consultation liaison psychiatry – Go Retire Psychiatrist

Thoughts on Retirement, MIB Style

Sena alerted me to an article about the 28^th anniversary of when the first Men in Black movie hit the theaters in 1997. The author praises it and says it’s still pretty good.

I can’t remember the first time I saw it, but it was probably not in 1997. I was in my second year of being an assistant professor of psychiatry at the University of Iowa Hospitals & Clinics (now called University of Iowa Health Care). I was too busy to do much of anything except run around the hospital responding to requests for psychiatry consultations from medicine and surgery. I did that a long time.

I’ve been blogging since 2010. I cancelled my first blog which was called The Practical Psychosomaticist. I then restarted blogging, calling it Go Retire Psychiatrist. One blog that pays homage to my career and to the Men in Black films is “The Last White Coat I’ll Ever Wear.”

It’s part reminiscence and part comedy in the style of Men in Black dialogue and jokes. Since I retired, I have not been back to the hospital except for scheduled appointments in the eye and dentistry clinics. I don’t know if I’ve ever reconciled myself to being retired. If someone were to tell me “We have a situation and we need your help” (think Men in Black II), I would probably say something like “There is a free mental health clinic on the corner of Lilac and East Valley.”

Thoughts on Long Covid

I read Dr. Ron Pies, MD’s essay today, “What Long COVID Can Teach Psychiatry—and Its Critics.” As usual, he made thought- provoking points about the disease concept in psychiatry. What I also found interesting was the connection he made with Long Covid, a debilitating illness. He cited someone else I know who was involved with a group assigned to create a working definition for it—Dr. E. Wes Ely, an intensive care unit physician at Vanderbilt University in Nashville, Tennessee.

I remember when I first encountered Dr. Ely, way back in 2011 when I was a consulting psychiatrist in the University of Iowa Health Care general hospital. I was blogging back then and mentioned a book he and Valerie Page and written, Delirium in Critical Care. Back then I sometimes read parts of it to trainees because I thought they were amusing:

“…there is a clearly expressed opinion about the role of psychiatrists. It’s in a section titled “Psychiatrists and delirium” in Chapter 9 and begins with the sentence, “Should we, or should we not, call the psychiatrist?” The authors ask the question “Can we replace them with a screening tool, and then use haloperidol freely?” The context for the following remarks is that Chapter 9 is about drug treatment of the symptoms and behaviors commonly associated with delirium.”

I would point out that the authors say, while acknowledging that the opinions of psychiatrists and intensivists might differ, “…we would advocate that a psychiatrist should be consulted for patients already under the care of a psychiatrist or on antipsychotic medications”. Usually, in most medical centers in the U.S.A. a general hospital consultation-liaison psychiatrist sees the delirious inpatient rather than the patient’s outpatient psychiatrist. And many delirious patients don’t have a previous formal history of psychiatric illness and so would not have been seeing an outpatient psychiatrist in the first place.” (Page, V. and E.W. Ely, Delirium in Critical Care: Core Critical Care. Core Critical Care, ed. A. Vuylsteke 2011, New York: Cambridge University Press).

I’m pretty sure I got an email from Wes shortly after I posted that, with his suggestion that I write more about the delirium research he was doing. He sent me several references. I met him in person at a meeting of the American Delirium Society later on and attended an internal medicine grand rounds he presented at UIHC in 2019, “A New Frontier in Critical Care Medicine: Saving the Injured Brain.” He’s also written a great book, “Every Deep-Drawn Breath.”

Anyway, Dr. Ely and others were tasked by the Administration for Strategic Preparedness and Response and the Office of the Assistant Secretary of Health in the Department of Health and Human Services tasked the National Academies of Sciences, Engineering, and Medicine (NASEM) with developing an improved definition for long Covid.

At first, I was puzzled by the creation of criteria that essentially defined Long Covid as a disease state which didn’t even necessitate a positive test for Covid in the history of patients who developed Long Covid. I then read the full essay by Family Medicine physician, Dr. Kirsti Malterud, MD, PhD, “Diagnosis—A Tool for Rational Action? A Critical View from Family Medicine.”

I was hung up on the dichotomy between physical illness and somatization and thought the Long Covid definition posed a dilemma because it purposely omits any need for an “objective” test to verify previous Covid infection, making the Long Covid diagnosis based completely on clinical grounds. The section on persistent oppositions (dichotomies) was helpful, especially the 2^nd point on the dichotomy of the question of whether an illness is physical or psychological (p.28).

The point on how to transcend the dichotomy was well made. I guess it’s easy to forget how the body and mind are related when a consultation-liaison psychiatrist is called to evaluate somebody for “somatization.” Often that was the default question before I ever got to see the patient.

