After a beautiful one-hour drive into the countryside, an imposing six-story concrete building rises from the hillside. Locals comment about the Soviet-era architecture. The campus also includes several smaller dormitories near the main building. It started out as a sanitorium for tuberculosis patients in the early 20th century.
The enthusiastic coordinator sets me up with a badge, parking permit, and color-coded set of keys in the first 10 minutes, a huge contrast with the VA where time stands still in the face of bureaucratic requirements. She explains how to open doors in the hospital. “Before you can go through the second door, you have to ensure the first door is fully closed behind you. Some of the doors you have to jiggle to open. We recently had an elopement so everyone is on alert about the doors.” (In the mental health world, to elope is simply to run away and does not imply a marriage.)
She shows me the cafeteria, open for staff meals at unusual times, e.g., 9:15-10:15 for lunch and 4-5 pm for dinner. She gives me a tour of the facilities, including the small dormitories for staff and visiting students and drops me off at a lecture on personality disorders by the medical director. I meet the three other medical students. All of them are staying in the dorms and admit to being creeped out by trying to sleep through the on-campus screams. They have no cell service and only intermittent WiFi.
The hospital has six floors: Two for adult males, two for adult females, and two for geriatric patients. I meet Pranav, a short attending from India loved by all the staff for his patience, on the long-term geriatric resident floor. Opening the door from the stairwell reveals several patients waiting by the exit. I squeeze through and quickly shut the door as patients lunge for the open exit. After it’s closed the patients go back to their normal routine of walking the halls and pulling on any locked doors. The nursing station is a locked room with a customer service window through which patients can receive medications.
Pranav shows me the paper charting system, a sharp contrast with the VA, which was an early adopter of computerized medical records. Binders of color-coded papers are placed on a turntable in the middle of the nursing station. Each patient corresponds to at least one binder, which may have up to 600 pages. When a new order, e.g., medication change, occurs, you pull a 3-inch by 6-inch tab out from the binder so the nurses see that there is a “To-Do” item for that binder. Orders end up being performed faster than at my home institution, despite its $100+ million Epic system, due to face-to-face communication between doctors and nurses. The attending sits at the nursing station instead of retreating to a computer room or office.
Pranav instructs me to review the charts of the two new admissions. “We’ll see them for the first time together in the afternoon. “Go get lunch and let’s meet back up for the 1:00 pm staff meeting.” I struggle to navigate the various parts of the paper chart, so I ask a nurse. “Purple is prior admission records, Blue is transfer documents, Red is admission H&P and progress notes. You’ll get used to it, honey!” She adds: “The red binders are [Pranav’s], the Blue binders are the other attendings’.” I scan the binders for patients on our service. During a manic episode, one patient murdered her husband, and then set herself on fire to burn out the Devil that she believes is inside her. Three patients are here after being found not guilty by reason of insanity (“NGRI”). Most of the geriatric floor patients are here because of dementia that progressed to include delusions, hallucinations, and acts of verbal or physical abuse to caretakers.
I join Calvin, a third-year medical student studying at a Caribbean medical school planning to do psychiatry (one of the easier-to-get-into residencies), for lunch. Spaghetti and meatballs with a bowl of apple crumble is $2.15 (cash only). Calvin’s family is two hours away, so he typically returns home for the weekend. He describes his first night sleeping in the dormitory. “The WiFi doesn’t work in my room, so I went to the common area and heard two people having sex in the security office. I learned the next day that it was the security guard and a new nursing assistant who was finishing orientation week. Someone apparently reported them… it wasn’t me. This was the guard’s last week so she did not face any consequences, but he apparently was fired.”
A PGY-4 (senior) resident doing an elective here joins us. He describes the hot job market for psychiatrist graduates. “I just signed a $300,000 salary with a $100,000 signing bonus for an outpatient practice in the Bay Area.”
[Editor (2019):: With $300,000/year, he’ll have a one-bedroom apartment, a Nissan Leaf, and enough left over to splurge on Blue Bottle coffee once a week. Editor (2022): Good news is $300,000 per year; bad news is that’s also the price of a Diet Coke.]]
