‘ay, this here be international talk like a gentleman o’ fortune day

The title of this post is a translation of “Hey, This is International Talk Like a Pirate Day.” I used a Pirate Speak translator to generate it.

Sena reminded me about this holiday, which got started back in 1995 by a couple of guys from Albany, Oregon.

She says she heard about it on the Mike Waters radio show this moring, Waters Wake-Up on the Iowa radio station KOKZ 105.7. Sena either heard Waters call it National Pirates Day or she misheard him. She also said that Waters denied that any pirates ever said “Arrr,” back in the heyday of pirates.

I beg to differ, arrr, Matey! The Wikipedia entry says that the dialect was real and probably was based on the dialect of sailors from West Country in the southwest corner of Britain.

Sena and I couldn’t find any holiday called National Pirates Day. I did find National Meow Like a Pirate Day, which, interestingly, is also a holiday today. It got started in 2015.

But the main event be international talk like a gentleman o’ fortune day—which I darn nearrr forgot!

I have a dim memory of writing a blog post using the pirate translator several years ago. It was on a different blog, which I canceled in 2018. I didn’t keep that particular post. I think the topic was teaching internal medicine doctors and medical students about delirium so that they would know when they actually need consultation from a psychiatrist.

So, in honor of International Talk Like a Pirate Day, I’m going to post a piratical translation of one of my similar posts from way back in 2011:

“Do ye ‘ave to be interested in psychiatry to volunteer fer the delirium prevention project?”

“I’ve been thinkin’ about what a couple o’ the medical students said when I broached the idea o’ some o’ them volunteerin’ to participate in the multicomponent intervention o’ the delirium prevention project.

 they said that there the first an’ second yearrr students might want to volunteer—especially the ones interested in pursuin’ psychiatry as a career.

 now think about that there a minute. Why would ye necessarily need to be interested in psychiatry? ‘ere be a few facts:

1.Delirium be a medical emergency; it just ‘appens to mimic psychiatric illness because it’s a manifestation o’ acute brain injury.

 2.The most important treatment fer delirium be not psychiatric in nature necessarily; the goal be to find an’ fix the medical problems causin’ the delirium.

 3.Many experts in delirium ain’t psychiatrists; the authors o’ the new book “delirium in critical care”, valerie page an’ wes ely, ain’t psychiatrists—they’re intensivists.

 4.Some o’ the best teachers about delirium be geriatric nurse specialists an’ geriatricians.

 I thought that there by reachin’ aft further into a physician’s trainin’ career, I would find people less biased toward thinkin’ o’ delirium as a primary mental illness. It turns out that there bias runs deep in our medical education system.

 it isn’t that there psychiatrists shouldn’t be interested in studyin’ an’ ‘elpin’ to manage delirium. Psychiatrists, especially them specializin’ in psychosomatic medicine, be among the best qualified to inform other medical an’ surgical disciplines about the importance o’ recognizin’ delirium fer what it is—a medical problem that there threatens the brain’s integrity an’ resilience, raises the risk o’ mortality by itself regardless o’ the medical problems causin’ it, prolongs medical ‘ospitalization, an’ makes discharge to long term care facilities more likely, especially in the elderly.

 delirium be a problem fer doctors, not just psychiatrists. So it makes sense fer all medical students, regardless o’ their goals fer career specialty, to be interested in learnin’ about delirium.

 delirium be also a problem fer nurses, who frankly ‘ave led the way in education about delirium fer many years now. You’ll find few experts pointin’ to the american psychiatric association practice guidelines fer the treatment o’ delirium as the ultimate authority these days—because they’ve not been updated formally since 1999. All one ‘as to do be spell out “delirium prevention guidelines” in web browser search bars an’ choose from several sets o’ free, up-to-date guidelines that there be supported by the research evidence base in the medical literature to within a yearrr or two o’ the present day. Some o’ the best ones be authored by nurses.

 so maybe the pool o’ volunteers fer the delirium prevention multicomponent intervention might be nursin’ students.

 on the other ‘and, from what pool does the ‘ospital elder life program (help) recruit volunteers? an’ the australian resource center fer ‘ealthcare innovation multicomponent program, revive (recruitment o’ volunteers to improve vitality in the elderly, ‘ow do they do it?

they think outside the box an’ include people who care about people. That’s the really the key criterion, not whether one wants to be a psychiatrist or not.”

‘appy international talk like a gentleman o’ fortune day, arr, matey!

Looking Back on Gunslingers and Chess Masters

I was looking at an early version of the handbook of consultation-liaison psychiatry that eventually evolved into what was actually published by Cambridge University Press. I wrote virtually all of the early version and it was mainly for trainees rotating through the consult service. The published book had many talented contributors. I and my department chair, Dr. Robert G. Robinson, co-edited the book.

In the introduction I mention that the manual was designed for gunslingers and chess masters. The gunslingers are the general hospital psychiatric consultants who actually hiked all over the hospital putting out the psychiatric fires that are always smoldering or blazing. The main problems were delirium and neuropsychiatric syndromes that mimic primary psychiatric disorders.

The chess masters were those I admired who actually conducted research into the causes of neuropsychiatric disorders.

