Thoughts for Martin Luther King, Jr. Day

I’m sitting here still getting used to phased retirement. It’s a bit awkward, especially now that the Martin Luther King Jr Day is coming up here at The University of Iowa on Monday, January 15, 2018. That’s because part of the theme, which comes from a MLK quote is “Where do we go from here?”

It’s not just me wondering about where I go from here as my retirement approaches. It’s really more about what gave me a sense of purpose and meaning in my career in medicine, specifically in psychiatry—and how should I carry that forward in my life.

As Reverend King’s nephew, Isaac Newton Farris, Jr., put it, the MLK day is really about what I’m doing in the here and now for others. It fits right in with role as a physician.

It’s impossible not to begin by reflecting on what I’ve done and what I’ve not done—about which I would never bore anyone. But what comes to mind is a wish I’ll be forgiven for my mistakes.

I just finished reading the book Hidden Figures by Margot Lee Shetterly. It’s about the African American women who filled a labor shortage in the aeronautics industry by using their considerable skill in mathematics. It was a little hard for me to get used to the convention of calling them “computers,” but that’s what they were, back in the days before computers you plug in were invented.

One of the most compelling parts of the book was in the Epilogue, in which one of the women told the author how she felt about her job— “I loved every single day of it. There wasn’t one day when I didn’t wake up excited to go to work.” Those human computers didn’t want “…to stand out because of their differences; they wanted to “…fit in because of their talent.”

Okay, I can’t honestly say that I’ve loved every day of my work. In fact, there were a lot of days I dreaded going to work. I don’t think I’m the only one who has ever felt that way.

And they also expected that the society they lived in would improve, especially the feature of systemic racism. No one would argue that it’s gone. But it’s better, in part because of laws and policies that, as Reverend King put it in his speech, “The other America,” at Stanford University in 1967, didn’t change hearts but influenced behavior for the better.

Eventually, though, I believe the hearts of many changed. And so, it’s right to ask, “Where do we go from here?”

Which brings me back to what can I do to help others, especially in my role as a retiring psychiatrist.

Well, it may turn out to be that it’s more about what I can refrain from doing than what I can do. It’s pretty common for geezers to get in the way as they’re moving toward retirement. I offer too much advice; complain too much about the new ways of doing things and praise too highly the old ways; insist that my rule is the best or the only rule. This raises the issue of institutional memory (sometimes called institutional knowledge).

I gave a lecture to the junior residents a while ago about the importance of preserving institutional knowledge. I did that because sometimes it sometimes gets lost when a person retires. Much of it “…resides in the heads, hands, and hearts of individual managers and functional experts.”- “How to Preserve Institutional Knowledge” by Ron Ashkenas, Harvard Business Review, 2013. On the other hand, too much of anything for too long can be bad, including institutional knowledge.

I can think of one example of my institutional memory that I think is worth keeping, if for no other reason than food for thought. It’s the Janus head logo for the Academy of Psychosomatic Medicine (APM). This name will soon change to the Academy of Consultation-Liaison Psychiatry (ACLP).

The Janus head logo was used from about 1961 to 2011. I asked someone in APM administration a while back about why it was chosen and used for over 50 years before it was switched to something that is, well, pretty nondescript. No one knew.

Here’s what I think: Janus is the god of beginnings, gates, transitions, passages—crossroads, if you will. I think of Consultation-Liaison (C-L) Psychiatry as a sort of crossroads between medicine and psychiatry—mind and body.

And, as C-L Psychiatry evolves, I expect that relationship to evolve too. However, the shortage of psychiatrists in general, and of C-L psychiatrists specifically, still leads me to believe that George Henry was right when he said:

“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.”–George W. Henry, MD, 1929 (Henry, G.W., SOME MODERN ASPECTS OF PSYCHIATRY IN GENERAL HOSPITAL PRACTICE. Am J Psychiatry, 1929. 86(3): p.481-499.)

