Discharge from practice while hospitalized

[nexus73]

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Is this an adequate practice discharge strategy.

A patient previously seen at a clinic serving relatively high functioning patients severely decompensates into a psychotic or manic episode and is hospitalized. The clinic calls the hospital to notify them patient is discharged from their clinic due to severity of symptoms and hospital will need to refer patient elsewhere for mental health follow up.

I can see both sides. It seems lame to dump someone who is now struggling more, with assumption that the clinic just doesn't want to take back someone who will require more time and have more risk. But at the same time many clinics are not setup like community mental health to continue with treating someone with newly developed severe symptoms increasing complexity of care, time, risk, etc.

Is the inpatient admission an opportunity to pass the baton to the hospital to manage the transfer of care elsewhere?

 

[the5thelement]

If its an established patient, I would deem this to be highly unprofessional. We have a fiduciary duty and have to act in the best interest of the patient. Its like someone who offers his umbrella when its not raining, but as soon as the rain starts snatches the umbrella quickly.

 

[calvnandhobbs68]

Yeah I hate when people say it's okay to do this. I've heard of private practices doing this who basically use this as an excuse to dump patients who don't just check in to complain about their mom in psychotherapy and pick up their Adderall and Lexapro once a month. If you can't handle complicated patients who have been hospitalized as a psychiatrist, what kind of specialist are you?

I have multiple people in residential programs currently who will be discharging back to me, multiple other people in IOPs/PHPs currently and at least 2 patients who have just been discharged from the hospital within the last month coming back to me. I work in a larger therapy practice but it's not like I have social work or MA support services or something.

I mean if they clearly can't function when discharged without support services through a CMHC like social work to check on them and bring them to appointments, okay then yes they need that. Also difficult in private practice to do monitoring for clozapine or administer LAIs unless you're comfortable doing them yourself. Not too much of a stretch to monitor for lithium though, I'm doing it myself right now. Otherwise, if they don't require drastically increased social support and you can monitor the meds, not sure what your excuse is.

 

[splik]

Yes. The best time to terminate with a patient is when they are admitted inpatient.

 

[Celexa]

If I had a nickel every patient prescribed stimulants by an outpatient provider who subsequently developed a manic episode and/or had a substance use disorder and/or had a suicide attempt and their (cash-only) outpatient provider wouldn't take them back, I'd have too many nickels. And yes, some of those people were board-certified psychiatrists.

Have also encountered board certified psychiatrists who won't take lithium patients.

It sucks and I hope karma catches up to some of those people, but at the same time they clearly can't serve the patients needs so it's not like it's going to be good for the patient to go back to them.

 

[TexasPhysician]

Like most things, the answer is highly individualized.

We shouldn’t dump patients that just need more intensive care. We should make every reasonable effort to address their needs.

Some patients are just not a good fit for your practice, and an admission is a potentially good time to transition patients to an IOP and the psych associated.

I’ll give you an example: In an attempt to reduce admissions, I told a patient that any single weekday, I would work them in if they would just call or show up. This went for our counseling staff or med changes. This patient is very low odds of actual self-harm with poor coping strategies. How many outpatient psych clinics offer appointments on-demand? We had scheduled visits every 2 weeks as well. Instead of utilizing the plan, this patient would just admit themselves the day of our appointment without even calling me. While I normally don’t charge a no-show fee with emergent admissions, I informed this patient that every missed visit would now be a full fee charge regardless of reason after already letting it slide 2x in a row. None of the admissions were good admissions. After informing this patient of the fees and need to follow our plan, the trend continued for 2 more visits. Despite every effort, the patient preferred to utilize inpatient as their outpatient care and still pay me for nothing. At this point, it is in the patient’s best interest for me to walk away. A psych associated with the inpatient and IOP would be better at strategically managing this patient and reducing admissions.

 

[PikminOC]

A patient complained to the board about me doing this. I won.

 

[Celexa]

Like most things, the answer is highly individualized.

We shouldn’t dump patients that just need more intensive care. We should make every reasonable effort to address their needs.

Some patients are just not a good fit for your practice, and an admission is a potentially good time to transition patients to an IOP and the psych associated.

