Hospitalists.....

I was a hospitalist before the word was fashionable.  It was July 1988 and I had just completed a 3 year post residency stint at a community mental health center as part of a public health service scholarship payback.  For one of those years I commuted another 300 miles to keep a community hospital psychiatric unit open.   I headed for the hospital where I did my rotating internship in Internal Medicine, Pediatrics and Neurology.  It was the only real metropolitan inpatient treatment setting I had known at that point.  In my residency program, the interns were split up into two groups and each group worked at one of the major county hospitals in the Twin Cities.  It was a unique setting at that time because psychiatrists provided almost all of the medical coverage.  They had to be able to diagnose and treat a lot of common medical problems, write for all of the patient's medications, attend to acute medical problems and do the appropriate diagnosis and triage.  I had a wide range of medical problems admitted directly to me ranging from gunshot wounds to delirium.  Any psychiatrist working in these conditions realizes that the term "medically stable" is a relative one.  I had many patients admitted to my service with severe medical problems only because they also had a severe psychiatric disorder and were symptomatic at the time.  In many cases I had to rapidly assess them and transfer to medicine or an intensive care setting.

I had excellent back up by consultants and many of them to this day are some of the best physicians I have ever seen.  But they really did not want to hear from me unless I had a very specific probable diagnosis and most of the evaluation was done.  There are not too many places in psychiatry where jobs like that exist anymore.  If anyone asks me about similar positions - I actively discourage them from accepting a similar job.  With this arrangement the work is far too long and all of the medical care is provided for free - psychiatrists do not get any extra credit for it.

In those days there were six of us covering 3- 20 bed wards, five days a week.  The ads for psychiatrists these days often speak of "psychiatric hospitalists" - but every one of them specified no medical coverage.  They also tend to leave out the part that it is basically a rapid triage and discharge position and the job is to either maintain or cooperate with high discharge rates.  The only thing they have in common with the Internists and Family Physicians who have come to be designated as hospitalists is that they work 7 days on and 7 days off.  A schedule that very few people question.

I naturally picked up this week's copy of the New England Journal of Medicine to see what the two perspective pieces on hospitalists (1,2) had to say.  I was also interested because my brother is an Internist and over the years we have discussed the issue at length.  The initial essay by Wachter and Goldman documents the rapid rise of hospitalist care as a medical specialty.  Since 2003 the number of hospitalists has increased 5-fold to 50,000.  That makes hospitalists the largest speciality within Internal Medicine.  They cite the growth of managed care, Medicare DRG payments, and possible evidence as reasons for the growth of the field.  I am always skeptical of the term efficiency especially when it is combined with the term quality.  I guess it is difficult for some people to accept the fact that managed care and Medicare DRG payments are rationing mechanisms that are tied to quality only by the tenuous thread of government and healthcare company rhetoric and advertising.  The other critical question is efficiency for who?  It certainly is more efficient to administer a group of physicians who work 7 days on and 7 days off and happen to all be in the same chain of command.  It is a lot easier to get them to accept the role of rationing care in the interest of the hospital or health care group than the patient's personal physician who may see their part of their role as patient advocacy.

The authors have an interesting take on the deficiencies of the model.  They talk about the 7- days-on, 7-day-off model as implying that during the off period the physician is literally off and suggests that time might be better spent contributing to key institutional programs.  To me - this schedule seems more conducive to burnout and anyone who works it needs the off time to fully recover.  I have never seen a study on the cognitive efficiency during the 7-days-on, but my conversations with hospitalists suggests that by day 6 it starts to plummet.  With hospitalists supplanting specialists and subspecialists as inpatient attendings they suggest that trainees have less exposure to basic and translational science.  Although not stated in the article, the model involves eliminating whole blocks of specialty care.  I worked at a hospital where an entire Neurology service was eliminated by hospitalist care.  When I questioned that decision I was told: "We have an Internist who is interested in strokes."  Changing neurologists from attendings to consultants with hospitalists as the primary physicians for neurological problems changes the entire nature of care.  It also changes the associated nursing care when staff have no ongoing interest in the care of complex neurology patients.  The authors also note that hospitalists do not seem to have focused on investigating common inpatient illnesses.  They suggest possible remedies - but these seem like major problems that will only get worse with the increasing business rather than academic emphasis in medicine.

