consultation-liaison psychiatry – Page 4

I began rereading the book Invisible Man by Ralph Ellison today, which is Leap Day. Given what little I know about Leap Day and Leap Year in general, there isn’t a connection.

I first read Invisible Man well over 40 years ago. It was a paperback and I took it with me to Huston-Tillotson College in Austin, Texas (now Huston-Tillotson University), one of the historically black colleges and universities (HBCUs) in the United States.

It was very hot in Austin in my freshman year and the students didn’t have air-conditioned dormitories in those days. It must have been over 90 degrees. The glue melted on most of my paperback books, including Invisible Man. I suppose that’s why I eventually threw the book away, because it was falling apart.

After all these years, I bought a hardcover edition. We have air-conditioning now. I was motivated to read it again after I read Invisible Hawkeyes: African Americans at the University of Iowa during the Long Civil Rights Era, edited by Lena M. Hill and Michael D. Hill. See my blog posts, Milestones, and The Iowa River Landing Sculpture Walk, for background.

When I was a young man, I identified with the protagonist in Invisible Man. The Prologue still strikes a chord.

On the other hand, I googled my name today and found a few links that made me feel less invisible. Probably the most surprising link was to an interview with me entitled “James Amos, MD,” which you can read here. The piece evoked memories of a past version of me—which has not changed much since then. It mentions my former blog The Practical Psychosomaticist which I later renamed The Practical C-L Psychiatrist (C-L stands for Consultation-Liaison) after the flagship organization, the Academy of Psychosomatic Medicine changed its name to the Academy of C-L Psychiatry in response to a poll of its membership asking whether the name should be changed.

This biography makes me more visible, at least on the web. On the other hand, the blog no longer exists, due in part from my concerns about the General Data Protection Regulation (GDPR), which was enforced in 2018. I posted a lot of educational material about C-L Psychiatry on the blog along with pictures and presentations of my trainees. In a way, I did not protect their privacy and I was uncomfortable about that.

Other web pages surfaced during my self-googling. They included my article on delirium, “Psychiatrists Can Help Prevent Delirium,” posted on Psychiatric Times in 2011.

I also found my blog post on physician burnout, “How I left the walking dead for the walking dead meditation,” published on the Gold Foundation web site in 2014.

And there was my other Gold Foundation post about rude doctors, “Are doctors rude? An insider’s view,” posted in 2013.

There are a couple of petitions left over from years ago as well, about the controversial Maintenance of Certification (MOC) and the closure of state mental hospitals in Iowa several years ago.

I also found my review of Dr. Jenny Lind Porter’s book, The Lantern of Diogenes and Other Poems (published 1954).

The book seller’s note to me when Porter’s book was delivered in 2011 read as follows:

“Thanks for your purchase! It’s rare to find a book of this age that when you open the pages, it creaks like it is unread. I guess someone liked the way it looked on their bookshelf! Haha! Enjoy the book and Happy New Year, Rob J.”

An unread author is an invisible author. The first poem in the book is below:

The Lantern of Diogenes

by Jenny Lind Porter

All maturation has a root in quest.

How long thy wick has burned, Diogenes!

I see thy lantern bobbing in unrest

When others sit with babes upon their knees

Unconscious of the twilight or the storm,

Along the streets of Athens, glimmering strange,

Thine eyes upon the one thing keeps thee warm

In all this world of tempest and of change.

Along the pavestones of Florentian town

I see the shadows cower at thy flare,

In Rome and Paris; in an Oxford gown,

Men’s laughter could not shake the anxious care

Which had preserved thy lantern. May it be

That something of thy spirit burns in me!

Dr. Porter’s house in Austin, Texas was demolished a few years ago. There were plans to build a house there reminiscent of the architectural style of her original home and also a remembrance of her published work. I just noticed a satellite image of the property. There is no visible evidence that anything of that nature was ever built. Dr. Porter is, in a sense, invisible although her lantern still burns.

Visibility is a relative term. My advancing age and approaching retirement sometimes lead me to feel like I’m becoming invisible, gradually vanishing from the landscape of consultation-liaison psychiatry and general medicine.

Ralph Ellison’s book Invisible Man is a visible legacy. My legacy is small—yet the flame flickers, visible after all.

The Martin Luther King Jr. Day of Service is today and the University of Iowa has taken a quote from King to set the tone each year for this event. This year it is:

“Let us build bridges rather than barriers, openness rather than walls. Rather than borders, let us look at distant horizons together in a spirit of acceptance, helpfulness, cooperation, peace, kindness and especially love.”—Dr. Martin Luther King, Jr.
Dr. Martin Luther King, Jr.

