Metaphorical Brain Talk

 

There is a current paper written by Kenneth Kendler on metaphorical brain talk in psychiatry (1).  It is open access and I encourage people to read it.  I automatically read anything written by Kendler because he is probably my last remaining hero.  That is ironic given that he is only slightly older than me.  If you are not familiar with his work there is a Wiki page that will partially bring you up to speed.  I have referenced him many times on this blog.  His writing is consistently next level when it comes to psychiatric research and theory.  If you find yourself reading collections of “greatest papers in psychiatry” and don’t find his work there.  Throw that collection away and read Kendler.

In this paper he reviews the history of metaphorical brain talk (MBT) in psychiatry and what he sees as four implications for the field. He defines this as describing the altered brain function is psychiatric disturbances in a way that seems explanatory but have no explanatory power.  Examples would include the infamous chemical imbalance trope.  He reviews MBT across discrete periods in psychiatric history and gives examples in each one of these time frames.  Since this is an open access paper – I encourage any interested readers to look at all the examples.   I will touch on a few points that I find interesting.

He first reviews Asylum Psychiatry from 1790-1900.  Several authors wrote about conditions they observed in their patients using descriptive phrases like brain excitement, disordered nervous system, morbid action of vesicular neurine, peculiar and special force in the cerebral masses, excitement and vividness always emanate from one portion or spot of the brain, etc.  On the one hand the metaphors are obvious and consistent with Kendler’s characterization that they are biologically meaningless.  On the other the images are vague and the significant part of the metaphor is descriptive language of mental activity. 

In other writing Kendler has referred to this era is psychiatry as the era of protopsychiatrists. I have reviewed that history on this blog and agree that psychiatry as the profession we know today probably did not start until the 1920s in the US even though it was well established in Europe for a longer period.  The European version included physicians who were also described as neurologists, neuropathologists, psychiatrists, psychologists, and alienists.  If you read references to these physicians today – the descriptions are often interchangeable and research is required to clarify their qualifications and training. 

There was more going on during this period than meaningless metaphors.  Alois Alzheimer was a psychiatrist and neuropathologist (11).  Between 1891 and 1907, Alzheimer described several neurodegenerative diseases including vascular dementias and the disorder that would eventually come to be known as Alzheimer’s disease along with the clinical correlations of memory loss, inadequate self-care, and paranoia. Otto Binswanger (1852-1929) was a Swiss psychiatrist, neurologist, and neuropathologist who was also active at the time. In 1894, he described “encephalitis subcorticalis chronica progressive” while attempting to differentiate types of dementia from dementia caused by tertiary syphilis that was called general paresis of the insane or GPI at the time.  GPI was a very common reason for institutionalization at the time accounting for 20% of admission and 34% of the death in asylums in the 19th and early 20th century before the advent of antibiotics.  Both Alzheimer’s Disease and Binswanger’s Disease remain controversial entities to this day in terms of the definitive neuropathology and likely etiopathogenesis.  An important historical lesson is that these early psychiatric researchers did practice psychiatry while doing neuropathology and often had students who went on to have significant contributions to the field outside of neuroanatomy.  In the case of Alzheimer, Franz Nissl (1869-1919) became his longtime collaborator and head of the Psychiatric Clinic at the University of Heidelberg where Karl Jaspers (1883-1969) was his student.  Jaspers wrote his text General Psychopathology while working for Nissl.         

His next historical period is The First Biological Revolution in Psychiatry 1870s – 1880s.  Griesinger was a key figure and his central thesis that mental illnesses were brain diseases.  He also published an influential textbook and journal.  His students promoted neuropathological research through autopsies as the primary method of scientific inquiry during that period. Kendler concludes that this method of research was a dead end for classical psychiatric disorders – but there seems to be more going on in the field than that.  Several of these physicians over the next 50 years identified themselves not just as psychiatrists but also neurologists and neuropathologists. Otto Binswanger ((1852–1929) and Wilhelm Griesinger (1817-1868) were designated as neurologists and psychiatrists.  Freud (1856-1939) did 6 years of basic research in comparative neuroanatomy, published a monograph on aphasia (6) wherein he coined the term agnosia, and was a Privadozent in neuropathology.  All of that before he invented psychoanalysis.

 The Reaction to the Revolution 1880-1910 is described next with a critique by Kraepelin of excessive and speculative biological theories of psychiatric disorders.  The critique largely is focused on Meynert’s (1833-1891) work.  The critiques focus primarily on highly speculative hypotheses based on neuroanatomy. Meynert’s neuroanatomy work and that of his colleagues and students is still recognized today (2-4).  His poetic license may have been excessive, but the neuroanatomy was solid.

Metaphorical Brian Talk of the 20^th Century focuses initially in Adolf Meyer. Like the other psychiatrists discussed so far, Meyer had additional skills and was employed as a neuropathologist following his emigration to the United States from Switzerland. He famously said: “My entrance into psychiatry was through the autopsy room”(8).  Meyer had an indirect link to Meynert because his supervisor August Forel was one of Meynert’s students.  A quote is included from a 1907 paper in which Meyer suggests that early American psychiatrists:

“…pass at once to a one-sided consideration of the extra-psychological components of the situation, abandon the ground of controllable observation, translate what they see into a jargon of wholly uncontrollable brain-mythology, and all that with the conviction that this is the only admissible and scientific way.”

Meyer is credited with psychobiology model of psychiatry.  He saw the brain and mind as an evolved unitary and dynamic structure reacting to the environment.  As such it would not necessarily show typical disease related changes at the gross or microscopic levels and could only be studied if environmental and social variables were considered. 

Meyer’s psychobiology approach championed a detailed clinical approach to psychiatric disorders and avoidance of biological reductionism.  That would put Meyer along with Kraepelin squarely in the camp against not only MBT but also any theory suggesting that there was a direct biological explanation for mental behavior or psychiatric disorders. Both were trained as neuropathologists and Kraepelin worked with Alzheimer. That would seem to lend a measure of credibility to their concerns.  

Kendler ends that section with a quote from Jaspers that the neuroanatomy discovered by the neuropsychiatrists is one thing but it cannot possible be correlated with mental phenomenon.  He refers to this as “brain mythologies”.  Meyer’s and Karl Jasper’s approached have been credited by McHugh and Slavney in their comprehensive 4 perspective approach to mental disorders (7).