Gunderman points out that as opposed to the usual delineators of speciality care - patient age, physician skillset and body system hospitalists are delineated only by patient location.  He doesn't make it explicit but what is the relationship between location and his list of putative benefits? Looking at length of stay for example - that could logically follow as a concentrated effort in the location, but is that a clinical effort or an administrative one?  He points out that the increasing number of hospitalists per se,  cannot be taken as evidence of benefit and that perverse incentives exist.  I agree with the most perverse being the low reimbursement incentive for high volume practice. Seeing complex inpatients with a high frequency of initial and discharge assessments may reduce the volume necessary for productivity demands.  When I was a psychiatric hospitalist, this dimension was manipulated in a number of ways.  I was initially told, I was responsible for a set number of inpatient beds.  At some point there was a great deal of pressure for me to start running outpatient clinics because they would be more "interesting" than just seeing inpatients.  I resisted that and had significant leverage because nobody else wanted to do my job.  I eventually did run a Geriatric Psychiatry and Memory Disorder Clinic for many years while continuing inpatient work.  That clinic was eventually closed by administrators because they claimed our productivity was not high enough to work with a nurse.  The neurologist and I needed all of the collateral data that she collected to do our work.  The expectation was that we would see complex dementia patients and do everything that the nurse in our clinic did - so we closed.  In over two decades of political wrangling around inpatient productivity the current consensus is that covering 10-12 inpatient beds is a reasonable approach.  At one point I was covering 20 beds with the help of an excellent physician assistant but at the cost of doing no teaching.

The critical aspect of Gunderman's thesis is his emphasis on the physician-patient relationship exemplified by this sentence:

"The true core of good medicine is not an institution but a relationship - a relationship between two human beings."

He points out that physicians being affiliated with institutions creates significant conflicts of interest,  isolates hospital staff from the rest of the medical community and that naturally leads to less expertise in the entire community.  It also creates the illusion that an institution rather than the relationship is the core of medical care and it is not.  Government-business constructs like Accountable Care Organizations have a similar effect.  I have experienced this first hand many times as I dealt with the iterations of hospitalists consulting on my patients.  In one case I talked with a young hospitalist about a patient with Type 2 diabetes mellitus.  The patient had a trace of renal insufficiency and was on metformin - a medication that is risky in that context.  The hospitalist advised me to call the primary care Internist taking care of the patient because "He has been doing it a long time and probably knows more about it than I do."  In addition to the relationship - there is clear expertise associated with caring for people with multiple complex medical problems for years in an outpatient setting - compared to a few days as an inpatient.  The medical industrial complex does not adequately value that expertise.                             

I think that there is room for hospitalists and psychiatric hospitalists.  They have to be focused on the needs of both the patient and the patient's outpatient physician.  There have to be clear goals for the hospitalization and one of those goals is what the patient's personal physician would like to see accomplished.  Since making the transition to strictly outpatient care - it is clear that the hospitalists no matter who they might be don't have much control over who gets admitted to the hospital and what happens there.  They are having less to say about when a person is discharged.  This is probably more true for psychiatry than medicine and it results in a large number of psychiatric outpatients not being able to access needed care.

And I can't help but notice that inpatient hospital medicine is still a far better resource than inpatient hospital psychiatry.



George Dawson, MD, DFAPA




References:

1:  Wachter RM, Goldman L. Zero to 50,000 - The 20th Anniversary of the Hospitalist. N Engl J Med. 2016 Aug 10. [Epub ahead of print] PubMed PMID:27508924.

2:  Gunderman R. Hospitalists and the Decline of Comprehensive Care. N Engl J Med. 2016 Aug 10. [Epub ahead of print] PubMed PMID: 27509007.

The CMS Investigation Of Anoka Metro Regional Treatment Center

In a previous post I discussed a recent local news article that pointed out the increase in incidents of aggression at one of the state's major psychiatric facilities and a threatened loss of Medicare funding unless certain deficiencies were corrected.  The deficiencies were determined by an investigation of the facility by the Centers for Medicare & Medicaid Services (CMS).  No specifies from the report were available from the news article or the Minnesota Department of Human Services.  They did provide me with a contact person at CMS and after another forwarded e-mail, I was sent 4 attachments detailing the results of the investigation.   I will report on those reports in this post.  The documents were all typed on a standard government form as noted in the graphic below.  The entire CMS report is written in the column labelled "Summary Statement of deficiencies...".  No comments were written in the column labelled "Provider's Plan of Correction...":

I have coded them AMRTC 1-4 for convenience and will refer to them that way in the summaries below.

