Philip Greenspun’s Weblog

Consultation and Liaison (C&L) service. I meet the team at 7:45 am in the C&L workroom, a windowless room that crams 3 computers and a loveseat. The 35-year-old attending who completed an Internal Medicine and Psychiatry dual residency runs the list with the 40-year-old PGY3 resident who was a psychiatrist in India and myself. We then go down to the ED to begin seeing the new consultations for the day where we are joined by the ED psych social worker. 

I interview the first patient, a 40-year-old obese Black female with major depressive disorder presenting for suicidal thoughts. She has been working with the homeless assistance team (HAT) to get set up in housing. She has rejected two different apartments. When the social worker informs her that she needs to work with HAT, she responds: “I want an apartment that I want. It cannot be across town.” She adds, “Also when I get admitted, I want a good doctor, not just any doctor.”

The next patient is a 28-year-old obese female with bipolar disorder presenting for suicidal ideation. She is also a regular. When our team goes into her alcove, she is busy eating french toast. We barely understand her one word responses. She proceeds to get up from her bed, and beds over to reach her purse on the floor. “What other specialty would you get to see that?” asks the attending. “She doesn’t stop stuffing her mouth with french toast, and then moons us slowly.”

We then proceed to see consults in the hospital who have been admitted to other services. I am assigned two to see alone while the attending is busy performing transcranial magnetic stimulation therapy.

The first patient is a 65-year-old grandmother with rheumatoid arthritis who overdosed on her opioids and benzodiazepines. “I regret that it did not work,” she says. “I wouldn’t have done it if I knew it would not work. I’d have tried something different.” What are your stressors? “Well son, take a seat. My daughter is a heroin addict who brings strangers to our house to shoot up. I have custody of her and our grandson. I live in chronic pain.  CPS have already been contacted by the primary team. We recommend inpatient psychiatry after medical clearance. The primary team is surprised that she is still alive. She had a five-day ICU stay.

My next patient is a 65-year-old with Lewy body dementia admitted for a GI bleed. We were consulted due to concern for MDD. His wife has cancer and cannot have sex. “I want to express my love for her while I am still here. I know I don’t have much time left.” We explain to him that an SSRI might help improve his depression, but may cause sexual dysfunction and decreased libido. “That’s good, give me that!”

I attend psychiatry grand rounds regarding a controversial topic: Combat Addiction, a recently proposed new syndrome within the umbrella of PTSD. The former Stanford clinical psychologist presenting describes Combat Addition as an addicted phenotype in which afflicted individuals seek to recreate the adrenaline rush. “This is not a new phenomenon, but just one that is increasingly common. The soldiers in Vietnam and World War II had limited combat exposure, and the ones that did had few recurrences. The Middle East wars are different. They are the perfect storm for addiction: high intensity, repeated exposures.”

[Editor: From the above we can learn that people at Stanford were well-insulated from anything that went on in Vietnam and World War II. There were, for example, 11,846 helicopters shot down or crashed during the Vietnam War compared to roughly 400 in Iraq and Afghanistan together. Approximately 340,000 American troops died in World War II and Vietnam, compared to fewer than 5,500 in Iraq and Afghanistan.]

Our speaker goes around the country recording combat veterans’ stories. He retells one soldier’s comment: “The first fire fight is an unreal experience, better than sex. You want it again.” These experiences are defined by a loss of context, revenge, betrayal (by country and politics). They undergo an intense bonding with their brothers, then return home to what they see as a meaningless life.” In an effort to recreate the environment, he reports, “One soldier told me that he got a concealed carry permit and was ‘waiting for someone to shoot at me to make me live it again.'”  He cites dangerous speeding on motorcycles to recreate the adrenaline rush of combat.

Our hospital had set up an audio-video link to the VA and several of their psychiatrists call in with questions. “Thank you for highlighting this. Your definition so accurately portrays many of the combat veterans that I see. Are there any diagnostic criteria or evidence-based interventions?” He responds, “The VA forbids any research into this syndrome. We haven’t even characterized the progression of the disease so we have no trials investigating treatments. Some of the patients I have followed for several years seem to age out of the longing to simulate combat, but they seem to still struggle with disillusionment.” He continues, “The one item I see that helps is community with comparable peers. It is challenging for providers to engage them because they look down on those claiming PTSD symptoms, believing that patients are motivated by the prospect of disability benefits.” He ended by citing several ongoing clinical trials with psilocybin and other psychedelics that may be beneficial, although “I cannot imagine some of my older veterans doing this.”

Statistics for the week… Study: 4 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Four of our classmates brought their respective dogs for a playdate at the local park. Only one ran away.

