A Change is Gonna Come

I’ve been bad again, talking out of school and passing email messages that are too long and not paying any attention to the rules of the core group on communicating about the delirium prevention project.

One of the members suggested we use the mini-cog as a cognitive test to identify patients who might be at high risk for delirium. The mini-cog is a simple test I’ve mentioned in another blog. It is to be used alongside of the Confusion Assessment Method (CAM) since the CAM by itself doesn’t include a test for cognitive disorganization. It has a little memory test and a clock drawing task as well as orientation questions in it. A nurse could do it and it’s quick. I carry a laminated copy of the mini-cog and the CAM in my coat pocket[1, 2].

I’ve talked about the clock drawing task in a previous blog and described it as sort of a trick I use to persuade physicians who consult me that delirium is the problem with their patient, not depression, anxiety, or mania. The clock drawing task was not really designed for screening delirium; it’s actually a test for dementia. But many psychiatric consultants like me use it to yield a quick, graphic way of teaching doctors and nurses about delirium.

I liked the suggestion to use it, but I was also saddened because I had worked with a neuropsychologist and her research assistant on using another more sensitive cognitive test to check for subtle cognitive impairment. It was the Coding task, a quick subtest included in the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). You may have seen the exchange between me and Dr. Burgard in the comment section of a recent blog about it. That conversation was the beginning of the end for an ambitious plan to try an innovative way to assess subtle cognitive assessment in order to select patients for screening with the CAM or the CAM-ICU. The assumption is that those patients would be at higher risk for developing delirium and that may be a target population for delirium prevention interventions.

I was saddened because I felt like I had to give up on using the Coding task because it would probably add too much time to screening tasks for nurses, making it less likely to be a sustainable strategy in our delirium prevention efforts. I was sad because research by this same neuropsychology team has shown it to be a predictor for delirium in a sample of bone marrow transplant patients. The research assistant used good arguments in defense of keeping the Coding task in the game—but I got too many dissenting opinions about the risk of frustrating nurses with extra tasks.

These are the inner gears I’m seeing in the delirium prevention program machine. My colleague’s suggestion about using the mini-cog made me a little wistful because the CAM-ICU by itself probably underrepresents the construct of delirium. I suspect the mini-cog would be an inferior substitute for the Coding task.

But change is coming, especially if the kind of thinking that I see continues to flourish. Change is slow and I’m impatient, I know. But a “change is gonna come” Playing For Change | A Change Is Gonna Come. I’ve been here in this academic center as a medical student, resident, and staff psychiatrist for going on 23 years and I see change coming in the way we think about delirium—finally.

1.            Inouye, S.K., et al., Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med, 1990. 113(12): p. 941-8.

2.            Borson, S., et al., The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 2000. 15(11): p. 1021-7.

Hogan’s Heroes and the Delirium Project Committee

Remember the 1960s TV sitcom Hogan’s Heroes? I suppose mostly baby boomers would recollect the show about the exploits of 5 main prisoners of war in Stalag 13 during World War II. They were Hogan, LeBeau, Newkirk, Carter and Kinchloe. Their prisoner of war status was just a cover for their sabotage of the German war effort using a variety of clever communication devices and secret tunnel systems which allow them almost unlimited access to cash, travel, and uniforms.  Of course the enemy was portrayed as gullible and incompetent, like Sergeant Schultz (“I see nothing, nothing!”), and camp Kommandant Klink (“No one has ever escaped from Stalag 13!).  The heart of the show was the byzantine but unfailingly effective ruses the prisoners created and enacted to be successful in their missions. In fact, everyone escaped from Stalag 13 through the elaborate underground railroad-like system of tunnels and outside contacts.

So that you don’t think I’m minimizing the horrors of WWII, the Stalag 13 TV episodes were not based in a POW camp styled after those run by the SS or Gestapo. The prisoners invariably won the day in the end. I don’t recall anyone getting even slightly bruised.

