Giving Credit Where Credit is Due

Here’s another vintage post from around a decade ago after my former Psychiatry Dept chairperson, Dr. Robert G. Robinson and I published our book, Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry” in 2010.

Blog: Who Gets The Credit?

When I think about peak moments, I remember this guy back in junior high school who decided to try to break the Guinness Book of World Records for skipping rope. I don’t remember his name but the school principal and his teachers all agreed to let him do it during class hours. They marked out a little space for him in our home room. He was at it all day. And he was never alone because there was always a class in the room throughout the day. We didn’t get much work done because we couldn’t keep our eyes off him. It was mesmerizing. The longer he jumped, the more we hoped. We were very careful about how we encouraged him. We didn’t want to distract him and make him miss a jump. And so, we watched him with hope in our hearts. It was palpable.  As he neared the goal, we were all crowded around him, teachers and students cheering. He was exhausted and could barely swing the rope over his head and lift his knees. When he made the time mark, we lifted him high above our heads and you could have heard us yelling our fool heads off for miles. Time stood still. He was a hero and we were his adoring fans. It didn’t occur to us to be jealous. His achievement belonged to all of us.

Another peak moment occurred more recently, when my colleagues and I published a book this summer. It’s my first book. It’s a handbook about consultation-liaison psychiatry which my department chairman and I edited, and the link is available on this page. This time, the effort was collaborative with over 40 contributors. The work took over 2 years and often, being an editor felt like herding cats. But we worked on it together. Many of the contributors were trainees working with seasoned psychiatrists who had much weightier research and writing projects on their minds, I’m sure. Like any first book, it was a labor of love. The goal was to teach fundamental concepts and pass along a few pearls about psychosomatic medicine to medical student, residents, and fellows. The book grew slowly, chapter by chapter. And when it was finally complete, this time the achievement was ours and again it belonged to all of us.

I made a lot of long-distance friends on the book project and occasionally get encouragement to do something else we could work together on. I suppose one thing everyone could do is to propose some kind of delirium early detection and prevention project at their own hospitals and chronicle that in a blog to raise awareness about delirium—sort of like what I’ve been trying to do here. We could share peak moments like:

  1. Getting the Sharepoint intranet site up and going so that group members can talk to each other about in discussion groups about how to hammer out a proposal, which delirium rating scale to use, or which management guidelines to use—and avoid the email storms.
  2. Being invited to give a talk about delirium at a grand rounds conference or regional meeting.
  3. Talking with someone who is interested in funding your delirium project (always a big hit).

That way if one of us falters, we always know that someone else is in there pitching. Copyrighting ideas and tools are fine. Hey, everybody has a right to protect their creative property. I’m mainly talking about sharing the idea of a movement to teach health care professionals, and patients about delirium, to help us all understand what causes it, what it is and what it is not, and how to prevent it from stealing our loved ones and our resources.

“It is amazing what you can accomplish if you do not care who gets the credit”-Harry Truman, Kansas Legislature member John Solbach, Ronald Reagan, Charles E. Montague, Benjamin Jowett, a Jesuit Father, a wise man, Edward T. Cook, Edward Everett Hale, a Jesuit Priest named Father Strickland.

Short History of C-L Psychiatry Fellowship at Iowa

I read a short article, “The case for pursuing a consultation-liaison psychiatry fellowship” by Samuel P. Greenstein, MD in Current Psychiatry (Vol. 1, No. 5, May 2022). After 3 years as an attending, he found his calling as a C-L psychiatrist, especially after getting teaching awards from trainees. But when he applied to academic institutions for position as a C-L academic psychiatrist, people kept advising him to complete a fellowship training program in the subspecialty first. He gave it careful thought and did so, even he called it going “backwards” in his career.

On the other hand, he believes C-L fellowships will help meet the challenges of addressing rising health care costs and improving access to what most people see as the critically important goal of providing access to integrated mental health and medical care.

I’ve been retired from consultation-liaison psychiatry for two years now. I get an enormous sense of achievement on the rare occasions when I hear from former trainees who say things like “For me you were…one of the most outstanding attendings I had at my time at Iowa.” And “I can at least take comfort that University of Iowa is still at the forefront of psychiatry.”

Several years ago, one of the residents suggested starting a Psychosomatic Medicine Interest Group (PMIG). This was before the name of the subspecialty was formally changed to Consultation-Liaison Psychiatry in 2018. I know many of us were very pleased about that.

I sent a short survey (see the gallery below the slide show) to the faculty and residents in an effort gauge support for the idea and readiness to participate. I used a paper published at the time to guide the effort, (Puri NV, Azzam P, Gopalan P. Introducing a psychosomatic medicine interest group for psychiatry residents. Psychosomatics. 2015 May-Jun;56(3):268-73. doi: 10.1016/j.psym.2013.08.010. Epub 2013 Dec 18. PMID: 25886971.).

You’ll notice on slide 4 one faculty member’s comment, “I think it doesn’t matter whether faculty are certified in PM.” As Dr. Greenstein discovered, it probably does matter, at least if you want to be board certified.

I was initially certified by the American Board of Psychiatry & Neurology (ABPN), but I objected to the whole Maintenance of Certification (MOC) program, as did many other psychiatrists. I eventually declined to continue participating in the MOC process. However, I notice that the Delirium Clinical Module that I and a resident put together is still accessible on the ABPN website.

