A Psychiatrist Looks at “Fiat Lux”

I’ve been ignoring the news for the most part in the last few days–lots of sharply polarized, adversarial content. I notice I feel a lot better. My habit is to read the news in the morning over coffee in my home office. But for the last couple of days, I’ve been sitting in my chair, not facing the computer.

This has given me a chance to notice a print on the opposite wall, “Fiat Lux: Ansel Adams, Trilogy.”

In addition to my observation for the first time since I hung the picture that it hangs crooked, the three images are more evocative than I’ve thought.

I know almost nothing about the history of the work, except that it was part of a huge anthology commissioned by the University of California at Berkeley in the turbulent 1960’s. The book was intended to encourage looking forward to the future of the University of California rather than looking back at its past. It was one of the biggest projects of Ansel Adams’s life. I wonder what happened to the option of being in the present mindfully and non-judgmentally?

Anyway, I don’t know how I missed it but the arrangement of the images suggests the extremes of emotions. The serenity of the beach contrasts with the storm cloud while the balance and symmetry of the tree in the middle is an expected resolution, suggestive of a dialectic.

Almost any psychiatrist might then think of Dialectical Behavioral Therapy (DBT). According to the Oxford English Dictionary, “dialectical” means “… the process of thought by which apparent contradictions are seen to be part of a higher truth.” In other words, we try to resolve and integrate opposite ideas or emotions into a different form, which will help us evolve, hopefully, into wiser and happier people. DBT is a form of Cognitive Behavioral Therapy and both can be very helpful for those who have trouble with regulating extremes of emotion and its consequences for relationships.

However, there can be dialectics for everyone in life. Not that everyone needs or should want formal psychiatric treatment, but reflection on the polarities, antitheses, and ironies across the lifespan can be a healthy thing.

For example, my view of myself as a Consult-Liaison Psychiatrist is gradually being eclipsed by my view of myself as a soon-to-be retiree. Almost anyone who is thinking about retiring or has retired will recognize the challenge in redefining one’s self at this stage in life.

You can view a lot of issues through the lens of dialectics. Often it seems like moving from either/or to both/and thinking is a transition that health care reform has needed for a long time. We often tend to ask questions like “Is it psychological or physical?” “Is it mind or body?” Pretty soon we might sound like we’re saying “Is it real or fake?”

Does that remind anybody of the news? Take a break from it for a while, and let there be light.

Fiat Lux Ansel Adams Trilogy
Fiat Lux Ansel Adams Trilogy

Vintage Geezer

I have a vintage calculator which is probably over 33 years old and running just fine on only its second set of batteries. It’s the Sharp Elsimate EL-505–with Auto Power Off mind you. I read an online article about it. It was written by someone who said it was listed on a website for vintage calculators. I didn’t see it mentioned anywhere. I guess to be vintage, something has to be at least 20 years old. Are there any other criteria?

I’m over twenty–slightly.

My wife uses it to balance the checkbook. Yes, we still use checks. I don’t use the scientific function, which reminds me of why I bought it in the first place. I had delusions of becoming an engineer at one time in my life. I got over it with only a few minor scars on my psyche, although they probably led to my going to medical school, which led to more scars but which I hardly notice. Doctors are very good at denial, especially psychiatrists.

I’m now a garrulous old fart of a psychiatrist in phased retirement, fooling around on this blog which will probably also be retired because I’m not sure what I’ll gas about when I’m not working. And just in the last couple of days there has been a outbreak of ads on my blog site which even WordPress Support staff agree is excessive and which  may hasten my hobby to the Vintage Home for Geezer Blog Sites.

For now they’ve been temporarily disabled while WordPress works on the issue and while they and I watch to see who blinks first regarding the Ad Policy which is driven by an incentive to purchase an upgrade to eliminate ads. The ads are not malignant but very distracting. The policy is fair and so is the price–I guess. However, I think stinginess should be respected. It arises from a need to pinch pennies which vintage people learn by certain experiences-experiences like working as a newspaper delivery boy.

