Having a hard time dealing with VA patients

[PistolPete]

Hi all,

So I've been having a hard time dealing with some of my VA patients. The successes have truly been few and far between. So many bounce-backs.

And oh my god, the malingerers... I have such a hard time dealing with them. It's not like the meds do that much, really. Half of them simply need to get clean from alcohol or drugs, and find housing. No 4 or 5 day stay will change that.

I try to approach each patient as a unique individual and do what I can, but when I see them come back and come back, with no change, it is quite disheartening. I for sure do not want to practice at the VA, at least not inpatient.

The majority of our first year and a good chunk of our 2nd year is at the VA, and it feels so dull.

How do you guys deal with this? I'm sure I'm not the only one. Do you feel like you make a difference? How do you deal with the malingerers and manipulative patients?

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[gibits]

That sucks dude. And here I really wanted a job at the VA with those nice federal benefits and all the PTSD and substance abuse.
Do you have a therapist to refer to? CBT is the way to go IMO. Great for PTSD, depression, anxiety. Also, therapists can test for malingering as well.

 

[benjee]

Hi all,

So I've been having a hard time dealing with some of my VA patients. The successes have truly been few and far between. So many bounce-backs.

And oh my god, the malingerers... I have such a hard time dealing with them. It's not like the meds do that much, really. Half of them simply need to get clean from alcohol or drugs, and find housing. No 4 or 5 day stay will change that.

I try to approach each patient as a unique individual and do what I can, but when I see them come back and come back, with no change, it is quite disheartening. I for sure do not want to practice at the VA, at least not inpatient.

The majority of our first year and a good chunk of our 2nd year is at the VA, and it feels so dull.

How do you guys deal with this? I'm sure I'm not the only one. Do you feel like you make a difference? How do you deal with the malingerers and manipulative patients?

did you use motivation interviewing? why were they readmitted in the first place if they love substances so much? If they have no motivation to change , nothing will help in this world, not even CBT cuz they will be no shows for appts.

 

[SmallBird]

Hi all,

So I've been having a hard time dealing with some of my VA patients. The successes have truly been few and far between. So many bounce-backs.

And oh my god, the malingerers... I have such a hard time dealing with them. It's not like the meds do that much, really. Half of them simply need to get clean from alcohol or drugs, and find housing. No 4 or 5 day stay will change that.

I try to approach each patient as a unique individual and do what I can, but when I see them come back and come back, with no change, it is quite disheartening. I for sure do not want to practice at the VA, at least not inpatient.

The majority of our first year and a good chunk of our 2nd year is at the VA, and it feels so dull.

How do you guys deal with this? I'm sure I'm not the only one. Do you feel like you make a difference? How do you deal with the malingerers and manipulative patients?

I have had very rewarding experiences at the VA, but I can totally understand how it could feel exactly as you described. You make the point that "half of them simply need to get clean... find housing" - I feel my experience has been that this is precisely what we are able to do through the VA. I have had many patients that I first admitted on the psych floor with a suicide attempt, and are now living in supportive housing, attending substance abuse treatment, and really doing so much better. But without all the supportive services I do not think I would have made any kind of headway in addressing their mental health concerns.

I guess it all dependss on the VA - here in CT the VA has an insane amount of services, and we are able to do much more for these patients than at the state or academic hospital. We also tend to get a lot of patients coming from other states in order to get services through this VA, so I can imagine its not as comprehensive in other states.

 

[strangeglove]

I have had very rewarding experiences at the VA, but I can totally understand how it could feel exactly as you described. You make the point that "half of them simply need to get clean... find housing" - I feel my experience has been that this is precisely what we are able to do through the VA. I have had many patients that I first admitted on the psych floor with a suicide attempt, and are now living in supportive housing, attending substance abuse treatment, and really doing so much better. But without all the supportive services I do not think I would have made any kind of headway in addressing their mental health concerns.

I guess it all dependss on the VA - here in CT the VA has an insane amount of services, and we are able to do much more for these patients than at the state or academic hospital. We also tend to get a lot of patients coming from other states in order to get services through this VA, so I can imagine its not as comprehensive in other states.

Even though they are in and out quickly, because they come back so frequently, it might help to see them more like long-term outpatients. This might help you to do things like helping to motivate them for longer term sobriety and also help them get housing, which is a process. It may also help with your feelings of hopelessness, which are understandably high if you are expecting gains in a single hospital stay. Good ER doctors take a similar approach.

