Report from the field: This personal chronicle of one doctor’s recent journeys into some corners of his profession, currently rarely noticed by most colleagues and the public, illuminates 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 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.
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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 decades of psychiatric practice in many settings, including 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 and 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.
Others are drunk. Many have some abused substance in their urine. Some may be described by nursing homes as violent, but are actually dumped for economic reasons. Others are dumped by other hospital EDs that intentionally exaggerate or even invent suicidal risk, even university-based hospitals. Some may be churned in profitable mills between nursing homes and units under the care of the same doctor. Some come to save themselves and others from themselves.
Hospitalized folks can include: executives who lost everything or other once-employed people fallen on hard times or people who were never employed; union members; illiterate and the markedly retarded or demented; those with graduate degrees; African-, Latino-, European-, Asian-, other-Americans; immigrants and asylum refugees who require a sometimes unavailable interpreter; parents of infants and grown children; residents of inner cities, farms, and suburbs.
These people are also housewives, prostitutes, teen moms; someone’s moms, dads, uncles, aunts, grandkids; panhandlers, laborers, voluntary sign-ins or certified, homeless people, substance abusers and alcoholics denying, substance and alcohol abusers detoxifying and resolving this is their bottom, felons under indictment, and violent sociopaths.
Our neighbors can include newly admitted patients still agitated or heavily sedated from their admission ordeal; the meek and shy; beautiful, deformed, cachectic, obese, weathered, athletic, and/or toothless people; those with poor personal hygiene; those well groomed first-timers; the neuro-developmentally disordered; and the “frequent flyers.” All are poor. (But not for long, as new ACA subscribers flood this very same system.)
They are desperate, dispirited, demoralized people who live in extreme stress with extreme fear, hurt, and anger, and yet retain amazing dignity and decency. They know the terror and shame of mental illness, I am sure you can imagine, reader. So some deny their illness and refuse treatment, hiding in their beds. Yet, most mix together minimally, vulnerable and mostly frightened, lonely, and disempowered, cut off from family and home, almost like the sad uncaged cats in a shelter I know. They mostly move silently past each other. They are the invisible people, the “walking dead,” as one woman, a mother, reminded me.
Many can be engaged once they get over the initial panic of being on the unit and their medications are adjusted. These individuals have a lot to say when given a chance: Many would like a visit from the chaplain. Some have a sense of humor. Most welcome a personal fist bump or shaking hands with the doctor and a discussion of their past and future. They appreciate a conversation about how this hospitalization could be a turning point in their lives. They like being asked what they need or what name they prefer to be called. Many want their own clothes returned to them ASAP and have important wishes and plans no one asks about.
When given a chance, men can ask for razorblades because they do not like electric razors. An 18 year old man could be coaxed into showing off his rapping talent and appreciates the interest. Some ask for a roommate who does not snore. Many are quite engageable and capable of participating in their own care. Mealtime is important to many patients, especially the homeless or those from group homes. All eat together from hospital trays in a dining room that doubles as an activities room. Many ask for double helpings, and it is not usually allowed.
Average length of stay is extremely short, often less than a week. Some people are admitted inappropriately in the first place, so it is easy to discharge them early. Others are “frequent flyers” and those whose lifestyle includes frequent hospitalizations with quick spontaneous remissions or responses to resumption of medication. Some people remain longer because they just do not improve quickly enough for discharge or have no other place to go. However, whatever the length of stay, discharge timing depends on improvement. Improvement should also be gauged by talking with patients to assess how well their neurobiological illness is remitting. In these units, credible mental status examinations hardly ever happen.
THE DEAL
Much like military field hospitals where time is of huge importance, units do not cuddle patients into time-costly regressive states. Patients are expected to fit in immediately and stretch themselves to cope with daily living demands, restore self-management skills, and return to a higher level of functioning quickly. Social workers are busy arranging discharge placement for patients and have little time for therapeutic conversations. A chaplain is available for the asking.
IMHO these Behavioral Health units can send this powerful restorative message. Here’s the deal: We have little time, we know. But you are expected to improve anyway, relearn to behave civilly, take your meds, and leave fast. We will get to know you and your situation, give you competent, caring, psychiatric services, feed you, take care of your health, and protect you, other patients, ourselves, and our property from anything you might try — so don’t, and then send you on to the next step in your healing journey.
IMHO, patient improvement can reasonably come from this deal. If it worked well with competent psychiatrists as lynchpins, it would be acceptable. The place can be about doctors restoring our neighbors to their best with expert understanding of the nuances of being both human and complexly ill, not merely as receptacles for poorly chosen medication. It can be about a thorough understanding that each of these regular folks has a unique past, present, and future, and may suffer from a uniquely individual complex disorder of thinking, behavior, and / or feeling that damages their ability to go through daily life. The place can be about a solid appreciation that it is not just about molecules in unseen synapses, but actually about capable but desperate people and their families, each with a unique life, that need humane healing.
But it often doesn’t work well at all: When they are admitted and daily thereafter, people are processed by psychiatrists piece by piece according to specific protocols, with little attention to their diversity or individual needs. One by one, they are marched to a chair across the table from an unsupervised “doctor” or a nurse coordinator who scatter their attention between the computer (typing, reading) and eye contact with the patient. There is no full engagement with the patient. The patient often sits closer to the door, often guarded by a burly mental health technician. Sometimes a social worker invaluably assists with planning. (The patient chair is only sometimes wiped with a disinfectant, but staff always avoids it or covers it with a pillowcase.)
Most patients don’t know it, and neither do many modern staffers and administrators, but psychiatric care can be as egregiously naïve and unprofessional as paintings by the numbers by careless, unimaginative children who seem to have learned neither basic painting nor the subtleties of using a paintbrush. There is too often no good deal here for patients (but you should see what the execs who run these hospitals and some “doctors” earn.)
Almost no one actually gets to know our neighbors sufficiently to provide reasonable care. Too often, patients all get the same mindless conversations full of infantilizing platitudes from MDs with marginal and RNs with no psychiatric training, or even knowledge of idiomatic English or American culture. Little or no clinical or programmatic distinction is made among chronically ill, low-functioning, often demented older “frequent flyers”, the homeless, the mentally retarded, and frightened younger first-timers, often higher functioning and ripe for well-designed interventions. One size fits all in this production line.
Our neighbor, the consumer, does not know what someone else is buying for her and how the doctor / hospital may be failing her. Units are run according to insurer specs, especially Medicare and Medicaid, and must balance expenditures on providers and their expensive time with shrinkingreimbursements. The actual buyer is the mega insurer who pays the bill, and I seriously doubt these buyers know much more than numbers, so no one is responsible here! Various agencies apparently inspect and audit such units and patient records, but only the most egregious are detected. The system often abandons individual folks at the lowest quality and quantity of psychiatric care.
Psychiatrists are apparently interchangeable and can easily travel among hospitals, nursing homes, and outpatient practices, and they may be major clients for some medical temp placement firms. In fact, help wanted ads for doctors often specify exact hourly outputs. Local news media report on these units rarely, but I have never seen an accurate portrayal in any media.
The system is broken. It is functionally and professionally bankrupt. Good basic psychiatric practice seems totally irrelevant to hurried administrators, but often pleasingly novel to experienced unit staff. Almost nothing else seems to matter to the employer, as long as their “queen bees” are licensed and minimally trained, no matter how or where, and quickly credentialed. In fact, piecework output per hour and documentation with insurance-preferred wording are the only monitored queen bee activities.
Fortunately, some decent unit leadership and staff provide enough intelligent, personalized professionalism to make real differences sometimes. Such administrators, nurses and technicians eagerly oriented me and very quickly and competently translated our clinical plans and my medical recommendations into effective actions, and there was a large amount of respect as partners and colleagues. I relied heavily on these professionals, and they never disappointed. (Sometimes, FYI, such nurses buy patients clothing or other needed items (a used bicycle!) to enable their success after discharge.)
ON BECOMING A BAD FIT 1: WHY I DID NOT GO ALONG WITH THE FLOW
So this is what happened: I did not fit in. I guess I just wasn’t trained to be a “queen bee”. A helpful senior RN suggested warmly in broken English that I just “go with the flow,” but I resented the message because I didn’t really understand it until later. The flow of what?
I did understand quickly that my piecework production pace was the main issue. I sometimes needed to see as many as five or six complicated and poorly communicative patients an hour, sometimes for up to five to eight hours consecutively. In fact, admissions took more time, but I also spent more time with about 2/3 of patients who already had nicely typed admission notes by another practitioner already in the chart.
Why? I could not trust most doctors’ notes to be complete or accurate. So I preferred reading nursing notes and raw lab data and interviewing patients more fully myself. And what’s more, in a squeeze, I prioritized young patients with even more time because the younger the patient, the bleaker their future in this system and greatest the difference good doctoring could make now. Why? Nobody else was doing what credible care called for. And apparently I wasn’t hired to do that either. But eventually I learned to meet my quotas.
Being a bad fit was just fine with me. What I saw led me to the present essay. Here are specific examples of individual incompetence and systemic, medical, and ethical failures illustrating what today routinely pass for psychiatric standards in at least some inpatient Behavioral Health units.
– Psychiatry in these facilities appeared to me to have little to do with even minimally competent diagnosis, treatment, humaneness or the healing uses of language. A permanent “psychiatrist”, doubling as the “medical director” I partially covered early in my work in Behavioral Health units drove home a radical point shamelessly. He meticulously dictated his notes, signing off and billing for each step of the revolving door cookie cutter, doing his piecework on the assembly line of human souls flowing between nursing homes and the unit, and documented, documented, documented to the letter compliance with the insurer’s language. Many “frequent flyers” (repeatedly admitted people) were also his patients in nursing homes, and he repeatedly profited by their passage through each gate he was keeping. So I refused to treat these folks.
This alleged board certified “psychiatrist” chided me to comply with his standards (polypharmacy, diagnoses in perpetuity, etc.) because I was now working in his type of practice, and not in the suburbs. He insisted repeatedly and forcefully and with all seriousness in the same formal meeting (and we were not alone — people in the room exchanged raised eye brows) that it is wrong to review and change patients’ diagnoses or medications because “so many good doctors (in such facilities, practices like his own, or similarly staffed outpatient programs, group homes, or nursing homes he services) have already diagnosed the patient.” He needlessly piled on for almost every patient a recently released medication on top of a similar drug already given, claiming that he intended to “switch them over”, which I did not see, nor evidence that he explained his intent nor obtained informed consent. Such is the appalling pill mill standard.
I was so astounded that I thought him dangerously impaired. I thought his judgment was bad, not only in the medical sense, but also both in terms of making such outlandish statements so matter-of-factly in public. (BTW thisindustrious “doctor” was probably getting richer and closer to the American dream faster than most.)
I even started the process of reporting this man as an impaired physician. And that’s not something that I had ever done before. And eventually he corrected some of his egregious practices when I refused to continue them with his patients. I later understood that he was just telling me how it is. In his own way, he was orienting me. Apparently, his is just a routine and expected practice in his corner of psychiatry, where industrial pill mills can thrive and turn a profit.
Truth be told, his position was in fact pretty typical, as I found out later. To these psychiatrists and their patients, apparently “continuity of care” meant not making waves while perpetuating continuity of wrong diagnosis and wrong treatment for years as patients rotated through the gates they are keeping.
However, while I was initially mostly troubled by the way doctors in this system function, I have also come to see most as hard-working poorly trained people who probably did not grasp that their standard of functioning was extremely low by US university-trained colleague standards, rather than being merely impaired or greedy perpetrators. There are also, apparently, the more powerful large corporate chains (shareholders are owners — I wonder how many know), who crave these doctors’ signatures so intensely, and who know exactly what’s going on, or should know, who qualify for the latter distinction.
Doctors are nevertheless professionally accountable. These examples illuminated for me aspects of psychiatry’s stunning professional and social failure, especially as it turns away from language-based therapeutic interactions. These practices appear standard and spreading to all specialties as the ACA now also brings more people into such units, and these folks are not necessarily poor.
– Absent and wrong diagnoses and treatments hurt people. Competent, rational, and legitimate medical encounters require several or all of these actions: Connecting with the patient through language, reviewing history, examining the patient, evaluating current functioning, confirming a diagnosis and considering alternatives (this anchors the whole process), initiating or adjusting a treatment and discharge plan with nursing and social work, talking with family members, writing orders or prescriptions, calling other specialists for consultations, and charting the above.
But not in these facilities. They often used terms like “This 39 year old woman with known Bipolar Disorder…” or “This man with known chronic alcohol abuse in again brought to the ED…” to identify patients they actually have no personal knowledge or much information about, other than that the prior doctor may have used the same words. They shortcut obtaining a careful history from patients and / or significant others. And this happens time after time — to the same patient! So when was the last time anyone bothered to act like a doctor and really diagnose this person? In these facilities, doctors apparently do not diagnose but copy the diagnosis the prior doctor made, etc. etc. Looks like poor diagnosis, poor treatment. In perpetuity.
Very ill and poor psychiatric patients in some Behavioral Health facilities are prescribed the almost-random pick of the same few medications for years without validated diagnoses. Most patients in these systems share the same few recurring diagnoses and treatments, despite their actual diagnostic diversity. Getting the wrong medication may not be obvious at first because the broad spectrum of action of some meds, especially initially, obviates precise diagnosis.
Many of these folks are not aware of their current valid diagnoses, or if asked, what the currently commonly used cookie-cutter labels “Schizoaffective Disorder” or “Bipolar Disorder” or “Borderline,” masquerading as legitimate diagnoses, actually mean other than justifying the medications they are asked to take and their hospital admissions. There is no informed consent process. For example, a mood stabilizer widely known to cause ovarian disease in young women is prescribed for them perfunctorily without their informed consent, even when clear alternatives are easily available.
Adult ADHD, PTSD, enuresis, and depression are widespread and almost never noticed or treated. If you are a poor person, you will also probably be diagnosed incorrectly if you have learning disabilities, post-partum depression, dyslexia, or dissociative disorders, and even hysterical symptoms.
Too many trauma or child abuse survivors, people 18 to 55 year old who have sustained severe psychological injury, continue suffering additional and probably more crippling abuse from an incompetent medical work up (that fails to diagnose and treat correctly). That these folks respond poorly to most medications because of PTSD or a variant almost never comes up. Instead, they are loaded up with ineffective medication. No doctor seemingly ever bothered to use simple language to ask most of the obvious questions, such as: “Has anybody ever hurt you physically or touched you in private places against you will? . . . What happened then?” And so, nobody ever listens to a story many badly need to tell to know themselves as human.
With emphasis only on observable behavior, people whose illnesses were initially triggered by severe losses are not diagnosed as grieving because nobody listened or got the facts available just for the asking, “When was the last time you felt healthy? . . . What happened then?” Instead these folks may be prescribed strong meds for years. If you are a poor mentally ill person, your grief is not ever known.
Too many doctors in this current system seem to forget that every patient encounter is an opportunity for screening for general health and improvement and verification of psychiatric diagnoses and treatment plans, but instead perpetuate unproven, incorrect psychiatric diagnoses and pile the same sets of powerful ineffective medications into ill people, no matter the age, often discharging them into a therapeutic vacuum where no one can observe the evolving main and side effects of medications. So if you are poor, you might have a wrong diagnoses and be taking the wrong pill mill style medications for years without knowing it.
– I have seen how some youngsters survive their train-wrecked lives as wards of DCFS since early childhood, hanging on to sanity and humanity by finding strength in themselves through art or music. They bring their treasured notebooks into the hospital. When asked, “How do you get yourself to feel better?” they show their work proudly and appreciate a kind but honest reaction. These are diagnostically important clues, too. Some work shows personal resources and talent. The interaction sparked by a simple question provides opportunities for empowerment and dignified human contact with a doctor. No medical provider, and few other staff members to my knowledge, ever asked the question nor showed an interest of these kids’ art.
– “Did you ever hurt your head so badly that you passed out?” is almost never asked of folks who live in a culture of violence and are therefore more vulnerable to closed head injury and its sequelae. That your symptoms could be related to a closed head injury could be overlooked if you are a poor person.
– Polypharmacy (unless clearly justified, the practice of prescribing together several very similar medications to treat the same symptoms — considered sloppy practice because of increased side effect risks) is rampant in these medical practices, except where hospital IT systems question the order. Often, my documented efforts to undo these incompetent practices were reversed immediately by the permanent doctors without discussion. One doctor routinely placed almost every patient on a recently released medication. Patients discontinue or “cheek” and then secretly spit out medications they need because of side effects nobody cares about.
– Very young children are admitted and treated by incompetent providers without specialized training in child psychiatry. Children’s brains are especially delicate growing organs, unlike adult brains, and we all know they require a specialist with two additional years of training. But having fewer child psychiatrists available, these units often struggle to meet community needs. So this is what happens: If you are a non-psychotic five year old with a chaotic family and a mentally ill father, you would actually be prescribed a powerful mood stabilizer with possibly serious side effects immediately upon admission by an unqualified Behavioral Health doctor without a minimal history, family evaluation, or anything close to a specialized psychiatric examination that would lead to a diagnosis, even though a boarded child psychiatrist nearby is already associated with this facility. Did it come down to how much the facility was willing to pay this specialist? Can you imagine a fully accredited hospital in a city here in the US daring such a practice routinely? Does the public know?
So this is what happened: I was coming on call one morning just after such a girl was admitted, and wandered into the children’s unit looking for an open office. When I saw the new child, who now was my responsibility, I briefly engaged her in diagnostic play and then spoke with her cooperative grandmother and hostile father, concluding with certainty there was no need for any medication, that the vulnerable child was agitated by chronic family chaos, and that therefore the first dose given was an error. I spoke collegially with the admitting doctor about removing his standing medication order and referring to DCFS, and he easily agreed. I reminded a young nurse of her important role as the last line of defense detecting medical errors (admittedly, not my official role, so I was asked to apologize to the nurse, except that patient advocacy is always a doctor’s role).
This is what happened next: Two stern administrators appeared quickly demanding to know what I was doing in the children’s unit and why I upset the nursing staff. The patient’s care was not mentioned. Were these the final straws that quickly ended my contract in this facility and employment by the locum tenens firm — my “intrusive” efforts to “impose” my “methods” on the doctors of that little vulnerable child? It was a sad eye-opening moment for me, especially since so many good people work so proudly to make this community facility the best they can. Don’t they know what psychiatric (vs. “Behavioral Health”) means professionally and to the patients who trust them? Has psychiatry failed by failing to teach and insist on minimal standards?
– Chaplain visits are rarely offered despite their powerful help healing some patients.
– Medication non-compliance is formally often blamed on patients for relapses and frequent readmissions, but outpatient facilities can often be inaccessible or care also cookie-cutter by the same “providers” and bureaucratic social services. Some patients know the medication they are prescribed hurts them and the prescribers incompetent, so they refuse it or stop it after it runs out. Some stop because they are too disturbed to see its value. Many welcome questions like, “How did you sleep last night?” and “How’s your thinking today?” with increased collaboration and compliance. Too many doctors do not actually look at or touch and examine their patients for easily manageable side effects.
– Electronic medical records are typically administrator-centered. They are awkward and more time consuming for psychiatrists than some patients. Available health records often only go back a year or so for folks who suffer lifelong chronic illnesses, so nobody really has the entire history to see the context for the present. Doctors don’t seem to trouble looking for the whole picture. This means that one illness episode can last a lifetime with care so fragmented that it appears to be for a series of acute illness episodes in the record. That you are not improving is not necessarily visible to doctors if you are poor.