Newspapers were made with a printing press, were made from paper and ink, and the ink got all over your hands when you read the paper. Guys like me used to pick them up on the dark street corners at 4:00 in the morning from a distributor who generally drove a an old station wagon loaded with newspapers, dropping them off on street corners for skinny newspaper boys to pick up, fold expertly, and deliver to people who often didn’t want to pay their bills when I came around to collect. Collecting was how I got the money in my early teens at this, my first job. Some people used to tell me the paper wasn’t worth a tinker’s damn. Years later, I read the news online and think the same thing.

I carefully counted out the money, which was mostly quarters. There was a kind of clubhouse where newspaper boys could go and buy stuff with their hard-earned cold cash. I bought an alarm clock with a glass face through which you could see the clockworks inside. I have never really needed an alarm clock since then. I just wake up, often at 4:00 in the morning.

Anyway, getting back to the vintage calculator, I think it’s surprising that in the last few days I’ve learned for the first time you could spell words on calculators. They’re not very interesting words and you have to turn the calculator upside down to see them because you need to “spell” them backwards with numbers that resemble certain letters when you see them backwards.

How’s that for teaching an old dog new tricks?

Blogging has been fun for me. I’m not sure how or what or if I’ll transition to some other writing when I retire from being a physician. I remember how much fun writing has been all of my life. I wrote little stories which I would read to my mother. I wrote my first “book” when I was in grade school. My teacher helped me make a little cover for it.

People who know I’m retiring ask me, “But what are you going to do?” I usually answer that I don’t really know yet. I read somewhere that one person’s reply was that she would enjoy her “unstructured time.” I suppose that’s sort of what retirement is like. Maybe it’s probably more accurate to say that retirees structure their own time instead of adjusting to the structure made for them by others.

Maybe instead of AARP, I could start a club called Retirees On Unstructured Time Efforts (R.O.U.T.E.)–maybe call it ROUTE 66 since many people retire in their mid-sixties. Membership would be free to all vintage people. Coming up with a new calculator word as an initiation rite would be optional.

I guess I better get this posted before the ads come back, like zombies.

World Delirium Awareness Day and QTc Prolongation Update

Today is World Delirium Awareness Day! And this is also National Patient Safety Awareness Week!

Here’s an issue relevant to both. As a psychiatric consultant in the general hospital, I get questions from colleagues about psychotropic drugs and cardiac conduction prolongation, often measured by the EKG parameter called the corrected QT interval or QTc. Relevant to delirium is the use of antipsychotics to help manage agitation. Although there is no drug for the treatment of delirium itself, there is often a compelling need to address severe agitation in patients who are delirious.

The delirious person can believe that health care personnel are trying to murder her, can see bizarre and terrifying visions, and can respond to these with violent behavior making it nearly impossible to treat the underlying severe medical conditions that led to the delirium in the first place. It is devastating for family members to witness.

While antipsychotics can sometimes be helpful to calm the agitation seen in delirious persons, there is a risk of torsades de pointes (TdP), which can lead to potentially deadly cardiac arrhythmias, making physicians cautious about administering drugs like haloperidol. I was just notified today of the latest issue of Psychosomatics, the journal of the Academy of Consultation-Liaison Psychiatry (ACLP). In it is a valuable update on this problem of QTc prolongation (see reference below).

We depend on the length of the QTc to tell us whether it would be dangerous to administer antipsychotics. However, the best ways to measure it are still being studied. I was amazed to see that the method a couple of trainees taught me and other learners in a CPCP about 5 years ago is still usable.

“Practically, it may be best and simplest to remember the standard QTc cufoff values of concern (like 500 ms) and simply do a wide QRS adjustment, such as QTc (wide QRS adjusted) = QTc – [QRS-100]. This simply normalizes the QTc as if depolarization were not prolonged. In other words, if because of ventricular pacing or BBB, the QRS measured 220ms, and the computer-derived QTc was 560ms (which was confirmed as accurate), then the “wide QRS adjusted QTc” would equal 560ms – [220-100] = 560-120 = 440ms.”

