What’s the Quick Fix for the Quick Fix?

Well, I just ran across some news items which remind me of our quick-fix nation. One is a Washington Post article about a project associated with President Obama’s Brain Research through Advancing Innovative Neurotechnologies (BRAIN Initiative) involving the development of computer chips to help treat neuropsychiatric syndromes such as post-traumatic stress disorder.

The program manager at the Defense Advanced Research Projects Agency (DARPA) envisions that the chip would be an alternative to medications–which, by the way, are viewed by many as just another quick fix. A physician blogger who does bariatric surgery also “weighs in” on the issue:

Another funny item seems connected to our drive to have things our way yesterday. There’s a new study which makes older people trip in order to prevent them from falling. You heard that right–to prevent falls, make them trip.

Note the woman who was the subject of this study frankly admits that “she still occasionally falls–even after the training.” Part of the impetus for the study was frustration over the length of time it takes for other proven methods to be effective for fall prevention, things like physical conditioning and avoiding medications that predispose to falls, the latter of which implicates many drugs prescribed by doctors for off-label purposes.

Explain to me again why we can’t teach patience to patients–and doctors?

So what would be the analogous trip-them-up method for preventing emotional distress or psychiatric syndromes? Intentional exposure to the wrong motivational speakers? The idea would be to desensitize you to shame and guilt, I guess.

Are there any other methods for developing resilience and homeostasis other than implantable computer chips and practicing judo on the elderly for their own good?

Well, in fact, mindfulness comes to mind. A recent study published in the American Journal of Psychiatry used mindfulness training to enhance physiologic recovery after inducing predeployment training stress (yes, deliberately) in Marines [1]. In the discussion section, the authors say that mindfulness “…demonstrated beneficial effects across multiple domains indicating enhanced recovery from stress. Moreover, these effects were observed in a nonclinical sample and suggest that responses to stress may be improved through training prior to stress exposure, even in individuals without a mental health condition. Given these results, it is reasonable to speculate that even stronger treatment effects may be observed in treatment-seeking clinical populations. Taken together, these findings constitute evidence for the prevention and treatment of stress-related pathology. In addition, using measures in multiple domains, this study is an important step toward the application of Research Domain Criteria and neuroscience-based diagnoses. The results also have important implications for stress-related mental health research and evidence-based foundations for nonpharmacological prevention and treatment options.”

Did you get that? “Research Domain Criteria” or (RoDC), the holy grail of modern psychiatric research. If we could just speed up that process!

Geddown from there already!
Geddown from there already!

Because here’s the deal about mindfulness–it takes a while to develop a consistent mindfulness practice which would provide the kind of longer term benefit typically seen in experienced meditators. It reminds me of what I learned in the Mindfulness-Based Stress Reduction (MBSR) class I recently “completed” (you never really finish MBSR; you embark on a lifelong learning path to integrate mindfulness into your daily life). When you meditate, one of the first things you notice is the tendency for the mind to wander away repeatedly from focusing on the breath. So you have to “teach the puppy to stay,” which can often feel like telling the puppy repeatedly to get down off the furniture.

It makes me wonder whether this quick-fix culture we have in the training of physicians could use a little early intervention. One way to introduce a sort of tolerance to the time we need to develop well-rounded, humanistic doctors (clinician-teachers as well as research scientists) would be to pay more attention early on in our college careers to the importance of patience. Some of the posts I read on the Humanizing Medicine Blog seem to have a subtext pointing to what seems to be both a symptom and a cause of what’s been called the “hidden curriculum” in medical education.

When I read between the lines of Nina Stoyan-Rozenzweig’s post, I get a sense of the pervasive dark shadow that may lead to much of the stress and burnout in residency and beyond. A couple of excerpts may help reveal what tends to be concealed in everyday life on the wards:

“The development of humanism in medicine requires that these lessons be firmly imprinted, since there are so many factors in medical training and medicine that can throw people off track.”

“Undergraduates tend to admire medical students for having successfully navigated the required medical school hoops, and feel that medical students can be trusted (since students may perceive that certain professors or other authority figures may not truly be on a student’s “side”). Medical students also lack the intimidating level of authority of some professors.”