Over the loudspeaker, we hear that a Code White has been called. Several staff get up and hurry to the exit. Calvin: “Come on, let’s go.” On the female adult floor, two overweight African American patients admitted for bipolar disorder got into a fight. They’re both roughly 30 years old and Patient A has accused Patient B of using her perfume. Patient B allegedly threw the perfume bottle on the floor and says that she has a piece of glass and threatens to stab the other patient. It turned out that the perfume was in a plastic bottle, and the “glass” was merely a plastic cap. Everyone disperses as the attending, a funny overweight 45-year-old white psychiatrist, diffuses the situation. Afterwards she explains to me, “Neither patient should be here. [Patient A] claims that she is bipolar and that she stopped taking her medications to the EM physician, who then calls the state psych admission service. Lamictal [mood stabilizer] does not stop in five days. She gets violent when she does cocaine.”
Caribbean Calvin and I head upstairs to the geriatrics staff meeting with three social workers, the head nurses, and both geriatric attendings. We discuss each of the new admissions, and concerns regarding prior admissions. The meeting focuses on a 56-year-old with rapidly progressive dementia over the course of six months. The chart states that his wife started to notice he would become confused about daily activities, then started to have behavioral outbursts. Last month, he became disinhibited, yelling at people for nothing and groping strangers in public. He was admitted to a rural hospital and then transferred to here for further evaluation. He is not oriented to where he is and he has lost the ability to communicate to others except for random unintelligible outbursts. The nurses are having a crisis because he goes into other resident’s rooms, grabs their clothes, and puts them on himself. “He goes into Ms. [Georgia]’s room, a frail 90-year-old, rips her sheets off her bed while she is lying on them, twists them around himself, then grabs her panties and shirts, and puts them on. He’s almost choking how tight they are on him. And then walks down the hallway. Clothes fall off him. It’s a danger to other residents because they can trip on them. Last week, Ms. [Hansen], tripped on some of this clothing and broke her hip. And he’s strong. What are we going to do about him?” Pranav: “I’ve never seen anything like this. We’re taking a broad differential with him. He has some language skills and memory. He is reciting several verses from the Bible out of memory at the nursing station every morning. We’re waiting on tests, but this could be frontotemporal dementia or prion disease. Let’s see how he does on lithium, which should kick in during this week.”
Tuesday morning begins with a physician-turned-ethics-consultant teaching grand rounds on transgender cases. He went through several landmark court cases, and asks for audience participation on what should be done to resolve the issues.
The Case of Ms. V:. A transgender female wants to go to a residential group home for survivors of rape. The home has been reserved for women who were raped by men. Ms. V was accepted to the home under the condition that she inform the other residents that she was endowed with a penis. Litigation ensued. Should the group home have accepted her unconditionally?
He asks the audience (of about 60, including social workers, nurses, and psychologists) for a show of hands: “Who thinks we should accept Ms. V to the home with no conditions?” Hands go up from most of the audience. Who thinks she should not be accepted? No one has the temerity to raise a hand. Pranav asks some of us sitting nearby, ‘Shouldn’t we consider the rights of the other residents? Will they be traumatized when they see a penis in the shower or hallway?” The larger audience hears this question and competes for who can offer the most vehement “No.” Example: “We would not deny placement for Muslim women if all the residents had PTSD from 9/11.”
Case 2: A Transgender male with bipolar disorder and borderline personality disorder requests gender-affirming surgery. On review of charts, he has a history of factitious disorder (the desire to play the role of a patient, not necessarily with any intention of financial gain). Although there is nothing wrong with his hearing or vision, he has previously presented to the emergency room with deafness and blindness. Should he be allowed to undergo this surgery? “I used to treat these individuals. You never start gender-affirming therapy until the patient is stable.” Pranav interjets: “That used to be standard of care. We all know that this is not true in some cities now. You can go in and be scheduled for surgery in two days.”
[Editor: Pranav sounds like a potential hater. He might want to read “Factitious sexual harassment,” by Sara Feldman-Schorrig, MD, 1996 (“prompted by the lure of victim status”), and “The Psychodynamics of Factitious Sexual Harassment Claims,” (Bales and Spar, 2016, Journal of Psychiatry, Psychology and Law), “Factitious sexual harassment claims are those in which the plaintiff’s wish for victim designation is a major driving force behind the claim.”]
Case 3: GG vs. Gloucester County School Board. “G.G. is a transgender male student that requested use of the boys’ bathroom. The Gloucester, Virginia high school originally agreed, but student and parent complaints led to a reversal of this decision and creation of a gender neutral bathroom. The court ruled that the school had violated Title IX,” said the ethics consultant. “Keep in mind that Title IX was written in the 1970s before any notion of gender identity existed.” The student graduated in 2017, but the litigation lives on (at least through 2019) and now the girl-turned-boy is hoping for monetary damages. If our group of 60 were the jury, Gavin Grimm would prevail. Everyone agreed that being restricted to a special bathroom was discrimination.
