Meatball Psychiatrists Finding Ways to Improve

Every 4 weeks or so the psychiatry consultation service gets a new crop of learners including residents (psychiatry and family medicine, sometimes neurology, occasionally pharmacy), and medical students, which is always exciting for me when I’m on service (most of the time). Often I tell them that consultation psychiatry reminds me of something I always thought Colonel Sherman Potter said in one of the M.A.S.H. (Mobile Army Surgical Hospital ) episodes, which I paraphrase because I can’t recall it exactly. The kind of surgery in a M.A.S.H. unit is sort of rough and ready, designed to save lives though sometimes by sacrificing limbs and making other tough decisions quickly. Potter once told Hawkeye something like “This is meatball surgery, son,” or something like that. And I frequently tell the trainees that consultation psychiatry in a general hospital is similar. I’ve described it as “meatball psychiatry.”

Dr. Amos putting out firesJust like meatball surgery, meatball psychiatry is fast-paced. The kind of assessments my colleagues ask me to do and the number of requests I get are many and varied, and they must be done rapidly or else I’ll get behind in my role as the leader of a psychiatric fire brigade.

But I never watched M.A.S.H. in its regular season at all and watched only a few episodes in rerun. I tried to find the one about meatball surgery on line but all I turned up was an Urban Dictionary item which supports my analogy. But I’m not sure it’s accurate. I might have to buy the original book the military surgeon wrote which spawned the movie and the TV series, the latter of which the author didn’t care for. By the way, my search also turned up an article which refutes the idea that African American surgeons were not involved in the Korean War…so much for writing out Spearchucker.

Retirement bookHowever, I’m reading other books, the latest one about adjusting to retirement, which I talk about more and more and, in fact, toward which I’m taking active steps now for several reasons. I guess the chief one is that I’m getting old although I can still climb the stairs.

Pedometer daze

I should say I’m taking small active steps because I’m ambivalent about it. My job gives me a sense of purpose and meaning, and that can be hard to leave behind. I’ve known a few people who retired who I never saw again after their last day of work. But I’ve seen more who return. A resident mentioned that one faculty member had told her frankly that it’s no longer fun to practice medicine and that a big contributor to that impression is the erosion of autonomy physicians have experienced over the years.

I imagine that’s disappointing for trainees to hear. It doesn’t seem to stop them. On a similar note, I often give extemporaneous harangues which can wax a little long about Maintenance of Certification (MOC) and Electronic Health Records (EHRs) and how I think they interfere with doctors’ efforts to improve their practice. I’ve noticed that sometimes residents seem to have difficulty stifling yawns when I talk about some purely clinical matters. They seem more animated during my tirades against the MOC and other bureaucratic numbskullery like the Clozapine REMS Program.

I suppose you could interpret that to mean that I must be more passionate (I’m probably a little comical, “Now you whippersnappers need to listen to a geezer…”) when I’m speechifying about what I think drags against a physician’s ability to develop the habit of reflective self-improvement from the inside out–which is the only way it can happen.

But there is no denying that incompetence exists in medical and psychiatric practice. I see it every day in some of the disasters that come to the hospital, often object lessons for residents about the dangers of psychiatric polypharmacy, and of not taking the time to make psychiatric diagnoses carefully and accurately before applying treatments, some of which can be toxic.

There must be individually tailored systematic approaches to improving safe and excellent medical and psychiatric practices and there must be some way for outside regulatory agencies to objectively verify that the approaches positively changes outcomes and are consistently and regularly engaged in by rank and file doctors.

The MOC is not measuring up and I hope young physicians continue to remind board executives that there must be better ways to help us improve which do not create suspicion that regulators are just in it for the money.

piggy bankBut I have to think about money if I want to retire. I’m thinking about it more because you don’t want to outlive your money. There’s more to life than money, though, and retirement can’t just be an escape from what I don’t like about my work. The Bogleheads are good at pointing that out.

I think it’s more fun to let doctors experiment with ways for us to learn and to teach the next generation of doctors. It doesn’t have to be boring.


Changing the way a bureaucratic regulatory organization operates has to be done carefully. I think it’s sort of like drying dishes. There is a hodgepodge of precariously balanced rules and practices which can result in breakage if we’re not aware and just reaching in and pulling stuff out. But just leaving things the way they are is unacceptable.

Kitchen sink - Copy

2 thoughts on “Meatball Psychiatrists Finding Ways to Improve

  1. Jim,

    Glad to hear that you are getting the mental set for retirement. My strategy is to think that for the first time on the past 30+ years I will be able to live a normal life. That means actually being able to do things in the daytime without taking PTO, not getting agitated for days to months about the latest administrative manipulation, and actually being able to worry more about the people in your family than people you have just met.

    I like the Meatball Psychiatry Concept. I can recall having to do 15 admission plus consults on a Saturday and working from 8AM to 1AM. The main thing that ate up my time was not the assessments but the documentation and billing. Unfortunately there is no Meatball Documentation – but I am a strong advocate for bringing it back. I have posted my experience as a 3rd and 4th year medical student on a busy neurosurgery team in the 1980s many times. Out note on 95% of the patients was “afebrile VSS” and that was just about it. The dirty little secret in medicine is that mountains of documentation for the purpose of billing codes is probably the largest single waste of physician time in this country.

    It also does not capture the fact that you probably know more about complex patients readmitted over time than you can document. Put that all in a paragraph after doing the assessment and call that Meatball Documentation.


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