And these folks have predicted life span decades less than most of us, succumbing to decades from medical neglect, accidents, and suicide. So they need extra careful screenings for physical ailments. Yet access to inpatient specialists like rare child neurologists, child psychiatrists, urologists, psychological testing, long-term histories, EEGs, endocrinologists, or even gynecologists is spotty in such facilities and is postponed until after discharge, but rarely happens then because the links between outpatient and inpatient care are so poor that too many just fall through the cracks. If you are a poor child who might have a learning disability that gets you into trouble, don’t count on a doctor to check it out before diagnosing and treating you as needing a medication. If you are a poor person, don’t count on ever getting a thyroid or kidney test (24 hour urine collection), even though you have been taking lithium salts for decades.
– Too many poor mentally ill people use their now 6.8 days or so as inpatients as a lifestyle choice as the only safe havens and shelters from their crises-filled lives. So, known by many staffs as “frequent flyers,” some of these patients have told me openly that they claim to “hear voices that tell me to kill myself” to get admitted, and do easily get admitted without anyone even inquiring into the nature, location, and history of the alleged hallucinations. Often someone on the inpatient staff then says something like, “It must be getting really too cold out,” as the patients are admitted. In fact, several have revealed to me that they have not hallucinated for years. Yet, some insist on carrying the wrong diagnoses that guarantee Social Security Disability payments. Some are dumped by nursing or group homes and become homeless. It is really difficult to say how many such patients exist, but I would estimate that proportion can be as high as 1/4 of total admissions.
– So the admission charade continues 24/7, as too many seemingly “financially strapped” inpatient Behavioral Health facilities, claiming they have a hard time recruiting, uniformly settle for doctors who consistently seem not to need to communicate thoroughly with their patients. A routine medical conversation that might provide crucial information hardly ever happens.
– Things can look a lot better on paper than they actually are. Thankfully, I have not seen anyone lying or using language dishonestly or misleadingly. It is more subtle: On initial readings of a few random patient charts, writings by one of these doctors would seem complete and nicely detailed. However, seeing more and more charts and the patients themselves reveals another picture: In fact, many of these records are empty facades that show little clinical thinking. But they do comply with insurance language. These reports are insidiously too alike in language, wrong diagnoses made and wrong medications prescribed over and over. I would guess that they could easily escape random routine audits and that this is already an epidemic staying meticulously within the law.
– Monitoring of psychiatric care quality was totally absent in the facilities I saw. While they should be part of self-governance, there were no actual working quality controls for psychiatrists except for utilization reviewers monitoring insurer-required language usage and “suggesting” to doctors it’s proper use. Administrators are quick to point out that they have no direct control over how doctors practice, and rely on the medical staff self-governing structure and bylaws. Under this arrangement, psychiatrists are supposedly monitored by a department chairperson. But functioning department chairs or other monitors were nowhere to be seen.
– Well-meaning folks at all levels who work in such facilities are incentivized to keep the system going as is. Administrators scramble to compete in a hot market to fill medical positions with almost anybody in order to keep needed beds open and budgets positive. So they retain many doctors with marginal language skills for understanding idiom and speech, unfamiliar with the norms of patients of diverse American cultural backgrounds, further handicapping any healing relationship and distancing practitioner from patient.
– And are these units really “financially strapped”? Many all over the US are closing. But I also heard grumbled things like these “full units actually earn such substantial revenue that they can sometimes carry the whole hospital financially.” So, if that’s true, what could make these private Behavioral Health units so profitable at the very same time when excellent private hospitals like LA’s famed Cedars-Sinai had to close these very same services because they could not afford to provide good care to the poor for the same money? If true, how can services already reimbursed at bare bones leave anything over an a profit? Are poor mentally ill people being ripped off?
ON BECOMING A BAD FIT 2: USING LANGUAGE AS A NEUROSCIENCE TOOL
This is the second thing that happened to cause me to be a misfit in the places I worked. And it was more obvious and very telling: How I was using language seemed to some folks in the trenches — patients and nurses — to work quite well, sometimes even miraculously. There were moments of genuine synergy. Maybe that’s why these two very different groups of people marveled at the sight of a psychiatrist who actually dignifies, empowers, and converses seriously with patients and uses language as a demonstrably powerful diagnostic and treatment tool, and fine tunes medication treatments using basic knowledge.
Nurse practitioners and patients both reacted with pleased surprise, as people do when they unexpectedly discover a new way to improve something vital but frustrating. They actually saw a psychiatrist touch to examine a patient to determine rigidity (side effect of some medications), do a brief neurological examination and a full mental status examination, including interpretation of proverbs, or auscultate the chest to hear a possible pneumonia.
They saw a psychiatrist try to connect and engage ill people with a fist bump and colloquial conversation about their pasts, explain diagnoses and treatment, identify strengths, assess medications and alternatives, and assist patients to plan personal goals for their futures and articulate and make sense of their personal stories. They also saw a doctor actually invite the chaplain to visit some patients and confer about how together to reach and heal some folks. And they saw that work.
These veteran residents today’s Behavioral Health trenches became fascinated by how language can be one of our most powerful neuroscience tools to bridge mind, brain, and behavioral change. Some patients were eager to know what their diagnoses mean and what medications are supposed to do, and were pleased to have enough information to make their own decisions. The nurse, patient, and I learned together that doctors and nurses working together still can have very powerful effects to the good. We learned that when patients and staff understood the same narrative, hope and compliance increased and progress accelerated. We learned that a language-based psychiatrist’s signature can also guarantee competent care. “You are the first doctor to ever do this,” many said many times.
And we thought I was doing my job pretty well because patients were dramatically improving and nurses were learning. This point came home dramatically when one “frequent flyer” proclaimed proudly, after three months of her deliberate medication refusal (so I was expected to get her to take it), that her mind was now clear for the first time after 40 years “in the desert”, and mostly that she finally has “a name“, after the America tune. And I did thank her sincerely for teaching me the song.
She had been seen daily for weeks by other psychiatrists, with little change in her resolve (good for her!) We made a decision with the patient to support her because here was a woman finally making her own careful choices towards health, and the medical risk was quite low. As the nurse and I planned with her how to succeed, she volunteered “anxiety” as her main problem, so we reviewed her psychosocial options and planned her discharge accordingly (with medication from a doctor she trusted). And there are many other stories and similar moments, even with less healthy folks.
And, BTW, this humane and effective approach was not that expensive: I was actually able to see about 4 (up to six in a pinch) people an hour and do a competent job, once I learned to triage who was most likely to benefit after a lengthier first meeting, and once I learned the ropes and Epic(commonly used very costly electronic medical record and charting software), and once we had met and connected. Altogether, working with this woman took maybe 60 minutes of my and the nurse’s time spread over several days. It would have taken less had a proper history been obtained by her admitting provider.
(This is sarcastic:) Attention administrators and investors: Language-based psychiatry is a wonderful invention that has already undergone proof of concept and extensive market penetration. Any novice entrepreneur today would understand that the secret sauce is putting the most skilled time in front — enough time to meet the people who are patients.
Once a trusting relationship is formed (it goes both ways), as much time is not needed later. This is not patentable – it is an old process called “Building the Therapeutic Alliance” that every psychiatrist needs to know cold.
So this is how it is a great improvement over your other current Behavioral Health competition. At the end of the first meeting, the patient, nurse, social worker, and this expert language-based psychiatrist agree that they need ASAP an outline of goals for hospitalization and discharge, and that the patient will bring a written list of her thoughts, and she does write down her goals, and she does bring the list to the next interview, and a medication discussion fits into this context. She is empowered to collaborate.
The rest follows with greater ease in most patients. And you need language savvy doctors, especially in psychiatry, although I am sure this is true even for the hospitalists you employ. This actually worked to some extent with at least 3/4 of the hundreds of people I met as patients in my Behavioral Health stint. Entrepreneurs, your challenge now is to scale this proven concept. Why? Because a woman finding her name can be a bargain, costing altogether, say, $80-250 for language-based psychiatric and nursing times spent with this patient. And there are millions of missed opportunities for such cheap interventions daily in a multibillion dollar potential market, especially as ACA spotlights value added. And think of the marketing you can do: “We’ll reach out and hear you!” But then, why would you, dear businessman?– you seem to clean up really well anyway.
Bottom line — what shocked me in private Behavioral Health was this: Poor mentally ill folks are being served the dregs of the dregs of what psychiatry can and should offer them. Shameful psychiatric neglect or incompetence in the Behavioral Health units I saw with my own eyes, and many outpatient services and nursing homes I learned about, all supported by taxpayers, remind me of what I had seen in the large old state hospitals as a medical student well over four decades ago when these places were widely considered the sewers of American medicine.
A STATE HOSPITAL UNIT
Finally, for about forty immersive hours a week for seven weeks, I had sole psychiatric responsibility for a special closed unit of about fifteen severely chronically ill, difficult-to-place men, most transferred from a high security facility. This part of my journey, including admissions and routine coverage to the entire hospital, opened my eyes and touched my heart.
State hospitals are old institutions that have a long and checkered history that reflects our posture towards poor people who are mentally ill. A common view of these institutions has been that they are second rate at best. I expected to find an inflexible, lazy, even a bit corrupt pill mill and bureaucracy, and did have reservations about fitting. This is what I saw:
Unlike the patients in Behavioral Health units, those in state hospitals today can benefit from longer stays, psychiatric collegial monitoring, working standards for psychopharmacology, and major improvements in patient rights, medical care, security, therapeutic activities, staff educational activities, and cleanliness. If deemed safe, patients can go off the unit alone and even on field trips in groups. The level of staff psychiatric care and of activities and occupational therapies too seemed higher in general than in the Behavioral Health units I saw. Similarly, salaried doctors appeared more of a community practicing at a higher standards and more communicative with patients, although there were laggards.
Administrators are mostly competent hard-working civil servants, but tired. Who can blame them? Their professionalism and patient, kind, gentle devotion to all the people in their charge — individual staff and individual patients — penetrates deeply to steady, warm, and nourish all layers of the hospital. These precious people do come from caring nursing, medicine, and social work backgrounds. What an accomplishment! For this reason alone, but there are many others, IMHO this state hospital is preferable to the Behavioral Health facilities I saw.
Support mental health staff — social workers, activities and occupational therapists, and contractual part-time group therapists — are mostly very good, but more than a few obviously unstable and incompetent professional employees do stay on. Like Behavioral Health units, therapeutic or educational contact with families is essentially absent.
Strangely, just as in Behavioral Health units, occupational therapists, excellent professionals who know the patients well, are not included in routine clinical discussions. Physical facilities were clean and up to date, and services and security were at least as good as in Behavioral Health units I saw. Housekeeping staff and security officers are a familiar part of the community and interact well with patients.
Nurses varied in professionalism, but, as in the Behavioral Health units, too few had psychiatric training, let alone language-based backgrounds or familiarity with the diversity of patient cultures. Their interests seemed to be careful management of patient sleep, dosing, and hygiene, and most were generally helpful, flexible, caring, excited about patient progress, and eager to learn.
Technicians, otherwise also known as mental health workers or nurses’ aides, interact most closely with patients daily and are most culturally sensitive. Especially when I invited them to meetings and included them in treatment planning, these devoted folks were as outstanding as any experienced clinician anywhere, but this is not routine.
As in the Behavioral Health units I saw, nursing can provide a solid and predictable container for healing. But there was another set of staff problems — seemingly a fatal flaw. Initial appearances to the contrary, a malignant culture of fear, greed, mediocrity, and daily degradation of patients permeates daily life and defeats healing. It seems that to keep public jobs and generous benefits, all who work at this facility have apparently become habitually vigilant to “keep their head low”, limiting most workplace interactions to mediocre, well practiced, safe, “by the book” routines.
It became clear to me after several weeks that something insidious might be poisoning the culture and eroding its potential for healing: A few employees, mostly nurses constantly splitting their own ranks in petty bickering, also “fracture” the unit and damage its mission. To get what they want, they are known to provoke administrators, doctors, patients, and other employees, and then apparently complain to what some refer to as “the union”, something the administrators seem to dread.
These jittery public employees treat patients appallingly. Barricaded, often noisily, in nursing stations, they imperiously cackle orders and manage the place like something between a POW facility and a cookie cutter kindergarten. Instead of delivering active, creative empowerment towards self sufficiency, personal responsibility, and ultimate discharge, they create a unit that persistently herds, degrades, and infantilizes. The rest of the staff and patients seem intimidated and step around them whenever possible. But these nurses run the unit.
In this unit’s oppressive Kafkaesque culture, there is almost no spontaneous, meaningful, open, professional communication about patients. Instead, inane, superficial gossiping about the latest “pet” patients’ behavior serves to bridge staff differences and release tension through an unprofessional lowest common denominator and replaces even minimal clinical relevance. I tried to fit in by “talking the talk” at first. Later, I tried to raise the professionalism of conferences by sharing my observations and thoughts to elicit others’, with some success.
In this unit of throwaway men, I saw years of gross misdiagnoses/mistreatments, layers of polypharmacy, especially with poor attention to PTSD, closed head injuries, depression, anxiety, adult ADHD, and current treatments. There is lots of required paperwork to document proper care, but in reality little effort to individualize in real time.
Last and definitely least are those who pay the price: In this unit, voiceless men, eyes glazed, speech slurred, beds wet, silent or sounding crazy, have learned well to manage daily degradation long ago in units far away — by folding deeper into their illnesses, burrowing deeper in thickets of their head and facial hair, and hiding in sleep and masturbation in yet darker smellier rooms.
Our patients, our neighbors, unlucky men in their 20s through 60s, whose only bedroom and only home (only street, only neighborhood, only social group, only place and only hope in this entire world) is this little room in this unit in this impersonal hospital, are abandoned, totally alone and cut off, and disenfranchised at the very bottom of an invisible hierarchy, much as they have traditionally been in state hospitals. These fellow Americans, can they not still sing, laugh, joke, be proud, pray, create art, have fun, have legitimate anger, care deeply, feel pain and sadness, long for companionship, and strive to live more fully?
Has everybody gone mad and forgotten this? The health and rehabilitation of our neighbors are the sole reasons for the existence of the entire PUBLIC institution and all the PUBLIC jobs and PUBLIC pay checks and PUBLIC benefits . . . Where is this PUBLIC? We are all shareholders here.
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(On becoming a bad fit 3)
A most amazing accidental discovery 1: Human souls can be revived unexpectedly. Like in Dr. Oliver Sack’s Awakenings. After about three weeks, we saw a renewed spirit sprouting. Patients lifted their heads to look with sparkling eyes at a more hopeful world and solidified their community and nourished each other. The world was opening up for them. They were opening up for the world. Knowledgeable people noticed and nodded and quietly smiled when I repeatedly checked with them if we were on the right track.
What was happening?
The men got good doctoring, and enough good staff joined a healing fest. I made ongoing, careful assessments of each patient’s individual psychological and medical needs during my daily on-site real- time psychiatric presence: I got to know them as people who are now my patients, as their doctor. Sensitive, courteous, thoughtful conversation and careful listening, casual interactions, impromptu meetings on the unit and in my office, checking on how a man is doing after we changed a medication. Just sitting together.
Each man had his own, colorful, consistent narrative about himself, his past, and future that deserved a serious respectful hearing, no matter how illogical or delusional he made it to survive with an impaired brain over the years. We used language…Just checking on the progress of a project or physical complaint. Focusing on the here and now. I decided to wear my doctor coat after a couple of weeks to legitimize my reality. A doctor’s uniform.
Then, they needed working doses of the right medications based on the right diagnoses refined in real time for current symptoms, and they needed a voice about their fate. The state required this, and it was done routinely but perfunctorily. I engaged them to their limits in this conversation early, establishing a connection that served as the basis for what came next:
“What medication worked best for you?…How?” They do know which, and they do know how. And they do know that trust has to go both ways. For example, one man’s request (btw, he dressed impeccably, had a gracious manner about him, and loved singing hymns for the group) for ibuprofen to help him stay calm and relieve his chronic headache was repeatedly rejected because it is not standard and can cause rare GI bleeding. The internist also believed the man’s request was delusional. Well, it turns out that current research shows that such anti inflammatory meds can be helpful in schizophrenia and they did calm him down and relieve his headache. Competent about this matter, the patient made that discovery for himself, and the internist approved after a small change in medical management.
Medications today are often really better, and there are more of them to carefully weave together with language-based doctoring and existing social work/supportive activities by competent, genuinely caring staff. We started them off gently as healing sprouted, and stayed present and in the moment with them as they took their first steps, safely refined their medication and tweaked their social environment, focused them on daily personal and community goals, and began to collaborate with some on long term discharge plans.
There was plenty of testing of limits, too — it was definitely not a rose garden. And they each watched closely as I treated others and what happened, and they liked how I encouraged their own little community and mentored their leaders to succeed.
But the secret sauce — what largely made this possible — was language as a powerful neuropsychiatric tool. It turned out that they could thrive. They needed strong, well-timed sparks to restart their engines, and then basic navigating guidance and a safe, fenced road.
Up real close, smell-to-smell. Ready to fist bump. Visible. Approachable. Meticulous about small requests and symptom follow up. Respectful of boundaries. Fair. Patient. Firm. Insisting on some behaviors and punishing others, not intimidated, and always following through: “You are men. This is a hospital, not the street. You live here. I am your doctor. I look out for you. You deserve to have a caring doctor who treats you like a person. Manage your selfand relationships with self respect and kindness, or we’ll do it for you.”
Most of our patients’ brains — in various conditions of gross and fine repair, development, and/or functionality, are apparently still well wired enough to welcome proper stimulation. And the spark is wired into our mammalian brains. The spark was simply the thing that excites all humans from birth. That spark electrified mirror neurons and their neural social networks and the many other circuits that feed off them to make our brains miraculous social organs.
This spark is well known, and our brains are prepared to accept it from the first day of life — a human face. A vigorous, safe, interactive human presence that affirms. Stimulation from a full, close, eye-to-eye, face-to-face smiling and nodding. Like the painful knuckle rub on the chest that initiates CPR. A multidimensional sensory human engagement, especially amplified when coming safely from a trusted doctor. Our patients were ready to react with healing, hope, and a natural reaching out.
After about five weeks, the men engaged in more vigorous self-governing, emerged from their rooms, showered more, showed kindnesses to each other, and clamored in community meetings to sing and rap. People were further away from their verge of rage or panic. Those who spoke about it did reveal a personal faith they do not abandon. Singing for most and rapping for some is their celebration as a community. Amazingly, one reclusive aggressive man revealed such creative intelligence in his rapping and conversation that knowing staff exchanged surprised and approving nods. No more slurred speech, no more drooling, more smiles, straighter smoother walking. Less bed wetting. Less smelly rooms. Cleaner clothes. Less tremor. Less ADHD, less depression.
Several more men started their long ways towards discharge. One reticent man diligently sought his daily quota of fist bumps and started showing me his shiny basketball card collection. Another sat next to me in meetings and often invited me to prompt more appropriate behavior. Most dramatically, one reclusive man surprised and delighted everyone and actually had the barber shave off his hairy thicket and started to attend meetings. (And yes, the changes seemed entirely lost on some of our nurses. It would be interesting to compare their daily charting notes with technician notes, mine, and those of the language-based psychologist and social worker.)
