It was a long day so this is a short post. It’s different from other long days in that my wife and I had fun besides doing all the yard work.
Sena got the hummingbird feeders (3) and I mixed the sugar water since I need all the practice I can get regarding cooking. It’s 4 parts water to 1 part sugar.
We’ve got Columbine flowers in our garden and that helps attract hummingbirds.
I’m pooped. That’s all I got.
My wife and I are trying to attract hummingbirds this weekend. This is a new project for us. She got a couple of feeders and some nectar we mixed with water and a little beer. No, I’m kidding; we wouldn’t try to get any hummingbirds drunk.
One of the feeders is pretty fancy. You know, it sort of looks like an upside-down beer bottle–just sayin’.
I’ve tried to get snapshots and videos of hummingbirds before. They’re usually pretty blurry and jittery, just like the birds.
We’re hoping that the flowers will help lure them to our garden.
They probably don’t care for Allium; it’s in the onion family.
We’ve got a garden ornament that might help draw them. And as long as our garden goonbird (a well-known cryptid) behaves and doesn’t scare them off–we might see the little guzzlers in a few days.
I guess I’m incorrigible; there are now 4 eggs in the robins’ nest. Progress there reminded me of another kind of progress–in integrated health care.
On that note, this is just a brief update on the Medical-Psychiatry Unit (MPU). I thought it would be a good time to do this since a hard-working Pennsylvania psychiatrist notified me of the very successful Medical Complexity Unit (MCU) in operation at Reading Hospital. See my post from May 23, 2019.
I co-attended on our MPU for 17 years before I chose to concentrate on the Consultation-Liaison Psychiatry (CLP) service. The health insurance payer system challenges have probably not changed much. I still believe that the MPU is a great place to teach trainees to appreciate the rewards and challenges of caring for patients with complex, comorbid psychiatric and medical issues.
I hope the video makes the case for that. I decided it didn’t need a voice over. I welcome any comments and questions.
I received exciting news from Dr. Kolin Good, M.D., a colleague in Reading, Pennsylvania. There is a thriving Medical-Psychiatry Unit (MPU) at Reading Hospital. Dr. Good consulted with The University of Iowa several years ago on how to get it started, since we have a 15 bed MPU.
They call it the Medical Complexity Unit (MCU) and the highlights of her message are:
“We now have 19 beds.
Nursing 1:4 ratio.
Staffing is 1 internist ( hospitalist) and 1 psychiatrist ( me) with a psychiatric social worker and physician’s assistant.
We have a LOS that is the same as other units of the hospital.
We have decreased 1:1’s throughout our entire hospital ( > 650 beds ).
We are a favorite rotation for training.
Most important: we provide excellent care for complex patients.”
Congratulations are in order!
Reading Hospital is also looking for a Consultation-Liaison Psychiatrist (although not to staff the MCU).
A former teacher of mine and a major mover and shaker in the integrated care effort is Dr. Roger Kathol, MD, the leader of Cartesian Solutions, Inc. Check his web site by googling the name. The credit goes to him, Dr. Good, and the rest of the Reading Hospital staff who made the MCU a reality.
There are now 3 eggs in the robins’ nest. I saw a big turkey vulture soaring close by. I wonder if that’s what got the House Finch chicks. The bird that made a noise with it’s wings that was as loud as a big sheet flapping on a line in the wind, and looked too big to be a crow or even a raven–I wonder.
I wonder if I somehow was partly to blame for the murder of the baby birds, always messing around the tree. Still, I take pictures–and maybe draw death nearer.
And that leads to other strange thoughts. It’s odd that the nearer I get to retirement, the more I think about my life way before I ever even thought about medical school.
I remember the first time I ever heard about death was when I was in kindergarten. My mother woke me up early one morning to tell me that Steven, one of my schoolmates, was killed the evening before. He was playing around the railroad yard just a few blocks from our house. A train ran over him.
I remember my mother talking about it but I didn’t make any sense out of it. I was too young. I only wondered what it meant.
