Thoughts on this job?

[Merovinge]

You're equating doing the "right thing" (whatever that means) and the "cover your butt" thing.

What is actually the least likely thing to happen here is that a patient in that situation goes home and actually kills themselves sometime within a timeframe which you might actually be held liable for this. It's even less likely that a bad outcome occurs AND the parents try to sue you for it (as they would be the ones with standing for a suit) AFTER agreeing to take the kid home. That is actually far and away the statistically least likely thing to occur here, no matter what they say in the ER. The comparison between smoking and lung cancer isn't even close.

The right thing as in what is professionally or legally expected in the situation, aka the "standard of care".

I am fine agreeing to disagree on that point. There is absolutely no world in which a patient details a plan to end their life that they have means/access to with intent is ever not having a 911/ED evaluation regardless of what a parent tells me. I have had this situation arise on several occasions and had a board complaint (that incidentally was immediately dropped) for requiring this, but I stand very steadfast in my resolve to continue to do this. I have heard the whole we sleep in the same room, have everything locked up speech and have also seen multiple patient's sneak into a bathroom and enact high lethality attempts despite that (once with an ICU, permeant injury outcome).

I personally care relatively little about the lawsuit issue, this has very little to do with covering my butt. It does have to deal with not being able to sleep at night if I did not do everything in my power to save the life of a child who confided in me as their doctor. I have absolutely no problem with hospitalizing 100 kids if it saves the lives of 1, although actually determining NNT is clearly impossible as the counterfactual can never be determined. I certainly am persuaded by the large body of research suggesting placing barriers between access to means results in less suicide. I guess I can imagine a reasonable argument for almost never hospitalizing someone for SI and using some alternative diversion process/treatment but I would certainly need to see literature to support it.

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[Stagg737]

I am fine agreeing to disagree on that point. There is absolutely no world in which a patient details a plan to end their life that they have means/access to with intent is ever not having a 911/ED evaluation regardless of what a parent tells me. I have had this situation arise on several occasions and had a board complaint (that incidentally was immediately dropped) for requiring this, but I stand very steadfast in my resolve to continue to do this. I have heard the whole we sleep in the same room, have everything locked up speech and have also seen multiple patient's sneak into a bathroom and enact high lethality attempts despite that (once with an ICU, permeant injury outcome).

Those that have been around for a while will probably remember the case from a couple of years ago when an outpatient doc (IM, not psych) in NYC did a thorough safety plan with patient and wife present, both of whom wanted the patient to come home after reporting SI with plan, and let them go but then got sued after the patient killed himself at home a few days later. Jury awarded the family $10 million which was later reversed on appeal (imo correctly). However, part of the argument of the family was that the doc should have forced them to go to an ER for further eval and an expert shill psychiatrist testified to that on the stand. If there is that significant of a concern that a patient needs inpatient admission like you describe and the patient is willing then I agree that they should be getting sent to the ER. That being said....

I personally care relatively little about the lawsuit issue, this has very little to do with covering my butt. It does have to deal with not being able to sleep at night if I did not do everything in my power to save the life of a child who confided in me as their doctor. I have absolutely no problem with hospitalizing 100 kids if it saves the lives of 1, although actually determining NNT is clearly impossible as the counterfactual can never be determined. I certainly am persuaded by the large body of research suggesting placing barriers between access to means results in less suicide. I guess I can imagine a reasonable argument for almost never hospitalizing someone for SI and using some alternative diversion process/treatment but I would certainly need to see literature to support it.

Do you really think that an ER doc or ER psychiatrist who is seeing this patient once, likely for less than an hour or even 20-30 minutes, is going to know more about the patient's diagnoses, situation, and what would actually benefit better than you do? I ask because when a patient comes into the ER with SI with plan but does not want admission, family does not want admission, and they are able to do extensive safety planning with family present/involved and have good support from family and outpatient psychiatrist/therapist, they will often be discharged. If the ER discharges them do you tell them to go back? Do you personally contact the ER saying they require admission and would petition for involuntary if necessary and file report with CPS or whatever agency against parents? I'm not trying to criticize you, but being in the ER I see a lot of outpatient docs seemingly dumping liability by "forcing" an ER eval or situations where it probably really is necessary but when I try and get in contact with outpatient doc they're suddenly nowhere to be found. Again, not saying this is you, but curious about what your expectations are when they're sent to an ER and how what "everything in my power" actually means.