AMRTC-1 is a 34 page document that states the visits was done to see if the hospital was in compliance with 42 CFR Part 482 for acute care hospitals.  The survey was conducted from 10/19 to 10/23/2015.  The report indicates that there is a 108 patient capacity at the facility and that 30 records were reviewed as the basis for the report.  Problems were found in 2/30 cases with regard to patient care.  There were additional administrative problems that also resulted in noncompliance with the federal standard.  There were problems noted  It was determined that the hospital was not in compliance with the Conditions of Participation of 42 CFR Part 482.  The main finding of the first report is that The Governing Body of the hospital failed to ensure that services provided by staff or contracted staff were proved in a safe and effective manner.  The highlighted areas include failure to assure that quality processes were in pace to minimize or prevent medical errors, failure to assure that comprehensive nursing plans were developed, and a patient's rights condition that occurred when a patient was given forced medications that were prohibited by a court order.

The Quality Assessment Performance Improvement (QAPI) programs extended across a number of clinical and nonclinical disciplines.  In some cases,  they involved the administration not doing what they stated they would do in their descriptions of quality improvement.  The best example I can think of is the reference to Six Sigma.  I have always found it a questionable practice to apply engineering management processes to any medical field.  I sat through a presentation of this paradigm in a previous job and it just seemed like the standard management buzzwords that we hear in different iterations by people who think they are inventing management every 5-10 years of so.  At that job we suffered through a couple of presentations and printed Powerpoints and it faded as soon as it came up.  We moved on to a different paradigm.  Since it was widely promoted, the Six Sigma approach has been shown to not be uniformly effective in business and manufacturing models.  What the proponents of Six Sigma to medical fields don't seem to understand is that measurement is a limiting factor and it has nowhere near the precision or accuracy of measuring products in electronics or automobiles.  At the philosophical level the administration probably made the common error of espousing a philosophy that they could not live up to.  I am not aware of any major healthcare corporation that uses the Six Sigma management model and they probably have many more resources than a state hospital. 

One of the case examples cited was an agitated patient who was physically aggressive and received olanzapine and then intramuscular haloperidol despite a court order excluding haloperidol and risperidone.  The psychiatrist and nurse involved were questioned and said they were unaware of the order at the time the medication was administered.  The patient got this medication for a period of 3 days before it was discontinued.  CMS investigators comment how the physician in this case could be held in contempt of court for ignoring a District Court judge's order.  There was a question of whether or not there were two different orders and the one barring the medications showed up later.  As a physician who has worked with different court orders in these cases for over 20 years, I can attest to the fact that they are not necessarily clear.  In many cases there is a temporary order until the final document can be typed up.  It would seem that the quality process here would be to appoint a person to make sure the latest order is in the chart and read by the attending physician before any medication orders are written.  There is also a question of how paper documents from the court are placed in an electronic record and how easily they can be read in that record.

At the end of the document problems with the care of 10 different patients with different diagnoses and problems are reviewed.   These clinical examples were given to illustrate that that patient with varied problems were all given treatment plans that were not comprehensive, even in the case of patients with aggressive or self injurious behavior.  The reports describes this as: 

"Interventions on the Patient Treatment Plan were generic and were normal functions of the professional disciplines involved in the patient's care and were not individualized to the patient."  

What does all of this mean?  A recent article in the StarTribune (1) had quotes from several mental health experts and advocates about the state of affairs at AMRTC.  The commentary seemed to vary in the level of outrage expressed as "egregious" and "appalling" and "no excuse."  As an expert - when I read the report it seems to scratch the surface.  Would correcting the deficiencies in the report right the ship out at AMRTC?  Possibly - but the previous news report suggests there is a much bigger problem.  That report was about incidents  of aggression, how they were increasing, and there was an opinion that aggressive inmates transferred based on new legislation was the main reason.  A union representative was quoted as saying that some of the inmates transferred from correctional facilities had "taken over" and that they were more aggressive than non-correctional patients.  None of those problems are specifically addressed in the report.  The report comments on problems in the care of specific individuals, only one of whom seem to be as aggressive as two of the patients mentioned in the original article (2).  The errors in the report may be largely documentation and reading errors, but administrators always emphasize "if it isn't documented it did not happen."  Some of the problems at AMRTC have been decades in the making.

