Week 2 of inpatient psych. The resident is late for the 8:30 am handoff, so I talk to the night resident. There were two “soft” admissions (people who could have gone home) overnight, which I relay to the team for 9:00 am rounds. Robin Williams is frustrated that the night team put several patients on one-to-one precautions (patient cannot have a roommate), and did not re-evaluate them throughout the shift. “Guess they didn’t want to do any work.”
The 46-year-old white female with a history of MDD (major depressive disorder) and childhood abuse presents for suicidal ideation without plan. She described her abuse as a child: “Let’s just say my mother would put me on the hood in the driveway, accelerate briefly and slam the brakes. And she was the nice one.” She currently takes care of her husband, who is on dialysis for end-stage renal disease due to uncontrolled diabetes and hypertension. “My mother-in-law has been yelling at me all the time. She doesn’t think any decision I make is right for her son. She’s not the one taking care of him everyday. She comes into our house once a week, and smothers him with love, bakes cookies, and changes his sheets. So now my husband thinks I am inadequate.” She concludes: “I would have been fine if I just talked to my therapist, but it was a Sunday.”
After lifting a one-to-one precaution, we are able to admit a 40-year-old white female with MDD who arrived late last week in the ICU for an overdose of Xanax (one bottle). “It’s hard to kill yourself by overdosing on benzos,” says the attending, reviewing her chart and seeing a prescription for oxycodone for back pain. “But add a pinch of opioid, and boom, there goes your respiratory drive. She’s lucky that she didn’t take any of her oxy. We’ll keep that little secret to ourselves. Not all patient education is good.” He continues, “It’s my understanding this was a completely spontaneous overdose attempt without any contemplation. These are the people who will end up killing themselves. Really hard for the family to intervene.”
New this month is a hospitalist stationed on the inpatient psych unit tasked with medically optimizing patients. The psychiatrists see this as a revenue-maximizing gimmick. “We don’t need a damn echo on this patient. Who cares about a new murmur when she just overdosed on Xanax? What’s going to kill her?”
(Two days later, she had yet to get out of bed or interact with anyone. While the resident and I are interviewing her, the attending jumps in and shocks us by scolding her to get out of bed and attend group sessions if she wants to be released.)
Afterwards he explained to me: “The goal of our interaction is not for me to make the patient feel bad, make me virtuous and show the patient how much smarter I am compared to her. If I need to be the bad cop and let nurse Tammy be the good cop, then so be it… Even if satisfaction is how I’m now being graded on. I’ll take a hit if it gets the patient out of bed and moving forward.”
He continues: “Unfortunately, health systems are realizing that it is cheaper and more profitable to hire 12 ACPs [advanced care practitioner, e.g., physician assistant or nurse practitioner] who write expensive medications over shorter visits with only one supervising doctor instead of focusing on counseling.”
Our psych practice has been profitable enough that we’ll get a brand-new building 18 months from now, but in the intervening time all of the hallway door handles are going to be replaced to comply with a new regulation to prevent patients from choking themselves with sheets tied to handles. Robin Williams: “A $2 million renovation for a building that will be knocked down soon. But what am I supposed to do?”
After rounds, Robin Williams invites me to walk with him to the main hospital and join for a consult with the endocarditis service. “Endocarditis [infected heart valve] used to be a disease of the immunocompromised, but now is almost entirely IV heroin and meth users. Cardiothoracic surgery will replace an infected valve and just for a few months later the patient, who will have resumed recreational IV drug use with non-sterile equipment, will present with an infected replacement valve. In addition to the replacement valve, endocarditis treatment requires six weeks of IV antibiotics so we start them on Suboxone in the hospital and get them set up with MAT [medication assisted therapy] to see if this will decrease the rate of using again.”
[Editor: this reflects the American best practice of treating people who are addicted to opioids by giving them an addictive opioid (Suboxone). Note that if this works out as planned, the health system gets to bill Medicaid for surgery, a six-week hospital stay, and a lifetime of Suboxone therapy.]
The first patient, a 31-year-old white male, is angry at the nursing staff because he signed the Suboxone documents without realizing that he was agreeing to his visitors being searched, a policy enacted after quite a few visitors brought drugs to patients during their six-week IV antibiotic stays. His girlfriend was caught last week injecting an unknown substance via his IV catheter. Robin Williams talks to the patient about working together to get sober. The patient explains that he tried methadone and Suboxone and claims to be allergic to Suboxone. Robin Williams: “You tried methadone? How long?” He responds that he visited the clinic for a month. “Wow, that takes a lot of dedication. You should be proud of sticking with it for a month.” He concludes: “Now I am willing to work with you. You say you are allergic to Suboxone, I will give you buprenorphine. You have to start a MAT program at [our institution]. People who are on buprenorphine get monitored a little closer, so one wrong step and you will be out of the program.” The next endocarditis patient is a “VIP” (politician) so I am sent back to the inpatient psychiatry unit.
At noon, I attend the twice daily music and art therapy group sessions. The art therapist passes out paper and coloring instruments to all the participants. The schizophrenia patient walks into the room, and sits behind on the cafeteria tables. He somehow obtains a sharpened color pencil, which makes everyone nervous. The therapist then asks each participant to pull a slip of paper out of a hat. We then draw a picture based on the word written on the slip. My word was “crossroads.”
