What do you hate about it?

[sideways]

For the residents and attendings is psych, what do you hate about the specialty? Or severely dislike. Or maybe just dislike.

What did you downplay or overlook as a hopeful med student choosing the profession that now weighs heavier on your mind than you would have expected?

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[393656]

For me its the entire financial crisis of mental health care. this is VERy different based on location so it probably varies. I did not really give it a thought before but where I did residency, people without insurance had NO psych access other than emergency service. So that entire dillema.

Second is probably the litigation against psychiatrists for stupidity but not sure if this is psych specific or not.

 

[RugbyJC]

Second is probably the litigation against psychiatrists for stupidity but not sure if this is psych specific or not.

Can you explain what you mean by this? The program I am in is a little non-traditional and we don't see a lot of this. Do you mean psychiatrists doing stupid crap or patient's filing lawsuits over stupid crap?

Thanks

 

[Doctor Bagel]

I really dislike emergency psychiatry and the whole cover your a&& attitude that results in lots of needless admissions (and harm to patients and society). Not huge, but I hate it, and there's no way in hell I'll do anything close to emergency psych when I'm out of residency. And rotating at inpatient psych in the VA where all your patients are these people who shouldn't be admitted who are because of that whole attitude I talked about above.

And I hate getting patients transferred from medicine and surgery services just to discharge them to jail. Totally an administrative issue that maybe doesn't happen elsewhere, but it sucks. I feel like I'm just doing the dirty work for the other team ( and lying to the patient because we're not allowed to tell them about the whole cops coming for them thing).

So there you have it. I'll see what I hate once I get out of lower level resident inpatient psych rotations and emergency psych call stuff.

 

[Doctor Bagel]

Second is probably the litigation against psychiatrists for stupidity but not sure if this is psych specific or not.

So my question about this, is is this based in reality? I feel like in lots of medicine we engage in this CYA stuff when our risk of litigation is really quite low. For example, getting sued for a pt committing suicide is super unlikely to happen, and yet we practice all sorts of bad psychiatry because of this fear. Unfortunately, we hear a lot of anecdotal stories from the one random guy who got sued and assume that there's a statistically significant risk of litigation for something when there isn't. And listening to lawyers on this issue isn't useful because lawyers don't focus on the probability of risk, they focus on the remote chance of any exposure to risk. I've been to law school, so I know the mindset.

 

[nitemagi]

According to my malpractice company, psychiatrists get sued less than pretty much ANY other specialty. The number they told me was on average once every 33 years. That's pretty good.

Wonder why? Because what's the most important factor in preventing litigation? A good relationship.

Now of course this wasn't subdivided by subspecialties. Emergency psych might have higher, or in forensics.

 

[Doctor Bagel]

According to my malpractice company, psychiatrists get sued less than pretty much ANY other specialty. The number they told me was on average once every 33 years. That's pretty good.

Wonder why? Because what's the most important factor in preventing litigation? A good relationship.

Now of course this wasn't subdivided by subspecialties. Emergency psych might have higher, or in forensics.

That's pretty consistent with what I've heard too. I would be curious to see the emergency psych figures -- they probably are somewhat higher but likely not that high. I will say that whenever anybody uses the term "medicalegal" I tune 'em out because in my experience it's always used as an excuse for practicing bad (expensive and overly defensive) medicine.

Now, my bitching about the stuff I don't like about psychiatry probably isn't that relevant for making a career decision because, as we've discussed here before, no one does inpatient psychiatry or emergency psychiatry outside of residency for all sorts of good reasons. It's kind of like a family medicine doc not liking ICU -- it's a painful part of residency but not a big part of most of our lives afterwards (at least this is what I tell myself). Residency is painful regardless of what field you're in.

 

[turkeyjerky]

According to my malpractice company, psychiatrists get sued less than pretty much ANY other specialty. The number they told me was on average once every 33 years. That's pretty good.

Wonder why? Because what's the most important factor in preventing litigation? A good relationship.

Now of course this wasn't subdivided by subspecialties. Emergency psych might have higher, or in forensics.

Interesting--I think I heard more about medicolegal liability on psych than any other rotation, could never figure out why they talked about it so much. We did a week of emergency psych on our rotation and it was such a disappointment. Made me really lose a lot of respect for the profession.

 

[Sharpie1]

We did a week of emergency psych on our rotation and it was such a disappointment. Made me really lose a lot of respect for the profession.

What was so disappointing?

 

[393656]

Its not about pure numbers and I do not know where psych ranks on most lawsuits, but there is no other field where the whole culture is obsessed with cya mentality. Also when a lawsuit comes, it is often a vengeful lawsuit filled with emotion by family after a suicide. There is a stigma, good or bad, that a lawsuit is really bad for a psychiatrist but other specialities kind of build it in as something likely to happen. Its more the stigma we created of being so scared of this. Makes for a lot of documentation that could be spent seeing patients instead of reiterating 10 ways the patient was assessed for suicidality

 

[turkeyjerky]

What was so disappointing?

