In my off-service time, I discovered that you need to exercise
150 minutes a week or a little over 20 minutes a day. Exercise guidelines come from
the Department of Health and Human Services and the World Health Organization
who are behind this conspiracy, I mean this recommendation.
I’ve adopted this to some extent, at least what I consider reasonable for a geezer in his mid-60s. I even added something for speed and dexterity. The video shows an abbreviated version of my routine as a demo.
I divide up my mindfulness and sitting meditation with the exercise when I’m on service. I do floor yoga and sitting meditation on alternate mornings and exercise in the evening after I get home from work.
You’ll notice I don’t have a fancy exercise machine. My
exercise equipment is simple. I’m an older guy and I’ve got other stuff I need
to spend my money on—health insurance, muscle cream, beef jerky.
I realize my plank is not absolutely the best form, but I’m
working on it.
I would not make this regimen a requirement for membership in a new retirement club I’m considering. I think a good name might be Retiree On My Own Time (ROMOT). There would be no membership dues. You could make your own card, similar to the one I made. Meetings would be optional because many retirees are actually pretty busy, believe it or not.
I’m an amateur bird watcher. Last August, I saw a toeless Mourning Dove with what some people would call String Foot, a foot deforming condition that might be caused by a variety of injuries. I had never seen anything like it.
Toeless Mourning Dove
In the slide show you can see a bird seemingly sitting in its own poop, which is said by some to cause the problem—which I suspect is doubtful. The last shot is that of a pair of doves trying to nest in our window box, which was full of sharp, plastic artificial plants. It was painful to watch and I wonder if their hazardous habits could lead to injuring their feet.
Mourning Doves nesting on a speaker
I’ve seen Mourning Doves do strange things, mainly nesting in areas that don’t make much sense. Years ago, we could not dissuade a pair of them from building a home on top of one of the audio speakers mounted outside on our deck. Cranking up the volume didn’t work.
I clicked around the web trying to find out about the problem. Speculation about the causes of these injuries range from something called String Foot (string or human hair used to build nests getting wrapped around toes leading to amputation), sitting in poop leading to infections, and frostbite.
In the book, Birds of
Massachusetts and Other New England States by Edward Howe Forbush, you can
read one of the many anecdotes from amateur ornithologists about bird behavior
that Forbush collected for his book, which was published circa 1929 (I actually
plucked it from one of E.B. White’s essays):
“Mrs. Olive Thorne Miller. Reported case of female
tufted titmouse stealing hair from gentleman in Ohio for use in nest building.
Bird lit on gentleman’s head, seized a beakful, braced itself, jerked lock out,
flew away, came back for more. Gentleman a bird lover, consented to give hair
again. No date.”– Forbush, Edward Howe, 1858-1929. Birds of Massachusetts And Other New England States. [Norwood,
Mass.: Printed by Berwick and Smith Company], 192529.
I wonder why a bird would risk String Foot by using hair in
nests?
I’ve noticed that I’m getting more garrulous as I age. In fact, I call this anecdotal garrulity and I always warn my trainees that I’m about to tell them yet another war story which usually involves some activities or processes in my job as a Consultation-Liaison (C-L) Psychiatrist that nobody knows about anymore–but should.
My anecdotes tend to grow longer and more woolly as the years pass. I add a detail or nuance to the story that adds extra angles, twists and turns, and bits of hair-raising action. Some of them never happened. No, I ‘m just kidding. I don’t actually lie; I just polish the history a little bit.
One example of anecdotal garrulity in which the tales get hairier with each performance, I mean embellishment, no I mean repetition–involve people I’ve encountered while blogging on WordPress.
One of them is Dr. Igor Galynker, a brilliant psychiatrist at Beth Israel in New York who has done very important research in suicide risk assessment. He has recently published a book about the suicide crisis syndrome, The Suicidal Crisis: Clinical Guide to the Assessment of Imminent Suicide Risk. I purchased a copy and am reading it whenever I get a chance. I wrote a post about a paper he published regarding his suicide risk assessment research in my previous blog, The Practical C-L Psychiatrist, which started off with the name The Practical Psychosomaticist for goodness sakes, what a name! The name Psychosomatic Medicine (PM), by the way, was chosen by the American Board of Psychiatry and Neurology (ABPN) and the American Board of Medical Specialties (ABMS) about 2,000 years ago when this subspecialty got approved by the Accreditation Council on Graduate Medical Education (ACGME).