Sometimes I have a little daydream about being as clever, resourceful, and powerful as Hogan’s Heroes. Hospital organizations and committees can be stifling occasionally in my opinion. And it’s challenging to be patient enough to let the wheels grind slowly. In my heart of hearts I believe in the careful and considered approach that the delirium project committee is taking. And I would never undercut it just for the sake of speeding things along. If I did that, there’s a real chance that patients and families, doctors and nurses, and hospital administrations would not be well served in the long run. Still, we need to think both/and about the complementary roles of spirit and structure in program development.

There’s no denying I have a problem staying in my own backyard, which leads to the occasional smack-down from my collaborators. Part of the reason for that is the nature of my job as a psychiatric consultant in a large academic medical center. It’s basically crisis management. Our consult service is a fire brigade, putting out minor and major behavioral conflagrations around the hospital. I learned to do medication management and meatball psychotherapy on the run because I had to. There was no sit-down, classroom, or mentoring service available to prepare me for the jungle. Like many consultants, I had to use my own ingenuity and wits to make up solutions on the fly. My team, consisting of me and a few trainees, is a hit and run movable feast in that I can’t keep my head down because I’m so visible. People take bites out of me in the hall, on the ward, in the lobby, and I have long ago given up trying to make it to conferences because I have no schedule. It’s a miracle I can even make to delirium project meetings.

Ironically, the reason my days are so hectic is because I’m so frequently asked to evaluate what doctors think are cases of depression, anxiety, mania, and psychosis—but which turn out to be cases of delirium more than half the time. Medical students and resident physicians get to see this several times during their rotation on the consult service when I’m on duty (which is most of the time). When a consulting physician (often a resident) is trying to tell me that a patient is behaving oddly because they’re manic or depressed, I pull out my crude clock-drawing task I administered while I was interviewing his patient and show it to him. It’s usually a mess, indicating the patient’s profoundly impaired cognition pointing to delirium being the real problem. It’s a lot like pulling a rabbit of a hat. Everyone gets to see the resident’s usual reaction: jaw drops, eyes dilate—and he shuts up.

A light goes on. It’s a neat little show but it’s time for something more systematic and scientific, automated, and smarter so that someday I won’t continually have to run a dime store magic act, fun as it may be sometimes.

No wonder I’m having trouble getting used to committees. I’m geared for dramatic, mobile, top speed, thin-slicing, commando MacGyver-style guerilla operations while committees sit down at scheduled meetings and define, measure, analyze, improve, and control using tools I’ve never heard of like Gantt Charts, FMEA Analysis, Pareto (isn’t that a chicken spice?) and SWOT Analysis.

I’m used to a different kind of SWAT team.

That’s why I sometimes get a little impatient and fire off a few rounds into the air or smuggle a few educational pearls out of the camp under Kommandant Klink’s nose.

I hope I may be forgiven for it.

Multicomponent Methods in the Prevention of Delirium

There are many ways to prevent and manage delirium without using drugs. These often form the multicomponent method treatment of delirium. They can be used in lieu of medication, which would usually be antipsychotic, or alongside of it. Another medication issue is to ensure that exposure to medications known to cause delirium be minimized or prevented. This would include but not necessarily be limited to sedative-hypnotic, e.g., Lorazepam and its cousins, and anticholinergic agents. Multicomponent methods have been shown to prevent delirium and there’s good evidence to support the use of hospital-based multicomponent preventive strategies[1]. The list is long, and the one below is taken from William Breitbart’s paper[2]. Its part of a Palliative Care consultation note recommendation set at our hospital.

“Non-Pharmacologic treatment of delirium, focus on a non-stimulating environment for most of the day, with episodes of stimulation. This of course is difficult in the ICU, but the stimuli can certainly be reduced.