I agree with being overly cautious in terms of hospitalization if the concerns are legit. On the flip side, there have been cases where patients were forced to be hospitalized and later died when they refused to seek help again. There was one on here a while ago about a patient who went to the ER for pulmonary issues, admission was forced, and they refused to go back in several months later because they didn't want treatment forced and died. Family sued the docs that previously forced treatment and won. Point being that sometimes hospitalization causes more harm than benefit, and we don't have a crystal ball to determine when this could be true.

Relating this back to the OP, stuff like this is why an ER telepsych job where you're seeing 1.5 patients per hour (especially at the rate given) is an absolutely horrible set up. The way to mitigate these risks is with a thorough evaluation and strong documentation, both of which take time. Part of what I teach my residents and med students is that there isn't always a black and white correct answer, and sometimes a bad outcome is going to happen. What's important is that you're at least meeting the standard of care (which is often quite low in psychiatry) and that your documentation justifies your decisions.

 

[calvnandhobbs68]

Those that have been around for a while will probably remember the case from a couple of years ago when an outpatient doc (IM, not psych) in NYC did a thorough safety plan with patient and wife present, both of whom wanted the patient to come home after reporting SI with plan, and let them go but then got sued after the patient killed himself at home a few days later. Jury awarded the family $10 million which was later reversed on appeal (imo correctly). However, part of the argument of the family was that the doc should have forced them to go to an ER for further eval and an expert shill psychiatrist testified to that on the stand. If there is that significant of a concern that a patient needs inpatient admission like you describe and the patient is willing then I agree that they should be getting sent to the ER. That being said....

Shouldis v Strange

Shouldis v Strange - 2019 NY Slip Op 51993 (U)

law.justia.com

Lol you mean this case? Hardly call that a "thorough safety plan". Read the whole thing too, the guy even modified his chart and MSE afterwards...

According to Mrs. Shouldis, her husband told Dr. Strange that he was depressed, losing interest in the things that he had enjoyed, was nervous and anxious and it was getting worse and worse, and that she told the doctor: "I wanted him admitted to the hospital. . . I thought he wanted to kill himself after what he was saying in the night, I can't take this, I can't live like this." Mrs. Shouldis testified that Dr. Strange then "looked at Rick and he said, everyone goes through this, Rick, you're not going to hurt yourself, right?" Mrs. Shouldis said that Dr. Strange asked no further questions about hurting himself, did not ask about Richard killing himself, nor was the word suicide mentioned.

Mrs. Shouldis recalled that her husband then said, "I'll be okay." Then, "Dr Strange told us that he wanted to prescribe the anti-depressants[FN4] and that it would take about a few weeks to kick in and I said, we don't have a few weeks, he needs something done right now. . . I told him I thought he was going to kill himself." The jury was entitled to credit Mrs. Shouldis' trial testimony over her deposition testimony of February 21, 2014 : "I just told him that I never saw my husband like this before and . . . because Dr. Strange said the medication would take weeks to kick in, and I said isn't there something else." Mrs. Shouldis indicated that Dr. Strange's response was that the Xanax would "get [him] through those few weeks."

HOWEVER even given that and the fact that this guy died the next day

Here, the causal link, if any, was too attenuated. Plaintiff's sole medical expert, neurologist Lawrence Shields, did not supply such a basis. There was nothing in Dr. Shield's testimony that properly linked any departure to the suicide when it occurred.[FN5]

When asked whether Richard Shouldis should have been sent to an emergency room from the June 6 consult, Dr. Shields answered vaguely as to the time frame: "Ultimately, yes."

Continuing with Dr. Shields' lack of specificity:

"Q. Well should he have arranged to have the patient sent to an emergency room?A. Yes.Q. That day?A. Or a psychiatrist or any other doctor knowledgeable about suicide patients."
* * *

In view of the foregoing, IT IS ORDERED that defendant's motion to set aside the verdict and direct a verdict in favor of Dr, Theodore Strange is granted.

 

[Merovinge]

Those that have been around for a while will probably remember the case from a couple of years ago when an outpatient doc (IM, not psych) in NYC did a thorough safety plan with patient and wife present, both of whom wanted the patient to come home after reporting SI with plan, and let them go but then got sued after the patient killed himself at home a few days later. Jury awarded the family $10 million which was later reversed on appeal (imo correctly). However, part of the argument of the family was that the doc should have forced them to go to an ER for further eval and an expert shill psychiatrist testified to that on the stand. If there is that significant of a concern that a patient needs inpatient admission like you describe and the patient is willing then I agree that they should be getting sent to the ER. That being said....