I’ll give you an example: In an attempt to reduce admissions, I told a patient that any single weekday, I would work them in if they would just call or show up. This went for our counseling staff or med changes. This patient is very low odds of actual self-harm with poor coping strategies. How many outpatient psych clinics offer appointments on-demand? We had scheduled visits every 2 weeks as well. Instead of utilizing the plan, this patient would just admit themselves the day of our appointment without even calling me. While I normally don’t charge a no-show fee with emergent admissions, I informed this patient that every missed visit would now be a full fee charge regardless of reason after already letting it slide 2x in a row. None of the admissions were good admissions. After informing this patient of the fees and need to follow our plan, the trend continued for 2 more visits. Despite every effort, the patient preferred to utilize inpatient as their outpatient care and still pay me for nothing. At this point, it is in the patient’s best interest for me to walk away. A psych associated with the inpatient and IOP would be better at strategically managing this patient and reducing admissions.

This is completely reasonable. I would hope/assume you were in communication with the inpatient team about the history and reasons the pt could not come back to your practice around the time of admission. My experience has much more frequently been, the outpatient person is unreachable for the duration of the hospitalization - - > social work calls for an appt prior to DC and at that point the outpatient person says no dice, look elsewhere.

 

[forchinet121]

Yes this is standard of care

 

[forchinet121]

Yeah I hate when people say it's okay to do this. I've heard of private practices doing this who basically use this as an excuse to dump patients who don't just check in to complain about their mom in psychotherapy and pick up their Adderall and Lexapro once a month. If you can't handle complicated patients who have been hospitalized as a psychiatrist, what kind of specialist are you?

I have multiple people in residential programs currently who will be discharging back to me, multiple other people in IOPs/PHPs currently and at least 2 patients who have just been discharged from the hospital within the last month coming back to me. I work in a larger therapy practice but it's not like I have social work or MA support services or something.

I mean if they clearly can't function when discharged without support services through a CMHC like social work to check on them and bring them to appointments, okay then yes they need that. Also difficult in private practice to do monitoring for clozapine or administer LAIs unless you're comfortable doing them yourself. Not too much of a stretch to monitor for lithium though, I'm doing it myself right now. Otherwise, if they don't require drastically increased social support and you can monitor the meds, not sure what your excuse is.

You are not obligated to see patients you don’t want to see, especially when you’re in private practice. Given that, inpatient is a very good time to transition someone to a different provider as they are safe and can usually schedule something soon after discharge

 

[allantois]

Jeez imagine, internists did this.. oh your CHF is decompensating - you are now on your own!
If they warrant higher level of care, that should be set up for them but until then I cannot imagine dumping them would lead to any sort of benefit to the patient. Also, administering LAIs is not complicated

 

[michaelrack]

Also, administering LAIs is not complicated

Unless you're willing to inject your own patient in the ass (for those that can't be given in deltoid), it can be quite difficult to make sure a patient gets lai if you don't have clinic nursing staff.

 

[Merovinge]

Unless you're willing to inject your own patient in the ass (for those that can't be given in deltoid), it can be quite difficult to make sure a patient gets lai if you don't have clinic nursing staff.

Absolutely, I do all the deltoids myself, but no way am I having an adolescent dropping their pants even with any amount of chaperones in the room.

 

[calvnandhobbs68]

Jeez imagine, internists did this.. oh your CHF is decompensating - you are now on your own!
If they warrant higher level of care, that should be set up for them but until then I cannot imagine dumping them would lead to any sort of benefit to the patient.

Correct. This is almost non-existent in other specialities. Non-compliance/failure to follow treatment planning repeatedly, failure to followup or bad behavior absolutely gets discharged in other specialities but I've yet to meet an endocrinologist who just discharges a patient for being "too diabetic" if they're compliant/not beligerent and refuses to see them again. They may refer them to a more specialized center and encourage them to followup there but they don't just kick them out of the practice if they show up again. Oh and also guess what happens if they can't find some other psychiatrist taking new patients for the next 3-6 months? They just end up going back to their PCP, who valiantly backstops everything.

