What setting/subspecialty of psychiatry do you like/hate the most, and why?

[hamstergang]

I don't know what state this is but in NJ, at least while I was there, there was a law where if you entered an ER once processed as a patient you couldn't leave the ER until a doctor let you go.

I know you're several years ahead of me, but I've been in NJ for all my medical training and remain in NJ now, and I don't know what you're talking about. It feels like you are interpreting something not the way it was intended and not the way I've seen it play out.

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[Celexa]

I know you're several years ahead of me, but I've been in NJ for all my medical training and remain in NJ now, and I don't know what you're talking about. It feels like you are interpreting something not the way it was intended and not the way I've seen it play out.

I believe what we are seeing in this thread is the insanely hyperlocal interpretation of all laws related to mental health, which could be multiple lengthy discussion threads in and of itself.

 

[G Sheb]

I can buy this. Our hospital system's lawyers also decided that we basically had legal authority to hold people overnight in a medical hospital if they tried to leave AMA without having to initiate any kind of involuntary commitment proceedings, which seems...alarming.

This is how it's done in my state in all of the hospitals I work at.
As long as you document pt has no capacity to leave AMA, you can hold them overnight without initiating any kind of legal process or signing legal paperwork.
Unless you wan to commit them to a psychiatric unit.

I know you're several years ahead of me, but I've been in NJ for all my medical training and remain in NJ now, and I don't know what you're talking about. It feels like you are interpreting something not the way it was intended and not the way I've seen it play out.

This does seem bizarre.
As long as there is no concern that pt is a risk to self or others, pt not having capacity...etc, they can leave the ER whenever they want.
Usually this can be determined right from the triage RN and patients are placed on a "hold".
Though frankly I would not be totally surprised if terrible hospital administration interpreted the law differently and reached a conclusion that no one can leave without being seen by an MD. I imagine some kind of bad event happened for a patient that left without being seen. But it does sound really egregious.

 

[psychmd03]

This is how it's done in my state in all of the hospitals I work at.
As long as you document pt has no capacity to leave AMA, you can hold them overnight without initiating any kind of legal process or signing legal paperwork.
Unless you wan to commit them to a psychiatric unit.

We have a similar system we have no medical hold. But floors always want a psychiatric involuntary cert to hold people even though there is no psychiatric complaint and no need for psychiatric inpatient care within 24hr which is how the involuntary cert reads. So I always refuse to sign it and they can consult a different psychiatrist if they want that because how I read it and how I was taught it’s basically fraud since it isn’t true that the patients needs involuntary psychiatric treatment.

 

[hallowmann]

I loathed CL with a fiery passion during training, but state regulations make it uniquely terrible here. In our state anyone who has any kind of psych history has to receive a full psychiatric evaluation before they can be placed in any kind of SNF by law. So if Grandma saw a therapist in 1984 after her first divorce, she can't go to her placement until she gets a full psychiatric assessment. You say she has literally never complained about any kind of mental health difficulty this century? Too d**n bad, she sees psychiatry before she goes to the home.

The law was meant to prevent warehousing of people with mental illnesses, which was a noble goal, but also constitute a plurality of all inpatient C\L consults for obvious reasons.

This actually seems consistent with what I experienced often in training as well in a different state than the one you trained in. It was not a strict legal requirement per se, but no nursing homes would accept any patient with any form of psychiatric history without a psychiatric evaluation as part of the PASRR evaluation to determine if they met criteria for that level of care. This turned into a de facto way to push against admitting patients when they were "unfavorable" for whatever reason. So few nursing homes actually offered psychiatric cares, that this essentially shut people out of the nursing homes in the state. The social workers would often do some gymnastics with regards to the documentation to imply PASRR with a psych evaluation wasn't necessary, and sometimes it would slip past the nursing homes.

 

[PsyDr]

Except for CAP, I've met extremely few "certified" specialists in psychiatry. Like shockingly few.

 

[whopper]

I know you're several years ahead of me, but I've been in NJ for all my medical training and remain in NJ now, and I don't know what you're talking about. It feels like you are interpreting something not the way it was intended and not the way I've seen it play out.

They might've (rightfully) changed the laws since I left NJ over 15 years ago. Seriously how can it be constitutional for a physician to detain you if there's no significant proof you're a public health risk? Even if one has a sickness that should be treated that doesn't mean you're a public health risk to others.

But as I mentioned, when I was a resident, you tried to leave the ER, once processed as a patient, even if you waited in the ER for 10 hours and wanted to leave you had to wait for the ER doc to okay it, and sometimes that ER doctor didn't okay it for a lengthy period of time cause they're busy. Either that or you were forcefully told to comply, and if you kept it up that you were leaving, knocked out with an antipsychotic or other medication.

We didn't see these patients everyday but I saw them once in awhile, especially on weekends. I even said to myself then "how can this be constitutional." The hospital lawyer said in his opinion it likely wasn't constitutional either but had to be challenged in court or taken off the books by the legislature.

Back in the 80s NJ passed a law where you couldn't get excused from jury duty if you were a doctor. Seriously. My dad was a surgeon back then and it affected him. Seriously after it went to the headlines that doctors had to go to jury duty with no one to replace them in say the ICU or ER within a few weeks the laws were re-examined and taken off.

But I remember him and a bunch of doctors who were in the first wave of getting the jury duty letter were in that small period of time of a few weeks where they were told they couldn't use the "being a physician" excuse anymore and all of them were thinking WTF? It was taken off just a few weeks after being made a new law.