Category: Education

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Education Funding Policy Systems

Jail Costs versus Hospital Costs.

We received the State of Washington Voters’ Pamphlet in the mail today. One of the initiatives, I-1401, concerns “trafficking of animal species threatened with extinction”.

Have no fear: This post is unrelated to trafficking of animal species threatened with extinction.

The “Fiscal Impact Statement” includes a statement about jail costs (highlighted for emphasis):

jailcost

“No wonder why people with psychiatric conditions end up in jail!” I exclaimed. “It’s so much cheaper for them to be there!”

Information about hospital costs are public. This page shares inpatient hospital rates for people who have Medicaid insurance in August 2015. All the hospitals in Washington State are listed in the leftmost column. One of the columns has the title “Psych_ Per Diem”. That column tells you how much money each hospital is paid if a patient with Medicaid is admitted there for psychiatric reasons. First, you will note that hospitals are paid[1. Forgive the passive voice when I write “hospitals are paid”. In Washington, hospitals send bills for Medicaid patients to the state. The state pays the hospital bill. The state then turns around and sends a bill to the region that the patient “belongs” to. The region then pays that state bill. The region gets money to pay that bill from a mix of federal and state Medicaid dollars, which ultimately come from taxpayers. Confusing, right?] different amounts. That alone is fascinating—what accounts for that? who decides how much money each hospital will receive?

More to the point, it costs anywhere between $711.55 and $1788.93 per day for an adult with Medicaid to stay in a hospital. The average cost of incarceration in Washington is $88 per day. Thus, it is at least eight times cheaper for someone to stay in jail than in a psychiatric hospital.[2. This page shares inpatient hospital rates for people who don’t have any insurance. Note that the rates are lower compared to the Medicaid rates. They are nonetheless still much higher than the daily jail rate.]

On the one hand, the differences in cost aren’t surprising: Hospitals often have more staff, equipment, and services. On the other hand, we also know that jails are often the largest psychiatric hospitals in any given region. For example, in Seattle, the jail has about 120 psychiatric beds. The largest psychiatric hospital in Seattle has about 61 beds.

I really want to believe that no one intentionally designed the system this way. Surely no person or system could be so heinous and miserly to funnel people into jail instead of a psychiatric hospital. Right?

Right?

But, then the disgust kicks in: What if the costs were reversed? What if it cost $88 a day for someone to stay in a psychiatric hospital and $712 a day for someone to stay in a jail? Would we see as many people with psychiatric conditions in jail? Of course not.[3. To be clear, we should also help people stay out of psychiatric hospitals, too. Inpatient services should be available if people need them, but let’s focus on prevention and help people stay in their communities. Being in a hospital generally sucks.]

It shouldn’t be all about money, but when the cost differences are that big, money has undue weight. If we actually want to help people with psychiatric conditions, we must pay for services. Otherwise, we will only see more and more of them in jail.

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Education

Full Moons and Lunacy.

supermoon

Now that the supermoon has passed, here’s a reminder that there is scant evidence that full moons are associated with erratic, violent, or unusual behavior.

Dr. Chudler offers a brief summary of studies related to human behavior and full moons on his website and notes

Although most experiments fail to show a relationship between the phase of the moon and abnormal behavior, the belief in the “lunar effect” is still strong among many people.

Scientific American also published a piece about this a few years ago and concludes

… the lunar lunacy effect appears to be no better supported than is the idea that the moon is made of green cheese.

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Consult-Liaison Education Medicine Observations Reflection

Pay It Forward.

Prior to starting medical school, I had no desire to work as a psychiatrist. I had a plan: I’d become an infectious disease physician[1. I studied microbiology and molecular genetics in college. My fondness for bacteria persists.] or an oncologist.

During my psychiatry rotation as a medical student I spent four weeks on a consult-liaison service. I worked with an attending who was smart and excellent with patients. Though everyone agreed he wasn’t warm, he was genuinely kind. (He also wore bow ties and suspenders. His clothes never had wrinkles in them. Was this due to his military background?) My plans started to change.[2. It wasn’t a single moment that made me abandon my original intention to go into internal medicine. I still remember the case, though, that tipped me to go into psychiatry: One of my patients on the medicine service was a firefighter who had suffered a significant bleed in his stomach. I was able to talk about the cells and chemistries in his blood, the risk factors that contributed to his condition, and what he could do in the future to prevent this from happening again. Yet, I couldn’t tell anyone anything about him as a person, how he came to have those risk factors, how he perceived those risk factors, and if he had any desire or intentions to change his behaviors so that he could prevent this form happening again.]

