Achieving best results or convience?

[gibits]

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I'm in a bit of profession bind here. I really need some advice here because im getting to be really jaded.
I just started with this practice and have been under proctorship. I have been seeing patients that are under my colleague's/boss' name. One patient is floridly delusional. He has no insight at all and has been terrorizing his neighbor and family with his paranoia. He was brought in on a hold, refused meds for 4 days. His probable cause and Reise hearing were both upheld.
So now he is complelled to take his meds and stay for treatment. He requests another hearing in downtown LA, this time a Writ hearing. Up to this point I was willing to go just to make sure he would get treatment. But my colleague/boss steps in and vetoes the court date. Says he'll just discharge him, paranoia and all back home with no injections at all, just oral medications (that I suspect the pt is cheeking).
I know why he doesn't want me going to court, it wont be seeing pts while waiting in court. I personally don't want to either but the thought of letting this pt go back to the wild without any deconate medication sits uneasy with me.
Am I being too idealistic here? Is this just the real world and I need to deal with it?

My boss'/colleague's name is on the chart so I guess it is his call in the end but this really doesn't sit well with me

 

[nitemagi]

All too common. Occurs with priv practice docs who don't want to take the time to go to court, basically b/c they're not getting paid for it. Therefore it's too much of a hassle.

This also illustrates an effective part of the system - if the patient makes it inconvenient enough to be held, they'll be let go. I remember all the threats of lawsuits for every 5150. Some ppl get scared enough that they cave just from that. It's an effective strategy by the patient.

Whether it's in their best interest is another story.

I'd talk to the big dog and give your opinion on the matter, but tread cautiously. There's a lot of politics involved, obviously. And maybe figure out a good aftercare plan, particular setting a low threshold for re-hospitalization.

 

[OldPsychDoc]

If I were you I would gently request an explanation from this "proctor", for your future educational understanding, of why he's willing to accept the risk of a paranoid patient escalating the terroristic behaviors that got him there in the first place.

 

[michaelrack]

I'm in a bit of profession bind here. I really need some advice here because im getting to be really jaded.
I just started with this practice and have been under proctorship. I have been seeing patients that are under my colleague's/boss' name.

My boss'/colleague's name is on the chart so I guess it is his call in the end but this really doesn't sit well with me

I doubt that you have been signing your boss's name to the chart, so your name is in the chart and you will be held responsible, at least in part.

 

[tishage]

Unethical, pure & simple, but embarrassingly happens so much that now it's largely accepted. Akin to just letting a grandmother with dementia leave bc she's requesting it and too cognitively impaired to know what's best, even though you know her UTI may quickly lead to something more serious and potentially even life threatening. I believe in the need to constantly evaluate and balance patients rights and "doctor knows best," but there are some individuals who we know cannot adequately give informed consent about refusing treatment, and allowing them to walk is undoubtedly doing them harm

 

[MacDonaldTriad]

Tell your boss you are uncomfortable with the discharge and you will let him make the call. If his arguments are not convincing, you ask him to write the discharge note, rational and order. If he becomes uncomfortable with that, I would rethink working with him. I would not chart the dissagreement, just let the chart reflect who made the decision.

 

[gibits]

So the impression I'm getting is 1) I'm not too zealous and 2) it's just the nature of the beast.
Interesting of events. I told my boss I wasn't comfortable discharging him and asked him to do the dictation. Then he calls me and says I should just go to court. Funny how that works eh?

 

[whopper]

Even if the guy is your boss, you still have the duty to do what is right for the patient unless the instituion removes you from the case, in which case you need to do a transfer summary saying what you think. If you and your boss disagree, and I've been in this position before.

Try to talk to your boss diplomatically.

If he orders you to do something on the case against your judgment, tell him you have to write down what you think is going on in the chart.

If you still disagree, what I do is either strongly consider leaving the institution, and/or ask the boss to kindly remove me from the case so he could get a doctor that agrees with him to take over, but still summarizing my opinion in the chart when I get off of the case.

Most institutions have an even higher person that could be consulted above your boss.

Also bear in mind that psychiatry is sometimes not as flat-out obvious as other fields. If the boss wants something that is reasonable but I disagree, I'll often yield on the rationale that his treatment approach is completely reasonable and worth considering, and that you sometimes need other eyes checking something out. If it doesn't work out, then I go with what I originally thought.