When I was a difficult teenager and made a conscious effort not to smile for pictures, I remember hitchhiking along a lonely highway in a bad rainstorm. I was glad when the man pulled over. I was not glad when he began to rub the back of my neck and asked, “How about a ride for trade?” I was not too young to know what he meant. When I said, “Let me out,” he did. I was too young to know that was miraculous.
I sometimes catch myself wondering if my life has been a grand illusion since then, only to protect my fragile soul from knowing the true horror. Maybe the driver really didn’t let me out. Why should I wonder that?
I remember a man who taught me how to do the work of a land surveyor. I looked up to him. He committed suicide by shooting himself in the chest over a failed relationship. I couldn’t help wondering why.
Of course, death visited me several times after I became a physician. They sometimes led to decisions I would rather I had not made about the direction of my career. I always wonder.
We have a couple of brand new birds’ eggs in what may be a second nest by the robin pair. Now that made me wonder about whether or not the first nest under our deck was a decoy or dummy nest. You probably won’t believe me, but I thought of that before I googled it.
What got me wondering was the nest the robins build under our deck about a week ago and which they seemingly abandoned. See the progress in the video:
My last picture of the first robins’ nest showed that it was empty.
There was only one egg that ever turned up in this nest.
And then we found the new robins’ nest in our front yard crab apple tree.
I wondered if the nest under our backyard deck was a dummy or decoy nest, maybe to discourage a persistent birdwatcher. I checked the web and found a short article on Sialis, “Dummy and Abandoned Nests.” Since Google identified the site as “Not secure,” I can just summarize that the author (who is not identified), reports that some males build nests to provide the female with a number of choices. She picks one and finishes the nest–much more neatly.
Some birds build decoy nests because they might have been scared by a possible predator in the area–like a large black crow in our area, which actually did make off with an entire clutch of House Finch nestlings only a week ago.
I found another web site that essentially gave the same explanation and both mentioned somebody named Benjamin E. Leese, who wrote about this topic in something called BlueBird Journal, Summer 2018, p.14 and 15. Unfortunately, I couldn’t find the article, possibly because it’s a print journal and not available on line.
Another thing I wonder about: if the crab apple nest is the real McCoy and the under-the-deck nest was a decoy (hey, those rhyme), the problem with the crab apple nest is that, when approached from the back, it’s wide open to flying predators.
Anyway, both nests were done in a couple of days, although the crab apple nest probably was done after the under-the-deck model. I’m pretty confident that the breeding pair built both of them. I know they all look alike, but that’s my story and I’m sticking to it, evidence or no.
This reminds me of another nest that robins built on our property a few years ago, this one right between our house and the rail of our deck. It was a real Hoorah’s Nest!
Occasionally, despite my being in phased retirement, I get a reminder that my colleagues may need some advice about an issue for which I might be a useful source of institutional memory.
One of them is the psychiatric consultation for assessment of candidates for organ transplant. I have a slide set and a YouTube video that are still useful as long as viewers remember that some of the slides and the text are dated.
For example, the video refers to my former blog The Practical Psychosomaticist (which l later renamed the Practical C-L Psychiatrist), and which I cancelled June 1, 2018. The references are also old, but much of the information is still useful.
I’ve included both the video and the slides for the Dirty Dozen on Psychosocial Assessments for Organ Transplant. You can view the slides and just listen to the audio like a voice over in the video. That way you don’t have to giggle at the back of my head and my camera comically reflected in the office window behind me. Turn on the video, click in the slide set to open it, and listen to my prompts for which slide I’m on.
The most frequent question that consultees from the transplant team ask is whether the candidate is a good risk for receiving an organ that is in short supply, which therefore must be allocated carefully, and of which the candidate must be prepared to be a good steward. Psychosocial screening is a feature of most transplant programs. Rather than seeing ones self as a gatekeeper, most experts agree that the most useful part of the psychosocial screening process is to identify psychosocial factors that would interfere with the candidate’s successful adaptation to life posttransplant, and to develop a plan for managing them using available resources.
