Tuesday, August 26, 2014

Psychiatrists Implicitly Asked To Fill In Large Gaps

I didn't realize this until relatively late in my career and it has been interesting to counsel several younger colleagues about not making the same mistakes.  Psychiatrists are continuously called upon to make up for significant deficiencies in the system.  Any one of these gaps can lead to a crisis situation that the psychiatrist has to address immediately or lapses in the quality of care.  In the extreme case they can render care impossible.  Many of these deficiencies also require a considerable time commitment by the psychiatrist.  That time is usually not compensated and often takes valuable time away from spouse and family.  The deficiencies are the direct result of rationing resources and not having enough resources available.  Another variation is that some of the staffing personnel available have no training or experience in how to assess and treat mental health problems or even discuss problems with psychiatric patients.  There are many people who are assigned to that role and I am convinced they make things worse rather than better.

Community mental health centers are often places where the deficiencies exist.   They depend on government funding sources and the bureaucracy involved with some of these sources is only exceeded by the lack of adequate funding.  In many places, the managed care model is adapted and that means that nearly all patient concerns are translated into medication complaints of the form "I am having problems because I am not taking enough medication(s)."  Frequently the patients adapt to saying the same thing.  Any astute psychiatrist walking into this setting may see all of the usual markers including most drugs being prescribed at or above the manufacturers suggested maximum dose, far too many benzodiazepine and sedative hypnotic prescriptions, drugs being prescribed for questionable indications, medications being prescribed for a condition that should be treated first with psychotherapy (and the affected patients never received that therapy), and a lot of medications being prescribed to patients who clearly have a substance use problem.   There is generally a lackadaisical approach taken to the medical side of monitoring the patients including no monitoring or intervention for the metabolic side effects of medication, no attention to drug interactions, and no diagnosis and treatment of the neurological effects of medication.  Psychiatric practice is simplified to a contracted practitioner prescribing medications for a broad array of problems.  In many cases staff from the mental health center will call that practitioner when they are not on site and the request and/or response will be an increase in medication dose or a new prescription for medications.

Inpatient psychiatric units tend to attract psychiatrists with a lot of medical expertise and an interest in those matters.   The first problem is often a lack of medical services in terms of consultants or the necessary hardware.  Unless there are medical consultants and a clear delineation of responsibilities this may result in a significant additional time commitment to psychiatrists.  Thinking of admissions, the first step is who does the history and physical.  After a comprehensive psychiatric assessment it might only take an 20 minutes to do a medical review of systems and physical exam.  Depending of the medical complexity of the patients it may take an additional hour or two.  The second point is what is now called medication reconciliation.   That means that all of the medications the patient taking for medical and psychiatric purposes.  That is very easy in the case of one medication.  It is not so easy when a patient cannot accurately report their medications or they are taking up to 20 medications.  Those medication may include several apiece for chronic medical conditions like hypertension and diabetes mellitus.  There are also decisions that need to be made about which medications can be restarted and which medications need to be acutely discontinued.   That can lead to hours of time for an admission procedure that in a typical system of care is supposed to take an hour or less.  There is a strong incentive for administrators to have the same physician cover both the medical and psychiatric side of inpatient treatment.  It is far more cost effective for medical consultants to see patients elsewhere in the hospital.   Young psychiatrists wanting to do both jobs should be aware of the fact that most places would be more than willing to have you commit that kind of time.

Other residential settings can lead to problems similar to inpatient psychiatric units, but tend to be less intense on the admission side.  In many cases psychiatrists are consultants to a number of facilities like corrections, drug and alcohol treatment facilities, and nursing homes.  All of these settings present unique challenges to rational psychiatric care ranging from subtle to more obvious.  In many cases the obvious problems seem to escape notice by many of the people in charge today who have no clinical training.

An example of some of the most subtle but disruptive problems are the psychodynamics of treating groups of people in an environment with a significant number of treatment staff.  In that setting some of the characteristic psychodynamics of people with personality disorders occurs and leads to significant problems.  A  couple of good examples include staff splitting and projective identification and I will deal with these defense mechanisms extensively in a second post.  In this post I will give a hypothetical example of how disruptive these defenses can be in a staff and an administration that is poorly set up to deal with them.

Consider Dr. A. a seasoned inpatient psychiatrist with many years of experience.  Dr. A is highly regarded by the inpatient staff and her colleagues, but not so by administrators in her department.  With administrators, she is regarded as having a length of stay that is too long, because she refuses to discharge patients with inadequate evaluations or evidence that they will not be able to adequately function.  She has had several meetings with department administrators on this subject but stands her ground on what she sees as professional standards as opposed to managed care guidelines.   Nevertheless, she does feel the pressure from the administrators and does end up discharging a young man to a group home.  He has difficult to treat bipolar disorder and diabetes mellitus Type II and she made the difficult decision to treat him with an atypical antipsychotic despite the metabolic warnings for this class of medication.  He did not have all of the markers of adequate progress for discharge that she likes to see but he was sleeping well and no longer grandiose.  

