I’ve been thinking a lot about that deFOO cult today.

Families are terrible. I say this as someone with a really great family who have always gone above and beyond to help me and whom I love a lot. I thought families were generally great until I went into psychiatry. But there are so many people screwed up in every way by their family that I’m starting to think I’m just a weird outlier.

I remember a case where I got a call from a distressed father. He wanted to know if he could have his son committed to the psychiatric hospital, because the son was constantly trying to beat and assault and murder people, including the father and other family members. The only problem was that as far as we could tell, this didn’t have anything to do with psychiatric illness. He was just a murderous kind of guy.

The boss said we wouldn’t take him, and told me to call the father back and advise him to press charges and have the son sent to prison. I felt kind of dumped on, because this was going to be an absolutely miserable phone call. Tell a father to have his son sent to prison? I prepared myself to get either yelled at, cried at, or both.

Actually, he was super-receptive and thanked me for excellent advice that he had apparently never thought of before. Press charges against someone just because they tried to murder you? You can DO that? I guess he had just internalized that this wasn’t the way the father-son relationship worked, and resigned himself to probably getting murdered one of these days.

One of the really common AskReddit thread topics is “If you could send one short message to everyone in the world that they had to read, what would it be?” And usually I think of kind of joke answers like “DON’T TRUST SOCIAL SCIENCE HYPOTHESES WITHOUT CHECKING IF THERE IS A TWIN STUDY THAT CONTRADICTS THEM FIRST”, but maybe my real answer, if I were ever in this situation, would be something like “CONSIDER THE POSSIBILITY THAT YOUR FAMILY MEMBERS ARE HORRIBLE, AND IF THEY ARE, TAKE THE SAME SORT OF ACTION THAT YOU WOULD AGAINST A HORRIBLE PERSON WHO IS NOT YOUR FAMILY MEMBER.”

Public service announcement: if you have a kid with some kind of horrifying predatory criminal, and now your kid is a horrifying predatory criminal, and you have no idea how this happened because the father left before he was even born and your new husband is a great guy and you’ve both always done your best to raise your kid well and give him a good home, your kid’s psychiatrist will listen empathetically to your story, and then empathetically give you a copy of The Nurture Assumption.

…maybe not actually. But it will definitely be on his mind. And maybe it would get people to stop having so many kids with horrifying predatory criminals. Seriously, I’m doing inpatient child psychiatry now and I get multiple cases like this every day.

A psychiatrist I work with recently learned through the obituaries that one of her former patients had died. She was upset, both because it’s always sad when someone you know dies, and because she didn’t know what he died of and hoped that it wasn’t because of anything she did or didn’t do (he was really young, like 45, so something must have gone wrong, and he was on a lot of medications, and all medications have potential side effects).

I suggested she look at his medical chart, since whatever killed him probably landed him in the hospital first, and since as his doctor it is 100% her right to view his chart (much of which she has written herself).

She said she’d asked about this, and the hospital lawyer had said she should not look in his chart, since our electronic chart system logs whenever anyone looks in somebody’s chart, and if his family sued over his death then looking in his chart might hurt the hospital’s case. The exact argument would be something like “This doctor was obviously curious about what killed Mr. A, which could have been because she wanted to know if it was her fault, which means it was something she considered a strong possibility.”

I guess this might be something a lawyer could argue. But we’re a teaching hospital. The whole point of our being at this hospital is to learn how to treat patients well. If we’re not even allowed to check whether something killed a patient or not, that makes it kind of hard to get any feedback and learn not to do patient-killing things.

If you come to a psych ER saying “Help, I have no money and no friends and I want to die,” the first time we will just hear the “I want to die” part and admit you for depression + suicidal ideation. We will give you some antidepressants, one to two group therapy sessions, and if you are lucky also a piece of paper with the names and phone numbers of helpful social services.

If you come back a month later saying “Help, I still have no money and no friends and want to die,” we will look at each other awkwardly, then admit you for “treatment-resistant depression,” because we feel bad and we don’t want to just do nothing. We will switch your antidepressant to a different antidepressant. We can also give you another sheet of social service phone numbers again, but it will just have the same ones as last time.

If you come back a third time a month or two after that saying “Help, I still have no money and no friends and want to die,” we will politely inform you that the psychiatric hospital might not be the right place for you, and wish you luck finding other means of support. If you ask us where else you can go, we will tell you that we are very busy and we have lots of other patients to see, and maybe give you the same list of social service phone numbers again.

I wish there was a social services ER that I could transfer people to.

It’s only 12:00 on my call night, and I am already just one more depressed person’s life story away from becoming one of those supervillains whose origin story is that there is so much suffering and evil in humanity that it would be better off destroyed.

