Category: Policy

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My Thoughts about Torrey’s “American Psychosis”.

This weekend I began and finished E. Fuller Torrey’s American Psychosis: How the Federal Government Destroyed the Mental Illness Treatment System. (That’s not an inflammatory title. At all.) Though I have read a few of his articles, I have avoided reading his books. Part of this was due to all the other books I have wanted to read; most of this was due to my discomfort with how he frequently presents people with severe mental illnesses as dangerous and violent. Torrey is probably best known for his arguments to change the law so that it is easier to hospitalize people against their wills.

You can see how that is controversial. What his Treatment Advocacy Center says is advocacy, others say is coercion and social control.

In this book Torrey presents a history of the Community Mental Health Act of 1963 and presents compelling arguments that it was flawed since its inception. He also argues that patients with severe psychiatric conditions now continue to suffer consequences from the Act.

Although I do not agree with all of Torrey’s opinions, I do agree that the current “mental illness treatment system” doesn’t work. People—social workers, patients, nurses, therapists, case managers, psychiatrists—are all doing the best that they can, but the system could improve. A lot.

Fuller offers ten solutions to make the “mental illness treatment system” better:

Public psychiatric hospitals cannot be completely abolished. A minimum number of beds, perhaps 40 to 60 per 100,000 population, will be needed. This is approximately four times more beds than we have available today.

Torrey argues that a small percentage of people, due to their chronic and severe psychiatric symptoms, will need to stay in hospitals for a long period of time.

I am torn about that: On the one hand, I have my own anecdotal experiences working with patients who, with the “right”[1. “Right” is a relative term and depends on the individual. I also recognize that my anecdotal experiences are just that: anecdotal.] support, were able to stay out of hospitals despite their significant symptoms. The lack of public hospital beds forced all of us—the patients and the supporting team—to figure out creative ways to keep patients out of the hospital.

On the other hand, people get caught up in where patients with severe psychiatric symptoms are. There is an underlying assumption that being in a [state] hospital is bad, an evil to be avoided at all costs. Yes, there were and are hospitals that do not provide good care. That does not mean all psychiatric hospitals are terrible. Some people who are in jails, on the streets, or sitting in emergency rooms night after night are those who could benefit from treatment in public psychiatric hospitals.

As someone who has worked in all three systems—jails, homeless services, and emergency/crisis centers—I must say that the stability and structure of a [state] hospital is much more therapeutic and safe than the chaos often inherent in the other sites.

Lack of awareness of illness (anosognosia) must be considered when planning any mental illness treatment system and provision made for the implementation of some form of involuntary treatment, such as assisted outpatient treatment (AOT) or conditional release for approximately 1% of all individuals with severe mental illnesses who are living in our communities.

Prior to reading this book I had never considered the comparison of anosognosia in people with dementia with the anosognosia of people with psychiatric conditions. People readily commit people with dementia (who can be as violent, though perhaps without the same sense of purpose, as people with psychosis) into homes and institutions without discussions about their civil liberties. Why don’t we do the same with people who are psychotic?

The conditions are different, of course.[2. We will put aside commentary about Kraeplin’s dementia praecox for now.] Dementia is a global phenomenon; it affects nearly all spheres of a person’s existence. Psychosis is often sphere specific. There are people with psychotic conditions who pay their rent, buy food, take showers, and spend time with friends and family… and earnestly argue that cameras are monitoring them, that chips were implanted into their bodies in the past, and the FBI is trying to kill them.

The system often tries to avoid admitting people with dementia into hospitals for psychiatric reasons. Why? Because, at this time, we have no interventions or expectations that people with dementia will get better.

We admit people with psychiatric conditions into hospitals because we expect people will recover.

Community treatment of mentally ill individuals will only be successful if carried out by community mental illness centers, not in community mental health centers. The change of one word is crucial to the success of any such program. Mental illness centers may be freestanding or integrated as part of medical centers.

The italics are Torrey’s, not mine. You now see why Torrey calls it the “mental illness treatment system”.

While I agree that words matter, I don’t think using the word “illness” will endear the system to either patients or those who work in them. There is already stigma attached to psychiatric conditions. Who wants to walk into a “mental illness treatment facility”? Furthermore, when we do understand etiologies of psychiatric conditions, why not invest energy in prevention?

There are dialysis centers, children’s hospitals, and heart and vascular institutes. If a name change is indicated, why not “mental treatment system” or “mental institute”? Some people will maintain their mental health; others will receive active treatment for mental illness.

Continuity of care, especially continuity of caregivers, is essential for good psychiatric care of individuals with serious mental illnesses.

