Ethical ambiguity: When to certify a psychiatric patient

The greatest difficulty I've had during my psychiatry sub-internship is deciding when to take away someone's personal freedom by placing them on a mental health hold (MHH) or a short-term certification (STC). My attending told me at the beginning of the rotation, "I want you to make decisions about your patients. We'll do what you want, so long as you can explain why you're doing it and you have your head screwed on straight."

This responsibility hit home a few weeks ago when I knocked on my attending's office door to talk with him about a patient. I was uncertain about whether to place this patient on a STC. My attending sat back in his chair and listened while I explored both sides of the argument.

On the one hand...

This is a middle-aged guy with an unclear history of psychosis who's experiencing paranoid delusions to the extent that he has isolated himself from the entire world, including his family. He has a history of attempting suicide, and there is evidence of increasingly bizarre and disorganized thoughts. According to the police who originally placed him on a MHH, the patient's apartment was a disaster. Charcoal briquettes were placed around the periphery of each room, bed and couch and lamps were turned upside down, curtains were turned inside out, and two pennies were placed in strange places like in the refrigerator and in the shower. This is a man who could certainly benefit from continued hospitalization and treatment.

On the other hand...

The patient does not want to stay in the hospital, does not want treatment, and does not believe he has a mental illness. He shows no depressive symptoms and denies wanting to hurt himself or other people. He sure has some bizarre and paranoid thoughts, and doesn't have a job, but he pulls in a Social Security disability check each month and is able to clothe and feed himself. He may or may not meet legal criteria for being "gravely disabled," which would justify holding him on a STC.

When I finished, my attending leaned forward, looked at me intently, and asked, "So, what are you going to do?" I understood what he was doing: pushing me to make a tough decision and stick by it. This is part of my education, the process of becoming a doctor.

"I don't know, that's why I came to you for advice."

"Do you think this patient is mentally ill and needs treatment?"

"Yes."

"Do you believe that he is a danger to himself or others?"

"No."

"Do you believe that he is gravely disabled?"

"Possibly."

My attending then advised me to remember that my primary responsibility is to my patients. As long as I believe that I am following the law, I should do what I think is necessary to take proper care of my patients and let the judge decide if our actions should be upheld.

"So, what are you going to do?" my attending asked again, this time with an amused smirk.

"I'm going to cert him."

Although he never explicitly said so, it was clear to me that my attending thought that we should keep this patient on a STC.  I made the decision, though, based on my gut feeling that my patient was indeed gravely disabled and would benefit from treatment.

The patient stayed for another week with nominal improvement of his paranoia and disorganization. He agreed to keep taking medications after he left the hospital. That was something.

Everything about this patient's case was ambiguous to me. Did I really help him by keeping him in the hospital against his will? Was I justified in holding him on a STC? Was he really gravely disabled? Sometimes there are no clear answers, and I just have to make a decision that seems best at the time. I feel better knowing that I would make the same decision again if I had to do it over.

The legal side of psychiatry

Most of the inpatient psychiatry patients I have seen were admitted voluntarily. But some patients can be held involuntarily if they meet certain criteria: 1) They pose a threat to themselves, 2) They pose a threat to others, and 3) They have grave disability. Those first two are self-explanatory; "grave disability" just means that a patient's psychiatric illness impairs his or her ability to properly care for themselves. Think food, clothes, and shelter.

A mental health hold (MHH) is the shortest involuntary hold at 72 hours. Its purpose is to further evaluate a patient's mental state according to the above three criteria. There are important legal implications of the MHH. Most importantly, since the purpose of the MHH is fact-finding, the psychiatrist is allowed to obtain medical records from other institutions, and talk with the patient's friends and family, without the patient's consent. This means that if a patient is initially admitted on a MHH then switches to voluntary status, the psychiatrist is no longer able to get that information if the patient doesn't agree to it. I saw this happen a few times.

Short-term certification, which lasts for 3 months, is the next step of involuntary hospitalization. By the end of a 72 hour of a MHH, the psychiatrist must convince a judge that short-term certification is necessary, again demonstrating that the patient poses a threat to himself or others or has grave disability. Long-term certification lasts an additional 6 months and also has to be argued before a judge to be granted.

