This is just a post to offset the grumpy one from a couple of days ago. Sena and I took a walk on the Clear Creek Trail and she broke me up with her shenanigans.
Along the way, we found a painted rock in a tree which had
the word “corridor rocks” printed on it.
It looked like something you could google—which I did. It’s a cute story titled “The Corridor Rocks! —Brightening Days One Stone at a Time” by Sara C. Painting rocks, hiding them and giving people like us a fun time discovering them. Sara says it was a way to stop and smell the roses.
It’s one way to remember how happiness works. It leaks…sort of. We put the rock back where we found it. The only clue we’ll give you is that it’s somewhere out there on the Clear Creek Trail. Have fun!
It’s been a long while since my last post. I’ve been busy looking for signs to help guide me in adjusting to this retirement gig. It’s a tough skill set to learn.
I saw this bug on our house the other day. It turned out to
be a Praying Mantis. Don’t quibble about the precious difference between mantids
and mantises—I don’t have the patience for that. Anyway, this one didn’t have
the typical pose, with the long forelegs cocked into a prayerful posture. It
looked more like it was just trying to find its way—kind of like how I feel.
I read a little bit on the web about the Praying Mantis. One
culture says seeing one is good luck and another says it’s bad. I read just
enough to hope there is no such thing as reincarnation. I hope never to come
back as a male Praying Mantis, if you get what I mean. Look it up.
What I really would appreciate is somebody telling me about
what would be the best way to adjust to retirement. Many days go by when I
struggle to shake the notion that I was never really any good at anything other
than being a doctor.
I need a sign. I need many signs, as a matter of fact. Just
to clear my head, I went for a long walk out on the Clear Creek Trail. I
noticed quite a few signs out there. Most of them seemed to have some special
significance. That’s just because I’m preoccupied with getting used to being
retired.
There were signs of September on the trail. Specific signs telling you to do something or not do something else. And there were signs that you generally see every September that tell you autumn is on the way.
It reminded me of that song, “Try to Remember,” which has always struck me as lugubrious.
I just need a sign and I don’t care if the Praying Mantis points it out or not.
Starting this month, I’ve got a 10-month countdown to retirement. I was reminded of that when I got a brochure in the mail for the University of Wisconsin 7th Annual Update and Advances in Psychiatry. It’s scheduled for October 11-12, 2019 at the Monona Terrace, which is the usual location.
I’ve received these announcements in the mail every year for
longer than 7 years. I’ve never had the time to make it to a single of these
meetings. I’ve always been on duty. I’m not sure why they are advertising them
as though they started only 7 years ago.
I can remember getting an announcement in 2009 in which the
title of the update was Nontrivial Neuropsychiatric Nourishment from Noble
Notable Nabobs. How’s that for a sense of humor? There were several like that
prior to 2009 but I never kept the brochures. I haven’t seen any brochures like
that for the last seven years.
I don’t know who came up with the humorous titles. I wonder
if it was Dr. Jefferson. I noticed this year’s brochure had an In-Memoriam notice
about James W. “Jeff” Jefferson, MD, who has been a luminary of psychiatry for
decades. He was also a major presenter at these psychiatry advances meetings.
He was active in psychiatry for over 50 years.
And me? I’m retiring after a much shorter career, by
comparison. I’ve been running all over the hospital as a Consult-Liaison Psychiatrist
during the busiest time in academic medical centers everywhere–July and the
early part of August when senior medical students become full-fledged resident physicians.
Newly-minted doctors tend to request many psychiatric consultations. On average
I’m putting close to 4 miles and 30-odd floors on my step counter (with C-L
psychiatrists, maybe it’s not the years but the miles that count—literally). I’ve
not taken vacation during the past 2 years of my current phased retirement
contract—and don’t plan one for this final year.
That reminds me of time in 2012 when my wife, Sena, and I went
to Madison, Wisconsin on a vacation, the first in a long time. The residents
were wondering when I was going to get away. Madison is a great place to visit
and we lived there briefly when I took a stab at private practice.
We stayed at the Monona
Terrace, which gives a great view of Lake Monona. We loved Olbrich Botanical
Gardens. We rented a couple of bikes at Machinery Row Bicycles and rode all the
way to Olbrich. The rental bikes were a far sight more affordable than a lot of
the ones you could buy. Many were priced at several thousand dollars.
And I found an old copy
of Robbins Pathologic Basis of Disease at Browzers Bookshop on State Street. I
used that book as a medical student. My class used the nearly 7 pound red 3rd edition
containing 1,467 pages. This book is hailed as an outstanding foundational
text, which it is. Dr Stanley Robbins has been eulogized as an exacting editor
who championed writing of the type espoused by Will Strunk in The
Elements of Style.