Kendler concludes that the metaphorical brain talk in psychiatry arises from several sources.  First, our identity as physicians dictates that like other specialists, we need an organ to focus on and that has been the brain. That relationship was impacted by neurology seeming to take over conditions with overt and definable brain pathology.  He concedes that there is overwhelming evidence that psychiatric disorders arise in the brain (in fact he is a world expert in this) but there are still no specific mechanisms.  MBT is one way to address that fact.  He defers to a historian that this may be status anxiety relative to other specialties with more definable pathology and in some cases mechanisms and MBT is a way to address that.  His own take on MBT is much more reasonable when he describes it as a wish that at some point we will get to the deeper understanding of the brain that we all seek.

Despite the historical digressions, Kendler comes to the same conclusion that I did decades ago.  We do not have to make things up in discussions with patients and we do not need to use metaphors devoid of biological reality.  That does not mean there is no room for real brain talk – the kind that occurs when you are discussing the effects of brain trauma, strokes, dementia, epilepsy, and endocrinopathies.  It does mean that you can flatly say for any diagnosis there is no known etiology but the research supports this treatment plan and beyond you can provide a discussion or references to the latest research.

The explanatory gap in psychiatry between the biological substrate and mental life or associated disorder is obviously there but it is present in every other organ system to one degree or another.  It is quite easy to pretend that basic medical conditions like asthma or diabetes have all been worked out with biologically precise mechanisms of action – but nothing could be farther from the truth.  Endophenotypes exist for both conditions, most people are symptomatic despite treatment, and death still occurs even in mild cases. There is a definite dynamic of idealizing medical conditions as completely knowable and treatable – when they are not.  In those cases, the explanatory gap is very basic between biology and wheezing or blood glucose. In the case of psychiatric disorders – many more symptoms and ordinary functions are across that gap.  The explanation is much harder and any symptoms are less clearly rooted in biology.  

I am less concerned about the effects of MBT and how it potentially affects understanding the mental life of our individual patients.  That is what psychiatrists are trained to do.  We are face-to-face with a person who we are supposed to help and, in that situation, it is doubtful that MBT will add much. 

There are a few other reasons that may have facilitated MBT in the historical contexts discussed. Rhetoric is a powerful and rarely discussed aspect of the scientific and medical literature.   The metaphor users were all active neuroscientists in their day.  As such they were likely competing for positions, labs, associations, recognition, and funding.  This is commonly how rhetoric occurs in research communities and scientific literature. 

 A related issue is personality and notoriety. It is rare to see much commentary about these issues with 19th and 20th century scientists.  Once a certain level of fame is reached, are you more likely to speculate and theorize?  Can some of those speculations take on the form of MBT?  One of the most criticized neuropsychiatrists in this paper was Meynert for suggesting overly elaborate mechanisms that had no basis in science.  On the other hand, Meynert is still renowned for some of his neuroanatomical findings (4).  Is it possible that a scientist with that level of accomplishment did not care about the difference between speculation and scientific findings?  Is it possible that his students and post docs encouraged him to speculate beyond his findings – just brainstorming? Is he just taking a chance that he might be correct in order get credit for an innovative finding?  I suppose a translation of his book might offer a few addition clues, but the reason I have these suggestions is that I have seen this happen in current times.  We might reassure ourselves that our publications are not suffering from metaphorical overreach but problems with irreproducible findings suggest otherwise.          

The state of neuroscience for much of the timeline of this paper could be a factor.  Not a lot was known about neurons or neuronal transmission.  Neuron theory and the term neuron did not happen until 1891. I have a slightly different take on the history of psychiatry in the US and how psychiatry and neurology split.  Until 1934, most psychiatrists were also practicing neurology. Many were self-designated as neuropsychiatrists.  The ABPN decided to require board exams in both neurology and psychiatry to practice both and at that time psychiatry began to grow disproportionately relative to neurology.  It is still possible to be doubled boarded in both. It is also possible to practice neuropsychiatry or medical psychiatry based on residency training and practice.  I have long promoted the idea that modern day psychiatrists should practice intellectually interesting psychiatry and for me that uses the DSM as a scope of practice specifier and knowing all the medicine and neurology necessary to care of those patients.  

Revisiting the main point of Kendler’s paper.  In his summary he states his major concern has been an impoverished conceptual foundation in the field based on a brain centric focus and metaphorical talk about it.  I agree with anything metaphorical and on this blog have numerous posts addressing the chemical imbalance and biomedical metaphors being paced upon us by our critics.  In many ways – I don’t think the clinical brain focus has been enough. Psychiatrists need to be able to rapidly recognize neurological and medical emergencies in addition to the medical and neurological causes of psychiatric syndromes. Psychiatrists need to be able to diagnose aphasias as well as they can diagnose thought disorders.  Those skills can all be traced back to late 19^th century and early 20^th century psychiatry. I also see that era as precipitating controversy, dialogue, and pendulum swinging so far in the other direction that at one point the medical internship was temporarily removed from residency programs.   

The reality is that we will see people referred to us or walking in off the street who have brain lesions and/or medical problems or not. They will generally have a psychiatric problem that has been assessed and treated by several other people that did not work. Our job is to do a thorough assessment of their physical and mental problem and come up with a plan – even when there is no known treatment.  That plan includes relationship building, helping them be more competent, and helping them make sense of their world. 

All the irrelevant metaphors can easily be ignored.

 

George Dawson, MD, DFAPA

 

 

1:  Kendler KS. A history of metaphorical brain talk in psychiatry. Mol Psychiatry. 2025 Aug;30(8):3774-3780. doi: 10.1038/s41380-025-03053-6. Epub 2025 May 13. PMID: 40360726; PMCID: PMC12240831.

2:  Liu AK, Chang RC, Pearce RK, Gentleman SM. Nucleus basalis of Meynert revisited: anatomy, history and differential involvement in Alzheimer's and Parkinson's disease. Acta Neuropathol. 2015 Apr;129(4):527-40. doi: 10.1007/s00401-015-1392-5. Epub 2015 Jan 30. PMID: 25633602; PMCID: PMC4366544.

3:  Meynert T, Putnam J (translated) (1872) The brain of mammals. In: Stricker S (ed) A Man. Histol. W. Wood & company, New York, pp 650–766

4:  Judaš M, Sedmak G, Pletikos M. Early history of subplate and interstitial neurons: from Theodor Meynert (1867) to the discovery of the subplate zone (1974). J Anat. 2010 Oct;217(4):344-67. doi: 10.1111/j.1469-7580.2010.01283.x. PMID: 20979585; PMCID: PMC2992413.