Admittedly the dichotomy was romanticized. I saw myself as a gunslinger, often shooting from the hip in an effort to manage confused and violent patients. Looking back on it, I probably seemed pretty unscientific.

But I can tell you that when I followed the recommendations of the scientists about how to reverse catatonia with benzodiazepines, I felt much more competent. After administering lorazepam intravenously to patients who were mute and immobile before the dose to answering questions and wondering why everyone was looking at them after the dose—it looked miraculous.

Later in my career, I usually thought the comparison to a firefighter was a better analogy.

The 2008 working manual was called the Psychosomatic Medicine Handbook for Residents at the time. This was before the name of the specialty was changed back to Consultation-Liaison Psychiatry. I wrote all of it. I’m not sure about the origin of my comment about a Psychosomatic Medicine textbook weighing 7 pounds. It might relate to the picture of several heavy textbooks on which my book sits. I might have weighed one of them.The introduction is below (featured image picture credit pixydotorg):

“In 2003 the American Board of Medical Specialties approved the subspecialty status of Psychiatry now known as Psychosomatic Medicine. Long before that, the field was known as Consultation-Liaison Psychiatry. In 2005, the first certification examination was offered by the American Board of Psychiatry and Neurology. Both I and my co-editor, Dr. Robert G. Robinson, passed that examination along with many other examinees. This important point in the history of psychiatry began many decades ago, probably in the early 19th century, when the word “psychosomatic” was first used by Johann Christian Heinroth when discussing insomnia.

Psychosomatic Medicine began as the study of psychophysiology which in some quarters led to a reductionistic theory of psychogenic causation of disease. However, the evolution of a broader conceptualization of the discipline as the study of mind and body interactions in patients who are ill and the creation of effective treatments for them probably was a parallel development. This was called Consultation-Liaison Psychiatry and was considered the practical application of the principles and discoveries of Psychosomatic Medicine. Two major organizations grew up in the early and middle parts of the 20th century that seemed to formalize the distinction (and possibly the eventual separation) between the two ideas: the American Psychosomatic Society (APS) and the Academy of Psychosomatic Medicine (APM). The name of the subspecialty finally approved in 2003 was the latter largely because of its historic roots in the origin of the interaction of mind and body paradigm.

The impression that the field was dichotomized into research and practical application was shared and lamented by many members of both organizations. At a symposium at the APM annual meeting in Tucson, AZ in 2006, it was remarked that practitioners of “…psychosomatic medicine may well be lost in thought while…C-L psychiatrists are lost in action.”

I think it is ironic how organizations that are both devoted to teaching physicians and patients how to think both/and instead of either/or about medical and psychiatric problems could have become so dichotomized themselves.

My motive for writing this book makes me think of a few quotations about psychiatry in general hospitals:

“Relegating this work entirely to specialists is futile for it is doubtful whether there will ever be a sufficient number of psychiatrists to respond to all the requests for consultations. There is, therefore, no alternative to educating other physicians in the elements of psychiatric methods.”

“All staff conferences in general hospitals should be attended by the psychiatrist so that there might be a mutual exchange of medical experience and frank discussion of those cases in which there are psychiatric problems.”

“The time should not be too long delayed when psychiatrists are required on all our medical and surgical wards and in all our general and surgical clinics.”

The first two quotes, however modern they might sound, are actually from 1929 in one of the first papers ever written about Consultation Psychiatry (now Psychosomatic Medicine), authored by George W. Henry, A.B., M.D. The third is from the mid-1930s by Helen Flanders Dunbar, M.D., in an article about the substantial role psychological factors play in the etiology and course of cardiovascular diseases, diabetes, and fractures in 600 patients. Although few hospital organizations actually practice what these physicians recommended, the recurring theme seems to be the need to improve outcomes and processes in health care by integrating medical and psychiatric delivery care systems. Further, Dr. Roger Kathol has written persuasively of the need for a sea change in the way our health care delivery and insurance systems operate so as to improve the quality of health care in this country so that it compares well with that of other nations (2).

This book is not a textbook. It is not a source for definitive, comprehensive lists of references about all the latest research. It is not a thousand pages long and does not weigh seven pounds. It is a modest contribution to the principle of both/and thinking about psyche and soma; consultants and researchers; — gunslingers and chess masters.

In this field there are chess masters and gunslingers. We need both. You need to be a gunslinger to react quickly and effectively on the wards and in the emergency room during crises. You also need to be a chess master after the smoke has cleared, to reflect on what you did, how you did it—and analyze why you did it and whether that was in accord with the best medical evidence.

This book is for the gunslinger who relies on the chess master. This book is also for the chess master—who needs to be a gunslinger.

“Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat”—Sun Tzu.”

References:

1.        Kathol, R.G., and Gatteau, S. 2007. Healing body and mind: a critical issue for health care reform. Westport, CT: Praeger Publishers. 190 pp.

2.        Kornfeld, D., and Wharton, R. 2005. The American Psychiatric Publishing Textbook of Psychosomatic Medicine. Psychosomatics 46:95-103.

They Did Learn How to Check for Delirium!

Here’s another oldie but goodie blog post, “It’s Survey Time.” It’s a blast from the past (May of 2011) but it needs a short introduction on why I’m reposting it.

