Monday, January 17, 2022

This Is How Civilization Ends...

I had that thought immediately after seeing the above graph on the CDC web site. Over a million new cases.  An all-time high by far.  At that point, the news had been heavy with discussions about the Omicron virus for about 3 weeks. The trail though Africa and Europe was described.  In the United States we had plenty of warning and plenty of time to adjust.  It wasn’t like that first peak in the fall and winter of 2020-2021.  Back then there were no vaccinations.  My wife an I finally got vaccinated in March of 2021 and then only by an extraordinary stroke of luck.  Before Omicron we were flush with vaccinations.  Two different retail pharmacy chains were scheduling appointments and they were free. When the booster came out that was also free and much easier to get. The overwhelming scientific evidence was that the immunizations were safe and effective.

The public health measures seemed less effective. That could be confirmed by a walk around Target or Walmart. At the absolute peak of mask wearing in Minnesota, my estimates were up to 30% of shoppers were masked. Half of those masks were loose fitting cloth masks and probably not very effective. Today, at the height of the Omicron spike 10% of the people in my coffee shop were masked and I was the only guy wearing an N95.  Despite an increasingly vocal group of aerosol scientists most people remain shockingly ignorant or willfully ignoring the airborne route of transmission. The most easily observed scenario is restaurant dining where the customers wear a mask to the table and then take it off to eat and talk for the next two hours. There is no magical protection from airborne virus in that scenario. Forget about the 6 feet safe distance rule at the start of the pandemic. Looking for restaurants that have improved their HVAC systems to improve airflow and air exchanges over time was also disappointing. So far in the Twin Cities Metro area I have found 1 restaurant. No restaurant or business as far as I know is posting their air exchanges per hour or carbon dioxide measurements to describe the potential risk of their environment. They are posting that they adhere to social distancing and all of the surfaces are wiped clean between diners.

Despite all of that inertia, the restaurants are packed.  Typically, shutdown occurs when a significant number of staff are ill with coronavirus and they cannot stay open. I dodged a bullet at Christmas just as infections were increasing. My wife and I were supposed to meet another couple at a restaurant. My suggestion to get take out and eat it at either of our homes was met with resistance. I was saved by a call from that restaurant that significant numbers of their staff were ill and they would be closing until things improved.   

The general cultural landscape has been even more grim. I follow all of the experts in the media on a regular basis – Drs. Fauci, Hotez, Jha, and Walensky.  On an average day they are awash in a sea of misinformation.  That sea contains the entrepreneurs who see the pandemic as a money-making scheme as well as the purely irrational who find that conspiracy theories about the virus, vaccine, and public health measures are easier to understand and believe than the science. Political opportunists are in the mix and as recently as today were suggesting that “white people” were being discriminated against and were less likely to get the vaccine as a result. The Florida Governor made this statement:

“We reject the biomedical security state that curtails liberty, ruins livelihoods and divides society.”

Biomedical security state? The politicization of this pandemic knows no bounds. It obscures both the science and goodwill toward the scientific and medical communities.  But it doesn’t stop there.  In some large health care organizations 10% of the workforce has been fired for not complying with workplace mandates on COVID-19 immunizations.  Some of these workers are physicians who should have been taught basic epidemiological concepts – the most basic being that vaccinations are a rare medical miracle that have saved the lives of tens of millions of people.  Disease have been eradicated, prevented, and the course of infectious diseases has been altered.  And even if you are not a physician, everyone has the experience of taking all of the mandatory vaccinations required to attend school.  Most of these vaccinations had a significantly worse side effect profile than the currently available COVID-19 vaccinations.

Apart from reducing rates of infection, hospitalization, and death these modern vaccinations also reduce the risk of chronicity. Chronic or “long COVID” symptoms might occur in as many as 70% of patients after the infection. Remission rates and rates of disability are still being determined at this time.  Given the risk/benefit considerations of the vaccinations it is difficult to see how any rational person would refuse it.  It is even more difficult to understand how a rational person would not take basic measures to protect themselves and their families from airborne virus or justify ignoring the pandemic on the basis of a completely implausible conspiracy theory. In some cases, the motivations are very clear.  Politicians would rather use various forms of rhetoric to attack the idea of a pandemic and what it takes to resolve it for political gain rather than taking positive steps recommended by experts. It is a standard political tactic.  That rhetoric has been advanced to extreme levels and to the point where scientists and their families are being threatened.  Today the suggestion that “white people” were being discriminated against struck me as white nationalist rhetoric.  It was viewed just as another “falsehood” in the media.  Certainly, blind partisan acceptance of these statements is not very likely to exhibit flexibility in thinking about the pandemic, the virus, or possible solutions.