Come to think of it, I probably ought to call it a supraspecialty instead of a subspecialty and that name originated with another grand beacon of academic C-L Psychiatry (I mean besides me), Dr. Theodore Stern, at an annual meeting of the Academy of Psychosomatic Medicine (that’s what it was called then, if you can believe it; but now, because the members of the academy (including me) howled about it and voted to change it to something that made some darn sense, it is now rightly called the Academy of C-L Psychiatry; we’re finally correctly identified, good gahd’amighty) and you will not find “supraspecialty in Webster’s Dictionary although “supra” comes from the Latin for “above, beyond, earlier”. One of the definitions is “transcending”. I tried to Google “supraspecialty” and came up empty, so it’s a bona fide neologism. Dr. Stern coined the term while talking about the scope of practice of PM. As he went through the long list, it gradually dawned on me why “supraspecialty” as a title probably fits our profession. It’s mainly because it makes us, as psychiatrists, accountable for aspects of general and specialty medical and surgical care above and beyond that of Psychiatry alone. That doesn’t make us deities; just better than most doctors on the planet. Of course not; I’m only kidding. Can’t you take a joke?
Where was I ? Oh, getting back to Igor Galynker, I wrote a post about one of his papers on the assessment of imminent suicide risk, published in about 2014 I believe, a few years after the book Robert G. Robinson and I edited was published, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry, a block bluster that you cannot put down and will read cover to cover; the level of interest just climbs, almost the effect you get from my award-winning and wildly popular video on pseudobulbar palsy.
Command Performance by Jim Amos, MD
Anyway, shortly after I posted that, I got a box in the mail with a very strange-looking address for me:
Hey, what do you know, I work for WordPress!
Even more astonishing was what was in the box. It was Bumpy the Bipolar Bear, an item that evidently was a part of his Mood Disorder Division at Beth Israel.
Bumpy is the one with the Fire Chief helmet
I have never really figured out whether he did this tongue-in-cheek or what. We’ve never met and we don’t correspond. It doesn’t look like Bumpy is a thing anymore at Beth Israel.
I’m not a research scientist, but I wonder if anyone would fund a center for the study of Anecdotal Garrulity? More importantly, would a statue of me, sculpted from Play-Doh (originally wallpaper cleaner, something you’d know if you watched the Travel Channel as much as I do now that I’m retiring), be erected in the rotunda?
Retirement takes a back seat today for this announcement: Dr. Wes Ely, Critical Care Specialist and one of the foremost experts in intensive care unit (ICU) delirium at Vanderbilt University will be speaking at The Newman Center in Iowa City on April 11, 2019 at 7:00 PM, “Maximizing Dignity at End of Life: Insights from the ICU.” He’ll also deliver the Internal Medicine Grand Rounds at the University of Iowa at noon, “A New Frontier in Critical Care: Saving the Injured Brain.”
I was notified by one of our critical care specialists, Dr. Gregory A. Schmidt, MD, who co-authored the recently published study showing that antipsychotics are not effective treatment for delirium. Wes talks about the study in the video below:
Dr. Wes Ely
I met Dr. Ely briefly at one of the annual meetings of the American Delirium Society several years ago. He’s enthusiastic, brilliant, and inspiring. He’s published hundreds of articles and book chapters on delirium and taking care of the brain. Along with Dr. Valerie Page (another critical care specialist) he co-authored a book entitled Delirium in Critical Care, originally published in 2011 and I see that there is a 2nd edition available, published in 2015 by Cambridge University Press.
That is the same publisher, incidentally, for the book I co-edited with Dr. Robert G. Robinson, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry)–shameless plug for my book.
I have a copy of the first edition, which contains a section about the role of the psychiatrist in ICU delirium. It’s very short, which I think is very appropriate. Dr. Alasdair MacLullich, Professor of Geriatric Medicine, Professor of Geriatric Medicine at the University of Edinburgh and past President of the European Delirium Association, wrote the foreword to the 2nd edition and he describes Dr. Ely as “…perhaps the best recognized expert in this field worldwide,” referring to delirium.
