Category: Education

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Education Medicine Observations Policy Seattle Systems

A Primer on Psychiatric Boarding.

The Washington State Supreme Court recently stated that “psychiatric boarding” is unconstitutional.[1. You can read the court’s opinion here. It’s a fairly easy read.] I agree with and support the court’s decision. “Boarding” is a terrible practice.

To be clear, though, the consequences of this decision may be undesirable.

Some background: In the state of Washington, the only people who can hospitalize individuals against their will for psychiatric reasons are “designated mental health professionals” (DMHPs). Police officers can bring people to emergency rooms against their wills and physicians and other professionals can evaluate people who show distress. A DMHP, as an agent of the state, makes the ultimate decision whether to detain someone against his will.

Let’s be clear about this: Being hospitalized against your will is stressful, upsetting, and frightening. The state is taking away the rights and freedoms from an individual. Civil liberties? Gone. It is a big deal. No one enjoys the process.

In order for a DMHP to hospitalize someone against his will, a person first must show evidence of a “mental disorder”.[2. A finer point about “showing evidence of a mental disorder” is that there should be some proof that hospitalization is an effective treatment for the mental disorder in question. This is why some people go to jail and not to the hospital. This path can lead us into the weeds.] Having a mental disorder alone, however, is not reason enough to hospitalize someone against his will. At least one of the following three criteria must also apply:

  • He is a danger to himself. (Consider a man with major depression who was found nearly unconscious; a noose made of bedsheets was around his neck.)
  • He is a danger to others. (Consider the woman who is walking across the highway multiple times because she believes that God wants her to proselytize to the drivers.)
  • He shows “grave disability”, or is unable to meet his basic needs. (Consider the man who has not eaten any food in nearly two weeks because he believes that all food is actually composed of his internal organs.)[3. If you think that none of these scenarios ever really happen, I encourage you to go volunteer at your local emergency room.]

Thus, at least two people–the person who wanted the individual to go to the hospital and the DMHP–were concerned enough about the individual to believe that he needed to be in the hospital to get care.[4. For now, let us put aside arguments that psychiatric hospitalization is never helpful or indicated. Some people believe that psychiatric hospitalization is a veiled form of incarceration.]

That “to get care” part is the crucial point when we talk about “boarding”.

People who are involuntarily detained in Washington are only allowed to be hospitalized in certain facilities (or certain beds). Facilities submit an application to the state to become a “certified” place where they can treat people who are hospitalized against their wills.[5. Indeed, there are psychiatric hospitals in Washington State that are not certified to treat people who are hospitalized against their wills.] These places can be entire buildings (called “evaluation and treatment facilities”, or “E&Ts”, here). They can also be specific beds within a hospital, usually on psychiatric wards.

There has been concern if “inpatient psychiatric capacity is sufficient to meet [a] potential increased demand” for involuntary hospitalizations. All certified beds are frequently occupied. Most people who are referred for involuntary hospitalization are not in psychiatric hospitals; they are in hospital emergency rooms.

There are medical centers (and, by extension, hospital emergency rooms) in Washington State that do not have any psychiatric providers on staff.

Thus, DMHPs have been hospitalizing people against their wills, but no certified treatment beds are available. These detained individuals therefore are admitted to hospital emergency rooms or random hospital wards while they wait for certified beds to open up.

If the hospital does not have psychiatric providers on staff, that means these detained individuals don’t receive any psychiatric care. People could wait hours, days, or even weeks before they are transferred to a certified facility to receive formal psychiatric services.

In the meantime, these individuals are often physically restrained to their beds. There might not be enough hospital staff to fulfill the state’s mandate that they remain in the hospital against their wills.

Sometimes these individuals receive doses of sedating medication for multiple days in a row. (Imagine you work in an emergency department. Someone who is detained in your emergency department will not stop screaming obscenities at other patients. He also tries to spit at everyone. He has also tries to punch the nurses whenever they walk by.)

This isn’t treatment. (Remember, the state ordered that this person be hospitalized against his will to get care.)

Thus, you can now see why the state supreme court decreed that it is not okay to “board” psychiatric patients. People who are detained against their will, by the state’s definition, need treatment. “Boarding” isn’t treatment.

This is why I agree with and support the court’s decision.

However, now that you know that there aren’t enough certified psychiatric beds in the state, you can guess what undesirable consequences might come from this decision.