You're right--I didn't really say anything in my post. It seemed like they spent the whole time talking about legal liability and risk (not of poor outcomes for the patient, but for the physician--which are two completely different things that are often conflated), and the default path was to admit the patient on a 72 hr hold, no matter if the patient actually desired or required admission.

 

[Doctor Bagel]

You're right--I didn't really say anything in my post. It seemed like they spent the whole time talking about legal liability and risk (not of poor outcomes for the patient, but for the physician--which are two completely different things that are often conflated), and the default path was to admit the patient on a 72 hr hold, no matter if the patient actually desired or required admission.

Honestly, I think it's an ethical issue when thoughts about legal liability are the dominant factor in treatment decisions. Admittedly I'm being a little idealistic here, and I don't want to be sued either. And I'm guessing that being sued is so traumatic that is understandably shapes your practice. Still, it's problematic when you're not doing the right thing by your patient (and yes, psych admission can be harmful) primarily because of worries about legal consequences.

I don't know, though, emergency psych is just a tough area. It doesn't bring out the best in me, and I'm guessing that's true for most of us. So you wind up cynical and burnt out and maybe less concerned with your patients than you should be. I feel like it's too bad that it was such a big part of your exposure to our profession because we really are better than how we seen in the emergency setting.

 

[393656]

Honestly, I think it's an ethical issue when thoughts about legal liability are the dominant factor in treatment decisions. Admittedly I'm being a little idealistic here, and I don't want to be sued either. And I'm guessing that being sued is so traumatic that is understandably shapes your practice. Still, it's problematic when you're not doing the right thing by your patient (and yes, psych admission can be harmful) primarily because of worries about legal consequences.

I don't know, though, emergency psych is just a tough area. It doesn't bring out the best in me, and I'm guessing that's true for most of us. So you wind up cynical and burnt out and maybe less concerned with your patients than you should be. I feel like it's too bad that it was such a big part of your exposure to our profession because we really are better than how we seen in the emergency setting.

I dont get what your statement about hospital being harmful for legal reasons? You must have not gotten much exposure to the legal system or probate. There is no judge or magistrate who ever penalizes a doctor for erroring on the side of safety for his patient. Especially anyone who shows up in an emergency room with an acute psychiatric issue has bought themselves an admission until proven otherwise. It is NOT normal to wait in an ED for 8 hours in the middle of the night to see a psychiatrist unless something is really wrong, either psychiatrically or characteralogically, both of which are big risks for self harm.

Hospitalizing someone is never dangerous for anyone and that is why it is absolutely not an ethical dillema when hospitlizing someone. It is never in their worst interest so you are by no means crossing any ethical boundry.

 

[Ibid]

Hospitalizing someone is never dangerous for anyone and that is why it is absolutely not an ethical dillema when hospitlizing someone. It is never in their worst interest so you are by no means crossing any ethical boundry.

You could not be more wrong. Hospitals are toxic environments in every respect even if some are less bad. They should be a last resort not an easy option.

 

[Daedra22]

You could not be more wrong. Hospitals are toxic environments in every respect even if some are less bad. They should be a last resort not an easy option.

Agreed. I've known some people who viewed their psychiatric hospitalization as more traumatic than the event that placed them there.

 

[Suedehead]

You could not be more wrong. Hospitals are toxic environments in every respect even if some are less bad. They should be a last resort not an easy option.

agreed

 

[bashir]

Hospitalizing someone is never dangerous for anyone and that is why it is absolutely not an ethical dillema when hospitlizing someone. It is never in their worst interest so you are by no means crossing any ethical boundry.

This is one of the most bizarre statements I have ever read on SDN. That's saying something.

 

[atsai3]

I dont get what your statement about hospital being harmful for legal reasons? You must have not gotten much exposure to the legal system or probate. There is no judge or magistrate who ever penalizes a doctor for erroring on the side of safety for his patient. Especially anyone who shows up in an emergency room with an acute psychiatric issue has bought themselves an admission until proven otherwise. It is NOT normal to wait in an ED for 8 hours in the middle of the night to see a psychiatrist unless something is really wrong, either psychiatrically or characteralogically, both of which are big risks for self harm.

Hospitalizing someone is never dangerous for anyone and that is why it is absolutely not an ethical dillema when hospitlizing someone. It is never in their worst interest so you are by no means crossing any ethical boundry.

You may be one-half correct.

I cannot think of a case where a physician was penalized, either by court or by a professional (psychiatric) society, for hospitalizing a patient he had determined to be DTS/DTO/GD. This probably explains a large proportion of the variance in psychiatrists' involuntary admission decisions: if you mistakenly discharge a patient who commits suicide, you may be successfully sued; but if you mistakenly admit a patient, s/he is at much lower risk of completed suicide in a monitored environment and therefore your legal exposure is limited.

However, it is not true that "hospitalizing someone is never dangerous". Hospitalization may expose a patient to iatrogenic harms, including necessary or unnecessary medications, necessary or unnecessary seclusion and restraint, and infectious diseases. It may also expose a patient to the trauma of being involuntarily hospitalized with a patient population s/he perceives to be different (eg., a patient with borderline personality disorder who is hospitalized on the high-acuity ward along with much lower-functioning patients with psychotic disorders who are smearing feces). For patients whose psychopathology involves repeated patterns of hospitalization, there may be cases where hospitalization does not do them any psychological benefit and represents a setback in whatever progress they have been making in the outpatient setting with their psychotherapists.

