Monday, February 23, 2009


In psychiatry, even more than in internal medicine, we treat a lot of patients who are currently or have been homeless. From work I used to do at a clinic for homeless patients, I'm aware that there are different "levels" if you will of homelessness. There are people who stay with family or friends, people who live in motels, people who sleep in their cars, people who live in shelters, and people who sleep on the street. Sometimes whole families are homeless, but most of my patients are single. There are people who are transiently homeless, and people who are chronically without a permanent place to stay. Many are "mentally ill", but this covers a very wide range of possible diagnoses. I've met some patients with chronic psychotic disorders, often untreated, who have no family to look out for them and were homeless. Many of my patients, though, have personality disorders (usually narcissistic, borderline, or antisocial) and/or are chronic drug and/or alcohol abusers.

In psych, we refer to some of the last group as "having poor coping skills." In other words, they don't know how to be "grown-ups" as our culture and society mandates. Especially when substances are involved, their only method of coping with stressful situations may be to pop a pill or drink a bottle. They may come to psychiatric attention because of a suicide attempt or accidental overdose; sometimes they come to the emergency room voluntarily because they "feel suicidal" or "think I'm going to hurt someone". Patients in the latter group sometimes aren't admitted to the hospital, and are discharged back to the streets.

I've noticed that I have a bias against this latter group. Even though psychiatrists (and other physicians) treat substance abuse, many of us seem to think of these disorders as non-psychiatric and non-medical for some reason. It's easier sometimes to make allowances for someone with bipolar or schizophrenia than for someone who's "just drunk" or "just high" or "just a borderline". I think part of it is because there is such a large volitional component to drug use, ie, no one MADE them do the drugs (we assume), whereas no one chooses schizophrenia (although schizophrenics may choose not to take their meds, or may choose to do drugs). It's true that there is a heritable component to addiction, and also true that many patients start using substances as young teenagers (13-14 years old) before they're able to fully appreciate the consequences of their actions.

So why the bias? Why do I feel like I have a hard time treating these patients? (For that matter, I think many doctors have a hard time treating such patients). Part of it is the volition thing. Part of it is that there's a narcissism involved with substance abuse--people who are addicted care mostly about their addiction, and often (at least the ones who come to the psych ER) can be less than friendly. Some become outright abusive. Part of it is what some of these patients do to feed their habit--I've had some say they prostitute themselves, some who beg, and some who steal, and these are just the ones who talk about it. Some are on disability, which is frustrating to someone who works hard; why should they get their $3000 check per month and get to spend it all on crack?

It would also be different if these patients were asking for help with their addiction when I see them. Instead, many of them seem to be saying "the right words" to get admitted to the psych hospital because it's cold outside, or raining, and have no intention of quitting their drug of choice. This irritates me. It's a hospital, not a free hotel. If I admit all of these patients, then there's no room for the acutely psychotic patients wandering off from home or the manic who hijacked a bus.

One of my patients said something profound to me the other day. This person had been homeless in the past, and was facing discharge to the streets. The quote: "I've been homeless before, man, I've slept on the streets before. Man, when you're out there, it's like you're not a person anymore, it's like you're not a human being."

So how to balance humanity with doing the right thing, which often means denying these patients admission? I'll be honest, this is hard for me. I find this emotional balance to be very tiring. I guess just like the paging etiquette thing, I just have to keep trying. I don't have an actual solution, at least not yet.

Wednesday, February 18, 2009

I'm a Big Kid Now!

There comes a time in every young doctor's life when they realize that they are now an adult. Eight years (in the US) beyond high school, the medical resident has put off true adulthood for perpetual studenthood for a long time, especially if they did not take time off and work or pursue an alternate career. For some residents, it's the time they put on the long white coat; it may be the first code attended, the first time they signed an order as "X Y, MD"; the first time a nurse asked "What should we do, Doctor?" All of these experiences have happened to me, and they made me feel a little bit grown-up, but this one really takes the cake. This one says I'm really an adult and there is NO GOING BACK. This cat is out of the bag.
Friends, I got a jury duty summons the other day, and I CAN NO LONGER JUST TELL THEM I'M A STUDENT SO I DON'T HAVE TO GO!
So here soon, I will present myself to a court house and go through whatever jury duty entails. Somehow I doubt I'll actually get picked for anything, so I predict I'll show up and waste a lot of time and then get to go home $15 richer. Or, just my luck, I'll get seated for a really long trial and be sequestered in a motel surviving on bad sandwiches--it'll be just like a John Grisham novel, except half as exciting.
Adulthood--not all it's cracked up to be? Although the shopping part is pretty fabulous, as well as being over the legal drinking age, and getting to do what I want to do... I guess you have to earn that part somehow, so jury duty, here I come!