So, I’m about a week out from my surgery for a detached retina. I’m doing pretty well. I keep thinking about a question a nurse asked me right after I was taken to the recovery room from the operating room. I was a little hazy because I’m pretty sure I got some sedation medication, although I was definitely mostly awake for the procedure. The nurse asked me, “Well, can you answer a question for me; will a stone float on water?”

First of all, I gave the right answer, “No.” More importantly, I was momentarily stunned because I recognized the question is from the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). And I told the nurse that. It reminded me of my early career as a general hospital consultation-liaison psychiatrist.

Most of my old blog posts from The Practical Psychosomaticist are about my frustration over what seemed to be my fruitless efforts to teach nurses and physicians about how to prevent, assess, and manage delirium.

I can’t tell you how happy I was that my recovery room nurse asked me a CAM-ICU delirium screening question.  

I mentioned the American Delirium Society (ADS) in the post and also found a fairly recent article on the CAM ICU. Among the authors were those I met at one of t he first ADS meetings: Malaz Boustani and Babar Kahn.

“It’s Survey Time!”:

“I know, I know, I can hear it out there, “Doesn’t Dr. Amos ever learn? Nobody does surveys and polls!” Hey, that’s OK; I have so much fun doing them anyway. Of course, it would be nice to get some responses… I’ve talked to you and I’ve talked to you, and I’m done talkin’ to you! Come back here, I’m not done talkin’ to you!

Anyway, the new poll for what’s hot and what’s not about delirium screening scales is up on the home page. The original one was partly to help our delirium prevention project committee to decide on which one to use. Well, the original got only 16 responses…but they were great responses! The amazing thing was that, despite the paucity of votes, the results were plausible. See the results:

Recall that at our 7th project meeting we selected the DOSS. What? There is good literature supporting all of these scales and a lot of factors influence selection of any tool, not the least of which is feasibility, which is mainly ease of use. That means it’s quick and doesn’t require a lot of training or additional assessments. And you should use a tool that’s validated for the patient population you want to protect from delirium. I probably got a lot of questioning looks at the screen when this poll came out because the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) was not on the list. Well, you heard it from one of the main dudes on the team that developed the CAM-ICU that it’s probably not appropriate for use on general medical units…Dr. E. Wesley Ely himself (see post April 29, 2011). Hey, as far as the ICU patient population goes, the CAM-ICU is the holy grail. We need to keep looking for a sensitive and specific tool which is quick and easy for nurses to administer on general medical units.

We’re going with the DOSS. And one of my neuropsychologists, John, is offering to run neuropsychology test batteries on the patients that nurses screen with the DOSS. Atta boy, John! Neuropsychologists are going to be indispensable in this area. I remember pushing for the addition of subtests of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), especially the Coding test in order to detect delirium early as possible. It didn’t make it, but it was close. This has been advanced by another one of our neuropsychologists here who’s done some delirium research in the bone marrow transplant unit with delirious patients. Hey, I still wonder what we could accomplish if the Coding test were added to the DOSS or even the Nursing Delirium Screening Scale (Nu-DESC). Maybe there’s already somebody out there putting a practical implementation plan for that into the real world.

So why do the poll again? Because I’d like to see if I could persuade nurses from large American and world organizations to put the nickel down and vote. And if I keep shoving this thing out there, maybe somebody will let us know that, hey, we’re not in this alone and offer to collaborate.

And I stole a couple of survey questions from our group to see what physicians and nurses think about how they manage delirium. It’s a way to take a snapshot of the culture of how docs and nurses work together on delirium recognition and interventions. And hey, why am I doing that? Because I’m a thief…no, no, I mean the reason is delirium is a medical emergency and we all need to work together to find ways to understand it better in order to prevent it. The American Delirium Society (ADS) tell you why delirium prevention is critical in the endless search to find ways to deliver high-quality medical care to patients:

Delirium Simple Facts:

  • More than 7 million hospitalized Americans suffer from delirium each year.
  • Among hospitalized patients who survived their delirium episode, the rates of persistent delirium at discharge, 1, 3 and 6 months are 45%, 33%, 26%, and 21% respectively.
  • More than 60% of patients with delirium are not recognized by the health care system.
  • Compared to hospitalized patients with no delirium and after adjusting for age, gender, race, and comorbidity, delirious patients suffer from:
  • Higher mortality rates at one month (14% vs. 5%), at six months (22% vs. 11%), and 23 months (38% vs. 28%);
  • Hospital stay is longer (21 vs. 9 days); Receive more care in long-term care setting at discharge (47% vs. 18%), at 6 months (43% vs. 8%) and at 15 months (33% vs. 11%); and
  • Have higher probability of developing dementia at 48 months (63% vs. 8%).

And have you registered for the ADS inaugural conference on June 5-7 in Indianapolis? Good for you! And are you going to bring back something from that conference for The Practical Psychosomaticist, and I don’t mean doughnuts? That’s the spirit! The surveys have spaces for free-text comments as well, which I want to hear!”

The Chicken Finally Lays An Egg

Below is an old post from a previous blog that I published on June 6, 2010. Although the title in my record is simply PM Handbook Blog, there must have been another title. Maybe it should have been more like The Chicken Has Finally Laid an Egg (you’ll get the joke later).

