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.”

Safety contracts are a tool in psychiatry where you get patients to formally promise to take certain actions if they start feeling suicidal. The research doesn’t really support them, but they’re pretty common anyway.

I just learned that my boss writes really formal safety contracts in Olde English and seals them by making his patients swear a formal oath with their hand on a copy of the DSM-V.

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)

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.

Lots of people seem to agree with me about making FDA approval easier, but every so often I flirt with a much crazier position - I think we need to overhaul the prescription system, with less of an emphasis on making people get constant prescriptions from doctors every time they want to take drugs. Let me give an example.

Yesterday I was called in to evaluate a patient who had attempted suicide. He’d attempted suicide because his pain was so bad. His pain was so bad because he “couldn’t afford” the one medication that could control his pain.

(I’m being deliberately vague for confidentiality reasons, sorry)

I looked up the medication that could control his pain on GoodRx.com. It costs $5 per month in our area. This guy was poor, but not so poor he couldn’t pay $5/month to prevent pain so bad it made him want to die.

Turned out the problem was: he’d been receiving the medication happily for a couple of years, getting new prescriptions from his doctor each month. Then he lost his house. Somehow his Medicare (Medicaid? I can’t remember) was tied to his home address, such that by missing some stuff they sent to his home address he lost the insurance and had to re-apply for it. This took however long it takes to re-apply for things with government agencies. During the interim, he had no insurance. When he had no insurance, he couldn’t afford to see a doctor. Without a doctor, he couldn’t get his monthly refill on the prescription that he’d been receiving without any problem for years. So he couldn’t get the $5 medication he needed to control his pain. So he decided to commit suicide.

This is an interesting case because it cuts through a lot of the pat solutions that people have for these kinds of things. “Oh, just regulate the price of everything!” Wouldn’t help. I guess making applying for government insurance less bureaucratic would help, but good luck with that.

I know this isn’t the most consequentialist way to think about things, but imagining that I’m in terrible pain, and there’s a medication which I *know* works, and which I’ve used safely for years, and which only costs $5, but nobody will let me buy it because I don’t have an Official Piece Of Paper from a suitably credentialled rich person, would make me…well, it’d make me want to kill myself.

Life lessons from my patients: If you get pulled over by the police, and you have a bunch of drugs in your car, swallowing all the drugs at once so that the police can’t find them isn’t as clever a solution as it might seem.

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.