Patients, doctor, and most staff joined together to form scaffolds for growth, embodied in an invigorated daily or impromptu community meeting. Once primed, impulses to health cascaded exponentially, recruiting existing neural and social networks, and even entraining otherwise aloof staff to participate. Wow. That’s the best of modern neuroscience at work! That’s psychiatry how it can be! That’s exactly what I signed up for in medical school.
No one, including me, had expected the amazing inspiring awakenings that happened. Language-based staff were openly thrilled. Administrators with mental health backgrounds recalled them proudly to me so that I would know they too are colleagues. There was a buzz. Word spread beyond the hospital. Something in this contagious flare up of life touched every man and deserves further attention. At least, it was a powerful placebo that kicked brains into gear beyond decades of dormant hospital “care” (and, not infrequently, beyond the around 15 lbs. of brain medication a decade poured into each man, or about 450 lbs. into all the men in this group to date while under state care — correct me if I am wrong, based on an my estimated averages: 2000 mg daily, 20 yrs. LOS. That’s industrial strength neuroscience).
Anyway, IMHO, the power of placebos and healing relationships are still understudied in neuroscience (Louis Lasagne, M.D. and Jerome Frank, M.D., Ph.D., were among my most memorable and wisest teachers). Placebos were always powerful medicines. Great physicians from antiquity recognized the power of hope in healing. Hope works wonders, as does great advertising and great leadership. And that too is probably wired into our brains (as are trust and faith and love). But you must access hope through language and mind. And there seems to be a lot more room for more on this unit.
On the unit, I began to speak with staff about slowly reducing my active pace to prepare patients for my departure when my contract ended. But I was abruptly and quickly removed (some staff actually gasped when I announced my departure) exactly halfway through. So what happened next to the men on this unit? I won’t know. Sadly. That’s the contract.
Most amazing discovery 2: A human spirit can blossom in most folks who work in a state hospital, too. A majority of seemingly competent and caring administrators and staff, much as in the private sector, “go with the flow”. In hushed sincerity they bemoan and attempt to disown the “jaded system,” shaking their heads and gazing down at their feet, almost like apologizing. They are hanging on, too, I guess, to avoid falling down cracks in the system. But they also are devoted.
Many employees do clearly and even cynically grasp the charade, yet can patiently stay on anyway to steadfastly, quietly care for and connect and give to our thrown-away neighbors — and that’s awesome. Even some housekeepers make their peace with this hell and join the singing. That’s love. These precious people are truly our best healers, our humane, gentle, saintly fixers of the world.
Even as a powerful few dehumanize, these steadfast folks manage to steadily rehumanize to keep patient hope alive. Each has a story about how many times they almost quit. They do resist the flow selectively, I guess, and they also like their state benefits and overtime pay and pensions; nothing wrong with that. Those who give so much deserve it. You know who you are. Thank you. I wish I could have your strength!
~~~~~~~
This is what also happened, from my POV: Patients in all hospitals depend on productive collaborations between physicians and nursing leadership, and a new doctor especially needs clear communication with the head nurse.But unlike most of their colleagues, a few nurses — the ruling clique — openly and stubbornly made a show of their refusal to communicate and collaborate with me.
I was tipped off early by several clandestine self-appointed “allies” that, should I have any friction with one particularly hostile nurse, I will be the one who ends up leaving. It was a no brainer for them. Near the end, another self-appointed ally tipped me off to a “setup” that will be coming soon and to how it might happen.
Indeed, the ruling clique and their allies seemingly mounted its offensive more openly when it became clear that I was succeeding. They apparently had critical words with the nursing staffers that did work well with me. They apparently spread stories that made their replacement in the unit difficult by transferring other nurses. They also apparently stonewalled for weeks administration efforts to respond to my urgent demands for a simple nursing protocol for quickly evacuating to an ER a severely medically ill uncooperative man in a manner that could save his life. (I learned later, to my relief, that my persistence did indeed finally lead to life-saving abdominal surgery soon after I left.)
And the ambushes did come, wrapped in plausible deniability, always in front of witnesses. In one meeting, during a discussion of transitioning a soon-to-be-discharged man back to his family, a social worker employee, non-language oriented and mostly functioning as a case worker and psychoeducational group and activities leader, suddenly burst into tears, complaining that I did not like her but liked another (female on another unit) social worker better, and that I did not like women in general (a first for me). Crossfire quickly followed, even as I made a stunned strategic retreat for the door while tactfully trying to calm her. This time the attack came from another employee, known by others for such behaviors, who goaded me maliciously with something like, “You are the psychiatrist. Don’t go. Please keep talking with her.” This setup happened just around the time and in the manner predicted.
Another ambush followed quickly during morning rounds when the hostile nurse, in the presence of her supervisor, refused to report blood pressures of a patient who had fallen during the night. It is routine nursing practice to check BP sitting / lying and standing in such events and inform the doctor, but only one measurement was done, it turned out. The nurse told me to check the chart myself.
Had the supervisor not been there to give tacit approval, I’d have merely faced yet another bit of familiar nastiness by the same nurse. Instead, I now saw a flagrant abuse of medical protocol and clearly and shamelessly arranged by the entire nursing hierarchy to scuttle me. So I asked the supervisor to contact her boss, the head of nursing. It was all very calm. Soon, head of nursing arrived with my own boss in tow, grumbling sadly something like, “We just can’t have more fracturing in this unit. In a few days, they will miss having a doctor here. Today is your last day, so do what you need to leave.”
Alas, as an experienced administrator and clinician, careful to prevent new conflicts or splits that could harm morale and patient care, in the end, I did eventually succumb to profound system failures and deep splits. And good people counseled me repeatedly to compromise more and stay away from the edge of splits, to sugarcoat my approach more, and to put away my “sledge hammer.” I pushed a tired status quo too hard, seemingly well beyond its willingness to respond, and it pushed back. Fortunately, I had the advantage of naïveté, relative administrative insularity as a non-employee, an irreverent sense of humor, and speed and surprise that all bought me the time to invest myself fully and enthusiastically. All things move slowly in this system, as did my undoing.
While I did want to continue serving the men on this unit in some capacity beyond the term of my contract, I eventually understood that I could not fit for very much longer. I even joked about that to those I trusted. I had neither the time nor temperament to slow down, hang my head down and navigate around land mines hidden by entrenched, well-practiced experts. Keeping my vision focused on patients took all of my energy. I felt helpless and mostly alone, without effective administrative interest, guidance, or protection (or interference), even after my repeated threats to leave, which were “getting old”, as one top administrator semi-warmly quipped. In retrospect, I now want to believe that the administrators helped more than I know.
Reader: You really have to see this jaded culture of devotion, incompetence, grace, competence, courage, dignity, love, moral corruption, and fear to believe it. It is tucked right into our midst and is also part of who we truly are. (Anyway, BTW, I may have also discovered a new treatment method. Let’s give it a name — GPP, for Good Psychiatric Practice. That’s sarcastic.)
CHILDREN’S SERVICES IN A WELL-REGARDED FAMILY SERVICE AGENCY
Still hoping to work in a facility serving poor people in a setting that respects them and their caregivers by striving for good care, I continued my journey, returning to a private outpatient community agency that had employed me for eight great years at the beginning of my professional career, when a team of social work colleagues and I had set up and ran a large aftercare clinic for over 250 state hospital adult dischargees. We had worked energetically and collaboratively in the tradition of the community service team model I learned from family therapy educator and pioneer Charles Kramer, M.D. (who got me the job) and child / adolescent psychiatry innovator Sherman Feinstein, M.D. I thought it a hopeful sign that the term “behavioral health” was not mentioned even once in my return to this agency.
American-trained M.A.- level social workers and psychologist therapists varied widely in competence. I worked only with staff members having children patients on medication, but it would be reasonable to assume that they represented at least minimal agency standards. Hoping to manage expectations, and as a way of introducing myself, I asked that administration and staff read an earlier version of this article before I was hired, and some supposedly did, adding to my optimism that I would fit into this agency’s enlightened culture.
So, for five hours every two weeks my duties now were to evaluate and treat high risk children and adolescents with a variety of disorders. In addition, these children are growing up under the stressors, physical and psychological risks, and the challenges of poverty, sometimes extreme. Often, parents may be mentally ill, substance users or criminals, and poor parenting, displacements, moves, violence, and early parent loss are frequent.
My predecessor had practiced like a “queen bee”, without bothering to talk with patients or parents in very brief and infrequent visits. One child on medication was actually seen twice or three times a year for a total annual time of less then an hour. So I began to get to know the kids and parents with increased time spent with each.
One dedicated staff member worked closely with me, and we sometimes met with kids and parents together. This beginning paid off quickly. The dramatic changes began. For example, a bright teen girl who had chronically avoided school because of long undiagnosed ADD was now successfully back in the classroom, an anxious boy with severe PTSD was finally engaged in treatment and was getting traction in a job, and most parents were relieved and word was getting around that a doctor was finally spending time with them and their children. My goal was to upgrade the care of each child to the best level possible within the six months of my contract, and then possibly stay on.
To accomplish this, I needed information about the whole child and family, apparently for some reason not routinely collected at this well-regarded agency. To provide essential actionable credible information for basic evaluation and treatment of children and families, I requested that pediatric and family information be obtained via the parent questionnaires, and school functioning data via the teacher questionnaires I introduced. We were beginning to implement this and important predictive information began to flow, but some professional staff were surprisingly suspicious and resistant.
To increase time with each patient, I proposed steps to streamline receptionist management of patient flow, chart preparation, and scheduling. In spite of passive grumbling, the first two were starting to improve. But the scheduling issue quickly became a deal breaker because this was where this well-regarded agency’s broken core became exposed.
—————
(On becoming a bad fit 4)
An anemic culture of mediocrity and poor communication dominated. I had insufficient meetings with staff to discuss cases, and encounters I initiated with the clinician-administrator were rushed, procedural, and uncollaborative. He never seemed to be around for curbside consultations, often leaving me isolated with a new load of his clients and setting a tone for the rest of his staff.
What’s worse, teamwork was relegated to mostly useless occasional one-paragraph notes left for me. Agency practice apparently no longer included the modern, decades old, multidisciplinary collegial integrative team approach, developed almost a century ago in the child guidance movement. This crucial innovation enabled work with complex childhood disorders in their family, school, and community contexts. An ongoing formal and informal conversation among staff in real time is needed to understand and effectively treat multi-system childhood disorders, and has been standard practice. This movement also spawned a proud, enlightened, and humane social work profession, and additionally pioneered the now pervasive practice of using multidisciplinary collaborative teams in many progressive workplaces.
Instead of energy and teamwork, this is what I found: inadequate, naive, and superficial diagnostic conceptualizations and treatment planning; seeming ignorance or distrust of the biopsychosocial model (“I don’t believe in medication for children”); insufficient history, paltry developmental information, and poor communication with schools; reactive rather than proactive therapy with unclear treatment goals; and rigid isolation of the psychiatrist as merely a pill dispenser, with staff mostly resistant to open collaboration (“The psychiatrist should just prescribe and not talk too much or do therapy”). I have spent a lifetime working in many capacities with agencies serving children, even some with poor leaderships, but this one really took the cake.
We are back to the dark ages of services for children, to an era even before the child guidance movement many decades ago. The basic minimal underpinnings of good practice at this well-regarded agency too have deteriorated, much as at the hospital units I describe above. I was now witnessing how young voiceless children and their parents are shafted as outpatients too.
So I struggled from the beginning with, “Should I stay and work slowly to improve things for these underserved children? Who will serve these voiceless high risk kids and broken families?” So I hung in. A colleague friend pointed out that, clearly, I was simply not hired to make changes. She was right. I eventually realized that there was no support forthcoming from the top for actual collaborative work, just increasing grumbling, apathy, hostility, and resentment.
The final irony and deal breaker was this: despite — or because of — my efforts to spend more time with each child, as many as five or even six ended up regularly squeezed by the receptionist into my last hour on site. The locum tenens arrangement dictates strict adherence to contracted hours, so staying late repeatedly was not an option. That basically shortchanges five children to ten or less minutes per child that hour, if you count coming in and out and settling down.
Obvious solutions would have been to redistribute these appointments over the five hours to allow at least twenty minutes, or to shift my working hours to later to better accommodate after-school needs. But for weeks, administration just would not respond to my repeated written requests to redistribute my time, nor have a dialogue, nor itself suggest a strategy to solve this problem.
Things came to a head early one cold afternoon, about three months into my contract, when I arrived at the office. A stunning unequivocalIy clear answer did come in the form of my schedule for that afternoon: not only were five children with parents yet again squeezed into the last hour, but, additionally, in the first ninety minutes, not one patient was scheduled. Not a one in the ninety earlier minutes, yet five in a later hour.
Wow. Stonewalling. That was the agency’s clear answer to my requests for more reasonable scheduling. The administrator did not comment when I found him, but when I asked him on the spot to reschedule some right then, he firmly refused: “Agency policy”. Unbelievable. So agency policy is to curtail and withhold adequate care. Unnecessary, arbitrary, bad practice, shameful.
So what’s the big deal here? Why make a fuss?
First, complexity. These high risk children suffered from poverty, behavior disorders, depression, anxiety, ADD/HD, PTSD, LD, OCD, bipolar disorder, eating disorders, and usually a hard-to-sort-out mixture of several of these together to tease apart and treat, and the always-accompanying impaired home, school, and community functioning to track. They deserve adequate time with a doctor.
Second, urgency. I have known first hand the special urgency here, having just worked immersively inside the hellish futures some of these kids will most definitely have, described above. It is especially important to get it right the first time now, when we can still make a difference. These kids have the same histories as hundreds of adults I had just treated in hospitals. These kids are very high risk and deserve the best possible care now, their mind / brain maturation still sensitive, when we can still push their developmental trajectories towards healthier futures.
Third, thoroughness. With collaborative teamwork and administrative support lacking, a child psychiatrist wanting to practice good medicine at this agency has one hand tied behind his back. No matter the setting, patients deserve his professional best. So he needs even more time to do his work: greet and connect with a child and parent, separately or together, sometimes using a translator; break the ice; catch up; engage; interact (assessing kids must include flexible pacing and careful tuning into the child and cannot be rushed — it takes more time, but kids trust people who respect that); sometimes measure HR and BP and assess physical complaints (I auscultated one athletic teen boy’s heart when he reported chest pain and referred him to his pediatrician for the murmur is heard); review questionnaires; complete an entry in the medication log; write a progress note; code the visit by figuring out how many minutes I spent on medication-related and how many speaking with the child and mom to further our relationship, while assessing functioning and stressors; and hand-write multiple prescriptions in carbon paper triplicate (the old kind, where a cardboard flap prevents ruining the next set if you press too hard. Well, you can guess how that goes when you’re in a hurry.)
Fourth, cruelty. This administrative shortcut amounts to unnecessary callousness and cruelty. At this well-regarded agency, they had no problem nor professional shame about administratively arm-twisting a doctor so crassly, expecting him to agree, with full knowledge ahead of time, to routinely unethically withhold good care. What was the big necessity here? Why schedule hurried, insufficient, bad care? In essence why be cruel, yes, cruel, the opposite of kind and healing?
Fifth, callousness. Having stonewalled discussion, this agency seemingly actually planned to resolve the issue unilaterally with an arbitrary administrative maneuver. No explanation to me or the patients. And do the parents and kids have a choice? Maybe the administrator-clinician and his superiors got away with such outrageous callousness in the past with the “queen bees” they had hired for their several offices. Maybe it was a sign of poor leadership, bad standards, inadequate internal communication, ignorance, or just indifference. Whatever the reason, that’s how far standards have fallen for serving poor people.
I do understand well the uphill pursuit of excellence against the constraints of shrinking funding as a recent board member of another well-regarded large multi-site family agency serving children and teens. I had a view from my high perch near management, working closely with site directors and the executive director for over ten years. But in this agency it was not about that. It was mainly about shamefully low professional standards, callousness, and poor leadership.
Bottom line: Even here, in the midst of a nice suburb of a major metro area, in a nice office located on a nice street among houses with nice lawns and neat businesses, mostly poor high risk kids as young as five and their parents routinely and intentionally receive sloppy dregs of mental health care, the ultimate of professional cruelty, disrespect, and irresponsibility, from a well-regarded agency with a prominent blue-ribbon board of directors.
My heart sank at this clumsy Kafkaesque brutality. This well-regarded family agency is pathetically failing its mission, and it is too broken inside for me to function there. This confrontation clearly signaled that there was no hope of continuing my work at this awful place and maintain my standards.
So I immediately resigned on the spot, and I walked out. I could no longer participate in this charade. I did trust that parents and kids scheduled for that afternoon would be given a copy of the apologetic note I insisted on hurriedly drafting. I had some difficulty endorsing how the facility would now use family practitioners in the community for filling in psychiatric care that only a specialist could deliver well. But people needed continuity of some care — another compromise. One staff member asked why I hadn’t contacted a board member, but no one from the agency ever followed up with me.
I wonder, do agency leaders and staff even know how bad the fundamental flaws really are in their culture, basic integrity, and professionalism? How did they view and react to this incident? Would they care? Would they minimize or cover up? Would they even get it?
I did feel a deep sadness, this time close to home, that high risk savable children needing the best care in the worst way are not getting anything close, and nobody seems to know or care.Looking back at my four failures to fit, I am most upset about this one because of needlessly lost precious opportunities to reformat the futures of these high risk kids. So innocent, so voiceless, many so savable.
WHAT I THINK HAPPENED, AND PSYCHIATRY’S ROLE
Something really bad has been happening in the past few decades that few speak openly about. Of course, it is all about priorities, values, money, governance, ethics, morality, taxes, etc., and there is plenty of blame to go around for anyone who wants to sling it or accept it. (One urgent matter I know little about is that too many poor Americans who are mentally ill end up in overcrowded jails receiving even worse services I have described here.)
But let’s be real — the buck has to stop somewhere, and more than a few cents stop with psychiatrists, individually and as a profession. If you are poor and mentally ill, no matter anything else, you will get relatively little relevant personal attention, spotty psychiatric expertise, and it is rare that anyone really knows you or speaks with you seriously about your past and future in a Behavioral Health system.
Our public and private psychiatry delivery systems right now are dangerously broken (much as the entire medical care system) and not bringing even a small fraction of the promises of neuroscience to people who are poor because its current psychopharmacology application is too often incompetent. And because largely “mindless” queen bees can barely reach people.
The tragedy is that a patient is lucky to get a fraction of the value taxpayers buy. Except that these days, facilities are mostly decent physically, subject to modern hospital standards, medications can work pretty well when used correctly, and there are probably some very fine programs, staffed by psychiatrists and others, struggling to give the best possible care in an abysmal climate.
IMHO the reality has become a national disgrace and crisis infecting all of medicine. People still believe that they can trust care based on professional medical standards based on the accumulated scientific and professional wisdom of American medicine as a special patient-centered calling that takes years of sound training to master. No more. Patient-centered medical standards have become largely defunct over the past few decades. Instead, rich and poor folks alike and their hospitals and doctors are now harnessed to mostly money-centered insurers who pay the bills.
While we psychiatrists are celebrating the wonders of the human genome and neuroscience, we are also justifiably losing our credibility as physicians because too many of our colleagues practice extremely poorly in some Behavioral Health hospital units and outpatient settings serving poor chronically ill people, and too many have delegated their best skills to others who serve folks who are not poor.