Lastly, there are involuntary medications (i-meds), which are exactly what they sound like. Typically, a patient flies out of control after refusing voluntary medications, emergency medications (e-meds) are given to control the patient in the short-term, then the case is brought before a judge to grant power to administer i-meds. Concern for the physical safety of fellow patients and staff is often cited as justification for requesting i-meds.

The gravity of depriving a person of freedom is not lost on me.

Going to court

One particularly memorable patient took his case to court. Among other problems, this patient had delusions of grandeur that led to increasingly serious run-ins with the law.

The patient was shackled and escorted to the courthouse by a sheriff, while the rest of us piled into a government-issued van for a field trip. The intern would be testifying, a first for him. He practiced his testimony on the ride over, and the attending prepared him for what to expect. "The public defender is going to try to discredit you as an expert witness. Don't worry: It's not personal, and the judge will likely rule in your favor."

That's exactly what happened. My intern became a newly-minted "expert" with the privilege of providing testimony related to the matter of placing our patient on a short-term certification. He stood at the podium with his hands clasped tightly behind him, so tightly in fact that his fingertips were white. His back was straight, his shoulders squared, his head held high, and in that pose he answered questions thoroughly but succinctly in a clear and certain voice. I was very impressed.

After some back-and-forth questioning from the public defender and city attorney, the patient/defendant had the opportunity to address the court. It turned out that our patient sealed his own fate with a diatribe that clearly demonstrated to the judge that he poses a threat to himself and suffers grave disability. We won short-term certification and the ability to administer involuntary medications.

Observing the legal process in action was fascinating, a valuable component of my psychiatry education.


Update: This patient is now doing fairly well. My intern writes:

The patient became less and less resistant to medications as he become more linear and logical. He never quite thanked us for forcing medication on him, but he did start saying positive things about the way he was thinking. Before he left, he actually became quite socially appropriate, responding to social cues, which previously he had not been able to do. He started telling jokes, some pretty funny and some bizarre. But he would occasionally follow a bizarre comment with reality testing saying, "Does that sound crazy?" and then laugh it off. At discharge, he was nervous to go home and thought it was happening too fast. Last I checked, he was making his outpatient appointments. His home visits have found him pleasant; he has been very welcoming to his case worker and showing off how clean and organized his apartment is, as well as new writings he has been working on.

Acting intern

Two weeks into my psychiatry sub-internship at Denver Health, and I'm having a blast. I was right in guessing that Denver Health would be a great place for a psychiatry sub-internship, given that it is a county hospital and a safety net for indigent and socioeconomically disadvantaged people.

The psychiatry inpatient service is capped at 12 patients, 6 patients for each of the two interns covering the service. On the first day, my attending told me that he wants me to build up to seeing 6 patients by the end of the month. This is consistent with the purpose of a sub-internship to prepare medical students for being an intern.

I'll get a chance to do exactly that this coming week. For the first part of next week, my attending will be away at a conference, and one of my interns will be out taking Step 3. The doctor who is covering for my attending spent some time with the team on Friday to help smooth the transition on Monday.

"You take three patients, and I'll take three patients," he said.

"What?" I said it without thinking, and it may have come out somewhat indignantly.

The new attending looked a bit surprised. He sat back in his chair, smirked, and asked me, "How many patients have you been carrying?"

I told him that I had been carrying 5-6 patients this past week. "Good! Then you can take your own team." He went over to the white board at the nurse's station, where all the patients are listed according to which resident is taking care of them. He erased my intern's name and wrote in my name. "Make sure to bring your pager on Monday. The nurses are going to be paging you when they have questions about your patients."

This promises to be an interesting week.

Fourth year scheduling

As rigid and uncompromising as third year was, that's the degree of flexibility that I have in determining my fourth year schedule. Senior year of medical school is all about further exploring specific career interests, taking courses that will help for getting into residency, and filling gaps in education. The requirements: take at least 32 weeks of coursework (out of 52 total weeks), take at least one sub-internship, and take enough research to finish the mentored scholarly activity requirement.

Also, fourth year is all about add/drop. A web-based program is used for scheduling. At any time, I can log in and sign up for a new class or drop a class that I signed up for earlier. The only restriction is that any dropped courses must be dropped at least 30 days prior to the start of that course.

