology (ABPN) in January of 2023, replacing Larry Faulkner, MD. It was a letter explaining how I could recertify. I decided not to renew several years ago and I’m not thinking of coming out of retirement. I have always been an opponent of the MOC.

Maybe he sent me the letter because he found the Clinical Chart Review Module on delirium that a resident and I made in 2018. As of January 24, 2024 you can still find the module on the web site just by typing in the word “delirium” in the search field. It could be the only document about delirium on the ABPN web site, although that’s difficult to believe.

On the other hand, it’s one of two modules that are labeled as approved although valid through December 31, 2023. Maybe it’s headed for retirement.

Heed Warnings About Risk for Frostbite

I just saw an article in the Daily Iowan about the importance of knowing how to avoid frostbite during wind chill advisory and warning periods. As a consulting psychiatrist in the general hospital, I saw what can happen to people who suffered frostbite injuries. They were treated on the Burn Unit.

The risk for frostbite will continue to be high for the next few days with wind chills as low as minus 30 below zero, according to the National Weather Service.

The University of Iowa Hospital has a frostbite education web page worthing reviewing. There is also a compelling story posted in 2022 about how two patients were treated for severe frostbite injuries.

Martin Luther King Upcoming Schedule of Events

Upcoming Events for Martin Luther King Celebration of Human Rights includes:

“Service Day – Kit Building for Those in Need | Jan. 20, 2024 from 5:00 p.m. – 8:00 p.m.
Location: Activity Center (260 IMU)
Come together to make a positive impact by assembling kits for individuals facing various challenges. Your participation will contribute to creating a better community.”
“MLK Distinguished Lecture by Michele Norris | Jan. 23, 2024 at Noon
Location: Prem Sahai Auditorium, 1110 Medical Education and Research Facility, MERF
Title: Our Hidden Conversations
Join us for a distinguished lecture by Michele Norris, NPR Journalist, on the theme “Our Hidden Conversations.”

Iowa Update for Martin Luther King Events!

The frigid weather has led to updates in the events for the MLK Celebration. Among them is the postponement of the Unity March and Community-wide Celebration. This is planned for February.

Martin Luther King Jr Day 2024!

Dr. Martin Luther King Jr Day is officially the third Monday of January every year. It’s January 15, 2024 this year. It’s really a community affair, which hopefully expands more broadly out to all people.

There are a number of events planned. In the spirit of emphasizing the community projects, here’s the high points:

The University of Iowa general announcement highlights the food drive and service goals.

The City of Coralville web site lists many activities, including an opportunity to help paint a community mural on January 15th!

The Iowa City web page lists several activities as well, including an MLK Day Family Storytime on January 15^th.

Complexity Intervention Units Past And Present

Here’s another blast from the past about Complexity Intervention Units (CIUs) or what used to be called Medical-Psychiatry Units. I co-staffed one for 17 years at Iowa Health Care, the organization formerly known as Prince. No wait, that used to be called the University of Iowa Hospitals & Clinics. They’re rebranding.

I was looking up CIU on the web. It’s a common search term now, so Roger Kathol, the guy who built the CIU at Iowa Health Care, was right.

On the other hand, I was also puzzled when the results showed that a hospital in Wisconsin has what’s called a brand new CIU-only it’s not a psychiatric unit.

I thought a CIU was, by definition, a combined specialty unit, with facilities for acute care of both psychiatric and medical problems. But Froedtert Medical Center in Milwaukee has a new CIU and yet says: “The department is licensed as a Medical Unit – not a Psychiatric Unit.”

In fact, Medical College of Wisconsin says essentially the same thing about the CIU: “Please note that the CIU is not an inpatient psychiatric unit, but rather a facility dedicated to integrated care.”

OK, so I probably missed the memo about what a CIU is nowadays. It’s tough to find out how many CIUs are in operation in the U.S., maybe partly depending on how you define it and who you ask. Anyway, this is what I wrote about them 12 years ago:

The Complexity Intervention Unit for Managing Delirious Patients

Is there such a thing as a specialized unit in the general hospital where patients with delirium could be treated, where both their medical and behavioral issues could be managed by nurses and doctors specifically trained for that purpose? It turns out there is. Although they are usually called medical-psychiatry units, an internationally recognized expert about designing and staffing these specialized wards, Dr. Roger Kathol, M.D., F.A.P.M., would prefer to call them “Complexity Intervention Units” (CIUs). It’s a mouthful, but it’s a better description of the interaction between physical and psychiatric illness, along with social and health care system challenges typically managed in these units.

