How to Approach Patients You Feel Aren't a Good Fit?

[Mad Jack]

So I currently have a patient that strongly feels like a bad fit for my level of experience and skillset. Multiple comorbidities, likely personality disorder, eating disorder, substantial trauma history, really someone that would need an entire team to care for them and I just feel it's a disservice to try and manage them on my own. It's a child and adolescent case as well, and the parent and child both have treatment priorities that are in strong disagreement with my own assessment. How do I approach this?

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[annoyedpsychiatrist]

"It seems like we have different ideas and directions that we want to go. I think that is understandable, and I respect your autonomy and thought process- sometimes people aren't a good fit for each other. It may be wise to obtain a second opinion through a different provider, who may be able to offer you a different opinion/plan that you would prefer to go with"

 

[Sushirolls]

2nd opinion just means second opinion.
That doesn't mean transfer of care or referral.
Need to be more clear than that. If you want to terminate care, do so, explain why, and make it happen.

I've had 2-3 patients over the years for more severe medical comorbid I referred to Big Box shops so they would have their records in Epic and their other doctors could see their notes more readily.

One recently, had a CAP (adult patient), but wasn't happy with the responsiveness the doc was providing. I explained in context of their axis II, don't change, and the CAP is better suited to diagnosis their concerns of autism... I didn't take the patient on it, but called it a 2nd opinion.

Being CAP, and this a child patient, you might actually be it...

 

[annoyedpsychiatrist]

I try to think of it from a empathetic standpoint too- getting the person to start accept the idea of another provider and start making movement towards that direction. I hate the idea of firing someone (unless they have earned that then it is what it is) and giving 3 months of meds. Some areas the waitlist to see a decent psychiatrist can be long, especially CAP pts. If empathy doesnt work then you may have to go the more assertive route though for sure.. Also sometimes patients go for a second opinion, realize how good they have it with you, and are more apt at changing once they realize their alternative...

Also the goal is psychiatry isnt always to cure people, its to do your best to improve someones quality of life/functioning. Some people never get past a certain baseline.

 

[calvnandhobbs68]

So I currently have a patient that strongly feels like a bad fit for my level of experience and skillset. Multiple comorbidities, likely personality disorder, eating disorder, substantial trauma history, really someone that would need an entire team to care for them and I just feel it's a disservice to try and manage them on my own. It's a child and adolescent case as well, and the parent and child both have treatment priorities that are in strong disagreement with my own assessment. How do I approach this?

I run into this sometimes but a major issue is (and this comes up a lot in psychiatry), does such a service exist in your area? Where can they access this entire coordinated team you're referring to? If they don't already have a separate therapist or a competent therapist, referring them to someone who can do pediatric trauma is absolutely warranted. If you have a specific place or organization in mind that you know can offer such services and may be open to taking new patients, then send them that way. In my area you can refer pediatric patients to community family based therapist teams or MST teams through the county board of mental health but you still end up being the one who manages meds.

I am careful too though about the fact that you might actually be some of the best care in the area....send them to a community mental health center and they may end up with a NP who graduated 4 months ago and a rotating cast of social workers/LPCs.

It's like borderline patients who you can never get into real high fidelity DBT programs...sure that's the ideal but that doesn't even exist in most places or if it does it has a 9 month waitlist or isn't taking new patients unless you can pay out of pocket.

Now if they're blatantly noncompliant with recommendations or rude or aggressive or whatever, then sure discontinue services for that. I also tend to draw the line at real active eating disorders and tell them they need to go to a real eating d/o clinic for at least an assessment and treatment recommendations, as that's very difficult to manage on your own.

 

[clausewitz2]

So I currently have a patient that strongly feels like a bad fit for my level of experience and skillset. Multiple comorbidities, likely personality disorder, eating disorder, substantial trauma history, really someone that would need an entire team to care for them and I just feel it's a disservice to try and manage them on my own. It's a child and adolescent case as well, and the parent and child both have treatment priorities that are in strong disagreement with my own assessment. How do I approach this?

"There's obviously a lot going on in your life and you are dealing with a heck of a lot. nothing is easy for you and there a lot of different issues that are causing you trouble, a lot of them very serious. I think you deserve way more help than I can offer you meeting with you for 30 minutes every [INSERT VISIT FREQUENCY], you need a team of people who can actually address everything you're dealing with all at once and who you can meet with as much as you need to. Honestly, if you were my relative, and I found out that the most you were offered for help was meeting with just a single psychiatrist every [INSERT VISIT FREQUENCY], I'd be furious on your behalf. I think you ought to have the best treatment available, and right now, in this situation, I don't think I'm it."

 

[Merovinge]

I think you need to break this down further. Is the patient:

1) Too symptomatic currently to be appropriate for OP treatment? If so refer to HLoC and make clear that this is a requirement to return to you in treatment that they complete this. This may be for SIB, SI, or the ED. Assuming they get good care, then you may be able to care for them when they step down.

2) Too complex for your skill set? I think fine to refer this out, just making sure you know of places that will take patients like this. My CAP OP colleagues all have extensive screening process to try to avoid having this conversation after establishing care but inevitability some things will slip through the cracks.

3) Pulling out significant counter-transference but otherwise appropriate for OP care? I think it's best to ask colleagues to discuss the case and figure out if you can wrap your head around being able to care for the patient. Especially as a sub-specialist, it's good to be trying to care for the vast majority of patient's that come our way but still know our limits.

 

[comp1]

This is not an answer to how to dump the patient. I'll second the others above here where they said if you're even asking the question, you might actually be the best provider they have access to even if it doesn't feel great. Instead, if you're thinking the patient actually needs a whole team, is there a partial hospitalization program in your area that takes kids? Or if not, a residential program they could be sent to using whatever funding source they have? Of course they'd still be returning to you after the program, but who knows, it might be a better fit after some more acute treatment. I also second the above person asking you to review your countertransference (preferably in your own therapy or supervision).

