IDAA 2017 - Snowbird, Utah -Closing Comments

IDAA 2017 Annual Meeting has concluded for another year. I loved Cliff Lodge in Utah.  The venue, other than the altitude at 8100 feet, was spectacular. The views were incredible, mountains, pine trees and spruce. We had blue sky and sunshine.  People who hiked the trails encountered moose, elk and deer.  I love the little ground squirrels called pot guts. 

I loved the 5 k run. It got me outside in the early morning.  I enjoyed jogging down hill on the trail and by the day of the run I’d acclimatized enough to walk up hills without a myocardial infarction. Later I loved sitting in the outdoor hot tub and then swimming in the pool.  The view really was incredible.

I was moved to tears to see so many faces I knew. I loved that they smiled back.  We hugged and bubbled over with news.  A year had gone by. I spoke of the death my brother and friends. I heard of deaths of others I knew.  We grieved together.  There were struggles with practice and licensing bodies and we laughed at those struggles knowing they too would pass. There was an emphasis on the spiritual , the  immutables.  Some talked of babies born. Lots of white hair and wisdom and young doctors still full of innoscent enthusiasm.  

I arrived scarred and fatigued, burnt out, on my  more than 19th nervous break down, just short of pulling my hair out and running naked through the halls of the high school. It’s ever like this. But this time I knew how it worked,  More people arrived. More friends.  Amazing doctors. Sharing together in psychiatry  meetings, discussing the systems, the challenges, the research, the feelings, the changes, the difficulties.  We supported each other. Like minded doctors.  Representatives come from several continents.

We listened to a  talk about the 25 million who suffered from addictive disorders in the US and the 2 to 3 million in Canada. Each country had it’s incredible numbers and the fentanyl epidemic was killing people everywhere.  It was sobering.  

I enjoyed the speaker who said, “I’m in recovery and I vote.”  The need for public awareness was never more important.

I sat mostly in the 12 step meetings. I love the format. Running parallel with the conventional CME each year a doctor or sometimes two discuss the steps 1-12 and how they matter personally and professionally.  

The genius of Dr. Bob and Bill Wilson and the contributions  of Dr. Talbot,  Dr. Paul O and Dr.  Hal Marley and so many others come to be reflected on and discussed in the open time following the formal presentations.  Presentations run 20 minutes then the discussions run for another 30 minutes. Sometimes we split in small groups around a table. Other times we walk up to the mike to make our comments.  The discussants aren’t just anyone but doctors of the highest order for family medicine and all the specialities with experience and intimate knowledge and profound insights to share.  The leaders of treatments centres from Betty Ford to 12 alone come together in these amazing discussions. 

This is the real CME for me. This is the language of the heart. This is what I know personally and what I understand the first 50 men and women who wrote their experience strength and hope in the Big Book of Alcoholics Anonymous had learned.  I love learning the Steps this way.  

Sometimes the Nucleus Accumbens and Amygdalla make their way into these discussions. No one is pontificating. It’s different from the didactic. It’s observations and suggestions and insights. It’s a man or woman relating the step to his family and children.  Another talking about emotional development and family and marital therapy.  I love it. People who are themselves 30 and 40 years abstinent and sometimes 40 and 50 years married talk of the program in terms of family and relationships.  I learn so much here. I am astounded at the genius of my colleagues. 

I get up for the 7 am meeting. That was Hal Marley’s Attitude of Gratitude meeting where the new comers are encouraged and a lot of surgeons show up not knowing what to do with themselves  when others are content to sleep.  I loved Dick and Art’s guidance and Cheryl’s comments. Gordie always has the most rewarding insights. I believe it’s partly because he’s a retired surgeon and the rest of us are waking up.  It’s a tough time for the psychiatrists. I loved meeting Larry, an ophthalmologist. A neuro surgeon provided brilliant commentary. The psychologist soft spoken added her insights. It’s all so inspiring and sheer brilliance.

The resort coffee and breakfast and banquet food was excellent.  The new comers banquet is where the scholarship recipients come forward and remind us all of our first meetings. Then the Al Anon banquet shows the work of Jerry Moe and fills us with hope at the brightness of youth.  The family is central and we view this world as a systems phenomena.  Elsewhere the reductionism is stimying whereas here we look at all comments and hear from every angle of the solution. 