Incidentally, about 8 years ago Dr. MacLullich and I corresponded about his research team’s development of the Edinburgh Delirium Test Box (EDTB), an instrument for detecting attentional abnormalities that are a defining feature of delirium. He loaned us the box and I eventually turned it over to a colleague for continuing use of it as part of an ongoing delirium committee project to improve the early detection and prevention of delirium at our hospital. There is now a smartphone application for it.
Where is this thing called an “app”?
Regrettably, I probably won’t get to hear Wes give his presentation—because I’m on duty as the general hospital psychiatric consultant and most likely will be trying to help physicians care for delirious patients.
References:
Girard, T. D., et al. (2018). “Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness.” N Engl J Med 379(26): 2506-2516.
BACKGROUND: There are conflicting data on the effects of antipsychotic medications on delirium in patients in the intensive care unit (ICU). METHODS: In a randomized, double-blind, placebo-controlled trial, we assigned patients with acute respiratory failure or shock and hypoactive or hyperactive delirium to receive intravenous boluses of haloperidol (maximum dose, 20 mg daily), ziprasidone (maximum dose, 40 mg daily), or placebo. The volume and dose of a trial drug or placebo was halved or doubled at 12-hour intervals on the basis of the presence or absence of delirium, as detected with the use of the Confusion Assessment Method for the ICU, and of side effects of the intervention. The primary end point was the number of days alive without delirium or coma during the 14-day intervention period. Secondary end points included 30-day and 90-day survival, time to freedom from mechanical ventilation, and time to ICU and hospital discharge. Safety end points included extrapyramidal symptoms and excessive sedation. RESULTS: Written informed consent was obtained from 1183 patients or their authorized representatives. Delirium developed in 566 patients (48%), of whom 89% had hypoactive delirium and 11% had hyperactive delirium. Of the 566 patients, 184 were randomly assigned to receive placebo, 192 to receive haloperidol, and 190 to receive ziprasidone. The median duration of exposure to a trial drug or placebo was 4 days (interquartile range, 3 to 7). The median number of days alive without delirium or coma was 8.5 (95% confidence interval [CI], 5.6 to 9.9) in the placebo group, 7.9 (95% CI, 4.4 to 9.6) in the haloperidol group, and 8.7 (95% CI, 5.9 to 10.0) in the ziprasidone group (P=0.26 for overall effect across trial groups). The use of haloperidol or ziprasidone, as compared with placebo, had no significant effect on the primary end point (odds ratios, 0.88 [95% CI, 0.64 to 1.21] and 1.04 [95% CI, 0.73 to 1.48], respectively). There were no significant between-group differences with respect to the secondary end points or the frequency of extrapyramidal symptoms. CONCLUSIONS: The use of haloperidol or ziprasidone, as compared with placebo, in patients with acute respiratory failure or shock and hypoactive or hyperactive delirium in the ICU did not significantly alter the duration of delirium. (Funded by the National Institutes of Health and the VA Geriatric Research Education and Clinical Center; MIND-USA ClinicalTrials.gov number, NCT01211522 .).
Tieges, Z., Stíobhairt, A.,
Scott, K., Suchorab, K., Weir, A., Parks, S., . . . MacLullich, A. (2015).
Development of a smartphone application for the objective detection of attentional
deficits in delirium. International Psychogeriatrics, 27(8),
1251-1262. doi:10.1017/S1041610215000186
Retiring takes practice, like a great many skills. I know it’s
puzzling to think of retiring as a skill. Skill building feels awkward at first
and with time, managing the transition slowly feels more natural. At least that’s
what I hope about this retirement thing.
I remember way back in the day of the dinosaurs when I was
working for consulting engineers. It was my first real job. I had to learn many
new skills in my role as a land surveyor assistant. I started out mainly as a
rear chain man and a rod man. These are special tools to measure distance and
elevation.
Throwing a chain is a term for wrapping a 100-foot chain. This skill is almost impossible to describe just by writing about it. I could find only one fairly straightforward video about it which shows the proper technique.