 

[393656]

Come on you are trying to predict the future here. You are splitting hairs with the "dangers of hospitlization" Obviously things happen in a hospital but to take your example of uncessary restraints/seclusions-that makes no sense.

In your arguement you take a hypothetical patient who according to you may "not" need hospitlization and doing so would be dangerous since he ends up getting restrained. Now what do you think the odds of any patient restrained or medicated for agitation forcefully was functioning at a level to be roaming around on their own? So sure its "more dangerous" than what... them roaming around disorganized, aggressive etc?

Also you cannot predict the future and usually a psychiatrist has a reason to hospilize someone-you have some concern they are not caring for themselves or making poor decisions. Their poor decision making puts them in a lot worse spot of something bad happening than a random infection or bad uncessary medication in a hospital. Such as someone blowing all their money, having unprotected sex, binging and being arrested etc etc.

Sure something bad can always happen anywhere but by and large I stand by the fact that no doctor EVER will be frowned upon if they are acting in the safety of the patient.

 

[loveoforganic]

You are impinging upon the patient's rights by involuntarily committing him. By that very fact, you have an ethical situation. If someone is blowing all their money, having unprotected sex, whatever, and that behavior isn't stemming directly from a mental illness, you have no right to involuntarily commit that patient when the patient presents no immediate threat to himself or others and they are able to care for themselves to some degree.

 

[Manicsleep]

You could not be more wrong. Hospitals are toxic environments in every respect even if some are less bad. They should be a last resort not an easy option.

Wrong.

The sad thing is that Ibid is probably not on the extreme...although at times he/she makes me think there is dianetics book on the table and pictures of Ron-Ron and Tommy C on his walls.

Hospitalizing someone is never dangerous for anyone and that is why it is absolutely not an ethical dillema when hospitlizing someone. It is never in their worst interest so you are by no means crossing any ethical boundry.

Nope. The other extreme although you explained your position later. The fact remains you cannot take away someones civil liberties on a whim. That is crossing ethical boundaries.

Inpatient hospitalization can be very helpful to patients of all kinds, including psychiatric patients. Involuntary commitment is a necessary tool but one that must be used with great care and the patient's rights as well as their health in mind. It is an unfortunate balancing act that we have to do as psychiatrists but it is why we train as long as we do.

 

[digitlnoize]

In my meager couple of months of inpatient psych, I've seen multiple cases where a hospitalized patient was interacting with other patients with negative consequences. Aside from the obvious violent incidents, there can also be behavior reinforcement and good old sex, which has at times led to pregnancy (although I haven't seen this, the psychiatrists at my institution told me it has happened there before).

Sometimes the last thing someone needs is to be in a small, locked space with a bunch of other people with similar tendencies. I've seen this be especially problematic in younger patients with criminal histories (they teach each other tricks of the trade), and especailly, teenage borderline girls.

 

[393656]

This is one of the most bizarre statements I have ever read on SDN. That's saying something.

YOu are a premed-enough said young chap

 

[Doctor Bagel]

Well, hospitalizing a patient is probably rarely harmful if your concern is avoiding legal liability. In my statement about hospitalization having the potential to be harmful, you'll note that I didn't mention the word legal in there.

I think everyone else has done a great job pointing out how hospitalization can be harmful.

 

[Ibid]

Wrong.

The sad thing is that Ibid is probably not on the extreme...although at times he/she makes me think there is dianetics book on the table and pictures of Ron-Ron and Tommy C on his walls.

Very funny. Although I don’t get the sad bit.

In order for me to be wrong and you to be right you would have to come up with a list of redeeming features that are exclusive the inpatient experience. I put it to you that their is nothing that happens in a hospital that could not just as easily be delivered to a person in their own home. The only differential aside from all the negative aspects to admission (to numerous to mention and I expect we would agree about them anyway)and all the positive aspects of home treatment is that hospital affords containment. Containment being a last resort.

Unless you can come up with something I rest my case.

In my meager couple of months of inpatient psych, I've seen multiple cases where a hospitalized patient was interacting with other patients with negative consequences. Aside from the obvious violent incidents, there can also be behavior reinforcement and good old sex, which has at times led to pregnancy (although I haven't seen this, the psychiatrists at my institution told me it has happened there before).

Sometimes the last thing someone needs is to be in a small, locked space with a bunch of other people with similar tendencies. I've seen this be especially problematic in younger patients with criminal histories (they teach each other tricks of the trade), and especailly, teenage borderline girls.

Teenage borderline girls know when you will be on duty before you do. The system is an open book to them. The alpha and omega of it is they will always be one step ahead.


The interactions with staff can be equally damaging. As I have said before a few minutes a week with a psychiatrist and all day with a kaleidoscope of staff made up of frustrated martial artists, beauty school drop outs and paramilitary vegetarians all with their own idiosyncratic outlook on mental health issues.
And not adverse to sharing these notions with a captive audience either.

