At the child psych hospital, we have a kid who came in with a photo of his parents, freaked out when staff tried to take it away from him, said he carries it with him everywhere he goes.
Those of you who haven’t worked in institutions before are probably saying “Awww, how cute, he really loves his family.”
Those of you who have worked in institutions before are probably asking “Was there a shiv hidden in the photo frame?” And yeah, there was.
For once I can be financially irresponsible and have it be ultimately useful.
I’ve heard a lot of bad things about the mental health care system, but this seems to cut against @slatestarscratchpad ‘a claim that people are often shunted off too early because they really need the beds as soon as possible. Anyone know what’s going on here?
I don’t want to claim too much expertise here, because my guess is this is very different in different hospitals, in different states, and with different pay structures. But here’s how things work at our hospital:
– If somebody needs to be committed, but has no insurance, we call some kind of government program called CareLink, which gives them temporary mental health insurance. This is all done by social workers so I’m not entirely sure how it works, but I think it’s some kind of means-tested insurance for poor people. I’m constantly confused by this, because it seems to have existed about the same both before and after Obamacare, and “everyone can get their mental health care paid for if they need it” doesn’t fit what I hear about the US health care system. Maybe it’s Detroit-specific?
– If we keep someone more than a few days, their insurance starts calling us and griping about how maybe we should release him and maybe they’re not going to keep paying us. Then we have to argue that we can’t release him because he’s suicidal/homicidal/otherwise dangerous/otherwise really sick. If it’s super-clear this is true, the insurance will usually keep paying us.
– If the insurance company refuses to pay us, but we’re convinced that the person is dangerous and can’t go home, we just have to eat the losses and treat the patient without getting paid. This is partly for ethical reasons, and partly because we could be sued if we discharge and then the patient hurts themselves/someone else. That’s right - we can be legally obligated to treat people without getting paid.
– I’ve been involved in a lot of “should we discharge this guy today or not?” discussions, and never ever has “he’s fine, but we could get more insurance money by keeping him” been involved. Occasionally “our judgment is we should keep him, but insurance won’t pay us” has been involved, but subject to the caveat above. Nobody paying us can weigh as one factor to get rid of someone, but it’s not an overwhelming factor if we think the patient is really ill. It mostly just affects edge cases.
– In theory, we can just keep someone without any insurance and send
them the bill for their own care. We don’t like to do this, both because
it’s not that ethical and because realistically the bill will be tens
of thousands of dollars and they won’t be able to pay. I think usually
what happens in this situation (both for mental health care and normal
medical care) is that the hospital collection department makes all sorts
of threats, the patient makes all sorts of protests that he’ll never be
able to pay, and then depending on how convincing each side was they
settle for some tiny fraction (eg 10%) of the listed price that leaves
everyone unhappy.
– There was one time that one of the new doctors didn’t know how to write documentation, so he looked it up and discovered that we were all doing something called “underdocumenting”, which meant that insurance companies were only paying us about half as much as they would if we were documenting correctly. We started writing our documentation differently and our revenue doubled in the space of a week. We’d been doing it the wrong way for years and nobody had every checked. I bring this up just to point out that this is not the sort of thing that happens in an enterprise with such a dastardly focus on profit that we’re frequently conspiring how to keep people locked up longer to wring a few extra bucks out of the system.
– I don’t know how much it matters that we’re a teaching hospital, and so get a lot of our money from the government and various educational initiatives. Maybe we are unusually non-money-focused.
– I’d be pretty surprised if you could just immediately cancel your insurance from a psych hospital. I would think capacity issues (ie can you make legal decisions while mentally ill?) would come up.
– I’d be pretty surprised if this method worked but hadn’t caught on among frequent-flier patients, who seem pretty clued in about a lot of stuff and are always trying long-shot ways to get out of the hospital.
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.
Related to the “toxic masculinity” discourse from the other day:
Today I had to go to a committee meeting on doctor burnout. According to a survey, a lot of doctors in one of our departments felt overworked and burnt out, and the committee was supposed to come up with suggestions.
The committee was mostly administrators, mostly female, and although they didn’t use the exact phrase “toxic masculinity”, they talked about “macho culture” a lot. I think their theory was that male doctors had a macho culture where they felt like they didn’t need to take any time for self-care, and they shouldn’t speak up about excessive workload, and they had to look perfect or else they would lose their aura of invincibility. And that having to be this way all the time produced burnout.
So then I, as the doctor representative at the meeting, got up and said that I knew a lot of the doctors in this department, I’d talked to them a lot, and they all said the same thing. They would all love to take some time off for self-care, but there were too many patients and not enough doctors to deal with them, and if any one of them took extra time off, then one of their equally overworked colleagues would have to work even more hours covering for them.
The reason they “weren’t complaining” was that they had already complained to every administrator they could think of, and the administrators had said stuff like “you shouldn’t just complain, you have to be proactive in coming up with a solution” and refused to devote extra resources to the problem.
I said that doctors were really good at complaining about things, and really some of the best complainers-about-things you will ever meet, but that they weren’t going to keep banging their heads against the wall when nobody listened to them and there was no good solution.
The administrators thanked me for my input and went back to talking about macho culture.
hey parents: there is literally no non-abusive reason a person would want the ability to read someone’s emails, track their location, and go through their calls and text messages without their knowledge or consent.
