I need a thicker skin. But where can I get one?

[meow1985]

I have a tendency to get lingering awful feeling when I run into unpleasant, stressful, but overall rather routine situations. Patient with borderline and chronic SI refuses to safely plan but is not hospitalizable because SI is not bad enough *lately*? Anxiety for the rest of the day. Had to set limits about taking med not as prescribed and patient started crying or accusing me of not helping? Feel like I’m **** and how awful next visit is going to be with them. Feel like that all day. Don’t know what to do with a patient, patient not opening up, patient not following treatment recs but still keeps coming to see me for some reason? All of that just leads to awful feelings of how bad of a doctor and a person I am that I drag around like a ball and chain for days.

Update on notes — I’d really do them much faster if I didn’t feel like each note was me essentially revisiting the encounter and all the feelings that came with it. Many are just fine, but some are unnecessarily difficult not only because I’m defensively over documenting and managing the feelings that come up.

PS: on a related note, can you tell patients that if they will not follow treatment recs, such as safely planning, going to rehab, or whatever else you want them to do to reduce their risk, you are not going to be their doctor anymore? How often do other people do it? Obviously I’d refer elsewhere, so as not to run afoul abandonment laws.

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[robellis]

I have a tendency to get lingering awful feeling when I run into unpleasant, stressful, but overall rather routine situations. Patient with borderline and chronic SI refuses to safely plan but is not hospitalizable because SI is not bad enough *lately*? Anxiety for the rest of the day. Had to set limits about taking med not as prescribed and patient started crying or accusing me of not helping? Feel like I’m **** and how awful next visit is going to be with them. Feel like that all day. Don’t know what to do with a patient, patient not opening up, patient not following treatment recs but still keeps coming to see me for some reason? All of that just leads to awful feelings of how bad of a doctor and a person I am that I drag around like a ball and chain for days.

Update on notes — I’d really do them much faster if I didn’t feel like each note was me essentially revisiting the encounter and all the feelings that came with it. Many are just fine, but some are unnecessarily difficult not only because I’m defensively over documenting and managing the feelings that come up.

PS: on a related note, can you tell patients that if they will not follow treatment recs, such as safely planning, going to rehab, or whatever else you want them to do to reduce their risk, you are not going to be their doctor anymore? How often do other people do it? Obviously I’d refer elsewhere, so as not to run afoul abandonment laws.

As long as it’s not an emergency situation you can certainly fire a patient for whatever reason you want. Also why would a patient refuse to safety plan? I don’t understand what you mean just discuss quickly what they would do if having SI and call that a safety plan it doesn’t have to be this complicated thing, I feel you’re likely over complicating a lot of things and if you see other peoples notes they are not that complicated. Also if a patient is not taking meds as prescribed you don’t need to confront them and “set limits” just document it and be empathetic and state your recommendations and move on

 

[meow1985]

As long as it’s not an emergency situation you can certainly fire a patient for whatever reason you want. Also why would a patient refuse to safety plan? I don’t understand what you mean just discuss quickly what they would do if having SI and call that a safety plan it doesn’t have to be this complicated thing, I feel you’re likely over complicating a lot of things and if you see other peoples notes they are not that complicated. Also if a patient is not taking meds as prescribed you don’t need to confront them and “set limits” just document it and be empathetic and state your recommendations and move on

By refuse to safety plan I mean I ask them what they could do or who they could talk to if SI escalated and they don’t have a meaningful answer, and they reject offers of emergency resources. But SI is not bad enough to hospitalize so you are stuck.

Not taking controlled meds as prescribed can be dangerous and is against the controlled substance rules, which exist for a reason. Telling them that = setting limits.

 

[meow1985]

As long as it’s not an emergency situation you can certainly fire a patient for whatever reason you want. Also why would a patient refuse to safety plan? I don’t understand what you mean just discuss quickly what they would do if having SI and call that a safety plan it doesn’t have to be this complicated thing, I feel you’re likely over complicating a lot of things and if you see other peoples notes they are not that complicated. Also if a patient is not taking meds as prescribed you don’t need to confront them and “set limits” just document it and be empathetic and state your recommendations and move on

But you are right. I tend to be a pretty complex thinker and that is just not a good fit for modern clinical medicine.

Too bad research was not a good fit either every time I tried to do it in my life

It’s also annoying that so many other “providers” provide substandard clinical care with very little time and thought put into anything they do, and probably lose not a wink of sleep.

 

[robellis]

But you are right. I tend to be a pretty complex thinker and that is just not a good fit for modern clinical medicine.

Too bad research was not a good fit either every time I tried to do it in my life

It’s also annoying that so many other “providers” provide substandard clinical care with very little time and thought put into anything they do, and probably lose not a wink of sleep.

LOL you think everyone is taking your controlled meds as prescribed? LOL..calm down man it’s not that big of a deal..you’re not their mother..you give your recommendation and move on..also what do you mean they don’t have a meaningful answer to safety planning? You simply tell them what they can do..call mom or call 911 or go for a walk or whatever the hell it is and then document you reviewed a safety plan..again not that complicated

 

[Auvelity]

I would add also you should evaluate your own countertransference that you are having with this patient and discuss it with your supervisor if you have one. Or your own psychologist

Seems like you are taking this patient personality as a personal offense and we all get patients like that. Confronting is not always a good approach and should be done when the time is correct. Remember you have to establish therapeutic alliance first for things to flow and sounds like patient closed off and got dismissive based on the confrontation. At times supportive therapy, letting them be and know that you are there for them and they can go to the emergency if at any point he feels he can’t control his SI works as reviewing the safety plan.

 

[calvnandhobbs68]

By refuse to safety plan I mean I ask them what they could do or who they could talk to if SI escalated and they don’t have a meaningful answer, and they reject offers of emergency resources. But SI is not bad enough to hospitalize so you are stuck.

