August 4, 2005

It was a very fun day at the psychiatric hospital, although sad too, as is usual. I mean, all of the activity and stimuli is a constant kick. However, it is heartbreaking really that people experience so much pain and suffering, you know?

The funniest part of the day was interacting with a staff member, actually two staff members in the medical records office. The RN from Utilization Review department and the medical records clerk were looking at a montage that they came across of cartoon animations with headings such as "frustrated," "rageful," and "sad." We were joking that it would be a useful form we could incorporate into the medical record to help the managed care companies with their managed healthcare reviews of patient charts, or our psychiatrists could use the form as part of the progress notes to capture the patient's mental status. You have to learn to be comical and joke because the job and environment is stressful.

Later on the ward of the most acute patients, one nurse complained, "I've been here 14 months and I've never seen it this bad." I told her that perhaps she needed a break after 14 months. That's a long time to be on her feet. No actually, I told her, "it could be worse; you could be working in an radiation oncology outpatient clinic." I explained that before I was a doctor I volunteered at one of those places and it was depressing, slow-moving and morbid. She said, "Oh, that would be harder to work there." I elaborated that when I worked there the people would walk in all slow and skinny, depressed and down-hearted." She said, "and dying too." She added, "Oh, I feel like crying now. I don't feel badly about working here anymore. Thanks. I feel better now."

Today I placed one man on an involuntary psychiatrtic hold. He was recieving day treatment only. Today I forced him to be admitted against his will into the psychiatric hospital because yesterday he told me that he almost tried to kill himself last week and he has been feeling very badly. Last night, I worried about him over night, and was concerned that I should have admitted him into the hospital yesterday. I hoped he was safe and I was looking forward to see that he had arrived safely back to the day program today. Today, he returned to our outpatient program and said that he wanted to quit his psychiatric medications for his psychotic condition and wanted to quit the program, never to return. I felt morally obligated to admit him into the psychiatric unit against his desire because I feared for his safety. He had a prior history of suicide attempts, had poor reasoning, had no family or social support, etc. Tonight I saw him on the inpatient unit. By the end of the evening he wasn't angry with me anymore. We changed his medications around to one he was more comfortable, as he complained about side effects with the medication he suddenly decided to stop.

Having people get angry with me is not my intention, but it frequently can not be avoided, and what the patient thinks about you has to be secondary to doing what is best, especially when you are placed in a position of responsibility over them. So you just do the best you can and do what you think is in the best interest of the patient. (I get suspicious of psychiatrists that refer frequently to their level of reimbursment, because the priority has to be the patient and patient care irrespective of reimbersement. All of us psychiatrists make a good enough living not to quibble, but the managed care companies can get the best of us down.) Usually the patient comes to like you and appreciate your care, although they don't often see what you're doing as "care," and that can be discouraging sometimes. Eventually, they usually come to see that you actually do care for them, and you can gain some of their trust and respect. When it gets discouraging, I just go to the medical records department and joke with the UR nurse and medical records clerk over cartoons or something.

Last week the same three of us in there were joking and I told the UR nurse how I had to take my dog once to the vet to be put down, because he was terminally ill and was in too much pain, and too debilitated. The vet told me he was not ill enough to be put down (he died naturally a few weeks later). She said, "that's okay, just tell the vet it is cheaper than Board and Care." To understand the joke, you have to understand that all day long she deals with insurance companies who are trying to deny or limit services and sometimes it seems that the insurance companies care more about the bottom dollar than about the lives of people. A Board and Care is a supportive living environment. Well, you just got to laugh sometimes.