Much of what disheartens you seems to be around the loss of autonomy on the inpatient unit and the boundaries of the hospitalization. I definitely don't feel good when the patient is communicating that my decisions are not in line with those of a physician, which is to help people. Even though I can blame it on the patient that they are making me feel that way, in the asymmetric role of a physician, I know it's up to me to contain it, digest it, and process their difficult emotions, not the patient. It's tough to work through the projective identification from the patient without help from others, mainly because it's unconscious. It may be that there are some specific pattern of topics that come up that feel difficult for you, but require lots of self-reflection and consultation with others to make the experience more tolerable.
Here are a few of my thoughts on the specific things you brought up:
draining treating patients who don't want treatment or don't even want to be on the unit.
This is also draining for me because of the importance of autonomy. One of my attendings dealt with this by presenting two options to my patient once they have been determined to need an involuntary hold—they can either:
1) follow the appropriate treatment recommended by the psychiatrist which is likely to lead to shorter hospital stay, or
2) go through court to either obtain involuntary medications or leave AMA, which will likely lead to a longer hospital stay.
It can feel pretty disheartening going from dealing with a severely agitated patient wanting to leave
- If I've determined that they meet criteria for a hold, then I tell them that leaving is not an option.
- If they are severely agitated, I offer them a PRN medication and if they become more agitated to the point of violence, then I ready the nurse for potential emergent meds.
- When they are too agitated to have a meaningful conversation, I immediately end the interview and leave the physical space to decrease the patient's environmental stimulation which can make the agitation worse.
to another patient who you've been working so hard to build an alliance with suddenly curse you out while demanding a transfer
A therapeutic alliance hinges on the treatment goals which is different on an acute inpatient unit than an outpatient one, where the goals are more aligned.
I tell them that transfers are not allowed unless we don't have a service that can be provided elsewhere (e.g., transfer to medicine or surgery, ECT, etc).
to then having another patient accuse you of violating their rights and wanting to talk to patient advocacy.
If you've determined in your clinical judgment that the person meets criteria for an involuntary hold, you are not violating their rights. This is within the law for all the states. You can be wrong in your clinical judgment, but that doesn't necessarily mean malpractice.
When a patient says this to me, I give them an outlet to address this frustration. I let them know next specific day (twice a week) they can see the behavioral health judge/officer to let the court decide if they don't meet criteria and that they will be represented by a public defender/attorney. If they want to be seen sooner, I give them the number for the public defender so the patient can talk to her/him over the phone.
When there's a really difficult patient that causes my emotions to stir up to the point that I am distracted by my previous patient when I am with my next patient, I will usually leave the unit for about 5 minutes to take a breather, then come back when my emotions are a bit less so I can think more clearly.