For a long time the message given to most professionals in the state is that the state hospital system including AMRTC (like practically all other hospitals in the state system) was going to be shut down. Only the practical fact that there is always a backlog of committed patients waiting to get in to AMRTC prevents it from being shut down.  But the key question remains - is this really the attitude of managers at the level of the State of Minnesota?

The second problematic attitude that I have heard about constantly is written about in the recent article (1):

"Nearly half of the 101 patients currently there no longer meet the hospital-level criteria for care but are kept at the hospital because they have nowhere to go in the community. In 2013 alone, patients spent a total of 13,800 unnecessary days at Anoka-Metro after they were treated — enough to care for another 140 patients, according to a state legislative report."

This is a good example of circular reasoning.  The reason why patients spend so-called "unnecessary days" at AMRTC is that there are no other facilities that can manage their behavior.  I am aware of programs where very aggressive individuals are managed in very small settings (2 to 4 resident group homes) and the staff is taught to physically restrain them when they become very aggressive.  That is really an unacceptable long term solution to the problem for many reasons.  It is time to stop pretending that long term hospitals are acute care hospitals and that they should be managed like acute care community hospitals.  A transient reduction in symptoms does not mean that a patient at AMRTC is spending "unnecessary days" at the hospital.  If they cannot successfully transition to a community placement - they probably need to be there.

The real and unaddressed issues (beyond the CMS report):

1. The effect of the message that state hospitals should all be closed: As a psychiatrist in the state, this is what I have been hearing for a long time. It is really not possible to develop a quality of care focus or have the necessary stable staffing patterns of experienced staff, when those same staff are hearing that the state is trying to close down the facility and that many people at the facility don't need to be there. Instead - the facility should be managed as one that can provide state-of-the-art care to patients with complex problems including violence and aggression. Another aspect of that is eliminating the positions of experienced staff to save money. You will never have a high quality program using this approach and yet the state has used this approach.

2. The effect of management from higher levels: This seemed to stand out as I read the issue of "generic treatment plans" from the CMS report. At some level all treatment plans become "generic treatment plan". The evidence is that you can purchase treatment planning texts for nursing, psychotherapy and to a lesser degree psychiatry that will show you generic treatment plans for an entire list of problems. Is the problem really a generic treatment plan that covers most interaction or the lack of a treatment plan that addresses a high degree of aggression? I would contend that it is the latter.

Complicating that issue are previous stories about how plans were implemented by state administrators with no psychiatric experience to address patient aggression. I sat in on one of these sessions that suggested that a focus on the aggressive person as a psychologically traumatized individual was the best way to proceed, but not much specifics after that. Is at least part of the problem that state hospital staff have inadequate guidance on what to do about aggression? Are they reluctant to intervene early or clearly document what happened and their response because the response from administrators is inconsistent? Are they being advised to use interventions that are ineffective?

3. The lack of teamwork and possibly a split staff: One of the most dangerous problems in any inpatient psychiatric environment is staff splitting - some of the staff are praised and well liked and other are criticized and disliked. This emotional environment in inpatient care leads to problems in patient care. Splitting needs to be minimized or eliminated largely by recognizing that professionalism and the objective analysis and treatment of problems is the real priority. I have been in treatment environments where staff were disliked or falsely accused and that lead to major problems in patient care and episodes of aggression. It also leads to staff turnover.  The attitude of administrators can be particularly insidious and create an immediate rift among the staff.

4. The influx of inmates into AMRTC that is caused by the current public policy of rationing community psychiatric care and the resulting shift in the cost of care to the correctional system: Instead of addressing the widespread problem of rationing psychiatric care for the severely mentally ill - the solution is currently to dump at least some of them from law enforcement facilities to a rationed long term care facility. How is that a solution to anything?