This is true for anyone for any condition (cardiologists and people who have had heart attacks; students and teachers; parents and children; etc.).

We must create a system where staff retention is a priority. So many people leave community psychiatry because they burn out and don’t receive support. Patients should leave us because they recover and become independent; we should not leave them.

In addition to medication, individuals with serious mental illnesses need access to decent housing, vocational opportunities, and opportunities for socialization. The clubhouse is the best model for meeting these needs.

Note that Torrey argues that medication is the anchor for psychiatric treatment. Others disagree. I think it depends on the person and situation.

Clubhouses don’t receive the attention they should. They’re inspiring. Fountain House in New York City is the original clubhouse. One of the primary arguments against clubhouses is that they do not foster integration with people who don’t have psychiatric conditions. We all, however, are free to choose who we want to spend our time with and people with psychiatric conditions are no different. If they want to spend time at the clubhouse, they can. If they don’t, they won’t.

To protect vulnerable mentally ill individuals living in nursing homes and board-and-care homes, there must be periodic, unannounced inspections by an independent state agency. Evaluations and corrective actions must be made public.

I agree.

My work has not brought me into nursing homes and adult family homes (what “board-and-care homes” are called here in Washington State). Torrey presents heartbreaking anecdotes and data about the treatment people did not receive and the abuses they experienced in these facilities. (They mirror reports that came out of some state hospitals in the past.)

Unfortunately, people with psychiatric conditions generally don’t pull at heartstrings the way kids with cancer do. I worry that, given the relative apathy to the number and conditions of people who are homeless, the public may not have any reaction upon learning what happens in adult family homes.

For-profit funding of public mental illness services has been tried and does not work.

I agree.

Torrey and I share the same perspective: If the organization’s goal is to make a profit, money will always trump patient care. People with significant psychiatric conditions will somehow exit the system[3. And by “exit the system”, I mean patients are actively pushed out, not let back in, or made to jump through hoops that they cannot get through in order to receive services.] because they often require resources—time, money, energy—that are antithetical to saving or earning money.

This is why I am biased against for-profit correctional systems.

In selected cases, psychiatric information on mentally ill individuals who have a history of dangerousness should be made available to law enforcement personnel, because they are now the frontline mental health workers.

This point is tied to Torrey’s arguments that people with severe mental illnesses are dangerous. To Torrey’s credit, he does state that people with psychiatric conditions are vulnerable and are often victims of violence, but he spends a lot more time discussing the murders that people with psychiatric conditions have committed.

There are obvious privacy concerns about this. Are police officers familiar with HIPAA? How else might law enforcement officers use this information?

The single biggest problem with the present anarchic system of mental illness services is that nobody is accountable. It will be necessary to assign responsibility to a single level of government, and to then hold such individuals accountable, before any improvement can occur.

Torrey makes it clear that the federal government should not be the responsible party. I agree with that.

While I understand the Torrey’s sentiment, it is much easier said than done. The “mental illness treatment system” now spans multiple domains: the legal system, emergency departments, medical clinics, homeless shelters, law enforcement, mental “health” centers, hospitals, etc. Working with all these groups and aligning efforts to a set of goals will require significant culture change.

If you made it this far in the post, let me conclude by saying that, even if you don’t agree with Torrey’s thesis, this book is still an engaging and thoughtful read. I will confess that I began to feel hopeless and overwhelmed as he laid out all the failures of the system. However, he did finish the book with compelling solutions and highlighted that we can’t give up. This is not easy work, but it is meaningful work, and there is value both to individuals and the community if we take care of the vulnerable people in our lives.

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Thoughts on Stuff.

Recent things I have read that I have found interesting, curious, or vexing:

The Social Security Administration maintains a “compassionate allowances” list, which is a list of “medical conditions [that] are so serious that their conditions obviously meet disability standards”.[1. You can learn more about how diseases make it on to the “compassionate allowances” list here.] Cancers, genetic conditions, and diseases still known by eponyms make the list. (Medical types: This is your list of zebras, not horses.)

“Can you receive SSI (Supplemental Security Income)[2. The Social Security Administration mails a check of about $721 once a month to individuals who receive SSI. To receive SSI, you must have “limited income and resources” AND you must be disabled, blind, or age 65 and older. I got lost while digging through all the subsections, so I don’t know what the “limited” income is. “The limit for countable resources is $2,000 for an individual and $3,000 for a couple.”] while living in a public shelter for the homeless?” the Social Security Administration asks.