As of now, my fourth year schedule is as follows:

May: Adult psychiatry sub-internship (at Denver Health)
June: Medicine sub-internship (at Denver Health)
July: Child psychiatry elective (at The Children's Hospital)
August: Time off to study for USMLE Step 2 CK and CS, and to work on residency applications
September - November: Set aside for externships
December - January: Set aside for interviews
February: International Spanish immersion elective (I'll write more about this once it's finalized)
March: ICC, and a fun "Film in Mental Illness" 2-week elective
April - May: More ICC, plus a 2-week "Cardiac Diagnostic Skills" elective

Then graduation at the end of May!

It's shaping up to be a good year.

Taking stock of year three: Advice for rising third-years

"The transition from classroom learning to the the clinical years will be the most difficult transition of your careers."

So said one lecturer preparing my class for clinical rotations, one year ago. This sentiment has been echoed by numerous other doctors over the past year. The transition from classroom to clinic represents a fundamental shift in the way that learning takes place, not to mention the additional considerations of teamwork and professionalism. Other major transitions in the medical career (e.g. graduating medical school and becoming an intern, or finishing residency and becoming an attending physician) represent increased responsibility, which is arguably more easy to deal with than a fundamental shift in the way one thinks.

Because of this, I decided that now would be an ideal time to step back, think about all that I have learned over the past year, and pass some of those lessons on to those who will follow me. Keep in mind that that what follows are my own opinions drawn from my own experiences. Other people will have different opinions, and I don't pretend to have all the answers.

1. Attitude. This can be said about anything in life, but I think it's especially true during third-year: A good attitude goes a long way. You are transitioning from learning in a classroom setting to learning in a clinical setting. You will have to figure out how to function well as part of the healthcare team. The reality is that there are many factors outside of your control that will cause you to be a burden on the team. This is more true at the beginning of third year than at the end. Try to minimize your burden on the team, and the best way to do that is to have a good attitude.

• Be happy; if you're not happy, don't show it.
• Be easy and fun to work with, even if you don't like your resident or attending.
• Be excited to learn, even when you're exhausted.
• Take the initiative when caring for patients.
• Take as much responsibility as your resident is willing to give you, even if you feel it's a stretch. If a question starts out with "Do you want to..." then the answer is always "Yes."

2. Perspective. Approach every clerkship as if that will be your specialty for the rest of your career. This may sound silly, or impossible, if you know 100% that you do not want to go into that specialty. But I found that this helped me to maintain a good attitude when I very well could have done otherwise. It's a lot easier to work hard if you feel that what you're doing is important. For that matter, if you absolutely hate a clerkship, remember that it will be over in just a few weeks; just push through it.

3. Study. Treat all of third-year as one long study period for Step 2 Clinical Knowledge. In my opinion, every shelf exam that I took was harder than Step 1. For each shelf exam, start studying early and study frequently, a little bit every day. My general approach to studying:

• Learn from patients. Your patients are your best teachers. Read about your patient's disease on UpToDate: review its pathophysiology, learn different ways that it presents clinically, know its diagnostic criteria and how to treat it. Do a pubmed literature search, if there are any questions related to your patient that can be answered by evidence-based medicine. Then bring back to the team what you find. Information sticks way better when you associate it with one of your patients.
• Pre-Test. This is a specialty-specific series that offers about 500 questions meant to prepare for shelf exams. I only used the surgery, psychiatry, pediatrics, and Ob/Gyn versions. They are all available as real books or as apps on iTunes. I borrowed the book versions of pre-test for psychiatry and pediatrics but decided to splurge for the $30 iTunes apps for surgery and Ob/Gyn. I'm glad I did, too, because there is a lot of waiting around during those two clerkships, so I would just crank out 5-10 questions whenever I had some time to burn. I finished all 500 questions before each respective test. It's important to note that these questions aren't nearly at the level of difficulty as questions on the real exam. In retrospect, I think pre-test would have been helpful for my family medicine departmental exam. I would stay away from pre-test for Internal Medicine, though, because there's MKSAP, a question bank published by the American College of Physicians. 
• Step 2 CK question bank. I bought a year-long subscription to Kaplan's Step 2 CK question bank at the beginning of my surgery clerkship and immediately wished that I had gotten it earlier in third year. I'm told that, like Step 1, Kaplan's Step 2 questions are a little harder than what is on the real test. They worked well for me as a shelf exam study aide. Throughout the clerkship, up until the last week, I did just 5-10 questions every other day or so. Then during the last week I did timed full blocks of 44 questions until I ran out of questions, of course reviewing explanations for every question. If I had extra time, I re-answered questions that I got wrong.
• Specialty-specific textbook. Most clerkships recommended specific text books. The family medicine departmental exam was drawn heavily from Essentials of Family Medicine, which unfortunately is an awful textbook (poorly written, poorly edited, too much emphasis on arcane statistics rather than big picture). The Internal medicine text is Internal Medicine Essentials for Clerkship Students 2 versus Step-Up to Medicine. I chose the first option because it is published by the ACP and is linked to the MKSAP question bank, which I also bought. The surgery departmental exam was drawn heavily from Essentials of General Surgery, which is actually a very well-written book, albeit heavy on text. Ob/Gyn recommended Beckman's Obstetrics and Gynecology, which provided a decent start to studying for the shelf exam. The rest of my clerkships did not recommend any specific textbook.
• Case Files. This is a specialty-specific series that offers case studies as a means of learning the materials. A patient's case is presented, then questions such as the most likely diagnosis or the diagnostic tests to establish the diagnosis or the means of treatment are asked. A short discussion then expands on those learning points. Each chapter is accompanied by a few softball questions that I found relatively useless. The major utility of Case Files, in my opinion, was talking over the cases with classmates. I only used Case Files for neurology and psychiatry, clerkships without a recommended textbook.