Mel B was the Saturday night speaker and a thrill to hear.  His leadership in the field has long been felt but what a joy to hear the ‘story’ of how it had all come about.  We’d only just applauded the 4 men in the countdown with forty plus years each of continuous abstinence. My mentor and psychiatrist colleague Hugh was among them. We are a group that appreciates life long contribution of members and even honor our dead.  It’s a community and a family in ways like no other place I know.  

George was dear to me as we talked  between meetings, as we’ve talked year after year, Tom and Bobbie, Nathan, John and Dave and so many others. There were 700 or so there, or more, and as many are already signed up for Reno next year.  It’s often a thousand or more.  The meeting moves each year, east and west and north and south with the Local  Committee organizing the event. It’s no small deal.  I was amazed at just how many volunteers were needed for a simple 5 k run let alone all the different meetings and banquets and events that go on which I don’t participate in.  I specialize in the 5 K run/walk while I know Dick is always finding the best golf course in the neighbourhood.  There are competitions and general fun.  I loved the jazz band in the south and the country singer in Phoenix.  Here folk enjoyed taking the tram to the top of the mountain  where they hiked and took photos of wild flowers.  

Every year its the same, the core program with variations of region and characters.  I love it.  I’ve loved the food and music of all the different cities the meetings have been in America.

But it’s the people, Stephen, and Alistair from overseas and Jan and Bry and Brent .  It’s a special high school reunion for me, a ‘same time next year’ love affair without the sex. It’s the most profound learning time.  

I liked meditating this year with Katie, the California psychiatrist who specializes in mindfulness meditation. I so liked listening to the depth of Penny’s insights into people and cats.  

It’s all over too soon.  Yet it’s a spiritual boost. I don’t know what happens but I’m ready for another year. I’ve learned about my most difficult clinical problems, discussing them with my most learned mentors, discussed my administrative issues, discussed electronic record keeping, business practice and government beurocracy and legal concerns.  Every issue too tough to deal with alone has had a chance to be put through the Cray  computer of shared knowledge.  Then there’s talk of love and relationship and loss and confusion.  

We are open with each other. All the hippocracy and gamesmanship I know in other groups are absent as mutually vulnerable we turn to each other for wisdom and give what we gain. It’s here I find that wonderful collegial sharing that first attracted me to academia in Oxford England.  I still feel  this vibe sometimes in  the clinical workplace but we’re all too often pressured and stressed to really take the time to address matters. Here that’s what we do.  

It’s another year.  I feel like I’ve had a transfusion of gratitude and now will give what I can. I feel like I’m  a search and rescue plane whose flown far and wide and finally come back to the mother ship to be refuelled for the next stretch of caregiving.  It’s all about the Spirituality  of Imperfection and I mourned the loss of Ernie Kurtz.

So many books to read, so many new references.  

Macdougall was the spiritual speaker. An awesome breakfast supplied by the resort then this amazing Methodist preacher shared an impossible journey of hope telling stories which would be too crazy were  they not true.

Then it was over.  I’d laughed till my sides hurt and cried.  I’d hugged dozens and dozens, only  a few of whose names I’ve shared.  We touch and greet and hug and I realize I don’t hug other doctors at all the way we hug each other here. I don’t hug colleagues.  Doctors touching anyone even themselves is increasingly verboten. 

At church I hug other professionals.  It’s not something approved of by the increasingly sterile government.  I loved watching my  friend Art put his arm around the shoulder of a man crying over sharing his loss and what it meant to him. Julie hugs me each year and she’s from New York.  

I am so grateful. It’s been so good to be a member of IDAA.   I remember when I thought to leave psychiatry when an academic  evangelical fundamentalist aetheist told me that ‘meditation harms your brain’ and ‘prayer damages the mind.”  I’m so glad the research these last 20 years have proved him dead wrong. Here I am able to pray with psychiatrists and other health professionals to a higher power and God of my understanding.  I love the ecumenicalism of this place and the ‘live and let live’ mentality.  IDAA 2017 was a true blessing for me and I so look forward to same time, next year in Reno, Nevada at the Peppermill Hotel. 