I mean borderline patients do this all the time. That's like par for the course. If BPD patients could safety plan effectively all the time, they wouldn't keep ending up in the ER and the hospital. Rest easy in knowing that the best treatment for borderline personality disorder is consistent contact with outpatient treatment, not inpatient hospitalization, so you are in fact providing best care for this patient by teaching them they can manage their chronic suicidality in the community and you aren't going to freak out every time they say they're having worse thoughts about wanting to kill themselves.

If you haven't read this book already, it may be helpful in conceptualizing the goals of long term treatment for chronic suicidality/borderline personality disorder:

APA - Handbook of Good Psychiatric Management for Borderline Personality Disorder

www.appi.org

 

[meow1985]

I told them to call 911 and go to the ER if they had SI and they said no. They even explained why they did not like those options based on their last crisis experience. If it’s not a hold worthy situation in the moment, I guess I just document that and move on?

 

[robellis]

I told them to call 911 and go to the ER if they had SI and they said no. They even explained why they did not like those options based on their last crisis experience. If it’s not a hold worthy situation in the moment, I guess I just document that and move on?

Correct this is textbook borderline they are just trying to get an emotional response from you..at the end of the day you cannot stop this person from killing themselves..you can just advise of what you would recommend and the rest is on them..some will die and some you will save and that is the life we live

 

[meow1985]

I mean borderline patients do this all the time. That's like par for the course. If BPD patients could safety plan effectively all the time, they wouldn't keep ending up in the ER and the hospital. Rest easy in knowing that the best treatment for borderline personality disorder is consistent contact with outpatient treatment, not inpatient hospitalization, so you are in fact providing best care for this patient by teaching them they can manage their chronic suicidality in the community and you aren't going to freak out every time they say they're having worse thoughts about wanting to kill themselves.

If you haven't read this book already, it may be helpful in conceptualizing the goals of long term treatment for chronic suicidality/borderline personality disorder:

APA - Handbook of Good Psychiatric Management for Borderline Personality Disorder

www.appi.org

Good psychiatric management is well and good until a chronically suicidal person offs themselves and the family sues you for not doing enough. Good psychiatric management is all about tolerating risk as a clinician.

I try to meet patients where they are at and not force or confront unless very much necessary. I am all about therapeutic rapport. But it makes it very hard to sleep at night when people are gamey and decline therapy, decline rehab, refuse to stop their high risk behavior and won’t even agree to go to the ER if they were to be unable to maintain safety, but they are not quite bad enough for you to commit them… yet. Borderlines also need clear boundaries and I am getting less and less patient with any new ones who end up on my panel. This high risk person lands in my lap and I’m responsible for their safety from the word go and they give non answers and turn everything down? Beyond frustrating.

But to return to the original point, all this is fairly routine. I feel like I’m getting worked up excessively here, and yet it’s really hard to let it go.

 

[calvnandhobbs68]

Good psychiatric management is well and good until a chronically suicidal person offs themselves and the family sues you for not doing enough.

I try to meet patients where they are at and not force or confront unless very much necessary. I am all about therapeutic rapport. But it makes it very hard to sleep at night when people are gamey and decline therapy, decline rehab, refuse to stop their high risk behavior and won’t even agree to go to the ER if they were to be unable to maintain safety. Borderlines also need clear boundaries and I am getting tired of the gaminess.

But to return to the original point, all this is fairly routine. I feel like I’m getting worked up excessively here.

Hey that's fine if you already feel you know how to manage a borderline patient outpatient, no problem. You also must have a very good medico-legal grasp of what criteria constitute police being called for involuntary evaluation and hospitalization in your state. You've clearly got it, just like the other threads you open which end up at some point with you arguing with everyone about how whatever they suggest just doesn’t work for you.

I honestly need to stop opening up threads started by you cause all the whining and help rejecting is starting to get annoying.

 

[meow1985]

Hey that's fine if you already feel you know how to manage a borderline patient outpatient, no problem. You also must have a very good medico-legal grasp of what criteria constitute police being called for involuntary evaluation and hospitalization in your state. You've clearly got it and have nothing else to learn.

I honestly need to stop opening up threads started by you cause all the whining and help rejecting is starting to get annoying.

At the risk of sounding help rejecting, the question in the thread was how do I manage my feelings about my patients and my decisions, not how do I manage a borderline. Also if I can fire patients, to which the answer is yes.

 

[Crayola227]

I don't know how to help you come to terms and realize that yes, these people are sick and a lot of this is a manifestation of their illness, but no, eve though you are here to help them, you are not responsible for them.

They are coming to your office for help, so they have some insight and obviously some desire to help themselves. If they don't want to go further and take your actual advice, that's on them, not you. Obviously document and take the steps you need to medicolegally to CYA.

Don't want to get into medical advice, but you sound like a patient. A lot of psychs need meds themselves and certainly a hefty dose of psychotherapy to get some insight and deal with these feelings.

I personally rely on rationalization, a lot. Continually reminding myself this isn't personal and it isn't actually my problem. See yourself as a professional advice giver. You give advice. It isn't your job to make people do things or fix them. (If you need to call cops that's a different matter, do it.)

Therapy might help you identify other things for coping. As a physician, I've found it important to have pleasant things I do have more control over and help me feel good and effective, so I'm getting that need met despite work, because work is not always a good place to get your feelings of effectiveness and competency, because of the degree that can depend on patients, who you can't control. For me, that can be gardening and cooking.

The reality is it's a job and a grind. Expect to go through the motions and not fix people. Be pleasantly surprised and pleased when it's clear that you really made a difference and reached someone. Which frankly, has as much to do with the luck of running across who that particular patient is as a person, as it is anything you specifically did for them. Patients that can be helped, tend to be. Many others, remains to be seen with time if at all.

 

[splik]

Good psychiatric management is well and good until a chronically suicidal person offs themselves and the family sues you for not doing enough. Good psychiatric management is all about tolerating risk as a clinician.