Answer: “Yes. You can receive up to the maximum SSI benefit payable in your State while living in a public shelter for up to 6 months out of any 9 month period.” (Emphasis mine.)

While it is true that most people are in the shelter system for less than three months, is it possible that some people who receive SSI will need more help over a longer period of time to get out of the system?

If someone must stay in a shelter, that usually means that he can’t pay rent. Most employers prefer to hire employees who have actual home addresses. No job means no income. No income means difficulties finding affordable housing. And it is mighty difficult to pay for housing and food with only $721 a month.

Psychiatry has little to offer in the realm of prevention.[3. Some would also argue that psychiatry has little to offer in the realm of treatment. In moments of frustration, I agree.] We have no medications to prevent schizophrenia, though omega-3 fatty acids might reduce the likelihood that a youth already showing some signs of psychosis will develop “full blown” psychosis. (Researchers are putting efforts into preventing psychosis, which is exciting.) Most people don’t go to therapy prior to experiencing uncomfortable and distressing emotions.

The WHO has a paper about social determinants of mental health that cover the entire lifespan. Frequent themes in the paper include providing education for women; attending to the mental health of mothers before, during, and after pregnancy; reducing poverty; and providing support to people in school and in work. The prevention of and reductions in psychiatric symptoms were not due to medical interventions.

Incorporating mental health into daily living helps people stay well and develop the resiliency to deal with crap. It’s not a separate thing. We know that people who have had adverse childhood experiences are more likely to have psychiatric and medical problems as adults. Exercise, spending time with friends and family, maintaining stable relationships, eating nutritious foods, learning about stuff, finding value in work and hobbies, avoiding conflict and trauma—all of these activities are useful in preventing major psychiatric conditions.

How many of us in psychiatry focus on these social determinants in our daily work? How have we let ourselves become “prescribers”? Can we change that so that we “prescribe” education and activity more often, and only prescribe medications in the most severe circumstances?[4. This is easier said than done, given that we cannot control the behavior of other people or systems. I also detest the word “prescriber”. That’ll be another post.]

Someone pointed me to this article with the polarizing title: Bad Managers Talk, Good Managers Write. The author argues:

When managers write, you create work product — white papers, product requirement documents, FAQs, presentations — that lasts and is accessible to everyone in the organization. From marketing to sales to QA to engineering, everyone has a document off which they can work and consult.

The upshot is that the manager also takes public responsibility for what happens when the rest of the team executes on the point of view taken by the documents. That ratchets up accountability through the organization.

This is also the benefit of keeping a blog. You create a body of work that people can read, refer to, and learn from. More importantly, regardless of your work (whether it is your formal profession or what you do “on the side”), it gives you the opportunity to reflect on things that matter to you, clarify your thinking, express your ideas, and connect with interesting people, including yourself.

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Education Homelessness Lessons Medicine Nonfiction Policy Reflection Systems

Involuntary Commitment (VII).

This post is overdue by one year! It may help to review the third scenario and a primer on involuntary commitment before reading on.

Why the delay? Because I still wrestle with the question at the end of this post.

Recall in the third scenario the man, described as a chronic inebriate, who frequently tried to kill himself while intoxicated. He recently had slapped a woman in a laundromat and had thrown a can of soda at outreach workers. How would you apply involuntary commitment criteria here?

1. Does this person want to harm himself or someone else?

While intoxicated, he has said that he wants to kill himself and we know that he has, in fact, harmed other people: He slapped a woman in the laundromat and he threw a can of soda at some outreach workers. While these may be minor insults in the grand scheme of things, they still suggest that he is disinhibited enough potentially harm someone.

2. How imminent is this risk of harm to self or others?

Probably imminent. Since he is frequently intoxicated, he is frequently disinhibited.

3. Are these behaviors due to a psychiatric condition?

Maybe.

Is an alcohol use disorder a psychiatric condition?

Think about your answer again.

Though “alcohol use disorder” is listed as a condition in DSM-5, some would argue that it is not a psychiatric condition. They would say that it is a choice. They would also argue that the mental disturbance that comes from alcohol use is temporary while “true” psychiatric conditions do not have the same cause-and-effect phenomena that we often see with alcohol.

However, we also know that this man has reported auditory hallucinations in the past and, regardless if his alcohol use is a psychiatric condition or not, his intoxication is clearly affecting his ability to function.

At least that is how I formulated it.

Related: Will hospitalization help treat the underlying psychiatric condition?

Possibly. The likelihood that he can become intoxicated with alcohol in the hospital is very low (but not impossible).

What actually happened?

