Category: Policy

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Education Homelessness Lessons Medicine NYC Policy

Involuntary Commitment (I).

It’s winter in New York City. The temperature is hovering around 32 degrees Fahrenheit. Large, slushy snowflakes are falling from the pewter sky.

You are already familiar with this woman; you had met her the previous Spring. No one is sure of her age, but she looks over 65 years old. She had said that she had immigrated to the US when she was in her 20s because she had a scholarship to a prestigious university. Something interrupted her schooling. She ultimately stopped attending classes and hitchhiked here. She’s been homeless on the streets of New York ever since.

She has never shared her date of birth for fear that the government would use that information against her. It’s not clear if her stated name is really her name. She’s a familiar figure in the neighborhood; people regularly give her styrofoam bowls steaming with hot soup, sandwiches wrapped in white butcher paper, shiny cans of soda, and cups of coffee. Some people have been giving her food for the past ten years. Upon receipt she murmurs, “Thank you,” and nods her head on her slender neck.

She never makes eye contact. The irises of her eyes have grey halos and her gaze is usually over your right shoulder. You’ve tried to learn more about her past, what led to her homelessness, and her interest in housing, but she usually ends the conversation and walks away. One time before bidding you good-bye she did comment, “The government secrets are safe with me.”

People in New York walk past her everyday while she sleeps and never realize it: She buries herself underneath black garbage bags stuffed with paper. What looks like a mountain of trash on the curb or underneath scaffolding is actually her private fort.

“The paper keeps me warm,” she has said. To prove her point while the autumn winds sent the dying leaves swirling through the air, she rolled up a sleeve of her parka to reveal wads of newspaper crumpled in her clothing. At times she donned a hat made out of a paper bag and stuffed it with newspaper to warm her head.

It is not yet 10am on this snowy morning and the weather forecasters predict that the storm will worsen as the day goes on. The snow is already sticking to the sidewalk. Over six inches are predicted to fall in the next few hours.

Today, the woman’s camp is underneath the short awning of the back door of a clothing boutique. Underneath her is a flattened cardboard box, the corners already beginning to darken and soften from the snow. On top of her are only four or five garbage bags, fewer than what usually covers her. Upon hearing you, she sits up and her face, as expected, does not show any expression.

Her parka is unbuttoned and underneath is a thin white shirt with a tattered collar. The skin of her neck is mottled and red.

“There’s a snowstorm coming through, it’s supposed to be pretty bad. Would you be willing to stay in a shelter until it’s done?” you ask.

“No, I’ll be fine.”

“It looks like you’re cold; you don’t have as many bags as you usually do and your skin is turning red. We don’t want you to be outside when it is this cold out,” you try again.

“I’m fine.”

“We worry that if you stay out here, you might get frostbite.”

“I’m fine.”

“Where have you gone in the past when there were big snowstorms?”

“I’m fine.”

Meanwhile, snow is beginning to collect on her coat, her bags, and in her hair. She makes no motion to move.

Does this woman have a mental illness? Does she need to be sent to the hospital for psychiatric evaluation? If she doesn’t want to go to the hospital, should she be forced to go to the hospital against her will?

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Fiction Policy

Automated Psychiatrist Machine.

Are you tired of waiting fifteen minutes only to spend ten minutes with your psychiatrist? Do you hate rearranging your busy schedule, fighting traffic, and trolling for a parking space just to spend a few minutes with your doctor? Wouldn’t it be easier if you could take care of your mental health according to your schedule, instead of someone else’s?

We are pleased to introduce the Automated Psychiatrist Machine (APM). The APM is an advance in medical technology that dramatically increases the efficiency of patient care and results in high patient satisfaction scores.

We know what a typical appointment with your psychiatrist is like: You check in and sit in an uncomfortable, crowded waiting room with strangers. You then see your psychiatrist, who may (or may not) ask you about your current symptoms. Maybe you just talk about your recent vacation or your plans for the holidays. He might ask you about side effects. Maybe the only question he asks you is how many refills you want. You wish that you didn’t have to see him every three (or six… or nine…) months, but he won’t write prescriptions for you if he doesn’t see you.

“But I’m fine. Do I really need to come in every six months?” you ask. The meds help. You don’t want to talk about stuff. You are a busy person with things to do and multiple lives to live. Who has time for anything else?

This is where the Automated Psychiatrist Machine comes in.

Located outside of various medical centers, APMs allow you to take control of your care. Do you work day shifts or care for children and it’s just not convenient to see your doctor during the day? Go see the APM after work. Did you get sick and now must reschedule your appointment? Go see the APM when you are feeling better. The APM is open and available 24 hours a day, seven days a week.