There are two reasons for posting it today. One is to illustrate how the Windows voice recognition dictation app works. It’s a little better than I thought it would be. The last time I used it, it was ugly. I’m using it now because I thought it might be a little easier than trying to type it since I still have problems with vision in my right eye because of the recent retinal tear injury repair. So, instead of doing copy paste, what you’re seeing is a dictation—for the most part.

On the other hand, I’m still having to proofread what I dictate. And I still find a few mistakes, though much fewer than I expected.

The other reason for this post is to help me reflect on how far the fellowship has come since that time. It did eventually attract the first fellow under a different leader. That was shortly after I retired. It was a great step forward for the department of psychiatry:

“Here is one definition of a classic:

“Classic: A book which people praise but don’t read.” Mark Twain.

When I announced the publishing of our book, Psychosomatic Medicine, An Introduction to Consultation Liaison Psychiatry, someone said that it’s good to finally get a book into print and out of one’s head. The book in earlier years found other ways out of my head, mainly in stapled, paperclipped, spiral bound, dog eared, pages of homemade manuals, for use on our consultation service.

It’s a handbook and meant to be read, of course, but quickly and on the run. As I’ve said in a previous blog, it makes no pretension to being the Tour de Force textbook in America that inspired it. However, any textbook can evolve into an example of Twain’s definition of a classic. The handbook writer is a faithful and humble steward who can keep the spirit of the classic lively.

We must have a textbook as a marker of Psychosomatic Medicine’s place in medicine as a subspecialty. It’s like a Bible, meant to be read reverently, venerated, and quoted by scholars. But the ark of this covenant tends to be a dusty bookshelf that bows under the tome’s weight. A handbook is like the Sunday School lesson plan for spreading the scholar’s wisdom in the big book.

Over the long haul, the goal of any books should mean something other than royalties or an iconic place in history. No preacher ever read a sermon to our congregation straight out of the Bible. It was long ago observed by George Henry that there will never be enough psychiatric consultants. This prompts the question of who will come after me to do this work. My former legacy was to be the Director of a Psychosomatic Medicine Fellowship in an academic department in the not-so-distant past. Ironically, though there will never be enough psychiatric consultants, there were evidently too many fellowships from which to choose. I had to let the fellowship go. My legacy then became this book, not just for Psychosomatic Medicine fellows, but medical students, residents, and maybe even for those who see most of the patients suffering from mental illness—dedicated primary care physicians.

My wife gave me a birthday card once which read: “Getting older: May each year be a feather on the glorious Chicken of Life as it Soars UNTAMED and BEAUTIFUL towards the golden sun.” My gifts included among the obligatory neckties, a couple of books on preparing for retirement.

Before I retire, I would like to do all I can to ensure that the next generation of doctors learn to respect the importance of care for both body and mind of each and every one of their patients. That’s the goal of our book. And may the glorious chicken of life lay a golden egg within its pages to protect it from becoming a classic.”

Chicken picture credit: Pixydotorg.

Quiz Show on Delirium

Here’s an old post from February 15, 2011 from my previous blog The Practical Psychosomaticist called Quiz Show Versus Grand Rounds for Delirium Education:

“So you want to put on a game show contest to educate clinicians about delirium? Contact David Meagher, a psychiatrist in (where else?) Limerick, Ireland. He reported on this innovative educational workshop in the November 2010 Vol. 3 issue of the Annals of Delirium, the newsletter for the European Delirium Association (EDA). He also published the study which describes the contest in International Psychogeriatrics[1].

The workshop focused on clinician attitudes toward drug therapy for distressed delirious patients. It explored pre-existing attitudes and practice toward the use of medications to manage delirium and exposed participants to a very interactive educational event modeled after a popular TV quiz show. There were two teams (skeptics versus neuroleptics) furnished with a list of statements about delirium pharmacotherapy. The participants later completed a post-workshop questionnaire that explored changes in attitudes as a result of the workshop.

The participants were all experts on the subject and there was a good deal of variability in attitudes and practice. Some of the questions put to the teams involved using antipsychotics prophylactically to prevent delirium, the mechanism of action of antipsychotics, and what role benzodiazepines play in the treatment of non-alcohol withdrawal delirium.

One of the more puzzling findings was that the frequency of antipsychotic use was inversely proportional to the perception of the strength of supporting evidence. In other words, the less they knew about antipsychotics, the more often they used them. Most participants seemed to believe that the principal mechanism of action of antipsychotics is sedation, despite the lack of supporting evidence.

Some clinicians used antipsychotics to relieve the stress of caregivers rather than that of delirious patients, an example of patients getting the right treatment for the wrong reasons as observed by Meagher—and many of us in the field.

The workshop also highlighted the tendency of clinicians to focus on risk management rather than effective therapeutic intervention in the management of delirious patients with disruptive behavior and severe distress. This mainly relates to focus on the potential adverse effects of antipsychotics such as extrapyramidal side effects, metabolic, and cerebrovascular effects.

The quiz show activity was fun and challenging. The device of dividing the participants into two small teams with larger audience participation cut down on the anxiety that could be provoked by giving the “wrong answer”. The questions were true/false and didn’t always have clear right or wrong answers. It was highly interactive, a component of continuing medical educational (CME) activities that is increasingly encouraged because it’s more likely to lead to changes in clinician attitude and practice. The one-time Grand Rounds CME “seat time” is going the way of the dinosaur.