 

[Merovinge]

Not sure if it helps, but this is the exact experience myself and my co-residents face at our VA. I train in an area where crack and heroin run rampant through the city, making the work tough. The VA unit is so predictable it is scary, right before the first of the month, the whole place evacuates, then days 7-30 or so everyone returns as they have burned through their checks. I take it as an oppertunity to work with substance abuse/dependence and lots of personality disorders, but I must say the low point of my intern year was having been threatened by the second straight person to hunt me down and kill me if I did not admit him and give him benzodiazapines. Unfortunately, the staff know's this is a losing battle and most attendings recommend admitting every patient who requests hospitalization regardless of symptomotology, diagnosis, or previous hospitalization record. By the end of the day, the enabling of the entire system makes me more hopeless than the patients themselves, who have almost all had tough lives.

 

[PistolPete]

Even though they are in and out quickly, because they come back so frequently, it might help to see them more like long-term outpatients. This might help you to do things like helping to motivate them for longer term sobriety and also help them get housing, which is a process. It may also help with your feelings of hopelessness, which are understandably high if you are expecting gains in a single hospital stay. Good ER doctors take a similar approach.

Interesting viewpoint. I have been doing quite a bit of motivational interviewing, but there's only so much you can do if the pt doesn't want to change. I also hate addictions, don't see how anyone would want to do a fellowship in this. I am not expecting large gains in a single hospital stay, or even single day, but I do expect some improvement 6 months or 1 year down the line, which I haven't seen much of, unfortunately.

 

[PistolPete]

Not sure if it helps, but this is the exact experience myself and my co-residents face at our VA. I train in an area where crack and heroin run rampant through the city, making the work tough. The VA unit is so predictable it is scary, right before the first of the month, the whole place evacuates, then days 7-30 or so everyone returns as they have burned through their checks. I take it as an oppertunity to work with substance abuse/dependence and lots of personality disorders, but I must say the low point of my intern year was having been threatened by the second straight person to hunt me down and kill me if I did not admit him and give him benzodiazapines. Unfortunately, the staff know's this is a losing battle and most attendings recommend admitting every patient who requests hospitalization regardless of symptomotology, diagnosis, or previous hospitalization record. By the end of the day, the enabling of the entire system makes me more hopeless than the patients themselves, who have almost all had tough lives.

THANK YOU! I'm in a meth-infested area, so many of my VA pts are addicted to this. Definitely see similar issues towards middle/end of month when people use up their SSI checks, and magically get better a day or 2 before the end of the month. We definitely have a lot of soft admits, but from the attending's viewpoint I can see why it's just easier to admit for liability reasons.

What bothers me is if a patient is discharged on a friday, is a known homeless pt, and then comes back saturday or sunday stating they have SI. Obviously if you thought they were stable enough to dc on fri, things generally do not change so quickly so as to warrant re-admission, but it happens all the time.

Would like to hear if anyone has objective testing for malingering that I can do more of for these types of pts?

 

[heyjack70]

THANK YOU! I'm in a meth-infested area, so many of my VA pts are addicted to this. Definitely see similar issues towards middle/end of month when people use up their SSI checks, and magically get better a day or 2 before the end of the month. We definitely have a lot of soft admits, but from the attending's viewpoint I can see why it's just easier to admit for liability reasons.

What bothers me is if a patient is discharged on a friday, is a known homeless pt, and then comes back saturday or sunday stating they have SI. Obviously if you thought they were stable enough to dc on fri, things generally do not change so quickly so as to warrant re-admission, but it happens all the time.

Would like to hear if anyone has objective testing for malingering that I can do more of for these types of pts?

That 1st week, or 1st month, after psych discharge is supposed to be the most dangerous for self harm. Discharge on a friday without good dispo is suboptimal for the on call psych resident.

Hi all,

So I've been having a hard time dealing with some of my VA patients. The successes have truly been few and far between. So many bounce-backs.

And oh my god, the malingerers... I have such a hard time dealing with them. It's not like the meds do that much, really. Half of them simply need to get clean from alcohol or drugs, and find housing. No 4 or 5 day stay will change that.

I try to approach each patient as a unique individual and do what I can, but when I see them come back and come back, with no change, it is quite disheartening. I for sure do not want to practice at the VA, at least not inpatient.

The majority of our first year and a good chunk of our 2nd year is at the VA, and it feels so dull.

How do you guys deal with this? I'm sure I'm not the only one. Do you feel like you make a difference? How do you deal with the malingerers and manipulative patients?