IDAA 2017 Snowbird UTAH - CME - Crucial Conversations with your patient: pain and cannabis - Dr. Mark Weiner

I really enjoyed Dr. Mark Weiner’s  presentation because it clearly delineated “cannabinoid research and treatment’ from the whole area of “medical marijuana”.  Marijuana is a 100 compounds in one with a wide diversity of response and much marketing these days of the ‘anecdotal evidence’ without consideration of the overall  science.   I’ve been prescribing for some years ‘medical marijuana’ and pharmaceutical “nabilone”  and the excellent ‘SATIVEX ”(Bayer)  buccal spray with considerable discrimination and concern.  It’s never a first line choice.  I have seen a lot more negative results than positives. Admittedly the occasional positive result is, like any success, a joy.
There is however a religious devotion especially among  the heavily addicted devotees to the ‘herbal’ treatments with a whole lot of religious claims of “panacea”.  There is  little consideration of cannabinoids as just another ‘medication’ to doctors like myself.
I’ve seen people respond to marijuana like I have to other treatments but it’s not a panacea.  There are also serious side effects.   It certainly was widely available and passed over in favour of the most successful modern treatments that have been associated with cures of epidemics, increased longevity and amazing cures of once deadly diseases.
I was commonly recommending marijuana for my patients with HIV and Aids when they developed anorexia. It was an excellent ‘adjunctive treatment’ but it wasn’t curative. Today being diagnosed with HIV is similar to being diagnosed with Diabetes. The life expectancy is shortened by perhaps 10 years.  When I first worked with HIV it was a deadly disease with few survivals and large death toll despite the ubiquity of marijuana.  Today the pharmaceutical companies and medical researchers have produced retrovirus medications in combinations that have caused the extraordinary successes in treatment of new cases. The latest of these treatments, Truvada, is truly a god send but I know some of the nutbars in the ‘medical marijuana cult’ would tell people not to take it because it is produced by their ‘devil god’ "Big Pharma”.  I can honestly say as a simple clinician it’s increasingly difficult to do my job with all the argumentative stoners with their overnight Google MD’s.  Now that Big Tobacco is backing Big Marijuana with Big Smoke Money at the public health level we know whatever tax benefits we see for politicians will be off loaded in increased suffering for patients and health care costs.
I have a head injury patient whose response to marijuana was truly remarkable. I had tried a wide variety of medications for his various symptoms before the trial of marijuana which had a profoundly beneficial response. Unfortunately clinically the majority of my head injured patients have been made worse by marijuana as it disrupts mood stability and motivation and interferes with memory and learning in these other cases.  I read the heavily funded marketing literature on marijuana and it reminds me of when Cocaine was said to be a ‘cure-all’ without addiction. Then Belushi died.
As a clinician, typical of my colleagues. I don’t care what works. I just want to see my patients get better and we welcome treatments. The paranoia associated with the ‘us and them’ crowds of ‘health food’ ‘pusher’s’ is difficult to tolerate.  Today’s marijauania is 30% THC compared to the 3 % THC of the highest grade marijuana of my college days. The dangers to developing brains of this high dosage compound and the longevity issue of using a potentially toxic substance over long periods is worth consideration.
I enjoyed Dr. Mark Weiner’s discussion  of  the effects of cannabinoids on the heart especially in elderly patients causing me to be better equipped to discuss the pros and cons of medical marijuana in the increasing numbers of retired patients who ask me about it’s use in various chronic diseases.
Some patients commonly in clinical practice try to pidgeon hole the doctor into an “either you are for or against marijuana’ categorizatio.  As a psychiatrist I’m well aware of this   ‘black and white thinking” and profiling  so common in paranoid disorders and drug abuse.”  I enjoyed how Dr. Mark Weiner side stepped this issue simply by presenting the clinical evidence. This is what we know. This is what we can say about the cost/benefit of this treatment for individuals.. It’s really no different than what we say when a person wants cosmetic surgery or some other medical treatment which isn’t ‘first line’ and might even be classified as ‘experimental’.  He was clear in presenting the ‘evidence’ and maintaining his comments in this realm. It was refreshing. I learned from his example.
(I reflected that a patient had told me that my dog who had his eye removed recently for glaucoma could have been saved with the cannabinoid oil this patient promotes.  Its been shown to be of some benefit in human glaucoma.  So feeling guilty that my dog had lost his sight in one eye I was willing to consider anything to help him keep his sight in the other eye.  His veterinarian ophthalmologist, Dr. King, hadn’t recommended cannabinoid but another medication which has been working very well in keeping the pressure down in his remaining eye.  I reviewed the veterinary research literature that evening and found that in fact marijuana had been researched and was contraindicated in dogs. Veterinary medicine is fascinating because a drug that can save a cat’s life can kill a dog.  They’ve been researching cannabinoids just as we have.  My patient is a religious nut about marijuana.   I definitely have prayed for my dog’s eyesight.  I have trusted  Dr. King whose treatment is working just fine.  I had a delightful dinner with Dr. Larry Cooper a San Diego Opthalmologist who was kind enough to share some stories of his successful surgical and medical cures of eye disease, being especially thankful for the gifts of modern medicine which have resulted in him being able to save a person’s sight or life.  I really don’t think he as a compassionate clinician would withhold any treatment but I expect that if I smoked a joint I could even imagine this wonderful mensch of a doctor could indeed be an evil operative of Big Pharma and Big Surgery. )
I enjoyed the lecture because it dealt with the science of today. Dr. Mark Weiner is simply one of the leading authorities and yet also broad minded. He does emphasize what the research says about cannabinoids and questions what is in a marijuana plant in general.  He’s a scientist and not a snake oil proponent. It was an interesting lecture from this perspective.  What we know. What we don’t know. What research says. What research doesn’t say.  I enjoyed that.  Great ideas.  I will make a point to follow him in future and consider adjusting my practice to take account of the insights that he provided.
 This is not a reflection of the overall lecture which was much more extensive. I’ve just selected certain slides and some ideas that were of interest to me. I wouldn’t want anyone to see this writing in any other light than this. I certainly will be attending more of his lectures if I can and would strongly recommend him as a presenter, communicator and scholar.

