Category: Consult-Liaison

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Consult-Liaison Reflection

Killing and Suffering.

To become a doctor, one learns how to prevent disease and death. To do this, one first must become acquainted with them: What happens? What does disease and death look like? sound like? smell like? What are their textures and patterns? What shifts over time, until the patient has no more time left?

As medical students learn what disease and death look like, they witness human suffering. Many students are unprepared for this. The tears that physicians in training shed are not from recognition of the mechanisms of disease and death. They cry because of the human suffering that surrounds them, that submerges them.

We don’t cry because we recognize that the proteins in the coagulation cascade aren’t reacting fast enough. We weep because there is so much blood everywhere. We see how pale their skin is, hear their rapid heartbeat on the monitor, and feel the coolness of their skin.

We see the contortions of their loved one’s face. We hear them scream, their sobs escaping their throats.

If we cry when we witness the suffering of one or two human beings, won’t we still cry when this happens to multiple human beings who are infected with a pandemic illness?

What if the cause of death isn’t a disease, but is instead a person? How do we then react?

Some psychiatrists recently shared the mental model of projection to explain why people kill others. Briefly: Projection is an unconscious process. People generally don’t think of themselves doing “bad” things:

  • I would never hate people because of their religion.
  • I would never treat people differently because they are poor.
  • I would never deny someone a place to live.

… even though they may have fleeting thoughts or impulses that align with these.

In projection, someone will “project” negative thoughts and impulses onto someone else and deny that they themselves ever have them:

  • I’ve done the work and I don’t have implicit biases. That guy, though, hates anyone who belongs to that religion.
  • I’m open-minded and understand that people who are poor are still people. That person, though, thinks poor people are all lazy and stupid. Just a bunch of moochers.
  • Of course everyone deserves a place to live. That guy, though, thinks some people deserve to be homeless. He thinks they’re all criminals and deserve to die.

In projection, we (unconsciously) don the gown of righteousness. We can do no wrong. Our intentions and motives are pure. In projection, we (unconsciously) coat The Other Person in the rags of depravity. They are evil. They only want to do bad things.

We are nothing like them. We could never be like them. They could never be like us. Anything we do glows with virtue. Anything They do is wrong.

We crush cockroaches underfoot because we are nothing like them and could never be like them.

How different are They from cockroaches?

We can’t test for projection. This is supposed to be an entirely unconscious process. (If we were conscious that this were happening, we would (should?) be horrified. We could not tolerate this and would take steps to stop it.)

I don’t discount the idea of projection for killing, but because there is no way to validate it, this is not the first explanation I go to. There are also a lot of steps: I’m a good person, you’re a bad person, you’re so bad that I don’t think you’re a person anymore, so killing you isn’t actually killing a person.

The dehumanization that comes from neglect is more compelling to me than the dehumanization that comes from projection. Indifference can cause more harm. It can be a conscious choice.

It’s not that I think you’re subhuman or an animal. I just don’t think about you at all. Torturing and killing an animal, even a cockroach, means that I at least thought of you as something that can react. If I don’t think about you at all, then you already don’t exist. And what sort of reaction could you possibly have if you don’t exist?

What harm could torture, rape, and murder have on nothing? If you don’t exist, then I’m not killing anyone in hospitals and schools. There are no children. I’m just flattening buildings.

You don’t matter. You have no matter.

People, like you and me, weep around the world.

A man cries for his son who will not live to start school because of the cancer in his brain. A son cries for his mother who died in an accidental plane crash. Someone cries for a friend of 60 years because their heart stopped beating.

Death from disease and the random events of life already causes suffering. Do not cause more suffering by killing other people. You will not only destroy others, but you will also destroy yourself.

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Consult-Liaison Medicine

Analysis of How a Baseball Team Responded to Alcohol Misuse.

Three glasses of alcohol with ice cubes in the foreground.

Related to my ongoing efforts to be a better spouse by learning more about baseball: On August 1, 2023, New York Yankees pitcher Domingo Germán was reportedly intoxicated from alcohol and ended up “flipping over a couch and smashing a TV” in the team clubhouse.