Doorway to homeWhile mindfulness could be the way out of the morass of medical training, the ironic part of this solution is that we can’t use it like just another quick-fix goal. That’s because it’s a way of being instead of doing. We can open a door with it, which can let us out–and let other things in.

References and Resources:

1. Johnson, D. C., et al. (2014). “Modifying resilience mechanisms in at-risk individuals: a controlled study of mindfulness training in marines preparing for deployment.” Am J Psychiatry 171(8): 844-853.

OBJECTIVE: Military deployment can have profound effects on physical and mental health. Few studies have examined whether interventions prior to deployment can improve mechanisms underlying resilience. Mindfulness-based techniques have been shown to aid recovery from stress and may affect brain-behavior relationships prior to deployment. The authors examined the effect of mindfulness training on resilience mechanisms in active-duty Marines preparing for deployment. METHOD: Eight Marine infantry platoons (N=281) were randomly selected. Four platoons were assigned to receive mindfulness training (N=147) and four were assigned to a training-as-usual control condition (N=134). Platoons were assessed at baseline, 8 weeks after baseline, and during and after a stressful combat training session approximately 9 weeks after baseline. The mindfulness training condition was delivered in the form of 8 weeks of Mindfulness-Based Mind Fitness Training (MMFT), a program comprising 20 hours of classroom instruction plus daily homework exercises. MMFT emphasizes interoceptive awareness, attentional control, and tolerance of present-moment experiences. The main outcome measures were heart rate, breathing rate, plasma neuropeptide Y concentration, score on the Response to Stressful Experiences Scale, and brain activation as measured by functional MRI. RESULTS: Marines who received MMFT showed greater reactivity (heart rate [d=0.43]) and enhanced recovery (heart rate [d=0.67], breathing rate [d=0.93]) after stressful training; lower plasma neuropeptide Y concentration after stressful training (d=0.38); and attenuated blood-oxygen-level-dependent signal in the right insula and anterior cingulate. CONCLUSIONS: The results show that mechanisms related to stress recovery can be modified in healthy individuals prior to stress exposure, with important implications for evidence-based mental health research and treatment.

Link to book Staying Human in Residency


Look Out; He’s Using Shortcode Again! Decisional Capacity Assessment

I’m incorrigible; I’m trying to use WordPress Presentation Shortcode again to make a short presentation on decisional capacity assessment. This is a frequent request, I mean to help with decisional capacity assessment, not shortcode, of course.

This by no means does much more than scratch the surface of this issue, but it’s what’s essential for trainees to know when they rotate through the psychiatry consultation service.

What a lot of non-psychiatric clinicians don’t know is that they’re often the ones in the best position to assess the decisional capacity of their patients. Psychiatrists are helpful when there’s a neuropsychiatric syndrome present which we can evaluate to see if it’s substantially interfering with decision-making.

As always with this presentation shortcode thingy, you have to use the arrow keys to navigate each and every line on the slides. If you want to see the slideshow in full screen, click the 4 arrrow icon in the lower right hand corner. Hit ESC to exit full screen.

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My Comments on Affirming Lifelong Learning and Opposing MOC in Iowa

cropped-dr-jim-amos-md.jpgThe Iowa Medical Society (IMS) new Policy Forum will meet on September 25, 2014 to discuss a half-dozen pivotal issues including my Policy Request Statement (PRS) 14-02: Support of Lifelong Learning and Opposition to Mandatory Maintenance of Certification (MOC). Below are my comments on the IMS LinkedIn site. I’ve already submitted written comments required by rule, and they’re very similar.

What makes this issue very important to me was brought home by an article on MOC in the most recent issue of the Academy of Psychosomatic Medicine Newsletter. I’m a member of the APM and justly proud of how this growing organization (now over a 1,000 members strong) has met the challenge of helping its members meet the demanding MOC requirements.

The author of the article “Changes in the Recertification Process,” Bob Boland, MD, FAPM, notes the recent flexibility in the MOC process according to the American Board of Psychiatry and Neurology (ABPN). However, you have to love his sense of humor in his answer to the question, “Why do I have to do this?”–“Because the ABPN said so.”