IDAA 2017 Snow Bird, UTAH - CME - Science of Recovery - Dr. Ray Baker

Dr. Ray Baker provided insights into the latest research into Recovery.  A lot of research had gone into addiction but this is the beginning of the study of the health after addiction. The research documents the success of recovery. Epidemiological research showed the percent of population serious problems and its significance. The research into what had worked for individuals to achieve recovery showed a variety of tools had been used. The importance of the treatment centres was highlighted as was the value of the 12 step programs.  Dr. Baker went on to discuss the importance of Recovery Capital especially as this related to response to treatment and prevention of relapse.
Even though I’m an addiction psychiatrist working in the field I am amazed at the cutting edge work that Dr. Baker highlights in his presentations. He’s known as a great clinician but his academic credentials, presentation skills and research are often not as well known. This is possibly because if you talk to him personally he’ll be more likely to talk about his family, or his increasing love of running.  I thoroughly enjoyed the presentation and have only poorly given a taste of it with a very few of the slides he used. I trust this will encourage others to catch a future presentation of Dr. Baker’s, watch for his coming book, and follow up on the references he has provided in the area of the Science of Recovery.
I’d personally been interested enough in the commonly misquoted Cochrane study which suggested 12 step programs weren’t beneficial to seek out the chief addiction medicine researchers for those Cochrane Studies at the ISAM presentation in Malaysia.
“We said it couldn’t be studied as a addiction ’treatment ‘ because it wasn’t simply a " treatment." It’s always misquoted.  We ourselves  recommend 12 step programs clinically.”  I remembered that conversation because the chief Cochrane researcher lamented that there wasn’t research to date to support the obvious evidence of the success of 12 step programs especially with regard to long term recovery.  I enjoyed that Dr. Baker had shown that studying Recovery as opposed to  Addiction Treatment supported what we all saw clinically.  Further by looking at the idea of Recovery Capital conceptually there was increasing opportunity to standardize and research aspects which we all know clinically are most relevant to treatment success.  I often have to point out that the Cochrane Studies were originally developed solely for the purpose of comparing one medication treatment to another  and as a tool are best when  limited to this narrow focus. Unfortunately, it’s easiest to show with a short weekly to months  pharmacological trial the benefit of one limited treatment compared with another.  Recovery by contrast is a concept of life change that shows increasingly over years. The cost of research selects in favour of an acute intervention but not so much for chronic conditions as addiction is.  Dr. Baker raised these issues and proposed solutions some of which included paradigmatic shifts in thinking about treatment.  I loved his use of lay persons as recovery coaches and recovery monitors to help get patients to meetings or to doctors appointments and follow up.
All round for me a highlight of the CME presentations this year. I see myself taking some of these ideas back to my clinical practice and changing the questions and recording I do in my continuing care of patients.