Tuesday, February 17, 2009

Say What?

[Homeless patient receiving disability payments from the government, angry with me for not admitting him to the hospital to protect him from homelessness]: "I pay your salary, did you know that?"

[Sleepy, cranky me on call]: "...?"

[Well-rested co-intern the next day, upon hearing the story]: "Actually, my tax dollars pay for your health care AND my salary."


More Truisms from Psych Call:

1. The "urgency" of the patient in the emergency room is indirectly correlated with how late it is.

2. If you get angry and yell at me for being "racist" because I won't admit you to the hospital, it isn't going to make me relent--it's going to make me call security to escort you from the ER.

3. The potential dangerousness of the patient is indirectly correlated to the likelihood that the nurses will actually have changed him/her out of their street clothes, put them in a gown, and removed their belongings from the room. We've seen bottles of alcohol and sometimes weapons.

4. If you come to the ER with a wussy overdose attempt, like, taking a couple extra antipsychotic or antidepressant pills (barely over the therapeutic limit, and not a drug like lithium or a tricyclic), it is entirely possible that the ER doc will have the nurse place an NG tube and do a gastric lavage. No, I will not pull it out of your nose for you. Actions --> consequences.

5. The "urgency" of the patient in the emergency room is indirectly correlated to the likelihood they caught an ambulance to come to the ER. This holds true in most areas of medicine, not just psych.

6. The corollary to #5: the urgency of the patient is entirely unrelated to whether the police brought them in. Sometimes the police bring in the really outraged, psychotic, agitated patients who were swinging an axe at traffic; sometimes the police bring in the chronically suicidal "I called 911 and said I wanted to kill myself and no it has nothing to do with how much wine I drank tonight".

7. The lateness of the ER consult is directly correlated to my level of crankiness and indirectly correlated to my level of "give-a-shit"ness.

Sorry for the rant, but psych call is mentally stressful and involves dealing with a lot of manipulative people trying to angle their way into the hospital. I hope that venting like this will help me not burn out and be able to keep showing up for call. /crankiness

Sunday, February 08, 2009

Paging Etiquette

Rules for Paging Properly:

1) If you are going to be allowed to page me incessantly, then you should be required to wear a pager so I can return the favor.

2) If you page me, please wait 5-10 minutes for a response before paging back. Heaven forbid I be answering another page, seeing to an emergency, walking in a hallway without a phone, or sitting on the john. I am very conscientious about returning pages and really try hard not to make you wait, but sometimes it's unavoidable.

3) Please attempt to coordinate your pages. Having 2 different nurses page me about the same patient within 30 seconds of each other (indeed, I received page #2 while I was on the phone with nurse #1) is a little annoying. Especially when said patient isn't actually dying of a heart attack or writhing in severe pain, but "just wanted to talk to the doctor."

4) I know mistakes happen, but please attempt to look through the medications before paging me to say Ms. so-and-so needs a sleeping pill. If I stop what I'm doing and pull up the chart only to find Ambien in their list of meds, it's a little irritating.

5) Blood pressure of 135/anything does not excite me and I do not need to be paged for this, unless it was 220/190 5 minutes ago (in which case, why are they on a psych floor?).

6) The primary team arrives around 8 am M-F. I do not need to be paged at 7:20 (while I'm trying to check out and leave) for 2-day long sore throats or potassium of 3.2 drawn 4 days ago. I appreciate your incentive and that you are trying to help care for your patient, but it can wait.

7) When possible, please page me to an extension you'll be easily reached at. If you page me and I call you right back, only to reach someone who puts me on hold "while I find out who paged you", I get a little irritated, especially when this happens frequently.

8) Perhaps most importantly, when I call you back, please introduce yourself and state the patient's name clearly (perhaps even spell it) before rushing into the story of how the patient has an urgent foot rash. I have some hearing problems--not your fault--and I will have to interrupt your story to ask you to repeat the name, spell it, and wait while I access that patient's chart in the computer before you get going again. Also, if you have a non-American accent, it is going to be difficult for me to understand you over the phone, especially if you speak rapidly.

9) On my end, I promise to keep trying to answer pages promptly, identifying myself clearly when I call back, being really nice (or at least non-snarky) when I answer, and trying to educate the people paging me about appropriate paging. (Hey, I said "trying", didn't I? Stop looking at me, swan!) I know I fail at this frequently, but I really do try, I swear. I don't like paging people only to get yelled at, so I don't want to be the person yelling.