 

[PikminOC]

"But I came to you. Can't you put a band aid on it?"

 

[randomdoc1]

It's not you, it's me...

Although I agree it is good to evaluate our countertransferance, sometimes it really is not a good fit. Sometimes it truly is hard to keep a therapeutic relationship going and the patient deserves an environment that is safe, supportive and helpful. I have discharged patients who are not a good fit. Some reasons are that I just don't have certain levels of expertise in some said areas, although try as I might to do my best and I may know a place that is available and has more of what they need. Other times I discharged patients is for patient non-adherence to treatment. There reaches a point where every visit literally for years becomes the same discussion over and over and it literally goes no where. Such as continued dysfunction personally and occupationally due to personality disorder/substance use/etc. But yet the patient refuses to engage in more intensive evidence based treatment, they are making zero progress, show no evidence of effort. It's just my stance, but I feel like it is really a waste to come to a visit and vent. Whereas there are so many people ready to make the jump and change. A little tough love may be just the right amount of push to incentivize change.

 

[Stagg737]

Lay out your treatment plan and explicitly state what you believe the appropriate treatment is along with what you are and are NOT willing to do. Explain why you feel that's the correct plan, what you feel acceptable alternatives could be, and why you are not willing to do X, Y, and Z. Provide them with alternative options to other psychiatrists/therapists/whoever that they can turn to for a second opinion or to seek further care. Set firm and clear boundaries and let them choose.

At that point, you've done everything you can. If they choose to leave, then best of luck to them. If they choose to stay, you've already laid out all expectations for care and what this relationship will be. If they don't respect those boundaries or are causing problems, you can fire them and remind them of the other clinics/options you initially gave them.

Situations like this are part of why I hated my outpatient year in residency, as my panels seemed to be heavy with patients who I had to have this discussion with. Most of them begrudgingly accepted my general plan, several of them agreed that we were not a good fit, and I fired a one or two of them. One or two of them ended up coming back and doing surprisingly well, but I believe it was primarily because we set firm boundaries early and were straightforward and realistic with setting expectations.

 

[Mad Jack]

I just wanted to thank everyone for your advice and guidance. I had an honest discussion with the family about my opinions regarding care and my clinical justifications for my treatment decisions. I encouraged neuropsychiatric testing if the family thought it would be helpful in diagnostic clarification, and guided them to resources for same. Basically did some collaborative informed decision making and I'm hopeful I can salvage the case. Seems to be heading in a positive direction at the moment, we shall see. Biggest thing I did was foster hope and direction for future treatment options and decisions, which made the family feel a bit less directionless.

 

[Mad Jack]

This is not an answer to how to dump the patient. I'll second the others above here where they said if you're even asking the question, you might actually be the best provider they have access to even if it doesn't feel great. Instead, if you're thinking the patient actually needs a whole team, is there a partial hospitalization program in your area that takes kids? Or if not, a residential program they could be sent to using whatever funding source they have? Of course they'd still be returning to you after the program, but who knows, it might be a better fit after some more acute treatment. I also second the above person asking you to review your countertransference (preferably in your own therapy or supervision).

Without making the case too specific, higher levels of care have been tried and failed. Patient basically needs ongoing supports and resources, as they don't tend to do well with high-intensity but brief services.

 

[whopper]

I just terminated a patient I've had for years. She's rude to my assistant, often times misses appointments, is on a stimulant and asks for a 4th month prescription after we already gave the legally allowable 3 month's worth.

She just did it again 2 days ago, and I told her she cannot ask us again to do something illegal, and we offered an appointment. She refused. She then asked again today for the 4th month's presecription.

Termination letter is being written this moment by my assistant.

 

[randomdoc1]

I just terminated a patient I've had for years. She's rude to my assistant, often times misses appointments, is on a stimulant and asks for a 4th month prescription after we already gave the legally allowable 3 month's worth.

She just did it again 2 days ago, and I told her she cannot ask us again to do something illegal, and we offered an appointment. She refused. She then asked again today for the 4th month's presecription.

Termination letter is being written this moment by my assistant.

I just could never get my head around why people think it is ok to behave like this and that offices will just tolerate them indefinitely. It makes me feel old when I say "back in my day." lol!

I remember one patient who clearly incurred a bill that was due to his deductible and then a flat out no show. Which he admitted. But he felt he should not have to pay because "think of my long term value to you as a customer." No bro, I don't need you. pay or gtfo. Even though we are healthcare providers, in this private sector we don't HAVE to see anyone or owe you anything. It's not an excuse for being a nasty person.

 

[whopper]

I remember seeing a lot of extremely rude patients in the ER. I'm not talking inappropriate cause of Axis I, I'm talking cluster B stuff. Then finding out they have an outpatient psychiatrist and asking why not see them instead of going to the ER.

Of course sometimes they had a bad outpatient doctor, and I still say this, about 50% of the psychiatrists from my experience are terrible.

But als there's also the hearing replies of "my doctor won't talk to me," or such, and then when we did contact the outpatient doctor the doctor sending us the records showing a litany of no shows, rude behavior, and the doctor terminating the patient after several sincere attempts to work with this difficult person who wasn't doing their own responsibilities.

 

[calvnandhobbs68]

I just could never get my head around why people think it is ok to behave like this and that offices will just tolerate them indefinitely. It makes me feel old when I say "back in my day." lol!

I remember one patient who clearly incurred a bill that was due to his deductible and then a flat out no show. Which he admitted. But he felt he should not have to pay because "think of my long term value to you as a customer." No bro, I don't need you. pay or gtfo. Even though we are healthcare providers, in this private sector we don't HAVE to see anyone or owe you anything. It's not an excuse for being a nasty person.

