The limits of what we can do

[lockian]

---

Members don't see this ad.

As a newish attending, I contemplate the moments when I feel the most dyspeptic about my job and I realized that it’s whenever I have to acknowledge the limits of what I can do and the tools that I have. Examples:

—A med is contraindicated and the other options are woefully inadequate. Common example is benzos.
—I need to refer a patient somewhere but I don’t know what places provide that service. Or I do know but the waitlist is years long or they are not taking patients or whatever.
—Patient should probably not be living alone and I don’t know how to get them the support they need
—Patient and I have fundamental disagreement about the recommended treatment plan but they still keep coming back expecting me to magically change my mind
—I generally just don’t know what to do or what’s going on and the clinic pace is too rapid to really reflect or to stop and ask someone
—I don’t have experience with a medication or treatment and I am too afraid to try it to gain experience.

We have a care coordinator who is great and does her best but is really overextended, I research a lot of things on my own, I can crowdsource questions to a colleague list serve, or can even chat to colleagues via our inter departmental communication system, but somehow it still all ends up being really emotionally exhausting and a time-drain. Any thoughts about how to change my MO or change my perspective?

 

[Crayola227]

I continually remind myself that it's not my job to fix these things. I am a source of validation and knowledge for what to do about problems, but that's about it. If you can help people with deciding to make different decisions, choices about what they do actually control, that's great.

The rest of it, sadly, as docs we clock in and clock out as cogs in the great machine, in this way being a physician isn't really much different than any other job. A job is a job because you wouldn't do it for free. There's an element of accepting the meaninglessness of that, that can actually be freeing, vs buying into some utopian concept where we think we can make things better than we actually can. We can't, and we don't have to to find meaning in our lives.

Then I suggest retreating focusing time and attention on things that do give you a sense of mastery and control, say cooking or gardening.

 

[SeniorWrangler]

The last two items are things you have some influence on, though; could you find a more experienced colleague to have a coffee/beer with and discuss the tough situations and questions? Nobody knows everything.

 

[whopper]

Here's several WTF moments I've encountered where training did not arm me for what to do.

1) Elderly patient gets lost all the time and is always late. This is the majority of my patients over age 65. Person is noncompliant.
2) Person is seeing me but has no interest to do so because their spouse or other family member is making them do it.
3) Malingering. What do you do?
4) Patient keeps bringing up information that doesn't seem to create any therapeutic benefit. E.g. each time the they see me and bring up stuff like, "yeah I sucked his dic_ so much it was awesome." 15 minutes later they're still talking about it and I respond "where are you going with this?"
5) Patient is extremely and unfairly rude to staff members in a manner suggestive of narcissism.

Yeah in each of these cases I've figured out what to do but this was not covered in training except malingering in forensic training. I'll go as far as to say that it's like a form of PC. The teaching staff do not want to bring up that some patients are really just a-holes and need to be treated accordingly. Each time patients are brought up as if it's a "customer is always right" perspective when they are not customers in the traditional sense.

This should be handled in training to prevent the provider from doing something inappropriate, personal, and emotional against the patient. E.g. patient is abusive to my therapist, there is an appropriate response back and it doesn't involve me or my assistant taking this person's verbal abuse. With good training on this, this will prevent providers from inappropriately handling such cases.

E.g. I've never seen any conventional publication teach residents well on the issues of refusing to provide benzos to an inappropriate patient, kicking people out of the ER who are abusing services, or being abusive to the provider and staff.

 

[randomdoc1]

As said above, our role is to be a good healthcare provider. Patients come to us to benefit from our medical knowledge and evidence based treatments offered. It's their decision whether or not they choose to follow through be it taking a medication or life style change. There is a level of ownership on their end. That's relieved a lot of emotional weight. After further knowing the resources around you, you'll get more info about what else is in the community that would be of benefit to the patient. Finding other providers who are taking new patients for med management is tough, but I have found a few places. The ones that are most open may not offer the best quality care but they are available. This is helpful especially if there's differences in opinion about treatment recommendations and I tell the patient they are always free to consult with someone else and they do deserve to work with someone they feel more comfortable with when available. But I get what you're saying, patient keeps coming back hoping they convinced you of how bad they are doing without said stim or benzo.

