Another neurotic new grad needing reassurance (inpatient discharges)

[uhmocksuhsillen]

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Seems there's been a spate of these posts lately - must be the time of year.

I've just started off on an inpatient unit and I'm feeling exactly like I did during intern year - just change afraid to order Tylenol with afraid to discharge patients. I got burned badly during my PGY3 year in which a seemingly low risk patient I advocated to discharge committed suicide within hours of leaving the hospital. Clearly I wasn't the one who officially signed off on that, but it still haunts me.

Now that I'm discharging multiple people a day, I'm living in a constant state of fear. I write in depth suicide risk assessments for fear of getting sued and even worse, losing my license. Every day I go into work I'm dreading what I'll walk into - who needs to be discharged today, how risky are they going to be, etc.

I deal with a lot of psychotic people who have been hospitalized 20+ times - nothing ever changes. It just seems like it's a matter of time before there is a bad outcome...it feels like a game of hot potato. I've got to go back in tomorrow and all I want to do is hide under a rock. Advice, please.

 

[deleted1162863]

It sounds like you are doing the right thing from a medico-legal perspective. Is there someone at work you want to talk with to confirm that? Possibly chat with a colleague to make sure you aren't missing anything and they are doing things similarly? Aside from that, how about stress-reduction techniques (or whatever you recommend to patients who have issues with fearfulness)? If none of that works, perhaps a change in practice setting should be considered? We can't control what people do all of the time, I wouldn't blame yourself if you are doing your best.

 

[Sushirolls]

Re-calibrate.
You have liability insurance. Let it shoulder the burden and fears of being sued.
I changed my tune, and started practicing medicine with a mantra "what would I want if this were my brother/sister/aunt/father/mother/etc.?"
You do that, you'll sleep at night.
The liability insurance will cover you for if/when the day comes you get sued.
And if the catastrophic fear of no license, no practicing ever again happens? Meh, refine your identity, have a plan B loosely bumbling around in your mind and don't get so entrenched in Medicine that it is the only thing you can do.

Then go read the other 2 or 3 threads on this topic.
I'm too lazy right now to link them to this thread.

Or start singing in your mind, to the tune of Frozen, "the lawyers never bothered me anyways! ... let it go, let it go!"

 

[comp1]

Therapy! You even see that you're projecting your 3rd year experience on to your current patients. Unpacking that and being cognitively aware (in addition to emotionally) is absolutely crucial. Therapy will also help you do some reality testing. If you work inpatient, there will be completed suicides and there will be even more serious attempts. You're working with the highest of the highest risk people. The chance of going through your career without another suicide is non-existent. Depression and borderline PD can, in many inpatient cases, be just as terminal as any cancer requiring inpatient treatment. Therapy can help you accept this reality and your inability to both fix and save everyone. That opening line of your last paragraph definitely seems to indicate an expectation (or hope?) that you or some mythical perfect psychiatrist is going to be be able to make meaningful changes in everybody's life you encounter...you can't and the perfect psychiatrist doesn't exist. What you can hope to do is make meaningful changes in some of your patient's lives and extremely meaningful changes in a few. As far as your license...I have never heard of a physician losing their license for a suicide. There certainly are malpractice suits, generally lost by the plaintiff, but juries and courts in general recognize the extremely high risk patient population we work with and our near complete inability to accurately predict who will kill themselves. If it helps, you could move to a state like CA that prejudicially prohibits malpractice suits for suicide if a reasonable risk and protective factor assessment was done which scares off most malpractice attorneys. But even in other states...you lose your license for sleeping with your patients or pill milling Xanax. That, you have control over. You do NOT have control over other people killing themselves.

 

[Merovinge]

I'll let the wise folks here give you advice on how to handle your situation, however I would add that if this simply is not the right environment for you, it's very easy to change your job. I'm a bit surprised you went for an IP job given what happened to you and how you feel in that role. The overwhelming majority of psychiatry takes place in OP settings and it will be a very different level of acuity/cadence that may better suit you.