The press has stepped in and commented on the process as a “mass delusion” or “mass psychosis” as if the use of psychiatric jargon by a journalist would add credibility to the criticism of many people thinking and acting irrationally. Many of them are agitated, visibly angry, and can become aggressive typically when confronted about pandemic precautions in schools and businesses.  Hardly a day goes by without seeing an airline passenger or town hall meeting participant screaming until they are red in the face and carted away by security. None of these people has a psychiatric disorder.  They can cool off somewhere, suppress their irrational thoughts and the associated anger, and get up and go to work the next morning.  During the run up to the 2020 Presidential election there was heated commentary about President Trump’s mental health and fitness for office. There was some debate in the psychiatric community if it was appropriate to discuss that issue based on Trump’s observed behavior rather than a psychiatric assessment. This essay looks at the other side of that debate. Why do so many people follow leaders who make repeatedly false statements that in some cases are viewed as potentially inciting people to do the wrong thing? And conversely – how do so many people accept the more obvious rational path and reject all of the paranoia and conspiracy theories?

There are of course numerous theories about how this comes about.  The theories generally depend on the same theories that have been used to describe normal development, psychopathology, and normal learning processes.  In some cases the theories have a philosophical basis – that seem to be fashionable these days. And despite many of these theorists incorporating a neurobiological model – very little explanation about how that is relevant.

The relevance is obvious to me starting with the relationship between emotion and cognition specifically decision making. In order for it to be obvious, the relationship between emotions and normal decision making needs a brief exploration. Human decision making typically occurs as an integrated process in the frontal cortex. I won’t digress into any subdivisions or tracks in this post. The key word here is integrated. That means the frontal cortex takes a large number of inputs and uses them to varying degrees in the ultimate decision. That includes a lot of memory input, specific types or learning, emotional input, and real time sensory and perceptual data.  The amount of input is large and much of it occurs at an unconscious level. How it occurs is largely unknown at this point but with our limiting inputs have been determined.  One of those inputs is emotion. We know for example from lesion studies that emotional input is absolutely critical for normal day to day decision making. Of the vast number of potential decisions we all have a subset that are associated with emotional valences that can affect our preferences. Without access to those valences decision making slows and grinds to a halt.

Restricting our consideration of the decision space to all of the possible decisions about the pandemic and how to proceed – all of the medical, scientific, personal, political, manipulative, and conspiracy theories the possibilities are very large. If we have 300 million decision makers and they all have unique conscious states and personal capacities for decision making the potential outcomes are large. It is also a more complex scenario than all of the typical explanations for pandemic denial.  Each one of our 300 million decision makers has unique experience affecting the emotional valences of their decisions. The overt decisions may seem to coalesce at some points but for many different reasons. For example, believing what a politician says despite the clear documentation that they are lying can occur as the result of identification with similar people in the past, identification with a general class attitude or ethos that it represents, or it simply could be activated by the angry emotion that politician effects. Those are just a few possibilities.

The pandemic vaccination vs. anti-pandemic antivaxx is by definition a binary polarized debate – the reality based on what we know about how the brain works it is far from that simple.  Even on what appears to be the rational side there is no Spock-like analysis.  The public health experts are all accessing emotion when making their decisions. Rational thought is reward-based learning and associated to one degree or another with a “Eureka” moment.    

The key question going forward is what can be done to address the degrees of freedom associated with the possible decisions of this brain process.  What can be done to improve the process and by improve, I mean assure that civilization survives the current and potentially more lethal pandemics. To that end, there are numerous cinematic depictions of apocalyptic pandemics. Based on the depictions prior to this pandemic they are probably fairly accurate. Once a lethal pandemic takes hold, the decision space for survival collapses as fewer and fewer decisions are possible. An intuitive writer or film maker knows that at some level.  Time to make it general knowledge.


George Dawson, MD, DFAPA

Sunday, January 2, 2022

Yes - I am Retired and here is why....


Yes – I am Retired

Last January I posed the question  ”Are there any good jobs left for psychiatrists?”  Eleven months later – I have the answer and the answer is NO.  For the past 11 months I have been looking and have seen at least a hundred jobs descriptions forwarded to me by various people. I have also interviewed and negotiated a couple of times only to get a contract that was completely unworkable.  I am not an attorney but I don’t think you have to be when you see a contract suggesting that you are going to indemnify and hold harmless a large corporation for any problems that might arise during the course of your employment. I did incorporate that experience into a CME lecture I gave in November about telepsychiatry and encouraged legal consultation with contracts.