The rest of the book: http://fifthchance.com/MedicalSchool2020

Full post, including comments

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

Full post, including comments

After a 45-minute drive, I arrive at 8:30 am for paperwork at the local Veterans Administration (VA) hospital. Unfortunately, due to my short time here, I won’t get access to their electronic medical record system. I am joined by a podiatry resident, an internal medicine resident, and a medical student from a different school. After 2.5 hours of picture-taking and forms, we have our ID cards and are ready to experience the largest healthcare system in the United States.

Tuesday was a typical day: Arrive at 8:20 am for the first patient at 8:30. He is a no-show and the psychiatrist says that the no-show rate is roughly 50 percent. We chat about various psych topics while he does calf and neck stretches. One topic is the difference between ego-syntonic and ego-dystonic. “Both terms have fallen out of favor,” he said. “In DSM-3, homosexuality was considered ego-syntonic because it was a behavior that did not go against a person’s ego. This is compared to the dystonic behavior of obsessive-compulsive disorder in which the patient knows these compulsions are interfering with his/her life.” He explain the components of a mental status exam, including identifying common cognitive distortions, such as all-or-nothing thinking, emotional reasoning (equating transient feelings to reality), and overgeneralization (assuming one negative outcome results in inevitable failure of that goal)

I saw 2-4 patients per day, each for a 30-minute visit (workload would have been 4X at our home institution). When a patient arrives, I begin the interview and the psychiatrist interjects with clarifying questions and counseling regarding medication changes. I leave at 4:00 pm.

[Editor: As of 2019, a VA psychiatrist could get paid up to $320,000 per year. If we assume 3 patients per day for outpatient work, plus a full 40-hour week once/month on inpatient duty, that’s 1000 hours per year (if we assume 30 minutes of paperwork after every 30-minute visit) and $320/hour plus pension and other benefits bringing total compensation to $500/hour?]

As in civilian psychiatry, the typical diagnoses are anxiety and depression. Most patients were in the military for only two or three years and were never deployed abroad nor served in combat. 

I see a 45-year-old who worked at a Pentagon desk for 10 years as an intelligence officer. She presents for follow-up on generalized anxiety disorder. Although the majority of wealthy white women voted for Trump, she is not among them. When asked how she has been doing since her last visit, she responds with a discourse on Donald Trump’s racism and sexism. How much of her day was spent thinking about politics? “A few months ago, it was 75 percent of my day. I’d say it is now only 25 percent.” What coping mechanisms had she implemented? “I watch MSNBC only once per day.” She then explains that another 20 percent of her worry is about the recent remodel of her house.  “We just got these custom-ordered massive glass pane windows. One of them is trapezoidal, and it has several streaks on them.” She gets up on a ladder every day to scrub these and then calls the glass vendor.

[Editor: This proves my general rule that people who rent are a lot happier and have more mental space to think about interesting things than homeowners, constantly burdened with their amateur property management tasks.]

A 38-year-old medically discharged Air Force pilot presents for follow-up on generalized anxiety disorder with panic attacks well-controlled on Prozac and Ativan. He had flown the C-130 in Afghanistan and Iraq. There was an explosion due to mechanical malfunction that left him with damage to his arena postrema (vomit zone in the brain) and asthma from chemical inhalation. He described the weekly intense bouts of nausea that come out of the blue. “All my buddies are now pilots for the airlines, but I’m not allowed to because of my asthma.” His biggest current stressor is finding a job that is meaningful and pays well. “Even with my disability payments and my wife’s earnings as a secretary, money is tight with two small children.”

A 27-year-old overweight white male describes his experience as a flight engineer in the Navy. He was bullied and did not fit in. His team was being investigated for a spy in their midst who was allegedly sabotaging equipment on behalf of China. “At first they thought it was me,” he said. “You don’t know what it’s like to have everyone looking over your back. When I left, they still hadn’t caught the spy. There was never any evidence that it was our team. I never had anxiety before this ordeal.” He had been dishonorably discharged, but was now trying to get that changed to a medical discharge for major depressive disorder and generalized anxiety disorder. He described symptoms that could have come straight from the DSM-5. If we supply the requisite documents to change his status, he will get 100 percent tuition, housing, and books for his computer science studies. Ultimately, we tailor the note to say that his symptoms began during and as a result of his service, so he should be on track for a taxpayer-funded college degree.

[Editor: It seems that a dishonorable discharge is a bar to receiving most VA benefits, but a veteran can still be seen at a VA facility for “disabilities determined to be service connected.”]

