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.”

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.

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.”

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.

Since I’ve been talking health economics lately:

Suppose there are two insurance companies, CheapoCare and PremiumHealth. CheapoCare is cheap for patients but doesn’t pay doctors very much. PremiumHealth is expensive for patients but pays doctors lots of money.

Suppose you’re a doctor trying to maximize profits. If you see a fixed number of patients a day, you might prefer to preferentially see PremiumHealth patients, and see CheapoCare patients only if you’ve finished seeing all the PremiumHealth patients who are sick that day.

You’re not allowed to do this. It’s against legally-binding ethical guidelines to prioritize some patients over others based on their insurance.

On the other hand, getting approved as a provider for any insurance company is a long and annoying process, and it’s totally ethical not to go through it. So perhaps our money-liking doctor above could just not bother to fill in the five billion forms that she needs to get approved by CheapoCare. Then she could take only PremiumHealth patients, and get her money after all.

The interesting thing about this arrangement is - well, suppose that the doctor can see ten patients a day. Suppose that in her area there are enough PremiumHealth patients to give her a steady stream of 7/day, and the same number of CheapoCare patients. And suppose PremiumHealth pays $200 per patient, and CheapoCare only pays $50.

In the world where there are no ethical guidelines, the money-liking doctor would see the 7 available PremiumHealth patients per day, and fill the remaining 3 slots with CheapoCare patients, for a total of 10 patients and $1550.

In the world where there are ethical guidelines, the doctor could choose to take both insurances to maximize her patient load. In this case, she will see a random mix of PremiumHealth and CheapoCare patients per day - and since there are equal amounts of both, on average she’ll see 5 each - for a total of 10 patients and $1250.

But if she wanted to maximize profits, she would never sign up for CheapoCare at all! If she doesn’t sign up for CheapoCare, she will see 7 PremiumHealth patients and 0 CheapoCare patients, for a total of $1400. Then she’ll go home a little early since she doesn’t have any patients to see the last three appointments of her day.

So the ethical guidelines are suppose to ensure that greedy doctors don’t deny care to the poor. But what they actually do is give doctors $150 extra a day to not even see the poor people they were going to see before!

And it’s actually even worse than this. Suppose you’re a doctor who does two different things. For example, maybe you see patients in your office, and you also go into the hospital to perform surgeries. Suppose that CheapoCare and PremiumHealth pay exactly the same amount per surgery, and PremiumHealth only pays more for the office visits.

In the absence of the guidelines, a greedy doctor would see fewer CheapoCare patients in her office, but she would still perform exactly the same number of surgeries on them. In the real world, agreeing to perform surgery for CheapoCare patients would require signing up with CheapoCare insurance in general, which would obligate her to take a big pay cut in her other job at the office. So the doctor is incentivized not to perform surgeries for poor people even if it’ll earn them exactly the same amount of money!

Note: I haven’t 100% verified this is true, just heard a teacher say it during a lecture on medical business. If it’s wrong for some reason please let me know.

I’ve had murderers as patients, and I’ve had child pornographers as patients, but I think today was the first time I (well, technically a colleague) had a patient who literally drowned puppies for fun :(

(at a lecture on the Oedipus complex)

Lecturer: Oedipus was a character from Greek mythology. He was the son of Laius and…uh…um…

Me: Jocasta?

Lecturer: No, that was his wi…wait, I’m an idiot.