I’ll give you an example: In an attempt to reduce admissions, I told a patient that any single weekday, I would work them in if they would just call or show up. This went for our counseling staff or med changes. This patient is very low odds of actual self-harm with poor coping strategies. How many outpatient psych clinics offer appointments on-demand? We had scheduled visits every 2 weeks as well. Instead of utilizing the plan, this patient would just admit themselves the day of our appointment without even calling me. While I normally don’t charge a no-show fee with emergent admissions, I informed this patient that every missed visit would now be a full fee charge regardless of reason after already letting it slide 2x in a row. None of the admissions were good admissions. After informing this patient of the fees and need to follow our plan, the trend continued for 2 more visits. Despite every effort, the patient preferred to utilize inpatient as their outpatient care and still pay me for nothing. At this point, it is in the patient’s best interest for me to walk away. A psych associated with the inpatient and IOP would be better at strategically managing this patient and reducing admissions.

Agree this is totally reasonable. This isn't dumping off a patient who has a psychotic/manic episode or suicide attempt, far from it you made every effort to engage the patient and encourage them to followup closely with you. The patient obviously needs more social support, stepdown to an intermediate level of care for a while and an attempt to transfer to an outpatient psychiatrist likely within that hospital system to prevent the revolving admission door.

You are not obligated to see patients you don’t want to see, especially when you’re in private practice. Given that, inpatient is a very good time to transition someone to a different provider as they are safe and can usually schedule something soon after discharge

I'm quite aware of this, being in private practice myself. The question isn't really is it legal, it's likely perfectly legal. The question is would most physicians find this kind of behavior ethical. I've heard multiple times of this happening or people asking about doing this with patients not really being someone who truly needs a "higher level of care" but just someone who's just essentially kind of more complex who the psychiatrist or "provider" doesn't really want to deal with in their boutique private practice.

I'd really question the idea that inpatient is the best time to "transition someone to a new provider" (guess you're lumping NPs in this mix), especially if this isn't something that's been discussed as a possibility like in the example above. Rather than an orderly outpatient transition where you essentially tell someone they have 30-60 days to find a new doctor while they're stable outpatient and explain your reasons for doing so. I don't know where you are but it's not exactly a cakewalk for an inpatient unit to find a practice taking new patients with openings anytime soon by the time they're discharged in 7-10 days or whatever the average inpatient LOS is there. Most likely if they do find someone, they get shuttled off to some new NP who has openings. There's also the obvious fear from the patient that their doctor abandoned them because their illness got too severe, so what if this happens again?

 

[claypigeon]

I have mixed feelings. I never discharge these cases from clinic but will tell the inpatient team it may be best if they're referred to someplace with more comprehensive services. I have no issue treating SMI when other ancillary services aren't needed. But our practice doesn't have a case manager, can't give LAIs, doesn't have therapists, etc. I've seen enough cases where I try to piece mail all of this together referring to local resources but it's just too many separate places for patients to get to or people to work with. Then they miss their LAI and decompensate. Or don't follow up with case management and lose their benefits, etc. Better if there's one integrated community clinic.

 

[nexus73]

I'd really question the idea that inpatient is the best time to "transition someone to a new provider" (guess you're lumping NPs in this mix), especially if this isn't something that's been discussed as a possibility like in the example above.

Best time for the patient or best time regarding medicolegal risk? Considering we are practicing in an adversarial system created by the lawyers.

 

[whopper]

I've terminated several patients but I've done so only after 1-the patient broke some type of rule to a large degree or repeatedly that made the treatment relationship not beneficial to either, 2-the patient would be better off with a lesser or higher care than I could provide.

A problem as mentioned above is a provider could terminate a patient out of convenience. E.g. that patient is high-maintenance and not in a drama way but in a way where that patient really needs the high-maintenance such as a Clozapine patient. We shouldn't do so for that reason. People need help and that's why we're in the field we're in.