The detained individual in the emergency room who yells and tries to punch all the nurses? Now he might end up in jail on charges of assault. Jail is not a therapeutic environment. Some jails do not offer any psychiatric services. Incarceration, like boarding, is not treatment.

Detained individuals might instead be released into the community if no certified beds are available at that time. Someone else–another police officer, another family member–might try to re-refer them back to the hospital a few hours after they were released. This results in a cycle in and out of hospitals and other institutions. That isn’t treatment, either.

Hospitals that have certified beds may feel pressure to discharge people more quickly due to the heightened demand. These individuals may not have recovered “enough” and may return to the hospital much sooner than anyone would like.

Another potential consequence is that those individuals who seek hospital services on their own–perhaps in an effort to avoid involuntary hospitalization–may not be able to get into a hospital at all. Those detained against their wills may occupy all of the certified hospital beds.

My understanding is that the state is considering various ways to work with the new law: This includes increasing the number of certified beds, creating different options to divert people from hospitals, and reducing the amount of referrals for involuntary hospitalization.

I don’t understand why some hospitals don’t employ psychiatrists.[6. Psychiatric services are not “revenue generators”, so I suspect this is the reason why some hospitals don’t hire psychiatrists.] If a pregnant woman about to have a baby shows up at an emergency room, hospitals have staff available with the expertise to manage her care.

Why isn’t this the case with psychiatry?

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Education Informal-curriculum Lessons Medicine Observations Reflection

Guiding Principles for Medical School.

Dear Jane:

Thank you for asking me about my perspectives on medical school. Here are some general principles that you might find useful in your own training:

View everyone as your teacher.

Everyone you encounter will teach you something. Be open to what they have to offer.

Yes, your professors and attendings, the “official” teachers, will educate you. Patients, however, will often be your best teachers. Listen to what they say, watch how they react to what you do, and acknowledge and accept the feedback they give to you. Their teachings are often the most useful and valuable.

You might see a physician condescending to a patient and decide that you never want to do that. You might see a nurse offer quiet comfort to a patient and decide that you want to mimic that manner. You might witness a technician help a patient feel less anxious before a procedure and decide that you will steal that technique. You might talk to a physician on the phone and decide that you will adopt that professional and kind manner when you talk to other physicians.

In this way you can be a student for life.

Reflect on your experiences every day.

This can take many forms: You can keep a journal. You can talk with friends. You can meditate. You can go for a ten-minute walk around your neighborhood. You can sit in a chair and stare out the window. It doesn’t have to be a big thing.

Reflecting on your experiences will help consolidate what you learn so you can apply that knowledge in the future. This applies to “book” knowledge (physiology, pharmacology, etc.) and “non-book knowledge” (how to redirect a patient or your colleague, how to manage your emotions in the face of disease and death, etc.).

There will be times when you will feel overwhelmed and cannot or choose not to reflect. That’s okay. It happens.

You will see terrible things.

You will see people suffer. You will see people die. You will hear hospital staff say derogatory things about patients. You will see your colleagues lie about things they should not lie about. You will see everyone—the patient, nurses, doctors, technicians, family members—work as hard as they can and none of it will help the patient. You will see people who need help, but don’t want it.

Remember the discomfort you feel when you see things you don’t like. These experiences are your teachers, too. They will help you stay human and humane. Medical training can steal that from us.

You will do terrible things.

You yourself will do things you will not like. (Hopefully infrequently.) You will snap at patients. You will be snarky to staff. You will bend the truth, if not lie, because you won’t know what else to do.

You must reflect on these events so they don’t become habits.

Connect with physicians who do not work in academic centers.

Some physicians in the community will have practice patterns and work in systems that will appall you. Some will inspire you. While academic medicine does happen in the “real world”, it’s often different from what is in the community.

Exposing yourself to the non-academic world will help you learn about a greater variety of patients, creative and innovative developments in health care, and provide more context about medical care in the world. Even if you end up working in an academic center, these experiences will shape your practice.

After you decide what kind of doctor you want to be, take rotations in every other specialty.

Medicine is compartmentalized, but people are not. Your patient with high blood pressure may become pregnant… develop a painless red eye… fracture a bone… have her gall bladder taken out… or develop an alcohol problem. Learning about a variety of conditions will help you take care of people, not just diseases.

The most useful guiding principle for me during my training (and now) is to remember that your work is to take care of the patient. It’s not about the letters after your name, long titles, or how big your salary is. Medicine isn’t about you. It’s about the patient. That attitude will keep you humble, curious, and grateful.