 

[vistaril]

I'm in a bit of profession bind here. I really need some advice here because im getting to be really jaded.
I just started with this practice and have been under proctorship. I have been seeing patients that are under my colleague's/boss' name. One patient is floridly delusional. He has no insight at all and has been terrorizing his neighbor and family with his paranoia. He was brought in on a hold, refused meds for 4 days. His probable cause and Reise hearing were both upheld.
So now he is complelled to take his meds and stay for treatment. He requests another hearing in downtown LA, this time a Writ hearing. Up to this point I was willing to go just to make sure he would get treatment. But my colleague/boss steps in and vetoes the court date. Says he'll just discharge him, paranoia and all back home with no injections at all, just oral medications (that I suspect the pt is cheeking).
I know why he doesn't want me going to court, it wont be seeing pts while waiting in court. I personally don't want to either but the thought of letting this pt go back to the wild without any deconate medication sits uneasy with me.
Am I being too idealistic here? Is this just the real world and I need to deal with it?

My boss'/colleague's name is on the chart so I guess it is his call in the end but this really doesn't sit well with me

being in private practice and spending unpaid time in court(especially if court isn't in the same building as your office) is simply not a workable model. I wouldn't do it, and I don't know anyone who would.

 

[notdeadyet]

All too common. Occurs with priv practice docs who don't want to take the time to go to court, basically b/c they're not getting paid for it. Therefore it's too much of a hassle.

being in private practice and spending unpaid time in court(especially if court isn't in the same building as your office) is simply not a workable model. I wouldn't do it, and I don't know anyone who would.

How often does a private practice doc have to go to court on a writ or 5250/Riese hearing? If a patient is on a hold or gets Riese'd, they're going to be inpatient and it's the inpatient doc going to court.

I'm curious of the circumstances in which the outpatient doc goes to the hearing...

 

[michaelrack]

How often does a private practice doc have to go to court on a writ or 5250/Riese hearing? If a patient is on a hold or gets Riese'd, they're going to be inpatient and it's the inpatient doc going to court.

I'm curious of the circumstances in which the outpatient doc goes to the hearing...

I agree that outpt private prac docs rarely have to go to hearings. Maybe Vistaril is referring to private practice docs who include both outpt and inpt in their practice

 

[vistaril]

I agree that outpt private prac docs rarely have to go to hearings. Maybe Vistaril is referring to private practice docs who include both outpt and inpt in their practice

yeah....traditional jobs(some inpt coverage and then mostly outpt clinic) are still fairly common, at least here.

 

[vistaril]

How often does a private practice doc have to go to court on a writ or 5250/Riese hearing? If a patient is on a hold or gets Riese'd, they're going to be inpatient and it's the inpatient doc going to court.

I'm curious of the circumstances in which the outpatient doc goes to the hearing...

it really is so state to state dependent that a single answer is impossible. Have family and friends in mh in other states and their systems for holds, committments, court, etc are so different than mine(and from others in neighboring states)

 

[Leo Aquarius]

it really is so state to state dependent that a single answer is impossible. Have family and friends in mh in other states and their systems for holds, committments, court, etc are so different than mine(and from others in neighboring states)

That doesn't answer the question. State differences don't explain how a private practice doctor would end up going to court for a Reise or hold issue.

 

[gibits]

Quick update; I went to court and the hold was upheld. I didn't get to see my inpatients that morning but was able to get back in time to see my outpatients. Had to go back to the hospital to round until 10:00 PM.

It sucked, but at least I can rest easy at night. This episode has made me wonder if I even want to do any inpatient work. If an open and shut case like this will waste my whole day I can see it as being sustainable. Back in my residency days, court was literally downstairs. Just go to the first floor, testify and go back to rounds upstairs. Now I have to drive to downtown LA during rush hour....

 

[vistaril]

That doesn't answer the question. State differences don't explain how a private practice doctor would end up going to court for a Reise or hold issue.

sure it can....in states that still have robust inpatient state beds with salaried state staffs they are more likely to have the resources to be dumped on like this.

I can think of one pt I had a little while back where the pts private practice psych would have been required to show up in court had this occured(he probably would have just dropped it) a hundred+ miles north/west but here they didn't.

 

[michaelrack]

xx

 

[hamstergang]

being in private practice and spending unpaid time in court(especially if court isn't in the same building as your office) is simply not a workable model. I wouldn't do it, and I don't know anyone who would.

Hmmm, this sounds bad to me. If the patient is truly dangerous (and that's why "he is complelled to take his meds and stay for treatment" by the court), then how are you ok with discharging the patient home without treatment just out of laziness/lack of billable hours?

 

[MLT2MT2DO]

So the impression I'm getting is 1) I'm not too zealous and 2) it's just the nature of the beast.
Interesting of events. I told my boss I wasn't comfortable discharging him and asked him to do the dictation. Then he calls me and says I should just go to court. Funny how that works eh?

Sketchy as hell is more like it

 

[billypilgrim37]

I'm curious of the circumstances in which the outpatient doc goes to the hearing...