I would not be so worried about risk of lawsuits with chronically suicidal patients. For high risk patients, there is often a feeling of inevitability that they might one day end their lives despite what we offer and families are either so grateful for the care you have provided or so dysfunctional and abusive that the jury will think the family is responsible for the death of the loved one (or there will be a ton of stuff they don't want coming out in deposition). It is quite hard to be sued successfully as an outpatient psychiatrist. Usually, successful lawsuits will involve care on inpatient units or emergency settings. In outpatient setting, failure to act with acutely suicidal patients (e.g. failure to hospitalize) may lead to lawsuits. Careful documentation will lessen your risk of a lawsuit as well. This documentation will have serial risk assessments indicating that the baseline risk of suicide is chronically elevated and the steps you have taken to mitigate this (and patient's failure to follow your recommendations etc). It is hard to terminate these patients, so if you're not equipped to deal with them (e.g. have no case management services, access to DBT, ability to see them regularly etc) then it is better to screen them out in the first place. If you are going to terminate, then it is better to hospitalize them first, then terminate, then it is on the inpatient team to arrange appropriate follow up care. Also, you should assume that terminating/abandoning pt will be a trigger for a suicide attempt for many of such patients so if handled inelegantly you could be liable.

 

[Fan_of_Meehl]

I have a tendency to get lingering awful feeling when I run into unpleasant, stressful, but overall rather routine situations. Patient with borderline and chronic SI refuses to safely plan but is not hospitalizable because SI is not bad enough *lately*? Anxiety for the rest of the day. Had to set limits about taking med not as prescribed and patient started crying or accusing me of not helping? Feel like I’m **** and how awful next visit is going to be with them. Feel like that all day. Don’t know what to do with a patient, patient not opening up, patient not following treatment recs but still keeps coming to see me for some reason? All of that just leads to awful feelings of how bad of a doctor and a person I am that I drag around like a ball and chain for days.

Update on notes — I’d really do them much faster if I didn’t feel like each note was me essentially revisiting the encounter and all the feelings that came with it. Many are just fine, but some are unnecessarily difficult not only because I’m defensively over documenting and managing the feelings that come up.

PS: on a related note, can you tell patients that if they will not follow treatment recs, such as safely planning, going to rehab, or whatever else you want them to do to reduce their risk, you are not going to be their doctor anymore? How often do other people do it? Obviously I’d refer elsewhere, so as not to run afoul abandonment laws.

I feel ya. This is a brutal profession. You have to be 'plugged in' enough and keep your eyes/heart open enough to be attuned to what's going on (psychopathologically) with your clients, but have the ability to objectify what's going on between you and the client enough to remain clear-headed and also to just survive to the end of the shift/week/month without completely burning out.

A few things I try to use:

1) mindfulness - whenever my own crazy worried mind starts to spin up possible catastrophic futures...take a step back and focus on my breath, anchoring in the moment, focus on the soles of my feet...focus on the fact that a lion isn't actually chasing me in the moment and I don't have to literally flee for my life
2) realize that I can only affect things that are actually under my control (acceptance?); even if the system or boss that I work for is being completely irrational and holding me responsible for ensuring the perfect safety of all my clients at all times, this is not the actual standard of care...the actual standard of care is far more reasonable and achievable
3) in mental health practice, chaos/uncertainty is the norm and the ether within which we swim, we can only MANAGE risk, not ELIMINATE it (again, supervisors and systems that are hell-bent on insulating themselves from any possibility of blame/accountability will tend to construct policies/procedures that place all the responsibility on the provider (while simultaneously stripping them of all authority) but this is a SYSTEMS issue
4) find at least one (preferably more) sane practicing colleagues within your system with whom you can have off-the-record conversations about the REALITY of clinical practice and its challenges rather than the IDEAL of clinical practice mandated/instituted in a top-down fashion by non-practicing administrator-types (as I like to call them these days, 'Experts Without Caseloads' ['EWOCs,' for short--think Star Wars])
5) finally, with respect to the borderline dynamics...I mean, I just try to realize and conceptualize that as a PHENOMENON that exists within the population I work with and try not to take it personally (I know it's hard)

Don't know if any of this helps, but it's what comes to mind for me.

Thanks for letting me vent.

 

[Old&InTheWay]

I wonder if it might be helpful to reframe your patients as "the people you work for." They are adults coming to you for advice and help, but at the end of the day they are free to make their own decisions (as they should).

It's a similar struggle for parents. It is easy to develop a narcissistic investment in our children and can see their behavior as reflective of us as parents and people. I used to have so much anxiety about how my kids were acting in public and how that reflected on me. I still do to a degree, but it's much better. I'm not exactly sure what shifted things for me, but I remember someone telling me, "we are responsible TO our children, not FOR their behavior." The only question is: how can I be most helpful to this person?

One more thought, I would also wonder whether a patient with BPD who is realizing that going to the ED and calling crisis every time they have SI is not helpful may actually be gaining some insight.

 

[Fan_of_Meehl]

I wonder if it might be helpful to reframe your patients as "the people you work for." They are adults coming to you for advice and help, but at the end of the day they are free to make their own decisions (as they should).

It's a similar struggle for parents. It is easy to develop a narcissistic investment in our children and can see their behavior as reflective of us as parents and people. I used to have so much anxiety about how my kids were acting in public and how that reflected on me. I still do to a degree, but it's much better. I'm not exactly sure what shifted things for me, but I remember someone telling me, "we are responsible TO our children, not FOR their behavior." The only question is: how can I be most helpful to this person?

One more thought, I would also wonder whether a patient with BPD who is realizing that going to the ED and calling crisis every time they have SI is not helpful may actually be gaining some insight.

