Red Pants Revolution for Lifelong Learning Day!


So I’ve designated today as Red Pants Revolution for Lifelong Learning Day (RPRLLD). I’m wearing my red pants to work and I’ve got a few items to discuss in honor of this new holiday. First of all, I wanted to make sure everybody has read Dr. George Dawson’s post on 10/27/13, mainly because he outlines the political dimensions of the Maintenance of Certification (MOC). It is also burdensome, time-consuming, and not relevant to the practice of many doctors, including me. Pagination alert; page numbers below the Like button!

Now, in that light, let me tell you what I found out yesterday at an evening meeting about the Joint Commission layer of regulation for physicians called the Ongoing Professional Practice Evaluation (OPPE). Recall I mentioned this in a recent post. OPPE is a hoop for all practitioners, not just doctors but nurse practitioners and physician assistants as well. We are now going to get a couple of OPPE reports a year. Hospital privileging and other credentialing depend on a practitioner’s standing on several key metrics in the OPPE.

Almost none of these metrics apply to Psychosomatic Medicine practitioners whose work can be almost wholly in general hospital psychiatry. The metrics are keyed to things like length of stay and other data that are meaningful mainly for those who are staffing inpatient wards or outpatient clinics.

When I pointed this out to the presenter and the audience, I got the sense many were caught off guard. There was even a comment that my privileging might be called into question. By the way, I received my first OPPE report a couple of weeks ago. It was pretty blank because there was no data.

No data, no hospital privileges? No, not necessarily. My handout clearly said, “It is also important to remember that zero data is in fact data. Zero data can actually be evidence of good performance, e.g., no returns to the OR, no complications, no complaints, no infections, etc.”

But you can see the OPPE was not designed for the psychiatric consultant, and it led to a comical paradox–what does “zero data” mean for a psychiatric consultant? Nearly everybody in the room knew that I had seen many of their patients in consultation, so it wasn’t that I was not seeing patients.

So I drew another breath and asked the next question, the answer to which I was dreading. “Will the Joint Commission accept the MOC instead of the OPPE?” The silence was deafening. I think hardly anyone knew what the MOC was, probably because many of them held time-unlimited certificates. Of course, the answer was that the MOC probably would be acceptable.

How’s that for irony? I fight the MOC and it’s kissing cousin, Maintenance of Licensure (MOL), tooth and nail only to discover I may need them both.


My Post on Humanizing Medicine Blog of Arnold P. Gold Foundation!

Note: The Gold Foundation links in this post were broken and had to be updated because the Arnold P. Gold Foundation is rebranding itself and has a redesigned web site. If you’re looking for something else, you can try searching from the main page.–J.A. 11/17/2016

I just had to shout out that the Humanizing Medicine – The blog of the Arnold P. Gold Foundation just yesterday published one of my posts with minor edits including the title:

Are doctors rude? An insider’s view – Humanizing Medicine

I’m so thrilled to be featured on the Arnold P. Gold Foundation web site!

They might also publish another one of my posts, maybe in the next couple weeks, Here Be Dragons.

Thank you Arnold P. Gold Foundation!

Are Doctors Just Rude?

My wife pointed out this CNN article about how resident doctors are just plain rude. The writer cites a media report on a Johns Hopkins study which comments on the study findings, which point to medical interns not doing basic things like introducing themselves to patients, sitting down to talk them eye-to-eye despite research showing that using these interpersonal skills improves medical outcomes [1].

It turns out that this problem is not isolated to trainees. Hospitalist physicians also don’t practice etiquette-based communication.

A simple chairAs the authors point out in the discussion section of this paper, about two-thirds of patients find a comforting touch from doctors reduces anxiety (and well over half find it healing), yet most young doctors didn’t do that in this study. A randomized trial found that most patients preferred a doctor sit down to talk with them, which was thought to be an indicator of more compassion. But most interns didn’t do that.