Can you work through your traumatic event and thrive on the IP setting? Pretty likely yes, but you also don't have to. Welcome to being an attending and having options, you are no longer an indentured servant and get to paint your own picture of your practice.

 

[Sushirolls]

OP isn't SI risk free.
Patients who express SI, but should they be admitted? Will they actually be admitted once at a facility or discharged same day?

The potential for fears and concerns about patient SI/SA doesn't stop with OP. I'm biased, I think OP is better, but the potential angst could still persist.

The haste of recommendations on here for therapy. Not everything needs therapy. Some times you need a friend, a good ear, an SDN gripe session. The OP is first month in attending status. Perhaps if the fears persist after 1-2 years, yeah, therapy, but right now? Nah.

I moonlighted like a machine, blowing way past 80hrs per week as a resident to diminish the new attending angst. Definitely helped, but even that first job, first few months post residency, there was still doubts in the back of my mind. It's normal. Those first few months post residency I was getting calls from former co-residents bouncing 'hypothetical' cases off me and vice-versa for re-assurance. In time these calls subsided. Now maybe once every year or two I might get a call for more perplexing cases, but usually more job/admin/Big Box shop contract related issues.

Some times new attendings just need a good ol' boy slap on the back and a hearty reassurance "you got this spring chicken."

 

[comp1]

With our job's extreme possibilities for countertransference, there are very few psychiatrists I wouldn't recommend at least a brief course of therapy to, particularly as they make life transitions like from resident to attending. It's not just for the psychiatrist, but actually even more for their patients. I could definitely see the possibility of the OP having trouble keeping patients at the lowest level of care possible as quickly as possible given the level of distress described. I actually found outpatient ALOT more stressful in regards to suicidal risk because I had such a brief time to assess the patient and make a plan, even if statistically the risks were much lower. So I'm not sure I'd jump to a new job.

 

[Merovinge]

The data is very clear that IP has a higher rate of liability than OP care. Nothing is without risk but pure OP psychiatrist is one of the lowest risk fields of medicine in America. Some people absolutely thrive in different settings (be it IP, RTC, PHP/IOP, OP, C/L, forensics, industry, concierge, VA, public, etc). Absolutely nothing wrong with talking to peers, mentors, and SDN, I encourage all of those things. But you can finally put the square peg in the square hole at this point in your life, go find your square hole is a really good life advice generally and, I think, applicable here.

 

[uhmocksuhsillen]

Therapy! You even see that you're projecting your 3rd year experience on to your current patients. Unpacking that and being cognitively aware (in addition to emotionally) is absolutely crucial. Therapy will also help you do some reality testing. If you work inpatient, there will be completed suicides and there will be even more serious attempts. You're working with the highest of the highest risk people. The chance of going through your career without another suicide is non-existent. Depression and borderline PD can, in many inpatient cases, be just as terminal as any cancer requiring inpatient treatment. Therapy can help you accept this reality and your inability to both fix and save everyone. That opening line of your last paragraph definitely seems to indicate an expectation (or hope?) that you or some mythical perfect psychiatrist is going to be be able to make meaningful changes in everybody's life you encounter...you can't and the perfect psychiatrist doesn't exist. What you can hope to do is make meaningful changes in some of your patient's lives and extremely meaningful changes in a few. As far as your license...I have never heard of a physician losing their license for a suicide. There certainly are malpractice suits, generally lost by the plaintiff, but juries and courts in general recognize the extremely high risk patient population we work with and our near complete inability to accurately predict who will kill themselves. If it helps, you could move to a state like CA that prejudicially prohibits malpractice suits for suicide if a reasonable risk and protective factor assessment was done which scares off most malpractice attorneys. But even in other states...you lose your license for sleeping with your patients or pill milling Xanax. That, you have control over. You do NOT have control over other people killing themselves.

I actually live and work in CA - I had no idea about these laws. Can you speak on this further?