Still, the person suffering from Long Covid often doesn’t seem to have a consistently effective treatment and may stay unwell or even disabled for months or years. Social Security criteria for disability look well-established.

I can imagine that many persons with Long Covid might object to have their care transferred to psychiatric services alone. I can see why there are Long Covid clinics in several states. It’s difficult to tell how many and which ones have psychiatrists on staff. The University of Iowa calls its service the Post Covid Clinic and can refer to mental health and neuropsychology services. On the other hand, a recent study of how many Long Covid clinics are available and what they do for people showed it was difficult to ascertain what services they actually offered, concluding:

“We find that services offered at long COVID clinics at top hospitals in the US often include meeting with a team member and referrals to a wide range of specialists. The diversity in long COVID services offered parallels the diversity in long COVID symptoms, suggesting a need for better consensus in developing and delivering treatment.” (Haslam A, Prasad V. Long COVID clinics and services offered by top US hospitals: an empirical analysis of clinical options as of May 2023. BMC Health Serv Res. 2024 May 30;24(1):684. doi: 10.1186/s12913-024-11071-3. PMID: 38816726; PMCID: PMC11138016.)

I’m interested in seeing how and whether the new Long Covid definition will be widely adopted.

Writing is Dope

I learned a new slang word from Houston White, the guy who makes that specialty coffee in Minneapolis I blogged about yesterday: Brown Sugar Banana (I’m not a fan, but I admire him just the same). The word is “dope.” That used to be an insult or an illicit drug when I was growing up. Now it means “very good.”

I guess writing, at least for me, is dope.

The further I get in time away from the day I retired from practicing consultation psychiatry, the more I reflect about how I became a psychiatrist. I’m a first-generation doctor in my family, so what follows is one way to write about it.

What has helped me get through life was this writing habit along with a sense of humor. When I was little, I wrote short stories for my mother. I was the “number one son” in the words of my father, which meant only that I was the first born. My younger brother came second only in order of birth. He was the track star. I was the paperboy. Our parents separated early on. Sena and I have been married for 47 years.

I have been writing my whole life. I used a very old typewriter. I wrote poetry for a while, eons ago. Like many aspiring writers, I tried to sell them to publishers. The only publisher I remember ever responding sent me a hand-scrawled note on a small sheet of paper. He told this really short, nearly incoherent story about his son, who had apparently died shortly before. His son had a “tough road.” It wasn’t clear exactly how he died, but I remember wondering whether it was suicide. It was very sad.

In the 1970s, while I was a student at one of the Historically Black Colleges and Universities (Huston-Tillotson College, now a university) in Austin, Texas, I submitted a poem to the school’s annual contest and for entry into the college’s collection, called Habari Gabani (which means “what’s going on” in Swahili). It was rejected. Years later, I finally was able to track down a digital copy of Habari Gani.

Habari Gani from Huston-Tillotson College

Eventually, thank goodness for everyone’s sake, I gave up writing poetry. It was as bad as Vogon poetry. You’ll have to read Douglas Adam’s book “A Hitchhiker’s Guide to the Galaxy,” for background on that. The Vogons were extraterrestrials who destroyed Earth in order to build an intergalactic bypass for a hyperspace expressway. Vogon poetry is frightfully bad; it’s the waterboarding torture of literature.

I wrote a short Halloween story for my hometown newspaper contest once. It got honorable mention, but I can’t recall what it was about, thank goodness.

I wrote a feature story in a journalism class taught by a nice old guy who made a long speech to the class about the unfortunate tendency for young writers to use flowery, polysyllabic words in their prose. He made it clear that journalists shouldn’t write like that. Although I didn’t consciously do the opposite to annoy him, I did it anyway. I even tossed the word “Brobdingnagian” in it, which might have referred to some high bluffs somewhere in Iowa. Despite being infested with Vogonisms, my teacher tolerated it, sparing my feelings. I must have passed the course although how I did it remains a mystery.

I wrote and co-edited a book with the chairman of the University of Iowa Healthcare Dept of Psychiatry, Dr. Robert G. Robinson, MD. It was “Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry”. There were several contributors. Many of them were my colleagues. It was published in 2010, and prior to that, I’d written an unpublished manual that I wrote for the residents.

There wasn’t any humor in either book, because they were supposed to be evidence of scholarly productivity from a clinical track academic psychiatrist. But I used humor and non-scientific verbiage in my lectures, albeit sparingly. I remember one visiting scientist remarked after one of my Grand Rounds presentations, “You are so—poetic” and I detected a faint disparaging note in his tone…probably a reaction to a latent Vogonism. It’s not impossible to monkey-wrench those into a PowerPoint slide or two.