Do you really think that an ER doc or ER psychiatrist who is seeing this patient once, likely for less than an hour or even 20-30 minutes, is going to know more about the patient's diagnoses, situation, and what would actually benefit better than you do? I ask because when a patient comes into the ER with SI with plan but does not want admission, family does not want admission, and they are able to do extensive safety planning with family present/involved and have good support from family and outpatient psychiatrist/therapist, they will often be discharged. If the ER discharges them do you tell them to go back? Do you personally contact the ER saying they require admission and would petition for involuntary if necessary and file report with CPS or whatever agency against parents? I'm not trying to criticize you, but being in the ER I see a lot of outpatient docs seemingly dumping liability by "forcing" an ER eval or situations where it probably really is necessary but when I try and get in contact with outpatient doc they're suddenly nowhere to be found. Again, not saying this is you, but curious about what your expectations are when they're sent to an ER and how what "everything in my power" actually means.

I agree with being overly cautious in terms of hospitalization if the concerns are legit. On the flip side, there have been cases where patients were forced to be hospitalized and later died when they refused to seek help again. There was one on here a while ago about a patient who went to the ER for pulmonary issues, admission was forced, and they refused to go back in several months later because they didn't want treatment forced and died. Family sued the docs that previously forced treatment and won. Point being that sometimes hospitalization causes more harm than benefit, and we don't have a crystal ball to determine when this could be true.

Relating this back to the OP, stuff like this is why an ER telepsych job where you're seeing 1.5 patients per hour (especially at the rate given) is an absolutely horrible set up. The way to mitigate these risks is with a thorough evaluation and strong documentation, both of which take time. Part of what I teach my residents and med students is that there isn't always a black and white correct answer, and sometimes a bad outcome is going to happen. What's important is that you're at least meeting the standard of care (which is often quite low in psychiatry) and that your documentation justifies your decisions.

Well firstly, I don't practice traditional OP anymore, I only see patients at PHP/IOP LoCs so I don't want anything I say here to be misleading about that.

Yes we 100% contact the accepting ED facility and I personally give signout to the charge nurse if the patient discussed the SI with me (in the event they discussed it with the therapist and I did not see the patient before parents/EMS arrive, then the therapist will speak to them). I give my personal cell and have a good relationship with the crisis teams at nearby EDs as we send patients there regularly, I have spoken to the ED attending or LCSW depending on the case anytime it is not a slam dunk admit. I don't take traditional call but will always accept a call from an ED for our patients out of hours.

By the time they have spoken to the crisis team and had the ED eval, 90% of the time everyone is in agreement on IP admission. In a small minority of times patients will oppose but their parents want them hospitalized, that gets taken care of at the ED. Very rarely the patient will want to be hospitalized and the parent will not, that also gets taken care of in the ED. We have had 1-2 cases in the past year that during the intervening time the apparent crisis was improved and they returned to PHP back the next day. We absolutely would send them right back if they continued to have active SI but I thankfully have not yet had to deal with such a case.

So no, I never send someone unless I think they should be hospitalized. I do the risk evaluation and documentation (or my team does), we do not rely on an ED for this, although I can imagine in a busy OP practice there may be cases where it might not be possible, although I've never had that experience personally as I would always make the time when I used to do traditional OP care and just run very late.

I will add that people seem to worry about rapport when being forceful about IP admission, however I get thanked by far more patient's/parents after the admission than you might expect and we have had 1 patient out of dozens that went IP not come back due to feelings of being forced into IP care.

 

[Stagg737]

Shouldis v Strange

Shouldis v Strange - 2019 NY Slip Op 51993 (U)

law.justia.com

Lol you mean this case? Hardly call that a "thorough safety plan". Read the whole thing too, the guy even modified his chart and MSE afterwards...



HOWEVER even given that and the fact that this guy died the next day

I'll have to look for the old SDN thread, but the stuff you quoted here is pretty different from what I recall was posted in the SDN thread which also included pretty in depth court transcripts. If what you posted was the reality though, then I agree it's bad and shouldn't meet any standards of care.