The job postings that I considered were remarkable for the obvious amount of leverage they would create for employers and some of those employers had clearly never worked with psychiatrists in the past.   What do I mean by leverage?  Leverage is bullet points in the job description. When I started out back in 1986 – job descriptions were straightforward.  I can still recall the first interview I had at a community mental health center where I was eventually hired as medical director. They asked me about my treatment philosophy in psychiatry and my exposure to community mental health.  They asked me if I would be comfortable supervising the community support staff and psychotherapists. I asked them about the medical resources in the area, where I could do physical examinations if necessary and where I could get laboratory testing done.  All of the stuff psychiatrists are trained to do.

Current job postings list a number of bullet points that seem irrelevant to the job of a psychiatrist. Things like customer and stakeholder focus, change management, systems thinking, courage, commitment, emotional resilience, training (prescribing appropriate medications, documentation, collaborating with therapists, considerable annual HR rules), and so on.  The term “stakeholder” is cringeworthy. For 36 years I have treated people who had the toughest psychiatric and medical problems. All of that treatment was based on establishing a relationship with the person.  In many cases that involved foreign language interpreters, deaf/hearing-impaired/ASL interpreters, and various attorneys, advocates, ombudsmen, case-managers, and social workers. Family involvement is often critical.  If there are any stakeholders besides me and the patient – those would be the stakeholders. But in the business world – the stakeholders are other businesses and bureaucrats. They also include middle managers in any business that hires me. I may go in to work one day and find a team of bureaucrats angry with the way I am doing things – not from a quality-of-care perspective but from a business perspective.  They may decide to make my life a living hell until I do what they want me to do. All of the irrelevant bullet points also come in handy at the annual review. A supervisor may solicit anonymous opinions about whether or not I am fulfilling the requirements of corporate citizenship irrespective of my work as a psychiatrist.  That is all corporate leverage.  It has happened too many times and I am done with it. As far as I can tell that eliminates me from the pool of psychiatrists eligible for employed positions.

I have considered private practice options and gotten a lot of advice about it. The problems at this stage are considerable due to the up-front investment and the issue of tail coverage or malpractice insurance coverage necessary when I eventually stop working. Establishing a reliable documentation and medical records system as well as the necessary network security and insuring that is also a wild card. Private practice seems like an option if I hit the lottery but not before.  It does lead me to give out the advice that starting all of these essentials for private practice earlier in a medical career is probably a good idea.  As an example, I have talked with psychiatrists younger than me who have carried their own malpractice policies independent of their employer's policy. That is something I never considered, but today see it as a great idea.   

I did a CME presentation in November and I think that went relatively well. I could do more – but doubt that will ever develop into anything sustainable. This blog will keep me going in the foreseeable future. I like reading about psychiatry, medicine, neuroscience, and basic science.  I have an interest in staying current as well as knowing where the research is headed. One of the reasons I started this blog was because I had a significant number of psychiatrists approach me and ask what I was reading and how I kept up on recent research.  This blog has enabled me to reach psychiatrists around the world and correspond with many on relevant issues. I have never capitalized this blog in order to avoid any appearance of financial conflict of interest. So, like most retirees I will be living on Social Security income and retirement savings.

I don’t anticipate many existential issues in retirement apart from the typical death anxiety from time to time.  One of my goals has been to live as long as possible, and based on my family history I have lived this long just by avoiding cigarette smoking, exercising, and getting timely medical care.  My diet has gradually transformed to a relatively healthy one.  Being married to an extrovert means that I am never socially isolated.  Retirement has resulted in a massive amount of freedom to finally do what I want.  For decades I was constantly working or worried about work – initially the patients but eventually the bureaucrats and patients. I also worked too long and found that I was living somewhat of an alternate existence. I did not know what it was like to go to a shopping mall in the afternoon – I was working. All of those daytime everyday activities were available to me during vacations where most of my time was spent recovering.  The freedom to go to a mall or Target or even to a local coffee shop for a mocha anytime I want to is something I really have not experienced since the first two years of medical school.  I plan on using it to the max as the pandemic clears.

Freedom also means much more time.  I have about 4,000 books in my library and a steady stream of incoming subscriptions of medicine and science journals. Not all of those books were meant to be read cover-to-cover, but I want to make sure that I read those that were meant to be read that way.  At some point I will probably reread Zen and the Art of Motorcycle Maintenance for a final time. That book is a mysterious connection to my past as well as one of my all-time favorites.