Relationship formation is an interesting point. I’ve seen countless relationship that led to marriage form. Inpatient unit as a sort of strange dating agency?

Female staff sleeping with male patients….happens all the time. People + beds = sex

Frankly if you gave most people a pile of money equal to the cost of the whole charade most people would sort themselves out and you would never see them again.

 

[whopper]

The biggest thing I hate about psychiatry are psychiatrists.

No joking.

I often seen patients treated by other doctors and I think WTF is this idiot doing to this poor patient? E.g. a guy who is pre-diabetic, telling his doctor he doesn't want meds that cause weight gain and the doctor puts him on Zyprexa and Depakote without warning the patient about the possible metabolic effects of those meds or the alternatives such as Lamictal and Geodon.

It's to the point where almost daily I see stuff that ticks me off. I'm surprised with the lack of quality I see on the part of other physicians. I'm not trying to specifically target psychiatrists because doctors I've seen in all fields pull this crap. It's just that since I'm a psychiatrist, I see this more often with psychiatrists.

 

[digitlnoize]

The biggest thing I hate about psychiatry are psychiatrists.

No joking.

I often seen patients treated by other doctors and I think WTF is this idiot doing to this poor patient? E.g. a guy who is pre-diabetic, telling his doctor he doesn't want meds that cause weight gain and the doctor puts him on Zyprexa and Depakote without warning the patient about the possible metabolic effects of those meds or the alternatives such as Lamictal and Geodon.

It's to the point where almost daily I see stuff that ticks me off. I'm surprised with the lack of quality I see on the part of other physicians. I'm not trying to specifically target psychiatrists because doctors I've seen in all fields pull this crap. It's just that since I'm a psychiatrist, I see this more often with psychiatrists.

Agreed. I'm seeing it in all fields right now. I know that everyone is strapped for time, but doctors are risking serious lawsuits by not warning people about very real side effects.

I just saw an old lady who had been on rx naproxen for a long time, per her family doc, and she got an ulcer and had a bowel perf we had to repair. No warning.

I can't count the number of docs I've worked with this year (3rd) who don't tell patients about side effects of meds, or more annoying to me, about the patients disease state.

I've met diabetics who have never been told that they should avoid soda, for example. "Huh? That has sugar in it?" Seriously. I know we think these things are common sense, but people just don't know. It takes 2 seconds to rattle off a list of very, very common foods to avoid, yet no one does it. Don't even give a handout or website recommendation. Just, "I'd like you to try this drug, Metformin." The only time a discussion of side effects happens is if the patient really questions it.

Don't even get me started on ER's not ordering a pregnancy test for a 21 year old female with abdominal pain. Seriously. Repeatedly.

Come on people, I'm a mediocre, average 3rd year DO student. These are no brainers. Step it up. Soapbox off.

 

[Bartelby]

In order for me to be wrong and you to be right you would have to come up with a list of redeeming features that are exclusive the inpatient experience. I put it to you that their is nothing that happens in a hospital that could not just as easily be delivered to a person in their own home.

Honestly I agree with you that hospitals are potentially quite harmful, but I don't agree that there are no exclusive advantages to inpatient care. For instance:

*It's really hard to kill yourself as an inpatient.
*Someone can see if you are taking your meds, and can do so on a schedule.
*The patient cannot assault a stranger on the street, step into heavy traffic, or gamble his/her home away.

Those things are an advantage. My take on it is minimize hospitalizations whenever you can but don't take that to a 'there is no advantage to hospitalization whatsoever' extreme.

 

[heyjack70]

For the residents and attendings is psych, what do you hate about the specialty? Or severely dislike. Or maybe just dislike.

What did you downplay or overlook as a hopeful med student choosing the profession that now weighs heavier on your mind than you would have expected?

I see you changed "Hate" to "dislike" in your post. I don't think there is anything I hate about this job. I would like to feel content with writing shorter, less descriptive notes. I love reading surgery notes:

PO day #4 (automatically inserted by EMR)
Interval Hx:
no acute events
pt s/p lap chole

Physical Exam
VSS afebrile
stomach ND/NT
wounds clean/dry

Plan:
d/c home tomorrow

=============

And POD 1 and POD 2 notes looked exactly the same. Copy and paste much? Psych notes done well are unfortunately more involved than this. I guess documentation is the bane of most physicians.

 

[whopper]

I'm a mediocre, average 3rd year DO student.

Likely not. I've noticed that the measure almost every school uses are board scores and grades. Hardly anyone uses measures such as the doctor actually doing the right thing, having some actual emotional investment (I'm not talking boundary violation, but feeling things like pride or dignity when doing the right thing and proper practice).

A guy who has good grades and doesn't give a damn is someone who doesn't give a damn.

 

[digitlnoize]

Likely not. I've noticed that the measure almost every school uses are board scores and grades. Hardly anyone uses measures such as the doctor actually doing the right thing, having some actual emotional investment (I'm not talking boundary violation, but feeling things like pride or dignity when doing the right thing and proper practice).

A guy who has good grades and doesn't give a damn is someone who doesn't give a damn.