After 30 minutes of art, we begin one hour of music. We go around the room each selecting a song to be played on a bluetooth speaker. The only rules: (1) no curse words, and (2) the therapist has the right to stop the song. A heroin addict starts with “It’s Been Awhile” by Staind. The therapist has to stop the song after a minute when the polysubstance users start nodding their heads and one says, “Oh yeah, gotten high to this lots of times.” A benzo and opioid addict plays a song by 5 Punch Death Metal. A 56-year-old alcoholic plays “Seen it in Color” by Jamey Johnson, which triggers a 34-year-old opioid addict who excuses himself with tears in his eyes. We then transition to group drumming. The music therapist passes around drums to each participant. Each member is allotted a 10-second solo to “bang out” his or her feelings.
At 3:00 pm, I attend the psychiatry lecture series. Out of the 52 weekly lectures, psych gets to pick one as an annual required talk for the internal medicine residents. Today’s lecture on “Gender-Affirming Treatment Overview” has been picked as information that internal medicine doctors need to hear. The PGY-3 begins: “The first important takeaway from this talk is that gender dysphoria is not a disease. We are still fighting this misconception because DSM-3 [Diagnostic and Statistical Manual of Mental Disorders, 1980s edition] had this under ‘delusional disorder’.”
“Current literature supports the ‘Minority Stress Theory’ in which external prejudice leads to internal stress and depression,” she continues. “This results in the high risk of depression and suicide seen in GD [gender dysphoria].” We then go through the UK’s Coming Out guide online. There are minimal specifics about how to initiate hormonal replacement therapy, the contraindications, etc. Much of the time was focused on discussing how to label patients in Epic. The Chief Information Officer of our hospital is in the audience and jumps in: “This has been an ongoing struggle because there is no good solution. We don’t want to change the sex designation because then it would change many screening algorithms [e.g., if female over 40, ask about mammograms] and create insurance issues. We have worked extensively to roll out a new Trans disclaimer.” (It might have been better if his office had worked harder on security; our institution was recently the victim of a ransomware attack.)
We have a 3:30 pm admission for a 21-year-old transgender male (female to male) with a history of bipolar disorder and polysubstance use presenting for suicidal ideation. The patient has a deep bass voice and cystic facial acne. Psychosocial stressors include: (1) missed appointment to get testosterone shot last month; (2) broke up with girlfriend during preparations for a marriage proposal; and (3) inability to reconnect on Facebook with an ex-girlfriend with whom the patient feels an “incredibly deep connection”. The patient shuts down after this description: “I do not want any help, I just want my testosterone shot.” During rounds the next morning, the social worker notes that she did intake on him in the ED six months ago. “He was saying he was a transgender female. Look, it’s in my note… and other notes from before. He’s got to get his story straight!”
Robin Williams: “Everyone talks about evidence-based medicine, but there is no evidence gender-affirming treatments improve patient outcomes like suicide rate. All the studies use subjective outcomes. What I find is that they become fixated on HRT [hormonal replacement therapy] as the solution to all their problems.”
Our last patient for the week is a 34-year-old contractor with opioid use disorder. He was kicked out of a Suboxone clinic for a dirty urine drug screen (positive for cocaine). He’s been buying Suboxone on the street to prevent opioid withdrawal, but hasn’t been able to find much. The social worker is trying to get him back into the Suboxone program, but it will take between 1-2 months for the next intake. The attending agrees to write a prescription bridge of Suboxone.
“Some of the highest level of opioid use is in the contractor community,” explains the attending. “I was getting a remodel done on my house and it was impossible to have anyone reliable. They work for their pay check to buy pills. Then I found a Mexican family who would arrive an hour early and pile out of their van. They finished the job two weeks early.”
This week I felt part of the team. I wrote notes on half the patients, including assessment and plan (e.g., medication changes, social worker communication, etc.) with minimal edits by the resident and signed by the attending, and I helped with determining if medical evaluation is necessary. I see several patients that need medical care. We prescribe penicillin for strep pharyngitis. I evaluate someone for LE pain with a raised leg test [rule out cauda-equina syndrome]. I recommend someone follow up with neuro for a parkinsonism tremor and bradykinesia.
Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Buff Bri, Ambitious Al, Jane, Straight-Shooter Sally, and I go to a local Blues/Jazz club. We dance the night away.
The rest of the book: http://fifthchance.com/MedicalSchool2020
Occasionally I take the trouble to actually read one of these hospital sagas. But generally don’t bother because they describe an unreal world populated by unreal people ;living unreal lives (by any rational, reasonable standards, that is.)
If they genuinely reflect Americans as they are in America, I feel very sorry for you all. Of course it might be as bad here too, m but of that I have no evidence.
Well, half doctors educated in US med schools I know are drug junkies. The whole system is designed to get as many medical students addicted to uppers just to stay awake during insanely long shifts (and then downers, to get at least some sleep). Cocaine and clonazepam seem to be a popular combination.