Everything You Wanted To Know About Psychiatry In 30 minutes or Less....

 

It has been a week since I gave a presentation to the Philolectian Society in Anoka, Minnesota.  The Philolectians are primarily retired educators and their colleagues who decided they wanted to promote education in their county. They do this by topical discussions on a monthly basis and fund raising for scholarships that they award to high school students.  They were founded 134 years ago.  I gave them a presentation on substance use disorders about 5 years ago – but my current presentation was entitled “Everything You Wanted To Know About Psychiatry In 30 Minutes of Less.”  It was the mile high view – but that is the one that is typically lacking in American culture.

The venue was a sports bar conference room in an old building. There was no projection equipment and it had spotty WiFi coverage so I decided I should test it out ahead of time. I opted to use a Chromecast device to the television HDMI port – but did not realize at the time that it does require WiFi in order to work.  Connection to my home TVs was not a problem but there is continuous WiFi as the background.  Failing the Chromecast, I was given an LED projector that also required WiFi. I ended up printing out hand outs for the attendees. The 12 slides follow and total time was about 45 minutes – 30 minutes of presentation and a 15 minute Q & A.  My presentation style is to focus on slide design.  For that reason I avoid the standard templates and try to cover as much of the slide with graphics as possible when they are used.  My second overall principle is to free associate to the slides and never read them. They are there to keep me on track.  What I actually end up saying varies considerably from lecture to lecture – modifiable by various factors including what the group has indicated what they want to hear, what I have been thinking about that day, and what I have been reding that week. The process is like Frank Zappa described his guitar playing. Every live performance is unique – no set of notes is identical.  I can’t claim mastering lectures like he mastered the guitar but there is some creative process involved in lecturing.

The title slide uses a background of abstract art taken off of one of my paintings at home. The artist is Stephen Capiz.  It represents a very small area of a larger abstract painting with the tile information superimposed. The title was chosen to keep the atmosphere casual. I wanted people to be comfortable that this was not a presentation to mental health professionals but to a general audience.

Slide number 2 is a critical three - fold message that is frequently missed or distorted.  Psychiatric disorders have been observed and discussed since ancient times.  That means they are easily recognizable to people with no training. It means that they are real and can’t be explained away.  You must be incredibly naïve or sheltered to not have that experience.  Psychiatrists only exist because they were the doctors interested in treating these disorders. That is as true today as it was in the 18^th and 19^th century.  The only difference is that modern psychiatrists have uniform training. And finally as you would expect, the diagnostic system has undergone successive refinement over the centuries.  The DSM is used as an example here but the ICD could be used as well. (with all slides click on them to expand and get a better quality graphic - this is apparently an artifact of the blogger format).

 

Slide 3  provides a little more detail on the evolution of the DSM systems. Counting the total diagnoses is always a point for rhetorical digressions.  I finally figured out how to do it and listed my specific technique in this post.  To a professional audience, I might include studies on how many of the diagnoses are actually used.  This audience did not find any of this controversial.

Slide 4 is a great timeline of how psychiatry developed from a discipline that Kendler refers to as protopsychiatry to the modern era starting in about 1920 in the US and about 40 years earlier in Europe.  The audience was extremely interested in the low percentage of physicians attending medical schools in 1900 and that lectures could be attended by purchasing tickets. The transition from asylum doctors with no particular training to psychiatrists was also a focal point.

Slide 5 was necessary because there is still a lot of emphasis on Freud. I remembered that Freud was an important figure to my college English professors and that some of the teachers in the audience were about that age. I emphasized that Freud was an important figure in psychoanalysis, but that there were many European psychiatrists that provided knowledge, literature, and training to their American counterparts and that many were self-taught and active across the fields of psychiatry, neurology, neuropathology, and neuropsychiatry.

Slide 6 is a very brief outline of the basic educational milestones of the various mental health disciplines.  Minnesota has a confusing array of designations including unlicensed mental health practitioners so I kept it simple.  In the previous slide on the psychiatry timeline I did mention how in the early 20^th century most practitioners considered themselves neuropsychiatrists and practiced both neurology and psychiatry. When the American board of Psychiatry and Neurology informed practitioners that they would need to take board exams in both psychiatry and neurology the era of separate specialties was begun.