It's because a lot of clinics will let them get away with it, especially in an academic center or large hospital system. It can be basically impossible to "fire" patients in a lot of big systems, at most they just get shuffled around to a different person in the same system. So yeah, sometimes patients are used to being treated like they're a customer at Target and can just act however they want.

 

[randomdoc1]

It's because a lot of clinics will let them get away with it, especially in an academic center or large hospital system. It can be basically impossible to "fire" patients in a lot of big systems, at most they just get shuffled around to a different person in the same system. So yeah, sometimes patients are used to being treated like they're a customer at Target and can just act however they want.

lol, I was thinking the same thing. You'd think eventually they'd get the hint. Because I remember at the VA, even though you could not fire anyone, it was clear certain people the psychiatrists did not want to work with and it made it harder for these patients to get an appointment and the continuity of care would get broken. The desk staff may not say things outright, but you can tell from the body language that they are not liked. Granted, if a person is antisocial, they don't care although many don't have antisocial and they do. I know, human behavior is human behavior.

People at my office get shocked because we set the boundaries straight away. In our text reminders, initials and signature on intake papers, signs in the office, voicemail greetings etc. If they cross that boundary, they get the feedback stat. Especially when it comes to finances, many are used to skipping by and accruing tens of thousands on their balance and still coming. But here, when they say "oh yea, I'll call back with my card" and most never do and they are contacted about the balance and future appointments, they're pretty shocked lol. Some very very personality disordered individuals try to fight it and get their way (e.g. lying, staff splitting). Especially when they realize it is a nice clinic with really good providers (so they want to stay in the clinic) but yet they don't want to show mutual respect. I just say "peace out..." If they are unwilling to demonstrate such basic skills sets for their own benefit in our common area soon as they step out of the therapy session--I really don't see the point of them continuing care here-->they don't want to actually make progress. Then the surprise when they are discharged lol.

At the end of the day, the mental health of my employees matters too. The flow of the clinic matters. I don't want to waste appointment slots because of someone being non-committal because other patients also deserve a chance. That and the chaos and actual labor costs of dealing with the chaotic dynamics--it actually costs money and reaches a point where you can even be at a net economic loss dealing with stuff like this chronically. So in the more difficult population the brutal answer is "no, the world does not revolve around you, whether you like it or not." Plus it can further entrench that behavior the more people put up with it. So in a way, the boundary is for their own good.

 

[whopper]

This is a significant reason why I enjoy doing private practice in my now older age. My tolerance for BS has gone down. I remember almost daily dealing with several extremely rude patients in the ER, and being treated like dirt by non-psych colleagues while in the hospital. At least weekly I'd hear some gibberish from some other doctor that "psychiatry is BS" and then same doctor a few days later is begging for a consult, then we get the patient better, same doctor is actually nice to me for a few days, then a few days later he's back to saying "psychiatry is BS."

 

[clozareal]

The best way to fire a patient is not to take them on in the first place. I still do phone calls with patients for this reason. How they communicate with me, the punctuality and if they miss it, the motivation to get it scheduled, and then listening to their concerns on the phone goes a long way. I've started to develop an ear for it now and it's tough to write what I mean by that. I don't think I get a ton of red flags for most patients, but mostly yellow ones. here is my list of yellow flags off the top of my head that is not all inclusive:

• if I ask a question and they don't answer it or give a long winded response
• if they're rude or hostile in their language
• if they call me by my first name without knowing me
• if they currently have a psychiatrist but can't say why they want to switch over to me. Red flag for bashing their old psychiatrist.
• if they are too idealistic and hopeful for treatment with me
• if they give me an indication of entitlement. For example, when they send a new patient request, they tell me that they want to be seen within the next few days for an intake and then get upset when I tell them I'm scheduling 2-4 weeks out (fast for CAP).
• if an adult patient has their family contact me instead of them. i make the adult contact me first.
• if a teenager doesn't want to be seen or doesn't think there is anything wrong
• if a person wants to be evaluated for a stimulant medication or benzo rather than for inattention or anxiety
• if another psychiatrist is referring them to me when they have openings. why don't they want to take that patient for themselves?
• if they're currently seeing an NP and on a wacky regimen (standing benzo+stimulant+antipsychotic+SSRI+2 non-benzo Z drugs. I kid you not) and want to switch over to me

If I have to fire a patient, I tend to make it about me and how I don't have the appropriate skillset or level of support for them rather than making it about them.

 

[randomdoc1]

If I have to fire a patient, I tend to make it about me and how I don't have the appropriate skillset or level of support for them rather than making it about them.

It's not you, it's me...(but it's really you!) lol

I really try to train the folks answering the phone how to gather baseline info, down to it being a script they just have to read off. Most of the people who answer the phone are young, naive, can be easily sucked into the Axis II although the young folks have good intentions at heart. Just yesterday, a prospective patient called and from the start it felt like a benzo call. He asked when our next opening was, was right to the point, quite goal directed. The girl on the phone thought he was "just a nice elderly man." Despite my intensive training of employees to never promise a psychiatry appointment until I've read through the info, she told him right away we are open in two weeks and what the time slots were. He did not directly answer her question about benzos and she told him on the phone we just need to verify everything and get him scheduled. I guess she thought she knew the situation--she was so confident he was just going to be a nice old man. Sure enough, database shows benzos galore, doctor shopping. I gave her another script of what to tell him, that the federal jurisdiction on telehealth practices we'd be unable to accommodate this and to refer him out. I said it will help her get out of the conversation fast because now that he knows there is an opening soon, he will push and push and push for it. Again, she did not use the script, I think she already thought they had some sort of working relationship. Well....she had to deal with 20 minutes of antisocial rage. She frantically looked over to me during the call and I literally fed her the rest of what to say because she had such a hard time getting off the call.