  • Minimize the use of immobilizing catheters, intravenous lines, and physical restraints
  • Avoid immobility, early mobilization
  • Monitor nutrition
  • Provide visual and hearing aids
  • Monitor closely for dehydration
  • Control pain
  • Monitor fluid-electrolyte balance
  • Monitor bowel and bladder functioning
  • Review medications
  • Reorient communications with the patient
  • Place an orientation board, clock, or familiar objects (i.e., family photographs) in patient rooms
  • Encourage cognitively stimulating activities such as word puzzles
  • Facilitate sleep hygiene measures, including relaxation music or tapes at bedtime, warm drinks, and gentle massage
  • Minimize noise and interventions at bedtime, e.g., by rescheduling medication times”

Whose role is to implement the multicomponent measures? Imagine we live in an ideal world and we’ve managed to implement a screening tool to assess delirium in hospitalized patients, say the Confusion Assessment Method-Intensive Care Unit (CAM-ICU). This would be implemented by nurses, preferably once per shift. This is yet another task we’ve added to their already tight schedules.

So we’re probably not going to ask the nurses to implement all of the multicomponent measures. Should I ask Occupational Therapy (OT) staff to take charge of these? Only if I’m sure I can outrun them.  Most hospitals have few OT staff and they’re also extremely busy. How about Physical Therapy (PT)? How about a knuckle sandwich? PT personnel are stretched so thin you can see through them. Can I ask the resident physicians? By all means, if I could wake them up; most of them are post-call and delirious themselves. Could medical students manage some of these tasks? They certainly could, though this could be hard to generalize to many hospitals not associated with medical schools.

The Hospital Elder Life Program (HELP), copyrighted by Dr. Sharon Inouye at Yale, uses volunteers (many volunteers) for their multicomponent program, which has elements similar to the list above and which forms the main part of delirium prevention at that institution. They offer assistance to those who want to start a HELP chapter, but caution that success at preventing delirium and reducing hospital costs requires close fidelity to the Yale program because adherence is critical, by itself providing an independent, graded protective effect against delirium[3]. Volunteers have to commit themselves to a minimum of one 4 hour shift per week for 6 months. The training is intensive with a 16 hour didactic group followed by 16 hours one-on-one training with patients. Following that there are quarterly competency-based checklists. Retention is maintained by daily staff communication, quarterly education and support sessions, a monthly newsletter, and incentive awards (no mention of whether chocolate is involved)—this material acknowledges (as required by copyright law) The Hospital Elder Life Program (Copyright, 2000. Sharon K. Inouye, M.D., MPH).

I’m not sure where we could find that many volunteers, but hang on…is there another way to look at the multicomponent list, which is daunting at first glance. Would it make sense to consider the personnel accountable for a delirium project as members of a team? Is it necessarily true that one person or even one department should be responsible for the whole list?

For example, if we chunk the tasks, could they be divisible into team-specific categories?


  • Monitor nutrition
  • Monitor bowel and bladder functioning
  • Reorient communications with the patient
  • Monitor closely for dehydration
  • Place an orientation board, clock, or familiar objects (i.e., family photographs) in patient rooms
  • Facilitate sleep hygiene measures, including relaxation music or tapes at bedtime, warm drinks, and gentle massage


  • Minimize the use of immobilizing catheters, intravenous lines, and physical restraints
  • Control pain
  • Monitor fluid-electrolyte balance
  • Review medications, and minimize noise and interventions at bedtime, e.g., by rescheduling medication times

Occupational Therapy:

  • Provide visual and hearing aids
  • Encourage cognitively stimulating activities such as word puzzles

Physical Therapy:

  • Avoid immobility, early mobilization

You can divide the tasks other ways, depending on what people are comfortable doing and job descriptions. The emphasis is on ease of administration and flexibility of stakeholders as to who does what and when.

I’m perfectly free to puff on my pipe dream in a blog, and I’m slowly learning (with gentle reminders) that trying to email group members about these ideas would be off-putting because the messages would be far too long. And I’m afraid the Sharepoint idea is not working out as I’d hoped.

Like it or not, I’m going to have to get used to waiting for meetings.


1.            Holroyd-Leduc, J.M., F. Khandwala, and K.M. Sink, How can delirium best be prevented and managed in older patients in hospital? CMAJ, 2010. 182(5): p. 465-470.