The New York Post further reported that he

was held in a sauna as the team tried to get him to sweat out the alcohol.

He was then placed in a team nap room as team security watched over him, but it’s uncertain when he left Yankee Stadium.

The Post also reported: “Witnesses determined that Germán was under the influence of alcohol and did not appear in control of his emotions.”

Germán ultimately “[sought] treatment for alcohol abuse”. Other outlets reported that he voluntarily went to residential treatment and will not play for the Yankees for the rest of the season.

Let’s discuss.

Humans do not “sweat out” alcohol. We each have an amazing organ called the liver, which is the primary organ that metabolizes alcohol. Enzymes in liver cells break down the alcohol so it is no longer toxic. (… though some groups, like some East Asians, may have a bum version of this enzyme, called aldehyde dehydrogenase.) Though skin is the largest organ we have, it does nothing to make alcohol leave the body faster.

Note that even pro-sauna sites discourage people from using saunas to sober up.

Putting Germán in a sauna could not help him get sober faster.

Livers work at their own steady pace to clear alcohol. The enzymes that break down alcohol do so in a “linear” fashion, meaning that the same amount of alcohol leaves the body over time. It doesn’t matter how much alcohol is in the body.

In the United States, the legal blood alcohol level is 0.08%, which means there are 0.08 grams of alcohol in 100 milliliters of blood. Because decimals require more precious brain power, we can convert that to 80 milligrams per deciliter of blood. And we’ll abbreviate that even more and just use the number 80 when talking about blood alcohol concentration.

Because livers break down alcohol in a linear fashion, we can talk about blood alcohol concentrations decreasing by a fixed number per hour. While in training, jaded and cynical health care professionals taught us that anyone who comes into the emergency department intoxicated with alcohol has an alcohol problem.

“Their blood alcohol level will drop 30 points an hour,” they said. This means that if someone came in with a blood alcohol concentration of 200, their blood alcohol level would drop to zero in about seven hours.

This rate is likely an overestimate. While it is true that people who routinely drink large amounts of alcohol will have livers that will metabolize alcohol faster (because, remember, your amazing liver is looking out for you and wants to get that toxin out of your system as soon as possible), most livers aren’t breaking down alcohol at 30 points an hour. This paper suggests that most people metabolize alcohol anywhere between 8 and 32 points an hour.

Putting Germán in the nap room did not help his liver work faster, but at least gave his liver a quiet space to do its amazing work.

No one is “in control” of their emotions. Emotions happen. They often give us valuable information about ourselves and the world around us. We are more likely to have some control over our behaviors. There seems to be a conflation of “emotions” and “behaviors” in baseball (see “Mariners’ Jarred Kelenic breaks his foot kicking a water cooler, makes emotional apology to team“.) They’re not the same thing. You may feel anger at someone, yet restrain yourself from punching them. Or frustration with yourself, but not drink alcohol or kick something.

Dr. Viktor Frankl shared wisdom about this:

“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”

Sure, emotions might cram into that space between stimulus and response, but a gap can appear where we can choose what behavior to do next.

“Voluntary” entry into residential treatment for alcohol misuse doesn’t mean there wasn’t coercion. Indeed, people may not be forced into rehab, but there might be conditions (e.g., if you don’t go into rehab, we’re kicking you off the team; or “interventions”, as John Mulaney described in his stand up special). To be clear, I have no idea what happened: Maybe there wasn’t any coercion at all. The timing just seems… curious.

If Germán actually entered treatment on the day reported, that’s remarkable (though not surprising): For people or corporations with gobs of money, you can pay for quick access. For people who don’t have money, it often takes weeks or months to enter residential treatment for substance use.

This was perhaps the most jarring aspect of the story for me: Where were the doctors? Sports teams have psychologists, physicians, and other health care professionals. Did they not know about his reported intoxication and behavior? Any one of them could have stopped the nonsense of sauna “treatment” and promoted rest, hydration, eating, etc. If they knew and didn’t do anything, that’s worrisome: What got in the way?