Maybe the VA isn't the place for you. Make the best of it. Learn what you can. With the right attitude, the worst case scenario is you will have gained immense experience in what you don't want to do post residency. It's like Edison's light bulb filaments, just because something is a failure doesn't mean it isn't useful.

 

[Merovinge]

That 1st week, or 1st month, after psych discharge is supposed to be the most dangerous for self harm. Discharge on a friday without good dispo is suboptimal for the on call psych resident.

This is a real problem for VA patients though, as despite the fact that they almost all have access to housing options due to their Vet status, a select group prefers to live on the streets (likely due to substance dependency). They will demand to be discharged and get physically aggressive if not let go, but then come back in 2 days later and the cycle repeats. I've had patients get admitted 15 times in the past year without being on psychotropics (except maybe demanded benzodiazapines) or receiving diagnosis other than substance induced mood disorder and anti-social personality disorder. This can just be really demoralizing if you get back-to-back patients or several in a night like this.

 

[vistaril]

Hi all,

So I've been having a hard time dealing with some of my VA patients. The successes have truly been few and far between. So many bounce-backs.

And oh my god, the malingerers... I have such a hard time dealing with them. It's not like the meds do that much, really. Half of them simply need to get clean from alcohol or drugs, and find housing. No 4 or 5 day stay will change that.

I try to approach each patient as a unique individual and do what I can, but when I see them come back and come back, with no change, it is quite disheartening. I for sure do not want to practice at the VA, at least not inpatient.

The majority of our first year and a good chunk of our 2nd year is at the VA, and it feels so dull.

How do you guys deal with this? I'm sure I'm not the only one. Do you feel like you make a difference? How do you deal with the malingerers and manipulative patients?

Inpatient VA isn't that much different than inpatient at a lot of academic or community places....yeah there are some differences, but you see the same type of patients everywhere.

 

[notdeadyet]

This is a real problem for VA patients though, as despite the fact that they almost all have access to housing options due to their Vet status, a select group prefers to live on the streets (likely due to substance dependency).

I'd be very cautious with that assumption. Housing is not a right guaranteed to veterans. In many locations the wait for VA-affiliated housing is in the months and very conditional.

 

[edieb]

Hi all,

So I've been having a hard time dealing with some of my VA patients. The successes have truly been few and far between. So many bounce-backs.

And oh my god, the malingerers... I have such a hard time dealing with them. It's not like the meds do that much, really. Half of them simply need to get clean from alcohol or drugs, and find housing. No 4 or 5 day stay will change that.

I try to approach each patient as a unique individual and do what I can, but when I see them come back and come back, with no change, it is quite disheartening. I for sure do not want to practice at the VA, at least not inpatient.

The majority of our first year and a good chunk of our 2nd year is at the VA, and it feels so dull.

How do you guys deal with this? I'm sure I'm not the only one. Do you feel like you make a difference? How do you deal with the malingerers and manipulative patients?

Wow, my colleagues and I have had the same experience at the V.A. The majority of the Veterans seen there have all the services in the world available to them, and still can't get it together. It is truly pathetic. However, you have to remember that many of the patients there are paid to be sick and, as one of the LCSWs used to say, the amount these people receive in benefits is much more than any job would pay that could manage to get.

The one good point from my tenure there: It made me admire/respect other cultures much more. I live right on the border of Mexico and the people over there would never ask for repeated handouts and, when given the opportunity to get ahead, really work at it. Then I see the majority of patients at the V.A. who just rape the system and have no shame being a drain on society. It is SUCH contrast.

 

[Merovinge]

I'd be very cautious with that assumption. Housing is not a right guaranteed to veterans. In many locations the wait for VA-affiliated housing is in the months and very conditional.

Sorry, I don't mean to speak for the country, only where I practice. Our inpatient unit specifically sets up every homeless vet with housing if they can follow through on a few simple things (like showing up to meet with outpatient social work). Admittedly the process does usually take on the order of 1-2 months, but is only conditional on not trashing the place. These services gets declined by patients not infrequently.

 

[SeniorWrangler]

Don't your VA attendings set patients up with payees? That really does a lot for harm reduction and making sure that rent gets paid and so on.

 

[Merovinge]

Don't your VA attendings set patients up with payees? That really does a lot for harm reduction and making sure that rent gets paid and so on.

Ours do when they can, but one of the biggest complaints of patients on the unit is that their payee is stealing their money and they demand to no longer have a payee. I am not sure the exact legality in negotiating it is, but I have noticed their is no easier way to lose any alliance with the patient.