As far as gaining more experience with certain treatments, not much we can do than take the plunge! I've learned MAOIs. I'm not super at it. But where else would these patients go? We are literally the best trained out there to offer these more specialized treatments. If you feel better, start low, go slow, read up on it a good chunk and do a thorough informed consent that is documented. 🙂

This should be handled in training to prevent the provider from doing something inappropriate, personal, and emotional against the patient. E.g. patient is abusive to my therapist, there is an appropriate response back and it doesn't involve me or my assistant taking this person's verbal abuse. With good training on this, this will prevent providers from inappropriately handling such cases.

E.g. I've never seen any conventional publication teach residents well on the issues of refusing to provide benzos to an inappropriate patient, kicking people out of the ER who are abusing services, or being abusive to the provider and staff.

Couldn't agree more. Some of the matter is also deeply entrenched especially in hospital systems who get reviews from patients which really need to be taken with a grain of salt. Physicians can feel pressured to appease the patient out of concern of their job security/standing. Good training and education overall about how clinically beneficial holding healthy boundaries would be great. I mean, does surgery hurt? What about orthopedic adjustments? _eck yea! But we don't say, oh, we'll hold off because the patient says it hurts. In private practice, some physicians fear losing the patient for income reasons and certain markets can be competitive but it does not justify inappropriate services. Not having healthy boundaries can lead things to be towards everyone's detriment. I remember one such case in medical school. A small town hospital where a patient with severe etoh use disorder had esophageal varices. Patient would come in needing huge blood transfusions using up a good chunk of their blood bank. But he started coming in every month which created an ethical dilemma as we can't just give all the blood supply to someone who clearly does not want to change. Definitely would be good if there was more a culture of ownership and responsibility on the patient so providers can feel rightfully empowered to make uncomfortable decisions that are medically necessary.

 

[whopper]

The first year Obamacare passed, the department did a breakdown.

Turned out the rich hospitals in town all had better numbers. Not surprising. Richer hospitals likely means better SES, better insurance, nicer facilities. They can put the nice fish tank in the waiting room instead of the iron bars and plastic furniture. Doctors and nurses weren't overworked as badly.

All of this translated to the system giving the richer hospitals more money instead of the doctors and nurses willing to be on the frontlines and deal with the harder situations.

Is this an attempt to bash Obamacare? No but deal with the clinical reality that patients can't be treated as if they're always right. In cardiology if a patient has a MI the cardiologist tells the patient to jump the patient almost always responds -how high?-. In psychiatry, ER, addiction, and pediatrics, the provider tries to do the right thing they're often times given a response of a refusal possibly with an "eff you."

To be incentivized to do what the patient wants instead of the right treatment is the major failing of Obamacare. I don't if any changes have been made to it. I tell this to people on the Right who want to bash it. Show me something better, and I'm often times not given a better response, and the few times I do get a response it's from someone who doesn't know anything. "If someone comes to your hospital and doesn't want to pay let them die."

 

[hallowmann]

The first year Obamacare passed, the department did a breakdown.

Turned out the rich hospitals in town all had better numbers. Not surprising. Richer hospitals likely means better SES, better insurance, nicer facilities. They can put the nice fish tank in the waiting room instead of the iron bars and plastic furniture. Doctors and nurses weren't overworked as badly.

All of this translated to the system giving the richer hospitals more money instead of the doctors and nurses willing to be on the frontlines and deal with the harder situations.

Is this an attempt to bash Obamacare? No but deal with the clinical reality that patients can't be treated as if they're always right. In cardiology if a patient has a MI the cardiologist tells the patient to jump the patient almost always responds -how high?-. In psychiatry, ER, addiction, and pediatrics, the provider tries to do the right thing they're often times given a response of a refusal possibly with an "eff you."

To be incentivized to do what the patient wants instead of the right treatment is the major failing of Obamacare. I don't if any changes have been made to it. I tell this to people on the Right who want to bash it. Show me something better, and I'm often times not given a better response, and the few times I do get a response it's from someone who doesn't know anything. "If someone comes to your hospital and doesn't want to pay let them die."