🤣​

 

[calvnandhobbs68]

if a teenager doesn't want to be seen or doesn't think there is anything wrong

One of my least favorites (up there with school refusal), parents dragging their teenager in, "please cure my teenager of being a teenager, he's been talking back to me and smoking weed with his friends".

I don't do my own screenings so I haven't found a way to screen for this yet.

 

[whopper]

My fourth year of residency we had a recurring patient who'd show up about every 2-4 weeks, usually a Friday night crashing from a cocaine high. His characteristic crash involved him going to the hospital, saying he was suicidal (he never really was but made the claims), expected to get admitted and have the nurses take care of him during his crash that lasted about 1-2 days. He'd just resume the behavior over and over. After seeing him admitted several times over the course of years, the treatment team was under the opinion that the hospitalizations were actually enabling his abuse because it gave him a comfortable place to stay after he used cocaine.

So I tried to have him blocked from being admitted. It worked the first time but by next time he made threats that if he didn't admit him he'd self-harm an if this happened he'd sue us. Aside that would likely never get far in court, I was still determined to put my foot down. Despite that I was a resident, I was the chief, I had more respect in keeping malingerers and other patients that weren't good fits for inpatient from being admitted and had more credibility among the department than many of the attendings.

A threat he made was that his brother was a VIP in the local community, and that if he self-harmed there would be hell to pay. I took it as a BS cluster B threat, but reported it to my department head who up until that point had my back and she too was familiar with this guy. She talked to the hospital legal and within a few hours they told her and I that this guy's BS threat was real. He was related to some bigshot family member who could make life hell for the hospital and our department. People from the administration (and yes I know this is inappropriate) gave us the order that we needed to admit this guy pretty much every single time.

So I'm pissed. A few days of thinking about it I came up with a new strategy. He had to be admitted? Fine. HE was going to be kept 23 of the 24 hour maximum we could keep him in the ER. While in the ER the only food you can get is pretzels and water. Then if he was going to be admitted, he got a low calorie, high potassium (edit: low potassium), lowfat vegan diet. So it's a few days later and he's back and plan was put into action. He was told to wait on a bed for 23 hours. Then he's admitted and he's pissed with his diet. He insisted on seeing the patient's right's advocate.

Patient's right's advocate told me I had to produce at least 2 evidenced based articles that a vegetarian diet improves mood, so voila went to Pubmed and found two articles that backed it up, printed them and showed them to the Advocate (not knowing before then if there was any evidence backing this up. Heck I just saw an article showing there's higher depression with vegetarians, but whatever).

So the Advocate told the guy that he couldn't advocate for a regular diet and that as a provider I was within my rights to only provide a diet that had evidenced-based data backing it up. The guy was pissed and wanted to leave AMA. So then I told him he couldn't leave AMA cause he just told us he was suicidal. Then he admitted all of it was BULL$HIT and told us he loves cocaine, is not going to stop it, and this was all drug abuse and not depression or anything else. Admitted he was manipulating us and everything I theorized he was doing, that was using the hospital as a place for other people to make his food, do his laundry etc. Then after I wrote down all of his comments in quotes we discharged him.

So it's a week later and he's back on the ER and I'm on duty and he sees me and he's like "you again? PHUCK!" and leaves AMA from the ER. All the residents on duty were told to follow the above instructions. Another time he showed up, we told him we were going to again do the 23 hour hold, after 12 hours of pretzels and water he got sick of it, said he was leaving AMA, and then the resident called me up, I told him to hold the patient another 8 hours saying we had the right to do so because the patient alleged he was suicidal (that we knew was BS), but then let him go 8 hours later while the guy kept asking us to be discharge. "No. You told us you're suicidal. We have to make sure you're safe. Would you like some pretzels?"

The guy showed up at least monthly, but after this "behavioral treatment" his self-admissions went to about 1-2 times a year. And yes each time he saw us we did sincerely refer him to substance abuse services but he told us he wasn't interested and often some type of "go eff yourself" type of comment.

Whenever I had reason to believe a patient was malingering when I ran a forensic unit I'd intentionally put the patient as roommates with the most annoying patient on the unit that wouldn't shut up. Often times guys pretending to be psychotic after being with the annoying patient would very clearly and coherently advocate that they wanted a different room? "You're showing some incredibly reasonable and goal-directed thinking. What happened to that guy that was acting confused and mumbling all the time?"

I also had a patient I nicknamed "Stool Pidgeon Jim." The guy was an NGRI patient who was stabilized on meds and had been stable for years but wasn't getting out cause he committed a violent crime. The guy was very cooperative and wanted a nice unit. Jim also spilled the beans on anyone that had a hidden agenda, whether it be malingering, or planning a violent act. So if the annoying guy wasn't available Stool Pidgeon Jim was the next best choice.

 

[PikminOC]

This is a great thread. Thanks for everyone posting. I agree wholeheartedly about protecting the staff too.

 

[Celexa]

My fourth year of residency we had a recurring patient who'd show up about every 2-4 weeks, usually a Friday night crashing from a cocaine high. His characteristic crash involved him going to the hospital, saying he was suicidal (he never really was but made the claims), expected to get admitted and have the nurses take care of him during his crash that lasted about 1-2 days. He'd just resume the behavior over and over. After seeing him admitted several times over the course of years, the treatment team was under the opinion that the hospitalizations were actually enabling his abuse because it gave him a comfortable place to stay after he used cocaine.