 

[uhmocksuhsillen]

I'll let the wise folks here give you advice on how to handle your situation, however I would add that if this simply is not the right environment for you, it's very easy to change your job. I'm a bit surprised you went for an IP job given what happened to you and how you feel in that role. The overwhelming majority of psychiatry takes place in OP settings and it will be a very different level of acuity/cadence that may better suit you.

Can you work through your traumatic event and thrive on the IP setting? Pretty likely yes, but you also don't have to. Welcome to being an attending and having options, you are no longer an indentured servant and get to paint your own picture of your practice.

I feel like I'm being avoidant if I skip out on inpatient because of my fears. Im trying to force myself to face them. Suicides aside, I'm also afraid of making a mistake with a med, overlooking something, and a patient being harmed. The protective layer of residency is gone and I feel like theres no one there to catch a mistake I make. It feels like I need to be a robot who catches everything...its an impossible feeling.

Like heres an example. I've got a guy super psychotic with psychogenic polydipsia. He's does well on depakote and risperdal but has been off for a while. So we restart them. Have him on fluid restrictions. Were doing what we can, but now as I titrate his depakote, I'm worried about what happens if he does develop hyponatremia it'll get blamed on the depakote and I'll shoulder the blame. Scenarios like this pop up in my mind multiple times a day for various issues.

I also have an outpatient practice which I like, but gets boring if I were to do it full time. I like the mix.

 

[shoomer]

Like heres an example. I've got a guy super psychotic with psychogenic polydipsia. He's does well on depakote and risperdal but has been off for a while. So we restart them. Have him on fluid restrictions. Were doing what we can, but now as I titrate his depakote, I'm worried about what happens if he does develop hyponatremia it'll get blamed on the depakote and I'll shoulder the blame. Scenarios like this pop up in my mind multiple times a day for various issues.

This is a scenario that can happen in any setting. Who are you worried about blaming you? I'm assuming you're documenting the risks comprehensively and you're communicating with the team/patient/family when appropriate. After all that, you're going with your clinical decision-making and that's what medicine is. There is always a risk with everything we do and everything we don't do.

If your concerns were strictly about being uncomfortable with disposition/frequent agitation/feeling like you're not helping with chronic mental illness, then I would say it's about inpatient not being the right fit. But it seems more like a global confidence and self-doubt issue that will get better with time and introspection, +/- therapy.

 

[Wheatbread]

I tell my residents often that I’m not a mind reader. I document clearly how patients have been appearing on the unit, I talk to collateral before discharge, and quote how the patient feels on day of discharge. Whatever they do after I let them go is on them. If I’ve done my due diligence and properly documented, I generally sleep really well at night.

 

[uhmocksuhsillen]

This is a scenario that can happen in any setting. Who are you worried about blaming you? I'm assuming you're documenting the risks comprehensively and you're communicating with the team/patient/family when appropriate. After all that, you're going with your clinical decision-making and that's what medicine is. There is always a risk with everything we do and everything we don't do.

If your concerns were strictly about being uncomfortable with disposition/frequent agitation/feeling like you're not helping with chronic mental illness, then I would say it's about inpatient not being the right fit. But it seems more like a global confidence and self-doubt issue that will get better with time and introspection, +/- therapy.

Essentially I'm worried there's a bad outcome and the family blames/sues me because he got hyponatremic and died or has some major consequence of this.