Obviously the tongue-in-cheek reply starts with this remark because most physicians feel burdened, sometimes mystified, and irked by this new regulatory layer which is especially ironic to APM because of the struggle to gain approval of Psychosomatic Medicine as a subspecialty. It took many years, and the  first try met with failure, partly because of resistance from the American Board of Medical Specialties (ABMS) which objected on the grounds that approving yet another subspecialty would contribute to the balkanization of medicine. I was among the first diplomates taking the exam for the first time ever in 2005.

Now APM has to put up with the MOC process–because the American Board of Medical Specialties (ABMS) says so.

It’s hard to disagree with Dr. Boland’s point that doctors do, in fact, need to have some formal, systematic way to continously assess and improve their medical knowledge and clinical skills. I agree completely. I just don’t think MOC adequately embodies the lifelong learning principle.

Yet, the APM leadership would definitely have political difficulties publicly opposing the MOC process, given all the trouble they went to in order to get Psychosomatic Medicine through the rigorous and complicated subspecialty approval protocol. It’s to their credit they soldier on because of the critical importance of Psychosomatic Medicine, especially now in this evolving health care delivery environment in which the drive to integrate medical and psychiatric care figures so prominently.

At any rate, below are my comments on why I treasure the path of lifelong learning and why I think MOC impedes our progress on it and may even be a blind alley.

“I submitted PRS 14-02 and I have no conflicts of interest or anything to gain personally by doing so. I’ve submitted written comments to the Policy Forum for the discussion at The University of Iowa on September 25th, although I’ll probably be unable to attend in person because of my clinical duties.

I was also the sponsor for the resolution (adopted) to support the principle of lifelong learning and oppose Maintenance of Licensure (MOL) last spring at the IMS House of Delegates prior to the switch to the Policy Forum format.

There are several reasons why I think PRS 14-02 is necessary in addition to the opposition to MOL policy.


  • I think MOC as it stands would create a strong disincentive for physicians to relocate to or stay in Iowa to practice (a physician shortage area), because most doctors believe:
  • MOC is time-consuming, expensive, often not relevant to our practices, and not supported by high-level research to improve patient outcomes
  • Despite the American Board of Medical Specialties (ABMS) assertion that MOC is voluntary, it has becoming essentially mandatory in order to obtain hospital privileges, third party reimbursement, and most recently it’s being promoted by the Federation of State Medical Boards (FSMB) to be used as a condition for state medical licensure


Although I’ve not yet seen the results of the Iowa Physician Acceptability Survey results regarding MOL (administered by the Iowa Board of Medicine [IBM]), which was completed in April this year, I’m confident that many doctors answered Question 31 (asking for free-text comments about it) indicating their opposition to MOL. Indeed, most of the states supposedly collaborating on MOL implementation projects have adopted resolutions opposing it.

I’m not advancing PRS 14-02 just because so many other states are doing or planning to do likewise.  I’m doing this because, in my opinion, MOC and MOL do not adequately embody the principle of lifelong learning. In fact, I think they foster mediocrity because they are being foisted on doctors, most of whom favor pursuing excellence and who naturally bridle at being forced to do otherwise.

When I was interviewed in June this year by Becky Watt Knight, Senior Vice President of the public relations firm, Get Your Message Right, as part of the IBM implementation project for MOL (an important piece of which was the Iowa Physician Acceptability Survey), she asked me if I thought a systematic process for helping physicians achieve competency in lifelong learning is needed. I told her I agreed wholeheartedly that something like it is sorely needed.

However, I believe we should let individual physicians decide voluntarily how to embody the principle of lifelong learning in their practices. I agree that diplomates’ knowledge and skill base erode over time and that doctors need to engage in some form of lifelong learning. While I am openly opposing MOC and MOL, I’m also compliant with the American Board of Psychiatry & Neurology (ABPN) MOC program (I just recently passed the Psychosomatic Medicine recertification exam). However, the MOC products available to me are often not relevant to my practice, take significant time to complete, and are far from inexpensive.

I think we should give physicians an incentive to engage their own personally crafted lifelong learning practices. One way to do that might be for state medical boards and societies to formally and publicly recognize their efforts.”