So I tried to have him blocked from being admitted. It worked the first time but by next time he made threats that if he didn't admit him he'd self-harm an if this happened he'd sue us. Aside that would likely never get far in court, I was still determined to put my foot down. Despite that I was a resident, I was the chief, I had more respect in keeping malingerers and other patients that weren't good fits for inpatient from being admitted and had more credibility among the department than many of the attendings.

A threat he made was that his brother was a VIP in the local community, and that if he self-harmed there would be hell to pay. I took it as a BS cluster B threat, but reported it to my department head who up until that point had my back and she too was familiar with this guy. She talked to the hospital legal and within a few hours they told her and I that this guy's BS threat was real. He was related to some bigshot family member who could make life hell for the hospital and our department. People from the administration (and yes I know this is inappropriate) gave us the order that we needed to admit this guy pretty much every single time.

So I'm pissed. A few days of thinking about it I came up with a new strategy. He had to be admitted? Fine. HE was going to be kept 23 of the 24 hour maximum we could keep him in the ER. While in the ER the only food you can get is pretzels and water. Then if he was going to be admitted, he got a low calorie, high potassium, lowfat vegan diet. So it's a few days later and he's back and plan was put into action. He was told to wait on a bed for 23 hours. Then he's admitted and he's pissed with his diet. He insisted on seeing the patient's right's advocate.

Patient's right's advocate told me I had to produce at least 2 evidenced based articles that a vegetarian diet improves mood, so voila went to Pubmed and found two articles that backed it up, printed them and showed them to the Advocate (not knowing before then if there was any evidence backing this up. Heck I just saw an article showing there's higher depression with vegetarians, but whatever).

So the Advocate told the guy that he couldn't advocate for a regular diet and that as a provider I was within my rights to only provide a diet that had evidenced-based data backing it up. The guy was pissed and wanted to leave AMA. So then I told him he couldn't leave AMA cause he just told us he was suicidal. Then he admitted all of it was BULL$HIT and told us he loves cocaine, is not going to stop it, and this was all drug abuse and not depression or anything else. Admitted he was manipulating us and everything I theorized he was doing, that was using the hospital as a place for other people to make his food, do his laundry etc. Then after I wrote down all of his comments in quotes we discharged him.

So it's a week later and he's back on the ER and I'm on duty and he sees me and he's like "you again? PHUCK!" and leaves AMA from the ER. All the residents on duty were told to follow the above instructions. Another time he showed up, we told him we were going to again do the 23 hour hold, after 12 hours of pretzels and water he got sick of it, said he was leaving AMA, and then the resident called me up, I told him to hold the patient another 8 hours saying we had the right to do so because the patient alleged he was suicidal (that we knew was BS), but then let him go 8 hours later while the guy kept asking us to be discharge. "No. You told us you're suicidal. We have to make sure you're safe. Would you like some pretzels?"

The guy showed up at least monthly, but after this "behavioral treatment" his self-admissions went to about 1-2 times a year. And yes each time he saw us we did sincerely refer him to substance abuse services but he told us he wasn't interested and often some type of "go eff yourself" type of comment.

Whenever I had reason to believe a patient was malingering when I ran a forensic unit I'd intentionally put the patient as roommates with the most annoying patient on the unit that wouldn't shut up. Often times guys pretending to be psychotic after being with the annoying patient would very clearly and coherently advocate that they wanted a different room? "You're showing some incredibly reasonable and goal-directed thinking. What happened to that guy that was acting confused and mumbling all the time?"

I also had a patient I nicknamed "Stool Pidgeon Jim." The guy was an NGRI patient who was stabilized on meds and had been stable for years but wasn't getting out cause he committed a violent crime. The guy was very cooperative and wanted a nice unit. Jim also spilled the beans on anyone that had a hidden agenda, whether it be malingering, or planning a violent act. So if the annoying guy wasn't available Stool Pidgeon Jim was the next best choice.

This is my favorite thing I've read all week.

 

[Mad Jack]

My fourth year of residency we had a recurring patient who'd show up about every 2-4 weeks, usually a Friday night crashing from a cocaine high. His characteristic crash involved him going to the hospital, saying he was suicidal (he never really was but made the claims), expected to get admitted and have the nurses take care of him during his crash that lasted about 1-2 days. He'd just resume the behavior over and over. After seeing him admitted several times over the course of years, the treatment team was under the opinion that the hospitalizations were actually enabling his abuse because it gave him a comfortable place to stay after he used cocaine.

So I tried to have him blocked from being admitted. It worked the first time but by next time he made threats that if he didn't admit him he'd self-harm an if this happened he'd sue us. Aside that would likely never get far in court, I was still determined to put my foot down. Despite that I was a resident, I was the chief, I had more respect in keeping malingerers and other patients that weren't good fits for inpatient from being admitted and had more credibility among the department than many of the attendings.

A threat he made was that his brother was a VIP in the local community, and that if he self-harmed there would be hell to pay. I took it as a BS cluster B threat, but reported it to my department head who up until that point had my back and she too was familiar with this guy. She talked to the hospital legal and within a few hours they told her and I that this guy's BS threat was real. He was related to some bigshot family member who could make life hell for the hospital and our department. People from the administration (and yes I know this is inappropriate) gave us the order that we needed to admit this guy pretty much every single time.

So I'm pissed. A few days of thinking about it I came up with a new strategy. He had to be admitted? Fine. HE was going to be kept 23 of the 24 hour maximum we could keep him in the ER. While in the ER the only food you can get is pretzels and water. Then if he was going to be admitted, he got a low calorie, high potassium, lowfat vegan diet. So it's a few days later and he's back and plan was put into action. He was told to wait on a bed for 23 hours. Then he's admitted and he's pissed with his diet. He insisted on seeing the patient's right's advocate.