“The presence of neurons in the subcortical white matter of the human brain was first described and illustrated by Theodor Meynert in 1867, and additionally commented on in his subsequent publications (Meynert, 1867, 1872, 1884). Meynert illustrated these cells in both superior frontal (Fig. 1A) and primary visual (Fig. 1B) human cortex and pointed out that these are spindle-shaped (fusiform) neurons which are oriented vertically to the pial surface within the gyral crowns, but horizontally at the bottom of sulci. He also suggested that they have a special functional relationship to short corticocortical association fibres (fibrae arcuatae, or Meynert's U-fibres) and that these fusiform cells may therefore be regarded as intercalated cells of his Associations system of short corticocortical fibres (Meynert, 1872).”

5:  Cowan WM, Kandel ER.  A brief history of synapses and synaptic transmission. In:  Cowan WM, Sudhof TC, Stevens CF.  Synapses. The Johns Hopkins University Press, Baltimore, 2001. pp.  3-87.

6:  Freud S.  On aphasia: a critical study.  International Universities Press. New York, 1953.  Translation of 1891 German publication and introduction by E. Stengel.

7:  McHugh PR, Slavney PR: The Perspectives of Psychiatry, 2^nd ed. Baltimore, Johns Hopkins University Press, 1998

8:  Lamb S. Social Skills: Adolf Meyer's Revision of Clinical Skill for the New Psychiatry of the Twentieth Century. Med Hist. 2015 Jul;59(3):443-64. doi: 10.1017/mdh.2015.29. PMID: 26090738; PMCID: PMC4597240.

9:  Lamb S.  Pathologist of the Mind – Adolf Meyer and the Origins of American Psychiatry.  Johns Hopkins University Press,Baltimore, 2014. p. 255.

10:  Rutter M. Meyerian psychobiology, personality development, and the role of life experiences. Am J Psychiatry. 1986 Sep;143(9):1077-87. doi: 10.1176/ajp.143.9.1077. PMID: 3529992.

11:  Goedert M, Ghetti B. Alois Alzheimer: his life and times. Brain Pathol. 2007 Jan;17(1):57-62. doi: 10.1111/j.1750-3639.2007.00056.x. PMID: 17493039; PMCID: PMC8095522.

Photo Credit:  

I thank my colleague Eduardo Colon, MD for the surreal photo of the Foshay building in Minneapolis. 

We Need More Unapologetic Psychiatrists…..

 

I am not sure he would agree with the characterization but I came up with this title when I decided to comment on Daniel Morehead, MD.  I have never met him but I have read everything he has written in the Psychiatric Times.  He is director of residency training in general psychiatry at Tufts. In the most recent column, I notice the heading Affirming Psychiatry – that I wish I had thought of.  That was one of the primary goals of this blog when I started writing it 13 years ago.

This month’s column was titled Psychotherapy: Lies Cost Lives (1).  He starts writing about a New York Times column about psychotherapy that starts positive but rapidly shifts to ambivalent. He points out that this is characteristic of most headings that have to do with psychiatry and speculates about the origins.  Controversy, mouse clicks, and advertising dollars for sure.  He lists several titles and several themes of articles that with similarities and points out the only logical conclusion:

“The take-home message is that psychiatry rests on shaky foundations and does not quite know what it is doing, rather like someone feeling their way through a darkened room. Psychiatry, as usual, lags behind the breezy confidence of other medical fields, where no one wrings their hands about whether antihypertensives really work or whether surgery is just a lingering form of inhuman medieval butchery.”

That is certainly one way to describe journalistic gaslighting. I have offered several explanations for it on this blog.  First, folk psychology. Trying to figure out basic motivations and behavior of the people we encounter on a day-to-day basis is an adaptive human skill.  Many people think that psychiatry is therefore just common sense and that anyone can do it – at least until they encounter problems severe enough to where that level of common sense fails completely.  Second, there is the impression that anyone who prescribes psychiatric medications is basically equivalent to a psychiatrist. That is a trivialization of the psychiatric skill set and training.   Third, antipsychiatry is a cottage industry in the US and other countries and our detractors have had an inordinate amount of success in getting their rhetoric published in both the popular press and professional publications. The previous post on this blog was all about that. There are no other equivalent movements attacking other medical specialties even though their good outcomes are equivalent and their bad outcomes are generally much worse.  Fourth, , the reality is that about 40,000 psychiatrists go to work every day in the US.  The demand for psychiatrists is high. That demand is fueled by successful treatment and a niche that is unfilled by other medical staff.  Fifth, at least part of that demand is because psychiatrists have unique skills. We are the treatment providers of last resort, and other specialists know that and refer patients at all levels of acuity. The only way that happens is if you know what you are doing.

Psychotherapy is part of that skill set and that is the focus of Dr. Morehead’s column.  The science is there, even though there is a constant debate about clinical trial design and replicability.  Specific brands of psychotherapy have been investigated and shown to work.  There is also research into important non-specific factors in psychotherapy that branded therapies have in common. Even more basic than that are the interviewing techniques and courses taught to second year psychiatric residents focused on facilitating information exchange with patients for both diagnostic formulation and intervention. Communication is a critical skill in psychiatry.  In this era of checklists, screening, and electronic health records – it is easy to forget there is a much larger set of important information and like all things it requires a lot of training to do it right. It is that body of information that allows for the treatment of each patients as a unique person.  Personalized medicine has become a buzzword lately but from a communication perspective psychiatrists have been providing that for decades. 

These basic skills in talking with people and talking in therapeutic ways are hardly ever mentioned in discussions about psychiatrists. Criticism of psychiatry commonly seeks to portray psychiatrists unidimensionally - as excessive prescribers of medication rather than communicators.  Throughout my career the number one reason I was consulted was to establish communication with a person and figure things out where nobody else could.

Even in the case of prescribing medications, there is typically a lot more going on than a discussion of medications. One of my colleagues established the largest clozapine clinic and long-acting injectable medication clinics I have ever seen.  When he moved on, his patients asked me regularly where he was and how he was doing.  They valued the relationship with him even when he was providing a unique medical service. Ghaemi has written about existential psychotherapy and how it can occur during appointments that are medication focused (2,3).

The overall message that Dr. Morehead is trying to convey is that psychiatrists cannot let others characterize what we do.  When that happens there are multiple agendas operating that can lead to the clear distortion that psychiatry is not quite up to the level of other medical disciplines.  There is typically an overidealization of those other branches of medicine with a focus on innovations that often do not materialize.  The real message rarely gets out and that is – psychiatrists are uniquely trained, we are interested in problems that nobody else is and that other physicians often avoid, and we are good at what we do.  It is highly problematic that journalists seem reluctant to get that message out to the public. When I first read Dr. Morehead’s writing I found it refreshing because there are very few psychiatrists who want to get that message out. Most will cave in to the first suggestion of a level of uncertainty that every specialist in medicine has to deal with – the persistent risk no matter how small and the lack of a guaranteed outcome.