Oh, I agree 100%, but for some reason, those aren't the metrics we use. Instead, we're worried about whether I can memorize information on obscure zebras which can be looked up instantly on the phone in my pocket anyways.

I actually think we need to drastically change how we test and evaluate medical students. I think group problem solving should be part of our board exams. I think the emphasis on the memorization of facts should be greatly decreased, and great training provided in looking up and synthesizing information into clinically relevant information.

I am sightly worse than many of my classmates at bulk memorization (damn 33 year old brain), but I am about 10x faster at finding information and applying to correctly to a patient case. I also work very well on a team, and get along with others, without seeming like a tool. Something that can't be said for a classmate of mine who got a perfect board score. I'm also very humble. And funny...did I mention funny? Sorry ladies, I'm taken (that wink wasn't nearly creepy enough...)

Anyways, sorry to derail the discussion...back on topic...

 

[dl2dp2]

I actually think we need to drastically change how we test and evaluate medical students....

3rd year medical school is actually shockingly "real world" in terms of how you get a good clinical grade. In order to be a successful doctor, the key ingredient is the ability and availability and the astuteness in carrying out certain repetitive tasks in a team context.

Everyone can deconstruct the system every which way, but there is actually no clear superior alternative.

You could not be more wrong. Hospitals are toxic environments in every respect even if some are less bad. They should be a last resort not an easy option.

Going back to the topic of involuntary admission -- you CAN be sued for incorrectly involuntarily admit someone for illegal imprisonment. This is very rare though. Also, while you can complain on and on about how emergency psychiatrists are covering their liability in terms of being conservative in admitting patients, it's VERY hard to predict who will attempt suicide in the immediate future. And while it's possible that iatrogenic damage can be done in a hospital, just like in any other specialty, there is a STANDARD of CARE for certain presentations (i.e. suicide attempt). Think of it this way, if you had a heart attack, generally you need to be hospitalized. On rare occasions you might get away with not having to hospitalize someone, and in some cases being in a hospital get you infected with a deadly bug -- one which might even kill you. However, this does NOT mean that in general someone who had a heart attack he should not be hospitalized. That is not logical and is poor practice.

On the other hand, I agree with you that the amount of time that people spend in the hospital should be minimized. And it has been and it is getting shorter and shorter in the current insurance climate. in fact, in my experience the problem has now become the reverse: often patients don't get enough hospitalization days because insurance stops to pay for them and it has been observed in several studies that such circumstances result in adverse outcomes.

For the residents and attendings is psych, what do you hate about the specialty? Or severely dislike. Or maybe just dislike.

Echoing some of Whooper's sentiments, I think anecdotally the variability of ability within psychiatry might be larger than, say, cardiology--though I can't back this up with data. This is related to the lack of competitiveness in terms of residency match.

The two other things I dislike about psychiatry is first the science is on shaky ground, but that's in the process of being addressed. The second is the tediousness involved in dealing with non-medical/social work related issues that is universal in all of medicine, but is especially heavy in psych. This problem though can be leveraged in some ways, because in many cases the interdisciplinary nature of psychiatry also represents an opportunity to effect macroscopic changes on a social level that transcends the normal boundaries of medical practice. So if that kind of thing is your thing, then psychiatry is unique in its ability to give you these venues for exploration.

 

[nitemagi]

Going back to the topic of involuntary admission -- you CAN be sued for incorrectly involuntarily admit someone for illegal imprisonment. This is very rare though.

This varies by state. Some states actually have laws that limit litigation for civil commitment . At least that's the lore I've heard about california.

 

[Suedehead]

I suppose I hate how psych is prone to fads. to quote myself from another thread.... 20 years ago everyone had multiple personality or repressed memories. 40 years ago everyone was schizophrenic or had a schizophrenogenic mother. before that everyone was battling libido and aggression. Now, everyone has bipolar disorder.

 

[digitlnoize]

3rd year medical school is actually shockingly "real world" in terms of how you get a good clinical grade. In order to be a successful doctor, the key ingredient is the ability and availability and the astuteness in carrying out certain repetitive tasks in a team context.

Everyone can deconstruct the system every which way, but there is actually no clear superior alternative.

I guess it's kind of "real world," but my clinical grades have been EXTREMELY subjective. Our docs have to rate us from 1-10 in various categories...that's it. I guess that's "real world," since it's a purely subjective measure, but it seems weak to me.

Anyways, agreed that there is no clear superior alternative, but while the current system has worked fairly well for quite some time, the explosion of information we've had in the last couple of decades is only increasing, and is quickly becoming beyond the scope of anyone's ability to memorize. The key in the future (and we must look to the future) is the ability to quickly access information, since there will be (and arguably, already is) too much for a person to memorize.

 

[whopper]

Going back to the topic of involuntary admission -- you CAN be sued for incorrectly involuntarily admit someone for illegal imprisonment. This is very rare though. Also, while you can complain on and on about how emergency psychiatrists are covering their liability in terms of being conservative in admitting patients, it's VERY hard to predict who will attempt suicide in the immediate future

In the case of hospital psychiatry, if you are sued, the hospital will likely strongly back you so long as you did competent work.