2.            Breitbart, W. and Y. Alici, Agitation and Delirium at the End of Life. JAMA: The Journal of the American Medical Association, 2008. 300(24): p. 2898-2910.

3.            Inouye, S.K., et al., The Role of Adherence on the Effectiveness of Nonpharmacologic Interventions: Evidence From the Delirium Prevention Trial. Arch Intern Med, 2003. 163(8): p. 958-964.

Spare the Whip

The Delirium Early Detection and Prevention Project is essentially a committee and everyone knows the reputation committees have. Our facilitator is trying to use principles of group productivity mavens and we kept the number of the members down to seven. Others think 15 is the limit. Larger groups tend to form, which may break into sub-groups which lose too much time communicating rather than developing. However, if the group produces more consistent results, they may omit features or miss ideas that they’re unaware might be both innovative and practical. One solution is to create a broader circle of interested people around the main nucleus in a public mailing list, according to World Wide Web Consortium (W3C) an international community where member organizations, full-time staff, and the public work together to develop Web standards. This idea is on the web, in fact at Design by committee (An essay on W3C’s design principles). Read the rest of the essay only if you’re tired of living because there are a lot of computerese-type neologisms that can make your head spin, like maintainability, modularity, extensibility, learnability, implementability, internationality, and it looks like they’re taking them seriously.

I’d never heard of the W3C until today when I thought of how much our group resembles a committee, which I admit is a bad word in my vocabulary. The skeptical way I view committees, I tend to see us as getting snared in the net of making meetings, and protocols for effective meetings, and schedules, and Outlook Meeting Planners, and charters, and so on.

I tried to remember what one of my teachers said to me way back when at Huston-Tillotson College in Texas—“Brother Amos, patience is a virtue”.

Patience stepped out for a moment, and will return after a short break.

What seems to be evolving here is something like the W3C two level committee consisting of the nuclear small group, and a wider hospital network that I instigated mainly because of my impatience with progress in the core group—which is probably a mistake.

It’s really more like 3 levels. I tend to see the nuclear group being stalled and I forget that members have other priorities. Hey, it’s a small group of professionals who are definitely committed to the success of the Delirium Prevention Project—and who juggle a variety of other responsibilities. And there’s a wider circle which I’ve tapped into which could provide a useful perspective on practical implementation issues, but which may also just get in the way. And that may communicate something I don’t intend to the core group.

Then there’s the third level, which I’m going to call the “whip”. In politics, a whip’s role is to ensure party discipline in a legislature. They are enforcers. The other meaning comes from the hunting term whipping in, referring to preventing hounds from wandering away from the pack. You can probably see where I’m going with this—and now I can see too.

Some like me as the whip. Others probably do not. There’s a critically important lesson for me here and I’m learning it slowly. Finding the middle ground will entail my accepting the natural order of things, slow as they may seem from time to time.

There may be role for sparing use of a whip. On the other hand, there’s probably a lot to be said for sparing the whip.

Don’t Reinvent the Wheel When it comes to Delirium Prevention Projects

I know we’re behind in the delirium prevention initiative business, but that may not be a bad thing. I found a WordPress post dated December 7, 2010 that describes a delirium prevention program in the United Kingdom entitled NICE Clinical Guideline CG103. Delirium: Diagnosis, Prevention and Management. You can find a summary of the aptly named NICE guidelines at Diagnosis, prevention, and management of delirium: summary of NICE guidance — Young et al. 341 — bmj.com[1].

What I like most about the guidelines is that they’re free as well as evidence-based. You can grab pdf and PowerPoint files from the website at Delirium and the link is on the right hand side of this page. You can edit the educational slide sets to fit your organization’s needs. For example there’s a slide with only general guidance about how to screen for delirium using the CAM, the CAM-ICU, or the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The guide says only that you’ll need a trained healthcare professional to conduct the screening examination. I disagree with one of the recommendations about giving Olanzapine to patients with delirium in order to manage behavior. It has been shown to worsen delirium in some patients and even Larsen’s controlled trial of Olanzapine in delirious patients showed a tendency for delirium to be worse in severity in those who were given this atypical antipsychotic despite the much touted result of lowering the incidence of delirium[2].