Uh Oh…Using WordPress Shortcode Again: C-L Psychiatry and Delirium

Every once in a while, I get an urge to try WordPress Presentation Shortcode and the results are usually quirky for reasons I can’t fathom. But then I’m a geezer and can’t be expected to solve all these digital puzzles.

You have to use only the arrow keys to navigate through each and every line on the slides. If you use any other method, you’ll think the slideshow doesn’t work and give up in frustration and disgust. Gawd!

Don’t forget to view the presentation in full screen by clicking the 4-arrow icon on the right lower corner of the slideshow. Hitting ESC (not too hard!) on your keyboard will also exit full-screen mode.

Oh well, I see others have issues with it, too. Someday we’ll all just move on.

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Back on the MOC Again

Well, my wife and I just got back from vacation in downtown Milwaukee where I snapped quite a few pictures, and it’s remarkable how much of it reminded me of the first Policy Forum of the Iowa Medical Society, now in the Testimony Forum stage. Of course, I didn’t think about my Policy Request Statement (PRS) 14-02: Support of Lifelong Learning and Opposition to Mandatory Maintenance of Certification (MOC) the whole time we were in Milwaukee.

Part of the charm of the Milwaukee Riverwalk are its oddities, one of which puzzled us for a while until we checked it out with the Milwaukee County Historical Society. It was the plaque we found on a building just across the street from the Pabst Theatre:

A clue to famous Milwaukee restaurant

I thought the word “Histeric” was just misspelled until my wife pointed out the line “Department of the Ulterior.” Two misspelled words on the same plaque? That had to be more than a coincidence. And then I googled the name Margaretha Geertruida Zelle–which turned out to be Mata Hari, a famous spy. Gaining a bit of perspective by getting a picture from across the street revealed a helpful clue.

Clue to popular MKE restaurant

But we didn’t solve the mystery until a very knowledgeable historian at the local Milwaukee County Historical Society cleared it up by describing a popular spy-themed restaurant billing itself under the fake name “International Exports, Ltd,” located just around the corner from the plaque. We had heard about this club previously from the tour guide during our ride on The Milwaukee Trolley Loop. Unfortunately, we didn’t get a chance to experience the place. I’m sworn to secrecy about the real name because I looked it up on the internet and had to take a pledge. See if you can find it.

What were we talking about? Oh yeah, PRS 14-02: Support of Lifelong Learning and Opposition to Mandatory Maintenance of Certification (MOC). I’m struck by the similarity of the controversy over one of the art pieces (The Calling by Mark di Suvero) at the end of Wisconsin Avenue to that surrounding MOC…some people love MOC while others hate it.

The Calling by Mark di Suverno in MKE


The Calling really attracts a lot of hate and it’s often compared unfavorably with the Quadracci Pavilion behind it (obscured by fog in the shot above) at the Milwaukee Art Museum, frequently praised for its integration of form with function:

Quadracci Pavilion MKE


Combining form with function or otherwise making the pursuit of lifelong learning practical is how I prefer to frame the debate about MOC, which in its current form doesn’t help physicians in that regard. If you look at the petition signed by thousands of doctors who pledge to boycott MOC, you get the sense that MOC lacks everything which would make it successful. In general, physicians are dedicated to the principle of lifelong learning and the vast majority of us have been high-performing over-achievers who can find our own ways to continuously improve our medical knowledge and skills on our own.

Despite the much-criticized art piece’s ironic name, “The Calling,” that title is what’s most important, in my opinion, as it relates to the debate about MOC. I think of my profession as just that, a calling. The drive by the American Board of Medical Specialties (ABMS) and the Federation of State Medical Boards (FSMB) to make it more like a trade union (no disrespect to trade unions, which have fundamentally different goals) by attaching hospital privileging, insurance panel assignment, and medical licensure is not what a profession is about.