Patient's right's advocate told me I had to produce at least 2 evidenced based articles that a vegetarian diet improves mood, so voila went to Pubmed and found two articles that backed it up, printed them and showed them to the Advocate (not knowing before then if there was any evidence backing this up. Heck I just saw an article showing there's higher depression with vegetarians, but whatever).

So the Advocate told the guy that he couldn't advocate for a regular diet and that as a provider I was within my rights to only provide a diet that had evidenced-based data backing it up. The guy was pissed and wanted to leave AMA. So then I told him he couldn't leave AMA cause he just told us he was suicidal. Then he admitted all of it was BULL$HIT and told us he loves cocaine, is not going to stop it, and this was all drug abuse and not depression or anything else. Admitted he was manipulating us and everything I theorized he was doing, that was using the hospital as a place for other people to make his food, do his laundry etc. Then after I wrote down all of his comments in quotes we discharged him.

So it's a week later and he's back on the ER and I'm on duty and he sees me and he's like "you again? PHUCK!" and leaves AMA from the ER. All the residents on duty were told to follow the above instructions. Another time he showed up, we told him we were going to again do the 23 hour hold, after 12 hours of pretzels and water he got sick of it, said he was leaving AMA, and then the resident called me up, I told him to hold the patient another 8 hours saying we had the right to do so because the patient alleged he was suicidal (that we knew was BS), but then let him go 8 hours later while the guy kept asking us to be discharge. "No. You told us you're suicidal. We have to make sure you're safe. Would you like some pretzels?"

The guy showed up at least monthly, but after this "behavioral treatment" his self-admissions went to about 1-2 times a year. And yes each time he saw us we did sincerely refer him to substance abuse services but he told us he wasn't interested and often some type of "go eff yourself" type of comment.

Whenever I had reason to believe a patient was malingering when I ran a forensic unit I'd intentionally put the patient as roommates with the most annoying patient on the unit that wouldn't shut up. Often times guys pretending to be psychotic after being with the annoying patient would very clearly and coherently advocate that they wanted a different room? "You're showing some incredibly reasonable and goal-directed thinking. What happened to that guy that was acting confused and mumbling all the time?"

I also had a patient I nicknamed "Stool Pidgeon Jim." The guy was an NGRI patient who was stabilized on meds and had been stable for years but wasn't getting out cause he committed a violent crime. The guy was very cooperative and wanted a nice unit. Jim also spilled the beans on anyone that had a hidden agenda, whether it be malingering, or planning a violent act. So if the annoying guy wasn't available Stool Pidgeon Jim was the next best choice.

Legendary

 

[smalltownpsych]

Without making the case too specific, higher levels of care have been tried and failed. Patient basically needs ongoing supports and resources, as they don't tend to do well with high-intensity but brief services.

Don’t need to get too specific as this is all too often the case. The higher levels of care rarely “fix” or cure the problems and then we are left with how to help the individual function in the environment that they couldn’t function in the first time around. I charge about 2500 a month for supporting young people like this. Individual, family, and group psychotherapy, plus community mentoring with interns. Just need to figure out where we could find a child and adolescent psychiatrist to see these kids.

 

[clozareal]

Again, the ChatGPT response is pretty good but very generic:

1. Consult with colleagues or supervisors: Seek guidance from experienced colleagues or supervisors to discuss the case, and gather their insights and recommendations. They may offer valuable advice on how to handle the situation and help you develop a more comprehensive treatment plan.
2. Consider referral: If you believe the patient's needs are beyond your scope of expertise, it might be best to refer them to a specialist or a multidisciplinary team with experience in treating similar cases. Be transparent with the patient and their parent about your concerns and the reasons for the referral.
3. Communicate your concerns: Have an open and honest conversation with the parent and the child about your assessment and the treatment priorities you believe are important. Explain your reasoning and the potential risks of not addressing those priorities. It's essential to create a safe space for the parent and the child to express their concerns and preferences.
4. Engage in ongoing education: Use this opportunity to expand your knowledge and skills in managing complex cases. Attend workshops, seminars, or conferences, and consult relevant literature to learn about evidence-based practices for treating comorbidities, personality disorders, and trauma.
5. Collaborate with other professionals: Reach out to professionals in different fields, such as psychiatrists, psychologists, social workers, or nutritionists, to create a collaborative care plan for the patient. This approach can help address the various aspects of the patient's condition and provide more comprehensive care.
6. Documentation: Make sure to document your concerns, discussions, and decisions regarding the case. This will help you keep track of the steps you've taken and provide a reference for future consultations or referrals.
7. Self-care and supervision: Managing complex cases can be emotionally and mentally draining. Ensure that you engage in self-care and seek supervision or support from colleagues to maintain your own well-being.

 

[Mad Jack]

Again, the ChatGPT response is pretty good but very generic:

1. Consult with colleagues or supervisors: Seek guidance from experienced colleagues or supervisors to discuss the case, and gather their insights and recommendations. They may offer valuable advice on how to handle the situation and help you develop a more comprehensive treatment plan.
2. Consider referral: If you believe the patient's needs are beyond your scope of expertise, it might be best to refer them to a specialist or a multidisciplinary team with experience in treating similar cases. Be transparent with the patient and their parent about your concerns and the reasons for the referral.
3. Communicate your concerns: Have an open and honest conversation with the parent and the child about your assessment and the treatment priorities you believe are important. Explain your reasoning and the potential risks of not addressing those priorities. It's essential to create a safe space for the parent and the child to express their concerns and preferences.
4. Engage in ongoing education: Use this opportunity to expand your knowledge and skills in managing complex cases. Attend workshops, seminars, or conferences, and consult relevant literature to learn about evidence-based practices for treating comorbidities, personality disorders, and trauma.
5. Collaborate with other professionals: Reach out to professionals in different fields, such as psychiatrists, psychologists, social workers, or nutritionists, to create a collaborative care plan for the patient. This approach can help address the various aspects of the patient's condition and provide more comprehensive care.
6. Documentation: Make sure to document your concerns, discussions, and decisions regarding the case. This will help you keep track of the steps you've taken and provide a reference for future consultations or referrals.
7. Self-care and supervision: Managing complex cases can be emotionally and mentally draining. Ensure that you engage in self-care and seek supervision or support from colleagues to maintain your own well-being.