So a couple of findings from the quiz show post-activity questionnaire were that clinicians were more likely to use antipsychotics prophylactically and to use antipsychotics to manage hypoactive delirium.

 Our delirium intervention project group members are not quite as enthusiastic yet about these two interventions. We’re a bit more inclined at least initially to focus on non-pharmacologic multicomponent strategies such as the example below:

  • Minimize the use of immobilizing catheters, intravenous lines, and physical restraints
  • Avoid immobility, early mobilization
  • Monitor nutrition
  • Provide visual and hearing aids
  • Monitor closely for dehydration
  • Control pain
  • Monitor fluid-electrolyte balance
  • Monitor bowel and bladder functioning
  • Review medications
  • Reorient communications with the patient
  • Place an orientation board, clock, or familiar objects (ie, family photographs) in patient rooms
  • Encourage cognitively stimulating activities such as word puzzles
  • Facilitate sleep hygiene measures, including relaxation music or tapes at bedtime, warm drinks, and gentle massage
  • Minimize noise and interventions at bedtime, e.g., by rescheduling medication times

But I’m just as enthusiastic about interactive educational methods to engage learners in order to build a culture more likely to produce champions who will lead the delirium prevention effort—try the delirium multicomponent criss-cross puzzle below. The clues are contained in the list of multicomponent tactics above.”

  1. Meagher, D.J., Impact of an educational workshop upon attitudes towards pharmacotherapy for delirium. Int Psychogeriatr, 2010. 22(6): p. 938-46.

Going Down Blogging Memory Lane

I’ve been going down the blogging memory lane lately and thought I’d repost what was probably the very first post I published on my first blog, The Practical Psychosomaticist. The title was “Letter from a Pragmatic Idealist.”

While a lot of water has gone under the bridge since mid-December of 2010, some principles remain the same. Some problems still remain, such as the under-recognition of delirium.

Just a few thoughts about words, just because I’m a writer and words are interesting. The word “Psychosomaticist” is clunky and I’ve joked about it. I tried to think of another name for the blog.  I thought “Pragmatic Idealist” was original until I googled it—someone already had coined it. Then I considered “The Practical Idealist”, with the same result. The same thing happened with “The Practical Psychiatrist.” All of the terms had been used and the associations didn’t fit me. I couldn’t find anyone or any group using the term “The Practical Psychosomaticist.” 

Finally, after the Academy of Psychosomatic Medicine (APM) changed its name to the Academy of Consultation-Liaison Psychiatry (ACLP) in 2016, I changed the name of the blog to The Practical C-L Psychiatrist, finally dropping the name “psychosomatic” along with its problematic associations.

I guess the chronicle would be incomplete without an explanation of what happened to that blog. Around 2016, the General Data Protection Regulation (GDPR) was adopted by the European Parliament. WordPress, a popular blogging platform which I use, eventually decided that even hobby bloggers had to come up with a quasi-legal policy document to post on their websites to ensure they were complying with the GDPR regulation and not misusing anyone’s personal data.

I didn’t think that applied to hobby bloggers like me yet it was required. I wasn’t collecting anyone’s personal data and not trying to sell anything. I deleted my blog in July of 2018.  Because I loved to write, I eventually started a new blog around the last year of my phased retirement contract with my hospital in 2019.

Anyway, here’s the December 15, 2010 post, “Letter from a Pragmatic Idealist.”

“I read with interest an article from The Hospitalist, August 2008 discussing the Center for Medicare and Medicaid Services (CMS) requirement for hospitals to submit information on Medicare claims regarding whether a list of specific diagnoses were present on admission (POA)[1]. The topic of the article was whether or not delirium would eventually make the list of diagnoses that CMS will pay hospitals as though that complication did not occur, i.e., not pay for the additional costs associated with managing these complications. At the time this article was published, CMS was seeking public comments on the degree to which the conditions would be reasonably preventable through application of evidence-based guidelines.

I have no idea whether delirium due to any general medical condition made the list or not. But I have a suggestion for a delirium subtype that probably should make the list, and that would be intoxication delirium associated with using beverage alcohol in an effort to treat presumed alcohol withdrawal. There is a disturbing tendency for physicians (primarily surgeons) at academic medical centers to try to manage alcohol withdrawal with beverage alcohol, despite the lack of medical literature evidence to support the practice [2, 3]. At times, in my opinion, the practice has led to intoxication delirium in certain patients who receive both benzodiazepines (a medication that has evidence-based support for treating alcohol withdrawal) combined with beer—which generally does not.

I’ve co-authored a couple of articles for our institution’s pharmacy newsletter and several of my colleagues and pharmacists petitioned the pharmacy subcommittee to remove beverage alcohol from the formulary at our institution, where beer and whiskey have been used by some of our surgeons to manage withdrawal. Although our understanding was that beverage alcohol had been removed last year, it is evidently still available through some sort of palliative care exception. This exception has been misused, as evidenced by cans of Old Style Beer with straws in them on bedside tables of patients who are already stuporous from opioid and benzodiazepine. A surgical co-management team was developed, in my opinion, in part to address the issue by providing expert consultation from surgeons to surgeons about how to apply evidence-based practices to alcohol withdrawal treatment. This has also been a failure.