I look forward to a new generation of psychiatrists who can start to set the record straight.

 

George Dawson, MD, DFAPA

 

Supplementary:

Decided to add this explanation anticipating the typical criticism:  “Well he is arrogant isn’t he? We always knew he was arrogant.  All psychiatrists are arrogant!”  When I say unapologetic – I mean unapologetic for just existing and trying to help people.  That is the level that psychiatrists are forced to operate at that no other medical specialist is. There are the usual misunderstandings, errors, and adverse outcomes in psychiatry that there are in any other medical specialty.  There are psychiatrists who are burned out, forced to practice in a way that they would rather not, and even personality disordered - just like any other specialty.  But in those other specialties the assumption is that these problems are handled on a case-by-case basis by the responsible physician, clinic or hospital administrative structure, or medical board. There is no similar assumption in psychiatry.  Instead, there is an assumption that the entire profession can be condemned for some adverse outcome, unprofessional conduct, historical event, or any unreasonable criticism that someone can come up with. As I have pointed out in the previous post - many criticisms are fabricated or just absurd.

So when you read these unrealistic criticisms about psychiatry in the papers – keep in mind that there has been a doubling down on the rhetoric unlike what happens with any other specialty in medicine. Use that knowledge to moderate your reaction to it. 

References:

1:  Morehead D. Psychotherapy: Lies Cost Lives. Psychiatric Times 40(11).  Published online on November 10, 2023  https://www.psychiatrictimes.com/view/psychotherapy-lies-cost-lives

2:  Ghaemi SN. Rediscovering existential psychotherapy: The contribution of Ludwig Binswanger. American journal of psychotherapy. 2001 Jan;55(1):51-64.

3:  Ghaemi SN, Glick ID, Ellison JM. A Commentary on Existential Psychopharmacologic Clinical Practice: Advocating a Humanistic Approach to the" Med Check". The Journal of Clinical Psychiatry. 2018 Apr 24;79(4):6935.

Photo Credit:

Many thanks to Eduardo Colon, MD

 

  

The Best Neurosurgery Clinic in the World

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I wrote this editorial in 2010 for the Minnesota Psychiatric Society newsletter Ideas of Reference as part of my role as the President at the time. Since then things continue to go in the wrong direction.  We no longer have insurance that covers the Mayo Clinic. My wife continues to do very well.

 

"We have the best neurosurgery clinic in the world." My wife Linda was in a conversation with a staff person at the Mayo Clinic, and somewhere along the line that statement was made. Just a few weeks earlier she had been diagnosed as having a growth hormone secreting pituitary adenoma and we were in the process of looking for neurosurgeons. I was concerned about that statement and wondered what the motivation was. I have called a lot of clinics and never heard a statement like that. I had talked with a lot of doctors and had never really heard many physicians talk like that.

The pituitary fossa is a dark and dangerous place for even a small tumor. Psychiatrists are generally familiar with the area because of patients with microadenomas that have been discov­ered during evaluations for what is usually hyperprolactinemia secondary to D2 receptor antagonists. In Linda's situation it was a 1.3 cm diameter cystic lesion that involved the cavernous portion of the right carotid artery. The surgery involves a transnasal and transsphenoidal approach to remove the tumor through an endoscope. Cutting into the carotid artery is a potential catastrophe. Damaging the pituitary and needing lifelong hormone supplementation was also a possible outcome. We wanted the best neurosurgeon for the job.

I had just finished reading a NEJM article on robotic surgery that suggested that surgeons need to do 150-200 procedures with this device to be proficient. There was no data available for endoscopic transsphenoidal tumor resections, much less what might be reasonable stratifications like size and type. I figured that the surgeon doing the most was probably the best bet.

At Mayo we were given a timely appointment and met the surgeon. He was confident, detail oriented and personable.

He assured us that his goal was to cure Linda, but that he was not going to trade off safety at any point for a cure. He openly acknowledged the potential problem of the carotid artery being involved with the tumor.

He performed the surgery and the next day came by to explain the results. They were uniformly good but would need confirmatory IGF levels at 3 months. He carefully explained the possible post op complications, how long we had to look for them, and exactly what to do about them. He told me that if any­thing happened during recovery and I was not at the hospital, I would be called immediately. At the time of discharge, he said that he was available through the hospital operator, and that if we called from a cell phone we might have to pull over and wait for him to call back.

While all of this was going on, I learned from other health care providers in the state that the "Mayo Clinic option" was being eliminated from some employee health plans. I had just spoken with a local expert in health economics who said that this suggestion had been made in the past and plan subscribers had rejected it. I thought about the implications for all of the free market and "quality" hyperbole that we hear from politi­cians and business leaders. If we have the best neurosurgical service in the country, why are health plans limiting access to it? If it is the best on a competitive quality basis, why aren't they rewarded rather than being penalized by the market? Most of all, what are the implications for the most heavily rationed health care, namely mental health care?

From a quality perspective, I was hard pressed to think of the best psychiatric service in the state, and not because we lack great psychiatrists. Most of the ·inpatient units I know of are pretty intolerable places. The emphasis is largely to put the patient on medications and discharge them as soon as pos­sible, even when many are highly symptomatic. By comparison with medicine and surgery services, it is difficult to consider this as even a minimal standard of care. Imagine the patient with congestive heart failure being placed on medications and discharged, and making it the family's responsibility to monitor the response and adjust cardiac medications. Imagine me doing post operative neuro checks and monitoring urine volumes, labs, and pain medications on my wife in a Rochester hotel room. In either example, medicine and surgery patients are more likely to follow recommended discharge instructions compared with over half of discharged psychiatric patients not recognizing that they are ill.

What about actual time spent with a psychiatrist? The time that my wife and I spent with her neurosurgeon probably exceeded the time that many hospitalized patients see their psychiatrist. Inpatient settings are usually very poor work environments for psychiatrists because the central fact is that it is no longer an environment where high quality work can be done. Unlike our neurosurgeon, psychiatrists have been mar­ginalized to the role of medication prescribers in both inpatient and outpatient settings. In many inpatient settings psychiatrists no longer control crucial discharge decisions.