The patient in question is discharged and returned in 3 weeks.  He is agitated and manic.  Dr. A notes that the patient saw a practitioner in the time he was out of the hospital and the dose of medication was cut in half.  That acute dose reduction was associated with the recurrence of manic symptoms.  Dr. A ordered the full dose of the medication and to contain the patient also ordered 1:1 staffing to redirect him from conflicts with other patients.  There was a hospital wide initiative to reduce the amount of 1:1 observation time.  On of the nursing staff suggests that the patient is getting special treatment because Dr. A has the "hots" for him.  The patient was regarded as attractive and referred to Dr. A as his "girlfriend".  None of the nursing staff notice that the staff person doing the 1:1 observation was verbally accused by the patient of stealing money from him during the previous hospital stay.  Part way through the shift the patient punches the staffer in the arm with a good amount of force.  The staff person is not injured, but an inquiry is held.

Dr. A walks into the inquiry and notices the administrators, some of them from the various disciplines on the unit.  The administration of disciplines in this hospital is in a silo manner like most hospitals with separate administration for physicians and nurses.  The question the group will consider is apparently the accusation by the nursing staff that Dr. A was prescribing an "inadequate" amount of antipsychotic drug even though the orders clearly show that the patient was given a dose that was beyond the maximum FDA recommended dose and the patient has diabetes - a reason for caution when using this class of drugs.  None of the staff in the room was aware of the previous confrontation that the patient had with the staff that was assaulted.  By making these points Dr. A seemed to be able to satisfy the requirements of the inquiry but suddenly out of left field, one of the nursing administrators suggested that Dr. A had a "communication problem" with the nurses and had in fact "ignored" one them.   The entire room of administrators seemed to be in agreement about this despite the fact that all of the nursing staff working that day had been interviewed an none of them had seen this pattern.

The final result was that the panel decided that Dr. A would meet with the inpatient director and the aggrieved nurse on a regular basis to focus on the "communication problem" that Dr. A allegedly had.

The case of Dr. A is an excellent example of staff splitting the resulting very negative outcome for Dr. A.  The reality of the decision is that Dr. A had done nothing wrong.  She is very competent and used to making tough decisions in impossible situations like the one described above.  Her professional competence includes neutrality toward patients and she has never acted in an inappropriate manner with any patient.  In this case the process results in her being treated like a novice and punished for something that never occurred.  All of this is the result of treating a patient with difficult problems, and a lack of understanding on the part of the staff and the administrators about what was happening in terms of interpersonal dynamics.  Dr. A ends up being scapegoated and her confidence in decision making is temporarily affected until she can put the pieces together and figure out what happened.  Watching how the key staff interact in similar situations in the future is also helpful. 

What gap occurred in the scapegoating of Dr. A?  The best psychodynamic hospitals have group meetings for staff to examine the dynamics especially in the treatment of patients with complicated problems or complicated developmental histories.  Most acute care hospitals have no team meetings at all.  The basic premise is that the wards are short term holding tanks until the medications kick in and the patients can be discharged.  These days the medications don't even have to kick in as patients are discharged with a significant amount of symptomatology.  There is no analysis or discussion of defense mechanisms and projection that results in threatening behavior is generally handled as an acute psychotic symptom with medication.  I have really never seen any hospital administration recognize that this is a shocking deficiency and in many cases the splitting is worsened by administrative maneuvers.  Having an administrator with no clinical training  dictate how complicated patients with aggressive behavior are handled is a great example.

These large gaps also translate into a lack of quality in psychiatric care.   It is what happens when businesses and governments marginalize the role of physicians and exaggerate the importance of business administrators.  The practical implications are that psychiatrists should really avoid practice situations with these obvious gaps.

It would be great if the American Psychiatric Association would step up and comment on how these gaps should be closed but they appear to be disinterested in what is happening to the practice environment for psychiatry.

George Dawson, MD, DFAPA



  1. The APA leadership has no skin in this game and therefore they don't care.

  2. My unfortunate experience has been that there is a tremendous amount of character pathology in inpatient psych staff members, and that the group pathology will take over unless there is someone knowledgable and experienced enough to contain it. I've seen psychiatrists as well as head nurses fill this role, but not often.

    1. I agree and there are additional contributing factors. I thought a few few more the other day:

      1. Character pathology outside of the staff and that range from administrators to consultants to reviewers in managed care companies to regulatory bodies.

      2. A structurally split staff (the administrative silos).

      3. A functionally split staff as in I am the doctor who is in charge of these medications and another doctor is in charge of those medications.

      All of these situations can lead to a field day of staff splitting.