Congratulations on your admission to medical school! May you find the work rewarding and meaningful.

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Consult-Liaison Education Medicine Reading

DSM-5: Malingering.

My DSM-5 group has lost its previous vitality for the same reasons my blog has lost its previous verve (pending job change, ongoing family health concerns). But! The DSM-5 group has had a few updates; the most recent edition is below. If you’re interested in subscribing to the DSM-5 e-mail group, you can sign up here.

Malingering in DSM-5, like in DSM-IV, is a “V code”. “V codes” (in ICD-9) will turn into “Z codes” (in ICD-10) and these are considered “other conditions that may be a focus on clinical attention”. This means two things:

(1) Conditions listed as “V codes” are not diagnoses because

(2) Conditions listed as “V codes” are not mental disorders.

Therefore, malingering is not a mental disorder.

In crass terms, malingering means that people are faking or *really* embellishing physical or psychological symptoms. People who are malingering do this “consciously” (hat tip to the analysts) because there is an external incentive to do so. These external incentives might include:

a) avoiding military duty
b) avoiding work
c) obtaining financial compensation
d) evading criminal prosecution
e) obtaining drugs

Malingering can be hugely adaptive: If you were homeless and the temperatures outside are below freezing and a winter wind is whipping the frost off of the trees and there are no open shelter beds and you are hungry because the last time you ate was two days ago and that was a soggy, half-eaten sandwich you found in the trashcan–

–wouldn’t you consider going to the hospital and say that you want to kill yourself so you could be in a warm place for a few hours and get some non-soggy food?

DSM-5 argues that if “any combination” of the following four items is present in a patient, you should consider the condition of malingering:

(1) Medicolegal context of presentation (a lawyer sends the client for evaluation or the patient presents for care in the midst of criminal charges)

(2) There is a “marked discrepancy” between the individual’s “claimed stress or disability” and “objective findings and observations”

(3) “Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen” (some tired clinicians would summarize this as “a difficult patient”, though I much prefer DSM-5’s description)

(4) The presence of antisocial personality disorder

I applaud DSM-5’s efforts in keeping the description of malingering neutral. Some people have strong reactions towards (translation: self-righteous fury at) people who present with malingering. Keeping the focus on the behaviors helps temper the emotional reactions.

DSM-5 then clarifies the differences between malingering and factitious disorder, conversion disorder, and related conditions. Malingering is the only condition here where symptoms appear solely because there is an external incentive.

On a somewhat related note, the condition that follows malingering in DSM-5 is “wandering associated with a mental disorder”. This is apparently limited to walking (where the “desire to walk about leads to significant clinical management or safety concerns”).

The next post will hopefully show up less than one month away.

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Consult-Liaison Education Lessons Medicine Systems

Have You Thanked Your Nurse Today?

As I noted earlier, hospitals permit around-the-clock observation of patients. If you don’t need around-the-clock monitoring, you don’t need to be in the hospital.[1. “But what about ‘social admits’?” you may cry. “They don’t need to be in the hospital, but we admit them anyway.” True. “Social admits” reflect the intersections of social policy, politics, health, economics, and the lack of resources. That topic is beyond the scope of this post.]

Who is doing this around-the-clock monitoring? Nurses.

Therefore, whether you are a patient or a physician, one of the best things you can do is get on the good side of the nurses.

If you are a patient, a nurse watches over you and your care. Nurses make sure that you won’t fall. They make sure they give the right dose of the right medication in the right route to the right person at the right time (which can be easier said than done). Nurses provide education about medicines, tests, and health conditions. They make sure you know what day it is, where you are, and who you are. (Also easier said than done.) They monitor your progress and try to ensure that your health only improves. Nurses can also page the doctor for you or your family. They can find out when you are scheduled to go through a procedure. They can find out what you are waiting for. Nurses advocate for you.

Sometimes it may seem like they’re not “doing” anything. They are. They’re keeping an eye on what is happening with your health.

If you are a physician, you must already recognize the value of nurses. (If you are a medical student or resident and have fantasies that, one day, you will be “running the show”, don’t be a fool: There is no way you could do your work in the hospital without the help of nurses.) Nurses serve as our eyes and ears. They tell us information about patients that patients themselves cannot or will not tell us. They do triage with us when we have multiple patients who are not doing well simultaneously. They tell us if someone is starting to look a lot worse… or a lot better.