This is really on point. From the perspective of pretty much ANY school of psychotherapy, the role of the therapist is not to 'fix' the patient's life but, rather, to provide a specific context (therapy) within which the patient is invited to assume MORE responsibility for their life. Goals in therapy basically translate into either (1) how can/should I change how I relate or respond to other people (think assertiveness skills) and/or (2) how can I change how I relate to my own distress? (think cognitive restructuring, relaxation training, proper use of psychotropic medication). The underlying concept is ALWAYS SELF-CHANGE and the assumption of MORE responsibility for one's own patterns of thinking, feeling, and behaving. I can only INVITE (sometimes repeatedly and ad nauseum) the patient to adopt this perspective. I cannot MAKE them adopt this perspective. I can document my specific efforts to try to help them adopt this perspective (e.g., the specifics of motivational interviewing, Socratic questions, affirmations (of adaptive coping on their part), reflections, and summaries).

Tactically, I always try to respond to patient's complaints of, 'My pain/disorder is serious, you're not helping me (enough)!' with redirection to MORE active therapy (more responsibility/work for the patient). For example, maybe we should consider a more structured protocol therapy for your problem, maybe we need to collaborate in therapy for more structured between-session exercises (homework), maybe we need to meet more frequently, maybe you need a higher level of care (residential? intensive outpatient?). By doing this, you are effectively 'punishing' (from a behavior-analytic perspective) the patient for engaging in 'game-playing' if that is what is going on but you are also appropriately offering (sincerely) MORE therapy for the patient who is in fact serious about wanting the kind of 'help' that you are being paid to provide them.

 

[wolfvgang22]

I feel ya. This is a brutal profession. You have to be 'plugged in' enough and keep your eyes/heart open enough to be attuned to what's going on (psychopathologically) with your clients, but have the ability to objectify what's going on between you and the client enough to remain clear-headed and also to just survive to the end of the shift/week/month without completely burning out.

A few things I try to use:

1) mindfulness - whenever my own crazy worried mind starts to spin up possible catastrophic futures...take a step back and focus on my breath, anchoring in the moment, focus on the soles of my feet...focus on the fact that a lion isn't actually chasing me in the moment and I don't have to literally flee for my life
2) realize that I can only affect things that are actually under my control (acceptance?); even if the system or boss that I work for is being completely irrational and holding me responsible for ensuring the perfect safety of all my clients at all times, this is not the actual standard of care...the actual standard of care is far more reasonable and achievable
3) in mental health practice, chaos/uncertainty is the norm and the ether within which we swim, we can only MANAGE risk, not ELIMINATE it (again, supervisors and systems that are hell-bent on insulating themselves from any possibility of blame/accountability will tend to construct policies/procedures that place all the responsibility on the provider (while simultaneously stripping them of all authority) but this is a SYSTEMS issue
4) find at least one (preferably more) sane practicing colleagues within your system with whom you can have off-the-record conversations about the REALITY of clinical practice and its challenges rather than the IDEAL of clinical practice mandated/instituted in a top-down fashion by non-practicing administrator-types (as I like to call them these days, 'Experts Without Caseloads' ['EWOCs,' for short--think Star Wars])
5) finally, with respect to the borderline dynamics...I mean, I just try to realize and conceptualize that as a PHENOMENON that exists within the population I work with and try not to take it personally (I know it's hard)

Don't know if any of this helps, but it's what comes to mind for me.

Thanks for letting me vent.

Thank you very much for this post, it is helpful to know I'm not alone. I also thank OP and all the other posters.

I mostly like the organization I work at for several reasons, but they put 99% of the responsibility for patient risk or lack of improvement on the clinician. I've experienced a lot of vicarious trauma. I am ashamed to admit I have had passive suicidal thoughts. I told no one other than my spouse. Most of my patients have severe PTSD or C-PTSD with chronic suicidal ideation and substance abuse. When I see a patients with severe schizophrenia it is a relief! I also love my suboxone clinic because it is so easy in comparison. The conditions here result in burn out, and high turnover of colleagues. I think it amounts to psychological abuse by the system. I know there are much worse jobs in other ways, though.

I'm always working on acceptance, and I say the serenity prayer a lot. I am trying to hold on loosely, realizing I can't control much of what others including my employer do, even if it affects me negatively. It's hard to not just give in to apathy or hopelessness. I get outstanding evaluations and bonuses every year, but now the organization is starting to push production, which slowed because of COVID. Lately I'm starting to look into private telepsychiatry. I've considered seeking therapy of my own but I'm unsure they will tell me anything I don't know and just need to practice. Although I think I am very good professionally, I can't wait to retire.

 

[mistafab]

Your role in the patient’s life is to provide good advice. These patients are suffering - and their disease often manifests as maladaptive behaviors. However, just like noncompliance with insulin is maladaptive and is sure to lead to premature death, we do not lock people suffering with diabetes up and force them to take their doses. This comes back to the medical pillar of autonomy.

I would also say that many of your feelings are actually not your own. These are the feelings the patient is suffering with that you are responding to. This is an emotional barometer you can understand as telling you important functional data about how the patient interacts, feels, and sees the world. It’s normal to have emotions when working with patients - we are all humans. Talking about this with your peers or a supervisor may be helpful to help you process this.

 

[Candidate2017]

Good psychiatric management is well and good until a chronically suicidal person offs themselves and the family sues you for not doing enough. Good psychiatric management is all about tolerating risk as a clinician.

This high risk person lands in my lap and I’m responsible for their safety from the word go and they give non answers and turn everything down? Beyond frustrating.

But to return to the original point, all this is fairly routine. I feel like I’m getting worked up excessively here, and yet it’s really hard to let it go.

Yes.

I wonder why society even places a modicum of blame of us for suicide. All we can do is say, "Here's some pills +/- magic words (therapy), please give your guns away, call 911 if you do feel like killing yourself, and BTW do I need to lock you up?"

Look at cardiologists. Has any cardiologist been successfully sued for an MI death in a high risk cardiac patient because they didn't document they discussed removing all junk food/tobacco/cocaine/meth and recommending 30 minutes of daily exercise? Their A&Ps meet the standard of care with alphabet soup: ACS, ICD, EKG WNL, HFpEF 55, ASA, ACEI, WTF, RTC 6 mo etc.