 

[notdeadyet]

Sorry, I don't mean to speak for the country, only where I practice. Our inpatient unit specifically sets up every homeless vet with housing if they can follow through on a few simple things (like showing up to meet with outpatient social work). Admittedly the process does usually take on the order of 1-2 months, but is only conditional on not trashing place.

Interesting. So they are not discharged to housing but to an offering downstream with shelter in the interim? This is similar to ours, actually. My read of your post sounded like vets were given housing after leaving the inpatient unit.

Conditions our way can include things like no spouses/partners, which can be a deal killer for many. Some are sober only. The "no trashing the place" reduces options dramatically as well; when the vet gets flagged at a few places, he can quickly become SOL.

 

[freaker]

Ours do when they can, but one of the biggest complaints of patients on the unit is that their payee is stealing their money and they demand to no longer have a payee. I am not sure the exact legality in negotiating it is, but I have noticed their is no easier way to lose any alliance with the patient.

That's why you have the inpatient doctor do that and not the outpatient doctor. It doesn't really matter if the patient hates his inpatient doc. I've had attendings warn patients on on admission that if they come back again to the inpatient unit that they'll be forced to advise for a payee. When that fateful day comes, so be it.

We just referred them to the business office when they had a payee and didn' t like it. Funny, many of them actually turned things around when they didn't have immediate access to crack funds. One of the vets who had 27 lifetime admissions has now had the same job for 4-straight years and no further inpatient admissions during that time.

 

[PistolPete]

Wow, my colleagues and I have had the same experience at the V.A. The majority of the Veterans seen there have all the services in the world available to them, and still can't get it together. It is truly pathetic. However, you have to remember that many of the patients there are paid to be sick and, as one of the LCSWs used to say, the amount these people receive in benefits is much more than any job would pay that could manage to get.

The one good point from my tenure there: It made me admire/respect other cultures much more. I live right on the border of Mexico and the people over there would never ask for repeated handouts and, when given the opportunity to get ahead, really work at it. Then I see the majority of patients at the V.A. who just rape the system and have no shame being a drain on society. It is SUCH contrast.

Very true. Patients 100% service connected for PTSD (which is NOT determined by doctors but by some panel of lay people that looks at HOW MANY TIMES YOU'VE BEEN ADMITTED) get about 5-6,000 PER MONTH. It's crazy. They have an incentive to be "sick" and to be re-admitted every so often simply to keep their claim. Not saying all pts do this, but many do.

 

[PistolPete]

Don't your VA attendings set patients up with payees? That really does a lot for harm reduction and making sure that rent gets paid and so on.

We try. I've sent off forms for the same patient twice (at least) for a payee because he just uses the money to shoot up heroin. Nothing has changed over the past 4 months. Likely the form never gets to the person that is in charge of this stuff, or they simply don't care, and take months (if ever) to get to it.

 

[notdeadyet]

Patients 100% service connected for PTSD (which is NOT determined by doctors but by some panel of lay people that looks at HOW MANY TIMES YOU'VE BEEN ADMITTED) get about 5-6,000 PER MONTH.

Not true.

1. Veterans apply for disability to the VBA, which reviews the psych and medical records. Even with sufficient evidence (multiple psychologists or clinicians diagnosing the patient with testing backing up these diagnoses like CAPS, etc.), the veteran typically goes through an additional C&P exam (comp and pen), which is an independent psychologist/psychiatrist (ideally forensic qualified, but not always).

2. The number of times someone has been admitted (capitalized or not) does not determine whether they meet 100% disability for PTSD. Many veterans with full disability for PTSD are never hospitalized (though many are on the long waiting lists for residential PTSD programs). The C&P determination isn't that clear cut and takes a long time. The recent publicizing of folks waiting 18 months for their disability claim? It's exactly because the process is not the rubber stamp hinted at above.

3. VA Disability varies by severity, but for 100% disability, the 2013 rate is $2,816 per month.

Sorry you're having a rough go of it, PP. The VA definitely does not appeal to everyone, particularly the inpatient units, since there is typically a lower threshold for admission than you'd have at a busy county facility (hence the "Va Spa"). How many of your PGY-2 months are you going to be there?

 

[PistolPete]

OK, guess I was off, but that's what I was told by a psych tech who works for us and is service connected for PTSD. Maybe he gets additional monies for other stuff. Thanks for clarifying notdeadyet.

Yeah, seems like VA is not for me, but I guess that's also valuable information. I have 3 more months second year at the VA, thank god. Then a few rotations here and there later in residency (more addictions, outpt clinic stuff).