Patients with cardiac pacers and ICDs are probably relatively protected from TdP because it’s a very rate dependent phenomenon. Bradycardia and heart rate irregularity can raise the risk for TdP, which can be moderated by these cardiac devices. It’s also important to remember, though, that the presence of these devices indicates yet another risk factor for potentially dangerous cardiac events generally.

It’s important to be careful when using on line resources like CredibleMeds (which I typically use) because the “categories of risk are extremely broad.” The problem we run into is that many of the patients we typically see in the hospital already have at least a couple of medical risk factors for TdP, besides the medication-associated ones.

Understandably, the authors recommend more intensive cardiac monitoring when using antipsychotics for managing agitation in delirious patients, especially if using IV haloperidol. They recommend a pre-treatment EKG before starting an antipsychotic on a medical unit. Follow up EKGs are generally not necessary unless there is a change in clinical risk.

For all of the focus on EKG monitoring, the best advice according to the authors, is to be alert for other medical and medication contributors to the development of QT prolongation. I like their suggestion that psychiatrists refrain from recommending that our colleagues stop other drugs besides our “preferred” psychiatric agents. Collaborative negotiation about the safest things to do for our patients is always the best course.


Beach, S. R., et al. “QT Prolongation, Torsades de Pointes, and Psychotropic Medications: A 5-Year Update.” Psychosomatics 59(2): 105-122.
Background: Some psychotropic medications have been associated with prolongation of the QT interval and QT prolongation, especially in those with medical illness, and are linked to lethal ventricular arrhythmias, such as Torsades de Pointes (TdP). In 2013, we published a review of QT prolongation, TdP, and psychotropic medications.


Some psychotropic medications have been associated with prolongation of the QT interval and QT prolongation, especially in those with medical illness, and are linked to lethal ventricular arrhythmias, such as Torsades de Pointes (TdP). In 2013, we published a review of QT prolongation, TdP, and psychotropic medications.


We provide an update over the past 5 years on the specific concerns most relevant to clinicians who see medically ill patients.


In this nonsystematic review, we aimed to carefully and intensively identify new articles by utilizing a structured PubMed search from 2012-present.


QT prolongation remains an imperfect, though well-established marker of risk for TdP. Among antidepressant medications, citalopram does appear to prolong the QT interval more than other selective serotonin reuptake inhibitors, though the clinical significance of this prolongation remains unclear. Escitalopram appears to prolong the QT interval to a lesser extent. Haloperidol carries a risk for QT prolongation, but the assertion that intravenous haloperidol is inherently riskier may be confounded by its primary use in medically ill populations. Among atypical antipsychotic agents, ziprasidone—and possibly iloperidone—is associated with the greatest QT prolongation, whereas aripiprazole appears safest from this standpoint.


The evidence for clinically meaningful QT prolongation with most classes of psychiatric agents remains minimal. The most important risk-reducing intervention clinicians can make is undertaking a careful analysis of other QT risk factors when prescribing psychiatric medications.

World Delirium Awareness Day is Coming Like a Zombie!

World Delirium Awareness Day is coming like a zombie–and delirium will eat your brain! In keeping with upcoming World Delirium Awareness Day March 14, 2018, here are some oldies but goodies along with a reminders about special cases of delirium. First, a pretty good video summary of the basics which you can access from the American Delirium Society website:

Secondly, a free video about how to use the Mini-Cog to screen delirium. This was made by a couple of excellent UIHC Psychiatry residents a few years ago.