Using these materials, groups should be able to at least educate stakeholders about delirium in a way that is probably at least as effective as what leaders elsewhere have been doing on their own for at least the last 10 years. One of those is Dr. Jose Maldonado, M.D. at Stanford (remember his hilariously complicated slides about the neurobiology of delirium on January 4, 2011?). An excerpt from a Psychiatric New article in the June 1, 2001 issue says about his educational program about delirium[3]:

The nurses on the ICU and the main medical and surgical wards attend a two-day seminar that consists of lectures, case presentations, and a test at the beginning and end of the seminar. In addition, the subgroup of nurses specializing in caring for patients with delirium participate in a 12- to 16-hour practicum.

Once they complete this practicum, the nurses return to their units, where they present educational programs on delirium to the other nurses on their units.

To educate physicians about delirium, Maldonado presents six grand rounds at the beginning of the academic year. In addition, he educates internal medicine residents about delirium while they rotate through the consultation-liaison psychiatry service.

Maldonado and his colleagues conducted a study on these initiatives and found that before his program was implemented, only about 30 percent of the nurses and 12 percent of physicians at his facility accurately diagnosed and treated delirium. Now, the nurses recognize delirium 100 percent of the time, and the medical staff does so 60 percent of the time. “Consequently, these patients have shorter hospital stays, fewer complications, and require less treatment. This could amount to a projected savings to the hospital of approximately $30 million annually,” said Maldonado.

Creating and presenting the content of what’s known about delirium prevention and management is probably not as difficult as changing the culture of the institutions in which we work. Those we work with have to be above the contemplation stage of readiness to change. Changing the culture involves helping others learn to at least think of delirium first when assessing patients. One way is to create colorful reminder cards like the copyrighted one below[4]:

Remember to think about delirium

This one is called the Delirium Alert Protocol (DAP). Isabel Higgins tried a “partnership approach” to get stakeholders actively involved in becoming more aware of delirium as a critical problem in hospitalized patients. The language is exciting because the focus is on “participation and democracy” empowering stakeholders to tackle “practical issues” and put “knowledge in action”. The details about the specifics of her group’s approach are difficult to discern but in general Participatory Action Research (PAR) involves stakeholders systematically working together in groups in cycles of “looking, thinking, and acting to bring about practice change”.

The approach reminds me a little of what a Sociology professor at Huston Tillotson College in Austin, Texas back in the ‘70s encouraged us to do at the Austin City Police Department in order to bring about change in the way the local police were perceived to mistreat black people in the neighborhood. It’s a way to break inertia. One of the quotes from the participants sound a little like the “change talk” that we like to elicit from patients when we use a motivational interviewing style in order to move them along the readiness to change scale toward a willingness for and action toward giving up alcohol or monitoring blood sugars:

I’m not saying we get it right all the time, but we’ve kind of got a bit of idea about what we can do, how we can do it. I think the whole prevention thing is identifying these risk factors in our daily practice, is really important.

I think the key is persuading every stakeholder that delirium prevention programs are “really important” by pointing out we’re all accountable for delirium, a medical emergency that kills our patients.

1.            Young, J., et al., Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ, 2010. 341: p. c3704.

2.            Larsen, K.A., et al., Administration of olanzapine to prevent postoperative delirium in elderly joint-replacement patients: a randomized, controlled trial. Psychosomatics, 2010. 51(5): p. 409-18.

3.            Lipton, L. (2001) M.D.s Tackle Untreated Delirium to Save Lives. Psychiatric News Volume 36, 18-29

4.            Higgins, I., The detection & prevention of delirium in acute care: an evaluation of the uptake & utility of guidelines by health professionals 2005: Newcastle.

Which Cognitive Test Should We Use with a Delirium Screening Instrument?