Slide 7 is one of my favorite graphics.  It is produced from the current educational requirements for residency training and Melissa Farmer, PhD greatly assisted me with the graphic design. My overall emphasis was to point out how these training requirements should result in a physician who is not only an expert in diagnosis, but also interviewing, maintaining relationships over time, and capable of therapeutic discussions.

Slide 8 attempts to capture the pattern matching aspects of psychiatric practice and why training and experience are necessary.  It illustrates how previous exposure to various diagnostic and therapeutic elements can lead to problem recognition and resolution.

Slide 9 is a rough sketch of the diagnostic process and how it has to be adapted to the situation.  I provided several examples of referrals that I saw as referrals who needed immediate emergency medical attention.  We discussed how that can occur.

Slide 10 is a list of psychiatric subspeciality care.

Slide 11 is an explanation of the current workforce and how the practice environment has deteriorated over the past 40 years. I emphasized rationing as the main problem and several audience members were aware of the shortage of psychiatric beds and state hospital closures.  The city of Anoka has one of the few remaining state hospitals – Anoka Metro Regional Treatment Center. In the future if I am projecting - this slide would be split to 2 separate slides. 

Slide 12 – I had to leave the audience with a reason why they are exposed to antipsychiatry rhetoric and discussed the basis for it, the special interests involved, and in most cases - the lack of any basis in reality.

The presentation went very well. There was additional interest in the medical and psychiatric effects of the pandemic.  Several audience members were interested in my opinions about the Department of Human Services in Minnesota and how they factor into the current rationed system of care. I am currently expanding some of the graphics in case there is any additional interest and as an outline for some of my other writing.

 

George Dawson, MD, DFAPA

Associative Memory During A Formal Presentation - Keeping It Real

I just completed a formal presentation this morning at about 9:15 AM.  It was in a big conference room at a plush hotel near the Mall of America.  There was a little pressure because I was the lead off man in terms of the scheduled presentations.  I walked into the venue early and got up on the stage.  It was a black elevated platform about 25 feet square.  It looked like it was built to be portable.  There was a lectern with a fixed microphone.  The platform was positioned between two large 20 x 25 foot screens.  In order to see the screens or use a laser pointer, I had to walk out from behind the lectern to bring me about 12 feet away from the back wall.  I looked out over the audience filing into to 4 sections of tables and thought: "Not the most convenient set up - but I have done this before."

My experience with presentations like this is mixed over the years.  A lot of that has to do with neurotic behavior.  I have given many presentations that I became disgusted with and was glad they were over.  They were probably the ones that I did not think were good enough or up to my often unrealistic standards.  In the old days before everything was standardized as PowerPoints, the formatting and graphics would often throw me off.  For 5 dark years I was using a presentation program called Aldus Presentation followed by Harvard Graphics and there was always a lot of luck involved in what that final presentation looked like.  Those were also the days of 35 mm slide sets and projecting from carousel projectors.  There were also services that would charge significant fees to convert your presentation images to 35 mm slides.  Nowadays I can obsess about the presentation right up until the last moment and walk in with presentation, several modified versions, and several alternative graphics on a USB drive and make a last minute change.  Technically about the only thing I have to complain about is getting copyright permissions but all of the hardware and software is good.

Getting mentally prepared is much harder.  I received instructions that I had to make sure that the presentation was exactly 45 minutes long.  Right before I started I was told about 5, 2, and 1 minutes cards that would let me know how the time was running out.  I was supposed to rehearse it and I did.  I digitally recorded it and it ran 45 minutes exactly.  I went back and recorded as many key concepts as I could.  I thought about my self acknowledged deficiencies as a presenter.  I can suddenly start to isolate affect and drone on in a rapid and obsessive manner.  I can remember giving a presentation about medications to a large crowd and at one point I made eye contact with a fellow staff member in the audience as he mouthed the words: "Slow down!" - rather emphatically.  I am fairly humorless.  At least that is the general audience experience.  My humor is dry - often bone dry.  It is the humor that only introverts get at times.  When I hear more than a muffled response, I wonder: "What just happened?"  There is also the fear that I will choke in the same way I choked in a pharmacology seminar in medical school.  My seminars generally consisted of the same group of people.  They were all friendly and not threatening in any manner.  The same thing was true of the professor.  I knew the material on the cardiovascular pharmacology of calcium channel blockers cold.  There was no good explanation for me just blanking out at the ten minute mark.  I remember I was thinking about hiking through Glacier National Park.  I had the image of a photo I took of the moon high in the sky over Nebraska.  Everything seemed right with the world until my reverie was interrupted by the Professor saying: "Hello?  Mr. Dawson?  Are you going to get on with it?"  I don't know how long I was staring blankly in front of my fellow students.  I snapped out of it and completed my presentation.