When I walked out of the hospital with Linda, we were hope­ful that she had been cured. We knew what we needed to look out for and that there were future options. I noticed that the hospital looked like most of the teaching hospitals I had worked at in the past. There was no valet parking, massage or aroma therapy, harpsichord player, or high-end coffee shop. There were 19 plaques on the wall showing that Mayo Clinic Neurology and Neurosurgery was ranked #1 in the country for each of the past 19 years by US News and World Report. But most of all, we knew that we had just encountered medical and hospital staff with a high degree of expertise and professionalism and that there was an administration supportive of their efforts.

We need to get that back in psychiatry.

 

George Dawson, MD, DFAPA

 

Supplementary 1:

Since writing this I read Neurosurgeon Henry Marsh’s book Do No Harm. In it he describes how modern technology has reduced the risk of neurosurgery but not eliminated it and how even operations that seem to have gone well can have catastrophic results.

 

The Best Advice I Got In Medical School

It has been a long time but when you get to be an old man you can obsess about what you currently know, what you used to know, and how you got here.  I got some life-changing advice as an undergrad but not much good advice in medical school or residency. I can say without a doubt, the best advice I got was:

“If you are sure you are going into psychiatry, take as many medical electives as you can. Don’t take any psychiatry electives because you will be doing that for the rest of your life.”

I did not have to think too much about it because I enjoyed most aspects of medical education and training. The only two negative rotations I had in my training were based primarily on the staffing patterns at the time and they were not major medical or surgical rotations. They also did not seem to be very interesting. Practically all of the medical and surgical residents I worked with were outstanding in many ways. I felt like an integral part of the team and I was happy to do the necessary work.

As a result of the advice I took endocrinology, cardiology, renal medicine, allergy and immunology, neurology, infectious disease, and neurosurgery in addition to the required general medicine rotations. I took a little flak from the Dean. There was some concern that there were not that many spaces available in medical electives. At one point it was suggested that I should limit myself to two or three medical electives. I prevailed and got what I wanted largely because the specific rotations were at a public hospital and the local VA hospital. 

One of the aspects of medical training that is not discussed enough is camaraderie. When you are a medical student, your role is often ill-defined. The role generally depends on the staff you are working with, the institution, and the general culture within the medical school. At the hospitals where I spent most of my time medical students were an integral part of the team. On day one – you are assigned patients and admissions. You were expected to report on patient progress and write progress notes. You learn communicate with everybody in the hierarchy ranging from the intern to the resident to the attending physician. You are supposed to learn how to research and study the specific problems that your patients had and in some cases do a special report. Examples would include a chart review I did on gram-negative meningitis at the VA medical center and presentation on anaphylaxis on my allergy rotation at Milwaukee County Hospital. Both of those studies went extremely well.

But camaraderie is more than knowing the chain of command, hospital systems, and how to get the work done. A key component is the educational quest that everyone is on. Doing rounds with five or six different people at all levels of training ranging from novice to world expert is experience that you don’t get in many places. Some of the results can be stunning. I did a consult on a patient with possible spontaneous bacterial peritonitis (SBP). I wrote up the consult form and prepared to present to the attending physician that afternoon. When he walked in the room from about 10 feet away, he asked everyone else on the team what the problem was with the patient’s leg. I had been focused on abdominal, systemic, and laboratory findings. Nobody could answer the question. The attending physician who happened to be an expert in streptococcal infections, pointed to a rosy rash on the patient’s left shin and suggested that it was a form of streptococcal cellulitis. He did the necessary tests to confirm that diagnosis at his lab.  One of the many processes that must be attended to in these rounds is the pattern matching aspects of diagnosis. It was vaguely implicit in my training and I realized only later when teaching a course in avoiding diagnostic errors - that these rounds are the place to ask experts: “What are you seeing that nobody else is?” All experts including psychiatrists recognize certain patterns and can make more rapid and more accurate diagnoses than people outside their specialty.

A lot of people reading this may have a hard time believing that what you learned in medical school is relevant to a specialty that you practice your entire life. After all - aren’t these specialties updated at some point and doesn’t your knowledge base become dated? It is surprising how the basic approach to the patient that is unique to each specialty does not change much. There is still relevant review of systems, specialty specific diagnoses, and laboratory testing. Working with specialists for even a month gives medical students and residents a clear idea of how to approach patient problems in a systematic manner. Even though there have been radical changes in some specialties like cardiology, most medical specialties change slowly at the mechanistic level typically with some pharmacological innovation. A clear example relevant to psychiatrists is the endocrinology of metabolic syndrome and diabetes mellitus. Over the course of my career that has resulted in increasingly complex pharmacotherapy ranging from insulin, metformin, and sulfonylureas to an additional five classes of drugs and more complicated insulin preparations.

A unifying concept that I learned on all those medicine specialty rotations is that it is important to still know about these mechanisms and medications even if your specialty involves another bodily system and you are prescribing an additional treatment. No matter what specialty service I was on there was never the idea that we could focus only on a specific bodily system and ignore the rest. On all of those rotations including neurosurgery, I was often the person focused on what was going on with the patient’s brain.

Learning medicine and neurosurgery on all of these rotations was quite exciting. I am much more likely to retain information if I am excited about it. I was excited right up until 11 PM on the last day of medical school.  I was doing renal medicine at the time and the senior resident was going to be a rheumatology fellow. We finished rounding about 6 PM and he noticed we had 4 or 5 additional consults. He was the kind of guy that you really like working with. He had a great sense of humor and was always engaging. He could even engage an introvert like me. I remember him saying: “Look I know - this is your last day but you could really help us out by doing some of these these consults. The new team is coming in tomorrow and I don’t want to leave all of these consults behind.” He threw in a couple of politically incorrect jokes for good measure and I headed off to do two consults. We came back and met with the attending physician who was considerably older than I am right now and finished them all by 11 PM. I really did not want to say goodbye to that team. But I headed off by foot across the golf course sized county hospital grounds to my apartment on 89^th St.

The knowledge gained in that fourth year of medical school was a springboard for the next 30 years. I continue to read about all those medical specialties and remember what happened in 1982. I continue to research all the medical problems and medicines that my patients are taking. I continue to wish at times that I was still on that renal medicine team back at Milwaukee County Hospital.

I didn’t get a lot of good advice in medical school but for all those reasons the advice about what to do in my fourth year was the best.

George Dawson, MD, DFAPA





Supplementary 1:

Second best piece of advice in med school was from the head of our Biochemistry class in the first year.  Our biochemistry class consisted of lectures and research seminars where we read and critiqued biochemistry research. At one of the first lectures, the department head stated:

"Subscribe to the New England Journal of Medicine and read it."

I have been reading it ever since and that was definitely a good idea.


