Originally published by ThinkerMedia: BestThinking.com on September 21, 2013
A third (and rising) of all deaths in America come from medical errors, while mental illness is the most expensive of all illnesses. How are these facts related? A psychiatrist recounts his immersive professional journey through our crumbling medical infrastructure.
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Facts: Mental illness is the most expensive of all medical conditions, while an epidemic of preventable medical errors is the third largest killer in America. How are these facts related? A psychiatrist recounts his immersive professional journey through America’s crumbling medical infrastructure.
PART 1 of 2. For part 2 click here. Part 2 describes an amazing experience at a state hospital and a sad stint at a children’s service.
Report from the field: Careful and caring chronicles of one doctor’s recent journeys into some corners of his profession, currently rarely noticed by most colleagues and the public, illuminate issues now in the news with grave implications for all our futures. Some solutions to the basic conflict between the need to create billable records and the delivery of competent language-based psychiatric care are offered, including development of IT systems.
In the popular mind, mental hospitals may be pictured as gracious rural spas where gentle platitudes and long rests restore people; or as snake pits filled with agitated, violent, cross-eyed, drooling people and deranged sadistic nurses with poor dentition and doctors with thick accents tugging patients into canvas straight jackets; or as callous, filthy insane asylums dispensing punitive electric shocks and bizarre mind-destroying drugs. IMHO these images often mostly reflect common fears we all instinctively harbor about unlucky people with troubled minds and the hospitals where we hide them. We are also often creeped out by their strange caregivers and bearded humorless doctors, who must obviously also be somewhat odd themselves to actually choose to spend professional lives so close to them.
So OK, I am one of those doctors, well into my career, but there is absolutely nothing strange nor odd about me, and no beard, either. My recent journey into modern psych hospitals started like many today: I needed the income, so I was lucky to find several opportunities as an hourly temp. I was quickly placed in a succession of private Behavioral Health and public state hospitals, that sought psychiatrists. I also spent some months in a well-regarded outpatient family service agency. These seemingly agreeable settings and the locum tenens (temporary covering doctor) arrangements were new to me.
But I found my journey more novel and difficult to understand than I expected, with some realities as appalling as the popular stereotypes, yet with other aspects amazingly and wonderfully inspiring. The whole journey took me some time to sort out, but I can now begin to describe what I saw and what I did, much as a memoir, punctuated by personal comments in italics. My essay concludes with reflections and a personal note. Reader please note: From time to time, I may amend or edit this essay.
I made the following discoveries during recent immersive roles as a temporary substitute physician. In three adult inpatient units in hospitals in urban areas, I served several months for 10-40 hours weekly, taking over care already started by others or admitting new folks, and covering pediatrics, emergency rooms, drug rehab, medical consultation, and adolescent services nights and days. In a family agency, I spent about three hours a week as a child and adolescent psychiatrist. And so I came to care for hundreds of people of all ages, individuals, families, and staffs, and became intimately familiar with their experiences.
My professional standards are based on fortunately superb education and training, decades of successful and fulfilling psychiatric practice in many settings, including original widely cited published research, teaching and board certifications and many stints as a board examiner in adult and in child and adolescent psychiatry all over the US. I view patients as ordinary people doing their best to cope with neurobiological illnesses affecting their minds and dealing with the enormous stresses of being in a psychiatric facility (or currently,”Behavioral Health” unit, whatever that means) at the same time.
I set the bar pretty high because I believe doctors owe that to their patients. Giving poor care is an ultimate act of cruelty and disrespect when good care can reasonably be given. When it comes to compromising and shortcutting patient care because of selfish self interest, incompetence, or sloppiness, I am known to typically hold licensed professionals and institutions to non-negotiable standards, especially when they know or should know better; and especially when good care is within their grasp, as it often is. I give care to all as I would like to have it given me.
Although I believe the settings I saw are largely typical, I realize — and so should the reader — that drawing major conclusions about a whole industry or groups of people from such a small sample may be neither valid nor fair, but I saw what I saw that needs an urgent telling.
“BEHAVIORAL HEALTH” INPATIENT PSYCHIATRISTS AS QUEEN BEES
The several facilities I have worked, each occupying a part of a floor in a larger hospital, are roughly similar physically and in staffing patterns, since all hospitals are inspected regularly according to basic procedural and physical standards. A unit holds 30 patients usually roomed in clean, suicide-safe, unlockable double dorm-like rooms with a half-bath, special window glass, basic furniture built in or bolted to the floor, and no mobile phones nor computers. One or two land-line phones hang on hall walls. Common areas include stalled showers, a large, comfortable lounge or two where patients are encouraged to spend their time, and occupational therapy rooms.