We’ve had one at Iowa since Dr. Kathol started it in 1986. It was one of the first such units built and now that it has been redesigned, updated, and beds with cardiac monitors added, it’s arguably the only unit of its kind in the country. The CIU allows us to provide both intensive medical and psychiatric interventions that would be all but impossible to deliver on general medical floors with psychiatric consultation. The essential features of the CIU include:

Both medical and psychiatric safety features in the physical structure.
Consolidated general-medical and psychiatric policies and procedures.
Location in the general hospital under medical bed licensure and with psychiatric bed attributes.
Moderate-to-high medical and psychiatric acuity capability.
Physicians from combined residencies general medicine and psychiatry co-attending model with consistent communication and coordination of medical and psychiatric care.
Nurses and other staff cross-trained in medical and psychiatric assessments and interventions.

The unit is used to optimize management of a variety of patients with both medical and psychiatric diagnoses. The focus is on providing care for the 2%-4% of patients admitted to general hospitals who are too complicated to manage on either psychiatric or medical units. And it’s an excellent teaching resource for helping new doctors learn about the inevitable interaction between medical and psychiatric disorders in an environment that fosters both/and thinking. Trainees learn that delirium mimics nearly every other psychiatric disorder and how to distinguish delirium from primary psychiatric illness.

I co-staff the unit with a colleague from internal medicine when I’m not staffing the general hospital consultation service. That helps me blend the perspectives of each role. Often, acting in the role of psychiatric consultant, I can assist the generalist in managing patients with less complicated delirium without transferring them to the CIU. And for those whose behavioral challenges would be overwhelming for nurses and physicians on open medical units, it’s helpful to have the CIU option available.

While the CIU is a great resource for managing delirious patients, they are expensive to build and generally have a limited number of beds. So it’s still important to continue work on developing practical delirium early detection and prevention programs in every hospital.

An Old Blog Post About My College Days in Texas

There’s something embarrassing yet fascinating about reading my old blog posts from years ago. The one I read yesterday is titled simply “I Remember HT Heroes.” I make connections between my undergraduate college days at Huston-Tillotson College (now Huston-Tillotson University (an HBCU in Austin, Texas) and my early career as a consultation psychiatrist at The University of Iowa Hospitals & Clinics (now rebranded to Iowa Health Care).

My first remark about getting mail from AARP reminds me that organization is sponsoring the Rolling Stones current tour, Hackney Diamonds. And the name of my specialty was changed from Psychosomatic Medicine to Consultation-Liaison Psychiatry in 2017.

The photo of me attached to the original post reminds me of how I’ve gotten older—which also makes me hope that I’ve gotten wiser than how I sound in this essay. The pin in my lapel is the Leonard Tow Humanism in Medicine award I received in 2006.

I Remember HT Heroes

Getting membership solicitations in the mail from the American Association of Retired Persons (AARP) is a sure sign of aging, along with a growing tendency to reminisce. Reminiscence, especially about the seventies, may be a sign of encroaching senility.

Why would I reminisce about the seventies? Because I’m a baby boomer and because my ongoing efforts to educate my colleagues in surgery and internal medicine about Psychosomatic Medicine, (especially about how to anticipate and prevent delirium) makes me think about coming-of-age type experiences at Huston-Tillotson College (Huston Tillotson University since 2005) in Austin, Texas. Alas, I never took a degree there, choosing to transfer credit to Iowa State University toward my Bachelor’s, later earning my medical degree at The University of Iowa.