The profession that trained me — modern psychiatry — was first built on the careful and caring art of listening to speech and language in all their nuances and responding in kind as a central element of psychiatric practice. Medical and non-medical psychology pioneers have worked brilliantly and diligently for over a century to free the mentally ill from stigma and to understand and treat them humanely. These pioneers tried to base their practices on systematic notions of the brain/mind that made sense. They tried to infer brain function and structure from mental processes and behavior in the most humane ways — talking with and intensely and actively listening to patients. By “language-based” psychiatry and related professions I mean practice conceptually rooted in solid understandings of the human mind with all its richness as the function of the brain with all its blessings.
Paradoxically, at the very same time that neuroscience is confirming the biological bases of much of what we have learned clinically about the human mind in language-based therapies in the past century, actual American psychiatric practice in most areas away from rare metropolitan pockets is rapidly drifting too far away from its intelligent, disciplined, language-based roots that bridge the mind, brain, behavior, consciousness, and healthy living. A huge and increasing number of practices apparently neither utilize language nor correctly deploy medication. This disastrous trend is especially true of inpatient and outpatient care reimbursed by Medicaid and Medicare on behalf of poor people who are mentally ill.
As the use of language declines and “mind”lessness becomes the psychiatric norm, are we breaking our already broken neuroscience delivery system even more by starving poor people of humane language-based healing? Are we giving up our relevance as doctors? Are we abandoning our unique skills in integrating mind, brain, behavior, and healthy daily living for the whole patient? Are pill mills the new standard of care? Is this good for people?
Yes. Yes. Yes. Maybe! No!! Furthermore, IMHO in many ways psychiatry has been the “canary in the coal mine” of American medicine. So — all doctors and patients beware!
Medicaid- and Medicare-funded systems are a main funnel of today’s neuroscience applications, and these are badly broken. A few medical businesses, much like in other specialties, eventually became known as Medicare or Medicaid Mills or pill mills: Non-language based production lines for poor people — high volume / less quality control / lower profit margin / more errors. Some doctors — and I hate using that word for them — at first mostly western-trained in all specialties — innovated the earliest, Medicaid and Medicare mills a few decades ago. These providers were sometimes investigated and even indicted and jailed for fraud and other illegal practices that sometimes even caused hospitals and nursing homes to close. The problem of how to deal with bottom-feeding colleagues flirting with ethical boundaries is not unique to psychiatry nor to any profession, while the absence of language as a treatment tool is absolutely crucial to psychiatry.
Too many fellow Americans, especially poor folks and their children, are tragically not receiving the care they need simply because they are receiving the wrong care. The system is seriously and dangerously broken, even as everyone seems to choose words carefully to comply to the letter with reimbursement.
This is also part of major social problems in our country. But as citizens and individuals, each professional must search their own conscience to decide where they stand on this issue and how much, by deed done or silence, they are perpetuating or enabling this travesty. That’s the least we can do. Many who work in the system have become dulled to its egregious norms and incompetence. But that is not an excuse. Neither is economic hardship.
This is my main point: IMHO, psychiatric care is minimal and substandard in the Behavioral Health units I saw, and as long as that is the case, such units will not be truly competent, humane or optimally efficient. I have come to believe that patients in these facilities depend on too many Behavioral Health provider colleagues, who knowingly, intentionally, or not, are “keeping their heads down” and contributing to profound social injustice, as had doctors in state hospitals fifty years ago.
What we might have now is a failing system, featuring incompetent medical standards, that actually perpetuates social injustices and prejudices against our society’s throwaway peoples. It is a silent blight in our midst. I also fear that wither psychiatry goes, so does the rest of medicine — general decline in professionalism and attendant mediocrity and the gap between rich and poor have now become institutionalized, and we have a multi-tier system.
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Nor is this an overnight blight, but decades old. In fact, one of my most senior mentors, actually a pioneer department chair and psychopharmacologist, accurately predicted in the mid or late 1970’s or so, because at that time the National Institutes of Mental Health was stopping subsidies to psychiatry residency training in teaching hospitals, that the profession would sink seriously and move away from its best traditions.
I remember the moment I heard him (on a beach in Miami after a professional meeting), much as people remember what they were doing just before a bomb goes off. It has been in the back of my mind ever since, and now I see what my mentor meant as the trend is really accelerating and has become industrial strength.
We all saw psychiatric services in general hospitals “bleeding money” because of unequal coverage of mental illness by private and public insurers, especially those serving many poor people. Less than 20 years ago, I remember sitting in budget meetings in my doctor coat with growingly impatient, fidgety administrators wearing suits. We always lost money, especially children’s programs, because no insurance scheme paid enough to take care of sick families and children. And we had to account for every pencil and eraser in our programs because the hospital carried us as a goodwill service to the community.
Another piece of reality (not frequently discussed openly, but always a big elephant in the room) is that not all doctors or nurses are alike: Looking back, there has always been a big divide within medicine, especially psychiatry, with mostly US medical school, university hospital-trained graduates serving employed and insured (even if poorly) Americans and their families.
Our practices and settings were language-based, generally lower volume/customized service, higher quality/higher profit margin / fewer errors / commercial insurance and out of pocket fee payment. We continued naturally an identity, relationships, and other educational and practice activities. We worked in public clinics for an hourly pay, usually part-time, consulted, and set the pace and general treatment course of patients of a collaborative team.
My network of similar practitioners usually started off careers treating inpatients in community or university-affiliated hospitals right after our training, but then continued to outpatient practice settings, combining outpatient, teaching, research, consultation, and / or pro bono and other community work. Some colleagues continued in community, public, and academic settings. About half of today’s mental health professionals are now opted out of all insurance so that we can use language in our practices. This trend now continues with nurse practitioners, especially in states where they are able to prescribe medication.
But we all knew about another side, and very few of us engaged with it, or with their private practices. Doctors serving the poor in public institutions were mostly trained elsewhere, almost never the cutting edge West, and are industriously struggling for their place in American life. They tend to be much less expensive and a lot less trouble, much as also seem many RNs in the public settings I worked. Their numbers seem to have grown over the past decades, and they also predominated in some of the hospitals where I worked.
Historically, there wasn’t much mixing among psychiatrists from these systems. However, there were some excellent collegial collaborations between university-based biological psychiatry researchers and non-language based colleagues and scientists, especially in state-run facilities affiliated with teaching hospitals training programs. These were other strata of professionals, that few of us ever cared about or welcomed, to our shame, that were grateful to serve in public hospitals and shortage rural places. Whenever they can, however, these practitioners, including now nurse practitioners, usually later try to leave public psychiatry to start their own private practices, considered more lucrative and prestigious. Only rarely have language-based US-trained practitioners crossed over from their private or academic practices into public psychiatry, and when they try, they are rarely welcomed by administrators and threatened entrenched clinical staff, as I have discovered repeatedly.
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The wider context has been a general decline in humaneness in medicine. I have my own personal view of this general decline. Before WWII, most specialists retained strong callings as physicians and continued some general medical practice, while most generalists practiced some specialties. WWII military doctors were often assigned as generalists, no matter their training. In America’s neighborhoods, generalists engaged the whole patient and her family. People kept doctors for lifetimes in relationships of mutual loyalty.
Since about then, several powerful forces started changing that: Exponential knowledge and intensive skill sets, bureaucratization of hospitals and growth of insurers, the greening of medicine, changed American society, and eventually, flagrant corruption as government and large insurers came into medicine.
Fee payment, first embedded in a personal, ethical doctor-patient relationship, became a business transaction between insurers and doctors, and disenfranchised patients. The identity of “doctor” as person with a calling, as an ethical and moral healer in the best tradition of the profession and modern science, moved away, first to “specialist” and then, alas, “provider”, “hospitalist“, etc. Malpractice suit fears and astronomical premiums added a dimension of mistrust in an increasing estrangement between doctors and patients, as lawyers joined insurers and administrators at the bedside.
Private practice, where a doctor owns his own place and is free to be his best (and worst), is on the decline, and many experienced doctors are pulling away from a devoted engagement when they become someone else’s 9 to 5 employees. People left their trusted doctors who did not participate in new networks set up by insurers to control fees. Another factor today is how the economic crisis causes increased stress on the poor and damages safety nets serving them.
Yet another factor is that doctors have lost their sense of neighborliness to patients and to their own professional communities, as hospitals turn away from the local practitioners that gave them quality and professional accountability to become production lines. (Hospitals were centers of professional life. We used to have staff meetings, grand rounds, department meetings and doctor dining rooms. We used to talk to each other. We used to monitor each other formally and learn together from our mistakes, even in small community facilities.)
Nevertheless, last time I checked, psychiatry was still a fully credentialed medical specialty. So what happened to the American Oslerian ideal of rational medicine applied humanely that so many top medical students in my now retiring generation signed up for as psychiatrists?
What happened to the fundamental medical principles of “do no harm” and to the professional, ethical, and moral obligation to practice at least competently, if not creatively? What happened to following carefully made diagnoses with appropriate, thoughtful and effective treatments? What happened to the term “psychiatric treatment” in a world of “behavioral health”? How did I get to be a “behavioral health medical provider”? Can the promises of neuroscience be delivered by this broken system?
IMHO, You can’t get ever quality anything by rewarding the lowest bidder and “going with the flow”. And in medicine, that is deadly. In vital services, the lowest bidder is not the best healer. You end up getting the worst. Lives are at stake. It is plain wrong. Our taxes at work — I’d estimate we get about five cents, even on your cheap dollar, on a good day in both private and public sectors. Basically, both probably technically legal, is private Behavioral Health seemingly failing us with naked, active greed, and the state system with greed by a few rotten apples manipulating tired, unionized bureaucracies?
We all bear responsibility. Shareholders of corporations own many Behavioral Health facilities, as taxpayers own local and state public clinics. A wild thought: Why not merge the sectors after scooping out their purulent cores? Or, only if “caregivers” doctors and nurses just practiced according to the letter and spirit of their professional standards and refused to compromise, we would have a great start towards decency.
SO, IF NOT NOW, WHEN?
Would the words “Behavioral Health” now signal a new context and redefinition for psychiatry, just as the word “providers” in the 1990’s changed the professional context for all doctors, and most just accepted it? These words now pass for who we are to many people and ourselves, and apparently work as long as you don’t deal with people’s need for healing.
Here we are today, with the ACA here, in the age of the human genome, neuroscience, and technology, still with one foot in the sewer. We are all morally soiled by the muck. Looking forward, I doubt that poor mentally ill people will ever get many resources as they compete in a public service economy also struggling with broken physical infrastructures and educational systems. But they can get more if we stood up for our profession and its standards.
Things have changed in psychiatry and can be re-changed now that we have the brain in our vision: Psychiatrists are supposed to be the experts in accessing the mind / brain through language. Most language-based psychiatrists were trained for years in this craft and created the model now followed by other professionals, and they used to be tested to pass the boards.
But about a decade or two ago, psychiatry board exams stopped employing live patient interviews (paid volunteers) to assess doctors’ language-based interview skills. So now, most board-qualifying psychiatric residencies give only lip service to teaching language-based skills, once an egregious deficit reserved for the least competitive training programs. And now, it appears OK in some settings to interrupt the connection with patients by multitasking with the clinical onscreen computer record. Ironic, how we are doing to our patients what I have taught we must not do to our children and vice versa, as an expert such matters, I view full face to face engagement as necessary to provide the best professional healing care for the buck. That means no distractions, including frequently interrupting eye contact to engage in record keeping via computer, now considered a norm.
Shortsightedly trying to move psychiatry closer to the scientific medical mainstream, actually we have needlessly shamefully abandoned essential medical practices and values that make doctors healers. Instead, our “professional” signatures mainly enable systems very few of us would have our own family members go near.
And maybe there are many more creative solutions possible we have not considered, especially since as US medical school graduates we are supposed to be America’s best and brightest. In the general context of what is happening in medicine: If psychiatry wants to continue its humane leadership as the best hope for the mentally ill, we’d better examine our roles ASAP in this mess. Neuroscience is a basic science and cannot fix it directly (except if we all wake up use our brains), but its applications need our engineering skills.
As the best trained and placed scholars and professionals bridging the mind, the body, the brain and everyday healthy functioning, we must speak out from our credible history of compassionate intelligent care and design worthy systems. We psychiatrists must review our own roles in this shameful destruction of our profession and its humane — that means competent — treatment of poor mentally ill people.
We must shift our attention back to the severely ill in the facilities that treat them. We must advocate for our patients, provide and police better standards, support well-trained professionals of whatever discipline in the best professional and ethical tradition of medicine, and educate our colleagues.
For example, can we innovate and adapt tele psychiatry and IT systems to translate conversation in clinical encounters directly in real time into parsed text and codes, thereby removing the huge current obstacle to humane language-based care (here’s another great entrepreneurial opportunity!)? Detecting deficits and activated by strings of language (e.g. “Has anyone ever hurt you or touched you in private places?”) the software could require minimal language-based competence to yield coded texts and detect clinical omissions and, for trainees, position of the eyes? It will free clinicians to use language without interfering with creation of a billable record.
Can we welcome, empower, and help better train the new wave of eager, compassionate, talented, and diligent behavioral health RN+ nurse practitioners in the US, who do still practice in the best traditions of the nursing profession and evidence-based medicine, resist corruption, and serve the disenfranchised mentally ill as a “last line of defense” and advocacy. Like psychiatry residents, too few are learning the power of language-based practices today. Careful deployment of such well-trained and supervised Western-trained professionals, including doctorate-level psychologists, might alleviate the shortages that force today’s poorer care. Strong affiliations with university-based teaching programs could only improve professionalism at all levels.
We must try to influence policy makers to shift entrenched basic economic incentives driving this shameful system so that good medical practices dominate. I am not an expert in that, but our civil service and private industry have plenty of credible talent. A shift to greater professionalism should not be that expensive.
Here’s a silver lining: We all know that people and institutions in crises are actually more accessible to positive changes. We definitely have a crisis. Another: Behavioral Health and public services today are located nearby, inside cities, not exiled and isolated to the far-away countryside. Here’s another: At least, we are not burning mentally ill people at the stake any longer in our country, as we were doing just a few hundred years ago. We have laws against that now, I think.
PERSONAL NOTES
My repeated failures to fit have come as a shock (to everybody involved — the nice people who bet on my endurance, valued colleagues who recommended me, and to the cordial places that employed me, and to me. In retrospect, my naivety seems embarrassingly clear. How could I have missed it? Everybody, including me, assumed I knew what I was getting into.
I had not noticed, nor did anyone ever spell it out for me until I worked in several places, that I had been wrong to assume, as usual, that I was hired simply to do my best as a doctor. That meant practicing as competently as possible and advocating for the best medical care of my patients. But I was wrong. I was expected to understand automatically that I was also expected to cover up my own basic medical standards as I was covering these practices.
I see now how, from an administrator’s POV, requiring the most efficient coding to obtain payments, everything I did seemed disruptive: “Imposing” my own diagnoses and treatments, prioritizing, encouraging a collaborative atmosphere of learning, teaching, and largely “interfering.” I suspect that a major unspoken worry was how the contrast with my practice “methods” can place the permanent doctors, who are hard to find and whose daily signatures are desperately essential for the system’s financial viability, in a contrasting light. “Why bother to write about this at all? I could be embarrassing myself. Let it go,” I told myself, “Keep your head down.” The trouble is, no one, especially me, would ever come close to understanding what had happened until I had worked it out, out loud in writing for this chronicle.
“Also, why write this for public view? Isn’t that poor judgment?” Maybe. I hope not. After much careful reflection and many rewritings, I feel obligated to share what I saw. I believe that the details of misfittings by an accomplished psychiatrist with high standards can reveal enough about us and our institutions to accomplish my goal, which is to teach and to provoke discussion in the right circles that would lead to positive actions. I believe that as America experiments with new models of healthcare delivery, all current practices must be considered.
Reader: I beg your forgiveness for any errors of omission and commission and urge you to think critically, keeping in mind my goal. Of course, because I am too close to the subject and have only a small window on it, I cannot expect to be considered fair. But I do keep my biases clear and do try to be honest, balanced and transparent. This is, after all, a unique subjective account of a journey into controversial places. Once I understood what was happening, I found myself in the ethical quandary I pose above that I am now attempting to solve for myself. So far, I have decided to continue working to serve people who are poor and severely mentally ill, teach colleagues, and write. So — reader — please consider this essay a step.
Looking back and making sense of my recent journey, I initially sought locum tenens work because I needed the pay, but immediately became intensely wrapped up in rediscovering my medical and psychiatric roots, and was seduced by the immersive challenge of seeing very ill people actually quickly improving in front of my eyes again! That relit flame is still burning in me. But it blinded me at first. Now, as I pass a certain hospital and glance up at the second floor, I still think, “Folks could be stumbling through nightmarish medico – bureaucratic purgatories, right up there, just beyond those windows”.
I hope my writings here beget positive results. I realize fully — and so should any reader — that generalizing from what I saw in just a few units and drawing major conclusions about a whole industry and the people who man it is simply not valid nor fair. My use of “non language-based” is not intended to describe specifically any folks or colleagues. My intent here is only to create transparency and signal an alert from a professional and patient advocacy POV that would prompt more valid, larger, helpful studies.
In practical personal terms, however, IMHO these observations are reliable enough for me to now know how to find work that fits me. What I saw is extremely alarming and the valid bases for my own personal reactions described herein. And clearly, this is why fitting into the Behavioral Health inpatient and state hospital units I serviced, and going with the flow and keeping my head low to cover these practices, was impossible for me personally during my 44th year of practice and after a lifetime of pursuing professional excellence.
I am now obligated to take responsibility for my own part of the current mess, especially for ignoring the plight of so many neighbors. So this essay is not about bashing anyone, and I don’t even know who the main players behind this scenario are. The taxpayer pays and patients suffer with unacceptable psychiatric services –that much I know. I am grateful and humbled for being among US university-trained psychiatrists, well trained medically and then mind / brain diagnoses and treatments and always striving to excel on behalf of patients.
But, reader, you know who you are, and so do others. If you believe what I wrote, silence would put you too in a moral quandary, if you choose to see it that way. Of course, if this essay is too much of a challenge to some entities and hopefully has sufficient impact, predictably, my credibility could be questioned and conclusions even attacked ad hominem by anyone who disagrees (or the opposite, my opinions used out of context by activists).
My POV might be dismissed as coming from just another fading old dinosaur, longing for good old days that never existed; a self-righteous, self-serving wrinkled relic of the social activism of the turbulent Sixties; or from a disingenuous, effete, condescending elitist, an arrogant self-promoting eccentric, or just an ungrateful, hypocritical, conspiracy theorist and troublemaker. Or all of the above. Or worse. No matter. Even if I am found inaccurate in some of my perceptions or details or faulty in some of my conclusions, or have some personal failings, I did craft the above language carefully to describe what I see and think as a doctor. Please understand that, ethically, I am compelled to speak up for the sake of our present neighbors and to leave a better world for my grandchildren and their generations.
Finally, my fond personal thanks again to the dedicated administrators, nurses, staff, and doctors who accepted me into their workplaces, and additionally to the many patients, for collaborating in some of my most challenging and rewarding professional work in years. You know who you are
June, 2015.
http://psychiatrists.psychologytoday.com/rms/178252?_ga=1.62766633.441222680.