These are the real problems at AMRTC and within the state system as far as I can tell. This is all based on what I read in the papers, the CMS report, and my extensive inpatient and out patient experience as well as experience treating aggressive people. The CMS report while noting significant problems does not come close to addressing these issues and makes it seem that addressing problems in patient care or documentation will correct the problem with aggression within this system.

I doubt it is that easy.



George Dawson, MD, DFAPA


1:  Chris Serres.  Anoka state mental hospital violated basic rules for patient care, feds say generic treatment plans, other issues put mental hospital's federal funding at risk. StarTribune January 16, 2016.

2: Chris Serres. State psychiatric hospital in Anoka threatened with loss of federal funding. Minneapolis StarTribune January 4, 2016.

Delirium Reinvented

One of my colleagues posted an article from the The Atlantic on delirium to her Facebook feed a few days ago.  Most of my colleagues in that venue are hospital, consultation-liaison, addiction or geriatric psychiatrists and we diagnose a lot of delirium.  Entitled the Overlooked Danger of Delirium in Hospitals it makes it seem like this is some kind of new and strange diagnostic category.  The article talks about the prevalence, the association with critical illness and advanced age, and the diagnostic overlap of dementia and delirium.  We hear from an Internal Medicine specialist Sharon Inouye, MD about the need to correctly diagnose and prevent delirium.  She mentions that as opposed to a decade ago, physician and nurses are all taught about delirium.  There is mention of the CAM (Confusion Assessment Method) that Inouye developed.  Like all health care articles there are estimates of the massive cost of delirium as well some prevention techniques.  There is also political concern that Medicare will declare delirium a "never" event with penalties for any hospital with cases of delirium.  That would be unfortunate because it makes a mistake that also seems to be made in this article - that delirium is a manifestation of many illnesses, especially the kind of illnesses that patient's are hospitalized for.

The article seemed odd to me because it was written from the perspective that delirium is an iatrogenic preventable event!  Certainly that can be the case. Delirium is a primary feature of hundreds of different disorders and recognizing delirium and those etiologies is potentially life saving.  Delirium can mimic psychiatric conditions due to the presence of hallucinations and delusional thinking.  For example, it is entirely possible to see a patient in the emergency department with apparent paranoid delusions and miss the fact that they happen to be delirious.  Sometimes the only sign is that the patient is inattentive and when vital signs are checked they have an elevated temperature.  This can be a common presentation of viral encephalitis in younger patients or urinary tract infections in the elderly.  It is bad form to miss either of those diagnoses and attribute the symptoms to a psychiatric disorder.  Another common form of delirium that is missed is drug or alcohol intoxication or withdrawal states.  Some intoxicants will render the patient totally unable to care for themselves until they are detoxified.  Other deliriums from alcohol or sedative withdrawal are life threatening and can be associated with seizures and other life-threatening states.  An acute change in a person's mental state resulting in delirium needs to be recognized and assessed as a medical emergency.    

One of the first cases of delirium that I ran into after residency was a case of cerebral edema that I was consulted on because of "hysterical behavior".  After that, I worked in and eventually ran a Geriatric Psychiatry and Memory Disorders Clinic for about 8 years.  The majority of people coming to that clinic had dementia of some sort.  They would see me and a neurologist.  We started out with an internist who was also a geriatric specialist, but that turned out to be overkill in terms of the number of medical specialists seeing each person in an outpatient clinic.  We eventually opted for records from the patient's primary care physician.  One of the most valuable functions of that clinic was our ability to follow people with prolonged deliriums.  Once a delirium has been established by a disease state and that state has resolved the delirium can persist for months.  Some of the outliers in that clinic took up to 6 months to clear.  We found that in many cases, the patients were extensively tested for intellectual ability and functional capacity when they were in the delirious state and told that they had dementia.  It was always instructive for the patient and family to get the testing repeated when we were sure the delirium had resolved and find that they had been restored to baseline.  Many people know their full scale IQ score and were relieved to see that they were back to that level of functioning.

A valuable lesson from working in that clinic and in hospital settings was the use of the electroencephalogram (EEG) as a possible test for delirium.   EEGs are commonly viewed as diagnostic tools to determine if a person is having seizures, but they also contain a lot of information about brain metabolism.  EEGs can be difficult to interpret especially if the patient is on a number of medications that affects cerebral metabolism. There are two broad categories of EEG patterns for delirium: one with a predominance of slow frequencies (designated theta and delta) and one with faster frequencies (designated beta).  We found a number of people with very significant cognitive impairment that was thought to be either a psychiatric disorder or a dementia but with a profound degree of slowing more consistent with a delirium.    