Makes me feel a bit better to know that others are in a similar boat. I just wished things were a bit better, especially for those that really put their lives on the line for their countrymen.

Hmm.... gotta look more into child and adolescent. Maybe this will be more my thing, we'll see.

 

[notdeadyet]

Yeah, seems like VA is not for me, but I guess that's also valuable information. I have 3 more months second year at the VA, thank god. Then a few rotations here and there later in residency (more addictions, outpt clinic stuff)
...
Makes me feel a bit better to know that others are in a similar boat. I just wished things were a bit better, especially for those that really put their lives on the line for their countrymen.

If your exposure to the VA has been largely limited to inpatient, you might find your opinion and satisfaction at the VA change when you get more outpatient exposure there. The inpatient units tend to be over-represented with malingering (for 3 meals and a cot, for assistance with services, etc.).

On the outpatient side, you get a wider scope. And depending on your locale, you get a lot of exposure to very fresh PTSD and sequellae of trauma (such as substance abuse). If you're as grateful as you appear for folks who've served, playing a role in treatment in folks not long back and paying the price can be extremely satisfying. Probably more so than caring for a middle aged guy that admits himself to the inpatient unit every time he has a fight with his wife because he was lucky enough to have his first psychotic break during basic training.

And one thing that I try to keep in mind when doing the inpatient thing at the VA: one of the reasons you have such a low acuity at many VA inpatient units is because the veterans have a pretty impressive suite of mental health care options and social services as outpatient. There are a lot of veterans with very serious psychiatric pathology out there in the community, but one of the reasons you don't see them cycling through the VA inpatient unit as much is because of the hard work of a lot of social workers, psychologists, and psychiatrists with a pretty cool arsenal of programs. And you'll be doing your part there soon enough.

 

[markglt]

what does a typical va attending make?

 

[kugel]

When I was a resident at the VA and Univ hospital, and someone came in saying he/she needed to be admitted or would drink/drug himself to death or "beat up the next person I see," or "If you don't get me a bed by morning, I promise you that I'll be dead," I would tell the pt that, "There are were no beds open last I looked. I'm happy to go look again when I go back there in an hour or so, but we should make a plan for how you'll get through the night if there's no bed" Then we would spend time coming up with Plan B. As we talked I would get a better sense of whether an admit would solve a problem or just reinforce one. If the answer was that discharge was the correct response, my later search to see if any beds opened up always seemed to come up negative. It was a useful way to get pt's to start thinking about how they could utilize other resources. It worked ~80% of the time.

 

[nitemagi]

Working in enough settings, including more than my share of VA - I'd re-examine the expectations.

There are difficult patients everywhere - VA, community, academic, private hospitals, even in the ivory tower private practice. I know people who are miserable in every one of these, and consider theirs the worst.

To reframe it, though, difficult patients are a challenge. Ask yourself - "presuming there IS a way to help them, how could I do it." These are opportunities to stretch yourself. With chronic, refractory, recidivistic patients the "system" sets very low expectations as to outcome. You can continue that expectation and just do more of the same. Or try something different, on the possibility you could implement change, or grow as a psychiatrist. Even if the outcome isn't perfect, or isn't good, it may help you in practicing something outside of what you're already good at.

I was a VA chief, and sure we saw the revolving door. I liked to work with the system to do other things. What if this was a brief therapy opportunity? How might you do something different to try to prevent a future hospitalization.

 

[ConfettiMD]

Hi all,

So I've been having a hard time dealing with some of my VA patients. The successes have truly been few and far between. So many bounce-backs.

And oh my god, the malingerers... I have such a hard time dealing with them. It's not like the meds do that much, really. Half of them simply need to get clean from alcohol or drugs, and find housing. No 4 or 5 day stay will change that.

I'm glad I found this post so I know I'm not the only one feeling like this. I've been on VA inpatient psych for a couple months and I really dislike it. Dealing with all the malingerers, substance abusers, cluster B's -- it's very emotionally wearing and I'm feeling very burnt out from it, to the point where I have a hard time being emotionally present with the patients who are admitted for very legitimate reasons. I can honestly count the number of rewarding patient interactions I've had in the last couple months on one hand. The progress made with patients feels incredibly slow, or not at all. OP, did you find that it got better when you moved on to other settings?

 

[PistolPete]

Honestly, the stress mostly got better, although it's still very frustrating dealing with inpatients in general, and I don't think I want to do inpatient work (or at least not adults). I'm looking forward to adolescent, and I hope I really like it. I don't think that VA work is for me. Keep with it, the experience you are getting is valuable, even if you don't like it, because knowing what you like and don't is important in and of itself.