Not to be picky, but the book contained the phrase
“not excessively rare” in reference to some process or disease which I can’t
recall. I do recall that a majority of our class howled about this verbiage,
which seemed the antithesis of what Strunk tried to teach.
You could see a lot of interesting sights on State Street. During
a previous visit, we saw a guy walking down the middle of the street with a rattlesnake
coiled on his head, wore it like a hat.
We had a lot of fun in Madison. It’s that kind of relaxed,
good time that I want to retire to. Ten months to go.
We’re pretty dedicated to maintaining everything about our
property, including deck maintenance. Check that; actually, my wife is
dedicated. I’m usually hard to find when it comes to chores like that. When
it’s time for deck cleaning and sealing, there is always some emergency I need
to address on the other side of town or I’ve been temporarily abducted by
aliens.
Sena is usually not one for moaning and groaning about these
jobs, but painting the deck rail spindles is an exception—each and every
spindle, separately and painstakingly swabbed with a brush so that every tiny
spot is covered with sealant.
The right kind of sealant is critical. She usually likes water-based
sealant, but the local hardware store salesman managed to sell her an oil-based
product that was on sale. There’s debate about the relative merits of
water-based vs oil-based sealants.
In general, the water-based products are a lot easier to
work with and provide excellent deck protection. Oil-based sealants have been
around a lot longer, penetrate better, and naturally repel water. Most of them
nowadays have a low risk rating as volatile organic compounds (VOC), meaning
they are environmentally safe. On the other hand, Sena is finding it takes more
than one coat of the oil-based product to get adequate coverage, and she has to
use a brush instead of a pump pressure sprayer. It takes longer to finish the
job—which elicits more moaning and groaning.
We’re not 100% sold on the assurance by experts that either one puts down a finish that will last for several years. We live in Iowa and shovel the deck several times a season, so moaning and groaning about this could happen pretty much every two or three years.
Just for the sake of full transparency about my role in this job—I was banned last year for reasons which would normally remain opaque but who cares?
That cleaning and sealing chore last year was a major challenge. I somehow had to figure out how to reach the yard side of the spindles to cover them with sealant. The trouble was that I was not tall enough to reach them. I think it is to my credit and possibly my eternal fame that I immediately came up with an ingenious solution—a boom lift truck. I have some simple instructions to pass on to those who learn certain skills quickly and don’t mind spending a little time in a state penitentiary.
Boom lift truck
Now, we didn’t own one but it just so happened that across the street there was a lot of construction going on in a new subdivision development. The average boom lift truck with a cage or bucket would have made a pretty big dent in our bank account.
You should pick a weekend day to successfully pull this
off—I mean execute this procedure. Usually the construction crews are
short-handed and they’re too busy smoking cigarettes to pay much attention to
what’s going on around them.
Pick a two-story house under construction, which is more
likely to need a boom lift truck for applying various exterior features like
windows, cedar shakes, shingles and escape hatches. It’s likely to be left
running with the key in the ignition. There might be a couple of construction
guys hanging around, which you can get rid of by shouting “Hey look, there goes
Elvis!”
This always works—pretty much. While they raced off,
fumbling with particle board scraps which they could possibly get an autograph
scribbled on using lumber crayon, I climbed into the nearest boom lift truck.
There’s usually a button to start it. The one I found was
already running. Reverse gear was difficult to find; it was just as easy to hit
the gas and dislodge the portico cover on the way back to the street. By this
time, a couple of construction workers and a rottweiler had spotted me and were
racing back across the lot, yelling and barking.
This was not a problem. I managed to get the rig up on two
wheels and whipped around. I contributed to their cardio workout as they
sprinted back the way they came. I finally caught all of the pursuers including
the dog in the basket. It didn’t take me long to figure out where to dump them.
There were plenty of basement holes dug. They were making quite a bit of progress
in that subdivision!
I made it back home in time for lunch. I had to eat fast
because I could hear sirens up the street. I could get only a few rail spindles
covered before I discovered that I might have to quick like find a hideout—I mean
alternative living quarters.
Anyway, you’ll have to do some calculations to figure out how much progress you can make with this method. I’ve refined it in several ways and I plan to post an update on these instruction when I’m out on parole—I mean back from vacation.
See you soon!
In any case, I think Sena is doing a great job. She’s been a tireless gardener, hospital volunteer, and the best wife a guy could ask for.