The man was going around in circles from emergency room to street to jail. The police wanted him admitted to the hospital because the only time the police weren’t picking him up was when he was sober, which was when he was in the hospital. The outreach team had housing for him (he could have moved in tomorrow!), but he was too intoxicated to accept the invitations.

There was a big meeting and we concocted a big plan: The outreach team would find and talk with the man in the park in five days at 11am. He would likely be intoxicated and belligerent by then. The police would meet us there. The police would help transport the man to the hospital on an involuntary order. The emergency department staff would admit him to the hospital, whether he agreed to or not. Once he received treatment in the hospital, he would be discharged into his own apartment, with hopes that he would stay off the streets and away from alcohol.

What could go wrong?

On the appointed day, we found him in the park.

“Hey hey hey,” he said, putting his arm around the outreach worker, a goofy grin on his face. He offered the 40-ounce can of beer to us. “It’s the first one. Half full. I’m an optimist.” He laughed.

My heart was starting to sink: Even though he slapped a woman and threw a can of soda at someone less than a week ago, he wasn’t doing anything right now that would warrant an involuntary hospitalization.

But the show must go on, right? Multiple people and systems were involved. We had a big plan. And going through with the plan would be in his best interests, right?

Right?

“So,” the outreach worker started, “what do you think about going to the hospital with us?”

He laughed. “I don’t need to go to the hospital. I’m fine.”

“The doctors can check your health, make sure everything is okay….”

“Naw, don’t need it. I feel fine.”

Indeed. He was buzzed, but that wasn’t a reason to go to the hospital.

He looked over our shoulders, smiled, and shouted, “HEY!”

Behind us were four men with broad shoulders and thick legs. We all recognized them as police officers, though they were wearing casual clothes. They nodded at us.

“Wanna go to that bar with me?” the man asked, pointing to the brick building down the street.

“Sure!” the police said, chuckling. “It’s 11am.”

The outreach worker and I stood by our car and watched them disappear into the bar. We said nothing. Still nothing had happened that would warrant hospitalization, voluntary or not.

Several minutes later, the police officers and the man emerged from the bar. The man was singing:

Hello!
Is it me you’re looking for?
’cause I wonder where you are
And I wonder what you do
Are you somewhere feeling lonely?
Or is someone loving you?

The officers started laughing. Everyone was having a good time.

The police led the man to a squad car and opened the back door.

“We’re going to the hospital.”

“F@ck no,” the man said, smiling, having no idea what was happening. My heart sank further.

“Get into the car.”

“No!”

“Look, get into the car—”

—and that’s when he spit at a police officer.

WHAM! It happened so fast that I couldn’t believe what happened. They threw him against the hood of the police car. Two officers pinned his arms down. The other two looked ready to strike him.

I wasn’t the only one who noticed. Pedestrians began to rubberneck. Some young men began to call, “What did he do? Why you doing that?”

“It’s none of your business. Keep walking. There’s nothing to see here,” a police officer barked.

“No, that ain’t right. Why did you do that?”

A woman with flowers in her grey hair and a flowing peasant dress around her thin frame approached.

“That’s police brutality, that’s what. We need to get rid of the cops.”

In the meantime, the police officers had handcuffed the man—for what? for what?—and placed a mesh bag over his head so that if he tried to spit again, the netting would catch it.[1. This mesh bag is called a “spit sack”.] They pushed him into the back of the car and closed the door.

The crowd on the sidewalk grew. Close to three dozen people started to shout and chant at the police officers.

The outreach worker and I got into our car. What was happening?

The ambulance the police had called arrived. A paramedic got out and, hands on his hips, talked with one of the police officers. His brow was furrowed and he was frowning. The officer shrugged, then pointed to our car.

The paramedic walked over and knocked on my window. I rolled it down.

“What did this man do? Why are we taking him to the hospital? Did he actually do anything that warrants an involuntary transport?”

My cheeks burned.

“No.”

The paramedic[2. God bless this paramedic. We need people like him to ask these questions.] glared at me. He then turned around and walked away.

The police and paramedics moved him from the back of the police car into the ambulance while the crowd continued to bristle. The ambulance honked as it tried to weave through the crowd.

After the police drove away, the crowd dispersed.

The outreach worker and I sat in our car in silence. My cheeks were still burning.

He was in the hospital for about two weeks. The first three days were against his will. He agreed to stay in the hospital for the remaining 11 days.

The outreach worker met the man when he was discharged from the hospital to escort him to his apartment. He attended AA meetings four days a week. He took his two medications every night. He saw his counselor every week.

He avoided the park. The police started calling our office: “We never see him anymore. Do you know what happened?”