I have given thousands of presentations since that pharmacology seminar incident and no similar episodes have occurred.  Even at the time, I don't  remember being embarrassed about it.  Also unusual.  That does not mean that I am any less neurotic.  Since reading Yalom as an intern, I have always seen the truth in existentialism,  so I was not surprised about this spontaneous thought on my drive to the hotel: "What do you care what people think about this?  You are going to be dead soon anyway and nobody is going to talk about it at the funeral."  .... Okay - focus George - you can only die after the presentation.  Don't work yourself up into a lather of death anxiety in addition to the fairly well controlled performance anxiety.

After surveying the venue, I decided to forgo the conference coffee and go to one of my favorite chain of coffee shops.  The conference rooms were set up so that they intersected a main skyway into the mall.  The coffee shop was about 100 yards away.  I had about 15 minutes until I started, so I headed down the hallway.  At about the 50 yard mark, there was a set of three steps followed by a landing and then another set of four steps.  I failed to notice it at the time but the height of the steps was unusually low and I was headed down these steps.  This is a major thoroughfare and the hallway was about 20 feet wide.  I made it to the third step tripped and went crashing onto my right knee and hands.  That's right - I fell almost flat on my face shortly before my presentation was scheduled to start.  The same thing happened to me in O'Hare one day as I was waiting to catch a flight to Boston.  I was balancing with a brief case against a guard railing in one of those large central areas that everybody seems to stream through headed to the other side of the airport at O'Hare.  I slipped sideways and hit the floor, the metal edge of my brief case making a loud cracking sound.  No fewer than a hundred people came sprinting over to me as if I had been shot.  It took a good ten minutes for the crowd to clear after they confirmed that I was apparently unscathed.

This morning I immediately pushed myself up off the floor and braced for the onslaught.  There were at least a hundred people in the area.  To my amazement, nobody seemed to have noticed the old man hitting the deck. I moved quickly to the coffee shop, placed my order and moved to a back corner where I could pull up my baggy trouser leg and inspect the knee damage.  Ten minutes later I was at the podium.  One of my colleagues commented on the way up that I never looked nervous.  He didn't see me just hit the floor like a bag of dirt.

This is it.  I am finally ready for the show.  I always have a number of jokes ready that I never use.  Instead I go to a few controversial remarks about the topic.  I am actually a student of PowerPoints.  I have attended the Tufte seminars and have his books.  I try to apply principles of good design to the slides and to use as many graphics as possible.  Tufte doesn't like PowerPoint.  He thinks it doesn't contain enough information.  I attended one of his seminars and he was using large sweeping graphics with no text.  It was visually interesting but content?  It reminded me of a TED talk - a lot of affect and minimal content.  TED talks are useful for that mode of communication, but the crowds I talk to deal in facts and a lot of them.

I know it is not going to be the Dave Chapelle show, but I know there is some important information I need to convey.  I want the slides to contain the information and where to get more information, but I never want to read them.  I also don't want to focus on talking points or read a script.  I just realized today that what I have is free association points on the slides, and I need to say whatever comes to mind when the slide pops up.  While the audience is reading the slide or looking at a graphic, I need to come up with the best illustration from my personal experience.  It went something like this:

And that is pretty much how it went.  Matching my associations to the lecture content.  It is only slightly more to obsess about.

And nobody had to die.

Oh well - on to the next presentation........


George Dawson, MD, DFAPA