 

[Candidate2017]

Thank you very much for this post, it is helpful to know I'm not alone. I also thank OP and all the other posters.

I mostly like the organization I work at for several reasons, but they put 99% of the responsibility for patient risk or lack of improvement on the clinician. I've experienced a lot of vicarious trauma. I am ashamed to admit I have had passive suicidal thoughts. I told no one other than my spouse. Most of my patients have severe PTSD or C-PTSD with chronic suicidal ideation and substance abuse. When I see a patients with severe schizophrenia it is a relief! I also love my suboxone clinic because it is so easy in comparison.

Ain't no shame in the psych game! It's 100% natural to be driven toward more than just passive SI in this field, as no long as there's no intent of course. Heck, we often joked amongst ourselves in residency about killing ourselves in front of particularly difficult patients. So, there's probably some truth to the adage that suicide is anger turned inwards.

And yes, treating pure mental illness is 1000x more rewarding than dealing with patients who have personalities that cling to substances and PTSD as part of their externalization.

 

[wolfvgang22]

Ain't no shame in the psych game! It's 100% natural to be driven toward more than just passive SI in this field, as no long as there's no intent of course.

I appreciate your supportive words.

 

[meow1985]

Yes.

I wonder why society even places a modicum of blame of us for suicide. All we can do is say, "Here's some pills +/- magic words (therapy), please give your guns away, call 911 if you do feel like killing yourself, and BTW do I need to lock you up?"

Look at cardiologists. Has any cardiologist been successfully sued for an MI death in a high risk cardiac patient because they didn't document they discussed removing all junk food/tobacco/cocaine/meth and recommending 30 minutes of daily exercise? Their A&Ps meet the standard of care with alphabet soup: ACS, ICD, EKG WNL, HFpEF 55, ASA, ACEI, WTF, RTC 6 mo etc.

Because people think suicide is purely a choice and a behavior that doctors can talk patients out of, medicate out of them, or lock them up to prevent, whereas MI’s are somehow more “biological” and “inevitable” because you don’t voluntarily make a plaque in your blood vessel break, thrombose, and clog the artery. (Except you do… by spending years and years setting up everything necessary for that event to happen). False dichotomy.

 

[calvnandhobbs68]

You’re all acting like psychiatrists are sued all the time when actually….you’re all the least likely to be sued out of any specialty. Literally dead last.

For all the bellyaching about possibly getting sued, it happens the rarest out of all the specialties. And when it does occur it rarely leads to anything. Because, as you all have alluded to above, it is very well known, both within the specialty and by the legal system, that one cannot predict when a suicide will occur (which is what most psychiatrists get sued for). However, on a cumulative scale, everyone’s probably going to get sued at least once in their career. So just embrace it. That’s why malpractice insurance exists.

So like all the complaining about not being able to predict suicides? No worries. Because nobody expects you to. There have literally been cases of suicides committed ON AN INPATIENT UNIT where the psychiatrist was not sued successfully.

 

[meow1985]

You’re all acting like psychiatrists are sued all the time when actually….you’re all the least likely to be sued out of any specialty. Literally dead last.

For all the bellyaching about possibly getting sued, it happens the rarest out of all the specialties. And when it does occur it rarely leads to anything. Because, as you all have alluded to above, it is very well known, both within the specialty and by the legal system, that one cannot predict when a suicide will occur (which is what most psychiatrists get sued for). However, on a cumulative scale, everyone’s probably going to get sued at least once in their career. So just embrace it. That’s why malpractice insurance exists.

So like all the complaining about not being able to predict suicides? No worries. Because nobody expects you to. There have literally been cases of suicides committed ON AN INPATIENT UNIT where the psychiatrist was not sued successfully.

Have you seen my posts on this forum about the absurd lawsuit I got named in as a psychiatry resident?

 

[robellis]

Have you seen my posts on this forum about the absurd lawsuit I got named in as a psychiatry resident?

Which was dismissed with prejudice? Yeah..

 

[Crayola227]

Every field is going to have to these issues.

To be fair, there is a reasonable standard of care that you can expect really any physician to have when faced with mentally ill patient in assessing suicide risk and dealing with it. That is really what the tort is there to enforce. Not that abuses don't occur.

You aren't expected to read minds or predict the future.

 

[Fan_of_Meehl]

Every field is going to have to these issues.

To be fair, there is a reasonable standard of care that you can expect really any physician to have when faced with mentally ill patient in assessing suicide risk and dealing with it. That is really what the tort is there to enforce. Not that abuses don't occur.

You aren't expected to read minds or predict the future.

Yeah. It's always interesting when a patient says something like, 'If I decided to do it (suicide) you wouldn't know about it, I wouldn't tell you, and you couldn't stop me.' To which I typically respond with a matter-of-fact attitude of....'yeah...of course (I'm a psychologist, not a Jedi/warlock/sorcerer)...and...?' while on the inside I'm like, 'works for me.' It sounds cynical, but it's just being realistic.

 

[comp1]

So to answer the OP's question...time and exposure will get you the thicker skin, like with any other callus. It seems like borderline PD is a particular trigger for the OP, which isn't rare. The coping skills in borderline PD very much target creating as much anxiety and distress in those around them as possible. I wonder if actively working to maintain awareness of that on a conscious level would help.

 

[Monocles]

Heck, we often joked amongst ourselves in residency about killing ourselves in front of particularly difficult patients.

I'm glad to hear that gallows humour is universal. In pgy2 year on a particular stuffy day in the resident room, I announced to all my juniors "yo if all of you promise not to jump Imma crack the window okay?" and all of our pgy-1s roared with laughter. Meanwhile the rotating pgy-1s from other program looked at me as if unspeakable horrors came out of my mouth.

 

[deleted1100659]

You’re all acting like psychiatrists are sued all the time when actually….you’re all the least likely to be sued out of any specialty. Literally dead last.