4. Practice. Your jobs as a third-year medical student are to learn how to take a good history, do a good physical exam, and present your findings both in notes and oral presentations. This is all easier said than done. If you're on your first clerkship and you think you're good, you're most likely overestimating yourself. Remember that there is always room for improvement. Don't worry if you're slow and clumsy at first; your residents and attendings expect that at the beginning of your third year, but they also expect steady improvement as you move through the year.

• Be methodical about how you collect your patient's history. The conventional order is 1) chief complaint, 2) past medical history, 3) past surgical history, 4) medications, 5) allergies, 6) family history, 7) social history. This will quickly be burned into your mind so deeply that it becomes the way you talk about patients in normal conversation. If it helps, create a template for you to fill in as you're interviewing your patient.
• Sit down when you're talking with patients, even if it means excusing yourself to get a chair or stool. It sets the patient at ease and gives them the impression that you're spending way more time with them than you actually do.
• Figure out how to end patient interviews without being rude or awkward. This is especially important because you'll often be pressed for time.
• Try to do a full physical examination, even if it means coming back to see the patient later when you have more time. Obviously this is not always practical, especially in the clinic where an entire patient visit is only 15-20 minutes. But the more normal exam findings you see, the easier it becomes to recognize an abnormal finding.
• Be proactive about seeing abnormal exam findings, even if it's not on one of your patients.
• Look to the fourth-year medical student notes as good examples to follow. The attendings and residents typically write more abbreviated and utilitarian notes that are not as useful for learning how to write a good note.
• Run your assessment and plan by the intern or resident before presenting a patient on rounds, if possible. This is an opportunity to see if he/she agrees with your plan or wants to change anything, and it helps make you look better in front of your attending.
• Find someone who you can present to as practice, if oral presentations make you nervous. This can be a friend or family member or a significant other. I was fortunate enough to have a resident who taught me how to present, but given how busy residents are, I think this is more the exception than the rule.
• When presenting, fall back on the methodical approach in which you took the patient's history. This will also save you if you're having a nervous brain-freeze. As you progress, you'll figure out how to pick out pertinent positives and negatives that tell the patient's story and guide the listener to your assessment.
• Don't forget to present the patient's vital signs!!! Some attendings want to hear each individual vital sign, but most of the time you can summarize it conversationally: "Patient is afebrile, normotensive, normal heart and respiratory rate, and satting well on room air." Or, more succinctly, "Vital signs stable and within normal limits."

5. Relax. No, seriously, relax. This isn't necessarily the most easy thing for me to do, but over the past year I learned how important it is for me to take full advantage of time off, even if that time is just a post-call day. Spend time with family and friends outside of the medical field, or at the very least try not to talk about medicine-related topics when you're hanging out with medical school friends. Think about what hobbies or activities recharge your batteries, and be proactive about scheduling time to do those. Be aggressive about protecting your relaxation time. Otherwise, you will burn out.