The authors speculated that interns don’t engage in these simple behaviors because they don’t see their teachers modeling them.

Now these were medicine interns, provoking the question of whether psychiatry interns might pay closer attention to these etiquette-based behaviors. I can tell you I don’t see it very often.

I think I should point out that chairs are not readily available in many patient rooms. And in the intensive care units, the beds are often elevated to facilitate nursing cares and certain types of invasive procedures.

Residents are used to leaving the room to hunt for a chair for me because I make it a point to try to sit down.

Role modeling is not enough. I need to provide specific feedback and don’t often do it.

I made a point of providing it on the day I read this article and gave them copies. Will that be enough? Probably not. Because of the Hawthorne effect, trainees may behave in the way they think I want them to behave. Then again, there will be those incredibly busy days on the psychiatry consultation service in which we typically do more flying than sitting.

One thing I know. Most resident physicians care deeply about their patients and they tell me that. I also witness their caring behaviors, etiquette-based or not.

The CNN article has a provocative title which probably overgeneralizes about resident physicians. By and large I think most doctors are not rude, at least not intentionally. Hospitals and clinics expect a lot from them and our systems of care are often ill-designed to accommodate the kinds of humanistic behaviors so important to patients and their families.

Most us think, “If only we had the time…”


1. Block, L., et al. (2013). “Do internal medicine interns practice etiquette-based communication? A critical look at the inpatient encounter.” Journal of Hospital Medicine: n/a-n/a.
Etiquette-based communication may improve the inpatient experience but is not universally practiced. We sought to determine the extent to which internal medicine interns practice behaviors that characterize etiquette-based medicine. Trained observers evaluated the use of 5 key communication strategies by internal medicine interns during inpatient clinical encounters: introducing one’s self, explaining one’s role in the patient’s care, touching the patient, asking open-ended questions, and sitting down with the patient. Participants at 1 site then completed a survey estimating how frequently they performed each of the observed behaviors. A convenience sample of 29 interns was observed on a total of 732 patient encounters. Overall, interns introduced themselves 40% of the time and explained their role 37% of the time. Interns touched patients on 65% of visits, asked open-ended questions on 75% of visits, and sat down with patients during 9% of visits. Interns at 1 site estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P < 0.01; 80% vs 37%, P < 0.01; and 58% vs 9%, P < 0.01, respectively). Resident physicians introduced themselves to patients, explained their role, and sat down with patients infrequently during observed inpatient encounters. Residents surveyed tended to overestimate their own practice of etiquette-based medicine. Journal of Hospital Medicine 2013. © 2013 Society of Hospital Medicine

Participate in a Study On Recognizing Delirium Using Video-Monitoring

So I got this very intriguing email about a invitation to participate in a delirium study on diagnosing delirium using a method involving video monitoring and wrist actigraphy in the intensive care unit (ICU). The announcement came from the European Delirium Association (EDA) and sprang from a poster presentation at the recent EDA conference in Leuven, Belgium.

If you’re a clinician or researcher, you can register to participate in the study and the authors will send videos of ICU patients which have been de-identified so that participants can decide whether the movements of the patients are indicative of delirium. I think the questionnaire (for clinicians only) is easy to complete.

This is very interesting and I’m still considering whether I’d like to participate. i found just a few papers about it below in the list of references.

I think one of the saddest spectacles anyone can witness is someone in the throes of delirium. It’s vitally important that we keep working to understand the biology and the clinical features of delirium. It’s also important to continue working toward changing the culture of medicine so that everyone views it as a medical emergency and that we work together to prevent it.