There was so much in Henry’s paper published in 1929 that still sounds current today. I can paraphrase the high points:

  • Practice humility and patience
  • Avoid psychiatric jargon
  • Stick close to facts; don’t get bogged down in theories
  • Prevent harm to patients from unnecessary medical and surgical treatment, e.g. somatization
  • “The psychiatrist deals with a larger field of medical practice and he must consider all of the facts.”
  • The psychiatrist should “…make regular visits to the wards…continue the instruction and organize the psychiatric work of internes…attend staff conferences so that there might be a mutual exchange of medical experience”
  • Focus on “…the less obvious disorders which so frequently complicate general medical and surgical practice…” rather than chronic, severe mental illness

The advantages of an integrated C-L Psychiatrist service (here I mean integrating medicine and psychiatry; mind and body) are that it increases detection of all mental disorders although that requires increasing the manpower on the service because of the consequent higher volume demand in addition to other requests, including but not limited to unnecessary consultation requests.

Further, what still astonishes me is the study which found that among consultee top priorities was an understanding of the core question (Lavakumar, M. et al Parameters of Consultee Satisfaction With Inpatient Academic Psychiatric Consultation Services: A Multicenter Study. Psychosomatics (2015). The irony is that the consultees frequently do not frame specific questions (Zigun, J.R. The psychiatric consultation checklist: A structured form to improve the clarity of psychiatric consultation requests. General Hospital Psychiatry 12(1), 36-44; (1990).

Moreover, it is sometimes necessary to give consultees bad news, as Lavakumar et al point out:

“There are situations in which a well-done consultation may require some level of disagreement or disappointment for the consultee.” “A consultant should have the courage and integrity to say, when necessary, what a consultee does not want to hear.”

This principle is applicable across many disciplines and contexts. And it is best delivered with civility.

How about manpower? One study concluded: In order to provide a minimum level of service for consultations to the expected range of serious and immediate psychiatric disorders present in the general hospital, a C-L service requires about 1.0 clinical EFT per100 beds. Holmes, A., et al. (2011). “Service use in consultation-liaison psychiatry: guidelines for baseline staffing.” Australas Psychiatry 19(3): 254-258.

An example is that one prominent eastern U.S. hospital has twelve C-L psychiatrists for a ~1,200 bed hospital while an outstanding mid-western hospital with ~700 beds has only one.

A former president of the ACLP said:

“A consultation service is a rescue squad.  At worst, consultation work is nothing more than a brief foray into the territory of another service…the actual intervention is left to the consultee.  Like a volunteer firefighter, a consultant puts out the blaze and then returns home… (However), a liaison service requires manpower, money, and motivation.  Sufficient personnel are necessary to allow the psychiatric consultant time to perform services other than simply interviewing troublesome patients in the area assigned to him.”—Dr. Thomas Hackett.

I don’t think it’s too much to expect things to improve. Speaking of improvement, Stephen Covey called it “sharpening the saw,” one of the 7 habits of highly effective people. For this, The University of Iowa Hospitals and Clinics C-L Psychiatry has the Clinical Problems in Consultation Psychiatry or CPCP. This was started by Dr. Bill Yates in the 1990s, and it was originally called Problem-based Learning.

“PBL…emphasis on the development of problem-solving skills, small group dynamics, and self-directed methods of education…most common types of problem categories identified for the conference were pharmacology of psychiatric and medical drugs (28%), mental status effects of medical illnesses (28%), consultation psychiatry process issues (20%), and diagnostic issues (13%)…PBL conference was ranked the highest of all the psychiatry resident educational formats.”

  • Yates, W. R. and T. T. Gerdes (1996). “Problem-based learning in consultation psychiatry.” Gen Hosp Psychiatry 18(3): 139-144.Yates, W. R. and T. T. Gerdes (1996). “Problem-based learning in consultation psychiatry.” Gen Hosp Psychiatry 18(3): 139-144.
  • Covey, S. R. (1990). The seven habits of highly effective people : restoring the character ethic. New York, Simon and Schuster.

I wrote more than I intended. Retirement probably won’t stop me from working on the answers to the question: Where do we go from here?