Go Retire Psychiatrist

Start My Engine!

Good Gahd Amighty, it was busy today! I really had to start my engine. It felt like I logged a lot more than 2.6 miles and 21 floors on the step counter. It’s days like this one that I’m not going to miss when I retire.

I don’t think I could exercise enough to withstand too many hectic days. I need to be a transformer of some kind.

I could use a break, so it’s a good thing I got the weekend off. I think I can feel my age.

The only time I want a wild ride like that is if I’m at an amusement park.

In fact, my wife and I had a great time at the Mall of America in Minnesota a few years ago. See for yourself.

Remembering My Calling

Back when I had the blog The Practical C-L Psychiatrist, I wrote a post about the Martin Luther King Jr. Day observation in 2015. It was published in the Iowa City Press-Citizen on January 19, 2015 under the title “Remembering our calling: MLK Day 2015.”

I have a small legacy as a teacher. As I approach retirement next year, I reflect on that. When I entered medical school, I had no idea what I was in for. I struggled, lost faith–almost quit. I’m glad I didn’t because I’ve been privileged to learn from the next generation of doctors.

“Faith is taking the first step, even when you don’t see the whole staircase.”
Martin Luther King, Jr.

As the 2015 Martin Luther King Jr. Day approached, I wondered: What’s the best way for the average person to contribute to lifting this nation to a higher destiny? What’s my role and how do I respond to that call?

I find myself reflecting more about my role as a teacher to our residents and medical students. I wonder every day how I can improve as a role model and, at the same time, let trainees practice both what I preach and listen to their own inner calling. After all, they are the next generation of doctors.

But for now they are under my tutelage. What do I hope for them?

I hope medicine doesn’t destroy itself with empty and dishonest calls for “competence” and “quality,” when excellence is called for.

I hope that when they are on call, they’ll mindfully acknowledge their fatigue and frustration…and sit down when they go and listen to the patient.

I hope they listen inwardly as well, and learn to know the difference between a call for action, and a cautionary whisper to wait and see.

I hope they won’t be paralyzed by doubt when their patients are not able to speak for themselves, and that they’ll call the families who have a stake in whatever doctors do for their loved ones.

And most of all I hope leaders in medicine and psychiatry remember that we chose medicine because we thought it was a calling. Let’s try to keep it that way.

You know, I’m on call at the hospital today and I tried to give my trainees the day off. They came in anyway.

I’ll Have to Make Time

I suppose you’re wondering why I’ve been saying that my wife has got me this or that item, like the pink dumbbells and whatnot. She also got me an extra yoga mat.

Part of the explanation is that I’ve recently had a birthday, which reminds me of the importance of time in my life–mainly because I have a shrinking supply of it. After all, I’m heading into the sunset of my journey on Earth.

Occasionally, I wonder what I ought to be trying to accomplish, if anything.

To achieve great things, two things are needed:
A plan and not quite enough time.
Leonard Bernstein

Bernstein’s quote is encouraging in a way. Hey, I’ve already got half of it–I don’t have enough time. Now all I have to do is achieve some great things.

I could go on the road to promote my idea for a hit song, “Put your hand in the hand of the man with a plan to get a tan, lead a band, roam the land, avoid the bladder scan, zippity do dah shazam.”

All I have to do is come up with lyrics…and a melody…and an agent…and a band…and a voice coach…and some talent.

Now, if I’m going to accomplish something great, it would make sense to keep working on building a more harmonious balance in my everyday life. I’m doing some of that, including regular exercise, mindfulness practice, and healthy eating.

That reminds me, the birthday cake was excellent, especially topped with white chocolate vanilla ice cream.

Every so often, my former mindfulness teacher sends out an email message about the upcoming mindfulness classes. She always includes an inspirational quote, like the one below:

Be a person here. Stand by the river, invoke
the owls. Invoke winter, then spring.
Let any season that wants to come here make its own
call. After that sound goes away, wait.

A slow bubble rises through the earth
and begins to include sky, stars, all space,
Even the outracing, expanding thought.
Come back and hear the little sound again.

Suddenly this dream you are having matches
everyone’s dream, and the result is the world.
If a different call came there wouldn’t be any
world, or you, or the river, or the owls calling.

How you stand here is important. How you
listen for the next things to happen. How you breathe.

William Stafford – “Being a Person”

There was also a couple of suggestions for yoga and meditation techniques specifically to help you sleep. I recognized one of them as the body scan. The body scan is one of the first things they teach you in Mindfulness Based Stress Reduction (MBSR).

The body scan invariably put me to sleep, which made me feel like I wasn’t doing it right. Early on in the course, that was not exactly the “goal” of the body scan. Except mindfulness is not exactly a goal-oriented activity.

That’s hard to conceptualize. And so, the other class that is offered to those who make mindfulness practice a regular part of their lives are follow-up groups. It helps reaffirm the regular commitment to practice mindfulness.

I noticed one of the follow-up groups is entitled “Embracing the Paradoxes of Mindfulness.” The description of the course makes the point that mindfulness really isn’t about reaching a goal or achieving great things. It’s about being rather than doing. It’s hard for me to get my head around that after getting into and through medical school, residency, and practicing psychiatry for umpteen years. And now I’m making a transition to retirement.

One of my biggest fears about making and sticking to a mindfulness practice was that I often didn’t think I would have enough time for it. My teacher just advised me that I would simply have to make time.