Before starting my psychiatry residency, I had no particular interest in working with people experiencing psychotic symptoms (e.g., hearing voices, holding firm beliefs that are not rooted in reality, etc.). I had a plan: I’d become a consult-liaison psychiatrist and spend my days in hospitals spanning the boundary between acute medical care and psychiatry. There was a little of everything in consult-liaison psychiatry: the full spectrum of psychiatric conditions; brief psychotherapy; teaching patients, families, and, often, the staff of the primary medical service; starting and stopping medications to reduce distressing symptoms.

During my residency I found myself finding the most meaning when providing care to people with limited means: refugees from Southeast Asian countries; military veterans with few supports upon their return from wars ranging from World War II to the wars in Iraq and Afghanistan; people living in homeless shelters or on the streets. Medications were not always useful or indicated. The senior residents and attendings in these settings were astute, unpretentious, compassionate, and just good with people. My plans started to change.

Now, as an attending, my interests are a mix of all those things: I like working with people with significant psychiatric symptoms who often have limited means. I like working in teams to help people get better and out of the system, whether that is the hospital, the jail, or the mental health system entirely.

I spent over eight years of medical training under the supervision of “attendings”. It took me a few years to get used to people calling me “Dr. Yang”.[3. I still find it jarring when colleagues who routinely call me “Maria” suddenly address me as “Dr. Yang”.] I guess I’m not yet used to the idea that I am now an attending and people expect me to “know”:

  • a high school student who wants to interview me to ask about my work as a psychiatrist
  • college students who want to learn more about non-traditional work in psychiatry[4. Thanks for helping to inspire this post, Anna!]
  • medical students who want to know which psychiatry residencies they should apply to if they want specific training in working with indigent populations
  • residents who want to know which fellowships they should apply to if they are interested in public sector clinical and administrative duties
  • fellows who want to know where they should apply for work in non-traditional settings

It’s weird. Impostor syndrome persists: These people think I’m qualified to tell them?

When I think about all the people who guided me—intentionally or not—to where I am today, I find that the second best way to thank them is to pay it forward.[5. The first best way to thank people, of course, is to directly thank them for the specific things they said or did.] We need people who have the will and energy to serve the community, who are willing to think about and do things differently. Yes, interests change, plans change, people change. However, we never know how our words and actions may inspire those around us.

Categories
Consult-Liaison Education Informal-curriculum Medicine Nonfiction Observations Reflection

Teaching Moment.

The Chief of Service ushered me into the room, but said nothing. His staff of fifteen looked at the Chief with expectation and, upon realizing that he was looking at me and probably wasn’t go to say anything—including my name or the reason for my visit—the fifteen people joined him in looking at me.

“Hi,” I said, taking the cue and flashing The Winning Smile. This is my name, this is my title, and this is why I’m here: As a psychiatrist, I think there is overlap in the work that we do and in the patients that we see—

“Is it okay if we refer to your patients as ‘wackos’?” the Chief blurted out. Nervous laughter twittered among his staff.

“I’d prefer that you didn’t.” My voice was light; my face was dark.

“Oh. I guess another psychiatrist should have told me that.” He was still smiling.

“I hope I’m not the first one to do so.” When he finally saw the lasers shooting from my eyes, his smile dissolved and he looked down.

There are several reasons why I believe that social skills are not his forte:

  • He either chose not to or did not think he needed to introduce me to his staff.
  • As a Chief of Service he should have known better than to say such things in front of his entire staff.
  • This exchange occurred within five minutes of us meeting each other.

I think his question—“Is it okay if we refer to your patients as ‘wackos’?”—was his honest effort to connect his staff and me together. Everyone would have a good laugh, we’d share something in common, and we could move forward with greater ease. He thought his comment was benign.

It makes me wonder, though: Had he made a similar comment in the past to another psychiatrist? And had that psychiatrist laughed? Did a ridiculous repartee follow?

Did another psychiatrist reinforce this sort of behavior?

He’s not a “schizophrenic”. He’s a guy with a diagnosis of schizophrenia. Maybe he’s even a guy who is skilled guitar player, a father of two children, and has a degree in political science who happens to have a diagnosis of schizophrenia.

She’s not a “brittle diabetic”. She’s a woman with a diagnosis of diabetes. Maybe she has a knack for training dogs, has a remarkable talent for singing, and was on her way to law school when she was first diagnosed with diabetes.

People are people with various interests, talents, and potentials. They are not their medical conditions.

No one is a “wacko”.