The APM has a touchscreen that will guide you through questions your current psychiatrist may (or may not) ask:

  • How many hours are you sleeping?
  • Have you noticed any changes in your appetite or weight?
  • Are you experiencing any side effects from medication?

The entire interaction takes less than five minutes. Once you answer the short set of questions, the APM will print out your prescriptions that you can take to a pharmacy at your leisure. Additions and adjustments are made to your medication regimen according to an algorithm.[1. The APM medication algorithm may not be evidence-based or take into consideration your specific symptoms or side effects.]

There is no reason for you to see a real psychiatrist anymore. Make no mistake: your psychiatrist will still be your psychiatrist, but you just don’t need to actually see him.

Psychiatrists, the APM can increase your productivity and efficiency, too! A small videocamera on the APM captures video of the patient so you can document a mental status exam. The more patients you refer to the APM, the more patients you can “see” in one day! According to research, the average interaction with an APM lasts about four minutes. That means you could potentially “see” 120 patients a day![2. Psychiatrists using APM could potentially see 15 patients an hour. An eight hour day thus equals 120 patients. Compare this to the 25 to 30 patients you see a day now.] And if insurance companies are willing to reimburse $120 a patient, you can see how the numbers add up.

And because of advances in technology, psychiatrists can now work from home. You don’t need to get up and go to your office. APM can securely channel video to your home computer so you can both review the questions patients answer at the APM and perform mental status exams. You’ll essentially go through the same interactions that you had with your patients before, except you don’t even need to be in the same room as them. You can still assert that you’re a psychiatrist, even though you never actually directly interact with patients!

The Automated Psychiatrist Machine will improve quality of life for both patients and psychiatrists alike. Ask your psychiatrist about the APM today.

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Consult-Liaison Education Informal-curriculum Lessons Medicine Observations Policy

Red Herring: Epilogue.

I encourage you to read the entire Red Herring series before reading this post. Consider this your “spoiler alert”.

The patient really is fine.

She returned to the gastroenterology clinic several times for treatments to widen her esophagus. (It’s a neat procedure: The GI doctors insert a small balloon into the esophagus. They gently inflate the balloon to stretch the stricture a few millimeters. With repeated stretching, the esophagus will remain open.) The patient ate more. She stopped vomiting. Her weight increased.

For the sake of flow, I did not include two complications that occurred during the course of events:

Medication problems. Although I had written a letter to hospital staff that included the patient’s history and list of medications, the psychiatrists in the first hospital omitted one medication from the patient’s regimen. As a result, the patient developed distressing symptoms consistent with schizophrenia. (In some ways, this was a blessing, as this omission confirmed her diagnosis. As the patient had demonstrated minimal symptoms of schizophrenia as an outpatient, I would have been tempted to taper off medications… which could have resulted in an “unnecessary” hospitalization.) I suspect this error prolonged her hospitalization.

Transfers of care from outpatient to inpatient settings (and vice versa) are fraught with problems that often adversely affect the patient. People have proposed universal health records, care managers, and other devices to help minimize this potential for harm. For now, most of us continue to do the best we can with the current system.

Decisional capacity issues. After the patient was hospitalized the second time, the gastroenterologists had concerns about the patient’s ability to consent to the procedure to evaluate her esophagus. While she could communicate a choice, they had doubts that she could appreciate her condition and understand the risks and benefits of intervention. Her worker ended up going to the hospital to discuss the procedure together with the patient and physicians. We were fortunate that he was available to do this.

I wanted to share the tale of the Red Herring for three reasons:

All physicians are subject to bias. Patients can suffer as a result. Patients with psychiatric diagnoses sometimes do not receive appropriate medical attention simply because of diagnostic labels. This can occur even if patients are not demonstrating psychiatric symptoms at the time of the encounter. Physicians, including psychiatrists, may assume that these patients exaggerate or misreport medical symptoms. Alternatively, physicians may assume that medical symptoms are due solely to psychiatric conditions.

According to Wikipedia (not the best source of medical information, but anyway…), the prevalence of esophageal strictures is 7 to 23% in the US. The prevalence of schizophrenia is less than 1%. The prevalence of bulimia in the US is about 5%. Though esophageal strictures are more common than either psychiatric condition, we all somehow believed that the latter was the culprit in the case of the Red Herring.

We all often forget that people are not simply mind or body. People with psychiatric conditions still have physical bodies that can bleed, break, and hurt.

Physicians need time to provide good care. 15 minute appointments maximizes profits for organizations and physicians in private practice. 15 minute appointments often do not maximize benefit and value for patients. (To be fair, organizations and individuals need money to maintain clinics. If clinics go bankrupt, everyone loses.)

If I saw this patient for only 15 minutes, once a month, it would have taken me much longer to build a relationship with her. Without that relationship, I could not have directed her to go to the hospital. She would have (accurately) experienced that as coercion. Furthermore, my understanding of her symptoms and condition would have been limited.