Throwing a chain
The last part of it, which is collapsing the figure 8 shape
of the chain into a circle is done almost by feel and was easier when I didn’t
think about it. Overthinking a technique or skill can get in the way of just
doing it.
I did those kinds of things every day for years. I gradually
learned other skills until I felt like I fit in with land surveyors. I got a
lot of satisfaction out of this kind of work when I was a young man.
But when it was time to move on to college, I found it
difficult to adjust initially. I was used to doing work with my hands more than
my head. It felt awkward to be in a class with a lot of students who were much
younger than I was.
I made the transition and moved on eventually to medical
school. That was another difficult transition in which I needed to develop new
skill sets. It felt so unnatural that I thought of going back to working for
consulting engineers.
But I hung in there and finally settled on being a consultation-liaison psychiatrist. I’ve gone from a consulting engineer world to a consulting psychiatrist world. They both involve consulting. The WHKS company I used to work for has a vision, purpose, and values that are arguably similar to consultation psychiatry in some ways.
I try to listen carefully to my patients and help them shape
a better understanding of themselves and their relationships.
I try to provide consultation that ultimately benefits
patients, sustains a healthy interpersonal environment for them and clarifies
their values, the things that mean the most to them.
I value listening; communicating; being of service to both
patients and their physicians, nurses, and other health care professionals;
being practical (I used to write the blog The Practical C-L Psychiatrist after
all); and I like to think I’m sometimes innovative in my approach to psychiatric
assessment, patient care, and teaching the next generation of doctors.
I’ve been a physician for over 26 years counting residency. And of course I spent 4 years in medical school. Retirement is a little jarring and doesn’t yet feel completely natural, frankly. I keep waiting for the chain to just fall into place.
First, thanks so much for the Likes from the cooks out there on yesterday’s post “Back on the Wards”! I have not yet had a chance to really dig into your recipes, but I’m definitely interested. There was also a Like on a previous post (“Mindfully Retiring from Psychiatry”) from someone who devotes a part of her website to great cooking as well. Thank you!
I used to know how to do at least a little cooking. I got a recipe for Shoo-Fly cake from a guy I used to work with eons ago when I was working for consulting engineers as a land survey assistant and drafting technician. I lost that recipe a long time ago.
Anyway, moving right along to how my second day went back on the wards—it was busy. My step counter logged 2.4 miles and 21 floors. I did sitting meditation this morning and didn’t fall asleep. And when I got home, I exercised. So far, so good.
My exercise routine is about 20 minutes every day, and I modified it from something I found on line. It’s based on the latest recommendation calling for about 150 minutes of moderate exercise a week, which works out to about 22 minutes a day. I do about 2 minutes of deep breaths, pass out briefly, and then 20 minutes of thumb wrestling (see the fitted sheet folding video in my post “Back in the Saddle—So Soon?”).
The residents asked me the dreaded retirement question today.
What are you going to do? I can’t just keep saying “I don’t know” or “I’m
working on it” or “I’ll be finding exciting new adventures in my unstructured
time.” I think I got that last one from a retirement web site. I guess there’s
a rumor that after I retire, I’ll end up just coming back to work. That happens
to a lot of retirees, although right now I don’t think that’s going to be my
path.
I could look for a good Shoo-Fly recipe or somebody could
just send me one.
I was back on the wards today. It was pretty busy in the hospital over the weekend as usual. Mondays are almost always days when psychiatry consultations are pretty heavy, and Fridays are about the same. I got 2.3 miles and 17 floors on the step counter today.
I’m trying out adjusting my exercise and mindfulness practice—mindfulness in the morning and exercise in the evening. Since I get up pretty early anyway, I tried the yoga this morning and after the day was done, I did my exercise routine. It might be hard to stay awake through sitting meditation tomorrow morning. We’ll just have to see how it goes.
In my off-service time, I’ve been trying to work on cooking—sort
of. I’m fair at best even with frozen pizzas. That’s a shame for someone who
used to make pizza.
Home-made pizza I made–not that long ago.
I’m just OK with microwave popcorn. On the other hand, I managed not to ruin Jiffy Pop popcorn. Remember that?
