It's almost frightening how I've shifted from "admit all" mentality to "how can we safely discharge"

[ExcaliburPrime1]

As a baby intern, I would leap at any excuse to (voluntarily) admit someone to the inpatient psychiatry unit. For good or ill, we are given huge autonomy, so 100% of the times I advocated for admitting someone, they were admitted, even though in retrospect some of those patients could have been treated as outpatients.

Now, as a still baby PGY-2, I have taken the "least restrictive environment" mantra to heart. I'm not sure if that's a good thing, but there have been times where I had some low-level worries about sending someone home. Of course, you can have those types of worries discharging someone from the unit, so you're not necessarily helping the patient with an unnecessary and confining inpatient experience, but I know that if I was to hear on the news that something happened to someone I discharged, I'd be devastated.

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[FlowRate]

If it's a dramatic swing in your dispo practices, it's a swing in a riskier direction. Typically the progression is a little more gradual. I'm no further than you in training, but I've noticed that most of us tend to dispo based more on what the accepted "right" answer is at each of our training locations.

 

[clausewitz2]

If it's a dramatic swing in your dispo practices, it's a swing in a riskier direction. Typically the progression is a little more gradual. I'm no further than you in training, but I've noticed that most of us tend to dispo based more on what the accepted "right" answer is at each of our training locations.

So much this. Our dual diagnosis unit has a very different idea of what is a safe discharge compared to our psychosis unit.

At the same time, I think this is maybe a natural progression in some respects. As an intern with minimal inpatient experience I think I had an idea of the hospital as being a faintly magical place that was highly therapeutic for all comers. As one learns that this is not true of many, if not most, people who present in a psychiatric emergency setting, the medical necessity type thinking becomes more appealing. I also have a better sense of the different units in our hospital and how likely it is that a given patient is going to benefit much from the units that have space when they are being admitted; there are certainly people who might, for instance, benefit from admission to our trauma-focused unit who would do very, very badly on our dual diagnosis unit, but if they drink a bit too much and that is where there is space when they turn up, I might be looking at sending them there if I admit them, and so maybe I think harder about how necessary hospitalization is.

 

[thoffen]

My training environment was more or less the reverse. However, as an attending, I evaluate the decision making mostly on what seems to be in the interest of the patient. If the disposition is not transparently obvious, I feel I have the skills to justify and document my decision making without being negligent.

 

[DD214_DOC]

Yes, it's usually more gradual. After almost 8 years in doing this (3.5 as an attending), I rarely admit. Mainly because acute hospitalizations don't really provide much benefit, and more often than not, my patients get discharged with goofy diagnoses and unnecessary medication regimens. I'd rather develop a good safety plan and monitor more closely. Patients will also be more willing to be honest if they know you won't throw them into the hospital for any little thing.

 

[Armadillos]

Have heard numerous medicine and surgery attendings observe that it's the PGY2s who kill patients. Not to say your wrong, but first half of PGY2 is probably when residents are most dangerous due to over confidence.

 

[smalltownpsych]

As a baby intern, I would leap at any excuse to (voluntarily) admit someone to the inpatient psychiatry unit. For good or ill, we are given huge autonomy, so 100% of the times I advocated for admitting someone, they were admitted, even though in retrospect some of those patients could have been treated as outpatients.

Now, as a still baby PGY-2, I have taken the "least restrictive environment" mantra to heart. I'm not sure if that's a good thing, but there have been times where I had some low-level worries about sending someone home. Of course, you can have those types of worries discharging someone from the unit, so you're not necessarily helping the patient with an unnecessary and confining inpatient experience, but I know that if I was to hear on the news that something happened to someone I discharged, I'd be devastated.

I hear you. I tend to go from one extreme to the other as I am learning. Just remember that each case is unique and to think it through and consider how you would explain your decision in court if it's the wrong one. Sometimes explaining your rationale to another professional can help with that. In my mind, the worst case is if you send someone home and the perception was that the person needed help and nothing was done for them. Always justify your discharge. If you can, then the risk, which is always there, is more tolerable since you did what you could.

I have had two patients die in my care and it will always haunt me and I will always second-guess. One who had just been discharged from a hospital, I should have tried to send back, but that would have been futile so I tried to manage the risk by having case manager follow up and a psychiatrist appointment the next day and support from a family member and two days later patient jumped from bridge on the way to my appointment. Second-guessing was maybe I should have talked to psychiatrist, maybe try to send back to inpatient, maybe... I don't know what else. The truth was that the patient had already lost their career and spouse left a few days after discharge and had years of chronic pain and opiate addiction and almost every risk factor you can think of. I just know that I will try to do better the next time and still might end up with same result. We do save many lives but sometimes we can't and that's the job we signed up for.

 

[Nasrudin]

Taking someone's autonomy is a huge intervention. With tremendous side effects. That should be weighed very carefully against its potential benefits.

Treating your own personal or institutional anxiety with this intervention should be considered the mark of negligent, unethical clinical practice. Unfortunately it is often not. And making cowardly decisions along these lines are nearly invisible in bureaucratic processes of actual clinical practice.

No one seems to want to talk about how lefty paternalism is upstream of ****ty clinical practice in this regard.

For example, OMH, in New York State should be put on trial for human rights violations. And yet they imagine they are the vangaurd of protection for them.

Their former slogan: "Suicide. A never event." And the pressure they put into monitoring and pushing a particular agenda, in my estimation, has resulted in more death and injury than doing.... ab-so-lutely.... nothing.

They've done more to turn our inpatient units into hotels for antisocial, crackicidal, **** turkeys than anything I could otherwise imagine. Who knows how many nurses got assaulted for not providing meds at 10 o'clock sharp. Or how many patients got terrorized. Or many units got turned into prison like environments as a result.

But not to worry. Treat your anxiety with admissions. Nobody's keeping track.