The questions about the delirium project yesterday were helpful to sharpen my thinking about what we’re doing and why. It’s that kind of feedback that helps move us forward.

The question of what cognitive test to use is not trivial as I pointed out. The Modified Mini-Cog Test is a combination of the Clock Drawing Task and some orientation and memory questions. It’s generally used with the Confusion Assessment Method (CAM). The clinician doing the assessment has to remember to conduct the Modified Mini-Cog, which can facilitated by making laminated double-sided reminder cards with the CAM on one side and the Modified Mini-Cog on the other. The pocket cards can be downloaded from the internet and laminated. They have Dr. Sharon Inouye’s reference and the reference for the Modified Mini-Cog Test printed on them as well [1, 2].

The Confusion Assessment Method for the ICU (CAM-ICU) incorporates questions assessing cognitive disorganization into the delirium assessment itself [3]. A nice feature is that inattention, one of the required symptoms to identify delirium, has a specific test called the Attention Screening Examination (ASE) to see if the patient can signal when the examiner says a specific letter from a list of letters, for example, the letter “A” from SAVEAHAART. The visual version of the ASE uses pictures, which are available from Vanderbilt University Medical Center. You can also assess disorganized thinking from the CAM-ICU using yes/no questions, e.g., will a stone float on water or does two pounds weight more than one pound?

The Richmond Agitation and Sedation Scale (RASS) is commonly used with the CAM-ICU and it’s a sedation assessment scale ranging from +4 (combative) to -5 (unarousable). That adds a little more complexity and time although not that much.

What about the innovation in the cognitive test that our group proposes? This rests on research in delirious bone marrow transplant patients. The decision to supplant the cognitive tests in the CAM and the CAM-ICU with the Coding Task, a subtest in the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was suggested by results found on RBANS subtest results in this population. These tests identified cognitive impairment early on after bone marrow transplantation, tending to mark those who later became delirious. Because the goal is to identify at risk patients earlier to allow prevention of full-blown delirium, we thought this might be a strategy that would ultimately help patients faster.

Now the plan is open to criticism as Dr. Burgard pointed out. Is the Coding Task a test that a non-neuropsychologist can administer? My colleague in neuropsychology says yes. The goal is to identify cognitive impairment early using the Coding Task. The question is how often to use this as a screen. I would probably not administer it every shift with the CAM. It could be a one time screen at admission to the hospital or in addition to that maybe once a day.

No one has ever suggested you can screen for delirium or rate its severity without some kind of cognitive test. I don’t believe there is an established, well-validated and quick cognitive test that would be preferred above others. Delirium is a cognitive disorder and administering tests that can detect cognitive troubles early before full-blown delirium develops seems like a good idea.

I welcome your questions and comments.

1.         Inouye, S.K., et al., Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med, 1990. 113(12): p. 941-8.

2.         Borson, S., et al., The mini-cog: a cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 2000. 15(11): p. 1021-7.

3.         Ely, E.W., et al., Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA, 2001. 286(21): p. 2703-10.

Preserve and Protect Integrated Care

One of the resident physicians told me that the hospital where she did part of her early training closed down its medical-psychiatry unit—at the insistence of the Chief Executive Officer (CEO), because the unit was losing money. I was astonished to hear it. Based on our experience here at our academic medical center, I suspect the CEO would be tarred and feathered before he’d get the words “close the unit” out of his mouth.

I just assumed that once a hospital established a Complexity Intervention Unit (CIU), which is the preferred name for them nowadays, physicians and nurses become dependent on them to provide integrated medical and behavioral health care for patients with complex comorbid medical and psychiatric diagnoses as well as other complicated issues such as access to health care. I would be willing to bet if we surveyed our clinicians here, there would be almost unanimous support for our 15 bed CIU with telemetry capability.

But it didn’t save one at least one CIU with comparable capabilities from the chopping block, and that’s troubling.