The Chief of Service sent me an e-mail later:

Thank you for visiting us and also for your gentle way of reminding me of my crudeness and insensitivity. I am sure you hear enough negative attitudes towards your clients that you would welcome the opportunity to create a more positive attitude towards mental health issues.

I actually don’t hear many “negative attitudes” about my patients. Perhaps this is because every moment can be a teaching moment and, over time, people learn not to use such language (at least around me). As I noted several years ago:

Doc­tors, like most peo­ple, often assign adjec­tives to patients because it can be hard to iden­tify and then acknowl­edge emo­tions. It is much eas­ier to say, “She is such a dif­fi­cult patient! She is never happy with her care!” than to say, “I feel angry and help­less when I see her because it seems like noth­ing improves her symp­toms!” Leav­ing out the sub­jec­tive “I” gives the illu­sion of objec­tiv­ity and professionalism.

I can only hope that the Chief of Service shared his reflection about his “crudeness and insensitivity” with his staff.

Categories
Education Medicine Observations Systems

Everything Changes, Nothing Changes.

The Mutter Museum Instagram account recently posted this photo:

Thorazine

“Thorazine” is the trade name for chlorpromazine. It is considered the medication that ushered in the “psychopharmacological revolution”, thus allowing some patients to leave psychiatric institutions. (You can read the interesting history of chlorpromazine here. Spoiler alert: It was designed for use in surgery, not psychiatry.)

Chlorpromazine is often touted as the first medication that could reduce symptoms of schizophrenia. Other FDA-approved “psychiatric” uses of chlorpromazine[1. Other FDA-approved uses of chlorpromazine that are unrelated to psychiatry include acute intermittent porphyria; intractable hiccoughs; nausea and vomiting; and tetanus, “adjunct”.] include:

  • Apprehension, presurgical
  • Bipolar disorder, manic episode
  • Problem behavior, severe

I don’t know the context of the ad (who was the intended audience: physicians? patients? husbands?). One wonders why the ad features a woman and puts greater emphasis on “emotional stress”. A hefty dose of chlorpromazine will result in “prompt” sedation that will give someone—perhaps not the patient—”sustained relief” for several hours.

Did physicians in that era tell patients that the original use of this medication was for schizophrenia? Or did physicians focus primarily on the tranquilizing effects of chlorpromazine for those individuals who had more neurotic, not psychotic, symptoms?

Everything changes, nothing changes. Quetiapine (tradename: Seroquel) was also developed for the treatment of schizophrenia. Now, its uses include:

(1) add-on treatment to an antidepressant for patients with major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; (2) acute depressive episodes in bipolar disorder; (3) acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; (4) long-term treatment of bipolar disorder with lithium or divalproex; and (5) schizophrenia.

The header for the page (what shows up on the browser tab) doesn’t even list the drug’s name. It says only “bipolar disorder medication”.

If you search for “Abilify” (generic name: aripiprazole) on Google, the brief summary that shows up under the first link says:

Official pharmaceutical site for this antipsychotic medication indicated for the treatment of schizophrenia.

However, when you actually go to the official website, the listed uses include:

Use as an add-on treatment for adults with depression when an antidepressant alone is not enough
Treatment of manic or mixed episodes associated with bipolar I disorder in adults and in pediatric patients 10 to 17 years of age
Treatment of schizophrenia in adults and in adolescents 13 to 17 years of age
Treatment of irritability associated with autistic disorder in pediatric patients 6 to 17 years of age

Asenapine (trade name: Saphris) also has approval to treat both schizophrenia and bipolar disorder. Should we be surprised if paliperidone (trade name: Invega[2. Does it mean anything that, of the five photos on the landing page for paliperidone, only one of them features white males?]) and iloperidone (trade name: Fanapt) soon also receive FDA approval to treat conditions other than schizophrenia?

This is why skepticism is indicated—nay, essential—whenever people exclaim with confidence that “we” understand the biology of psychiatric conditions. We live in an era where cancer drugs can be designed to interact with specific receptors because scientists have located and studied those specific receptors. That specificity does not exist in psychiatry. If it did, one drug class would treat one condition, not four.

While I am probably more reluctant than the “average” psychiatrist to prescribe medications, I believe that, for some people with significant psychiatric conditions, medications can offer great benefit. First, however, do no harm.

It is frustrating when many in the field of psychiatry insist that the serotonin hypothesis is true when, in fact, it is just a hypothesis that is probably false. Also frustrating are the multiple forces that insist that medications are the primary and sole forms of treatment for psychiatric conditions. What about exercise? Therapy? Diet? Social support?

If medications alone could successfully treat these conditions, wouldn’t the pharmaceutical companies have saved us all by now?