Delirium is an augenblick diagnosis for most psychiatrists.  The patient could appear disinterested, apathetic, agitated, or overtly confused.  It occurs in situations where brain physiology is compromised such as post surgical/anaesthesia states, drug intoxication states, drug reaction states, or possible physical illness delirium should be high on the differential diagnosis.  The Atlantic article makes it seem like knowledge about delirium is something very recent, but psychiatrists have been focused on it for a long time.  In the first two iterations of the DSM, delirium was subsumed under the categories of acute and chronic brain syndromes (DSM-I 1952) and organic brain syndromes (DSM-II 1968).  The current diagnostic code and name has been with us since the DSM III in 1980.  One of the early experts in delirium was Zbigniew J. Lipowski, MD, FRCP(C) - a Professor of Psychiatry from the University of Toronto.  His first text on the condition was Delirium: Acute Brain Failure in Man published in 1980.  That was followed by his classic text,  Delirium: Acute Confusional States published in 1990.  A comparable text from a neurological standpoint was Arieff and Griggs Metabolic Brain Dysfunction in Systemic Disorders published in 1992.

Any psychiatrist trained in the past 30 years should be able to diagnose delirium and come up with a differential diagnosis and monitoring or treatment plan.  A significant number of people can be followed on an outpatient basis as long as they are in a safe environment with the appropriate level of assistance.  The main goal of treatment is to make sure that the primary medical illness that led to the problem has been treated.  There are no known medications that will accelerate the resolution of these symptoms and medical management usually involves getting rid of medications that can lead to cognitive problems.  That can include benzodiazepines, antidepressants and antipsychotics but also more common medications like antihistamines and anticholinergic medications that are used for various purposes.  Like most psychiatric interventions in our health care system, clinics with staff interested in doing this work are few and far between generally because they are rationed resources.

There is a current movement underway to train Family Physicians and Internists (like Dr. Inouye) to recognize and prevent delirium.  In the minority of hospitals where psychiatrists work they are also a clear resource.  A delirium in a previously healthy person should signal a fairly comprehensive evaluation to figure out what happened.

And whenever there is a question of whether a person has a delirium or a psychiatric disorder - call a psychiatrist.  Psychiatrists know a lot about delirium and have for decades.



George Dawson, MD, DFAPA



Reference:

Sandra G. Boodman.  Overlooked Danger of Delirium in Hospitals.  The Atlantic.  June 7, 2015.


Supplementary 1:  The graphic is a standard EEG.  I tried to post a slowed EEG seen in delirium, but the publisher wanted what I consider to be an exorbitant fee for a non-commercial blog.  If anyone has a slow anonymous EEG laying around, send me a copy and I will post it.

The Retirement Party

There aren't too many retirement parties that you can go to and spend a lot of time talking about violence.  I suppose it might happen with law enforcement and the military.  When I went in to psychiatry I never seriously thought about the fact that I might have to go to work every day and face people with serious problems with aggression and violence.  In some cases that would mean seeing people who had threatened to kill me and my family.  It would also mean seeing people with documented incidents of aggression toward others, toward themselves, and toward property.

I went to a retirement party yesterday for a nurse I had worked with in an acute inpatient setting for about 20 years.  Like most of the nursing staff I work with she has excellent skills but was also renown for her sense of humor and positive attitude.  She was the kind of person I counted on when things were particularly grim - a frequent occurrence on inpatients units.  I could only make it to the last 2 hours of the party, so I missed the evening shift who all had to leave and go to work.  There were about 20 people there including a psychiatric colleague who worked with me on that unit and who I have known for 30 years.  I always consider retirement parties to be very happy events.  I have known too many medical professionals who never made it to retirement.  I want everybody to make that goal, especially people I have been in the trenches with.  I previously posted here many times about the inpatient environment and its importance is treating and containing aggression and how that function has been subverted by political and administrative forces and rationed to the point of being minimally effective.  When you are working on an inpatient psych unit, it is a lot like going to war every day.  You are facing many patients who don't want to be there despite significant problems.  Many are involved in contested commitment hearings based on whether they have a suicide or aggression risk.  Many have severe substance use problems that intensify suicidal thinking and aggression.  They are generally not interested treatment for the substance use problems or do not see that as a significant issue.  There are minimal resources to work with.  The team social workers generally don't last too long because there are very few community resources that want to cooperate with discharge plans from acute care psychiatric units.  Everyone is working under an administration that is focused on restricting resources and providing suboptimal care.  Everybody at that party worked with me in that environment at one point or another for 23 years.  At times it was like we were in foxholes under siege for weeks at a time, just looking for a break.