Maybe I could accept the time I do have left and just be the geezer I am.

Talk About Change

Let’s talk about change. I’ve had a couple of brand-new tie bars (gifts from my wife) in my dresser drawer for a couple of months now. I’d forgotten them until last night. I used to wear a tie bar many years ago. I’m discovering that I probably wore it wrong, according to fashion experts who know a lot about these things.

I never knew you were supposed to wear a tie bar between the 3^rd and 4th button of your shirt (counting from the neck). I guess I always wore it too low. It was always coming loose from the shirt, and that’s why I quit wearing it for years. It’s long gone. I think I probably just threw it away, or maybe it got lost in one of our many moves. And I never knew that the part of the shirt you attach the tie bar to is called a “placket.”

There are different kinds of tie bars. Most of them are made with what resembles an alligator clip. I guess you’re supposed to call that a slide clasp. Another kind of bar is difficult to manage without wrinkling your tie. It’s an awful lot like a cotter pin, but you’re supposed to call it a pinch clasp—I think. I have one of each. Pictures don’t always seem to match up with the names.

Look close to see the tie bar; it’s there. It’s just not in the right spot according to GQ.

I also used to wear bow ties. You don’t need a tie bar for those. They were very colorful. They’re long gone.

I also used to wear the old-style suspenders and even had buttons on the inside of my trousers to secure them. They’re long gone, maybe because I felt insecure without a belt. That was back before I got a paunch—which is now starting to shrink, probably because I’m exercising daily.

And speaking of daily exercise, my wife got me a pair of 5-pound dumbbells. She says pink was the only color left. Anyway, I began using them this evening. I’m not sure, but I may need some liniment.

I used to wear a heavy pair of wingtip Oxford brogues. Believe it or not I would tramp all over the hospital in those shoes. I still thought they looked sharp, but they also looked dated—kind of like me. I used to keep the old-fashioned cedar shoe trees in them, just to keep the creases out of the instep. They’re long gone. Now I wear lighter shoes. When I exercise, I wear Velcro tennis shoes.

My wife also got me an autographed copy of Dave Barry’s new book, Lessons from Lucy: The Simple Joys of an Old, Happy Dog. I’ve always been partial to his sophisticated humor—classic booger joke style.

However, I think Barry’s new book is more about how he’s changing as he ages. I haven’t had chance to read it yet except just enough from the jacket to suspect that the booger joke style will be there, but there’ll be something beyond that. He’s 70 years old and likely reflecting—about the mechanism of action of booger jokes. I used to have nearly all of his books, but they’re long gone. Just like the tie bar, I lost most of them in the many moves we’ve made.

The point is I’m changing in a lot of little ways. The big change coming up is, of course, retirement. I’m changing from a physician to a retiring physician—a retiring psychiatrist. Not all of the changes are to my liking, either about myself or my path.

“A flower falls even though we love it; and a weed grows even though we do not love it.”
Dogen

Change is not always comfortable. I have not stayed the same across the decades. Some changes have been painful. Others have been so much fun that I wouldn’t mind reliving them. They’re all long gone. We’ll just have to make new ones.

Darn Weird Socks

Today, a colleague and I compared socks. I noticed he was wearing a pair of Go Iowa Hawkeye-type socks. They looked pretty good—and then I showed him my brand-new Taco Avocado Alien socks. He was pretty impressed. They are the Darn Weird socks of America.

On the other hand, around 3 years ago, I found out about Darn Tough socks and got a couple pairs. They’re still tough, no matter how many stairs I climb.

Darn Tough socks have an unconditional lifetime replacement guarantee. They’re made in Vermont. They’re not cheap. But hey, if they’re good enough for dairy farmers in Wisconsin, they got to be good enough for me.

I’m not sure how long my Taco Avocado Alien socks are going to last. I usually get about 2-3 miles and 20 floors and more logged on my step counter as I hoof it around the hospital in my job as a Consultation-Liaison Psychiatrist. Today I logged 2.9 miles and 27 floors. And when I got home, I exercised in them. I wore my geezer Velcro tennis shoes, of course.

That kind of punishment often leads to my wearing out socks in a few weeks. Usually the toes go quick. Maybe my Darn Weird socks won’t last. I Like the Taco Avocado Alien theme anyway. I still haven’t figured out what the connection is between aliens, tacos, and avocados. Sure, you make guacamole from avocado for tacos and so they’re all green. Maybe that’s all there is to it.

Then again, we have to ask ourselves, do aliens like tacos with guacamole? I guess you’d have to ask the guys on the Ancient Aliens TV show (it’s on the History Channel), which I watch every Friday. It’s relaxing and often puts me to sleep. Does Giorgio A. Tsoukalos, a.k.a. the hair guy, wear Taco Avocado Alien socks? There are so many memes out there about him, it wouldn’t surprise me if you could find a picture of him wearing them—photo-shopped, of course.

Jim’s Exercise Routine

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.

Toeless Mourning Doves

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.

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.

I think frostbite is plausible, and so did a birdwatcher named Nickell, who published an article about it over a half century ago; Nickell, W. P. (1964). “The Effects of Probable Frostbite on the Feet of Mourning Doves Wintering in Southern Michigan.” The Wilson Bulletin 76(1): 94-95, complete with hand-drawn illustrations that look exactly like the one in the slide show.

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?

Anecdotal Garrulity

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?

Wes Ely to Visit University of Iowa in April

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.

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

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.

I’m probably overthinking it.