I updated my suicide risk assessment presentation today in
light of new data on suicide risk assessment stratification. It turns out that
using such tools might not be supported by the research evidence. That’s not
going to stop the use of such tools, which include the Columbia–Suicide
Severity Rating Scale, which is in wide use.
I found criticism of these scales in a recently published
article in Clinical Psychiatry News, published June 21, 2019, “Why we need
another article on suicide contracts,” by Nicholas Badre, MD and Sanjay S. Rao,
MD.
For many years now, psychiatrists and other health care professionals have learned that trying to use no-suicide or no-self harm contracts are controversial and don’t prevent suicide. Badre and Rao sound like they’re easing away from that contention although they still say that a thorough clinical suicide risk assessment ought to be done.
Until I saw this article, I was not aware of a recent review
of 70 studies showed that: “no individual predictive instrument or pooled
subgroups of instruments were able to classify patients as being at high risk
of suicidal behavior with a level of accuracy suitable to be used to allocate
treatment.”
Carter, G., et al. (2017). “Predicting suicidal
behaviours using clinical instruments: systematic review and meta-analysis of
positive predictive values for risk scales.” Br J Psychiatry 210(6):
387-395.
This was even more interesting because we recently changed our
practice regarding suicide risk assessments on the psychiatry consultation service
based on relatively new recommendations from the Joint Commission on
Accreditation of Hospital Organizations (JCAHO). The Joint Commission favors
the risk assessment tools.
Of course I’m not going to second-guess the Joint Commission
but after 27 years (counting residency) of struggling to assess suicide risk, I’ve
learned that it can hardly be reduced to any single rating instrument.
I have often said to patients that I don’t use no-suicide
contracts because they’re too much like promises—and promises are broken every
day. That segues into what I prefer which is to work with the patients on
developing a safety plan, which I compare to no-suicide contracts by saying “a
plan is better than a promise any time.”
Working on the safety plan with patients gives me another way
of assessing the strength of my alliance with them and a way to improve it as
well as a method for evaluating their ability to formulate a workable way to
stay safe that emphasizes their individuality.
On the other hand, the safety plan is no guarantee of safety,
any more than the no-suicide contract.
But often enough I’ve gotten the sense that some patients
and I have even had a little fun working on suicide safety plans—ironic as that
sounds. I find how important pets are, hear little anecdotes about a favorite hobby
or goal, aspirations, hopes, and memories of better times when they coped
really well.
Listening for understanding to someone who is contemplating suicide or who has attempted suicide is never easy. It’s the hardest thing I do. I can’t say that I’ll miss it when I retire. I have great faith in the next generation of doctors.
We saw this rabbit in our front yard
today, stretched out on the grass under our crabapple tree. It’s 117 degrees
this afternoon with the heat index and we won’t get out from under the Excessive
Heat Warning until later this evening. Thank goodness for air conditioning.
Rabbits don’t have air conditioning and can’t escape the heat.
Sena stands the heat better than I do; she waters the lawn and garden, keeping it beautiful. On the other hand, I felt body-slammed just walking out to get the mail.
Out in Sena’s garden
The old saying goes, “If you can’t
stand the heat, get out of the kitchen.” It means you if you can’t take the
pressure of a situation, then you should move and let somebody else take over.
It was popularized by President Harry S. Truman, who said the originator of the
proverb was Judge Buck Purcell of the Jackson County, Missouri Court—whoever he
was.
Anyway, I’m on call this weekend
and got to talking with a colleague who is thinking about retirement. We go
back a long way in our education and careers. He asked me about what phased
retirement is like. I told him I thought if I’d tried to retire outright, I
probably would have just come back to work.
That’s a twist on standing the heat. As a psychiatric consultant, I’m like a fireman (get it?) in the general hospital, putting out fires, so to speak, all over the hospital. Most often the problem still tends to be delirium, an acute change in mental status that should be considered a medical emergency rather than a psychiatric problem per se. It’s just one of many crises that I encounter every day. Over 23 years (not counting residency), I learned how to stand the heat in that kitchen. When I retire, somebody else will have to get in there and cook. Speaking of cooking—I still can’t.
I guess I’m mixing my metaphors
(fireman and kitchens, etc.). So what? I’m a retiring geezer and I guess I’ve
earned the right to mix my metaphors as much as I want.
But in my first year of the 3-year
phased retirement contract, I felt a different kind of heat–the heat of trying
to find something to do with my unstructured time. It was a struggle for a guy
who’s accustomed to being in almost constant motion, climbing up and down 20-30
floors (I hate waiting for elevators) and covering 2-3 miles a day.