The evaluation phase is critical to diagnosis of major psychiatric problems and to treatment planning for evidence-based interventions. However, providing follow-up through the other phases of transplant allow optimizing the development of a therapeutic alliance to foster adherence to both psychiatric and medical treatment and further evaluation of psychosocial challenges as well. The waiting phase is a very stressful time and often the candidate must tolerate deteriorating health while watching others transplanted sooner. In the post-transplant period, about 20% of patients develop any psychiatric disorder, most notably depression and PTSD.
There’s a triple advocacy role for evaluators conducting organ transplant assessments: advocacy for the patient; for the persons on the waiting list; and for society in general in terms of husbanding allocation of scarce resource (“organ stewardship”).
That makes it critically important to examine the nature of the therapeutic alliance.
Transactional/Adversarial or Transformational?
Transactional/Adversarial:
Atmosphere is typically highly charged emotionally, with a sense of urgency.
Interrogation mode rather than exploration of motivations and feelings. Focus is on past rather than future, exclusive approach with emphasis on utilitarian paradigm and wait list advocacy. Methodically and meticulously confrontive; blaming. Team asks “Who else could we help?” Little or no interpersonal room to witness the patient make sense of impending death.
Withholding, rejecting, paternal, authoritarian (rather than shared) experience.
Win/Lose or Lose/Win.
Transformational:
Atmosphere of created space for calmer review and listening for understanding.
More likely to have focus on future rather than past, and an inclusive approach with emphasis on medical necessity paradigm and patient advocacy. Affirming and supportive of change. The team asks, “What would we need to do in order to help?” May be a better opportunity to be a witness to coming to terms with imminent death.
Shared experience, with both participants on a more level playing field.
Win/Win.
This is a very complex and challenging aspect of Consultation-Liaison Psychiatry and, probably in part because we’re in short supply in many areas, many transplant centers rely on written assessment batteries or checklists. It’s hard to do justice to the topic in a blog post. I hope it’s helpful.
References:
1. Anne M. Larson, J.P.R.J.F.T.J.D.E.L.L.S.H.J.S.R.F.V.S.G.O.A.O.S.W., Acetaminophen-induced acute liver failure: Results of a United States multicenter, prospective study. Hepatology, 2005. 42(6): p. 1364-1372.
2. DiMartini, A.F., M.D.,, M.A. Dew, M.D.,, and P.T. Trzepacz, M.D.,, Organ Transplantation, in Textbook of Psychosomatic Medicine, J.L.M.D. Levenson, Editor. 2005, American Psychiatric Publishing, Inc.: Washington, DC. p. 675-700.
3. Huffman, J.C., M.K. Popkin, and T.A. Stern, Psychiatric considerations in the patient receiving organ transplantation: a clinical case conference. General Hospital Psychiatry, 2003. 25(6): p. 484-491.
4. Klapheke, M.M., The Role of the Psychiatrist in Organ Transplantation. Bulletin of the Menninger Clinic, 1999. 63(1): p. 13-39.
5. Novack, V., et al., Deliberate self-poisoning with acetaminophen: A comparison with other medications. European Journal of Internal Medicine, 2005. 16(8): p. 585-589.
6. Turjanski, N. and G.G. LLoyd, Transplantation, in Psychosomatic Medicine, M.J. Blumenfield, M.D. and J.J. Strain, M.D., Editors. 2006, Lippincott Williams & Wilkins: New York. p. 389-399.
I just saw the Clinical Psychiatry News article “Evidence poor on medical marijuana for neuropathic pain,” by Andrew D. Bowen. It was published May 2019, Vol. 47, No. 5 and I couldn’t find it on line yet.
I should also hasten to add that there are a couple of other important articles on management of pain in this issue of Clinical Psychiatry News. One of them expresses a similar opinion about the lack of clear evidence pointing to a clear best choice for a medication for neuropathic pain, “No clear winner emerges for treating for chronic pain” also by Andrew D. Bosen, who interviewed a neurologist, Dr. Raymond Price, associate professor of neurology at the University of Pennsylvania, Philadelphia about his review of the evidence for treatment of neuropathic pain.