Some patients I've terminated include-a patient that wasn't getting his Clozapine labs and when this happened his mother would call my office trying to bully me into prescribing the meds without a lab. The termination letter specifically recommended he get a case manager and my office didn't have a case manager. Got to the point where I told her if she continued this I'd have to get a restraining order on her (she wasn't the patient, the patient repeatedly didn't follow the lab requirements), patient repeatedly non-compliant and skipping appointments to the point where I said to that patient why even see me? Patient who'd call my receptionist daily for hours asking for things that were not relevant for treatment. We told him to stop this or I'd have to see him much more often to address why he felt some odd reason (that didn't seem to fit any DSM disorder) as to why he called us so much.

Another patient I terminated called me asking for a refill of a stimulant ahead of schedule. I asked why, she told me that she could tell her father had the same problem she had, so she gave him her meds, and that he's so much better thanks to me so now she needs more. Yes-I already told her and she knew you're not supposed to give out controlled substances to other people.

 

[Candidate2017]

Jeez imagine, internists did this.. oh your CHF is decompensating - you are now on your own!
If they warrant higher level of care, that should be set up for them but until then I cannot imagine dumping them would lead to any sort of benefit to the patient.

There are additional responsibilities placed upon us that "medical" doctors don't have to handle. Pychiatrists in most settings do not have resources to handle every psych patient, due to such responsibilities. Hence, discharge may be necessary, while timing can be up to philosophical debate.

A cardiologist can see a 450 lb cardiac patient in 8 minutes, prescribe a 6 month supply of meds, write a 1-2 line note, and bill a level 2. The cardiologist fails to collect collateral, fails to diagnose morbid obesity, fails to recommend exercise, fails to refer to a dietician/nutritionist/personal trainer, fails to communicate a safety plan to the wife about what to do if the patient experiences chest pain. The only thing done beyond meds is checking the box about smoking cessation ($7), and glancing at the EKG done by the MA ($10).

The patient is compliant with meds, but continues to smoke and ingest 8000 calories a day. They suffer a massive MI while driving, crash into a school bus, killing 20 kids. Neither the patient's family nor the kids' families can successfully sue based on the cardiologist not doing more, or not recognizing the blatant "warning signs" of impending doom.

Now, replace the above with a psychiatrist, and the patient expires in the midst of a depressive/manic/psychotic episode, and takes out a school bus.

 

[Sushirolls]

My office is me, part time.
An assistant even more part time than me.
I have a single executive office suite now.
We don't have the logistics to be an everything psychiatry practice. Perhaps if every insurance company paid me more, I could financially support having expanded services, but right now, I do what I can and that's good enough.

I don't have sharps containers or contracts for biohazard disposal. Nor is it financially worthwhile for me to offer LAI services.

It most definitely is professional and reasonable to discharge a patient while inpatient. I would consider doing it for a patient who is schizophrenic and needs LAI or severe Bipolar I who is needing LAI, or perhaps an Axis II who is exhibiting boundary issues.

I've not yet done yet done this. But is on the table as an option if needed.

In general I try and aspire to keep/treat as many as I can; but if I can't I will refer out. People with ED, I don't treat but refer out. I will keep and treat anxiety/depression, but not the ED elements. I keep SUDs. MRDD I don't treat. I anticipate with time as some patients age, I will be referring out the dementia.

 

[allantois]

I am certainly not suggesting that one should take on more than one can provide in terms of their services. However, I have seen plenty of crap services provided by CMHCs, that I am confident I can take better care of a lot of schizophrenics as well as bipolar 1 patients provided they have good psychosocial support (granted that is atypical and I do not currently have anyone on LAIs). It is unfortunate that we have to consider medicolegal implications in taking on challenging cases due to the malpractice environment in this country.

 

[Stagg737]

You are not obligated to see patients you don’t want to see, especially when you’re in private practice. Given that, inpatient is a very good time to transition someone to a different provider as they are safe and can usually schedule something soon after discharge

True, as long as you're not the outpt doc getting a call the day of discharge to schedule the patient's f/up and then telling the inpatient team "too bad". We're not obligated, but it's pretty unethically to just flip them the bird because we don't want to treat them post-hospitalization.

I do think it's reasonable to see them back once or twice to ensure they can continue their meds and refer them to other clinics if you can't meet their needs, but seems like OP was talking about a situation of just dumping a patient because they got admitted. I also think it's reasonable to call the hospital early and tell them they need to arrange other f/up.