If they didn’t know, I’m not sure if that points to problematic team dynamics or stigma. Alcohol misuse and alcohol withdrawal can cause literal disease and death. Did the team want to hide Germán’s substance use from the team doctors? Did team members simply not recognize that alcohol misuse is a health problem that responds to psychological and health interventions? Did the team health care professionals view alcohol misuse as outside of their purview?

Although deaths from opioids (especially fentanyl) are getting a lot of attention these days, way more people suffer injuries and die from causes related to alcohol. I hope that Domingo Germán and anyone else who has alcohol overtaking their lives will receive useful support and won’t be relegated to saunas and other bunk interventions.

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Consult-Liaison Observations Systems

Demoralization and Status.

This TikTok video provides an accurate (and shouty) summary of the National Guard member who leaked classified military documents. In short, it appears that the Airman shared these documents in an effort to elevate his status within an online cohort. (Someone on the internet opined something like, “This was a cosmic level of stepping on a rake that hits you in the face.” Correct.)

We all have engaged in behaviors to heighten our position in relation to others. Depending on who you ask, some argue that we are constantly adjusting our behaviors to communicate and maximize our status.

Our perception of our own status is not always accurate. It seems that we sometimes exert tremendous effort to demonstrate high status to make ourselves feel better, rather than to assert that we have higher rank than others. (Much research has been done to show how humans assess and react to status.)

Maybe it’s a stretch to link demoralization and status to each other, though this is what has come to my mind over the past few weeks. Demoralization is usually framed as an individual process, whereas status involves groups of people.

Merriam-Webster provides the following definitions:

  • demoralization: weakened morale; to be discouraged or dispirited
  • status: position or rank in relation to others

I’ve written about demoralization before, though it was more in reference to individuals experiencing medical illness. The paper I reference in that post offers this definition of demoralization:

the “various degrees of helplessness, hopelessness, confusion, and subjective incompetence” that people feel when sensing that they are failing their own or others’ expectations for coping with life’s adversities. Rather than coping, they struggle to survive.

This is where I might be speaking out of turn: Is it fair to apply principles usually applied to a single person, particularly one’s intrapsychic processes, to groups of people? (Would I be a true psychiatrist if I didn’t use the word “intrapsychic“?)

But let’s consider this together. I’m starting with the Airman, but that isn’t actually the point of this post.

What if that Airman was feeling demoralized? Within his Discord group, he may have been able to rely on his age to maintain high status. What teenager doesn’t think a 21 year-old person is cool? But what if group dynamics shifted and, suddenly, the Airman was no longer the proverbial “alpha”, but had been demoted to a “beta”?

In an effort to restore his status, he might have employed any one of the strategies to reduce his vulnerability:

The sharing of classified military documents isn’t a demonstration of resilience, but it is a display of power that produces postures of coherence, agency, and courage. In sharing classified papers that only he has access to, he is dissolving any confusion he or anyone else may have about his “rightful” status. To combat feelings of helplessness, he demonstrated agency to provide evidence of his power. It takes some flavor of courage (…) to share sensitive information. By sharing these documents with his Discord cohort, he facilitated communion, established a purpose for himself, and got to bask in the gratitude of his friends. What a way to escape the isolation that accompanies a degradation of status!

So let’s consider other things that are happening in the nation that might be reactions to demoralization and efforts to reinstate high status: states banning TikTok, banning abortions at six weeks, protecting access to transgender care.

Again, is it fair to apply individual, intrapsychic processes to groups of people, particularly groups of people in politics? (But aren’t political groups comprised of individual people?)

The passage of laws—something that feels real and concrete—brings coherence and fosters communion! It brings hope and purpose! Doing something—exhibiting agency—summons courage and generates gratitude! Your rank in relation to others feels like it is rising. Even though there are people who will view your actions as further erosion of your status, it doesn’t matter: You feel better. You feel more power.