The only trouble is—I can’t get out of the kitchen of retirement. I’m getting up there in age and even though most of the time, I seem to leave some of the trainees huffing and puffing getting up the stairs, I know they’ll replace me someday. But I can’t find a replacement to do my retirement time for me.
I have 11 months to go before I
retire. I can feel the heat.
I got an email from Don R. Lipsitt, MD yesterday which reminded me of the Janus Head logo for the Academy of Consultation-Liaison Psychiatry (ACLP). It was changed to another sort of nondescript logo several years ago for reasons I didn’t understand.
Dr. Lipsitt is a luminary in C-L Psychiatry and recently published a definitive history of the field, Foundations of C-L Psychiatry: The Bumpy Road to Specialization (2016).
Go ahead; buy this book!
I posted a blog or two about Don and his book in a previous blog, The Practical C-L Psychiatrist. We’ve never formally met. A few years ago, he noticed that I had written about him and his book. I had sent him an email message about it at around the same time the APM was considering the name change for the organization, telling him that I had plugged his book and asking him what he thought of the name change. Incidentally, he thought both of our books made a great package, so I guess I’m allowed to plug mine, strangely titled Psychosomatic Medicine: An Introduction to C-L Psychiatry, editors James Amos and Robert Robinson (2010).
Go ahead; buy my book, too…
Don expressed his
opinion about the name change:
“I feel I have dealt with that at some length in my book. I
still feel C-L is most fitting and that the Board made a big mistake naming it
PM. Who were they? Any C-L psychiatrists among them? Any Psychosomaticists? Why
are not the “complex medically ill” a special population? And why is
APA now offering courses on “integrated” care (which is what C-L
psychiatry has always been about? The notion that C-L was not
declared a specialty because it was considered a skill of ALL psychiatrists
(with minimal training), then how do geriatric or child psychiatry become specialties
(that all psychiatrists also have training in)? Don’t get me started.”
He considered his book, in large part, a “polemic” against
the name “Psychosomatic Medicine.”
Anyway, the ACLP was formerly the Academy of Psychosomatic
Medicine (APM) until a couple of years ago when the organization responded
robustly to the membership (of which I was one at the time) to abandon the term
“Psychosomatic Medicine” and adopt what rank and file practitioners
preferred—Consultation-Liaison Psychiatry.
It was a kind of rebranding and it was not the first time
the academy had considered a name change. I and a lot of other C-L
Psychiatrists cringed at the term “psychosomatic,” not so much because of the
word itself in terms of its true denotation, but because of the unfortunate
negative connotations it had acquired.
Another luminary of C-L Psychiatry, Dr. Thomas Hackett, MD,
wrote about the term “psychosomatic” in the Massachusetts General Hospital:
Handbook of general hospital psychiatry: edited by Hackett and Ned Cassem
(1978):
“The term ‘psychosomatic service’ has had a variable
history. The term generally leaves a bad taste in the mouths of physicians. It
reminds them of the 1930s, 1940s, and 1950s, when various psychosomatic schools
espoused doctrines linking specific psychological conflicts or unique
personality profiles with diseases designated as psychosomatic. Compounding
this misunderstanding has been the term’s abuse by the general public, who
regard anything psychosomatic as either imaginary or nervous in origin. As a
consequence, most people believe that a psychosomatic disease is not to be
taken seriously.”
Well, anyway, because of my anecdotage, I’ve strayed a
little from my original story about the Janus head logo.
I already mentioned that the logo was abandoned in favor of something that looks like waves and could lead to seasickness. I inquired about the history of the use of the Janus head logo.
In addition to my curiosity about why the logo was changed, I also wondered why it was chosen in the first place and when. According to Don, it was part of the organization’s journal, Psychosomatics, in the late ‘60s and ‘70s. What was interesting is that it was already in use by the Journal of Geriatric Psychiatry when the Psychosomatics editors started using it. However, a conflicting view was that it was not introduced to the cover until 2010. Hmmmm.
I saw the 2012 issue of the APM Newsletter had a pretty funny picture of Drs. Shuster and Rosenstein posing as Janus and the statement “Thank you, Janus. You served us well for over 50 years.” That might put the origin of the logo, at least, around 1962 although my understanding is that APM was started in 1953 (TN Wise, A Tale of Two Societies, Psychosomatics 1995).
Time to say “Hello, again, Janus?”
It’s
just my opinion, but because Janus is the ancient god of beginnings and
transitions, gates, doorways, endings and time, and typically depicted as
two-faced because he looks to the future and the past, I think the symbol is a
better image for what C-L Psychiatry has been through over the years.
Anyone for re-rebranding and go retro back to the Janus head logo?