 

[Sushirolls]

There is the section in your notes:
Assessment or Formulation, etc.
Opine there...
"concerns of past hyponatremia of unknown etiology but considered to be related depakote/ZYZ in past, which prompted cessation. However, patient has decompensated again with a re-admission. Due to doubts/concerns that ZYZ was the etiology, Patient Bounce Back, consents to retrial of these medicines previously tolerated and efficacious. Will cautiously monitor here on unit with routine CMP testing"

follow up notes:
meds going up and well, Patient Bounce Back doing awesome
CMP rsults going well, fluid intake fantastic
Soon to lift fluid restrictions

follow up ntoes
still great
practically to dose levels
CMPS are stellar
no fluid restrictions, patient self regulating well

Discharge Summary
Concerns, still did
no concerns observed on unit
patient regulated fluids well
symptoms stabilized
no longer IP care appropriate, discharged
Encouraged f/u with PCP and recheck CMP in XYZ days/weeks/months
instructed to look out for ABCD and go to UC ED if blah blah

Now that you have regurgitated in the note your thought process and the why you did things, go to sleep at night with ease, and if something lawyer bites you in the future you can simply look at your note, and be like "note speaks for itself"

 

[uhmocksuhsillen]

There is the section in your notes:
Assessment or Formulation, etc.
Opine there...
"concerns of past hyponatremia of unknown etiology but considered to be related depakote/ZYZ in past, which prompted cessation. However, patient has decompensated again with a re-admission. Due to doubts/concerns that ZYZ was the etiology, Patient Bounce Back, consents to retrial of these medicines previously tolerated and efficacious. Will cautiously monitor here on unit with routine CMP testing"

follow up notes:
meds going up and well, Patient Bounce Back doing awesome
CMP rsults going well, fluid intake fantastic
Soon to lift fluid restrictions

follow up ntoes
still great
practically to dose levels
CMPS are stellar
no fluid restrictions, patient self regulating well

Discharge Summary
Concerns, still did
no concerns observed on unit
patient regulated fluids well
symptoms stabilized
no longer IP care appropriate, discharged
Encouraged f/u with PCP and recheck CMP in XYZ days/weeks/months
instructed to look out for ABCD and go to UC ED if blah blah

Now that you have regurgitated in the note your thought process and the why you did things, go to sleep at night with ease, and if something lawyer bites you in the future you can simply look at your note, and be like "note speaks for itself"

This is all common sense but I appreciate you writing it out.

The thing is I do all of this. The other thing is, my brain is telling me even if I document my reasoning like you did here, I'm going to get in trouble if there's a bad outcome anyways.

 

[the5thelement]

There is a saying in my language "If the grave digger cries every time he has to dig a grave, he will go blind".

 

[PikminOC]

There is a saying in my language "If the grave digger cries every time he has to dig a grave, he will go blind".

So that's what makes you blind...

 

[TexasPhysician]

You are expecting a lot of yourself.

You can’t see the future. Psychiatric does not equal psychic. Patients are going to commit suicide. You won’t be able to prevent it. Your work may help to reduce 100+ suicides per year, but that won’t be 100%. In rare cases, family looks to blame someone. That could be you even if it wasn’t your fault. That is what insurance and good documentation is for.

Hyponatremia is something that can be caused by tons of things. I’ve had patients get admitted for hyponatremia with the medical team blaming my SSRI. I disagreed. Patient agreed with me and essentially demanded to restart it. It made a big difference. Many CMP’s and years later - no hyponatremia on same SSRI. It could have gone the other way with another hospitalization. It is a risk benefit discussion and documentation.

Nothing is risk free.

 

[PikminOC]

Up is right. In the Monday morning quarterbacking of a lawsuit, they will always come up with something you did that was inadequate. After all there was a bad outcome right?

 

[Stagg737]

Essentially I'm worried there's a bad outcome and the family blames/sues me because he got hyponatremic and died or has some major consequence of this.

You document that risk and that you considered it along with the fact that benefit outweighed the risk. You make sure to discuss with patient or guardians and document that you discussed it. Then you go home and live your life.

This is all common sense but I appreciate you writing it out.

The thing is I do all of this. The other thing is, my brain is telling me even if I document my reasoning like you did here, I'm going to get in trouble if there's a bad outcome anyways.