I never saw the man again, though heard occasional updates from his psychiatrist. The man didn’t drink any alcohol for nearly a year. When he did slip, he asked to go to the hospital. The police never got involved.

Even now, I still ask myself, “Did we do the right thing?”

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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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Blogosphere Medicine Observations Policy Systems

Why I Work at the Fringe.

This article is making the rounds among physicians on Twitter. Much of the information in the article, unfortunately, is accurate.

For some of the reasons stated there, I left the “traditional” health care system and pursued work at the “fringe”.

Part of this is due to my clinical interests: I like working at the intersections of different fields. For example, I like the intersection of psychiatry and hospital medicine, which is called psychosomatic medicine. Another example is my interest in public psychiatry, which focuses on the intersection of social factors and mental health (e.g., individuals with psychiatric and substance use conditions in the context of homelessness and poverty).[1. Really, though, all of medicine could be “psychosomatic medicine” or “public psychiatry”; the divisions between mind, body, and environment are arbitrary.]

Part of this, though, was my sense that the system would not let me be the kind of doctor I want to be.

For a brief period I worked in a clinic where I had slots for four new intakes a day (60 minutes each) and 15-minute follow-up appointments for the rest of the day. If my schedule was completely filled with follow-up appointments, I could have seen up to 34 patients a day. (I never got to this point because I quit well before my panel got full.)

In reality, the 15-minute appointments were 12-minute appointments. I needed about three minutes to type out some notes to myself for clinical documentation.[2. I don’t like typing my note while I am seeing a patient. I’m not fully attending to either one when I do that.]

Because I was building a new practice, people with a wide variety of conditions and concerns came to see me. I was advised to refer patients out of the medical center who were “too sick”. This included individuals who were frequently in and out of psychiatric hospitals, had significant psychiatric symptoms, or otherwise had other stressors in their lives that made them “difficult“.

In other words, they told me to refer out the people who needed specialist care the most.

The reality, too, was that no psychiatrist could provide quality care to these individuals in 12 minutes. Imagine someone with depression so severe that he lacks the energy or interest to share his current distress with you. Or someone who is psychotic and insists that her ex-husband is tracking her through all the electronics in her home. Or someone who is so anxious about leaving his house that his attendance to the clinic is worthy of celebration.

Obtaining an accurate history guides diagnosis, which then guides treatment. An insufficient history can thus lead to haphazard interventions. You can see how the 15-minute appointment model results in heavy reliance upon (potentially unnecessary) medications. If someone says he feels depressed, it’s difficult to validate his emotional experience, provide education about his condition and non-pharmacological ways to manage it (e.g., behavioral activation, sleep hygiene, etc.), and have a discussion about medications, which should always include risks, benefits, and alternatives, in 12 minutes.

It is much easier to write a script and ask someone to return in a month. (This inspired my post about the Automated Psychiatrist Machine.)

Furthermore, this clinic was in a medical center with a group of primary care physicians. Primary care doctors referred their patients with diagnoses of schizophrenia and bipolar disorder to the psychiatry clinic (as they should). These individuals, however, were “too sick”. Never mind that, unlike the primary care physicians, we psychiatrists had the training to diagnose, treat, and manage these individuals with significant psychiatric conditions.

Thus, these patients often returned to their poor primary care physicians, who tried to care for them the best they could… which often entailed medication regimens that were unnecessary. (Primary care physicians deserve no blame for this: How are they supposed to know?)

This clinic also “rewarded” psychiatrists for “productivity”. The more patients a psychiatrist saw, the more money the psychiatrist would earn. This led to “cherry-picking” patients. Psychiatrists would keep patients who either had minor conditions or symptoms that had resolved, because those are the patients you can adequately see in 12 minutes. As a consequence, patients with more debilitating symptoms could not access the clinic. The psychiatrists had no incentives in either time or money to send these “cherry-picked” patients back to their primary care doctors.

My frustration and disillusionment compelled me to leave the job. I returned to positions at the “fringe” to work with patients who often are also not part of the system or patients that the system had failed. Consider the man who has been homeless for the past ten years and is too paranoid to access any health care service. Or the woman who was beaten and molested as a child, sent to foster care and group homes, never completed high school, “aged out” of youth care, and now has no resources or support.

I couldn’t wait for the system to change, so I sought out settings where both my skills would be useful and I could be the kind of doctor I want to be. There may not be many physician jobs at the “fringe” and certainly not all physicians want to work there. When we physicians vote with our feet, though, we show what we value, the kind of care patients deserve, and how the system must change.