The fact of the matter is in emergency psychiatry, doctors often have to make decisions based on extremely limited information and patient observation. So long as you demonstrated that you did what you reasonably could've done with what you had, you are not supposed to lose a lawsuit.

E.g. if someone came in to the crisis center already unconscious because the ER doctor had the patient injected with Haldol, and the ER doctor wrote down the guy was psychotic, and you admit the guy, even if the guy was not psychotic, you did the best you could under the circumstances. You were told information that was erroneous, but because of the situation you had to take it at face value because it was given by another medical professional.

Now getting sued in private practice is another thing because you don't have a lot of ammo at your disposal that you would've had as a hospital employee such as the hospital lawyer, the dept, colleagues, etc. being able to support you. You're on your own except for the malpractice carrier that can offer you with assistance.

In the state hospital where I work at, the state covers all malpractice and other lawsuits against a physician employee for work done for the state. Further, if the suit does happen, the laws here are mandated so it'll usually go to a s specific court where it's a 3 judge panel, and those judges are experienced and can fish out a frivolous suit. Further, from what I heard, those judges pretty much never let any malpractice suit go on the side of the plaintiff.

I know this because I had to research the state laws thoroughly during my fellowship, but during my initial year as an attending, a family was threatening to sue based on frivolous reasons, and the mental health board's lawyer told me about the 3 judge panel and told me those 3 specific judges were there for a reason---because there's plenty of BS lawsuits against the state and those judges were of the type that they'd give the plaintiff a new hole for filing one if it were frivolous.

 

[393656]

Not sure where you have worked but going off an ED's opinion without evaluating the patient would never fly anywhere I have been. They will sit in the ED until they can be evaluated.

Also in the end I think people are making this too complicated. You CAN technically be sued for all sorts of things but you have to talk about realistically what will get you sued and what will not. Bottom line is there would have to be flagarent documentation or lack of documentation regarding pink slipping someone for a reason deemed inappropriate. That is why the probate process is in place. keep in mind most states carry the 3 days evaluation period. This means there is no expectation of diagnosis or final evaluation when you pink slip them (or whatever color it is in your area) but rather you have reason for concern and they purposely leave it flexible in most states with a criteria 4- "would benefit from inpatient psychiatric care" So it leaves the legal door open to muddy situations that maybe dont clearly fit into SI/HI/not caring.

People can do what they like but if I were a doctor id rather bet on me winning a lawsuit for hospitlizing someone over letting them go and something bad happens because they maybe were not "technically" suicidal or what not.

 

[TexasPhysician]

What to hate about psychiatry? Hmmmm maybe off-service months.....

 

[OldPsychDoc]

...
People can do what they like but if I were a doctor id rather bet on me winning a lawsuit for hospitlizing someone over letting them go and something bad happens because they maybe were not "technically" suicidal or what not.

As one of my attendings famously said, "It is much easier to defend yourself in the presence of a living patient".

 

[notdeadyet]

I guess it's kind of "real world," but my clinical grades have been EXTREMELY subjective. Our docs have to rate us from 1-10 in various categories...that's it. I guess that's "real world," since it's a purely subjective measure, but it seems weak to me.

I can't help but notice that most gripes about the medical school clinical evaluation process get cyclical pretty quick.

It usually starts with something along the lines of "There's too much focus on board scores and grades."

This is soon followed by "There's too much subjectivity in evaluations."

I'm sure there's a lot of interschool variation, but I think most good schools clinical evaluations have a component of objectivity (which falls to shelf exams and board scores) and subjectivity (mostly subjective clinician evaluation of student performance). This is a yin and yang or check and balance.

There always needs to be an evaluation of the increasing fund of knowledge that digitlnoize mentions, which is at least partially captured by things like shelf exams. But there also always needs to be an evaluation of a student's clinical performance, professionalism, compassion, and character, like mentioned by whopper, which are targeted with evals. It's not a perfect system at my school, but it sure seems more fair than what I've typically find in the professional world.

 

[sunlioness]

I want to know when I get the crystal ball. I had a consult today for "mental status changes." It was on a woman on a crap ton of methadone for chronic pain who was found stuporous by her family and brought to the ED where she was admitted medically. The woman's family was concerned she was abusing her pain meds. The patient herself adamantly denied it. I get consulted to tell them whether she's abusing her pain meds or not. Which you know is hard when the patient is adamantly denying it, refuses me permission to talk with her family, and I wasn't there to see what happened.

Emergency psychiatry and consults are my least favorite things in psychiatry, I have to say. I don't even really like good, legitimate consults. Like the other one I saw today was a woman with a long h/o depression who was admitted medically for unexplained weight loss (which they were appropriately working up) and who was c/o continued severe depressive sx and they were wondering if the depression might be a factor and how best to manage it. Totally legitimate consult. I still didn't enjoy it though.

 

[Majesty]

Very funny. Although I don't get the sad bit.