I think it’s ironic that some professionals feared being sanctioned by CMS for using Haloperidol to manage suffering and dangerous behavior by delirious people as reported by Stoddard in the winter 2009 article in the American Academy of Hospice and Palliative Medicine (AAHPM) Bulletin[4]. Apparently, CMS in fact did have a problem with using PRN Haloperidol (not FDA approved of course, but commonly used for decades and recommended in American Psychiatric Association practice guidelines for management of delirium), calling it a chemical restraint while having no objection to PRN Lorazepam, which has been identified as an independent predictor of delirium in ICU patients[5]. Would the CMS approve of using beer to treat alcohol withdrawal, which can cause delirium?

As a clinician-educator and Psychosomatic Medicine “supraspecialist” (term coined by Dr. Theodore Stern, MD from Massachusetts General Hospital), I’ve long cherished the notion that we, as physicians, advance our profession and serve our patients best by trying to do the right thing as well as do the thing right. But I wonder if what some of my colleagues and trainees say may be true—that when educational efforts to improve the way we provide humanistic and preventive medical care for certain conditions don’t succeed, not paying physicians and hospitals for them will. I still hold out for a less cynical view of human nature. But if it will improve patient care, then add this letter to the CMS suggestion box, if there is one.”

1.        Hospitalist, D. (2008) Delirium Dilemma. The Hospitalist.

2.        Sarff, M. and J.A. Gold, Alcohol withdrawal syndromes in the intensive care unit. Crit Care Med, 2010. 38(9 Suppl): p. S494-501.

3.        Rosenbaum, M. and T. McCarty, Alcohol prescription by surgeons in the prevention and treatment of delirium tremens: historic and current practice. General Hospital Psychiatry. 24(4): p. 257-259.

4.        Stoddard, J., D.O. (2009) Treating Delirium with Haloperidol: Our Experience with the Center for Medicare and Medicaid Services. Academy of Hospice and Palliative Medicine Bulletin.

5.        Pandharipande, P., et al., Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology, 2006. 104(1): p. 21-6.

Our Impressions of University of Iowa Free Webinar Yesterday: The Stories That Define Us”

We were overall delighted with yesterday’s presentation, University of Iowa Free Webinar: “Breaking Barriers: Arts, Athletics, and Medicine (1898-1947).” It’s one in a series of 4 virtual seminars with two more scheduled this month, which you can register for at this link.

February 15: Endless Innovation: An R1 Research Institution (1948–1997)

February 22: The Next Chapter: Blazing New Trails (1998–2047)

The moderator was university archivist and storyteller, David McCartney.

Presenters include:

Yesterday’s presentation was recorded and will be uploaded to The University of Iowa Center for Advancement YouTube site at a later date.

McCartney did an excellent job as moderator, although got stumped from a question from a viewer about who was the first African American faculty member in the College of Medicine. He’s still working on tracking that down. It wasn’t me. I’m not that old and I am not risen from the dead, as far as I can tell; but to be absolutely clear, you should ask my wife, Sena. I was able to google who was the first African American graduate of the University of Iowa law school: Alexander Clark, Jr. McCartney thinks he might have been the first University of Iowa alumnus, although he couldn’t confirm that.

On the other hand, I could have been the first African American consulting psychiatrist (maybe the only African American psychiatrist ever) in the Department of Psychiatry at UIHC—but I can’t confirm that. Maybe McCartney could work on that, too.

 There are a few words about me in the department’s own history book, “Psychiatry at Iowa: The Shaping of a Discipline: A History of Service, Science, and Education by James Bass: Chapter 5, The New Path of George Winokur, 1971-1990:

“If in Iowa’s Department of Psychiatry there is an essential example of the consultation-liaison psychiatrist, it would be Dr. James Amos. A true in-the-trenches clinician and teacher, Amos’s potential was first spotted by George Winokur and then cultivated by Winokur’s successor, Bob Robinson. Robinson initially sought a research gene in Amos, but, as Amos would be the first to state, clinical work—not research—would be Amos’s true calling. With Russell Noyes, before Noyes’ retirement in 2002, Amos ran the UIHC psychiatry consultation service and then continued on, heroically serving an 811-bed hospital. In 2010 he would edit a book with Robinson entitled Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry.” (Bass, J. (2019). Psychiatry at Iowa: A History of Service, Science, and Education. Iowa City, Iowa, The University of Iowa Department of Psychiatry).”

And in Chapter 6 (Robert G. Robinson and the Widening of Basic Science, 1990-2011), Bass mentions my name in the context of being one of the first clinical track faculty (as distinguished from research track) in the department. In some ways, breaking ground as a clinical track faculty was probably harder than being the only African American faculty member in the department.

I had questions for Lan Samantha Chang and for Dr. Patricia Winokur (who co-staffed the UIHC Medical-Psychiatry Unit with me more years ago than I want to count.

I asked Dr. Chang what role did James Alan McPherson play in the Iowa Writers Workshop. She was finishing her presentation and had not mentioned him, so I thought I’d better bring him up. She had very warm memories of him being her teacher, the first African American to win a Pulitzer Prize for fiction, and a long-time faculty member at the Workshop.