If I only had 15 minutes a month with this patient, I would not have been able to advocate for her as I did. If we want our physicians to provide this level of care, we all must recognize that physicians need time to do so. (My patient was enrolled in a program for individuals with severe psychiatric conditions. My “caseload” of patients was purposely kept low; this allowed me to spend a flexible amount of time with people and to see them on a more frequent basis.)

Physicians must advocate for their patients. For those patients who are able to advocate for themselves, we must encourage them to do just that. Helping patients obtain the services they need to lead healthy, independent lives with limited contact with medical establishments should be one of our primary goals. This is particularly true in psychiatry: we should do what we can to get people out of the mental health system so they can get on with living their lives.

For those patients who cannot advocate for themselves, we must advocate for them. They otherwise will not receive the care and interventions they need to maximize the chances that they can lead healthy, independent lives. We have all read articles citing the enormous financial costs associated with undertreated or untreated medical problems. Furthermore, we will have failed our moral obligation to promote beneficience.

Thank you for reading the Red Herring. I appreciate your attention.

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Education Homelessness Informal-curriculum Lessons Medicine NYC Observations Policy PPOH

Supervision and Support.

To conclude a description of my previous job at PPOH in New York, let me tell you about Friday afternoons.

Every Friday afternoon, the staff psychiatrists met as a group for three hours.

Those three hours were important and valuable. During that time, a variety of activities occurred:

Case presentations. Different psychiatrists presented cases to solicit ideas and help. Hearing the thoughts of others provided fresh perspectives and helped us “think outside of the box”. Each psychiatrist had his specific strengths and this forum allowed us to access his expertise.

Example: Someone once presented a case about a woman who was refusing to accept treatment for a major medical problem. The psychiatrist had assessed her decisional capacity and it appeared intact. This meant that we—other doctors, her psychiatrist, other non-medical staff members—had to respect her wishes… and also watch her become more ill and eventually die. The psychiatrist who presented this case wanted to (1) ensure that his assessment of her decisional capacity was thorough, (2) learn how to manage the (often angry and frustrated) reactions of the other physicians and non-medical staff, (3) get ideas about how to coach the other physicians involved in the patient’s care when they wanted to do something and she refused, and (4) vent and get support from us, as managing his own reactions and the reactions of others was taxing.

Sometimes the case presentations were less complicated: How can I encourage this patient to try medication? Is there anything I can do to get this patient to stop asking for medication? Do you have any ideas as to how we can keep this guy out of the hospital?

Grand Rounds. Grand rounds refers to a lecture on a specific medical topic. It is often considered a “big event” (i.e. lots of people are invited or expected to go). In academic medical centers, someone well-known in the subject usually gives the lecture.

PPOH established a Grand Rounds committee[1. The PPOH Grand Rounds committee was comprised of two people: a senior PPOH psychiatrist and me, as we were both interested in medical education. If you would like me to speak at your Grand Rounds or provide other teaching, let me know.] to organize a series related to homelessness and mental health. Speakers with expertise on schizophrenia, common infections in the homeless, harm reduction, housing first, tobacco use and cessation, and other topics shared their knowledge with us.

These lectures were an essential part of continuing medical education. We need and want to learn so we can provide excellent care for our patients, particularly since there is a dearth of literature for this population.

Peer supervision/support. Every job has its challenges. In psychiatry, it is no different. Working with individuals who have significant mental health problems, homeless or not, can be stressful. Sometimes we feel anger towards patients. Sometimes we feel frustration with other psychiatrists or physicians. Sometimes we feel scared that we did something wrong. Sometimes we worry that our patients will die.

Much of psychiatric training uses the apprenticeship model. While in residency, we meet with “supervisors” (attending psychiatrists) on a regular basis. Supervisors provide coaching and guidance to help residents learn psychotherapy and prescribing practices. This is also where the informal curriculum is taught: Supervisors are essential in teaching (demonstrating) professionalism and attitudes. It is during supervision that we also learn to examine our own reactions to clinical encounters… and, oftentimes, our reactions tell us more about ourselves than about our patients.

I was deeply grateful for these weekly three-hour meetings. (I have since realized that this set-up is rare. No money is gained while physicians are meeting for supervision. Neither patients nor insurance companies are billed. From a financial standpoint, it is wasted time. However, I’d like to think that this investment in physicians ultimately provides benefits for patients. I don’t know if there is any data to support this, though I believe it is absolutely true.) The built-in network of peers gave me security: I knew I could trust them to help me become a better doctor.

Many medical students and residents feel embarrassed to ask questions. They might feel ashamed to say “I don’t know”. With time and experience, that shame goes away. It’s okay if you don’t know. What you do next is what matters: If you need help, ask for it. You will (re)learn something, you will take better care of your patients, and you can then help another doctor in the future.