Rank-and-file physicians feel like an oppressed group in this struggle, leading to the formation of the website, Change Board Recertification. And, perhaps predictably, the art piece which reminded me of that was “Common Comrades,” by Manu Garay, described as conveying “…the message of inclusion for the poor, oppressed, and outcast.”:

Common Comrades by Manu Garay in MKE


I think the boards are working very hard at excluding doctors from the decision-making process about how to make it easier for us to develop our own efforts at systematic professional development processes. As Iowa Medical Society President, Dr. Jeffrey Maire, DO, says, “No one is in a better position than the individual physician to determine how best to maintain the needed skills.”

I sponsored the resolution to support lifelong learning and oppose Maintenance of Licensure (MOL) in Iowa last year (it was co-sponsored by the Iowa Psychiatric Society) and it was adopted. I’m hopeful that PRS 14-02 will also be adopted by the Policy Forum in September. And if it is, I wonder what the Fonz would say?

Hanging out with the bronze fonz (2)

Let’s Hear It for CHOPs On Delirium!

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I really can’t say enough about how practical and evidence-based the website CHOPs is regarding assessing and managing delirium in hospitalized, elderly patients. Dr. Helen Creasey, who is a geriatrician, never mentions even once in this stunningly clear presentation that you should call for the consulting psychiatrist immediately for this disturbingly common neuropsychiatric complication that is promoted, in part, by hospital culture–which she also warns us about.

In fact, that’s what I appreciate so much about Dr. Creasey. She talks about the same things I do, but she’s from the internal medicine culture. It’s physicians like her who are more likely to help lead change in the hospital culture, although consulting psychiatrists are more than happy to assist.

Ruminating On Whatever Happened to POLL?

It’s Friday so how about chewing on a news item which will satisfy anyone’s limited appetite for pseudoscience? The premise is that the more times you chew, the more likely you’re to eat less and therefore more likely to lose weight. Get your Bite Monitor soon, while they’re hot.

OK, so I’ve been called the slowest eater in the world and it’s probably because I chew so much. This happens especially every time I try to eat shredded coconut, because the texture is so much like shredded newspaper. I just can’t bring myself to swallow the stuff.

This might be an opportunity to coin a name for a new phobia–ruminatococophagophobia.

POLL ButterflySo this is as good an excuse as any to finally broach the subject of our now defunct Psychiatry Online Journal Club (POLL), which hit the dirt back in June after we got close to zero participation for about 6 months on the LinkedIn site. I’ve been ruminating about it ever since and I guess the reason it’s still up there (caught in LinkedIn’s throat) is because of a reluctance to swallow the failure of this attempt to demonstrate that clinicians can find a free, practical, and effective way to conduct lifelong learning without choking on the Maintenance of Certification (MOC) process. Psych Practice blogger tried to collect some feedback from readers, but the fish just weren’t biting.

I’ve been trying to be as mindful about this issue as I tried to be with the mindfulness class raisin-eating exercise. Maybe what members were trying to tell us was that POLL participation was about as stimulating as chewing a raisin very slowly. But then, even large and notably successful projects occasionally fail, including the collaborative care enterprise:

I still believe that individual clinicians can make a difference in the practical application of the principle of lifelong learning. I think first of my personal favorite, the Clinical Problems in Consultation Psychiatry (CPCP) case conferences.

I also like the small bites of my skinny talks. One of those could be just like a pinch between your cheek and gum. And then there’s the dirty dozens that any geezer or non-geezer could gum his way through.

Apparently some people have not gotten the message that POLL was more or less spat out. Amazingly, new members are waiting to be approved to join. I’m not the owner of the site and neither do I consider myself a manager anymore, so I’m afraid they’ll sit.

In Jon Kabat-Zinn’s book about mindfulness meditation, “Full Catastrophe Living,” he tells the story about holding on and letting go which involves catching monkeys by baiting a coconut (which I can chew but not swallow, remember?) with a banana. You cut a hole in the coconut big enough to for the monkey to put its hand through to grab the banana, but too small for it to pull it’s fist back out with the banana. The coconut is tied to a tree and the hunters hide. Some monkeys get caught even though all they’d have to do to avoid capture is to let go of the banana.

I guess you can catch a few monkeys this way. Moral of the story? You can’t chew a banana with your fist.

Seriously, the trick for me has been to become aware that I’m holding on in the first place.