The passage of laws reduces confusion, despair, and helplessness. Instead of feeling isolated, people can channel their feelings of helplessness and resentment into doing something, which makes cowardice evaporate. You may already possess high status—all the other people around you may already defer to you because they view themselves as having lower status. And, yet, if you feel demoralized, the positive regard from others may be insufficient to elevate your own status in your own eyes.

We can never get away from ourselves.

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Consult-Liaison Reading

Biased Thoughts.

The only social media platform I have yet to abandon is Twitter. It’s a good example of “variable ratio reinforcement”. Think of a slot machine: People put money into it with hopes of winning a jackpot. A reinforcer increases the likelihood that a specific behavior will happen. Here, the reinforcer is the pay out. The chance of a jackpot makes it more likely that someone will stay and continue to put money into the slot machine. However, the slot machine doesn’t pay out money on a predictable schedule or ratio. Jackpots happen on a variable schedule. This “variable ratio reinforcement” is what keeps people at slot machines (a specific behavior) for hours.

The Twitter algorithm occasionally (on an unpredictable, variable schedule) shows me interesting and useful information. It recently introduced me to a paper called Toward Parsimony in Bias Research: A Proposed Common Framework of Belief-Consistent Information Processing for a Set of Biases. (Though the paper isn’t too jargony, it is wordy… but worth your attention if you like this sort of stuff.) Of course, this paper played right into my biases: I like parsimony (or, more simply put, in a world of Lumpers and Splitters, I am generally on Team Lumper) and I like thinking about biases and how they affect our emotions and behaviors.

The authors argue that bias is embedded in every step we take when we process information. We already have a set of beliefs. Unless we exert deliberate effort, our thinking habits automatically try to confirm what we already believe. This bias manifests in what we pay attention to, how we perceive things, how we evaluate situations, how we reconstruct information, and how we look for new information.

The authors also put forth the idea that most of our biases are forms of confirmation bias. (The list of biases is biased towards Splitters; see this enormous list of cognitive biases on Wikipedia.) As Lumpers, the authors distill common biases down to two:

  • “My experience is a reasonable reference.”
  • “I make correct assessments.”

As a result, they argue that we can significantly reduce our biases “if people were led to deliberately consider the notion and search for information suggesting that their own experience might not be an adequate reference for the respective judgments about others” (see comment above about article wordiness) and “if people deliberately considered the notion that they do not make correct assessments”.

My mind then ties these biases into the primary framework of cognitive behavioral therapy (CBT). CBT is a type of psychotherapy that focuses on identifying and changing thoughts to then alter emotions and behaviors. The three “categories” of “thought targets” include:

  • core beliefs (things we believe about ourselves, other people, and the world that come from our past experiences)
  • dysfunctional assumptions (we tend to believe “negative” things, rather than “positive” things)
  • automatic negative thoughts (these are “habits of thought” that we are often unaware of; much of CBT focuses on recognizing and identifying these thoughts)

(This is a common complaint about CBT: “So you’re telling me that my problem is that I think ‘wrong’ thoughts. Thanks a lot.”)

If it is true that biases can be reduced to only two, then can we assume that these two beliefs—that we ourselves are reasonable reference points and that we make correct assessments—should be common “thought targets” in CBT? Instead of chasing down every single “automatic negative thought”, could we instead focus on these two common beliefs? (I see value in reframing it this way. Labeling something as an “automatic negative thought” can preclude the value that the thought has in our daily lives. For example, I might have the automative “negative” thought, “I am not entirely safe when I go outside.” However, this automatic thought—which may have led me to take self-defense classes and always monitor my surroundings—may have contributed to me staying out of harm’s way. Astute readers will note that my example included the word “entirely”. It is up for debate about whether the inclusion of that word makes it an adaptive, nuanced thought or a true “negative” automatic thought.)