Although response numbers were low, there was clearly an interest in starting the interest group. There was also an incentive to reapply to the ACGME for approval of a Psychosomatic Medicine (Consultation-Liaison Psychiatry now) fellowship.

My attempt years earlier had been frustrating. While it was approved, I couldn’t attract any fellows, forcing me to withdraw it without prejudice (meaning another application for approval could be attempted). Fortunately, that situation changed later. The Psychiatry Department at The University of Iowa now has an early career C-L psychiatrist who graduated from the reinstated C-L fellowship.

As the saying goes, “What goes around comes around.” Although the origin of that saying might have originated in the 1970s, at least one person thought his grandmother had her own version in the 1950s: “You get what you give.”

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.

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.

Whatever Happened to the Janus Head Logo for ACLP?

I got an email from Don R. Lipsitt, MD yesterday which reminded me of the Janus Head logo for the Academy of Consultation-Liaison Psychiatry (ACLP). It was changed to another sort of nondescript logo several years ago for reasons I didn’t understand.

Dr. Lipsitt is a luminary in C-L Psychiatry and recently published a definitive history of the field, Foundations of C-L Psychiatry: The Bumpy Road to Specialization (2016).

Go ahead; buy this book!

I posted a blog or two about Don and his book in a previous blog, The Practical C-L Psychiatrist. We’ve never formally met. A few years ago, he noticed that I had written about him and his book. I had sent him an email message about it at around the same time the APM was considering the name change for the organization, telling him that I had plugged his book and asking him what he thought of the name change. Incidentally, he thought both of our books made a great package, so I guess I’m allowed to plug mine, strangely titled Psychosomatic Medicine: An Introduction to C-L Psychiatry, editors James Amos and Robert Robinson (2010).

Go ahead; buy my book, too…

 Don expressed his opinion about the name change:

“I feel I have dealt with that at some length in my book. I still feel C-L is most fitting and that the Board made a big mistake naming it PM. Who were they? Any C-L psychiatrists among them? Any Psychosomaticists? Why are not the “complex medically ill” a special population? And why is APA now offering courses on “integrated” care (which is what C-L psychiatry has always been about? The notion that C-L was not declared a specialty because it was considered a skill of ALL psychiatrists (with minimal training), then how do geriatric or child psychiatry become specialties (that all psychiatrists also have training in)? Don’t get me started.”

He considered his book, in large part, a “polemic” against the name “Psychosomatic Medicine.”

Anyway, the ACLP was formerly the Academy of Psychosomatic Medicine (APM) until a couple of years ago when the organization responded robustly to the membership (of which I was one at the time) to abandon the term “Psychosomatic Medicine” and adopt what rank and file practitioners preferred—Consultation-Liaison Psychiatry.

It was a kind of rebranding and it was not the first time the academy had considered a name change. I and a lot of other C-L Psychiatrists cringed at the term “psychosomatic,” not so much because of the word itself in terms of its true denotation, but because of the unfortunate negative connotations it had acquired.

Another luminary of C-L Psychiatry, Dr. Thomas Hackett, MD, wrote about the term “psychosomatic” in the Massachusetts General Hospital: Handbook of general hospital psychiatry: edited by Hackett and Ned Cassem (1978):

“The term ‘psychosomatic service’ has had a variable history. The term generally leaves a bad taste in the mouths of physicians. It reminds them of the 1930s, 1940s, and 1950s, when various psychosomatic schools espoused doctrines linking specific psychological conflicts or unique personality profiles with diseases designated as psychosomatic. Compounding this misunderstanding has been the term’s abuse by the general public, who regard anything psychosomatic as either imaginary or nervous in origin. As a consequence, most people believe that a psychosomatic disease is not to be taken seriously.”

Well, anyway, because of my anecdotage, I’ve strayed a little from my original story about the Janus head logo.

I already mentioned that the logo was abandoned in favor of something that looks like waves and could lead to seasickness. I inquired about the history of the use of the Janus head logo.

In addition to my curiosity about why the logo was changed, I also wondered why it was chosen in the first place and when. According to Don, it was part of the organization’s journal, Psychosomatics, in the late ‘60s and ‘70s. What was interesting is that it was already in use by the Journal of Geriatric Psychiatry when the Psychosomatics editors started using it. However, a conflicting view was that it was not introduced to the cover until 2010. Hmmmm.

I saw the 2012 issue of the APM Newsletter had a pretty funny picture of Drs. Shuster and Rosenstein posing as Janus and the statement “Thank you, Janus. You served us well for over 50 years.” That might put the origin of the logo, at least, around 1962 although my understanding is that APM was started in 1953 (TN Wise, A Tale of Two Societies, Psychosomatics 1995).

Time to say “Hello, again, Janus?”

 It’s just my opinion, but because Janus is the ancient god of beginnings and transitions, gates, doorways, endings and time, and typically depicted as two-faced because he looks to the future and the past, I think the symbol is a better image for what C-L Psychiatry has been through over the years.

Anyone for re-rebranding and go retro back to the Janus head logo?

Back to the future, Dr. Janus Amos?
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