Then once you get home, you schedule your therapy appointment or go to therapistaid.com and fill out some CBT worksheets. Or just watch the Bob Newhart video from MadTV. I think it was posted here recently, but here it is again just in case:

 

[PikminOC]

And I understand the concern about losing the license you fought so hard for. I have seen that happen

 

[Psyche0248]

And I understand the concern about losing the license you fought so hard for. I have seen that happen

Over what? Surely not over a patient suicide?

 

[PikminOC]

Over what? Surely not over a patient suicide?

Over all different things.

 

[Candidate2017]

Essentially I'm worried there's a bad outcome and the family blames/sues me because he got hyponatremic and died or has some major consequence of this.

You're a physician. Like all physicians, you treat diseases, from which people sometimes die, including from medicines you prescribe. You're not necessarily responsible for outcomes, whether good or bad. But you are responsible for adhering to the standard of care.

I can't imagine other physicians, like oncologists, that deal with actual dying and death up close, being as neurotic as psychiatrists. But us, we don't really see our patients' dying process. We have patients that are doing ok, and then hear secondhand of their unexpected deaths. So it's more distressing to us. We're like non-frontline soldiers in that they experience higher rates of PTSD than soldiers who are on the frontlines who regularly see death and are involved in killing.

Psychiatrists are more prone to childlike fantasies in which we can control everything (and it's our fault if something bad happens), none of our patients succumb to their disease, everything can be cured, and everyone lives forever yay! But this avoidance only serves to increase neuroticism. We need acknowledge we are physicians and our daily work involves life, for which the flipside is death. This reality in which physicians work is both beautiful and brutal.

 

[PikminOC]

You're a physician. Like all physicians, you treat diseases, from which people sometimes die, including from medicines you prescribe. You're not necessarily responsible for outcomes, whether good or bad. But you are responsible for adhering to the standard of care.

I can't imagine other physicians, like oncologists, that deal with actual dying and death up close, being as neurotic as psychiatrists. But us, we don't really see our patients' dying process. We have patients that are doing ok, and then hear secondhand of their unexpected deaths. So it's more distressing to us. We're like non-frontline soldiers in that they experience higher rates of PTSD than soldiers who are on the frontlines who regularly see death and are involved in killing.

Psychiatrists are more prone to childlike fantasies in which we can control everything (and it's our fault if something bad happens), none of our patients succumb to their disease, everything can be cured, and everyone lives forever yay! But this avoidance only serves to increase neuroticism. We need acknowledge we are physicians and our daily work involves life, for which the flipside is death. This reality in which physicians work is both beautiful and brutal.

Psychiatrists are responsible for the things people do outside of the office. Like if they shoot up a theater or kill themselves or take all of their psych meds at once to kill themselves. Other fields aren't held to that standard.

 

[comp1]

I mean internists are blamed for bouncebacks when their patient doesn't adhere to their heart failure sodium restricted diet. It's not really a metric thing that separates us. It's more that our patients tends to make the news.

 

[PikminOC]

I mean internists are blamed for bouncebacks when their patient doesn't adhere to their heart failure sodium restricted diet. It's not really a metric thing that separates us. It's more that our patients tends to make the news.

There's a huge difference between a bounceback and a patient who kills 5 people

 

[annoyedpsychiatrist]

Seems there's been a spate of these posts lately - must be the time of year.

I've just started off on an inpatient unit and I'm feeling exactly like I did during intern year - just change afraid to order Tylenol with afraid to discharge patients. I got burned badly during my PGY3 year in which a seemingly low risk patient I advocated to discharge committed suicide within hours of leaving the hospital. Clearly I wasn't the one who officially signed off on that, but it still haunts me.

Now that I'm discharging multiple people a day, I'm living in a constant state of fear. I write in depth suicide risk assessments for fear of getting sued and even worse, losing my license. Every day I go into work I'm dreading what I'll walk into - who needs to be discharged today, how risky are they going to be, etc.

I deal with a lot of psychotic people who have been hospitalized 20+ times - nothing ever changes. It just seems like it's a matter of time before there is a bad outcome...it feels like a game of hot potato. I've got to go back in tomorrow and all I want to do is hide under a rock. Advice, please.

have you considered a different practice setting? Maybe something with less acuity?