Focusing on these two beliefs seems to tread into Buddhist psychological thought, too. From a lens of impermanence, are thoughts even real? Can they be sustained? Our ideas—our thoughts—can be reasonable in one moment, and completely unreasonable in the next. Same with our assessments: New data and new context can make our assessments wrong in a moment. And what about non-self? Can we even speak of “my reasonable reference” and “my correct assessments” if, in fact, there is no “self”? And aren’t thoughts yet another concept that keep us trapped in suffering?

So, I think there are three main ideas to take from this post:

  • Twitter has some value, some of the time, and is an excellent demonstration of variable ratio reinforcement.
  • You might be able to significantly reduce your cognitive bias if you adopt two habits of thought: (1) Look for evidence that your own experience is inadequate when assessing other people and situations, and (2) Look for evidence that you do not make correct assessments.
  • An oldie but goodie: You can’t always believe what you think.
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Consult-Liaison Nonfiction

Delirium Adventures with ChatGPT.

I still think one of the most valuable skills psychiatrists have is to help distinguish psychiatric illness from “delirium”, which, for the purposes of this post, we can call “acute brain failure”. Other organs can abruptly stop working for a variety of reasons. Hepatitis infections can cause acute liver failure; dehydration can lead to acute kidney failure; we’re all familiar with acute heart failure, too.

Delirium is a symptom of an underlying medical condition. It’s like a fever or a cough: Many conditions can cause fevers or coughs, so you have to seek out the “real” reason. When people develop delirium, their thinking, behavior, and levels of consciousness change abruptly. People can get confused about who or where they are; they might start seeing things or hearing things that aren’t there; sometimes they seem to “space out” for periods of time. These are all vast departures from their usual ways of thinking. (The abruptness here is key; people with dementia may have similar symptoms, but those typically develop over months to years.)

(Fellow psychiatrists and hospital internists recognize that delirium isn’t always that dramatic. Sometimes people are lying quietly in bed, hallucinating and feeling confused, but never behave in a way that would suggest otherwise.)

Because I spent a few years working in medical and surgical units (where the risk of delirium is higher than in the community), it is still my habit to consider delirium when I am meeting with people. Given the disease burdens that people experiencing homelessness and poverty face, this is prudent. (Fellow health care workers might also more likely to believe a psychiatrist when we report that someone might be delirious, rather than psychiatrically ill.)

I wondered if there is any evidence to support that psychiatrists are more likely to detect delirium compared to other health care professionals. Enter ChatGPT.

ChatGPT cited two papers that reported that, yes, psychiatrists are more likely to detect delirium, though shared only the journal and the year, along with a summary of results. I asked for a list of authors for one, thinking that might help narrow down the search. It did not. So then I asked for the title of the two papers.

I could not find either title on Pubmed. This was curious. And concerning.

I then asked ChatGPT to share with me the Pubmed ID (a number assigned to each article) for each paper. Here’s what happened:

ChatGPT said that the first paper, “Detection of Delirium in the Hospital Setting: A Systematic Review and Meta-Analysis of Formal Screening Tools”, was published in the Journal of the American Geriatrics Society in 2018. ChatGPT said that the ID was 26944168. In PubMed, this leads to an article called “Probable high prevalence of limb-girdle muscular dystrophy type 2D in Taiwan”.

The second paper reportedly had the title of “Detection of delirium in older hospitalized patients: a comparison of the 3D-CAM and CAM-S assessments with physicians’ diagnoses”. (CAM stands for Confusion Assessment Method, which is a real, validated tool to help measure delirium.) ChatGPT said that the ID was 29691866. In PubMed, this leads to an article called “Gold lotion from citrus peel extract ameliorates imiquimod-induced psoriasis-like dermatitis in murine”. (I did learn that “gold lotion” is “a natural mixed product made from the peels of six citrus fruits, has recently been identified as possessing anti-oxidative, anti-inflammatory, and immunomodulatory effects.”)

It makes me wonder how ChatGPT generated these articles and their titles, where it created the summaries from, and where it found the PubMed ID numbers.

Indeed, ChatGPT is artificial, but not so intelligent. And it will take me a bit more time to find the answer to my question.