She didn’t mention whether McPherson had ever been a director of the Workshop, though she went through the list of directors from 1897 to when she assumed leadership in 2006. You can read this on the Workshop’s History web page. I have so far read two sources (with Wikipedia repeating the Ploughshares article item) on the web indicating McPherson had been acting director between 2005-2007 after the death of Frank Conroy. One source for this was on Black Past published in 2016 shortly after his death, and the other was a Ploughshares article published in 2008. I sent an email request for clarification to the organizers of the zoom webinar to pass along to Lan Samantha Chang.

I asked Dr. Winokur about George Winokur’s contribution to the science of psychiatric medicine. Dr. George Winokur was her father and he was the Chair of the UIHC Psychiatry Department while I was there. She mentioned his focus on research in schizophrenia and other accomplishments. I’ll quote the last paragraph from Bass’s history on the George Winokur era:

“Winokur, in terms of research, was a prototype of the new empirical psychiatrist. Though his own research was primarily in the clinical realm, he was guided by the new neurobiological paradigm (perhaps in an overbalanced way) that was solidifying psychiatry with comparative quickness. New techniques in imaging and revelations of the possibilities in genetic study and neuropsychopharmacology lay ahead. George Winokur had helped the University of Iowa’s Department of Psychiatry—and American psychiatry as a whole—turn a corner away from subjectivity and irregularity of Freudian-based therapies. And once that corner had been turned there was no going back.”

George Winokur was the department chair at University of Iowa Hospitals and Clinics from 1971 to 1990 and had a unique and memorable style. George also had a rough sense of humor. He had a rolling, gravelly laugh. He had strict guidelines for how residents should behave, only slightly tongue-in-cheek. They were written in the form of 10 commandments. Who knows, maybe there are stone tablets somewhere:

Winokur’s 10 Commandments

  1. Thou shalt not sleep with any UI Psychiatry Hospital patient unless it be thy spouse.
  2. Thou shalt not accept recompense for patient care in this center outside thy salary.
  3. Thou shalt be on time for conferences and meetings.
  4. Thou shalt act toward the staff attending with courtesy.
  5. Thou shalt write progress notes even if no progress has been made.
  6. Thou shalt be prompt and on time with thy letters, admissions and discharge notes.
  7. Thou shalt not moonlight without permission under threat of excommunication.
  8. Data is thy God. No graven images will be accepted in its place.
  9. Thou shalt speak thy mind.
  10. Thou shalt comport thyself with modesty, not omniscience.

Quinn Early has a lot of energy and puts it to good use. His documentary of the sacrifices of African American sports pioneers, including “On the Shoulders of Giants” (Frank Kinney Holbrook) is impressive.

There was a good discussion of the importance of the book “Invisible Hawkeyes: African Americans at the University of Iowa during the Long Civil Rights Era”, edited by former UI faculty, Lena and Michael Hill.

Sena and I thought yesterday’s presentation was excellent. We plan to attend the two upcoming webinars as well. We encourage others to join.

My Definitive Journey Revisited

A couple of days ago, I got my retirement gift from The University of Iowa. It’s a about a year and a half late because of the Covid-19 pandemic, but it’s welcome nonetheless. Normally there is an Annual Faculty Retirement Dinner, but it had to be cancelled. It’s a stunningly beautiful engraved crystal bowl with the University logo on it. It came with a wonderful letter of appreciation. It reminded me of my blog post in 2019, “My Definitive Journey.”

It’s a definitive symbol of the next part of my journey in life. For years I’d been a fireman of sorts, which is what a general hospital psychiatric consultant really is. The other symbols have been the fireman’s helmet and the little chair I carried around so that I could sit with my patients. I have changed a little.

I still have my work email access, which I’m ambivalent about, naturally. I check it every day, partly because of Fear of Missing Out (FOMO), but also to delete the junk mail. I still get a lot of it. I get a rare message from former trainees, one of whom said it “pained” her to learn I’m now Professor Emeritus.

I have not seriously considered returning to work. That doesn’t mean I have not been occasionally nostalgic for some aspects of my former life.

The poem, “El Viaje Definitivo” by Juan Ramon Jimenez evokes mixed feelings and thoughts now. I have gone away. But in looking back at the past, I now see now that the birds didn’t always sing. The tree was not always green.

I don’t miss my former home, the hospital, as keenly now, which is now a much harder place to work since the Covid-19 pandemic began.

And there is little that is definitive about my journey forward from where I now stand. I’m a little less afraid than I was over a year and a half ago. And the birds sing where I am now, sometimes more clearly than before.

El Viaje Definitivo (The Final Journey)

… and I will go away.

And the birds will stay, singing

And my garden will stay

With its green tree

And white water well.

And every afternoon the sky will be blue and peaceful

And the pealing of bells will be like this afternoon’s

Peal of the bell of the high campanile.

They will die, all those who loved me

And every year the town will be revived, again

And in my circle of green white-limed flowering garden

My spirit will dwell nostalgic from tree to well.

And I will go away

And I will be lonely without my home

And without my tree with its green foliage

Without my white water well

Without the blue peaceful sky

And the birds will stay

Singing

                                –Juan Ramon Jimenez

Reflecting on Ironies

Over the Easter weekend, we drove by James Alan McPherson Park. A lot of people were having a great time. Because it was crowded, we went to Terry Trueblood Recreation Area, planning to return another day.