 

[uhmocksuhsillen]

have you considered a different practice setting? Maybe something with less acuity?

I actually had no idea how acute my hospital was until I got started. I've been told there are a handful of places like this psych hospital in the country; on par with a Bellevue type facility.

That said, it seems like a good place to learn and if I can handle this I can handle anything.

 

[PikminOC]

I actually had no idea how acute my hospital was until I got started. I've been told there are a handful of places like this psych hospital in the country; on par with a Bellevue type facility.

That said, it seems like a good place to learn and if I can handle this I can handle anything.

I've worked in ngri places. And alot of different places. It's just different stresses in each one.

 

[clausewitz2]

There's a huge difference between a bounceback and a patient who kills 5 people

This is almost literally what the post you quoted and seem to be arguing with was saying.

 

[annoyedpsychiatrist]

I actually had no idea how acute my hospital was until I got started. I've been told there are a handful of places like this psych hospital in the country; on par with a Bellevue type facility.

That said, it seems like a good place to learn and if I can handle this I can handle anything.

my first attending year i did community psych. Wasnt uncommon id have people on 10+ psych meds. Also supervised peds clinic, and ID clinic. Saw some intense stuff, lots of polypharm, and combos of meds that kept me up at night. That was good for a year experience but after a year, I think that was enough for me. Funny enough a year after i left, they called me and wanted me to come back offering more money/changes/medical directorship type role in near future. But while learning/money are both nice, they dont beat not being able to sleep at night.

 

[PikminOC]

This is almost literally what the post you quoted and seem to be arguing with was saying.

Good then we agree 🤓

 

[TheRightMedication]

For me the solution to that anxiety is, as Sushirolls said, just do your best for the patient. And document it. People can sue you for anything, and, perhaps they will.

I don't ask myself "how can I avoid getting sued?" I ask myself "can I stand before any judge, mundane or celestial, and say I practiced medicine appropriately?"

 

[uhmocksuhsillen]

my first attending year i did community psych. Wasnt uncommon id have people on 10+ psych meds. Also supervised peds clinic, and ID clinic. Saw some intense stuff, lots of polypharm, and combos of meds that kept me up at night. That was good for a year experience but after a year, I think that was enough for me. Funny enough a year after i left, they called me and wanted me to come back offering more money/changes/medical directorship type role in near future. But while learning/money are both nice, they dont beat not being able to sleep at night.

Yeah thats a good point. I'm planning to stick with this for a bit, but it's definitely a grind. Numerous calls for prn IMs each shift. Patients complete disasters. Placement issues because they can only go to the state hospital. etc.

Part of me feels guilty for not sticking it out for the full year. How bad is it to start as a new doc and leave after a few months?

 

[shoomer]

Part of me feels guilty for not sticking it out for the full year. How bad is it to start as a new doc and leave after a few months?

It's going to be looked down upon to some extent, a little less if you give appropriate advance notice. But that shouldn't be the driving force behind whether you stay or not. If a job is bad for you (not saying this one is or isn't necessarily), then you should leave regardless of what other people think. The job market is open and you should never be in a position where you're stuck somewhere.

 

[Candidate2017]

Psychiatrists are responsible for the things people do outside of the office. Like if they shoot up a theater or kill themselves or take all of their psych meds at once to kill themselves. Other fields aren't held to that standard.

Not really. We are required to follow the standard of care such as risk assessment, safety plan, duty to warn, gun grabbing, etc. I do understand it can feel onerous because other specialties, for example cardiology, aren't required to tell families of obese cardiac patients to lock up all the junk food and refer them to personal trainers and nutritionists.

In any event, patient deaths occur via more lethal means such opioids, defenestration, guns, traffic/trains, and general health issues, rather than psych meds.