Supplementary 2:

I did take one psychiatry elective in the last two years of med school - Infant Development and Psychotherapy.  It was taught by two psychiatrists who were very excited about the field Frank Johnson, MD and Jerry Dowling, MD - both Medical College of Wisconsin psychiatrists. We screened infants and very young children at risk especially if they had one or both parents with severe mental illness. We instructed parents on how to interact with their children in order to overcome behavioral difficulties associated with disruption of the infant or child and parental bond.  Every week we had a research seminar where we read relevant papers on the subject.  We had a very large clinic where we did evaluations and saw large groups of parents. It was a very positive experience and has implications to this day.  As far as I know there are no clinics in the US like the one we had in 1982.  It provided a valuable service to infants, young children, and their families.

1: Wesner D, Dowling J, Johnson F. What is maternal-infant intervention? The role of infant psychotherapy. Psychiatry. 1982 Nov;45(4):307-15. PubMed PMID: 7146225.

There Is No Identity Crisis in Psychiatry

The New England Journal of Medicine published an opinion in their October 31, 2019 edition titled “Medicine and the Mind-The Consequences of Psychiatry’s Identity Crisis” (1).  Claiming that psychiatry (meaning organized psychiatry and all psychiatrists) has some sort of an identity crisis is a favorite editorial topic these days. It lacks face validity considering over 40,000 psychiatrists go to work every day, have working alliances with their patients, treat problems that no other doctors want to treat, and get results. Furthermore, most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administrators and politicians and have no clinical value.

The authors in this case fail to see that problem. In their first paragraph they critique “checklist amalgamations of symptoms” as if that is psychiatric practice or what psychiatrists are trained to do in their residency programs. I happen to be an expert in these checklists because I have been critiquing them from the outset. The state of Minnesota mandates that all patients being treated for depression in primary care settings have to be rated on these checklists over time, and that data is supposedly analyzed as a quality marker. Anyone familiar with the analysis of longitudinal data will realize that cross-sectional data points on different patients at different points in time are meaningless. But that doesn’t prevent politicians in Minnesota from dictating psychiatric practice and it doesn’t prevent these authors from blaming psychiatry for it.

Their additional opening critique on “medication management” ignores the fact that this procedure was invented by the federal government. This procedure and all the associated billing codes did not exist in psychiatry until HCFA thought it was a good idea to assign these codes to psychiatrists and call them “medication management”. It was only recently that psychiatry could use the same E & M codes that the rest of medicine uses for the provision of complicated care including psychotherapy. Instead of just stating that the authors say “We are facing the stark limitations of biological treatments, while finding less and less time to work with patients on difficult problems”.  Apart from the rhetoric I don’t know what that means. If I have a patient with a difficult problem - I make the time to work on it.  If there were any stark limitations in psychiatry – they occurred before the invention of biological treatments. In those days, people died from severe psychiatric disorders and the associated effects of severe hyperactivity, starvation, and dehydration.  Many people also had their lives disrupted when they were sent to state mental hospitals for years or in some cases decades.  Those were the historic limitations in psychiatry.

They move onto a critique about diagnosis and their opinion that “the solution to psychological problems involves matching the “right” diagnosis with the “right” medication". I don’t know where the authors went to psychiatry school but that is a new one on me.  At a different point in their opinion piece they critique the current diagnostic manual. If they read that manual they would notice there are conditions with strictly psychological and social etiologies that do not require medical treatment. They also minimize the role of tertiary consultants like myself. I see thousands of people who were started on psychiatric medications by non-psychiatrists. There is clearly a lack of expertise prescribing those medications and I make the necessary adjustments including stopping medications that were inappropriately prescribed. I also prescribe the indicated treatment when it was never provided in the first place. That all happens in the context of a therapeutic relationship and providing necessary psychotherapy.

Somehow the authors conclude that a lack of “scientific and intellectual integrity” does a disservice to patients, practicing psychiatrists, and medical colleagues. They suggest that medical colleagues are striving to provide the best possible and “most humane care to people with medically and psychologically complicated conditions”. I don’t know who the authors think is holding up the psychiatric and psychological end of that treatment. I worked in a multidisciplinary clinic with every imaginable consultant for 22 years. Nobody hesitated to refer patients to me for psychiatric care. They knew it would be comprehensive, that the assessment would be exhaustive, and that the treatment plan would be beneficial. We also had an active consultation-liaison team that provided active ongoing consultation to a large medical-surgical hospital. Without those psychiatric services there is no “humane care” to the medically complex psychiatric patient. This psychiatric function is widely known and these treatment plans can be read directly from the pages of the NEJM.

The authors provide a one sentence sketch of brain function and how the external world affects our “brain-minds”. They grudgingly acknowledge that basic science may be a necessity. They bemoan the fact that advances in neuroscience “are still far from offering real help to real people in hospital, clinic, and consulting room”.  That is not what I observed in 35 years of practice. There has been a steady improvement in psychopharmacology both in terms of safety and selectivity. There have been major advances in neuromodulation -both electroconvulsive therapy and transcranial magnetic stimulation. There have been pharmacological advances in addiction psychiatry with more medication assisted treatments. There have been advances in specific conditions like severe psychiatric disorders associated with pregnancy and various forms of catatonia. The diagnostic advances related to basic science research have been stunning. When I first started consulting in nursing homes 35 years ago - every diagnosis was either “senility”, “senile dementia”, or “atherosclerosis”. There were no science-based diagnoses of dementia in those days. We currently have a comprehensive approach to detailed dementia diagnoses as well as a comprehensive approach to diagnosing 127 different conditions associated with substance use disorders all neatly detailed in the diagnostic manual that they seem to have a problem with. Hopefully there is no more “senility” in nursing homes.

The authors attack neuroscience in the usual ways. They state they agree that discoveries in neuroscience are exciting but on the other hand “are still far from offering real help to real people in the hospital, clinic, and consulting room.” They restate that twice in the space of this brief essay. Is that true?  Some reading in the area of translational psychiatry might be in order. Every week I assess many patients for anxiety disorders. A significant number of them have been anxious their entire life. There are currently no good conceptualizations and indicated treatments that separate this group from people who develop anxiety later in life. From the work of Kalin and others (3,4), the biological basis of anxious temperament and potential solutions to lifelong anxiety is now becoming a possibility. Progress in neuroscience has gone from receptors and neuroendocrinology in the 1980s to genetics and multiomics in the 21^st century. Now there is more than speculation and empirical trials. Entire mechanisms that include genetics, transcription, anatomic substrate and the impact of the environment on brain systems are determined.