For all the bellyaching about possibly getting sued, it happens the rarest out of all the specialties. And when it does occur it rarely leads to anything. Because, as you all have alluded to above, it is very well known, both within the specialty and by the legal system, that one cannot predict when a suicide will occur (which is what most psychiatrists get sued for). However, on a cumulative scale, everyone’s probably going to get sued at least once in their career. So just embrace it. That’s why malpractice insurance exists.

So like all the complaining about not being able to predict suicides? No worries. Because nobody expects you to. There have literally been cases of suicides committed ON AN INPATIENT UNIT where the psychiatrist was not sued successfully.

Were lower risk than other specialties but I looked into this recently and it appears that roughly 40% of all psychiatrists have been sued at least once which still seems fairly high.

I think the issue is the stress/emotional toll it can take on a person, even if you win, you still lose a bit of sanity. And to my understand they always bring this up when applying for state licenses and all that, if I remember correctly (no matter the outcome) which really sucks.

I think a good therapeutic relationship can help, or being careful how you word things to patients sometimes. Setting limits. Perhaps even instead of firing a patient, letting the patient feel like they fired you and it was their idea. Eventually if you say no enough/don't give them what they want, they generally stop coming anyways.

 

[calvnandhobbs68]

Were lower risk than other specialties but I looked into this recently and it appears that roughly 40% of all psychiatrists have been sued at least once which still seems fairly high.

I think the issue is the stress/emotional toll it can take on a person, even if you win, you still lose a bit of sanity. And to my understand they always bring this up when applying for state licenses and all that, if I remember correctly (no matter the outcome) which really sucks.

I think a good therapeutic relationship can help, or being careful how you word things to patients sometimes. Setting limits. Perhaps even instead of firing a patient, letting the patient feel like they fired you and it was their idea. Eventually if you say no enough/don't give them what they want, they generally stop coming anyways.

It's even higher. 95% of physicians in high risk specialities have been sued once in their careers by age 65. 75% of physicians in low risk specialities by the age of 65. It's basically an inevitability...that's part of my point. Why worry MORE than other specialities about something that is LESS likely to occur on a year by year basis than all other specialities but almost inevitability occurs at some point in your career? I've said this before but I never heard as much concern about legal liability than I did when I started psychiatry...you know how many way more medically high risk things happen in a PCP office every day, much less an inpatient medicine floor that they don't go around documenting a paragraph about all the risks/benefits/the patient DEFINITELY gave consent for this. Their notes are like "patient needs to take BP meds cause his BP is 180/110 every time he comes into the office, keeps saying he doesn't really want to/forgets to take them, told patient high risk of having MI/stroke if he doesn't, hope he starts taking them. F/u 3 months".

Yes, you have to report it to medical boards. You could say "wow that really sucks that I have to report this, oh no I bet they don't give me a license" or "I bet it ends up not being that big of a deal because probably over 50% of the physicians they license have had some malpractice suit brought at some point". It's all about the cognitive approach to it.

 

[robellis]

New way to think: if you haven’t been sued at least once, you’re doing something wrong

 

[deleted1100659]

you know how patients are able to leave reviews for doctors? If only there was a website where doctors could leave reviews for patients, lol.

 

[meow1985]

I think the issue is the stress/emotional toll it can take on a person, even if you win, you still lose a bit of sanity. And to my understand they always bring this up when applying for state licenses and all that, if I remember correctly (no matter the outcome) which really sucks.

Yes, this. I was never the same after my lawsuit, which was in residency. Like, after it happened, I was like, holy cow this is real.

I also then had to mention it at every step of the way, from job applications to state licensure to credentialing and insurance applications. And it was truly absurd nothing-case.

 

[meow1985]

you know how patients are able to leave reviews for doctors? If only there was a website where doctors could leave reviews for patients, lol.

It’s called the medical record. You can write all about how difficult and unpleasant they were, you just have to use professional / medical terms. Too bad medical records do not automatically follow patients wherever they go.

 

[deleted1100659]

It’s called the medical record. You can write all about how difficult and unpleasant they were, you just have to use professional / medical terms. Too bad medical records do not automatically follow patients wherever they go.

i usually use neutral terms for the most part. Rude patient? Patient is somewhat "outspoken".

reason being is they can request their records and if they see things that offends them they may be more inclined to write vengeful reviews or something of that nature.

 

[Merovinge]

It’s called the medical record. You can write all about how difficult and unpleasant they were, you just have to use professional / medical terms. Too bad medical records do not automatically follow patients wherever they go.

Pasha, it's called anonymous student doctor networks or a bar with your other doctor friends (obviously without revealing PHI).

I do agree that flagrantly abusive language or actions do need to be conveyed in the medical record, even from a floridly psychotic patient, as it helps inform other medical professionals over what to be expecting. Always descriptive and never in a punitive or angry manner.

 

[clausewitz2]

Pasha, it's called anonymous student doctor networks or a bar with your other doctor friends (obviously without revealing PHI).

Hang out griping about patients with a lot of Turkish nobles, do you?

 

[meow1985]

i usually use neutral terms for the most part. Rude patient? Patient is somewhat "outspoken".

reason being is they can request their records and if they see things that offends them they may be more inclined to write vengeful reviews or something of that nature.

I tend to use euphemisms myself for the same reason. So in my sense my comment was aspiration rather than reality. But if they have specific behaviors such as splitting or care seeking/care rejecting, documenting those can send an evocative message to other medical professionals and serve as a manner of “review.” I sometimes even put, rather than care seeking care rejecting, “the patient is very particular about the type of care they will accept.”

However, I’ve seen others write in the record “patient was incredibly rude” followed by actual quotations of what they said.

 

[Mass Effect]

By refuse to safety plan I mean I ask them what they could do or who they could talk to if SI escalated and they don’t have a meaningful answer, and they reject offers of emergency resources. But SI is not bad enough to hospitalize so you are stuck.