ChatGPT literally described what I did. Perhaps I've just been a NPC this entire time lol

 

[PikminOC]

It's not you, it's me...(but it's really you!) lol

I really try to train the folks answering the phone how to gather baseline info, down to it being a script they just have to read off. Most of the people who answer the phone are young, naive, can be easily sucked into the Axis II although the young folks have good intentions at heart. Just yesterday, a prospective patient called and from the start it felt like a benzo call. He asked when our next opening was, was right to the point, quite goal directed. The girl on the phone thought he was "just a nice elderly man." Despite my intensive training of employees to never promise a psychiatry appointment until I've read through the info, she told him right away we are open in two weeks and what the time slots were. He did not directly answer her question about benzos and she told him on the phone we just need to verify everything and get him scheduled. I guess she thought she knew the situation--she was so confident he was just going to be a nice old man. Sure enough, database shows benzos galore, doctor shopping. I gave her another script of what to tell him, that the federal jurisdiction on telehealth practices we'd be unable to accommodate this and to refer him out. I said it will help her get out of the conversation fast because now that he knows there is an opening soon, he will push and push and push for it. Again, she did not use the script, I think she already thought they had some sort of working relationship. Well....she had to deal with 20 minutes of antisocial rage. She frantically looked over to me during the call and I literally fed her the rest of what to say because she had such a hard time getting off the call.

🤣​

Good to know I'm not the only one who deals with staff like this

 

[PikminOC]

ChatGPT literally described what I did. Perhaps I've just been a NPC this entire time lol

This explains everything. 🤡

 

[whopper]

Most of the people who answer the phone are young, naive, can be easily sucked into the Axis II although the young folks have good intentions at heart.

While I was at U of Cincinnati, the ER-psych staff, residents, attendings were all on the same page with keeping malingerers out, with people we didn't know we'd thoroughly evaluate them and write the record so that if they showed up again the next clinician would be up to speed on this person.

So I moved out of that area and moved to a new area and joined another institution. There was no ER psych, the ER docs wanted psych patients out of the ER ASAP without thoroughly vetting if they really needed to be admitted, and add on top of this the inpatient psych attendings rotated every 2 weeks among about 8 doctors (but 2 were on duty at a time). I was the only attending that would kick out people where it was blatantly apparent the patient was manipulating the hospital.

So I sincerely tried to get that system changed. Several of the other psychiatrists more or less voiced they would never discharge a patient who wanted to stay saying it wasn't "compassionate." Anti-social and other cluster B patients were filled up the inpatient unit that weren't appropriate for the unit leading to assaults against truly sick patients, those same patients having their homes robbed (cluster B patients would befriend the truly sick patients, get their info, and have an accomplice break into that patient's home) and I brought it up in department meetings but was pretty much ignored.

There were even patients other attendings thought were malingering and wanted me to check them out, but instead of doing the easy and right thing, and discharge the patient themself, or the next best thing, that would be call me up and ask me to check the patient out despite that we had a rotation schedule on inpatient and I was doing something else at that time, the attendings who did this already wrote the patient was "suicidal" even though they didn't believe the patient was suicidal.

So I'd tell them I thought the patient could be discharged but they created a paper mess on the chart where two doctors have conflicting opinions, and because of this I couldn't endorse a dischage, and then the other attending would tell me "but I have to protect myself. I was hoping you'd discharge the patient so I wouldn't have to do it."

I had one patient one day, I walked into his room, and he said "om my god it's you doctor," cause he was from Cincinnati and said, "I know it you're going to kick me out right?" I recognized who he was. He was a known malingerer. I asked him what he was doing in this new city 5 hours away and he told me he hooked up with this girl over the Internet, decided to move over to this new city to give it a try, it didn't work out and he had no place to stay after she kicked him out so he decided to do his usual thing. That is go to the ER and say he was suicidal. I discharged him. He told me he had been in the inpatient unit about 1 week and was even considering moving to this new city permanently cause it was so easy to be admitted. HE was at least nice and polite so I told him my usual in a polite manner. Get out of the hospital, get a job, and stop pretending he's suicidal whenever he has a problem.


When I was on duty, I remember walking into work on a Monday morning and out of my 15 patients literally discharging over 10 the first day. Residents even telling me, "I was counting the days you would come in so we could kick this malingerer out." That was yet another reason why I left that place. That place is still in shambles from what I hear.

So the question is how to deal with it? While I was at U of Cincinnati it was handled the right way. I tried to get it handled the right way at the new place and was pretty much told patients would get to stay as long as they wanted. I left. That's how I dealt with it. I couldn't fight the fire in the house cause my department didn't want to do so. I decided instead to walk away from it.

 

[forchinet121]

While I was at U of Cincinnati, the ER-psych staff, residents, attendings were all on the same page with keeping malingerers out, with people we didn't know we'd thoroughly evaluate them and write the record so that if they showed up again the next clinician would be up to speed on this person.

So I moved out of that area and moved to a new area and joined another institution. There was no ER psych, the ER docs wanted psych patients out of the ER ASAP without thoroughly vetting if they really needed to be admitted, and add on top of this the inpatient psych attendings rotated every 2 weeks among about 8 doctors (but 2 were on duty at a time). I was the only attending that would kick out people where it was blatantly apparent the patient was manipulating the hospital.