Well firstly, I don't practice traditional OP anymore, I only see patients at PHP/IOP LoCs so I don't want anything I say here to be misleading about that.

Yes we 100% contact the accepting ED facility and I personally give signout to the charge nurse if the patient discussed the SI with me (in the event they discussed it with the therapist and I did not see the patient before parents/EMS arrive, then the therapist will speak to them). I give my personal cell and have a good relationship with the crisis teams at nearby EDs as we send patients there regularly, I have spoken to the ED attending or LCSW depending on the case anytime it is not a slam dunk admit. I don't take traditional call but will always accept a call from an ED for our patients out of hours.

By the time they have spoken to the crisis team and had the ED eval, 90% of the time everyone is in agreement on IP admission. In a small minority of times patients will oppose but their parents want them hospitalized, that gets taken care of at the ED. Very rarely the patient will want to be hospitalized and the parent will not, that also gets taken care of in the ED. We have had 1-2 cases in the past year that during the intervening time the apparent crisis was improved and they returned to PHP back the next day. We absolutely would send them right back if they continued to have active SI but I thankfully have not yet had to deal with such a case.

So no, I never send someone unless I think they should be hospitalized. I do the risk evaluation and documentation (or my team does), we do not rely on an ED for this, although I can imagine in a busy OP practice there may be cases where it might not be possible, although I've never had that experience personally as I would always make the time when I used to do traditional OP care and just run very late.

I will add that people seem to worry about rapport when being forceful about IP admission, however I get thanked by far more patient's/parents after the admission than you might expect and we have had 1 patient out of dozens that went IP not come back due to feelings of being forced into IP care.

Good on you, I wish I knew OP docs around here that would do this. I can say that other than when the academic outpatient clinic send someone down and the residents/attending messages/calls me directly, I can count on 2 fingers the number of times I've even been able to talk to the outpatient doc and only one of those times the doc called us. Ironically that doc is telehealth across the country but had seen the patient for 10 years before they moved to our state. The other time was when the outpatient doc was someone I'd done residency with and have their personal info and a good relationship, so they were happy to clarify things (which helped a ton).

I wish your approach was more reflective of what I dealt with in our ER. But I've found that a large percentage of the time when a patient is sent by their OP doc that the OP psychiatrist is either impossible to get a hold of or the patient called their VM/office with SI and the doc just told them to go to an ER, ie liability dump. I get that OP docs can't always see people in a reasonable time and that the ER is the necessary back-up, but the number of patient that come in with fleeting, passive SI or mildly worsened depression where the OP doc knee-jerks to "go to the ER" can get frustrating. Though I guess it does keep the psych RNs and SW employed doing safety plans and calling to help patients schedule their f/ups...

 

[calvnandhobbs68]

The right thing as in what is professionally or legally expected in the situation, aka the "standard of care".

I am fine agreeing to disagree on that point. There is absolutely no world in which a patient details a plan to end their life that they have means/access to with intent is ever not having a 911/ED evaluation regardless of what a parent tells me. I have had this situation arise on several occasions and had a board complaint (that incidentally was immediately dropped) for requiring this, but I stand very steadfast in my resolve to continue to do this. I have heard the whole we sleep in the same room, have everything locked up speech and have also seen multiple patient's sneak into a bathroom and enact high lethality attempts despite that (once with an ICU, permeant injury outcome).

I personally care relatively little about the lawsuit issue, this has very little to do with covering my butt. It does have to deal with not being able to sleep at night if I did not do everything in my power to save the life of a child who confided in me as their doctor. I have absolutely no problem with hospitalizing 100 kids if it saves the lives of 1, although actually determining NNT is clearly impossible as the counterfactual can never be determined. I certainly am persuaded by the large body of research suggesting placing barriers between access to means results in less suicide. I guess I can imagine a reasonable argument for almost never hospitalizing someone for SI and using some alternative diversion process/treatment but I would certainly need to see literature to support it.

(OP I think everyone agrees your original job offer stinks which is why we're on this tangent now)

My original point was about involuntary psychiatric admission of a minor over the parent's objections when the parents are clearly stating to you in the ER that they are comfortable taking the minor home and supervising said minor after a discussion of the possible risks and benefits of this decision. The point was not about active SI. The point was not about sending patients to the ER for an evaluation of SI. There is a much lower threshold for an ED evaluation than involuntary admission over everyone's objection.