 

[allantois]

True, as long as you're not the outpt doc getting a call the day of discharge to schedule the patient's f/up and then telling the inpatient team "too bad". We're not obligated, but it's pretty unethically to just flip them the bird because we don't want to treat them post-hospitalization.

I do think it's reasonable to see them back once or twice to ensure they can continue their meds and refer them to other clinics if you can't meet their needs, but seems like OP was talking about a situation of just dumping a patient because they got admitted. I also think it's reasonable to call the hospital early and tell them they need to arrange other f/up.

I don't ever get calls from hospital when patient is admitted. I will get them at discharge (rarely) or never get them at all. Usually they don't even send the notes either

 

[hippopotamusoath]

I really struggle with this. I work in a rural area with no resources. I used to accept anyone, no matter how complex--my reasoning being that I would probably do a better job than the PCP, even though the patient really deserved a level of care just unavailable in our area.

After a while, it became a type of moral injury. I hated trying to treat people with inadequate resources, and seeing predictable bad outcomes. I started saying no. I just accept patients whom I feel are a good fit for the resources my clinic can offer. I feel awful that the system doesn't make provisions for the more complex patients, but in a way, accepting them into my practice was a tacit admission that these patients were getting appropriate care.

I don't want to cover for a broken system any more. If I can't deliver quality care, I say no. If that leaves a large number of patients without psychiatric care--that's a systems issue, and the fix is at a level far above my pay grade.

 

[mistafab]

I really struggle with this. I work in a rural area with no resources. I used to accept anyone, no matter how complex--my reasoning being that I would probably do a better job than the PCP, even though the patient really deserved a level of care just unavailable in our area.

After a while, it became a type of moral injury. I hated trying to treat people with inadequate resources, and seeing predictable bad outcomes. I started saying no. I just accept patients whom I feel are a good fit for the resources my clinic can offer. I feel awful that the system doesn't make provisions for the more complex patients, but in a way, accepting them into my practice was a tacit admission that these patients were getting appropriate care.

I don't want to cover for a broken system any more. If I can't deliver quality care, I say no. If that leaves a large number of patients without psychiatric care--that's a systems issue, and the fix is at a level far above my pay grade.

This rings deep in the soul

 

[nexus73]

I really struggle with this. I work in a rural area with no resources. I used to accept anyone, no matter how complex--my reasoning being that I would probably do a better job than the PCP, even though the patient really deserved a level of care just unavailable in our area.

After a while, it became a type of moral injury. I hated trying to treat people with inadequate resources, and seeing predictable bad outcomes. I started saying no. I just accept patients whom I feel are a good fit for the resources my clinic can offer. I feel awful that the system doesn't make provisions for the more complex patients, but in a way, accepting them into my practice was a tacit admission that these patients were getting appropriate care.

I don't want to cover for a broken system any more. If I can't deliver quality care, I say no. If that leaves a large number of patients without psychiatric care--that's a systems issue, and the fix is at a level far above my pay grade.

There’s a financial burden as well. Higher complexity does not equate to higher pay from insurance. It means more to time and usually more risk, usually lower pay overall because you see fewer patients. Everyone is a 99214 these days. Very hard to hit 99215 unless hospitalizing.

These societal/systems issues are definitely above our pay grade. It’s not as though psychiatry is making 1.5 million a year and avoids high need patients. If you have a large cohort of high need patients a small practice could be losing 25% of revenue devoting time and resources to manage them.

 

[whopper]

I don't want to cover for a broken system any more. If I can't deliver quality care, I say no. If that leaves a large number of patients without psychiatric care--that's a systems issue, and the fix is at a level far above my pay grade.

I'm in a backwards state. It's a main reason I went into private practice. States systems are so backwards they'd be shut down if if this were another state. Seriously. Just as an example forced-labor in jails was going on here not until the 50s but until 2 years ago. (Someone's going to say "isn't that illegal?" I thought so too but I guess my state didn't know it was supposed to be illegal).