I see the robins are back. One of the activities that I’m gradually picking up again is bird watching. I’m still getting used to the new DSLR camera I bought last summer. I’m not a fanatic about it nor an expert photographer by any stretch of the imagination, but it’s fun.
One of my earlies encounters with birds was when I was a newspaper
delivery boy. That was also when I had to get up very early in the morning to
get my papers at the drop-off corner. I used an alarm clock with a transparent
face which revealed the inner works, all in different colors. I’m still an early
riser.
Swallow nestling waiting for lunch
Anyway, I had to cross a railroad yard to get to the corner and each and every morning birds would swoop at my head. I had to swing my paper bag at them, just to get across several sets of tracks. They might have been swallows nesting nearby although I’m just guessing.
Swallow feeding nestling
I never understood why birds would hang around busy, noisy railroad
tracks. I just did a web search today and it turns out that railroad tracks don’t
necessarily deter birds from hanging out there. The intermittent noise of trains
may be less of a deterrent than constantly busy highways.
Last spring, I got a video of Mourning Doves billing and cooing.
They hung around our property and actually tried to build a
nest in our front window box. They are not very careful nest builders. We had
very pointy, sharp, plastic artificial plants in the window box and it looked
painful for them to pick their way around them.
I’m looking forward to bird-watching again this spring.
A robin singing
Wiącek, J., Polak, M., Filipiuk, M. et al. Do Birds Avoid Railroads as Has Been Found for Roads? Environmental Management (2015) 56: 643. https://doi.org/10.1007/s00267-015-0528-7
I’m still trying to find more information in the literature
about retirement for psychiatrists. What happens to psychiatrists who retire? In
fact, there is an article published several years ago with an interesting
title: “A psychiatrist retires: the happening.” It was written by Dr. Norman A.
Clemens, MD, a psychiatrist who was a psychoanalyst for many decades and
retired in his mid-seventies. Dr. Clemens writes from the psychoanalyst’s perspective. He
had many psychotherapy patients with whom he had developed long term
therapeutic relationships. He was in private practice. His situation is vastly
different from mine in those respects.
As a consulting psychiatrist in the general hospital
exclusively, I have no long-term relationships with patients. I am so busy that
I have no time for an outpatient clinic practice in the academic medical center
where I work. I see my patients in the general medical wards, the critical care
units, and, less often, in the specialty medical clinics.
My role is to, above all, understand the interaction of medical illness with psychiatric symptoms and to find some way to ameliorate them. My time is limited because I’m paged from all over the hospital throughout the day. Often, I see patients for only one or two visits—and never see them again. The C-L Psychiatrist is the fireman of psychiatry. My colleagues in medicine and surgery call me for help in putting out fires: suicide statements or attempts, the terror and agitation of delirium, the medically unexplained physical symptoms, the depressed and demoralized.
I don’t conduct formal psychotherapy like Dr. Clemens did. I do my best to sit and listen to the patient. It’s the main part of supportive psychotherapy, which underpins all others. My main prop is a chair (not a couch), any chair I can find in the room. If there are none, either I or a medical student or resident trots out to the hallway and fetches one for me. A few years ago, a colleague gave me a folding camp stool that I now carry around, slung around my shoulder. It’s very handy.
After a consultation, I then speak with the physicians who
called me for my help. Frequently, nurses, social workers, medical students,
residents, and other learners are present. I often sit down for that, too. I
teach them and they teach me.
And also, I think about the larger perspective, which is the
shortage of psychiatrists generally. About 60% of psychiatrists are over the
age of 55 and many of them, including me, will soon retire. This will augment
the need to replace us.
So, what happened finally to Dr. Clemens? How did he cope
with retiring? Did he really retire? At the end of the paper, he confesses that
he mourned for the patient relationships but relished the freedom. And he
frankly admitted he’s not “totally retired,” still engaged in teaching. He says
he doesn’t know if he could ever fully retire from being a psychiatrist or a
psychoanalyst.
I spend a lot of time ruminating about how retirement will
affect me. Dr. Clemens’ practice and mine differ in many ways.
However, there is this similarity. My retirement will no
doubt affect many others.
Clemens, N. A. (2011).
“A psychiatrist retires: the happening.” J Psychiatr Pract 17(6):
425-428.