You don’t have to use a pre-printed Mini-Cog form, although they are useful. I usually like them because the circle is nice and big, making it easier to see what the patient draws. The instructions are simple and can be on a laminated pocket card:

The other thing to be alert for is the catatonic variant of delirium, the management of which can sound counter-intuitive. It involves administering the IV lorazepam challenge test to break the spell of catatonic stupor. Usually we try to avoid benzodiazepines in delirious patients because they can cause delirium. The exceptions to avoiding benzodiazepines are then: catatonia and alcohol or sedative-hypnotic withdrawal, the latter of which can itself cause catatonia.

You can find out more about medical catatonia and delirium in the Psychiatric Times article “Update on Medical Catatonia: Highlight on Delirium,” by J. Wilson, L. Denysenko, and A. Francis. It looks like you can get access to this article without logging in, which you could not do last year. Maybe that’s because the site is under new management. In any case, if you can’t, registration is free.

And there’s a nice slide set you can modify to meet your organization’s needs, available from the NICE guidelines.

There is no good evidence that antipsychotics of any type treat delirium per se. That doesn’t mean we let patients suffer from relentless agitation, fragmented delusions, and terrifying hallucinations, all of which can themselves lower quality of life and shorten life as well. It means we need to have a thorough discussion with families about the risks and benefits of using any kind of psychotropic drugs in the setting of delirium, especially antipsychotics. For the most part, multi-component non-pharmacologic methods are recommended. Remember, delirium is a zombie. It’ll eat your brain.


Neufeld, K. J., Yue, J., Robinson, T. N., Inouye, S. K., & Needham, D. M. (2016). Antipsychotics for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-analysis. Journal of the American Geriatrics Society64(4), 705–714. http://doi.org/10.1111/jgs.14076

Amos, J. J. (2012). “Lorazepam withdrawal-induced catatonia.” Ann Clin Psychiatry 24(2): 170-171.

National Patient Safety Awareness Week 2018

I saw Dr. George Dawson’s post about Dr. Michael Weinstein’s commentary entitled “Out of the Straitjacket” in the NEJM published on March 1, 2018. I agree that Dr. Weinstein’s experience is compelling and he specifically mentions burnout, a key factor critically important in his depression. Physician burnout fits with National Patient Safety Awareness Week, March 11-17, 2018. Burnout can lead to problems with maintaining patient safety, according to many sources one can easily find on a cursory internet literature search.

Physician burnout rates probably exceed 50% according to Shanafelt and colleagues (reference below). There are both physician-related and health care system-related factors involved in making doctors vulnerable to burnout. The systems factors probably don’t get enough press, although I found one well-written article about it by Markian Hawryluk, published February 22, 2018 on line in the BendBulletin, an Oregon newspaper. Hawryluk mentions a study which speaks to the relationship between burnout and patient safety:

“In a study of some 7,100 U.S. surgeons, burnout was an independent predictor of medical errors and medical malpractice suits. While the researchers said it was unclear whether burnout led to mistakes or the mistakes led to burnout, they concluded it was likely a two-way street. Burnout led to errors, which in turn fueled greater burnout.”

Physician burnout is one factor contributing to the shortage of psychiatrists, according to the NPR article “Severe Shortage Of Psychiatrists Exacerbated By Lack Of Federal Funding” by Samantha Raphelson, published March 9, 2018 on line.

The shortage is keenly felt across the Midwest, including Iowa, despite the recent listing in U.S. News and World Report as the best state in the nation for health. That said, the state medical and psychiatric societies are working diligently to generate solutions to the shortage and also are committed to addressing burnout. I’m eagerly anticipating the Match Day results coming this Friday, March 16, 2018. The University of Iowa Hospitals and Clinics typically does very well in the Match every year, including the Psychiatry residency. And I’m also wishing the new Psychiatry Residency programs well at Mercy Medical Center and Broadlawns in Des Moines.

The shortage of psychiatrists is likely to get worse before it gets better, according to Raphelson. That’s because of the graying out effect, which refers to the upcoming retirement of the 59% of us who are in the baby boomer age range.