 

[Scorcher31]

I've worked with more outpatient and residential VA which I have loved. I have no VA inpatient experience, but have worked in inner cities on large hospital system inpatient units where drug use was rampant.

To me the most logical thing to do is note all the discrepancies in the sx and their stories, potentially using notes from previous admissions as well, diagnose malingering and send them home. We do this all the time with primary substance users faking withdrawal sx (for benzo or opiates) or psychiatric sx (for shelter/food). If patient comes in all the time on the 15 of the month and leaves the 1st of the month, then document the heck out of it.

Option 2 which is less ideal is call it depressive/mood NOS or substance induced, confront them on it tell them you'll let them stay and eat a day or 2 but then they are gone. If you really think they are malingering do not give them a true axis 1 dx or it is just going to perpetuate the problem.

 

[VentJockey]

Part of my work is in the medical side of a VA system, and we see many of these same issues. I have developed a way of looking at it. As I go through one of these patients records, I see something like, 10 admissions over the last three months. I'd love to fix that person and have this one admission be their last. But who about a goal of getting their admissions down to five in the next month. That is a clear trend towards improvement. That's how I keep myself moralized. Smaller goals, one step at a time. Its kind of like the diabetic homeless person with an A1C of 14. I don't expect to get their person to an ideal A1C goal, but that doesn't mean I can't still help them. Get the A1C down to 9 and you have tremendously reduced the chances (or at least delayed the onset) of things like kidney failure and microvascular disease. Let's try to take these hard cases, and figure out realistic interventions that can help these people.

Also, I find that not many people have candid conversations with the patients. Like, hey man, you're abusing the system. This is a hospital, not a homeless shelter, and you are taking a bed from someone who is really sick when you just need a place to stay. This behavior is wrong, so let's make a plan to help you do the right thing in the future. Its quite amazing, sometimes no one has ever told them that its wrong to malinger and that they are taking resources away from people who really need them. This won't impact everyone but there are some people who will take such a talk to heart.

 

[Shikima]

Two issues about Vets and the VA system - They've been institutionalized to some degree and depend on the system to keep giving to them. (Look at how the military is in general.)

The other is that they've relished in engaging with the sick role and don't want to get better.

Mind you, these are blanket statements and there are always exceptions to the rule. Once you understand the basic tennents, then it'll be easy to work through.

 

[9675flamingo]

When doing a lethality assessment, ALWAYS test for goal orientation. "I Want to Kill Myself." Brush over this with a minimum of concern and take an interest in life problems....especially family members, children, grandchildren. Once you've chatted a bit, say, " And when are you going to see little Johnny ( grandchild) again, do you have plans? They will inadvertantly blurt out that they are going there for Thanksgiving, Christmas, or will see them next week or whatever...FUTURE ORIENTATION. Negates lethality. I did lethality assessments EVERY DAY for 70 patients a day while working in a prison. This is a trick the clinicians there taught me. It was never a wrong call.

Also remember Maslow's Hierarchy, and use your social workers. If people are not reasonably housed, clothed, and fed, they will do WHATEVER they need to do to obtain those things. If those needs are met, the manipulation stops.

You can also REFUSE to medicate a drug user, unless they are willing to seek treatment. I had a great psychiatrist once say, "I'm not going to supplement your drug use. These are ineffective unless you stop using. Until I get a clean urine, you get NOTHING from me. I will happily sign admission papers to the rehab unit." Many, when faced with that, will turn on their heel and leave - or seek treatment. For chronic psychotics, use a long acting injectable and make high use of your social workers.

Just some experience from down in the trenches for the last 18 years....

 

[Shikima]

When doing a lethality assessment, ALWAYS test for goal orientation. "I Want to Kill Myself." Brush over this with a minimum of concern and take an interest in life problems....especially family members, children, grandchildren. Once you've chatted a bit, say, " And when are you going to see little Johnny ( grandchild) again, do you have plans? They will inadvertantly blurt out that they are going there for Thanksgiving, Christmas, or will see them next week or whatever...FUTURE ORIENTATION. Negates lethality. I did lethality assessments EVERY DAY for 70 patients a day while working in a prison. This is a trick the clinicians there taught me. It was never a wrong call.

Also remember Maslow's Hierarchy, and use your social workers. If people are not reasonably housed, clothed, and fed, they will do WHATEVER they need to do to obtain those things. If those needs are met, the manipulation stops.