I want to address the person who tagged this “what if they’re missing??”
that’s it, that’s the answer.
what this does is allow you to set up a list of people who are able to request your location. when they do so, you have five minutes to either refuse or grant the request. if you don’t respond within five minutes, the request is automatically accepted, in case you’re hurt or otherwise unable to get to your phone. your trusted contacts can also see how recently you used your device.
in other words: if someone genuinely wants to know if you’re okay, they can check the app and see that you’ve used your phone five minutes ago, and that can be the end of it. if they want to be doubly sure, or it says you haven’t used your phone recently, they can request your location. if you want them to know where you are, or you can’t answer, they’ll have your exact location within five minutes. if you don’t want them to know where you are, you click deny, and they still see that you got the request and responded to it, meaning, again, they know you’re okay. this is safety with accountability: you can’t track someone’s location without their consent unless they fail to respond to the notification, and you can’t do it without them knowing about it.
if you want to track a friend or loved one for genuine safety reasons, set this up. it gives you all the access you need if your concern is actually for the other person’s well-being, rather than a desire for control. (it’s not out for iOS yet, but Google says that’s coming soon).
(also: don’t be the jackass that makes a rule that someone has to accept all your location requests because that makes you just as bad as the people who install tracking shit covertly.)
It’s not abusive in any way for a parent to want to know where their underage child is and who they’re talking to, and saying so is a foul misuse of the term “abuse”.
anyway like I said there is literally no non-abusive reason a person would want the ability to read someone’s emails, track their location, and go through their calls and text messages without their knowledge or consent
I’m glad you live in a world where adults don’t groom kids on the net, or by calling them or sending them text messages.
I live in this world:
a world where parents are an order of magnitude more dangerous to children than “adults grooming them on the internet”, and giving parents unchecked powers of surveillance is for that reason alone more likely to put kids at risk than to keep them safe.
I live in this world:
a world where the psychologically debilitating effects of surveillance are well-established and well-known, yet adults do everything in their power to invade young people’s privacy and then ask dumbass questions like “why are kids so anxious?” and come up with answers like “it’s probably because of selfies”
I live in this world:
a world where invasion of privacy is recognized as an integral part of emotional abuse, but parents still get away with it because “they’re just doing it to keep them safe uwu~”, despite the fact that this is the same line the goddamn NSA gives us and most of us don’t take that sack of lies from them.
tldr, I live in a world where you’re not just wrong, you’re promoting attitudes that are actively harmful and you need to sit down, shut up, and listen when people are trying to educate you about issues of justice and safety.
Slaaaaaay
I remember my first foray into child psychiatry.
My patient was this teenager with a history of behavioral problems. He complained that his family didn’t trust him and monitored everything he did. I sympathized, said that this must be really hard, and that no wonder he was acting out. I had a conversation with the kid and his parents, I told the parents I thought that their overprotectiveness was inappropriate and contributing to their child’s issues, and told them that if they cooperated with him by treating him more maturely, he would cooperate with them by acting more maturely.
A few days later, I called the parents to ask how the son was doing. “We don’t know,” they said. “He disappeared and we haven’t heard from him in days.” Later we learned that he had run off with some people, gone on a multi-day drug binge, and ended up in the hospital.
This was the last time I let my self-righteousness get away from me by lecturing parents on how they were bad people for watching over their kids too closely before I was really sure I knew all the details.
Today we had a patient who seemed a bit slow, and we were trying to screen for intellectual disability. The conversation went like this:
BOSS: Did you ever have to take special classes in school?
PATIENT: All the time.
BOSS: Have you ever taken an IQ test?
PATIENT: I don’t know.
MY BOSS: Has anyone ever told you that you’re intellectually disabled?
PATIENT: I don’t know what that means.
BOSS: Has anyone ever told you that you were mentally retarded?
PATIENT: Yeah, and I punched them in the fucking face.
Me: Hi, I’m the psychiatrist here.
Patient: Why…they….send….psychiatrist?
Me: I think your doctor was worried you might be depressed.
Patient: Not…depressed…why…think…that?
Me: According to your chart, since your medical problems started last year, you’ve become paralyzed in both arms and both legs, have to eat through a tube, can barely speak, and all you can do is lie in bed and watch TV all day.
Patient: Yes…but…I…love…lying…in…bed…watching…TV…all…day.
We have a “quiet room”, which is the polite name for the padded room where we put people trying to hurt themselves.
Today someone went into the quiet room and hurt themselves pretty badly banging themselves against the wall really hard.
So my boss went in, punched the walls a few times, and ended up kind of bruised.
He went to the hospital administrator and said that the padded room wasn’t padded enough and we needed to put more padding on it.
The hospital administrator said that this had already been discussed, and they had decided against because the extra padding would be really obvious and “we don’t want to make people feel like it’s an institutionalized environment”
Tonight an Armenian man was admitted to the psychiatric hospital on an emergency basis with some kind of really serious psychotic break, but we couldn’t figure out what was going on with him because he didn’t speak English.
So we called the hospital administration for an Armenian translator, which is apparently complicated at the best of times but practically impossible on Christmas Eve. Finally somebody agreed to come in from far away, but he seemed pretty confused and angry by the whole thing and didn’t actually speak English that well. My boss tried to explain the situation to him, but he wasn’t interested and might not have even really understood. He just demanded “Take me to man, I will translate.” So we did.
So the translator goes into the patient’s room, and the patient gets really excited and starts talking in Armenian in this very animated way. The translator gets more and more upset, and finally he takes my boss into the corridor outside the room and shouts,
“THIS MAN IS A FUCKING LUNATIC!”
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.
Anonymous asked:
… if my thought process is really lazy why would it make me tired? wouldn’t you expect the opposite?