Alert to Colleagues: Hypo-Professionalism in Psychiatry
Report from the field: This personal chronicle of one doctor’s recent journeys into some corners of his profession, currently rarely noticed by most colleagues and the public, illuminates 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 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.
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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 decades of psychiatric practice in many settings, including 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 and 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.
Others are drunk. Many have some abused substance in their urine. Some may be described by nursing homes as violent, but are actually dumped for economic reasons. Others are dumped by other hospital EDs that intentionally exaggerate or even invent suicidal risk, even university-based hospitals. Some may be churned in profitable mills between nursing homes and units under the care of the same doctor. Some come to save themselves and others from themselves.
Hospitalized folks can include: executives who lost everything or other once-employed people fallen on hard times or people who were never employed; union members; illiterate and the markedly retarded or demented; those with graduate degrees; African-, Latino-, European-, Asian-, other-Americans; immigrants and asylum refugees who require a sometimes unavailable interpreter; parents of infants and grown children; residents of inner cities, farms, and suburbs.
These people are also housewives, prostitutes, teen moms; someone’s moms, dads, uncles, aunts, grandkids; panhandlers, laborers, voluntary sign-ins or certified, homeless people, substance abusers and alcoholics denying, substance and alcohol abusers detoxifying and resolving this is their bottom, felons under indictment, and violent sociopaths.
Our neighbors can include newly admitted patients still agitated or heavily sedated from their admission ordeal; the meek and shy; beautiful, deformed, cachectic, obese, weathered, athletic, and/or toothless people; those with poor personal hygiene; those well groomed first-timers; the neuro-developmentally disordered; and the “frequent flyers.” All are poor. (But not for long, as new ACA subscribers flood this very same system.)
They are desperate, dispirited, demoralized people who live in extreme stress with extreme fear, hurt, and anger, and yet retain amazing dignity and decency. They know the terror and shame of mental illness, I am sure you can imagine, reader. So some deny their illness and refuse treatment, hiding in their beds. Yet, most mix together minimally, vulnerable and mostly frightened, lonely, and disempowered, cut off from family and home, almost like the sad uncaged cats in a shelter I know. They mostly move silently past each other. They are the invisible people, the “walking dead,” as one woman, a mother, reminded me.
Many can be engaged once they get over the initial panic of being on the unit and their medications are adjusted. These individuals have a lot to say when given a chance: Many would like a visit from the chaplain. Some have a sense of humor. Most welcome a personal fist bump or shaking hands with the doctor and a discussion of their past and future. They appreciate a conversation about how this hospitalization could be a turning point in their lives. They like being asked what they need or what name they prefer to be called. Many want their own clothes returned to them ASAP and have important wishes and plans no one asks about.
When given a chance, men can ask for razorblades because they do not like electric razors. An 18 year old man could be coaxed into showing off his rapping talent and appreciates the interest. Some ask for a roommate who does not snore. Many are quite engageable and capable of participating in their own care. Mealtime is important to many patients, especially the homeless or those from group homes. All eat together from hospital trays in a dining room that doubles as an activities room. Many ask for double helpings, and it is not usually allowed.
Average length of stay is extremely short, often less than a week. Some people are admitted inappropriately in the first place, so it is easy to discharge them early. Others are “frequent flyers” and those whose lifestyle includes frequent hospitalizations with quick spontaneous remissions or responses to resumption of medication. Some people remain longer because they just do not improve quickly enough for discharge or have no other place to go. However, whatever the length of stay, discharge timing depends on improvement. Improvement should also be gauged by talking with patients to assess how well their neurobiological illness is remitting. In these units, credible mental status examinations hardly ever happen.
THE DEAL
Much like military field hospitals where time is of huge importance, units do not cuddle patients into time-costly regressive states. Patients are expected to fit in immediately and stretch themselves to cope with daily living demands, restore self-management skills, and return to a higher level of functioning quickly. Social workers are busy arranging discharge placement for patients and have little time for therapeutic conversations. A chaplain is available for the asking.
IMHO these Behavioral Health units can send this powerful restorative message. Here’s the deal: We have little time, we know. But you are expected to improve anyway, relearn to behave civilly, take your meds, and leave fast. We will get to know you and your situation, give you competent, caring, psychiatric services, feed you, take care of your health, and protect you, other patients, ourselves, and our property from anything you might try — so don’t, and then send you on to the next step in your healing journey.
IMHO, patient improvement can reasonably come from this deal. If it worked well with competent psychiatrists as lynchpins, it would be acceptable. The place can be about doctors restoring our neighbors to their best with expert understanding of the nuances of being both human and complexly ill, not merely as receptacles for poorly chosen medication. It can be about a thorough understanding that each of these regular folks has a unique past, present, and future, and may suffer from a uniquely individual complex disorder of thinking, behavior, and / or feeling that damages their ability to go through daily life. The place can be about a solid appreciation that it is not just about molecules in unseen synapses, but actually about capable but desperate people and their families, each with a unique life, that need humane healing.
But it often doesn’t work well at all: When they are admitted and daily thereafter, people are processed by psychiatrists piece by piece according to specific protocols, with little attention to their diversity or individual needs. One by one, they are marched to a chair across the table from an unsupervised “doctor” or a nurse coordinator who scatter their attention between the computer (typing, reading) and eye contact with the patient. There is no full engagement with the patient. The patient often sits closer to the door, often guarded by a burly mental health technician. Sometimes a social worker invaluably assists with planning. (The patient chair is only sometimes wiped with a disinfectant, but staff always avoids it or covers it with a pillowcase.)
Most patients don’t know it, and neither do many modern staffers and administrators, but psychiatric care can be as egregiously naïve and unprofessional as paintings by the numbers by careless, unimaginative children who seem to have learned neither basic painting nor the subtleties of using a paintbrush. There is too often no good deal here for patients (but you should see what the execs who run these hospitals and some “doctors” earn.)
Almost no one actually gets to know our neighbors sufficiently to provide reasonable care. Too often, patients all get the same mindless conversations full of infantilizing platitudes from MDs with marginal and RNs with no psychiatric training, or even knowledge of idiomatic English or American culture. Little or no clinical or programmatic distinction is made among chronically ill, low-functioning, often demented older “frequent flyers”, the homeless, the mentally retarded, and frightened younger first-timers, often higher functioning and ripe for well-designed interventions. One size fits all in this production line.
Our neighbor, the consumer, does not know what someone else is buying for her and how the doctor / hospital may be failing her. Units are run according to insurer specs, especially Medicare and Medicaid, and must balance expenditures on providers and their expensive time with shrinkingreimbursements. The actual buyer is the mega insurer who pays the bill, and I seriously doubt these buyers know much more than numbers, so no one is responsible here! Various agencies apparently inspect and audit such units and patient records, but only the most egregious are detected. The system often abandons individual folks at the lowest quality and quantity of psychiatric care.
Psychiatrists are apparently interchangeable and can easily travel among hospitals, nursing homes, and outpatient practices, and they may be major clients for some medical temp placement firms. In fact, help wanted ads for doctors often specify exact hourly outputs. Local news media report on these units rarely, but I have never seen an accurate portrayal in any media.
The system is broken. It is functionally and professionally bankrupt. Good basic psychiatric practice seems totally irrelevant to hurried administrators, but often pleasingly novel to experienced unit staff. Almost nothing else seems to matter to the employer, as long as their “queen bees” are licensed and minimally trained, no matter how or where, and quickly credentialed. In fact, piecework output per hour and documentation with insurance-preferred wording are the only monitored queen bee activities.
Fortunately, some decent unit leadership and staff provide enough intelligent, personalized professionalism to make real differences sometimes. Such administrators, nurses and technicians eagerly oriented me and very quickly and competently translated our clinical plans and my medical recommendations into effective actions, and there was a large amount of respect as partners and colleagues. I relied heavily on these professionals, and they never disappointed. (Sometimes, FYI, such nurses buy patients clothing or other needed items (a used bicycle!) to enable their success after discharge.)
ON BECOMING A BAD FIT 1: WHY I DID NOT GO ALONG WITH THE FLOW
So this is what happened: I did not fit in. I guess I just wasn’t trained to be a “queen bee”. A helpful senior RN suggested warmly in broken English that I just “go with the flow,” but I resented the message because I didn’t really understand it until later. The flow of what?
I did understand quickly that my piecework production pace was the main issue. I sometimes needed to see as many as five or six complicated and poorly communicative patients an hour, sometimes for up to five to eight hours consecutively. In fact, admissions took more time, but I also spent more time with about 2/3 of patients who already had nicely typed admission notes by another practitioner already in the chart.
Why? I could not trust most doctors’ notes to be complete or accurate. So I preferred reading nursing notes and raw lab data and interviewing patients more fully myself. And what’s more, in a squeeze, I prioritized young patients with even more time because the younger the patient, the bleaker their future in this system and greatest the difference good doctoring could make now. Why? Nobody else was doing what credible care called for. And apparently I wasn’t hired to do that either. But eventually I learned to meet my quotas.
Being a bad fit was just fine with me. What I saw led me to the present essay. Here are specific examples of individual incompetence and systemic, medical, and ethical failures illustrating what today routinely pass for psychiatric standards in at least some inpatient Behavioral Health units.
– Psychiatry in these facilities appeared to me to have little to do with even minimally competent diagnosis, treatment, humaneness or the healing uses of language. A permanent “psychiatrist”, doubling as the “medical director” I partially covered early in my work in Behavioral Health units drove home a radical point shamelessly. He meticulously dictated his notes, signing off and billing for each step of the revolving door cookie cutter, doing his piecework on the assembly line of human souls flowing between nursing homes and the unit, and documented, documented, documented to the letter compliance with the insurer’s language. Many “frequent flyers” (repeatedly admitted people) were also his patients in nursing homes, and he repeatedly profited by their passage through each gate he was keeping. So I refused to treat these folks.
This alleged board certified “psychiatrist” chided me to comply with his standards (polypharmacy, diagnoses in perpetuity, etc.) because I was now working in his type of practice, and not in the suburbs. He insisted repeatedly and forcefully and with all seriousness in the same formal meeting (and we were not alone — people in the room exchanged raised eye brows) that it is wrong to review and change patients’ diagnoses or medications because “so many good doctors (in such facilities, practices like his own, or similarly staffed outpatient programs, group homes, or nursing homes he services) have already diagnosed the patient.” He needlessly piled on for almost every patient a recently released medication on top of a similar drug already given, claiming that he intended to “switch them over”, which I did not see, nor evidence that he explained his intent nor obtained informed consent. Such is the appalling pill mill standard.
I was so astounded that I thought him dangerously impaired. I thought his judgment was bad, not only in the medical sense, but also both in terms of making such outlandish statements so matter-of-factly in public. (BTW thisindustrious “doctor” was probably getting richer and closer to the American dream faster than most.)
I even started the process of reporting this man as an impaired physician. And that’s not something that I had ever done before. And eventually he corrected some of his egregious practices when I refused to continue them with his patients. I later understood that he was just telling me how it is. In his own way, he was orienting me. Apparently, his is just a routine and expected practice in his corner of psychiatry, where industrial pill mills can thrive and turn a profit.
Truth be told, his position was in fact pretty typical, as I found out later. To these psychiatrists and their patients, apparently “continuity of care” meant not making waves while perpetuating continuity of wrong diagnosis and wrong treatment for years as patients rotated through the gates they are keeping.
However, while I was initially mostly troubled by the way doctors in this system function, I have also come to see most as hard-working poorly trained people who probably did not grasp that their standard of functioning was extremely low by US university-trained colleague standards, rather than being merely impaired or greedy perpetrators. There are also, apparently, the more powerful large corporate chains (shareholders are owners — I wonder how many know), who crave these doctors’ signatures so intensely, and who know exactly what’s going on, or should know, who qualify for the latter distinction.
Doctors are nevertheless professionally accountable. These examples illuminated for me aspects of psychiatry’s stunning professional and social failure, especially as it turns away from language-based therapeutic interactions. These practices appear standard and spreading to all specialties as the ACA now also brings more people into such units, and these folks are not necessarily poor.
– Absent and wrong diagnoses and treatments hurt people. Competent, rational, and legitimate medical encounters require several or all of these actions: Connecting with the patient through language, reviewing history, examining the patient, evaluating current functioning, confirming a diagnosis and considering alternatives (this anchors the whole process), initiating or adjusting a treatment and discharge plan with nursing and social work, talking with family members, writing orders or prescriptions, calling other specialists for consultations, and charting the above.
But not in these facilities. They often used terms like “This 39 year old woman with known Bipolar Disorder…” or “This man with known chronic alcohol abuse in again brought to the ED…” to identify patients they actually have no personal knowledge or much information about, other than that the prior doctor may have used the same words. They shortcut obtaining a careful history from patients and / or significant others. And this happens time after time — to the same patient! So when was the last time anyone bothered to act like a doctor and really diagnose this person? In these facilities, doctors apparently do not diagnose but copy the diagnosis the prior doctor made, etc. etc. Looks like poor diagnosis, poor treatment. In perpetuity.
Very ill and poor psychiatric patients in some Behavioral Health facilities are prescribed the almost-random pick of the same few medications for years without validated diagnoses. Most patients in these systems share the same few recurring diagnoses and treatments, despite their actual diagnostic diversity. Getting the wrong medication may not be obvious at first because the broad spectrum of action of some meds, especially initially, obviates precise diagnosis.
Many of these folks are not aware of their current valid diagnoses, or if asked, what the currently commonly used cookie-cutter labels “Schizoaffective Disorder” or “Bipolar Disorder” or “Borderline,” masquerading as legitimate diagnoses, actually mean other than justifying the medications they are asked to take and their hospital admissions. There is no informed consent process. For example, a mood stabilizer widely known to cause ovarian disease in young women is prescribed for them perfunctorily without their informed consent, even when clear alternatives are easily available.
Adult ADHD, PTSD, enuresis, and depression are widespread and almost never noticed or treated. If you are a poor person, you will also probably be diagnosed incorrectly if you have learning disabilities, post-partum depression, dyslexia, or dissociative disorders, and even hysterical symptoms.
Too many trauma or child abuse survivors, people 18 to 55 year old who have sustained severe psychological injury, continue suffering additional and probably more crippling abuse from an incompetent medical work up (that fails to diagnose and treat correctly). That these folks respond poorly to most medications because of PTSD or a variant almost never comes up. Instead, they are loaded up with ineffective medication. No doctor seemingly ever bothered to use simple language to ask most of the obvious questions, such as: “Has anybody ever hurt you physically or touched you in private places against you will? . . . What happened then?” And so, nobody ever listens to a story many badly need to tell to know themselves as human.
With emphasis only on observable behavior, people whose illnesses were initially triggered by severe losses are not diagnosed as grieving because nobody listened or got the facts available just for the asking, “When was the last time you felt healthy? . . . What happened then?” Instead these folks may be prescribed strong meds for years. If you are a poor mentally ill person, your grief is not ever known.
Too many doctors in this current system seem to forget that every patient encounter is an opportunity for screening for general health and improvement and verification of psychiatric diagnoses and treatment plans, but instead perpetuate unproven, incorrect psychiatric diagnoses and pile the same sets of powerful ineffective medications into ill people, no matter the age, often discharging them into a therapeutic vacuum where no one can observe the evolving main and side effects of medications. So if you are poor, you might have a wrong diagnoses and be taking the wrong pill mill style medications for years without knowing it.
– I have seen how some youngsters survive their train-wrecked lives as wards of DCFS since early childhood, hanging on to sanity and humanity by finding strength in themselves through art or music. They bring their treasured notebooks into the hospital. When asked, “How do you get yourself to feel better?” they show their work proudly and appreciate a kind but honest reaction. These are diagnostically important clues, too. Some work shows personal resources and talent. The interaction sparked by a simple question provides opportunities for empowerment and dignified human contact with a doctor. No medical provider, and few other staff members to my knowledge, ever asked the question nor showed an interest of these kids’ art.
– “Did you ever hurt your head so badly that you passed out?” is almost never asked of folks who live in a culture of violence and are therefore more vulnerable to closed head injury and its sequelae. That your symptoms could be related to a closed head injury could be overlooked if you are a poor person.
– Polypharmacy (unless clearly justified, the practice of prescribing together several very similar medications to treat the same symptoms — considered sloppy practice because of increased side effect risks) is rampant in these medical practices, except where hospital IT systems question the order. Often, my documented efforts to undo these incompetent practices were reversed immediately by the permanent doctors without discussion. One doctor routinely placed almost every patient on a recently released medication. Patients discontinue or “cheek” and then secretly spit out medications they need because of side effects nobody cares about.
– Very young children are admitted and treated by incompetent providers without specialized training in child psychiatry. Children’s brains are especially delicate growing organs, unlike adult brains, and we all know they require a specialist with two additional years of training. But having fewer child psychiatrists available, these units often struggle to meet community needs. So this is what happens: If you are a non-psychotic five year old with a chaotic family and a mentally ill father, you would actually be prescribed a powerful mood stabilizer with possibly serious side effects immediately upon admission by an unqualified Behavioral Health doctor without a minimal history, family evaluation, or anything close to a specialized psychiatric examination that would lead to a diagnosis, even though a boarded child psychiatrist nearby is already associated with this facility. Did it come down to how much the facility was willing to pay this specialist? Can you imagine a fully accredited hospital in a city here in the US daring such a practice routinely? Does the public know?
So this is what happened: I was coming on call one morning just after such a girl was admitted, and wandered into the children’s unit looking for an open office. When I saw the new child, who now was my responsibility, I briefly engaged her in diagnostic play and then spoke with her cooperative grandmother and hostile father, concluding with certainty there was no need for any medication, that the vulnerable child was agitated by chronic family chaos, and that therefore the first dose given was an error. I spoke collegially with the admitting doctor about removing his standing medication order and referring to DCFS, and he easily agreed. I reminded a young nurse of her important role as the last line of defense detecting medical errors (admittedly, not my official role, so I was asked to apologize to the nurse, except that patient advocacy is always a doctor’s role).
This is what happened next: Two stern administrators appeared quickly demanding to know what I was doing in the children’s unit and why I upset the nursing staff. The patient’s care was not mentioned. Were these the final straws that quickly ended my contract in this facility and employment by the locum tenens firm — my “intrusive” efforts to “impose” my “methods” on the doctors of that little vulnerable child? It was a sad eye-opening moment for me, especially since so many good people work so proudly to make this community facility the best they can. Don’t they know what psychiatric (vs. “Behavioral Health”) means professionally and to the patients who trust them? Has psychiatry failed by failing to teach and insist on minimal standards?
– Chaplain visits are rarely offered despite their powerful help healing some patients.
– Medication non-compliance is formally often blamed on patients for relapses and frequent readmissions, but outpatient facilities can often be inaccessible or care also cookie-cutter by the same “providers” and bureaucratic social services. Some patients know the medication they are prescribed hurts them and the prescribers incompetent, so they refuse it or stop it after it runs out. Some stop because they are too disturbed to see its value. Many welcome questions like, “How did you sleep last night?” and “How’s your thinking today?” with increased collaboration and compliance. Too many doctors do not actually look at or touch and examine their patients for easily manageable side effects.
– Electronic medical records are typically administrator-centered. They are awkward and more time consuming for psychiatrists than some patients. Available health records often only go back a year or so for folks who suffer lifelong chronic illnesses, so nobody really has the entire history to see the context for the present. Doctors don’t seem to trouble looking for the whole picture. This means that one illness episode can last a lifetime with care so fragmented that it appears to be for a series of acute illness episodes in the record. That you are not improving is not necessarily visible to doctors if you are poor.