Osse, R. J., et al. (2009). “Screening methods for delirium: early diagnosis by means of objective quantification of motor activity patterns using wrist-actigraphy.” Interact Cardiovasc Thorac Surg 8(3): 344-348; discussion 348.
Delirium after cardiac surgery is a risk factor for adverse outcome and even death. Disturbance of motor activity is a core feature of delirium, but hypoactive delirium often remains unrecognized. We explored wrist-actigraphy as a tool to objectively quantify postoperative recovery of 24-h rest-activity patterns to improve the early recognition of delirium after surgery. Motor activity was recorded by wrist-actigraphy after cardiac surgery in 88 patients over 65 years of age. Patients were assessed daily by using the CAM-ICU. Our final analyses were based on 32 non-delirious patients and 38 patients who were delirious on the first day after surgery. The delirious patients showed lower mean activity levels during the first postoperative night (P<0.05), reduced restlessness during the first day (P<0.05), and a lower mean activity of the 5 h with lowest activity within the first 24 h (P=0.01), as compared to the non-delirious patients. Already at a very early stage after cardiac surgery, a difference in motor activity was observed between patients with and without a delirium. As an unobtrusive method, actigraphy has the potential to be a screening method that may lead to early diagnosis and treatment of delirium.

Hourmand-Ollivier, I., et al. (2006). “Actigraphy: A new diagnostic tool for hepatic encephalopathy.” World J Gastroenterol 12(14): 2243-2244.
AIM: To assess the actigraphy, an ambulatory and continuous monitoring of wrist motor activity fitted to study sleep/wake patterns in hepatic encephalopathy (HE). METHODS: Twenty-five cirrhotic patients (17 M, 8 F, mean age 56+/-11 years, 24/25 alcoholic, Child-Pugh A , B, C: 2, 6, 17) were included. The patients were classified into 3 groups: stage 0 group (n = 12), stage 1-2 group (n = 6), and stage 3-4 group (n = 7) of encephalopathy. Over three consecutive days, patients had clinical evaluation 3 times a day with psychometric test, venous ammoniemia, flash visually evoked potentials (VEP), electroencephalogram and continuous actigraphic monitoring for 3 d, providing 5 parameters: mesor, amplitude, acrophase, mean duration of activity (MDAI) and inactivity (MDII) intervals. RESULTS: Serum ammonia and VEP did not differ among the 3 groups. Electroencephalography mean dominant frequency (MDF) correlated significantly with clinical stages of HE (r = 0.65, P = 0.003). The best correlation with HE stage was provided by actigraphy especially with MDAI (r = 0.7, P < 10(-4)) and mesor (r = 0.65, P < 10(-4)). MDAI correlated significantly with MDF (r = 0.62, 0.004) and was significantly shorter in case of HE compared to patients without HE (stage 0: 5.33+/-1.6 min; stage 1-2: 3.28+/-1.4 min; stage 3-4: 2.52+/-1.1 min; P < 0.05). Using a threshold of MDAI of less than 4.9 min, sensitivity, specificity, positive predictive value, negative predictive value for HE diagnosis were 85%, 67%, 73% and 80%, respectively. CONCLUSION: Actigraphy may be an objective method to identify HE, especially for early HE detection. Motor activity at the wrist correlates well with clinical stages of HE. MDAI and mesor are the most relevant parameters.

Osse, R. J., et al. (2009). “Disturbed circadian motor activity patterns in postcardiotomy delirium.” Psychiatry Clin Neurosci 63(1): 56-64.
AIMS: More than 20% of patients of 65 years or older may develop a delirium after cardiac surgery. Patients with delirium frequently show a disturbed 24-hr motor activity pattern, but objective and quantitative data are scarce. Our aim was to quantify motor activity patterns in elderly patients with or without a postcardiotomy delirium after elective cardiac surgery. METHODS: Wrist-actigraphy was used to quantify 24-hr motor activity patterns for a 5-day period following cardiac surgery in 79 patients of 65 years or older. Clinical state was monitored daily by means of the Confusion Assessment Method-Intensive Care Unit and the Delirium Rating Scale-Revised 98. RESULTS: The activity Amplitude, and the daytime Activity/minute and Restlessness index were significantly higher and the daytime number of Immobility minutes significantly lower for the patients without delirium or with short delirium episodes, as compared to patients with a sustained delirium (>3 days). CONCLUSIONS: Actigraphy proves to be a valuable instrument for evaluating motor activity patterns in relation to clinical state in patients with a postcardiotomy delirium.