There are workshops for the five VA psychiatry residents at lunch, led by an attending. I told them I was still waiting to see psychosis or mania. The chief resident responds: “Oh you’ll see that at the state mental hospital.” A graduate of an Iranian medical school now doing her residency here interjects: “No, no, if you really want to see mania or psychosis, go to Iran. Only about 10 percent of patients in state hospitals are legitimately psychotic. In Iran, it is 100 percent. You only get into a hospital psych bed if you are truly psychotic.” What about those who suffer from depression or anxiety? She laughed: “That’s life. Deal with it.” What was her psych rotation in Iran like?: “Everyone was telling me they are Jesus, Moses, or Muhammad. One asked me, ‘Have you ever spoken with God?’ When I said no, the patient responded, ‘Well you are now.'”

The chief resident describes the challenge in choosing between a position at a state mental hospital versus at the VA. “The state mental hospital job is a two-year contract with the government contractor that staffs the state hospital. There are no guarantees at the end of the contract and the work is intense. The VA offers more money and stability for much less work, but I think that I have too much energy for the VA, I want to change things.” He explained his plans to take the state hospital job and supplement that income with part-time work for a telemedicine psych company.

[Editor: An FAA employee told me, “I was unhappy in this job until I accepted that I was never going to accomplish or change anything.”]

The VA has implemented a new program in which a psychiatrist goes to the VA’s primary care clinic for consults with veterans who were flagged for mental illness by the primary care docs. This eliminates the waiting period from primary care to psych appointments. I see a 50-year-old former intelligence officer who is presenting for depression and anxiety. Her immediate concern is that the state is trying to euthanize her pit bull after the animal attacked a neighbor’s child. The psychiatrist decides to set an appointment up for her to come see him before and after the upcoming court hearing.

[Editor: Our Florida neighborhood, for a radius of about 1 mile, is entirely pit bull-free due to homeowner association rules.]

We then walk to the inpatient psychiatry unit to cover for an attending who has to leave for a family emergency. We admit a 65-year-old who served in the infantry during Vietnam. His diagnosis is polysubstance abuse, primarily crack cocaine. He was recently paroled after 15 years in prison for drug-related offenses and has been working as a mechanic, but was tripped up with a positive test for cocaine on a routine drug screen. The parole officer gave him the option of voluntarily admitting himself to inpatient psychiatry instead of going back to jail. We screen him for depression. He describes feeling that he has nothing to live for. His wife divorced him, took all of the joint assets, and now receives the lion’s share of his veteran’s pension. He lost touch with his daughters while he was in prison and they don’t want to reconnect. “I know I am going to kill myself if I keep using. Can you help me?”

On Friday afternoon, I say farewell to the VA and attend a required lecture on motivational interviewing (“MI”) led by a child psychiatrist. Primary care physicians can now deal with addiction easily if they can remember “SBIRT”: Screen, Brief Intervention, Referral to Treatment. We watch William Miller, a founder of MI, in video interviews with addicts. He gives us another acronym, OARS: open-ended questions, affirmation, reflexive statements, summary/synopsis. “There should be a 2:1 ratio of statements to questions. Once the patient begins talking, don’t interrupt him/her with a targeted question, but instead make an affirming or reflective statement.”

After the prepared PowerPoint ends, we do live practice. He goes into role as Johnny, a 10th-grade pothead taking several AP classes and maintaining a 4.3 GPA. He adds, “Weed is the number one cause of outpatient referrals. From now on, I am not myself, so I don’t want anyone writing me up on evaluations for what could be said.”

As a group we practice MI. What brought you in today, Johnny?” Johnny: “My father and I used to build cars and hang out. Now he is on my back about school and smoking pot. I used to not have any friends, but now I actually hang out with people. Smoking pot hasn’t impacted my grades, it’s just my dad is butthurt. I’m a parent’s wet dream!” We continue to practice responding with statements, and not questions. Bad: “Do you miss spending time with your dad?”; Good: “It must be challenging to balance spending time with your dad and with your new pot-head friends.” The goal of motivational interviewing is to make the patient reflect on the benefits and costs of a bad behavior, e.g., smoking. Do they actually like smoking, or do they smoke because of some other stressor? 

After the conclusion of the exercise, he becomes animated on the subject of marijuana. “I will come out and say that I support legalization,” says the child and adolescent psychiatrist who just told us that marijuana leads to demand for adolescent mental health services. “I think the war on drugs has proven time and time again that locking up nonviolent pot smokers is not the answer, and overall is not effective in addiction treatment. The answer is education and awareness about the real harms of marijuana, especially THC and cannabinoids. There is quite convincing evidence that adolescent pot smoking can lead to harmful impact on depression, anxiety and development of psychosis.”

[Editor: … but a beneficial impact on the incomes of psychiatrists….]

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Stopped by Gentle Greg’s house for his birthday party. Several physical therapist (PT) students attend.

The rest of the book: http://fifthchance.com/MedicalSchool2020

Full post, including comments

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

Full post, including comments