As I look back on my career in medicine, it’s only natural for me to think of my role as a consultation-liaison psychiatrist as a sort of bridge between medicine and psychiatry. I’m pretty sure most would agree that as I chased around the hospital up and down the stairs doing the 3 and 30 (3 miles and 30 floors; I never take the elevator), I was doing my level best to bring psychiatric care to the patients in the general hospital who were suffering from medical illness as well.

The featured image shows the cover of a little book of kind remembrances I received from colleagues and trainees when, during one of my two such lapses in good judgment, I left the University of Iowa to have a try at private practice. The book has an image of a bridge on it. At the time, I thought of it as a depiction of my path between academia and community psychiatry. We need bridges there too, although one person let me know that someone has to teach new doctors.

I also got a fancy birdhouse as a going-away gift. I still do some bird-watching.

As I head into retirement, I hope that I’ve been a bridge of sorts between the old ways and the new to the next generation of doctors. After all, I’m the institutional memory of psychiatry on the medical and surgical units, in a manner of speaking.

The Medical-Psychiatry Unit (MPU) at University of Iowa Hospitals & Clinics was where I learned how this ward of patients with both medical and psychiatric illness served as a bridge between the departments of psychiatry and medicine. My teachers were doctors who were and still are great leaders. I still recall Dr. Roger Kathol, MD, an internist who also trained in psychiatry, and who designed and started the MPU decades ago, gave readings during sit-down rounds in the unit conference room. He read passages from the works of Galen, the Greek physician, surgeon, and philosopher in the Roman Empire.

Dr. Kathol assigned to me a task one day, which was to give a short presentation the following day on hyponatremia and how to distinguish psychogenic polydipsia from the Syndrome of Inappropriate Antidiuretic Hormone (SIADH). That night I was on call and got 4 admissions on the unit, which was chaotic. One patient actually broke a bed. I didn’t get any sleep. I was up running around until we all sat down to discuss patients.

I struggled through presentations of the 4 patients I had admitted the night before. I could barely talk. I had actually looked up a little information for my assigned presentation on hyponatremia but I was sweating it because I could barely stay awake. I was not the first resident to have episodes of microsleep on rounds and I knew Dr. Kathol saw it happening to me. That was in the days of 32 hours of call. They don’t make trainees do that now.

Dr. Kathol gave me sort of a sidelong glance as we finished discussing patients, which was usually when trainees were expected to give short educational talks. That day, he skipped me.

I should mention that he thought the proper name for the MPU was the Complexity Intervention Unit (CIU), owing to not just the medical and psychiatric complexity of our patients, but also to their social environments and the U.S. payer system which often led to many having inadequate, dis-integrated health care, meaning that there was no bridge between psychiatric and medical illness treatment and split health insurance coverage even though research showed that mental illness definitely lessened quality of life and increased health care costs. He has his own company, aptly named Cartesian Solutions, and it’s a major organization dedicated to helping hospitals and clinics set up collaborative ways to bridge the needs of patients with comorbid psychiatric and medical illness.

The University of Iowa model for the MPU has been disseminated to a number of other hospitals in the country, one of them in Pennsylvania, which I mentioned in a previous post, “Brief News Item,” on May 23, 2019. I’ve just received word a couple of days ago from Dr. Kolin Good that the unit, called the Medical Complexity Unit (MCU), a name which bridges the underlying intent of MPU and CIU, has saved the hospital a great deal of money, has drastically cut the use of sitters doing one to one observation (an extremely expensive intervention), is treasured by patients, and popular with trainees. They are very proud of it and have every right to be so. They are bridge builders too.

Dr. Louis Kirchhoff has been one the most notable internal medicine co-attendings on the MPU. He’s an infectious disease specialist, but has a knack for communicating effectively with patients who are mentally and medically ill, even speaking fluent Spanish with some of them. He and I shared triage call to the MPU every other night before the triage system was changed to a more humane schedule. He was a bridge between internal medicine and psychiatry trainees rotating on the ward. He could explain psychiatry to the medicine residents as well as I could.

I have had a penchant for finding a chair to sit down when I interview patients in their hospital rooms. There are usually not enough chairs in the rooms. A few years ago, Dr. Tim Thomsen, a surgeon and Palliative Care Medicine specialist as well, lent me a camp stool which I carry around with me so that I’m never at a loss for a chair. Everyone likes it. I think the camp stool helps build an emotional bridge with patients.

There are special combined specialty residencies at the University of Iowa Hospitals and Clinics which bridge Internal Medicine and Psychiatry and Family medicine and Psychiatry. Slowly but surely the siloed departments of academic medical centers are broadening their curricula and training regimens to rebuild the bridge between mind and body.

It’s been evolving for years. I’m proud to have played a small role in it. This is a place where teachers, researchers, and clinicians build bridges in many ways, foster openness, and search the “distant horizons in a spirit of acceptance, helpfulness, cooperation, peace, kindness and especially love.”