You can also REFUSE to medicate a drug user, unless they are willing to seek treatment. I had a great psychiatrist once say, "I'm not going to supplement your drug use. These are ineffective unless you stop using. Until I get a clean urine, you get NOTHING from me. I will happily sign admission papers to the rehab unit." Many, when faced with that, will turn on their heel and leave - or seek treatment. For chronic psychotics, use a long acting injectable and make high use of your social workers.

Just some experience from down in the trenches for the last 18 years....

👍👍

 

[Armadillos]

..FUTURE ORIENTATION. Negates lethality. I did lethality assessments EVERY DAY for 70 patients a day while working in a prison. This is a trick the clinicians there taught me. It was never a wrong call.

.

I think this effect is more related to your specific population working in a prison. If looking at it statistically its more of a predictive value situation, than a sensitivity/specificity situation. If you have a population with exceedingly high levels of malingering and relatively low genuine suicidality this sort of assessment is going to appear to function well.

In the "real world" of assessing someone at a hospital (which the VA is probably somewhere between prison and real world), seems like there are plenty of people who would be a really high suicide risk while still having thoughts about the future. Suicide is often extremely impulsive, so having plans for christmas is in no way sufficient to say someone is not at risk.

 

[SeniorWrangler]

Once you get out of the mindset that you're there to fix people, it can be a pleasant and educational experience. Just understand that the system is much more powerful than you are, and the system is not designed to make people better. As a psych resident, you are aught up in the VA system, just like your patients.

 

[whopper]

These articles were written by my fellowship PD years ago.

http://www.nationalaffairs.com/public_interest/detail/at-the-va-it-pays-to-be-sick
http://www.jaapl.org/content/24/1/27.full.pdf

And the guy is a liberal, but what goes on is beyond being political. Anyone in such a system, whatever your political bent, if you believe in treating real disorders and not enabling malingering, you'd have to agree with the articles..

 

[CounselortoMD]

When doing a lethality assessment, ALWAYS test for goal orientation. "I Want to Kill Myself." Brush over this with a minimum of concern and take an interest in life problems....especially family members, children, grandchildren. Once you've chatted a bit, say, " And when are you going to see little Johnny ( grandchild) again, do you have plans? They will inadvertantly blurt out that they are going there for Thanksgiving, Christmas, or will see them next week or whatever...FUTURE ORIENTATION. Negates lethality. I did lethality assessments EVERY DAY for 70 patients a day while working in a prison. This is a trick the clinicians there taught me. It was never a wrong call.

Also remember Maslow's Hierarchy, and use your social workers. If people are not reasonably housed, clothed, and fed, they will do WHATEVER they need to do to obtain those things. If those needs are met, the manipulation stops.

You can also REFUSE to medicate a drug user, unless they are willing to seek treatment. I had a great psychiatrist once say, "I'm not going to supplement your drug use. These are ineffective unless you stop using. Until I get a clean urine, you get NOTHING from me. I will happily sign admission papers to the rehab unit." Many, when faced with that, will turn on their heel and leave - or seek treatment. For chronic psychotics, use a long acting injectable and make high use of your social workers.

Just some experience from down in the trenches for the last 18 years....

Good call. I agree 100%.

Also,

"If you were feeling so suicidal yesterday (or last night, two days ago, last week, etc.), then why did you not develop any actual plan for killing yourself? And if you did have a plan, then why are you sitting here today safe-and-sound?

"If you were still actively suicidal this morning (when we discharged you from the inpatient unit), then why didn't you tell anyone about it? Why do you think treatment would help you this time, since it obviously did not work the last time?"

"If you want to kill yourself right now, then why do you care so much about which medications you should receive? Why does it matter to you when your next disability check arrives?

"Since you intend to kill yourself, what difference does it make that you cannot go back to live with your mother unless you complete a treatment program?"

 

[9675flamingo]

I think this effect is more related to your specific population working in a prison. If looking at it statistically its more of a predictive value situation, than a sensitivity/specificity situation. If you have a population with exceedingly high levels of malingering and relatively low genuine suicidality this sort of assessment is going to appear to function well.

In the "real world" of assessing someone at a hospital (which the VA is probably somewhere between prison and real world), seems like there are plenty of people who would be a really high suicide risk while still having thoughts about the future. Suicide is often extremely impulsive, so having plans for christmas is in no way sufficient to say someone is not at risk.