I actually did try to fix some of the problems. I was literally told by state agencies that pretty much no one cares and drop it. When the university I worked for told me they didn't care I knew it'd have to be a one man revolution thing on my part, with me playing a Dr Kevorkian role, not killing patients but having to resort to histrioinics, to fix it or I'd have to drop it.

It wasn't the only factor but a major factor in me leaving academia. At least in private practice I can see patients under much better treatment controls than I could do working for the state, a local university (which too had standards I couldn't accept) or a community hospital.

 

[calvnandhobbs68]

There are additional responsibilities placed upon us that "medical" doctors don't have to handle. Pychiatrists in most settings do not have resources to handle every psych patient, due to such responsibilities. Hence, discharge may be necessary, while timing can be up to philosophical debate.

A cardiologist can see a 450 lb cardiac patient in 8 minutes, prescribe a 6 month supply of meds, write a 1-2 line note, and bill a level 2. The cardiologist fails to collect collateral, fails to diagnose morbid obesity, fails to recommend exercise, fails to refer to a dietician/nutritionist/personal trainer, fails to communicate a safety plan to the wife about what to do if the patient experiences chest pain. The only thing done beyond meds is checking the box about smoking cessation ($7), and glancing at the EKG done by the MA ($10).

The patient is compliant with meds, but continues to smoke and ingest 8000 calories a day. They suffer a massive MI while driving, crash into a school bus, killing 20 kids. Neither the patient's family nor the kids' families can successfully sue based on the cardiologist not doing more, or not recognizing the blatant "warning signs" of impending doom.

Now, replace the above with a psychiatrist, and the patient expires in the midst of a depressive/manic/psychotic episode, and takes out a school bus.

Except that's not actually borne out by data. A cardiologist is over 2x as likely year over year to be sued than you. Inpatient psychiatry or ER based are also much more likely to be successfully sued than outpatient. So you can make up all these theoretical rare cases but in real life, that doesn't seem to be happening.

I really struggle with this. I work in a rural area with no resources. I used to accept anyone, no matter how complex--my reasoning being that I would probably do a better job than the PCP, even though the patient really deserved a level of care just unavailable in our area.

After a while, it became a type of moral injury. I hated trying to treat people with inadequate resources, and seeing predictable bad outcomes. I started saying no. I just accept patients whom I feel are a good fit for the resources my clinic can offer. I feel awful that the system doesn't make provisions for the more complex patients, but in a way, accepting them into my practice was a tacit admission that these patients were getting appropriate care.

I don't want to cover for a broken system any more. If I can't deliver quality care, I say no. If that leaves a large number of patients without psychiatric care--that's a systems issue, and the fix is at a level far above my pay grade.

For sure, if patients are clearly needing more social support services or medical services than you can offer, totally, this isn't saying accept any patient no matter how complex they are in a single person outpatient private practice.

 

[Liquid8]

It doesn’t really sit right with me.

But let’s say I see a patient in clinic, they’re stable and we make a followup in 3 months. In between, something happens and they get admitted for say 2 weeks. In most cases I’ve had some contact from the inpatient team for collateral and treatment history. The acute management is in their hands, but there’s usually an understanding that I’ll continue to manage them after the admission. After all, the followup is already booked and there’s an unsaid assumption that they’re not going to discharge the patient half baked, will make a recovery close to their usual baseline and am reasonably confident in being able to continue looking after the patient. Now while there are a couple of things I can't provide such as LAIs or clozapine monitoring, it's not like I know that's what they're going to be doing at the very start of the admission so the discharge call as the OP describes seems premature.

I can see that on a pragmatic level it makes sense to discharge while an inpatient as they’re arguably in the safest possible care, but it also feels a bit too much like abandoning the patient when they’re at their lowest and most vulnerable point. Relaying the end of the therapeutic relationship to the patient by way of their admitting psychiatrist also seems somewhat inappropriate. Does the patient not deserve to hear it to their face, or be provided the opportunity to have some closure are questions that come to mind.

 

[Candidate2017]

Except that's not actually borne out by data. A cardiologist is over 2x as likely year over year to be sued than you.

I didn't say anything about rate of lawsuits. I'm pointing out we have more responsibilities imposed upon us than other specialties, which is why psychiatrists in PP need to discharge certain patients to CMHCs or large hospital clinics.

