Is that how you actually feel about patients who come into the ER who have been taking MAOIs and used drugs? That it's "not our fault" and you don't need to know the interactions between MAOIs and demerol (which was part of the case, if you recall?)? And that it's ok if your patient dies who's in that situation because you are off your rocker with fatigue that is induced by New York Hospital's exploitation of resident labor? And you are SURE New York Hospital wasn't exploiting residents? Do you know their history? Really??
Read the case
http://www.nejm.org/doi/full/10.1056/NEJM198803243181209 (guessing her actual long term diagnoses were Briquet's/Borderline and multiple SUDs)
In the 1980s serotonin syndrome was NOT nearly as well known as it is today (Sternbach's criteria came out in 1991, Hunter in 2003). Anyway, she probably came in with serotonergic toxicity (jerks were probably myoclonus and I guess demerol was not infrequently used back then). Also bear in mind the case was staffed with her PCP who had privileges at NYH and recommended admission in the first place (who later lied under oath). Likewise, multiple toxicologists and other experts testified that the interaction of demerol and and an MAOI was not well known. Yes it was in the PDR but in those days people had to go to Index Medicus to look things up, and there were no pharmacy checks on drug drug interactions either.
Obviously there were lapses in care, and the management was peculiar, but her dad's reaction was ridiculous and was only able to toxically manifest because he was a well known writer and attorney- murder charges with absolutely no
mens rea?? Really? He will forever be remembered as a pariah and a huge POS.
Oh please. There have been weaklings in medicine forever. Medicine is as frail a profession as any other. And the thing about resident work hours depriving trainees of the chance to see patients through their illness came from surgery, not psych. Personally I know of no psychiatric illness that requires a 24 hour in person observation period in order to stabilize the patient. It's hard to come up with many psych illnesses that can't be summed up and dispo'd in half an hour, honestly, if you're on your toes.
I've covered call at over a dozen hospitals at this point, and I know of no hospital that requires psych attendings to come in in the middle of the night for new admissions. Academic hospitals pay lip service to the idea by making residents come in - to justify their existence, no doubt.
But in this field, as far as I'm aware, we have three potentially deadly conditions: dementia, alcohol or barbiturate withdrawal, or anorexia nervosa. All of which are heralded in advance because they are chronic conditions. And none of which we actually manage in the acute or end stage ourselves. So what's with the 24 hours thing? Like, what will be accomplished with that? Will we fill out more forms? Is that it? Because I fill out a lot of forms as it is, and did as a resident. And they are not saving lives.
What's funny is, I agree with you that we could benefit from a full year of internal medicine. But that has nothing to do with "toughness" or work hours.
You are speaking from the point of view of an attending, where practicing inpatient psychiatry is ingrained into your procedural memory, which for most people comes from A LOT of patient experience (high volume, high acuity) and following them longitudinally (unfortunately in acute units and the current revolving door model this is only about a week) I remember as an intern how frustrating it was admitting a lot of patients overnight and then not being able to see their care through to discharge or conversely, getting signout in the morning on a patient without seeing the rawest pathology. As simplistic as it is, I had to actually see dystonic reactions, possible serotonergic toxicity (see above), possible NMS, PNES, emergent withdrawal, etc to actually learn how to manage them (which I could now do over the phone).
Of course I still was fortunate enough to admit and see a large amount of psychopathology and pushed myself to read read read to the point that now I could probably manage everything by phone, but I felt that night float robbed me of an indispensable experience.
I felt weak and useless as a medical student, but as an intern during my inpatient internal medicine months (where we are treated the same as other internal med interns with high volume/high acuity/SICK) is when I really began to "grow up" as a physician- being able to respond calmly when the nurse calls me when a patient becomes septic, starts bleeding out, desats, etc- this was a really maturing experience, but without ICU and with psych intermixed it felt fragmented and incomplete.