Not taking controlled meds as prescribed can be dangerous and is against the controlled substance rules, which exist for a reason. Telling them that = setting limits.

What do you mean they're not taking it as prescribed? If they won't take controlled substances as prescribed, you can always tell them you'll take them off said controlled substances? Obviously no early refills. Are they skipping doses? For stimulants, that's fine. For benzos, maybe not. Suboxone is a whole other matter.

In fairness, you've started about a dozen of these same exact threads, all saying you have a problem with countertransference, feeling anxious about lawsuits and having a tough time making patients angry. Our advice is always the same. So have you looked into your own therapy? Have you implemented behavioral strategies to help you sleep at night despite the uncertainty of patient outcomes or patients being rude or not following your recommendations? That's what you can do to get a thicker skin.

 

[meow1985]

What do you mean they're not taking it as prescribed? If they won't take controlled substances as prescribed, you can always tell them you'll take them off said controlled substances? Obviously no early refills. Are they skipping doses? For stimulants, that's fine. For benzos, maybe not. Suboxone is a whole other matter.

In fairness, you've started about a dozen of these same exact threads, all saying you have a problem with countertransference, feeling anxious about lawsuits and having a tough time making patients angry. Our advice is always the same. So have you looked into your own therapy? Have you implemented behavioral strategies to help you sleep at night despite the uncertainty of patient outcomes or patients being rude or not following your recommendations? That's what you can do to get a thicker skin.

I need to get a new therapist because mine is worse then useless. Watching Netflix is less of a waste of time than talking to him. It’s a daunting process though to start all over. As far as behavioral strategies, I have some but all my time and energy is spent either working or engaging in said strategies or passed out from exhaustion. I need more efficient ways to deal and that’s why I try to crowdsource to try and see what works for others.

The not taking as prescribed issues are mostly when patients take more than prescribed and/or for reasons other than what is prescribed, usually due to lacking coping skills. I recently told a person that this is not safe and that if it kept happening I might have to take them off the med, and how this means they need more support and therapy. Fairly routine thing to say. Well, I should not go into details but I may as well have stepped on an interpersonal landmine.

 

[Mass Effect]

I need to get a new therapist because mine is worse then useless. Watching Netflix is less of a waste of time than talking to him. It’s a daunting process though to start all over. As far as behavioral strategies, I have some but all my time and energy is spent either working or engaging in said strategies or passed out from exhaustion. I need more efficient ways to deal and that’s why I try to crowdsource to try and see what works for others.

But you're not everyone else and we've told you what will work more than anything else and that's therapy. Find a therapist yesterday. If the new therapist sucks, find another. Put on your psychiatrist hat. What you're experiencing (and have been experiencing since residency or before), isn't the experience of most others. That isn't to say there's something wrong with you, but it's to emphasize a one-size-fits-all approach will not work for you because your situation is unique. If I had to guess, I'd suggest maybe there's something in your past, likely prior to the malpractice suit when you were a resident, that isn't fully resolved and those old feelings resurface around this theme of "getting in trouble" and/or not being liked (upsetting or failing patients, getting sued, notes not being perfect). I could go on, but won't because I don't want this to get into giving medical advice. I'm just telling you what I'm getting from your posts and why I keep repeating therapy, therapy, therapy. You need to explore where this is coming from in a safe space with a trusted guide.

The not taking as prescribed issues are mostly when patients take more than prescribed and/or for reasons other than what is prescribed, usually due to lacking coping skills. I recently told a person that this is not safe and that if it kept happening I might have to take them off the med, and how this means they need more support and therapy. Fairly routine thing to say. Well, I should not go into details but I may as well have stepped on an interpersonal landmine.

I generally tell patients at the outset that they either take (the controlled substance) as prescribed or I stop prescribing them. I tell them if they feel they need it more than prescribed or differently than prescribed, I'm open to that as long as they tell me. I hold them to that. If a patient misuses a controlled substance and I feel I can't prescribe for them anymore, then I look for alternatives (Wellbutrin instead of Ritalin, Vistaril or trazodone prn instead of Ativan) and if they're not willing to switch, then I may just say they need a new prescriber then and refer them to someone else. I've never had to do that yet.

 

[watto]

It might be interesting to actually enact some anger and frustration with your current therapist. See what it is like to be on the other side, to make the therapist feel like they are not doing their job. You may be able to come out the other side with an appreciation for the safety of this type of conflict from the patient perspective...and internalize that the therapist is not really being threatened by the conflict, either.

 

[wolfvgang22]

I recently told a person that this is not safe and that if it kept happening I might have to take them off the med, and how this means they need more support and therapy. Fairly routine thing to say. Well, I should not go into details but I may as well have stepped on an interpersonal landmine.

Yeah, this happens all the time. Like, 3 times a day in my clinic. You aren't responsible for other's unhappiness. You are a compassionate person with special skills doing a job most people can't do. Don't let anyone tell you otherwise. Just document you told the patient it's unsafe and you offered alternatives. Safety trumps everything. Some patient or administrator gives you **** about a decision to restrict or stop a med? Sorry, safety comes first. It is therapeutic limit setting.

 

[meow1985]

It might be interesting to actually enact some anger and frustration with your current therapist. See what it is like to be on the other side, to make the therapist feel like they are not doing their job. You may be able to come out the other side with an appreciation for the safety of this type of conflict from the patient perspective...and internalize that the therapist is not really being threatened by the conflict, either.

Interesting thought. I kind of hate my therapist and I see us as being in a constant conflict because he just says things that are…. So unhelpful and past the point at times I wonder if he has dementia. (He is like 80.) I’ve learned from him how painful it is to not feel understood and heard, which influenced my own practice, so that is one indirect benefit of therapy I guess. I’ve given him specific feedback multiple times and sometimes in frustrated terms. He’s actually pretty good at one thing — the psychoanalytical approach where he is an unflappable and doesn’t react much at all to anything the patient says. He does not seem affected by our conflict and I kind of wish I could be more like him in that way, but how…. And who knows, maybe he is affected by it in private and I just don’t know anything about it.