And these folks have predicted life span decades less than most of us, succumbing to decades from medical neglect, accidents, and suicide. So they need extra careful screenings for physical ailments. Yet access to inpatient specialists like rare child neurologists, child psychiatrists, urologists, psychological testing, long-term histories, EEGs, endocrinologists, or even gynecologists is spotty in such facilities and is postponed until after discharge, but rarely happens then because the links between outpatient and inpatient care are so poor that too many just fall through the cracks. If you are a poor child who might have a learning disability that gets you into trouble, don’t count on a doctor to check it out before diagnosing and treating you as needing a medication. If you are a poor person, don’t count on ever getting a thyroid or kidney test (24 hour urine collection), even though you have been taking lithium salts for decades.
– Too many poor mentally ill people use their now 6.8 days or so as inpatients as a lifestyle choice as the only safe havens and shelters from their crises-filled lives. So, known by many staffs as “frequent flyers,” some of these patients have told me openly that they claim to “hear voices that tell me to kill myself” to get admitted, and do easily get admitted without anyone even inquiring into the nature, location, and history of the alleged hallucinations. Often someone on the inpatient staff then says something like, “It must be getting really too cold out,” as the patients are admitted. In fact, several have revealed to me that they have not hallucinated for years. Yet, some insist on carrying the wrong diagnoses that guarantee Social Security Disability payments. Some are dumped by nursing or group homes and become homeless. It is really difficult to say how many such patients exist, but I would estimate that proportion can be as high as 1/4 of total admissions.
– So the admission charade continues 24/7, as too many seemingly “financially strapped” inpatient Behavioral Health facilities, claiming they have a hard time recruiting, uniformly settle for doctors who consistently seem not to need to communicate thoroughly with their patients. A routine medical conversation that might provide crucial information hardly ever happens.
– Things can look a lot better on paper than they actually are. Thankfully, I have not seen anyone lying or using language dishonestly or misleadingly. It is more subtle: On initial readings of a few random patient charts, writings by one of these doctors would seem complete and nicely detailed. However, seeing more and more charts and the patients themselves reveals another picture: In fact, many of these records are empty facades that show little clinical thinking. But they do comply with insurance language. These reports are insidiously too alike in language, wrong diagnoses made and wrong medications prescribed over and over. I would guess that they could easily escape random routine audits and that this is already an epidemic staying meticulously within the law.
– Monitoring of psychiatric care quality was totally absent in the facilities I saw. While they should be part of self-governance, there were no actual working quality controls for psychiatrists except for utilization reviewers monitoring insurer-required language usage and “suggesting” to doctors it’s proper use. Administrators are quick to point out that they have no direct control over how doctors practice, and rely on the medical staff self-governing structure and bylaws. Under this arrangement, psychiatrists are supposedly monitored by a department chairperson. But functioning department chairs or other monitors were nowhere to be seen.
– Well-meaning folks at all levels who work in such facilities are incentivized to keep the system going as is. Administrators scramble to compete in a hot market to fill medical positions with almost anybody in order to keep needed beds open and budgets positive. So they retain many doctors with marginal language skills for understanding idiom and speech, unfamiliar with the norms of patients of diverse American cultural backgrounds, further handicapping any healing relationship and distancing practitioner from patient.
– And are these units really “financially strapped”? Many all over the US are closing. But I also heard grumbled things like these “full units actually earn such substantial revenue that they can sometimes carry the whole hospital financially.” So, if that’s true, what could make these private Behavioral Health units so profitable at the very same time when excellent private hospitals like LA’s famed Cedars-Sinai had to close these very same services because they could not afford to provide good care to the poor for the same money? If true, how can services already reimbursed at bare bones leave anything over an a profit? Are poor mentally ill people being ripped off?
ON BECOMING A BAD FIT 2: USING LANGUAGE AS A NEUROSCIENCE TOOL
This is the second thing that happened to cause me to be a misfit in the places I worked. And it was more obvious and very telling: How I was using language seemed to some folks in the trenches — patients and nurses — to work quite well, sometimes even miraculously. There were moments of genuine synergy. Maybe that’s why these two very different groups of people marveled at the sight of a psychiatrist who actually dignifies, empowers, and converses seriously with patients and uses language as a demonstrably powerful diagnostic and treatment tool, and fine tunes medication treatments using basic knowledge.
Nurse practitioners and patients both reacted with pleased surprise, as people do when they unexpectedly discover a new way to improve something vital but frustrating. They actually saw a psychiatrist touch to examine a patient to determine rigidity (side effect of some medications), do a brief neurological examination and a full mental status examination, including interpretation of proverbs, or auscultate the chest to hear a possible pneumonia.
They saw a psychiatrist try to connect and engage ill people with a fist bump and colloquial conversation about their pasts, explain diagnoses and treatment, identify strengths, assess medications and alternatives, and assist patients to plan personal goals for their futures and articulate and make sense of their personal stories. They also saw a doctor actually invite the chaplain to visit some patients and confer about how together to reach and heal some folks. And they saw that work.
These veteran residents today’s Behavioral Health trenches became fascinated by how language can be one of our most powerful neuroscience tools to bridge mind, brain, and behavioral change. Some patients were eager to know what their diagnoses mean and what medications are supposed to do, and were pleased to have enough information to make their own decisions. The nurse, patient, and I learned together that doctors and nurses working together still can have very powerful effects to the good. We learned that when patients and staff understood the same narrative, hope and compliance increased and progress accelerated. We learned that a language-based psychiatrist’s signature can also guarantee competent care. “You are the first doctor to ever do this,” many said many times.
And we thought I was doing my job pretty well because patients were dramatically improving and nurses were learning. This point came home dramatically when one “frequent flyer” proclaimed proudly, after three months of her deliberate medication refusal (so I was expected to get her to take it), that her mind was now clear for the first time after 40 years “in the desert”, and mostly that she finally has “a name“, after the America tune. And I did thank her sincerely for teaching me the song.
She had been seen daily for weeks by other psychiatrists, with little change in her resolve (good for her!) We made a decision with the patient to support her because here was a woman finally making her own careful choices towards health, and the medical risk was quite low. As the nurse and I planned with her how to succeed, she volunteered “anxiety” as her main problem, so we reviewed her psychosocial options and planned her discharge accordingly (with medication from a doctor she trusted). And there are many other stories and similar moments, even with less healthy folks.
And, BTW, this humane and effective approach was not that expensive: I was actually able to see about 4 (up to six in a pinch) people an hour and do a competent job, once I learned to triage who was most likely to benefit after a lengthier first meeting, and once I learned the ropes and Epic(commonly used very costly electronic medical record and charting software), and once we had met and connected. Altogether, working with this woman took maybe 60 minutes of my and the nurse’s time spread over several days. It would have taken less had a proper history been obtained by her admitting provider.
(This is sarcastic:) Attention administrators and investors: Language-based psychiatry is a wonderful invention that has already undergone proof of concept and extensive market penetration. Any novice entrepreneur today would understand that the secret sauce is putting the most skilled time in front — enough time to meet the people who are patients.
Once a trusting relationship is formed (it goes both ways), as much time is not needed later. This is not patentable – it is an old process called “Building the Therapeutic Alliance” that every psychiatrist needs to know cold.
So this is how it is a great improvement over your other current Behavioral Health competition. At the end of the first meeting, the patient, nurse, social worker, and this expert language-based psychiatrist agree that they need ASAP an outline of goals for hospitalization and discharge, and that the patient will bring a written list of her thoughts, and she does write down her goals, and she does bring the list to the next interview, and a medication discussion fits into this context. She is empowered to collaborate.
The rest follows with greater ease in most patients. And you need language savvy doctors, especially in psychiatry, although I am sure this is true even for the hospitalists you employ. This actually worked to some extent with at least 3/4 of the hundreds of people I met as patients in my Behavioral Health stint. Entrepreneurs, your challenge now is to scale this proven concept. Why? Because a woman finding her name can be a bargain, costing altogether, say, $80-250 for language-based psychiatric and nursing times spent with this patient. And there are millions of missed opportunities for such cheap interventions daily in a multibillion dollar potential market, especially as ACA spotlights value added. And think of the marketing you can do: “We’ll reach out and hear you!” But then, why would you, dear businessman?– you seem to clean up really well anyway.
Bottom line — what shocked me in private Behavioral Health was this: Poor mentally ill folks are being served the dregs of the dregs of what psychiatry can and should offer them. Shameful psychiatric neglect or incompetence in the Behavioral Health units I saw with my own eyes, and many outpatient services and nursing homes I learned about, all supported by taxpayers, remind me of what I had seen in the large old state hospitals as a medical student well over four decades ago when these places were widely considered the sewers of American medicine.
A STATE HOSPITAL UNIT
Finally, for about forty immersive hours a week for seven weeks, I had sole psychiatric responsibility for a special closed unit of about fifteen severely chronically ill, difficult-to-place men, most transferred from a high security facility. This part of my journey, including admissions and routine coverage to the entire hospital, opened my eyes and touched my heart.
State hospitals are old institutions that have a long and checkered history that reflects our posture towards poor people who are mentally ill. A common view of these institutions has been that they are second rate at best. I expected to find an inflexible, lazy, even a bit corrupt pill mill and bureaucracy, and did have reservations about fitting. This is what I saw:
Unlike the patients in Behavioral Health units, those in state hospitals today can benefit from longer stays, psychiatric collegial monitoring, working standards for psychopharmacology, and major improvements in patient rights, medical care, security, therapeutic activities, staff educational activities, and cleanliness. If deemed safe, patients can go off the unit alone and even on field trips in groups. The level of staff psychiatric care and of activities and occupational therapies too seemed higher in general than in the Behavioral Health units I saw. Similarly, salaried doctors appeared more of a community practicing at a higher standards and more communicative with patients, although there were laggards.
Administrators are mostly competent hard-working civil servants, but tired. Who can blame them? Their professionalism and patient, kind, gentle devotion to all the people in their charge — individual staff and individual patients — penetrates deeply to steady, warm, and nourish all layers of the hospital. These precious people do come from caring nursing, medicine, and social work backgrounds. What an accomplishment! For this reason alone, but there are many others, IMHO this state hospital is preferable to the Behavioral Health facilities I saw.
Support mental health staff — social workers, activities and occupational therapists, and contractual part-time group therapists — are mostly very good, but more than a few obviously unstable and incompetent professional employees do stay on. Like Behavioral Health units, therapeutic or educational contact with families is essentially absent.
Strangely, just as in Behavioral Health units, occupational therapists, excellent professionals who know the patients well, are not included in routine clinical discussions. Physical facilities were clean and up to date, and services and security were at least as good as in Behavioral Health units I saw. Housekeeping staff and security officers are a familiar part of the community and interact well with patients.
Nurses varied in professionalism, but, as in the Behavioral Health units, too few had psychiatric training, let alone language-based backgrounds or familiarity with the diversity of patient cultures. Their interests seemed to be careful management of patient sleep, dosing, and hygiene, and most were generally helpful, flexible, caring, excited about patient progress, and eager to learn.
Technicians, otherwise also known as mental health workers or nurses’ aides, interact most closely with patients daily and are most culturally sensitive. Especially when I invited them to meetings and included them in treatment planning, these devoted folks were as outstanding as any experienced clinician anywhere, but this is not routine.
As in the Behavioral Health units I saw, nursing can provide a solid and predictable container for healing. But there was another set of staff problems — seemingly a fatal flaw. Initial appearances to the contrary, a malignant culture of fear, greed, mediocrity, and daily degradation of patients permeates daily life and defeats healing. It seems that to keep public jobs and generous benefits, all who work at this facility have apparently become habitually vigilant to “keep their head low”, limiting most workplace interactions to mediocre, well practiced, safe, “by the book” routines.
It became clear to me after several weeks that something insidious might be poisoning the culture and eroding its potential for healing: A few employees, mostly nurses constantly splitting their own ranks in petty bickering, also “fracture” the unit and damage its mission. To get what they want, they are known to provoke administrators, doctors, patients, and other employees, and then apparently complain to what some refer to as “the union”, something the administrators seem to dread.
These jittery public employees treat patients appallingly. Barricaded, often noisily, in nursing stations, they imperiously cackle orders and manage the place like something between a POW facility and a cookie cutter kindergarten. Instead of delivering active, creative empowerment towards self sufficiency, personal responsibility, and ultimate discharge, they create a unit that persistently herds, degrades, and infantilizes. The rest of the staff and patients seem intimidated and step around them whenever possible. But these nurses run the unit.
In this unit’s oppressive Kafkaesque culture, there is almost no spontaneous, meaningful, open, professional communication about patients. Instead, inane, superficial gossiping about the latest “pet” patients’ behavior serves to bridge staff differences and release tension through an unprofessional lowest common denominator and replaces even minimal clinical relevance. I tried to fit in by “talking the talk” at first. Later, I tried to raise the professionalism of conferences by sharing my observations and thoughts to elicit others’, with some success.
In this unit of throwaway men, I saw years of gross misdiagnoses/mistreatments, layers of polypharmacy, especially with poor attention to PTSD, closed head injuries, depression, anxiety, adult ADHD, and current treatments. There is lots of required paperwork to document proper care, but in reality little effort to individualize in real time.
Last and definitely least are those who pay the price: In this unit, voiceless men, eyes glazed, speech slurred, beds wet, silent or sounding crazy, have learned well to manage daily degradation long ago in units far away — by folding deeper into their illnesses, burrowing deeper in thickets of their head and facial hair, and hiding in sleep and masturbation in yet darker smellier rooms.
Our patients, our neighbors, unlucky men in their 20s through 60s, whose only bedroom and only home (only street, only neighborhood, only social group, only place and only hope in this entire world) is this little room in this unit in this impersonal hospital, are abandoned, totally alone and cut off, and disenfranchised at the very bottom of an invisible hierarchy, much as they have traditionally been in state hospitals. These fellow Americans, can they not still sing, laugh, joke, be proud, pray, create art, have fun, have legitimate anger, care deeply, feel pain and sadness, long for companionship, and strive to live more fully?
Has everybody gone mad and forgotten this? The health and rehabilitation of our neighbors are the sole reasons for the existence of the entire PUBLIC institution and all the PUBLIC jobs and PUBLIC pay checks and PUBLIC benefits . . . Where is this PUBLIC? We are all shareholders here.
~~~~~~
(On becoming a bad fit 3)
A most amazing accidental discovery 1: Human souls can be revived unexpectedly. Like in Dr. Oliver Sack’s Awakenings. After about three weeks, we saw a renewed spirit sprouting. Patients lifted their heads to look with sparkling eyes at a more hopeful world and solidified their community and nourished each other. The world was opening up for them. They were opening up for the world. Knowledgeable people noticed and nodded and quietly smiled when I repeatedly checked with them if we were on the right track.
What was happening?
The men got good doctoring, and enough good staff joined a healing fest. I made ongoing, careful assessments of each patient’s individual psychological and medical needs during my daily on-site real- time psychiatric presence: I got to know them as people who are now my patients, as their doctor. Sensitive, courteous, thoughtful conversation and careful listening, casual interactions, impromptu meetings on the unit and in my office, checking on how a man is doing after we changed a medication. Just sitting together.
Each man had his own, colorful, consistent narrative about himself, his past, and future that deserved a serious respectful hearing, no matter how illogical or delusional he made it to survive with an impaired brain over the years. We used language…Just checking on the progress of a project or physical complaint. Focusing on the here and now. I decided to wear my doctor coat after a couple of weeks to legitimize my reality. A doctor’s uniform.
Then, they needed working doses of the right medications based on the right diagnoses refined in real time for current symptoms, and they needed a voice about their fate. The state required this, and it was done routinely but perfunctorily. I engaged them to their limits in this conversation early, establishing a connection that served as the basis for what came next:
“What medication worked best for you?…How?” They do know which, and they do know how. And they do know that trust has to go both ways. For example, one man’s request (btw, he dressed impeccably, had a gracious manner about him, and loved singing hymns for the group) for ibuprofen to help him stay calm and relieve his chronic headache was repeatedly rejected because it is not standard and can cause rare GI bleeding. The internist also believed the man’s request was delusional. Well, it turns out that current research shows that such anti inflammatory meds can be helpful in schizophrenia and they did calm him down and relieve his headache. Competent about this matter, the patient made that discovery for himself, and the internist approved after a small change in medical management.
Medications today are often really better, and there are more of them to carefully weave together with language-based doctoring and existing social work/supportive activities by competent, genuinely caring staff. We started them off gently as healing sprouted, and stayed present and in the moment with them as they took their first steps, safely refined their medication and tweaked their social environment, focused them on daily personal and community goals, and began to collaborate with some on long term discharge plans.
There was plenty of testing of limits, too — it was definitely not a rose garden. And they each watched closely as I treated others and what happened, and they liked how I encouraged their own little community and mentored their leaders to succeed.
But the secret sauce — what largely made this possible — was language as a powerful neuropsychiatric tool. It turned out that they could thrive. They needed strong, well-timed sparks to restart their engines, and then basic navigating guidance and a safe, fenced road.
Up real close, smell-to-smell. Ready to fist bump. Visible. Approachable. Meticulous about small requests and symptom follow up. Respectful of boundaries. Fair. Patient. Firm. Insisting on some behaviors and punishing others, not intimidated, and always following through: “You are men. This is a hospital, not the street. You live here. I am your doctor. I look out for you. You deserve to have a caring doctor who treats you like a person. Manage your selfand relationships with self respect and kindness, or we’ll do it for you.”
Most of our patients’ brains — in various conditions of gross and fine repair, development, and/or functionality, are apparently still well wired enough to welcome proper stimulation. And the spark is wired into our mammalian brains. The spark was simply the thing that excites all humans from birth. That spark electrified mirror neurons and their neural social networks and the many other circuits that feed off them to make our brains miraculous social organs.
This spark is well known, and our brains are prepared to accept it from the first day of life — a human face. A vigorous, safe, interactive human presence that affirms. Stimulation from a full, close, eye-to-eye, face-to-face smiling and nodding. Like the painful knuckle rub on the chest that initiates CPR. A multidimensional sensory human engagement, especially amplified when coming safely from a trusted doctor. Our patients were ready to react with healing, hope, and a natural reaching out.
After about five weeks, the men engaged in more vigorous self-governing, emerged from their rooms, showered more, showed kindnesses to each other, and clamored in community meetings to sing and rap. People were further away from their verge of rage or panic. Those who spoke about it did reveal a personal faith they do not abandon. Singing for most and rapping for some is their celebration as a community. Amazingly, one reclusive aggressive man revealed such creative intelligence in his rapping and conversation that knowing staff exchanged surprised and approving nods. No more slurred speech, no more drooling, more smiles, straighter smoother walking. Less bed wetting. Less smelly rooms. Cleaner clothes. Less tremor. Less ADHD, less depression.
Several more men started their long ways towards discharge. One reticent man diligently sought his daily quota of fist bumps and started showing me his shiny basketball card collection. Another sat next to me in meetings and often invited me to prompt more appropriate behavior. Most dramatically, one reclusive man surprised and delighted everyone and actually had the barber shave off his hairy thicket and started to attend meetings. (And yes, the changes seemed entirely lost on some of our nurses. It would be interesting to compare their daily charting notes with technician notes, mine, and those of the language-based psychologist and social worker.)