In NYS, over the last 20 years, they have completed a "shell game" in which psychiatric hospital patients were "deinstitutionalized". The 20, 000 or so long term psychiatric patients were sent to inadequate services in the community. The Legislators proudly announced, "LOOK, we have reduced the population in psych centers and have saved millions by closing several of them." Meanwhile, there is one psychiatric center that deals with the entire forensic population of NYS - inpatient, outpatient, medication management, crisis observations, Special Housing Unit Assessments, and Day Treatment programs ( in the prisons). This agency had an increase in it's budget of approximately 1.5 - 6 million dollars per year, as we gradually outfitted the prisons to deal with the exact same population that used to be in the psychiatric centers. I worked for both the forensic hospital, and the satellite units that were within the prisons. Each satellite unit provided day treatment, crisis intervention, mental health assessment, care for the Special Housing Unit, and a regular "outpatient clinic" where patients came for therapy 2X monthly and psych meds once monthly. What happened was the the SPMI population that had been in the institutions, gradually drifted over to the prisons, and the prisons were outfitted to care for this population. I worked all aspects of that for 6 years. I also spent 3 years as the mobile crisis intervention worker in Cattaraugus County. When Gowanda psych center closed, over 800 SPMI people drifted to Cattaraugus County. I would get a call, jump in my truck, run to the site, and either deescalate the crisis, or write an order to get the person emergency psych committed based on their lethality. I also spent 4 years doing rural hospital emergency room assessments. I apologize for leading you to believe the prison was the only forum in which I practiced lethality assessments.

 

[Shikima]

These articles were written by my fellowship PD years ago.

http://www.nationalaffairs.com/public_interest/detail/at-the-va-it-pays-to-be-sick
http://www.jaapl.org/content/24/1/27.full.pdf

And the guy is a liberal, but what goes on is beyond being political. Anyone in such a system, whatever your political bent, if you believe in treating real disorders and not enabling malingering, you'd have to agree with the articles..

Have to agree with this.

It does pay to be sick. The system doesn't encourage wellness, it's more concerned with the bureaucratic process than being engaged with wellness. Same can be said for Medicare(CMS)/Medicaid/JACHO.

 

[motherofmurray]

OK, guess I was off, but that's what I was told by a psych tech who works for us and is service connected for PTSD. Maybe he gets additional monies for other stuff. Thanks for clarifying notdeadyet.

Yeah, seems like VA is not for me, but I guess that's also valuable information. I have 3 more months second year at the VA, thank god. Then a few rotations here and there later in residency (more addictions, outpt clinic stuff).

Makes me feel a bit better to know that others are in a similar boat. I just wished things were a bit better, especially for those that really put their lives on the line for their countrymen.

Hmm.... gotta look more into child and adolescent. Maybe this will be more my thing, we'll see.

Dear PistolPete,
I'm a Child/Adolescent & Adult Psychiatrist in private practice doing lots of psychotherapy and meds as well as having a long stint and a local mental health center treating kids, now doing disability chart reviews part time. I graduated from medical school in 1991, so I'm older but not anywhere near retirement.

Child and Adolescent is no walk in the park either. At least at the VA, you are likely treating the identified patient. What has sucked my soul in my career has been parental/generational psychopathology played out through the children that are brought in to be evaluated… It takes a long time to figure this out, not just the 60" psychiatric evaluation paid for by insurance, that now incorporates the incredibly tedious and useless documentation necessary to get what meager compensation is deemed "usual and customary". Despite what you hear about Veterans not getting services or disability in a timely manner, mental health services for children are woefully underfunded and will stay that way as more of the population ages and our country stays at war. Funding for research in children's mental health issues is pathetic. Drug companies are reluctant to test meds in child psych populations secondary to liability, which is typically when the child becomes an 18 plus a few years, depending upon your state. And guess what, you as a child psychiatrist are liable for medicating children for the same length of time, even if you saw them for one appointment at the age of 4. To add to that, there are very few psych meds approved for children and adolescents so most of the meds you will be prescribing will be off-label, further increasing your liability. Luckily, child psychiatrists are rarely sued, but that doesn't mean that you won't have to document all of this every single time you prescribe a new medication.

Oh yeah, dosing options are rarely appropriate for children, few chewables or liquids (I stopped bothering drug reps about this when Eli Lilly came out with "Puppy Prozac", beef flavored chewable. Clearly, medicating animals was more profitable).

Only 1 of my 8 Child Psychiatrist friends is still seeing a majority of child/adolescents in her practice, the rest see only adults or have left clinical medicine or medicine all together. My advice, learn to love the VA or something like it if you want to stay in psychiatry for the long haul.