In my state, if the outpatient doc is the one who initiated the petition for the involuntary commitment, then the outpatient doc is the one who has to be there to give testimony. It could also be the outpatient therapist, social worker, whomever is the one who officially declared the grounds for the warrant and subsquent commitment. In these cases, both the petitioner and the inpatient treating physician are present. It doesn't happen too often. I work with a pretty high acuity population, so it has been more for me. I once had to commit an outpatient who identified as a vampire and made it clear she could not keep her (or her upcoming victims) safe. That was something other than fun. I've had to commit (including calling the police with the warrant) several people who told me they were suicidal and then took off when I told them they needed to be in the hospital. The police were really good at finding them.

Where I am, if a private practice doc regularly had the habit of petitioning for involuntary commitment and not showing up for court, well, let's just say I would LOVE to be the malpractice attorney on that case after something goes wrong. That could very well result in a lost license, even. That's my state and even county, though, so who knows. Even within this state some counties interpret things differently and will even allow physicians to call in by conference call.

 

[gibits]

That doesn't answer the question. State differences don't explain how a private practice doctor would end up going to court for a Reise or hold issue.

You don't seem to understand what privite practice really is then. I'm a privite psychiatrist that does inpatient care at a privite hospital. I also do outpatient, partial cares, group homes and SNFs.
And if you get a pt in your office that meets criteria for a hold and is unwilling to go then you SHOULD put them on a hold privite practice or not.

 

[Leo Aquarius]

You don't seem to understand what privite practice really is then. I'm a privite psychiatrist that does inpatient care at a privite hospital. I also do outpatient, partial cares, group homes and SNFs.
And if you get a pt in your office that meets criteria for a hold and is unwilling to go then you SHOULD put them on a hold privite practice or not.

Granted I have much to learn as I'm only a 2nd year resident, but it seems to me that once that patient is sent to the hospital they fall under the care of its psychiatrists who will take that patient to court if needed. The private practice doc is not involved in writing holds at that point or taking the patient to court for TCON applications. The private practice doc writes the 3-day hold, and then the 14-day and 30-day are by the presiding psychiatrist. Right?

 

[billypilgrim37]

Wrong, in my state, if the outpatient doc is the petitioner for the hold' you have to go, based on the right to face your accuser in court. It doesn't matter if you're the cashier at taco bell or the outpatient doc. I you file the petition based on your first hand account of dangerous things (and sometimes the outpt doc is the one who witnessed it), and you don't show up to court, the pt would be released. If something bad happened after that, you are absolutely f#cked.

 

[michaelrack]

Agree with Billpilgrim's 7:50 am post.

Also, assuming that the hold was initiated by the outpt doc (or family or anyone else other than the inpt doc), whether the inpt doc needs to be involved depends on the laws and procedures of the state. Often there are periodic legal reviews for the need for continued hospitalization that the inpatient doc is required to be involved in (incidentally, this is one reason why some psych facilities will only accept voluntary patients).

 

[michaelrack]

The private practice doc writes the 3-day hold, and then the 14-day and 30-day are by the presiding psychiatrist. Right?

The length of the initial hold and the timing of reviews/subsequent committments is VERY state dependent.

 

[gibits]

Wrong, in my state, if the outpatient doc is the petitioner for the hold' you have to go, based on the right to face your accuser in court. It doesn't matter if you're the cashier at taco bell or the outpatient doc. I you file the petition based on your first hand account of dangerous things (and sometimes the outpt doc is the one who witnessed it), and you don't show up to court, the pt would be released. If something bad happened after that, you are absolutely f#cked.

What strange state is this? If the outpt doc doesn't have priviledges at the hospital how can his testimony hold up when he hasn't seen the pt in several days?

In CA the outpt doc places the first 72 hour hold and the inpt doc places the 14 day hold. The second hold is contestable and is done by the inpt doc since he wrote the hold and has been treating the pt since admission. The same for a conservatorship.

 

[Leo Aquarius]

That's what I'm accustom to as I'm training in CA.

 

[billypilgrim37]

What strange state is this? If the outpt doc doesn't have priviledges at the hospital how can his testimony hold up when he hasn't seen the pt in several days?

In CA the outpt doc places the first 72 hour hold and the inpt doc places the 14 day hold. The second hold is contestable and is done by the inpt doc since he wrote the hold and has been treating the pt since admission. The same for a conservatorship.

What strange state is this? I say, good sir, this is a state without the benefit of nearly as much sun as your dear CA. Perhaps if we were less Vitamin D deficient, we might be more enlightened.

In the state of BillyPilgrimLand, there is actually testimony from a) a petitioner who initiated the commitment (we don't call them holds), and b) the treating physician on the inpatient unit. So, when an outpt doc is required to testify, the outpt doc isn't doing it as a physician per se, but as the person who witnessed the behaviors that occurred in the past 30 days that make you think the person is a danger blah blah blah. That role is often filled by parents, other clinicians, friends, spouses, siblings, 15th cousins twice removed, what have you. Sometimes, however, it's the outpt physician.