I used to write a former blog called The Practical Psychosomaticist, later changed to The Practical CL Psychiatrist when The Academy of Psychosomatic Medicine changed their name back to The Academy of Consult-Liaison Psychiatry back in 2017. I wrote The Practical CL Psychiatrist for a little over 7 years. I stopped, but then missed blogging so much I went back to it in 2019 after only 8 months. I guess I was in withdrawal from writing.

That’s because writing is dope.

New Consultation-Liaison Psychiatry Focused Practice Designation in Emergency Behavioral Certification in Emergency Rooms

I just found out about the American Board of Medical Specialties (ABMS) announcement of a new addition to the Consultation-Liaison Psychiatry subspecialty: Focused Practice Designation. It looks like it’s going to be administered by the American Board of Emergency Medicine (ABEM), possibly in collaboration with the American Board of Psychiatry & Neurology (ABPN).

I’m unsure of the nuts and bolts, but on the surface, it looks like it might be a promising way to address meeting the needs of the many patients who appear in hospital emergency rooms.

On the other hand, I’m unclear on whether this might also lead to the addition of yet another layer of medical and psychiatry board maintenance of certification exams and fees. It looks like some boards of medicine and surgery require those who want to pursue the Focused Practice Designation (FPD) specialization route sit for an initial certification exam which would be time-limited followed by something called “continuous certification” which is a form of maintenance of certification (MOC). This often entails periodic exams and fees which many physicians find burdensome and expensive, leading to petitions opposing MOC and finding alternatives to fulfill the continuing education needs in less costly and time-consuming ways. One notable alternative is the National Board of Physicians and Surgeons (NBAS).

I’m not sure why another layer of bureaucracy needs to be added to achieve the goal of ensuring that emergency room patients with mental health challenges have access to mental health professionals. In fact, there is an American Association for Emergency Psychiatry open to membership which includes psychiatrists, physician assistants, psychologists, nurses, social workers and other professionals. However, the goal behind the FPD route is to increase the presence of physicians in the emergency room. This creates a specific and arguably needed role for consultation-liaison (C-L) psychiatrists.

I get the impression the exact way this will be rolled out is under construction, so to speak. Although I can’t find language in the announcements for the new FPD specifically saying that there’s going to be another MOC for C-L psychiatrists, there doesn’t seem to be any language assuring there won’t be. The FPD web page for the American Board of Obstetrics & Gynecology (ABOG) makes it pretty clear—there’s a MOC for that.

Just because you don’t see anything currently on the ABEM and ABPN web sites about MOC being required for the FPD doesn’t mean that it won’t appear in the near future. For now, the ABMS table outlining the differences between the certification requirements for specialty/subspecialty designation and the FDP doesn’t specify extra certification for the FDP for C-L psychiatrists per se.

I’m hoping for the best for patients and doctors.

How About Artificial Intelligence for Helping Reduce Delirium in the ICU?

I got the Winter 2025 Hopkins Brain Wise newsletter today and there was a fascinating article, “Using AI to Reduce Delirium in the ICU: Pilot Study will explore AI headset can help reduce delirium and delay post-delirium cognitive decline.”

The article has exciting news about what researchers are doing which will, hopefully, reduce the incidence of delirium in the intensive care unit (ICU). Another Hopkins researcher has published a study that has already used AI algorithms to detect early warning signs of delirium in the ICU;

Gong, Kirby D. M.S.E.1; Lu, Ryan B.S., M.D., Ph.D.2; Bergamaschi, Teya S. M.S.E., Ph.D.3; Sanyal, Akaash M.S.E.4; Guo, Joanna B.S.5; Kim, Han B. M.S.E.6; Nguyen, Hieu T. B.S., Ph.D.7; Greenstein, Joseph L. Ph.D.8; Winslow, Raimond L. Ph.D.9; Stevens, Robert D. M.D.10. Predicting Intensive Care Delirium with Machine Learning: Model Development and External Validation. Anesthesiology 138(3):p 299-311, March 2023. | DOI: 10.1097/ALN.0000000000004478

The list of references for the study of course include those by Dr. E. Wesley Ely, who delivered an internal medicine grand rounds about delirium at the University of Iowa in 2019.

Anybody who reads my blog knows I’ve been knocking AI for a while now. However, anybody who also knows that I’m a retired consultation-liaison psychiatrist knows how interested I am in preventing delirium in the hospital. I worked as a clinical track professor for many years at The University of Iowa Health Care in Iowa City.

It’s fortuitous that I found out about what Johns Hopkins research is doing on this topic because the director of the Johns Hopkins psychiatry department happens to be Dr. Jimmy Potash MD, MPH, who’s identified on the newsletter. He was the head of the psychiatry department at the University of Iowa from 2011-2017.

Besides all the name-dropping I’m doing here, I’m also admitting that I’ll probably soften my position against AI if the research described here does what the investigators and I hope for, which is to reduce delirium in the ICU.