The author uses his own recent experience as a basis for
discussing the actualities of retiring and closing a private, solo, psychiatric
practice of psychotherapy and psychoanalysis. The extended process includes a
personal decision about whether, when, and how to retire; preparation of
patients and arrangements for their ongoing care; dealing with legal
requirements and professional obligations; and the mechanics of closing an
office one has occupied for decades. Not the least of concerns is one’s own
personal transitions in lifestyle, professional persona, attachments to
patients, and engagement in psychotherapeutic or psychoanalytic treatment relationships.
I’ve been off service for months and I’ll return to staff the general hospital psychiatry consultation service on Monday. It can be a stressful role and I’m “mindful” of how helpful mindfulness meditation has been. The featured image above shows my yoga mat and some might say a much too comfortable chair for sitting meditation. And of course, mindfulness is not really about relaxation; that’s just an old pillow.
About 5 years ago the editors of the Arnold P. Gold Foundation Humanism in Medicine Blog saw one of my blog posts (from a previous blog) describing my path to mindfulness practice, which included burnout, a problem for nearly half of all physicians, the causes of which include the health care system itself as well as physician vulnerabilities. It was posted under the title “How I left the walking dead for the walking dead meditation.” I was also the recipient of what was called in 2007 the Leonard Tow Humanism in Medicine Award, sponsored by the Gold Foundation.
Leonard Tow Humanism in Medicine pin
Getting the Humanism in Medicine Pin
This has me thinking about my motivations for retiring and what I’m going to do after I’m fully retired. Interestingly, the phased retirement program I’ve been in has given me a strong sense of how difficult this transition from full-time doctor to retired doctor entails. The meaning and purpose gap require more than a bridge made of recreational pastimes. The breath of relief after the great escape from work can soon become the sigh of boredom. On the other hand, my work as a psychiatric consultant has also been an enormous source of personal satisfaction. The video below gives a sort of Pecha Kucha account of what a Consultation-Liaison Psychiatrist does.
What C-L Psychiatry is about
It can get pretty hectic. Over the last two years of the phased retirement schedule, I’ve struggled to craft a daily routine at home that replaces the sense of accomplishment my work schedule provided—despite the pressures it exerted on my sense of well-being. Only now, in my third and final year am I starting to wonder the opposite.
For example, I’ve been exercising daily as well as practicing my mindfulness meditation. I’ve actually lost a little weight and my wife has noticed my shrinking paunch. I’m not laboring on my workouts by any means; my quads are not flopping over my knees. But I used to think that by climbing all those stairs and running all over the hospital I was staying in pretty good shape. It looked pretty impressive that my smartphone step counter logged around 20 floors and 2-3 miles a day. However, the consult service work demand can run hot and cold. It just doesn’t beat daily exercise.
How do I keep my daily exercise routine? I can hear myself saying that I won’t have time for it. I think my mindfulness teacher would probably remind me that my response could be to make time for it—just as I learned how to make time for mindfulness.
I’m looking for guidance in the literature on retiring
psychiatrists, especially C-L specialists, and it’s pretty scant. So far, the
best summary of it I’ve found were a couple of blog posts by H. Steven Moffic,
MD on the Psychiatric Times web site. You can easily view them for free. In the
first one, “Mental Bootcamp: Today is the First Day of Your Retirement,” published
in 2012, he highlights the difficulty of psychological adjustment to retirement
for psychiatrists. He advises, “Plan how to replace financial, personal,
social, and generative needs that work has fulfilled.” There is no doubt I
could do a better planning job.
In the second one, “Reviewing Retirement,” which was posted
in 2014 (two years after he retired), he advises “Retire, even if you are not
retired. Take enough time off periodically, and completely, with no connections
to work, so that you can feel emotionally free from concerns about patients and
practice.”
That speaks to me. In fact, the title of my blog site, Go
Retire Psychiatrist, actually echoes this suggestion, although I never made the
title with that connection in mind. I wish it were that easy to follow. You would
be very lucky in today’s work environment to pull that off, even in academia. Phased
retirement programs are one approach to preparing for retirement and could be
effective for preventing burnout.
Go Retire Psychiatrist 