For example, I had one woman who came to an intake with me a few years ago. She told me (seemingly cluelessly) about three dangerous suicidal gestures she had made in the past week (overdose attempts with escalation). She was super high risk for another, and she agreed with this. She didn't want to go in the hospital. I told her she had to go in the hospital, and she literally ran out of the office and out the door. I called the county, filled out the paperwork, faxed the county-approved warrant to the police station in her area, and they went and picked her up. I had to testify at the hearing a few days later, along with the inpatient treating physician, about what she had said to me in the outpt appointment. The treating doc also provided what had happened in the time between admission and the hearing.

Now, while being a petitioner doesn't have to be a physician, as a physician, you have a greater responsibility for a person's care than the average person on the street. So, failing to commit an outpatient who is clearly dangerous is negligent, and not showing up for the hearing is negligent, as the person will almost inevitably be allowed to leave the hospital without testimony from the practitioner. If that person left and something bad happened, that would be medical malpractice in my state.

I like this system, personally, as I think it's a bit better check on the robbing of civil liberties we unfortunately participate in so often. The constitution guarantees the right to face your accuser in a criminal trial (not necessarily civil trial), and while this is civil commitment, most civil proceedings do not involve detainment/holds/commitment/what-have-you.

I know that in the other major metropolitan area in our state, the criteria for involuntary commitment are much more stringently applied than in my area of the state. Even beyond states, just from county to county sometimes commitment proceedings can vary dramatically.

As an additional point, in BillyPilgrimLand, if the initial "hold" (it's 120 hours here, the subsequent 20 days) is upheld during the hearing (which has to take place within 120 hours), then the person on the commitment also cannot purchase a handgun in the state ever again, and cannot have jobs that require holding a weapon (like being a policeman, etc). I'm guessing Vistaril and a few others just pooped their pants. Even I recognize that's a very imperfect policy.

 

[wolfvgang22]

What strange state is this? I say, good sir, this is a state without the benefit of nearly as much sun as your dear CA. Perhaps if we were less Vitamin D deficient, we might be more enlightened.

In the state of BillyPilgrimLand, there is actually testimony from a) a petitioner who initiated the commitment (we don't call them holds), and b) the treating physician on the inpatient unit. So, when an outpt doc is required to testify, the outpt doc isn't doing it as a physician per se, but as the person who witnessed the behaviors that occurred in the past 30 days that make you think the person is a danger blah blah blah. That role is often filled by parents, other clinicians, friends, spouses, siblings, 15th cousins twice removed, what have you. Sometimes, however, it's the outpt physician.

For example, I had one woman who came to an intake with me a few years ago. She told me (seemingly cluelessly) about three dangerous suicidal gestures she had made in the past week (overdose attempts with escalation). She was super high risk for another, and she agreed with this. She didn't want to go in the hospital. I told her she had to go in the hospital, and she literally ran out of the office and out the door. I called the county, filled out the paperwork, faxed the county-approved warrant to the police station in her area, and they went and picked her up. I had to testify at the hearing a few days later, along with the inpatient treating physician, about what she had said to me in the outpt appointment. The treating doc also provided what had happened in the time between admission and the hearing.

Now, while being a petitioner doesn't have to be a physician, as a physician, you have a greater responsibility for a person's care than the average person on the street. So, failing to commit an outpatient who is clearly dangerous is negligent, and not showing up for the hearing is negligent, as the person will almost inevitably be allowed to leave the hospital without testimony from the practitioner. If that person left and something bad happened, that would be medical malpractice in my state.

I like this system, personally, as I think it's a bit better check on the robbing of civil liberties we unfortunately participate in so often. The constitution guarantees the right to face your accuser in a criminal trial (not necessarily civil trial), and while this is civil commitment, most civil proceedings do not involve detainment/holds/commitment/what-have-you.

I know that in the other major metropolitan area in our state, the criteria for involuntary commitment are much more stringently applied than in my area of the state. Even beyond states, just from county to county sometimes commitment proceedings can vary dramatically.

As an additional point, in BillyPilgrimLand, if the initial "hold" (it's 120 hours here, the subsequent 20 days) is upheld during the hearing (which has to take place within 120 hours), then the person on the commitment also cannot purchase a handgun in the state ever again, and cannot have jobs that require holding a weapon (like being a policeman, etc). I'm guessing Vistaril and a few others just pooped their pants. Even I recognize that's a very imperfect policy.

BillyPilgrimLand is like AZ.

 

[billypilgrim37]

BillyPilgrimLand is like AZ.

I'm not an Arizonian, though the good dear Brandon Webb, the former Diamondbacks Cy Young winner, was in fact from my home town and used to come read "The Night Before Christmas" to my mother's kindergarten class.