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.

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.

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.

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)

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.

Online continuing medical education courses are notorious for being easy. Doctors are required to take some, but there’s no rules about which ones they have to take, and they all cost money and are for-profit enterprises. The companies have figured out that if they fail people, those people probably won’t be return customers, so they make it hard to fail.

The course I’m taking now has a pre-test which is word-for-word the same as the post-test. This is fine. It helps me figure out what to watch for when I’m taking the course.

But they seriously just copy-pasted the post-test. So much so that one of the questions on the pre-test is “how did you like this course?” You’re not allowed to begin the course until you tell them whether you liked it or not.

I said it was okay.

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.

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.