Alright, so I didn’t come of age at HT but I can see that a few of my most enduring habits of thought and my goals spring from those two years at this small, mostly African-American enrollment college on what used to be called Bluebonnet Hill. I learned about tenacity to principle and practice from a visiting professor in Sociology (from the University of Texas, I think) who paced back and forth across the Agard-Lovinggood auditorium stage in a lemon-yellow leisure suit as he ranted about the importance of bringing about change. He was a scholar yet decried the pursuit of the mere trappings of scholarship, exhorting us to work directly for change where it was needed most. He didn’t assign term papers, but sent me and another freshman to the Austin Police Department. The goal evidently was to make them nervous by our requests for the uniform police report, which our professor suspected might reveal a tendency to arrest blacks more frequently than whites (and yes, we called ourselves “black” then). He wasn’t satisfied with merely studying society’s institutions; he worked to change them for the better. Although I was probably just as nervous as the cops were, the lesson about the importance of applying principles of change directly to society eventually stuck. I remember it every time I encounter push-back from change-resistant hospital administrations.

I’m what they call a clinical track faculty member, which emphasizes my main role as a clinician-educator rather than a tenure track researcher. I chose that route not because I don’t value research. Ask anyone in my department about my enthusiasm for using evidence-based approaches in the practice of psychiatry. I have a passion for both science and humanistic approaches, which again I owe to HT, the former to Dr. James Means and the latter to Dr. Jenny Lind Porter. Dr. Means struggled to teach us mathematics, the language of science. He was a dyspeptic man, who once observed that he treated us better than we treated ourselves. Dr. Porter taught English Literature and writing. She also tried to teach me about Rosicrucian philosophy. I was too young and thick-headed. But it prepared the way for me to accept the importance of spirituality, when Marcia A. Murphy introduced me to her book, “Voices in the Rain: Meaning in Psychosis”, a harrowing account of her own struggle with schizophrenia and the meaning that her religious faith finally brought to it.

Passion was what Dr. Lamar Kirven (or Major Kirven because he was in the military) also modeled. He taught black history and he was excited about it. When he scrawled something on the blackboard, you couldn’t read it but you knew what he meant. And there was Dr. Hector Grant, chaplain and professor of religious studies, and champion of his native Jamaica then and now. He once said to me, “Not everyone can be a Baptist preacher”. My department chair’s echo is something about how I’ll never be a scientist. He’s right. I’m no longer the head of the Psychosomatic Medicine Division…but I am its heart.

I didn’t know it back in the seventies, but my teachers at HT would be my heroes. We need heroes like that in our medical schools, guiding the next generation of doctors. Hey, I’m doing the best I can, Dr. Porter.

Another Look at an Old Blog Post on Psychiatric Case Formulation

I just had a look at a blog post on case formulation I wrote about 12 years ago. Aside from sounding a little pompous, I decided to check on the title I gave it back then: “What Kind of Disease Does the Person Have And What Kind of Person Has the Disease?”

I looked at the web site that researches who said what as far as quotes go. It’s Quote Investigator and their conclusion is that the above quote should be attributed to Henry George Plimmer, a lecturer on Pathology and Bacteriology at St. Mary’s Hospital Medical School. He said:

“You will have to acquire, too, for any success to be given you, an accurate knowledge of human nature, and you will find that it is quite as important for the doctor to know what kind of patient the disease has for host, as to know what sort of disease the patient has for guest.”

Anyway, the post is below; the cases are all fictional:

I recently had the pleasure of evaluating one of our junior residents using the new clinical skills exam format. These evaluations are taking the place of the oral board examinations for certification in Psychiatry. The oral board exams have been the bane of examinees for many years in part because of the extreme anxiety they provoke. Preparing a resident in psychiatry involves a rigorous educational program over 4 to 6 years and they must master a vast amount of content knowledge just to become certified as safe and competent practitioners as defined by regulatory organizations. Elements of the clinical skill exam include interviewing skills, a mental status exam, case presentation, and case formulation.

Case formulation is the most demanding element. There are many references trainees can Google on line to find. A classic paper often cited is the one by Perry and others[1]. It helps doctors and patients by balancing the focus on both what kind of disease the person has, and what kind of person has the disease. Case formulation is an essential skill which takes years of practice to master and I’m inclined to give a lot of latitude to trainees in their ability to demonstrate it, especially in the first year of residency. Formulations can be used by psychiatrists in every subspecialty, including Psychosomatic Medicine, as the fictionalized examples will demonstrate.