Free Psychiatry Online Journal: Respectable Venue

Well, I think we’re probably pretty close to deciding on the venue for the free online journal club for psychiatrists. Therefore, we’re going to officially close the survey. There were only 10 responses and the results are below:

Online Journal Club Survey Results Main Oct 27 2013

Online Journal Club Survey Results Oct 27 2013

Online Journal Club Survey Results 2 Oct 27 2013

Given the results, it may come as a surprise to some that we lean toward using LinkedIn as the venue for the online journal club. While we appreciate the opinions offered in the survey and thank the respondents, we’ve given this a lot of thought and we believe that LinkedIn would be a bit more,,,respectable.

Iowa Board of Medicine and MOL: The New Red Pants Revolution

I had a constructive telephone conversation on October 25, 2013 with the Licensure Committed of the Iowa Board of Medicine (IBM) regarding my position supporting the principle of lifelong learning and opposition to Maintenance of Licensure (MOL). Hey, pagination alert; look for the page numbers below the Like button!

I got about 15 minutes and after the quick introductions, I quickly ran through my slides:

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What I heard was that IBM doesn’t necessarily support MOL–and I heard one board member specifically criticize the proposal. While I was not sure I understood the board’s rationale for participating in the MOL Pilot Projects in the first place if they don’t favor it, they clarified that “Pilot Project” is probably a misnomer. The idea is to gather data, not make MOL a reality. That was interesting, because the Federation of State Medical Board’s (FSMB) clear agenda on their website was to make MOL a part of medical licensure renewal in the next 10 years.

Well, then I learned from IBM that leadership is changing at FSMB and that the MOL project strategy might shift under the new chairman– Dr. Jon V. Thomas, MD, MBA, who is from Minnesota, a state where MOL  may or may not be popular. It’s difficult to tell. During the Iowa Medical Society House of Delegates meeting in April 2013 when my resolution to support lifelong learning and to oppose MOL was adopted, a Minnesota physician remarked that the MOL initiative was not supported by Minnesota doctors. I searched the Minnesota Medical Society records and found one resolution that is clearly opposed to the secure examination as part of the Maintenance of Certification (MOC). Minnesota was not one of the 11 test states for implementing the MOL Pilot Projects.

What will be coming next from IBM is a survey of licensees and that may appear in the next 3-4 months as an on-line questionnaire of around 35 questions, which I hope will include queries regarding Iowa physicians’ opinions and preferences about MOL.

I probably don’t need to stress the critical importance of full participation by Iowa licensees in this upcoming survey. I will complete the survey, which will be a product that has already been used by the Colorado and Virginia state medical boards. Hopefully, this will be modified to be suitable for Iowa doctors.

If the survey is fair and allows for my comments, I’ll clearly support the principle of lifelong learning and say that MOL will not facilitate putting the principle in action.

Clobbered by “Colloborative Care”: Reality vs Perception?

Are we getting clobbered by “colloborative care”?

I just recently read Dr. George Dawson’s blog post on collaborative care, which was his response to the American Psychiatric Association (APA) president Dr. Jeffrey Lieberman’s video above. You can find more information about integrated and collaborative care at this link.

I think it’s important that we present both sides of this issue because not everyone believes in the APA version of the state of psychiatric treatment today. Dr. Dawson has a lot of experience in this area and has definite views on it that deserve a wide audience.

Dr. Art Smukler is another psychiatrist who seems to share similar views.

Dr. Dawson has been quite frank and said “Our direction needs to be 180 degrees away from collaborative care. This is more than a battle about care delivery. This is a battle for psychiatry,” in a comment on one of my recent posts.

Americans should know that psychiatrists are not necessarily of one mind on this issue. In fact, many seem to say, “Don’t you do it!”