IDAA 2017 Snow Bird UTAH - CME - Trauma of the Monitoring Program, Dr. Penny Ziegler

I love Dr. Penny’s lectures. I think of her as the Joni Mitchell of the lecture circuit. Her insights are as deep as  Sarah McLaughlin lyrics. Her experience is as broad as Carole King. I always hear that huge heart of hers as she speaks , her compassion for patients so readily apparent.  She is the therapist who speaks the language of the heart.   I really want to be like her whenever I leave I a lecture of hers. It’s like watching a scene beside some guy named Monet only to find that when you’re asked to draw that scene later , you’ve got stick figures in black and white and that Monet guy  has this wondrous picture of colour and form.
This lecture was no different.  It was also cat lady funny, not in a "laughing at" but a "laughing with” way.   We all deal with difficult people. We survive them. We love them. We want so much to make things work for them. We see them doing things that must have worked at some time in their lives but have long worn out their usefulness.  Dr. Penny helps professionals having difficulties in the workplace.  She described “all the usual suspects”.
The licensing board is a legal entity established to protect the patients and at the same time manage the business and law of health care professions.  Dr. Penny worked with the professional assistance program providing therapy and monitoring and helping the individuals over the hurdles and trying if possible to restore them to their workplace.
She presented a number of case studies which she’d clearly made confidential but maintained the conflicts and dynamics. Some of us recognized ourselves in the scenarios. I identified with them all.  There’s a quality in coping strategies that they are valuable but it’s the subtle or not so subtle differences like assertiveness and aggressiveness. Not only could we as professionals see ourselves in the cases but we could see our colleagues and some of our patients.  What was clear in Penny’s presentation was that she never lost sight of the humanity and struggling child and the fear that occasioned the behaviours.
It was a marvellous lecture. I love cats. I know how they behave when they’re afraid. It’s a worthwhile lesson to remember for my own practice and to remember with my own behaviour.   For the academic and therapist in me it was like getting to hear another performance of Stevie Nicks. I’m forever thankful that there are psychiatrists like Penny who remind me to the core of the compassion that drew me to this field.  There was  spirituality and  mystery.  There was also the  reminder to us all that individually when we think of ourselves as one T.S. Elliots’ CATS, we may well be coming across as one of Dr. Penny Ziegler's Cats. Callico Cats! Callico Cats!
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Five Fundamentals of Civility for Physicians, Dr. Michael Kaufman, IDAA 2017 Snow Bird Utah

Dr. Michael Kaufman is a fine,  kind, caring, learned, gentleman and physician.  His presentation on the Five Fundamentals of Civility for Physicians was especially superb.  He began it with a clip from Dr. House which though hilarious had at least half of us physicians cringing.  It was a priceless performance by Dr. House who indeed presented at times the best and worst of medicine.  I have selected some slides that appealed especially to me. They in no way represent the overall presentation but give some idea of the breadth and depth of the CME.
 Dr. Kaufman is a leading expert and communicator in this field as well as humorous in his presentation.  I found myself thinking nostalgically of suburbs and childhood and safety, a world far away because frankly, myself and others have become to uncivil.  Yet it’s so very important as Dr. Kaufman and the research clearly show.  By discussing incivility and it’s impact, Dr. Kaufman showed how civility could counter that.
I confess as a Canadian, given our public image for politeness and  civility, I thought it fitting that Dr. Kaufman a truly admirable Canadian should be presenting on this.  Personally I think of him as the ambassador to own  more a warrior like self.  I would and have  "argued" the need for both. Dr. Kaufman would 'discuss' the matter more respectful and likely have a deeper and more lasting impact.
His presentation showed the need for more civility, especially for doctors,  and not less, something I would not argue with at all.  He definitely makes a strong case for civility as a learned behaviour.  He showed that it  can be taught and learned.  There’s a skills set. I’d say it was part of what we once called the art , of the art and science of medicine, now with the support of more science.