There is in fact a group dedicated to bringing neuroscience into the clinical realm – The National Neuroscience Curriculum Initiative. It is possible to think of a neuroscience-based formulation as easily as one might think of a psychodynamic formulation.  The point of neuroscience research in psychiatry is the same as it is in any other specialty with one exception - the organ being studied is more complex and generates a conscious state. The basic science of practically every other field has been studied more intensely and with more resources than brain science has been studied. Many other fields have not produced miracle cures when it comes to chronic illnesses and the basic treatments of these illnesses have been static for decades. The cures or disease altering interventions often occur after much more time has been spent studying them then we have spent studying the brain. In that context, basic science brain research is as on track as any other field

The most erroneous opinion advanced by these authors is that psychiatry has somehow abandoned the social and psychological elements of care. They cite an author who is a historian and who suggests that psychiatrists should limit their scope to “severe, mostly psychotic disorders”. There are many authors with similar irrelevant opinions about psychiatry but they generally aren’t quoted in an opinion piece for the NEJM. Nothing that author says is realistic or accurate in this article, but that is typical of the so-called critics of psychiatry. The authors own proposals for change in psychiatry are similarly irrelevant because it is apparent that they have a limited understanding of what is going on in the field or what psychiatrists do on a day-to-day basis.

The next section of their opinion piece is about funding and how biological funding has “replaced all other forms of psychiatric research”. They provide no evidence in terms of actual numbers. I expended some effort to try to do that.  I asked NIH, NIMH, SAMHSA, one of my US Senators and I tweeted the director of the NIMH to get an answer to the question about the proportion of funding for basic science versus psychosocial mental health research. I also searched the AAAS research reports to see if anything was listed there. What I got back was largely devoid of any useful data.  The above links were sent to me by a public affairs specialist at the NIH.   

I remembered reading about an analysis in American Psychologist suggesting that 30% of the $1.6B NIMH budget goes to psychosocial research. I was able to find the article (2) and it was not straightforward as most advocates of increased psychosocial research think. That 30% figure comes from a graphic generated by a review of research abstracts of 15% (2,028) of all funded studies from 1997-2015. They were coded on a 1 - 5 scale by doctoral level students where 1 = entirely focused on biomedical topics to 5 = entirely focused on psychosocial topics.  There was a positive trend in favor of biomedical research but the authors point out several limitations in the data and areas for further study. And they make this important comment:

“A test of the differences in regression slopes indicated that there was, however, no difference in the increase in award size for R01 grants, F(1,475) = 3.97, p = ns, suggesting that the proportion of biomedical grants awarded increased, but they did not receive disproportionately larger awards than psychosocial grants. This is notable given that biomedical research is often more costly because of expensive procedures and larger research teams.” (p. 417-418)

This reference provides a very balanced look at the issue including a discussion of the significant limitations of psychosocial treatments - something that you do not see in the NEJM piece or from the people claiming that basic science research is clinically worthless. 

Although the authors are critical of neuroscience results, they don’t seem to mention the lack of innovation in psychotherapy and other psychosocial therapies. More significantly they ignore the fact that these therapies are routinely not funded by managed-care companies, government insurers, and responsible counties. They blame psychiatry for the “abandonment and incarceration of people with chronic, severe mental illness” when in fact the necessary psychiatric beds and inpatient facilities as well as community housing for these patients has been actively shut down by businesses and governments over the past 30 years.  It seems that counties have adapted managed-care practices that includes rationing services for the chronically mentally ill to the point that they end up in jail. The authors seem to conveniently blame psychiatry for that. Once again they could read about what psychiatry really does in the pages of the NEJM and how these very patients are served by ACT teams. The treatment approach was invented to improve the quality of life of people with chronic mental illness and support them in independent living. It does not work in a vacuum and there has to be a funding source.

The authors suggest that psychiatry needs to be “rebuilt”. From their suggestions about training programs I wonder if they participate in training programs, teach residents, and work on resident curricula.  And if they do - I wonder what that training program looks like. I say that because all the suggestions they have seem to have been in place for decades. In fact, their entire argument is reminiscent of the old "biological psychiatry versus the therapists" argument from about 1984. That argument should stay firmly planted in the "old history" folder.

Their concluding paragraph is a extension of earlier rhetoric.  They talk about psychiatry having an exclusive focus on “biological structure” rather than meeting the needs of real people. I go to work every day and talk to real people all day long. I know quite a lot about the biological structure the brain and its function. I must because I don’t want to be treating a stroke, brain tumor, a traumatic brain injury, or multiple sclerosis like a purely psychiatric problem. I also realize that if I conceptualize the psychiatric disorder as a specific brain area or network - that is still occurring in a unique conscious state. That conscious state is generated by the most complex organ in the body. It is an organ with tremendous computational power. All psychiatrists are treating people with unique conscious states and there is no specialty more aware of that. And in that complex setting psychiatrists are focused on helping the people they are seeing. They are the only ones accountable.

There is no “identity crisis” in psychiatry. Making that claim requires a suspension of the reality about how psychiatrists are trained and the grim practice environments that many of us face. Those grim practice environments are the direct result of governments and businesses actively discriminating against psychiatrists and their patients. That has resulted in discrimination that is so gross that county jails are now regarded as the largest psychiatric hospitals in the USA.  Pretending that these problems are the result some flaw in psychiatrists one of the greatest medical myths of the 21^st century.  These authors and the New England Journal of Medicine are promoting it.  This opinion piece is so poorly done it makes me wonder what the editorial staff at NEJM are doing. It is as bad as another opinion piece that should never have been published in the psychiatric literature.   

The real message from the profession that should be out there is:

“Give us a practice environment where we can do what we are trained to do! Get out of the way and let us do our work! Give us the resources that every other medical specialist has!”

Very few of those environments exist.  They have been rationed out of existence by politicians, bureaucrats and administrators.  People who know nothing about the field seem to be totally unaware of that problem and like these authors they never comment on it. Only people lacking that awareness would believe an article like this - or write it.

George Dawson, MD, DFAPA

References:

1: Gardner C, Kleinman A. Medicine and the Mind - The Consequences of Psychiatry's Identity Crisis. N Engl J Med. 2019 Oct 31;381(18):1697-1699. doi:10.1056/NEJMp1910603. PubMed PMID: 31665576.

2: Teachman BA, McKay D, Barch DM, Prinstein MJ, Hollon SD, Chambless DL. How psychosocial research can help the National Institute of Mental Health achieve its grand challenge to reduce the burden of mental illnesses and psychological disorders. Am Psychol. 2019 May-Jun;74(4):415-431. doi: 10.1037/amp0000361. Epub 2018 Sep 27. PubMed PMID: 30265019.  

