Bullshit Medicine
Today I was in the ER talking with one of the pediatric residents about jobs. We are both in the same boat, in that we are in the final year of our fellowships and are both studying for the licensing exams and looking for jobs (not to mention working well more than full-time). I suggested to Dr. F that she should become a child psychiatrist, as there is a huge need for them and she could easily get a job. A nearby nurse looked up and, not knowing I'm chief resident for Psychiatry, said, "Yeah, if you want to practice Bullshit Medicine!"
The problem is that there is a kernel of truth to that statement that makes me feel squicky inside. The reason I was in the ER in the first place was to transfer a kid from our ER to a psychiatric hospital for an assessment, a task which ordinarily takes 1-2 hours. It took me 4, simply because she was from a different county so that, instead of following the usual routine, I had to wade through mires of bullshit to find out where to send this girl and then get that hospital to accept the transfer. Meanwhile, what I was sending her for- an assessment of suicidality- was something I do weekly in that very ER and am fully competent and qualified to perform. I wasn't performing it in this case solely because the girl was 13 instead of 11-and-under and was from the wrong county. We only get paid by our county, and then only for kids 11-and-under. All others get shipped out.
There is an element of warehousing and bureaucracy inherent to crisis mental health work that is repugnant. The security guard I worked with on this case gave a good example of this. He used to work at the local adult psychiatric hospital, and told me about their "frequent fliers," folks who weren't mentally ill, but used the mental health system and the 5150 laws to secure a bed and a meal simply by calling 911 and reporting suicidal ideation. These individuals take up space designed for psychiatrically impaired adults, and cost us a fortune by doing so that could be better spent in other types of (less expensive) social services. Meanwhile, a large, large portion of the mentally ill adult population is warehoused in prisons, where they receive no treatment at all.
In my own 5150 assessments this sort of dilemma becomes apparent when a child who would, in an ideal environment, be able to go home ends up being sent to a psychiatric hospital because I don't trust their parent or their environment to keep them stabilized. In a lot of these "soft calls" the problem seems to me to be largely an issue of family, community, and environmental dynamics rather than a function of sincere mental illness, namely suicidal/homicidal ideation or being gravely disabled. Yet I send them off because, on the ethical scales, it is better to keep them in a safe warehouse for a few days than send them back to a sickness-inducing environment that cannot contain them.
I frequently wonder what it would be like to be in private practice- something I may be finding out in the not-to-distant future. I think of the multitudes of private practitioners who have never done these types of assessments or confronted these issues, but live in a narrowly confined and defined version of mental health. The idea scares me, because it makes Dr. Phil's out of my colleagues rather than psychologists with a holistic experience of mental health in its varied and extreme forms. While I am under a lot of stress, and find this job overwhelming at times, I am grateful for being forced to confront these types of ethical dilemmas; these problems belong to everyone, not just those in the mental health professions.
The problem is that there is a kernel of truth to that statement that makes me feel squicky inside. The reason I was in the ER in the first place was to transfer a kid from our ER to a psychiatric hospital for an assessment, a task which ordinarily takes 1-2 hours. It took me 4, simply because she was from a different county so that, instead of following the usual routine, I had to wade through mires of bullshit to find out where to send this girl and then get that hospital to accept the transfer. Meanwhile, what I was sending her for- an assessment of suicidality- was something I do weekly in that very ER and am fully competent and qualified to perform. I wasn't performing it in this case solely because the girl was 13 instead of 11-and-under and was from the wrong county. We only get paid by our county, and then only for kids 11-and-under. All others get shipped out.
There is an element of warehousing and bureaucracy inherent to crisis mental health work that is repugnant. The security guard I worked with on this case gave a good example of this. He used to work at the local adult psychiatric hospital, and told me about their "frequent fliers," folks who weren't mentally ill, but used the mental health system and the 5150 laws to secure a bed and a meal simply by calling 911 and reporting suicidal ideation. These individuals take up space designed for psychiatrically impaired adults, and cost us a fortune by doing so that could be better spent in other types of (less expensive) social services. Meanwhile, a large, large portion of the mentally ill adult population is warehoused in prisons, where they receive no treatment at all.
In my own 5150 assessments this sort of dilemma becomes apparent when a child who would, in an ideal environment, be able to go home ends up being sent to a psychiatric hospital because I don't trust their parent or their environment to keep them stabilized. In a lot of these "soft calls" the problem seems to me to be largely an issue of family, community, and environmental dynamics rather than a function of sincere mental illness, namely suicidal/homicidal ideation or being gravely disabled. Yet I send them off because, on the ethical scales, it is better to keep them in a safe warehouse for a few days than send them back to a sickness-inducing environment that cannot contain them.
I frequently wonder what it would be like to be in private practice- something I may be finding out in the not-to-distant future. I think of the multitudes of private practitioners who have never done these types of assessments or confronted these issues, but live in a narrowly confined and defined version of mental health. The idea scares me, because it makes Dr. Phil's out of my colleagues rather than psychologists with a holistic experience of mental health in its varied and extreme forms. While I am under a lot of stress, and find this job overwhelming at times, I am grateful for being forced to confront these types of ethical dilemmas; these problems belong to everyone, not just those in the mental health professions.
posted by Mollynonymous | 9:48 PM
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