Making useful case formulations can be frustrating for both trainees and experienced clinicians. On the other hand, if it’s not, there’s a good chance that oversimplification is becoming a problem. One pitfall that ironically comes with experience is dashing off a formulation that sounds deep using “psychobabble” but which misses the mark in describing the patient’s problems in the real world. Striking a balance between over inclusiveness and superficiality takes practice. Often, tying the formulation to only one model seems constrictive.

In general, making an integrative synthesis of the relevant factors in a patient’s clinical situation (abstracted from the history) is easier than making an integrative inference about why her problem exists. It helps to look for clues in the form of repetitive themes in a patient’s life which lead to conflicts that are resolved in maladaptive ways. There is no standardized format, and so there may seem to be as many formulation strategies as there are clinicians. Starting with a manageable framework can help. The phrases in bold type are the connectors that guide thinking and writing about the patient and help keep the focus on central issues:

This is a age, employment status, illness state (acutely v. chronically ill), marital status, male/female, with psychiatric symptoms list, duration of, complicated by, head injury, substance abuse, medical syndromes, that we were asked to evaluate because of consult requestor question. She meets criteria for Diagnostic and Statistical Manual-IV-TR diagnosis.

Her psychiatric symptoms can be associated with or precipitated by medical diagnoses. They are also known to have familial pattern, affected/exacerbated by drugs, environmental triggers.

The current behavior may have been determined by a developmental background marked by abuse, neglect, conflict in family of origin, maintained longitudinally by pattern of maladaptive management of relationships and situational stressors. Although cross-sectional exam cannot typically confirm one central conflict, she may have difficulties with independence v. dependence, intimacy v. isolation, generativity v. stagnation.

Typical defenses may include acting out, denial, reaction formation, etc., which appears to be interfering with medical management, not an issue on the ward, and may be predictive of chronic noncompliance with therapy, conflict with caregivers, eventual return to adaptive coping, etc.

Although the scaffold looks unwieldy and long, in practice (and with practice) it can be tailored to fit the clinical need. Certain neuropsychiatric problems seen by consultants don’t require any detailed analysis of defenses, e.g., uncomplicated drug-induced deliria in patients without any psychiatric histories. But just because someone does have a complicated psychiatric history doesn’t imply that the formulation must be long and detailed. The goal is always to succinctly summarize the central issues that describe and explain the patient’s current problems so as to guide recommendations for management.

Example case formulations:

44-year-old multiply divorced, alcoholic, unemployed white male without formal psychiatric history, but with acute subsyndromal depressive symptoms without suicidality in the context of recent diagnosis of diabetes mellitus after being hospitalized with diabetic ketoacidosis. His father (who also had diabetes) died of suicide when the patient was 9 years old. Consult triggered by patient refusing to get up to toilet himself, crying, insulting the nurses, yet constantly on his call light. Depression is known to be associated with Diabetes Mellitus and can run in families. He may be conflicted between dependence and independence or struggling with stagnation developmentally, given his social and occupational marginalization. Regression appears to be major defense. Tolerance of nonthreatening behavior and allowing him control over non-essential features of his care may facilitate face-saving return to more adaptive coping with grief. Monitor for development of a more well-defined depressive syndrome; supportive approach with encouragement of affect but engage effective coping by modeling; query into past successful problem solving.
37-year-old divorced white female teacher aide with abrupt onset of medically unexplained slow, garbled speech. Previous psychiatric history notable for one brief hospitalization in her mid-teens after impulsive overdose over a breakup with boyfriend. Temporal association of dysarthria with her discovering her current boyfriend in bed with her teenage daughter (reported by a friend). Her presentation is consistent with conversion reaction. Major conflict is desire to confront boyfriend but fear of rejection and abandonment. Major defense is somatization. Confrontation generally contraindicated; suggest that recovery will be fairly rapid; no invasive procedures or specialist referrals needed and the condition is not dangerous. Quick follow-up in mental health clinic scheduled.
57-year-old disabled man who had a liver transplant and who has polysubstance dependence in remission and longstanding antisocial behavior referred for subsyndromal depression and anxiety along with insomnia. Recently arrested for shoplifting. Also engaging in reckless driving and fistfights, neither of which he’s done in decades either. No organic brain disease identified that could explain the behavior. Possibly struggling with generativity v. stagnation because of chronic unemployment leading to regressive acting out. Refer to psychotherapy, although resistance expected with more acting out and non-adherence.
49-year-old woman with Hepatitis C (HCV) on interferon (IFN) for last 3 months and with gradually increasing symptoms of syndromal depression, personality change with marked irritability, and somatic complaints. Previously diagnosed recurrent depression in the context of Cluster B personality traits complicated by alcoholism and cocaine abuse, now in sustained full remission. Consult triggered by her erupting in the GI clinic at the gastroenterologist’s suggestion that cutting interferon dose might be recommended in light of her psychiatric status. She thinks that this means she’ll get cirrhosis, be denied liver transplant because of her drug history, and be condemned to die of liver failure. She blames doctors for missing the HCV diagnosis for years, yet feels stigmatized by everyone because of the diagnosis, and at the mercy of doctors who control the only effective treatment. Several cognitive distortions could be the issues in her depression including personalization, catastrophizing, control fallacies and blaming. Interferon is also known to be associated with depression and cognitive impairment. Cognitive Behavioral Therapy (CBT) intervention may be influenced by the latter side effect; antidepressants are an effective drug treatment of IFN-induced depression.