Maybe, the additional responsibilities (and willingness to discharge from PP) has a protective effect on lawsuits. What if politicians imposed duties upon cardiologists to petition cardiac patients for involuntary treatment based on lack of insight, noncompliance with meds, and danger to themselves based on BMI/age/diet/tobacco/past MIs/ECHO? CVD is the top 1-2 leading causes of mortality.

As an aside, consider this case: post partum nurse strangles 3 kids, lawyer says psych meds "zombiefied" her and gave her SI/HI, academic psychiatrist chimes in with a First Aid for Psych response:

Judge permits forensic psychologist to examine Lindsay Clancy as she awaits arraignment in deadly attack on her children - The Boston Globe

When she allegedly strangled her three children inside their Duxbury home last week, Lindsay Clancy was in the throes of homicidal and suicidal thoughts brought on by overmedication of drugs prescribed for mood disorders, anxiety, and psychosis, her new defense lawyer, Kevin J. Reddington, said.

www.bostonglobe.com

It's not clear whether all 13 meds were prescribed simultaneously (by an NP?), or between a PCP and psychiatrist, or were various trials/tapers, etc.

Either way, too many psych meds = bad, made her kill. But not enough psych meds = bad, more meds would've stopped her from killing. I wouldn't be surprised if her clinician gets drawn into a 5-10 year lawsuit and will discharge every pregnant patient going forward.

 

[birchswing]

<Not a doctor or medical student>

With my ex-therapist, I was once discussing inpatient hospitalization. I can't remember at all how it came up—it was never on the table for me seriously, but something I must have been curious about. I asked him how his patients had done in inpatient hospitalization. And his answer was quite surprising to me. He said he had no idea. He had only ever had patients involuntarily committed. I still didn't follow why that would preclude him knowing how they did. And he said, Well obviously I couldn't see them after that. I still didn't follow. And he said, Well you can never forgive someone after they've involuntarily committed you.

This was years before our therapy ended. It was actually quite ominous. He did not know how to terminate. He did it like a botched execution in that he never committed to it or even spoke the words. He just became bizarre and danced around why he became so bizarre. No termination letter, not even an ability to articulate anything about termination. I couldn't even pull it out of him. Weird passive aggressive things like saying (after weekly therapy), oh are you still a patient? I'll put you on a waiting list. Then saying it would be a week, then two, then a month, etc before I could get in again. Then seeing me for "cancelations" where he mealy-mouth vacillated in these pained expressions about his "piles" of patients (IIRC, there were long-term patients he couldn't understand why they didn't leave, longterm patients who he stopped seeing who wanted to see again, and new patients he was agonizing seeing). I had seen him for 15 years and he ended it in the worst way possible, like a single musical note stretched out over a year. Could not let go or even say he wanted to let go and so made himself so odious there was no option but for him to become as he saw himself, unforgivable.

I can see why he never saw people he committed again. He was just really bad at ending therapy.

(If anyone remembers, he was the one who inspired the dancing psychiatrist—the one who refused to stop dancing when an elderly patient fell and broke her hip because it would break the "the frame" of therapy. I actually did have a medical emergency in the waiting room and he wouldn't leave his office he later told me because it would have broken the frame, which is what inspired the story.)

 

[Liquid8]

Speaking about ending therapy, just saw a funny exchange on Twitter that reminded me of the termination process – I might have to model my discharges on this now.



It starts with an innocuous comment by a psychiatrist (Australian as they have FRANZCP in the bio) in the context of doctor billings, but it leads to an unrelated angry response from someone called "DearPlanA" who clearly doesn’t like doctors (GPs/PCPs) and goes on about having to wait in waiting rooms with all the usual entitlement about how their time is valuable too. To provide some additional context, they have complained about having to pay to see a GP for a specialist referral as is the system here.

It’s goes for a bit but has projection, mistaken identity (DearPlanA doesn't realise the doctor is a specialist), personal attacks and some projective identification about being replaced by AI - the response are calm, until it gets threatening, or interpreted as such - and called out.