Again today, I hoofed it around the hospital. I put 43
floors and a little over 4 miles on my step counter.
I don’t like waiting for elevators so I take the stairs. And
a Consult-Liaison Psychiatrist is like a fireman, running all over putting out
fires.
I did other things today. I gave the usual lecture on
delirium and dementia to the medical students. I notice that as I have gotten
older, I tend to tell more anecdotes about my experiences managing delirium in
patients on the medical side of the hospital.
I’m in my anecdotage, as I told the students today.
I also lamented the decision by the powers that be to
copyright the Montreal Cognitive Assessment (MoCA). The medical students will
be able to use it for free, but faculty won’t.
I think that’s ageism. I won’t pay so I won’t use the MoCA anymore.
Well, I’m pretty tapped out, so it’ll be a short post today.
I’m back in the saddle, running around the hospital on the psychiatry consult
service. This is my last year of phased retirement and in 11 months—I’ll be fully
retired.
I put 36 floors and 3 miles on the step counter. I’m feeling
every one of those. Sena bought me some banded collar shirts and I’m wearing
those instead of a shirt with a necktie. I don’t need a tie bar.
And I don’t worry about a delirious, violent patient
strangling me with my necktie.
We had a small scare tonight. We were looking at my total compensation statement (the last one) and got the Sharp Elsi Mate EL-505 vintage calculator out to crunch some figures. The calculator went dead.
Still going…
I put some new batteries in it, hopeful. It still didn’t work. We’ve had this calculator for over 30 years and it ran more than a decade on the first set of AA batteries.
I tried another pair of batteries. It worked! The vintage calculator lasted longer than the batteries. It’s nice to know that just because something’s old doesn’t mean it’s useless.
We visited Hickory Hill Park today in Iowa City. We’ve lived in this area for 30 years and have been near it but never walked a trail until now. It’s full of trees, birds, and other wildlife, including deer, which seemed to pose for the camera.
Deer posing
I say we’ve been near it because we have visited Oakland Cemetery, where the famous Black Angel monument is. At least one of the trails leads to one end of the cemetery—which we discovered today.
There are many legends about the
Black Angel, most of which are in the vein of various curses and some of which
claim that the curses can kill visitors—not true, of course. Many take selfies
in front of the Black Angel and toss coins in the base (probably to ward off any
curses, just in case).
I was feeling pretty reckless on the day Sena took a snapshot of me in front of the Black Angel. I left a little pocket change. That was a few years ago. The object of the visit was not to visit the Oakland Cemetery but to take part in the picnic and Psychiatry Department Matball Challenge game, Faculty vs Residents at Happy Hollow Park about a block away from the cemetery.
The Black Angel of Oakland Cemetery
Anyway, it was pretty hot today,
in excess of 100 degrees with the heat index. We kept the walk short for that
reason. It was warm, but the tree canopy kept the heat down a little. There’s
something about walking through a thickly wooded area in which most of the
sounds you hear are of nature. It tends to make me a little reflective.
Because I’m in my last year of a
phased retirement contract and will fully retire next year, I’ve been thinking
about transitions, the end of one era of my life and the unknowns about the
beginning of another. There are a lot of unknowns. Sometimes I feel a little lost.
Retirement tends to lead me to
think about death, which is pretty morbid, I know. I don’t ruminate about it,
but walking past some of the park benches, some of which are memorialized to certain
persons, got me to wondering about the next bend in the path. On one of them
was a small plaque bearing a quote,
“Not all those who wander are lost.”
JRR Tolkien
There was a baseball on the bench.
And not long before we got to that bench, we saw a shoe, apparently lost by someone—who might have been lost. Hickory Hill Park is big. A person could get lost in there.
Lost shoe
We followed a path that others seemed
to be taking. It led to the back of Oakland Cemetery where we saw a couple of
headstones which puzzled us. The names were very familiar; man and wife, with
only the birth years carved in them. But the strange thing was—as far as we
knew they were still very much alive! The man had been the closest thing to a
mentor that I could remember ever having.
Naturally, later I realized that
it was just that they had thought through their own transitions a lot farther
than many of us do. They had planned not only for retirement. They had planned
for their own deaths. But until I finally got it, I actually searched on the
web for obituaries.
Strange, I actually found a pdf
file posted that sort of sounded like one—an exquisitely written letter from a
relative who described the person we knew in enough detail that it seemed to
identify him beyond much doubt. Why would such a beautiful and presumably
private remembrance be posted on the web?
Maybe because the relative wanted the world to know how deeply loved this person is—while he is still alive.
Go Retire Psychiatrist 