1. Perry, S., A.M. Cooper, and R. Michels, The Psychodynamic Formulation: Its Purpose, Structure, and Clinical Application. Focus, 2006. 4(2): p. 297-305.

Gratitude to Pastor Robert Stone

I came across a couple of items that prompted my renewed gratitude. One of them was an article in Bloomberg on the web, “US Medical Schools Grapple With First Admissions Since End of Affirmative Action” by Richard Abbey, Ilena Peng, and Marie Patino, published on December 14, 2023. It’s about how hard it is for black students to get into and graduate from medical school. Just getting to college is a major hurdle.

The other item is an obituary of one of the most important persons in my life, Pastor Robert Leroy Stone. He authorized scholarships for two years of my undergraduate college education, which were at Huston-Tillotson College (now Huston-Tillotson University, one of the HBCUs) in Austin, Texas. That was back in the 1970s, ancient history now. The issue of Affirmative Action was widely discussed during that time.

As usual, I’m dumbfounded by how often I miss the passing of the critically important people who made my success in life possible. And there is this astonishing connection which followed me even to Iowa City—but of which I was unaware. After he retired, Pastor Stone moved from Mason City to Iowa City in November of 2001. At that time, I had graduated from The University of Iowa College of Medicine, finished my residency in psychiatry in 1996, and was on staff in University of Iowa Dept of Psychiatry. I never knew he was so close. He died in 2002.

Pastor Stone was a Board Member and Chair of the Mason City YMCA, where I lived for a while. He was also a Member of the Board of Chemical Dependency Services of North Iowa as well as the Mental Health Center of North Iowa.

Although I didn’t graduate from Huston-Tillotson College, I was able to transfer credit to Iowa State University. And from there I went to medical school at The University of Iowa.

I’ve read other stories about how hard it is for Black students to get into and finish medical school. My path was indirect and not easy, but Pastor Stone made it possible. And for that, I am grateful.

This is National Influenza Vaccination Week!

This is National Influenza Vaccination Week (Dec. 4-8, 2023) and the CDC word is:

“National Influenza Vaccination Week (NIVW) is a critical opportunity to remind everyone 6 months and older that there’s still time to protect themselves and their loved ones from flu this flu season by getting their annual flu vaccine if they have not already. CDC data shows that flu vaccination coverage was lower last season, especially among certain higher risk groups, such as pregnant people and children. When you get a flu vaccine, you reduce your risk of illness, and flu-related hospitalization if you do get sick. This week is meant to remind people that there is still time to benefit from the first and most important action in preventing flu illness and potentially serious flu complications: get a flu vaccine today. Check out CDC’s NIVW toolkit for more shareable resources and content.”

It’s also big news that a recent CDC co-authored study showed strong evidence for flu vaccine effectiveness. Among the university medical centers participating in the study was the University of Iowa Hospitals.