Patients, doctor, and most staff joined together to form scaffolds for growth, embodied in an invigorated daily or impromptu community meeting. Once primed, impulses to health cascaded exponentially, recruiting existing neural and social networks, and even entraining otherwise aloof staff to participate. Wow. That’s the best of modern neuroscience at work! That’s psychiatry how it can be! That’s exactly what I signed up for in medical school.
No one, including me, had expected the amazing inspiring awakenings that happened. Language-based staff were openly thrilled. Administrators with mental health backgrounds recalled them proudly to me so that I would know they too are colleagues. There was a buzz. Word spread beyond the hospital. Something in this contagious flare up of life touched every man and deserves further attention. At least, it was a powerful placebo that kicked brains into gear beyond decades of dormant hospital “care” (and, not infrequently, beyond the around 15 lbs. of brain medication a decade poured into each man, or about 450 lbs. into all the men in this group to date while under state care — correct me if I am wrong, based on an my estimated averages: 2000 mg daily, 20 yrs. LOS. That’s industrial strength neuroscience).
Anyway, IMHO, the power of placebos and healing relationships are still understudied in neuroscience (Louis Lasagne, M.D. and Jerome Frank, M.D., Ph.D., were among my most memorable and wisest teachers). Placebos were always powerful medicines. Great physicians from antiquity recognized the power of hope in healing. Hope works wonders, as does great advertising and great leadership. And that too is probably wired into our brains (as are trust and faith and love). But you must access hope through language and mind. And there seems to be a lot more room for more on this unit.
On the unit, I began to speak with staff about slowly reducing my active pace to prepare patients for my departure when my contract ended. But I was abruptly and quickly removed (some staff actually gasped when I announced my departure) exactly halfway through. So what happened next to the men on this unit? I won’t know. Sadly. That’s the contract.
Most amazing discovery 2: A human spirit can blossom in most folks who work in a state hospital, too. A majority of seemingly competent and caring administrators and staff, much as in the private sector, “go with the flow”. In hushed sincerity they bemoan and attempt to disown the “jaded system,” shaking their heads and gazing down at their feet, almost like apologizing. They are hanging on, too, I guess, to avoid falling down cracks in the system. But they also are devoted.
Many employees do clearly and even cynically grasp the charade, yet can patiently stay on anyway to steadfastly, quietly care for and connect and give to our thrown-away neighbors — and that’s awesome. Even some housekeepers make their peace with this hell and join the singing. That’s love. These precious people are truly our best healers, our humane, gentle, saintly fixers of the world.
Even as a powerful few dehumanize, these steadfast folks manage to steadily rehumanize to keep patient hope alive. Each has a story about how many times they almost quit. They do resist the flow selectively, I guess, and they also like their state benefits and overtime pay and pensions; nothing wrong with that. Those who give so much deserve it. You know who you are. Thank you. I wish I could have your strength!
~~~~~~~
This is what also happened, from my POV: Patients in all hospitals depend on productive collaborations between physicians and nursing leadership, and a new doctor especially needs clear communication with the head nurse.But unlike most of their colleagues, a few nurses — the ruling clique — openly and stubbornly made a show of their refusal to communicate and collaborate with me.
I was tipped off early by several clandestine self-appointed “allies” that, should I have any friction with one particularly hostile nurse, I will be the one who ends up leaving. It was a no brainer for them. Near the end, another self-appointed ally tipped me off to a “setup” that will be coming soon and to how it might happen.
Indeed, the ruling clique and their allies seemingly mounted its offensive more openly when it became clear that I was succeeding. They apparently had critical words with the nursing staffers that did work well with me. They apparently spread stories that made their replacement in the unit difficult by transferring other nurses. They also apparently stonewalled for weeks administration efforts to respond to my urgent demands for a simple nursing protocol for quickly evacuating to an ER a severely medically ill uncooperative man in a manner that could save his life. (I learned later, to my relief, that my persistence did indeed finally lead to life-saving abdominal surgery soon after I left.)
And the ambushes did come, wrapped in plausible deniability, always in front of witnesses. In one meeting, during a discussion of transitioning a soon-to-be-discharged man back to his family, a social worker employee, non-language oriented and mostly functioning as a case worker and psychoeducational group and activities leader, suddenly burst into tears, complaining that I did not like her but liked another (female on another unit) social worker better, and that I did not like women in general (a first for me). Crossfire quickly followed, even as I made a stunned strategic retreat for the door while tactfully trying to calm her. This time the attack came from another employee, known by others for such behaviors, who goaded me maliciously with something like, “You are the psychiatrist. Don’t go. Please keep talking with her.” This setup happened just around the time and in the manner predicted.
Another ambush followed quickly during morning rounds when the hostile nurse, in the presence of her supervisor, refused to report blood pressures of a patient who had fallen during the night. It is routine nursing practice to check BP sitting / lying and standing in such events and inform the doctor, but only one measurement was done, it turned out. The nurse told me to check the chart myself.
Had the supervisor not been there to give tacit approval, I’d have merely faced yet another bit of familiar nastiness by the same nurse. Instead, I now saw a flagrant abuse of medical protocol and clearly and shamelessly arranged by the entire nursing hierarchy to scuttle me. So I asked the supervisor to contact her boss, the head of nursing. It was all very calm. Soon, head of nursing arrived with my own boss in tow, grumbling sadly something like, “We just can’t have more fracturing in this unit. In a few days, they will miss having a doctor here. Today is your last day, so do what you need to leave.”
Alas, as an experienced administrator and clinician, careful to prevent new conflicts or splits that could harm morale and patient care, in the end, I did eventually succumb to profound system failures and deep splits. And good people counseled me repeatedly to compromise more and stay away from the edge of splits, to sugarcoat my approach more, and to put away my “sledge hammer.” I pushed a tired status quo too hard, seemingly well beyond its willingness to respond, and it pushed back. Fortunately, I had the advantage of naïveté, relative administrative insularity as a non-employee, an irreverent sense of humor, and speed and surprise that all bought me the time to invest myself fully and enthusiastically. All things move slowly in this system, as did my undoing.
While I did want to continue serving the men on this unit in some capacity beyond the term of my contract, I eventually understood that I could not fit for very much longer. I even joked about that to those I trusted. I had neither the time nor temperament to slow down, hang my head down and navigate around land mines hidden by entrenched, well-practiced experts. Keeping my vision focused on patients took all of my energy. I felt helpless and mostly alone, without effective administrative interest, guidance, or protection (or interference), even after my repeated threats to leave, which were “getting old”, as one top administrator semi-warmly quipped. In retrospect, I now want to believe that the administrators helped more than I know.
Reader: You really have to see this jaded culture of devotion, incompetence, grace, competence, courage, dignity, love, moral corruption, and fear to believe it. It is tucked right into our midst and is also part of who we truly are. (Anyway, BTW, I may have also discovered a new treatment method. Let’s give it a name — GPP, for Good Psychiatric Practice. That’s sarcastic.)
CHILDREN’S SERVICES IN A WELL-REGARDED FAMILY SERVICE AGENCY
Still hoping to work in a facility serving poor people in a setting that respects them and their caregivers by striving for good care, I continued my journey, returning to a private outpatient community agency that had employed me for eight great years at the beginning of my professional career, when a team of social work colleagues and I had set up and ran a large aftercare clinic for over 250 state hospital adult dischargees. We had worked energetically and collaboratively in the tradition of the community service team model I learned from family therapy educator and pioneer Charles Kramer, M.D. (who got me the job) and child / adolescent psychiatry innovator Sherman Feinstein, M.D. I thought it a hopeful sign that the term “behavioral health” was not mentioned even once in my return to this agency.
American-trained M.A.- level social workers and psychologist therapists varied widely in competence. I worked only with staff members having children patients on medication, but it would be reasonable to assume that they represented at least minimal agency standards. Hoping to manage expectations, and as a way of introducing myself, I asked that administration and staff read an earlier version of this article before I was hired, and some supposedly did, adding to my optimism that I would fit into this agency’s enlightened culture.
So, for five hours every two weeks my duties now were to evaluate and treat high risk children and adolescents with a variety of disorders. In addition, these children are growing up under the stressors, physical and psychological risks, and the challenges of poverty, sometimes extreme. Often, parents may be mentally ill, substance users or criminals, and poor parenting, displacements, moves, violence, and early parent loss are frequent.
My predecessor had practiced like a “queen bee”, without bothering to talk with patients or parents in very brief and infrequent visits. One child on medication was actually seen twice or three times a year for a total annual time of less then an hour. So I began to get to know the kids and parents with increased time spent with each.
One dedicated staff member worked closely with me, and we sometimes met with kids and parents together. This beginning paid off quickly. The dramatic changes began. For example, a bright teen girl who had chronically avoided school because of long undiagnosed ADD was now successfully back in the classroom, an anxious boy with severe PTSD was finally engaged in treatment and was getting traction in a job, and most parents were relieved and word was getting around that a doctor was finally spending time with them and their children. My goal was to upgrade the care of each child to the best level possible within the six months of my contract, and then possibly stay on.
To accomplish this, I needed information about the whole child and family, apparently for some reason not routinely collected at this well-regarded agency. To provide essential actionable credible information for basic evaluation and treatment of children and families, I requested that pediatric and family information be obtained via the parent questionnaires, and school functioning data via the teacher questionnaires I introduced. We were beginning to implement this and important predictive information began to flow, but some professional staff were surprisingly suspicious and resistant.
To increase time with each patient, I proposed steps to streamline receptionist management of patient flow, chart preparation, and scheduling. In spite of passive grumbling, the first two were starting to improve. But the scheduling issue quickly became a deal breaker because this was where this well-regarded agency’s broken core became exposed.
—————
(On becoming a bad fit 4)
An anemic culture of mediocrity and poor communication dominated. I had insufficient meetings with staff to discuss cases, and encounters I initiated with the clinician-administrator were rushed, procedural, and uncollaborative. He never seemed to be around for curbside consultations, often leaving me isolated with a new load of his clients and setting a tone for the rest of his staff.
What’s worse, teamwork was relegated to mostly useless occasional one-paragraph notes left for me. Agency practice apparently no longer included the modern, decades old, multidisciplinary collegial integrative team approach, developed almost a century ago in the child guidance movement. This crucial innovation enabled work with complex childhood disorders in their family, school, and community contexts. An ongoing formal and informal conversation among staff in real time is needed to understand and effectively treat multi-system childhood disorders, and has been standard practice. This movement also spawned a proud, enlightened, and humane social work profession, and additionally pioneered the now pervasive practice of using multidisciplinary collaborative teams in many progressive workplaces.
Instead of energy and teamwork, this is what I found: inadequate, naive, and superficial diagnostic conceptualizations and treatment planning; seeming ignorance or distrust of the biopsychosocial model (“I don’t believe in medication for children”); insufficient history, paltry developmental information, and poor communication with schools; reactive rather than proactive therapy with unclear treatment goals; and rigid isolation of the psychiatrist as merely a pill dispenser, with staff mostly resistant to open collaboration (“The psychiatrist should just prescribe and not talk too much or do therapy”). I have spent a lifetime working in many capacities with agencies serving children, even some with poor leaderships, but this one really took the cake.
We are back to the dark ages of services for children, to an era even before the child guidance movement many decades ago. The basic minimal underpinnings of good practice at this well-regarded agency too have deteriorated, much as at the hospital units I describe above. I was now witnessing how young voiceless children and their parents are shafted as outpatients too.
So I struggled from the beginning with, “Should I stay and work slowly to improve things for these underserved children? Who will serve these voiceless high risk kids and broken families?” So I hung in. A colleague friend pointed out that, clearly, I was simply not hired to make changes. She was right. I eventually realized that there was no support forthcoming from the top for actual collaborative work, just increasing grumbling, apathy, hostility, and resentment.
The final irony and deal breaker was this: despite — or because of — my efforts to spend more time with each child, as many as five or even six ended up regularly squeezed by the receptionist into my last hour on site. The locum tenens arrangement dictates strict adherence to contracted hours, so staying late repeatedly was not an option. That basically shortchanges five children to ten or less minutes per child that hour, if you count coming in and out and settling down.
Obvious solutions would have been to redistribute these appointments over the five hours to allow at least twenty minutes, or to shift my working hours to later to better accommodate after-school needs. But for weeks, administration just would not respond to my repeated written requests to redistribute my time, nor have a dialogue, nor itself suggest a strategy to solve this problem.
Things came to a head early one cold afternoon, about three months into my contract, when I arrived at the office. A stunning unequivocalIy clear answer did come in the form of my schedule for that afternoon: not only were five children with parents yet again squeezed into the last hour, but, additionally, in the first ninety minutes, not one patient was scheduled. Not a one in the ninety earlier minutes, yet five in a later hour.
Wow. Stonewalling. That was the agency’s clear answer to my requests for more reasonable scheduling. The administrator did not comment when I found him, but when I asked him on the spot to reschedule some right then, he firmly refused: “Agency policy”. Unbelievable. So agency policy is to curtail and withhold adequate care. Unnecessary, arbitrary, bad practice, shameful.
So what’s the big deal here? Why make a fuss?
First, complexity. These high risk children suffered from poverty, behavior disorders, depression, anxiety, ADD/HD, PTSD, LD, OCD, bipolar disorder, eating disorders, and usually a hard-to-sort-out mixture of several of these together to tease apart and treat, and the always-accompanying impaired home, school, and community functioning to track. They deserve adequate time with a doctor.
Second, urgency. I have known first hand the special urgency here, having just worked immersively inside the hellish futures some of these kids will most definitely have, described above. It is especially important to get it right the first time now, when we can still make a difference. These kids have the same histories as hundreds of adults I had just treated in hospitals. These kids are very high risk and deserve the best possible care now, their mind / brain maturation still sensitive, when we can still push their developmental trajectories towards healthier futures.
Third, thoroughness. With collaborative teamwork and administrative support lacking, a child psychiatrist wanting to practice good medicine at this agency has one hand tied behind his back. No matter the setting, patients deserve his professional best. So he needs even more time to do his work: greet and connect with a child and parent, separately or together, sometimes using a translator; break the ice; catch up; engage; interact (assessing kids must include flexible pacing and careful tuning into the child and cannot be rushed — it takes more time, but kids trust people who respect that); sometimes measure HR and BP and assess physical complaints (I auscultated one athletic teen boy’s heart when he reported chest pain and referred him to his pediatrician for the murmur is heard); review questionnaires; complete an entry in the medication log; write a progress note; code the visit by figuring out how many minutes I spent on medication-related and how many speaking with the child and mom to further our relationship, while assessing functioning and stressors; and hand-write multiple prescriptions in carbon paper triplicate (the old kind, where a cardboard flap prevents ruining the next set if you press too hard. Well, you can guess how that goes when you’re in a hurry.)
Fourth, cruelty. This administrative shortcut amounts to unnecessary callousness and cruelty. At this well-regarded agency, they had no problem nor professional shame about administratively arm-twisting a doctor so crassly, expecting him to agree, with full knowledge ahead of time, to routinely unethically withhold good care. What was the big necessity here? Why schedule hurried, insufficient, bad care? In essence why be cruel, yes, cruel, the opposite of kind and healing?
Fifth, callousness. Having stonewalled discussion, this agency seemingly actually planned to resolve the issue unilaterally with an arbitrary administrative maneuver. No explanation to me or the patients. And do the parents and kids have a choice? Maybe the administrator-clinician and his superiors got away with such outrageous callousness in the past with the “queen bees” they had hired for their several offices. Maybe it was a sign of poor leadership, bad standards, inadequate internal communication, ignorance, or just indifference. Whatever the reason, that’s how far standards have fallen for serving poor people.
I do understand well the uphill pursuit of excellence against the constraints of shrinking funding as a recent board member of another well-regarded large multi-site family agency serving children and teens. I had a view from my high perch near management, working closely with site directors and the executive director for over ten years. But in this agency it was not about that. It was mainly about shamefully low professional standards, callousness, and poor leadership.
Bottom line: Even here, in the midst of a nice suburb of a major metro area, in a nice office located on a nice street among houses with nice lawns and neat businesses, mostly poor high risk kids as young as five and their parents routinely and intentionally receive sloppy dregs of mental health care, the ultimate of professional cruelty, disrespect, and irresponsibility, from a well-regarded agency with a prominent blue-ribbon board of directors.
My heart sank at this clumsy Kafkaesque brutality. This well-regarded family agency is pathetically failing its mission, and it is too broken inside for me to function there. This confrontation clearly signaled that there was no hope of continuing my work at this awful place and maintain my standards.
So I immediately resigned on the spot, and I walked out. I could no longer participate in this charade. I did trust that parents and kids scheduled for that afternoon would be given a copy of the apologetic note I insisted on hurriedly drafting. I had some difficulty endorsing how the facility would now use family practitioners in the community for filling in psychiatric care that only a specialist could deliver well. But people needed continuity of some care — another compromise. One staff member asked why I hadn’t contacted a board member, but no one from the agency ever followed up with me.
I wonder, do agency leaders and staff even know how bad the fundamental flaws really are in their culture, basic integrity, and professionalism? How did they view and react to this incident? Would they care? Would they minimize or cover up? Would they even get it?
I did feel a deep sadness, this time close to home, that high risk savable children needing the best care in the worst way are not getting anything close, and nobody seems to know or care.Looking back at my four failures to fit, I am most upset about this one because of needlessly lost precious opportunities to reformat the futures of these high risk kids. So innocent, so voiceless, many so savable.
WHAT I THINK HAPPENED, AND PSYCHIATRY’S ROLE
Something really bad has been happening in the past few decades that few speak openly about. Of course, it is all about priorities, values, money, governance, ethics, morality, taxes, etc., and there is plenty of blame to go around for anyone who wants to sling it or accept it. (One urgent matter I know little about is that too many poor Americans who are mentally ill end up in overcrowded jails receiving even worse services I have described here.)
But let’s be real — the buck has to stop somewhere, and more than a few cents stop with psychiatrists, individually and as a profession. If you are poor and mentally ill, no matter anything else, you will get relatively little relevant personal attention, spotty psychiatric expertise, and it is rare that anyone really knows you or speaks with you seriously about your past and future in a Behavioral Health system.
Our public and private psychiatry delivery systems right now are dangerously broken (much as the entire medical care system) and not bringing even a small fraction of the promises of neuroscience to people who are poor because its current psychopharmacology application is too often incompetent. And because largely “mindless” queen bees can barely reach people.
The tragedy is that a patient is lucky to get a fraction of the value taxpayers buy. Except that these days, facilities are mostly decent physically, subject to modern hospital standards, medications can work pretty well when used correctly, and there are probably some very fine programs, staffed by psychiatrists and others, struggling to give the best possible care in an abysmal climate.
IMHO the reality has become a national disgrace and crisis infecting all of medicine. People still believe that they can trust care based on professional medical standards based on the accumulated scientific and professional wisdom of American medicine as a special patient-centered calling that takes years of sound training to master. No more. Patient-centered medical standards have become largely defunct over the past few decades. Instead, rich and poor folks alike and their hospitals and doctors are now harnessed to mostly money-centered insurers who pay the bills.
While we psychiatrists are celebrating the wonders of the human genome and neuroscience, we are also justifiably losing our credibility as physicians because too many of our colleagues practice extremely poorly in some Behavioral Health hospital units and outpatient settings serving poor chronically ill people, and too many have delegated their best skills to others who serve folks who are not poor.