I also got an email from a Psychosomatic Medicine fellow who is finishing her training and interviewing for employment at various private practice and academic medical centers. She’s afraid that at least one of the organizations where she interviewed, structural and cultural factors, including too much of a focus on the bottom line, would probably not allow her to provide integrated care in the way she envisions.

It might be instructive for hospital CEOs and other health care organization administrators to learn a little more about how to make integrated inpatient and outpatient care systems profitable.

One of my introductory slide sets for trainees and staff who are just beginning to work on our CIU contains essential information, starting with the following quotation:

“The body and mind function as a unit. To approach treatment of either in isolation is a disservice to those suffering with comorbid conditions and a financial catastrophe to those who have to pay for it” Roger Kathol, MD

Dr. Roger Kathol is a former teacher of mine and an internist and psychiatrist with medical management credentials. He has well over 25 years of experience as a physician board certified in both internal medicine and psychiatry providing hands on integrated clinical care to complex patients at the University of Iowa; 2 years experience integrating mental and medical health business practices at Blue Cross Blue Shield of Minnesota; and 12 years experience assisting hospitals and clinics, health plans, employers, government agencies, and care management organizations and vendors integrate services for their constituencies.

The blurb about him at the website for his company Cartesian Solutions (Cartesian Solutions – Home Page) describes him as the “Innovative health strategist who has extensive experience in the development of integrated programs and systems for patients with health complexity, many of whom have concurrent physical health and mental health/substance use disorders (mental conditions). His background ideally positions him to assist stakeholders in the health care industry to create integrated physical and mental condition solutions which improve care quality, augment clinical outcomes, reduce impairment, and lower total health care and health-related costs”.

If you ever met Roger, you’d know immediately that the above-mentioned attributes are not exaggerations. Whenever I think of him I’m reminded of what an effective teacher and charismatic leader he is. I remember him discreetly letting me off the hook one morning on rounds in the CIU when I was a junior resident in psychiatry. I was expected to give a short talk on electrolyte abnormalities but I was post-call and had dealt with 4 admissions along with numerous crises the night before. I had not hit the sack all night, which was a routine call experience for many residents then.

There is something about the bedraggled, unshaven, exhausted appearance of a post-call resident that must trigger sympathy. I saw one recently as he fell in and out of awareness in front of me as he struggled to give report on a patient he had taken care of overnight. I must have looked something like that to Roger and even though I had my index card with my notes on it, he skipped over me as he pimped (a form of socratic questioning which when done skillfully elicits knowledge from trainees which they were unaware they had and when done poorly is simply a form of verbal abuse) the other residents around the table.

Roger knew delirium in a post-call resident when he saw it, for which I will always be grateful.

My slide set borrows heavily from Roger’s book, Healing Body and Mind: A Critical Issue for Health Care Reform[1]. The slide about the consequences of rising health care costs leading to managed care in the 1980s era for example notes:

  • “Disintegrated Care”
    • Medical Care Organization (MCO) v. Managed Behavioral Health Organization (MBHO or carve-outs)
    • MCOs and MBHOs separate and unequal organizations and funding sources with disastrous consequences for patients with concurrent medical and psychiatric illness
    • Fostered the evolution of lack of shared accountability of non-psychiatrists and psychiatrists for both medical and psychiatric illness
  • “Integrated Care”
    • Recognizes the interaction of medical and psychiatric illness
    • Recognizes that psychiatric illness costs are simply shifted to the medical budget
    • Emphasizes avoidance of carve outs
    • Emphasizes value-added services
    • Complexity Intervention Units (Med-Psych Units)
    • Delirium Prevention Programs
    • Integrated outpatient clinics

Roger is a champion from whom everybody in health care can learn important lessons about integrated care. There are so many of us who learned to think both/and rather than either/or because of his zeal, his compassion, and his dedication to the basic principle in EH (Ned) Cassem’s pithy statement,

“Mind and body remain stubbornly one”.

1.            Kathol, R.G. and S. Gatteau, Healing body and mind : a critical issue for health care reform. Praeger series in health psychology,. 2007, Westport, Conn.: Praeger Publishers. xviii, 190 p.