He has not changed his approach though. I’m not getting what I need from therapy either in that I have realized where my fears come from, and yes it is not just the lawsuit, but then I’m stuck as to what to do about it. When I ask for ideas or how to problem solve my behaviors, his style is not directive enough to be helpful (I.e. I get stuck in freeze mode of fight or flight so behavioral activation is hard, and whatever I am worried about I overfocus on — it used to be extreme, I would spend an entire weekend researching HIPAA in residency when I thought I violated it, which is clearly unhelpful and just makes things worse. I don’t do anything approaching that anymore, so that’s good at least — but that is the influence of a prior therapist who was more of a CBT guy and the issue there was we did not go deep enough into the root of things, as well as the influence of my partner and friends). My current therapist, the psychoanalytically inclined guy, pointed me to James Gordon’s book “Transforming Trauma” which I read, and that’s the most helpful thing he has done all year, I learned some self soothing techniques from there, but it’s slow going. I meditate, deep breathe, and do biofeedback exercises and it takes me like an hour of that daily after work to be ok enough to start my notes. I also need breaks to do more of the same between notes (which makes them take longer) and if I have a free moment during the clinic day (so not much doing notes between visits and putting out inbasket fires). So that’s what I mean when I say my coping skills are not efficient.

Anyway, for me being in a conflict with the therapist is something that makes me want to leave every time and think, ugh this thing again, but I just don’t do it because I’m constantly tired and change averse. And there is something about having a therapist if not a very good one that makes me feel like I’m “doing what Im supposed to do” as a person with mental health issues of my own. It’s nonsensical.

 

[meow1985]

Yeah, this happens all the time. Like, 3 times a day in my clinic. You aren't responsible for other's unhappiness. You are a compassionate person with special skills doing a job most people can't do. Don't let anyone tell you otherwise. Just document you told the patient it's unsafe and you offered alternatives. Safety trumps everything. Some patient or administrator gives you **** about a decision to restrict or stop a med? Sorry, safety comes first. It is therapeutic limit setting.

Yes, thank you. Also, people saying forceful, pithy things that carry wisdom and experience like that have always been able to knock me out of my worry cycles.

 

[splik]

Interesting thought. I kind of hate my therapist and I see us as being in a constant conflict because he just says things that are…. So unhelpful and past the point at times I wonder if he has dementia. (He is like 80.) I’ve learned from him how painful it is to not feel understood and heard, which influenced my own practice, so that is one indirect benefit of therapy I guess. I’ve given him specific feedback multiple times and sometimes in frustrated terms. He’s actually pretty good at one thing — the psychoanalytical approach where he is an unflappable and doesn’t react much at all to anything the patient says. He does not seem affected by our conflict and I kind of wish I could be more like him in that way, but how…. And who knows, maybe he is affected by it in private and I just don’t know anything about it.

He has not changed his approach though. I’m not getting what I need from therapy either in that I have realized where my fears come from, and yes it is not just the lawsuit, but then I’m stuck as to what to do about it. When I ask for ideas or how to problem solve my behaviors, his style is not directive enough to be helpful (I.e. I get stuck in freeze mode of fight or flight so behavioral activation is hard, and whatever I am worried about I overfocus on — it used to be extreme, I would spend an entire weekend researching HIPAA in residency when I thought I violated it, which is clearly unhelpful and just makes things worse. I don’t do anything approaching that anymore, so that’s good at least — but that is the influence of a prior therapist who was more of a CBT guy and the issue there was we did not go deep enough into the root of things, as well as the influence of my partner and friends). My current therapist, the psychoanalytically inclined guy, pointed me to James Gordon’s book “Transforming Trauma” which I read, and that’s the most helpful thing he has done all year, I learned some self soothing techniques from there, but it’s slow going. I meditate, deep breathe, and do biofeedback exercises and it takes me like an hour of that daily after work to be ok enough to start my notes. I also need breaks to do more of the same between notes (which makes them take longer) and if I have a free moment during the clinic day (so not much doing notes between visits and putting out inbasket fires). So that’s what I mean when I say my coping skills are not efficient.

Anyway, for me being in a conflict with the therapist is something that makes me want to leave every time and think, ugh this thing again, but I just don’t do it because I’m constantly tired and change averse. And there is something about having a therapist if not a very good one that makes me feel like I’m “doing what Im supposed to do” as a person with mental health issues of my own. It’s nonsensical.

have you discussed with your therapist that you feel he is worse than useless and not helping you? This is exactly the thing you need to be bringing up and discussing in your sessions. If they are any good, you will make a lot of progress through navigating the negative transference affect. If not, then you would terminate and find someone who is skilled in working with complex developmental trauma.

 

[meow1985]

have you discussed with your therapist that you feel he is worse than useless and not helping you? This is exactly the thing you need to be bringing up and discussing in your sessions. If they are any good, you will make a lot of progress through navigating the negative transference affect. If not, then you would terminate and find someone who is skilled in working with complex developmental trauma.

Yep, that’s what I meant by giving him feedback. He billed himself as a developmental trauma specialist too. Which is why I decided I need a new therapist, it’s just a barrier to get over to coordinate finding someone new.

The one thing I like about my current therapist is that he can see me after business hours and agreed to waive copays when I told him, in all but these same words, that his help is not worth the $25 copays.

 

[Old&InTheWay]

Yep, that’s what I meant by giving him feedback. He billed himself as a developmental trauma specialist too. Which is why I decided I need a new therapist, it’s just a barrier to get over to coordinate finding someone new.

The one thing I like about my current therapist is that he can see me after business hours and agreed to waive copays when I told him, in all but these same words, that his help is not worth the $25 copays.

Isn't waiving copays illegal?