There are organizational factors which can be addressed to manage burnout. As Shanafelt and colleagues point out:

“The evidence indicates that actions at the organization and individual level can counter a national problem. Substantive progress, however, is unlikely to occur until there is a coordinated effort to address this issue at the national and state, organization, leader, and individual levels.”

However, I think they don’t go far enough on the issue of Maintenance of Certification (MOC):

“Organizational policies that require physician maintenance of their certification must be accompanied by appropriate allocation of professional time for physicians to complete these tasks.”

I have zero time for the empty busy work of MOC, as anyone can clearly see from my post about a day in the life of a C-L Psychiatrist. And I refuse to allocate “pajama time” to it, which means even more time at home working on medical documentation (see the Hawryluk article):

“And every hour spent at home on work-related tasks — a phenomenon doctors call pajama time — increases the risk by 2 percent” [of burnout-J.A.].

There is plenty to do for Patient Safety Awareness Week–fifty two weeks a year.


Shanafelt, T. D., et al. (2017). “Addressing Physician Burnout: The Way Forward.” JAMA 317(9): 901-902.

World Delirium Awareness Day 2018

I just received a message from Professor Luisella Magnani with her contribution to the upcoming World Delirium Awareness Day 2018:

As a Consultation-Liaison Psychiatrist, I see delirium every day. Every physician and allied health care professional should be aware of the myths about delirium and how to counter them:

There are numerous ways to participate in raising awareness about delirium. One of the ways we did it at the University of Iowa Hospitals and Clinics in the past was to make educational screensavers:

There are delirium prevention teaching materials available like the one a former resident made here:

You could take a stab at explaining step by step Dr. Jose Maldonado’s picture of the potential treatment targets for delirium:

It is just that easy!

OK, so maybe it’s not that easy. The point is there are a lot of ways to assess, manage, and conduct research on this acute brain injury.  We can do this every day.

“Knowing is not enough; we must apply. Willing is not enough; we must do.”–Johann Wolfgang von Goethe.

A Day in the Life: A Consultation-Liaison Psychiatrist

In the last couple of days while I’ve  been trying to update the broken links on my blog, I’ve been thinking about what my “typical day in the life” is like as a consultation-liaison (C-L) psychiatrist. I’m taking a break from the broken links to outline my typical day on the job. I can reflect on it more because I’m in phased retirement and actually spend less time working. Times are approximate and won’t account for every minute.

4:30-5:30 AM

I have a light breakfast and check the consultation list from home using remote access. This gives me a sense of where to prioritize my time, usually the critical care units. The number of consultation requests and what my consultees may be expecting from me is important to know ahead of time. I have access to the electronic health record (EHR) folder listing the new consultation requests. It sometimes makes me look clairvoyant to the trainees.

I check to see if there are any open beds on our general psychiatric units and the medical-psychiatry unit. Most of the time there are none. I note the yellow warning messages about the emergency department (ED) and general hospital beds being full and the need to safely expedite discharges. I resist the development of alarm fatigue.

I look over EKG results to see who already has a prolonged QTc interval, which will influence a decision to use antipsychotics for agitation. I check the lab values to see who might need transfer to the medical-psychiatry unit. I look over any consultation notes left by the residents who were on call overnight and which I will need to edit, make comments, and co-sign after I’ve interviewed the patients.

I look at the Medication Administration Record to see what medications the patients are actually getting, and compare it to the Pharmacy Medication History note, which lists what the patients are prescribed.

I check the demographics information about any family contacts (Legal Next of Kin) of the patients. I also check our scanned media file for records documenting guardianship or Durable Power of Attorney for Health Care Decisions. That’s where I can find other legal paperwork including mental health commitment papers which alert me to involuntary treatment status.