In addition, on a more hopeful note, there is good evidence for the effectiveness of cognitive behavioral therapy (CBT) for chronic pain, “In chronic pain, catastrophizing tied to disrupted circuitry,” by Kari Oakes, who interviewed Drs. Robert R. Edwards, PhD, psychologist at Brigham and Women’s Hospital/Harvard Medical School (Boston) Pain Management Center, and Vitaly Napadow, PhD. Connectivity between certain areas of the brain can lead to the perception that pain is a part of who we are. This can even interfere with the effectiveness of pain medications.
Dr. Ellie Grossman, MD, MPH said at the annual meeting of the American College of Physicians that there’s “a lot of the Wild West” in medical marijuana research regarding its use in neuropathic pain. I got the impression she was being as diplomatic as she could when she described the level of evidence as being marked by a lot of “squishiness.”
It’s a frankly cautious comment compared with the more positive opinions expressed just a month ago in Clinical Psychiatry News. Dr. Grossman is quoted, “The upshot here is that there may be some evidence for neuropathic pain, but the evidence is generally of poor quality and kind of mixed.” Dr. Grossman is an instructor at Harvard Medical School and Primary Care Lead for Behavior Health Integration, Cambridge Health Alliance, Somerville, Massachusetts.
In fact, as the author points out, the research in this area is marked by inconsistencies in the medical marijuana formulations, small numbers of patients enrolled in studies, and equivocal results from meta-analyses.
The title of the article says it all and it’s really no surprise. I have little to add except the following very short opinion based on a very superficial scan of PubMed.
First, I happened to find a couple of papers from the mid-1970s about cannabis and pain in cancer patients. They were written by Russell Noyes, MD and Art Canter, Ph.D. and colleagues. Dr. Noyes has retired for the second time from the Psychiatry Dept at University of Iowa and Dr. Canter was enjoying his retirement until his death in October, 2018; he was in his late 90s.
Even in 1975, there was very little reason for enthusiasm about the analgesic effect of cannabis in cancer patients. Admittedly, the number of subjects were low in each study but the side effects of cannabis were severe in a few cases.
The summary from the first Noyes et al paper is essentially that, why analgesic effect was demonstrable at high dose levels, so was “…substantial sedation and mental clouding…”
In the second paper by Noyes et al, the concluding remarks are telling— “Finally, particular difficulty was experienced in evaluating the pain of patients after receiving THC. In many instances they appeared exceptionally peaceful while, at the same time, reporting little pain relief. In other instances, they claimed that, though the pain was unchanged, it bothered them less.”
There seems to be nothing new under the sun in this setting although most of the studies involved patient with chronic non-cancer pain. One study found some benefit and modest tolerability—see the caveat below (Ware et al 2015).
“In conclusion, this study suggests that the AEs of medical cannabis are modest and comparable quantitatively and qualitatively with prescription cannabinoids. The results suggest that cannabis at average doses of 2.5 g/d in current cannabis users may be safe as part of a carefully monitored pain management program when conventional treatments have been considered medically inappropriate or inadequate. However, safety concerns in naive users cannot be addressed. Moreover, long-term effects on pulmonary functions and neurocognitive functions beyond 1 year cannot be determined. Further studies with systematic follow-up are required to characterize safety issues among new cannabis users and should be extended to allow estimation of longer-term risks.”
See the abstracts below. They tend to echo Dr. Grossman’s impressions. I wonder whether the quality of the research in this area will ever be strengthened.
References:
NOYES, R., et al. (1975). “Analgesic Effect of Delta‐9‐Tetrahydrocannabinol.” The Journal of Clinical Pharmacology 15(2‐3): 139-143.
Noyes, R., et al. (1975). “The analgesic properties of delta‐9‐tetrahydrocannabinol and codeine.” Clinical Pharmacology & Therapeutics 18(1): 84-89.