It was good to see everyone in a much less stressful context, but like most groups of people who have been immersed in a high intensity work experience the conversation tends to gravitate back to the humorous and stressful events that we were all a part of.  One of the common threads was aggression.  I learned that one of the nurses had recently been assaulted and sustained broken nose and a traumatic brain injury.  She discussed the incident and her reactions to it.  My psychiatric colleague added her personal experiences with aggression directed toward her.  As I looked around the room, I was aware of the fact that significant physical aggression had occurred toward about 25 % of the people there.  In some cases there were episodes of repeated physical aggression.  At some point in my career,  I realized that there was really nobody who was interested in helping inpatient staff contain aggression.  There are always administrators around who are ready to assign blame.  I can remember one particularly unhelpful "consultation" that suggested that the problem was a lack of rapidly forced medications.  The most recent administrative initiatives have to do with not forcing anything.  Suddenly everyone was supposed to respond to quiet deescalation.  Sitting in a quiet office somewhere and looking at spreadsheets does not lead to any insights into containing aggression on an inpatient unit.  I guess the typical administrator does not realize that.  My realization was that as a team we had to discuss the issues with patients constantly, emphasize the violence risk, emphasize that we did not want anyone to take chances in these situations, and discuss a detailed plan that included ways to approach the patient and their family as much as medication.

About halfway through the party, one of the nurses handed me her iPhone with the the story about a psychiatrist who had shot a patient in a crisis clinic.  It reminded me of the time I had to consider about whether or not to arm myself.  I was after all a tree hugger and a Child of God from the 1970's.  The last thing I wanted to do was have guns in my house.  I was aware of psychiatrists who had been killed by patients, in several cases with firearms.  I had just read an article about a psychiatrist who was also a Sheriff's deputy who carried a handgun.  In my case it was a patient who threatened to shoot me when I was walking out to my car from my clinic.  He made the additional threat to burn down my house and kill my family.   He proved that he knew where to find me by reciting my home address.  Going to work under those conditions every day and treating other aggressive patients is stressful to say the least.  But it is expected of psychiatric staff, in some cases even after they have been assaulted and the patient who initiated the assault is still in treatment.

I have no personal knowledge of the shooting incident but the descriptions suggest common system wide issues that are never well addressed these days.  Rather than speculate about media reports there are some common safeguards that I have learned apply everywhere and serve to contain violence and aggression in clinics and on inpatient units:

1.  The atmosphere - you can't really expect to reduce the potential for violence or aggression unless the environment is adequately managed.  Psychiatrists used to talk about the milieu but that ship has apparently sailed.  The largest professional organization of psychiatrists is silent on inpatient treatment and the treatment of aggression and violence.  The American Psychiatric Association (APA) used to have guidelines on such matters, but nothing has been written in a long time.  I don't know if that is just giving up to the widespread managed care blight or an open acknowledgement of the hopeless situation.  The APA has been reduced to homilies about how increasing access may reduce violent events rather than speciality units set up to treat aggression and violence associated with severe psychiatric disorders.

Inpatient units can literally be staff on one side of the plexiglass and the violent and aggressive patients on the other.  I worked on a unit like that at one point.  We were all shocked one day to learn that we really were not behind plexiglass when a steel chair came flying through a shattering tempered glass window.  It sailed right over my head and I was standing up at the time.  It must take quite a bit of force to throw a steel chair that distance through glass and to that height.  Nursing staff dove for cover with the explosion of the glass.  In addition to the staff it took two Sheriff's Deputies to resolve the situation.   There are any number of reasons given for running units like this and none of them are good.  It puts the patients and staff at risk by eliminating one of the most important aspects of psychiatric care - the interpersonal relationship between patients and staff.  Without it a correctional atmosphere can develop that is more conducive to rioting than treating mental illness.