I check PubMed for any pertinent articles which would guide my recommendations about complicated medical and psychiatric issues. I make a mental note of anything that might be a good topic for a Clinical Problems in Consultation Psychiatry (CPCP) practice-based learning opportunity. It’s getting harder to find time for them as the service has gotten steadily busier over the years. I’m ambivalent about using a PubMed app for my smartphone. The abstracts are hard to read on such a small screen. On the other hand, I think it’s important to ask focused questions when consulting the evidence based medical literature.

I look for Social Work notes which are often the most helpful source of background information about the patients I’ll be seeing during the day.

I look over my consultee’s History and Physical and Progress Notes. I take a quick look at the Physical and Occupational Therapy Notes. I look for Neuropsychology testing results.

8:00-8:45 AM

I round with the trainees, often a couple of residents and a couple of medical students. We discuss the patients we need to see in enough detail to work out who we need to see right away and anticipate who might need to be transferred to a secure psychiatric unit.

I go over some of what I usually do to assess delirium, suicide risk assessment, and decisional capacity assessments–but this often gets interrupted by calls for new consultations or Code Greens. A Code Green in the general hospital or med-surg clinic, or the ED is a crisis involving a patient who is potentially or actively violent and needs immediate attention from a dedicated pit crew of nurses, the C-L Psychiatrist, and others in order to manage the issue as safely as possible.

I can usually manage to give quick instructions about the Mini-Cog for evaluation of delirium, the suicide safety plan, and the bare bones of the 4 Abilities Model of decisional capacity assessment before we get called to put out a fire somewhere in the hospital. I also mention how frequently I find patients who are demoralized from their medical problems. They are the ones who nod vigorously in agreement when I ask they if they are “sick and tired of being sick and tired.” I have a few handouts some of which can be used as assessment tools.

We decide whether the number of consult requests for the morning allow us to visit the patients as a group (which I prefer) or if we need to divide and conquer. It isn’t the raw number of consultations that dictates the approach–it’s the level of difficulty.

8:45-11:30 AM

The pager goes off, sometimes incessantly as we rush around the hospital, usually without using the elevator. That’s just an idiosyncrasy of mine and I don’t insist everyone take the stairs just because I do. It’s the only exercise I get anymore and that’s my justification.

I bring my chair with me and the patients get a big kick out of this. It was a gift to me from Dr. Tim Thomsen, who spent a lot of his own money on buying a few for his Palliative Care service. I will always be grateful for his generosity.

We get about 15-20 minutes with each patient but there’s wide variability in how much time we spend with them. Our interviews are often interrupted with pages to go hither and yon. That’s what it’s like to be a smoke jumper on a one man hit-and-run C-L Psychiatry service.

11:30-12 Noon

Time to grab a working lunch and I usually take the resident’s pager at least 3 days of the week so they can attend lectures and Grand Rounds. I confess I usually don’t have time to go to Grand Rounds and I tell the residents who ask me if I’m going, “Somebody’s gotta mind the shop.” I would just get paged out anyway on most days. During this time or shortly before, I complete any legal paperwork and run errands to the business office for processing them. This has to be done before the day gets too far gone because the county courthouse closes early most days anymore.

12 Noon-5:00 PM

This can be the busiest time and we can be paged right up until just before 5 PM. Usually, there’s a late page around 4 PM or a little later. This not uncommonly is a urgent call and may entail getting an Emergency Hold order which we can’t get until after 5:00 PM because the courthouse closes by 3:00 PM.

There is no schedule per se. The pages are unpredictable. It’s almost impossible to plan for any other activity, which is why I appreciate the supplementary C-L Psychiatry lectures made by the Academy of C-L Psychiatry (ACLP). I’m not sure how often the residents view these outstanding powerpoint presentations, mostly because I’m always on the move. I check my pedometer, which usually looks like the one below.

At the end of each day, I practice mindfulness meditation, something I’ve been doing since the summer of 2014. That’s a quick and dirty example of a day in the life of a C-L Psychiatrist, at least for me. It doesn’t include everything I do, but it’s a pretty fair idea.