We just got our copy of McPherson’s Pulitzer Prize winning fiction anthology, Elbow Room. We’ve ordered his other collection of short fiction, Hue and Cry and it’s been shipped.

McPherson was impressed with the neighboring culture of Iowa City. He’s described as being kind and neighborly himself.

He was self-effacing, which probably seemed ironic to some people, given he was the first African American to win the Pulitzer Prize for fiction for Elbow Room. He was on faculty at the Iowa Writers’ Workshop for many years, won the inaugural Paul Engle award from the Iowa UNESCO City of Literature, graduated from Harvard Law School, recipient of a Guggenheim Fellowship, a MacArthur Fellowship, and was inducted into the American Academy of Arts and Sciences.

I’m struck by a few ironies. Our paths never crossed but that’s probably not surprising given our different professional trajectories. I graduated from medical school at Iowa and just retired last year from the University of Iowa Hospitals & Clinics (UIHC) Dept of Psychiatry where I was a Consultation-Liaison Psychiatrist.

However, McPherson in his essay, [Pursuit of the Pneuma, McPherson, J. (2011). Pursuit of the “Pneuma”. Daedalus, 140(1), 183-188]. described being treated by Iowa City psychiatrist, Dr. Dorothy “Jean” Arnold. And, ironically, Dr. Arnold was white (both she McPherson came from the racially polarized South) and originally graduated from the University of Alabama Medical School. She was also the first female psychiatrist to open a private practice in the state of Iowa in 1957. She taught at the University of Iowa Hospital, but I could not find her mentioned in the history of the UIHC Psychiatry Dept, although Dr. Peg Nopoulos, the first woman chair of the department, has her own chapter [Psychiatry at Iowa: The Shaping of a Discipline: A History of Service, Science, and Education, written by James Bass.]

I’m mentioned in Bass’s history, which is sort of ironic. The book is actually about scientists in the field of psychiatry, and I was anything but. I was a clinician. For comparison, if you ever watch the Weather Channel, I’m not a meteorologist. I’m more like the guys on Highway Thru Hell or Heavy Rescue 401, although I’m not practical in that sense. I am African American though, and it was a good idea for Bass to mention me, since I think I’m the only Black psychiatrist to have ever been hired by the department.

McPherson was impressed with the generous and receptive nature of Iowans, which he ascribed to a quality captured by the word “Pneuma,” a Greek word meaning “the vital spirit of life itself.”

There’s another irony in connection with one of my most influential teachers at Huston-Tillotson College, in Austin, Texas, one of the historically black colleges and universities (HBCU) in America. McPherson attended the HBCU at Morris Brown College in Atlanta, Georgia. Dr. Jenny Lind Porter-Scott, who recently died, was a white Professor of English at H-TC, writer and translator of poetry, teacher to thousands, and popular with students of all races, yet there is no tangible, permanent remembrance of her by Texans. To be sure, she is listed in the Texas Women’s Hall of Fame and in 1964, she was appointed Poet Laureate of Texas by Governor John Connally. Her house was demolished in 2016. In 2016, an architect sent me an email message describing a plan to build a mini-library of her published work in the neighborhood, and a house similar in style to the one demolished on the lot. Whenever I check on Google Maps, the lot remains empty and overgrown with weeds. 

James Alan McPherson taught and formed close bonds with many students who came from different countries, ethnic, and racial backgrounds. Enjoy the park named for him in the “the vital spirit of life itself.”

The Firefighter Retires

I’m writing this post today because this firefighter retires tomorrow—and I’ll probably be very busy and too weary at the end of my last day on the psychiatry consult service to write. In fact, I’ve been too busy and tired to post for the last several weeks because we’ve been in the process of moving. Does that ever really end?

I can tell that what will really end at around 5:00 PM tomorrow is my career as a general hospital psychiatric consultant. It has been a long time coming. I’ve been on a 3-year phased retirement contract and going back and forth between wishing for it to end sooner and being scared to death as the final day approaches.

There are those last things: handing in the keys, the white coats, the parking hang tag and the like. I’ve cleaned out my office and somebody already wants it. I’m surprised that I’m just the tiniest bit territorial about the place, which is strange. I never spent much time in it because I was always chasing consults around the hospital.

I’ve never retired before. I wonder what the rules are. I still don’t know how to answer everybody’s question: “What are you going to do?”

There is the “new” house. It’s actually an older home, which fits my status as an older person, I guess.

The floors squeak and creak, a lot like my joints. There are little jobs and slightly bigger jobs to do for which I’m painfully aware of the need to develop a whole new skill set—or at least relearn them.

It’s about new noises and new animals. A fox trots across our yard occasionally. I’m used to deer, but we’ve never spotted a fox on our lawn. It has a rusty coat streaked with a lot of gray. It looks old. But it’s a good hunter and more than once we’ve seen it carrying a big mouthful of something that might have put up a pretty good fight.

I’m touched by the well-wishers, and those who say thanks for the memories. Just about every day of the last week, I’ve seen and done something at the hospital which makes me say, “That is what I’ll miss.”

One day to go.

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