I thank these authors for making this paper available on ResearchGate.

3: Kalin NH. Mechanisms underlying the early risk to develop anxiety and depression: A translational approach. Eur Neuropsychopharmacol. 2017 Jun;27(6):543-553. Doi: 10.1016/j.euroneuro.2017.03.004. Epub 2017 May 11. Review. PubMed PMID: 28502529; PubMed Central PMCID: PMC5482756.

4: Fox AS, Kalin NH. A translational neuroscience approach to understanding the development of social anxiety disorder and its pathophysiology. Am J Psychiatry. 2014 Nov 1;171(11):1162-73. doi: 10.1176/appi.ajp.2014.14040449. Review. PubMed PMID: 25157566; PubMed Central PMCID: PMC4342310.



Supplementary:

The Psychiatry Milestone Project: an indication of what psychiatry residents are evaluated on in their training programs. Link.

Graphic Credit: 

The graphic was downloaded from Shutterstock per their standard user agreement.

What Do Surgeons and Psychiatrists Have In Common? - Dread

I have had two surgeries this summer that have really impacted my work and daily life.  I only consent to surgery if it is a problem severe enough that I can't function or will kill me and the first one was for that.  I found a highly skilled surgeon who had done more of the procedures than occur in most countries in the world.  The procedure itself seemed to go surprisingly well. He gave me a prescription for oxycodone but the only treatment I needed for post op pain was acetaminophen.

I went in to see him a month later and everything was still going very well. No surgical complications and the target symptoms were in good remission. I did well for another 2 weeks and then got symptomatic again.  I was reexamined and the original surgery had scarred over requiring a second surgery to remove the scar tissue. He explained that is was very rare in his practice for that to happen, but that he did need to fix is as soon as possible.  The second surgery as done and I was functioning as good as new again.  He advised me to come back in 6 months for follow up.

There were post operative complications.  Despite antibiotic prophylaxis given during surgery I developed an infection with a fever and tachycardia.  He prescribed antibiotics but it got worse. I eventually went into the emergency department at midnight and was given intravenous Rocephin and told to continue the oral antibiotics until they were gone.  The infection cleared up in about 5 days.

I did very well and then at the 6 week mark again, I got progressively symptomatic and called the surgeon again:

Me:  "The symptoms are back, at about the same time frame and course of onset as they were in the past. Do I need surgery again?"

Surgeon: "Well probably.  It is highly unusual that it happened the first time and even more unusual if this has happened again.  I will just schedule the OR so we can take care of it early next week.  Can you do it then."

Me: "Well yes - I will do whatever I need to do to take care of this problem. I can't really go on like this."

Surgeon:  "I was just talking with my partner here and we need to alter the procedure to really remove more tissue when we take out the scar tissue this time. We really need to open that area up"

He sounded a little shaken. He is a top surgeon in his field and this is not just one complication but a second complication of the same initial surgery.  He was consulting his colleague and in this group all of the surgeons are very experienced and highly regarded. I wondered if he was concerned about what I was thinking?  He was safe there - even though it is practically an American standard to blame surgeons for sub-optimal outcomes that was never going to happen. I have seen surgeons with less skill than others and I picked him because of his record. There was no way that I was not going to let him do his job or suggest that I was in any way dissatisfied with his work.

I started to think about all of my years in acute care and how common it was to walk in the door in the morning and get blamed for everything by people who I have never seen before.  People who were there because they were in an alcohol or drug induced state and ended up under my care because there were unsafe and needed to be detoxified and in some cases treated for the psychiatric complications of substance use. People who were admitted for severe psychiatric disorders and associated aggressive or suicidal behavior.  Once they learned I was their psychiatrist - it was my fault that they were there - even though it was my job to get them out of there as soon as possible. My failure to do that resulted in a second tier of blame.  This time by hospital administrators who were often quite aggressive in encouraging me to get patients out of the hospital whether I though they were stable or not.  Shortly before I left the job, one of them actually told me that if I did not get the patient out - he would come down and discharge the patient himself.

I smiled to myself at that point and realized it was a very good thing that I was not blaming my surgeon for anything.

And then I thought about being in the same situation. Most people who have not practiced in acute care have not seen some of the problems that have no solutions.  Aggressive behavior that does not respond to medications.  Catatonic behavior that rapidly leads to life threatening dehydration or starvation.  Bipolar patients on dialysis who are delirious for months waiting for kidney transplants.  Patients with multiple medical complications who are agitated and can't sleep.  On some days an endless list of problems that would keep me up all night long trying to figure out solutions.  I would call and email one of three colleagues who I knew I could count on. They had been working acute care as long as me and I always appreciate their input. We only consulted one another in situations where we had no obvious solutions and we also had a sense of dread. Dread in the sense that you start to ask yourself: "Is there really no solution here? What am I missing? Have I lost it? Do I need to take a break and work somewhere else for awhile?"

There were a lot of nights where I would just lay in bed, thinking about the situation - sensing the blood pulsate throughout my body and feeling a light sweat on my skin. I would get out of bed in the morning amped up on adrenaline and feeling like I had slept for 8 hours when it was probably closer to 1 or 2.

Luckily in my case, there was resolution.  It could happen after a couple of sleepless nights. On many of those nights I would have contact with the nursing staff to see if any modifications could be done while I was away.  I would finally get a break and things would be all right for 2-4 weeks before another crisis hit. It would usually be a surprise. I walk into the unit in the morning and hear "Mr/Mrs Smith is up out of bed eating this morning.  They made a big turnaround last night."

Hoping for that break is the only thing that kept me going. You can only tell yourself that you have done everything right for so long. I never got to the point where I expected that break. It always struck me as very lonely and bleak. My senses seem dulled and everything slowed down around that problem. When the break happened - life was finally good again.

I was able to step back from these associations and realize that my surgeon was likely experiencing some of the dread I typically encountered in acute care.  Despite extended and best efforts - things are not going well and you don't really know why. There are no easy or apparent solutions.

Surgeon: "I should probably see you tomorrow before the surgery. I am sorry this happened. Can you be there are 7:30?"

Me: "Thanks. Yeah I can be there at 7:30.  See you then."

I was very calm and I slept well that night.


George Dawson, MD, DFAPA





Image Credit:

1.  Above image as my second preop identification and allergy band.

2.  Image for Twitter post was from Shutterstock per their standard agreement by Francey Scary Foggy Road downloaded on 10/14/2018.