More time for exercise will be a challenge. I decided to adopt a treadmill strategy for workouts so that when a cardiologist orders another stress test I will be ready. So far that strategy has worked well.  My only limitation is joint pain and back pain.  I think a lot about the day that pain might not go away and necessitate surgical intervention. This is my hopeful exercise routine going into retirement (I have actually bumped the 6 MET treadmill routine to 8 METS).  The cycling section is currently on hold after doing about 71 sessions due to a medical problem.

I plan to push this as far as possible, but the writing is on the wall based on 4 decades of high levels of activity. The decision about surgery will depend on how things are going at the time as well as the quality of consultation. The insight I have developed here is that maintaining high levels of activity as you age is more than determination. It is a matter of back and joint preservation and what can be done to restore it, as well as what other medical problems exist.

The final existential issue in retirement is the one that many people seem to fear and that is meaningfulness.  I can recall running early retirement groups as part of residency training that were based on that theory, but it was never evident to me that was really the issue. I certainly have not found any physicians who found retirement to be a problem.  I have a number of goals in place that involve writing.  A senior psychopharmacologist sent me an email and suggested that I cover mechanisms of action of biological treatments in psychiatry. I will certainly try to maintain the position of being an advocate and defender of the profession for the basic reason that nobody else seems to be willing to do it.  I explain how this has evolved and happened in the past few decades and the previous post on this blog captures some of my thinking on this topic. Several papers are in the works on the diagnostic method in psychiatry, rhetoric used against psychiatry, and sleep transitions.  I am also in the process of outlining a book on diagnostic and treatment methods in psychiatry.  My goal with the book is too keep it as short as possible and not to get into all of the trivia seen in typical textbooks. The target audience will be trained, early career psychiatrists, and like most old people – I hope to pass on some wisdom that will prevent common mistakes.

Along with the meaningfulness, a few words about ageism are required here.  I have encountered it in blatant forms in the past 5-10 years from psychiatrists. It bothers me only in that these psychiatrists seemed to be unaware of their attitude and I have the position that psychiatrists need to be aware of their biases. To some degree it is expected of physicians in their 30 and 40s.  Medical training encourages competitiveness and it takes a while to develop a collegial attitude. Is that transition is the same in psychiatry as in other specialties? There are several reasons why it might be lagging. First and foremost is the constant barrage of negative and inappropriate criticism the field is under compounded by the lack of response by any leaders in the field or professional organizations. That atmosphere encourages people to come forward and say: “I am not like the rest of the psychiatrists who you are criticizing. Your criticism does not apply to me and here is why?”  That is an attitude I was explicitly critical of when I started to write this blog but probably did not articulate that well. I did say that my experience with psychiatrist-colleagues is that they are thoughtful, professional, and very competent with few exceptions. I don’t accept the unique psychiatrist defense against inappropriate criticism even though many authors of these articles come off that way. If the competitiveness and the unique psychiatrist defense is in the background, does it make ageist biases more likely?  I think that it does.  I have experienced the comments and the smirks from people who should have known better – even not counting the obvious gaslighting comments here on my blog. Psychiatrists should know better.  

Another factor are special interest groups like the managed care industry and recertification boards. The managed care industry has emphasized at times that younger physicians are more "managed care savvy" (as if that is a good thing) and the need to train residents with that same goal in mind. The implicit suggestion is that older physicians who generally do not like managed care are less "savvy".  Medical boards, after rolling out years of questionable recertification processes and data to suggest that older physicians may know less than younger recertified physicians have apparently come around to the position that a lifelong continuing medical education approach is now acceptable for board recertification.  That was where all of this started. In the meantime there has been about 20 years of rhetoric suggesting that older physicians, especially those who were grandfathered in to lifelong certification were self-serving and had less knowledge than the people being run through the recertification mill. In reality, there was not a single older physician who did not believe that lifelong education rather than an arbitrary recertification examination was a superior process. Managed care and the recertification boards were essentially splitting physicians based on age and facilitating ageist biases. 

The meaningfulness dimension also includes collaborating with others. I am currently working with a friend of mind on postmodernism.  He happens to be an expert in all things postmodern and I am running my theory about postmodern rhetoric by him.  I hope to collaborate with other researchers on theory and even experimental design and analysis for a number of problems in psychiatry. I also like making basic graphics and would consider collaborating on that. I don’t need any reimbursement for the right projects – authorship credit will do.