In order for me to be wrong and you to be right you would have to come up with a list of redeeming features that are exclusive the inpatient experience. I put it to you that their is nothing that happens in a hospital that could not just as easily be delivered to a person in their own home. The only differential aside from all the negative aspects to admission (to numerous to mention and I expect we would agree about them anyway)and all the positive aspects of home treatment is that hospital affords containment. Containment being a last resort.

Unless you can come up with something I rest my case.

I have heard this said by a few people over the years and I am suprisingly shocked every time I hear it.

1) The cost of having the inpatient to each person delivered to the house would be immense. I put this first not to be callous but because it is a reality.
2) You still could not account for safety because of adequate monitoring, physical plant etc (I am not talking about containment here).
3) The doctor and staff would not be working on their own turf and would be unfamiliar and therefore prone to more errors.
4) The patient could be HOMELESS!
5) There exist, I know its shocking, home environments that are detrimental to a patient's health. These can be minor annoyances or downright abuse.
6) Fast access to other staff when needed such as consults, labs, imaging etc.

Of course, there is the containment issue but that is in the most serious cases. I agree that prolonged stays in the hospital can be harmful but lets not throw the baby out with the bath water.

 

[digitlnoize]

I can't help but notice that most gripes about the medical school clinical evaluation process get cyclical pretty quick.

It usually starts with something along the lines of "There's too much focus on board scores and grades."

This is soon followed by "There's too much subjectivity in evaluations."

I'm sure there's a lot of interschool variation, but I think most good schools clinical evaluations have a component of objectivity (which falls to shelf exams and board scores) and subjectivity (mostly subjective clinician evaluation of student performance). This is a yin and yang or check and balance.

There always needs to be an evaluation of the increasing fund of knowledge that digitlnoize mentions, which is at least partially captured by things like shelf exams. But there also always needs to be an evaluation of a student's clinical performance, professionalism, compassion and character, like mentioned by whopper, which are targeted with evals. It's not a perfect system at my school, but it sure seems more fair than what I've typically find in the professional world.

Yeah, my school certainly tries to balance subjective and objective measures, but they're just so extreme on both ends. During years 1 & 2 our grade is 80% tests and 20% subjective evaluations. During years 3 & 4, our grade is 100% subjective evaluations with shelf exams being pass/fail. Residencies, according to most sources, seem to care most about the objective measures (i.e. board scores), while the subjective (LOR's) matter less.

It's the subjective nature of the evals that gets me. One doc, who LOVED me (I caught more than a couple of nice, life-saving, pickups on his patients, leading him to say to me, "you rock!") gave me great comments, but one of the lowest "grades" I've gotten all year, a B. He circled 8's and 9's on my eval form, which averages out to a 80-something, obviously. Another doc, who I didn't get such warm fuzzies from, gave me a solid A. Go figure. It is entirely based on the docs understanding of my school's cryptic eval form (circle the number 1 to 10 in various categories, from medical knowledge to patient interaction to understands osteopathic principles...very vague).

Anyways, not the place for this discussion, sorry to have sidetracked things a bit...just venting really. Almost. Done.

 

[heyjack70]

Yeah, my school certainly tries to balance subjective and objective measures, but they're just so extreme on both ends. During years 1 & 2 our grade is 80% tests and 20% subjective evaluations. During years 3 & 4, our grade is 100% subjective evaluations with shelf exams being pass/fail. Residencies, according to most sources, seem to care most about the objective measures (i.e. board scores), while the subjective (LOR's) matter less.

It's the subjective nature of the evals that gets me. One doc, who LOVED me (I caught more than a couple of nice, life-saving, pickups on his patients, leading him to say to me, "you rock!") gave me great comments, but one of the lowest "grades" I've gotten all year, a B. He circled 8's and 9's on my eval form, which averages out to a 80-something, obviously. Another doc, who I didn't get such warm fuzzies from, gave me a solid A. Go figure. It is entirely based on the docs understanding of my school's cryptic eval form (circle the number 1 to 10 in various categories, from medical knowledge to patient interaction to understands osteopathic principles...very vague).

Anyways, not the place for this discussion, sorry to have sidetracked things a bit...just venting really. Almost. Done.

I believe the 3rd year clinical rotation grades are #1, then step scores, then whatever after that.

 

[digitlnoize]

I believe the 3rd year clinical rotation grades are #1, then step scores, then whatever after that.

Well, that would be awesome, because I rock at that. I'm less good at standardized tests, partially because I'm old and haven't been training for them my whole life, but also because I'm just not that good at them...but I do ok.

I'm far better in the real world. So far this year, I've gotten almost all A's (couple of B's), many of those A's have been very high, especially psych (98's). Hopefully, that, and my good letters will get me somewhere...

 

[notdeadyet]

During years 1 & 2 our grade is 80% tests and 20% subjective evaluations.

This seems about right. I think most schools are all or almost all objective measuring during the pre-clinical years, which is fair since it's almost entirely knowledge management without actual application.

And frankly, I don't think residencies put much (or any) stock in pre-clinical grades. Heck, more and more schools are migrating towards pass/fail anyway. The only use for pre-clinical grades at this point is to incent those who need it to master the fund of knowledge for later use and Step 1 preparation.

During years 3 & 4, our grade is 100% subjective evaluations with shelf exams being pass/fail.