[Editor: Gavin won at the appeals court level in 2020 and the Supreme Court refused to hear the school board’s petition in June 2021. The school board paid $1.3 million and Gavin got $1. The rest was pocketed by his/her/zir/their lawyers, mostly the ACLU.]
After grand rounds, the ethics consultant shifts gears to consider the rapidly progressing dementia patient. Several ideas have been floated, including moving clothes from resident rooms to a communal closet. The ethics consultant predicted that this would be a difficult case to make to a court. “It is well established that having access to your own clothes is a basic human right. I just don’t see how we can violate everyone’s basic human right because of one offender.” The lead nurse: “They would still have access to their clothes, just they would ask a nurse to go to the closet.” The two-hour meeting results in no solution to the clothes-covered floors and the nurses having to spend much of their time picking up so as to avoid more broken hips. “I have nurses saying they are going to quit because of this patient,” says the head nurse. “We are already short staffed.” They decide to try to rotate nurses to different floors one day per week and revisit the case next week.
We admit a frail 85-year-old with dementia for psychosis. She refuses to speak or look at me or Pranav for several hours as she stares at staff through the customer window. Pranav asks, “I know you can talk. Tell us what you feel?” No response. “Are you scared?” After a 5-minute staring contest, she finally responds, “Oh, I know what you are doing. You don’t fool me, silly man.”
Two patients stand outside the nursing station most of the day reading the Bible. One patient believes she is here because the FBI stole her money (she actually was robbed of nearly $1 million, but by identity thieves whose connection to the FBI was never established). A patient with antisocial personality disorder (a sociopath) stabbed two people to death including his cousin and believes that the FBI owes him two million dollars for him “sending in secret codes every week that they used to do their job.”
A 58-year-old male is transferred from the county jail because he refused to take his medications. The female head nurse says,”There is no reason this patient needs to be here. Tell the police officer to watch how the ‘real men’ [her all-female nursing staff] do it.” After the “real men” (nurses) solve the medication problem, I interview the patient alone. He is difficult to keep on topic as he tries to relate every detail in his life. He was living behind an abandoned church. New owners of the property called the police who informed him he had to vacate. When he refused, he was arrested for trespassing. At the jail, he refused to take the medications on his chart, which he had not taken for years. “Since I was a young boy, I never liked sleeping under a roof. I always liked sleeping on the porch. My parents would be so confused, but I knew what I liked. Four walls makes me restless.” He continued to describe how he is applying for a patent for the Uber of grocery cart transportation. “People say Uber started the gig economy, but trust me, I thought of it first.” He knows all the medications he is supposed to take, including blood pressure medications, cholesterol and anticoagulation for atrial fibrillation. “I don’t like the entire concept of pills. No, I’m not taking them. I know why they tell me I need them, but no.” I report back to Pranav, “I think he has schizotypal personality disorder. He is not psychotic, and doesn’t even really have delusions. He just has magical thinking!”
On Friday morning, I attend a temporary detention order (TDO) hearing in a conference room. The patient sits at the table with a public defender, an administrative coordinator, a representative from the community service board, and finally the judge. Witnesses and observers such as myself are in chairs along the walls. The first case deals with continuing medications for a patient who does not have capacity. Judge: “Ms. [J], do you have anything to say about your care?” The patient responds that she trusts completely in Pranav, there are no objections from the public defender, and the order is continued. The next patient, a 24-year-old African American with bipolar disorder, is accused of raping two preteen girls. He plans to plead not guilty by reason of insanity. I overhear the public defender discussing the case with the patient before the hearing. “You have two options: you can either be willingly admitted to the hospital, or undergo a TDO. I strongly recommend you willingly accept admission.” During the hearing he stares at the ground.
Statistics for the week… Study: 6 hours. Sleep: 6 hours/night; Fun: 1 night. Burgers and beers with Sarcastic Samantha, Lanky Luke, and Mischievous Mary. Mary was excited that she was just accepted for two away rotations, one month each, in cardiothoracic surgery at prestigious institutions. She is hoping to do a 5-year direct cardiothoracic (CT) surgery residency instead of going through 5 years of general surgery followed by a 2-year CT fellowship.
The rest of the book: http://fifthchance.com/MedicalSchool2020
I like the term “disinhibited” — sounds like the loveable Cuomo Bros.
Also, that there is a vote to determine gender.
“diffuses the situation.” This substitution seems to almost be normal practice nowadays. Of course the author should have written “defuses”.