The profession that trained me — modern psychiatry — was first built on the careful and caring art of listening to speech and language in all their nuances and responding in kind as a central element of psychiatric practice. Medical and non-medical psychology pioneers have worked brilliantly and diligently for over a century to free the mentally ill from stigma and to understand and treat them humanely. These pioneers tried to base their practices on systematic notions of the brain/mind that made sense. They tried to infer brain function and structure from mental processes and behavior in the most humane ways — talking with and intensely and actively listening to patients. By “language-based” psychiatry and related professions I mean practice conceptually rooted in solid understandings of the human mind with all its richness as the function of the brain with all its blessings.
Paradoxically, at the very same time that neuroscience is confirming the biological bases of much of what we have learned clinically about the human mind in language-based therapies in the past century, actual American psychiatric practice in most areas away from rare metropolitan pockets is rapidly drifting too far away from its intelligent, disciplined, language-based roots that bridge the mind, brain, behavior, consciousness, and healthy living. A huge and increasing number of practices apparently neither utilize language nor correctly deploy medication. This disastrous trend is especially true of inpatient and outpatient care reimbursed by Medicaid and Medicare on behalf of poor people who are mentally ill.
As the use of language declines and “mind”lessness becomes the psychiatric norm, are we breaking our already broken neuroscience delivery system even more by starving poor people of humane language-based healing? Are we giving up our relevance as doctors? Are we abandoning our unique skills in integrating mind, brain, behavior, and healthy daily living for the whole patient? Are pill mills the new standard of care? Is this good for people?
Yes. Yes. Yes. Maybe! No!! Furthermore, IMHO in many ways psychiatry has been the “canary in the coal mine” of American medicine. So — all doctors and patients beware!
Medicaid- and Medicare-funded systems are a main funnel of today’s neuroscience applications, and these are badly broken. A few medical businesses, much like in other specialties, eventually became known as Medicare or Medicaid Mills or pill mills: Non-language based production lines for poor people — high volume / less quality control / lower profit margin / more errors. Some doctors — and I hate using that word for them — at first mostly western-trained in all specialties — innovated the earliest, Medicaid and Medicare mills a few decades ago. These providers were sometimes investigated and even indicted and jailed for fraud and other illegal practices that sometimes even caused hospitals and nursing homes to close. The problem of how to deal with bottom-feeding colleagues flirting with ethical boundaries is not unique to psychiatry nor to any profession, while the absence of language as a treatment tool is absolutely crucial to psychiatry.
Too many fellow Americans, especially poor folks and their children, are tragically not receiving the care they need simply because they are receiving the wrong care. The system is seriously and dangerously broken, even as everyone seems to choose words carefully to comply to the letter with reimbursement.
This is also part of major social problems in our country. But as citizens and individuals, each professional must search their own conscience to decide where they stand on this issue and how much, by deed done or silence, they are perpetuating or enabling this travesty. That’s the least we can do. Many who work in the system have become dulled to its egregious norms and incompetence. But that is not an excuse. Neither is economic hardship.
This is my main point: IMHO, psychiatric care is minimal and substandard in the Behavioral Health units I saw, and as long as that is the case, such units will not be truly competent, humane or optimally efficient. I have come to believe that patients in these facilities depend on too many Behavioral Health provider colleagues, who knowingly, intentionally, or not, are “keeping their heads down” and contributing to profound social injustice, as had doctors in state hospitals fifty years ago.
What we might have now is a failing system, featuring incompetent medical standards, that actually perpetuates social injustices and prejudices against our society’s throwaway peoples. It is a silent blight in our midst. I also fear that wither psychiatry goes, so does the rest of medicine — general decline in professionalism and attendant mediocrity and the gap between rich and poor have now become institutionalized, and we have a multi-tier system.
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Nor is this an overnight blight, but decades old. In fact, one of my most senior mentors, actually a pioneer department chair and psychopharmacologist, accurately predicted in the mid or late 1970’s or so, because at that time the National Institutes of Mental Health was stopping subsidies to psychiatry residency training in teaching hospitals, that the profession would sink seriously and move away from its best traditions.
I remember the moment I heard him (on a beach in Miami after a professional meeting), much as people remember what they were doing just before a bomb goes off. It has been in the back of my mind ever since, and now I see what my mentor meant as the trend is really accelerating and has become industrial strength.
We all saw psychiatric services in general hospitals “bleeding money” because of unequal coverage of mental illness by private and public insurers, especially those serving many poor people. Less than 20 years ago, I remember sitting in budget meetings in my doctor coat with growingly impatient, fidgety administrators wearing suits. We always lost money, especially children’s programs, because no insurance scheme paid enough to take care of sick families and children. And we had to account for every pencil and eraser in our programs because the hospital carried us as a goodwill service to the community.
Another piece of reality (not frequently discussed openly, but always a big elephant in the room) is that not all doctors or nurses are alike: Looking back, there has always been a big divide within medicine, especially psychiatry, with mostly US medical school, university hospital-trained graduates serving employed and insured (even if poorly) Americans and their families.
Our practices and settings were language-based, generally lower volume/customized service, higher quality/higher profit margin / fewer errors / commercial insurance and out of pocket fee payment. We continued naturally an identity, relationships, and other educational and practice activities. We worked in public clinics for an hourly pay, usually part-time, consulted, and set the pace and general treatment course of patients of a collaborative team.
My network of similar practitioners usually started off careers treating inpatients in community or university-affiliated hospitals right after our training, but then continued to outpatient practice settings, combining outpatient, teaching, research, consultation, and / or pro bono and other community work. Some colleagues continued in community, public, and academic settings. About half of today’s mental health professionals are now opted out of all insurance so that we can use language in our practices. This trend now continues with nurse practitioners, especially in states where they are able to prescribe medication.
But we all knew about another side, and very few of us engaged with it, or with their private practices. Doctors serving the poor in public institutions were mostly trained elsewhere, almost never the cutting edge West, and are industriously struggling for their place in American life. They tend to be much less expensive and a lot less trouble, much as also seem many RNs in the public settings I worked. Their numbers seem to have grown over the past decades, and they also predominated in some of the hospitals where I worked.
Historically, there wasn’t much mixing among psychiatrists from these systems. However, there were some excellent collegial collaborations between university-based biological psychiatry researchers and non-language based colleagues and scientists, especially in state-run facilities affiliated with teaching hospitals training programs. These were other strata of professionals, that few of us ever cared about or welcomed, to our shame, that were grateful to serve in public hospitals and shortage rural places. Whenever they can, however, these practitioners, including now nurse practitioners, usually later try to leave public psychiatry to start their own private practices, considered more lucrative and prestigious. Only rarely have language-based US-trained practitioners crossed over from their private or academic practices into public psychiatry, and when they try, they are rarely welcomed by administrators and threatened entrenched clinical staff, as I have discovered repeatedly.
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The wider context has been a general decline in humaneness in medicine. I have my own personal view of this general decline. Before WWII, most specialists retained strong callings as physicians and continued some general medical practice, while most generalists practiced some specialties. WWII military doctors were often assigned as generalists, no matter their training. In America’s neighborhoods, generalists engaged the whole patient and her family. People kept doctors for lifetimes in relationships of mutual loyalty.
Since about then, several powerful forces started changing that: Exponential knowledge and intensive skill sets, bureaucratization of hospitals and growth of insurers, the greening of medicine, changed American society, and eventually, flagrant corruption as government and large insurers came into medicine.
Fee payment, first embedded in a personal, ethical doctor-patient relationship, became a business transaction between insurers and doctors, and disenfranchised patients. The identity of “doctor” as person with a calling, as an ethical and moral healer in the best tradition of the profession and modern science, moved away, first to “specialist” and then, alas, “provider”, “hospitalist“, etc. Malpractice suit fears and astronomical premiums added a dimension of mistrust in an increasing estrangement between doctors and patients, as lawyers joined insurers and administrators at the bedside.
Private practice, where a doctor owns his own place and is free to be his best (and worst), is on the decline, and many experienced doctors are pulling away from a devoted engagement when they become someone else’s 9 to 5 employees. People left their trusted doctors who did not participate in new networks set up by insurers to control fees. Another factor today is how the economic crisis causes increased stress on the poor and damages safety nets serving them.
Yet another factor is that doctors have lost their sense of neighborliness to patients and to their own professional communities, as hospitals turn away from the local practitioners that gave them quality and professional accountability to become production lines. (Hospitals were centers of professional life. We used to have staff meetings, grand rounds, department meetings and doctor dining rooms. We used to talk to each other. We used to monitor each other formally and learn together from our mistakes, even in small community facilities.)
Nevertheless, last time I checked, psychiatry was still a fully credentialed medical specialty. So what happened to the American Oslerian ideal of rational medicine applied humanely that so many top medical students in my now retiring generation signed up for as psychiatrists?
What happened to the fundamental medical principles of “do no harm” and to the professional, ethical, and moral obligation to practice at least competently, if not creatively? What happened to following carefully made diagnoses with appropriate, thoughtful and effective treatments? What happened to the term “psychiatric treatment” in a world of “behavioral health”? How did I get to be a “behavioral health medical provider”? Can the promises of neuroscience be delivered by this broken system?
IMHO, You can’t get ever quality anything by rewarding the lowest bidder and “going with the flow”. And in medicine, that is deadly. In vital services, the lowest bidder is not the best healer. You end up getting the worst. Lives are at stake. It is plain wrong. Our taxes at work — I’d estimate we get about five cents, even on your cheap dollar, on a good day in both private and public sectors. Basically, both probably technically legal, is private Behavioral Health seemingly failing us with naked, active greed, and the state system with greed by a few rotten apples manipulating tired, unionized bureaucracies?
We all bear responsibility. Shareholders of corporations own many Behavioral Health facilities, as taxpayers own local and state public clinics. A wild thought: Why not merge the sectors after scooping out their purulent cores? Or, only if “caregivers” doctors and nurses just practiced according to the letter and spirit of their professional standards and refused to compromise, we would have a great start towards decency.
SO, IF NOT NOW, WHEN?
Would the words “Behavioral Health” now signal a new context and redefinition for psychiatry, just as the word “providers” in the 1990’s changed the professional context for all doctors, and most just accepted it? These words now pass for who we are to many people and ourselves, and apparently work as long as you don’t deal with people’s need for healing.
Here we are today, with the ACA here, in the age of the human genome, neuroscience, and technology, still with one foot in the sewer. We are all morally soiled by the muck. Looking forward, I doubt that poor mentally ill people will ever get many resources as they compete in a public service economy also struggling with broken physical infrastructures and educational systems. But they can get more if we stood up for our profession and its standards.
Things have changed in psychiatry and can be re-changed now that we have the brain in our vision: Psychiatrists are supposed to be the experts in accessing the mind / brain through language. Most language-based psychiatrists were trained for years in this craft and created the model now followed by other professionals, and they used to be tested to pass the boards.
But about a decade or two ago, psychiatry board exams stopped employing live patient interviews (paid volunteers) to assess doctors’ language-based interview skills. So now, most board-qualifying psychiatric residencies give only lip service to teaching language-based skills, once an egregious deficit reserved for the least competitive training programs. And now, it appears OK in some settings to interrupt the connection with patients by multitasking with the clinical onscreen computer record. Ironic, how we are doing to our patients what I have taught we must not do to our children and vice versa, as an expert such matters, I view full face to face engagement as necessary to provide the best professional healing care for the buck. That means no distractions, including frequently interrupting eye contact to engage in record keeping via computer, now considered a norm.
Shortsightedly trying to move psychiatry closer to the scientific medical mainstream, actually we have needlessly shamefully abandoned essential medical practices and values that make doctors healers. Instead, our “professional” signatures mainly enable systems very few of us would have our own family members go near.
And maybe there are many more creative solutions possible we have not considered, especially since as US medical school graduates we are supposed to be America’s best and brightest. In the general context of what is happening in medicine: If psychiatry wants to continue its humane leadership as the best hope for the mentally ill, we’d better examine our roles ASAP in this mess. Neuroscience is a basic science and cannot fix it directly (except if we all wake up use our brains), but its applications need our engineering skills.
As the best trained and placed scholars and professionals bridging the mind, the body, the brain and everyday healthy functioning, we must speak out from our credible history of compassionate intelligent care and design worthy systems. We psychiatrists must review our own roles in this shameful destruction of our profession and its humane — that means competent — treatment of poor mentally ill people.
We must shift our attention back to the severely ill in the facilities that treat them. We must advocate for our patients, provide and police better standards, support well-trained professionals of whatever discipline in the best professional and ethical tradition of medicine, and educate our colleagues.
For example, can we innovate and adapt tele psychiatry and IT systems to translate conversation in clinical encounters directly in real time into parsed text and codes, thereby removing the huge current obstacle to humane language-based care (here’s another great entrepreneurial opportunity!)? Detecting deficits and activated by strings of language (e.g. “Has anyone ever hurt you or touched you in private places?”) the software could require minimal language-based competence to yield coded texts and detect clinical omissions and, for trainees, position of the eyes? It will free clinicians to use language without interfering with creation of a billable record.
Can we welcome, empower, and help better train the new wave of eager, compassionate, talented, and diligent behavioral health RN+ nurse practitioners in the US, who do still practice in the best traditions of the nursing profession and evidence-based medicine, resist corruption, and serve the disenfranchised mentally ill as a “last line of defense” and advocacy. Like psychiatry residents, too few are learning the power of language-based practices today. Careful deployment of such well-trained and supervised Western-trained professionals, including doctorate-level psychologists, might alleviate the shortages that force today’s poorer care. Strong affiliations with university-based teaching programs could only improve professionalism at all levels.
We must try to influence policy makers to shift entrenched basic economic incentives driving this shameful system so that good medical practices dominate. I am not an expert in that, but our civil service and private industry have plenty of credible talent. A shift to greater professionalism should not be that expensive.
Here’s a silver lining: We all know that people and institutions in crises are actually more accessible to positive changes. We definitely have a crisis. Another: Behavioral Health and public services today are located nearby, inside cities, not exiled and isolated to the far-away countryside. Here’s another: At least, we are not burning mentally ill people at the stake any longer in our country, as we were doing just a few hundred years ago. We have laws against that now, I think.
PERSONAL NOTES
My repeated failures to fit have come as a shock (to everybody involved — the nice people who bet on my endurance, valued colleagues who recommended me, and to the cordial places that employed me, and to me. In retrospect, my naivety seems embarrassingly clear. How could I have missed it? Everybody, including me, assumed I knew what I was getting into.
I had not noticed, nor did anyone ever spell it out for me until I worked in several places, that I had been wrong to assume, as usual, that I was hired simply to do my best as a doctor. That meant practicing as competently as possible and advocating for the best medical care of my patients. But I was wrong. I was expected to understand automatically that I was also expected to cover up my own basic medical standards as I was covering these practices.
I see now how, from an administrator’s POV, requiring the most efficient coding to obtain payments, everything I did seemed disruptive: “Imposing” my own diagnoses and treatments, prioritizing, encouraging a collaborative atmosphere of learning, teaching, and largely “interfering.” I suspect that a major unspoken worry was how the contrast with my practice “methods” can place the permanent doctors, who are hard to find and whose daily signatures are desperately essential for the system’s financial viability, in a contrasting light. “Why bother to write about this at all? I could be embarrassing myself. Let it go,” I told myself, “Keep your head down.” The trouble is, no one, especially me, would ever come close to understanding what had happened until I had worked it out, out loud in writing for this chronicle.
“Also, why write this for public view? Isn’t that poor judgment?” Maybe. I hope not. After much careful reflection and many rewritings, I feel obligated to share what I saw. I believe that the details of misfittings by an accomplished psychiatrist with high standards can reveal enough about us and our institutions to accomplish my goal, which is to teach and to provoke discussion in the right circles that would lead to positive actions. I believe that as America experiments with new models of healthcare delivery, all current practices must be considered.
Reader: I beg your forgiveness for any errors of omission and commission and urge you to think critically, keeping in mind my goal. Of course, because I am too close to the subject and have only a small window on it, I cannot expect to be considered fair. But I do keep my biases clear and do try to be honest, balanced and transparent. This is, after all, a unique subjective account of a journey into controversial places. Once I understood what was happening, I found myself in the ethical quandary I pose above that I am now attempting to solve for myself. So far, I have decided to continue working to serve people who are poor and severely mentally ill, teach colleagues, and write. So — reader — please consider this essay a step.
Looking back and making sense of my recent journey, I initially sought locum tenens work because I needed the pay, but immediately became intensely wrapped up in rediscovering my medical and psychiatric roots, and was seduced by the immersive challenge of seeing very ill people actually quickly improving in front of my eyes again! That relit flame is still burning in me. But it blinded me at first. Now, as I pass a certain hospital and glance up at the second floor, I still think, “Folks could be stumbling through nightmarish medico – bureaucratic purgatories, right up there, just beyond those windows”.
I hope my writings here beget positive results. I realize fully — and so should any reader — that generalizing from what I saw in just a few units and drawing major conclusions about a whole industry and the people who man it is simply not valid nor fair. My use of “non language-based” is not intended to describe specifically any folks or colleagues. My intent here is only to create transparency and signal an alert from a professional and patient advocacy POV that would prompt more valid, larger, helpful studies.
In practical personal terms, however, IMHO these observations are reliable enough for me to now know how to find work that fits me. What I saw is extremely alarming and the valid bases for my own personal reactions described herein. And clearly, this is why fitting into the Behavioral Health inpatient and state hospital units I serviced, and going with the flow and keeping my head low to cover these practices, was impossible for me personally during my 44th year of practice and after a lifetime of pursuing professional excellence.
I am now obligated to take responsibility for my own part of the current mess, especially for ignoring the plight of so many neighbors. So this essay is not about bashing anyone, and I don’t even know who the main players behind this scenario are. The taxpayer pays and patients suffer with unacceptable psychiatric services –that much I know. I am grateful and humbled for being among US university-trained psychiatrists, well trained medically and then mind / brain diagnoses and treatments and always striving to excel on behalf of patients.
But, reader, you know who you are, and so do others. If you believe what I wrote, silence would put you too in a moral quandary, if you choose to see it that way. Of course, if this essay is too much of a challenge to some entities and hopefully has sufficient impact, predictably, my credibility could be questioned and conclusions even attacked ad hominem by anyone who disagrees (or the opposite, my opinions used out of context by activists).
My POV might be dismissed as coming from just another fading old dinosaur, longing for good old days that never existed; a self-righteous, self-serving wrinkled relic of the social activism of the turbulent Sixties; or from a disingenuous, effete, condescending elitist, an arrogant self-promoting eccentric, or just an ungrateful, hypocritical, conspiracy theorist and troublemaker. Or all of the above. Or worse. No matter. Even if I am found inaccurate in some of my perceptions or details or faulty in some of my conclusions, or have some personal failings, I did craft the above language carefully to describe what I see and think as a doctor. Please understand that, ethically, I am compelled to speak up for the sake of our present neighbors and to leave a better world for my grandchildren and their generations.
Finally, my fond personal thanks again to the dedicated administrators, nurses, staff, and doctors who accepted me into their workplaces, and additionally to the many patients, for collaborating in some of my most challenging and rewarding professional work in years. You know who you are
June, 2015.
http://psychiatrists.psychologytoday.com/rms/178252?_ga=1.62766633.441222680.