I have to give a short presentation on some episode from the history of psychiatry next month, topic is my choice. Any of you know any really weird, really interesting history-of-psychiatry episodes?

(right now the best I can think of all the psychedelic psychiatry experiments of the 60s, especially if I can work in the part where John Lilly’s assistant had sex with dolphins for important science-related reasons)

Seen on an alcoholic patient’s chart: “Patient says he is tired of being tired of drinking.”

I give my ER patients a cognitive exam to assess for dementia. One of the questions is “Who’s the President?” Many people voluntarily add who they’re supporting for President in November.

So far the pattern is that the depressed people are voting for Hillary and the alcoholics are voting for Trump. This is probably a metaphor for something.

Today in health care economics:

One of the psychiatrists in the hospital reads somewhere that, by slightly changing the way he writes his notes, it will get classified in a different “billing category” and the hospital will make twice as much money per patient seen. He tries this and it turns out to be true.

He gets very excited and tells all the other psychiatrists, who had never heard anything about this before. They briefly consider it, then decide that slightly changing the way they write their notes sounds hard, and their salary is unrelated to how much money the hospital makes off each patient. Nothing changes.

One would think that the hospital would either mandate this new type of note directly, or link the psychiatrists’ salaries to the amount of money the hospital gets per patient in order to incentivize changes like this. It doesn’t. One would think the hospital would at least have somebody come around and tell people that a slight change to the notes would make twice as much money, in case somebody wanted to act on it. They didn’t.

I’ve been told that it’s wrong to care too much whether a hospital is for-profit or non-profit. My hospital is non-profit, and I wonder if a for-profit handles this kind of thing differently.

Sometimes we have to transfer psychiatric patients from our hospital to a different hospital. Usually it’s because they came in for a medical problem, somebody realized during their stay that they also had a psychiatric problem, but our psych unit is either full or doesn’t take their insurance.

Regulations say that every transfer from one hospital to another has to be done by ambulance. It doesn’t matter if the patient is in the hospital for depression, or obsessive-compulsive disorder, or something else where it’s hard to see why an ambulance would be necessary. If we send them by some kind of transportation method other than ambulance, maybe they’ll have a heart attack, or decide to commit suicide mid-taxi-ride despite never having been suicidal before, or whatever, and then someone will sue us. So those are the rules. Every transfer has to be done by ambulance (this adds a few thousand dollars onto their final bill, but whatever, that’s the insurance companies’ or the taxpayers’ problem, right?)

Ambulance companies refuse to transport psychiatric patients without a petition. A petition (technically a clinical certificate; to real lawyers the petition is something else) is an official legal paper signed by psychiatrists saying that somebody is a danger to themselves or others and needs to be hospitalized against their will. The ambulance companies say that if they don’t have that, then the patient can just ask them to get off the ambulance at any point, and they could get sued if this caused problems down the line. Or something. I don’t really know what the ambulance companies are thinking.

The problem is, a lot of the time we want to transfer patients who aren’t dangerous or in need of involuntary commitment. A lot of times there’s a depressed person at our hospital, and they’re not suicidal or homicidal or anything, and they’re asking for psychiatric help, and we want to give it to them, but our hospital is full and we need to send them somewhere else.

So the first thing I tried was just to tell the ambulance companies “Yes, we’re sending this patient to another hospital. No, they’re not dangerous.” The ambulance companies said they didn’t care. No petition, no ambulance.

The second thing I tried was explaining this to the patient. “I know you’re requesting to come into the hospital voluntarily, and I know you’re not suicidal and you’re just looking for help, but for bureaucratic reasons I just have to sign this paper that says you’re a grave danger and takes away all of your rights. It doesn’t actually mean anything and it will probably get thrown away after the ambulance ride, although really that’s the other hospital’s call and if they want they can just keep it and then you’ll continue not to have any rights.” This was not popular among patients. Also, it turns out that the legal document says “THIS IS AN OFFICIAL LEGAL DOCUMENT AND YOU HAVE TO SWEAR EVERYTHING ON IT IS TRUE AND IF IT ISN’T THEN YOU ARE GUILTY OF PERJURY AND CAN GO TO JAIL”, so I’m kind of wary about falsifying it.

Now what I do is give the ambulance companies a petition, but instead of actually filling it out I just write in the comments field that the patient is fine and no legal action is required. Whoever is on the receiving side apparently just confirms that they received a petition-looking piece of paper, nobody reads any of it, and the patient gets sent where they need to be without me risking a jail sentence. Although I guess if the patient ever decides to just stop the ambulance and get out halfway, and then gets hit by a car or something, I’m going to get in a lot of trouble.

Everything in medicine is like this.