While it is true that nurses provide around-the-clock observation of patients in hospitals, it is also true that nurses provide around-the-clock monitoring of doctors in hospitals.

Nurses know when doctors typically meet with patients. They know which doctors are more likely to spend time with patients and answer questions. They know which doctors work in collaboration with nurses and which ones treat them like second-class citizens. They know which doctors return pages promptly. Nurses quickly learn how to alter their approaches with various doctors to get work done.

This is yet another reason why, as a patient, you want to get on the good side of nurses. Nurses manage doctors. Skilled nurses will know how to work with different doctors to help you get what you want (e.g., answers to your questions, a meeting with your family, better pain control).

(Patients, you should also know that nurses also manage you. Nurses tell doctors which patients yell at nurses, which family members are berating them, which patients are trying hard to follow recommendations, and which family members left cookies and treats for them.)

Physicians, thank your nurses for helping you do your job better. Positive reinforcement and good manners go a long way. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you and make your job easier.

Patients, thank your nurses for watching over you. Nurses play an essential role in your care in the hospital. Be kind to them. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you to get you back to health as soon as possible.

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Consult-Liaison Education Medicine Observations Reflection

The Patience of Patients.

When I was a resident one of my attendings said, “You know why patients are called ‘patients’? It’s because they have a lot of patience. For us.”

Patients in hospitals do a lot of waiting. They wait for physicians. They wait for nurses. They wait to use the bathroom. They wait to undergo procedures. They wait for their IVs to stop beeping. They wait for the person next door to stop vomiting up what sounds like all of their internal organs. They wait for the person down the hall to stop screaming. They wait to eat. (Doctors: Reverse those NPO orders as soon as you can! Food is at the base of Maslow’s hierarchy of needs! Food is more important than safety and security of health!) They wait for the nursing assistants to finish taking their blood pressures so they can sleep. They wait for the unit clerk to answer the phone so a nurse can help them get out of bed without the bed alarms screeching throughout the unit.

They wait to feel better. They wait for good news.

No one has any idea how much patients wait in the hospital until you become a patient in the hospital.

Sometimes it’s not even clear what patients are waiting for. Hospital staff arrive and they have no idea why they are there:

  • “Hi, I’m the physical therapist.”
  • “Hi, I’m here to take you down for an ultrasound.”
  • “Hi, I’m the dietician.”
  • “Hi, I’m the consulting psychiatrist.”[1. Hospitalists: If you call a psychiatry consult for your patient, tell your patient. Most people, with or without psychiatric issues, do not appreciate an unexpected visit from a psychiatrist. “I’m not crazy! Get out of my room! No one asked you to come here!”]

Because of the nature of acute care in hospitals, rarely do things run on a consistent, predictable schedule. This lack of punctuality is not intentional; things change. Hospital staff triage patients all the time and, unfortunately, patients and patient care are shuffled around in order of acuity.

Thus, if you’re in a hospital and someone tells you that So-and-So will see you at 2pm, don’t believe it. Yes, So-and-So might actually see you at 2pm, but it takes extraordinary planetary alignment for that to happen. So-and-So might show up at noon… or at 4:30pm.

Yes, doctors wait, too. The waiting doctors do, though, is informed by the knowledge they have about why they’re waiting. Doctors wait for patients to come out of the bathroom. They wait for patients to go for a study or imaging test. They wait for family members to arrive to get more history. They wait for the pathology or study results to clarify diagnosis and treatment. They wait for information that affects what happens next.

Patients often wait without knowing what will happen next.

If you work in a hospital, remember that most patients have an extraordinary amount of patience, given the circumstances. Yes, there is a minuscule minority who have the frustration tolerance and impulse control of toddlers, but that is not a common means of coping in adults. (Physicians tend to call psychiatry when this happens. This is not a common consult.)

Do what you can to orient patients to what is going on. Give them approximate times for your visits and if you are running late, send a message to them to let them know. (Technology could help here: What if we could send text messages to patients through the television? or if the text message could become a voice message on their in-room telephones?) If patients are not around when you come by to see them, leave a note to let them know that you’ll try again later. (Technology could help with this, too.) Tell them why you don’t want them to eat after midnight. Tell them why you want them to work with physical therapy. Tell them the purpose of the bed alarm.

Help them understand what they are waiting for. Don’t take their patience for granted.