That same floor had a history of firearm related events.  There was the case of a patient who had a firearm smuggled in.  He held the psychiatric resident hostage and ended up shooting a Sheriff's deputy at the control desk out in the hallway.  When I worked there, I was surprised one morning  to find a number of men on the unit in suits.  I learned they were federal agents.  I was more surprised to find out they were carrying machine guns.  People armed with automatic weapons really do detract from the therapeutic atmosphere of a psychiatric unit.

2.  Relationships - one of the most dangerous situations I have ever been in was ending up on the wrong side of the plexiglass at the wrong time.  The wrong time was at a time I was being blamed for a staffing problem that I really had nothing to do with.  Many people don't know how the attitudes that staff have toward one another can be played out in an intensified version by patients.  I found myself surrounded by 4 young aggressive paranoid and antisocial patients who threatened to beat me up.  After I talked my way out of that situation, my solution at the time was to transfer off that unit with the idea that I would not let that happen again and hopefully pass that knowledge along to other staff.  Unfortunately that same pattern of behavior can occur if it is activated by someone outside of the treatment team.  When that happens it is impossible to deal with in a constructive manner.

3.  Systems issues - the lack of administrative support for any functional approach to aggression is often the biggest obstacle to solving the problem.  This is not an issue in many places where the approach is to kick the can down the road.  Many community hospitals don't accept violent or aggressive patients or even patients who are highly suicidal and may require 1:1 staffing.  They are transferred to tertiary care centers where these problems tend to concentrate.  In those tertiary care centers it is important to segregate patients based on their potential for aggression.  I have heard all kinds of arguments against this procedure  that do not hold water.  I think people may be confused about the segregation issue.  I am  talking about separating men with a high potential for physical aggression from other inpatients who are generally more vulnerable than the average person.  Trying to treat those populations on the same unit is a recipe for disaster.  If the most aggressive mentally ill people in the state are being concentrated in a few hospitals, it is the only safe way to proceed with treatment.  Even then, there needs to be considerable expertise on the part of the staff involved.

4.  Serious administrative deficiencies - I have never seen a clinician with the knowledge required to address any of the above issues in an administrative position.  In an a new twist, there are some hospitals where administrators with no experience at all are charged with running hospitals for patients with severe forms of mental illness and associated aggression.  The commonest excuse for not addressing any of the concerns on this list is finances.  There is not enough money to provide adequate staffing.  In many cases there are now elaborate methods to decide on adequate staffing.  At times the staffing differences between an all male unit housing patients with psychotic and personality disorders with aggressive behavior is not much different from a mood disorders unit where there is practically no aggressive behavior.  Security on the units with a high potential for aggression often depends on other staff being available by cell phone or alarm.  In some cases it is a 911 call to local law enforcement.  I have had to ask that the 911 call be made when an entire male unit essentially rioted and it was no longer safe for the staff.

5.  It is all about the nurses - A key lesson that nobody ever learned in medical school and few physicians seem to learn after is that the only reason anybody needs to be in the hospital is nursing care.  Doctors can go in and out for 20-30 minute blocks and write orders, do procedures, and write prescriptions anywhere.  The nurses are with the patients 24/7.  It follows that one of the primary tasks as a physician is to assist the nurses.  That ranges from taking care of medical and psychiatric problems in a timely manner to backing them up in highly contentious situations.   Nurses are not there to make physicians miserable.  Nurses have an incredibly hard job to do and they know it takes a team effort.  There can't be any "personality conflicts".  In the interest of the team they need to be set aside.

Those are some of the thoughts I had about this party.  Of course I thought about the person being honored and my direct and very positive professional experiences with her.

And I looked around and hoped that everybody there could function as a team, take care of one another, and make it to retirement.

They have nobody else looking out for them.

George Dawson, MD, DFAPA


Supplementary 1:  I had thought about posting the following disclaimer at the top of this post:

"In case you thought this was my retirement party and thought you would enjoy reading about that and rejoicing - you can stop reading right here.  I have not retired and this blog continues...."

But I thought it flowed better the current way.