The administration of single oral doses of delta‐9‐tetrahydrocannabinol (THC) to patients with cancer pain demonstrated a mild analgesic effect. At a dose of 20 mg, however, THC induced side effects that would prohibit its therapeutic use including somnolence, dizziness, ataxia, and blurred vision. Alarming adverse reactions were also observed at this dose. THC, 10 mg, was well tolerated and, despite its sedative effect, may have analgesic potential.
Ware, M. A., et al. (2015). “Cannabis for the Management of Pain: Assessment of Safety Study (COMPASS).” The Journal of Pain 16(12): 1233-1242.
Cannabis is widely used as a self-management strategy by patients with a wide range of symptoms and diseases including chronic non-cancer pain. The safety of cannabis use for medical purposes has not been systematically evaluated. We conducted a prospective cohort study to describe safety issues among individuals with chronic non-cancer pain. A standardized herbal cannabis product (12.5% tetrahydrocannabinol) was dispensed to eligible individuals for a 1-year period; controls were individuals with chronic pain from the same clinics who were not cannabis users. The primary outcome consisted of serious adverse events and non-serious adverse events. Secondary safety outcomes included pulmonary and neurocognitive function and standard hematology, biochemistry, renal, liver, and endocrine function. Secondary efficacy parameters included pain and other symptoms, mood, and quality of life. Two hundred and fifteen individuals with chronic pain were recruited to the cannabis group (141 current users and 58 ex-users) and 216 controls (chronic pain but no current cannabis use) from 7 clinics across Canada. The median daily cannabis dose was 2.5 g/d. There was no difference in risk of serious adverse events (adjusted incidence rate ratio = 1.08, 95% confidence interval = .57–2.04) between groups. Medical cannabis users were at increased risk of non-serious adverse events (adjusted incidence rate ratio = 1.73, 95% confidence interval = 1.41–2.13); most were mild to moderate. There were no differences in secondary safety assessments. Quality-controlled herbal cannabis, when used by patients with experience of cannabis use as part of a monitored treatment program over 1 year, appears to have a reasonable safety profile. Longer-term monitoring for functional outcomes is needed. Study registration The study was registered with http://www.controlled-trials.com (ISRCTN19449752). Perspective This study evaluated the safety of cannabis use by patients with chronic pain over 1 year. The study found that there was a higher rate of adverse events among cannabis users compared with controls but not for serious adverse events at an average dose of 2.5 g herbal cannabis per day.
Andreae, M. H., et al. (2015). “Inhaled Cannabis for Chronic Neuropathic Pain: A Meta-analysis of Individual Patient Data.” The Journal of Pain 16(12): 1221-1232.
Chronic neuropathic pain, the most frequent condition affecting the peripheral nervous system, remains underdiagnosed and difficult to treat. Inhaled cannabis may alleviate chronic neuropathic pain. Our objective was to synthesize the evidence on the use of inhaled cannabis for chronic neuropathic pain. We performed a systematic review and a meta-analysis of individual patient data. We registered our protocol with PROSPERO CRD42011001182. We searched in Cochrane Central, PubMed, EMBASE, and AMED. We considered all randomized controlled trials investigating chronic painful neuropathy and comparing inhaled cannabis with placebo. We pooled treatment effects following a hierarchical random-effects Bayesian responder model for the population-averaged subject-specific effect. Our evidence synthesis of individual patient data from 178 participants with 405 observed responses in 5 randomized controlled trials following patients for days to weeks provides evidence that inhaled cannabis results in short-term reductions in chronic neuropathic pain for 1 in every 5 to 6 patients treated (number needed to treat = 5.6 with a Bayesian 95% credible interval ranging between 3.4 and 14). Our inferences were insensitive to model assumptions, priors, and parameter choices. We caution that the small number of studies and participants, the short follow-up, shortcomings in allocation concealment, and considerable attrition limit the conclusions that can be drawn from the review. The Bayes factor is 332, corresponding to a posterior probability of effect of 99.7%. Perspective This novel Bayesian meta-analysis of individual patient data from 5 randomized trials suggests that inhaled cannabis may provide short-term relief for 1 in 5 to 6 patients with neuropathic pain. Pragmatic trials are needed to evaluate the long-term benefits and risks of this treatment.