I mean to be fair, I've seen plenty of patients tell their Cardiologist, "F that, I'm not changing my diet" or "I'm not quitting smoking" or "I'm not taking a medicine every day" or "I'm not having a heart attack, I don't care what that ECG and those labs say, its just heartburn". Maybe they're a bit more willing, but plenty of non-adherence in other fields of medicine as well.

 

[Candidate2017]

—A med is contraindicated and the other options are woefully inadequate. Common example is benzos.
—I need to refer a patient somewhere but I don’t know what places provide that service. Or I do know but the waitlist is years long or they are not taking patients or whatever.
—Patient should probably not be living alone and I don’t know how to get them the support they need
—Patient and I have fundamental disagreement about the recommended treatment plan but they still keep coming back expecting me to magically change my mind
—I generally just don’t know what to do or what’s going on and the clinic pace is too rapid to really reflect or to stop and ask someone
—I don’t have experience with a medication or treatment and I am too afraid to try it to gain experience.

1. No, therapy is absolutely great. So is exercise and broccoli, but ain't no one want none of that good stuff.
2. With Dr Google's help, I have compiled a list of resources for substance rehab, crisis services, OSA, TMS, ECT etc. Also, look at private practice websites in your area. You can copy their list of resources. My fave list by far is a list of NP psych clinics to which I refer patients who are smarter than me about adult ADHD or benzos.
3. Adult Protective Services
4. Discharge patients who keep trying to change your mind. Or not. Because getting paid to mindlessly repeat myself and copy-paste the same note is... a low key awesome break in the day. At worst, the patient thinks I'm an idiot and leaves for an NP. At best, the patient begins to listen.
5. Welcome to the asylum.
6. Cue: "Practice, we talking about practice." Practice makes perfect. As long as there's a rationale for the treatment, why not?

TLDR:

God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference

 

[lockian]

Here's several WTF moments I've encountered where training did not arm me for what to do.

1) Elderly patient gets lost all the time and is always late. This is the majority of my patients over age 65. Person is noncompliant.
2) Person is seeing me but has no interest to do so because their spouse or other family member is making them do it.
3) Malingering. What do you do?
4) Patient keeps bringing up information that doesn't seem to create any therapeutic benefit. E.g. each time the they see me and bring up stuff like, "yeah I sucked his dic_ so much it was awesome." 15 minutes later they're still talking about it and I respond "where are you going with this?"
5) Patient is extremely and unfairly rude to staff members in a manner suggestive of narcissism.

Yeah in each of these cases I've figured out what to do but this was not covered in training except malingering in forensic training. I'll go as far as to say that it's like a form of PC. The teaching staff do not want to bring up that some patients are really just a-holes and need to be treated accordingly. Each time patients are brought up as if it's a "customer is always right" perspective when they are not customers in the traditional sense.

This should be handled in training to prevent the provider from doing something inappropriate, personal, and emotional against the patient. E.g. patient is abusive to my therapist, there is an appropriate response back and it doesn't involve me or my assistant taking this person's verbal abuse. With good training on this, this will prevent providers from inappropriately handling such cases.

E.g. I've never seen any conventional publication teach residents well on the issues of refusing to provide benzos to an inappropriate patient, kicking people out of the ER who are abusing services, or being abusive to the provider and staff.

This. I am lucky in that my department chair is an MD who only ever eyeballs my patient feedback and says “well, you can’t please everyone.” But I still feel a lot of the time like I am abused by patients and can’t do much about it. They pour insults on me for allegedly being unhelpful and not caring, and there is nothing I can do but squeeze out some mewling platitude like “you deserve a doctor whose view on care aligns with yours; there are others you can see.” But often there are no others because of staffing shortages, the pandemic, and the like.

 

[randomdoc1]

1. No, therapy is absolutely great. So is exercise and broccoli, but ain't no one want none of that good stuff.
2. With Dr Google's help, I have compiled a list of resources for substance rehab, crisis services, OSA, TMS, ECT etc. Also, look at private practice websites in your area. You can copy their list of resources. My fave list by far is a list of NP psych clinics to which I refer patients who are smarter than me about adult ADHD or benzos.
3. Adult Protective Services
4. Discharge patients who keep trying to change your mind. Or not. Because getting paid to mindlessly repeat myself and copy-paste the same note is... a low key awesome break in the day. At worst, the patient thinks I'm an idiot and leaves for an NP. At best, the patient begins to listen.
5. Welcome to the asylum.
6. Cue: "Practice, we talking about practice." Practice makes perfect. As long as there's a rationale for the treatment, why not?

