consult psychiatry – Go Retire Psychiatrist

Retiree Musings

I’ve just discovered a web site that calculates the time that has passed since an event occurred. So, it calculated that I’ve been retired for 19 months—or 580 days, or 13,909 hours and so on. But I’m not counting.

What has been happening since then? I’ve had the usual problems with letting go of my professional identity, still having them in fact. I’ve posted a quote from another retired psychiatrist, H. Steven Moffic, MD.:

Plan for retirement, even if you don’t plan to retire. This means sound financial planning, developing other interests, and nurturing your relationships with significant others. 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. Of course, there is no reason to retire if you really love your work and relationships just as they are.
H. Steven Moffic, MD

There was also an article entitled “When Should Psychiatrists Retire?” written by Dinah Miller, MD. It was published in Clinical Psychiatry News January 2022 issue, Vol.50, No. 1 as well as Medscape on November 17, 2021. There is no consensus on the answer to the question, although there are several opinions by the commenters.

There are a lot of articles out there about what it’s like to lose your professional identity and the potential consequences of that. One thing I’m learning is that, while I may not be fully reconciled with losing my identity as a consult-liaison psychiatrist, I’m gradually starting to have more fun just being a clown sometimes, which pre-dated my becoming a doctor.

Maybe I just need to grow up, but my interests are everyday stuff I tend to make fun of.

Like dryer balls. Now, I don’t want to offend anybody who believes that dryer balls are effective at drying clothes quicker and the like—but the jury is still out on that claim.

In fact, there are many articles on the web, both pro and con about dryer balls. One of them is by somebody who did what sounds like an exhaustive study (just with his own laundry; you won’t find it published in any journal). He swears by them. Then there was the article which pretty much debunked dryer balls. It mentioned an “in-depth experiment” by an 8^th grader in 2013 proving that they don’t reduce dryer time. My wife, Sena, says they don’t work. One ball got snagged in a fitted sheet pocket.

What I don’t get is why dryer balls look so much like the spiky massage balls (hint, it’s the green ball; the dryer balls also have holes in them). I think everybody just takes for granted that massage balls work. Sena says it works. She also has what she calls a massager which looks vaguely like a headless alien doing the downward dog yoga thing.

But what I find puzzling is why I can’t find any mention on line of clamshell eyeglass cases which have a steel trap-like spring-loaded hinge. You don’t want to get your fingers caught in them. They should have a safety protocol for use—so of course I came up with one.

Please Take Your Seat

I brought my camp stool home from my office at the hospital yesterday. For the past several years and up until the time of the COVID-19 pandemic, I used it while interviewing hospitalized patients as part of my job as a consultation-liaison psychiatrist in the general hospital. I stopped only when I wondered whether carrying around an object which could be contaminated with the virus was a safe thing to do.

A colleague lent me the little chair when he and his colleagues on the Palliative Care Medicine consultation service started using them. I asked him whether he wanted it back and he graciously said I could take it with me now that I’m retiring—and use it as a camp stool (in a way, saying “Please take your seat”). For many years prior to getting the stool, I had been finding a chair or sending my trainees to find one for me. I felt more comfortable sitting eye to eye with patients and I got the impression that my patients appreciated that as well.

I got a lot of positive feedback from patients, family members, and other hospital staff about the little chair. I think it helped break the ice with patients and was a great opener, especially if they felt well enough to express a sense of humor— “Hey, doc; you don’t need nunchucks; I promise I’ll be good!”

There are a few papers in the medical literature supporting the usefulness of sitting with patients. Most authors assert that it helps build rapport and increases the patients’ perception of how interested their physicians or other health care clinicians are in their welfare (see the reference list below).

Once, when my original little chair broke beneath me during an evaluation for catatonia in one patient, the stool abruptly became a novel catatonia assessment tool.

The patient was mute but there was little evidence otherwise for catatonia, one of the chief features of which is the inability to react to any stimulus in the environment. I was seated on the chair explaining in detail the intravenous lorazepam challenge test for catatonia (which often interrupts the episode of muteness and immobility).

I was sitting in front of the patient but facing the family and the consult service trainees while expatiating on the topic. As I was droning on, I heard a sudden pop—and I fell flat on my fundament as the chair collapsed beneath me.

My audience exploded in loud laughter, and pointed at the patient. When I turned to look at him, he was convulsed with silent mirth.