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Education Lessons NYC Policy PPOH

Assertive Community Treatment.

While at PPOH, I spent two days a week working with an Assertive Community Treatment (ACT) team.

ACT is somewhat like a psychiatric hospital outside of a hospital. It is an evidence-based practice[1. From the New York State Office of Mental Health: “When comparing recipients before and after receiving ACT services, studies have shown ACT recipients experience greater reductions in psychiatric hospitalization rates, emergency room visits and higher levels of housing stability after receiving ACT services. Research has also shown that ACT is more satisfactory to recipients and their families and is no more expensive than other types of community-based care.”] that features a multidisciplinary team (social workers, psychologists, psychiatrists, nurses, case workers) that works with a small group of patients who often experience impairing psychiatric symptoms. It provides comprehensive and flexible psychiatric services. All of the care occurs in the community.

The ACT team I worked on was staffed with:

  • one program director (social worker)
  • one team leader (social worker)
  • one MICA (“mental illness and chemical addiction”) specialist (social worker)
  • one vocational specialist (social worker)
  • one entitlements specialist (almost-graduate from social work school)
  • two case workers (one who had recently earned a social work degree)
  • one registered nurse
  • one secretary (who did much more than clerical work)
  • two psychiatrists (our combined hours did not fill a full-time position)

During my time there, I provided care for about 35 patients. (The other psychiatrist provided care for the other 35 patients.) The staff to patient ratio is purposely kept low, as ACT is considered an intensive intervention.

Patients who are referred for ACT services must have been psychiatrically hospitalized (often involuntarily) at least four times in the past year. They often have multiple emergency room or mobile crisis visits. Other outpatient services have often failed or have been insufficient to prevent crises and hospitalizations.

Thus, a chief goal of ACT is to keep people out of the hospital.

The ACT model dictates that the team (as a whole) must make a total of at least six contacts with each client[2. There is a movement in mental health—and in other parts of medicine—to move away from the term “patient”. In this particular ACT setting, patients were called “clients”. Sometimes they are called “consumers”.] every month, preferably in the community. One of these visits should be a meeting with the psychiatrist. Some patients regularly came to the office for their visits. Others, however, could not or would not come in. We thus went out to them. (Hence the adjective “assertive”, which, in some cases, could be construed as “coercive”. More about coercion later.)

If I did not see patients in the office, I often saw them in their apartments. (Limits and boundaries do not blur, but they certainly shift. My experiences in these residential settings inspired this post. To be clear, there were a few individuals who I never met alone. I insisted they meet me outside or in the clinic. Some of this was due to their past behaviors; some of this was my gut instinct.) For those who did not feel comfortable meeting in their apartments, we met in lobbies, parks, or chatted during walks. (During my time on ACT, I came to value talking and walking as a therapeutic intervention.)

ACT was formerly deemed “long term care”; some patients have been on ACT teams for over a decade. (This is often due to repeated psychiatric hospitalizations despite ACT services.) Most of the patients had psychotic disorders (such as schizophrenia) and, surprisingly, many of them had actively involved family members. I suspect that this impacted who was referred to ACT; family members were often the ones bringing people to the hospital for care (versus calling the police, etc.) Most patients “graduate” from ACT within a few years: They stay out of the hospital, become more involved in the community, and no longer need that level of care.

I learned in this position that people with chronic psychotic disorders can get better. Their symptoms decrease. They learn how to temper their behavior so that they do not attract undue attention while out in the community. They set and reach personal goals, like earning high school and college degrees, securing employment, getting sober from alcohol and drugs, and taking care of their physical health. They stop smoking! Sometimes they need a lot of support and a number of years need to pass before things settle down, but people with diagnoses of schizophrenia are not doomed to a life of poverty and “low function”.[3. The public rarely hears about positive outcomes for people with schizophrenia. There is research that suggests that a significant number of people with diagnoses of schizophrenia either experience improvement or recovery of their condition. Anecdotally, I agree.]

I also learned the importance of seeing patients in their environments. So much of contemporary medicine now occurs outside of a person’s living situation. That is often appropriate and fair (e.g. patients shouldn’t undergo surgery in their own homes). Because of the intimate nature of medicine, meeting in a “third” location can help preserve privacy and security. However, we can learn so much about how people function (or do not function) when we see their living spaces. We also realize strengths that we would otherwise overlook. A neat home, a sack full of old prescription pills, vinyl records of classical music, papers all over the floor, photographs of friends and family, roaches climbing over dozens of empty cans of soda: All of that is information that doctors often never have.

It is amazing how people live their lives. It is remarkable how much people will tolerate. And it is humbling that people are willing to share their lives with you.