So I sincerely tried to get that system changed. Several of the other psychiatrists more or less voiced they would never discharge a patient who wanted to stay saying it wasn't "compassionate." Anti-social and other cluster B patients were filled up the inpatient unit that weren't appropriate for the unit leading to assaults against truly sick patients, those same patients having their homes robbed (cluster B patients would befriend the truly sick patients, get their info, and have an accomplice break into that patient's home) and I brought it up in department meetings but was pretty much ignored.

There were even patients other attendings thought were malingering and wanted me to check them out, but instead of doing the easy and right thing, and discharge the patient themself, or the next best thing, that would be call me up and ask me to check the patient out despite that we had a rotation schedule on inpatient and I was doing something else at that time, the attendings who did this already wrote the patient was "suicidal" even though they didn't believe the patient was suicidal.

So I'd tell them I thought the patient could be discharged but they created a paper mess on the chart where two doctors have conflicting opinions, and because of this I couldn't endorse a dischage, and then the other attending would tell me "but I have to protect myself. I was hoping you'd discharge the patient so I wouldn't have to do it."

I had one patient one day, I walked into his room, and he said "om my god it's you doctor," cause he was from Cincinnati and said, "I know it you're going to kick me out right?" I recognized who he was. He was a known malingerer. I asked him what he was doing in this new city 5 hours away and he told me he hooked up with this girl over the Internet, decided to move over to this new city to give it a try, it didn't work out and he had no place to stay after she kicked him out so he decided to do his usual thing. That is go to the ER and say he was suicidal. I discharged him. He told me he had been in the inpatient unit about 1 week and was even considering moving to this new city permanently cause it was so easy to be admitted. HE was at least nice and polite so I told him my usual in a polite manner. Get out of the hospital, get a job, and stop pretending he's suicidal whenever he has a problem.


When I was on duty, I remember walking into work on a Monday morning and out of my 15 patients literally discharging over 10 the first day. Residents even telling me, "I was counting the days you would come in so we could kick this malingerer out." That was yet another reason why I left that place. That place is still in shambles from what I hear.

So the question is how to deal with it? While I was at U of Cincinnati it was handled the right way. I tried to get it handled the right way at the new place and was pretty much told patients would get to stay as long as they wanted. I left. That's how I dealt with it. I couldn't fight the fire in the house cause my department didn't want to do so. I decided instead to walk away from it.

I don’t think this is relevant to what the OP is talking about. He’s talking about an outpatient clinic and how to end a relationship in clinic not how to discharge malingerers in the ER

 

[PikminOC]

I don’t think this is relevant to what the OP is talking about. He’s talking about an outpatient clinic and how to end a relationship in clinic not how to discharge malingerers in the ER

I think all of it is helpful as we all work in different settings

 

[hamstergang]

I think all of it is helpful as we all work in different settings

But discharging a malingerer from the hospital is really not relevant to telling an outpatient you're not a good fit. Make a new thread about the former if you want it.

 

[randomdoc1]

But discharging a malingerer from the hospital is really not relevant to telling an outpatient you're not a good fit. Make a new thread about the former if you want it.

Well...with all due respect, the patient is now has a relationship going with the hospital. It could be a demonstration of boundary and treatment plan setting like what the OP does in the outpatient setting. If the patient respects it, great. If not, they can go elsewhere. But an outpatient provider or hospital system provider is completely in their right to set those ground rules focused on good care. We're communicating that the continued maladaptive dynamics are not a good fit. This commonly leads the patient to go elsewhere although some think it over and learn from it. <3

 

[Mad Jack]

I think all of it is helpful as we all work in different settings

+1. I also work in adult inpatient, so it's all helpful

 

[PsyDr]

"This is really out of my depth. You deserve someone who knows how to handle cases like yours."

You're not claiming a lack of education, you're not pointing the blame at them, and you're not lying.

 

[Ceke2002]

So I currently have a patient that strongly feels like a bad fit for my level of experience and skillset. Multiple comorbidities, likely personality disorder, eating disorder, substantial trauma history, really someone that would need an entire team to care for them and I just feel it's a disservice to try and manage them on my own. It's a child and adolescent case as well, and the parent and child both have treatment priorities that are in strong disagreement with my own assessment. How do I approach this?

I'm sorry I missed this when you first posted. I have been in this situation, from the patient end, obviously. The one thing I appreciated was that any potential Psych and/or Therapist was upfront and honest with me regarding their willingness and/or ability to take someone with complex mental health issues on as a patient. Having said that, I personally found there was a right and a wrong way for a healthcare professional to brooch the subject of not being able to, or not feeling able to take me on as a patient at that time.

An example of the right way (in my experience):

I go for an initial assessment appointment, it soon becomes clear that the Psych and/or Therapist is either unable or unwilling to take me on as a patient. They are upfront about it, at the same time also letting me know that it's not my fault, that my case requires a level of care they are unable to give & they don't wish to see me short changed (so to speak). They then provide me with a list of Psychs/Therapists who they feel are better suited, and write up a basic care plan for me to take back to my GP including a request for re-referral to any Psych/Therapist on the recommended list I may choose to see. They round things out by ensuring they reiterate a note of hopefulness as opposed to helplessness & ending the session on a positive note.

An example of the wrong way (in my experience):

Any variation of the following words or phrases coming out of a healthcare professionals mouth after an initial assessment appointment -"I doubt you'll find anyone willing to treat you, considering how complex your case is", "You're what we call a 'hopeless case'", "Your condition is simply too chronic for any sort of meaningful treatment," "Your chances of achieving any sort of meaningful recovery are virtually nil, I am only willing to help you live with your condition".