 

[PikminOC]

Yeah thats a good point. I'm planning to stick with this for a bit, but it's definitely a grind. Numerous calls for prn IMs each shift. Patients complete disasters. Placement issues because they can only go to the state hospital. etc.

Part of me feels guilty for not sticking it out for the full year. How bad is it to start as a new doc and leave after a few months?

Not really. We are required to follow the standard of care such as risk assessment, safety plan, duty to warn, gun grabbing, etc. I do understand it can feel onerous because other specialties, for example cardiology, aren't required to tell families of obese cardiac patients to lock up all the junk food and refer them to personal trainers and nutritionists.

In any event, patient deaths occur via more lethal means such opioids, defenestration, guns, traffic/trains, and general health issues, rather than psych meds.

Yet psych gets blamed for any action a patient takes.

And what do you mean by defenestration?

 

[clausewitz2]

Yet psych gets blamed for any action a patient takes.

And what do you mean by defenestration?

There's really only the one definition:

Defenestration - Wikipedia

en.wikipedia.org

Although poster may be referring more to people throwing themselves out of windows in hospitals.

EDIT: Weird, I'm personally related to one of the people on that list.

 

[PikminOC]

There's really only the one definition:

Defenestration - Wikipedia

en.wikipedia.org

Although poster may be referring more to people throwing themselves out of windows in hospitals.

EDIT: Weird, I'm personally related to one of the people on that list.

Thanks, how common is that?

 

[ObsequiousAplomb]

Thanks, how common is that?

Common enough that many doctors know a hospital where it's happened. Most doctors will tell a story of knowing someone who was there when it happened or something to that effect.

Also common enough that it's almost universally considered the facility's fault when it happens.

 

[FlowRate]

This is all common sense but I appreciate you writing it out.

The thing is I do all of this. The other thing is, my brain is telling me even if I document my reasoning like you did here, I'm going to get in trouble if there's a bad outcome anyways.

Are you familiar with ERP? You could always try the exposure/extinction approach.

 

[PikminOC]

Common enough that many doctors know a hospital where it's happened. Most doctors will tell a story of knowing someone who was there when it happened or something to that effect.

Also common enough that it's almost universally considered the facility's fault when it happens.

Do you a case for that? A law case? Because lawyers sue everyone....and I mean everyone

I am a doctor who has never heard of that

 

[mistafab]

Do you a case for that? A law case? Because lawyers sue everyone....and I mean everyone

I am a doctor who has never heard of that

Dude, that is the easiest lawsuit ever. The concept is "control" - a facility is assumed to have "control" if a patient is in their care. Any sentinel event (suicide, elopement -> death, jumping out of window) is an easy lawsuit for the hospital, and they will lose that case - so they will settle.

And yes I've heard this happening and yes it results in a big settlement.

 

[surfguy84]

Dude, that is the easiest lawsuit ever. The concept is "control" - a facility is assumed to have "control" if a patient is in their care. Any sentinel event (suicide, elopement -> death, jumping out of window) is an easy lawsuit for the hospital, and they will lose that case - so they will settle.

And yes I've heard this happening and yes it results in a big settlement.

Is the doc at fault too for a facility failure?

 

[PikminOC]

Dude, that is the easiest lawsuit ever. The concept is "control" - a facility is assumed to have "control" if a patient is in their care. Any sentinel event (suicide, elopement -> death, jumping out of window) is an easy lawsuit for the hospital, and they will lose that case - so they will settle.

And yes I've heard this happening and yes it results in a big settlement.

Who did they sue? Just the hospital? Because I have seen lawyers sue everyone on the chart and every staff present. Then you have to extricate yourself from the suit. Show me the suit.

 

[mistafab]

Who did they sue? Just the hospital? Because I have seen lawyers sue everyone on the chart and every staff present. Then you have to extricate yourself from the suit. Show me the suit.

The facility is at fault, not the providers. The one I’m referring to, not to get too specific, ended up being settled out of court.