Maybe you do have some anecdotes of suicide attempts when parents agreed to supervise a kid which I guess you're assuming would have been prevented with an inpatient psychiatric admission? I think your last paragraph would make sense if we had good evidence that hospitalizations prevent suicides from occurring. However, using your logic we should just literally blanket admit everyone from the ER who presents for an evaluation because we are terrible at predicting short term risk. So, you have no idea if within those 100 kids you admitted there were ACTUALLY any of the ones who would have died from suicide in the next week while they were in the hospital vs the 100 you discharged over the same time period EVEN IF you thought those 100 you discharged were "low risk".

This is the thing people just can't seem to grasp about suicide or harm risk assessments. It's all cover your butt short term. It is NOT long term, where the utility may lie is trying to figure out who is higher risk over long run.

 

[Merovinge]

(OP I think everyone agrees your original job offer stinks which is why we're on this tangent now)

My original point was about involuntary psychiatric admission of a minor over the parent's objections when the parents are clearly stating to you in the ER that they are comfortable taking the minor home and supervising said minor after a discussion of the possible risks and benefits of this decision. The point was not about active SI. The point was not about sending patients to the ER for an evaluation of SI. There is a much lower threshold for an ED evaluation than involuntary admission over everyone's objection.

Maybe you do have some anecdotes of suicide attempts when parents agreed to supervise a kid which I guess you're assuming would have been prevented with an inpatient psychiatric admission? I think your last paragraph would make sense if we had good evidence that hospitalizations prevent suicides from occurring. However, using your logic we should just literally blanket admit everyone from the ER who presents for an evaluation because we are terrible at predicting short term risk. So, you have no idea if within those 100 kids you admitted there were ACTUALLY any of the ones who would have died from suicide in the next week while they were in the hospital vs the 100 you discharged over the same time period EVEN IF you thought those 100 you discharged were "low risk".

This is the thing people just can't seem to grasp about suicide or harm risk assessments. It's all cover your butt short term. It is NOT long term, where the utility may lie is trying to figure out who is higher risk over long run.

Of course there is more to be done to better identify risk of attempting suicide and the likelihood of being able to do this accurately in our professional careers is quite low. That said I think almost everyone would accept that are elements associated with suicidality that increase risk. From the continuum of keep every kid on earth in an IP to unit, to every kid who mentions having ever had SI, to thought about not waking up to, to wanting to die without a plan, to articulating a specific feasible plan, I think it's pretty easy to understand why we lean towards the last group even when we cannot accurately predict.

Maybe you truly believe that any risk assessment is just CYA and has absolutely no clinical validity and IP stays for SI are no different than asking a magic 8 ball. I strongly disagree if that's your stance and I think it is an overinterpretation of the limitations of (the very limited) studies in this area. I have seen how IP stays change parental perception of mental illness, the almost forced f/u and likelihood of close PHP stepdown that often ensues so even independent of anything occurring on the IP unit, I often see pathways for stays having tangible value.

 

[psyspy]

Based on my outpatient practice, the majority of my patients that express suicidal thoughts and go to the ED end up denying it. Say you are brought to the ER by family and you are depressed. You’ll now wait in the waiting room for a few hours bored. By the time you actually talk to someone, you’ve had hours to contemplate how this will go. If you have decided to end your life, you now have a plan to get out of the ED to follow through with it, or you have utilized a coping skill by force (nothing else to do in the ED) and you begin to think that anywhere but a psych hospital seems better at the moment. There still may be a 40% chance that you try something, but maybe calling an ex-girlfriend or hitting the bar sounds better first.

Another possibility that I’ve had: Adolescent states acutely suicidal. Has plan and intent. Parent after waiting hours has decided that parent can adequately monitor patient - parent starts stating that patient is a liar and just wants attention to get child discharged. Parent is the liar in this case. How much time if you aren’t intimately involved with this case would spend figuring this out?

I mean if the kid has a plan and intent, and some degree of exacerbating factors, and no need for secondary gain, I honestly don’t see what the hesitancy would be to admit for safety purposes, unless the parent can block it in whatever state you’re in (I’m an intern and haven’t done cap yet).

Edit: I guess the parent can attempt to stop it and then you’d have to admit the kid involuntarily. Still, I don’t see the hesitancy. But again I also haven’t done cap yet at all