TLDR:

God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference

I love it and do the same thing. Win win.

 

[deleted1100659]

As a newish attending, I contemplate the moments when I feel the most dyspeptic about my job and I realized that it’s whenever I have to acknowledge the limits of what I can do and the tools that I have. Examples:

—A med is contraindicated and the other options are woefully inadequate. Common example is benzos.
—I need to refer a patient somewhere but I don’t know what places provide that service. Or I do know but the waitlist is years long or they are not taking patients or whatever.
—Patient should probably not be living alone and I don’t know how to get them the support they need
—Patient and I have fundamental disagreement about the recommended treatment plan but they still keep coming back expecting me to magically change my mind
—I generally just don’t know what to do or what’s going on and the clinic pace is too rapid to really reflect or to stop and ask someone
—I don’t have experience with a medication or treatment and I am too afraid to try it to gain experience.

We have a care coordinator who is great and does her best but is really overextended, I research a lot of things on my own, I can crowdsource questions to a colleague list serve, or can even chat to colleagues via our inter departmental communication system, but somehow it still all ends up being really emotionally exhausting and a time-drain. Any thoughts about how to change my MO or change my perspective?

1. I think of psyhiatry as an art, my goal is the least amount of meds possible at just the right doses. Usually if you have gone through multiple meds and nothing is working, then i expect there is more to the story. Possibly undiagnosed bipolar, drug use, severe stressors, noncompliance, etc. I start going through that mental list.

2. Psychiatry is a team sport, while referring patients is great and helps the process along, I want the patient invested in their treatment. I give them a list of therapists in the area and want to know they're making phone calls. Patients invested in their own wellness have a better prognosis. Patients that are on 15 medications, i have them pull out their pill bottles and try to get them to understand what they're taking sometimes and why they're taking it. People appreciate it sometimes if you help them understand why they're doing all these things that various providers have told them.

3. This is variable based upon the state youre in. Sometimes I strongly recommend that the patient considers a personal care home setting which are affordable to most people who get some form of income. I assess family situations in these circumstances. Is anyone involved in their life? Theres definitely a lot of limits here and I think its important to take comfort in knowning you're doing what you can; reducing fall risk via ensuring safe medications, assessing for cognitive impairment, family interventions if possible, etc

4. Once I tell them no they generally dont come back. I do my best to take control of these situations, without being hateful/spiteful but being concise and blunt. Some of them I have straight up said "Look, if you're sole purpose here is to obtain benzos, you have the wrong clinic. I suggest you see a private psychiatrist, you wont get what you want here. If you want to try safer, alternative measures then im more than willing to work with you". You know best, not them. In psychiatry, the customer is never right, lol. I try to give patients the feeling of empowerment though; often instead of saying "were going to start xyz", I will give the patient 3 options and let them choose the one they like the most

5. You're a super smart person, and we all have those moments. What to do as far as referalls, clinic policies or medication management? You have the knowledge. I read the maudsley pretty extensively and thats a great book. Also going through the new K & S synopsis and that has covered a few small gaps for me. Also im not afriad to pull out uptodate or medscape during a visit, I just do it a bit nonchalantly. We all have these moments

6. Luckily im in a CMH setting, ive tried every new drug you can imagine and have better exposure than a lot of other psychiatrists I would guess. I routinely use LAIs, newer antidepressants, newer antipsychotics, etc. Read and learn about the medication. Search it. Why would it be beneficial to a certain person? What patient type? And if you feel it could be useful, ensure you can get it covered and try it. Thats how you learn. Trust me its a lot harder to mess up than you realize. 99% of the the time, the worst case scenario is that it doesnt work. Run interaction checkers if youre scared. See what the effect is on CYP system, and check for liver/renal impairment dosing, etc. I routinely prescribe things like vraylar, latuda, trintellix, austedo, invega, etc