Ashrafioun, L., et al. (2015). “Characteristics of substance use disorder treatment patients using medical cannabis for pain.” Addictive Behaviors 42: 185-188.
Background This study was designed to assess the prevalence and correlates of self-reported medical cannabis use for pain in a substance use disorder (SUD) treatment program. Method Participants (n=433) aged 18years and older were recruited from February 2012 to July 2014 at a large residential SUD treatment program. They completed a battery of questionnaires to assess demographics, usual pain level in the past three months (using the 11-point Numeric Rating Scale for pain), depression (using the Beck Depression Inventory), previous types of pain treatments, and lifetime and past-year use of substances (using the Addiction Severity Index). Using both adjusted and unadjusted logistic regression models, we compared those who reported medical cannabis use for pain with those who did not report it. Results Overall, 15% of the sample (n=63) reported using medical cannabis for pain in the past year. After adjusting for age, medical cannabis use for pain was significantly associated with past-year use of alcohol, cocaine, heroin, other opioids, and sedatives, but was not associated with usual pain level or depression. It was also associated with past year treatment of pain using prescription pain relievers without prescriptions. Conclusions These results indicate that medical cannabis use for pain is relatively common and is associated with more extensive substance use among SUD patients. Future work is needed to develop and evaluate strategies to assess and treat individuals who report medical cannabis for pain in SUD treatment settings.
Hefner, K., et al. (2015). “Concomitant cannabis abuse/dependence in patients treated with opioids for non‐cancer pain.” The American Journal on Addictions 24(6): 538-545.
Background and Objectives Cannabis use is common among patients taking prescription opioids, although rates of concomitant cannabis use disorder (CUD) have been largely unexamined. CUD may increase safety risks in those taking opioid pain medications but it is unknown whether cannabis and opioids function as substitutes (cannabis use is associated with less prescription opioid use), or rather as complements (cannabis is associated with increased use of prescription opioids). Methods We examined rates of CUD in a national sample of Veterans Health Administration (VHA) patients (n = 1,316,464) with non‐cancer pain diagnoses receiving opioid medications in fiscal year 2012. Using bivariate analysis to identify potentially confounding variables associated with CUD (eg, psychotropic medication, other substance use disorders) in this population, we then utilized logistic regression to examine rates of cannabis use disorder among individuals receiving different numbers of opioid prescriptions (0, 1–2, 3–10, 11–19, 20+). Results Descriptive analysis, largely confirmed by logistic regression, demonstrated that greater numbers of prescription opioid fills were associated with greater likelihood of CUD. This relationship was reduced somewhat for those receiving the most opioid prescriptions (20+) in the logistic regression, which controlled for potentially confounding variables. Discussion and Conclusions These results warrant increased attention to CUDs among patients receiving numerous opioid prescriptions. Increasing legalization of cannabis is likely to further increase use and abuse of cannabis in patients prescribed opioids. Scientific Significance These findings suggest that clinicians should be alert to concomitant CUD and prescription opioid use, as these substances appear to complement each other. (Am J Addict 2015;24:538–545)
I just saw a great post on Fear of Missing Out (FOMO) on Bob Lowry’s blog, Satisfying Retirement. The link is on my home page and it’s a great read, along with many of his other posts.
FOMO for me is different because I’m not actually retired yet. Bob has been retired for a long time and knows what he’s talking about. I’m still just trying to get used to the idea of being retired for now.
Even though I’ve been in phased retirement for over two years now and this coming year is my last before full retirement (see my countdown!), I’m still coping with FOMO.
I check my email several times a day, even when I’m not on service. My position will likely be filled with my replacement well before the year is out. Occasionally I’ll find a trainee evaluation that is time sensitive that I have to complete. I updated the guide to the psychiatry consultation service and notified others about that just yesterday.