I considered this a negative test for catatonia in this case, though impractical for regular use.

My colleague gave me a replacement camp stool, more securely built. However, he mentioned he might give up using his as a result of my accident which, incidentally, befell (rimshot) another doctor on his team. I’m not sure whether I’ll use the little chair. If I sit on it too long, my legs go numb. I think that’s about 10-15 minutes, about the length of time mentioned in one of the studies below. It didn’t seem to influence the positive perception of the visit—but it did make me walk funny.

I probably spend about the same time with patients now that I don’t use the little chair. But I don’t feel right about it. I’m always reminded of what Hackett said:

“As a matter of courtesy, I sit down when interviewing or visiting patients. Long accustomed to the ritual of making rounds, many physicians remain standing as a matter of course. Standing, physicians remind me of missiles about to be launched, poised to depart. Even if that is not necessarily true, they look the part. Patients sense this and it limits conversation. In addition, when standing, the physician necessarily looks down on the patient. This disparity in height is apt to encourage the attribution of arrogance. Looking down at a patient who is prone emphasizes the dependency of the position. Sitting at the bedside equalizes station. Sitting with a patient need not take longer than standing with him.”—Thomas Hackett, in MGH handbook of general hospital psychiatry, 1978.

References:

Johnson RL, Sadosty AT, Weaver AL, Goyal DG. To sit or not to sit?. Ann Emerg Med. 2008;51(2):188‐193.e1932. doi:10.1016/j.annemergmed.2007.04.024

Swayden KJ, Anderson KK, Connelly LM, Moran JS, McMahon JK, Arnold PM. Effect of sitting vs. standing on perception of provider time at bedside: a pilot study. Patient Educ Couns. 2012;86(2):166‐171. doi:10.1016/j.pec.2011.05.024

Strasser F, Palmer JL, Willey J, et al. Impact of physician sitting versus standing during inpatient oncology consultations: patients’ preference and perception of compassion and duration. A randomized controlled trial. J Pain Symptom Manage. 2005;29(5):489‐497. doi:10.1016/j.jpainsymman.2004.08.011

Orloski CJ, Tabakin ER, Shofer FS, Myers JS, Mills AM. Grab a Seat! Nudging Providers to Sit Improves the Patient Experience in the Emergency Department. J Patient Exp. 2019;6(2):110‐116. doi:10.1177/2374373518778862

Merel SE, McKinney CM, Ufkes P, Kwan AC, White AA. Sitting at patients’ bedsides may improve patients’ perceptions of physician communication skills. J Hosp Med. 2016;11(12):865‐868. doi:10.1002/jhm.2634

Coach’s Corner On Delirium

I’m anticipating a busy time next month on the psychiatry consultation service. I suspect delirium will be the main event, as it is most of the time.

So I made a very short YouTube video on delirium. It’s cast in the style of a coach’s corner because I was one of the many clinicians who won the Excellence in Clinical Coaching Award this year.

I’m honored to be in such distinguished company and congratulate all the winners.

Coach’s Corner on Delirium

Organ Transplant Overview

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.

Use this as a voice over for slide set below

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.

Dirty Dozen on C-L Psychiatry

I’m back in the saddle again after a brief hiatus according to the terms of my phased retirement contract. During my time away, I thought about what a short introduction to Consultation-Liaison (C-L) Psychiatry might include to give medical students and other trainees a snapshot look at what CL psychiatrists encounter in their work in a busy general hospital.

As I considered what to include, it occurred to me that common consult questions typically could be classified into three basic groups:

Manage Crises: This often involves assessment of medically ill patients for whom there are concerns about suicide or violence toward others, including health care professionals.

Manage Medications: Frequently, I get questions about how to manage psychiatric medications, often in patients who are being treated with multiple medications; or need authorization for clozapine (an atypical antipsychotic which usually must be authorized initially by a psychiatrist); or need adjustment of medications in the setting of medical problems like cardiac disease or bowel resection (in which absorption might be affected).

Manage Behavior: This doesn’t always involve violent behavior but may include challenging and potentially disruptive acting out in the setting of delirium, or associated with patients who might have personality disorders or abnormal illness affirming disorders.

These broad categories make up the biggest share of the concerns my colleagues in general medicine hospitalists and surgery have about a significant proportion of patients in a large hospital.