So . . . I got in my car the other day and, much like every other day, put on my blindfold and sped off to work . . .
“WHAT?????” you might be rightfully saying . . . “put on your blindfold and started driving?????” . . . “you CRAZY!!!”
Well, of COURSE I didn’t cover my eyes and start driving. That would be foolish. That would be dangerous. I could hurt people . . . you have to see where you are going. Have to be able to read the signs. Steer clear of the pot-holes. Know when to stop. Know when to go. And . . . especially important . . . when to realize you are going in the wrong direction.
I met with the parents of a young lady the other day. I will call her Daisy. Daisy has had a long history of low grade psychiatric issues that have worsened significantly over the last several months. The parents are at wits end because of the escalation of her difficulties. The piece of the story that bothers me the most is how she has floated in and out of several psychiatric hospitalizations and day program stints and has not gotten much better. And she is, from their description, really, really ill. The doctors have not been available and there has been a series of fairly rapid medication changes that leave her parents scratching their heads and wondering what is going on. All this treatment, all this time, all these medications have had little positive impact on how well Daisy is doing. In the short time I had with them, however, their story hung together and, even without speaking to the patient, I believe I have a fair idea of what is going on with her. And I have concerns about how she is being medicated.
The details of her presentation and the details of her medication trials are not important here. It is the process. In this age of HIPAA and attempts to strictly protect a patients confidentiality, we sometimes miss opportunities to gather information that could, in some circumstances, save lives. There is NO substitute for good history gathering. Without it, a physician is prescribing like he is playing darts. And the consequences of this somewhat random application of psychoactive chemicals can be devastating. Mental illness is much like rolling a boulder down a steep hill. Once it gets rolling, it is hard to stop. And getting the boulder back up on top can take a lot of time and effort. It is imperative, therefore, that all efforts are employed to get accurate and complete information prior to the introduction of medications to a patient. Once an accurate diagnosis is made, it is imperative that medications be given time to work. Sometimes the medications are switched after only a day or two . . . as if 48 hours constitutes an adequate trial of any medication. We all know that it can take weeks to get benefit from some medicines. Yet, it is not uncommon for patients to enter my practice from an inpatient hospitalization having had three or four “medication trials” in the space of a week. This makes no sense (at best) and is potentially dangerous (at worst). I HOPE that the doctors that do this are knowledgeable enough to know that this is not good clinical practice. I can only imagine that they are under tremendous pressure to do something . . . ANYTHING . . . to justify continued treatment in the inpatient setting (authorization for inpatient stays are metered out a day at a time by the insurance company and the hospital must justify each day; medication adjustment is one of the best justifiers for continued stay). Taking a day or two to get information and plan treatment is not supported in the current health care environment. Yet the failure to do this has, in this case, resulted in numerous additional inpatient days and partial-hospital days. When Daisy does come out of the hospital, it is likely that she will need another partial hospital stay. When she is done with that, she will likely need intensive outpatient treatment, as well as frequent visits with the psychiatrist. I suspect that much of this could have been avoided with more time devoted to history-taking.
Basic third-year medical student stuff.
How could we have let these most basic principles slip by us in the name of (supposed) fiscal responsibility?
–Dan Hartman, MD