The most significant aspect of meaningfulness for many physicians is realizing how your profession has impacted your family. For too many years, physicians are emotionally involved with strangers often to the point of exhaustion. That process takes its toll on the people who you are supposed to be the most emotionally involved with and that is your spouse and your family. The increased freedom of retirement allows for a fuller realization of that emotional involvement and reflecting on what has happened over the decades of work.

That is my current retirement process. I will post any changes here on the blog.  I hope there will be a noticeable improvement in the quality of writing here on the blog.  I know there is information contained here that can’t be found anywhere else and I am satisfied with that accomplishment as well adhering to the general goals that I started out with.  If anyone reading this has any suggestions for topics that I should be covering feel free to post it in the comments section below or send me an email.

George Dawson, MD, DFAPA

Supplementary 1:

With no good jobs being available for psychiatrists what are the options?  Unless you can identify a funding source and open up a free clinic there really aren't many.  People in my situation can simply retire and I think that many are.  In fact, one of my medical school colleagues told me that all it took was the pandemic on top of the current administrative headaches to make that decision. I am sure that somewhere somebody can find a niche and avoid some of the administrative headaches.  Learning what it takes for private practice at an early age seems like a possibility but the administrative costs are shockingly high.  I recall an internist telling me that for his 2 physician practice they required 3 full time office staff just to handle the billing and coding requirements for hundreds of insurance companies. In my 3 psychiatrist outpatient clinic we needed 1 fulltime staff person to handle phone calls and prescription refills and could have used  nurse just to handle the prior authorization calls. The business world has conveniently set things up so that the barrier to private practice is high and it is easier to settle for one of their problematic jobs.  I am not sure there is much that can be done to reverse this.

Supplementary 2:

To paraphrase an old automotive commercial: "Quality is no longer job one!"  I was a quality and utilization reviewer for psychiatric hospitalizations in both Minnesota and Wisconsin in the 1980s and 1990s.  We had stringent criteria for reviewing records and making these decisions. As the federal government invented the managed care industry and turned control over to them including all of the reviewing - quality dropped off the radar. Now what consumers see are media polls of "Top 100" hospitals and curiously most of the hospitals that you drive by seem to have made that list.   The same administrative processes that have removed physicians from the decisions about program design and how patients are seen in a clinic have also removed them from monitoring quality and designing quality improvement programs.  I know because I have been in the meetings where administrators presented their ideas about quality.  They were clearly less knowledgeable about healthcare than Toyota is about producing cars.  At least Toyota listens to the people making the cars. 

Supplementary 3:

I have always dreamed about working. It is always inside a massive hospital that is staffed like you would expect a university hospital to be staffed – teams of specialists and their residents and medical students. None of the buildings look familiar – they are all brain fabricated and in technicolor. The people in those dreams all look, sound, and move realistically. The predominate mood in the dream is anxiety.  Some of it is the real anxiety of everyday medical practice – did I miss anything and have I remembered everything? It is the anxiety that you experience when you are under pressure and on the edge of being overwhelmed. It is the kind of anxiety that leads to physical symptoms like accelerated heart rate, palpitations, muscle tension, and restlessness. Last night (01/08/2022) I dreamed I was in another large medical center.  In this case I was on both a Renal Medicine team and an Internal Medicine team.  I could sense that I was a resident and paying attention to multiple deadlines and schedules.  In real life no resident would do rotations on both of those services at once.  There is just too much work and it would never happen. I was looking at labs and notes on Renal patients and figuring out what I needed to do – but then realized I needed to be on Medicine rounds and started to get increasingly panicked.  I recall thinking that this was an impossible position and asking myself how that came about.  I woke up with a fast heart rate and feeling anxious but immediately realizing it was just another working dream. Various interpretations of that dream are possible ranging from the affective tone of the dream (work anxiety) to possibly wishing I was still at work.  I have definitely experienced elements of both. In medical school Renal Medicine was one of my favorite rotations and I was one of a few people who rotated through Renal, Infectious Disease, Cardiology, and Endocrinology in addition to the required Medicine and Surgery rotations. There was very little that I did not like about medical school or training. On the other hand it was extremely stressful and I was never able to lose that stress and anxiety in 35 years of practice. If anything, the way I practiced tended to increase the stress and anxiety. So here it is almost a year since seeing my last patient and medicine is still very much on my mind.  With any luck it will get to the point that I can stop working in my dreams.

Photo Credit:  Eduardo Colon, MD