What am I going to do when I’m retired? That’s what so many ask me and which I sometimes ask myself. I’m actually having a pretty good time now that I’m finally adjusting to phased retirement. According to the 2018 Report on U.S. Physicians’ Financial Preparedness: Retired Physicians Segment, one suggestion is that physicians try to retire gradually rather than abruptly.
I agree with that and the phased retirement program I’m in has felt right for me. It hasn’t stopped me from FOMO so far, but I’m gradually getting more and more enjoyment from doing things that are not work-related—even though FOMO makes me check my email and the electronic medical record every day.
My wife and I started saving very early on in my medical training and we were fortunate enough to eliminate educational debt early. We’ve always lived simply and don’t need a lot of expensive toys.
I find ways to build a schedule into my day. I exercise and meditate.
I’m not much for yard work, but I try. I get a big kick out of hobbies I’ve rediscovered such as bird-watching.
I like to make silly videos as some of my medical students have noticed. One of them learned how to fold a fitted sheet from one of my YouTube videos. I really enjoy blogging and combining that with my mostly short YouTube movies. You’ll notice I do have some work-related videos, though, some of them fairly recent.
The featured image for this post was actually partly a creation of one the residents a few years ago, who by some miracle found a way to combine my photo with a picture of a smartphone. I added a little more to it to make the point about FOMO.
I actually didn’t have a smartphone until about 4 years ago. And I still mainly use it just as a phone. I check the step counter when I’m staffing the psychiatry consultation service, but I’ll quit doing that.
In fact, the residents persuaded me to get a smartphone. I had a flip phone for a few years prior to that mainly because a snowstorm caught my wife out on the road while she was driving to the hospital to pick me up from work. I had no way of knowing where she was and was worried out of my mind. That convinced me we needed more than land lines.
I still use a desk phone at work. For the first time in my career, last weekend it just quit working. You can’t imagine how happy I was.
Whenever I drop my pager, I always say out loud to the trainees, “Oh my gosh, I hope it’s broken!” I’m only half-joking.
I dropped most of my social media accounts over a year ago, including Facebook, LinkedIn, Twitter, and even Doximity believe it or not. I don’t miss them.
I’ll keep you posted on how my struggle with FOMO goes.
Man, it was hot yesterday—par for the course for this time of year. Sometimes it seems like we skip spring and just start with summer. It was in the 90’s and muggy.
So Sena and I decided to head to Kalona to do some outdoor shopping at the Maple Avenue Greenhouse. Sena is the gardener and I mostly stood by the cart to make sure the surface temperature maintained a steady first degree burn level.
Sena found the Jacob’s Ladder plants and I found the martins houses near the entrance to the greenhouse property. I looked up Jacob’s Ladder later and found out that the name comes from how the plant’s pinnate leaves grow up the stem like the steps on the Biblical ladder of Jacob’s dream.
I also found out that Jacob’s Ladder prefers shady and cooler temperatures. Did I mention that the temperature was 90 degrees out in the sun?
We passed the Kalona Creamery on the way out to the greenhouse. After purchasing the Jacob’s Ladder plants, we suddenly got a craving for something cold and creamy.
The Kalona Creamery was established in 2015 and does a pretty good business. It’s bigger than it looks from the outside. Don’t let the cow sculpture scare you. Kalona cows are what this extra sweet creamery is all about.
And in turn, cheese curds and fancy, hand-rolled butter (3rd place at the 2018 Iowa State Fair) is what humans are all about.
And don’t forget the ice cream. I have a lot of imagination and cosmopolitan, discriminating tastes—so I got the “Plain ol’ Vanilla.” Sena got the Kalona Crunch—with pecans. You get a chocolate cow with any selection. It brought back memories of hand-churned ice cream in grade school. Man, that’s good.
And the people were sure friendly in Kalona—even in 90 degree heat.
Go Retire Psychiatrist 