When you are buzzed into a unit, you see a Spartan hospital wing as the solid security door gently locks behind you. The wing is always locked, confining patients because of security and insurance preferences. Visitors are allowed, but must be identified and are sometimes searched or the entire visit monitored.
It is generally quiet and peaceful. Some staff work in their offices, often with doors open, or offices are outside the unit. People can be found gathering or milling in the halls, their rooms, an activity room, community therapy meeting, or watching TV, and some patients must always remain in staff’s direct line of sight.
Staff members, including nurses, wear street clothes or distinctly-colored nursing “pajamas.” Nurse practitioners, master’s- or doctorate-level nurses specializing in psychiatric care can offer enlightened leadership and and clinical care rooted in nursing traditions. Patients can be seen in safety-screened street clothes or bundled in layered, loose hospital gowns over surgical “pajamas.” Nursing and other staff and patients often congregate around wide open or enclosed and locked nursing stations. Hospitalists are hospital physician employees and can wear surgical “pajamas”. Psychiatrists and internists often wear ties.
Patients are screened medically upon admission by private practitioners or hospitalists. Street clothes and personal belongings are stored. Security is tight, and unit hygiene fair. Patients or staff can be injured rarely by sudden patient violence. Many can become more agitated, especially initially, and require emergency injections after frightening staff and patients. For example, a man who just learned of a brother’s death became violent in his despair.
Most patients attend group and occupational therapies. Any type of individual or family therapy is absent. Physical restraints are rarely used and considered a last resort, and then governed with strict protocols. ECT (electro convulsive therapy) is generally not available.
A uniformed, unarmed, usually quite friendly security officer (often an actual retired or off-duty policeman) can appear when the buzz and activity level are high. Some staff visibly carry a device to activate the general sound and light safety alarm. Male staff capable of restraining people are scheduled every shift. Staff avoids sitting in chairs just occupied by some patients.
In some units psychiatrists are hospital employees. However, in the units I saw, unlike most others who interact with inpatients and are held closely accountable within a supervisory hierarchy, psychiatrists are not actual employees of the hospital. They are independent unsupervised practitioners, legally distanced from the facility, who bill insurers and are reimbursed separately. Medical practices are supposed to be monitored by a medical governance structure, but I saw no evidence whatsoever of sorely needed real-time medical quality control. Psychiatrists see patients during daily rounds, practiced in a private conference room with the doctor, a nurse, and at least one computer.
The effects of healthcare reforms, doctor shortages, and budget cuts in social services are dramatically seen here: in the units I saw, doctors’ output is essential to the profits of an enterprise that seems to teeter on the edge of catastrophe because of thin and fluctuating profit margins and stiff competition in some places. Like efficient queen bees producing eggs for their hives, doctors must labor assiduously to yield a stream of dictated admission, daily progress, orders, and discharge notes.
A person’s entire hospital stay and almost every associated charge hinge on crucial wording that is then carefully coded by an office full of cordial clerical staff to enable billing and profit from the unit.
The basis for care is mostly driven by economies and statistics and not by what’s medically best. Often units cannot survive financially, especially these days, leaving serious gaps in the safety net of too many Americans. Census (how many beds are occupied) is the topic most often discussed by staff and doctors. Average length of stay (LOS) is less than a week, but can extend into several, depending on severity of illness and availability of discharge placements. Everyone is relieved when units are full and resources really stretched. Unit nursing and other staffing commonly expands and contracts every eight hour shift, paralleling unit census to avoid waste. So jobs and income are at stake to keep census high.
Charting is a crucial activity, and staff and doctors closely monitored by specially trained utilization reviewers to comply to the letter with the language of rules imposed by the insurer to avoid raising red flags and assure reimbursement. Key language terms must be included in nursing and medical notes to allow for smooth coding and reimbursements.
THE PEOPLE RECEIVING BEHAVIORAL HEALTH SERVICES I MET
Our neighbors, people past high-school age, are brought in, mostly in the evening hours, by ambulance or police, family members, or from emergency departments and far away nursing and group homes, or transferred from other hospital medical units. Some just tried to jump off a bridge. Many are ordinary folks who are extremely stressed by overwhelming crises. Others overdosed and are admitted after medically cleared.