But by this stage, the "patient" has disengaged of their own accord.

 

[birchswing]

My therapist didn't exactly use "self-deportation" (reference to Mitt Romney's 2012 immigration policy if anyone recalls). In retrospect, I think he was *hoping* for that, or was at the very least ambivalent (he did say several times that he didn't think any other therapist could help me and I even asked for referrals and he said he could not in good conscience give one). It was a state of purgatory. I was seeing him semi-regularly when he had cancelations, and he would never give a direct answer as to why I stopped being able to schedule on his portal as I had before. But it became more and more difficult to come by these "cancelations." I was always unsure if they really were cancelations. I one time wrote him very directly asking when I would be able to be a regular patient again, and he wrote back: "I never helped you." He was such a depressive. And again, never a direct answer on my status with him. Always like Eeyore. He didn't know his value. I was the cheerleader. I was enough for both of us (I know how sick that sounds).I never told him this, but all he had to do was be a houseplant. It's just that he was the houseplant of fifteen years. He was trying to find something more endlessly without putting any effort into it when all he had to do was what he was already doing. It helped me, but he wouldn't believe that it did. As far as him trying to find something more, I recall I wrote a poem many years ago in which I was Prometheus and he was he eagle, in which he had me up against the wall, had taken everything from me (the eagle eating the liver that perpetually regrew to be eaten again) and still wanted something more. Even looking back on our e-mail exchanges, he was so lazy. He insisted on finding some deep, hidden psychodynamic secret that would unlock everything and had me write pages of exploration and then would just write back, "I think there's something more." No commentary on what I wrote, just, "I think there's something more." He wanted to unlock something but I gave him everything and it was like vomiting everything to him and him saying, "No, I think there's something more." His progress notes were always one word followed by a question mark. He was the height of laziness. But it worked. I got better (left the house again, went back to college, etc.). He cared about nothing in the external world. Only what happened in that room and whether he was responsible for effecting it or not. He was a confidante, and no matter how much I told him that's all I needed, he wanted art, for lack of a better term, but wouldn't even do the work. Anyhow, to put it more clearly as perhaps I left it ambiguous (as did he), I took the last text, "I never helped you" (god he was both lazy AND melodramatic) to be the "termination."

Edit: When I later got my progress notes, on the day he texted "I never helped you" he did write in the progress note that he had stated to me that he would not see me anymore (which he never directly stated to me). That was the most he ever wrote in a progress note. So, I was correct in that interpretation that that was the end. But we had no final session. And he never actually stated it to me. Nothing like that. He botched the whole thing—and again, this was over the course of a year that he gave these vague answers and would see me sporadically. So in the end, it wasn't self-deportation. It was over in his eyes. But he couldn't confront it. Wouldn't even refer me.

Sorry to go on so long, I just worry my anecdote inspired the above Twitter exchange which seemed to be about self-termination. In my case, I really did try hard for a year to figure out what the hell was going on and kept it going past the finish line until it was beyond running on fumes. There really was nothing more for me to ask for him as he wasn't offering anything.

 

[Liquid8]

Sorry to go on so long, I just worry my anecdote inspired the above Twitter exchange which seemed to be about self-termination. In my case, I really did try hard for a year to figure out what the hell was going on and kept it going past the finish line until it was beyond running on fumes. There really was nothing more for me to ask for him as he wasn't offering anything.

No, I read your post after Twitter and I doubt it was related.

What I was also reminded of was a patient who detailed being discharged from a long standing and helpful psychologist (seen for about 5 years for complex trauma and distorted family dynamics). The therapist was known for putting in place a lot of boundaries and structure which was to my patient's benefit, but things suddenly changed with little in the way of explanation which had then triggered significant distress over abandonment. Even the patient's family doctor was concerned as the account and reasons behind ending the relationship weren't clear and seemed to be conflict with previous statements. We wondered if something had happened to the therapist (i.e. as in a stroke or other health condition) as they stopped responding to either of us, and it didn't seem that my patient had done anything wrong for the therapeutic relationship to end. In her words she had not broken any of the rules outlines at the start of therapy, but kept ruminating on the notion that she'd done something wrong she was sorry.