Another sentinel event, sex on the unit, is again a “never” event. That one I’m privy to also ended in settlement. If you don’t know about cases like this, maybe you worked at only small hospitals? Or perhaps you didn’t really do inpatient? Or no exposure to forensics?

Work anywhere big enough, long enough, and sentinel events happen. If it’s a matter of “control” - then it’s the facility’s fault. The treating physician won’t get sued, or their name eventually dropped because they don’t have “control.”

A medical director may be on the hook if they ‘should have known’ it was a risk, I.e. they were at fault due to poor policy and practice management they had “control” over. The cases I’ve been privy to, however, named the facility and got payouts, I don’t think in those cases an MD or ‘leader’ ended up singled out or had to pay out. Both were paid out by big daddy deep pockets I.e. big box shop.

Is the doc at fault too for a facility failure?

Again, it’s about ‘control.’ The physician is in charge of treatment. The facility is in charge of security, patient safety, equipment. Unless the argument is that the treating physician failed to utilize X treatment so another patient got assaulted on the unit (“but for”), then there’s nothing the treating physician has to do with it - or at least that’s the obvious argument to extricate yourself from a case like this. I mean a janitor can get named in a case, but the lawyer is going to go after who they know will be forced to pay.

Why chase down a little psychiatrist with questionable “control” when the facility is obviously on the hook and has way bigger pockets, and incentives to not take the case publicly in court?

And this connects to why outpatient psych docs are successfully sued so infrequently. It’s hard to really prove to a reasonable degree of certainty that it was specifically action X that caused Y. There is far less “control” outpatient, so the bar of terrible practice/negligence is much harder to hit for a lawsuit.

 

[smalltownpsych]

Yeah thats a good point. I'm planning to stick with this for a bit, but it's definitely a grind. Numerous calls for prn IMs each shift. Patients complete disasters. Placement issues because they can only go to the state hospital. etc.

Part of me feels guilty for not sticking it out for the full year. How bad is it to start as a new doc and leave after a few months?

Part of the way that I have been able to work more effectively with some of the highest risk patients is by sharing the responsibility by being part of an effective team. I personally tend to take on too much responsibility for patient outcome which is actually a better tendency than taking on too little so I temper that with handing part off to psychiatrist or social worker or case worker and if possible, the family. If it isn’t possible to include any family support, that is documented so that if they were to come out of the woodwork and try to sue, it is clear that they didn’t do their part. If there is truly no one else helping then you are probably just supporting/enabling a broken system that won’t really help the patient anyway.

 

[PikminOC]

Th

Part of the way that I have been able to work more effectively with some of the highest risk patients is by sharing the responsibility by being part of an effective team. I personally tend to take on too much responsibility for patient outcome which is actually a better tendency than taking on too little so I temper that with handing part off to psychiatrist or social worker or case worker and if possible, the family. If it isn’t possible to include any family support, that is documented so that if they were to come out of the woodwork and try to sue, it is clear that they didn’t do their part. If there is truly no one else helping then you are probably just supporting/enabling a broken system that won’t really help the patient anyway.

The level of responsibility for a physician is very high. I have many psychologist friends and their malpractice is minimal.

And court determines the liability. Everyone is always sued.

 

[smalltownpsych]

Th

The level of responsibility for a physician is very high. I have many psychologist friends and their malpractice is minimal.

And court determines the liability. Everyone is always sued.

All true. Still a good idea to share responsibility for care of high risk patients. From both an emotional stances of not feeling like you’re on an island and from a liability stance since you documented that steps were taken to mitigate the risk such as recommending increased therapy or other supports. If a lawsuit ever does happen the ability to demonstrate a plan to mitigate risk will help. From my end, I might have the patient reach out to their psychiatrist for that very reason in addition to that it might be of help. It would seem that a psychiatrist who had concerns about safety might want to ensure that therapist is aware and available for additional treatment and document that. Sounds a lot better in court than something like “I didn’t know that they hadn‘t seen their therapist in two weeks and didn’t have an appointment”.