Ugh. That's a problem. Third year should be a mix of subjective and objective measures, the only challenge is finding that sweet spot. With 100% subjective evaluations, student ability to honor is much more dependent on luck and much more vulnerable to bias and prejudice. Most schools have the weighting of subjective and objective factors left up to the individual departments, but most at my school are about 40-60% subjective and 40-60% objective (shelf exam). Oral exams also play a role (a mix of objective and subjective, I think).

Residencies, according to most sources, seem to care most about the objective measures (i.e. board scores), while the subjective (LOR's) matter less.

Meh, I'd probably disagree. For one thing, I think it's nigh on impossible to say what "residencies" value most, as there seems to be a lot of difference among the fields (not to mention among the various programs in each field).

If anything, I'd say Psych (along with Family, from what I've heard) value objective measures like Step scores much less than others. Personally, I know that I had a below average Step 1 and Step 2 and still got interviews at almost all programs I applied to, and matched into a competitive one. It never came up in interviews. But my LORs were mentioned frequently as was my third year performance. I think psych residencies probably look more at third year clinical performance > LORs/Step 1 >>>>> pre-clinical performance.

 

[notdeadyet]

During years 1 & 2 our grade is 80% tests and 20% subjective evaluations.

This seems about right. I think most schools are all or almost all objective measuring during the pre-clinical years, which is fair since it's almost entirely knowledge management without actual application.

And frankly, I don't think residencies put much (or any) stock in pre-clinical grades. Heck, more and more schools are migrating towards pass/fail anyway. The only use for pre-clinical grades at this point is to incent those who need it to master the fund of knowledge for later use and Step 1 preparation.

During years 3 & 4, our grade is 100% subjective evaluations with shelf exams being pass/fail.

Ugh. That's a problem. Third year should be a mix of subjective and objective measures, the only challenge is finding that sweet spot. With 100% subjective evaluations, student ability to honor is much more dependent on luck and much more vulnerable to bias and prejudice. Most schools have the weighting of subjective and objective factors left up to the individual departments, but most at my school are about 40-60% subjective and 40-60% objective (shelf exam). Oral exams also play a role (a mix of objective and subjective, I think).

Residencies, according to most sources, seem to care most about the objective measures (i.e. board scores), while the subjective (LOR's) matter less.

Meh, I'd probably disagree. For one thing, I think it's nigh on impossible to say what "residencies" value most, as there seems to be a lot of difference among the fields (not to mention among the various programs in each field).

If anything, I'd say Psych (along with Family, from what I've heard) value objective measures like Step scores much less than others. Personally, I know that I had a below average Step 1 and Step 2 and still got interviews at almost all programs I applied to, and matched into a competitive one. It never came up in interviews. But my LORs were mentioned frequently as was my third year performance. I think psych residencies probably look more at third year clinical performance > LORs/Step 1 >>>>> pre-clinical performance.

 

[bashir]

YOu are a premed-enough said young chap

This slight was written a couple of days ago and the thread has obviously moved on from the topic of the potential harm of unnecessary psychiatric hospitalization, but this attitude is a pet peeve of mine and I can't let it go unchallenged.

Being pre-med does not preclude a person from having life experience relevant to a discussion of what constitutes appropriate mental health care. I was speaking as a daughter and sister of people suffering from severe mental illness, who has spent more time in inpatient and outpatient treatment environments than many resident psychiatrists and has seen the best and the worst of what involuntary hospitalization can do for (or to) a person. I speak also as a former case manager for adults with mental illness, and as someone who largely grew up in her parents' assisted living facility for adults with mental illness. But no, I'm not a doctor yet, so I guess I have zero credibility.

 

[whopper]

It usually starts with something along the lines of "There's too much focus on board scores and grades."

This is soon followed by "There's too much subjectivity in evaluations."

The problem with board scores is that while they are a poor indicator, they actually are the best indicator available. LORs actually have almost no reliability and validity in studies. I'm basing this opinion from studies done in industrial psychology where college students and employees tried to enter college or the workplace.

IMHO, a way to ensure better quality is for state medical boards to randomly have professional evaluators see doctors. Kind of like a restaurant critic, but the evaluator has to grade on very objective things. E.g. Did the doctor wash his or her hands before a physical exam and afterwards? Did the doctor explain the diagnosis, the treatment, the risks and benefits, and the alternatives? Did the doctor answer your questions?

I mentioned this before, but I was thinking of doing a study where I get a bunch of grad students, have them go to a doctor, complain of symptoms and see if the doctors actually do the things they're supposed to do (mentioned above) because from my experience a significant percentage do not do this.

A problem with several doctors in practice that I've seen is many practice with very little fear that their poor practice will lead to repurcussions.

 

[digitlnoize]

Here's the page with the NRMP survey of what program directors find important: http://www.nrmp.org/data/index.html

For psych, it seems that the Dean's Letter, Clerkship Grades, and LOR's are ultra important. It's important to not have gaps in education, and how you interact with people during the interview is very important. It's bad if you have a match violation flag. As stated, test scores are important, but farther down the list. I like good news.